Primary Care Validation of a Single-Question Alcohol Screening Test

BACKGROUND Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings. OBJECTIVE To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). DESIGN Cross-sectional study. PARTICIPANTS Adult English-speaking patients recruited from primary care waiting rooms. MEASUREMENTS Participants were asked the single screening question, "How many times in the past year have you had X or more drinks in a day?", where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method. MAIN RESULTS Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics. CONCLUSIONS. The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.National Institute on Alcohol Abuse and Alcoholism (R01-AA010870

Perioperative complications and neurological outcomes of first and second craniotomies among patients enrolled in the Glioma Outcome Project

Journal ArticleIn many new clinical trials of patients with malignant gliomas surgical intervention is incorporated as an integral part of tumor-directed interstitial therapies such as gene therapy, biodegradable wafer placement, and immunotherapy. Assessment of toxicity is a major component of evaluating these novel therapeutic interventions, but this must be done in light of known complication rates of craniotomy for tumor resection. Factors predicting neurological outcome would also be helpful for patient selection for surgically based clinical trials. Methods. The Glioma Outcome Project is a prospectively compiled database containing information on 788 patients with malignant gliomas that captured clinical practice patterns and patient outcomes. Patients in this series who underwent their first or second craniotomy were analyzed separately for presenting symptoms, tumor and patient characteristics, and perioperative complications. Preoperative and intraoperative factors possibly related to neurological outcome were evaluated

Editorial "special issue on educational design research (EDR) in post-secondary learning environments

Along with many ASCILITE members, we have grown increasingly concerned that current approaches to educational technology research lack value and practical application in the field. Educational design research (EDR) is an emerging approach that bridges the demand for rigorous research with the development of relevant solutions to educational problems. EDR is an intervention and process-oriented approach that uses a variety of methods to examine the development and implementation of instructional solutions to current educational problems. As evidence about the inner workings of interventions accumulates over time, design principles and learning theories are derived from work in local contexts, and their limits can be tested in other settings. This genre of research is currently underrepresented in the literature. To advance scholarship through the execution and reporting of EDR, we identified an urgent need for examples across fields, and especially related to educational technology in higher education. The purpose of this special issue is to advance the field by showcasing exemplars of high quality EDR in post-secondary educational settings. We have sought manuscripts that detail EDR projects involving the use and/or development of educational technology in tertiary education (higher and further), lifelong learning, and training. This manuscript set therefore promotes research and scholarship on innovative instructional designs that integrate technology in those settings, promote effective practice, and help inform policy

Adding Natural Frequency Data to a Decision Aid for Colorectal Cancer Screening: Results of a Randomized Trial

Guidelines recommend that decision aids provide natural frequency data regarding baseline risk, risk reduction, and chances of false positives and negatives. Such quantitative information may confuse patients, especially those with low numeracy. We conducted a randomized trial to compare effects of 2 colorectal cancer (CRC) screening decision aids—one with and one without natural frequency data

Successful Treatment of an MTBE-impacted Aquifer Using a Bioreactor Self-colonized by Native Aquifer Bacteria

A field-scale fixed bed bioreactor was used to successfully treat an MTBE-contaminated aquifer in North Hollywood, CA without requiring inoculation with introduced bacteria. Native bacteria from the MTBE-impacted aquifer rapidly colonized the bioreactor, entering the bioreactor in the contaminated groundwater pumped from the site, and biodegraded MTBE with greater than 99 % removal efficiency. DNA sequencing of the 16S rRNA gene identified MTBE-degrading bacteria Methylibium petroleiphilum in the bioreactor. Quantitative PCR showed M. petroleiphilum enriched by three orders of magnitude in the bioreactor above densities pre-existing in the groundwater. Because treatment was carried out by indigenous rather than introduced organisms, regulatory approval was obtained for implementation of a full-scale bioreactor to continue treatment of the aquifer. In addition, after confirmation of MTBE removal in the bioreactor to below maximum contaminant limit levels (MCL; MTBE = 5 μg L−1), treated water was approved for reinjection back into the aquifer rather than requiring discharge to a water treatment system. This is the first treatment system in California to be approved for reinjection of biologically treated effluent into a drinking water aquifer. This study demonstrated the potential for using native microbial communities already present in the aquifer as an inoculum for ex-situ bioreactors, circumventing the need to establish non-native, non-acclimated and potentially costly inoculants. Understanding and harnessing the metabolic potential of native organisms circumvents some of the issues associated with introducing non-native organisms into drinking water aquifers, and can provide a low-cost and efficient remediation technology that can streamline future bioremediation approval processes

Presenting Stool Testing as the Default Option for Colorectal Cancer Screening: Results of a Randomized Trial

Individuals eligible for colorectal cancer (CRC) screening can choose from multiple approved tests, including colonoscopy and stool testing. The existence of multiple options allows patients to choose a preferred strategy but also may lead to indecision and delay. Behavioral economics suggests presenting one option as a default choice, i.e. the one that patients should receive if they do not wish to decide. We conducted a randomized trial to measure the impact of describing stool testing as the default option for CRC screening in a decision aid (DA)

Impact of including quantitative information in a decision aid for colorectal cancer screening: A randomized controlled trial

Objective: Guidelines recommend that decision aids provide quantitative information about risks and benefits of available options. Impact of providing this information is unknown. Methods: Randomized trial comparing two decision aids about colorectal cancer (CRC) screening with colonoscopy or fecal immunochemical test (FIT). 688 primary care patients due for CRC screening viewed a decision aid that uses words only (Verbal arm) vs. one that provides quantitative information (Quantitative arm). Main outcomes included perceived CRC risk, intent to be screened, and test preference, measured before and after viewing decision aid, and screening uptake at six months. Analyses were performed with ANCOVA and logistic regression. Results: Compared to the Verbal arm, those in the Quantitative arm had a larger increase in intent to undergo FIT (p = 0.011) and were more likely to switch their preferred test from non-FIT to FIT (28% vs. 19%, p = .010). There were decreases in perceived risk in the Verbal Arm but not the Quantitative Arm (p = 0.004). There was no difference in screening uptake. Numeracy did not moderate any effects. Conclusions: Quantitative information had relatively minor impact and no clearly negative effects, such as reducing uptake. Practice implications: Quantitative information may be useful but not essential for patients viewing decision aids

Providing Quantitative Information and a Nudge to Undergo Stool Testing in a Colorectal Cancer Screening Decision Aid: A Randomized Clinical Trial

Background. Guidelines recommend that patient decision aids should provide quantitative information about probabilities of potential outcomes, but the impact of this information is unknown. Behavioral economics suggests that patients confused by quantitative information could benefit from a “nudge” towards one option. We conducted a pilot randomized trial to estimate the effect sizes of presenting quantitative information and a nudge. Methods. Primary care patients (n = 213) eligible for colorectal cancer screening viewed basic screening information and were randomized to view (a) quantitative information (quantitative module), (b) a nudge towards stool testing with the fecal immunochemical test (FIT) (nudge module), (c) neither a nor b, or (d) both a and b. Outcome measures were perceived colorectal cancer risk, screening intent, preferred test, and decision conflict, measured before and after viewing the decision aid, and screening behavior at 6 months. Results. Patients viewing the quantitative module were more likely to be screened than those who did not (P = 0.012). Patients viewing the nudge module had a greater increase in perceived colorectal cancer risk than those who did not (P = 0.041). Those viewing the quantitative module had a smaller increase in perceived risk than those who did not (P = 0.046), and the effect was moderated by numeracy. Among patients with high numeracy who did not view the nudge module, those who viewed the quantitative module had a greater increase in intent to undergo FIT (P = 0.028) than did those who did not. Limitations. The limitations of this study were the limited sample size and single healthcare system. Conclusions. Adding quantitative information to a decision aid increased uptake of colorectal cancer screening, while adding a nudge to undergo FIT did not increase uptake. Further research on quantitative information in decision aids is warranted

The abstract boundary---a new approach to singularities of manifolds

A new scheme is proposed for dealing with the problem of singularities in General Relativity. The proposal is, however, much more general than this. It can be used to deal with manifolds of any dimension which are endowed with nothing more than an affine connection, and requires a family \calc\ of curves satisfying a {\em bounded parameter property} to be specified at the outset. All affinely parametrised geodesics are usually included in this family, but different choices of family \calc\ will in general lead to different singularity structures. Our key notion is the {\em abstract boundary\/} or {\em $a$-boundary\/} of a manifold, which is defined for any manifold \calm\ and is independent of both the affine connection and the chosen family \calc\ of curves. The $a$-boundary is made up of equivalence classes of boundary points of \calm\ in all possible open embeddings. It is shown that for a pseudo-Riemannian manifold (\calm,g) with a specified family \calc\ of curves, the abstract boundary points can then be split up into four main categories---regular, points at infinity, unapproachable points and singularities. Precise definitions are also provided for the notions of a {\em removable singularity} and a {\em directional singularity}. The pseudo-Riemannian manifold will be said to be singularity-free if its abstract boundary contains no singularities. The scheme passes a number of tests required of any theory of singularities. For instance, it is shown that all compact manifolds are singularity-free, irrespective of the metric and chosen family \calc.Comment: 40 pages (amslatex) + 5 uuencoded figures (A postscript version is also available on http://einstein.anu.edu.au/), CMA Maths. Research Report No. MRR028-9

Real Time Enzyme Inhibition Assays Provide Insights into Differences in Binding of Neuraminidase Inhibitors to Wild Type and Mutant Influenza Viruses

The influenza neuraminidase (NA) inhibitors zanamivir, oseltamivir and peramivir were all designed based on the knowledge that the transition state analogue of the cleaved sialic acid, 2-deoxy,2,3-dehydro N-acetyl neuraminic acid (DANA) was a weak inhibitor of NA. While DANA bound rapidly to the NA, modifications leading to the improved potency of these new inhibitors also conferred a time dependent or slow binding phenotype. Many mutations in the NA leading to decreased susceptibility result in loss of slow binding, hence this is a phenotypic marker of many but not all resistant NAs. We present here a simplified approach to determine whether an inhibitor is fast or slow binding by extending the endpoint fluorescent enzyme inhibition assay to a real time assay and monitoring the changes in IC50s with time. We carried out two reactions, one with a 30 min preincubation with inhibitor and the second without. The enzymatic reaction was started via addition of substrate and IC50s were calculated after each 10 min interval up to 60 min. Results showed that without preincubation IC50s for the wild type viruses started high and although they decreased continuously over the 60 min reaction time the final IC50s remained higher than for pre-incubated samples. These results indicate a slow equilibrium of association and dissociation and are consistent with slow binding of the inhibitors. In contrast, for viruses with decreased susceptibility, preincubation had minimal effect on the IC50s, consistent with fast binding. Therefore this modified assay provides additional phenotypic information about the rate of inhibitor binding in addition to the IC50, and critically demonstrates the differential effect of incubation times on the IC50 and Ki values of wild type and mutant viruses for each of the inhibitors