A feasibility and pilot additive randomised control trial of attachment security priming during behavioural activation

BACKGROUND

There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes.

AIMS

This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming.

METHOD

This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates.

RESULTS

All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes.

CONCLUSIONS

Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

Information Overload in Emergency Medicine Physicians: A Multisite Case Study Exploring the Causes, Impact, and Solutions in Four North England National Health Service Trusts

Background

Information overload is affecting modern society now more than ever because of the wide and increasing distribution of digital technologies. Social media, emails, and online communications among others infuse a sense of urgency as information must be read, produced, and exchanged almost instantaneously. Emergency medicine is a medical specialty that is particularly affected by information overload with consequences on patient care that are difficult to quantify and address. Understanding the current causes of medical information overload, their impact on patient care, and strategies to handle the inflow of constant information is crucial to alleviating stress and anxiety that is already crippling the profession.

Objective

This study aims to identify and evaluate the main causes and sources of medical information overload, as experienced by emergency medicine physicians in selected National Health Service (NHS) trusts in the United Kingdom.

Methods

This study used a quantitative, survey-based data collection approach including close- and open-ended questions. A web-based survey was distributed to emergency physicians to assess the impact of medical information overload on their jobs. In total, 101 valid responses were collected from 4 NHS trusts in north England. Descriptive statistics, principal component analysis, independent sample two-tailed t tests, and one-way between-group analysis of variance with post hoc tests were performed on the data. Open-ended questions were analyzed using thematic analysis to identify key topics.

Results

The vast majority of respondents agreed that information overload is a serious issue in emergency medicine, and it increases with time. The always available culture (mean 5.40, SD 1.56), email handling (mean 4.86, SD 1.80), and multidisciplinary communications (mean 4.51, SD 1.61) are the 3 main reasons leading to information overload. Due to this, emergency physicians experience guideline fatigue, stress and tension, longer working hours, and impaired decision making, among other issues. Aspects of information overload are also reported to have different impacts on physicians depending on demographic factors such as age, years spent in emergency medicine, and level of employment.

Conclusions

There is a serious concern regarding information overload in emergency medicine. Participants identified a considerable number of daily causes affecting their job, particularly the traditional culture of emergency departments being always available on the ward, exacerbated by email and other forms of communication necessary to maintain optimal, evidence-based practice standards. However, not all information is unwelcome, as physicians also need to stay updated with the latest guidelines on conditions and treatment, and communicate with larger medical teams to provide quality care.

Habitual protein intake, protein distribution patterns and dietary sources in Irish adults with stratification by sex and age

BACKGROUND

Given the importance of habitual dietary protein intake, distribution patterns and dietary sources in the aetiology of age-related declines of muscle mass and function, the present study examined these factors as a function of sex and age in Irish adults aged 18-90 years comprising The National Adult Nutrition Survey (NANS).

METHODS

In total, 1051 (males, n = 523; females, n = 528) undertook a 4-day semi-weighed food diary. Total, body mass relative intake and percentage contribution to total energy intake of dietary protein were determined in addition to protein distribution scores (PDS), as well as the contribution of food groups, animal- and plant-based foods to total protein intake.

RESULTS

Total and relative protein intake [mean (SD)] were highest in those aged 18-35 years [96 (3) g day^-1 , 1.32 (0.40) g kg^-1  day^-1 ], with lower protein intakes with increasing age (i.e. in adults aged ≥65 years [82 (22) g, 1.15 (0.34) g kg^-1  day^-1 , P < 0.001 for both]. Differences in protein intake between age groups were more pronounced in males compared to females. Protein distribution followed a skewed pattern for all age groups [breakfast, 15 (10) g; lunch, 30 (15) g; dinner, 44 (17) g]. Animal-based foods were the dominant protein source within the diet [63% (11%) versus 37% (11%) plant protein, P < 0.001].

CONCLUSIONS

Protein intake and the number of meals reaching the purported threshold for maximising post-prandial anabolism were highest in young adults, and lower with increasing age. For main meals, breakfast provided the lowest quantity of protein across all age categories and may represent an opportunity for improving protein distribution, whereas, in older adults, increasing the number of meals reaching the anabolic threshold regardless of distribution pattern may be more appropriate.

Nematic liquid crystal director structures in rectangular regions

We consider a shallow rectangular well of nematic liquid crystal subject to weak anchoring on the sides of the well. By considering weak anchoring instead of infinitely strong anchoring, we are able to analyze nematic equilibria in the well without the need to exclude point defects at the corners, as done in previous work in the area. For relatively weak anchoring, we are able to derive analytic expressions for the director alignment angle in terms of an infinite series of modes, involving roots of a transcendental equation. The analytic forms of the director configuration are then used to calculate critical anchoring strengths at which uniform and distorted director structures exchange stability. We also consider the asymptotic behavior of the director structure and energy for very strong anchoring. We show that in both cases-for the transitions from uniform to distorted states and the limit of infinitely strong anchoring-the approximate analytic expansions agree very well with corresponding numerical calculations of the full model.

Warming drives a front of white spruce establishment near western treeline, Alaska

Regional warming has led to increased productivity near the boreal forest margin in Alaska. To date, the effects of warming on seedling recruitment have received little attention, in spite of forecasted forest expansion. Here, we used stand structure and environmental data from 95 white spruce (Picea glauca) plots sampled across a longitudinal gradient in southwest Alaska to explore factors influencing spruce establishment and recruitment near western treeline. We used total counts of live seedlings, saplings, and trees, representing five life stages, to evaluate whether geospatial, climate, and measured plot covariates predicted abundance, using current abundance distributions as a surrogate for climate conditions in the past. We used generalized linear models to test the null hypothesis that conditions favorable for recruitment were similar along the environmental gradient represented by longitude, by exploring relationships between per-plot counts of each life stage and the covariates hypothesized to affect abundance. We also examined the relationship between growing degree days (GDD) and seedling establishment over a period of three decades using tree-ring chronologies obtained from cores taken at a subset of our sites (n = 30). Our results indicated that seedling, sapling, and tree abundance were positively correlated with temperature across the study area. The response to longitude was mixed, with earlier life stages (seedlings, saplings) most abundant at the western end of the gradient, and later life stages (trees) most abundant to the east. The differential relationship between longitude and life-stage abundance suggests a moving front of white spruce establishment through time, driven by changes in environmental conditions near the species' western range limit. Likewise, we found a positive relationship between periods of seedling establishment and GDD, suggesting that longer summers and/or greater heat accumulation might enhance establishment, consistent with the positive relationship we found between life-stage abundance and temperature.

Patterns of dairy food intake, body composition and markers of metabolic health in Ireland: results from the National Adult Nutrition Survey

Background:

Studies examining the association between dairy consumption and metabolic health have shown mixed results. This may be due, in part, to the use of different definitions of dairy, and to single types of dairy foods examined in isolation.

Objective:

The objective of the study was to examine associations between dairy food intake and metabolic health, identify patterns of dairy food consumption and determine whether dairy dietary patterns are associated with outcomes of metabolic health, in a cross-sectional survey.

Design:

A 4-day food diary was used to assess food and beverage consumption, including dairy (defined as milk, cheese, yogurt, cream and butter) in free-living, healthy Irish adults aged 18–90 years (n=1500). Fasting blood samples (n=897) were collected, and anthropometric measurements taken. Differences in metabolic health markers across patterns and tertiles of dairy consumption were tested via analysis of covariance. Patterns of dairy food consumption, of different fat contents, were identified using cluster analysis.

Results:

Higher (total) dairy was associated with lower body mass index, %body fat, waist circumference and waist-to-hip ratio (P<0.001), and lower systolic (P=0.02) and diastolic (P<0.001) blood pressure. Similar trends were observed when milk and yogurt intakes were considered separately. Higher cheese consumption was associated with higher C-peptide (P<0.001). Dietary pattern analysis identified three patterns (clusters) of dairy consumption; 'Whole milk', 'Reduced fat milks and yogurt' and 'Butter and cream'. The 'Reduced fat milks and yogurt' cluster had the highest scores on a Healthy Eating Index, and lower-fat and saturated fat intakes, but greater triglyceride levels (P=0.028) and total cholesterol (P=0.015). conclusion: Overall, these results suggest that while milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.

Conclusion:

Overall, these results suggest that although milk and yogurt consumption is associated with a favourable body phenotype, the blood lipid profiles are less favourable when eaten as part of a low-fat high-carbohydrate dietary pattern. More research is needed to better understand this association.

Dietary strategies for achieving adequate vitamin D and iron intakes in young children in Ireland

BACKGROUND

Inadequate intakes of vitamin D and iron have been reported in young children in Ireland. The present study aimed to identify the main foods determining vitamin D and iron intakes and to model the impact of dietary strategies to improve adequacy of these micronutrients in young children.

METHODS

The present study is based on the Irish National Pre-School Nutrition Survey (NPNS), which estimated food and nutrient intakes in a representative sample (n = 500) of children (aged 1-4 years) using a 4-day weighed food record. Dietary strategies were modelled using DaDiet^© software (Dazult Ltd, Co. Kildare, Republic of Ireland) and the usual intake distribution, prevalence of inadequate intakes and risk of excessive intakes were estimated using the National Cancer Institute method.

RESULTS

Fortified foods and nutritional supplements were the key foods influencing the intakes of vitamin D and iron. Adding a 5 μg day^-1 vitamin D supplement, fortifying cow's milk (CM) with vitamin D or replacing CM with growing-up milk (GUM) would modestly increase intakes of vitamin D. A combined strategy of fortifying CM with vitamin D or replacing CM with GUM plus a 5 μg day^-1 vitamin D supplement would increase mean intakes of vitamin D (from 3.5 μg day^-1 at baseline to ≥11 μg day^-1 ) and substantially reduce the prevalence of inadequate intakes (from >95% to 12-36%). Fortifying CM with iron or replacing CM with GUM would increase mean intakes of iron (from 7.3 mg day^-1 to >10 mg day^-1 ), achieving adequate intakes across all ages.

CONCLUSIONS

Based on real food consumption data in a representative sample of Irish children, we have shown that through targeted dietary strategies adequate intakes of iron are achievable and intakes of vitamin D could be greatly improved.

Popliteal venous reflux is not abolished by superficial venous ligation

Introduction: The role of superficial venous surgery in the presence of deep venous reflux is not well defined. Abolition of deep reflux in the femoral segment after superficial venous surgery has been reported. The popliteal segment has not been investigated similarly.

Aims: To investigate if popliteal venous reflux can be abolished by superficial venous ligation.

Method: Retrospectively identified consecutive patients with mild category exclusive popliteal reflux were invited by post to attend for a repeat duplex scan after surgery. They had previously undergone superficial venous surgery aiming to eliminate all sites of superficial reflux identified on duplex scanning.

Results: Of the 34 patients invited, 21 attended: eight males and 13 females, mean age 60 years. Seven patients were suitable for bilateral investigation. Of the 28 segments scanned, the reflux category improved in three, deteriorated to the moderate category in six and remained unchanged in 18.

Conclusion: Superficial venous surgery does not abolish mild popliteal reflux.

A review of sugar consumption from nationally representative dietary surveys across the world

BACKGROUND

Government and health organisations worldwide have recently reviewed the evidence on the role of dietary sugars in relation to health outcomes. Hence, it is timely to review current intakes of dietary sugars with respect to this guidance and as a benchmark for future surveillance.

METHODS

This review collates data from nationally representative dietary surveys across the world and reports estimates of intakes of total and added sugars, and sucrose in different population subgroups. Total sugars includes all mono- and disaccharides; namely, glucose, fructose, lactose, sucrose and maltose. Added and free sugars differ in the quantity of natural sugars included in their definitions. Free sugars include sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates, whereas added sugars typically only refer to those added during processing.

RESULTS

Most countries reported intakes of total sugars, with fewer reporting intakes of added sugars and sucrose. No country reported intakes of free sugars. The available data suggest that total sugars as a percentage of energy were highest in the infant (<4 years), with mean values ranging from 20.0% to 38.4%, and decreased over the lifespan to 13.5-24.6% in adults. Intakes of added sugars were higher in school-aged children and adolescents (up to 19% of total energy) compared to younger children or adults.

CONCLUSIONS

Further research into the dietary patterns contributing to added sugars intake in children and adolescents is warranted. It would also be beneficial to policy guidance if future dietary surveys employed a uniform way of expressing sugars that is feasible to measure and has public health significance.

Community health workers in primary care practice: redesigning health care delivery systems to extend and improve diabetes care in underserved populations

New, comprehensive, approaches for chronic disease management are needed to ensure that patients, particularly those more likely to experience health disparities, have access to the clinical care, self-management resources, and support necessary for the prevention and control of diabetes. Community health workers (CHWs) have worked in community settings to reduce health care disparities and are currently being deployed in some clinical settings as a means of improving access to and quality of care. Guided by the chronic care model, Baylor Health Care System embedded CHWs within clinical teams in community clinics with the goal of reducing observed disparities in diabetes care and outcomes. This study examines findings from interviews with patients, CHWs, and primary care providers (PCPs) to understand how health care delivery systems can be redesigned to effectively incorporate CHWs and how embedding CHWs in primary care teams can produce informed, activated patients and prepared, proactive practice teams who can work together to achieve improved patient outcomes. Respondents indicated that the PCPs continued to provide clinical exams and manage patient care, but the roles of diabetes education, nutritional counseling, and patient activation were shifted to the CHWs. CHWs also provided patients with social support and connection to community resources. Integration of CHWs into clinical care teams improved patient knowledge and activation levels, the ability of PCPs to identify and proactively address specific patient needs, and patient outcomes.

Replacement of fish oil with a DHA-rich algal meal derived from Schizochytrium sp. on the fatty acid and persistent organic pollutant levels in diets and flesh of Atlantic salmon (Salmo salar, L.) post-smolts

The replacement of fish oil (FO) with a DHA-rich Schizochytrium sp. algal meal (AM) at two inclusion levels (11% and 5.5% of diet) was tested in Atlantic salmon post-smolts compared to fish fed a FO diet of northern (NFO) or southern hemisphere (SFO) origin. Fish were preconditioned prior to the 19-week experimental feeding period to reduce long-chain polyunsaturated fatty acid (LC-PUFA) and persistent organic pollutant levels (POPs). Dietary POP levels differed significantly between treatments in the order of NFO>SFO>11 AM/5.5 AM and were subsequently reflected in the flesh. Fish fed the 11 AM diet contained similar DHA levels (g 100 g(-1) flesh) to FO-fed fish, despite percentage differences. However, the low levels of EPA in the diets and flesh of algal-fed fish compromised the overall nutritional value to the final consumer. Nevertheless, further developments in microalgae culture offer a promising alternative lipid source of LC-PUFA to FO in salmon feeds that warrants further investigation.

Microscopic study of the corrosion behaviour of mild steel in ionic liquids for CO2 capture applications

Exposure of mild steel to ionic liquids (IL) results in two main types of degradation that may be significantly limited by addition of molybdate without affecting the IL's CO₂ capture performance.

An apparatus to manipulate and identify individual Ba ions from bulk liquid Xe

We describe a system to transport and identify barium ions produced in liquid xenon, as part of R&D towards the second phase of a double beta decay experiment, nEXO. The goal is to identify the Ba ion resulting from an extremely rare nuclear decay of the isotope (136)Xe, hence providing a confirmation of the occurrence of the decay. This is achieved through Resonance Ionization Spectroscopy (RIS). In the test setup described here, Ba ions can be produced in liquid xenon or vacuum and collected on a clean substrate. This substrate is then removed to an analysis chamber under vacuum, where laser-induced thermal desorption and RIS are used with time-of-flight mass spectroscopy for positive identification of the barium decay product.

Infectious agent screening in canine blood donors in the United Kingdom

OBJECTIVES

Transfusion of blood products is an important component of veterinary emergency medicine. Donors must be carefully selected to minimise risk of transmission of blood-borne infectious agents. This study was devised to assess the prevalence of such agents in healthy, non-travelled UK dogs screened as prospective donors.

METHODS

Ethylenediaminetetraacetic acid blood samples from dogs donating blood between August 2007 and January 2012 were screened by polymerase chain reaction for haemotropic mycoplasmas, Bartonella, Babesia, Leishmania, Ehrlichia and Anaplasma spp. Dogs with positive or inconclusive results underwent repeat polymerase chain reaction testing.

RESULTS

Four of 262 dogs had positive or inconclusive results at initial screening. Repeat polymerase chain reaction testing in each dog was negative, and none of the dogs developed clinical signs of disease.

CLINICAL SIGNIFICANCE

The positive results on initial screening may have represented false positives from sample contamination or amplification of non-target DNA. It is also possible that dogs were infected at initial sampling but successfully cleared infection before repeat testing. The low number of positive results obtained suggests that prevalence of these agents in a population of healthy UK dogs is low and that use of blood products is unlikely to represent a significant risk of transmission of these diseases.

Nutritional quality of the school-day diet in Irish children (5-12 years)

BACKGROUND

The European Commission has identified schools as a priority setting for health promotion, including nutrition education and intervention. The present study examined the school-day diet of Irish primary-school children with the aim of identifying opportunities for dietary improvement.

METHODS

Data from The National Children's Food Survey (2003-2004) were used to establish a dataset of school-days. Dietary intake data were collected from 594 children (5-12 years) using a 7-day weighed food-record. The nutritional quality of the diet was examined for the total school-day and for food eaten 'before school', 'at school' and 'after school'.

RESULTS

Examination of dietary intake on school-days has highlighted nutritional imbalances for intakes of fat, saturated fat, added sugars, sodium and dietary fibre (DF). Mean energy (E) intake for the overall school-day was 7.1 MJ, with 16% of energy provided from food eaten 'before school', 33%E from food eaten 'at school' and 53% of energy from food eaten 'after school'. Relative to the overall school-day, food eaten 'before school' was lower in saturated fat and sodium, and higher in DF and many micronutrients. Food eaten 'at school' was relatively high in added sugars and sodium; lower in DF and micronutrients; and similar in saturated fat compared to the overall school-day. Food eaten 'after school' was relatively high in DF and vitamin A; similar in saturated fat, magnesium and sodium; and lower in added sugars and other micronutrients compared to the overall school-day.

CONCLUSIONS

To improve the overall nutritional quality of the school-day diet, food eaten at school should be targeted.

Water intakes and dietary sources of a nationally representative sample of Irish adults

BACKGROUND

Despite evidence that even mild dehydration is associated with various morbidities, water intake estimates in free-living populations are lacking. The present study aimed to estimate water intakes and dietary sources in a nationally representative sample of the Irish adult population.

METHODS

A 4-day semi-weighed food record was used to collect dietary intake data from 1500 free-living adults aged 18-90 years in the Irish National Adult Nutrition Survey (NANS) (2008-2010) from which water intake was estimated. To enable fluid intake estimation, additional questions on how water and milk were consumed were incorporated. Total water intake was calculated as drinking water plus water from other beverages and food moisture.

RESULTS

The mean (SD) daily total water intake for Irish adults was 2.31 (0.92) L day(-1) [males 2.52 (1.00) L day(-1) ; females 2.09 (0.79) L day(-1)]. Intakes were lowest in elderly adults, as well as in those with less education, a lower social class, less energy expenditure and a higher body mass index and body fat percentage. In total, 67% of water came from beverages and 33% came from food moisture. Alcoholic beverages and teas individually contributed to total water intake in amounts similar to the drinking water contribution.

CONCLUSIONS

These data may be used as a foundation for further research in the area of the effect of under consumption of water on health outcomes to guide public health messages regarding adequate water intakes.

The effects of a community-based partnership, Project Access Dallas (PAD), on emergency department utilization and costs among the uninsured

BACKGROUND

Approximately 19% of non-elderly adults are without health insurance. The uninsured frequently lack a source of primary care and are more likely to use the emergency department (ED) for routine care. Improving access to primary care for the uninsured is one strategy to reduce ED overutilization and related costs.

METHODS

A comparison group quasi-experimental design was used to evaluate a broad-based community partnership that provided access to care for the uninsured-Project Access Dallas (PAD)-on ED utilization and related costs. Eligible uninsured patients seen in the ED were enrolled in PAD (n = 265) with similar patients not enrolled in PAD (n = 309) serving as controls. Study patients were aged 18-65 years, <200% of the federal poverty level and uninsured. Outcome measures include the number of ED visits, hospital days and direct and indirect costs.

RESULTS

PAD program enrollees had significantly fewer ED visits (0.93 vs. 1.44; P < 0.01) and fewer inpatient hospital days (0.37 vs. 1.07; P < 0.05) than controls. Direct hospital costs were ∼60% less ($1188 vs. $446; P < 0.01) and indirect costs were 50% less ($313 vs. $692; P < 0.01).

CONCLUSIONS

A broad-based community partnership program can significantly reduce ED utilization and related costs among the uninsured.

Increased lead biomarker levels are associated with changes in hormonal response to stress in occupationally exposed male participants

BACKGROUND

Lead (Pb) exposure has been associated with a host of pathological conditions in humans. In rodents Pb exposure has been shown to alter the hypothalamic-pituitary-adrenal (HPA) axis function.

OBJECTIVE

We investigated the effects of lead on responses of the HPA axis to a psychosocial laboratory stressor administered to Pb-exposed workers.

METHODS

Seventy male participants completed the Trier Social Stress Test (TSST). Serum cortisol (CORT) and plasma adrenocorticotropic hormone (ACTH) were assessed in response to and during recovery from the stressor. We measured Pb in blood, a biomarker of recent exposure, and in tibia bone by X-ray fluorescence (XRF), a biomarker of chronic exposure.

RESULTS

The TSST induced statistically significant increases in ACTH and CORT in the participants. At baseline, ACTH was not significantly higher (p = 0.052) in participants with higher blood Pb concentration, but CORT was significantly lower in these participants (p = 0.016). Adjusted linear regression models indicated a positive association between blood and bone Pb and the increase in ACTH in response to stress. However, Pb was not strongly associated with changes in CORT in response to stress. Pb was also associated with the ACTH:CORT ratio at baseline and throughout the course of the protocol, suggesting an adrenal hyporesponsiveness in participants with higher Pb concentrations.

CONCLUSION

The altered HPA-axis stress response observed in participants exposed to higher levels of Pb further supports the idea that lead may contribute to a host of biological dysfunctions beyond the classical neurotoxic effects.

General or Local Anesthesia for Carotid Endarterectomy—The “Real-World” Experience

Perioperative complications from carotid endarterectomy (CEA) are the main drawbacks of the procedure. The aim of this study was to assess the complication rates in patients undergoing CEA under general anesthesia (GA) or regional anesthesia (local anesthesia [LA]) at our institution. Patients undergoing CEA at our regional vascular unit between 2000 and 2004 were included. Data were collated retrospectively from a prospective database. Follow-up was up to 62 months. In all, 383 endarterectomies were performed, 260 of which were under LA. Outcome measures included 30-day death (2.1%), stroke (1.8%), and combined stroke and death (2.8%). A 30-day incidence of stroke, death, and combined stroke and death was lower in the LA group. Incidence of myocardial infarction and transient ischemic attacks, and annual mortality were higher in the LA group. No significant difference was found between the 2 groups. In a unit where CEA is preferentially performed under LA, anesthesia technique failed to significantly influence outcome.

Gender, race/ethnicity, personality, and interleukin-6 in urban primary care patients

Gender, race/ethnicity, and personality are markers of significant psychosocial and biological variability. Each may have implications for allostatic load and resulting inflammatory processes, yet findings have been largely mixed. We investigated whether women, minorities, and those higher in Neuroticism and lower in Extraversion were at risk for elevated circulating levels of the pro-inflammatory cytokine interleukin (IL)-6 in a sample of 103 middle aged and older urban primary care patients. Regression analyses controlling for age, education, current depression levels, and chronic medical conditions revealed that women, minorities, and individuals lower in Extraversion had higher circulating levels of IL-6. Analyses of more specific personality traits revealed that the sociability and positive emotions components of Extraversion were unassociated with IL-6, but the activity facet-reflecting dispositional vigor and energy-was robustly associated with IL-6. The difference between high (+1 Standard Deviation (SD)) and low (-1 SD) trait activity was sufficient to shift IL-6 levels beyond a previously established high risk cut-point in both white and minority women. These findings suggest that while broad group differences between genders and races/ethnicities exist, personality represents an important source of individual differences in inflammation within groups. Future work should examine to what extent IL-6 levels are linked to temperament or genetic activity levels vs. physical activity itself, and whether IL-6 levels may be reduced by boosting regular activity levels in demographic segments such as women and minorities who appear susceptible to greater inflammation.

Patient perceptions of a community-based care coordination system

Community health workers (CHWs) work with health professionals to improve health outcomes by facilitating community-based health education and increase access and continuity to health services within a community. Uninsured, low-income participants of a community-based program, Project Access Dallas, participated in focus group sessions for determining participants' perceptions of CHW effectiveness and participants' abilities to independently manage their health needs. Of the 95 adults invited, 24 (25.3%) attended. Participants reported that CHWs are an invaluable asset in learning how to navigate the health care system, obtaining appointments and being better able to care for themselves with CHW emotional/psychological support. Results suggest that CHWs in a case management model improved patient comprehension of health issues, patient navigation through a health care system, and patients' abilities to independently manage health issues. Implementation of CHWs within a case management model appears to be an effective mechanism for providing health services to underserved populations.

Mapping the platelet profile for functional genomic studies and demonstration of the effect size of the GP6 locus

BACKGROUND

Evidence suggests the wide variation in platelet response within the population is genetically controlled. Unraveling the complex relationship between sequence variation and platelet phenotype requires accurate and reproducible measurement of platelet response.

OBJECTIVE

To develop a methodology suitable for measuring signaling pathway-specific platelet phenotype, to use this to measure platelet response in a large cohort, and to demonstrate the effect size of sequence variation in a relevant model gene.

METHODS

Three established platelet assays were evaluated: mobilization of [Ca(2+)](i), aggregometry and flow cytometry, each in response to adenosine 5'-diphosphate (ADP) or the glycoprotein (GP) VI-specific crosslinked collagen-related peptide (CRP). Flow cytometric measurement of fibrinogen binding and P-selectin expression in response to a single, intermediate dose of each agonist gave the best combination of reproducibility and inter-individual variability and was used to measure the platelet response in 506 healthy volunteers. Pathway specificity was ensured by blocking the main subsidiary signaling pathways.

RESULTS

Individuals were identified who were hypo- or hyper-responders for both pathways, or who had differential responses to the two agonists, or between outcomes. 89 individuals, retested three months later using the same methodology, showed high concordance between the two visits in all four assays (r(2) = 0.872, 0.868, 0.766 and 0.549); all subjects retaining their phenotype at recall. The effect of sequence variation at the GP6 locus accounted for approximately 35% of the variation in the CRP-XL response.

CONCLUSION

Genotyping-phenotype association studies in a well-characterized, large cohort provides a powerful strategy to measure the effect of sequence variation in genes regulating the platelet response.