The Impact of Antithrombotic Medications on Postoperative Bleeding Events Following Hemorrhoidectomy.

BACKGROUND: Bleeding complications are a risk associated with hemorrhoid procedures. Despite the prevalence of anticoagulant and antiplatelet therapies, including newer direct oral anticoagulants (DOACs) in the aging patient population there is a paucity of data regarding the impact of the use of antithrombotic therapy (AT) especially DOACs, on bleeding complications of hemorrhoid procedures. METHODS: We retrospectively reviewed charts of patients who had undergone a total of 1152 procedures, including hemorrhoid excision and ligation, at a single institution in the years 2016-2018. We noted whether they were prescribed AT, the indication for therapy, perioperative medication management, whether a PBE occurred, and how the PBE was managed. RESULTS: PBE's were noted in 5.92% of patients on ATs, as opposed to 2.66% of patients not on ATs (P = .014.) The odds ratio of having a PBE when on ATs vs not on ATs is 2.3 (95% CI 1.21 to 4.38, P = .011). Seven out of 40 (17.5%) total PBE's required hospital admission or repeat procedure, and this was not associated with AT use. Surprisingly, although males represented most of the patients on ATs, females were statistically more likely to have a PBE following a hemorrhoidectomy if on ATs. DISCUSSION: Patients on AT have an elevated risk of PBE compared to patients not on AT. No significant difference was found between the two groups when considering only those PBE's severe enough to require hospital admission or repeat procedure. Further research is required to establish clear guidelines regarding the perioperative management of AT for hemorrhoid procedures.

Impact of Interprofessional Care Conferences Across Primary Care and Mental Health Organizations on Family Medicine Resident Learning.

BACKGROUND AND OBJECTIVES: Patients with severe mental illness often lack care coordination between primary care and mental health providers which can negatively impact patient outcomes. Team-based care is integral in the effective management of patients with multiple comorbidities, with the family physician central in coordinating holistic care. Family medicine residency programs must provide models of effective interprofessional collaboration and mental health treatment to prepare residents to navigate an evolving health care landscape. The objective of this study was to evaluate family medicine residents' learning about providing holistic care with an interprofessional team and medication safety monitoring from the interprofessional cross-organizational care conference experience. METHODS: To bridge care and cultivate the necessary skills, a family medicine clinic and mental health clinic implemented monthly interprofessional care conferences to coordinate care for their shared patients during 2019. Residents who participated in the care conference each (n=11) completed a retrospective pre/postsurvey (11/11=100% response rate) to gather perceptions of what they learned from the interprofessional care conference experience. RESULTS: After participating in the care conference, all residents agreed they understood the elements that must be considered to provide holistic patient care, were confident conducting medication safety monitoring for their patients taking second-generation antipsychotics (eg, lipids, A1C, ECG), and agreed the care conference helped them develop a more comprehensive patient-centered care plan. Additionally, they all intend to work collaboratively across professions in the future. CONCLUSIONS: Interprofessional and cross-organizational care conferences create an authentic learning environment that enhances family medicine residents' understanding and confidence in providing collaborative and holistic care for patients with severe and persistent mental illness.

Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania.

INTRODUCTION: Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS: A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS: Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.

Bridging Community Mental Health and Primary Care to Improve Medication Monitoring and Outcomes for Patients With Mental Illness Taking Second-Generation Antipsychotics-HDC/DFMC Bridge Project, Phase 1: Group Concept Mapping.

OBJECTIVE: Patients with severe mental illness often lack care coordination between primary care and mental health providers. Siloed patient care across separate health care systems can negatively impact quality and safety of patient care. The purpose of the project discussed in this article is to effectively engage stakeholders from separate primary care and mental health organizations to develop an ideal cross-organization communication system to improve metabolic monitoring for their comanaged patients prescribed second-generation antipsychotics (SGAs). METHODS: The mixed method approach of group concept mapping was used to engage stakeholders across a nonaffiliated primary care clinic and a community mental health organization over the time period of March 2018 through May 2018. RESULTS: Three important domains in communication were identified: (1) process/workflow, (2) advocacy, and (3) a patient-centered focus. Seven high priority/easier to implement brainstormed items were identified and resulted in practice changes across both organizations, including developing a standard release of information, identifying a point person from each clinic focused on cross-organization care coordination, endorsing an SGA monitoring protocol across organizations, agreeing that metabolic monitoring of SGAs will be the responsibility of the primary care clinicians, beginning monthly medication reconciliation and cross-organization care conferences, developing standard electronic health record documentation, and providing education. CONCLUSIONS: Care coordination across all health systems is critical to optimize patient care for chronic medical and psychiatric conditions. Group concept mapping provides a strategic process to allow shared decision-making among stakeholders to take steps toward solving more complex systematic problems such as poor electronic health record interoperability across health systems.

Data quality, floor and ceiling effects, and test-retest reliability of the Mild Cognitive Impairment Questionnaire.

BACKGROUND: The Mild Cognitive Impairment Questionnaire (MCQ) is a 13-item measure that assesses health-related quality of life (HRQoL) in people with mild cognitive impairment (PWMCI); it has two domains assessing the emotional and practical effects. OBJECTIVE: The aim of this study was to assess the psychometric properties of the MCQ. DESIGN: This is a longitudinal questionnaire-based study. SETTING: The participants were recruited from the memory clinics and research databases in the South of England. SUBJECTS: A total of 299 people aged 50 years and older with a diagnosis of mild cognitive impairment confirmed within the preceding 12 months. METHODS: MCQs were distributed to patients in memory clinics and those listed on research databases. Participants who returned completed questionnaires were sent a second copy of the MCQ to return 2 weeks after receiving the first questionnaire. RESULTS: Five hundred and seven questionnaires were distributed; response rates were 68.2% initially and 89.2% for the second questionnaire. From the returned questionnaires, response rates for each item were high (>98%) and a full range of responses for each item was received with no evidence of significant floor or ceiling effects. Internal consistency reliability for both scale scores at both time points was good, with Cronbach's a≥0.84 in all cases. Test-retest reliability was excellent for both domains with the intraclass correlation coefficients of 0.90 and 0.92 for the practical and emotional domains, respectively. Paired sample t-tests also confirmed the stability of scale score distributions over time. CONCLUSION: The MCQ has robust psychometric properties, which make it suitable for assessing HRQoL in PWMCI, including comparison of group level data in intervention studies.

Biodegradability of Poly-3-hydroxybutyrate/Bacterial Cellulose Composites under Aerobic Conditions, Measured via Evolution of Carbon Dioxide and Spectroscopic and Diffraction Methods.

Poly-3-hydroxybutyrate (PHB) and bacterial cellulose (BC) are both natural polymeric materials that have the potential to replace traditional, nonrenewable polymers. In particular, the nanofibrillar form of bacterial cellulose makes it an effective reinforcement for PHB. Neat PHB, bacterial cellulose, and a composite of PHB/BC produced with 10 wt % cellulose were composted under accelerated aerobic test conditions, with biodegradability measured by the carbon dioxide evolution method, in conjunction with spectroscopic and diffraction methods to assess crystallinity changes during the biodegradation process. The PHB/BC composite biodegraded at a greater rate and extent than that of PHB alone, reaching 80% degradation after 30 days, whereas PHB did not reach this level of degradation until close to 50 days of composting. The relative crystallinity of PHB and PHB in the PHB/BC composite was found to increase in the initial weeks of degradation, with degradation occurring primarily in the amorphous region of the material and some recrystallization of the amorphous PHB. Small angle X-ray scattering indicates that the change in PHB crystallinity is accompanied by a change in morphology of semicrystalline lamellae. The increased rate of biodegradability suggests that these materials could be applicable to single-use applications and could rapidly biodegrade in compost on disposal.

Characteristics of starch-based films plasticised by glycerol and by the ionic liquid 1-ethyl-3-methylimidazolium acetate: a comparative study.

This paper reports the plasticisation effect of the ionic liquid, 1-ethyl-3-methylimidazolium acetate ([Emim][OAc]), as compared with the traditionally used plasticiser, glycerol, on the characteristics of starch-based films. For minimising the additional effect of processing, a simple compression moulding process (which involves minimal shear) was used for preparation of starch-based films. The results show that [Emim][OAc] was favourable for plasticisation, i.e., disruption of starch granules (by scanning electron microscopy), and could result in a more amorphous structure in the starch-based materials (by X-ray diffraction and dynamic mechanical analysis). (13)C CP/MAS and SPE/MAS NMR spectroscopy revealed that not only was the crystallinity reduced by [Emim][OAc], but also the amorphous starch present was plasticised to a more mobile form as indicated by the appearance of amorphous starch in the SPE/MAS spectrum. Mechanical results illustrate that, when either glycerol or [Emim][OAc] was used, a higher plasticiser content could contribute to higher flexibility. In spite of the accelerated thermal degradation of starch by [Emim][OAc] as shown by thermogravimetric analysis, the biodegradation study revealed the antimicrobial effect of [Emim][OAc] on the starch-based materials. Considering the high-amylose starch used here which is typically difficult to gelatinise in a traditional plasticiser (water and/or glycerol), [Emim][OAc] is demonstrated to be a promising plasticiser for starch to develop "green" flexible antimicrobial materials for novel applications.

Role of depression in predicting time to conversion to mild cognitive impairment.

OBJECTIVE: To establish whether, in a cohort with normal cognition, severity of depressive symptoms at baseline was related to the time taken for conversion to mild cognitive impairment (MCI) and whether this interacted with other potential risk factors, including APOE ε4 status and demographic and cognitive variables. METHODS: In a population-based cohort study, 126 cognitively normal subjects were assessed for depressive symptoms at baseline using the Geriatric Depression Scale (GDS) and were then followed over 20 years with regular cognitive assessments. The interval-censored accelerated failure time model was used to establish whether GDS and other factors, including APOE ε4 status, predicted the median time to development of MCI. RESULTS: Fifty subjects developed MCI. In APOE ε4 noncarriers, the degree of depressive symptoms at baseline predicted the time to development of MCI: An increase in GDS of 1 standard deviation (3.85) was associated with shortening of the median time to conversion to MCI by 25.4% (p = 0.0024, z = -5.6). This relationship remained statistically significant after controlling for cognitive and other confounding variables. The relationship was not significant in APOE ε4 carriers. CONCLUSION: Depressive symptoms (measured by GDS) predict time to conversion to MCI in cognitively normal people who do not carry the APOE ε4 allele. This may explain conflicting results of previous studies where APOE ε4 status was not taken into account when exploring the relationship between depression and MCI. It may also have a clinical application in helping to identify people at greater risk of developing MCI.

The development and validation of a patient-reported quality of life measure for people with mild cognitive impairment.

BACKGROUND: No validated patient-reported outcome measure (PROM) exists specifically to assess quality of life in mild cognitive impairment (MCI); we report a study conducted to develop such a measure. METHODS: Semi-structured in-depth interviews were carried out with 23 people with MCI in order to determine items for a draft questionnaire. These interviews were audio-recorded, transcribed, and content analyzed. The draft questionnaire was refined following feedback from a focus group. 280 questionnaires were posted to subjects recruited from memory clinics and research databases, the response rate was 56% i.e. 146 questionnaires were included in the final analysis. The completed questionnaires were analyzed using factor analytic techniques to produce the final measure; construct validity was assessed by correlation with a generic patient-reported outcome measure, the SF-12v2. RESULTS: Factor analysis produced a 13-item measure tapping two domains of patient-reported quality of life ("Emotional Effects" and "Practical Concerns"). Internal consistency reliability was high for both domains (α was 0.91 and 0.85 respectively). Both dimensions were highly and significantly correlated with the Mental Component Summary score of the SF-12v2 ("emotional effects" ρ = -0.43, p < 0.001 and "practical concerns" ρ = -0.56, p < 0.001). CONCLUSIONS: The Mild Cognitive Impairment Questionnaire (MCQ) is a 13-item measure developed specifically to measure patient-reported outcomes in people with MCI. It was created on the basis of patient report and has been shown to have good psychometric properties. It is likely to prove valuable in the evaluation of treatment regimes in this patient group.

False-positive rapid plasma reagin testing in patients with acute Plasmodium vivax malaria: a case control study.

Non-treponemal tests such as the rapid plasma reagin (RPR) assay are mainstays of syphilis diagnosis, but false-positive tests are common. We identified false-positive RPR titers in 8.2% of patients with malaria due to Plasmodium vivax in northern Peru. Similar rates were not detected in patients with other acute febrile illnesses.

Exploring the experiences of people with mild cognitive impairment and their caregivers with particular reference to healthcare - a qualitative study.

BACKGROUND: The aim of this study was to investigate the experiences of people with mild cognitive impairment (MCI; PWMCI) and their "advocates," particularly within healthcare services. METHODS: Semi-structured interviews were conducted with 23 PWMCI diagnosed ≤6 months ago and 20 advocates recruited via patients. The resulting data were content-analyzed. RESULTS: PWMCI interviewed rarely reported negative impressions of their general practitioner (GP). Reports regarding memory services were more mixed: positive impressions related to finding the service to be "well run" and the staff "pleasant," negative ones to the assessment process or a perceived lack of feedback. Aside from improved information provision, most PWMCI had no suggestions for improvements to their healthcare. However, these results should be interpreted with caution as many of the PWMCI interviewed displayed evidence of impaired recall and/or insight relating to their condition and healthcare. Advocates generally reported more negative impressions of both contact with the PWMCI's GP (most commonly reporting a "dismissive" attitude) and memory services (with common complaints relating to the assessments used in clinics and lengthy waiting times). This group generally had suggestions for improvements to services - particularly regarding information provision, changes in the assessment process, and improvements in communication by services. CONCLUSIONS: To our knowledge, this is the first in-depth study of the difficulties experienced by PWMCI and their advocates which includes the context of healthcare provision. The specific needs of these groups, as described here, as well as those of people with dementia, should be considered when designing memory clinics and other related services.

In situ modifications to bacterial cellulose with the water insoluble polymer poly-3-hydroxybutyrate.

Bacterial cellulose is a pure, highly crystalline form of cellulose produced from the bacteria Gluconacetobacter xylinus that has become of increasing interest in materials science due to its nanofibrillar structure, ideal for incorporation into other materials as a reinforcing material. The morphology and properties of bacterial cellulose can be altered by including additives not specifically required for growth of the bacteria in liquid media. The bioplastic poly-3-hydroxybutyrate (PHB), along with hydroxypropylmethyl cellulose (HPMC) and Tween 80 were selected and added to the growth media at different concentrations to examine their impact on the resulting cellulose, leading to changes in yield, crystallinity and morphology. The crystallinity index of the nanofibrils was found to vary greatly when using these different methods to calculate it from XRD data, indicating that particular care must be taken when comparing crystallinity results reported in the literature. PHB was able to be incorporated into the bacterial cellulose fibrils during production, increasing the potential for favourable interactions of the bacterial cellulose microfibrils with a neat PHB matrix with the aim of making a fully degradable nanocomposite system.

Living with mild cognitive impairment: the patient's and carer's experience.

BACKGROUND: Mild cognitive impairment (MCI) is a relatively common condition and rates of diagnosis are likely to increase in the near future. Little is known about the experiences of patients with MCI and their carers nor about the most appropriate interventions to support this group. METHODS: The existing literature on this topic up to July 2011 was identified via systematic searches of the Embase and Medline databases, the Cochrane Library and relevant sections of the National Electronic Library for Health. The main search term "mild cognitive impairment" was used in combination with other relevant terms. The reference lists of reviewed articles were also examined for any additional papers of significance. Papers identified by this method were examined and those deemed relevant were included in this review. RESULTS: Twenty-one suitable papers were identified for inclusion in this review, a relatively small number. The studies reviewed suggest that patients with MCI and their carers face a variety of practical and emotional challenges. No interventional studies of support have been undertaken, but the authors of relevant observational studies have suggested provision of information, psychosocial support and strategies to enhance patient interaction with carers and social contacts. CONCLUSIONS: MCI results in significant challenges for both patients and their carers. Further work is required in order to establish the best way to help patients and carers meet these challenges.

Altering the growth conditions of Gluconacetobacter xylinus to maximize the yield of bacterial cellulose.

An extensive matrix of different growth conditions including media, incubation time, inoculum volume, surface area and media volume were investigated in order to maximize the yield of bacterial cellulose produced by Gluconacetobacter xylinus, which will be used as reinforcement material to produce fully biodegradable composites. Crystallinity was shown to be controllable depending on the media and conditions employed. Samples with significant difference in crystallinity in a range from 50% to 95% were produced. Through experimental design, the yield of cellulose was maximized; primarily this involved reactor surface area design, optimized media and the use of mannitol being the highest cellulose-producing carbon source. Increasing the volume of the media did achieve a higher cellulose yield, however this increase was not found to be cost or time effective.

Exploring the relationship between employment history and retired women's social relationships.

This study explores the relationship between retired women's employment history and their social integration and social support networks in retirement. Employment history is defined by former occupation (professional, paraprofessional, nonprofessional) and job continuity (discontinuous and continuous). The sample consists of 330 retired women ranging in age from 50 to 83 years, with diverse occupational histories, who were retired an average of 3.5 years. Results indicate occupational status may influence women's social integration, part-time employment, caregiving tasks, and satisfaction with social support. Continuity of employment appears to only marginally influence social integration with no impact on social support or satisfaction with social support.

Effect of annealing and pressure on microstructure of cornstarches with different amylose/amylopectin ratios.

This work focuses on the effect of annealing and pressure on microstructures of starch, in particular the crystal structure and crystallinity to further explore the mechanisms of annealing and pressure treatment. Cornstarches with different amylose/amylopectin ratios were used as model materials. Since the samples covered both A-type (high amylopectin starch: waxy and maize) and B-type (high amylose starch: G50 and G80) crystals, the results can be used to clarify some previous confusion. The effect of annealing and pressure on the crystallinity and double helices were investigated by X-ray diffraction (XRD) and (13)C CP/MAS NMR spectroscopy. The crystal form of various starches remained unchanged after annealing and pressure treatment. XRD detection showed that the relative crystallinity (RC) of high amylopectin starches was increased slightly after annealing, while the RC of high amylose-rich starches remained unchanged. NMR measurement supported the XRD results. The increase can be explained by the chain relaxation. XRD results also indicated that some of the fixed region in crystallinity was susceptible to outside forces. The effect of annealing and pressure on starch gelatinization temperature and enthalpy are used to explore the mechanisms.

Obstetrical complications in people at risk for developing schizophrenia.

Many factors have been associated with the development of schizophrenia, yet few studies have looked at these same factors in individuals considered at risk for schizophrenia, but who have not yet reached diagnostic threshold. The rate of obstetrical complications was assessed as part of a comprehensive battery in subjects at risk (N=52), or in the first episode of schizophrenia (N=18), and in normal comparison subjects (N=43). The rate of obstetrical complications was increased in the at risk (46%) and first episode (39%) samples compared to the normal comparison (19%) group, however, follow-up analyses were only significant between the at risk and normal comparison subjects. Obstetrical complications may be an important risk factor in identifying vulnerable subjects and ultimately may, along with other risk factors, be part of an algorithm for determining likelihood of developing schizophrenia.

Wheat-gluten-based natural polymer nanoparticle composites.

A series of wheat-gluten-based nanocomposites were produced by dispersing Cloisite-30B nanoclay particles into plasticized wheat gluten systems under thermal processing conditions. The exfoliation of the nanoparticles as confirmed by wide-angle X-ray diffraction and transmission electron microscopy has resulted in significant enhancement of the mechanical properties for both deamidated proteins and vital gluten systems under 50% relative humidity (RH). Such strength improvement was also pronounced for wheat gluten (WG) systems under a high humidity condition (RH = 85%). A similar level of further strength enhancement was obtained for the WG systems that had been strengthened by blending with poly(vinyl alcohol) (PVA) and cross-linking with glyoxal. Although the nanoclay modifier, a quaternary ammonium, caused an additional plasticization to the materials, the interactions between the gluten matrix and the nanoparticles were predominant in all of these nanocomposites. A solid-state NMR study indicated that the polymer matrix in all of these nanocomposites displayed a wide distribution of chain mobilities at a molecular level (less than 1 nm). The interactions between the nanoparticles and the natural polymer matrix resulted in motional restriction for all components in the mobile phases including lipid, plasticizers, and plasticized components, although no significant influence from the nanoparticles was obtained in the mobility of the rigid phases (unplasticized components). On a scale of 20-30 nm, the deamidated protein systems tended to be homogeneous. The small domain size of the matrix resulted in modifications of the spin-lattice relaxation of these systems via spin diffusion. The residual starch seemed to remain in a relatively larger domain size in WG systems. The nanoparticles could enhance the miscibility between the starch and the other components in the WG nanocomposite, but such miscibility enhancement did not occur in the WG/PVA blend and the cross-linked system. These polymer matrixes were still heterogeneous on a scale of 20-30 nm.