IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study.

BACKGROUND: Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations. METHOD: As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves. RESULTS: At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013. CONCLUSIONS: Proactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.

Machine learning corroborates subjective ratings of walking and balance difficulty in multiple sclerosis.

Machine learning can discern meaningful information from large datasets. Applying machine learning techniques to raw sensor data from instrumented walkways could automatically detect subtle changes in walking and balance. Multiple sclerosis (MS) is a neurological disorder in which patients report varying degrees of walking and balance disruption. This study aimed to determine whether machine learning applied to walkway sensor data could classify severity of self-reported symptoms in MS patients. Ambulatory people with MS (n = 107) were asked to rate the severity of their walking and balance difficulties, from 1-No problems to 5-Extreme problems, using the MS-Impact Scale-29. Those who scored less than 3 (moderately) were assigned to the "mild" group (n = 35), and those scoring higher were in the "moderate" group (n = 72). Three machine learning algorithms were applied to classify the "mild" group from the "moderate" group. The classification achieved 78% accuracy, a precision of 85%, a recall of 90%, and an F1 score of 87% for distinguishing those people reporting mild from moderate walking and balance difficulty. This study demonstrates that machine learning models can reliably be applied to instrumented walkway data and distinguish severity of self-reported impairment in people with MS.

Operation analysis of the tele-critical care service demonstrates value delivery, service adaptation over time, and distress among tele-providers.

Background: Our study addresses the gaps in knowledge of the characterizations of operations by remote tele-critical care medicine (tele-CCM) service providers interacting with the bedside team. The duration of engagements, the evolution of the tele-CCM service over time, and the distress during interactions with the bedside team have not been characterized systematically. These characteristics are critical for planning the deployment of teleICU services and preventing burnout among remote teleICU providers. Methods: REDCap self-reported activity logs collected engagement duration, triggers (emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone), expediency, nature (proactive rounding, predetermined task, response to medical needs), communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by teams consisting of telemedicine medical doctors (eMD), telemedicine registered nurses (eRN), and telemedicine respiratory therapists (eRT). Results: 39,915 total engagements were registered. eMDs had a significantly higher percentage of emergent and urgent engagements (31.9%) vs. eRN (9.8%) or eRT (1.7%). The average tele-CCM intervention took 16.1 ± 10.39 min for eMD, 18.1 ± 16.23 for eRN, and 8.2 ± 4.98 min for eRT, significantly varied between engagement, and expediency, hospitals, and ICUs types. During the observation period, there was a shift in intervention triggers with an increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements, and the tele-CCM module of electronic medical records at the expense of the share of proactive rounding. eRT communicated more frequently with bedside staff (% MD = 37.8%; % RN = 36.8, % RT = 49.0%) but mostly with other eRTs. In contrast, the eMD communicated with all ICU stakeholders while the eRN communicated chiefly with other RN and house staff at the patient's bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor. Conclusions: Delivery of tele-CCM services has to be tailored to the specific beneficiary of tele-CCM services to optimize care delivery and minimize distress. In addition, the duration of the average intervention must be considered while creating an efficient workflow.

Improving Students' Knowledge and Skills Through a Tele-ICU Clinical Rotation.

BACKGROUND: In the course of their education, respiratory therapy students participate in clinical rotations, which are essential to their education. Recently, the number of clinical sites has decreased as some have been eliminated. During the COVID-19 pandemic, schools were challenged to find hospitals to accommodate students due to the risk of infection. Tele-ICU has emerged as a means for staff therapists to assess and monitor patients via remote monitoring systems. We hypothesized that a clinical rotation at a tele-ICU would strengthen students' knowledge of mechanical ventilation, telemedicine, and COVID-19. METHODS: In this study, students completed clinical rotations in a tele-ICU. Students spent two 4-h clinical rotations rounding on 320 ICU beds at 5 hospitals. Under the supervision of experienced therapists, students performed remote patient-ventilator assessments, including review and interpretation of ventilator waveforms, patient-ventilator interaction, arterial blood gases, and chest x-rays. Students completed pre- and post-rotation surveys assessing their confidence managing mechanical ventilation, experience with telemedicine, ARDS, and patients with COVID-19. RESULTS: Mean self-confidence in mechanical ventilation (P = .001), assessing waveforms (P = .001), and knowledge of ARDS increased after the clinical rotation (P = .001). Similarly, reported knowledge related to spontaneous breathing trial protocols (P = .009), lung-protective ventilation (P = .002), patient care planning (P = .001), and use of Excel spreadsheets (P = .002) increased from the beginning to the end of the clinical rotation. Student confidence in interprofessional communication increased from 85 [69-98] to 95 [78-100]; P = .03). Overall, the largest change was students' ability to assess patients with COVID-19 (pre-rotation 50.0 [11.5-65.7], post-rotation 80.0 [58.5-100]; P = .001). Qualitative results revealed overwhelmingly positive results for both students and preceptors. CONCLUSIONS: Students' confidence in assessing patients via remote monitoring increased in a tele-ICU clinical rotation. Self-assessed knowledge related to COVID-19 also increased to statistical significance.

Machine learning classification of multiple sclerosis patients based on raw data from an instrumented walkway.

BACKGROUND: Using embedded sensors, instrumented walkways provide clinicians with important information regarding gait disturbances. However, because raw data are summarized into standard gait variables, there may be some salient features and patterns that are ignored. Multiple sclerosis (MS) is an inflammatory neurodegenerative disease which predominantly impacts young to middle-aged adults. People with MS may experience varying degrees of gait impairments, making it a reasonable model to test contemporary machine leaning algorithms. In this study, we employ machine learning techniques applied to raw walkway data to discern MS patients from healthy controls. We achieve this goal by constructing a range of new features which supplement standard parameters to improve machine learning model performance. RESULTS: Eleven variables from the standard gait feature set achieved the highest accuracy of 81%, precision of 95%, recall of 81%, and F1-score of 87%, using support vector machine (SVM). The inclusion of the novel features (toe direction, hull area, base of support area, foot length, foot width and foot area) increased classification accuracy by 7%, recall by 9%, and F1-score by 6%. CONCLUSIONS: The use of an instrumented walkway can generate rich data that is generally unseen by clinicians and researchers. Machine learning applied to standard gait variables can discern MS patients from healthy controls with excellent accuracy. Noteworthy, classifications are made stronger by including novel gait features (toe direction, hull area, base of support area, foot length and foot area).

From hardship to scholarship.

While there is much of the last two years we may wish to forget, it is imperative that we share our pandemic chemistry teaching experiences.

Monocytes Expose Factor XIII-A and Stabilize Thrombi against Fibrinolytic Degradation.

Factor XIII (FXIII) is a transglutaminase that promotes thrombus stability by cross-linking fibrin. The cellular form, a homodimer of the A subunits, denoted FXIII-A, lacks a classical signal peptide for its release; however, we have shown that it is exposed on activated platelets. Here we addressed whether monocytes expose intracellular FXIII-A in response to stimuli. Using flow cytometry, we demonstrate that FXIII-A antigen and activity are up-regulated on human monocytes in response to stimulation by IL-4 and IL-10. Higher basal levels of the FXIII-A antigen were noted on the membrane of the monocytic cell line THP-1, but activity was significantly enhanced following stimulation with IL-4 and IL-10. In contrast, treatment with lipopolysaccharide did not upregulate exposure of FXIII-A in THP-1 cells. Quantification of the FXIII-A activity revealed a significant increase in THP-1 cells in total cell lysates following stimulation with IL-4 and IL-10. Following fractionation, the largest pool of FXIII-A was membrane associated. Monocytes were actively incorporated into the fibrin mesh of model thrombi. We found that stimulation of monocytes and THP-1 cells with IL-4 and IL-10 stabilized FXIII-depleted thrombi against fibrinolytic degradation, via a transglutaminase-dependent mechanism. Our data suggest that monocyte-derived FXIII-A externalized in response to stimuli participates in thrombus stabilization.

Recruiting Low-Income African American Men in Mental Health Research: A Community-Based Participatory Research Feasibility Study.

African Americans (AAs) are 20% more likely to develop serious psychological distress compared to Whites but are less likely to use mental health services. The study objective was to evaluate the effectiveness of recruitment strategies to engage AA fathers in a mental health intervention.Using the community-based participatory research (CBPR) approach, a community-academic partnership (CAP) developed and implemented direct and indirect referral strategies to engage AA fathers in a mental health intervention. Direct referral strategies focused on community partner identification of potentially eligible participants, providing information about the study (i.e., study flyer), and referring potential participants to the study. Indirect referrals included posting flyers in local businesses frequented by AA men, radio advertisements, and social media posts from community organizations.From January to October 2019, 50 direct and 1388 indirect referrals were documented, yielding 24 participants screened and 15 enrolled. Of all participants screened, 58% were referred through indirect referral, 38% were referred directly by community partners, and 4% of the participants were referred through both direct and indirect referrals. Twenty percent of those exposed to the direct referral methods and 1% of those exposed to the indirect referral methods were enrolled. The indirect referrals accounted for 60% of enrollment, whereas the direct referrals accounted for 33.3% of enrollment.Collaborating with the community partners to engage hard-to-reach populations in mental health studies allowed for broad dissemination of recruitment methods, but still resulted in low participant accrual. Additional focus on increasing direct referral methods appears to be a fruitful area of CBPR.

Red blood cell mannoses as phagocytic ligands mediating both sickle cell anaemia and malaria resistance.

In both sickle cell disease and malaria, red blood cells (RBCs) are phagocytosed in the spleen, but receptor-ligand pairs mediating uptake have not been identified. Here, we report that patches of high mannose N-glycans (Man5-9GlcNAc2), expressed on diseased or oxidized RBC surfaces, bind the mannose receptor (CD206) on phagocytes to mediate clearance. We find that extravascular hemolysis in sickle cell disease correlates with high mannose glycan levels on RBCs. Furthermore, Plasmodium falciparum-infected RBCs expose surface mannose N-glycans, which occur at significantly higher levels on infected RBCs from sickle cell trait subjects compared to those lacking hemoglobin S. The glycans are associated with high molecular weight complexes and protease-resistant, lower molecular weight fragments containing spectrin. Recognition of surface N-linked high mannose glycans as a response to cellular stress is a molecular mechanism common to both the pathogenesis of sickle cell disease and resistance to severe malaria in sickle cell trait.

"Save the Vein" Initiative in Children With CKD: A Quality Improvement Study.

RATIONALE & OBJECTIVE: The preferred vascular access for hemodialysis recipients is an arteriovenous fistula in the nondominant arm. Prior placement of a peripheral intravenous (PIV) catheter can lead to vascular injury and limit options for arteriovenous fistula creation, a particular problem for children, who may need hemodialysis for their entire lifetime. We instituted an initiative to increase the frequency of PIV catheter placement in the dominant arm for hospitalized pediatric patients with advanced chronic kidney disease (CKD). STUDY DESIGN: Quality improvement initiative. SETTING & PARTICIPANTS: Children with CKD stage 3-5, receiving dialysis, and/or following kidney transplantation who were hospitalized at one children's hospital between September 2018 and August 2020. QUALITY IMPROVEMENT ACTIVITIES: Retrospective data on PIV catheter location for patients from January 1 to June 30, 2017, served as baseline data. Quality improvement activities consisted of: 1) education of the multidisciplinary treatment team, patients, and parents regarding importance of vein preservation; 2) placement of individualized notes in the electronic medical record identifying the preferred arm for PIV catheter placement; 3) use of "restricted extremity" arm bands; and 4) vascular access team participation to minimize attempts for PIV catheter placement. OUTCOME: Monthly compliance with placement of PIV catheters in dominant arms. ANALYTICAL APPROACH: Location of PIV catheter placements were determined monthly and used to create run charts describing compliance. RESULTS: At baseline and before institution of this initiative, 34 of 72 (47%) PIV catheters were placed in patients' dominant arms, with only 2 of 8 (25%) PIV catheters placed in the dominant arm for children aged<5 years. After instituting the initiative, 345 of 371 (93%) PIV catheters were placed in the dominant arm of 93 children; in children aged<5 years, 58 of 62 (94%) PIV catheters were placed in the dominant arm. Only 38 of 371 (10%) PIV catheters were placed in the antecubital vein. LIMITATIONS: Single-center study. CONCLUSIONS: Education regarding the importance of vein preservation, along with implementation of a standardized process for identifying children for whom vein preservation is important, can help direct PIV catheter placement and potentially preserve vasculature in pediatric patients with CKD.

The Pathfields Tool: a frailty case-finding tool using primary care IT-implications for population health management.

BACKGROUND: older people living with frailty benefit from targeted interventions which improve health and independence. However, it has been challenging within primary care to systematically identify patients living with frailty. METHODS: primary care IT was re-programmed to create a 'Pathfields High Risk Cohort' (PHRC, patients felt likely to have undiagnosed frailty) and invite clinicians to opportunistically assess and diagnose frailty. Results were compared with NHS England's current approach to frailty identification using Electronic Frailty Index (eFI) to see which approach had the highest diagnostic yield. RESULTS: the Pathfields Tool identified 1,348 patients in PHRC group, of whom 951 (70.5%) were clinically assessed and diagnosed:eFI (moderate and severe) identified 683 patients of whom 598 (87.6%) were clinically assessed and diagnosed:Extrapolated data would estimate frailty prevalence at 22.5% (1,024/4,552) (5.5% severe, 8.8% moderate, and 8.1% mild) in the practice population aged 65+. CONCLUSIONS: the Pathfields Tool identified more patients with clinically confirmed previously undiagnosed frailty than eFI 'moderate and severe frailty' alone.Sub-segmenting frailty by residential status could significantly improve the population health management of older people.

Factors associated with overweight cats successfully completing a diet-based weight loss programme: an observational study.

BACKGROUND: The most common approach for controlled weight loss in cats is dietary caloric restriction, using a purpose-formulated diet. Most previous studies have only assessed short-term outcomes, and no previous study has examined overall success (i.e. odds of reaching target weight). The aim of this study was to determine the factors associated with overweight cats successfully completing a diet-based weight loss programme to reach target weight. RESULTS: Sixty-two cats were included, and 28 (45%) completed their weight loss programme. The remaining 34 cats (55%) did not reach target weight, of which 2 (3%) were euthanised for unrelated reasons. Reasons for cats stopping the programme prematurely included inability to contact owner (n = 19), owner requested that the programme be completed prior to reaching target weight (n = 5), the cat developed another illness (n = 3), refusal to comply with requirements for weight management (n = 2), owner illness (n = 2), and personal issues of the owner (n = 1). Multiple logistic regression analysis revealed that rate of weight loss and weight loss required were positively (odds ratio [OR] 157.81, 95% confidence interval [CI] 10.00-2492.67) and negatively (OR 0.89, 95% CI 0.81-0.98) associated with the odds of completing the weight loss programme, respectively. CONCLUSIONS: Future studies should consider developing better methods of supporting the owners of the most obese cats during weight management, since these cats are least likely to complete reach target weight.

A novel compound heterozygous mutation in the POMK gene causing limb-girdle muscular dystrophy-dystroglycanopathy in a sib pair.

We describe two Finnish siblings in whom an incidentally detected elevated creatine kinase activity eventually led to a diagnosis of limb-girdle muscular dystrophy-dystroglycanopathy (Type C12; MDDGC12). When diagnosed at age 10 and 13 years, they were mildly affected with a slow or non-progressive disease course. The main symptoms comprised infrequent hip cramps triggered by flexion, neck cramps triggered by yawning, transient growing pains, calf hypertrophy and mild proximal muscle weakness. Their cognitive and motor developments were unremarkable and they were physically active. Whole-exome sequencing revealed compound heterozygous mutations, both of which were novel, in the protein O-mannosyl kinase (POMK) gene in both siblings; a missense mutation, p.Pro322Leu (c.965C > T), and a nonsense mutation, p.Arg46Ter (c.136C > T). The results were confirmed by Sanger sequencing, showing that the parents were heterozygous carriers of one mutation each. This report adds to the literature by providing phenotype and genotype data on this ultra-rare POMK-related dystroglycanopathy.

Enteral Feeding Set Handling Techniques.

BACKGROUND: Enteral nutrition therapy is common practice in pediatric clinical settings. Often patients will receive a pump-assisted bolus feeding over 30 minutes several times per day using the same enteral feeding set (EFS). This study aims to determine the safest and most efficacious way to handle the EFS between feedings. METHODS: Three EFS handling techniques were compared through simulation for bacterial growth, nursing time, and supply costs: (1) rinsing the EFS with sterile water after each feeding, (2) refrigerating the EFS between feedings, and (3) using a ready-to-hang (RTH) product maintained at room temperature. Cultures were obtained at baseline, hour 12, and hour 21 of the 24-hour cycle. A time-in-motion analysis was conducted and reported in average number of seconds to complete each procedure. Supply costs were inventoried for 1 month comparing the actual usage to our estimated usage. RESULTS: Of 1080 cultures obtained, the overall bacterial growth rate was 8.7%. The rinse and refrigeration techniques displayed similar bacterial growth (11.4% vs 10.3%, P = .63). The RTH technique displayed the least bacterial growth of any method (4.4%, P = .002). The time analysis in minutes showed the rinse method was the most time-consuming (44.8 ± 2.7) vs refrigeration (35.8 ± 2.6) and RTH (31.08 ± 0.6) ( P < .0001). CONCLUSIONS: All 3 EFS handling techniques displayed low bacterial growth. RTH was superior in bacterial growth, nursing time, and supply costs. Since not all pediatric formulas are available in RTH, we conclude that refrigerating the EFS between uses is the next most efficacious method for handling the EFS between bolus feeds.

Therapeutic Targeting of Histone Modifications in Adult and Pediatric High-Grade Glioma.

Recent exciting work partly through The Cancer Genome Atlas has implicated epigenetic mechanisms including histone modifications in the development of both pediatric and adult high-grade glioma (HGG). Histone lysine methylation has emerged as an important player in regulating gene expression and chromatin function. Lysine (K) 27 (K27) is a critical residue in all seven histone 3 variants and the subject of posttranslational histone modifications, as it can be both methylated and acetylated. In pediatric HGG, two critical single-point mutations occur in the H3F3A gene encoding the regulatory histone variant H3.3. These mutations occur at lysine (K) 27 (K27M) and glycine (G) 34 (G34R/V), both of which are involved with key regulatory posttranscriptional modifications. Therefore, these mutations effect gene expression, cell differentiation, and telomere maintenance. In recent years, alterations in histone acetylation have provided novel opportunities to explore new pharmacological targeting, with histone deacetylase (HDAC) overexpression reported in high-grade, late-stage proliferative tumors. HDAC inhibitors have shown promising therapeutic potential in many malignancies. This review focuses on the epigenetic mechanisms propagating pediatric and adult HGGs, as well as summarizing the current advances in clinical trials using HDAC inhibitors.

Enteral Feeding Set Handling Techniques: A Comparison of Bacterial Growth, Nursing Time, Labor, and Material Costs.

BACKGROUND: Enteral nutrition therapy is common practice in pediatric clinical settings. Often patients will receive a pump-assisted bolus feeding over 30 minutes several times per day using the same enteral feeding set (EFS). This study aims to determine the safest and most efficacious way to handle the EFS between feedings. METHODS: Three EFS handling techniques were compared through simulation for bacterial growth, nursing time, and supply costs: (1) rinsing the EFS with sterile water after each feeding, (2) refrigerating the EFS between feedings, and (3) using a ready-to-hang (RTH) product maintained at room temperature. Cultures were obtained at baseline, hour 12, and hour 21 of the 24-hour cycle. A time-in-motion analysis was conducted and reported in average number of seconds to complete each procedure. Supply costs were inventoried for 1 month comparing the actual usage to our estimated usage. RESULTS: Of 1080 cultures obtained, the overall bacterial growth rate was 8.7%. The rinse and refrigeration techniques displayed similar bacterial growth (11.4% vs 10.3%, P = .63). The RTH technique displayed the least bacterial growth of any method (4.4%, P = .002). The time analysis in minutes showed the rinse method was the most time-consuming (44.8 ± 2.7) vs refrigeration (35.8 ± 2.6) and RTH (31.08 ± 0.6) (P < .0001). CONCLUSIONS: All 3 EFS handling techniques displayed low bacterial growth. RTH was superior in bacterial growth, nursing time, and supply costs. Since not all pediatric formulas are available in RTH, we conclude that refrigerating the EFS between uses is the next most efficacious method for handling the EFS between bolus feeds.

Implementation of an Obstructive Sleep Apnea Screening Program at an Overseas Military Hospital.

Anesthesia providers and surgeons do poorly at consistently identifying patients with obstructive sleep apnea (OSA) without use of screening tools. Aims of this evidence-based-practice project were to determine whether educating nurses about OSA and incorporating the STOP-BANG Questionnaire into preoperative forms was associated with an increased identification of patients with suspected OSA and an increased frequency of nurse-generated anesthesia consultation for OSA. A retrospective chart review of 100 consecutive records over a 1-month period using the STOP-BANG Questionnaire criteria was completed before and after implementation of the education and screening program at US Naval Hospital Okinawa, Japan. A STOP-BANG Questionnaire score of 3 or higher indicated high risk of OSA. Descriptive and inferential statistics were used to analyze results. Two hundred charts were reviewed. The prevalence of a STOP-BANG score of 3 or more increased from 5% to 21% after program implementation (P = .001). The frequency of anesthesia consultation for known or suspected OSA by our nursing staff increased from 5% to 26% after implementation (P = .0001). After this educational intervention with preoperative nurses and redesign of preoperative forms to incorporate the STOP-BANG Questionnaire, an increased proportion of patients at high risk of OSA were identified.

Exteriorisation of Mannoses on Human Erythrocyte Membrane Skeleton Provides 'Eat Me' Signals for Oxidatively Damaged Cells to be Cleared By Macrophages: A Pathway Mediating Hemolysis in Sickle Cell Disease.

DISCLOSURES: Vickers: University of Aberdeen: Patents & Royalties: About to apply for patent. Barker: University of Aberdeen: Employment, Patents & Royalties: About to apply for patent. Cao: University of Aberdeen: Patents & Royalties: About to apply for patent.