American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care.

OBJECTIVE: Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes. METHODS: Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus. RESULTS: The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education. CONCLUSION: The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.

Use of Integrative, Complementary, and Alternative Medicine in Children with Epilepsy: A Global Scoping Review.

(1) Background: Epilepsy is one of the most common chronic neurological disorders in childhood. Complementary and alternative medicine (CAM) use is highly prevalent in patients with epilepsy. Despite CAM's widespread and increasing popularity, its prevalence, forms, perceived benefits, and potential risks in pediatric epilepsy are rarely explored. (2) Methods: We performed a scoping review of the available literature on the use of CAM in pediatric epilepsy. (3) Results: Overall, global cross-sectional studies showed a variable degree of CAM usage among children with epilepsy, ranging from 13 to 44% in prevalence. Popular types of CAMs reported were supplements, cannabis products, aromatherapy, herbal remedies, dietary therapy, massage therapy, and prayer. Families often report that CAM is effective, although there are limited objective measures of this. Potential risks lie in the use of CAM, such as herbal remedies, and/or unregulated, contaminated, or unpurified products. Studies also underscored inadequate patient-physician discussions regarding CAM. (4) Conclusions: A better understanding of this topic would aid clinicians in guiding patients/families on the use of CAM. Further studies on the efficacy of the different types of CAM used, as well as potential side effects and drug interactions are needed.

Reducing the burden of knee osteoarthritis through community pharmacy: Protocol for a randomised controlled trial of the Knee Care for Arthritis through Pharmacy Service.

INTRODUCTION: Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio-economic wellbeing of those affected. Little community-based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Maori and non-Maori with knee OA in community pharmacy and providing co-ordinated, evidence- and community-based care may be a scalable, sustainable, equitable, effective and cost-effective approach to improve health and wellbeing. AIM: Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee-related physical function and pain (co-primary outcomes). Secondary aims assess impacts on health-related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Maori. METHODS AND ANALYSIS: A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12 months for Maori and non-Maori who have knee OA. Participants will be recruited in community pharmacies. Knee-related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee-related pain will be measured using an 11-point numeric pain rating scale. Primary outcome analyses will be conducted on an intention-to-treat basis using linear mixed models. Parallel within-trial health economic analysis and process evaluation will also be conducted. ETHICS AND TRIAL DISSEMINATION: Ethical approval was obtained from the Central Health and Ethics Committee (2022-EXP-11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants.

Influence of a rural interprofessional education placement on the rural health workforce: working in primary care, rural settings, and with Maori.

Introduction Pre-registration interprofessional rural immersion programmes provide students with first-hand insight into challenges faced in rural clinical practice and can influence future practice intentions. The impact of short rural and hauora Maori interdisciplinary placements on early healthcare careers is unknown. Aim Explore whether a 5-week rural interprofessional education programme influenced graduates' choices to work in primary care, rurally, and with Maori patients. Methods We conducted a survey-based, non-randomised trial of graduates from eight healthcare disciplines who did (n = 132) and did not (n = 479) attend the Tairawhiti interprofessional education rural programme with hauora Maori placements. Participants were surveyed at 1-, 2-, and 3-years' post-registration. Self-reported practice location and vocation were analysed with mixed-model logistic regression. Free-text comments were analysed with Template Analysis. Results We did not identify any measurable impact on rural or community workforce participation at 3-years' post-registration. Free-text analysis indicated that a short rural interprofessional immersion placement had long-term self-perceived impacts on desire and skills to work in rural locations, and on desire and ability to work with Maori and embrace Maori models of health. Discussion Our study suggests that short rural immersion placements do not increase rural workforce participation during early healthcare careers. Three-years' post-graduation may be too early to determine whether rural placements help to address rural health workforce needs. Reports from rural placement participants of increased ability to care for people from rural backgrounds, even when encountered in a city, suggest that assessment of practice location may not adequately capture the benefits of rural placement programmes.

Subphenotypes of frailty in lung transplant candidates.

Heterogeneous frailty pathobiology might explain the inconsistent associations observed between frailty and lung transplant outcomes. A Subphenotype analysis could refine frailty measurement. In a 3-center pilot cohort study, we measured frailty by the Short Physical Performance Battery, body composition, and serum biomarkers reflecting causes of frailty. We applied latent class modeling for these baseline data. Next, we tested class construct validity with disability, waitlist delisting/death, and early postoperative complications. Among 422 lung transplant candidates, 2 class model fit the best (P = .01). Compared with Subphenotype 1 (n = 333), Subphenotype 2 (n = 89) was characterized by systemic and innate inflammation (higher IL-6, CRP, PTX3, TNF-R1, and IL-1RA); mitochondrial stress (higher GDF-15 and FGF-21); sarcopenia; malnutrition; and lower hemoglobin and walk distance. Subphenotype 2 had a worse disability and higher risk of waitlist delisting or death (hazards ratio: 4.0; 95% confidence interval: 1.8-9.1). Of the total cohort, 257 underwent transplant (Subphenotype 1: 196; Subphenotype 2: 61). Subphenotype 2 had a higher need for take back to the operating room (48% vs 28%; P = .005) and longer posttransplant hospital length of stay (21 days [interquartile range: 14-33] vs 18 days [14-28]; P = .04). Subphenotype 2 trended toward fewer ventilator-free days, needing more postoperative extracorporeal membrane oxygenation and dialysis, and higher need for discharge to rehabilitation facilities (P ≤ .20). In this early phase study, we identified biological frailty Subphenotypes in lung transplant candidates. A hyperinflammatory, sarcopenic Subphenotype seems to be associated with worse clinical outcomes.

Knee osteoarthritis and the knowledgeable, trustworthy pharmacist: Patient and pharmacist perceptions of community pharmacy-based education and support.

BACKGROUND: Osteoarthritis (OA) clinical guidelines recommend self-management education, but education is often not included in primary care consultations. OBJECTIVE: To explore pharmacists' and patients' perceptions of a pharmacist-led model of service delivery for knee OA that was integrated within pharmacies' day-to-day workflow. METHODS: Cross-sectional qualitative design using Thematic Analysis. Community pharmacies were recruited in New Zealand and Australia. Pharmacy patients were screened for knee OA and offered tailored explanations, self-management information and referral for further support. Pharmacist focus groups and patient 1:1 interviews explored perceptions of the service delivery model. RESULTS: Nineteen pharmacists and 12 patients with knee OA participated. Pharmacist and patient data were analysed separately, with themes compared and contrasted to derive three meta-themes. Meta-theme 1: 'Welcome Engagement' included two pharmacist themes ('putting my broad skill set to use' and 'we're here and happy to help') and two patient themes ('information delivered well' and 'a welcome offer of help'). Meta-theme 2: 'The Knowledgeable and Trustworthy Pharmacist' included two pharmacist themes ('professional knowledge to help all sorts of patients' and 'managing time to help my patients') and one patient theme ('the accessible professional who I know and trust'). Meta-theme 3: 'The Opportunity for More Support' included one pharmacist theme ('this is not the end of the story') and one patient theme ('more help is available'). CONCLUSION: Community pharmacists are well-positioned to provide information and support to people with knee OA. Pharmacists appreciate the opportunity to better use their skills and accessibility for OA care, and patients welcome this engagement.

Sustainable interprofessional education programmes: What influences teachers to stay involved?

Delivery of interprofessional education (IPE) initiatives for pre-licensure students is increasingly the norm in health and social care training programmes. This collaborative form of education relies on teachers from various disciplines joining together to facilitate IPE. When IPE programmes first start, goodwill often prevails and facilitators are keen to take part. But as time goes on, retaining the IPE facilitator workforce is challenging. Research was undertaken to explore the experience of IPE facilitators who were part of a New Zealand university-based ten year old IPE programme. The research used a qualitative survey approach. Responses were received from 29% of all those invited to participate. Closed questions were collated and free-text survey responses analyzed using Template Analysis. Three themes and one integrative theme were identified. Themes include facilitators who are recognized, facilitators who are confident, and facilitators who are inspired. Themes were mediated by macro, meso and micro level forces. The cross-cutting integrative theme showed IPE facilitators experienced individual tipping points, with the potential to influence their continued involvement. These tipping points need to be recognized and addressed by those in senior level positions (macro-governance and meso-management), to ensure IPE facilitators continue and IPE programmes remain sustainable.

The osteoarthritis knowledge scale.

OBJECTIVE: Accurate knowledge is central to effective self-care of osteoarthritis (OA). This study aimed to assess the measurement properties of the Osteoarthritis Knowledge Scale (OAKS) with versions for the hip and knee. METHODS: Participants with hip OA (n = 144), knee OA (n = 327), and no OA (n = 735) were recruited. Rasch analysis was conducted to assess psychometric properties using data from all participants with hip OA and 144 randomly selected participants with either knee OA or no OA. Test-retest reliability and measurement error were estimated among those with hip (n = 51) and knee (n = 142) OA. RESULTS: Four items from the draft scales were deleted following Rasch analysis. The final 11-item OAKS was unidimensional. Item functioning was not affected by gender, age, educational level, or scale version (hip or knee). Person separation index was 0.75. Test-retest intraclass correlation coefficient was 0.81 (95% CI 0.74, 0.86; hip version 0.66 [0.47, 0.79]; knee version 0.85 (0.79, 0.90)). Smallest detectable change was 9 points (scale range 11-55; hip OA version 11 points; knee OA version 8 points). CONCLUSION: The OAKS is a psychometrically adequate, unidimensional measure of important OA knowledge that can be used in populations with and without hip and knee OA. Caution is needed when using with populations with only hip OA as test-retest reliability of the hip version did not surpass the acceptable range.

Feasibility of a randomised controlled trial of two types of written information for people with knee osteoarthritis.

Objective: Test the feasibility of conducting an individually randomised controlled trial recruiting people with knee osteoarthritis (OA) in community pharmacies and evaluate the impacts of a novel information booklet. Design: People with knee OA were identified by pharmacy staff using clinical criteria and randomised to receive a novel information booklet (intervention) or the currently available written OA resource (active control). Mixed-methods process evaluation assessed participant recruitment, retention, and experience. Participant-reported outcome measures, assessing OA illness perceptions, OA knowledge, fear of movement, and pain when walking at baseline and 4-weeks, were analysed using linear regression models (adjusted for baseline). Results: Of 72 eligible people, 64 were randomised to intervention (n â€‹= â€‹33) or control (n â€‹= â€‹31). The randomisation sequence was followed correctly and no protocol deviations identified. Mean recruitment rate was 2.7 participants per pharmacy per week. One-in-five participants had no educational qualifications and one-in-four had not received a knee OA diagnosis prior to the trial. Three meta-themes emerged from pharmacist and participant qualitative analysis: 'pleased to be asked'; 'easy process'; and 'successful process'. Three participants were lost to follow-up. At 4 weeks, intervention arm Knee Osteoarthritis Knowledge Scale scores improved (mean difference â€‹= â€‹3.6, 95%CI 0.7 to 6.5). Brief Illness Perceptions Questionnaire scores were similar between groups (mean difference 0.4, 95%CI -3.7 to 4.5). Conclusion: It is feasible to conduct an individually randomised trial in community pharmacy, a potentially effective setting to initiate accessible OA care. A novel information booklet improved OA knowledge, but is unlikely to affect illness perceptions on its own.

MDMA-assisted psychotherapy; Inclusion of transgender and gender diverse people in the frontiers of PTSD treatment trials.

Introduction: Transgender and gender diverse (TGD) people experience stigma, discrimination, trauma, and post-traumatic stress disorder (PTSD) at higher rates compared to the general population; however, TGD people have been underrepresented in PTSD research. Clinical trials of 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy demonstrate promising safety and efficacy for the treatment of PTSD. Issues related to equitable access, power imbalances in the therapeutic relationship, and vulnerable states of consciousness occasioned by MDMA are magnified when working with people affected by structural vulnerabilities and health disparities, and community engagement in research planning and implementation is essential. To inform the inclusion and safety of TGD people in future MDMA-assisted psychotherapy research, the aims of the current study were to: characterize TGD experiences with trauma-related mental health care, assess openness of TGD people to participate in experimental PTSD research, and to gather specific feedback on protocol design for conducting MDMA-assisted psychotherapy with TGD people. Materials and methods: We conducted three virtual focus group discussions (FGDs) with 5-6 participants each (N = 17). Eligible TGD participants had a history of receiving trauma-related mental health care. Each FGD was facilitated by two licensed clinicians who identified as TGD. Qualitative data analysis was conducted via an iterative process of identification of recurrent patterns and themes. Results: We have identified several key issues TGD people face when seeking and engaging in trauma-related mental health care, including barriers to receiving adequate gender-affirming and trauma-informed mental health care and frustration with providers lacking cultural humility. Suggested amendments to MDMA-assisted psychotherapy protocols include: routine collection of trans-inclusive gender identity data, implementing an explicit gender-affirming treatment approach, ensuring a culturally safe setting, and diversifying co-therapy dyads. Discussion: The inclusion of TGD voices in early conversations about emerging experimental PTSD interventions promotes equitable access, in the context of health and healthcare disparities, and helps researchers understand the needs of the community and tailor research to meet those needs. Through an ongoing conversation with the TGD community, we aim to incorporate a gender-affirming approach into existing research protocols and inform future applications of MDMA-assisted psychotherapy in addressing the effects of minority stress and boosting resilience.

Physician Health and Wellness.

Physician health and wellness is a complex topic relevant to all pediatricians. Survey studies have established that pediatricians experience burnout at comparable rates to colleagues across medical specialties. Prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. Women currently constitute a majority of pediatricians, and surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts. The purpose of this report is to update the reader and explore approaches to pediatrician well-being and reduction of occupational burnout risk throughout the stages of training and practice. Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the American Academy of Pediatrics; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). The development of this clinical report has inevitably been shaped by the social, cultural, public health, and economic factors currently affecting our communities. The coronavirus disease 2019 (COVID-19) pandemic has layered new and significant stressors onto medical practice with physical, mental, and logistical challenges and effects that cannot be ignored.

The Lung Allograft Microbiome Associates with Pepsin, Inflammation, and Primary Graft Dysfunction.

Rationale: Primary graft dysfunction (PGD) is the principal cause of early morbidity and mortality after lung transplantation. The lung microbiome has been implicated in later transplantation outcomes but has not been investigated in PGD. Objectives: To define the peritransplant bacterial lung microbiome and relationship to host response and PGD. Methods: This was a single-center prospective cohort study. Airway lavage samples from donor lungs before organ procurement and recipient allografts immediately after implantation underwent bacterial 16S ribosomal ribonucleic acid gene sequencing. Recipient allograft samples were analyzed for cytokines by multiplex array and pepsin by ELISA. Measurements and Main Results: We enrolled 139 transplant subjects and obtained donor lung (n = 109) and recipient allograft (n = 136) samples. Severe PGD (persistent grade 3) developed in 15 subjects over the first 72 hours, and 40 remained without PGD (persistent grade 0). The microbiome of donor lungs differed from healthy lungs, and recipient allograft microbiomes differed from donor lungs. Development of severe PGD was associated with enrichment in the immediate postimplantation lung of oropharyngeal anaerobic taxa, particularly Prevotella. Elevated pepsin, a gastric biomarker, and a hyperinflammatory cytokine profile were present in recipient allografts in severe PGD and strongly correlated with microbiome composition. Together, immediate postimplantation allograft Prevotella/Streptococcus ratio, pepsin, and indicator cytokines were associated with development of severe PGD during the 72-hour post-transplantation period (area under the curve = 0.81). Conclusions: Lung allografts that develop PGD have a microbiome enriched in anaerobic oropharyngeal taxa, elevated gastric pepsin, and hyperinflammatory phenotype. These findings suggest a possible role for peritransplant aspiration in PGD, a potentially actionable mechanism that warrants further investigation.

Longitudinal impact of preregistration interprofessional education on the attitudes and skills of health professionals during their early careers: a non-randomised trial with 4-year outcomes.

OBJECTIVE: To assess whether a preregistration interprofessional education (IPE) programme changed attitudes towards teamwork and team skills during health professionals' final year of training and first 3 years of professional practice. DESIGN: Prospective, longitudinal, non-randomised trial. SETTING: Final year health professional training at three academic institutions in New Zealand. PARTICIPANTS: Students from eight disciplines eligible to attend the IPE programme were recruited (617/730) prior to their final year of training. 130 participants attended the IPE programme; 115 intervention and 372 control participants were included in outcome analysis. INTERVENTION: The 5-week Tairawhiti IPE (TIPE) immersion programme during which students experience clinical placements in interdisciplinary teams, complete collaborative tasks and live together in shared accommodation. MAIN OUTCOME MEASURES: Data were collected via five surveys at 12-month intervals, containing Attitudes Towards Healthcare Teams Scale (ATHCTS), Team Skills Scale (TSS) and free-text items. Mixed-model analysis of covariance, adjusting for baseline characteristics, compared scores between groups at each time point. Template analysis identified themes in free-text data. RESULTS: Mean ATHCTS scores for TIPE participants were 1.4 (95% CI 0.6 to 2.3) points higher than non-TIPE participants (p=0.002); scores were 1.9 (95% CI 0.8 to 3.0) points higher at graduation and 1.1 (95% CI -0.1 to 2.4) points higher 3 years postgraduation. Mean TSS scores for TIPE participants were 1.7 (95% CI 0.0 to 3.3) points higher than non-TIPE participants (p=0.045); scores were 3.5 points (95% CI 1.5 to 5.5) higher at graduation and 1.3 (95%CI -0.8 to 3.5) points higher 3 years postgraduation. TIPE participants made substantially more free-text comments about benefits of interprofessional collaboration and perceived the TIPE programme had a meaningful influence on their readiness to work in teams and the way in which they performed their healthcare roles. CONCLUSIONS: TIPE programme participation significantly improved attitudes towards healthcare teams and these changes were maintained over 4 years.

Pilot Study: Pneumatic Compression Garment Therapy for Postradiotherapy Laryngopharyngeal Edema.

OBJECTIVES: Pneumatic compression garment therapy (PCGT) has been established as treatment for postradiotherapy lymphedema, and its use in head and neck patients is becoming more common. Although effects on interstitial edema of the cervical soft tissues have been studied, effects on internal laryngopharyngeal edema, as well as associated symptoms of dysphagia and dysphonia, have yet to be published. METHODS: We surveyed 7 patients treated with radiation for head and neck cancer (HNC) who had also been prescribed PCGT for cervical lymphedema. Patients were asked about subjective experience with the device, and also administered the Eating Assessment Tool-10 (EAT-10) and Voice Handicap Index-10 (VHI-10) surveys regarding their symptoms after using PCGT. Laryngoscopy videos from these same periods were also reviewed and scored using a validated tool for assessing laryngopharyngeal edema. RESULTS: 85% of patients reported at least some improvement in dysphagia and dysphonia following PCGT. Average EAT-10 score after PCGT was 11.4 and average VHI-10 score after PCGT was 8.7. These compare more favorably to historical scores for the same questionnaires in similar patient populations. Laryngeal edema scores on endoscopic examination were not significantly different after at least 3 months of therapy (pre: 20.15, post: 20.21, P = .975); however, the utility of this result is limited by a low inter-rater reliability (Krippendorff α = .513). CONCLUSIONS: While we are unable to show any difference in objective assessment of laryngopharyngeal edema on endoscopic examination in this small pilot study, patients report substantial subjective improvement in postradiotherapy dysphagia and dysphonia following cervical PCGT that warrants more formal investigation.

Fluoroscopic Swallowing Examination: Radiologic Findings and Analysis of Their Causes and Pathophysiologic Mechanisms.

Dysphagia is a common symptom in the general population, and its prevalence increases with patient age. The deterioration of swallowing function has many acute and chronic causes, including cerebrovascular and neuromuscular diseases, radiation, and surgery. In an elderly population, diagnosis and treatment of swallowing abnormalities is a high priority because it improves the patient's quality of life and helps them to avoid medical complications. Fluoroscopic swallowing examinations and modified barium swallow studies are the most used and most reliable diagnostic procedures to evaluate swallowing disorders. Functional anomalies include disturbances of the oral preparatory, oral propulsory, and pharyngeal phases of swallowing as premature spillage from the mouth, nasal regurgitation, delayed initiation of pharyngeal swallowing, incomplete displacement of the hyolaryngeal complex, abnormal epiglottic tilt, incomplete laryngeal closure, and pharyngeal dysmotilities. Anatomic abnormalities of the pharynx include diverticula, benign strictures, and tumors. The abnormalities diagnosed on the basis of fluoroscopic examination have a variety of treatment strategies, and the choice of treatment depends on the cause of the anomaly and its pathophysiologic characteristics. The radiologist's interpretation of these characteristics is crucial to therapeutic decision making and achieving the best patient outcomes. Online supplemental material is available for this article. ©RSNA, 2021.

Best Practices for Using Telehealth in Hospice and Palliative Care.

Hospice and palliative care providers throughout the United States have continued to provide compassionate patient- and family-centered care during the COVID-19 (coronavirus disease 2019) pandemic while adapting to the need for scrupulous infection control measures and the accelerated use of telehealth. Prior to the pandemic, hospice and palliative care adopted telehealth slowly compared with other specialties, but its rapidly increasing utilization during the COVID-19 pandemic has long-term implications for access to primary and specialty palliative care, particularly for patients in rural communities and populations experiencing inequitable access to services. Telehealth also shows great promise for leveraging technology to provide care more effectively and efficiently. As more provider organizations become equipped with telehealth infrastructure, and as advocacy for broader reimbursement of these services grows, telehealth services for hospice and palliative care are expected to continue. This article highlights the work of expert clinicians from multiple hospice and palliative care organizations to develop best practices for conducting telehealth visits in inpatient and community settings. The authors propose that best practices be compiled and considered to ensure quality-driven, evidence-based clinical practice guidelines with interprofessional applicability.

An investigation of two methods of DNA recovery from fired and unfired 9 mm ammunition.

Cartridge cases are often recovered from crime scenes involving firearms and, in the United Kingdom (where gun possession is strictly controlled), these are commonly from 9 mm calibre ammunition. The ability to obtain informative DNA profiles from touch DNA on recovered cartridges could have a significant impact on the investigation of that type of offence. However, this avenue may not be routinely considered as investigators in the UK have historically had a low expectation of obtaining useful DNA profiles. This stance may not be unreasonable given that (a) only trace amounts of DNA are likely to have been transferred onto the cartridge cases through handling; and (b) when the cartridge is spent, the potential deterioration of that DNA caused by the act of discharging the weapon. We introduce a novel semi-automatable method using direct lysis for the recovery of DNA from ammunition and compare it with a traditional double-swabbing method (using wet and dry swabs). DNA profiling of the DNA recovered using both methods was carried out using the ESI17 FAST STR system (Promega). This demonstrated a significant increase in DNA recovery using the direct lysis approach, and correspondingly improved STR results. We also investigated the effect on the recovery and profiling of DNA from fired, and unfired, 9 mm cartridges using the direct lysis technique. These results demonstrate that DNA suitable for STR analysis can still be recovered from fired ammunition with only slightly reduced yields compared to unfired ammunition. In these experiments, the handler of the ammunition was most commonly either the sole contributor or the major contributor to the recovered DNA profile.

Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation.

The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.

Mobile health technology to improve emergent frailty after lung transplantation.

We evaluated the feasibility, safety, and efficacy of a mHealth-supported physical rehabilitation intervention to treat frailty in a pilot study of 18 lung transplant recipients. Frail recipients were defined by a short physical performance battery (SPPB score ≤7). The primary intervention modality was Aidcube, a customizable rehabilitation mHealth platform. Our primary aims included tolerability, feasibility, and acceptability of use of the platform, and secondary outcomes were changes in SPPB and in scores of physical activity, and disability measured using the Duke Activity Status Index (DASI) and Lung Transplant-Value Life Activities (LT-VLA). Notably, no adverse events were reported. Subjects reported the app was easy to use, usability improved over time, and the app enhanced motivation to engage in rehabilitation. Comments highlighted the complexities of immediate post-transplant rehabilitation, including functional decline, pain, tremor, and fatigue. At the end of the intervention, SPPB scores improved a median of 5 points from a baseline of 4. Physical activity and patient-reported disability also improved. The DASI improved from 4.5 to 19.8 and LT-VLA score improved from 2 to 0.59 at closeout. Overall, utilization of a mHealth rehabilitation platform was safe and well received. Remote rehabilitation was associated with improvements in frailty, physical activity and disability. Future studies should evaluate mHealth treatment modalities in larger-scale randomized trials of lung transplant recipients.