Tracking physical activity using smart phone apps: assessing the ability of a current app and systematically collecting patient recommendations for future development.

BACKGROUND: Within the United Kingdom's National Health System (NHS), patients suffering from obesity may be provided with bariatric surgery. After receiving surgery many of these patients require further support to continue to lose more weight or to maintain a healthy weight. Remotely monitoring such patients' physical activity and other health-related variables could provide healthworkers with a more 'ecologically valid' picture of these patients' behaviours to then provide more personalised support. The current study assesses the feasibility of two smartphone apps to do so. In addition, the study looks at the barriers and facilitators patients experience to using these apps effectively. METHODS: Participants with a BMI > 35 kg/m2 being considered for and who had previously undergone bariatric surgery were recruited. Participants were asked to install two mobile phone apps. The 'Moves' app automatically tracked participants' physical activity and the 'WLCompanion' app prompted participants to set goals and input other health-related information. Then, to learn about participants' facilitators and barriers to using the apps, some participants were asked to complete a survey informed by the Theoretical Domains Framework. The data were analysed using regressions and descriptive statistics. RESULTS: Of the 494 participants originally enrolled, 274 participants data were included in the analyses about their activity pre- and/or post-bariatric surgery (ages 18-65, M = 44.02, SD ± 11.29). Further analyses were performed on those 36 participants whose activity was tracked both pre- and post-surgery. Participants' activity levels pre- and post-surgery did not differ. In addition, 54 participants' survey responses suggested that the main facilitator to their continued use of the Moves app was its automatic nature, and the main barrier was its battery drain. CONCLUSIONS: The current study tracked physical activity in patients considered for and who had previously undergone bariatric surgery. The results should be interpreted with caution because of the small number of participants whose data meet the inclusion criteria and the barriers participants encountered to using the apps. Future studies should take note of the barriers to develop more user-friendly apps. TRIAL REGISTRATION: ClinicalTrials.gov- NCT01365416 on the 3rd of June 2011.

The Prevalence and Management of Metabolic Acidosis of Chronic Kidney Disease

Aim Emerging evidence supports initiating oral sodium bicarbonate (OSB) at a serum bicarbonate (HCO3) level of less than 22mmol/L. We look to identify the prevalence of metabolic acidosis of chronic kidney disease (MA-CKD) and its management with OSB at a regional university hospital. Methods Retrospective data was collected using the national electronic renal database (eMED) to identify chronic kidney disease (CKD) patients with MA-CKD over a one-year period. Results One-hundred and forty-four patients were identified with CKD, of which 131 (89%) were tested for HCO3. MA-CKD was present in 44 patients (34%), all had eGFR< 30ml/min/1.73m2, 7 (16%) were prescribed OSB, 7(16%) OSB was contraindicated, and 37 (84%) patients managed with dietary input only. Mean HCO3 level at initiation in OSB group was 18.3±1mmol/L compared to 19.4±1.4mmol/L in dietary input only group which was statistically significant (p<0.05). Conclusion A high burden of advanced CKD was found in the regional nephrology centre, with one third of patients demonstrating MA-CKD. Majority had dietary input only. Further awareness and consensus need to be established on the benefits of treating MA-CKD with OSB.

Acquaintance of dental implants as a treatment modality in edentulous states among health workers in Aseer Province, KSA.

PURPOSE: To identify the acquaintance of dental implant (DI) as a treatment modality in edentulous states among health workers in the Aseer region and also to assess the level of understanding about DI among them. MATERIALS AND METHODS: A questionnaire set of 18 questions was used for 500 health workers from the concerned area about DI. Questionnaire set basically consists of questions to assess the attitude, perception, and knowledge among them about DI. The data collected and association with the factors were tested for significance using the Chi-square test and P < 0.05 was considered statistically significant. RESULTS: The response rate was 89%. More than 75% were aware of DI, but only 50% of the total respondents were knowing about the difference between the DI, fixed prosthesis, and removable prosthesis. Of the latter, 47.4% have suggested implants for patients and about 55% respondents were agreeing to get DI done for themselves. Dental health care workers have more knowledge than the medical health workers, and the difference was found to be statistically significant. Of respondents, >90% were willing to know more about DI. CONCLUSION: The practice of implant dentistry is growing in the Aseer region. However, general health workers are not fully aware of proper DI information. In addition, all the efforts should be made to include basic implant education in all the branches of health sciences and the CDE program should be conducted regularly to enhance the knowledge, so that correct information can be channelized to the patients.

Cost-utility analysis of bariatric surgery.

BACKGROUND: The objective of the study was to evaluate the cost-utility of bariatric surgery in England. METHODS: A state-transition Markov model was developed to compare the costs and outcomes of two treatment approaches for patients with morbid obesity: bariatric surgery, including gastric bypass, sleeve gastrectomy and adjustable gastric banding; and non-surgical usual care. Parameters of the effectiveness of surgery and complications were informed by data from the UK National Bariatric Surgery Registry, the Scandinavian Obesity Registry and the Swedish Obese Subjects study. Costs and utilities were informed by UK sources. RESULTS: Bariatric surgery was associated with reduced mean costs to the health service by €2742 (£1944), and gain of 0·8 life-years and 4·0 quality-adjusted life-years (QALYs) over a lifetime compared with usual care. Bariatric surgery also had the potential to reduce the lifetime risks of obesity-related cardiovascular diseases and diabetes. Delaying surgery for up to 3 years resulted in a reduction of 0·7 QALYs and a minor decrease of €2058 (£1459) in associated healthcare costs. CONCLUSION: Currently used surgical methods were found to be cost saving over the lifetime of individuals treated in England.

Positive clinical outcome in a patient with recalcitrant bullous pemphigoid treated with rituximab and intravenous immunoglobulin.

A 41-year-old white man was treated for bullous pemphigoid (BP) for 4 years, using high-dose prednisone as well as ciclosporin and mycophenolate mofetil. Sustained clinical improvement was not observed. He suffered several serious side effects. Consequently, he was treated with a combination of rituximab (RTX) and intravenous immunoglobulin (IVIg). He received 12 infusions of RTX in 6 months and monthly IVIg until the end of the therapy. Within 5 weeks of this therapy, appearance of new lesions ceased. Within 8 weeks, all previous lesions resolved and previous medications were discontinued. No hospitalizations, relapses, infections or other serious adverse events occurred. The high levels of pathogenic autoantibody decreased and have remained undetectable. After three infusions of RTX, CD19+ B cells were undetectable and returned to normal levels within 18 months. The patient remains in complete clinical remission off all systemic therapy and free of disease for a 20-month follow-up.

Systematic review of risk prediction models for diabetes after bariatric surgery.

BACKGROUND: Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery. METHODS: A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration. RESULTS: Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two. CONCLUSION: A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Ferulsinaic acid attenuation of diabetic nephropathy.

BACKGROUND: Different factors are involved in the development of diabetic nephropathy (DN). Oxidative stress and inflammation play an important role in the pathogenesis of DN. Ferulsinaic Acid (FA) was isolated in 2007. In 2011, we found that FA prolonged the lifespan of C. elegans due to its antioxidative effect, and we hypothesized that FA restores the kidney function of diabetic rats via its antioxidant activity. METHODS: Male Wistar rats were injected with STZ and divided into 5 groups of 10 each: control, diabetic untreated, diabetic treated with 500, 750 and 1000 ng/kg FA. FA treatment was continued for 21 weeks after induction of diabetes. RESULTS: In the diabetic rats treated with FA, fasting blood sugar, HbA1C kidney/body weight ratio, creatinine, BUN, sodium and albuminurea were significantly decreased compared with untreated diabetic rats. Diabetic rats showed decreased activities of superoxide dismutase, glutathione peroxidase and catalase, increased concentrations of malondialdehyde and IL-6 in the kidney homogenate. In addition levels of 8-hydroxy-2'-deoxyguanosine in the urine and in the renal cortex DNA were increased. Moreover, severe destruction in glomerular and tubulointerstitial lesions such as glomerular sclerosis, atrophy, interstitial expansion and interstitial cellular infiltration was seen in the kidney of the diabetic untreated rats. Furthermore, the diabetic kidney was found to be positive for NF-κB p65 antigen in the immunohistochemistry examinations. Treatment with FA restored all the altered parameters in a dose-dependent manner. Furthermore, all the ultra-morphologic abnormalities and NF-κB activation in the kidney of diabetic rats were markedly ameliorated by FA treatment. CONCLUSION: FA confers a considerable protection against kidney injuries of the diabetic rats by increasing activities of antioxidant enzymes, attenuating the formation of AGEs, attenuating the NF-κB activation, ameliorating the inflammatory markers and inhibiting the accumulation of oxidized DNA in the kidney, suggesting a potential drug for the prevention and therapy of DN.

Comparison of immunological parameters in patients with pemphigus vulgaris following rituximab and IVIG therapy.

BACKGROUND: Information on certain immunological parameters in patients with pemphigus vulgaris (PV) treated with rituximab (RTX) and intravenous immunoglobulin (IVIG) therapy is limited. OBJECTIVE: Comparing immunological parameters in patients who achieved long-term clinical remission (LTR) with those who relapsed. METHODS: Retrospective analysis of 19 patients treated at a single centre using the same protocol. Comparisons were made between patients who went into LTR and those who relapsed following completion of the protocol. Treatments prior to IVIG and RTX included prednisone with or without an immunosuppressive agent. The immunological parameters measured included peripheral blood B cells (CD19+), serum quantitative immunoglobulin levels, and levels of antibodies to desmogleins (Dsg) 1 and 3. RESULTS: Eleven patients achieved LTR. Eight patients developed 15 relapses. The mean follow-up time for the LTR group was 29·6±11·2months, and for the relapse group, 40·0±7·0 months. There were no significant differences in times to B-cell depletion, repopulation, or recovery to pretreatment levels between the patients who achieved LTR and those who relapsed. Recurrences usually occurred after B-cell repopulation. Repeated treatments did not influence the time to B-cell repopulation. IgM levels were decreased after therapy and remained decreased. A consistent increase in anti-Dsg1 antibody levels occurred at the time of relapse in patients with mucocutaneous disease. CONCLUSIONS: The majority of patients treated with rituximab and IVIG therapy achieved LTR. Retreatment of relapses can induce LTR. Decreased serum IgM levels persisted following treatment. Increases in anti-Dsg1 antibodies during therapy in patients with mucocutaneous disease suggests a close follow-up for a potential relapse is required.

Treatment of epidermolysis bullosa acquisita with intravenous immunoglobulin in patients non-responsive to conventional therapy: clinical outcome and post-treatment long-term follow-up.

BACKGROUND: Epidermolysis bullosa acquisita (EBA) is a chronic subepidermal blistering disease that is caused by antibodies binding to type VII collagen within anchoring fibrils. It is rare disease with an incidence of 0.25 cases per 1,000,000 population. OBJECTIVE: The objective of this study is to report the treatment outcomes with intravenous immunoglobulin (IVIg) therapy in 10 patients with severe and widespread EBA non-responsive to conventional therapy. METHODS: Patients were treated according to a protocol published in a Consensus Statement to treat autoimmune mucocutaneous blistering diseases, including EBA with IVIg. A dose of 2 g/kg/cycle was used. RESULTS: Ten patients: four males and six females, all were North American Caucasian. The age at onset varied from 37 to 75 years (mean 57.4). A satisfactory clinical response was observed in all 10 patients. The patients received 16-31 cycles (mean 23.1) of IVIg over a period of 30-52 months (mean 38.8). Once IVIg was initiated, earlier drugs (prednisone, dapsone and others) were gradually withdrawn over a 5-9 month period (mean 7.2). Thereafter, IVIg was used as monotherapy. No serious side-effects were observed. The follow-up period since discontinuation of IVIg varied from 29 to 123 months (mean 53.9). During this follow-up period, recurrence of disease was not observed. CONCLUSION: The data suggest that IVIg can produce a long-term sustained clinical remission in patients with EBA. In the patients, of this study concomitant therapy could be discontinued and IVIg was used as monotherapy.

Assessment of radiographic morphology of mandibular condyles: a radiographic study.

BACKGROUND: Panoramic radiographs are the most common radiographic tool used by the dental clinicians to evaluate teeth, mandible and other related structures of the jaws. Mandibular condyle is an important anatomical landmark for facial growth, expressed in an upward and backward direction. The presentation of mandibular condyle differs widely among different group of ages and individuals. MATERIALS AND METHODS: The retrospective cross-sectional study was conducted from November 2018 to March 2019 at Dow International Dental College Karachi that includes radiographic evaluation of 500 mandibular condyles. All retrievable orthopantomograms were obtained and data were extracted regarding age, gender and condylar morphology. RESULTS: The morphological appearances of mandibular condyle have great variation among different age groups and subjects. Normally, we recognise five basic shapes i.e. oval, bird beak, crooked finger, diamond and mixed. Out of 250 pair of condylar heads that were evaluated, 50% were oval, 40% bird beak, 4.8% crooked finger and diamond 4.8%. CONCLUSIONS: All four morphological types of mandibular condyles were observed and the oval shape condyles were most prevalent among both genders and all age groups. In future studies, the inclusion of other parameters and large sample size may provide unique information.

Association of HMGBP1 expression with clinical periimplant parameters among smokers and never-smokers with and without peri-implantitis.

OBJECTIVE: With our study we aimed at investigating the levels of high mobility group box chromosomal protein-1 (HMGB-1), tumor necrosis factor-alpha (TNF-α) and interleukin (IL)-1ß in periimplant crevicular fluid (PICF) of smokers and never-smokers, with and without periimplantitis, and correlate these levels with the clinical and radiographic periimplant parameters. SUBJECTS AND METHODS: Sixty participants (n=15/group) were recruited and divided into 4 groups: cigarette smokers with periimplantitis (CSPI); cigarette smokers without periimplantitis (CSNPI); never-smokers with periimplantitis (NSPI); and never-smokers without periimplantitis (NSNPI). Clinical and radiographic periimplant parameters, including plaque scores (PS), bleeding on probing (BOP), probing depth (PD) and crestal bone level (CBL), were assessed. Crevicular levels of HMGB-1, TNF-α, and IL-1ß were quantified using human enzyme linked immunosorbent assay. p-values were generated using Kruskal-Wallis' test for comparison between the study groups, while correlations between HMGB-1, TNF-α, IL-1ß levels and clinical variables were analyzed using Spearman rank correlation coefficient analysis. RESULTS: Bleeding on probing was least in NSNPI and CSNPI followed by CSPI and NSPI (p<0.05). The highest PD and CBL was recorded for CSPI and NSPI groups, while the least PD and CBL were recorded among non-periimplantitis groups. HMGB-1 and IL-1ß were found to be significantly highest in CSPI groups followed by NSPI and CSNPI groups with no statistically significant difference between CSPI and NSPI groups (p<0.05). CSPI groups reported the highest TNF-α levels in the PICF in comparison to other groups (p<0.05). A significant negative correlation was observed between plaque scores (p=0.0187) and CBL (p=0.0049) in NSNPI and CSPI groups with HMGB-1, respectively. A significant positive correlation was seen for HMGB-1 in groups CSPI (p=0.0023) and NSPI (p=0.0018) for BOP. In CSPI group, a significant positive correlation was observed between TNF-α and PD (p=0.0443). On correlating IL-1ß, a significant positive correlation was observed for CBL in CSPI (p=0.0006) and NSPI (p=0.0275) groups, respectively. CONCLUSIONS: HMGB-1 could play a significant role in periimplant inflammatory response and inflammation. Higher crevicular fluid HMGB-1 levels are indicative of a possible surrogate biomarker for peri-implantitis.

Improved bandwidth and F/B ratio of a CPW-fed planar monopole antenna.

A directional planar monopole antenna is described. The antenna comprises of a circular monopole, coplanar waveguide (CPW) feed line and a ground plane. To achieve unidirectional radiation, a stub is also attached to on the ground plane to increase the lower end impedance bandwidth and also increase the Front-to-Back ratio (F/B). The proposed antenna is etched on a 50 × 50 mm2 FR4 substrate. Simulated and experimental results reveal that the proposed antenna can achieve an impedance bandwidth from 2.3 - 10.5 GHz for S11 < -10 dB, and unidirectional radiation patterns with high gain and high efficiency.

Use of intravenous immunoglobulin therapy during pregnancy in patients with pemphigus vulgaris.

BACKGROUND: Pemphigus vulgaris (PV) is a potentially fatal autoimmune disease characterized by the presence of in vivo deposition of antibodies against cell surface antigens desmoglein 1 and desmoglein 2 in the epidermis. OBJECTIVES: To report the treatment outcomes in pregnant PV patients treated with intravenous immunoglobulin (IVIg) therapy. METHODS: Eight patients with active disease during pregnancy were treated. Patients were treated with a dose of 2 g/kg/cycle. Seven patients were treated for 2 months on post-partum basis. Main outcome measures were as follows: (i) pregnancy outcome; (ii) presence of neonatal pemphigus; (iii) post-partum flare; (iv) effect of IVIg on present and future pregnancies; (v) immediate and long-term side-effects in the mother and child. RESULTS: Patients ages ranged from 20 to 43 years (mean 29.6). All patients had severe and widespread disease involving the skin and multiple mucous membranes. Patients one to seven responded to IVIg therapy and did not have a post-partum flare. Patient eight could not tolerate IVIg because of intense headaches and significant post-partum flare. None of the neonates had pemphigus. Three patients who completed the IVIg protocol had normal second pregnancies. One patient who did not complete the protocol had a miscarriage during the second pregnancy. Since last observation, none of the patients have had a recurrence of the disease or another pregnancy. CONCLUSIONS: The data suggests that IVIg can be useful and safe in treating pregnant patients with PV. No long-term adverse effects of IVIg in the mother or in the child were observed based on a long-term follow-up.

Linkage of pemphigus vulgaris antibody to the major histocompatibility complex in healthy relatives of patients.

Pemphigus vulgaris (PV) is an autoimmune disease caused by high concentrations of antibody to an epidermal cadherin. The disease is associated with two kinds of HLA-DR4, DQ8 haplotypes dominantly distributed among Jewish patients, and these plus DR6, DQ5 haplotypes in non-Jewish patients. Low levels of the PV antibody were found in 48% of a total of 120 asymptomatic parents, children, and siblings of 31 patients, thus exhibiting dominant inheritance. The inheritance of these low levels of antibody in asymptomatic relatives was linked to the major histocompatibility complex with a highly significant logarithm of the odds score of 9.07, almost always to a DR4 or DR6 haplotype of the patient. Disease appears to occur in susceptible individuals with low levels of antibody when a second factor, either environmental or genetic, induces high levels, sufficient to produce blisters.

Major histocompatibility complex susceptibility genes for dermatitis herpetiformis compared with those for gluten-sensitive enteropathy.

Dermatitis herpetiformis (DH) shares some clinical features and major histocompatibility complex (MHC) markers with gluten-sensitive enteropathy (GSE). We compared MHC haplotypes in 27 patients with DH, 35 patients with GSE, and normal controls. As in GSE, the frequencies of two extended haplotypes, [HLA-B8, SC01, DR3] and [HLA-B44, FC31, DR7], were increased in patients with DH. Distributions of fragments of extended haplotypes, consisting of some but not all of the elements of complete extended haplotypes, were analyzed to attempt to localize a susceptibility gene. Besides complete extended susceptibility haplotypes, (DR3, DQ2) and (DR7, DQ2) fragments were most common in GSE. In contrast, DH showed only a few such fragments but many instances of the fragment (SC01). The differences in distribution of these fragments in the two diseases were highly significant (P < 0.002). HLA-DQ2 and DR3 had the highest odds ratios for GSE, but the highest odds ratio for DH was for the complotype SC01. These findings suggest that the MHC susceptibility gene for DH is between class II and complotype regions, closest to the complotype, whereas that for GSE is in the class II region.

Relationship between target antigens and major histocompatibility complex (MHC) class II genes in producing two pathogenic antibodies simultaneously.

In this report,we present 15 patients with histological and immunopathologically proven pemphigus vulgaris (PV). After a mean of 80 months since the onset of disease, when evaluated serologically, they had antibodies typical of PV and pemphigoid (Pg). Similarly, 18 patients with bullous pemphigoid (BP) and mucous membrane pemphigoid (MMP) were diagnosed on the basis of histology and immunopathology.After a mean of 60 months since the onset of disease, when their sera were evaluated they were found to have Pg and PV autoantibodies. In both groups of patients the diseases were characterized by a chronic course, which included several relapses and recurrences and were non-responsive to conventional therapy. The major histocompatibility complex class II (MHC II) genes were studied in both groups of patients and phenotypes associated typically with them were observed. Hence, in 33 patients, two different pathogenic autoantibodies were detected simultaneously. The authors provide a computer model to show that each MHC II gene has relevant epitopes that recognize the antigens associated with both diseases. Using the databases in these computer models, the authors present the hypothesis that these two autoantibodies are produced simultaneously due to the phenomena of epitope spreading.

Coexistence of mucous membrane pemphigoid and connective-tissue disease.

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disease that predominantly affects the mucosa. We report eight patients with MMP who also had systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), or both. Eight women (six white, two Hispanic; mean age of onset 53.5 years [range 44-68]) were studied. In four patients, both diseases were detected simultaneously, and in the other four patients, MMP preceded SLE or MCTD. MMP was widespread and resistant to conventional immunosuppressive therapy, but responded to intravenous immunoglobulin (IVIg). During a mean follow-up of 10.25 years (range 6-18), three patients had stable SLE/MCTD, whereas in the other five patients the SLE/MCTD required systemic corticosteroids either with or without immunosuppressive agents. Renal, serosal, pulmonary and neurological features were not observed in any patient. At the time of reporting, the MMP was in a prolonged sustained remission in all eight patients. The SLE/MCTD remained mild, did not involve vital organs and had continued with low-grade activity. In summary, we report the simultaneous occurrence of two rare diseases in a group of patients.