An Educational Session for Medical Students Exploring Weight Bias in Clinical Care Through the Lens of Body Diversity.

Introduction: Weight bias is pervasive in health care and can lead to inadequate care for people with higher weight. However, few medical schools offer training on mitigating weight bias and incorporating body diversity into clinical care. Methods: As part of a course for second-year medical students, we developed and implemented a 3-hour multimodal educational session on mitigating weight bias. Didactics included content on body diversity and addressing weight bias, followed by a facilitated case discussion in small groups focused on debunking common myths related to weight. Assessment consisted of an open-content quiz and evaluation of a postsession survey. We performed a thematic analysis of the essay quiz responses and evaluation survey results. Results: Three hundred fifty-three students participated in academic years 2020-2021 and 2021-2022. In the postsession quiz, students described several learning points, including understanding environmental influences on body size, improving communication by reducing weight bias, and strengthening the patient-provider relationship. In the postsession evaluation, students reported that their knowledge and skills had improved with respect to the learning objectives, with means of 4.0-4.1 on a 5-point Likert scale. Areas for suggested improvement included more time for discussion and more guidance on weight-inclusive care. Discussion: This multimodal educational session on weight bias was successful in meeting the stated learning objectives. Future work will consist of building on this content and extending future iterations to residents and attendings, with the goal of disrupting harmful assumptions and improving access to holistic, evidence-based care for all people, regardless of size.

Pharmacist-led medication review in a residential in-reach service leads to deprescribing.

OBJECTIVE: To examine the effect of a pharmacist-led medication review on deprescribing medications in a Residential In-Reach (RIR) service which provides acute care substitution to residential aged care residents. METHODS: A pre-post observational study was conducted. Patient characteristics and admission and discharge medications were collected over two 3-month phases before (prephase) and after (postphase) the introduction of a pharmacist who performed a comprehensive medication review and provided deprescribing recommendations. The Screening Tool of Older Persons' Prescriptions (STOPP) version 2 was used to identify potentially inappropriate medications (PIMs). The Drug Burden Index (DBI) was used to measure cumulative anticholinergic and sedative medication burden. Outcome of deprescribing was measured by the reduction in the number of PIMs, DBI scores and proportion of polypharmacy from admission to discharge. RESULTS: The prephase included 59 patients (mean age 87.3 years, 63% female), and the postphase included 88 patients (mean age 87.3 years, 63% female). There was a significant reduction in the mean number of PIMs (pre +0.05 ± 2.59 vs. post -0.78 ± 2.32, p = 0.04) and median DBI (pre -0.004 ± 0.17 vs. post -0.07 ± 0.2, p = 0.03) in postphase compared to prephase. The proportion of polypharmacy at discharge was reduced in the postphase (pre-100% vs. post-90%, p = 0.01). The most deprescribed PIMs as measured by STOPP in postphase were drugs without indication, cardiovascular system drugs and gastrointestinal system drugs. CONCLUSIONS: The introduction of a pharmacist-led medication review in RIR service was associated with a significant reduction in the mean number of PIMs, median DBI and polypharmacy. Future studies are needed to determine whether deprescription is sustained to examine correlations to long-term patient outcomes.

Evaluation of a dedicated outpatient hip fracture clinic.

OBJECTIVES: There is a lack of guidance on how to manage the multiple post-discharge issues of older people following minimal trauma hip fracture. We developed a geriatrician-staffed outpatient service for people aged ≥65 years admitted with a hip fracture who were not discharged to a nursing home. We aimed to evaluate the potential benefits of the addition of a dedicated hip fracture follow-up clinic by measuring the actions performed by such a clinic. METHODS: We evaluated the potential benefit of the clinic through a retrospective review of the medical records of all those referred to the clinic over a 2-year period. RESULTS: A total of 80 people were provided a clinic appointment, with 43 (54%) attending. The median age of clinic attendees was 81 years. A total of 40/43 (93%) of attendees received inpatient rehabilitation in a sub-acute facility before discharge. At the dedicated outpatient clinic, multiple issues were identified and managed including further fall reduction strategies (n = 12), commencement of anti-resorptive medications (n = 11) and medication deprescribing (n = 11). CONCLUSIONS: We found that the introduction of a dedicated hip fracture outpatient clinic identified and managed a broad range of issues. It is unclear if these needs would have been met by previously existing services. Further work is required to clarify whether managing these issues translates into improved patient outcomes and whether a dedicated clinic is a cost-effective practice of achieving this.

Psychosocial volunteer support for older adults with cognitive impairment: development of MyCare Ageing using a codesign approach via action research.

BACKGROUND AND OBJECTIVES: Older adults with cognitive impairment are vulnerable to frequent hospital admissions and emergency department presentations. The aim of this study was to use a codesign approach to develop MyCare Ageing, a programme that will train volunteers to provide psychosocial support to older people with dementia and/or delirium in hospital and at home when discharged from hospital. SETTING: Melbourne, Victoria, Australia. RESEARCH DESIGN: This study adopts an action research methodology. We report on two co-design workshops with keystakeholders: Workshop 1: identification of components from three existing programmes to inform the development of the MyCare Ageing program logic and, Workshop 2: identification of implementation strategies. PARTICIPANTS: The key stakeholders and workshop participants included clinicians (geriatricians, nurses and allied health), hospital staff (volunteer coordinators and hospital executives), Baptcare staff, a consumer, researchers and implementation experts and project staff. RESULTS: Workshop 1 identified the components from three existing programmes-the Volunteer Dementia and Delirium Care programme, Home-Start and MyCare for inclusion in MyCare Ageing. In workshop 2, the p implementation plan was developed taking into consideration hospital-specific processes, training and support needs of volunteers and safety and risk management processes. DISCUSSION AND CONCLUSION: The codesign process was successfully applied to develop the MyCare Ageing programme to provide volunteer support to patients with dementia and/or delirium in hospital and their transition home. MyCare Ageing is an innovative programme that meets an identified need from hospitals and consumers to support patients with dementia and/or delirium to improve psychosocial outcomes on discharge from hospital.

Beyond the Motor Cortex: Theta Burst Stimulation of the Anterior Midcingulate Cortex.

BACKGROUND: While the facilitatory and inhibitory effects of intermittent theta burst stimulation (iTBS) and continuous TBS (cTBS) protocols have been well documented on motor physiology, the action of TBS protocols on prefrontal functioning remain unclear. Here we asked whether iTBS or cTBS can differentially modulate reward-related signaling in the anterior midcingulate cortex (aMCC). METHODS: Across 2 experiments, we used a robot-assisted transcranial magnetic stimulation system, combined with electroencephalogram recordings, to investigate the aftereffects of prefrontal iTBS and cTBS on the reward positivity, an electrophysiological signal believed to index sensitivity of the aMCC to rewards. Twenty adults (age, 18-28 years) participated in experiment 1 in which we used a scalp landmark for TBS targeting, and 14 adults (age, 18-28 years) participated in experiment 2, in which we aimed to increase TBS effectiveness by utilizing cortical thickness maps to select individualized dorsal lateral prefrontal cortex targets. RESULTS: We demonstrated that prefrontal iTBS suppressed reward-related signaling in the aMCC (reduction in reward positivity) and caused a decrease in postfeedback switch choices. cTBS displayed no effect. We replicated and strengthened this effect on the reward positivity by targeting dorsal lateral prefrontal cortex regions displaying maximal cortical thickness. CONCLUSIONS: While these results are inconsistent with reported TBS effects on motor cortex, the present findings offer a novel transcranial magnetic stimulation targeting approach and normative insights into the magnitude and time course of TBS-induced changes in aMCC excitability. By modulating how the aMCC links value to goal-directed behavior, this research opens an exciting new era of investigative possibilities in the understanding of aMCC function and treatment of aMCC dysfunction.

Decision-making for older patients by Australian and New Zealand doctors with Advance Care Directives: a vignette-based study.

BACKGROUND: Little is known about doctors' decision-making patterns when using Advance Care Directives (ACDs), particularly for older patients in Australia and New Zealand. AIMS: To determine the level of agreement among Australian and New Zealand doctors' decisions when using ACDs to guide treatment decisions for older patients. To evaluate factors that may affect decision-making including doctors' demographics, vignette complexity and Advance Care Directive (ACD) content. METHODS: In December 2016-January 2017, a survey was distributed to doctors working within one tertiary hospital network in Melbourne and to doctors registered with the Australian and New Zealand Society of Geriatric Medicine. The survey comprised of three vignettes (1, 2, 3) presented with deidentified versions of genuine ACDs (A and B) volunteered by community members via a tertiary hospital ACD service. RESULTS: Five hundred and sixty doctors submitted completed surveys. The level of agreement between doctors when using ACDs varied by vignette complexity, ACD content, doctor speciality (P = 0.006 vignette 1 ACD A, P = 0.04 vignette 1 ACD B, P = 0.04 vignette 2 ACD A, P = 0.04 vignette 3 ACD B) and doctor seniority (P = 0.04 vignette 1 ACD A, P < 0.0001 vignette 2 ACD A). Australian and New Zealand doctors are infrequently exposed to ACDs in their work, 30% did not know the legal status of ACDs and majority of the cohort requested more education on ACDs. CONCLUSION: Despite the presence of an ACD, the level of agreement on treatment decisions for older patients when using ACDs varies by vignette complexity, ACD content, speciality and seniority of doctors.

SMART--Sunflower Mutant population And Reverse genetic Tool for crop improvement.

BACKGROUND: Sunflower (Helianthus annuus L.) is an important oilseed crop grown widely in various areas of the world. Classical genetic studies have been extensively undertaken for the improvement of this particular oilseed crop. Pertaining to this endeavor, we developed a "chemically induced mutated genetic resource for detecting SNP by TILLING" in sunflower to create new traits. RESULTS: To optimize the EMS mutagenesis, we first conducted a "kill curve" analysis with a range of EMS dose from 0.5% to 3%. Based on the observed germination rate, a 50% survival rate i.e. LD50, treatment with 0.6% EMS for 8 hours was chosen to generate 5,000 M2 populations, out of which, 4,763 M3 plants with fertile seed set. Phenotypic characterization of the 5,000 M2 mutagenised lines were undertaken to assess the mutagenesis quality and to identify traits of interest. In the M2 population, about 1.1% of the plants showed phenotypic variations. The sunflower TILLING platform was setup using Endo-1-nuclease as mismatch detection system coupled with an eight fold DNA pooling strategy. As proof-of-concept, we screened the M2 population for induced mutations in two genes related to fatty acid biosynthesis, FatA an acyl-ACP thioesterase and SAD the stearoyl-ACP desaturase and identified a total of 26 mutations. CONCLUSION: Based on the TILLING of FatA and SAD genes, we calculated the overall mutation rate to one mutation every 480 kb, similar to other report for this crop so far. As sunflower is a plant model for seed oil biosynthesis, we anticipate that the developed genetic resource will be a useful tool to identify novel traits for sunflower crop improvement.

Organelle transformation.

The source of genetic information in a plant cell is contained in nucleus, plastids, and mitochondria. Organelle transformation is getting a lot of attention nowadays because of its superior performance over the conventional and most commonly used nuclear transformation for obtaining transgenic lines. Absence of gene silencing, strong predictable transgene expression, and its application in molecular pharming, both in pharmaceutical and nutraceuticals, are some of many advantages. Other important benefits of utilizing this technology include the absence of transgene flow, as organelles are maternally inherited. This may increase the acceptability of organelle transformation technology in the development of transgenic crops in a wider scale all over the globe. As the need for crop productivity and therapeutic compounds increases, organelle transformation may be able to bridge the gap, thereby having a definite promise for the future.

Health perspectives: international epidemiology of ageing.

Populations globally are ageing, in part due to dramatic increases in life expectancies, forcing a reconsideration of what constitutes being "elderly" and "old." The proportion of older adults living with disability may be decreasing, yet older individuals are living with a significant burden of chronic disease, geriatric impairments in cognition, vision and hearing and reduced physiological reserve (frailty). Caring for a growing number of medically complex individuals has implications for medical workforce size and composition, health programmes and expenditure. Future responses to an ageing population will require further innovation in health-care delivery models, and increasing representation of older adults in clinical trials.

Correlations of nursing home characteristics with prescription of osteoporosis medications.

BACKGROUND: Osteoporosis is highly prevalent in the nursing home (NH) populations but medications that increase bone mineral density are used infrequently. Prior research finds few patient characteristics predict treatment. NH characteristics have been associated with prescription of some medications. We examined associations of NH-level characteristics with osteoporosis treatment in elderly patients admitted to a NH after a fracture. METHOD: We conducted a cohort study of patients with hip, wrist and humeral fractures admitted to a NH in NJ. They were followed for 12 months from 1999 to 2004. Possible NH-level predictors of receiving osteoporosis treatment were assessed in mixed multivariable models to account for clustering within individual NHs. RESULTS: Of the 2838 post-fracture patients identified from 180 NHs, 156 (5.5%) were prescribed an osteoporosis medication. There was wide variation in treatment between individual NHs (0-40%), which was substantially reduced after adjusting for patient case mix. Several patient characteristics did associate with osteoporosis treatment-female gender (odds ratio (OR) 2.56, 95% confidence interval (CI) 1.42, 4.61), younger age per year (OR 0.98, 95%CI 0.96, 0.99), white race (OR 2.37, 95%CI 1.23, 4.56) and prior history of fracture (OR 4.41, 95%CI 1.04, 18.73). However no NH characteristics significantly associate with treatment (profit status, NH chain member, occupancy rate, and bed size). CONCLUSION: NH characteristics did not predict pharmacological treatment of osteoporosis. Further studies of osteoporosis prescribing in NHs need to consider other types of variables as possible correlates of prescribing.

Statin utilization in nursing home patients after cardiac hospitalization.

BACKGROUND: Coronary artery disease (CAD) is highly prevalent in nursing home residents and is associated with a substantial clinical and economic burden. Statins reduce mortality and hospitalization rates in older patients with CAD. OBJECTIVES: To assess rates and predictors of statin use among high-risk patients with symptomatic coronary artery disease (CAD) admitted to nursing homes after acute cardiac hospitalization. DESIGN: Cohort study. PARTICIPANTS: Medicare beneficiaries enrolled in either a state-run drug assistance program or Medicaid in nursing homes in New Jersey from 1994 through 2005. MEASUREMENTS: Statin utilization within 60 days of nursing home admission was determined for patients recently hospitalized with symptomatic CAD in whom statins are indicated consisting of those with: acute coronary syndrome (ACS) without revascularization, ACS with revascularization and congestive heart failure (CHF) with revascularization. Predictors of statin use were evaluated with multivariate logistic regression models. RESULTS: While statin use over the 11-year period increased from 1.2% to 31.8%, overall utilization was very low. Predictors of greater statin use included prior cardiac hospitalization [odds ratio (OR) 1.32, 95% confidence interval (95% CI) 1.13 to 1.57], prior statin use (OR 6.92, 95% CI 5.86 to 8.82) and receipt of a concurrent cardiac medication (range of odds ratios, 2.36-3.40). Older patients admitted for ACS with or without revascularization were less likely to receive a statin. Patients who had received anti-platelets or angiotensin-modifying agents prior to their hospitalization were less likely to receive statins after discharge. Renal disease, prior stroke, diabetes, hypertension and hyperlipidemia did not influence statin utilization. Predictors of treatment did not change when the cohort was dichotomized according to length of stay. CONCLUSIONS: Patients are infrequently treated with statins when discharged to nursing homes following hospitalization for a symptomatic cardiovascular event. Barriers to statin treatment in this setting require closer examination.

Pathologic correlates of primary central nervous system lymphoma defined in an orthotopic xenograft model.

PURPOSE: The prospect for advances in the treatment of patients with primary central nervous system lymphoma (PCNSL) is likely dependent on the systematic evaluation of its pathobiology. Animal models of PCNSL are needed to facilitate the analysis of its molecular pathogenesis and for the efficient evaluation of novel therapeutics. EXPERIMENTAL DESIGN: We characterized the molecular pathology of CNS lymphoma tumors generated by the intracerebral implantation of Raji B lymphoma cells in athymic mice. Lymphoma cells were modified for bioluminescence imaging to facilitate monitoring of tumor growth and response to therapy. In parallel, we identified molecular features of lymphoma xenograft histopathology that are evident in human PCNSL specimens. RESULTS: Intracerebral Raji tumors were determined to faithfully reflect the molecular pathogenesis of PCNSL, including the predominant immunophenotypic state of differentiation of lymphoma cells and their reactive microenvironment. We show the expression of interleukin-4 by Raji and other B lymphoma cell lines in vitro and by Raji tumors in vivo and provide evidence for a role of this cytokine in the M2 polarization of lymphoma macrophages both in the murine model and in diagnostic specimens of human PCNSL. CONCLUSION: Intracerebral implantation of Raji cells results in a reproducible and invasive xenograft model, which recapitulates the histopathology and molecular features of PCNSL, and is suitable for preclinical testing of novel agents. We also show for the first time the feasibility and accuracy of tumor bioluminescence in the monitoring of a highly infiltrative brain tumor.

Pharmacological management of osteoporosis in nursing home populations: a systematic review.

Nursing home (NH) residents fall 11 times as frequently as their age-matched community-dwelling counterparts. The benefits of fall prevention strategies and hip protectors in terms of fracture risk in this setting are unclear. Moreover, there is no consensus on the efficacy of osteoporosis medication in NH residents. A systematic review was conducted to evaluate the efficacy of medications for osteoporosis in this population and to examine utilization studies in the NH setting to define prescribing practices. Electronic searches of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were supplemented with a hand search of bibliographies. All English-language studies published between January 1, 1974, and December 31, 2006, that studied osteoporosis pharmacotherapy in the NH environment were obtained, and studies of medication benefits and utilization patterns were identified. No restrictions were placed on study method. Studies required inclusion of NH patients and extractable data with bone mineral density (BMD) or fracture outcomes. Forty full-text articles were retrieved, of which 15 studies met selection criteria. In the nine studies examining medication effects, calcium (1,200 mg) and vitamin D (800 IU) supplementation were shown to reduce fracture risk and improve BMD. One study supported the role of alendronate, but none documented the utility of raloxifene, calcitonin, or teriparatide in NH residents. All six medication utilization studies reported infrequent use of osteoporosis medications (9-25%). Prescribing for elderly NH patients is difficult, considering the risk:benefit ratio and issues of longevity, but these medications may be underused in the NH environment.

Osteoporosis medication use in nursing home patients with fractures in 1 US state.

BACKGROUND: Little is known about osteoporosis medication use among high-risk patients in nursing homes (NHs). We studied the patterns and predictors of osteoporosis medication use in elderly patients who sustained a fracture and were admitted to an NH. METHODS: We linked pharmaceutical claims data from 2 state-run drug assistance programs for elderly patients to Medicare data for the years 1995 through 2004. We defined the rates of osteoporosis medication use among patients admitted to an NH following a hip, wrist, or humeral fracture for the 12-month period after the fracture. Predictors of using an osteoporosis medication were assessed in a multivariate Cox proportional hazards model adjusting for age and sex. RESULTS: Of the 4430 eligible postfracture patients, only 11.5% were prescribed an osteoporosis medication. There was a progressive increase in use from 1.6% in 1995 to 18.7% in 2001 but no increases in 2001 through 2004. Patient characteristics associated with osteoporosis medication use included a history of osteoporosis medication use in the prior 12 months (hazard ratio, 19.5; 95% confidence interval, 16.0-23.7) and female sex (hazard ratio, 1.57; 95% confidence interval, 1.13-2.21). A history of falls or fracture was not a significant factor. Calcitonin was the most commonly used osteoporosis medication (56%). CONCLUSIONS: While the rate of osteoporosis medication use increased across the 10-year period, a low rate of osteoporosis medication use persists in the NH setting. More appropriate use of drug treatment of high-risk patients is needed in NHs.

Gene expression and angiotropism in primary CNS lymphoma.

Primary CNS lymphoma is an aggressive form of non-Hodgkin lymphoma whose growth is restricted to the central nervous system. We used cDNA microarray analysis to compare the gene expression signature of primary CNS lymphomas with nodal large B-cell lymphomas. Here, we show that while individual cases of primary CNS lymphomas may be classified as germinal center B-cell, activated B-cell, or type 3 large B-cell lymphoma, brain lymphomas are distinguished from nodal large B-cell lymphomas by high expression of regulators of the unfolded protein response (UPR) signaling pathway, by the oncogenes c-Myc and Pim-1, and by distinct regulators of apoptosis. We demonstrate that interleukin-4 (IL-4) is expressed by tumor vasculature as well as by tumor cells in CNS lymphomas. We also identify high expression in CNS lymphomas of several IL-4-induced genes, including X-box binding protein 1 (XBP-1), a regulator of the UPR. In addition, we demonstrate expression of the activated form of STAT6, a mediator of IL-4 signaling, by tumor cells and tumor endothelia in CNS lymphomas. High expression of activated STAT6 in tumors was associated with short survival in an independent set of patients with primary CNS lymphoma who were treated with high-dose intravenous methotrexate therapy.

Meta-analysis of social inequality and the risk of cervical cancer.

Previous studies of the relationship between socio-economic status and cervical cancer have been mainly based on record linkage of routine data, such as cancer registry incidence rates and regional measures of social class based on census data. These routine data are liable to substantial misclassification with respect to socio-economic status. Previous reports are also primarily from developed countries, whereas the major burden of cervical cancer is in developing countries. We have therefore pooled the data from previously reported case-control studies of cervical cancer or dysplasia, which contain individual-level information on socio-economic characteristics to investigate the relationship between cervical cancer, social class, stage of disease, geographical region, age and histological type. Based on 57 studies, we found an increased risk of approximately 100% between high and low social class categories for the development of invasive cervical cancer, and an increased risk of approximately 60% for dysplasia, including carcinoma in situ. Although the difference was observed in all countries, it was stronger in low/middle income countries and in North America than in Europe. No clear differences were observed between squamous cell carcinoma and adenocarcinoma, or between younger and older women. These results indicate that both cervical infection with human papillomavirus, which is linked to both female and male sexual behaviour, and access to adequate cervical cancer screening programmes are likely to be important in explaining the large cervical cancer incidence rates observed in different socio-economic groups, and that the importance of these factors may vary between different geographical regions.