DEveloping a Complex Intervention for DEteriorating Patients using Theoretical Modelling (DECIDE study): study protocol

AIM: To develop a theory-based complex intervention (targeting nursing staff), to enhance enablers and overcome barriers to enacting expected behaviour when monitoring patients and responding to abnormal vital signs that signal deterioration. DESIGN: A mixed method design including structured observations on hospital wards, field notes, brief, un-recorded interviews and semi-structured interviews to inform the development of an intervention to enhance practice. METHODS: Semi-structured interviews will be conducted with nursing staff using a topic guide informed by the Theoretical Domains Framework. Semi-structured interviews will be transcribed verbatim and coded deductively into the 14 Theoretical Domains Framework domains and then inductively into 'belief statements'. Priority domains will be identified and mapped to appropriate behaviour change techniques. Intervention content and mode of delivery (how behaviour change techniques are operationalised) will be developed using nominal groups, during which participants (clinicians) will rank behaviour change techniques /mode of delivery combinations according to acceptability and feasibility. Findings will be synthesised to develop an intervention manual. DISCUSSION: Despite being a priority for clinicians, researchers and policymakers for two decades, 'sub-optimal care' of the deteriorating ward patient persists. Existing interventions have been largely educational (i.e., targeting assumed knowledge deficits) with limited evidence that they change staff behaviour. Staff behaviour when monitoring and responding to abnormal vital signs is likely influenced by a range of mediators that includes barriers and enablers. IMPACT: Systematically applying theory and evidence-based methods, will result in the specification of an intervention which is more likely to result in behaviour change and can be tested empirically in future research. This article is protected by copyright. All rights reserved

Prevalence of Overweight and Obesity in Asian American Students Using Asian Specific Criteria to Determine Weight Classification

Individuals of Asian descent have been found to be at greater risk of developing conditions associated with obesity at lower BMI levels compared to other ethnic groups. As a result, new criteria have been developed to identify overweight and obesity in Asian populations. The purpose of the current study was to assess the percentage of Asian children who may be at risk for health conditions associated with obesity, but are currently overlooked when standard criteria are used to determine weight classification. Data from a larger study examining the weight status of elementary students were analyzed. Participants included 585 Asian (47% female) kindergarten and 437 5th grade (46% female) students. Using standard criteria, 15.6% of kindergarteners and 29.3% of 5th graders were considered to be overweight or obese. Chi square analyses revealed that an additional 10.2% of kindergarten and 11.7% of 5th grade Asian students were identified as being at increased risk of developing conditions associated with obesity when using Asian specific criteria compared to standard criteria (χ2=309.7, p\u3c.001 and χ2=260.9, p\u3c.001, respectively). These findings suggest that when using the standard criteria to identify at risk children, a significant number of Asian students who would potentially benefit from intervention may be overlooked

Impact of Pediatric Obesity on Grades in Elementary School

Objective: The current study examines the relationship between obesity and academic performance among second grade students. We hypothesized that students who were overweight or obese would have poorer grades than students who were normal weight. Design: Cross-sectional. Setting: Seven elementary schools from a southeast Texas Independent School District. Participants: The sample was composed of 798 ethnically and racially diverse elementary school children. Students were classified as normal weight, overweight, and obese. Main Outcome Measures: Differences in cumulative grades (math, science, and reading) across weight classifications were examined using sex, race/ethnicity, and school socioeconomic level as covariates. Additionally, all subject areas were analyzed independently. Analysis: Linear mixed models and follow-up pairwise comparisons. Results:The linear mixed model revealed significant differences in grades across weight classifications (p\u3c.05). Conclusions and Implications: This study suggests that weight status is an important marker of scholastic success. Addressing overweight may bolster efforts to improve academic performance

Outbound Medical Tourism from Mongolia: a Qualitative Examination of Proposed Domestic Health System and Policy Responses to this Trend

Background: Medical tourism is the practice of traveling across international boundaries in order to access medical care. Residents of low-to-middle income countries with strained or inadequate health systems have long traveled to other countries in order to access procedures not available in their home countries and to take advantage of higher quality care elsewhere. In Mongolia, for example, residents are traveling to China, Japan, Thailand, South Korea, and other countries for care. As a result of this practice, there are concerns that travel abroad from Mongolia and other countries risks impoverishing patients and their families.   Methods: In this paper, we present findings from 15 interviews with Mongolian medical tourism stakeholders about the impacts of, causes of, and responses to outbound medical tourism. These findings were developed using a case study methodology that also relied on tours of health care facilities and informal discussions with citizens and other stakeholders during April, 2012.   Results: Based on these findings, health policy changes are needed to address the outflow of Mongolian medical tourists. Key areas for reform include increasing funding for the Mongolian health system and enhancing the efficient use of these funds, improving training opportunities and incentives for health workers, altering the local culture of care to be more supportive of patients, and addressing concerns of corruption and favouritism in the health system.   Conclusions: While these findings are specific to the Mongolian health system, other low-to-middle income countries experiencing outbound medical tourism will benefit from consideration of how these findings apply to their own contexts. As medical tourism is increasing in visibility globally, continued research on its impacts and context-specific policy responses are needed. &nbsp

No impact of CMV or EBV seropositivity on the frequency of highly differentiated T-cells in Mexican-American adolescents

Recurring activations of the prevalent latent herpes viruses Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) induces immune cell division leading to the premature terminal differentiation of T-cells. Terminally differentiated T-cells are known to accumulate with age causing a reduction in the naïve T-cell repertoire, which compromises the ability of the adaptive immune system to respond to novel pathogens. Although CMV and EBV seropositivity are hallmarks of the “immune risk profile” and are known to influence the frequency of terminally differentiated T-cells and increase infection risk in adults, it is not known if CMV or EBV impacts on the frequency of these cells in a young subject cohort. PURPOSE: To examine the impact of CMV and EBV seropositivity on the frequency of highly differentiated blood T-cells in Mexican-American adolescents. METHODS: Fasted resting blood samples were obtained from 77 adolescents consisting of both males and females. The presence of antibodies against CMV and EBV was determined in serum by ELISA. Lymphocytes isolated from peripheral blood were assessed for a combination of cell surface markers to determine their stage of differentiation. Monoclonal antibodies and four-color flow cytometry were used to identify senescent (CD27-, CD28-, CD57+), naïve (CCR7+, CD45RA+), memory (CCR7-, CD45RA-) and effector memory (CCD7-, CD45RA+) T-cell markers on pan CD3+ T-cells, CD4+ T-cells and CD8+ T-cells. Differences in T-cell phenotype between the CMV/EBV seropositive and seronegative participants were compared using independent Student t-tests. RESULTS: The prevalence of latent CMV and EBV infection among the subject cohort was 16% and 44% respectively, while 7% of all participants were carrying a latent infection for both. No differences in senescent and memory phenotypes were found between the CMV or EBV seropositive and seronegative groups. CONCLUSION: Despite the known influence of latent CMV and EBV infection on the frequency of senescent T-cells in adults, these preliminary data indicate that CMV and EBV seropositivity has no impact on the frequency of senescent T-cells in adolescents. These data suggest that the increased frequency of terminally differentiated T-cells that are associated with CMV and EBV seropositivity in adults is probably due to long-term infections. Future studies will assess the impact of CMV and EBV seropositivity on immunosenescence in association with other factors known to have an effect on T-cells differentiation, such as BMI and physical activity status

The Bead Maze Hand Function Test for Children

Importance: There is a need for a pediatric hand function test that can be used to objectively assess movement quality. We have developed a toy-based test, the Bead Maze Hand Function (BMHF) test, to quantify how well a child performs an activity. This is achieved by assessing the control of forces applied while drawing a bead over wires of different complexity. Objective: To study the psychometric properties of the BMHF test and understand the influence of age and task complexity on test measures. Design: A cross-sectional, observational study performed in a single visit. Setting: Clinical research laboratory. Participants: Twenty-three participants (ages 4–15 yr) were recruited locally. They were typically developing children with no illness or conditions that affected their movement. Interventions/Assessments: Participants performed the BMHF test and the Box and Block test with both hands. Outcomes and Measures: Total force and completion time were examined according to age and task complexity using a linear mixed-effects model. We calculated intraclass correlation coefficients to measure interrater reliability of the method and estimated concurrent validity using the Box and Block test. Results: Total force and completion time decreased with age and depended on task complexity. The total force was more sensitive to task complexity. The Box and Block score was associated with BMHF completion time but not with total force. We found excellent interrater reliability. Conclusions and Relevance: A familiar toy equipped with hidden sensors provides a sensitive tool to assess a child’s typical hand function. Plain-Language Summary: We developed the Bead Maze Hand Function (BMHF) test to determine how well a child performs an activity with their hands. The BMHF test is a toy equipped with hidden sensors. Twenty-three typically developing children with no illnesses or conditions that affected their hand movement participated in the study. We asked the children to perform the BMHF test with both hands. Our study found that occupational therapists can reliably use the BMHF test to assess a child’s hand function

ROSAT HRI X-ray Observations of the Open Globular Cluster NGC 288

A ROSAT HRI X-ray image was obtained of the open globular cluster NGC 288, which is located near the South Galactic Pole. This is the first deep X-ray image of this system. We detect a Low Luminosity Globular Cluster X-ray source (LLGCX) RXJ005245.0-263449 with an X-ray luminosity of (5.5+-1.4)x10^32 ergs/s (0.1-2.0 keV), which is located very close to the cluster center. There is evidence for X-ray variability on a time scale of <~ 1 day. The presence of this LLGCX in such an open cluster suggests that dense stellar systems with high interaction rates are not needed to form LLGCXs. We also searched for diffuse X-ray emission from NGC 288. Upper limits on the X-ray luminosities are L_X^h < 9.5x10^32 ergs/s (0.52-2.02 keV) and L_X^s < 9.3x10^32 ergs/s (0.11-0.41 keV). These imply upper limits to the diffuse X-ray to optical light ratios in NGC 288 which are lower than the values observed for X-ray faint early-type galaxies. This indicates that the soft X-ray emission in these galaxies is due either to a component which is not present in globular clusters (e.g., interstellar gas, or a stellar component which is not found in low metallicity Population II systems), or to a relatively small number of bright Low Mass X-ray Binaries (LMXBs).Comment: The Astrophysical Journal in press. Minor revisions to improve presentation. 6 pages with 3 embedded Postscript figures in emulateapj.st

Synthesis of indoloquinolines : an intramolecular cyclization leading to advanced Perophoramidine-relevant intermediates

We thank EPSRC (UK) for a DTA studentship for C.A.J.The bioactive natural product perophoramidine has proved a challenging synthetic target. An alternative route to its indolo[2,3-b]quinolone core structure involving an N-chlorosuccinimde mediated intramolecular cylization reaction is reported. Attempts to progress towards the natural product are also discussed with an unexpected deep-seated rearrangement of the core structure occurring during an attempted iodoetherification reaction. X-ray crystallographic analysis provides important analytical confirmation of assigned structures.Publisher PDFPeer reviewe

Influenza A Virus Host Shutoff Disables Antiviral Stress-Induced Translation Arrest

Influenza A virus (IAV) polymerase complexes function in the nucleus of infected cells, generating mRNAs that bear 5′ caps and poly(A) tails, and which are exported to the cytoplasm and translated by host machinery. Host antiviral defences include mechanisms that detect the stress of virus infection and arrest cap-dependent mRNA translation, which normally results in the formation of cytoplasmic aggregates of translationally stalled mRNA-protein complexes known as stress granules (SGs). It remains unclear how IAV ensures preferential translation of viral gene products while evading stress-induced translation arrest. Here, we demonstrate that at early stages of infection both viral and host mRNAs are sensitive to drug-induced translation arrest and SG formation. By contrast, at later stages of infection, IAV becomes partially resistant to stress-induced translation arrest, thereby maintaining ongoing translation of viral gene products. To this end, the virus deploys multiple proteins that block stress-induced SG formation: 1) non-structural protein 1 (NS1) inactivates the antiviral double-stranded RNA (dsRNA)-activated kinase PKR, thereby preventing eIF2α phosphorylation and SG formation; 2) nucleoprotein (NP) inhibits SG formation without affecting eIF2α phosphorylation; 3) host-shutoff protein polymerase-acidic protein-X (PA-X) strongly inhibits SG formation concomitant with dramatic depletion of cytoplasmic poly(A) RNA and nuclear accumulation of poly(A)-binding protein. Recombinant viruses with disrupted PA-X host shutoff function fail to effectively inhibit stress-induced SG formation. The existence of three distinct mechanisms of IAV-mediated SG blockade reveals the magnitude of the threat of stress-induced translation arrest during viral replication