Can Quality of Care for Patients with Cirrhosis Be Measured?

Abstract Introduction The ultimate purpose of measuring quality of care is to discriminate between healthcare providers in order to motivate improvement. Recently, a set of evidence-based indicators has been proposed for measurement of processes of care for patients with cirrhosis, for example early endoscopy for variceal bleeding. The objective of this study was to determine whether these indicators can be measured in a reliable and automated fashion in routine practice. Materials and methods We applied the top five indicators, based on agreement of a panel of experts, to hospitalized adults at our institution over a 3-year period. Results Only two of the indicators could be reliably measured on the basis of the published wording, and these two still required physician chart review. After applying some assumptions, the indicators were met in 46-100% of cases. None of the indicators was linked to a single physician or institution in all cases, and none occurred with sufficient frequency to discriminate quality between providers. Conclusion Measuring quality of care in cirrhosis is a laudable objective, but current indicators are not yet ready for administrative use

Controllability of structural brain networks.

Cognitive function is driven by dynamic interactions between large-scale neural circuits or networks, enabling behaviour. However, fundamental principles constraining these dynamic network processes have remained elusive. Here we use tools from control and network theories to offer a mechanistic explanation for how the brain moves between cognitive states drawn from the network organization of white matter microstructure. Our results suggest that densely connected areas, particularly in the default mode system, facilitate the movement of the brain to many easily reachable states. Weakly connected areas, particularly in cognitive control systems, facilitate the movement of the brain to difficult-to-reach states. Areas located on the boundary between network communities, particularly in attentional control systems, facilitate the integration or segregation of diverse cognitive systems. Our results suggest that structural network differences between cognitive circuits dictate their distinct roles in controlling trajectories of brain network function

Exercise-Associated Hyponatremia: The Effects of Carbohydrate and Hydration Status on IL-6, ADH, and Sodium Concentrations

Exercise-associated hyponatremia (serum sodium \u3c 135 mmol/L) is a rare, but serious condition that has been identified in those engaging in prolonged, physical activity conducted in the heat. PURPOSE: The purpose of this study was to evaluate the effect of hydration status and glycogen level on plasma IL-6, ADH, and sodium concentrations during and after prolonged exercise in the heat. METHODS: Ten male participants completed four trials: a glycogen depleted, euhydrated condition (DE); a glycogen depleted, dehydrated condition (DD); a glycogen loaded, euhydrated condition (LE); and a glycogen loaded, dehydrated condition (LD) consisting of cycling 90 minutes at 60% VO2 max in a 35˚C environment followed by a 3-h rehydration (RH) period. During RH, subjects received either 150% of fluid lost (DD & LD) or an additional 50% of fluid lost (DE & LE). Exercise and RH blood samples were analyzed for glucose, IL-6, ADH, and Na+. Sweat and urine samples were analyzed for [Na+]. RESULTS: Post-exercise to post-rehydration [Na+] changes for LD, DD, DE and LE were -6.85, -6.7, -1.45 and 0.10 mM, respectively. Post-exercise [IL-6] for DD, LD, DE, and LE were 5.4, 4.0, 3.7, and 3.49 pg/mL, respectively. Post-exercise [ADH] for LD, DD, DE, and LE were 21.5, 12.8, 7.6, and 1.9 pg/mL, respectively. The number of hyponatremic measurements for all RH samples was 5, 5, 20, and 10 for LD, DD, DE, and LE, respectively. CONCLUSION: Despite our glycogen and hydration manipulations, no regulatory effects of IL-6 and ADH on plasma sodium were observed. The timing of fluid intake did alter plasma sodium since euhydration during exercise combined with an additional 50% intake during RH, and a post-exercise RH volume of 150% of fluid lost both resulted in sodium concentrations below initial levels. Supported by a grant from the Gatorade Sports Science Institute

Second to fourth digit ratio (2D:4D) and concentrations of circulating sex hormones in adulthood

<p>Abstract</p> <p>Background</p> <p>The second to fourth digit ratio (2D:4D) is used as a marker of prenatal sex hormone exposure. The objective of this study was to examine whether circulating concentrations of sex hormones and SHBG measured in adulthood was associated with 2D:4D.</p> <p>Methods</p> <p>This analysis was based on a random sample from the Melbourne Collaborative Cohort Study. The sample consisted of of 1036 men and 620 post-menopausal women aged between 39 and 70 at the time of blood draw. Concentrations of circulating sex hormones were measured from plasma collected at baseline (1990-1994), while digit length was measured from hand photocopies taken during a recent follow-up (2003-2009). The outcome measures were circulating concentrations of testosterone, oestradiol, dehydroepiandrosterone sulphate, androstenedione, Sex Hormone Binding Globulin, androstenediol glucoronide for men only and oestrone sulphate for women only. Free testosterone and oestradiol were estimated using standard formulae derived empirically. Predicted geometric mean hormone concentrations (for tertiles of 2D:4D) and conditional correlation coefficients (for continuous 2D:4D) were obtained using mixed effects linear regression models.</p> <p>Results</p> <p>No strong associations were observed between 2D:4D measures and circulating concentrations of hormones for men or women. For males, right 2D:4D was weakly inversely associated with circulating testosterone (predicted geometric mean testosterone was 15.9 and 15.0 nmol/L for the lowest and highest tertiles of male right 2D:4D respectively (<it>P</it>-<it>trend </it>= 0.04). There was a similar weak association between male right 2D:4D and the ratio of testosterone to oestradiol. These associations were not evident in analyses of continuous 2D:4D.</p> <p>Conclusions</p> <p>There were no strong associations between any adult circulating concentration of sex hormone or SHGB and 2D:4D. These results contribute to the growing body of evidence indicating that 2D:4D is unrelated to adult sex hormone concentrations.</p

Burbot Early Life History Strategies in the Great Lakes

Burbot Lota lota exhibit four previously known reproductive strategies in the Great Lakes region. In this paper we review those strategies and provide evidence for a fifth one—delayed deepwater spawning. The four known, shallow‐water strategies are as follows: (1) spawning by self‐sustaining, landlocked populations, (2) spawning in tributaries in winter and the exit of larvae to a Great Lake, (3) spawning by residents in a spawning stream with access to a Great Lake, and (4) spawning on unconsolidated and rocky areas in shallow water in winter in the lake proper. Resident, landlocked populations exist in some Michigan and Wisconsin rivers (e.g., the Muskegon River in Michigan). The evidence for winter tributary spawning is the appearance of newly hatched Burbot in the St. Marys and Bark rivers during April–June. Evidence for Burbot juveniles leaving spawning streams is U.S. Fish and Wildlife Service tributory mouth trap data. The evidence for winter nearshore spawning comes from power plant monthly entrainment studies (Mansfield et al. 1983). Our proposed fifth strategy is spring and summer spawning at deep reefs, where there is probably cobble or boulder habitat. Our evidence comes from midlake reefs in Lake Michigan and offshore areas of Lake Huron: (1) we collected adult Burbot at midlake reefs in Lake Michigan, (2) we collected many Burbot larvae (many of which were newly hatched) from Lakes Michigan and Huron in June–August, and (3) we collected a Burbot egg in a PONAR grab in mid‐July from 73 m in southern Lake Huron. An important question remains, namely, which life history strategy provides the highest recruitment success for this species. It may be that adaptability ensures the survival of this important, top‐predator fish during periods of crisis (e.g., encounters with dams, Sea Lamprey Petromyzon marinus predation).Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141895/1/tafs1733.pd

Globally weaker and topologically different: resting-state connectivity in youth with autism

Abstract Background There is a lack of agreement about functional connectivity differences in individuals with autism spectrum disorder (ASD). Studies using absolute strength have found reduced connectivity, while those using relative strength––a measure of system topology––reveal mostly enhanced connectivity. We hypothesized that mixed findings may be driven by the metric of functional connectivity. Methods Resting-state echo planar 3 T functional magnetic resonance imaging scans were acquired on a Siemens Verio Scanner from 6 to 17-year-old youth with ASD (n = 81) and a matched typically developing control group (n = 82). All functional time series data were preprocessed using a confound regression procedure that has been previously validated in large-scale developmental datasets. It has also been shown to be highly effective at reducing the influence of motion artifact on connectivity data. We extracted time series data from a 333-node parcellation scheme, which was previously mapped to 13 functional systems. A Pearson’s correlation was calculated and transformed to Fisher’s z between every pair of nodes to create a weighted 333 × 333 adjacency matrix. Mean absolute functional connectivity strength was the mean Fisher’s z of the matrix. Relative functional connectivity was corrected for individual differences in mean absolute functional connectivity (i.e., each connection in the matrix was divided by their mean z), and functional connectivity was evaluated within and across each of the functional networks in the parcellation scheme. Results Absolute functional connectivity strength was lower in ASD, and lower functional connectivity was correlated with greater ASD symptom severity. Relative functional connectivity was higher for the ASD group in the ventral attention and retrosplenial-temporal systems, with lower cross-system functional connectivity between the ventral attention and somatomotor-mouth systems. Functional connectivity within the ventral attention and retro-splenial systems correlated significantly with ASD symptom severity. Conclusions Within a context of globally weaker functional connectivity, youth with ASD have an atypical topology of brain systems that support social perception and communication. This study clarifies the mixed results reported previously and demonstrates that the functional connectivity metric influences the observed direction of functional connectivity differences for individuals with ASD

The appropriateness of core group interventions using presumptive periodic treatment among rural Zimbabwean women who exchange sex for gifts or money.

To map the characteristics of rural based sex workers in Zimbabwe with regard to demographics, mobility, behavior, HIV and sexually transmitted infection (STI) prevalence, to explore the appropriateness and feasibility of presumptive periodic treatment (PPT) for bacterial STIs as an HIV prevention intervention among these women, and to compare tolerability of 2 PPT regimens (1 g of azithromycin and 2 g of metronidazole+/-500 mg of ciprofloxacin). Five commercial farms and 2 mines in Mashonaland West, Zimbabwe. Three hundred sixty-three sex workers were recruited and completed a structured interviewer-administered questionnaire. Each participant had blood tested for antibody to HIV, herpes simplex virus 2 (HSV-2), and syphilis; urine tested for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG); and a vaginal swab tested for Trichomonas vaginalis (TV). Women were randomly assigned to receive a single dose of 1 of 2 PPT regimens and then followed to assess rates of side effects and reinfection. The overall prevalence of antibody to HIV was 55.7% (95% confidence interval [CI]: 50.6-60.9) and that of HSV-2 was 80.8% (95% CI: 76.7-84.9). The prevalence of CT and NG was low (CT=1.7%, 95% CI: 0.3-3.0); (NG=1.9%, 95% CI: 0.5-3.4), with a much higher prevalence of TV (TV=19.3%, 95% CI: 15.2-23.4). Prevalence of CT, NG, and TV was appreciably reduced 1 month after PPT but rose to pretreatment levels at the 2- and 3-month visits. The rate of moderate or severe side effects after PPT was low, but it was higher in the women who received ciprofloxacin in addition to azithromycin and metronidazole (P=0.007). It was feasible to access women who reported exchanging money or gifts for sex in rural communities, although many of these women engaged in sex work only infrequently. The prevalence of bacterial STIs was low, suggesting that PPT may not be an appropriate intervention in this setting. Rapid reinfection after PPT suggests that this needs to be given at monthly intervals to reduce prevalence of STIs