Feasibility, effectiveness and patient satisfaction of telerehabilitation after thumb carpometacarpal arthroplasty and reverse total shoulder arthroplasty: A pilot study.

INTRODUCTION: Telemedicine is an effective, emerging interface to connect practitioners with patients. It facilitates access to healthcare expertise, reduces costs, time demands and health disparities while improving satisfaction. This pilot study evaluated the feasibility, effectiveness and patient satisfaction of telerehabilitation for thumb carpometacarpal (CMC) arthroplasty and reverse shoulder arthroplasty (rTSA). METHODS: This prospective investigation was performed at a single academic institution with two hand and upper extremity fellowship-trained orthopaedic surgeons. All patients undergoing CMC arthroplasty or rTSA were eligible for inclusion. Telerehabilitation was delivered by a hybrid model including an in-person post-operative visit, followed by alternating in-clinic and virtual videoconference visits. All patients were offered participation in the study arm; those that preferred in-person therapy were included as a control group. Therapy was initiated two weeks post-operative with an in-clinic evaluation. Patients then participated in alternating in-clinic and virtual visits weekly for eight weeks, followed by one virtual visit at 14-weeks post-operative and one clinical visit at 16-weeks post-operative. Patient reported and functional outcomes were collected at each visit. RESULTS: In the CMC group, 19 study and 11 control patients were enrolled. In the rTSA group, five study and 14 control patients were enrolled. No statistically significant differences between telerehabilitation and control for range-of-motion, pain and patient-reported functional outcomes was noted. All patients in the telerehabilitation arms reported high satisfaction. DISCUSSION: Utilizing telehealth in rehabilitation may be a viable option in upper extremity recovery. We hope this pilot programme can be a model for development of future telerehabilitation programmes.

Management Patterns for Benign Prostatic Hyperplasia: Impact of a Patient Decision Aid.

INTRODUCTION: Decision aids aimed at men with benign prostatic hyperplasia used in clinical trials have decreased the use of procedures and affected elements of decisional quality. We employed an online, interactive decision aid for men with benign prostatic hyperplasia as a routine part of care with a urologist and tracked subsequent treatment choice. We further evaluated the role of patient preferences on treatment selection. METHODS: Men scheduled for a new patient visit with a urologist for benign prostatic hyperplasia at a single tertiary care center were invited to use a decision aid prior to their visit. We compared treatment patterns in men who used the decision aid to a usual care group identified prior to the decision aid's introduction. Latent class analysis identified clusters of patients by their treatment preferences, which were then compared to their treatment choice. RESULTS: The rate of procedures in the decision aid group was significantly lower than in the usual care group (6% vs 15%; p=0.0250), matching the rates reporting a procedure as their preferred treatment choice in the post-consult questionnaire (5% vs 15%; p=0.0082). Of the patients in our project 36% had never tried an alpha blocker prior to their urology consult. Latent class analysis found 2 clusters of patient preferences but without a significant association with final treatment selection. CONCLUSIONS: Use of a decision aid was associated with a significant decrease in procedural management of benign prostatic hyperplasia. A high proportion of patients were evaluated by urologists without exhausting primary care management options.

Effect of acetic acid and pH on the cofermentation of glucose and xylose to ethanol by a genetically engineered strain of Saccharomyces cerevisiae.

A current challenge of the cellulosic ethanol industry is the effect of inhibitors present in biomass hydrolysates. Acetic acid is an example of one such inhibitor that is released during the pretreatment of hemicellulose. This study examined the effect of acetic acid on the cofermentation of glucose and xylose under controlled pH conditions by Saccharomyces cerevisiae 424A(LNH-ST), a genetically engineered industrial yeast strain. Acetic acid concentrations of 7.5 and 15 g L(-1), representing the range of concentrations expected in actual biomass hydrolysates, were tested under controlled pH conditions of 5, 5.5, and 6. The presence of acetic acid in the fermentation media led to a significant decrease in the observed maximum cell biomass concentration. Glucose- and xylose-specific consumption rates decreased as the acetic acid concentration increased, with the inhibitory effect being more severe for xylose consumption. The ethanol production rates also decreased when acetic acid was present, but ethanol metabolic yields increased under the same conditions. The results also revealed that the inhibitory effect of acetic acid could be reduced by increasing media pH, thus confirming that the undissociated form of acetic acid is the inhibitory form of the molecule.

Depression and heart rate variability in cardiac rehabilitation patients: exploring the roles of physical activity and fitness.

Cardiac patients with depression have shown altered autonomic nervous system functioning, expressed as reduced heart rate variability. This may be associated with poorer physical fitness and less physical activity among depressed patients. These relationships were explored among patients enrolled in outpatient cardiac rehabilitation. 22 depressed and 22 nondepressed patients, matched for sex and age, were assessed at enrollment. The Beck Depression Inventory and structured interviews were used to measure depression. Patients completed ambulatory monitoring of ECG (i.e., Holter) and physical activity, as well as a treadmill stress test. Depression was associated with several measures of heart rate variability. Activity and fitness were lower among the depressed patients. Although exploratory, accounting for activity and fitness attenuated the relationship between depression and heart rate variability. This suggests that altered fitness and activity may help explain altered autonomic tone that characterizes patients with cardiovascular diseases who are psychologically depressed.

Perioperative Considerations During Emergency General Surgery in the Era of COVID-19: A U.S. Experience.

The novel coronavirus SARS-CoV-2 (COVID-19) strain has caused a pandemic that affects everyday clinical practice. Care of patients with acute surgical problems is adjusted to minimize exposing health care providers to this highly contagious virus. Our goal is to describe a specific and reproducible perioperative protocol aiming to keep health care providers safe and, simultaneously, not compromise standard of care for surgical patients.

Depression symptoms predict heart rate recovery after treadmill stress testing.

BACKGROUND: Altered autonomic nervous system (ANS) functioning may help to explain the relationship between depression and cardiac mortality. Heart rate (HR) recovery after the cessation of a treadmill stress test assesses ANS functioning and predicts mortality. This study examined the relationship between depression symptoms and HR recovery among patients entering phase II cardiac rehabilitation. METHODS: Two hundred sixty patients were assessed at the time of their enrollment in cardiac rehabilitation. Patients completed a ramped-protocol treadmill stress test, providing an assessment of exercise capacity and HR recovery at 2 minutes post exercise. Depression symptoms were measured using the Beck Depression Inventory. Other medical information was obtained by chart review. RESULTS: Patients with higher Beck Depression Inventory scores exhibited slower HR recovery after exercise. This remained true after controlling for age, sex, and beta-blocker usage. Controlling for exercise capacity rendered the relationship between depression score and HR recovery non significant, suggesting that exercise capacity may partly account for this relationship. CONCLUSIONS: These findings confirm that depression is characterized by dysregulation of the ANS and implicate impaired exercise capacity as a potential mechanism.

Effect of salts on the Co-fermentation of glucose and xylose by a genetically engineered strain of Saccharomyces cerevisiae.

BACKGROUND: A challenge currently facing the cellulosic biofuel industry is the efficient fermentation of both C5 and C6 sugars in the presence of inhibitors. To overcome this challenge, microorganisms that are capable of mixed-sugar fermentation need to be further developed for increased inhibitor tolerance. However, this requires an understanding of the physiological impact of inhibitors on the microorganism. This paper investigates the effect of salts on Saccharomyces cerevisiae 424A(LNH-ST), a yeast strain capable of effectively co-fermenting glucose and xylose. RESULTS: In this study, we show that salts can be significant inhibitors of S. cerevisiae. All 6 pairs of anions (chloride and sulfate) and cations (sodium, potassium, and ammonium) tested resulted in reduced cell growth rate, glucose consumption rate, and ethanol production rate. In addition, the data showed that the xylose consumption is more strongly affected by salts than glucose consumption at all concentrations. At a NaCl concentration of 0.5M, the xylose consumption rate was reduced by 64.5% compared to the control. A metabolomics study found a shift in metabolism to increased glycerol production during xylose fermentation when salt was present, which was confirmed by an increase in extracellular glycerol titers by 4 fold. There were significant differences between the different cations. The salts with potassium cations were the least inhibitory. Surprisingly, although salts of sulfate produced twice the concentration of cations as compared to salts of chloride, the degree of inhibition was the same with one exception. Potassium salts of sulfate were less inhibitory than potassium paired with chloride, suggesting that chloride is more inhibitory than sulfate. CONCLUSIONS: When developing microorganisms and processes for cellulosic ethanol production, it is important to consider salt concentrations as it has a significant negative impact on yeast performance, especially with regards to xylose fermentation.

Quality by design: impact of formulation variables and their interactions on quality attributes of a lyophilized monoclonal antibody.

The purpose of this study was to use QbD approaches to evaluate the effect of several variables and their interactions on quality of a challenging model murine IgG3κ monoclonal antibody (mAb), and then to obtain an optimized formulation with predefined quality target product profile. This antibody was chosen because it has a propensity to precipitate and thus represents a challenge condition for formulation development. Preliminary experiments were conducted to rule out incompatible buffer systems for the mAb product quality. A fractional factorial experimental design was then applied to screen the effects of buffer type, pH and excipients such as sucrose, sodium chloride (NaCl), lactic acid and Polysorbate 20 on glass transition temperature ( [Formula: see text] ), monoclonal antibody concentration (A(280)), presence of aggregation, unfolding transition temperature (T(m)) of the lyophilized product, and particle size of the reconstituted product. A Box-Behnken experimental design was subsequently applied to study the main, interaction, and quadratic effects of these variables on the responses. Pareto ranking analyses showed that the three most important factors affecting the selected responses for this particular antibody were pH, NaCl, and Polysorbate 20. The presence of curvature in the variables' effects on responses indicated interactions. Based on the constraints set on the responses, a design space was identified for this mAb and confirmed with experiments at three different levels of the variables within the design space. The model indicated a combination of high pH (8) and NaCl (50mM) levels, and a low Polysorbate 20 (0.008 mM) level at which an optimal formulation of the mAb could be achieved. Moisture contents and other analytical procedures such as size exclusion chromatography, protein A analysis and SDS-PAGE of the pre-lyophilized and final reconstituted lyophilized products indicated an intact protein structure with minimal aggregation after formulation and lyophilization. In conclusion, experimental design approach was effective in identifying optimal concentrations of excipients and pH for this challenging monoclonal antibody formulation.

Depression predicts failure to complete phase-II cardiac rehabilitation.

Reduced adherence to medical treatment regimens may help to explain the higher risk of mortality among depressed cardiac patients. Participation in cardiac rehabilitation is a highly recommended part of the medical treatment regimen for cardiac patients. This study examined if elevated depressive symptomology, as measured by the Beck Depression Inventory (BDI), predicted failure to complete a 12-week phase II cardiac rehabilitation program for 600 patients. Logistic regression analysis showed that patients with elevated levels of depressive symptomology (BDI scores > or = 10) were 2.2 times less likely to complete cardiac rehabilitation compared to patients without depression (BDI < 10), after controlling for age, gender, body mass index, and employment. Somatic symptoms predicted non-completion due to medical reasons, whereas younger age predicted failure to complete cardiac rehabilitation due to non-medical reasons. Given the difficulty of reducing mortality by treating depression directly, interventions targeting behavior change to improve medical treatment adherence might be an effective complementary strategy.

Dimeric and monomeric Bacillus subtilis RNase P holoenzyme in the absence and presence of pre-tRNA substrates.

Ribonuclease P (RNase P) is a ribonucleoprotein enzyme that catalyzes the 5' maturation of tRNA precursors. The bacterial RNase P holoenzyme is composed of a large, catalytic RNA and a small protein. Our previous work showed that Bacillus subtilis RNase P forms a specific "dimer" that contains two RNase P RNA and two RNase P protein subunits in the absence of substrate. We investigated the equilibrium and the structure of the dimeric and the monomeric holoenzyme in the absence and presence of substrates by synchrotron small-angle X-ray scattering, 3' autolytic processing, and hydroxyl radical protection. In the absence of substrate, the dimer-monomer equilibrium is sensitive to monovalent ions and the total holoenzyme concentration. At 0.1 M NH4Cl, formation of the dimer is strongly favored, whereas at 0.8 M NH4Cl, the holoenzyme is a monomer. Primary hydroxyl radical protection in the dimer is located in the specificity domain, or domain I, of the RNase P RNA. The ES complex with a substrate containing a single tRNA is always monomeric. In contrast, the dominant ES complex with a substrate containing two tRNAs is dimeric at 0.1 M NH4Cl and monomeric at 0.8 M NH4Cl. Our results show that the B. subtilis holoenzyme can be a dimer and a monomer, and the fraction of the dimer is very sensitive to the environment. Under a variety of conditions, both the holoenzyme dimer and monomer can be present in significant amounts. Because the majority of tRNA genes are organized in large operons and because of the lack of RNase E in B. subtilis, a dimeric holoenzyme may be necessary to facilitate the processing of large precursor tRNA transcripts. Alternatively, the presence of two forms of the RNase P holoenzyme may be required for other yet unknown functions.

Collaborative initiatives: where the rubber meets the road in community partnerships.

Amajor challenge facing a community partnership is the implementation of its collaborative initiatives. This article examines the progress Community Care Networks (CCNs) made in implementing their initiatives and factors that helped or hindered their progress. Study findings suggest that partnership progress is affected by external market and regulatory factors beyond the control of the partnership, the availability of local community resources to support efforts, the scope and intensity of tasks associated with an initiative, expansion of the partnership to include new members, and the balance of work between partners and paid partnership staff. Implications of study findings for community partnerships include (1) recognizing and anticipating dependency on others, (2) acknowledging that the tasks that lie ahead will be more complicated than imagined, (3) maintaining focus on priorities, and (4) learning to be adaptive and creative, given a constantly changing environment.

Using theories of action to guide national program evaluation and local strategy in the community care network demonstration.

Evaluations of multisite community-based projects are notoriously difficult to conceptualize and conduct. Projects may share an overarching vision but operate in varying contexts and pursue different initiatives. One tool that can assist evaluators facing these challenges is to develop a "theory of action" (TOA) that identifies critical assumptions regarding how a program expects to achieve its goals. Community Care Network (CCN) evaluators used the TOA to refine research questions, define key variables, relate questions to each other, and identify when we might realistically expect to observe answers. In this article, the authors present their national-level CCN TOA. They also worked with sites to help them "surface" their local TOA; the article analyzes the results to determine the content, clarity, extent of evidence base, and strategic orientation of theories articulated by different sites.

Community care networks: linking vision to outcomes for community health improvement.

This article examines the relationship between progress toward the Community Care Network (CCN) vision and "intermediate outcomes" of 25 community-based health partnerships (CCNs). Specific components of the CCN vision were community accountability, community health focus, creation of a seamless service continuum, and managing under limited resources. Four community outcome dimensions were evaluated: access, cost, health, and quality of service delivery integration. Overall progress toward the CCN vision was significantly positively related to average intermediate outcome score and most highly correlated with two dimensions: access and quality of service integration. Qualitative analysis suggests that CCN sites accomplished the most along two dimensions--access and health--noting that intermediate health outcomes generally were in health assessment and information rather than actual health status improvement. Keys to outcome achievement appear to be (1) clearly focused intervention; (2) explicit, ongoing outcome measurement; and (3) strong integration of separate intervention components.

Evaluating partnerships for community health improvement: tracking the footprints.

Private-public partnerships are increasingly seen as an important mechanism for improving community health. Despite their popularity, traditional evaluations of these efforts have produced negative or mixed results. This is often attributed to weak interventions or an insufficient period of time to observe an impact. This study examines two additional possibilities--the need for a well-articulated shared vision and the governance and management capabilities of the partnership itself. We conducted a midstream process evaluation of twenty-five community partnerships associated with the Community Care Network (CCN) Demonstration Program. We examined how the roles of a common shared vision, strong governance, and effective management influence a partnership's ability to achieve its objectives. The findings, based on both qualitative and quantitative analyses, underscore the importance of membership organizations' perceived benefits and costs of participation and management capabilities to the partnership's progress toward a vision. Based on the qualitative data, six key governance and management characteristics are identified that separate the top performing partnerships from the lowest performing ones. We explore the implications of this research for future evaluations of public-private community health partnerships.