Enhancing POLST Completion in a Hospital Setting: An Interdisciplinary Approach.

EXECUTIVE SUMMARY: With increased therapeutic capabilities in healthcare today, many patients with multiple progressive comorbidities are living longer. They experience recurrent hospitalizations and often undergo procedures that are not aligned with their personal goals. That is why it is essential to discuss and document healthcare preferences prior to an acute event when significant interventions could occur, especially for patients with serious and progressive illness. Completion of an advance directive and a physician order for life-sustaining treatment (POLST) supports provision of goal-concordant care. Further, for patients who have do not attempt resuscitation (DNAR) orders or are diagnosed with advanced dementia, having a POLST is essential. This may be best accomplished with hospitalization discharge plans. Our 896-bed academic medical center, Cedars-Sinai Medical Center, launched a quality initiative in 2015 to complete POLSTs for patients being discharged with DNAR status or with dementia returning to a skilled nursing facility. As part of interdisciplinary progression of care rounds, emphasis was placed on those patients for whom POLST completion was indicated. Proactive, facilitated discussions with patients, family members, and attending physicians were initiated to support POLST completion. The completed forms were then uploaded to the electronic health record. Individual units and physicians received regular feedback on POLST completion rates, and the data were later shared at medical staff quality improvement meetings.During the initiative, POLST completion rates for DNAR patients discharged alive rose from 41% in fiscal year (FY) 2014 to 75% in FY 2019. Similar improvement was seen for patients with dementia discharged to skilled nursing facilities, regardless of code status (rising from 14% in FY 2014 to 54% in FY 2019). Subsequently, we have expanded our efforts to include early discussion and completion of these advanced care planning documents for patients recently diagnosed with high mortality cancers (ovarian, pancreatic, lung, glioblastoma), focusing on the completion of advanced care planning documentation and palliative care referrals.

A Fiber-Coupled Stimulated Emission Depletion Microscope for Bend-Insensitive Through-Fiber Imaging.

We present results for a new type of fiber-coupled stimulated emission depletion (STED) microscope which uses a single fiber to transport STED and excitation light, as well as collect the fluorescence signal. Our method utilizes two higher-order eigenmodes of polarization maintaining (PM) fiber to generate the doughnut-shaped STED beam. The modes are excited with separate beams that share no temporal coherence, yielding output that is independent of fiber bending. We measured the resolution using 45 nm fluorescent beads and found a median bead image size of 116 nm. This resolution does not change as function of fiber bending radius, demonstrating robust operation. We report, for the first time, STED images of fixed biological samples collected in the epi-direction through fiber. Our microscope design shows promise for future use in super-resolution micro-endoscopes and in vivo neural imaging in awake and freely-behaving animals.

The My Body Knows When Program Increased Intuitive Eating Characteristics in a Military Population.

INTRODUCTION: The purpose of this pilot study was to assess the effectiveness of the revised My Body Knows When (MBKW) program to promote intuitive eating behaviors within a sample of a military population through an online or in-person delivery mode. MATERIALS AND METHODS: Fifty-six overweight or obese adults (70% female); military service members (20%), retirees (38%) and family (42%) participated in the 10-week MBKW program at two military installations from 2012 to 2014. Body Mass Index, Intuitive Eating Scale-2 (IES-2; 23-item) and Motivation for Eating scale (MFES; 43-item) were collected at baseline and 10-weeks. Data were stratified by sex. Descriptive data were reported as mean ± standard deviation (SD), frequency, or percentage. A paired t-test was conducted with data at baseline and 10 weeks (α = 0.05, 80% power). RESULTS: Participants were predominantly female (70%); mean age of 51 ± 13 years; and BMI of 34.1 ± 5.5 kg/m2. There were no demographic, MFES, or IES-2 baseline differences between groups (in-person vs. online) or location. All subjects were collapsed into one group for a pre-post MBKW implementation assessment due to small sample size despite the original intent to stratify by online and in-person grouping. At 10 weeks, the remaining 26 participants exhibited a significant improvement (mean ± SD) in BMI (-0.4 ± 0.6 kg/m2; p = 0.012), environmental/social eating score (2.7 ± 0.4 points [pts]; -0.5 pt change; p < 0.001), emotional eating score (2.2 ± 0.5 pts; -0.6 pt change; p = 0.001), unconditional permission to eat score (3.4 ± 0.4 pts; +0.3 pt change; p = 0.017), eating for physical rather than emotional eating score (3.7 ± 0.8 pts; +1.0 pt change; p < 0.001), and reliance on hunger and satiety cues score (3.6 ± 0.5 pts; +0.8 pt change; p = 0.001). High attrition rates at the 10-week follow-up assessment precluded accurate assessment of long-term intervention effects. CONCLUSIONS: The MBKW program was associated with improved intuitive eating behaviors and with less external eating influence on behavior; however, a larger sample is required to assess the effectiveness of MBKW delivery mode. Modest weight loss was attained but testing the efficacy of the MBKW program in a large diverse sample with alternate scenarios may be worthwhile (e.g., primary prevention against weight gain, or during weight maintenance to prevent weight regain).

Determining the Spatial Relationship of Membrane-Bound Aquaporin-4 Autoantibodies by STED Nanoscopy.

Determining the spatial relationship of individual proteins in dense assemblies remains a challenge for superresolution nanoscopy. The organization of aquaporin-4 (AQP4) into large plasma membrane assemblies provides an opportunity to image membrane-bound AQP4 antibodies (AQP4-IgG) and evaluate changes in their spatial distribution due to alterations in AQP4 isoform expression and AQP4-IgG epitope specificity. Using stimulated emission depletion nanoscopy, we imaged secondary antibody labeling of monoclonal AQP4-IgGs with differing epitope specificity bound to isolated tetramers (M1-AQP4) and large orthogonal arrays of AQP4 (M23-AQP4). Imaging secondary antibodies bound to M1-AQP4 allowed us to infer the size of individual AQP4-IgG binding events. This information was used to model the assembly of larger AQP4-IgG complexes on M23-AQP4 arrays. A scoring algorithm was generated from these models to characterize the spatial arrangement of bound AQP4-IgG antibodies, yielding multiple epitope-specific patterns of bound antibodies on M23-AQP4 arrays. Our results delineate an approach to infer spatial relationships within protein arrays using stimulated emission depletion nanoscopy, offering insight into how information on single antibody fluorescence events can be used to extract information from dense protein assemblies under a biologic context.

Super-resolution imaging of ciliary microdomains in isolated olfactory sensory neurons using a custom two-color stimulated emission depletion microscope.

We performed stimulated emission depletion (STED) imaging of isolated olfactory sensory neurons (OSNs) using a custom-built microscope. The STED microscope uses a single pulsed laser to excite two separate fluorophores, Atto 590 and Atto 647N. A gated timing circuit combined with temporal interleaving of the different color excitation/STED laser pulses filters the two channel detection and greatly minimizes crosstalk. We quantified the instrument resolution to be ∼81 and ∼44 nm, for the Atto 590 and Atto 647N channels. The spatial separation between the two channels was measured to be under 10 nm, well below the resolution limit. The custom-STED microscope is incorporated onto a commercial research microscope allowing brightfield, differential interference contrast, and epifluorescence imaging on the same field of view. We performed immunolabeling of OSNs in mice to image localization of ciliary membrane proteins involved in olfactory transduction. We imaged Ca2+-permeable cyclic nucleotide gated (CNG) channel (Atto 594) and adenylyl cyclase type III (ACIII) (Atto 647N) in distinct cilia. STED imaging resolved well-separated subdiffraction limited clusters for each protein. We quantified the size of each cluster to have a mean value of 88±48 nm and 124±43 nm, for CNG and ACIII, respectively. STED imaging showed separated clusters that were not resolvable in confocal images.

Supplemental genistein, quercetin, and resveratrol intake in active duty army soldiers.

Previous reports indicate that the majority of U.S. Army soldiers consume dietary supplements (DSs) > 1 time/wk. However, these studies did not evaluate phytonutrient supplementation. A growing literature suggests inclusion of phytonutrients in DSs may pose a risk for toxicity, which could impact the performance of soldier duties, as well as long-term health and wellness. This study was conducted to assess and understand soldiers' motivations to consume phytonutrient-containing DSs, specifically genistein, quercetin, and resveratrol. The study was a cross-sectional, descriptive mixed-methods design using a survey and semistructured interviews. There were 436 soldiers stationed at Joint Base Lewis-McChord, Washington who completed the survey, from which 36 soldiers completed an interview. Overall, 34% of soldiers reported taking a single or multicomponent phytonutrient DS > 1 time/wk, from which 41 soldiers took >1 supplement/wk. Soldiers' reasons for use included unsure (54%), weight loss (12%), and other, unspecified (24%). The majority of interviewees did not consume DSs based on inclusion of genistein, quercetin, or resveratrol. The majority of soldiers, in our study, appear unable to rationalize their phytonutrient DS choices. Findings from this study illuminate the need for future research to further explore DS practices within military populations and encourage informed use of DSs.