Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI): Randomized Control Trial.

Background: Post spinal cord injury (SCI), sitting balance is considered a prerequisite for the effective performance of activities of daily living. Virtual Reality Training (VRT) may provide an interactive medium of rehabilitation, preventing a reduction in active participation of the patients while allowing for the training of sitting balance. Aim: The aim of this study was to evaluate the effect of the addition of VRT to conventional therapy in improving sitting balance in persons with SCI. Subjects and Methods: This was a single blinded randomized control trial conducted on 21 subjects with SCI (level of injury: D10 or below). They were randomly allocated into two groups; both groups received their routine exercise program. In addition, the intervention group, that is, Group B (n = 11) received 30 min of VRT in the seated position using Xbox-Kinect, while the conventional therapy group, that is, Group A (n = 10) received 30 min of additional conventional therapy to equalize the duration of the intervention (3 days/week, 4 weeks). The modified functional reach test and T-shirt test were measured at the beginning and at the end of 4 weeks. Results: MFRT changes for forward (Group A: 1.7 ± 1.09 cm; Group B: 4.83 ± 2.95 cm), right lateral (Group A: 2.43 ± 2.81 cm, Group B: 5.08 ± 1.85 cm), left lateral (Group A: 3.05 ± 4.65 cm, Group B: 6.19 ± 1.51 cm) were statistically significant for Group B (P < 0.05). No significant difference was observed between the two groups for T-shirt test (P > 0.05). Conclusion: VRT can be used as a part of a comprehensive rehabilitation program to improve sitting balance post-SCI.

Exploring Patterns of Stability and Change in Caregivers' Word Usage Across Early Childhood.

The linguistic input children receive across early childhood plays a crucial role in shaping their knowledge about the world. To study this input, researchers have begun applying distributional semantic models to large corpora of child-directed speech, extracting various patterns of word use/co-occurrence. Previous work using these models has not measured how these patterns may change throughout development, however. In this work, we leverage natural language processing methods-originally developed to study historical language change-to compare caregivers' use of words when talking to younger versus older children. Some words' usage changed more than others; this variability could be predicted based on the word's properties at both the individual and category levels. These findings suggest that caregivers' changing patterns of word use may play a role in scaffolding children's acquisition of conceptual structure in early development.

Genetic Lipid Disorders Associated with Atherosclerotic Cardiovascular Disease: Molecular Basis to Clinical Diagnosis and Epidemiologic Burden.

Genetic lipid disorders, ranging from common dyslipidemias such as familial hypercholesterolemia, lipoprotein (a), and familial combined hyperlipidemia to rare disorders including familial chylomicronemia syndrome and inherited hypoalphalipoproteinemias (ie, Tangier and fish eye diseases), affect millions of individuals in the United States and tens of millions around the world and are often undiagnosed in the general population. Clinicians should take into consideration the potential of inherited lipid disorders or syndromes when severe derangements in lipid parameters are observed. Patients' combined genotype and phenotype should be evaluated in conjunction with a host of environmental factors impacting their risk of atherosclerotic cardiovascular disease.

Clinical Management of Hypertriglyceridemia in the Prevention of Cardiovascular Disease and Pancreatitis.

PURPOSE OF REVIEW: Hypertriglyceridemia (HTG) is common and is a significant contributor to atherosclerosis and pancreatitis risk. Specific HTG treatments have had variable success in reducing atherosclerosis risk. Novel therapies for severe HTG treatment and pancreatitis risk reduction are likely to be available soon. These novel therapies are expected to have broader applications for more moderate HTG and atherosclerosis risk reduction as well. RECENT FINDINGS: NHANES 2012 data has confirmed a reduction in average triglyceride (TG) levels in the US population. Dietary modification and weight reduction when needed remain the core treatment elements for all individuals with HTG, while statin therapy is a foundational pharmacologic care for atherosclerotic cardiovascular disease (ASCVD) event risk reduction. In addition, the REDUCE-IT study provides evidence for additional benefit from the use of high-dose icosapent ethyl (IPE) on top of background medical therapy in adults with moderate HTG and ASCVD or type 2 diabetes mellitus (T2D) and additional ASCVD risk factors. However, treatment with eicosapentaenoic acid (EPA) combined with docosahexanoic acid (DHA) did not reduce ASCVD in a similar population studied in the STRENGTH trial. Furthermore, novel therapeutics targeting PPAR-ɑ, as well as ApoC-III and AngPTL3, effectively lower TG levels in individuals with moderate and severe HTG, respectively. These treatments may have applicability for reducing risk from ASCVD among individuals with chylomicronemia; in addition, ApoC-III and AngPTL3 treatments may have a role in treating individuals with the rare monogenic familial chylomicronemia syndrome (FCS) at risk for acute pancreatitis (AP). Residual ASCVD risk in individuals treated with contemporary care may be due in part to non-LDL lipid abnormalities including HTG. The findings from REDUCE-IT, but not STRENGTH, confirm that consumption of high-dose EPA may reduce ASCVD risk, while combination therapy of EPA plus DHA does not reduce ASCVD in a similar population. TG lowering likely reduces ASCVD risk in individuals with HTG, but ASCVD risk is multifactorial; the added benefit of IPE to contemporary preventive therapy is the consequence of differential non-TG biologic properties between the two fatty acids. Acute pancreatitis is more difficult to study prospectively since it is less common; however, TG lowering is likely critical for the care of at-risk individuals. Additional benefit from novel therapy that has an impact on this otherwise refractory condition is anticipated.

The Diversity-Innovation Paradox in Science.

Prior work finds a diversity paradox: Diversity breeds innovation, yet underrepresented groups that diversify organizations have less successful careers within them. Does the diversity paradox hold for scientists as well? We study this by utilizing a near-complete population of ∼1.2 million US doctoral recipients from 1977 to 2015 and following their careers into publishing and faculty positions. We use text analysis and machine learning to answer a series of questions: How do we detect scientific innovations? Are underrepresented groups more likely to generate scientific innovations? And are the innovations of underrepresented groups adopted and rewarded? Our analyses show that underrepresented groups produce higher rates of scientific novelty. However, their novel contributions are devalued and discounted: For example, novel contributions by gender and racial minorities are taken up by other scholars at lower rates than novel contributions by gender and racial majorities, and equally impactful contributions of gender and racial minorities are less likely to result in successful scientific careers than for majority groups. These results suggest there may be unwarranted reproduction of stratification in academic careers that discounts diversity's role in innovation and partly explains the underrepresentation of some groups in academia.

Alternating QRS Morphologies and PR Intervals After Transcatheter Aortic Valve Replacement.

Alternating bundle branch block pattern on electrocardiogram (ECG) is a concerning finding with important prognostic implications. This ECG challenge explores the electrophysiological mechanism of a case of alternating bundle branch block with alternating PR intervals. (Level of Difficulty: Beginner.).

Interactions between Dpr11 and DIP-γ control selection of amacrine neurons in Drosophila color vision circuits.

Drosophila R7 UV photoreceptors (PRs) are divided into yellow (y) and pale (p) subtypes. yR7 PRs express the Dpr11 cell surface protein and are presynaptic to Dm8 amacrine neurons (yDm8) that express Dpr11's binding partner DIP-γ, while pR7 PRs synapse onto DIP-γ-negative pDm8. Dpr11 and DIP-γ expression patterns define 'yellow' and 'pale' color vision circuits. We examined Dm8 neurons in these circuits by electron microscopic reconstruction and expansion microscopy. DIP-γ and dpr11 mutations affect the morphologies of yDm8 distal ('home column') dendrites. yDm8 neurons are generated in excess during development and compete for presynaptic yR7 PRs, and interactions between Dpr11 and DIP-γ are required for yDm8 survival. These interactions also allow yDm8 neurons to select yR7 PRs as their appropriate home column partners. yDm8 and pDm8 neurons do not normally compete for survival signals or R7 partners, but can be forced to do so by manipulation of R7 subtype fate.

Intrinsically disordered proteins and phenotypic switching: Implications in cancer.

It is now well established that intrinsically disordered proteins (IDPs) that constitute a large part of the proteome across the three kingdoms, play critical roles in several biological processes including phenotypic switching. However, dysregulated expression of IDPs that engage in promiscuous interactions can lead to pathological states. In this chapter, using cancer as a paradigm, we discuss how IDP conformational dynamics and the resultant conformational noise can modulate phenotypic switching. Thus, contrary to the prevailing wisdom that phenotypic switching is highly deterministic (has a genetic underpinning) in cancer, emerging evidence suggests that non-genetic mechanisms, at least in part due to the conformational noise, may also be a confounding factor in phenotypic switching.

Teaching methods used by internal medicine residents on rounds: what works?

BACKGROUND: The specific teaching methods used by internal medicine residents on walk rounds are unknown. OBJECTIVES: 1) To characterize in real time the specific teaching methods used by internal medicine residents on rounds and 2) to identify attributes of successful resident teaching on rounds. MATERIALS AND METHODS: We conducted a prospective mixed-methods study on inpatient medical services at a single academic medical center from September 2016 to January 2017. Participants were internal medicine residents (postgraduate year [PGY]-1, PGY-2, and PGY-3) and attending physicians. Teachers were PGY-2 and PGY-3 residents, and learners were PGY-1 residents. Residents' teaching on rounds was observed and characterized according to resident demographics, specific teaching methods, and length of time. Participants completed a survey with Likert scale and free-text questions. RESULTS AND CONCLUSION: Among 136 surveys across 28 separate teaching encounters, we noted that PGY-3 residents' teaching was rated significantly better than PGY-2 residents' teaching. Teaching lasting >1 minute was rated significantly better than teaching lasting <1 minute. Free-text responses emphasized the value of immediate clinical relevance, citing published evidence, conciseness, clarity, and pertinence to the patient. Our findings may help guide internal medicine residents aiming to teach better on rounds and inform further research into specific resident teaching methods.

Latent human traits in the language of social media: An open-vocabulary approach.

Over the past century, personality theory and research has successfully identified core sets of characteristics that consistently describe and explain fundamental differences in the way people think, feel and behave. Such characteristics were derived through theory, dictionary analyses, and survey research using explicit self-reports. The availability of social media data spanning millions of users now makes it possible to automatically derive characteristics from behavioral data-language use-at large scale. Taking advantage of linguistic information available through Facebook, we study the process of inferring a new set of potential human traits based on unprompted language use. We subject these new traits to a comprehensive set of evaluations and compare them with a popular five factor model of personality. We find that our language-based trait construct is often more generalizable in that it often predicts non-questionnaire-based outcomes better than questionnaire-based traits (e.g. entities someone likes, income and intelligence quotient), while the factors remain nearly as stable as traditional factors. Our approach suggests a value in new constructs of personality derived from everyday human language use.

Building informed trust: developing an educational tool for injection practices and health insurance in Cambodia.

Unnecessary injections increase the risk of blood-borne infections as well as pose an avoidable financial burden on patients. Perceptions in rural Cambodia that medical drug injections provide the best quality medical care have resulted in a large proportion of the population seeking injections across medical conditions. As private providers have a higher propensity to offer injections, patients pursue more expensive care contributing to a greater financial burden. This study aimed to use an educational intervention to improve participant knowledge about injections and health insurance in order to build informed trust in safer injection practices and health insurance. Using an experimental study design, villages in rural Cambodia were randomly assigned to an intervention or control arm. Community educational workshops were implemented to improve participant knowledge about injections and health insurance. Pre-and post-intervention assessments were used to record the resulting changes in knowledge and trust in providers. Statistical analysis of survey results from the two study arms showed increases of 16.8% and 15.9% in study participant knowledge regarding injections and health insurance, respectively. Trust in health insurance increased by 12.9%. However, trust in healthcare providers proved to be resilient with small to no change. These results show that knowledge about injection safety and health insurance, as well as trust in health insurance, can be increased through information dissemination in rural Cambodia. However, health information campaigns may not easily influence people's trust in healthcare providers. Education of the general populace about safe injection practices and health insurance can contribute toward the country's efforts to reach universal health coverage.

Carcass and meat quality characterization of indigenous and improved variety of chicken genotypes.

A study was conducted to examine four genotypes of chicken for their carcass and meat quality characteristics. From each genotype, 20 birds were slaughtered at their respective age of maturity. Breast and thigh muscles were evaluated for meat quality characteristics. Transport loss and carcass weight were highest in the white commercial broiler (WBR) and lowest in Aseel (ASL) and Indbro Aseel (ASR). Dressing percentage ranged between 66.41 and 72.56 and was not significantly different among genotypes. The yield of various cut-up parts for different genotypic birds was significantly different (P < 0.05). Highest percent yield for breast (29.15), thigh (15.57), drumstick (13.82) and wings (18.44) were observed in WBR, rainbow rooster (RR), ASR and rainbow rooster Plus (RRP), respectively. Giblet % was highest in RR and meat:bone ratio of thigh portion was highest in WBR. Higher ultimate pH was recorded for RR, RRP, and WBR, and higher water-holding capacity was detected in ASL and ASR. Further, bound water was higher in RR, RRP, and WBR, and free water was maximum in ASL and ASR. A significant (P < 0.05) higher shear force was observed in ASL and higher muscle fiber diameter in WBR. Cooking yield did not differ significantly among genotypes. The breast meat from ASL showed significantly (P < 0.05) higher redness value and WBR showed the lower redness. Further, ASL and ASR meats were darker and red in color than broiler meat. Meat from two indigenous birds (ASL and ASR) had significantly (P < 0.05) lower fat content compared to broilers and other crosses. ASL gave a slightly firmer meat as liked by consumers. The sensory evaluation showed breast meat from RR birds and ASL birds had better flavor scores than other birds. These results indicated that meat of indigenous chickens (ASL and ASR) has some unique features over commercial fast-growing birds that would increase their demand by consumers who prefer chewy, low-fat chicken meat.

Out-of-Pocket Household Expenditures on Medical Injections in Cambodia.

BACKGROUND: Cambodia has one of the highest rates of overall medical injection usage worldwide. Therapeutic injections, which are often unnecessary, contribute to the spread of blood-borne diseases. OBJECTIVE: This study describes injection practices and associated household expenditures in rural northwest Cambodia. METHODS: We assessed care-seeking patterns of surveyed adult family members who sought healthcare in the previous 30 days, including location of care, medical injection use, and out-of-pocket household expenditures for treatment. A regression model was used to explore the impact of injection use on out-of-pocket household expenditures. RESULTS: Among 480 households sampled, 298 included members who had been sick within the previous 30 days; a total of 342 episodes of care had been sought. Private providers accounted for over 66% (n = 226) of all episodes of care, with public and informal providers accounting for 20% (n = 69) and 14% (n = 47), respectively. Injections were administered in over 120 (35%) episodes of care, with 81% of injections administered by private providers. Patients who received injections incurred total out-of-pocket household expenditures that were, on average, 126,590 Cambodian Riel (KHR) (US$31.65) higher than those who did not receive injections (p < 0.01), equivalent to nearly half of the country's total annual health expenditure per capita. Receiving injections and perceived severity of illness were significantly associated with higher out-of-pocket household expenditures. CONCLUSION: This study found high levels of medical injection use, particularly among private healthcare providers, which was significantly associated with high healthcare expenditures. Reducing the number of medical injections would not only reduce disease transmission risk but also contribute to reduced healthcare costs and greater financial protection.

Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study.

OBJECTIVE: To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia. DESIGN: Retrospective cohort study. SETTING: 4767 hospitals caring for Medicare fee for service beneficiaries in the United States, 2008-10. PARTICIPANTS: More than 3 million Medicare fee for service beneficiaries, aged 65 years or more, surviving hospitalization for heart failure, acute myocardial infarction, or pneumonia. MAIN OUTCOME MEASURES: Daily absolute risks of first readmission to hospital and death for one year after discharge. To illustrate risk trajectories, we identified the time required for risks of readmission to hospital and death to decline 50% from maximum values after discharge; the time required for risks to approach plateau periods of minimal day to day change, defined as 95% reductions in daily changes in risk from maximum daily declines after discharge; and the extent to which risks are higher among patients recently discharged from hospital compared with the general elderly population. RESULTS: Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia. Risk of first readmission had declined 50% by day 38 after hospitalization for heart failure, day 13 after hospitalization for acute myocardial infarction, and day 25 after hospitalization for pneumonia; risk of death declined 50% by day 11, 6, and 10, respectively. Daily change in risk of first readmission to hospital declined 95% by day 45, 38, and 45; daily change in risk of death declined 95% by day 21, 19, and 21. After hospitalization for heart failure, acute myocardial infarction, or pneumonia, the magnitude of the relative risk for hospital admission over the first 90 days was 8, 6, and 6 times greater than that of the general older population; the relative risk of death was 11, 8, and 10 times greater. CONCLUSIONS: Risk declines slowly for older patients after hospitalization for heart failure, acute myocardial infarction, or pneumonia and is increased for months. Specific risk trajectories vary by discharge diagnosis and outcome. Patients should remain vigilant for deterioration in health for an extended time after discharge. Health providers can use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest risk periods for patients.

Hospital variation in noninvasive positive pressure ventilation for acute decompensated heart failure.

BACKGROUND: Although noninvasive positive pressure ventilation (NIPPV) for patients with acute decompensated heart failure was introduced almost 20 years ago, the variation in its use among hospitals remains unknown. We sought to define hospital practice patterns of NIPPV use for acute decompensated heart failure and their relationship with intubation and mortality. METHODS AND RESULTS: We conducted a cross-sectional study using a database maintained by Premier, Inc., that includes a date-stamped log of all billed items for hospitalizations at >400 hospitals. We examined hospitalizations for acute decompensated heart failure in this database from 2005 to 2010 and included hospitals with annual average volume of >25 such hospitalizations. We identified 384 hospitals that encompassed 524 430 hospitalizations (median annual average volume: 206). We used hierarchical logistic regression models to calculate hospital-level outcomes: risk-standardized NIPPV rate, risk-standardized intubation rate, and in-hospital risk-standardized mortality rate. We grouped hospitals into quartiles by risk-standardized NIPPV rate and compared risk-standardized mortality rates and risk-standardized intubation rates across quartiles. Median risk-standardized NIPPV rate was 6.2% (interquartile range, 2.8%-9.3%; 5th percentile, 0.2%; 95th percentile, 14.8%). There was no clear pattern of risk-standardized mortality rates across quartiles. The bottom quartile of hospitals had higher risk-standardized intubation rate (11.4%) than each of the other quartiles (9.0%, 9.7%, and 9.1%; P<0.02 for all comparisons). CONCLUSIONS: Substantial variation exists among hospitals in the use of NIPPV for acute decompensated heart failure without evidence for differences in mortality. There may be a threshold effect in relation to intubation rates, with the lowest users of NIPPV having higher intubation rates.

Most important outcomes research papers on hypertension.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, which have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, as well as general cardiology audience. The studies included in this article represent the most significant research related to hypertension.

Most important outcomes research papers on treatment of stable coronary artery disease.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have been published in the Circulation portfolio. The objective of this series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research related to treatment of stable coronary artery disease (CAD).

Regional density of cardiologists and rates of mortality for acute myocardial infarction and heart failure.

BACKGROUND: Cardiologists are distributed unevenly across regions of the United States. It is unknown whether patients in regions with fewer cardiologists have worse outcomes after hospitalization for acute myocardial infarction (AMI) or heart failure (HF). METHODS AND RESULTS: Using Medicare administrative claims data from 2010, we examined the relationship between regional density of cardiologists and risk of death after hospitalization for AMI and HF using hospitalizations for pneumonia as a comparison. We defined density as the number of cardiologists divided by population aged≥65 years within hospital referral regions, categorized into quintiles. Among 171 126 admissions for AMI, 352 853 admissions for HF, and 343 053 admissions for pneumonia, we tested associations between density of cardiologists and 30-day and 1-year mortality for each condition. We used 2-level hierarchical logistic regression models that adjusted for characteristics of patients and hospital referral regions. Patients hospitalized for AMI (odds ratios [OR], 1.13; 95% confidence interval [CI], 1.06-1.21) and HF (OR, 1.19; 95% CI, 1.12-1.27) in the lowest quintile of density had modestly higher 30-day mortality risk compared with patients in the highest quintile, unlike patients hospitalized for pneumonia (OR, 1.02; 95% CI, 0.96-1.09). Patients hospitalized for AMI (OR, 1.06; 95% CI, 1.00-1.12) and HF (OR, 1.09; 95% CI, 1.04-1.13) in the lowest quintile had slightly higher 1-year mortality risk, unlike patients hospitalized for pneumonia (OR, 1.00; 95% CI, 0.95-1.05). CONCLUSIONS: Patients hospitalized for AMI and HF in regions with a low density of cardiologists experienced modestly higher 30-day and 1-year mortality risk, unlike patients with pneumonia.