Digitally Inclusive, Healthy Aging Communities (DIHAC): A Cross-Cultural Study in Japan, Republic of Korea, Singapore, and Thailand.

One out of three people in Japan will be an older person before 2040. Half of those currently do not utilize the internet, smartphone apps, or digital technology. On the other hand, more than 70% of seniors in Republic of Korea use the internet, and 55% in Singapore had access to it in 2019. The use of digital technology for health promotion has the potential to promote individual and community empowerment, advocating for healthy, active aging. Maintaining equity in health promotion practice requires the digital inclusion of every senior. Therefore, we propose a cross-cultural study to explain the contextual influences of digital inclusion and its consequences on healthy aging in Japan, Korea, Singapore, and Thailand. Quantitatively: digital skills, e-health literacy, participation in health promotion, and quality of life will be analyzed in structural equation models. Qualitatively: thematic analysis will be developed to identify cultural patterns and contextual factors, making sense of what older persons in different countries materialize, say, do, think, and feel to reveal deeper beliefs and core values about digital inclusion and healthy aging. Logics and methods from this protocol would be useful to replicate the study in many countries globally. Evidence from this study is expected to pave the way to digitally inclusive, healthy aging communities (DIHAC) across Japan and Asia.

Graphene-Based Materials for the Fast Removal of Cytokines from Blood Plasma.

There is a range of medical conditions, which include acute organ failure, bacterial and viral infection, and sepsis, that result in overactivation of the inflammatory response of the organism and release of proinflammatory cytokines into the bloodstream. Fast removal of these cytokines from blood circulation could offer a potentially efficient treatment of such conditions. This study aims at the development and assessment of novel biocompatible graphene-based adsorbents for blood purification from proinflammatory cytokines. These graphene-based materials were chosen on the basis of their surface accessibility for small molecules further facilitated by the interlayer porosity, which is comparable to the size of the cytokine molecules to be adsorbed. Our preliminary results show that graphene nanoplatelets (GnP) exhibit high adsorption capacity, but they cannot be used in direct contact with blood due to the risk of small carbon particle release into the bloodstream. Granulation of GnP using poly(tetrafluoroethylene) as a binder eliminated an undesirable nanoparticle release without affecting the GnP surface accessibility for the cytokine molecules. The efficiency of proinflammatory cytokine removal was shown using a specially designed flow-through system. So far, GnP proved to be among the fastest acting and most efficient sorbents for cytokine removal identified to date, outperforming porous activated carbons and porous polymers.

The influence of lead content in drinking water, household dust, soil, and paint on blood lead levels of children in Flin Flon, Manitoba and Creighton, Saskatchewan.

Lead exposure continues to be an important health issue despite the general removal of lead sources in commercial and industrial applications. Low levels of lead exposure have been found to produce adverse neurodevelopmental effects in children with no evidence that a threshold exists for this critical endpoint. Blood lead levels (BLLs) were measured in children (n=118) under the age of 7years in the northern Canadian smelter community of Flin Flon, Manitoba and Creighton, Saskatchewan. An environmental sampling component was included to examine the relationship between lead content in outdoor soil, household dust, tap water, and paint within a given household and the corresponding BLLs in participating children. The geometric mean (GM) BLL for study participants was 1.41µg/dL. Blood lead levels varied slightly by age category with the lowest levels found among the children under age 2 (GM=1.11µg/dL) and the highest levels found among children between 2 and 3years of age (GM=1.98µg/dL). Results from the multivariate modeling indicated that BLLs had a significant positive association with the age of housing (p<0.05), with children living in households constructed prior to 1945 being more likely to have higher levels (p=0.034). Outdoor soil (GM=74.7µg/g), household dust from kitchen floors (GM=1.34µg/ft2), and maximum household lead paint were found to be significantly correlated (p<0.05) to BLLs. Although a statistically significant association between concentrations of lead in these household media and the corresponding BLLs exists, the variability in BLLs was poorly explained by these factors alone (r2=0.07, 0.12 and 0.06 for soil, household dust, and paint, respectively). Lead concentrations in flushed (GM=0.89µg/L) and stagnant (GM=2.07µg/L and 1.18µg/L) tap water samples were not significantly correlated (p>0.05) to BLLs.

Robustness and accuracy of feature-based single image 2-D-3-D registration without correspondences for image-guided intervention.

2-D-to-3-D registration is critical and fundamental in image-guided interventions. It could be achieved from single image using paired point correspondences between the object and the image. The common assumption that such correspondences can readily be established does not necessarily hold for image guided interventions. Intraoperative image clutter and an imperfect feature extraction method may introduce false detection and, due to the physics of X-ray imaging, the 2-D image point features may be indistinguishable from each other and/or obscured by anatomy causing false detection of the point features. These create difficulties in establishing correspondences between image features and 3-D data points. In this paper, we propose an accurate, robust, and fast method to accomplish 2-D-3-D registration using a single image without the need for establishing paired correspondences in the presence of false detection. We formulate 2-D-3-D registration as a maximum likelihood estimation problem, which is then solved by coupling expectation maximization with particle swarm optimization. The proposed method was evaluated in a phantom and a cadaver study. In the phantom study, it achieved subdegree rotation errors and submillimeter in-plane ( X- Y plane) translation errors. In both studies, it outperformed the state-of-the-art methods that do not use paired correspondences and achieved the same accuracy as a state-of-the-art global optimal method that uses correct paired correspondences.

Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo-sternotomy: a case report.

An 85-year-old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)-left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post-operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1-cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post-operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure.

National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries.

STUDY OBJECTIVE: We compare the association between barriers to timely primary care and emergency department (ED) utilization among adults with Medicaid versus private insurance. METHODS: We analyzed 230,258 adult participants of the 1999 to 2009 National Health Interview Survey. We evaluated the association between 5 specific barriers to timely primary care (unable to get through on telephone, unable to obtain appointment soon enough, long wait in the physician's office, limited clinic hours, lack of transportation) and ED utilization (≥1 ED visit during the past year) for Medicaid and private insurance beneficiaries. Multivariable logistic regression models adjusted for demographics, socioeconomic status, health conditions, outpatient care utilization, and survey year. RESULTS: Overall, 16.3% of Medicaid and 8.9% of private insurance beneficiaries had greater than or equal to 1 barrier to timely primary care. Compared with individuals with private insurance, Medicaid beneficiaries had higher ED utilization overall (39.6% versus 17.7%), particularly among those with barriers (51.3% versus 24.6% for 1 barrier and 61.2% versus 28.9% for ≥2 barriers). After adjusting for covariates, Medicaid beneficiaries were more likely to have barriers (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 1.30 to 1.52) and higher ED utilization (adjusted OR 1.48; 95% CI 1.41 to 1.56). ED utilization was even higher among Medicaid beneficiaries with 1 barrier (adjusted OR 1.66; 95% CI 1.44 to 1.92) or greater than or equal to 2 barriers (adjusted OR 2.01; 95% CI 1.72 to 2.35) compared with that for individuals with private insurance and barriers. CONCLUSION: Compared with individuals with private insurance, Medicaid beneficiaries were affected by more barriers to timely primary care and had higher associated ED utilization. Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.

Physiology and cell biology of acupuncture observed in calcium signaling activated by acoustic shear wave.

This article presents a novel model of acupuncture physiology based on cellular calcium activation by an acoustic shear wave (ASW) generated by the mechanical movement of the needle. An acupuncture needle was driven by a piezoelectric transducer at 100 Hz or below, and the ASW in human calf was imaged by magnetic resonance elastography. At the cell level, the ASW activated intracellular Ca(2+) transients and oscillations in fibroblasts and endothelial, ventricular myocytes and neuronal PC-12 cells along with frequency-amplitude tuning and memory capabilities. Monitoring in vivo mammalian experiments with ASW, enhancement of endorphin in blood plasma and blocking by Gd(3+) were observed; and increased Ca(2+) fluorescence in mouse hind leg muscle was imaged by two-photon microscopy. In contrast with traditional acupuncture models, the signal source is derived from the total acoustic energy. ASW signaling makes use of the anisotropy of elasticity of tissues as its waveguides for transmission and that cell activation is not based on the nervous system.

Ability of physicians to diagnose congestive heart failure based on chest X-ray.

BACKGROUND: Chest X-ray interpretation is an important skill in the diagnosis of congestive heart failure (CHF) by emergency physicians. OBJECTIVES: This study evaluated the ability of emergency physicians to recognize CHF on chest X-ray and the effect of level of training and confidence upon accuracy of interpretation. METHODS: This was a prospective, blinded study in which 24 patients with an elevated brain natriuretic peptide, low ejection fraction, and diagnosis of CHF were retrospectively identified. In addition, 31 patients without CHF were identified and used as controls. These 55 chest X-rays were presented to emergency attending and housestaff and a radiologist. We calculated the accuracy of the raters' diagnoses, and measured their confidence in that diagnosis and their level of training. RESULTS: Physicians correctly identified the CHF chest X-rays 79% of the time (sensitivity 59%, specificity 96%; positive likelihood ratio 14.6, negative likelihood ratio 0.43). Accuracy ranged from a low of 78% among first-year residents to a high of 85% among attending, and from 73% (confidence rating of 3/5) to 91% (confidence rating of 5/5). Increasing confidence was significantly correlated with accuracy across the spectrum (p = 0.001). An accuracy of 95% among radiologists suggests that a negative X-ray does not rule out CHF. CONCLUSIONS: High specificity (96%) and low sensitivity (59%) suggest that emergency physicians are excellent at identifying CHF on X-ray when present, but under-call it frequently. Sensitivity may be much higher in real life given clinical correlation. Both increased level of training and higher confidence significantly improved accuracy.

Emergency department control of blood pressure in intracerebral hemorrhage.

BACKGROUND: Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. STUDY OBJECTIVE: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED). METHODS: A single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100-110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. RESULTS: A total of 22 patients were enrolled over a 1-year study period. The average time to achieve our target MAP after implementation of our protocol was 123 min (range 19-297 min). The average time to arterial line placement was 84 min (range 36-160 min). Overall, 77% of the patients tolerated the 24-h protocol. The in-hospital mortality rate in this group of patients was 41%. CONCLUSIONS: Adopting a protocol to reduce and maintain the MAP to a target of 100-110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.

A pilot study to develop a prediction instrument for endocarditis in injection drug users admitted with fever.

OBJECTIVE: Seeking to evaluate the feasibility of a prediction instrument for endocarditis in febrile injection drug users (IDUs), we determined (1) the frequency percentage of IDUs admitted with fever diagnosed with endocarditis and (2) whether individual or combinations of emergency department (ED) clinical criteria (patient history, physical examination findings, and laboratory tests) are associated with endocarditis in IDUs admitted to rule out endocarditis. METHODS: The ED and inpatient charts of all IDUs with a diagnosis of rule out endocarditis admitted at 3 urban hospitals in 2006 were reviewed. Screening performance of individual criteria was determined, and the most sensitive combination of criteria was derived by classification tree analysis. RESULTS: Of 236 IDUs admitted with fever, 20 (8.5%) were diagnosed with endocarditis. Lack of skin infection, tachycardia, hyponatremia, pneumonia on chest radiograph, history of endocarditis, thrombocytopenia, and heart murmur had the best screening performance. The classification tree-derived best criteria combination of tachycardia, lack of skin infection, and cardiac murmur had a sensitivity of 100% (95% confidence interval, 84%-100%) and negative predictive value of 100% (95% confidence interval, 88%-100%). CONCLUSIONS: Using ED clinical criteria, a multicenter prospective study to develop an instrument for endocarditis prediction in febrile IDUs is feasible, with an estimated target enrollment of 588 patients.

Anti-inflammatory activity of azithromycin as measured by its NF-kappaB, inhibitory activity.

Growing data suggest that the antibiotic azithromycin mediates anti-inflammatory activity through the inhibition of the transcription factor NF-kappaB. The purpose of this study was to compare azithromycin's anti-inflammatory potency with that of hydrocortisone and dexamethasone as measured in an activated NF-kappaB assay. Dose-response curves and the corresponding inhibitory potencies (IC(50)) of azithromycin, hydrocortisone, and dexamethasone were evaluated in a fluorescence assay using A549 cells. All three compounds inhibited TNFalpha stimulated NF-kappaB activity in a dose-dependent manner. IC(50) values of azithromycin, hydrocortisone and dexamethasone were 56 microM, 2.6 nM, and 0.18 nM, respectively. Hydrocortisone was approximately 4 orders of magnitude more potent than azithromycin, while dexamethasone was approximately 14 times as potent as hydrocortisone. In relative terms the anti-inflammatory potency of azithromycin was about 4 orders of magnitude weaker than that of hydrocortisone.

A comparison of HIV testing in the emergency department and urgent care.

BACKGROUND: Although national guidelines recommend universal human immunodeficiency virus (HIV) testing, emergency departments (EDs) may choose to limit testing to certain patients, such as those triaged to urgent care (UC). OBJECTIVE: To compare the results of rapid HIV testing in an urban ED with an affiliated UC. METHODS: This was a retrospective analysis of an HIV testing program that included screening, which was initiated by triage nurses, and diagnostic testing, which was initiated by clinicians. Eligible patients were ≥ 12 years old and medically stable. RESULTS: From April 2005 through December 2006, HIV tests were completed in 6196 (8.3%) of the 74,331 ED visits and 3256 (8.8%) of the 37,169 UC visits. Screening accounted for 5009 (80.8%) of the ED tests and 2914 (89.5%) of the UC tests, and diagnostic testing accounted for the remainder. Eighty (1.3%) of the ED tests and 21 (0.6%) of the UC tests were positive (p = 0.0024). Compared with newly diagnosed HIV-positive ED patients, HIV-positive UC patients were less likely to have CD4 counts < 200 cells/µL (adjusted odds ratio 0.19, 95% confidence interval 0.05-0.65). CONCLUSION: Although the yield of HIV testing is greater among ED patients, UC patients are diagnosed at a less advanced stage of illness.

Chlamydophila pneumoniae infection leads to smooth muscle cell proliferation and thickening in the coronary artery without contributions from a host immune response.

Chlamydophila pneumonia (C. pneumonia) infection has been associated with the progression of atherosclerosis. It remains unclear, however, whether C. pneumoniae in the absence of an immune response can alone initiate atherogenic events within a complex vessel environment. Left anterior descending coronary arteries isolated from porcine hearts were dissected and placed in culture medium for 72 hours before infection with C. pneumoniae. C. pneumoniae replicated within the arterial wall for the duration of the experiment (up to 10 days). A significant increase in chlamydial-HSP60 protein expression from day 2 to 10 post-infection (pi) indicated the presence of metabolically active C. pneumonia within infected vessels. Significant arterial thickening in infected coronary segments was observed by a considerable decrease in the ratio of lumen to total vessel area (48 +/- 3% at day 4 pi versus 23 +/- 3% at day 10 pi) and a significant increase in the ratio of media to luminal area (113 +/- 16% at day 4 pi versus 365 +/- 65% at day 10 pi). Structural changes were accompanied by an up-regulation of host HSP60 and proliferating cell nuclear antigen expression levels. Immunohistochemical staining confirmed proliferating cell nuclear antigen expression to be primarily localized within smooth muscle cells of the medial area. These results demonstrate that C. pneumoniae infection can stimulate arterial thickening in a complex vessel environment without the presence of a host immune response and further supports the involvement of HSP60 in this action.

Ocular pharmacokinetics of AzaSite Xtra-2% azithromycin formulated in a DuraSite delivery system.

PURPOSE: The pharmacokinetics of a 2% ocular solution of azithromycin in DuraSite was evaluated in rabbits to determine whether the PK/PD parameters support a once-a-day for three-day therapeutic regimen against bacterial conjunctivitis. MATERIALS AND METHODS: Mean levels of azithromycin were determined in tears, bulbar conjunctiva, cornea, and plasma following a single drop of 2% azithromycin. The levels were determined by HPLC-MS. RESULTS: Concentrations of azithromycin peaked at 30 minutes. At the end of 24 hours, ocular tissue concentrations exceeded the MIC breakpoint for the most common causative pathogens of bacterial conjunctivitis by at least 7-fold. CONCLUSION: The PK/PD profile of 2% azithromycin suggests efficacy against common causative bacteria with just one dose per day for three days.

Infection control, ethics and accountability.

Health care-associated infections (HAIs) are a major clinical and economic problem in Australian hospitals, and a significant proportion are preventable. HAIs are the result of complex environmental, microbiological, pathological, behavioural and organisational factors, and prevention requires a multifaceted ("bundled") approach, including appropriate policies, educational programs for health care workers, and adequate resources to implement them effectively. Failure to protect patients from avoidable harm, including HAIs, has significant ethical implications; it often reflects both organisational systems failure and non-compliance of health care workers with evidence-based policies, including hand hygiene. If implemented with appropriate safeguards, infection control "bundles" that include sanctions for poor compliance with hand hygiene and other infection control policies, will achieve sustained improvements where previous approaches have failed.

Is the ordering of imaging for suspected venous thromboembolism consistent with D-dimer result?

STUDY OBJECTIVE: We assessed whether the ordering of imaging studies in patients with suspected venous thromboembolism was consistent with the results of D-dimer testing. METHODS: We performed a retrospective chart review of consecutive cases in which a D-dimer assay was performed at an urban academic emergency department during a 13-month period. Measurements included D-dimer result and results of imaging for venous thromboembolism. The primary outcome measure was the percentage of patients in each D-dimer category (positive or negative result with a cutoff value of 500 ng fibrinogen equivalent units/dL) who underwent subsequent imaging within 48 hours. We also report the results of the imaging studies obtained. RESULTS: A total of 553 D-dimer tests were ordered, with 266 (48.1%) negative and 287 (51.9%) positive results. Of patients with a negative D-dimer result, 37 (14%; 95% confidence interval [CI] 10% to 19%) underwent at least 1 imaging study. Of patients with a positive D-dimer result, 137 (48%; 95% CI 42% to 54%) did not undergo imaging. CONCLUSION: Evaluation for venous thromboembolism occasionally proceeded despite a negative D-dimer result, whereas frequently no further evaluation occurred despite a positive result. These findings suggest that actual clinical practice differs from what is recommended by published algorithms that guide evaluation of patients with suspected venous thromboembolism.

Vessel extraction under non-uniform illumination: a level set approach.

Vessel extraction is one of the critical tasks in clinical practice. This communication presents a new approach for vessel extraction using a level-set-based active contour by defining a novel local term that takes local image contrast into account. The proposed model not only preserves the performance of the existing models on blurry images, but also overcomes their inability to handle nonuniform illumination. The efficacy of the approach is demonstrated with experiments involving both synthetic images and clinical angiograms.

Ceramide regulation of nuclear protein import.

Nucleocytoplasmic trafficking is an essential and responsive cellular mechanism that directly affects cell growth and proliferation, and its potential to address metabolic challenge is incompletely defined. Ceramide is an antiproliferative sphingolipid found within vascular smooth muscle cells in atherosclerotic plaques, but its mechanism of action remains unclear. The hypothesis that ceramide inhibits cell growth through nuclear transport regulation was tested. In smooth muscle cells, exogenously supplemented ceramide inhibited classical nuclear protein import that involved the activation of cytosolic p38 mitogen-activated protein kinase (MAPK). After application of SB 202190, a specific and potent pharmacological antagonist of p38 MAPK, sphingolipid impingement on nuclear transport was corrected. Distribution pattern assessments of two essential nuclear transport proteins, importin-alpha and Cellular Apoptosis Susceptibility, revealed ceramide-mediated relocalization that was reversed upon the addition of SB 202190. Furthermore, cell counts, nuclear cyclin A, and proliferating cell nuclear antigen expression, markers of cellular proliferation, were diminished after ceramide treatment and effectively rescued by the addition of inhibitor. Together, these data demonstrate, for the first time, the sphingolipid regulation of nuclear import that defines and expands the adaptive capacity of the nucleocytoplasmic transport machinery.