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Background: Group medical visits (GMV) have been shown to improve metrics in patients with type 2 diabetes mellitus (DM). Overlook Family Medicine, a teaching residency program, anticipated that medical residents trained in the GMV model of care by interdisciplinary team members may improve cholesterol, HbA1C, BMI, and blood pressure in patients. The objective of this study was to compare metrics between group 1: GMV patients with DM whose primary care provider (PCP) was an attending physician/nurse practitioner (NP) and group 2: GMV patients with DM whose PCP was a family medicine (FM) medical resident receiving GMV training. We seek to provide guidance on implementation of GMV in residency teaching practices. Methods: We performed a retrospective analysis to evaluate total cholesterol, LDL, HDL, TG, BMI, HbA1C, and BP in GMV patients between 2015-2018. We used a t test to compare outcomes between the two groups. Diabetes training was provided to family medicine residents by an interdisciplinary team. Results: There were 113 patients enrolled in the study: 53 in group 1 and 60 in group 2. There was a statistically significant decrease in LDL and triglycerides, and an increase in HDL in group 2 (P

CAD is the most common type of CVD which is characterized by deposits of lipids within the intima of the coronary artery. CAD is the leading cause of mortality and morbidity in many countries worldwide. The investigators adopted a quantitative approach to assess the knowledge on risk factors of CAD among patients in selected OPDs of M.O.S.C Medical College Hospital, Kolenchery. A descriptive design with non-probability convenience sampling technique was used. 120 clients who have given consent and shown willingness to participate were enrolled in the study. Data was collected by using demographic proforma, and structured knowledge questionnaire The data was analyzed using descriptive and inferential statistics. The collected data was organized tabulated and analyzed by descriptive [mean, median, mode and standard deviation] and inferential statistics [chi-square test]. The data revealed that the level of knowledge on risk factors of cad among subjects attending selected OPDs, out of 120 samples 30 (25%) have good knowledge, 85 (71%) have average knowledge and only 5 (4%) have poor knowledge. There was significant association between knowledge level and education whereas there was no significant association between age, sex, religion, income, marital status, occupation and food habit.

Objective The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care. Methods We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo. Results Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm. Conclusions Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

Educators want to assess learners using assessment processes that provide valid measures of learner ability. An ideal assessment tool would include items that are appropriate for assessing the target attributes. Ideal assessment results would accurately differentiate learners across the spectrum of ability, determine which learners satisfied the required standard and enable comparison between learner cohorts (e.g., across different years). Similar considerations are relevant to researchers who are designing or revising methods used to gather other kinds of assessment data, such as participant responses to surveys or clinical measurements of performance. Analysing assessment scores using Rasch analysis provides information about scores and the nature of each assessment item, and analysis output guides refinement of assessment. However, few health professional educators have published research that includes Rasch modelling methods. It may be that health professional educators find the language used to describe Rasch analysis to be somewhat impenetrable and that this has, to date, limited engagement in exploring applications for Rasch. In this paper, we lay out an overview of the potential benefits of Rasch analysis in health professional education and research.

Iron sulfur (Fe-S) proteins are essential and ubiquitous across all domains of life, yet the mechanisms underpinning assimilation of iron (Fe) and sulfur (S) and biogenesis of Fe-S clusters are poorly understood. This is particularly true for anaerobic methanogenic archaea, which are known to employ more Fe-S proteins than other prokaryotes. Here, we utilized a deep proteomics analysis of Methanococcus voltae A3 cultured in the presence of either synthetic pyrite (FeS

BACKGROUND Self-management programs have demonstrated significant health benefits in people with musculoskeletal diseases. AIM To examine the benefits of a tailored ankylosing spondylitis self-management program (ASSMP) delivered by trained health professionals for people with ankylosing spondylitis (AS) relative to health status, quality of life and disease activity. METHODS ASSMP was developed within a continuous quality improvement framework following a needs assessment and focus group discussions. Formal feedback from the group after each 6 week program cycle group by questionnaire helped refine the ASSMP. Patient health status, quality of life and disease activity were assessed at multiple time points up to 12 months. RESULTS Fifty-five percent were female; mean age 48.5 ± 15.2 years. Median time to AS diagnosis was 4 years (interquartile range: 1-10). AS disease activity Bath Ankylosing Spondylitis Global Score scores improved at 3, 6 and 12 months (P

With benefits such as environmentally safe treatment methods to stimulate growth, to increase plant yield, and improve disinfection efficiency, literature on the field of plasma treatment of seeds is growing. Generalized variables and success criteria have not been well correlated between studies, so this review paper serves to connect plasma and agriculture technologies to coordinate future efforts in this growing area of research. The authors have particular interest due to space agriculture, where seeds are sanitized before being sent into space for crop production. In order to supply a spectrum of nutritional needs, it is necessary to provide a variety of crops and ensure biological decontamination before the seeds are being sent into space. Traditional seed sanitization methods are not viable for all seed types, so exploration of other options is needed to expand the astronaut diet on long-duration space missions. This review paper brings together the current state-of-the-art reported literature to aide in understanding plasma seed application apparatus, seed or crop performance pertaining to germination, growth, water interactions, inactivation of bacteria, and surface sanitization results. These recent works include evolving research themes for potential seed treatment sanitization processes for various seed types to ensure the viability of plants for future growth in microgravity crop production systems.

Thrombin plays a central role in thromboinflammatory responses, but its activity is blocked in the common ex vivo human whole blood models, making an ex vivo study of thrombin effects on thromboinflammatory responses unfeasible. In this study, we exploited the anticoagulant peptide Gly-Pro-Arg-Pro (GPRP) that blocks fibrin polymerization to study the effects of thrombin on acute inflammation in response to Escherichia coli and Staphylococcus aureus. Human blood was anticoagulated with either GPRP or the thrombin inhibitor lepirudin and incubated with either E. coli or S. aureus for up to 4 h at 37°C. In GPRP-anticoagulated blood, there were spontaneous elevations in thrombin levels and platelet activation, which further increased in the presence of bacteria. Complement activation and the expression of activation markers on monocytes and granulocytes increased to the same extent in both blood models in response to bacteria. Most cytokines were not elevated in response to thrombin alone, but thrombin presence substantially and heterogeneously modulated several cytokines that increased in response to bacterial incubations. Bacterial-induced releases of IL-8, MIP-1α, and MIP-1β were potentiated in the thrombin-active GPRP model, whereas the levels of IP-10, TNF, IL-6, and IL-1β were elevated in the thrombin-inactive lepirudin model. Complement C5-blockade, combined with CD14 inhibition, reduced the overall cytokine release significantly, both in thrombin-active and thrombin-inactive models. Our data support that thrombin itself marginally induces leukocyte-dependent cytokine release in this isolated human whole blood but is a significant modulator of bacteria-induced inflammation by a differential effect on cytokine patterns.

COVID-19, caused by SARS-CoV-2, is a systemic illness due to its multiorgan effects in patients. The disease has a detrimental impact on respiratory and cardiovascular systems. One early symptom of infection is anosmia or lack of smell; this implicates the involvement of the olfactory bulb in COVID-19 disease and provides a route into the central nervous system. However, little is known about how SARS-CoV-2 affects neurological or psychological symptoms. SARS-CoV-2 exploits host receptors that converge on pathways that impact psychological symptoms. This systemic review discusses the ways involved by coronavirus infection and their impact on mental health disorders. We begin by briefly introducing the history of coronaviruses, followed by an overview of the essential proteins to viral entry. Then, we discuss the downstream effects of viral entry on host proteins. Finally, we review the literature on host factors that are known to play critical roles in neuropsychiatric symptoms and mental diseases and discuss how COVID-19 could impact mental health globally. Our review details the host factors and pathways involved in the cellular mechanisms, such as systemic inflammation, that play a significant role in the development of neuropsychological symptoms stemming from COVID-19 infection.

Thrombin plays a central role in thromboinflammatory responses, but its activity is blocked in the common ex vivo human whole blood models, making an ex vivo study of thrombin effects on thromboinflammatory responses unfeasible. In this study, we exploited the anticoagulant peptide Gly-Pro-Arg-Pro (GPRP) that blocks fibrin polymerization to study the effects of thrombin on acute inflammation in response to

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

BackgroundInsights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers?MethodsThe Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice,S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receiveS.A.F.E. Firearmmaterials, including training and cable locks. Half of the practices (k= 16) will be randomized to receive Nudge; the other half (k= 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to theS.A.F.E Firearmprogram. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning.DiscussionThe ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care.Trial registrationClinicalTrials.gov,NCT04844021. Registered 14 April 2021.

Archaeal methanogens, methanotrophs, and alkanotrophs have a high demand for iron (Fe) and sulfur (S); however, little is known of how they acquire, traffic, deploy, and store these elements. Here, we examined the distribution of homologs of proteins mediating key steps in Fe/S metabolism in model microorganisms, including iron(II) sensing/uptake (FeoAB), sulfide extraction from cysteine (SufS), and the biosynthesis of iron-sulfur [Fe-S] clusters (SufBCDE), siroheme (Pch2 dehydrogenase), protoheme (AhbABCD), cytochrome c (Cyt c) (CcmCF), and iron storage/detoxification (Bfr, FtrA, and IssA), among 326 publicly available, complete or metagenome-assembled genomes of archaeal methanogens/methanotrophs/alkanotrophs. The results indicate several prevalent but nonuniversal features, including FeoB, SufBC, and the biosynthetic apparatus for the basic tetrapyrrole scaffold, as well as its siroheme (and F430) derivatives. However, several early-diverging genomes lacked SufS and pathways to synthesize and deploy heme. Genomes encoding complete versus incomplete heme biosynthetic pathways exhibited equivalent prevalences of [Fe-S] cluster binding proteins, suggesting an expansion of catalytic capabilities rather than substitution of heme for [Fe-S] in the former group. Several strains with heme binding proteins lacked heme biosynthesis capabilities, while other strains with siroheme biosynthesis capability lacked homologs of known siroheme binding proteins, indicating heme auxotrophy and unknown siroheme biochemistry, respectively. While ferritin proteins involved in ferric oxide storage were widespread, those involved in storing Fe as thioferrate were unevenly distributed. Collectively, the results suggest that differences in the mechanisms of Fe and S acquisition, deployment, and storage have accompanied the diversification of methanogens/methanotrophs/alkanotrophs, possibly in response to differential availability of these elements as these organisms evolved. IMPORTANCE Archaeal methanogens, methanotrophs, and alkanotrophs, argued to be among the most ancient forms of life, have a high demand for iron (Fe) and sulfur (S) for cofactor biosynthesis, among other uses. Here, using comparative bioinformatic approaches applied to 326 genomes, we show that major differences in Fe/S acquisition, trafficking, deployment, and storage exist in this group. Variation in these characters was generally congruent with the phylogenetic placement of these genomes, indicating that variation in Fe/S usage and deployment has contributed to the diversification and ecology of these organisms. However, incongruency was observed among the distribution of cofactor biosynthesis pathways and known protein destinations for those cofactors, suggesting auxotrophy or yet-to-be-discovered pathways for cofactor biosynthesis.

OBJECTIVES: To estimate the serum folate insufficiency threshold (sf-IT) corresponding to the red blood cell (RBC) folate insufficiency threshold for optimal neural tube defect (NTD) prevention. METHODS: Participants were 977 women of reproductive age (WRA; 15–40y; not pregnant or lactating) from a population-based biomarker survey in Southern India. Venous blood samples were collected at enrollment. Plasma, serum, and red blood cells were centrifuged, processed, and stored < -80°C until batch analysis. Total vitamin B12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were measured using the World Health Organization-recommended microbiological assay. Vitamin B12 deficiency was defined as total vitamin B12

Background Women of reproductive age (WRA) are a high-risk population for anemia and micronutrient deficiencies. However, there are few representative population-level data from India, which could help inform evidence-based recommendations and policy. Objective To conduct a population-based biomarker survey of anemia and vitamin B-12 and folate status in WRA as part of a periconceptional surveillance program in southern India. Methods Participants were WRA (15–40 y) who were not pregnant or lactating. Whole blood (n = 979) was analyzed for hemoglobin via a Coulter counter (Coulter HMX). Plasma, serum, and RBCs were processed and stored at −80°C or less until batch analysis. Vitamin B-12 concentrations were measured via chemiluminescence; RBC and serum folate concentrations were evaluated via microbiological assay. Anemia and severe anemia were defined as hemoglobin

BackgroundComplement activation is a central mechanism in systemic inflammation and remote organ dysfunction following major trauma. Data on temporal changes of complement activation early after injury is largely missing. We aimed to describe in detail the kinetics of complement activation in individual trauma patients from admission to 10 days after injury, and the association with trauma characteristics and outcome.MethodsIn a prospective cohort of 136 trauma patients, plasma samples obtained with high time resolution (admission, 2, 4, 6, 8 h, and thereafter daily) were assessed for terminal complement complex (TCC). We studied individual TCC concentration curves and calculated a summary measure to obtain the accumulated TCC response 3 to 6 h after injury (TCC-AUC3–6). Correlation analyses and multivariable linear regression analyses were used to explore associations between individual patients’ admission TCC, TCC-AUC3–6, daily TCC during the intensive care unit stay, trauma characteristics, and predefined outcome measures.ResultsTCC concentration curves showed great variability in temporal shapes between individuals. However, the highest values were generally seen within the first 6 h after injury, before they subsided and remained elevated throughout the intensive care unit stay. Both admission TCC and TCC-AUC3–6correlated positively with New Injury Severity Score (Spearman’s rho,p-value 0.31, 0.0003 and 0.21, 0.02) and negatively with admission Base Excess (− 0.21, 0.02 and − 0.30, 0.001). Multivariable analyses confirmed that deranged physiology was an important predictor of complement activation. For patients without major head injury, admission TCC and TCC-AUC3–6were negatively associated with ventilator-free days. TCC-AUC3–6outperformed admission TCC as a predictor of Sequential Organ Failure Assessment score at day 0 and 4.ConclusionsComplement activation 3 to 6 h after injury was a better predictor of prolonged mechanical ventilation and multiple organ dysfunction syndrome than admission TCC. Our data suggest that the greatest surge of complement activation is found within the first 6 h after injury, and we argue that this time period should be in focus in the design of future experimental studies and clinical trials using complement inhibitors.

Thrombin activation of C5 connects thrombosis to inflammation. Complement research in whole blood ex vivo necessitates anticoagulation, which potentially interferes with the inflammatory modulation by thrombin. We challenged the concept of thrombin as an activator of native C5 by analyzing complement activation and C5 cleavage in human whole blood anticoagulated with Gly-Pro-Arg-Pro (GPRP), a peptide targeting fibrin polymerization downstream of thrombin, allowing complete endogenous thrombin generation. GPRP dose-dependently inhibited coagulation but allowed for platelet activation in accordance with thrombin generation. Spontaneous and bacterial-induced complement activation by Escherichia coli and Staphylococcus aureus, analyzed at the level of C3 and C5, were similar in blood anticoagulated with GPRP and the thrombin inhibitor lepirudin. In the GPRP model, endogenous thrombin, even at supra-physiologic concentrations, did not cleave native C5, despite efficiently cleaving commercially sourced purified C5 protein, both in buffer and when added to C5-deficient serum. In normal serum, only exogenously added, commercially sourced C5 was cleaved, whereas the native plasma C5 remained intact. Crucially, affinity-purified C5, eluted under mild conditions using an MgCl2 solution, was not cleaved by thrombin. Acidification of plasma to pH ≤ 6.8 by hydrochloric or lactic acid induced a C5 antigenic change, nonreversible by pH neutralization, that permitted cleavage by thrombin. Circular dichroism on purified C5 confirmed the structural change during acidification. Thus, we propose that pH-induced conformational change allows thrombin-mediated cleavage of C5 and that, contrary to previous reports, thrombin does not cleave plasma C5 in its native form, suggesting that thrombin cleavage of C5 may be restricted to certain pathophysiological conditions.

All cells need iron. Both too much and too little iron lead to diseases and unwanted outcomes., Iron is an essential micronutrient for life. In mammals, dietary iron is absorbed primarily in the small intestine. Currently, the impacts of dietary iron on the taxonomic structure and function of the gut microbiome and reciprocal effects on the animal host are not well understood. Here, we establish a mouse model of low-iron challenge in which intestinal biomarkers and reduced fecal iron reveal iron stress while serum iron and mouse behavioral markers indicate maintenance of iron homeostasis. We show that the diversity of the gut microbiome in conventional C57BL/6 mice changes dramatically during 2 weeks on a low-iron diet. We also show the effects of a low-iron diet on microbiome diversity are long lasting and not easily recovered when iron is returned to the diet. Finally, after optimizing taxon association methods, we show that some bacteria are unable to fully recover after the low-iron challenge and appear to be extirpated from the gut entirely. In particular, operational taxonomic units (OTUs) from the Prevotellaceae and Porphyromonadaceae families and Bacteroidales order are highly sensitive to low-iron conditions, while other seemingly insensitive OTUs recover. These results provide new insights into the iron requirements of gut microbiome members and add to the growing understanding of mammalian iron cycling. IMPORTANCE All cells need iron. Both too much and too little iron lead to diseases and unwanted outcomes. Although the impact of dietary iron on human cells and tissues has been well studied, there is currently a lack of understanding about how different levels of iron influence the abundant and diverse members of the human microbiome. This study develops a well-characterized mouse model for studying low-iron levels and identifies key groups of bacteria that are most affected. We found that the microbiome undergoes large changes when iron is removed from the diet but that many individual bacteria are able to rebound when iron levels are changed back to normal. That said, a select few members, referred to as iron-sensitive bacteria, seem to be lost. This study begins to identify individual members of the mammalian microbiome most affected by changes in dietary iron levels.

Patient: Male, 75-year-old Final Diagnosis: Cholangiocarcinoma Symptoms: Postoperative pain Medication:— Clinical Procedure: Continuous erector spinae nerve block Specialty: Oncology Objective: Unusual clinical course Background: Regional nerve blocks ideally provide safe and effective post-operative pain control, decrease opiate requirements, and enhance recovery from intense pain following major thoracic, abdominal, and musculoskeletal surgeries. The erector spinae plane block, a recently described novel treatment for chronic neuropathic pain and acute pain after thoracic surgery, can be performed with in plane infiltration and placement of a continuous infusion catheter deep to the erector spinae muscle at the tip of the transverse process, resulting in diffusion of local anesthetic between vertebrae and the paravertebral space with sensory blockade of spinal nerves as well as sympathetic branches. Case Report: We describe the novel use of the erector spinae block for primary pain control and uncomplicated catheter removal in the setting of anticoagulation following a major hepatectomy for intrahepatic cholangiocarcinoma. The use of the erector spinae block in this context provided effective post-operative analgesia. Conclusions: Additional evidence from clinical trials will be helpful to evaluate the role of this relatively new block for peri-operative analgesia.

The argument for integrating interprofessional education (IPE) activities into the workplace has been made concurrently with the call for collaborative clinical practice. An exploratory case study investigation of existing activities in a large metropolitan health care network was undertaken to inform the development of future IPE initiatives. Purposive sampling invited clinicians involved in the design or delivery of workplace IPE activities to participate in a semi-structured interview to discuss their existing programs and the opportunities and challenges facing future work. Interviews were audiotaped, transcribed and thematically analysed. In total, 15 clinicians were interviewed representing medicine, nursing, occupational therapy, pharmacy, physiotherapy, psychology, social work and speech pathology. The IPE programs identified included one medical and midwifery student workshop, several dedicated new graduate or intern programs combining the professions and multiple continuing professional development programs. Three dominant themes were identified to inform the development of future work: clinician factors, organisational factors and IPE considerations. In addition to the cultural, physical and logistical challenges associated with education that integrates professions in the workplace, the time required for the design and delivery of integrated team training should be accounted for when establishing such programs. Considerations for sustainability include ongoing investment in education skills for clinicians, establishment of dedicated education roles and expansion of existing education activities.