Virtual Reality Job Interview Training in Adults with Autism Spectrum Disorder

The feasibility and efficacy of virtual reality job interview training (VR-JIT) was assessed in a single-blinded randomized controlled trial. Adults with autism spectrum disorder were randomized to VR-JIT (n = 16) or treatment-as-usual (TAU) (n = 10) groups. VR-JIT consisted of simulated job interviews with a virtual character and didactic training. Participants attended 90 % of laboratory-based training sessions, found VR-JIT easy to use and enjoyable, and they felt prepared for future interviews. VR-JIT participants had greater improvement during live standardized job interview role-play performances than TAU participants (p = 0.046). A similar pattern was observed for self-reported self-confidence at a trend level (p = 0.060). VR-JIT simulation performance scores increased over time (R ² = 0.83). Results indicate preliminary support for the feasibility and efficacy of VR-JIT, which can be administered using computer software or via the internet.     

Risk of AKI with Gentamicin as Surgical Prophylaxis

In 2009, the Scottish government issued a target to reduce Clostridium difficile infection by 30% in 2 years. Consequently, Scottish hospitals changed from cephalosporins to gentamicin for surgical antibiotic prophylaxis. This study examined rates of postoperative AKI before and after this policy change. The study population comprised 12,482 adults undergoing surgery (orthopedic, urology, vascular, gastrointestinal, and gynecology) with antibiotic prophylaxis between October 1, 2006, and September 30, 2010 in the Tayside region of Scotland. Postoperative AKI was defined by the Kidney Disease Improving Global Outcomes criteria. The study design was an interrupted time series with segmented regression analysis. In orthopedic patients, change in policy from cefuroxime to flucloxacillin (two doses of 1 g) and single-dose gentamicin (4 mg/kg) was associated with a 94% increase in AKI (P=0.04; 95% confidence interval, 93.8% to 94.3%). Most patients who developed AKI after prophylactic gentamicin had stage 1 AKI, but some patients developed persistent stage 2 or stage 3 AKI. The antibiotic policy change was not associated with a significant increase in AKI in the other groups. Regardless of antibiotic regimen, however, rates of AKI were high (24%) after vascular surgery, and increased steadily after gastrointestinal surgery. Rates could only be ascertained in 52% of urology patients and 47% of gynecology patients because of a lack of creatinine testing. These results suggest that gentamicin should be avoided in orthopedic patients in the perioperative period. Our findings also raise concerns about the increasing prevalence of postoperative AKI and failures to consistently measure postoperative renal function.Reported rates of postoperative AKI vary because of the heterogeneity of the populations studied. Uncomplicated AKI is associated with a mortality of 10%, rising to 50% in the context of multiorgan failure and up to 80% if RRT is required.^1,2 It was thought that the presence of AKI was a marker of coexisting pathology that increased mortality risk, but recent reports demonstrate AKI as an independent risk factor for mortality.^3,4 The increasing incidence of AKI and its long-term consequences have significant socioeconomic and public health effects globally.⁵Clostridium difficile infection (CDI) is an important healthcare-associated infection. Antibiotic use increases the risk of CDI for at least 3 months⁶ and short courses of perioperative antibiotic prophylaxis have also been associated with an increased risk of CDI, particularly in the context of an established outbreak.⁷In 2009, the Scottish government issued a new target for all health boards to reduce CDI by at least 30% over 2 years.⁸ The Scottish Antimicrobial Prescribing Group also produced recommendations for all National Health Service (NHS) boards to restrict the use of antibiotics associated with a high risk of CDI.⁹ As part of a widespread antibiotic policy change at NHS Tayside, orthopedic antibiotic prophylaxis was changed from cefuroxime to gentamicin and flucloxacillin. After concerns raised by nephrologists and a small uncontrolled study in the Dumfries and Galloway region of Scotland that described an increased rate of AKI in patients after orthopedic surgery after this policy change,¹⁰ it was felt that further investigation was required.This study aimed to use robust methodology, in a larger, population-based study of adult patients undergoing orthopedic implant surgery, to evaluate the effect of the policy change on postoperative AKI. It is noteworthy that patients who underwent repair of a neck of femur (NOF) fracture received coamoxiclav as antibiotic prophylaxis after the policy change because of concerns raised by orthopedic surgeons with regard to administering gentamicin in this particular patient group. This analysis was then extended to evaluate postoperative AKI in other surgical specialties (urology, vascular, gastrointestinal, and gynecology) that had changed to a gentamicin-based regimen.     

Characterization of Renal Toxicity in Mice Administered the Marine Biotoxin Domoic Acid

Domoic acid (DA), an excitatory amino acid produced by diatoms belonging to the genus Pseudo-nitzschia, is a glutamate analog responsible for the neurologic condition referred to as amnesic shellfish poisoning. To date, the renal effects of DA have been underappreciated, although renal filtration is the primary route of systemic elimination and the kidney expresses ionotropic glutamate receptors. To characterize the renal effects of DA, we administered either a neurotoxic dose of DA or doses below the recognized limit of toxicity to adult Sv128/Black Swiss mice. DA preferentially accumulated in the kidney and elicited marked renal vascular and tubular damage consistent with acute tubular necrosis, apoptosis, and renal tubular cell desquamation, with toxic vacuolization and mitochondrial swelling as hallmarks of the cellular damage. Doses≥0.1 mg/kg DA elevated the renal injury biomarkers kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin, and doses≥0.005 mg/kg induced the early response genes c-fos and junb. Coadministration of DA with the broad spectrum excitatory amino acid antagonist kynurenic acid inhibited induction of c-fos, junb, and neutrophil gelatinase-associated lipocalin. These findings suggest that the kidney may be susceptible to excitotoxic agonists, and renal effects should be considered when examining glutamate receptor activation. Additionally, these results indicate that DA is a potent nephrotoxicant, and potential renal toxicity may require consideration when determining safe levels for human exposure.Domoic acid (DA), a water-soluble, heat-stable tricarboxylic acid produced by diatoms belonging to the genus Pseudo-nitzschia, is responsible for a condition known as amnesic shellfish poisoning in humans.^1–4 Shellfish, such as clams and mussels, and fish that accumulate DA serve as vectors of exposure to various species of birds and aquatic mammals in addition to humans.^5,6 Initially recognized as a human toxicant when more than 100 people became ill after eating contaminated mussels in eastern Canada in 1987, DA poisoning was defined by the occurrence of gastrointestinal or neurologic symptoms ranging from abdominal cramps and headache to more severe cases of memory loss, seizures, coma, and even death.^2,4 Increased awareness and governmental regulation, which set a limit of 20 μg DA/g in shellfish tissue, has reduced the incidence of DA toxicity in humans since the 1987 outbreak. However, there is concern that exposure will increase because of the growing presence of toxic diatom-producing algal blooms, which are often attributed to human factors, such as pollution, shipping, and global warming, leading to greater nutrient availability, greater distribution of algal species, and longer growth periods.^7–14 Although the overt gastrointestinal and neurologic manifestations have defined the disease, emerging evidence from animal and human studies support previously unrecognized threats and novel toxicologic syndromes caused by subclinical toxicity from acute and chronic DA exposures, which may ultimately challenge the adequacy of the current acceptable limit.^15–18DA is a potent activator of kainate receptors (KRs) as well as a subpopulation of α-amino-3-hydroxy-5-methyl-4-isoxazoleproprionic acid receptors (AMPARs).¹⁹ The toxic response produced by DA is a coordinated effort, which involves initial activation of KR and AMPAR by DA and secondary activation of N-methyl-D-aspartate receptors (NMDARs) by glutamate, and it is associated with an influx of Ca²⁺ across the plasma membrane, inflammation, neuronal cell injury and death, and neurobehavioral alterations.^19–22 Although they are extensively characterized in the central nervous system, glutamate receptors are also expressed at peripheral sites and have been shown to exhibit toxicity in multiple tissues, including the kidney, where NMDARs contribute to organ damage in models of ischemia-reperfusion injury and gentamicin nephrotoxicity.^23–26 There is limited information about the effects of DA on the kidney; however, oral dosing in coho salmon has shown that the kidney is a primary site of DA accumulation in this species, and studies in rodents have shown that renal excretion is the exclusive route of systemic DA elimination.^27,28 Examination of sea lions after DA poisoning has also revealed some evidence of interstitial nephritis, renal edema, and elevated BUN, although the exact cause of these findings cannot be definitively attributed to DA toxicity.^29,30 Furthermore, sea lions with acute DA toxicosis seem to have an elevated hematocrit,³¹ suggesting that water reabsorption or red blood cell production could be affected, both of which are functions of the kidney. Despite this circumstantial evidence, a detailed examination of the renal response to DA administration has not been fully explored. The purpose of the current study was to characterize the acute renal effects of DA at doses that produce neurotoxicity and neurobehavioral changes (1.0–2.5 mg/kg) as well as several lower doses (0.0005–0.5 mg/kg), which are considered below the limit of toxicity.     

Analysis of the complement sensitivity of oral treponemes and the potential influence of FH binding,FH cleavage and dentilisin activity on the pathogenesis of periodontal disease

Treponema denticola, a periopathogen, evades complement‐mediated killing by binding the negative complement regulatory protein factor H (FH) to its surface via the FhbB protein. Paradoxically, bound FH is cleaved by T. denticola's dentilisin protease, a process hypothesized to trigger localized dysregulation of complement activation in periodontal pockets. The ability of other oral treponemes to evade complement‐mediated killing and bind and cleave FH has not been assessed. In this report, we demonstrate that representative isolates of Treponema socranskii, Treponema medium, Treponema pectinovorum and Treponema maltophilum are also serum resistant, whereas Treponema vincentii and Treponema amylovorum are serum sensitive. Although T. denticola's ability to evade complement‐mediated killing is strictly dependent on FH binding, other serum‐resistant treponemal species lack FhbB and do not bind FH, indicating an FH‐independent mechanism of complement evasion. To assess the influence of FhbB sequence variation on FH binding and cleavage by T. denticola, fhbB sequences were determined for 30 isolates. Three distinct phyletic types were identified. All T. denticola strains bound FH and were serum resistant, but differences in binding kinetics, dentilisin activity and FH cleavage ability were observed. Based on these analyses, we hypothesize that the composition of the T. denticola population is a determining factor that influences the progression and severity of periodontal disease.     

美国卫生信息管理职业发展

健康信息管理人员致力于为诊疗、科研和收费提供高质量的数据.本文介绍健康相关行业之一健康信息管理业的相关信息,包括职业发展简史、健康信息管理者在医疗机构中的职业角色,以及为获得注册健康信息管理人(RHIA)职业资格所应接受的教育科目.举例介绍了健康服务管理业与其他健康相关学科的合作关系,并讨论了行业的就业前景.     

Evaluation of the contemporary occurrence rates of metallo-beta-lactamases in multidrug-resistant Gram-negative bacilli in Japan: report from the SENTRY Antimicrobial Surveillance Program (1998-2002)

Metallo-beta-lactamases (M beta L) were initially characterized in Japan, usually of the IMP-type, and found in Pseudomonas aeruginosa (PSA), Acinetobacter spp. (ACB), or Serratia marcescens (SM). The number of M beta L types has increased worldwide, but geographic dissemination within Japan has appeared limited. This study compares baseline levels of M beta L resistance from two 22-center studies (1996-1997) to the longitudinal sample (3 sites) of Japanese isolates from the SENTRY Antimicrobial Surveillance Program (1998-2002). All minimal inhibitory concentration results were determined by reference methods. A total of 26.8% PSA, 3.4% ACB, and 3.1% Enterobacteriaceae (enterobacters and SM) with resistance to monitored carbapenems (CARB) (minimal inhibitory concentration, > or =8 microg/mL) were screened for M beta L production by disk approximation tests (EDTA and 2-MPA inhibitors), CARB hydrolysis by enzyme extracts, and selected PCR primers for known M beta L types. All M beta L-positive strains (10) were sequenced to determine enzyme identification. Clonality in each center was determined by automated ribotyping and PFGE. The CARB susceptibility rates in PSA decreased (80.7% to 62.0%) over the monitored interval (1998-2002), but varied by medical center location. Among CARB-resistant isolates, 10.8% were attributed to M beta L strains (1.1% of all PSA tested). M beta L identification showed the following: five PSA (three IMP-1, two IMP-2), four SM (one IMP-1, two IMP-1 + OXA-1, and one IMP-11). Also a single ACB had an IMP-1. Eight of 10 M beta L isolations occurred between 2000 and 2002; four occurred in 2002. BRL42715, an AMP-C inhibitor, confirmed AMP-C-mediated resistance in 87.3% of PSA, and outer membrane protein changes were also discovered by membrane studies. Prior results (22 sites, 1997-1998) showed CARB resistance at 22.4-25.6% and 0.5-0.9% M beta Ls (IMP-1) overall; it was slightly elevated in this SENTRY Program sample. In conclusion, M beta L-producing strains from several species persist in Japan, but represent a distinct minority of all CARB-resistant strains (1998-2002). Although M beta L rates appear generally stable in Japan, continued surveillance for these mechanisms seems to be a prudent practice, because of the mobility of the genetic determinants and the emergence of novel enzyme types, especially among the Enterobacteriaceae.