Development, implementation and evaluation of a multinational FLS mentorship programme in Latin America.

Realising the benefits of systematic secondary fracture prevention requires supporting local sites to get started and becoming effective. We here describe the development, implementation and impact of a regional fracture liaison service (FLS) mentorship programme in Latin America that led to 64 FLS getting started and coverage of 17,205 patients. INTRODUCTION: Despite treatments and service models to deliver effective secondary fracture prevention, most patients are left untreated after a fragility fracture. To improve the capability to get FLS started and more effective, we describe the development, implementation and evaluation of an international programme to develop national communities of FLS mentors as part of the Capture the Fracture Partnership in Latin America. METHODS: The IOF regional team and the University of Oxford developed the curriculum and associated resources for training mentors in setting up FLS, service improvement and mentorship. Mentors were selected during a preparatory meeting, trained using live online sessions followed by regular mentor-led post-training meetings. The programme was evaluated using a pre-training needs assessment and post-training evaluation based on Moore's outcomes. RESULTS: The mentorship programme was initiated in Mexico, Brazil, Colombia and Argentina. The mentors were multidisciplinary, including orthopaedic surgery, rehabilitation, rheumatology, endocrinology, geriatrics, gynaecology and internal medicine. There was 100% participation in training sessions and reported satisfaction with the training. Since the initiation of the training programme, 22 FLS have been set up in Mexico, 30 in Brazil, 3 in Colombia and 9 in Argentina, in comparison with two in Chile and none in any other LATAM countries that were not involved in the mentorship programme. This equates to approximately 17,025 additional patients identified from 2019 to 2021 after initiation of mentorship. The mentors have engaged with 58 FLS for service development. Post-training activities include two published national best practice guidelines and other country-specific resources for FLS in the local language. CONCLUSION: Despite the COVID pandemic, the mentorship pillar of the Capture the Fracture Partnership has developed a community of FLS mentors with measurable improvement in national FLS provision. The programme is a potentially scalable platform to develop communities of mentors in other countries.

Voriconazole-induced periostitis.

Voriconazole is a fluorinated drug from the triazole group that is widely used in the prophylaxis and treatment of fungal infections in immunosuppressed patients. Chronic use of this medication can generate, as an adverse effect, a multifocal, asymmetric, diffuse and nodular periosteal reaction, associated with severe and disabling skeletal pain and elevated alkaline phosphatase and serum fluoride. Radiography is the imaging technique of choice for periostitis diagnosis. In general, clinical manifestations and radiographic findings disappear, when the drug is discontinued. We report the clinical case of a 44 year-old woman diagnosed with acute myeloid leukemia, who developed an invasive fungal infection treated with voriconazole after a stem cell transplant. Nine months after starting antifungal treatment, she manifested symptoms and radiological signs compatible with periostitis. Due to clinical suspicion, we decided to suspend voriconazole, with consequent resolution of clinical manifestations and radiological findings.

Valor nutritivo de pastagens de Coastcross-1 em consórcio com diferentes leguminosas de ciclo hibernal / Nutritive value of coastcross-1 pastures mixed to different cool season legumes

Objetivou-se com esta pesquisa avaliar três sistemas forrageiros constituídos por Coastcross-1 (CC) + 100kg de N/ha/ano + ervilhaca comum; CC + 100kg de N/ha/ano + trevo vesiculoso; e CC + 200kg de N/ha/ano. Durante o período experimental (345 dias), foram realizados treze pastejos. O delineamento experimental utilizado foi o inteiramente ao acaso, com três tratamentos (sistemas forrageiros), três repetições (piquetes) em parcelas subdividas no tempo (valores médios dos pastejos em cada estação do ano). Para avaliação, foram utilizadas vacas em lactação da raça Holandesa. Amostras de simulação de pastejo foram coletadas para análise de proteína bruta (PB), fibra em detergente neutro (FDN) e ácido (FDA), digestibilidade in situ da matéria seca (DISMS) e da matéria orgânica (DISMO) e os nutrientes digestíveis totais (NDT). Os valores médios para PB, FDN, FDA, DISMS, DISMO e NDT foram de 18,1; 16,7 e 17,6%; 57,8; 58,9 e 58,7%; 26,5; 26,5 e 26,7%; 79,6; 78,9 e 80,6%; 79,8; 79,1 e 80,6%; 72,1; 71,4 e 72,7%, respectivamente. Melhores resultados de valor nutritivo foram obtidos no inverno, em especial para o consórcio de Coastcross-1 com ervilhaca.

The aim of this research was to evaluate three grazing systems with Coastcross-1 (CC) + 100kg N/ha/year + common vetch; CC + 100kg N/ha/year + arrowleaf clover; and CC + 200kg N/ha/year. Thirteen grazing cycles were performed during the experimental period (345 days). The experimental design was completely randomized with three treatments (grazing systems), three replicates (paddocks) in completely split-plot time (average values of grazing season). Lactating Holstein cows were used in the evaluation. Forage mass and botanical composition were evaluated. Samples from the hand-plucking method were collected to analyze crude protein (CP), neutral detergent fiber (NDF) and acid (ADF), in situ digestibility of dry matter (ISDMD) and organic matter (ISOMD) and total digestible nutrients (TDN). The averages of CP, NDF, ADF, ISDMD, ISOMD and TDN were 18.1, 16.7 and 17.6 %; 57.8, 58.9 and 58.7 %; 26.5, 26.5 and 26.7 %; 79.6, 78.9 and 80.6 %; 79.8, 79.1 and 80.6 %; 72.1, 71.4 and 72.7 %, respectively. Better results for nutritive value were found during winter, especially on Coastcross-1 mixed with common vetch.

Short-distance walking speed tests in people with Parkinson disease: reliability, responsiveness, and validity.

PURPOSE: The aims of this study were to determine test-retest reliability and responsiveness of short-distance walking speed tests for persons with Parkinson disease (PD). Discriminant and convergent validity of walking speed tests were also examined. METHODS: Eighty-eight participants with PD (mean age, 66 years) with mild to moderate severity (stages 1-4 on the Hoehn and Yahr Scale) were tested on medications. Measures of activity included the comfortable and fast 10-m walk tests (CWT, FWT), 6-min walk test (6MWT), mini balance evaluations systems test (mini-BEST Test), fear of falling (FoF), and the Activity-Specific Balance Confidence Scale (ABC). The mobility subsection of the PD quality of life-39 (PDQ39-M) served as a participation-based measure. RESULTS: Test-retest reliability was high for both walking speed measures (CWT, ICC(2,1) = 0.98; FWT, ICC(2,1) = 0.99). Minimal detectable change (MDC(95)) for the CWT and FWT was 0.09 m/s and 0.13 m/s respectively. Participants at Hoehn & Yahr levels 3/4 demonstrated significantly slower walking speed with the CWT and FWT than participants at Hoehn & Yahr levels 1 and 2 (P < .01). The CWT and FWT were both significantly (P ≤ .002) correlated with all activity and participation-based measures. CONCLUSIONS: Short-distance walking speed tests are clinically useful measures for persons with PD. The CWT and FWT are highly reliable and responsive to change in persons with PD. Short distance walking speed can be used to discriminate differences in gait function between persons with mild and moderate PD severity. The CWT and FWT had moderate to strong associations with other activity and participation based measures demonstrating convergent validity.

Produtividade de sistemas forrageiros consorciados com leguminosas / Productivity of grazing systems mixed with forage legumes

O objetivo desta pesquisa foi avaliar três sistemas forrageiros (SF) com capim elefante (CE) + azevém (AZ) + espécies de crescimento espontâneo (ECE); CE + AZ + ECE + amendoim forrageiro (AM); e CE + AZ + ECE + trevo vermelho (TV), usando-se a mesma área, sob pastejo rotacionado, no decorrer do ano agrícola. O CE foi estabelecido em linhas afastadas a cada 4m. No período hibernal, fez-se o estabelecimento do AZ entre as linhas do CE; o TV foi semeado e o AM foi preservado, considerando-se os respectivos SF. O delineamento experimental foi o inteiramente ao acaso, com três tratamentos (SF), duas repetições (piquetes) e avaliações independentes (ciclos de pastejos). Para avaliação, foram utilizadas vacas da raça Holandesa em lactação, que receberam suplementação alimentar com concentrado à razão de 1% do peso corporal/dia. Foram avaliados a massa de forragem, os componentes botânicos do pasto e estruturais do CE e a taxa de lotação. Durante o período experimental, foram efetuados oito ciclos de pastejo. Sistemas forrageiros que envolvem gramíneas e leguminosas de diferentes ciclos proporcionam a utilização da área durante todo o ano agrícola em pastejo rotativo com bovinos leiteiros. Considerando-se a predominância das avaliações em cada pastejo, os sistemas forrageiros consorciados apresentam melhor resultado tanto paras as variáveis de massa de forragem quanto para a taxa de lotação.

The objective of this research was to evaluate three grazing systems (GS) with elephant grass (EG) + ryegrass (RG) + spontaneous growing species (SGS); EG + RG + SGS + forage peanut (FP); and EG + RG + SGS + red clover (RC), in order to use the area in rotational grazing during the agricultural year. EG was planted in rows with a distance of 4m between each row. In the cool-season, RG was sowed between EG rows and FP was preserved on GS. The experimental design was completely randomized with three treatments (GS), two replicates (paddocks) and independent evaluations (grazing cycles). For the evaluation lactating Holstein cows receiving 1% of BW/day feed supplement concentrate were used. The herbage mass, botanical composition of pasture, structural component of EG and stocking rate were evaluated. Eight grazing cycles were performed during the experimental period. Grazing systems involving grass and legume forage in different cycles provided the use of the area during the agricultural year in rotational grazing with dairy cattle. Considering the predominance of the evaluations in each grazing, the mixed grazing systems have better results for both forage mass and stocking rate variables.

Community-based group exercise for persons with Parkinson disease: a randomized controlled trial.

The purpose of this study was to compare group boxing training to traditional group exercise on function and quality of life in persons with Parkinson disease (PD). A convenience sample of adults with PD (n = 31) were randomly assigned to boxing training or traditional exercise for 24-36 sessions, each lasting 90 minutes, over 12 weeks. Boxing training included: stretching, boxing (e.g. lateral foot work, punching bags), resistance exercises, and aerobic training. Traditional exercise included: stretching, resistance exercises, aerobic training, and balance activities. Participants were tested before and after completion of training on balance, balance confidence, mobility, gait velocity, gait endurance, and quality of life. The traditional exercise group demonstrated significantly greater gains in balance confidence than the boxing group (p < 0.025). Only the boxing group demonstrated significant improvements in gait velocity and endurance over time with a medium between-group effect size for the gait endurance (d = 0.65). Both groups demonstrated significant improvements with the balance, mobility, and quality of life with large within-group effect sizes (d ≥ 0.80). While groups significantly differed in balance confidence after training, both groups demonstrated improvements in most outcome measures. Supporting options for long-term community-based group exercise for persons with PD will be an important future consideration for rehabilitation professionals.

High-fidelity simulation for continuing education in nurse anesthesia.

Simulation represents a true paradigm shift in teaching and learning that has revolutionized healthcare education. However, few continuing education opportunities for anesthesia providers exist using simulation of any type. This article explores the usefulness of high-fidelity simulation (HFS) as a valuable tool for continuing education and reports the results of a needs assessment conducted among 22 practicing nurse anesthetists. The questions related to their exposure to HFS and asked them to rank their experience with 11 anesthesia events. Next, respondents were asked to rank a similar list of anesthesia events that would be useful for continuing education using simulation. Of participants, 71% ranked advanced cardiac life support scenarios, anesthesia machine mishaps, and malignant hyperthermia as highly effective choices for using HFS. Eighty-one percent of participants identified that they envision simulation as a valuable tool to assess competency, but respondents had mixed written responses when asked if simulation should be used for recertification. This needs assessment represents a beginning, grassroots attempt to establish nurse anesthetists' perceptions related to using HFS as a tool for continuing education.

Neurons responsive to face-view in the primate ventrolateral prefrontal cortex.

Studies have indicated that temporal and prefrontal brain regions process face and vocal information. Face-selective and vocalization-responsive neurons have been demonstrated in the ventrolateral prefrontal cortex (VLPFC) and some prefrontal cells preferentially respond to combinations of face and corresponding vocalizations. These studies suggest VLPFC in nonhuman primates may play a role in communication that is similar to the role of inferior frontal regions in human language processing. If VLPFC is involved in communication, information about a speaker's face including identity, face-view, gaze, and emotional expression might be encoded by prefrontal neurons. In the following study, we examined the effect of face-view in ventrolateral prefrontal neurons by testing cells with auditory, visual, and a set of human and monkey faces rotated through 0°, 30°, 60°, 90°, and -30°. Prefrontal neurons responded selectively to either the identity of the face presented (human or monkey) or to the specific view of the face/head, or to both identity and face-view. Neurons which were affected by the identity of the face most often showed an increase in firing in the second part of the stimulus period. Neurons that were selective for face-view typically preferred forward face-view stimuli (0° and 30° rotation). The neurons which were selective for forward face-view were also auditory responsive compared to other neurons which responded to other views or were unselective which were not auditory responsive. Our analysis showed that the human forward face (0°) was decoded better and also contained the most information relative to other face-views. Our findings confirm a role for VLPFC in the processing and integration of face and vocalization information and add to the growing body of evidence that the primate ventrolateral prefrontal cortex plays a prominent role in social communication and is an important model in understanding the cellular mechanisms of communication.

Boxing training for patients with Parkinson disease: a case series.

BACKGROUND AND PURPOSE: A nontraditional form of exercise recently applied for patients with Parkinson disease (PD) is boxing training. The primary purpose of this case series is to describe the effects of disease severity and duration of boxing training (short term and long term) on changes in balance, mobility, and quality of life for patients with mild or moderate to severe PD. The feasibility and safety of the boxing training program also were assessed. CASE DESCRIPTION: Six patients with idiopathic PD attended 24 to 36 boxing training sessions for 12 weeks, with the option of continuing the training for an additional 24 weeks (a seventh patient attended sessions for only 4 weeks). The 90-minute sessions included boxing drills and traditional stretching, strengthening, and endurance exercises. Outcomes were tested at the baseline and after 12, 24, and 36 weeks of boxing sessions (12-, 24-, and 36-week tests). The outcome measures were the Functional Reach Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Timed "Up & Go" Test, Six-Minute Walk Test, gait speed, cadence, stride length, step width, activities of daily living and motor examination subscales of the Unified Parkinson Disease Rating Scale, and Parkinson Disease Quality of Life Scale. OUTCOMES: Six patients completed all phases of the case series, showed improvements on at least 5 of the 12 outcome measures over the baseline at the 12-week test, and showed continued improvements at the 24- and 36-week tests. Patients with mild PD typically showed improvements earlier than those with moderate to severe PD. DISCUSSION: Despite the progressive nature of PD, the patients in this case series showed short-term and long-term improvements in balance, gait, activities of daily living, and quality of life after the boxing training program. A longer duration of training was necessary for patients with moderate to severe PD to show maximal training outcomes. The boxing training program was feasible and safe for these patients with PD.

The role of head-in-space stability on stepping reactions in young and elderly adults.

This study compared head kinematic responses and step latency following an anteriorly directed postural perturbation between two groups (Young, mean age 27.39; Elderly, mean age 71.9). We further attempted to demonstrate, for the first time, a positive linear relationship between sagittal plane head angular velocities and stepping responses in both groups. It was hypothesized that the Elderly would demonstrate higher head angular velocities and greater step latencies than the Young. We also hypothesized that a positive linear relationship would show that, following a perturbation, trials where head angular velocity was low yielded quicker step responses. Each participant experienced three perturbations under five different visual conditions designed to alter visual input and head/trunk coordination. Repeated-measures ANOVA was used, with α set at 0.05. For each test condition, the Elderly consistently demonstrated longer step latencies while exhibiting higher head angular velocities. For each group, a positive linear relationship was shown between the two dependent variables (Young: r=0.86; Elderly, r=0.84). During a postural perturbation, as head angular velocity increased, stepping responses were delayed.

Transfusion in the critically ill: does it affect outcome?

Anemia and red blood cell (RBC) transfusions are common in critically ill and injured, trauma, and surgical patients. Tolerance of anemia is highly variable, depending on the presence of cardiovascular and other comorbid diseases that may diminish the hemodynamic response to a lower hemoglobin (Hb) level. The quest to define a minimum threshold Hb concentration at which patients achieve significant benefit to improve outcome has not yet been identified. Complications related to RBC transfusion are related to RBC storage and intrinsic properties of donor allogeneic RBCs, including bacterial contamination, transfusion-related acute lung injury, and transfusion-related immunomodulation. The best evidence related to transfusion-related outcome involves titrating transfusion requirements to parameters of severity of illness rather than arbitrarily defined Hb levels.

Emerging issues for the postbariatric surgical patient.

Millions of individuals in the United States and around the world are overweight or obese. Bariatric surgery is now considered an evidenced-based choice for sustainable long-term weight loss and may reduce obesity-related comorbidities such as diabetes and obstructive sleep apnea. As bariatric surgical procedures increase, it can be expected that intensive care unit (ICU) admissions will increase as well. An emerging ICU population includes postbariatric patients either immediately after undergoing bariatric surgery or returning for subsequent surgical procedures. Massive weight loss following surgery leads to an excess of lax, overstretched skin, causing physical discomfort and psychosocial problems. It is important to understand the complex pathophysiological changes that occur in order to care for this growing population of patients. This review addresses the growing and evolving issues related to the complex nature of the postbariatric ICU patients.

The influence of gaze stabilization and fixation on stepping reactions in younger and older adults.

PURPOSE: To date, there has been little evidence to suggest the importance of foveal viewing versus peripheral retina viewing when trying to recover from a perturbation. The purposes of this investigation were to (1) determine whether a visual target can be stabilized on the fovea during a perturbation, (2) determine whether stepping responses following a perturbation are influenced by foveal fixation, and (3) compare gaze stability and stepping responses between young and aging adults. MATERIALS/METHODS: Ten young adults and 10 aging adults were asked to wear an eye-tracking device linked to a kinematic tracking system during perturbations. Perturbations were delivered under 2 conditions: control (no instructions regarding gaze location were given) and earth-fixed (EF) (subjects were asked to fixate gaze on an EF target). Stepping responses were recorded via force plates. Gaze stability, reported as percent foveal fixation (% FF), was calculated from eye-tracking data. Step latencies (SLs) were computed from force plate data. A 2 x 2 analysis of variance was used to assess statistical significance between groups. For the young and aging adults, linear correlations were made to identify relationships between % FF and SL. RESULTS: For each condition, aging adults took longer to initiate a step (control, P = .002; EF, P = .003). Young adults were better at maintaining gaze fixation than older adults (P = .0045). Linear correlations demonstrated significant negative relationships between SL and % FF for young (r = -0.76, P = .001) and older (r = -0.87, P = .0001) adults. As % FF increased, SL decreased. CONCLUSIONS: The ability to maintain gaze fixation of an EF target may be important in reducing SL following a perturbation. Older adult subjects demonstrated a decreased ability to fixate a target during balance tasks while also displaying longer SLs.

Social support in an Internet weight loss community.

PURPOSE: To describe social support for weight loss shared by members of a large Internet weight loss community. METHODS: We conducted a mixed-methods study with surveys (n=193) and interviews (n=13) of community members along with a content analysis of discussion forum messages (n=1924 messages). Qualitative data were analyzed for social support themes. RESULTS: Survey respondents were primarily white (91.4%) and female (93.8%) with mean age 37.3 years and mean body mass index 30.9. They used forums frequently, with 56.8% reading messages, 36.1% replying to messages, and 18.5% posting messages to start a discussion related to weight loss on a daily or more frequent basis. Major social support themes were encouragement and motivation, mentioned at least once by 87.6% of survey respondents, followed by information (58.5%) and shared experiences (42.5%). Subthemes included testimonies, recognition for success, accountability, friendly competition, and humor. Members valued convenience, anonymity, and the non-judgmental interactions as unique characteristics of Internet-mediated support. CONCLUSION: This Internet weight loss community plays a prominent role in participants' weight loss efforts. Social support within Internet weight loss communities merits further evaluation as a weight loss resource for clinicians to recommend to patients. Understanding these communities could improve how health professionals evaluate, build, harness, and manipulate social support for weight loss.

Spin structure of the pion.

We present the first calculation of the transverse spin structure of the pion in lattice QCD. Our simulations are based on two flavors of nonperturbatively improved Wilson fermions, with pion masses as low as 400 MeV in volumes up to (2.1 fm)(3) and lattice spacings below 0.1 fm. We find a characteristic asymmetry in the spatial distribution of transversely polarized quarks. This asymmetry is very similar in magnitude to the analogous asymmetry we previously obtained for quarks in the nucleon. Our results support the hypothesis that all Boer-Mulders functions are alike.

Parathyroid carcinoma presenting as a giant mediastinal retrotracheal functioning cyst.

Parathyroid carcinoma is a rare malignancy of the parathyroid glands, and is the cause of primary hyperparathyroidism in fewer than one percent of cases. Symptoms are mainly due to local compression or hypercalcaemia secondary to markedly elevated parathyroid hormone levels. A minority of patients remain asymptomatic. Mediastinal parathyroid cysts are infrequent and may or may not be functioning. We present an 84-year-old woman with a giant functioning cystic parathyroid carcinoma located in the middle mediastinum. We performed a thorough MEDLINE and LILACS database search on published cases of parathyroid carcinoma and functioning parathyroid cysts, and found no case report with identical features to the one presented here.

Real-time nonlinear feedback control of pattern formation in (bio)chemical reaction-diffusion processes: a model study.

Theoretical and experimental studies related to manipulation of pattern formation in self-organizing reaction-diffusion processes by appropriate control stimuli become increasingly important both in chemical engineering and cellular biochemistry. In a model study, we demonstrate here exemplarily the application of an efficient nonlinear model predictive control (NMPC) algorithm to real-time optimal feedback control of pattern formation in a bacterial chemotaxis system modeled by nonlinear partial differential equations. The corresponding drift-diffusion model type is representative for many (bio)chemical systems involving nonlinear reaction dynamics and nonlinear diffusion. We show how the computed optimal feedback control strategy exploits the system inherent physical property of wave propagation to achieve desired control aims. We discuss various applications of our approach to optimal control of spatiotemporal dynamics.

A late Eemian aridity pulse in central Europe during the last glacial inception.

Investigating the processes that led to the end of the last interglacial period is relevant for understanding how our ongoing interglacial will end, which has been a matter of much debate (see, for example, refs 1, 2). A recent ice core from Greenland demonstrates climate cooling from 122,000 years ago driven by orbitally controlled insolation, with glacial inception at 118,000 years ago. Here we present an annually resolved, layer-counted record of varve thickness, quartz grain size and pollen assemblages from a maar lake in the Eifel (Germany), which documents a late Eemian aridity pulse lasting 468 years with dust storms, aridity, bushfire and a decline of thermophilous trees at the time of glacial inception. We interpret the decrease in both precipitation and temperature as an indication of a close link of this extreme climate event to a sudden southward shift of the position of the North Atlantic drift, the ocean current that brings warm surface waters to the northern European region. The late Eemian aridity pulse occurred at a 65 degrees N July insolation of 416 W m(-2), close to today's value of 428 W m(-2) (ref. 9), and may therefore be relevant for the interpretation of present-day climate variability.