Digital intervention increases influenza vaccination rates for people with diabetes in a decentralized randomized trial.

People with diabetes (PWD) have an increased risk of developing influenza-related complications, including pneumonia, abnormal glycemic events, and hospitalization. Annual influenza vaccination is recommended for PWD, but vaccination rates are suboptimal. The study aimed to increase influenza vaccination rate in people with self-reported diabetes. This study was a prospective, 1:1 randomized controlled trial of a 6-month Digital Diabetes Intervention in U.S. adults with diabetes. The intervention group received monthly messages through an online health platform. The control group received no intervention. Difference in self-reported vaccination rates was tested using multivariable logistic regression controlling for demographics and comorbidities. The study was registered at clinicaltrials.gov: NCT03870997. A total of 10,429 participants reported influenza vaccination status (5158 intervention, mean age (±SD) = 46.8 (11.1), 78.5% female; 5271 control, Mean age (±SD) = 46.7 (11.2), 79.4% female). After a 6-month intervention, 64.2% of the intervention arm reported influenza vaccination, vers us 61.1% in the control arm (diff = 3.1, RR = 1.05, 95% CI [1.02, 1.08], p = 0.0013, number needed to treat = 33 to obtain 1 additional vaccination). Completion of one or more intervention messages was associated with up to an 8% increase in vaccination rate (OR 1.27, 95% CI [1.17, 1.38], p < 0.0001). The intervention improved influenza vaccination rates in PWD, suggesting that leveraging new technology to deliver knowledge and information can improve influenza vaccination rates in high-risk populations to reduce public health burden of influenza. Rapid cycle innovation could maximize the effects of these digital interventions in the future with other populations and vaccines.

Pharmacokinetics and safety of repeated oral dosing of acetaminophen in adult horses.

BACKGROUND: There are no published studies on the pharmacokinetics of acetaminophen at the dosage used clinically (20 mg/kg), nor has the safety of multiple doses in horses been investigated. OBJECTIVE: Define the pharmacokinetic parameters of oral acetaminophen at 20 mg/kg in adult horses as a single dose, and twice daily for 14 days to assess the safety of multiple dosing. STUDY DESIGN: Pharmacokinetic study, multiple dose safety study. METHODS: Eight healthy Thoroughbred geldings were given acetaminophen (20 mg/kg; 500 mg tablets) orally as a single dose followed by doses every 12 h for 14 days. Serial blood samples were collected for determination of plasma acetaminophen concentrations using high performance liquid chromatography with ultraviolet detection. Serum biochemical analysis, gastroscopy and liver biopsy were examined during the safety study. RESULTS: Following a single dose, mean maximum concentration (Cmax ) was 16.61 µg/mL at 1.35 h (Tmax ), and drug concentration was below the lower limit of detection in most horses by 24 h. Elimination half-life (T1/2 ) was 2.78 h. No significant accumulation was noted following multiple doses. Average Cmax of acetaminophen following multiple oral dosing was 15.85 µg/mL, with a Tmax of 0.99 h and T1/2 of 4 h. Serum activities of sorbitol dehydrogenase were significantly decreased and total bilirubin concentrations were significantly increased following the last dose. No statistically significant changes were noted in gastroscopy scores. MAIN LIMITATIONS: Only one dose level (20 mg/kg) was studied, sample size was small and only a single breed and sex was used, with no pretreatment liver biopsies. CONCLUSION: This study described the pharmacokinetics of acetaminophen following single and multiple 20 mg/kg oral doses in adult horses and demonstrated the safety of acetaminophen with multiple oral dosing over 14 days. The summary is available in Portuguese - see Supporting information.

Growth of epitaxial Pt1-xPbx alloys by surface limited redox replacement and study of their adsorption properties.

The surface limited redox replacement (SLRR) method has been used to design two-dimensional Pt-Pb nanoalloys with controlled thickness, composition, and structure. The electrochemical behavior of these alloys has been systematically studied as a function of alloy composition. A single-cell, two-step SLRR protocol based on the galvanic replacement of underpotentially deposited monolayers of Pb with Pt was used to grow epitaxial Pt1-xPbx (x < 0.1) alloys of up to 10 ML thickness on Au substrates. It is shown that by varying the terminating potential of the galvanic replacement step, the Pb atomic content can be controlled in the films. Electrochemical analysis of the alloys showed that the adsorption of both H and CO exhibits similar, and systematic, decreases with small increases in the Pb content. These measurements, commonly used in electrocatalysis for the determination of active surface areas of Pt, suggested area values much lower than those expected based on the net Pt composition in the alloy as measured by XPS. These results show that Pb has a strong screening effect on the adsorption of both H and CO. Moreover, changes in alloy composition result in a negative shift in the potential of the peaks of CO oxidation that scales with the increase of Pb content. The results suggest electronic and bifunctional effects of incorporated Pb on the electrochemical behavior of Pt. The study illustrates the potential of the SLRR methodology, which could be employed in the design of 2-dimensional bimetallic Pt nanoalloys for fundamental studies of electrocatalytic behavior in fuel cell reactions dependent on the nature of alloying metal and its composition.

What patients are reading about noninvasive prenatal testing: an evaluation of Internet content and implications for patient-centered care.

OBJECTIVE: Patients' use of the Internet as a source of health information is increasing. The objective of this study was to describe and evaluate Internet-based information about noninvasive prenatal testing (NIPT), an important new genetic test currently available to high-risk women in early pregnancy. METHODS: Websites were sampled using leading search engines to mirror Internet-based search patterns of individuals seeking information about NIPT. Content analysis was conducted to assess website reading level, quality, and content. RESULTS: Basic information about NIPT use as a screening test was accurately described. Overall, sampled websites lacked balance and comprehensive information about NIPT and the complexity of decision making involved in electing for its use. All websites were written at reading levels higher than currently recommended levels for public health information. CONCLUSION: While online resources should be used with reservation, they can be an important tool to support effective communication and patient-centered care. Online information can help both health care providers and pregnant patients who face a growing number of fetal genetic testing options.

A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process.

The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a wider remit of treatment options than the Do Not Resuscitate (DNR) order currently offers. Our experience suggests that the patient and family are rarely engaged in DNR discussions. This is acutely relevant considering that the Mental Capacity Act (MCA) now obliges these discussions to take place. The TEP is a form that the doctor completes, ideally with the competent patient or close relative, documenting what treatment options would be appropriate if that patient were to become acutely unwell. Ventilation of the lungs, cardiac resuscitation, renal replacement therapy, intravenous fluids and antibiotics are all discussed. The study evaluated patient and relative experiences with the TEP. 55 patients or their relatives were interviewed regarding their experience of the TEP and thoughts regarding the process. 96% of patients and relatives evaluated thought that the TEP was a good idea. Free text comments were all positive and only 34% of patients claimed to feel anxious when completing the form. Following this study, the TEP has been expanded hospital wide and into the community within our trust. Discussions are currently taking place in hospitals within our region to introduce the TEP form into other local trusts.

South Africans in flux: exploring the mental health impact of migration on family life.

In the context of post-apartheid South Africa mental health professionals are increasingly faced with the complexities linked to people leaving the country, those left behind and those returning. In an attempt to illustrate the mental health challenges linked to the South African migration phenomenon, this article will firstly explore the global phenomenon of migration and some of the theoretical approaches used to understand it. The psychological impact of immigration on individuals and their families will also be explored. In conclusion the author will propose some possible preventative measures which may be of use to mental health professionals.

A case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A.

We report the first known case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A. The patient required tracheal intubation and ventilation followed by surgical tracheostomy, prior to transfer to the intensive care unit for management of her coagulopathy with recombinant clotting factor products under the care of the haematologists.

Condom use after voluntary counselling and testing in central Mozambique.

OBJECTIVE: To evaluate the efficacy of voluntary counselling and testing (VCT) for HIV/AIDS in changing risky sexual behaviour in central Mozambique. METHOD: Longitudinal cohort study of men and women aged at least 18 years from October 2002 to June 2003. We interviewed 622 participants in VCT groups and 598 in non-VCT groups. The interviews occurred before counselling and 4 and 6 months afterwards. RESULTS: Reported use of condoms while having sex with a friends/prostitute increased over each time period in the VCT group and between baseline and first visit in the non-VCT group. Both men and women in the VCT group increased their condom use over time, but the women in the non-VCT group did not. Reported always/sometimes use of condoms for both literate and illiterate subjects was higher and rose over time in the VCT group. CONCLUSION: People who undergo voluntary counselling and testing fro HIV/AIDS change their behaviour, presumably as a result of their counselling.

Socioeconomic status and prevalence of allergic rhinitis and atopic eczema symptoms in young adolescents.

Environmental factors are known to influence the development of allergic rhinitis and atopic eczema in genetically susceptible individuals. Socioeconomic status (SES) may be an important indicator of risk for these conditions. The International Study of Asthma and Allergies in Childhood (ISAAC) Phase 1 written questionnaire was used to determine the prevalence and severity of allergic rhinoconjunctivitis and atopic eczema symptoms in 4947 pupils aged 13-14 years attending 30 schools in socioeconomically diverse areas of Cape Town. Home addresses were used to stratify participants into five SES bands. Relationships between symptom prevalence and severity, and SES, recent urbanization and upward socioeconomic mobility were examined. Logistic regression was used to generate odds ratios (OR) and 95% confidence intervals (CI) in order to assess overall trends by SES. The prevalences of self-reported allergic rhinitis symptoms and recurrent itchy rash in the past year were 33.2% and 11.9% respectively. Girls had a significantly higher prevalence of all symptoms than boys. The prevalence of allergic rhinitis symptoms increased from lowest to highest SES (overall OR for rhinitis symptoms in past year = 1.16, 95% CI 1.11-1.21). There was no significant trend in reported eczema symptoms by SES other than for the question, 'Have you ever had eczema' (OR = 0.88, 95% CI 0.83-0.93). Longer period of urbanization was weakly associated only with recurrent itchy skin rash (OR = 1.05, 95% CI 1.01-1.09). 'Socially mobile' pupils, i.e. those resident in the lowest SES areas but attending highest SES schools showed significantly higher prevalences of eczema and some rhinitis symptoms than pupils attending lowest SES schools. These findings may reflect differences in reporting related to language, culture and access to medical care rather than real differences in prevalence.

An assessment of protection of the airway from aspiration of oropharyngeal contents using the Combitube airway.

A Combitube airway was inserted blindly into 27 American Society of Anaesthesiologist (ASA) grade 1 and 2 patients undergoing general anaesthesia. All had Cormack and Lehane grade 1 direct views of the larynx. Ten ml of 0.1% methylene blue dye was instilled into each patients mouth for the duration of surgery. The oropharynx was then aspirated and dried at completion of surgery and the Combitube removed. The laryngeal inlet and trachea were examined for dye staining. In 25/27 patients (93%) no tracheal soiling was seen. In 2/27 patients (7%) tracheal soiling was seen (95% confidence interval 0.9-24.3%). The Combitube protects the airway in the majority of patients from aspiration of dye within the oral cavity, but the failure rate means it cannot be relied upon absolutely to do so. This has implications for management of the trauma patient.

Respiratory failure after tracheal extubation in a patient with halo frame cervical spine immobilization--rescue therapy using the Combitube airway.

A 78-yr-old man, with halo frame cervical spine immobilization, suffered rapid respiratory deterioration after tracheal extubation in the intensive care unit. Control of the airway was difficult as bag-valve-mask ventilation was ineffective, tracheal intubation was known to be difficult from management of a previous episode of respiratory failure on the ward, and laryngeal mask insertion proved impossible. Rescue therapy using a Combitube airway is described and discussed.

Antenatal syphilis in sub-Saharan Africa: missed opportunities for mortality reduction.

PURPOSE: Between 4-15% of pregnant women are believed to be infected with syphilis in sub-Saharan Africa. Active infection with syphilis in pregnant women results in foetal or infant death or disability for 50-80% of affected pregnancies, and is a major cause of adult morbidity as well. Antenatal syphilis screening is cheap and effective; however, it is often poorly implemented in countries with high syphilis risk. This study sought to estimate the missed opportunities for antenatal syphilis screening in sub-Saharan Africa. METHODS: Survey data were collected from 22 ministries of health in sub-Saharan Africa, complemented by data from published sources and key informants. Informants described their country's policies and experience with antenatal syphilis screening and estimated their national syphilis screening rates. FINDINGS: Seventy-three percent of women are reported by WHO to receive antenatal care in the study countries. Of women in antenatal care, 38% were estimated by survey respondents to be screened for syphilis. Costs and the organization of services were the principal reported obstacles to screening. With syphilis seroprevalence estimated at 8.3%, approximately 1 640 000 pregnant women with syphilis are undetected annually, including 1 030 000 women who attend antenatal care. DISCUSSION: Syphilis testing and treatment is a cost-effective intervention that deserves much greater attention, particularly in sub-Saharan Africa and other countries where syphilis infection is high.

Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer.

PURPOSE: The goal of the computer program Adjuvant! is to allow health professionals and their patients with early breast cancer to make more informed decisions about adjuvant therapy. METHODS: Actuarial analysis was used to project outcomes of patients with and without adjuvant therapy based on estimates of prognosis largely derived from Surveillance, Epidemiology, and End-Results data and estimates of the efficacy of adjuvant therapy based on the 1998 overviews of randomized trials of adjuvant therapy. These estimates can be refined using the Prognostic Factor Impact Calculator, which uses a Bayesian method to make adjustments based on relative risks conferred and prevalence of positive test results. RESULTS: From the entries of patient information (age, menopausal status, comorbidity estimate) and tumor staging and characteristics (tumor size, number of positive axillary nodes, estrogen receptor status), baseline prognostic estimates are made. Estimates for the efficacy of endocrine therapy (5 years of tamoxifen) and of polychemotherapy (cyclophosphamide/methotrexate/fluorouracil-like regimens, or anthracycline-based therapy, or therapy based on both an anthracycline and a taxane) can then be used to project outcomes presented in both numerical and graphical formats. Outcomes for overall survival and disease-free survival and the improvement seen in clinical trials, are reasonably modeled by Adjuvant!, although an ideal validation for all patient subsets with all treatment options is not possible. Additional speculative estimates of years of remaining life expectancy and long-term survival curves can also be produced. Help files supply general information about breast cancer. The program's Internet links supply national treatment guidelines, cooperative group trial options, and other related information. CONCLUSION: The computer program Adjuvant! can play practical and educational roles in clinical settings.

Immunologic impact and clinical outcomes after surgical exposure to bovine thrombin.

OBJECTIVE: To determine prospectively the immunologic response and adverse clinical events in surgical patients exposed to bovine thrombin during cardiac surgical procedures. SUMMARY BACKGROUND DATA: Topical bovine thrombin is used extensively as a hemostatic agent during cardiovascular surgery. Antibodies developing after exposure to bovine thrombin have been anecdotally associated with hemorrhagic complications. METHODS: One hundred fifty-one patients undergoing cardiac surgical procedures were prospectively recruited for this study before surgical exposure with topical bovine thrombin. Immunoassays were used to determine antibody levels against both bovine and human coagulation proteins before and after exposure to bovine thrombin. Alterations in coagulation assay parameters and adverse clinical events were followed in all patients enrolled in the study. RESULTS: Baseline elevated antibody levels to one or more bovine coagulation proteins were observed most frequently in patients with a prior history of a surgical procedure during which bovine thrombin is frequently used. More than 95% of patients developed a seropositive response to bovine coagulation proteins, and 51% manifested elevated antibody levels to the corresponding human coagulation proteins after bovine thrombin exposure. Postoperative coagulation abnormalities were more common in patients with antibodies to human coagulation proteins. Patients with multiple elevated antibody levels to bovine proteins before surgery were more likely to sustain an adverse clinical outcome after surgery. Using a logistic regression model, the adjusted odds ratio for sustaining an adverse event with multiple elevated antibody levels to bovine proteins before surgery was 5.40. CONCLUSIONS: Bovine thrombin preparations are highly immunogenic and appear to be associated with an increased risk for adverse clinical outcomes during subsequent surgical procedures. The clinical safety of these commonly used preparations needs to be reassessed, and reexposure to these agents should likely be avoided.