Assessing, updating and utilising primary care smoking records for lung cancer screening.

BACKGROUND: Lung cancer screening with low-dose computed tomography for high-risk populations is being implemented in the UK. However, inclusive identification and invitation of the high-risk population is a major challenge for equitable lung screening implementation. Primary care electronic health records (EHRs) can be used to identify lung screening-eligible individuals based on age and smoking history, but the quality of EHR smoking data is limited. This study piloted a novel strategy for ascertaining smoking status in primary care and tested EHR search combinations to identify those potentially eligible for lung cancer screening. METHODS: Seven primary care General Practices in South Wales, UK were included. Practice-level data on missing tobacco codes in EHRs were obtained. To update patient EHRs with no tobacco code, we developed and tested an algorithm that sent a text message request to patients via their GP practice to update their smoking status. The patient's response automatically updated their EHR with the relevant tobacco code. Four search strategies using different combinations of tobacco codes for the age range 55-74+ 364 were tested to estimate the likely impact on the potential lung screening-eligible population in Wales. Search strategies included: BROAD (wide range of ever smoking codes); VOLUME (wide range of ever-smoking codes excluding "trivial" former smoking); FOCUSED (cigarette-related tobacco codes only), and RECENT (current smoking within the last 20 years). RESULTS: Tobacco codes were not recorded for 3.3% of patients (n = 724/21,956). Of those with no tobacco code and a validated mobile telephone number (n = 333), 55% (n = 183) responded via text message with their smoking status. Of the 183 patients who responded, 43.2% (n = 79) had a history of smoking and were potentially eligible for lung cancer screening. Applying the BROAD search strategy was projected to result in an additional 148,522 patients eligible to receive an invitation for lung cancer screening when compared to the RECENT strategy. CONCLUSION: An automated text message system could be used to improve the completeness of primary care EHR smoking data in preparation for rolling out a national lung cancer screening programme. Varying the search strategy for tobacco codes may have profound implications for the size of the population eligible for lung-screening invitation.

Assessing impact of agroecological interventions in Niger through remotely sensed changes in vegetation.

Water scarcity is a major challenge in the Sahel region of West Africa. Water scarcity in combination with prevalent soil degradation has severely reduced the land productivity in the region. The decrease in resiliency of food security systems of marginalized population has huge societal implications which often leads to mass migrations and conflicts. The U.S. Agency for International Development (USAID) and development organizations have made major investments in the Sahel to improve resilience through land rehabilitation activities in recent years. To help restore degraded lands at the farm level, the World Food Programme (WFP) with assistance from USAID's Bureau for Humanitarian Assistance supported the construction of water and soil retention structures called half-moons. The vegetation growing in the half-moons is vitally important to increase agricultural productivity and feed animals, a critical element of sustainable food security in the region. This paper investigates the effectiveness of interventions at 18 WFP sites in southern Niger using vegetative greenness observations from the Landsat 7 satellite. The pre - and post-intervention analysis shows that vegetation greenness after the half-moon intervention was nearly 50% higher than in the pre-intervention years. The vegetation in the intervened area was more than 25% greener than the nearby control area. Together, the results indicate that the half-moons are effective adaptations to the traditional land management systems to increase agricultural production in arid ecosystems, which is evident through improved vegetation conditions in southern Niger. The analysis shows that the improvement brought by the interventions continue to provide the benefits. Continued application of these adaptation techniques on a larger scale will increase agricultural production and build resilience to drought for subsistence farmers in West Africa. Quantifiable increase in efficacy of local-scale land and water management techniques, and the resulting jump in large-scale investments to scale similar efforts will help farmers enhance their resiliency in a sustainable manner will lead to a reduction in food security shortages.

Outcomes of Sleeve Gastrectomy at a Veterans Affairs Medical Center.

Introduction: Bariatric surgery is the most effective treatment for obesity while improving comorbid conditions and decreasing mortality rates. The purpose of this analysis was to identify the predictive factors associated with the short-term outcomes of laparoscopic sleeve gastrectomy (LSG) at a single Veterans Affairs Medical Center (VAMC). Methods: This is a retrospective analysis of LSG performed at a VAMC from 2013 to 2019. Veterans were followed for 12 months postoperatively. The primary outcomes of interest were excess weight loss (EWL) and total weight loss (TWL) at 3, 6, 9, and 12 months along with resolution of comorbidities. Independent predictors included: demographics, pre- and postoperative findings, geographic distance from VAMC, and per-capita salary of the veteran's residence. Results: A total of 128 patients, including 50 males, completed 12 months' follow-up after LSG. There were no mortalities, transfusions, or conversions to open surgery. The mean length of stay was 2.3 days. At 3, 6, 9, and 12 months, EWL was 27.2%, 33.7%, 35.9%, and 36.6%, respectively; TWL was 12.3%, 15.3%, 16.3%, and 16.7%, respectively. Postoperative hemoglobin A1c and oral hyperglycemic medication usage significantly decreased. High-density lipoprotein levels significantly increased. At 6 months' follow-up, preoperative body mass index (BMI; odds ratio [OR] = 0.7 [95% confidence interval, CI 0.6-0.9]) and age (OR = 0.9 [95% CI 0.8-1.0]) were significant predictors of 50% EWL and EWL broadly (P = .002). Conclusion: Similar to the private sector, LSG is a safe and effective tool for morbid obesity with clinical and serological improvements. For Veterans, increasing BMI and age may portend less weight loss but does not affect resolution of some comorbidities.

Relationships between Home Literacy Practices and School Achievement: Implications for Consultation and Home-School Collaboration.

In a five-year longitudinal study of typical literacy development (grades 1 to 5 or 3 to 7) relationships were examined between (a) parental responses to questionnaires about home literacy activities and ratings of children's self-regulation at home, both completed annually by the same parent, and (b) children's reading and writing achievement assessed annually at the university. Higher reading and writing achievement correlated with engaging in more home literacy activities. Parental help or monitoring of home literacy activities was greater for low achieving than high achieving readers or writers. Children engaged more minutes per week in reading than writing activities at home, but parents provided more help with writing and reported computers were used more for homework than school literacy instruction. Parental ratings of self-regulation of attention remained stable but executive functions-goal-setting, hyperactivity and impulsivity tended to improve. Results are translated into consultation tips for literacy learning and best professional practices.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity at a Veterans Affairs Medical Center.

BACKGROUND: Class III obesity is a global health emergency associated with an increase in the incidence of many other diseases such as type 2 diabetes mellitus, hypertension, hyperlipidemia, cancer, obstructive sleep apnea, nonalcoholic fatty liver disease, osteoarthritis, infertility, and mental health disorders. Minimal work has been published regarding the efficacy of laparoscopic sleeve gastrectomy (LSG) in the veteran population to surgically manage morbid obesity. DESIGN: Retrospective analysis of LSG performed at a Veterans Affairs Medical Center (VAMC) between 2010 and 2017. Veterans were followed from their enrollment in the bariatric program until twelve months following LSG. The primary outcome of interest was excess and total weight loss with resolution of associated comorbidities. RESULTS: Excess weight loss at nine and 12 months was 43.5% and 40.7% and total weight loss was 20.1% and 19.0%, respectively. LSG performed at a VAMC resulted in 86.9% improvement in type 2 diabetes mellitus and a 66.1% improvement in hypertension and 74.3% improvement in hyperlipidemia. Approximately 10.0% of diabetics obtained partial and 9.0% obtained complete resolution of their disease. Similarly, 22.0% of Veterans obtained partial and 13.0% obtained complete resolution from hypertension. Complete resolution from hyperlipidemia was achieved in 8.8% of Veterans. There were no postoperative complications or staple line leaks. CONCLUSION: LSG is a safe and effective tool for morbid obesity with clinical and serological improvements for individuals who are unable to lose weight with medical management alone.

Quantitative microbial risk assessment to estimate the health risk from exposure to noroviruses in polluted surface water in South Africa.

This study assessed the risks posed by noroviruses (NoVs) in surface water used for drinking, domestic, and recreational purposes in South Africa (SA), using a quantitative microbial risk assessment (QMRA) methodology that took a probabilistic approach coupling an exposure assessment with four dose-response models to account for uncertainty. Water samples from three rivers were found to be contaminated with NoV GI (80-1,900 gc/L) and GII (420-9,760 gc/L) leading to risk estimates that were lower for GI than GII. The volume of water consumed and the probabilities of infection were lower for domestic (2.91 × 10-8 to 5.19 × 10-1) than drinking water exposures (1.04 × 10-5 to 7.24 × 10-1). The annual probabilities of illness varied depending on the type of recreational water exposure with boating (3.91 × 10-6 to 5.43 × 10-1) and swimming (6.20 × 10-6 to 6.42 × 10-1) being slightly greater than playing next to/in the river (5.30 × 10-7 to 5.48 × 10-1). The QMRA was sensitive to the choice of dose-response model. The risk of NoV infection or illness from contaminated surface water is extremely high in SA, especially for lower socioeconomic individuals, but is similar to reported risks from limited international studies.

Comparison of Risk Predicted by Multiple Norovirus Dose-Response Models and Implications for Quantitative Microbial Risk Assessment.

The application of quantitative microbial risk assessments (QMRAs) to understand and mitigate risks associated with norovirus is increasingly common as there is a high frequency of outbreaks worldwide. A key component of QMRA is the dose-response analysis, which is the mathematical characterization of the association between dose and outcome. For Norovirus, multiple dose-response models are available that assume either a disaggregated or an aggregated intake dose. This work reviewed the dose-response models currently used in QMRA, and compared predicted risks from waterborne exposures (recreational and drinking) using all available dose-response models. The results found that the majority of published QMRAs of norovirus use the 1 F1 hypergeometric dose-response model with α = 0.04, ß = 0.055. This dose-response model predicted relatively high risk estimates compared to other dose-response models for doses in the range of 1-1,000 genomic equivalent copies. The difference in predicted risk among dose-response models was largest for small doses, which has implications for drinking water QMRAs where the concentration of norovirus is low. Based on the review, a set of best practices was proposed to encourage the careful consideration and reporting of important assumptions in the selection and use of dose-response models in QMRA of norovirus. Finally, in the absence of one best norovirus dose-response model, multiple models should be used to provide a range of predicted outcomes for probability of infection.

Eighth Joint National Committee (JNC-8) Guidelines and the Outpatient Management of Hypertension in the African-American Population.

BACKGROUND: Hypertension is a common medical disease, occurring in about one third of young adults and almost two thirds of individuals over the age of 60. With the release of the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC-8) guidelines, there have been major changes in blood pressure management in the various subgroups. AIM: Optimal blood pressure management and markers of end-organ damage in African-American adult patients were compared between patients who were managed according to the JNC-8 hypertension management guidelines and those who were treated with other regimens. MATERIALS AND METHODS: African-American patients aged 18 years or older with an established diagnosis of hypertension were included in the study who were followed up in our internal medicine clinic between January 1, 2013 and December 31, 2103; the data on their systolic and diastolic blood pressure readings, heart rate, body mass index (BMI), age, gender, comorbidities, and medications were recorded. Patients were divided into four groups based on the antihypertensive therapy as follows - Group 1: Diuretic only; Group 2: Calcium channel blocker (CCB) only; Group 3: Diuretic and CCB; Group 4: Other antihypertensive agent. Their blood pressure control, comorbidities, and associated target organ damage were analyzed. RESULTS: In all 323 patients, blood pressures were optimally controlled. The majority of the patients (79.6%) were treated with either a diuretic, a CCB, or both. Intergroup comparison analysis showed no statistically significant difference in the mean systolic blood pressure, mean diastolic blood pressure, associated comorbidities, or frequency of target organ damage. CONCLUSION: Although diuretics or CCBs are recommended as first-line agents in African-American patients, we found no significant difference in the optimal control of blood pressure and frequency of end-organ damage compared to management with other agents.

Impact of weekly feedback on test ordering patterns.

OBJECTIVES: We examined the impact of weekly feedback reports on the test-ordering behavior of internal medicine residents. STUDY DESIGN: Retrospective analysis of a performance improvement effort. METHODS: In a large, urban, academic medical center, we extracted raw data on every inpatient laboratory test ordered by all internal medicine residents during two 26-week time periods. The pre-intervention phase established baseline ordering volume as each resident rotated through the various clinical services. The intervention consisted of a 1-hour educational seminar detailing the potential harm and costs of laboratory overutilization followed by the post intervention phase, which consisted of weekly feedback reports graphically illustrating individual versus group ordering patterns, where the identity of individual residents was protected. The total numbers of tests ordered during the 2 phases were compared using an independent t test. RESULTS: During the post intervention phase, we observed a net reduction of 21% in tests ordered-an average of 941 tests per week-with the greatest reduction in the chemistry section of the laboratory, followed by hematology, coagulation, and all others combined. This reduction in test volume corresponded to a $1.3 million reduction in charges. CONCLUSIONS: Providing physicians-in-training with a weekly feedback report detailing their test ordering volume in comparison with those of their peers is an effective method for reducing laboratory overutilization. Benefits to our approach include maintaining physician autonomy without alteration of existing infrastructure or disclosure of test fees.

Sharp, left-sided back pain · bilateral leg weakness · degenerative disc disease · Dx?

An 84-year old woman came to the emergency department with sharp back pain on her left side that she'd had for 4 days. The pain radiated to her posterior hips when standing. She said her whole body felt achy and she was experiencing weakness in both legs.

Clinical outcome analysis of male and female genital burn injuries: a 15-year experience at a level-1 burn center.

OBJECTIVES: The American Burn Association classifies a burn to the genitalia as a major injury. Isolated burns to the penis, scrotum or vulva are rare as a result of protection provided by the thighs and abdomen. Thus, burned genitalia represent an ominous sign of a more extensive total body surface area burn. METHODS: A retrospective analysis of consecutive patients admitted to a Level-1 Burn Unit with a burn involving the genitalia from January 1995 to December 2009 comprised the study population. RESULTS: A total of 393 patients of 5878 patients (6.7%) admitted to the Burn Unit suffered a burn involving the genitalia, including 253 males (64.4%) and 140 females (35.6%). The median total body surface area was 12% (range 1-100%), the most common cause of genital burn was scald (n = 246, 62.9%) and median length of stay was 9 days (range 1-472 days). A total of 269 patients (68.4%) were discharged to home from the hospital, and in-hospital mortality was 20.9%. CONCLUSIONS: The typical profile for those sustaining a genital burn include younger patients (≤30 years-of-age), sustaining a median total body surface area burn of 12% from a scald injury, with extensive genitalia involvement. Length of stay for genital burns is usually extended and, as a result of concomitant injuries, is associated with a 20% in-hospital death rate.

The cardiac lymphatic system.

The lymphatic system, a network of vessels carrying clear interstitial fluid called lymph, is found throughout the human body. The system maintains homeostasis, receiving proteins and excess fluid from the interstitial tissues, and returning them to the venous system. Understanding of lymphatic drainage remains important in the diagnosis, prognosis, and treatment of diseases, including the metastasis of malignant diseases. Information specific to the cardiac lymphatics is scarce. Indeed, quite often the topic is not even mentioned in many medical textbooks. The goal of our review is to compile and analyze the information currently available concerning the cardiac lymphatics, hoping further to demonstrate the clinical importance of this neglected system.

Neural interconnections between the nerves of the upper limb and surgical implications.

The knowledge of neural interconnections between adjacent nerves of the upper limb is important to the surgeon as such variations may lead to issues with surgical identification and thus iatrogenic injury. Trauma or entrapment of these nerves may cause functional losses different from those expected and thus result in misdiagnosis. The authors review the literature regarding such nervous system derangements.

Influence of intermittent hypoxia on myocardial and hepatic P-glycoprotein expression in a rodent model.

STUDY OBJECTIVE: Patients with obstructive sleep apnea who receive drug therapy for cardiovascular disease may experience resistant hypertension, arrhythmias, or more severe heart failure, and many of the drugs used to treat these conditions are substrates for P-glycoprotein (P-gp) transporters. Therefore, we sought to determine if intermittent hypoxia, which mimics obstructive sleep apnea, would upregulate myocardial and hepatic P-gp expression and Abcb1a and Abcb1b messenger RNA (mRNA) expression (genes that encode for P-gp) in an animal model. DESIGN: Prospective, randomized, blinded, parallel-design animal study. SETTING: University research laboratory. ANIMALS: Thirty adult, male Sprague-Dawley rats. INTERVENTION: Rats were assigned to either 2 weeks of intermittent hypoxia exposure similar to sleep apnea (12 rats) or no hypoxia exposure (controls, 18 rats). MEASUREMENTS AND MAIN RESULTS: After intermittent hypoxia or normoxia exposure, the rats were anesthetized. Heart and liver were harvested, and small samples were taken from the left ventricle (heart) and the liver for analysis. Expression of P-gp was measured by Western blotting, whereas Abcb1a and Abcb1b mRNA expression was assessed by real-time polymerase chain reaction. Band density of myocardial (but not hepatic) P-gp expression (standardized by beta-actin) was significantly higher in hypoxic rats than in control rats (p=0.03). Quantitative polymerase chain reaction revealed that myocardial and hepatic Abcb1a and myocardial Abcb1b mRNA expression were significantly increased in hypoxic rats compared with controls (p<0.05). CONCLUSION: Myocardial P-gp expression and myocardial and hepatic Abcb1a mRNA expression were significantly increased after 2 weeks of intermittent hypoxia. Hypoxia-induced increases in P-gp expression may partially explain drug-resistant cardiovascular disease in patients with obstructive sleep apnea.

Inactivation of Escherichia coli O157:H7 during thermophilic anaerobic digestion of manure from dairy cattle.

Inactivation of the pathogenic Escherichia coli serotype O157:H7 and a non-pathogenic E. coli strain isolated from dairy cattle manure was evaluated with batch tests at 50 and 55 degrees C in biosolids from a thermophilic anaerobic digester treating the manure. Using differential-selective plating on sorbitol-MacConkey (SMAC) agar to quantify E. coli, the decline in concentrations of both the sorbitol-negative (putative E. coli O157:H7) and sorbitol-positive (putative non-pathogenic E. coli) organisms followed a model that assumed there was a heat-sensitive fraction and a heat-resistant fraction. Inactivation rates of the heat-sensitive fractions were similar for both colony types at each temperature, suggesting that wild-type E. coli can be used as an indicator of inactivation of serotype O157:H7. The decimal reduction time for the heat-sensitive fractions was in the order of 10min at 55 degrees C and ranged from approximately 1-3h at 50 degrees C. Concentrations of heat-resistant organisms at 55 degrees C were 1.4-1.7log(10)cfu/mL. Confirmatory analyses conducted on 30 randomly selected colonies of heat-resistant sorbitol-negative cells from treatment at 55 degrees C indicated that none were serotype O157:H7, nor were they E. coli. Similar analyses on 10 sorbitol-negative isolates from untreated manure indicated that none were serotype O157:H7, although 16S rRNA gene sequence analysis indicated that eight were E. coli or closely related enteric bacteria. These findings suggest that plating on differential-selective media to quantify E. coli, including serotype O157:H7, in effluent samples from thermophilic anaerobic digestion can lead to false positive results. Therefore, more specific methods should be used to evaluate the extent of thermal inactivation of both pathogenic and non-pathogenic E. coli in manure treatment systems.

Laboratory evaluation of thermophilic-anaerobic digestion to produce Class A biosolids. 2. Inactivation of pathogens and indicator organisms in a continuous-flow reactor followed by batch treatment.

Thermophilic-anaerobic digestion in a single-stage, mixed, continuous-flow reactor is not approved in the United States as a process capable of producing Class A biosolids for land application. This study was designed to evaluate the inactivation of pathogens and indicator organisms in such a reactor followed by batch treatment in a smaller reactor. The combined process was evaluated at 53 degrees C with sludges from three different sources and at 51 and 55 degrees C with sludge from one of the sources. Feed sludge to the continuous-flow reactor was spiked with the pathogen surrogates Ascaris suum and vaccine-strain poliovirus. Feed and effluent were analyzed for these organisms and for indigenous Salmonella spp., fecal coliforms, Clostridium perfringens spores, and somatic and male-specific coliphages. No viable Ascaris eggs were observed in the effluent from the continuous reactor at 53 or 55 degrees C, with greater than 2-log removals across the digester in all cases. Approximately 2-log removal was observed at 51 degrees C, but all samples of effluent biosolids contained at least one viable Ascaris egg at 51 degrees C. No viable poliovirus was found in the digester effluent at any of the operating conditions, and viable Salmonella spp. were measured in the digester effluent in only one sample throughout the study. The ability of the continuous reactor to remove fecal coliforms to below the Class A monitoring limit depended on the concentration in the feed sludge. There was no significant removal of Clostridium perfringens across the continuous reactor under any condition, and there also was limited removal of somatic coliphages. The removal of male-specific coliphages across the continuous reactor appeared to be related to temperature. Overall, at least one of the Class A pathogen criteria or the fecal coliform limit was exceeded in at least one sample in the continuous-reactor effluent at each temperature. Over the range of temperatures evaluated, the maximum time required to meet the Class A criteria by batch treatment of the continuous-reactor effluent was 1 hour for Ascaris suum and Salmonella spp. and 2 hours for fecal coliforms.