Preparedness and response of assisted living facilities toward COVID-19 infection control in Houston, Texas, USA.

Background: Long-term care facilities (LTCFs) including assisted living facilities (ALFs) are hubs for high transmission and poor prognosis of COVID-19 among the residents who are more susceptible due to old age and comorbidities. Aim: Houston Health Department conducted assessments of ALFs within the City of Houston to determine preparedness and existing preventive measures at the facilities. Methods: Onsite assessments were conducted at ALFs using a modified CDC Infection Control Assessment and Response (ICAR) Tool. Data was obtained on IPC measures, training, testing, vaccination etc. Data was analyzed, frequencies generated, and bivariate associations determined. Results: A total of 118 facilities were assessed and categorized into small scale 46 (39%), medium scale 47 (40%), and large scale 25 (21%). The facilities had 2431 residents and 2290 staff. Thirty-one (26%) facilities reported an outbreak in 2020, while 14 (12%) had an ongoing outbreak. Twenty-three (97%) large-scale and 12 (26%) small-scale facilities had COVID-19 testing program. Vaccination coverage among residents ranged from 99% in large-scale to 40% in small-scale facilities but was smaller among staff at 748 (45%) in large scale, 71 (36%) in small scale, and 193 (45%) in medium scale. While 24 (96%) large-scale and 34 (77%) of small-scale facilities conducted staff training staff on IPC practices, 22 (92%) of large-scale and 19 (56%) of small-scale facility staff demonstrated capacity (p = 0.01), respectively. Visitor screening was done at 100% of large-scale and 80% of small-scale and the medium-scale ALFs. Discussion: Assisted living facilities within the city of Houston are at various levels of preparedness and interventions with respect to COVID-19 response.

Comparison of young male mice of two different strains (C57BL/6J and the hybrid B6129SF1/J) in selected behavior tests: a small scale study.

BACKGROUND: All mouse strains are different, before choosing a strain for a large study, a small scale study should be done. In this study, we compared young males of two mouse strains, C57BL/6J and the hybrid B6129SF1/J, and gained knowledge on their performance in three different behavioral tests; open field (OF) test, Barnes maze (BM) test and a restraint stress test. RESULTS: We found that the young males of the C57BL/6J strain spent more time moving in the OF. In the BM, the hybrid covered less ground before reaching the goal box during the first three sessions, than the C57BL/6J. The hybrid left more fecal pellets than C57BL/6J both in OF and BM. During the stress test, the C57BL/6J had a lower corticosterone response than the hybrid. CONCLUSIONS: Our findings indicate that the C57BL/6J has a presumably higher locomotor activity and/or explorative behavior than the hybrid, while the hybrid appeared more sensitive to stress.

Efficacy of contralaterally controlled functional electrical stimulation compared to cyclic neuromuscular electrical stimulation and task-oriented training for recovery of hand function after stroke: study protocol for a multi-site randomized controlled trial.

BACKGROUND: Multi-site studies in stroke rehabilitation are important for determining whether a technology and/or treatment can be successfully administered by sites other than the originating site and with similar positive outcomes. This study is the first multi-site clinical trial of a novel intervention for post-stroke upper limb rehabilitation called contralaterally controlled functional electrical stimulation (CCFES). Previous pilot and single-site studies showed positive effects of CCFES on upper limb impairment and hand dexterity in stroke survivors. The main purpose of this study is to confirm and demonstrate the efficacy of CCFES in a larger group of most likely responders across multiple clinical sites. METHODS: Up to 129 stroke survivors with moderate to severe upper extremity hemiparesis at 4 clinical trial sites will be randomized to CCFES, cyclic neuromuscular electrical stimulation (cNMES), or task-oriented-training (TOT). Participants will receive 12 weeks of group-specific therapy. Blinded assessments of upper limb impairment and activity limitation, quality of life, and neurophysiology will be used to compare outcomes at baseline, after treatment, and up to 6 months post-treatment. The primary endpoint is change in dexterity from baseline to 6 months post-treatment. DISCUSSION: Loss of hand function following stroke is a major rehabilitation problem affecting millions of people per year globally. More effective rehabilitation therapies are needed to restore hand function in these individuals. This study will determine whether CCFES therapy produces greater improvements in upper extremity function than cNMES or TOT, and will begin to elucidate the different mechanisms underlying each of the three treatments. This multi-site study is a critical step in advancing a novel method of rehabilitation toward clinical translation and widespread dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT03574623 . Registered prior to first enrollment; July 2, 2018.

Maternal exposure to a human based mixture of persistent organic pollutants (POPs) affect gene expression related to brain function in mice offspring hippocampus.

Male and female mice pups were exposed to a low and high dose of a human relevant mixture of persistent organic pollutants (POPs) during pregnancy and lactation. Most compounds detected in the dams were found in offspring brains. The mice offspring exhibited changed expression of hippocampal genes involved in cognitive function (Adora2a, Auts2, Crlf1, Chrnb2, Gdnf, Gnal, Kcnh3), neuroinflammation (Cd47, Il1a), circadian rhythm (Per1, Clock), redox signalling (Hmox2) and aryl hydrocarbon receptor activation (Cyp1b1). A few genes were differentially expressed in males versus females. Mostly, similar patterns of gene expression changes were observed between the low and high dose groups. Effects on learning and memory function measured in the Barnes maze (not moving, escape latency) were found in the high dose group when combined with moderate stress exposure (air flow from a fan). Mediation analysis indicated adaptation to the effects of exposure since gene expression compensated for learning disabilities (escape latency, walking distance and time spent not moving in the maze). Additionally, random forest analysis indicated that Kcnh3, Gnal, and Crlf1 were the most important genes for escape latency, while Hip1, Gnal and the low exposure level were the most important explanatory factors for passive behaviour (not moving). Altogether, this study showed transfer of POPs to the offspring brains after maternal exposure, modulating the expression level of genes involved in brain function.

The DANish randomized, double-blind, placebo controlled trial in patients with chronic HEART failure (DANHEART): A 2 × 2 factorial trial of hydralazine-isosorbide dinitrate in patients with chronic heart failure (H-HeFT) and metformin in patients with chronic heart failure and diabetes or prediabetes (Met-HeFT).

OBJECTIVES: The DANHEART trial is a multicenter, randomized (1:1), parallel-group, double-blind, placebo-controlled study in chronic heart failure patients with reduced ejection fraction (HFrEF). This investigator driven study will include 1500 HFrEF patients and test in a 2 × 2 factorial design: 1) if hydralazine-isosorbide dinitrate reduces the incidence of death and hospitalization with worsening heart failure vs. placebo (H-HeFT) and 2) if metformin reduces the incidence of death, worsening heart failure, acute myocardial infarction, and stroke vs. placebo in patients with diabetes or prediabetes (Met-HeFT). METHODS: Symptomatic, optimally treated HFrEF patients with LVEF ≤40% are randomized to active vs. placebo treatment. Patients can be randomized in either both H-HeFT and Met-HeFT or to only one of these study arms. In this event-driven study, it is anticipated that 1300 patients should be included in H-HeFT and 1100 in Met-HeFT and followed for an average of 4 years. RESULTS: As of May 2020, 296 patients have been randomized at 20 centers in Denmark. CONCLUSION: The H-HeFT and Met-HeFT studies will yield new knowledge about the potential benefit and safety of 2 commonly prescribed drugs with limited randomized data in patients with HFrEF.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain.

BACKGROUND: Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS: This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION: This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Convergent Validity and Responsiveness of the SULCS.

OBJECTIVE: To evaluate the convergent validity and responsiveness of the Stroke Upper Limb Capacity Scale (SULCS) in comparison to the Arm Motor Ability Test (AMAT), the Box and Blocks Test (BBT), and the upper limb Fugl-Meyer Assessment (FMA). The SULCS is a relatively new measure that was designed to be easier to score and less time consuming than some existing measures. DESIGN: Prospective repeated-measures design. SETTING: Clinical research laboratory of a large public hospital. PARTICIPANTS: Patients (N=61) <2 years poststroke with moderate to severe upper limb hemiparesis. INTERVENTION: Participants received 12 weeks of therapy that included neuromuscular electrical stimulation of the paretic finger and thumb extensors. The SULCS, AMAT, BBT, and FMA were administered at weeks 0, 6, 12 (end of therapy), 20, 28, and 36 (6mo post-therapy). MAIN OUTCOME MEASURES: Convergent validity was evaluated with Spearman's correlation coefficients between pairs of measures at each time point. Responsiveness from 0 to 12 weeks and 0 to 36 weeks was evaluated with the standardized response mean (SRM). RESULTS: The SULCS demonstrated strong correlation with the AMAT (ρ=0.81-0.93), BBT (ρ=0.73-0.92), and FMA (ρ=0.78-0.92), at all 6 time points. All 4 measures had moderate to large SRMs (SULCS, 0.71-0.77; AMAT, 0.83-0.97; BBT, 0.73-0.82; FMA, 0.75-0.76). There was no significant difference in responsiveness among the 4 measures. CONCLUSIONS: The results support the use of the SULCS to measure upper limb capacity in patients who are less than 2 years poststroke with moderate to severe hemiplegia.

Production of tetravalent dengue virus envelope protein domain III based antigens in lettuce chloroplasts and immunologic analysis for future oral vaccine development.

Dengue fever is a mosquito (Aedes aegypti) -transmitted viral disease that is endemic in more than 125 countries around the world. There are four serotypes of the dengue virus (DENV 1-4) and a safe and effective dengue vaccine must provide protection against all four serotypes. To date, the first vaccine, Dengvaxia (CYD-TDV), is available after many decades' efforts, but only has moderate efficacy. More effective and affordable vaccines are hence required. Plants offer promising vaccine production platforms and food crops offer additional advantages for the production of edible human and animal vaccines, thus eliminating the need for expensive fermentation, purification, cold storage and sterile delivery. Oral vaccines can elicit humoural and cellular immunity via both the mucosal and humoral immune systems. Here, we report the production of tetravalent EDIII antigen (EDIII-1-4) in stably transformed lettuce chloroplasts. Transplastomic EDIII-1-4-expressing lettuce lines were obtained and homoplasmy was verified by Southern blot analysis. Expression of EDIII-1-4 antigens was demonstrated by immunoblotting, with the EDIII-1-4 antigen accumulating to 3.45% of the total protein content. Immunological assays in rabbits showed immunogenicity of EDIII-1-4. Our in vitro gastrointestinal digestion analysis revealed that EDIII-1-4 antigens are well protected when passing through the oral and gastric digestion phases but underwent degradation during the intestinal phase. Our results demonstrate that lettuce chloroplast engineering is a promising approach for future production of an affordable oral dengue vaccine.

A human exposure based mixture of persistent organic pollutants affects the stress response in female mice and their offspring.

Persistent organic pollutants (POPs) are found in the food chain of both humans and animals and exert a wide spectrum of potentially adverse effects. The present experiment aimed to investigate whether a defined mixture of 29 POPs, based on the dietary intake of Scandinavians, could affect the stress response in female mice exposed through ingestion, and in their offspring. Female mice 129:C57BL/6F0 hybrids were exposed from weaning, throughout pregnancy, and up until necropsy, to either 5000 × or 100 000 × the estimated daily intake for Scandinavians. The offspring were fed a reference diet containing no POPs. Both the mothers and their offspring were tested for basal and stress responsive corticosterone levels, and in an open field test to measure locomotor activity and anxiety-like behaviours. We found mothers to have elevated basal corticosterone levels, as well as a prolonged stress response following POP exposure. In the offspring, there was no effect of POPs on the stress response in females, but the exposed males had an over-sensitised stress response. There was no effect on behaviour in either the mothers or the offspring. In conclusion, we found a human relevant POP mixture can lead to subtle dysregulation of the hypothalamus-pituitary-adrenal axis in mice. As HPA axis dysregulation is commonly associated with neurological disorders, further studies should explore the relevance of this outcome for humans.

PREPARE: guidelines for planning animal research and testing.

There is widespread concern about the quality, reproducibility and translatability of studies involving research animals. Although there are a number of reporting guidelines available, there is very little overarching guidance on how to plan animal experiments, despite the fact that this is the logical place to start ensuring quality. In this paper we present the PREPARE guidelines: Planning Research and Experimental Procedures on Animals: Recommendations for Excellence. PREPARE covers the three broad areas which determine the quality of the preparation for animal studies: formulation, dialogue between scientists and the animal facility, and quality control of the various components in the study. Some topics overlap and the PREPARE checklist should be adapted to suit specific needs, for example in field research. Advice on use of the checklist is available on the Norecopa website, with links to guidelines for animal research and testing, at https://norecopa.no/PREPARE .

[Medical tourism and its implications for patients and hospital services throughout the world].

This article provides a snapshot of global medical tourism and its positive and negative implications for healthcare around the world presented through selected examples. Medical tourism is an old phenomenon which has seen a rapid increase due to global technological advances thus enabling people to receive treatment anywhere in the world, often combined with a tropical vacation. Treatments are of a non-acute, voluntary nature and are driven largely by high prices and long waiting lists at the home countries and low prices and high service quality at the destination country.

The utility of a "trauma 1 OP" activation at a level 1 pediatric trauma center.

PURPOSE: To expedite flow of injured children suspected to require operative intervention, a "trauma 1 OP" (T1OP) activation classification was created. The purpose of this study was to review this strategy at a level 1 pediatric trauma center. METHODS: A retrospective review of T1OP activations between 2003 and 2015 was performed. Children suspected of requiring neurosurgical intervention were classified as trauma 1 OP neuro (T1OP(N)). Comparisons were made to trauma 1 (T1) patients who required emergent operative intervention, excluding orthopedic injuries. RESULTS: Overall, 461 T1OP activations occurred (72% T1OP(N)) compared to 129 T1 activations requiring emergent surgery. Demographics were not significantly different between groups, although T1OP patients were slightly younger and more often experienced falls or were victims of abuse. Compared to T1 activations, T1OP activations had a significantly higher mortality rate (21% vs. 7%, p<0.001). Repeat head imaging was more common in the T1OP(N) group compared to imaged children in the T1 group (20% vs. 37%, p=0.05). T1OP(N) patients more often went directly to the OR (45% vs. 33%, p=0.02) and did so in a significantly faster period of time (32min vs. 53min, p<0.001). CONCLUSIONS: Use of the T1OP activations appropriately triaged surgical patients, resulting in significantly faster transport times to the OR. LEVEL OF EVIDENCE: II, prognosis study.

Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center.

OBJECTIVE: The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport. METHODS: Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time. RESULTS: Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91). CONCLUSION: Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

Contrast blush in pediatric blunt splenic trauma does not warrant the routine use of angiography and embolization.

BACKGROUND: Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. METHODS: A retrospective review was conducted of all children (<18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean ± standard error of mean. RESULTS: Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. CONCLUSION: Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management.

Vascular injury is associated with increased mortality in winter sports trauma.

BACKGROUND: Trauma is the leading cause of injury and death for individuals aged 1-44 years. Up to 8% of the US population participates in winter sports, and although vascular injuries are uncommon in these activities, little is published in this area. We sought to identify the incidence, injury patterns, and outcomes of vascular injuries resulting from winter sports trauma. METHODS: Patients with winter sports trauma and the subset with vascular injuries were identified by accessing the National Trauma Data Bank querying years 2007-2010. Patients with and without vascular injuries were then compared. Admission variables included transport time, emergency department hypotension (systolic blood pressure < 90), Glasgow Coma Scale ≤ 8, Injury Severity Score ≥ 25, fractures, solid organ injury, and vascular injury. Outcomes were analyzed and associations with vascular injuries were determined. RESULTS: A total of 2,298 patients were identified with winter sports-related trauma and 28 (1.2%) had associated vascular injuries. Overall, the top 3 injuries were head trauma (16.7%), thoracic vertebral fractures (5.5%), and lumbar vertebral fractures (5.1%). The most common associated vascular injures were to the popliteal artery (17.7%), splenic artery (14.7%), and brachial blood vessels (14.7%). In the entire cohort, 1 patient (0.04%) suffered an amputation and 15 patients (0.7%) died. There were no amputations in the vascular injury group. Mortality was 0.6% in patients without a vascular injury compared with 7.1% of those with a vascular injury (P = 0.01). CONCLUSIONS: Although vascular injury is an uncommon associated finding in winter sports trauma, it is associated with a significant increase in mortality. These findings highlight the need for rapid identification of traumatic vascular injuries, which predicts worse overall outcomes in this patient population.

The impact of mesh fixation with a collagen-fibrin sealant in a murine ventral hernia model.

INTRODUCTION: Pain and adhesions represent the challenge in hernia surgery. AIM: To investigate mesh fixation and adhesion prevention with a collagen-fibrin sealant. MATERIALS AND METHODS: Twenty-seven male Sprague-Dawley rats were operated twice, to create and repair 2 ventral hernias. Mesh fixation was with collagen-fibrin sealant on 1 side (group I), whereas an additional peritoneal suture was added in group II. On day 60 animals were killed and mesh migration, integration and number, grade and location of adhesions noted. RESULTS: Migration occurred in 12 (44.4%) in group 1 and 3 (11.1%) in group 2, P=0.023. Adhesions developed to 18 (33.3%) meshes. There was no difference in adhesion grade or area for mesh center or edge between the groups (P=0.735 and P=0.829, respectively). Median adhesion grade for mesh center was 1 and edge 3 (range, 0 to 4), P=0.005 and P=0.001, respectively. Granuloma formation was noted in 8 (18.6%) animals; only with suture-fixed mesh. CONCLUSIONS: Mesh fixation with fibrin sealant is not satisfactory, however, adhesion prevention seems to be; adhesions to the edge of the mesh are most severe.

Infant car safety seats and risk of head injury.

BACKGROUND/PURPOSE: We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI. METHODS: We retrospectively queried scene crash data from our State Department of Transportation (2007-2011) and State Department of Public Health data (2000-2011) regarding infants who presented to a trauma center after MVC. RESULTS: Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR=12.7, CI 95% 5.6-28.8, p<0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p=0.34). Average head abbreviated injury scale was similar for properly restrained (3.2±0.2) and improperly/unrestrained infants (3.5±0.2, p=0.37). CONCLUSION: Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.

Contralaterally controlled neuromuscular electrical stimulation for recovery of ankle dorsiflexion: a pilot randomized controlled trial in patients with chronic post-stroke hemiplegia.

OBJECTIVE: The aim of this study was to compare the effects of contralaterally controlled neuromuscular electrical stimulation (CCNMES) vs. cyclic neuromuscular electrical stimulation (NMES) on lower extremity impairment, functional ambulation, and gait characteristics. DESIGN: Twenty-six survivors of stroke with chronic (≥6 mos) foot drop during ambulation were randomly assigned to 6 wks of CCNMES or cyclic NMES. Both groups had ten sessions per week of self-administered home application of either CCNMES or cyclic NMES plus two sessions per week of gait training with a physical therapist. Primary outcomes included lower extremity Fugl-Meyer score, modified Emory Functional Ambulation Profile, and gait velocity. Assessments were made at pretreatment and posttreatment and at 1 and 3 mos after treatment. RESULTS: There were no significant differences between the groups in the outcome trajectories for any of the measures. With data from both groups pooled, there were significant but modest and sustained improvements in the Fugl-Meyer score and the modified Emory Functional Ambulation Profile but not in gait velocity. CONCLUSIONS: The results support the hypothesis that gait training combined with either CCNMES or cyclic NMES reduces lower extremity impairment and functional ambulation but do not support the hypothesis that CCNMES is more effective than cyclic NMES in patients with chronic post-stroke hemiplegia.