Sharing the results of a patient satisfaction audit.

Regular service audits since 2008 gave a stoma care department confidence in the service it provides. In 2016 the department undertook a new audit to benchmark its services, using the Association of Stoma Care Nurses (ASCN) UK Revised Stoma Care Nursing Standards and Audit Tool (2015) . Of the 60 questionnaires given out, 43 were returned (71%). The results highlighted areas of good practice with positive patient feedback. However, it also identified that the team needed to improve documentation when offering patients the opportunity to meet a former patient with a stoma preoperatively and when discussing lifestyle issues. The results demonstrated poor preoperative compliance; this was lower than expected and did not concur with department statistics. The audit highlights the importance of clarity when developing a questionnaire to ensure all respondents not only interpret its meaning in the same way, but also only answer the questions specific to them.

Examining the Use of Mobile Technology to Deliver Tailored Sexual Assault Prevention in a Classroom Environment in the Military: Development and Usability Study.

BACKGROUND: Advances in mobile technology over the last 10 years have expanded its use in scientific research. However, there are challenges in creating a reliable system for intervention content delivery and data collection in an environment with limited internet connectivity and limited staffing capacity. The Sexual Communication and Consent (SCC) study used tablets to provide individualized Sexual Assault Prevention and Response training in a classroom environment that was both technologically and support staff limited. OBJECTIVE: We developed the SCC Basic Military Training app and a separate Sexual Assault Response Coordinator app to support individualized training within the new SCC program. This paper presents the functionality, protocols, challenges, and feasibility of deploying mobile technology in an educational environment in the military with limited resources. METHODS: We developed both mobile apps targeting the Apple iOS ecosystem. The Basic Military Training app provided a screening instrument that routed the trainee into 1 of 5 specific intervention programs. Over 2 days of basic military training set 2 weeks apart, trainees received a combined 6 hours of program-specific tablet training, combined with universal, interactive classroom training, led by qualified instructors. The Sexual Assault Response Coordinator app, used to deliver supplemental content to a subgroup of trainees, was made available for voluntary and private use at the Sexual Assault Response Coordinator's office on base. All anonymous data were manually transferred onto laptops, where the data were aggregated into files and securely transferred to the project staff for analysis. The study was conducted at the Lackland Air Force Base, Joint Base San Antonio, with 9196 trainees providing the data. RESULTS: A total of 7742 trainees completed both the sessions of the SCC program and a series of evaluative assessments. Some trainees did not receive day 2 training, and only received day 1 training because the COVID-19 pandemic shortened the study period. Of the 190 SCC classes taught, only one class was unable to complete tablet training because of Apple licensing-related technology failure. The 360 study tablets were distributed across 3 classrooms (120 per classroom) and were handled at least 16,938 times with no reports of breakage or requiring replacement. Wi-Fi access limitations exacerbated the complexity of Apple licensing revalidation and the secure transfer of data from the classroom to project personnel. The instructor staff's limited technical knowledge to perform certain technical tasks was challenging. CONCLUSIONS: The results demonstrated the feasibility of deploying a mobile app for tablet-based training in a military educational environment. Although successful, the study was not without technical challenges. This paper gives examples of technical lessons learned and recommendations for conducting the study differently, with the aim that the knowledge gained may be helpful to other researchers encountering similar requirements.

An Evidence-Based HIV Risk-Reduction Intervention for Young African American Women in the US South Using mHealth: Adaptation and Development Study.

BACKGROUND: Young African American women have higher rates of sexually transmitted infections, including HIV, than those of young women of other racial and ethnic groups. Gender-, culture-, and age-specific interventions are needed to end the HIV epidemic. The Women's CoOp (WC) is an HIV risk-reduction intervention that is proven to be efficacious in various face-to-face formats. OBJECTIVE: This study aims to adapt the delivery method of an evidence-based intervention, the WC, from an in-person format to a self-guided mobile health (mHealth) format while ensuring that core elements are maintained for intervention comparability and fidelity. METHODS: Several adaptation phases were conducted by using the Personal Health Informatics and Intervention Toolkit (PHIT) as a guiding point to create the mobile app version of the WC. Throughout 5 phases, we established the implementation groundwork for the app; conducted formative research activities to test the initial draft of the app and obtain feedback; applied the PHIT toolkit programming structure to produce the mHealth version of the WC intervention; conducted usability testing and pretesting with interested parties, followed by in-house testing by WC interventionists and PHIT developers; and deployed the app to tablets and distributed it to study participants. The app underwent regular maintenance updates during the study. RESULTS: The team converted the seven elements of the WC as accurately as possible for comparability to determine efficacy in a mobile app format while changing little about the basic delivery methods. For instance, cue card presentations of the materials delivered by the intervention staff were presented within the app but with voice-over narration and in a self-guided format rather than being led by a staff member. Other aspects of the intervention did not lend themselves to such straightforward adaptation, such as hands-on condom proficiency practice and one-on-one goal-setting activities. In these cases, the subject matter experts and app developers worked together to find comparable analogs to be used within the app. Once developed, tested, and finalized, the mHealth WC app was deployed into local health departments as part of a randomized trial. CONCLUSIONS: This systematic adaptation process created an accurate mHealth equivalent of an existing, in-person behavioral health intervention. Although participants' reception of the app during the formative developmental phase was overall positive, maintaining fidelity to the in-person delivery compromised the natural capabilities of a mobile app, such as further gamification, different types of interactivity, and integrated notifications and messaging, which could be helpful for participants' adherence to the intervention schedule. Given the development and implementation of the app, the next step is to examine the impact of the app and its efficacy in HIV and substance use risk-reduction.

Sex-specific differences in expression of histone demethylases Utx and Uty in mouse brain and neurons.

Although X inactivation is thought to balance gene expression between the sexes, some genes escape inactivation, potentially contributing to differences between males and females. Utx (ubiquitously transcribed tetratricopeptide repeat gene on X chromosome) is an escapee gene that encodes a demethylase specific for lysine 27 of histone H3, a mark of repressed chromatin. We found Utx to be expressed higher in females than in males in developing and adult brains and in adult liver. XX mice had a higher level of Utx than XY mice, regardless of whether they had testes or ovaries, indicating that the sexually dimorphic gene expression was a consequence of the sex chromosome complement. Females had significantly higher levels of Utx than males in most brain regions except in the amygdala. The regional expression of the Y-linked paralogue Uty (ubiquitously transcribed tetratricopeptide repeat gene on Y chromosome) was somewhat distinct from that of Utx, specifically in the paraventricular nucleus of the hypothalamus (high Uty) and the amygdala (high Utx), implying that the two paralogues may be differentially regulated. Higher expression of Utx compared with Uty was detected in P19 pluripotent embryonic carcinoma cells as well as in P19-derived neurons. This transcriptional divergence between the two paralogues was associated with high levels of histone H3 lysine 4 dimethylation at the Utx promoter and of histone H4 lysine 16 acetylation throughout the gene body, which suggests that epigenetic mechanisms control differential expression of paralogous genes.

Biofeedback-Assisted Resilience Training for Traumatic and Operational Stress: Preliminary Analysis of a Self-Delivered Digital Health Methodology.

BACKGROUND: Psychological resilience is critical to minimize the health effects of traumatic events. Trauma may induce a chronic state of hyperarousal, resulting in problems such as anxiety, insomnia, or posttraumatic stress disorder. Mind-body practices, such as relaxation breathing and mindfulness meditation, help to reduce arousal and may reduce the likelihood of such psychological distress. To better understand resilience-building practices, we are conducting the Biofeedback-Assisted Resilience Training (BART) study to evaluate whether the practice of slow, paced breathing with or without heart rate variability biofeedback can be effectively learned via a smartphone app to enhance psychological resilience. OBJECTIVE: Our objective was to conduct a limited, interim review of user interactions and study data on use of the BART resilience training app and demonstrate analyses of real-time sensor-streaming data. METHODS: We developed the BART app to provide paced breathing resilience training, with or without heart rate variability biofeedback, via a self-managed 6-week protocol. The app receives streaming data from a Bluetooth-linked heart rate sensor and displays heart rate variability biofeedback to indicate movement between calmer and stressful states. To evaluate the app, a population of military personnel, veterans, and civilian first responders used the app for 6 weeks of resilience training. We analyzed app usage and heart rate variability measures during rest, cognitive stress, and paced breathing. Currently released for the BART research study, the BART app is being used to collect self-reported survey and heart rate sensor data for comparative evaluation of paced breathing relaxation training with and without heart rate variability biofeedback. RESULTS: To date, we have analyzed the results of 328 participants who began using the BART app for 6 weeks of stress relaxation training via a self-managed protocol. Of these, 207 (63.1%) followed the app-directed procedures and completed the training regimen. Our review of adherence to protocol and app-calculated heart rate variability measures indicated that the BART app acquired high-quality data for evaluating self-managed stress relaxation training programs. CONCLUSIONS: The BART app acquired high-quality data for studying changes in psychophysiological stress according to mind-body activity states, including conditions of rest, cognitive stress, and slow, paced breathing.

Sexually dimorphic expression of the X-linked gene Eif2s3x mRNA but not protein in mouse brain.

Higher expression of X-linked genes in females might contribute to brain sexual differentiation. Although X-inactivation is thought to balance gene dosage between the two sexes, some X-linked genes escape X inactivation and therefore are expressed from both X chromosomes in females. Eif2s3x encodes subunit three of eukaryotic translation initiation factor 2, which regulates the rate of protein translation, and escapes X-inactivation in both humans and mice. By Northern blot analysis, we found Eif2s3x to be expressed higher in females than in males in developing and adult brains as well as adult liver. Gonadally intact XX mice had a higher level of Eif2s3x mRNA expression than XY mice regardless of whether they had testes or ovaries, suggesting that sexually dimorphic gene expression arises as a consequence of sex chromosome complement. In situ hybridization indicated that Eif2s3x mRNA was expressed preferentially in specific brain regions including the habenula, anterodorsal thalamic nucleus, hippocampus, hypothalamus, and cerebellum. Females had significantly higher levels of Eif2s3x mRNA expression than males in cortex, hippocampus and paraventricular nucleus but not in the habenula. The effect of a sex difference in Eif2s3x transcription, however, could potentially be offset by the additional expression in male brains of its Y-linked homologue Eif2s3y which was found in similar brain regions. The sex difference in Eif2s3x transcript appears not to be preserved at the protein level, since no difference in the levels of Eif2s3 protein was found between (1) males and females (2) XX and XY mice, or (3) XO and XX females.

Sex chromosome complement contributes to sex differences in coxsackievirus B3 but not influenza A virus pathogenesis.

BACKGROUND: Both coxsackievirus B3 (CVB3) and influenza A virus (IAV; H1N1) produce sexually dimorphic infections in C57BL/6 mice. Gonadal steroids can modulate sex differences in response to both viruses. Here, the effect of sex chromosomal complement in response to viral infection was evaluated using four core genotypes (FCG) mice, where the Sry gene is deleted from the Y chromosome, and in some mice is inserted into an autosomal chromosome. This results in four genotypes: XX or XY gonadal females (XXF and XYF), and XX or XY gonadal males (XXM and XYM). The FCG model permits evaluation of the impact of the sex chromosome complement independent of the gonadal phenotype. METHODS: Wild-type (WT) male and female C57BL/6 mice were assigned to remain intact or be gonadectomized (Gdx) and all FCG mice on a C57BL/6 background were Gdx. Mice were infected with either CVB3 or mouse-adapted IAV, A/Puerto Rico/8/1934 (PR8), and monitored for changes in immunity, virus titers, morbidity, or mortality. RESULTS: In CVB3 infection, mortality was increased in WT males compared to females and males developed more severe cardiac inflammation. Gonadectomy suppressed male, but increased female, susceptibility to CVB3. Infection with IAV resulted in greater morbidity and mortality in WT females compared with males and this sex difference was significantly reduced by gonadectomy of male and female mice. In Gdx FCG mice infected with CVB3, XY mice were less susceptible than XX mice. Protection correlated with increased CD4+ forkhead box P3 (FoxP3)+ T regulatory (Treg) cell activation in these animals. Neither CD4+ interferon (IFN)γ (T helper 1 (Th1)) nor CD4+ interleukin (IL)-4+ (Th2) responses differed among the FCG mice during CVB3 infection. Infection of Gdx FCG mice revealed no effect of sex chromosome complement on morbidity or mortality following IAV infection. CONCLUSIONS: These studies indicate that sex chromosome complement can influence pathogenicity of some, but not all, viruses.

Sex chromosome effects unmasked in angiotensin II-induced hypertension.

Sex differences in mean arterial pressure (MAP) are reported in many experimental models of hypertension and are ascribed to gonadal sex based on studies showing that gonadectomy and gonadal hormone replacement affect MAP. The interpretation of these studies, however, has been confounded by differences in the sex chromosome complement (XX versus XY). To investigate the sex chromosome complement independent of gonadal sex, we used the 4 core genotype mouse model in which gonadal sex is separated from the sex chromosome complement enabling comparisons among XX and XY females and XX and XY males. We found that, in the gonadectomized (GDX) 4 core genotype, MAP after 2 weeks of angiotensin II infusion (200 ng/kg per minute) was greater in XX than XY (MAP [in millimeters of mercury]: GDX-XX-female, 148+/-4.5; GDX-XY-female, 133+/-4.4; GDX-XX-male, 149+/-9.4; GDX-XY-male, 138+/-5.5; P<0.03, XX versus XY; n=8 to 9 per group). In contrast, no sex chromosome effects were found on heart rate, body weight, or plasma angiotensin II 2 weeks after angiotensin II infusion. This study suggests that, in addition to effects of gonadal hormones on blood pressure, X- or Y-linked genes, parental imprinting, or X mosaicism contributes to sex differences in hypertension. Furthermore, the finding that MAP was greater in XX mice compared with XY mice in the GDX state suggests that adverse sex chromosome effects encoded within the XX sex chromosome complement could contribute to hypertension in women with ovarian hormone deficiency, such as postmenopausal women and women with premature ovarian failure.

Sex chromosome complement affects nociception and analgesia in newborn mice.

UNLABELLED: In animal studies of nociception, females are often more sensitive to painful stimuli, whereas males are often more sensitive to analgesia induced by mu-agonists. Sex differences are found even at birth, and in adulthood are likely caused, at least in part, by differences in levels of gonadal hormones. In this report, we investigate nociception and analgesia in neonatal mice and assess the contribution of the direct action of sex chromosome genes in hotplate and tail withdrawal tests. We used the 4 core genotypes mouse model, in which gonadal sex is independent of the complement of sex chromosomes (XX vs XY). Mice were tested at baseline and then injected with mu-opioid agonist morphine (10 mg/kg) or with the kappa-opioid agonist U50,488H (U50, 12.5 mg/kg) with or without the N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 (0.1 mg/kg). On the day of birth, XX mice showed faster baseline latencies than XY in tail withdrawal, irrespective of their gonadal type. Gonadal males showed greater effects of morphine than gonadal females in the hotplate test, irrespective of their sex chromosome complement. U50 and morphine were effective analgesics in both tests, but MK-801 did not block the U50 effect. The results suggest that sex chromosome complement and gonadal secretions both contribute to sex differences in nociception and analgesia by the day of birth. PERSPECTIVE: Sex differences in pain may stem not only from the action of gonadal hormones on pain circuits but from the sex-specific action of X and Y genes. Identification of sex chromosome genes causing sex differences could contribute to better pain therapy in females and males.

Sex difference in neural tube defects in p53-null mice is caused by differences in the complement of X not Y genes.

To shed light on the biological origins of sex differences in neural tube defects (NTDs), we examined Trp53-null C57BL/6 mouse embryos and neonates at 10.5 and 18.5 days post coitus (dpc) and at birth. We confirmed that female embryos show more NTDs than males. We also examined mice in which the testis-determining gene Sry is deleted from the Y chromosome but inserted onto an autosome as a transgene, producing XX and XY gonadal females and XX and XY gonadal males. At birth, Trp53 nullizygous mice were predominantly XY rather than XX, irrespective of gonadal type, showing that the sex difference in the lethal effect of Trp53 nullizygosity by postnatal day 1 is caused by differences in sex chromosome complement. At 10.5 dpc, the incidence of NTDs in Trp53-null progeny of XY* mice, among which the number of the X chromosomes varies independently of the presence or absence of a Y chromosome, was higher in mice with two copies of the X chromosome than in mice with a single copy. The presence of a Y chromosome had no protective effect, suggesting that sex differences in NTDs are caused by sex differences in the number of X chromosomes.

Sex chromosome complement affects nociception in tests of acute and chronic exposure to morphine in mice.

We tested the role of sex chromosome complement and gonadal hormones in sex differences in several different paradigms measuring nociception and opioid analgesia using "four core genotypes" C57BL/6J mice. The genotypes include XX and XY gonadal males, and XX and XY gonadal females. Adult mice were gonadectomized and tested 3-4 weeks later, so that differences between sexes (mice with testes vs. ovaries) were attributable mainly to organizational effects of gonadal hormones, whereas differences between XX and XY mice were attributable to their complement of sex chromosomes. In Experiment 1 (hotplate test of acute morphine analgesia), XX mice of both gonadal sexes had significantly shorter hotplate baseline latencies prior to morphine than XY mice. In Experiment 2 (test of development of tolerance to morphine), mice were injected twice daily with 10 mg/kg morphine or saline for 6 days. Saline or the competitive NMDA antagonist CPP (3-(2-carboxypiperazin-4yl) propyl-1-phosphonic acid) (10 mg/kg) was co-injected. On day 7, mice were tested for hotplate latencies before and after administration of a challenge dose of morphine (10 mg/kg). XX mice showed shorter hotplate latencies than XY mice at baseline, and the XX-XY difference was greater following morphine. In Experiment 3, mice were injected with morphine (10 mg/kg) or saline, 15 min before intraplantar injection of formalin (5%/25 microl). XX mice licked their hindpaw more than XY mice within 5 min of formalin injection. The results indicate that X- or Y-linked genes have direct effects, not mediated by gonadal secretions, on sex differences in two different types of acute nociception.