Mixed Model Research Articles

The prevalence and topography of spinal cord demyelination in multiple sclerosis: a retrospective study

Spinal cord pathology is a major determinant of irreversible disability in progressive multiple sclerosis. The demyelinated lesion is a cardinal feature. The well-characterised anatomy of the spinal cord and new analytic approaches allows the systematic study of lesion topography and its extent of inflammatory activity unveiling new insights into disease pathogenesis. We studied cervical, thoracic, and lumbar spinal cord tissue from 119 pathologically confirmed multiple sclerosis cases. Immunohistochemistry was used to detect demyelination (PLP) and classify lesional inflammatory activity (CD68). Prevalence and distribution of demyelination, staged by lesion activity, was determined and topographical maps were created to identify patterns of lesion prevalence and distribution using mixed models and permutation-based voxelwise analysis. 460 lesions were observed throughout the spinal cord with 76.5% of cases demonstrating at least 1 lesion. The cervical level was preferentially affected by lesions. 58.3% of lesions were inflammatory with 87.9% of cases harbouring at least 1 inflammatory lesion. Topographically, lesions consistently affected the dorsal and lateral columns with relative sparing of subpial areas in a distribution mirroring the vascular network. The presence of spinal cord lesions and the proportion of active lesions related strongly with clinical disease milestones, including time from onset to wheelchair and onset to death. We demonstrate that spinal cord demyelination is common, highly inflammatory, has a predilection for the cervical level, and relates to clinical disability. The topography of lesions in the dorsal and lateral columns and relative sparing of subpial areas points to a role of the vasculature in lesion pathogenesis, suggesting short-range cell infiltration from the blood and signaling molecules circulating in the perivascular space incite lesion development. These findings challenge the notion that end-stage progressive multiple sclerosis is ‘burnt out’ and an outside-in lesional gradient predominates in the spinal cord. Taken together, this study provides support for long-term targeting of inflammatory demyelination in the spinal cord and nominates vascular dysfunction as a potential target for new therapeutic approaches to limit irreversible disability.

Analysing preference heterogeneity and willingness to pay for nature-based tourism activities in Gran Canaria for young Germans

ABSTRACT This paper examines the heterogeneity in preferences and willingness to pay for various nature-based tourism activities that can be carried out in natural areas on Gran Canaria Island (Spain). A discrete choice experiment is designed to obtain information about potential visitors’ preferences in a set of hypothetical scenarios involving various activity packages created by combining the levels of the attributes according to an efficient design. Collected information is used to estimate a Mixed Logit model which will allow us to evaluate random and systematic heterogeneity in preferences. A key finding of the research emanates from obtaining individual-specific parameters to calculate not only the willingness to pay for the various activities but also the amount that could guide a potential compensation when undesired activities are included in the package. Results provide interesting managerial tools that can be used by tourism entrepreneurs to promote nature-based tourism products in the area.

Implementation of sonopartogram: multicenter feasibility study.

Well-established clinical practice for assessing progress in labor involves routine abdominal palpation and vaginal examination (VE). However, VE is subjective, poorly reproducible and painful for most women. In this study, our aim was to evaluate the feasibility of systematically integrating transabdominal and transperineal ultrasound assessment of fetal position, parasagittal angle of progression (psAOP), head-perineum distance (HPD) and sonographic cervical dilatation (SCD) to monitor the progress of labor in women undergoing induction of labor (IOL). We also aimed to determine if ultrasound can reduce women's pain during such examinations. Women were recruited as they presented for IOL in three maternity units. Ultrasound assessments were performed in 100 women between 37 + 0 and 41 + 6 weeks' gestation. A baseline combined transabdominal and transperineal scan was performed, including assessment of fetal biometry, umbilical artery and fetal middle cerebral artery Doppler, amniotic fluid index, fetal spine and occiput positions, psAOP, HPD, SCD and cervical length. Intrapartum scans were performed instead of VE, unless there was a clinical indication to perform a VE, according to protocol. Participants were asked to indicate their level of pain by verbally giving a pain score between 0 and 10 (with 0 representing no pain) during assessment. Repeated measures data were analyzed using mixed-effect models to identify significant factors that affected the relationship between psAOP, HPD, SCD and mode of delivery. A total of 100 women were included in the study. Of these, 20% delivered by Cesarean section, 65% vaginally and 15% by instrumental delivery. There were no adverse fetal or maternal outcomes. A total of 223 intrapartum ultrasound scans were performed in 87 participants (13 women delivered before intrapartum ultrasound was performed), with a median of two scans per participant (interquartile range (IQR), 1-3). Of these, 76 women underwent a total of 151 VEs with a median of one VE per participant (IQR, 0-2), with no significant difference between vaginal- or Cesarean-delivery groups. After excluding those with epidural anesthesia during examination, the median pain score for intrapartum scans was 0 (IQR, 0-1) and for VE it was 3 (IQR, 0-6). Cesarean delivery was significantly associated with a slower rate of change in psAOP, HPD and SCD. Comprehensive transabdominal and transperineal ultrasound assessment can be used to assess progress in labor and can reduce the level of pain experienced during examination. Ultrasound assessment may be able to replace some transabdominal and vaginal examinations during labor. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Delivery routing for a mixed fleet of conventional and electric vehicles with road restrictions

The enforcement of stringent regulations capping carbon emissions has prompted city logistics enterprises to substitute electric vehicles (EVs) for conventional vehicles (CVs). For city logistics enterprises with a mixed fleet of CVs and EVs, this study investigates the delivery routing problem with road restrictions (DRPRR) for accessible time windows and bearing weight. We formulate the DRPRR as a mixed integer programming model to minimise the total operations cost. The model consists of the set-up cost of CVs and EVs, the diesel cost of CVs, the electricity cost of EVs, the carbon tax cost, and the penalty cost of vehicles waiting for roads to be accessible. To effectively solve the model, an adaptive large neighbourhood search (ALNS) algorithm is developed that consists of tailored destroy and repair operators with two alternative solution acceptance criteria. Numerical experiments are conducted to validate the effectiveness of the proposed model and ALNS algorithm. In small-scale instances, the ALNS with the Metropolis criterion finds the best solutions for 41 of 48 instances while maintaining a deviation of less than 2.5% from CPLEX in the remaining 7 instances, and its running time is significantly shorter than CPLEX. In large-scale instances, the ALNS with the Metropolis criterion has stronger solving ability and better stability than benchmark algorithms (i.e. GA-LS, LNS, and ALNS with a threshold acceptance criterion). We also address a real-world case and conduct a sensitivity analysis to provide useful managerial insights. Specifically, implementing road restrictions on accessible time windows and the carbon tax policy simultaneously is more appropriate from the comprehensive perspective of market activity and carbon emissions.

Using equivalence tests in higher tier studies of honey bees under the revised EFSA Bee Guidance-How?

The proposed use of equivalence tests instead of difference tests in the revised guidance on the risk assessment of plant protection products for bees is a reasonable approach given an adverse effect was observed in the lower tier studies, using the hypothesis that there is a risk as the null hypothesis places the burden to prove the opposite on the other side. However, some uncertainties regarding the application of equivalence tests in field studies are discussed in the present study. Here, we compare equivalence and difference testing methods using a control dataset of a honey bee field effect study conducted in northern Germany in 2014. Half of the 48 colonies were assigned to a hypothetical test item group, and the colony strength data were analyzed using t-tests, a generalized linear mixed model (GLMM), and the corresponding equivalence tests. The data reflected the natural variability of honey bee colonies, with initially approximately 12 000 adult bees. Although the t-test and GLMM confirmed that 24 + 24 colonies are sufficient to show "no adverse effect," the equivalence tests of the t-test and GLMM were not able to reject the null hypothesis and classified at least some of the assessments as "high risk," indicating a power that was too low. Based on this, different operating options to reduce the variability are discussed. One possible option, which may provide a more realistic application of equivalence to avoid false high risk, is to consider the lower confidence interval of the control as a baseline and use GLMMs. With this option, we demonstrate a relatively acceptable probability to prove that no high risk for initially similar groups can be achieved. Further studies with different numbers of colonies are still needed to develop and validate the suggested approach. Integr Environ Assess Manag 2024;20:1496-1503. © 2024 SETAC.

Relationship between duration of sick leave and time variation of words used in return-to-work programs for depression.

Return-to-work (RTW) programs are provided as rehabilitation for people who have taken sick leave from work because of mental health problems. However, methods to present this information to workplaces objectively remain limited. This study aimed to conduct an exploratory investigation of the relationship between duration of sick leave and time variation of words used in RTW programs for depression from textual data collected from electronic medical records as a new evaluation indicator. The study subjects were those who had taken sick leave because of major depressive or adjustment disorder and had participated in an RTW program. The study data comprised demographic characteristics and texts. Textual data were collected from electronic medical records and classified based on the SOAP note. Thereafter, the textual data were quantified into category scores based on a standard text analysis dictionary. A generalized linear mixed model was used for the statistical analysis, with the score for each category (emotional, social, cognitive, perceptual, biological, motivational, relativity, and informal) as the dependent variable and the duration of sick leave, time, and interaction between the duration of sick leave and time as the independent variables. The level of statistical significance was set at 0.05. In total, 42 participants were included in the analysis. The results revealed a significant interaction between the social (p = 0.001) and emotional (p = 0.002) categories. The findings suggest a relationship between word changes in electronic medical records and the duration of sick leave.

Multiple choice as formative assessment in dental education.

The effectiveness of multiple-choice questions (MCQs) in dental education is pivotal to student performance and knowledge advancement. However, their optimal implementation requires exploration to enhance the benefits. An educational tool incorporating MCQs was administered from the 5th to the 10th semester in a dental curriculum. The students filled out a questionnaire after the MCQ, which was linked to the learning management system. Four cohorts of four semesters generated 2300 data points analysed by Spearmen correlation and mixed model regression analysis. Demonstrated a significant correlation between early exam preparation and improved student performance. Independent study hours and lecture attendance emerged as significant predictors, accounting for approximately 10.27% of the variance in student performance on MCQs. While the number of MCQs taken showed an inverse relationship with study hours, the perceived clarity of these questions positively correlated with academic achievement. MCQs have proven effective in enhancing student learning and knowledge within the discipline. Our analysis underscores the important role of independent study and consistent lecture attendance in positively influencing MCQ scores. The study provides valuable insights into using MCQs as a practical tool for dental student learning. Moreover, the clarity of assessment tools, such as MCQs, remains pivotal in influencing student outcomes. This study underscores the multifaceted nature of learning experiences in dental education and the importance of bridging the gap between student expectations and actual performance.

Genomic dissection of brown planthopper, Nilaparvata lugens (Hemiptera: Delphacidae) resistance in Indica rice genotypes

AbstractThe population growth and the regular breakout of Nilaparvata lugens pose a significant risk to rice cultivation. Four different N. lugens biotypes have been identified worldwide, with biotype 4 being the most destructive and prevalent throughout Asia, particularly in India. Therefore, a rice variety with multiple resistance genes/alleles is required for effective management of N. lugens. Hence, 191 rice genotypes collected from various parts of India were evaluated for resistance to N. lugens. Further, SSR markers representing 23 different N. lugens resistant (R) genes were assayed to identify genomic regions associated with resistance. The results of the genetic analysis showed that the average genetic diversity value of all markers was 0.165 and polymorphic information content of 0.145 for all the markers used. The population structure and cluster analysis divided the studied genotypes into three distinct groups, with resistant genotypes grouped separately. These findings were confirmed by the principal coordinate analysis, which categorized resistant genotypes, moderately resistant genotypes, and susceptible genotypes into distinct components. Additionally, 90% of the genetic variation was between individuals of populations and 10% between the populations. Marker‐trait association study through mixed linear model and generalized linear model identified six SSR markers such as RM6732 (Bph15), RM314 (Bph6), RM16999 (Bph6), RM7 (QBph3), RM401 (bph4), and RM7102 (Bph1), which were significantly associated with various phenotypic parameters, such as feeding mark, honeydew excretion, percent damage and nymphal survival. The resistant genes identified in these genotypes could help in the marker‐assisted rice variety development with durable resistance against N. lugens.

Postprandial nutrient dynamics and their implications for formulated feed development for the ornate spiny lobster (Panulirus ornatus)

AbstractCrustacean feeding morphology and postprandial nutrient processing is a highly size‐selective procedure. The digestive system of lobsters is predicated on grinding feed to a fine particle size before digestion. Therefore, fine pregrinding of raw materials may bypass the need for extensive grinding in the proventriculus and expedite digestive and absorptive processes. Panulirus ornatus juveniles (N = 56) were allocated to four feed groups (n = 14). Groups A, B and C were fed nutritionally identical feeds featuring raw materials ground to 1000 µm (Feed A), 500 µm (Feed B) and 200 µm (Feed C) while the fourth group (Group S) acted as a 24‐h nonfeeding baseline control group. Sequential postprandial haemolymph extractions were performed at 0.5, 1, 1.5, 2, 3.5, 5.5 and 24 h across treatment groups. Haemolymph samples were assessed and analysed for brix (%), total proteins (g L–1), glucose (mmol L–1) and cholesterol (mmol L–1). Brix was found to have significant positive correlations with all the haemolymph biochemical properties while no significant correlations were identified between individual lobster size and haemolymph properties. Analysis of deviance applied to mixed effects models did not identify significant differences in haemolymph properties across feed groups. Trends identified here are indicative of diurnal rhythm patterns, likely orchestrated by the release of the crustacean hyperglycaemic hormone (CHH) when anticipating a meal. Additionally, the use of brix values, may not be optimal for identifying postprandial trends, yet could remain a valid indicator of longer‐term nutritional status.

Unveiling 8 years of duodenoscope contamination: insights from a retrospective analysis in a large tertiary care hospital

ObjectiveContaminated duodenoscopes caused several hospital outbreaks. Despite efforts to reduce contamination rates, 15% of patient-ready duodenoscopes are still contaminated with gastrointestinal microorganisms. This study aimed to provide an overview of...

The impact of COVID-19 workload on psychological distress amongst Canadian intensive care unit healthcare workers during the 1st wave of the COVID-19 pandemic: A longitudinal cohort study.

Intensive care unit healthcare workers (ICU HCW) are at risk of mental health disorders during emerging disease outbreaks. Numerous cross-sectional studies have reported psychological distress, anxiety, and depression amongst ICU HCW during the COVID-19 pandemic. However, few studies have followed HCW longitudinally, and none of these have examined the association between COVID-19 workload and mental health. We conducted a longitudinal cohort study of 309 Canadian ICU HCW from April 2020 to August 2020, during the 1st wave of the COVID-19 pandemic. Psychological distress was assessed using the General Health Questionnaire 12-item scale (GHQ-12) at 3 timepoints: during the acceleration phase of the 1st wave (T1), the deceleration phase of the 1st wave (T2), and after the 1st wave had passed (T3). Clinically relevant psychological distress, defined as a GHQ-12 score ≥ 3, was identified in 64.7% of participants at T1, 41.0% at T2, and 34.6% at T3. Psychological distress was not associated with COVID-19 workload at T1. At T2, psychological distress was associated with the number of COVID-19 patients in the ICU (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.00, 1.13) while at T3, when COVID-19 patient numbers were low, it was associated with the number of weekly hospital shifts with COVID-19 exposure (OR: 1.33, 95% CI: 1.09, 1.64). When analyzed longitudinally in a mixed effects model, pandemic timepoint was a stronger predictor of psychological distress (OR: 0.24, 95% CI: 0.15, 0.40 for T2 and OR: 0.16, 95% CI: 0.09, 0.27 for T3) than COVID-19 workload. Participants who showed persistent psychological distress at T3 were compared with those who showed recovery at T3. Persistent psychological distress was associated with a higher number of weekly shifts with COVID-19 exposure (OR: 1.97, 95% CI:1.33, 3.09) but not with a higher number of COVID-19 patients in the ICU (OR: 0.86, 95% CI: 0.76, 0.95). In summary, clinically relevant psychological distress was observed in a majority of ICU HCW during the acceleration phase of the 1st wave of the COVID-19 pandemic but decreased rapidly as the 1st wave progressed. Persistent psychological distress was associated with working more weekly shifts with COVID-19 exposure but not with higher numbers of COVID-19 patients in the ICU. In future emerging disease outbreaks, minimizing shifts with direct disease exposure may help alleviate symptoms for individuals with persistent psychological distress.

BDNF Val66Met moderates episodic memory decline and tau biomarker increases in early sporadic Alzheimer's disease.

Allelic variation in the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism has been shown to moderate rates of cognitive decline in preclinical sporadic Alzheimer's disease (AD; i.e., Aβ + older adults), and pre-symptomatic autosomal dominant Alzheimer's disease (ADAD). In ADAD, Met66 was also associated with greater increases in CSF levels of total-tau (t-tau) and phosphorylated tau (p-tau181). This study sought to determine the extent to which BDNF Val66Met is associated with changes in episodic memory and CSF t-tau and p-tau181 in Aβ + older adults in early-stage sporadic AD. Aβ + Met66 carriers (n = 94) and Val66 homozygotes (n = 192) enrolled in the Alzheimer's Disease Neuroimaging Initiative who did not meet criteria for AD dementia, and with at least one follow-up neuropsychological and CSF assessment, were included. A series of linear mixed models were conducted to investigate changes in each outcome over an average of 2.8years, covarying for CSF Aβ42, APOE ε4 status, sex, age, baseline diagnosis, and years of education. Aβ + Met66 carriers demonstrated significantly faster memory decline (d = 0.33) and significantly greater increases in CSF t-tau (d = 0.30) and p-tau181 (d = 0.29) compared to Val66 homozygotes, despite showing equivalent changes in CSF Aβ42. These findings suggest that reduced neurotrophic support, which is associated with Met66 carriage, may increase vulnerability to Aβ-related tau hyperphosphorylation, neuronal dysfunction, and cognitive decline even prior to the emergence of dementia. Additionally, these findings highlight the need for neuropsychological and clinicopathological models of AD to account for neurotrophic factors and the genes which moderate their expression.

A multi-ancestry genome-wide association study in type 1 diabetes.

Type 1 diabetes (T1D) is an autoimmune disease caused by destruction of the pancreatic β-cells. Genome-wide association (GWAS) and fine mapping studies have been conducted mainly in European ancestry (EUR) populations. We performed a multi-ancestry GWAS to identify SNPs and HLA alleles associated with T1D risk and age at onset. EUR families (N = 3223), and unrelated individuals of African (AFR, N = 891) and admixed (Hispanic/Latino) ancestry (AMR, N = 308) were genotyped using the Illumina HumanCoreExome BeadArray, with imputation to the TOPMed reference panel. The Multi-Ethnic HLA reference panel was utilized to impute HLA alleles and amino acid residues. Logistic mixed models (T1D risk) and frailty models (age at onset) were used for analysis. In GWAS meta-analysis, seven loci were associated with T1D risk at genome-wide significance: PTPN22, HLA-DQA1, IL2RA, RNLS, INS, IKZF4-RPS26-ERBB3, and SH2B3, with four associated with T1D age at onset (PTPN22, HLA-DQB1, INS, and ERBB3). AFR and AMR meta-analysis revealed NRP1 as associated with T1D risk and age at onset, although NRP1 variants were not associated in EUR ancestry. In contrast, the PTPN22 variant was significantly associated with risk only in EUR ancestry. HLA alleles and haplotypes most significantly associated with T1D risk in AFR and AMR ancestry differed from that seen in EUR ancestry; in addition, the HLA-DRB1*08:02-DQA1*04:01-DQB1*04:02 haplotype was 'protective' in AMR while HLA-DRB1*08:01-DQA1*04:01-DQB1*04:02 haplotype was 'risk' in EUR ancestry, differing only at HLA-DRB1*08. These results suggest that much larger sample sizes in non-EUR populations are required to capture novel loci associated with T1D risk.

Urban and Rural Attitudes toward School Food

AbstractIn the social sciences, it is a classic practice to contrast the development of the countryside and the city as two endpoints of a chain. However, since the beginning of the 21st century, the validity of the rural-urban dichotomy has been increasingly questioned, and we are now talking about two interconnected and complementary systems instead. In examining contemporary school meals, we ourselves observed this close and varied pattern of intertwining between the city and the countryside. Therefore, we believe it is useful to identify rural and urban features in contemporary public catering practices, and to outline mixed models that can be placed between the two endpoints in space and time. All of this can be edifying because urbanized foodways, following current food health and gastronomic trends, sustainability, climate and environmental protection requirements, as well as social considerations, return from time to time to the old village farming practices and foodways in various ways, and utilize knowledge related to traditional farming. Illustrated with specific examples, the study outlines three types of school catering models, from the oldest practice called “rural” to the “urban” (urbanized) type. A comparison of these types of public catering practices reveals the problems observed in today’s public catering.

Melanoma Brain Metastases: Immunotherapy or Targeted Therapy? A Systematic Review and Meta-Analyses

Background. Brain metastases are one of the leading causes of death in melanoma patients. This systematic review and meta-analysis aimed to look at the variables that affect melanoma patients’ intracranial treatment responses to immunotherapy and targeted therapy. Methods. A systematic search of PubMed and Scopus up to December 2023 was conducted to identify trials investigating treatment response of melanoma brain metastasis. This meta-analysis presents summary estimates (SEs) of treatment response and odd ratios (ORs) for the comparison between symptomatic and asymptomatic metastases. Generalised linear mixed models were used for the SE of the proportion of clinical responses and 95% CIs are reported. We investigated between-study heterogeneity using meta-regression. Results. We included 19 independent clinical trials for a total of 1074 patients with brain metastases. The SE of the overall response was 36% 95%CI [27%; 47%], I2 = 84%, similar to the SE for symptomatic metastases: SE = 29% 95%CI [16%; 47%], I2 = 80%. A significantly higher response of symptomatic metastases was observed between patients who had previously received immunotherapy compared to those who had not (47% vs. 9%, p-value = 0.001). The SE was greater for asymptomatic metastases (38% 95%CI [29%; 49%], I2 = 80%), and among these, patients that received the combo-immunotherapy importantly responded more than those who had received monotherapy (45% vs. 26.1%, p-value = 0.002). The major limit of our analysis is the absence of data about the specific intracranial response separately in asymptomatic and symptomatic patients in seven studies. Conclusions. This study shows the importance of starting immunotherapy as early as possible in asymptomatic patients. Randomised trials with greater statistical power are needed to find the best strategies for symptomatic and asymptomatic brain metastases.

Analysis of missed clinic visits, preferred languages, and telemedicine in a pediatric gastroenterology practice.

Previous studies have demonstrated a relationship between socioeconomic disparities and missed clinic visits (MCV). However, the relationship between patient-preferred language and MCVs, particularly with respect to telemedicine, remains relatively underexplored. We sought to characterize the associations between MCV and patient-level predictors, including preferred language, in a large single-center pediatric gastroenterology, hepatology, and nutrition practice. This retrospective longitudinal cohort study included all missed or completed outpatient visits in the Gastroenterology, Hepatology, and Nutrition Programs at Boston Children's Hospital from January 1, 2016to May 20, 2022. Univariate and multivariate hierarchical generalized linear mixed models were employed to identify associations between visit- and patient-level predictors and an MCV outcome. A total of 300,201 visits from 70,710 patients residing in Massachusetts were included. Univariate analyses revealed higher MCV odds for Hispanic patients and those from areas with the highest Social Vulnerability Index (SVI), and these odds increased with telemedicine (Hispanic in-person odds ratio [OR] 5.21 [(95% confidence interval) 4.93-5.52] vs. telemedicine OR 8.79 [7.85-9.83]; highest SVI in-person OR 5.28 [4.95-5.64] vs. telemedicine OR 7.82 [6.84-8.96]). Controlled multivariate analyses revealed that among six language groups, only Spanish language preference was associated with higher MCV odds, which increased with telemedicine (Spanish in-person adjusted OR [aOR]1.35 [1.24-1.48] vs. telemedicine aOR 2.1 [1.83-2.44]). Patients preferring Spanish experience unique barriers to care beyond those faced by other language preference groups, and telemedicine may exacerbate these barriers.

Microwave disinfection of facial silicone prostheses, Part 1: Color stability

The choice of cleaning method is an important consideration for lengthening the serviceable time of facial prostheses as microbial organisms and biofilms could degrade facial prostheses and cause skin irritation. Whether microwave disinfection is a suitable cleaning method without degradation of the properties of a prosthesis is unclear. The purpose of this in vitro study was to measure the color stability of 6 commonly used facial silicone elastomers after microwave disinfection over a simulated 1.5-year period. Six different facial silicone elastomers: MDX4-4210, MDX4-4210/Type A, M511, A-2186, VST-50, and A-2000 were mixed with intrinsic silicone white opacifier (except for the control group) and subsequently combined with 4 silicone intrinsic pigment color groups: red (R), yellow (Y), burnt sienna (B), and a mixture of R+Y+B (M). The control group was a silicone elastomer without opacifier or pigment. Each of the 30 experimental groups consisted of 5 specimens (N=150). Five specimens were placed in a 250-mL Erlenmeyer flask filled with 160mL of tap water. Seven flasks were then placed in a 660-W microwave oven. An exposure of 6 minutes was used according to the antimicrobial efficacy of microwave disinfection protocol on facial silicone prostheses with a final water temperature of 60°C for 18 times (simulating 1.5 years of microwave disinfection with one 6-minute exposure monthly). A spectrophotometer was used to measure reflectance color change values (∆E). Color differences were calculated following CIELab (∆E*ab) and CIEDE2000 (∆E00) formulae. ∆E*ab and ∆E00 were statistically analyzed by a linear mixed effects model with 3 factors (silicone type, color shade, and time) using the R Statistical software program (α=.05). Both ∆E*ab and ∆E00 of all silicone elastomers studied were less than the visual perceptibility thresholds (∆E*ab<1.1 and E00<0.7) and were considered clinically acceptable (∆E*ab<3.0 and E00<2.1) after the 1.5-year simulation of microwave disinfection. Yellow and blue pigments had more effect on MDX4-4210 and M511, while red pigment had more effect on MDX4-4210, MDX4-4210/Type A, and M511 (P<.05). Nevertheless, the values were still below the perceptibility threshold (∆E*ab≤1.0 and E00<0.6). All 6 facial silicone elastomers maintained clinically acceptable color after 18 months of exposure to microwave disinfection.

Having More Tender Than Swollen Joints is Associated With Worse Function and Work Impairment in Patients With Early Rheumatoid Arthritis.

Patients with early rheumatoid arthritis (RA) may present with more tender than swollen joints, which can persist. Elevated tender-swollen joint difference (TSJD) is often challenging, because there may be multiple causes and it may contribute to overestimating disease activity. Little is known about the phenotype and impact of TSJDs on patient function. Our objective was to evaluate the impact of TSJD on functional outcomes in early RA and to see whether associations vary by joint size. Data were from patients with active, early RA (≤12 months) enrolled in the Canadian Early Arthritis Cohort, who completed assessments of general function (Multidimensional Health Assessment Questionnaire [MDHAQ]), upper extremity (UE) function (Quality of Life in Neurological Disorders [Neuro-QoL] UE scale), and work/activity impairment (Work Productivity and Activity Impairment RA) over their first year of follow-up. A total of 28 joint counts were performed. TSJDs were calculated. Adjusted associations between TSJDs and functional outcomes were estimated in separate multivariable linear mixed effects models. Separate analyses were performed for large- versus small-joint TSJD. Patients (N=547) were 70% female, mean age 56 (SD 15) years, mean disease duration 5.3 (SD 2.9) months. At baseline, 287 (52%) had TSJD >0 (43% involved large joints and 34% small joints), decreasing to 32% at 12 months. A one-point increase in TSJD was significantly associated with worse function (MDHAQ: adjusted mean change 0.10, 95% confidence interval [CI] 0.08-0.13; Neuro-QoL UE function T score: adjusted mean change -0.59, 95% CI -0.76 to -0.43; and greater work impairment: adjusted mean change 1.95%, 95% CI 0.85%-3.05%). Higher large-joint TSJDs were associated with the worst functional outcomes. Having more tender than swollen joints is common in early RA and is associated with worse function, most notably when involving large joints. Early identification and targeted intervention strategies may be needed.

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life.

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals. Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life. Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04). Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

How Much Training Is Enough? Low-Dose, High-Frequency Simulation Training and Maintenance of Competence in Neonatal Resuscitation.

Facemask ventilation is a crucial, but challenging, element of neonatal resuscitation.In a previously reported study, instructor-led training using a novel neonatal simulator resulted in high-level ventilation competence for health care providers (HCPs) involved in newborn resuscitation. The aim of this study was to identify the optimal frequency and dose of simulation training to maintain this competence level. Prospective observational study of HCPs training through 9 months. All training was logged. Overall ventilation competence scores were calculated for each simulation case, incorporating 7 skill elements considered important for effective ventilation.Overall scores and skill elements were analyzed by generalized linear mixed effects models using frequency (number of months of 9 where training occurred and total number of training sessions in 9 months) and dose (total number of cases performed) as predictors. Training loads (frequency + dose) predictive of high scores were projected based on estimated marginal probabilities of successful outcomes. A total of 156 HCPs performed 4348 training cases. Performing 5 or more sessions in 9 months predicted high global competence scores (>28/30). Frequency was the best predictor for 4 skill elements; success in maintaining airway patency and ventilation fraction was predicted by performing training in, respectively, 2 and 3 months of 9, whereas for avoiding dangerously high inflating pressures and providing adequate mask seal, 5 and 6 sessions, respectively, over the 9 months, predicted success. Skills reflecting global performance (successful resuscitation and valid ventilations) and ventilation rate were more dose-dependent. Training frequency is important in maintaining neonatal ventilation competence. Training dose is important for some skill elements. This offers the potential for individualized training schedules.