Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin D-anaphylaxis hypothesis

Background: There is little information on the regional distribution of anaphylaxis in Australia. Objective: To examine the influence of latitude (a marker of sunlight/vitamin D status) as a contributor to anaphylaxis in Australia, with a focus on children from birth to the age of 4 years. Methods: Epinephrine autoinjector (EpiPen) prescriptions (2006 -2007) in 59 statistical divisions and anaphylaxis hospital admission rates (2002-2007) in 10 regions were used as surrogate markers of anaphylaxis. Results: EpiPen prescription rates (per 100,000 population per year) were higher in children from birth to the age of 4 years (mean, 951) than in the overall population (mean, 324). In an unadjusted model of children from birth to the age of 4 years, decreasing absolute latitude was associated with a decrease in EpiPen prescription rates, such that rates were higher in southern compared with northern regions of Australia (β, -44.4; 95% confidence interval, -57.0 to -31.8; P < .001). Adjusting for age, sex, ethnicity, indexes of affluence, education, or access to medical care (general, specialist allergy, or pediatric) did not attenuate the finding (β, -51.9; 95% confidence interval, -71.0 to -32.9; P < .001). Although statistical power was limited, anaphylaxis admission rates (most prominent in children aged 0-4 years) showed a similar south-north gradient, such that admission rates were higher in southern compared with northern regions of Australia. Conclusions: EpiPen prescription rates and anaphylaxis admissions are more common in southern regions of Australia. These data provide additional support for a possible role of vitamin D in the pathogenesis of anaphylaxis

Integration of Slack, a cloud-based team collaboration application, into research coordination

Background: Practitioners of epidemiology require efficient real-time communication and shared access to numerous documents in order to effectively manage a study. Much of this communication involves study logistics and does not require use of Protected Health Information. Slack is a team collaboration app; it archives all direct messages and group conversations, hosts documents internally, and integrates with the Google Docs application. Slack has both desktop and mobile applications, allowing users to communicate in real-time without the need to find email addresses or phone numbers or create contact lists. Method: We piloted the integration of Slack into our research team of one faculty member, one research coordinator, and approximately 20 research assistants. Statistics describing the app’s usage were calculated twelve months after its implementation. Results: Results indicating heavy usage by both research professionals and assistants are presented. our Slack group included a cumulative 51 users. Between October 2015 and November 2016, approximately 10,600 messages were sent through Slack; 53% were sent by RA’s and 47% were sent by us. Of the 106 files stored on Slack, 82% were uploaded by research staff. In a January 2016 survey, 100% of RA’s agreed or strongly agreed that Slack improved communication within the team. Conclusion: We demonstrate a model for integration of communication technology into academic activities by research teams. Slack is easily integrated into the workflow at an urban, academic medical center and is adopted by users as a highly effective tool for meeting research teams’ communication and document management needs.

Emergency department visits for acute asthma by adults who ran out of their inhaled medications

This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996–1998 (n = 64 EDs). In each study, consecutive adult patients, aged 18–54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27–32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26–31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8–14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p < 0.05). Among patients who ran out of medications, 49% (95% CI, 43–55%) ran out of inhaled beta-agonists and 72% (95% CI, 58–84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted

Variable geographic distribution of Blastocystis subtypes and its potential implications.

Blastocystis is a common intestinal micro-eukaryote found in both humans and non-human hosts and known to be genetically very diverse. It has been divided into numerous subtypes (STs), nine of which have been identified in humans to date. Surveys of ST prevalence have started to emerge over the past few years but to date no data are available for any African country except Egypt and Tanzania. In this study, we determined the prevalence of Blastocystis STs in populations from Libya, Liberia and Nigeria, as well as expanding the dataset available for the UK. A total of 356 Blastocystis STs were identified in this study, 271 from the UK, 38 from Libya, 25 from Liberia and 22 from Nigeria. SSU rRNA gene sequences revealed the presence of eight of the nine STs known from humans but at varying frequencies between countries. ST1 was the most common ST in Libya and Nigeria whereas ST3 showed the highest frequency in the other two countries, as indeed is the case in most populations around the world. ST4 was absent in Libya and ST2 in Nigeria, while no ST5, ST6, ST8 or ST9 infections were detected in any of the three African populations. The picture emerging from this and other surveys suggests that there is significant variation in ST prevalence between populations. Some of the possible reasons for and implications of this diversity are discussed

Serum 25-Hydroxyvitamin D Levels Among Boston Trainee Doctors in Winter

As indoor workers, trainee doctors may be at risk for inadequate vitamin D. All trainee doctors (residents) in a Boston pediatric training program (residency) were invited to complete a survey, and undergo testing for serum 25-hydroxyvitamin D [25(OH)D], PTH, and calcium during a 3-week period in March 2010. We examined the association between resident characteristics and serum 25(OH)D using Chi2 and Kruskal-Wallis test and multivariable linear and logistic regression. Of the 119 residents, 102 (86%) participated. Although the mean serum 25(OH)D level was 67 nmol/L (±26), 25 (25%) had a level <50 nmol/L and 3 (3%) residents had levels <25 nmol/L. In the multivariable model, factors associated with 25(OH)D levels were: female sex (β 12.7, 95% CI 3.6, 21.7), white race (β 21.7, 95% CI 11.7, 31.7), travel to more equatorial latitudes during the past 3 months (β 6.3, 95% CI 2.0, 10.5) and higher daily intake of vitamin D (β 1.1, 95% CI 0.04, 2.1). Although one in four residents in our study had a serum 25(OH)D <50 nmol/L, all of them would have been missed using current Centers for Medicare and Medicaid Services (CMS) screening guidelines. The use of traditional risk factors appears insufficient to identify low vitamin D in indoor workers at northern latitudes

The effects of changing climate on faunal depth distributions determine winners and losers

Changing climate is predicted to impact all depths of the global oceans, yet projections of range shifts in marine faunal distributions in response to changing climate seldom evaluate potential shifts in depth distribution. Marine ectotherms’ thermal tolerance is limited by their ability to maintain aerobic metabolism (oxygen- and capacity-limited tolerance), and is functionally associated with their hypoxia tolerance. Shallow-water (&lt;200 m depth) marine invertebrates and fishes demonstrate limited tolerance of increasing hydrostatic pressure (pressure exerted by the overlying mass of water), and hyperbaric (increased pressure) tolerance is proposed to depend on the ability to maintain aerobic metabolism, too. Here, we report significant correlation between the hypoxia thresholds and the hyperbaric thresholds of taxonomic groups of shallow-water fauna, suggesting that pressure tolerance is indeed oxygen-limited. Consequently, it appears that the combined effects of temperature, pressure, and oxygen concentration constrain the fundamental ecological niches (FENs) of marine invertebrates and fishes. Including depth in a conceptual model of oxygen- and capacity-limited FENs’ responses to ocean warming and deoxygenation confirms previous predictions made based solely on consideration of the latitudinal effects of ocean warming (e.g. Cheung et al., 2009), that polar taxa are most vulnerable to the effects of climate change, with Arctic fauna experiencing the greatest FEN contraction. In contrast, the inclusion of depth in the conceptual model reveals for the first time that temperate fauna as well as tropical fauna may experience substantial FEN expansion with ocean warming and deoxygenation, rather than FEN maintenance or contraction suggested by solely considering latitudinal range shifts

Detection of the number of changes in a display in working memory

Here we examine a new task to assess working memory for visual arrays in which the participant must judge how many items changed from a studied array to a test array. As a clue to processing, on some trials in the first two experiments, participants carried out a metamemory judgment in which they were to decide how many items were in working memory. Trial-to-trial fluctuations in these working memory storage judgments correlated with performance fluctuations within an individual, indicating a need to include trial-to-trial variation within capacity models (through either capacity fluctuation or some other attention parameter). Mathematical modeling of the results achieved a good fit to a complex pattern of results, suggesting that working memory capacity limits can apply even to judgments that involve an entire array rather than just a single item that may have changed, thus providing the expected conscious access to at least some of the contents of working memory

A scoping review of the unassisted physical exam conducted over synchronous audio-video telemedicine

Background This scoping review aims to provide a broad overview of the research on the unassisted virtual physical exam performed over synchronous audio-video telemedicine to identify gaps in knowledge and guide future research. Methods Searches for studies on the unassisted virtual physical exam were conducted in 3 databases. We included primary research studies in English on the virtual physical exam conducted via patient-to-provider synchronous, audio-video telemedicine in the absence of assistive technology or personnel. Screening and data extraction were performed by 2 independent reviewers. Results Seventy-four studies met inclusion criteria. The most common components of the physical exam performed over telemedicine were neurologic (38/74, 51%), musculoskeletal (10/74, 14%), multi-system (6/74, 8%), neuropsychologic (5/74, 7%), and skin (5/74, 7%). The majority of the literature focuses on the telemedicine physical exam in the adult population, with only 5% of studies conducted specifically in a pediatric population. During the telemedicine exam, the patients were most commonly located in outpatient offices (28/74, 38%) and homes and other non-clinical settings (25/74, 34%). Both patients and providers in the included studies most frequently used computers for the telemedicine encounter. Conclusions Research evaluating the unassisted virtual physical exam is at an early stage of maturity and is skewed toward the neurologic, musculoskeletal, neuropsychologic, and skin exam components. Future research should focus on expanding the range of telemedicine exam maneuvers studied and evaluating the exam in the most relevant settings, which for telemedicine is trending toward exams conducted through mobile devices and in patients’ homes

Oxygen-limited thermal tolerance is seen in a plastron-breathing insect and can be induced in a bimodal gas exchanger.

Thermal tolerance has been hypothesized to result from a mismatch between oxygen supply and demand. However, the generality of this hypothesis has been challenged by studies on various animal groups, including air-breathing adult insects. Recently, comparisons across taxa have suggested that differences in gas exchange mechanisms could reconcile the discrepancies found in previous studies. Here, we test this suggestion by comparing the behaviour of related insect taxa with different gas exchange mechanisms, with and without access to air. We demonstrate oxygen-limited thermal tolerance in air-breathing adults of the plastron-exchanging water bug Aphelocheirus aestivalis. Ilyocoris cimicoides, a related, bimodal gas exchanger, did not exhibit such oxygen-limited thermal tolerance and relied increasingly on aerial gas exchange with warming. Intriguingly, however, when denied access to air, oxygen-limited thermal tolerance could also be induced in this species. Patterns in oxygen-limited thermal tolerance were found to be consistent across life-history stages in these insects, with nymphs employing the same gas exchange mechanisms as adults. These results advance our understanding of oxygen limitation at high temperatures; differences in the degree of respiratory control appear to modulate the importance of oxygen in setting tolerance limits

Plants with antimalarial properties: A systematic review of the current clinical evidence

Introduction: Malaria is one of the most common major health problems in tropical low-and middle-income countries, with antimalarial drugs being highly effective but also threatened by increasing drug resistance. Clinically efficacious, well-tolerated antimalarial plants could be an important and sustainable alternative treatment. This systematic review aims at identifying and critically appraising clinical trials testing plants with antimalarial properties for malaria treatment and/or prophylaxis. Methods: Studies were identified through PubMed, Elsevier Scopus and Cochrane Central, and scanning article reference lists. Records were published in English between 01/01/2005 and 15/01/2018. A framework for analysis based on the CONSORT statement was used for data extraction. Risk of bias was assessed. Results: Nine studies met inclusion criteria. Extracts from Argemone mexicana, Artemisia annua, Citrus aurantifolia, Nauclea pobeguinii, Nycthanthes arbor-tristis and Vernonia amygdalina were examined. Methodological rigorosity varied. Adequate clinical response at day 14 with A. mexicana was 81% (p=0.027) in one study and 89% (95% CI 84.1–93.2) on day 28 in another study. Similarly, 87.9% of participants taking N. pobeguinii had an adequate clinical response at day 14 (p=0.003). The risk of bias and study quality varied. Two studies had a Jadad score of 3 and all others but one a score of 1. Conclusions: Studies have demonstrated that antimalarial plants show promise for malaria treatment and prophylaxis. A. mexicana and N. pobeguinii extracts were supported by the best evidence. More work should be undertaken to better understand relevant approaches