Applying the behaviour change wheel to assess the theoretical underpinning of a novel smartphone application to increase physical activity in adults with spinal cord injuries.

Background: People with spinal cord injuries (SCI) are physically inactive. Smartphone applications (or apps) may prove as one strategy to overcome this. This study examines the theoretical underpinning of a novel mHealth intervention that aims to improve physical activity in people with SCI, namely, the Accessercise smartphone app, using the behaviour change wheel (BCW). Methods: Accessercise was evaluated using the BCW in eight steps across the following three stages: (I) understanding the behaviour, (II) identifying intervention options, and (III) identifying content and implementation options. Results: Thirteen target behaviours were identified to improve physical activity and reduce sedentary behaviours in adults with SCI, including goal setting and monitoring, increasing self-confidence, interest and motivation for undertaking physical activity, improving the knowledge/awareness of available physical activity opportunities and resources, and reducing stigma and negative attitudes associated with physical activity. Accessercise incorporates the necessary components for adults with SCI to be physically and psychologically capable of undertaking physical activity, offering social and physical opportunities to reduce sedentary behaviours, and supports automatic and reflective motivation. Conclusions: This systematic approach of assessing the theoretical underpinning of Accessercise in the context of the BCW has revealed potential mechanisms of action for improving physical activity in adults with SCI. This serves as a blueprint to inform further intervention development, as well as high-quality effectiveness studies, namely, randomised controlled trials, assessing whether fitness apps can improve physical and psychological health outcomes in individuals with SCI.

In-situ digital image correlation and thermal monitoring in directed energy deposition additive manufacturing.

As in welding, directed energy deposition (DED) additive manufacturing (AM) generates complex residual stresses and distortions commensurate with the complexity of the scan pattern used for deposition. To date, measuring DED distortions on complex geometries has only been achieved post process, discarding the complex thermomechanical history that leads to that final material state. In this work, surround stereo digital image correlation (DIC) is used to 3D map surfaces and strain tensors in-situ in a powder-blown laser DED system. Infrared thermography is then projected onto these surfaces to record the full thermomechanical history of printed parts. DIC presents a unique challenge to DED AM, as no part exists at the beginning of deposition, which (a) prevents application of an appropriate speckle pattern and (b) denies the user a zero strain reference frame. Solutions to these problems are proposed and their limitations explored herein. In sum, this work presents a relatively low-cost solution to monitoring and optimizing the unique temporal artifacts induced by complex scan strategies that was previously unobtainable.

A Proximal Culture Method to Study Paracrine Signaling Between Cells.

Intercellular interactions play an important role in many biological processes, including tumor progression, immune responses, angiogenesis, and development. Paracrine or juxtacrine signaling mediates such interactions. The use of a conditioned medium and coculture studies are the most common methods to discriminate between these two types of interactions. However, the effect of localized high concentrations of secreted factors in the microenvironment during the paracrine interactions is not accurately recapitulated by conditioned medium and, thus, may lead to imprecise conclusions. To overcome this problem, we have devised a proximal culture method to study paracrine signaling. The two cell types are grown on either surface of a 10 µm-thick polycarbonate membrane with 0.4 µm pores. The pores allow the exchange of secreted factors and, at the same time, inhibit juxtacrine signaling. The cells can be collected and lysed at the endpoint to determine the effects of the paracrine signaling. In addition to allowing for localized concentration gradients of secreted factors, this method is amenable to experiments involving prolonged periods of culture, as well as the use of inhibitors. While we use this method to study the interactions between ovarian cancer cells and the mesothelial cells they encounter at the site of metastasis, it can be adapted to any two adherent cell types for researchers to study paracrine signaling in various fields, including tumor microenvironment, immunology, and development.

ETS1 induction by the microenvironment promotes ovarian cancer metastasis through focal adhesion kinase.

Metastatic colonization involves paracrine/juxtacrine interactions with the microenvironment inducing an adaptive response through transcriptional regulation. However, the identities of transcription factors (TFs) induced by the metastatic microenvironment in ovarian cancer (OC) and their mechanism of action is poorly understood. Using an organotypic 3D culture model recapitulating the early events of metastasis, we identified ETS1 as the most upregulated member of the ETS family of TFs in metastasizing OC cells as they interacted with the microenvironment. ETS1 was regulated by p44/42 MAP kinase signaling activated in the OC cells interacting with mesothelial cells at the metastatic site. Human OC tumors had increased expression of ETS1, which predicted poor prognosis. ETS1 regulated OC metastasis both in vitro and in mouse xenografts. A combination of ChIP-seq and RNA-seq analysis and functional rescue experiments revealed FAK as the key transcriptional target and downstream effector of ETS1. Taken together, our results indicate that ETS1 is an essential transcription factor induced in OC cells by the microenvironment, which promotes metastatic colonization though the transcriptional upregulation of its target FAK.

Functional characterization of a panel of high-grade serous ovarian cancer cell lines as representative experimental models of the disease.

Genomic analysis of ovarian cancer cell lines has revealed a panel that best represents the most common ovarian cancer subtype, high-grade serous ovarian cancer (HGSOC). However, these HGSOC-like cell lines have not been extensively applied by ovarian cancer researchers to date, and the most commonly used cell lines in the ovarian cancer field do not genetically resemble the major clinical type of the disease. For the HGSOC-like lines to serve as suitable models, they need to be characterized for common functional assays. To achieve that objective, we systematically studied a panel of HGSOC cells CAOV3, COV362, Kuramochi, OVCAR4, OVCAR5, OVCAR8, OVSAHO and SNU119 for migration, invasion, proliferation, clonogenicity, EMT phenotype and cisplatin resistance. They exhibited a range of efficacies and OVCAR5, OVCAR8 and Kuramochi were the most aggressive. SNU119 and OVSAHO cells demonstrated the lowest functional activities. Wide differences in expression of EMT markers were observed between cell lines. SNU119 were the most epithelial and OVCAR8 had the most mesenchymal phenotype. COV362 was the most resistant to cisplatin while CAOV3 was the most sensitive. Taken together, our systematic characterization represents a valuable resource to help guide the application of HGSOC cells by the cancer research community.

A Multidisciplinary Sepsis Program Enabled by a Two-Stage Clinical Decision Support System: Factors That Influence Patient Outcomes.

Sepsis is an inflammatory response triggered by infection, with risk of in-hospital mortality fueled by disease progression. Early recognition and intervention by multidisciplinary sepsis programs may reverse the inflammatory response among at-risk patient populations, potentially improving outcomes. This retrospective study of a sepsis program enabled by a 2-stage sepsis Clinical Decision Support (CDS) system sought to evaluate the program's impact, identify early indicators that may influence outcomes, and uncover opportunities for quality improvement. Data encompassed 16 527 adult hospitalizations from 2014 and 2015. Of 2108 non-intensive care unit patients screened-in by sepsis CDS, 97% patients were stratified by 177 providers. Risk of adverse outcome improved 30% from baseline to year end, with gains materializing and stabilizing at month 7 after sepsis program go-live. Early indicators likely to influence outcomes include patient age, recent hospitalization, electrolyte abnormalities, hypovolemic shock, hypoxemia, patient location when sepsis CDS activated, and specific alert patterns.

A two-stage clinical decision support system for early recognition and stratification of patients with sepsis: an observational cohort study.

OBJECTIVE: To examine the diagnostic accuracy of a two-stage clinical decision support system for early recognition and stratification of patients with sepsis. DESIGN: Observational cohort study employing a two-stage sepsis clinical decision support to recognise and stratify patients with sepsis. The stage one component was comprised of a cloud-based clinical decision support with 24/7 surveillance to detect patients at risk of sepsis. The cloud-based clinical decision support delivered notifications to the patients' designated nurse, who then electronically contacted a provider. The second stage component comprised a sepsis screening and stratification form integrated into the patient electronic health record, essentially an evidence-based decision aid, used by providers to assess patients at bedside. SETTING: Urban, 284 acute bed community hospital in the USA; 16,000 hospitalisations annually. PARTICIPANTS: Data on 2620 adult patients were collected retrospectively in 2014 after the clinical decision support was implemented. MAIN OUTCOME MEASURE: 'Suspected infection' was the established gold standard to assess clinical decision support clinimetric performance. RESULTS: A sepsis alert activated on 417 (16%) of 2620 adult patients hospitalised. Applying 'suspected infection' as standard, the patient population characteristics showed 72% sensitivity and 73% positive predictive value. A postalert screening conducted by providers at bedside of 417 patients achieved 81% sensitivity and 94% positive predictive value. Providers documented against 89% patients with an alert activated by clinical decision support and completed 75% of bedside screening and stratification of patients with sepsis within one hour from notification. CONCLUSION: A clinical decision support binary alarm system with cross-checking functionality improves early recognition and facilitates stratification of patients with sepsis.

Cardiac ß-Adrenoceptor Expression Is Reduced in Zucker Diabetic Fatty Rats as Type-2 Diabetes Progresses.

OBJECTIVES: Reduced cardiac ß-adrenoceptor (ß-AR) expression and cardiovascular dysfunction occur in models of hyperglycemia and hypoinsulinemia. Cardiac ß-AR expression in type-2 diabetes models of hyperglycemia and hyperinsulinemia, remain less clear. This study investigates cardiac ß-AR expression in type-2 diabetic Zucker diabetic fatty (ZDF) rats. METHODS: Ex vivo biodistribution experiments with [3H]CGP12177 were performed in Zucker lean (ZL) and ZDF rats at 10 and 16 weeks of age as diabetes develops. Blood glucose, body mass, and diet consumption were measured. Western blotting of ß-AR subtypes was completed in parallel. Echocardiography was performed at 10 and 16 weeks to assess systolic and diastolic function. Fasted plasma insulin, free fatty acids (FFA), leptin and fed-state insulin were also measured. RESULTS: At 10 weeks, myocardial [3H]CGP12177 was normal in hyperglycemic ZDF (17±4.1mM) compared to ZL, but reduced 16-25% at 16 weeks of age as diabetes and hyperglycemia (22±2.4mM) progressed. Reduced ß-AR expression not apparent at 10 weeks also developed by 16 weeks of age in ZDF brown adipose tissue. In the heart, Western blotting at 10 weeks indicated normal ß1-AR (98±9%), reduced ß2-AR (76±10%), and elevated ß3-AR (108±6). At 16 weeks, ß1-AR expression became reduced (69±16%), ß2-AR expression decreased further (68±14%), and ß3-AR remained elevated, similar to 10 weeks (112±9%). While HR was reduced at 10 and 16 weeks in ZDF rats, no significant changes were observed in diastolic or systolic function. CONCLUSIONS: Cardiac ß-AR are reduced over 6 weeks of sustained hyperglycemia in type-2 diabetic ZDF rats. This indicates cardiac [3H]CGP12177 retention and ß1- and ß2-AR expression are inversely correlated with the progression of type-2 diabetes.

Insulin therapy normalizes reduced myocardial ß-adrenoceptors at both the onset and after sustained hyperglycemia in diabetic rats.

AIMS: Reduced cardiac ß-adrenoceptors (ß-AR) and cardiovascular (CV) dysfunction occur in diabetes mellitus (DM) and can be normalized by insulin. It is unclear how the duration of untreated hyperglycemia prior to intervention impacts insulin's effects. This study assesses insulin's effect on reduced myocardial ß-AR and CV function, comparing insulin therapy at the onset of hyperglycemia and after a sustained period of hyperglycemia in streptozotocin (STZ) rats. MAIN METHODS: Ex vivo biodistribution experiments with [(3)H]CGP12177 were performed in high-fat fed STZ rats after 8 weeks of hyperglycemia evaluating cardiac ß-AR expression. Western blotting of ß-AR subtypes was completed in parallel. Serial echocardiography at 0, 6, and 8 weeks post-STZ investigated CV function. Sub-groups of hyperglycemic rats were treated with insulin early, at 1 week post-STZ (InsE) for 7 weeks, or late at 6 weeks post-STZ (InsL) for 2 weeks to observe how the duration of hyperglycemia prior to insulin impacts its effects. KEY FINDINGS: Reduced myocardial [(3)H]CGP12177 binding occurred 8 weeks post-STZ in hyperglycemics, but was normal in both insulin treatments. Western blotting supported reduced ß1-AR in hyperglycemics, but not in either treatment. InsE and InsL treatments improved prolonged mitral valve deceleration (MVD) observed in hyperglycemic animals, but hyperglycemic and InsL still displayed reduced heart rates (HR). SIGNIFICANCE: This work supports that glycemic control with insulin normalizes cardiac ß-AR effectively regardless of prior hyperglycemia but HR may not recover as readily, indirectly supporting the utility of [(11)C]CGP12177 positron emission tomography (PET) in assessing cardiac ß-AR and their modulation with glycemic therapy.

Plasma phospholipids identify antecedent memory impairment in older adults.

Alzheimer's disease causes a progressive dementia that currently affects over 35 million individuals worldwide and is expected to affect 115 million by 2050 (ref. 1). There are no cures or disease-modifying therapies, and this may be due to our inability to detect the disease before it has progressed to produce evident memory loss and functional decline. Biomarkers of preclinical disease will be critical to the development of disease-modifying or even preventative therapies. Unfortunately, current biomarkers for early disease, including cerebrospinal fluid tau and amyloid-ß levels, structural and functional magnetic resonance imaging and the recent use of brain amyloid imaging or inflammaging, are limited because they are either invasive, time-consuming or expensive. Blood-based biomarkers may be a more attractive option, but none can currently detect preclinical Alzheimer's disease with the required sensitivity and specificity. Herein, we describe our lipidomic approach to detecting preclinical Alzheimer's disease in a group of cognitively normal older adults. We discovered and validated a set of ten lipids from peripheral blood that predicted phenoconversion to either amnestic mild cognitive impairment or Alzheimer's disease within a 2-3 year timeframe with over 90% accuracy. This biomarker panel, reflecting cell membrane integrity, may be sensitive to early neurodegeneration of preclinical Alzheimer's disease.

Probable warfarin and dapsone interaction.

We describe a case of a 41-year-old woman who was stable for over a year on 22.5 mg/week of warfarin. At a follow-up visit, her international normalized ratio (INR) was found to be supratherapeutic at 3.9. Her only significant change was acyclovir initiation for shingles, and clindamycin and dapsone for infection on her right foot. An interaction report was run using Micromedex with no interactions reported. Sixteen percent of the weekly dose was held and maintenance dose was continued. Two weeks later, the INR remained supratherapeutic at 4.3, with discontinuation of clindamycin and dapsone, 5 days earlier, as the only change. This time an interaction report was run using Lexi-Comp, which identified an interaction between warfarin and dapsone. The INR has been therapeutic and stable since discontinuation of transient factors. It is hypothesized that warfarin and dapsone compete for binding on the CYP2C9 and CYP3A4 isoenzymes and therefore serum concentration of warfarin was elevated.

Tubby is required for trafficking G protein-coupled receptors to neuronal cilia.

BACKGROUND: Tubby is the founding member of the tubby-like family of proteins. The naturally occurring tubby mutation in mice causes retinitis pigmentosa, hearing loss and obesity. Tubby has been proposed to function as an accessory factor in ciliary trafficking. We directly examined a role for tubby in ciliary trafficking in vivo. METHODS: We used immunofluoresence labeling to examine the subcellular localization of rhodopsin, somatostatin receptor 3 (SSTR3) and melanin concentrating hormone receptor 1 (MCHR1), all of which are G protein-coupled receptors (GPCR), in the retina and brain of wild type (WT) and tubby mutant mice. RESULTS: In tubby mouse retina, rhodopsin is not fully transported across the connecting cilia to the outer segments with ensuing photoreceptor degeneration. In the tubby mouse brain, SSTR3 and MCHR1 fail to localize at the neuronal primary cilia in regions where these receptors play critical roles in neural signaling. The tubby mutant does not manifest a generalized defect in ciliogenesis or protein trafficking. CONCLUSIONS: Tubby plays a critical role in trafficking select GPCRs to the cilia. This role is reminiscent of tubby-like proteins 1 and 3, which have been proposed to facilitate trafficking of rhodopsin and select GPCRs in photoreceptors and the developing neural tube, respectively. Thus tubby-like proteins may be generally involved in transciliary trafficking of GPCRs.

Predictors of coronary artery disease in patients with left bundle branch block who undergo myocardial perfusion imaging.

BACKGROUND: Due to difficulties in diagnosing coronary ischemia in patients with left bundle branch block (LBBB), identifying clinical characteristics that might help to predict coronary artery disease (CAD) is important. Our study aimed to identify clinical predictors of CAD among patients with and without LBBB who undergo myocardial perfusion imaging (MPI). METHODS: All patients with LBBB who underwent MPI (LBBB group) from June 2005 to February 2007 were compared with patients with normal baseline electrocardiography who underwent treadmill MPI (non-LBBB group) during the same period. RESULTS: LBBB patients with CAD were younger and had lower ejection fraction (EF) compared to LBBB patients without CAD. Similarly non-LBBB patients with CAD had lower EF, but did not differ significantly in age compared to non-LBBB patients without CAD. Regression analysis among patients with LBBB showed that EF < 55% was the most significant predictor of CAD, after controlling for other factors. A regression analysis in non-LBBB patients showed that male gender and EF pound 55% were significant predictors of CAD. A regression analysis conducted in the combined data of both LBBB and non-LBBB groups showed male gender, EF pound 55% and LBBB to be the most significant predictors of CAD. CONCLUSIONS: Patients with LBBB have a high probability of CAD based on MPI findings. Patients with LBBB and reduced EF have a much higher likelihood of CAD compared to patients without LBBB and normal EF. Further studies on early invasive approach in patients with LBBB and reduced EF seem warranted.

Physicians' preferences and attitudes about end-of-life care in patients with an implantable cardioverter-defibrillator.

Clinical guidance is deficient regarding deactivation of implantable cardioverter-defibrillators (ICDs) in patients with terminal illnesses. We hypothesized that many physicians are apprehensive about discussing ICD deactivation with their dying patients. Thus, we conducted an anonymous survey of all the physicians in the Department of Medicine at Unity Health System in Rochester, NY. The survey collected information about the knowledge and preferences of these physicians regarding the medical, ethical, and legal issues involved in caring for patients with an ICD and terminal illness. Of the 204 surveys distributed, 87 (43%) were returned. Among the physicians who responded, 64 (74%) reported experience caring for a patient with an ICD and terminal illness. Forty physicians (46%) either thought it was illegal or were not sure if it was legal to deactivate an ICD in these circumstances. However, if reassured about the legality of discontinuing ICD therapy, 79 (91%) of these same respondents said that they would be willing to discuss voluntary ICD deactivation with their dying patients. With increased knowledge about managing the withdrawal of this potentially life-prolonging therapy, physicians are likely to become more skilled at caring for dying patients with an ICD.

College student suicide: a call to action.

This article examines current issues related to the topic of college student suicide and why it continues to be an issue of major concern. The nature/extent of the problem, risk and protective factors, responses to college student suicide, legal issues, and training issues are discussed. The importance of addressing the issue of college student suicide and its prevention on college campuses is emphasized as is the importance of protective factors. Although more is being done to address this issue than has been done in the past, it remains a major concern, and it is an issue that requires a strong national response.

Use of a data warehouse to monitor simvastatin tablet splitting.

A data warehouse was used to examine the LDL levels for patients who were switched from whole to half tablets of simvastatin. The LDL levels were available both pre and post conversion. 7,321 patients were switched and the LDL levels for these patients were tracked. 1,408 patients had a slight increase in LDL (less than 15% above baseline). Those patients whose LDL increased by greater than 15%, and was above 120 mg/dl, were switched back to whole tablets.

The prospectively observed course of illness among depressed patients who commit suicide.

OBJECTIVE: These analyses were conducted to describe the course of illness among patients with major affective disorders who commit suicide. METHOD: Twenty-nine patients who entered a long-term, high-intensity follow-up study of major affective disorders and who later committed suicide within 1 year of their last follow-up interview were individually matched to other patients by age, sex, the presence or absence of lifetime drug or alcohol abuse, time to last interview and polarity. Those who suicided were compared with their controls by depressive and substance abuse morbidity during follow-up, treatment resistance, treatment compliance, suicidal behavior and psychosocial adjustment. RESULTS: Among the various measures used to characterize the course of illness during a mean follow-up of 4.3 years, only those pertaining to suicidal behavior robustly separated the suicide group from their controls. Suicidal behavior in the remote past seemed as predictively important as suicidal behavior during follow-up. CONCLUSION: Of the various features monitored over time in patients with major affective disorder, suicidal behavior itself was the clearest correlate of risk for completed suicide.