"We have dealt with so much. There's more coming?": Improving Knowledge About Brain Health in Adults Living With Congenital Heart Disease.

Background: Significant advances in managing congenital heart disease (CHD) have occurred over the past few decades, resulting in a fast-growing adult patient population with distinct needs requiring urgent attention. Research has recently highlighted the prevalence of neurocognitive differences among adults living with CHD. Yet, there is a lack of knowledge about the perspectives of people living with CHD and family members/caregivers on brain health. We sought to explore their perspectives to guide future research and clinical endeavours. Methods: Using the principles of integrated knowledge translation and qualitative interpretive description, we conducted 2 focus groups with 7 individuals with CHD and their family members as part of a virtual forum on brain health in CHD. Data analysis followed the principles of interpretive description. Results: A lack of understanding about overall brain health and neurocognitive differences in adult CHD was identified. To increase overall knowledge about brain health, initiatives should (1) focus on the individual living with CHD, involving family members and peers; (2) use social media and health care encounters for knowledge exchange; and (3) ensure a "balancing act" in the information provided to avoid feelings of worry and uncertainty about the future while simultaneously empowering people living with CHD. Conclusions: There is a pressing need for better education about brain health among individuals living with CHD. Our findings can guide clinicians in developing programmes of care and (re)design health services that address the brain-heart axis and neurocognitive differences in CHD.

Contexte: Des progrès significatifs ont été réalisés au cours des dernières décennies dans la prise en charge des cardiopathies congénitales, et il en résulte une croissance rapide de la population des patients adultes dont les besoins distincts requièrent une attention urgente. Des études récentes ont mis en évidence la prévalence des différences neurocognitives chez les adultes atteints de cardiopathies congénitales (CC). À ce jour, les connaissances sur les points de vue des personnes qui vivent avec la CC, des membres de leurs familles et de leurs aidants au sujet de la santé du cerveau sont insuffisantes. Notre objectif était d'explorer ces points de vue afin d'orienter les recherches à venir et les initiatives cliniques. Méthodologie: En nous basant sur les approches d'application des connaissances intégrées et de description interprétative (DI) qualitative, nous avons organisé deux groupes de discussion avec 7 personnes atteintes de CC et les membres de leur famille, dans le cadre d'un forum virtuel sur la santé du cerveau dans les CC. L'analyse des données a été réalisée selon les principes de la DI. Résultats: Un manque de connaissances au sujet de la santé du cerveau en général et des différences neurocognitives chez les personnes atteintes de CC a été observé. Afin d'améliorer le niveau des connaissances générales sur la santé du cerveau, les initiatives doivent : (1) être centrées sur les personnes qui vivent avec la CC, avec la participation des membres de leur famille et d'autres patients; (2) tirer profit des médias sociaux et des rencontres en contexte de soins de santé pour le partage de connaissances; et (3) veiller à maintenir un équilibre, puisqu'il convient d'outiller les personnes atteintes de CC sans toutefois causer de sentiment d'inquiétude ou d'incertitude quant à l'avenir. Conclusions: Nous avons constaté le besoin urgent d'améliorer les connaissances des personnes qui vivent avec une CC au sujet de la santé du cerveau. Les résultats obtenus pourront guider les cliniciens dans l'élaboration de programmes de soins et la conception (ou la refonte) de services de soins de santé qui intègrent l'axe cerveau-cœur et les différences neurocognitives associées aux CC.

Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing.

Background: Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work. Method: We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized. Results: Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]). Conclusions: The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.

What is already known about the topic?: The causal assumptions and key components of implementation interventions are often not well described, which limits the influence of implementation science on implementation practice. What does this paper add?: This work provides an approach for surfacing the causal assumptions from intervention developers (through interviews with eight participants) and active ingredients from intervention materials, focusing on two real-world interventions already delivered at scale and designed to promote safer opioid prescribing. The analysis provides a comprehensive intervention description and reveals the extent to which final interventions align with developers' intentions. What are the implications for practice, research, or policy?: The findings provide a foundation for future work which will describe the effectiveness of these interventions (alone and in combination) and explore whether they achieve change in the intended ways, thereby providing an example of a more fulsome intervention evaluation. More broadly, our methods can be used by implementation practitioners to review and reflect on their intervention development process and support comprehensive intervention descriptions.

Engagement is a necessary condition to test audit and feedback design features: results of a pragmatic, factorial, cluster-randomized trial with an embedded process evaluation.

BACKGROUND: While audit & feedback (A&F) is an effective implementation intervention, the design elements which maximize effectiveness are unclear. Partnering with a healthcare quality advisory organization already delivering feedback, we conducted a pragmatic, 2 × 2 factorial, cluster-randomized trial to test the impact of variations in two factors: (A) the benchmark used for comparison and (B) information framing. An embedded process evaluation explored hypothesized mechanisms of effect. METHODS: Eligible physicians worked in nursing homes in Ontario, Canada, and had voluntarily signed up to receive the report. Groups of nursing homes sharing physicians were randomized to (A) physicians' individual prescribing rates compared to top-performing peers (the top quartile) or the provincial median and (B) risk-framed information (reporting the number of patients prescribed high-risk medication) or benefit-framed information (reporting the number of patients not prescribed). We hypothesized that the top quartile comparator and risk-framing would lead to greater practice improvements. The primary outcome was the mean number of central nervous system-active medications per resident per month. Primary analyses compared the four arms at 6 months post-intervention. Factorial analyses were secondary. The process evaluation comprised a follow-up questionnaire and semi-structured interviews. RESULTS: Two hundred sixty-seven physicians (152 clusters) were randomized: 67 to arm 1 (median benchmark, benefit framing), 65 to arm 2 (top quartile benchmark, benefit framing), 75 to arm 3 (median benchmark, risk framing), and 60 to arm 4 (top quartile benchmark, risk framing). There were no significant differences in the primary outcome across arms or for each factor. However, engagement was low (27-31% of physicians across arms downloaded the report). The process evaluation indicated that both factors minimally impacted the proposed mechanisms. However, risk-framed feedback was perceived as more actionable and more compatible with current workflows, whilst a higher target might encourage behaviour change when physicians identified with the comparator. CONCLUSIONS: Risk framing and a top quartile comparator have the potential to achieve change. Further work to establish the strategies most likely to enhance A&F engagement, particularly with physicians who may be most likely to benefit from feedback, is required to support meaningfully addressing intricate research questions concerning the design of A&F. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02979964 . Registered 29 November 2016.

Behavioral Nudges to Improve Audit and Feedback Report Opening Among Antibiotic Prescribers: A Randomized Controlled Trial.

Background: Peer comparison audit and feedback has demonstrated effectiveness in improving antibiotic prescribing practices, but only a minority of prescribers view their reports. We rigorously tested 3 behavioral nudging techniques delivered by email to improve report opening. Methods: We conducted a pragmatic randomized controlled trial among Ontario long-term care prescribers enrolled in an ongoing peer comparison audit and feedback program which includes data on their antibiotic prescribing patterns. Physicians were randomized to 1 of 8 possible sequences of intervention/control allocation to 3 different behavioral email nudges: a social peer comparison nudge (January 2020), a maintenance of professional certification incentive nudge (October 2020), and a prior participation nudge (January 2021). The primary outcome was feedback report opening; the primary analysis pooled the effects of all 3 nudging interventions. Results: The trial included 421 physicians caring for >28 000 residents at 450 facilities. In the pooled analysis, physicians opened only 29.6% of intervention and 23.9% of control reports (odds ratio [OR], 1.51 [95% confidence interval {CI}, 1.10-2.07], P = .011); this difference remained significant after accounting for physician characteristics and clustering (adjusted OR [aOR], 1.74 [95% CI, 1.24-2.45], P = .0014). Of individual nudging techniques, the prior participation nudge was associated with a significant increase in report opening (OR, 1.62 [95% CI, 1.06-2.47], P = .026; aOR, 2.16 [95% CI, 1.33-3.50], P = .0018). In the pooled analysis, nudges were also associated with accessing more report pages (aOR, 1.28 [95% CI, 1.14-1.43], P < .001). Conclusions: Enhanced nudging strategies modestly improved report opening, but more work is needed to optimize physician engagement with audit and feedback. Clinical Trials Registration: NCT04187742.

Neurodevelopment and Cognition Across the Lifespan in Patients With Single-Ventricle Physiology: Abnormal Brain Maturation and Accumulation of Brain Injuries.

The proportion of adults with single-ventricle physiology (SVP) has significantly increased over time. Improved longevity, however, may be associated with increased risks to brain health in adulthood. Children with SVP are at risk for neurodevelopmental impairment early in life and neurocognitive impairment as they age, and existing epidemiologic evidence suggests that adults with complex congenital heart disease, including SVP, are at increased risk of stroke and dementia, as compared with age-matched controls. Mechanisms that could contribute to increased potential for cognitive impairment in adults with SVP include the following: (i) baseline brain dysmaturation beginning in utero; (ii) subsequent acquired injury occurring in early childhood from staged surgeries; and (iii) pathophysiologic factors related to SVP itself, both in childhood and potentially throughout the lifespan as new arrhythmias, heart failure, and other issues may develop. Associated pathophysiologic mechanisms may include thromboembolism, hypercoagulability, hypoxia, hypoperfusion, and inflammation. Despite increasingly robust pediatric literature with neuroradiologic-neuropsychology correlates in SVP, there is a dearth of similar research in adults, with respect to both complex congenital heart disease overall and SVP specifically. Unanswered questions in adults with SVP include the following: (i) what is the prevalence of baseline brain injury and neurocognitive impairment in adulthood; (ii) what is the incident risk of these issues over time; and (iii) how much may be mediated by incident brain injury across the lifespan in adulthood, as opposed to from underlying susceptibility from dysmaturation and early childhood insults. In this review, we describe what is known regarding the brain health in individuals with SVP across the lifespan, and identify priority areas for future research.

CD34 Staining as a Useful Tool in Disorders of Collagen Degeneration.

ABSTRACT: The human progenitor-cell antigen CD34 is expressed in dermal dendritic cells and is lost in several disorders affecting dermal collagen. The loss of CD34 immunohistochemical staining has been demonstrated to be helpful in the histologic diagnosis of morphea, lichen sclerosus, and the classic pattern of granuloma annulare. This study characterized CD34 expression in 2 sclerosing disorders affecting the subcutis: lipodermatosclerosis (LDS) and the sclerodermoid form of chronic graft-versus-host disease (ScGVHD). In addition, we applied CD34 staining to the interstitial pattern of granuloma annulare (IGA), which is a diagnostically challenging entity with subtle amounts of dermal collagen degeneration. Fifteen cases of LDS, 6 cases of ScGVHD, and 4 cases of IGA were identified and stained with CD34. All cases of LDS showed loss of CD34 within subcutaneous septa, and 9 cases (60%) also exhibited full-thickness dermal loss of interstitial staining. All 6 cases of ScGVHD showed varying degrees of CD34 loss within the dermis and/or subcutaneous septa. The normal subcutis showed diffuse septal staining with CD34, with a density equal to that seen in the dermis. CD34 staining was lost in areas of dermal inflammation in half of the IGA cases. We conclude that CD34 staining is a useful ancillary test in disease processes affecting the subcutaneous collagen such as LDS and ScGVHD. Its utility also extends to diagnostically challenging disorders of dermal collagen degeneration such as IGA.

Population-Wide Peer Comparison Audit and Feedback to Reduce Antibiotic Initiation and Duration in Long-Term Care Facilities with Embedded Randomized Controlled Trial.

BACKGROUND: Antibiotic overprescribing in long-term care settings is driven by prescriber preferences and is associated with preventable harms for residents. We aimed to determine whether peer comparison audit and feedback reporting for physicians reduces antibiotic overprescribing among residents. METHODS: We employed a province wide, difference-in-differences study of antibiotic prescribing audit and feedback, with an embedded pragmatic randomized controlled trial (RCT) across all long-term care facilities in Ontario, Canada, in 2019. The study year included 1238 physicians caring for 96 185 residents. In total, 895 (72%) physicians received no feedback; 343 (28%) were enrolled to receive audit and feedback and randomized 1:1 to static or dynamic reports. The primary outcomes were proportion of residents initiated on an antibiotic and proportion of antibiotics prolonged beyond 7 days per quarter. RESULTS: Among all residents, between the first quarter of 2018 and last quarter of 2019, there were temporal declines in antibiotic initiation (28.4% to 21.3%) and prolonged duration (34.4% to 29.0%). Difference-in-differences analysis confirmed that feedback was associated with a greater decline in prolonged antibiotics (adjusted difference -2.65%, 95% confidence interval [CI]: -4.93 to -.28%, P = .026), but there was no significant difference in antibiotic initiation. The reduction in antibiotic durations was associated with 335 912 fewer days of treatment. The embedded RCT detected no differences in outcomes between the dynamic and static reports. CONCLUSIONS: Peer comparison audit and feedback is a pragmatic intervention that can generate small relative reductions in the use of antibiotics for prolonged durations that translate to large reductions in antibiotic days of treatment across populations. Clinical Trials Registration. NCT03807466.

Effectiveness of confidential reports to physicians on their prescribing of antipsychotic medications in nursing homes.

BACKGROUND: Antipsychotic medication use in nursing homes is associated with potential for harms. In Ontario, Canada, an agency of the provincial government offers nursing home physicians quarterly audit and feedback on their antipsychotic prescribing. We compared the characteristics of physicians who did and did not engage with the intervention, and assessed early changes in prescribing. METHODS: This population-level, retrospective cohort study used linked administrative databases to track prescribing practices in nursing homes pre-intervention (baseline), immediately post-initiative (3 months), and at follow-up (6 months). Exposure variables identified whether a physician signed up to participate (or not) or viewed the feedback following sign up (or not). Differences in the proportion of days that residents received antipsychotic medications at 6 months compared to baseline by exposure(s) were assessed using a linear mixed effects regression analysis to adjust for a range of resident, physician, and nursing home factors. Benzodiazepine and statin prescribing were assessed as a balance and tracer measures, respectively. RESULTS: Of 944 eligible physicians, 210 (22.3%) signed up to recieve the feedback report and 132 (13.9%) viewed their feedback. Physicians who signed up for feedback were more likely to have graduated from a Canadian medical school, work in urban nursing homes, and care for a larger number of residents. The clinical and functional characteristics of residents were similar across physician exposure groups. At 6 months, antipsychotic prescribing had decreased in all exposure groups. Those who viewed their feedback report had a signicantly greater reduction in antipsychotic prescribing than those who did not sign up (0.94% patient-days exposed; 95% CI 0.35 to 1.54%, p = 0.002). Trends in prescribing patterns across exposure groups for benzodiazepines and statins were not statistically significant. INTERPRETATION: Almost a quarter of eligible physicians engaged early in a voluntary audit and feedback intervention related to antipsychotic prescribing in nursing homes. Those who viewed their feedback achieved a small but statistically significant change in prescribing, equivalent to approximately 14,000 fewer days that nursing home residents received antipsychotic medications over 6 months. This study adds to the literature regarding the role of audit and feedback interventions to improve quality of care.

Enhancing Quality Care in Ontario Long-Term Care Homes Through Audit and Feedback for Physicians.

The province of Ontario in Canada is an example of a jurisdiction that is using a specific quality improvement mechanism, known as "audit and feedback," to help clinicians enhance the care they provide to long-term care (LTC) home residents. This program, launched in 2015, is unique in that the reports are provided across an entire jurisdiction. These reports were co-designed with clinicians, including medical directors, scientists, and other stakeholders, and are updated regularly to maintain their relevance to medical practice in LTC. The data for the reports is calculated using record linkage with available administrative data sources. The reports are updated with new data 4 times each year and emailed directly to physicians who have requested their report. The reports are designed to have an overall dashboard summarizing the practice level data with a comparison to all physicians in Ontario. More detailed information on their data such as trend data and resources for quality improvement are found in subsequent pages of the report. These reports are a tool to support physicians in quality improvement efforts in their LTC practice. We believe the role of a medical director is very important in both the uptake and use of these reports as the medical director would act as a trusted advisor who can influence quality of care overall within an LTC home. We are also testing a new format for delivering the reports in an interactive online format that enables more options for viewing practice data. Initial evaluation of these reports shows that there is a statistically significant impact on reducing the prescription of antipsychotic medications in LTC homes. In future, we hope to see a larger effect on the latest topic included in the reports: antibiotic prescribing.

Neurocognition in Adult Congenital Heart Disease: How to Monitor and Prevent Progressive Decline.

Children born with congenital heart disease (CHD) are now living to adulthood in unprecedented numbers and many will eventually live to become senior citizens. As care goals shift from surviving to thriving, a new focus on quality of life has emerged. Neurocognition and the ability to participate fully in society, form meaningful relationships, and collaborate effectively with the health care system are important considerations. As adults with CHD age, research regarding their cognitive function becomes prescient. The focus is now shifting from defining neurocognitive deficits in children with CHD to preventing neurocognitive decline in adults living with CHD. In this review, we describe the possible etiologies and predictors of neurocognitive decline in adults with CHD. We performed a comprehensive literature review to identify all of the current data available on neurocognitive function in adults with CHD. We summarize the available evidence by describing common deficits in this patient population and the potential effects of these deficits on adult functioning, health care decision-making, and long-term relationships with care providers. We review potential modifiable etiologies for progressive neurocognitive decline and suggest strategies for surveillance and prevention of the potential decline. We conclude that the current information available regarding the aging brain of adults with CHD and the effect of neurocognitive decline on morbidity and mortality is woefully insufficient. This review, therefore, provides a roadmap for future research endeavours to study neurocognition in older adults with CHD.

Adults With Complex Congenital Heart Disease: Cerebrovascular Considerations for the Neurologist.

As infant and childhood mortality has decreased in congenital heart disease, this population is increasingly reaching adulthood. Adults with congenital heart disease (ACHD) represent a group with increased risk of stroke, silent brain infarcts, and vascular cognitive impairment. Cyanotic and other complex cardiac lesions confer the greatest risk of these cerebrovascular insults. ACHD patients, in addition to having an increased risk of stroke from structural cardiac issues and associated physiological changes, may have an accelerated burden of conventional vascular risk factors, including hypertension and impaired glucose metabolism. Adult neurologists should be aware of the risks of clinically evident and subclinical cerebrovascular disease in this population. We review the existing evidence on primary and secondary stroke prevention in individuals with complex congenital heart disease, and identify knowledge gaps in need of further research, including treatment of acute stroke in this population. Multisystemic genetic syndromes are outside the scope of this review.

Characterisation of non-degraded oligosaccharides in enzymatically hydrolysed and fermented, dilute ammonia-pretreated corn stover for ethanol production.

BACKGROUND: Corn stover is lignocellulosic biomass that has potential to be used as raw material for bioethanol production. In the current research, dilute ammonia pretreatment was used to improve the accessibility of corn stover carbohydrates to subsequently added hydrolytic enzymes. Some carbohydrates, however, were still present after enzymatic hydrolysis and fermentation. Hence, this research was aimed to characterise the recalcitrant carbohydrates, especially the oligosaccharides that remained after hydrolysis and fermentation of dilute ammonia-pretreated corn stover (DACS). RESULTS: About 35% (w/w) of DACS carbohydrates remained after enzymatic hydrolysis and fermentation of the released monosaccharides. One-third of these recalcitrant carbohydrates were water soluble and composed of diverse oligosaccharides. By using UHPLC-MS n , more than 50 oligosaccharides were detected. Glucurono-xylooligosaccharides (UAXOS) with a degree of polymerisation (DP) less than 5 were the most abundant oligosaccharides. The (4-O-methyl) glucuronosyl substituent was mostly attached onto the terminal xylosyl residue. It was shown that the glucuronosyl substituent in some UAXOS was modified into a hexenuronosyl, a glucuronamide or a hexenuronamide residue due to the dilute ammonia pretreatment. Another group of abundant oligosaccharides comprised various xyloglucan oligosaccharides (XGOS), with a DP 5 annotated as XXG as the most pronounced. In addition, disaccharides annotated as xylosyl-glucose with different ß linkages as well as larger carbohydrates were present in the fermentation slurry. CONCLUSIONS: Around one-third of the 35% (w/w) recalcitrant DACS carbohydrates remained as water-soluble saccharides. In this study, more than 50 recalcitrant oligosaccharides were detected, which mostly composed of xylosyl and/or glucosyl residues. The most pronounced oligosaccharides were UAXOS and XGOS. Hence, α-glucuronidase and α-xylosidase were suggested to be added to the enzyme mixture to degrade these oligosaccharides further, and hence the fermentation yield is potentially increased.

Different action patterns of glucoamylases on branched gluco-oligosaccharides from amylopectin.

A bottleneck in enzymatic starch hydrolysis, like in biofuel industry, is relatively slow degradation of branched structures compared to linear ones. This research aimed to evaluate glucoamylases for their activity towards branched gluco-oligosaccharides. The activity of seven modified glucoamylases and two homologs was compared to that of a reference glucoamylase obtained from a commercial enzyme cocktail 'Distillase® SSF'. All enzymes were evaluated for their activity towards panose (glc(α1-6)glc(α1-4)glc), pullulan and a purified branched gluco-oligosaccharide with a degree of polymerisation of 5 (bDP5) identified as glc(α1-4)[glc(α1-4)glc(α1-6)]glc(α1-4)glc. The enzymes degraded bDP5 differently, which was mainly due to variation in their capability to cleave α-(1→6)-linked or the α-(1→4)-linked glucosyl residue at the non-reducing end of the branched glucosyl residue. By comparing the enzyme activity towards bDP5 with those towards panose and pullulan, it was suggested that the activity towards bDP5 could be estimated only when the activity towards both commercial substrates was evaluated.

Characterisation of branched gluco-oligosaccharides to study the mode-of-action of a glucoamylase from Hypocrea jecorina.

In the conversion of starch to fermentable glucose for bioethanol production, hydrolysis of amylopectin by α-amylases and glucoamylases is the slowest step. In this process, α-1,6-branched gluco-oligosaccharides accumulate and are slowly degraded. Glucoamylases that are able to degrade such branched oligosaccharides faster are economically beneficial. This research aimed at the isolation and characterisation of branched gluco-oligosaccharides produced from amylopectin digestion by α-amylase, to be used as substrates for comparing their degradation by glucoamylases. Branched gluco-oligosaccharides with a DP between five and twelve were purified using size exclusion chromatography. These structures were characterised after labelling with 2-aminobenzamide using UHPLC-MS(n) analysis. Further, the purified oligosaccharides were used to evaluate the mode-of-action of a glucoamylase from Hypocrea jecorina. The enzyme cleaves the α-1,4-linkage adjacent to the α-1,6-linkage at a lower rate than that of α-1,4-linkages in linear oligosaccharides. Hence, the branched gluco-oligosaccharides are a suitable substrate to evaluate glucoamylase activity on branched structures.

Small and large titanium plates are equally effective for treating mandible fractures.

PURPOSE: The use of small titanium plates for the management of mandibular fractures continues to be a source of controversy because of their load-sharing properties. The purpose of the present study was to determine whether the use of small plates for mandibular fractures is as efficacious as large plates in a large level I trauma center. MATERIALS AND METHODS: Consecutive subjects presenting with mandibular fractures were randomly allocated to the use of either small plates (group 1) or large plates (group 2). The primary predictor variable was the plate size. The primary outcome variable was fracture union. The secondary outcomes included complications and operative time. Statistical analysis was performed using the Wilcoxon rank sum test for ordinal and continuous variables and the χ(2) test or Fisher exact test for proportions. RESULTS: A total of 127 consecutive subjects with a fracture of the mandible were enrolled in the study. Of the 127 subjects, 53 completed the required follow-up of at least 6 weeks. There was no difference in the rate of fracture union between the 2 groups (P = .95). CONCLUSIONS: The study findings suggest that the use of small plates and monocortical screws for mandibular fractures results in favorable outcomes compared with using larger plates and bicortical screws.

Characterization and mode of action of two acetyl xylan esterases from Chrysosporium lucknowense C1 active towards acetylated xylans.

Two novel acetyl xylan esterases, Axe2 and Axe3, from Chrysosporium lucknowense (C1), belonging to the carbohydrate esterase families 5 and 1, respectively, were purified and biochemically characterized. Axe2 and Axe3 are able to hydrolyze acetyl groups both from simple acetylated xylo-oligosaccharides and complex non-soluble acetylglucuronoxylan. Both enzymes performed optimally at pH 7.0 and 40 °C. Axe2 has a clear preference for acetylated xylo-oligosaccharides (AcXOS) with a high degree of substitution and Axe3 does not show such preference. Axe3 has a preference for large AcXOS (DP 9-12) when compared to smaller AcXOS (especially DP 4-7) while for Axe2 the size of the oligomer is irrelevant. Even though there is difference in substrate affinity towards acetylated xylooligosaccharides from Eucalyptus wood, the final hydrolysis products are the same for Axe2 and Axe3: xylo-oligosaccharides containing one acetyl group located at the non-reducing xylose residue remain as examined using MALDI-TOF MS, CE-LIF and the application of an endo-xylanase (GH 10).

Effects of dietary fibre on subjective appetite, energy intake and body weight: a systematic review of randomized controlled trials.

Dietary fibres are believed to reduce subjective appetite, energy intake and body weight. However, different types of dietary fibre may affect these outcomes differently. The aim of this review was to systematically investigate the available literature on the relationship between dietary fibre types, appetite, acute and long-term energy intake, and body weight. Fibres were grouped according to chemical structure and physicochemical properties (viscosity, solubility and fermentability). Effect rates were calculated as the proportion of all fibre-control comparisons that reduced appetite (n = 58 comparisons), acute energy intake (n = 26), long-term energy intake (n = 38) or body weight (n = 66). For appetite, acute energy intake, long-term energy intake and body weight, there were clear differences in effect rates depending on chemical structure. Interestingly, fibres characterized as being more viscous (e.g. pectins, ß-glucans and guar gum) reduced appetite more often than those less viscous fibres (59% vs. 14%), which also applied to acute energy intake (69% vs. 30%). Overall, effects on energy intake and body weight were relatively small, and distinct dose-response relationships were not observed. Short- and long-term effects of dietary fibres appear to differ and multiple mechanisms relating to their different physicochemical properties seem to interplay. This warrants further exploration.