Morbidity and Complications of Diabetes Mellitus in Children and Adolescents in Ghana: Protocol for a Longitudinal Study.

BACKGROUND: Diabetes is associated with premature morbidity and mortality from its many complications. There are limited data on the chronic complications of diabetes in children and adolescents in sub-Saharan Africa. OBJECTIVE: The study aims to determine the (1) burden and related factors of chronic systemic complications of diabetes, including diabetic and nondiabetic ocular conditions in children and adolescents, and (2) quality of life (QoL) of participants compared to healthy controls. This manuscript describes the study methodology. METHODS: Demographic information, medical history, anthropometric measurements, and laboratory characteristics were collected, and the participants were screened for microvascular and macrovascular complications as well as nondiabetic ocular disease. QoL questionnaires were administered to participants, their caregivers, and controls. Participants were followed up annually up to 3 years to determine the natural history of and trends in these conditions. SPSS Version 25.0 will be used for data analysis. Continuous and categorical data will be presented as mean (SD) and as percentages (%), respectively. t tests and analysis of variance will be used to compare means, and chi-square tests will be used to compare categorical data. Correlation, regression, and logistic regression analyses will be employed to establish linear associations and causal associations as appropriate. Relative risk and odds ratios will be used to estimate risk. QoL outcomes in Ghanaian children and adolescents with diabetes mellitus compared with caregivers and healthy controls will be assessed using the Pediatric Quality of Life inventory. Significance will be set at α=.05. RESULTS: Institutional approval from the Ethical and Protocol Review Committee of the University of Ghana Medical School was received on August 22, 2014 (Protocol Identification Number: MS-Et/M.12-P4.5/2013-2014). Funding for the project was received from the University of Ghana Research Fund (#UGRF/9/LMG-013/2015-2016) in March 2016. Patient recruitment, clinical examination, and data collection commenced in August 2016 and was completed in September 2019. A total of 58 children and adolescents with diabetes mellitus have been recruited. Blood samples were stored at -80 °C for analysis, which was completed at the end of July 2020. Data analysis is ongoing and will be completed by the end of December 2020. Investigators plan to submit the results for publication by the end of February 2021. CONCLUSIONS: The prevalence, natural history, trends in diabetic complications and nondiabetic ocular disease, and QoL will be provided. Our data may inform policies and interventions to improve care given to children and adolescents with diabetes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21440.

The autism-associated gene chromodomain helicase DNA-binding protein 8 (CHD8) regulates noncoding RNAs and autism-related genes.

Chromodomain helicase DNA-binding protein 8 (CHD8) was identified as a leading autism spectrum disorder (ASD) candidate gene by whole-exome sequencing and subsequent targeted-sequencing studies. De novo loss-of-function mutations were identified in 12 individuals with ASD and zero controls, accounting for a highly significant association. Small interfering RNA-mediated knockdown of CHD8 in human neural progenitor cells followed by RNA sequencing revealed that CHD8 insufficiency results in altered expression of 1715 genes, including both protein-coding and noncoding RNAs. Among the 10 most changed transcripts, 4 (40%) were noncoding RNAs. The transcriptional changes among protein-coding genes involved a highly interconnected network of genes that are enriched in neuronal development and in previously identified ASD candidate genes. These results suggest that CHD8 insufficiency may be a central hub in neuronal development and ASD risk.

Handwashing and glove use in a long-term-care facility.

OBJECTIVES: To determine glove use and handwashing practices, the factors associated with infection control practices, and the frequency of potential microbial transmission in a long-term-care facility (LTCF). DESIGN: Observational study of 230 staff-resident interactions in an LTCF. We recorded resident characteristics, type of activity, staff credentials, and movements of the staff member's hands, then used the LTCF's guidelines to judge appropriateness of glove use and handwashing. SETTING: 255-bed, university-based LTCF in Baltimore, Maryland. PARTICIPANTS: A systematic sample of staff-resident interactions. RESULTS: Gloves were worn in 139 (82%) of 170 interactions when indicated, but changed appropriately in only 1 (16%) of 132. Hands were washed when needed before an interaction in 27%, during an interaction in 0%, and after an interaction in 63%. Gloves were less likely to be used when caring for residents with gastrostomy tubes compared with other residents (relative risk, 0.85; 95% confidence interval, 0.73-0.98). Guidelines were followed more frequently during wound care than during other activities. Microbial transmission potentially could have occurred in 158 (82%) of 193 evaluable interactions. CONCLUSIONS: We documented marked deficiencies in glove and handwashing, demonstrated the possible impact of these deficiencies, and identified factors associated with inadequate handwashing and glove use. This information can be used in future educational and research efforts to improve infection control practices.

Effects of TRH on acoustic startle, conditioned fear and active avoidance in rats.

The effects of intracerebroventricular injection of thyrotropine-releasing hormone (TRH) on acoustic startle, conditioned fear and active avoidance were examined in rats. Acoustic startle was significantly depressed by 12.5 microg TRH, while increasing motor activity. In a fear-potentiated startle paradigm, 12.5 microg TRH reduced the overall startle response amplitude, but did not decrease the amount of fear-potentiated startle. When TRH was administered 15 min before contextual fear conditioning, neither fear-related freezing in acquisition nor in a retention test was affected. In contrast, when TRH was administered 15 min before the retention test, TRH significantly reduced mean percentage of time spent freezing. TRH had no effect on active avoidance. The results demonstrate that TRH decreased acoustic startle and freezing responses, but had little effect on fear conditioning and active avoidance. It is suggested that the results may be due to TRH's effects on motor activity and arousal, independent of its effects on fear.

Performance measures: are we measuring what matters?

BACKGROUND: The ultimate intent of healthcare performance measures is to improve health status by stimulating improvements to healthcare quality. This report evaluates how well current performance measurement sets address the leading causes of illness and death in the United States, using the Health Plan Employer Data and Information Set (HEDIS) as an example. METHODS: We assessed whether HEDIS measures exist for the leading causes of illness and death according to five commonly used indices: physiologic cause of death, underlying cause of death, disability-adjusted life years, healthcare expenditures, and missed work days. RESULTS: Fewer than one half of the leading causes of morbidity and mortality are addressed by current measures. CONCLUSIONS: The opportunities for using accurate and meaningful measurement for disease prevention and health promotion are substantial, yet this potential remains only partly realized and depends on further expansion of performance measurement efforts.

Assessment of health risk behaviors. A tool to inform consumers, providers, health care organizations, and purchasers.

INTRODUCTION: Tobacco use, diet and physical activity patterns, and alcohol use are the leading causes of death in the United States. To make major improvements in the health status of the population, behavioral risk factors for disease must be addressed. METHODS: We propose a brief survey of behavioral risk factors for enrollees of health care organizations, employer groups, or other adult populations that can be used to profile the health risk behaviors of a population, assess performance of prevention and risk reduction programs, or make comparisons with other populations. The survey contains questions about tobacco, diet, physical activity, alcohol, firearms, motor vehicle safety, sexual behavior, and drugs. RESULTS: Recommendations for survey items, implementation, and calculation of performance measures are given. CONCLUSIONS: Widespread adoption of this type of survey would be a major step forward in acknowledging the impact that behavior has on health and in furthering individual and organizational accountability for improving health risk behaviors.

Measuring clinical performance: comparison and validity of telephone survey and administrative data.

OBJECTIVE: To compare and validate self-reported telephone survey and administrative data for two Health Plan Employer Data and Information Set (HEDIS) performance measures: mammography and diabetic retinal exams. DATA SOURCES/STUDY SETTING: A telephone survey was administered to approximately 700 women and 600 persons with diabetes randomly chosen from each of two health maintenance organizations (HMOs). STUDY DESIGN: Agreement of survey and administrative data was assessed by using kappa coefficients. Validity measures were assessed by comparing survey and administrative data results to a standard: when the two sources agreed, that was accepted as the standard; when they differed, confirmatory information was sought from medical records to establish the standard. When confirmatory information was not available ranges of estimates consistent with the data were constructed by first assuming that all persons for whom no information was available had received the service and alternately that they had not received the service. PRINCIPAL FINDINGS: The kappas for mammography were .65 at both HMOs; for retinal exam they were .38 and .40. Sensitivity for both data sources was consistently high. However, specificity was lower for survey (range .44 to .66) than administrative data (.99 to 1.00). The positive predictive value was high for mammography using either data source but differed for retinal exam (survey .69 to .78; administrative data .99 to 1.00). CONCLUSIONS: Administrative and survey data performed consistently in both HMOs. Although administrative data appeared to have greater specificity than survey data the validity and utility of different data sources for performance measurement have only begun to be explored.

Synthesis of 10alpha-methoxy-delta8,9-lysergaldehyde from elymoclavine.

A new synthesis is described for 10alpha-methoxy-delta8,9-lysergaldehyde involving the oxidation of elymoclavine with manganese dioxide in methanol. Lysergol and agroclavine provide no reaction under the same conditions.

Do patients' ethnic and social factors influence the use of do-not-resuscitate orders?

OBJECTIVES: To determine whether ethnic and other social factors affect how frequently do-not-resuscitate (DNR) orders are written, the timing of DNR orders, or patient involvement in the DNR decision. DESIGN: Retrospective cohort. METHODS: Patients who died in one urban teaching hospital on the medicine, cardiology, or family practice service during 1988 were eligible; 288 were included in the analyses. Chi-square tests and logistic regression were used to examine frequency of DNR orders and patient involvement; analysis of variance and linear regression were used to examine timing of the DNR orders. RESULTS: Non-whites were more likely than whites to have DNR orders (OR 1.76; 95% CI, 1.09-2.84) but timing of the DNR order did not vary significantly by race/ethnicity. Patients who spoke English fluently were more likely to be involved in the DNR decision than those who did not (OR 1.28; 95% CI, 1.01-1.61). Patients with documented human immunodeficiency virus were more likely than uninfected patients to have DNR orders (OR 3.51; 95% CI, 1.36-9.02), to be involved in the decision (OR 10.11; 95% CI, 4.87-21.00); and to have DNR orders written earlier (P = 0.02). Alcoholic patients were more likely than non-alcoholics to have DNR orders (OR 1.17; 95% CI, 1.04-1.33). CONCLUSIONS: Ethnic and other social factors do appear to play a role in DNR decisions. It needs to be determined if these differences are due to patient preferences or clinician characteristics.

A profile of required third-year family medicine clerkships.

A survey was conducted of programs which reported requiring a third-year clerkship in family medicine in the 1988-89 AAMC Curriculum Directory to determine the characteristics of these 36 programs. The program characteristics were compared to those outlined by the STFM Task Force on Predoctoral Education in the 1981 monograph, Predoctoral Education in Family Medicine. Only one third of schools nationwide had a required family medicine clerkship; for 36 schools it was scheduled in the third year. Based on the information provided by the 25 (72%) of these 36 programs which responded, the third-year clerkship was likely to be a stand-alone, decentralized six- or eight-week rotation. The curricula were based on a set of "common problems" and emphasized those areas which separate family practice from other specialties. Students were most likely to be graded by faculty rating and a multiple choice examination. The curricula of the programs reviewed did reflect the recommendations of the Task Force, but there was great variability across programs.

A clinical performance assessment for a third-year required clerkship in family medicine.

BACKGROUND: In planning a new family medicine clerkship, a clinical performance examination (CPE) using focused encounters was included in the student evaluation. This format was believed to best reflect the types of experiences that students would be exposed to during the primarily ambulatory care family medicine clerkship. METHODS: Testing scenarios were representative of either the problem-based cases on which the curriculum had been developed or the 20 common problems seen in family medicine. To date, 175 students have taken the CPE, each completing two cases. RESULTS: The first year of experience indicates that there are no differences in student performance between periods and that students do not perform differently on the first case than they do on the second. No significant effect for scenarios was found. Examiner effects have been found, however. CONCLUSION: These effects suggest a need for further work in standardizing the scoring of the examination.

Mexican-American folk medicine: implications for the family physician.

Literature of Mexican-American folk medicine and on Mexican-American utilization of conventional medical services suggests that folk medicine and utilization of conventional medical services are related. This study reports on interviews with 40 Mexican-American families randomly selected from the community. The results indicate that choice of conventional medical care and/or folk medicine is dependent upon the symptom, that families often use both folk and conventional medicine, that they are more likely to seek medical help for anxiety than for depression, and that knowledge of folk medicine is best acquired by asking about specific folk diseases. These findings have application in family practice.

Evaluating elderly patients: a critique of comprehensive functional assessment tools.

The need for long-term planning and efficient usage of resources in the health care field necessitates approaching the elderly patient from a biopsychosocial point of view, facilitating a more complete approach to patient care. This article critiques tools available for the comprehensive functional evaluation of older patients, and identifies their effectiveness in improving specific aspects of patient outcomes. The Comprehensive Older Persons' Evaluation tool is described and compared with two other tools that evaluate a patient's functional and instrumental activities of daily living, as well as the medical, social and psychological aspects of the patient.

Abuse of elders: a review for Texas physicians.

Abuse of elders is a widespread but largely invisible problem in the United States. This problem and its detection, management, and prevention are described. Specific attention is directed toward risk factors for abuse and toward suggestive signs and symptoms. Texas laws and the physician's responsibility for reporting and intervening in cases of elder abuse are discussed. Strategies for intervention and prevention are outlined.

Standardized patients: a long-station clinical examination format.

Data from the first 20 periods of a long-station clinical performance examination for a 4-week required clerkship in family medicine were examined in order to assess the reliability and validity of the examination. Data from 304 students were examined for station, case scenario and examiner effects and results compared to short-station formats. A significant examiner effect was found but there were no differences in student performance for station or case scenario. These findings reflect examiner specificity cited in the literature for short station examinations, but not case specificity. The source of variability for this examination appears to be primarily examiner effect. There was a significant correlation between student scores on the two cases, and raters tended to rank order students similarly in spite of variability in mean rater score. Scores on the CPE correlated with other measures of clinical performance as well as other methods of student evaluation for the clerkship providing some evidence for construct and criterion-related validity. CPE cases were developed from clerkship objectives but examination of the test blueprint revealed some gaps in the extent to which the CPE covers the course content. CPE developers are working to increase interrater reliability through examiner training and further standardize case scenarios through check-lists and patient training. Additional cases are being developed to increase the content validity of the examination.

Time course and pattern of compensatory ingestive behavioral adjustments to lysine deficiency in rats.

We and others have demonstrated that rats deficient in an essential amino acid (EAA) will consume sufficient quantities of the lacking nutrient to produce repletion when it is made available in solution. In the current series of experiments, we made rats deficient in lysine (LYS) by limiting the level of this EAA in the diet. We then examined licking behavior during approximately 23-h two-bottle intake tests over 4 consecutive days. In three separate experiments, rats were presented with the following: 1) 0.1 mol/L LYS and water, 2) 0.2 mol/L threonine (THR) and water and 3) 0.1 mol/L LYS and 0.2 mol/L THR. Lysine-deficient (LYS-DEF) rats drink significantly more LYS than did nondepleted controls (CON) when this amino acid was available. Meal pattern analysis revealed that the enhanced intake of LYS occurred as a function of a greater number of ingestive bouts, not changes in bout size. A cumulative analysis of LYS intake between CON and LYS-DEF rats revealed that a potentiation of intake developed within 30 min of sampling the solution when LYS and water were available and within 90 min when LYS and THR were the contrasting choices. In conclusion, increased LYS intake in the deficient rats occurs relatively rapidly and appears to be at least somewhat specific. Moreover, LYS deficiency does not seem to enhance the palatability of the limiting amino acid as judged by behaviors such as lick rate and bout size. Instead, LYS-DEF rats relieve the deficiency by increasing the number of drinking episodes initiated.

What people really know about their health insurance: a comparison of information obtained from individuals and their insurers.

OBJECTIVES: This study determined the validity of self-reported data on selected health insurance characteristics. METHODS: We obtained telephone survey data on the presence of health insurance, source of insurance, length of time insured, and type of insurance (managed care or fee-for-service) from a random sample of 351 adults in 3 Wisconsin counties and compared findings with data from respondents' health insurers. RESULTS: More than 97% of the respondents correctly reported that they were currently insured. For source of insurance among persons aged 18 to 64 years, sensitivity was high for those covered through private health insurance (93.8%) but low for those covered through public insurance (6.7%). Only 33.1% of the respondents accurately categorized length of enrollment in their current plan. Overall estimates for managed care enrollment were similar for the 2 sources, but individual validity was low: 84.2% of those in fee-for-service believed that they were in managed care. CONCLUSIONS: Information obtained from the general population about whether they have health insurance is valid, but self-reported data on source of insurance, length of time insured, and type of insurance are suspect and should be used cautiously.