Improving Post-Injury Follow-up Survey Response: Incorporating Automated Modalities.

Background: Incorporating post-discharge data into trauma registries would allow for better research on patient outcomes, including disparities in outcomes. This pilot study tested a follow-up data collection process to be incorporated into existing trauma care systems, prioritizing low-cost automated response modalities. Methods: This investigation was part of a larger study that consisted of two protocols with two distinct cohorts of participants who experienced traumatic injury. Participants in both protocols were asked to provide phone, email, text, and mail contact information to complete follow-up surveys assessing patient-reported outcomes six months after injury. To increase follow-up response rates between protocol 1 and protocol 2, the study team modified the contact procedures for the protocol 2 cohort. Frequency distributions were utilized to report the frequency of follow-up response modalities and overall response rates in both protocols. Results: A total of 178 individuals responded to the 6-month follow-up survey: 88 in protocol 1 and 90 in protocol 2. After implementing new follow-up contact procedures in protocol 2 that relied more heavily on the use of automated modalities (e.g., email and text messages), the response rate increased by 17.9 percentage points. The primary response modality shifted from phone (72.7%) in protocol 1 to the combination of email (47.8%) and text (14.4%) in protocol 2. Conclusions: Results from this investigation suggest that follow-up data can feasibly be collected from trauma patients. Use of automated follow-up methods holds promise to expand longitudinal data in the national trauma registry and broaden the understanding of disparities in patient experiences.

Centering patient perspectives to achieve injury-related health equity in trauma care systems: Improving trauma registry data.

BACKGROUND: Limitations in current data collection systems for patients who experience traumatic injury limit researchers' ability to identify and address disparities in injury and outcomes. We sought to develop and test a patient-centered data-collection system for equity-related data indicators that was acceptable to racially and ethnically diverse patients being treated for traumatic injuries. METHODS: Health equity indicators included in this study were race and ethnicity, language, education, employment, housing, and injury address. We conducted interviews with 245 racially and ethnically diverse trauma patients who were treated at a level-1 trauma center in the US in 2019-2020. We first interviewed 136 patients to develop a culturally resonant process and options for the health equity indicators to be added to a revised data collection system for the electronic medical record. English and Spanish interviews were audio-recorded and transcribed verbatim; qualitative analysis was used to assess patient preferences. We then pilot tested the revised data collection system with an additional 109 trauma patients to assess acceptability. Acceptability was defined as having more than 95% of participants self-identify with one of the proposed options for race/ethnicity, language, education, employment, and housing. Injury address (to identify geographic disparities) was pre-defined as acceptable if at least 85% of participants could identify exact address, cross streets, a landmark or business, or zip code of injury. RESULTS: A revised data collection system, including culturally resonant indicators and a process to be used by patient registrars to collect health equity data, was pilot tested, refined, and considered acceptable. Culturally resonant question phrasing/answer options for race/ethnicity, language, education, employment, housing status, and injury address were identified as acceptable. CONCLUSIONS: We identified a patient-centered data collection system for health equity measures with racially and ethnically diverse patients who have experienced traumatic injury. This system has the potential to increase data quality and accuracy, which is critical to quality improvement efforts and for researchers seeking to identify groups most impacted by racism and other structural barriers to equitable health outcomes and effective intervention points.

Improving Data Collection and Abstraction to Assess Health Equity in Trauma Care.

Current trauma registries suffer from inconsistent collection of data needed to assess health equity. To identify barriers/facilitators to collecting accurate equity-related data elements, we assessed perspectives of national stakeholders, Emergency Department (ED) registration, and Trauma Registry staff. We conducted a Delphi process with experts in trauma care systems and key informant interviews and focus groups with ED patient registration and trauma registry staff at a regional Level I trauma center. Topics included data collection process, barriers/facilitators for equity-related data collection, electronic health record (EHR) entry, trauma registry abstraction, and strategies to overcome technology limitations. Responses were qualitatively analyzed and triangulated with observations of ED and trauma registry staff workflow. Expert-identified barriers to consistent data collection included lack of staff investment in changes and lack of national standardization of data elements; facilitators were simplicity, quality improvement checks, and stakeholder investment in modifying existing technology to collect equity elements. ED staff reported experiences with patients reacting suspiciously to queries regarding race and ethnicity. Cultural resonance training, a script to explain equity data collection, and allowing patients to self-report sensitive items using technology were identified as potential facilitators. Trauma registry staff reported lack of discrete fields, and a preference for auto-populated and designated EHR fields. Identified barriers and facilitators of collection and abstraction of equity-related data elements from multiple stakeholders provides a framework for improving data collection. Successful implementation will require standardized definitions, staff training, use of existing technology for patient self-report, and discrete fields for added elements.

Beneficios de un programa de formación y de un algoritmo clínico de soporte nutricional mixto para mejorar la nutrición del paciente crítico: estudio antes-después / Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study

Introducción: la nutrición óptima del paciente crítico es clave para su recuperación. Objetivos: promover la formación y difusión del conocimiento acerca del soporte nutricional mixto (SNM) mediante un algoritmo clínico entre los intensivistas para mejorar el estado nutricional de los pacientes críticos. Métodos: estudio antes-después con la participación de 19 unidades de cuidados intensivos (UCI) polivalentes en 10 comunidades autónomas. Cinco miembros del comité científico formaron a los formadores mediante presentaciones orales y el algoritmo de SNM. Los formadores fueron responsables de la formación de los intensivistas en sus propias UCI. El cuestionario de 30 ítems fue completado por 179 y 105 intensivistas antes y después de la intervención, respectivamente. Resultados: se observó un aumento del conocimiento en seis (20 %) preguntas específicas relacionadas con el SNM. En 11 ítems (36,6 %), el conocimiento adecuado sobre diferentes aspectos del soporte nutricional que ya estaban presentes antes de la formación se mantuvieron, y en cinco ítems (16,7 %) hubo un aumento de la tasa de respuestas correctas. En cuatro ítems (13,3 %), las respuestas correctas no mejoraron y en otros cuatro (13,3 %), los porcentajes de respuestas correctas disminuyeron. Conclusiones: el algoritmo de SNM ha logrado una sólida consolidación de los principales conceptos de esta estrategia. Algunos aspectos referentes a cómo manejar al paciente desnutrido, cómo identificarlo y qué tipo de nutrición pautar desde el inicio del ingreso en la UCI, los aportes nutricionales en situaciones especiales y el seguimiento de posibles complicaciones como la realimentación, son áreas que requerirían estrategias formativas adicionales. (AU)

Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed. (AU)

[Benefits of an education program and a clinical algorithm in mixed nutritional support to improve nutrition for the critically ill patient: a before-and-after study]. / Beneficios de un programa de formación y de un algoritmo clínico de soporte nutricional mixto para mejorar la nutrición del paciente crítico: estudio antes-después.

INTRODUCTION: Introduction: optimal nutrition in the critically ill patient is a key aspect for recovery. Objectives: to promote training in and knowledge of mixed nutrition support (MNS) by means of a clinical algorithm among intensivists for improving the nutritional status of critically ill patients. Methods: a before-and-after study with the participation of 19 polyvalent intensive care units (ICUs) in 10 autonomous communities. Five members of the scientific committee trained the trainers by means of oral presentations and a clinical algorithm on MNS. Then, trainers were responsible for explaining the algorithm to local intensivists in their ICUs. The 30-item study questionnaire was completed before and after the intervention by 179 and 105 intensivists, respectively. Results: a clear improvement of knowledge was found in six (20 %) specific MNS-related questions. In 11 items (36.6 %), adequate knowledge on different aspects of nutritional support that were already present before the intervention were maintained, and in five items (16.7 %) an improvement in the rate of correct responses was recorded. There were no improvements in correct responses for four items (13.3 %), and for four (13.3 %) additional items the percentage of correct responses decreased. Conclusions: the use of the MNS algorithm has achieved a solid consolidation of the main concepts of MNS. Some aspects regarding how to manage the malnourished patient, how to identify them and what type of nutrition to guide from the beginning of admission to the ICU, nutritional contributions in special situations, and the monitoring of possible complications such as refeeding are areas for which further training strategies are needed.

INTRODUCCIÓN: Introducción: la nutrición óptima del paciente crítico es clave para su recuperación. Objetivos: promover la formación y difusión del conocimiento acerca del soporte nutricional mixto (SNM) mediante un algoritmo clínico entre los intensivistas para mejorar el estado nutricional de los pacientes críticos. Métodos: estudio antes-después con la participación de 19 unidades de cuidados intensivos (UCI) olivalentes en 10 comunidades autónomas. Cinco miembros del comité científico formaron a los formadores mediante presentaciones orales y el algoritmo de SNM. Los formadores fueron responsables de la formación de los intensivistas en sus propias UCI. El cuestionario de 30 ítems fue completado por 179 y 105 intensivistas antes y después de la intervención, respectivamente. Resultados: se observó un aumento del conocimiento en seis (20 %) preguntas específicas relacionadas con el SNM. En 11 ítems (36,6 %), el conocimiento adecuado sobre diferentes aspectos del soporte nutricional que ya estaban presentes antes de la formación se mantuvieron, y en cinco ítems (16,7 %) hubo un aumento de la tasa de respuestas correctas. En cuatro ítems (13,3 %), las respuestas correctas no mejoraron y en otros cuatro (13,3 %), los porcentajes de respuestas correctas disminuyeron. Conclusiones: el algoritmo de SNM ha logrado una sólida consolidación de los principales conceptos de esta estrategia. Algunos aspectos referentes a cómo manejar al paciente desnutrido, cómo identificarlo y qué tipo de nutrición pautar desde el inicio del ingreso en la UCI, los aportes nutricionales en situaciones especiales y el seguimiento de posibles complicaciones como la realimentación, son áreas que requerirían estrategias formativas adicionales.

Accuracy of new recommendations for adrenal incidentalomas in the evaluation of excessive cortisol secretion and follow-up.

OBJECTIVE: To evaluate whether the 2016 European Society of Endocrinology (ESE) recommendations for the management of adrenal incidentalomas accurately classifies those patients who do not require further follow-up. DESIGN AND METHODS: Single centre retrospective study. From 2010 to 2015, 130 patients with adrenal incidentaloma were evaluated and followed-up. Clinical, analytical and radiological data were recorded and the presence of comorbidities was assessed. Patients were grouped as nonfunctional or subclinical Cushing syndrome according to American guidelines; and nonfunctional, possible autonomous cortisol secretion and autonomous cortisol secretion, according to ESE guidelines. RESULTS: Based on American guidelines, 94% of patients had nonfunctional adrenal incidentalomas and 6% had subclinical Cushing syndrome. Based on ESE guidelines, patients were classified into nonfunctional (54%), possible autonomous cortisol secretion (40%) and autonomous cortisol secretion (6%) groups. No differences were observed in demographic characteristics and comorbidities between groups in either classification. Following ESE guidelines, no patient in the nonfunctional group was reclassified into the possible autonomous or autonomous cortisol secretion groups during follow-up, but one patient in the possible autonomous cortisol secretion group was reclassified into the autonomous cortisol secretion group. Also, 30 patients included in the groups of possible autonomous or autonomous cortisol secretion experienced progression of a comorbidity associated with cortisol excess, with diabetes mellitus as the most frequent comorbidity observed. CONCLUSION: Although adrenal incidentalomas with an excess of cortisol secretion were more frequently diagnosed with the new ESE recommendations, patients who did not require longer follow-up after first evaluation were accurately classified.

Activation of the Tumor Suppressor PP2A Emerges as a Potential Therapeutic Strategy for Treating Prostate Cancer.

Protein phosphatase 2A (PP2A) is a tumor suppressor complex that has recently been reported as a novel and highly relevant molecular target in prostate cancer (PCa). However, its potential therapeutic value remains to be fully clarified. We treated PC-3 and LNCaP cell lines with the PP2A activators forskolin and FTY720 alone or combined with the PP2A inhibitor okadaic acid. We examined PP2A activity, cell growth, prostasphere formation, levels of PP2A phosphorylation, CIP2A and SET expression, and AKT and ERK activation. Interestingly, both forskolin and FTY720 dephosphorylated and activated PP2A, impairing proliferation and prostasphere formation and inducing changes in AKT and ERK phosphorylation. Moreover, FTY720 led to reduced CIP2A levels. Treatment with okadaic acid impaired PP2A activation thus demonstrating the antitumoral PP2A-dependent mechanism of action of both forskolin and FTY720. Levels of PP2A phosphorylation together with SET and CIP2A protein expression were studied in 24 PCa patients and both were associated with high Gleason scores and presence of metastatic disease. Altogether, our results suggest that PP2A inhibition could be involved in PCa progression, and the use of PP2A-activating drugs might represent a novel alternative therapeutic strategy for treating PCa patients.

Serum sCD163 levels are associated with type 2 diabetes mellitus and are influenced by coffee and wine consumption: results of the Di@bet.es study.

OBJECTIVE: Serum levels of soluble TNF-like weak inducer of apoptosis (sTWEAK) and its scavenger receptor CD163 (sCD163) have been linked to insulin resistance. We analysed the usefulness of these cytokines as biomarkers of type 2 diabetes in a Spanish cohort, together with their relationship to food consumption in the setting of the Di@bet.es study. RESEARCH DESIGN AND METHODS: This is a cross-sectional, matched case-control study of 514 type 2 diabetes subjects and 517 controls with a Normal Oral Glucose Tolerance Test (NOGTT), using data from the Di@bet.es study. Study variables included clinical and demographic structured survey, food frequency questionnaire and physical examination. Serum concentrations of sTWEAK and sCD163 were measured by ELISA. Linear regression analysis determined which variables were related to sTWEAK and sCD163 levels. Logistic regression analysis was used to estimate odd ratios of presenting type 2 diabetes. RESULTS: sCD163 concentrations and sCD163/sTWEAK ratio were 11.0% and 15.0% higher, respectively, (P<0.001) in type 2 diabetes than in controls. Following adjustment for various confounders, the OR for presenting type 2 diabetes in subjects in the highest vs the lowest tertile of sCD163 was [(OR), 2,01 (95%CI, 1,46-2,97); P for trend <0.001]. Coffee and red wine consumption was negatively associated with serum levels of sCD163 (P = 0.0001 and; P = 0.002 for coffee and red wine intake, respectively). CONCLUSIONS: High circulating levels of sCD163 are associated with type 2 diabetes in the Spanish population. The association between coffee and red wine intake and these biomarkers deserves further study to confirm its potential role in type 2 diabetes.

Is plasma 25(OH) D related to adipokines, inflammatory cytokines and insulin resistance in both a healthy and morbidly obese population?

To analyse in a cohort of healthy subjects and in a group of morbidly obese patients, we studied the association amongst 25(OH) D and plasma concentrations of adipocytokines, inflammatory cytokines and insulin resistance. We also aimed to determine whether vitamin D-deficient patients showed a greater inflammatory profile. In the observational study that the authors conducted, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin and interleukine-18 were determined in 134 healthy men and 127 women. In the population consisting of 44 patients with morbid obesity, plasma concentrations of 25(OH) D, leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 and C-reactive protein were analysed. In the healthy population, plasma 25(OH) D showed a negative correlation with body mass index, body fat, waist, hip circumference and with leptin. However, no significant associations were found amongst 25(OH) D and plasma concentrations of resistin, adiponectin or interleukine-18. Patients with vitamin D deficiency showed higher body mass index, fat mass percentage and higher leptin concentrations compared with subjects with normal 25(OH) D concentrations. In the morbidly obese subjects, 25(OH) D did not correlate with leptin, resistin, adiponectin, interleukine-18, soluble tumor necrosis factor receptors 1 and 2 or with C-reactive protein. In patients with morbid obesity, no differences were found in adipokines and inflammatory cytokines concentrations regarding 25(OH) D status. No associations were found either between 25(OH) D and plasma glucose and insulin resistance or with lipid profile. Plasma 25(OH) D concentrations are associated with adiposity markers but not with adipocytokines implicated in inflammation. This lack of association does not support a major role of 25(OH) D in the pro-inflammatory environment observed in morbidly obese subjects. In addition, subjects with vitamin D deficiency are not characterized by a greater inflammatory state.

Lpin1 in human visceral and subcutaneous adipose tissue: similar levels but different associations with lipogenic and lipolytic genes.

LPIN1 is a gene with important effects on lipidic and metabolic homeostasis. Human subcutaneous LPIN1 expression levels in adipose tissue are related with a better metabolic profile, including insulin sensitivity markers. However, there are few data on the regulation of LPIN1 in visceral adipose tissue (VAT). Our aim was to perform a cross-sectional analysis of VAT compared with subcutaneous (SAT) LPIN1 expression in a well-characterized obese cohort, its relation with the expression of genes involved in lipid metabolism, and the in vitro response to lipogenic and lipolytic stimuli. A downregulation of total LPIN1 mRNA expression in subjects with obesity was found in VAT similarly to that in SAT. Despite similar total LPIN1 mRNA levels in SAT and VAT, a close relationship with clinical parameters and with many lipogenic and lipolytic genes was observed primarily in SAT depot. As shown in the in vitro analysis, the low-grade proinflammatory environment and the insulin resistance associated with obesity may contribute to downregulate LPIN1 in adipose tissue, leading to a worse metabolic profile.

Regulation of bone mineral density in morbidly obese women: a cross-sectional study in two cohorts before and after bypass surgery.

BACKGROUND: The mechanisms by which increased body weight influence bone mass density (BMD) are still unknown. The aim of our study was to analyze the relationship between anthropometric and body composition variables, insulin growth factor-I (IGF-I), adiponectin and soluble tumor necrosis factor-alpha receptors (sTNFR) 1 and 2 with BMD in two cohorts of morbid obese patients, before and after bypass surgery. METHODS: The first cohort included 25 women aged 48+/-7.6 years studied before bypass surgery. The second included 41 women aged 46+/-9.2 years, 12 months after surgery. We studied anthropometric variables obtained from whole body DEXA composition analysis. Serum IGF-I, intact serum parathyroid hormone, 25-hydroxivitamin D3, plasma adiponectin concentrations, sTNFR1, sTNFR2 concentrations were measured. RESULTS: In the first cohort, the BMI was 44.5+/-3.6 kg/m2, parathyroid hormone, IGF-I, and adiponectin concentrations were lower, and sTNFR1 concentrations were higher than in the second cohort. In the multiple regression analysis, BMD remained significantly associated with body fat percentage (beta -0.154, p=0.01), lean mass (beta 0.057, p=0.016) and phosphate concentration (beta 0.225, p=0.05). In the second cohort, BMI was 31+/-5.1 kg/m2. In the multiple regression analysis, BMD remained significantly associated with lean mass (beta 0.006, p=0.03). CONCLUSION: The inverse correlation found between body fat and BMD in the first cohort indicates morbid obesity increases the risk of osteoporosis and we found a positive correlation with lean and fat mass before bariatric surgery and with lean mass after bypass surgery.