Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION

Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination.

METHODS

Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey.

RESULTS

Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings.

CONCLUSION

Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Learning Through Diversity: Creating a Virtuous Cycle of Health Equity in Health Care Organizations

In the US, a growing number of organizations and industries are seeking to affirm their commitment to and efforts around diversity, equity, and inclusion (DEI) as recent events have increased attention to social inequities. As health care organizations are considering new ways to incorporate DEI initiatives within their workforce, the anticipated result of these efforts is a reduction in health inequities that have plagued our country for centuries. Unfortunately, there are few frameworks to guide these efforts because few successfully link organizational DEI initiatives with health equity outcomes. The purpose of this chapter is to review existing scholarship and evidence using an organizational lens to examine how health care organizations can advance DEI initiatives in the pursuit of reducing or eliminating health inequities. First, this chapter defines important terms of DEI and health equity in health care. Next, we describe the methods for our narrative review. We propose a model for understanding health care organizational activity and its impact on health inequities based in organizational learning that includes four interrelated parts: intention, action, outcomes, and learning. We summarize the existing scholarship in each of these areas and provide recommendations for enhancing future research. Across the body of knowledge in these areas, disciplinary and other silos may be the biggest barrier to knowledge creation and knowledge transfer. Moving forward, scholars and practitioners should seek to collaborate further in their respective efforts to achieve health equity by creating formalized initiatives with linkages between practice and research communities.

Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff

BACKGROUND

Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists).

METHODS

Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback.

RESULTS

Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules.

CONCLUSIONS

There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Written Advice Given by African American Smokers to Their Peers: Qualitative Study of Motivational Messages

BACKGROUND

Although African Americans have the lowest rates of smoking onset and progression to daily smoking, they are less likely to achieve long-term cessation. Interventions tailored to promote use of cessation resources in African American individuals who smoke are needed. In our past work, we demonstrated the effectiveness of a technology-assisted peer-written message intervention for increasing smoking cessation in non-Hispanic White smokers. In this formative study, we have adapted this intervention to be specific for African American smokers.

OBJECTIVE

We aimed to report on the qualitative analysis of messages written by African American current and former smokers for their peers in response to hypothetical scenarios of smokers facing cessation challenges.

METHODS

We recruited African American adult current and former smokers (n=41) via ResearchMatch between April 2017 and November 2017. We asked participants to write motivational messages for their peers in response to smoking-related hypothetical scenarios. We also collected data on sociodemographic factors and smoking characteristics. Thematic analysis was conducted to identify cessation strategies suggested by the study participants.

RESULTS

Among the study participants, 60% (25/41) were female. Additionally, more than half (23/41, 56%) were thinking about quitting, 29% (12/41) had set a quit date, and 27% (11/41) had used electronic cigarettes in the past 30 days. Themes derived from the qualitative analysis of peer-written messages were (1) behavioral strategies, (2) seeking help, (3) improvements in quality of life, (4) attitudes and expectations, and (5) mindfulness/religious or spiritual practices. Under the behavioral strategies theme, distraction strategies were the most frequently suggested strategies (referenced 84 times in the 318 messages), followed by use of evidence-based treatments/cessation strategies. Within the seeking help theme, subthemes included seeking help or support from family/friends or close social networks (referenced 56 times) and health care professionals (referenced 22 times). The most frequent subthemes that emerged from improvements in the quality of life theme included improving one's health (referenced 22 times) and quality of life (referenced 21 times). Subthemes that emerged from the attitude and expectations theme included practicing positive self-talk (referenced 27 times), autonomy/independence from the smoking habit (referenced six times), and financial cost of smoking (referenced five times). The two subthemes that emerged from the mindfulness/religious or spiritual practices theme were use of self-awareness techniques (referenced 36 times) and religious or spiritual practices to cope (referenced 13 times).

CONCLUSIONS

Our approach to adapt a prior peer-message intervention to African American smokers yielded a set of evidence-based messages that may be suitable for smokers at all phases of motivation to quit (ready to quit or not ready to quit). In future research, we plan to assess the impact of texting these messages to African American smokers in a smoking cessation trial.

Secure Asynchronous Communication Between Smokers and Tobacco Treatment Specialists: Secondary Analysis of a Web-Assisted Tobacco Intervention in the QUIT-PRIMO and National Dental PBRN Networks

BACKGROUND

Within a web-assisted tobacco intervention, we provided a function for smokers to asynchronously communicate with a trained tobacco treatment specialist (TTS). Previous studies have not attempted to isolate the effect of asynchronous counseling on smoking cessation.

OBJECTIVE

This study aimed to conduct a semiquantitative analysis of TTS-smoker communication and evaluate its association with smoking cessation.

METHODS

We conducted a secondary analysis of data on secure asynchronous communication between trained TTSs and a cohort of smokers during a 6-month period. Smokers were able to select their preferred TTS and message them using a secure web-based form. To evaluate whether the TTS used evidence-based practices, we coded messages using the Motivational Interviewing Self-Evaluation Checklist and Smoking Cessation Counseling (SCC) Scale. We assessed the content of messages initiated by the smokers by creating topical content codes. At 6 months, we assessed the association between smoking cessation and the amount of TTS use and created a multivariable model adjusting for demographic characteristics and smoking characteristics at baseline.

RESULTS

Of the 725 smokers offered asynchronous counseling support, 33.8% (245/725) messaged the TTS at least once. A total of 1082 messages (TTSs: 565; smokers 517) were exchanged between the smokers and TTSs. The majority of motivational interviewing codes were those that supported client strengths (280/517, 54.1%) and promoted engagement (280/517, 54.1%). SCC code analysis showed that the TTS provided assistance to smokers if they were willing to quit (247/517, 47.8%) and helped smokers prepare to quit (206/517, 39.8%) and anticipate barriers (197/517, 38.1%). The majority of smokers' messages discussed motivations to quit (234/565, 41.4%) and current and past treatments (talking about their previous use of nicotine replacement therapy and medications; 201/565, 35.6%). The majority of TTS messages used behavioral strategies (233/517, 45.1%), offered advice on treatments (189/517, 36.5%), and highlighted motivations to quit (171/517, 33.1%). There was no association between the amount of TTS use and cessation. In the multivariable model, after adjusting for gender, age, race, education, readiness at baseline, number of cigarettes smoked per day at baseline, and the selected TTS, smokers messaging the TTS one or two times had a smoking cessation odds ratio (OR) of 0.8 (95% CI 0.4-1.4), and those that messaged the TTS more than two times had a smoking cessation OR of 1.0 (95% CI 0.4-2.3).

CONCLUSIONS

Our study demonstrated the feasibility of using asynchronous counseling to deliver evidence-based counseling. Low participant engagement or a lack of power could be potential explanations for the nonassociation with smoking cessation. Future trials should explore approaches to increase participant engagement and test asynchronous counseling in combination with other approaches for improving the rates of smoking cessation.

Exploring Online Asynchronous Counseling With Tobacco Treatment Specialists in the QUIT-PRIMO and National Dental PBRN HI-QUIT Studies: Who Uses It and What Do They Say?

PURPOSE

To describe the content of messages sent by smokers through asynchronous counseling within a Web-based smoking cessation intervention.

DESIGN

Qualitative.

SETTING

National community-based setting of patients who had been engaged by the medical or dental practices at which they attended or via Google advertisements.

PARTICIPANTS

Adults older than 19 years who were current smokers and interested in quitting. Participants throughout the United States referred to a Web-based cessation intervention by their medical or dental provider or by clicking on a Google advertisement.

METHODS

We conducted a qualitative review of 742 asynchronous counseling messages sent by 270 Web site users. Messages were reviewed, analyzed, and organized into qualitative themes by the investigative team.

RESULTS

The asynchronous counseling feature of the intervention was used most frequently by smokers who were white (87%), female (67%), aged 45 to 54 (32%), and who had at least some college-level education (70%). Qualitative analysis yielded 7 basic themes-Talk about the Process of Quitting, Barriers to Quitting, Reasons to Quit, Quit History, Support and Strategies for Quitting, Quitting with Medication, and Quit Progress. The most common theme was Support and Strategies for Quitting with 255 references among all messages.

CONCLUSION

We found rich communication across the spectrum of the quit process, from persons preparing to quit to those who had successfully quit. Asynchronous smoking cessation counseling provides a promising means of social support for smokers during the quit process.

The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75.

INTRODUCTION

Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention.

METHODS

The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed.

RESULTS

Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41.

CONCLUSION

An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost.

TRIAL REGISTRATION

clinicaltrials.gov identifier NCT01507662.

Narratives to enhance smoking cessation interventions among African-American smokers, the ACCE project

Background

Low-income, African-American smokers are less likely to have resources to aid in quitting smoking. Narrative communication may provide an enhancement to traditional smoking cessation interventions like NRT, medications, or behavioral treatments for this audience. After extensive pilot testing of stories and personal experiences with smoking cessation from African-Americans from a low-income community, we conducted a randomized control trial using stories to augment routine inpatient treatment among African-Americans at an urban Southern hospital (N = 300).

Results

Differences in smoking cessation outcomes between the intervention (stories DVD + routine clinical treatment) and control (routine clinical treatment) arms were compared using self-report and carbon monoxide measurement at 6-months. Compared to control, individuals who viewed the intervention stories DVD reported greater intentions to quit. Although continuous quitting marginally favored the intervention, our main result did not reach statistical significance (p = 0.16).

Conclusion

Narrative communication via storytelling to promote smoking cessation among African-Americans in the South is one method to communicate smoking cessation. Results suggest this may not be sufficient as a stand-alone augmentation of routine clinical treatment for continuous smoking cessation. Smoking cessation efforts need to continually assess different means of communicating to smokers about quitting.

Clinical Trials Registration: The ClinicalTrials.gov Identifier is NCT00101491. This trial was registered January 10, 2005

Comparative pathology of neurovirulent lineage 1 (NY99/385) and lineage 2 (SPU93/01) West Nile virus infections in BALBc mice

The pathology in mice infected with neurovirulent South African lineage 2 West Nile virus (WNV) strains has not previously been described. Three- to 4-month-old male BALBc mice were infected with South African neurovirulent lineage 2 (SPU93/01) or lineage 1 (NY385/99) WNV strains and the gross and microscopic central nervous system (CNS) and extra-CNS pathology of both investigated and compared. Mice infected with both lineages showed similar illness, paralysis, and death from days 7 to 11 postinfection (PI). Two survivors of each lineage were euthanized on day 21 PI. WNV infection was confirmed by nested real-time reverse transcription polymerase chain reaction of tissues, mostly brain, in the majority of mice euthanized sick or that died and in 1 healthy lineage 2 survivor. Gross lesions caused by both lineages were identical and included marked gastric and proximal small intestinal fluid distension as described in a previous mouse study, but intestinal microscopic lesions differed. CNS lesions were subtle. Immunohistochemical (IHC)-positive labeling for WNV E protein was found in neurons multifocally in the brain of 3 lineage 1-infected and 3 lineage 2-infected mice from days 9 to 11 PI, 4 of these including brainstem neurons, and of cecal myenteric ganglion neurons in 1 lineage 2-infected day 8 PI mouse. Findings supported hypotheses in hamsters that gastrointestinal lesions are likely of brainstem origin. Ultrastructurally, virus-associated cytoplasmic vesicular or crystalline structures, or amorphous structures, were found to label IHC positive in control-positive avian cardiomyocytes and mouse thalamic neurons, respectively, and WNV-like 50-nm particles, which were scarce, did not label.

Smoking-cessation e-referrals: a national dental practice-based research network randomized controlled trial

BACKGROUND

Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs.

PURPOSE

The study purpose was to test two patient referral methods-paper referrals (information prescriptions) versus paper plus e-referrals-to a web-assisted smoking-cessation induction system.

DESIGN

RCT that used implementation research methods.

PARTICIPANTS/SETTING

A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system.

INTERVENTION

The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org.

MAIN OUTCOME MEASUREMENTS

The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010-2011 and analyses were completed in 2012.

RESULTS

Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p<0.01) in intervention compared with control practices. Subsequent rates of cessation among referred smokers were threefold higher (adjusted mean percentages: 3.0% vs 0.8%, p=0.03) in intervention practices as compared with control.

CONCLUSIONS

Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner.

CLINICAL TRIAL REGISTRATION

DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

Variations in tobacco control in National Dental PBRN practices: the role of patient and practice factors

We engaged dental practices enrolled in The National Dental Practice-Based Research Network to quantify tobacco screening (ASK) and advising (ADVISE); and to identify patient and practice -characteristics associated with tobacco control. Dental practices (N = 190) distributed patient surveys that measured ASK and ADVISE. Twenty-nine percent of patients were ASKED about tobacco use during visit, 20% were identified as tobacco users, and 41% reported being ADVISED. Accounting for clustering of patients within practices, younger age and male gender were positively associated with ASK and ADVISE. Adjusting for patient age and gender, a higher proportion of non-whites in the practice, preventive services and proportion on public assistance were positively associated with ASK. Proportion of tobacco users in the practice and offering other preventive services were more strongly associated with ASK and ADVISE than other practice characteristics. Understanding variations in performance is an important step toward designing strategies for improving tobacco control in dentistry.

Association between high aflatoxin B1 levels and high viral load in HIV-positive people

Since both aflatoxin and the human immunodeficiency virus (HIV) cause immune suppression, chronic exposure to aflatoxin in HIV-positive people could lead to higher levels of virus replication. This study was conducted to examine the association between aflatoxin B₁ albumin adduct (AF-ALB) levels and HIV viral load. Antiretroviral naive HIV-positive people (314) with median CD4 count of 574 cells/μl blood (mean ± standard deviation = 630±277) were recruited in Kumasi, Ghana. Sociodemographic and health data, and blood samples were collected from participants. The plasma samples were tested for AF-ALB and HIV viral load. Univariate logistic regression analysis was conducted using viral load (high/low) as the outcome and AF-ALB quartiles as exposure. Multivariable logistic regression analysis was performed between quartile AF-ALB, viral load and CD4 adjusting for sex, age, and year of HIV diagnosis. Both univariate and multivariable logistic regression showed that viral load increased as AF-ALB levels increased. By univariate analysis, high viral load was 2.3 times more likely among persons in the third AF-ALB quartile (95% confidence interval (Cl): 1.13, 4.51), and 2.9 times more likely among persons in the fourth AF-ALB quartile (Cl: 1.41, 5.88), compared to persons in the first quartile. In the multivariable model, persons in the fourth AF-ALB quartile were about 2.6 times more likely to have high viral loads than persons in the first quartile (Cl: 1.19-5.69). When AF-ALB and viral load were log transformed and linear regression analysis conducted, the univariate linear regression analysis showed that for each pg/mg increase in AF-ALB, viral load increased by approximately 1.6 copies/ml (P=0.0006). The association was marginally significant in the adjusted linear regression model (i.e. for each pg/mg increase in AF-ALB, the mean viral load increased by approximately 1.3 copies/ml, P=0.073). These data show strong and consistent increases in HIV viral load with increasing AF-ALB levels. Since the median and mean CD4 were greater than 500 cells for participants in each AF-ALB quartile, the results indicate that the immune modulating and virus transcription effects of aflatoxin may occur quite early in HIV infection, even while the CD4 count is still above 500, resulting in higher viral loads.

Development of early tissue cysts and associated pathology of Besnoitia besnoiti in a naturally infected bull (Bos taurus) from South Africa

Besnoitia besnoiti is an apicomplexan that causes serious economic loss in cattle in many countries and the disease is now spreading in Europe. At least 2 phases of bovine besnoitiosis are recognized clinically. An acute febrile phase characterized by anasarca and necrosis of skin is associated with multiplication of tachyzoites in vascular endothelium; this phase is short-lived and rarely diagnosed. Chronic besnoitiosis characterized by dermal lesions is associated with the presence of macroscopic tissue cysts and is easily diagnosed. Here we report the development of early B. besnoiti tissue cysts in a naturally infected Hugenoot bull from South Africa. Tissue cysts were 10-70 μm in diameter, contained 1-12 bradyzoites, and were most numerous in the dermis, testicles, and pampiniform venous plexus. Amylopectin granules in bradyzoites stained red with periodic acid Schiff (PAS) reaction. Bradyzoites varied in size and in the intensity of PAS reaction (some were PAS-negative), some were plump, and others were slender. With immunohistochemical staining with Besnoitia oryctofelisi and bradyzoite-specific antibodies (BAG-1 made against Toxoplasma gondii bradyzoites), the staining was confined to parasites, and all intracystic organisms were BAG-1 positive. With Gomori's silver stain only bradyzoites were stained very faintly whereas the rest of the tissue cyst was unstained. Ultrastructurally many tissue cysts contained dead bradyzoites and some appeared empty. Unlike bradyzoites from mature cysts, bradyzoites in the present case contained few or no micronemes. These findings are of diagnostic significance. Ultrastructually host cyst cells had features of myofibroblasts, and immunohistochemistry using antibodies against MAC387, lysozyme, vimentin, Von Willebrand factor, and smooth muscle actin confirmed this. Polymerase chain reaction on DNA extracted from lymph node of the bull confirmed B. besnoiti diagnosis. Associated clinical findings, lesions, and histopathology are briefly presented. The bull died of nephrotic syndrome; anasarca in acute besnoitiosis due to protein-losing glomerulopathy is a finding not previously reported in cattle.

Socio-demographic determinants of aflatoxin B1-lysine adduct levels among pregnant women in Kumasi, Ghana

OBJECTIVES

Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Although studies have linked these toxins to adverse birth outcomes and poor infant development, no study has investigated the socio-demographic and economic determinants of aflatoxin levels among pregnant women living in sub-Saharan Africa.

DESIGN

A cross-sectional study was conducted among 785 pregnant women in Kumasi. Aflatoxin B1 lysine adduct levels (AF-ALB) were determined by High Performance Liquid Chromatography. Analysis of variance was used to determine mean log AF-ALB levels and significance of differences in these levels according to socio-demographic variables. Logistic regression was used to identify independent associations of socio-demographics with having AF-ALB levels (≥ 11.34 pg/mg; upper quartile).

RESULTS

AF-ALB levels ranged from 0.44 pg/mg to 268.73 pg/mg albumin with a median level of 5.0 pg/mg. Bivariate analyses indicates that mean ln AF-ALB as well as the percent of women having high AF-ALB levels (≥ 11.34 pg/mg; upper quartile) were inversely associated with indices of higher socioeconomic status: higher education and income, being employed and having a flush toilet. Higher income, being employed, having one child (verses no children) and having a flush toilet (verses no toilet facilities) were each independently associated with a 30-40% reduced odds of high AF-ALB levels.

CONCLUSIONS

Additional research is needed to investigate how socio-demographic and economic factors interact to influence aflatoxin ingestion by individuals in regions with high aflatoxin crop contamination. This knowledge can be used to formulate and implement policies that will reduce exposure of women and their unborn children to these toxins.

Smoking cessation post-discharge following nicotine replacement therapy use during an inpatient admission

BACKGROUND

Cigarette smoking remains a health issue despite declining prevalence in Australia. The burden of tobacco-related morbidity affects hospitals, particularly those in lower socioeconomic areas where prevalence is highest.

AIM

We have shown that nicotine replacement therapy (NRT) use during hospitalization increases motivation to quit post-discharge. We postulated that subjects using the nicotine patch post-discharge, in comparison to the inhaler, would have higher rates of abstinence at 12 months after discharge. The aim was to compare the efficacy of the nicotine patch or inhaler formulation for cessation post-discharge, following use during admission.

METHODS

Post-discharge, subjects chose their preferred formulation (patch or inhaler) based on their experience with NRT during admission. Tailored, medium-intensity support was provided with subsidized NRT during outpatient visits. Subjects were followed for 12 months. Exhaled breath CO confirmed non-smoking.

RESULTS

Of 123 subjects enrolled, 37 elected to use the inhaler, 50 the patch and 36 no NRT. At 12 months continuous abstinence rates were 38%, 38% and 25% respectively.

DISCUSSION

This study built upon the 'teachable moment' provided by hospitalization and the inpatient use of NRT, encouraging cessation post-discharge. Both NRT formulations provided similar 12 month cessation rates, and were superior to those achieved by subjects electing not to use NRT. Although the patch was the most popular formulation, the inhaler provided an equally efficacious alternative which addressed other facets of cigarette addiction. Subjects electing not to use NRT were less successful. Continuous abstinence rates were equivalent to community-based studies using NRT. We recommend a similar programme to other hospitals.

Barbiturate ingestion in three adult captive tigers (Panthera tigris) and concomitant fatal botulism of one

Zoo animals, including tigers, have been reported to suffer from barbiturate intoxication, with pentabarbitone being most commonly recorded. Clinical signs range from mild ataxia to general anaesthesia with recovery over hours to days with several factors affecting hepatic barbiturate metabolism and tissue partitioning. Botulism is an often fatal intoxication in man, animals, birds and certain fish. The occurrence in carnivores is uncommon to rare, with only 2 reports found of botulism in felids. This report relates to 3 adult captive cohabiting tigers that simultaneously developed signs of abdominal discomfort, progressive ataxia, recumbency and comatose sleep resembling stage 2 anaesthesia, alternating with periods of distracted wakefulness and ataxic movements. These signs occurred 4 days after being fed the carcass of a horse that had ostensibly died of colic and not been euthanased. The male tiger that was the dominant animal in the feeding hierarchy was worst affected and had to be given intravenous fluids. The female that was lowest in hierarchy was unaffected. After 48-72 hours of treatment at the Onderstepoort Veterinary Academic Hospital the females could eat and made an uneventful recovery. The male tiger showed partial recovery but died during the night a few hours after drinking water on his return to the owner. Necropsy revealed severe oesophageal dilation and impaction with decaying grass; some of this material and water were present in the pharynx and trachea, and had been aspirated causing acute widespread bronchopneumonia. Colon content tested negative for common pesticides but, together with liver, tested positive for barbiturate. Serum taken on the day of admission had tested negative for barbiturate and the residual serum from the 3 animals later tested negative for botulinum toxin. Colon and oesophageal content from the male at necropsy were positive for Clostridium botulinum toxin type C by the mouse bioassay neutralisation test, confirming that this male had had concomitant barbiturate toxicity and botulism, and had succumbed to aspiration bronchopneumonia secondary to pharyngeal, laryngeal and oesophageal paralysis and oesophageal

Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation

BACKGROUND

Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions.

OBJECTIVE

The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care.

METHODS

We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings.

RESULTS

Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider-patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer).

CONCLUSIONS

Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial.

TRIAL

Clinicaltrials.gov NCT00797628; http://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy).

Association of high viral load and abnormal liver function with high aflatoxin B1-albumin adduct levels in HIV-positive Ghanaians: preliminary observations

We examined the association between certain clinical factors and aflatoxin B(1)-albumin adduct (AF-ALB) levels in HIV-positive people. Plasma samples collected from 314 (155 HIV-positive and 159 HIV-negative) people were tested for AF-ALB levels, viral load, CD4+ T-cell count, liver function profile, malaria parasitaemia, and hepatitis B and C virus infections. HIV-positive participants were divided into high and low groups based on their median AF-ALB of 0.93 pmol mg(-1) albumin and multivariable logistic and linear regression methods used to assess relationships between clinical conditions and AF-ALB levels. Multivariable logistic regression showed statistically significant increased odds of having higher HIV viral loads (OR=2.84; 95% CI=1.17-7.78) and higher direct bilirubin levels (OR=5.47; 95% CI=1.03-22.85) among HIV-positive participants in the high AF-ALB group. There were also higher levels of total bilirubin and lower levels of albumin in association with high AF-ALB. Thus, aflatoxin exposure may contribute to high viral loads and abnormal liver function in HIV-positive people and so promote disease progression.

A web-based diabetes intervention for physician: a cluster-randomized effectiveness trial

OBJECTIVE

To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control.

DESIGN

Cluster-randomized trial with baseline and follow-up cross sections of diabetes patients in each participating physician's practice.

SETTING

Eleven US Southeastern states, 2006-08.

PARTICIPANTS

Two hundred and five rural primary care physicians.

INTERVENTION

Multi-component interactive intervention including Web-based continuing medical education, performance feedback and quality improvement tools. Primary Outcome Measures 'Acceptable control' [hemoglobin A1c ≤9%, blood pressure (BP) <140/90 mmHg, low-density lipoprotein cholesterol (LDL) <130 mg/dl] and 'optimal control' (A1c <7%, BP <130/80 mmHg, LDL <100 mg/dl).

RESULTS

Of 364 physicians attempting to register, 205 were randomized to the intervention (n= 102) or control arms (n= 103). Baseline and follow-up data were provided by 95 physicians (2127 patients). The proportion of patients with A1c ≤9% was similar at baseline and follow-up in both the control [adjusted odds ratio (AOR): 0.94; 95% confidence interval (CI): 0.61, 1.47] and intervention arms [AOR: 1.16 (95% CI: 0.80, 1.69)]; BP <140/90 mmHg and LDL <130 mg/dl were also similar at both measurement points (P= 0.66, P= 0.46; respectively). We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures. Intervention physicians engaged with the Website over a median of 64.7 weeks [interquartile range (IQR): 45.4-81.8) for a median total of 37 min (IQR: 16-66).

CONCLUSIONS

A wide-reach, low-intensity, Web-based interactive multi-component intervention did not improve control of glucose, BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US.

The art and science of patient storytelling-harnessing narrative communication for behavioral interventions: the ACCE project

Narrative communication is an emerging form of persuasive communication used in health education to solicit actual patient stories. Eliciting a narrative is an open-ended process and may or may not map to desired intervention objectives or underlying behavioral constructs. In addition, incorporating actual, unscripted narratives into multimedia interventions is challenging. The authors evaluated a protocol of editing narratives for a multimedia intervention to promote smoking cessation in the African American community that maintains fidelity to the original message and was related to behavioral constructs from social cognitive theory. The authors used four steps: (a) narrative collection (videotaping), (b) narrative review (rating of content), (c) narrative editing (documentary style), and (d) pilot testing (usability and assessment of transportation). The authors videotaped 50 personal smoking cessation narratives. After coding for presence of theoretical constructs, perceived risks of smoking (present in 53% of narratives) was the most common related behavioral construct. Four narratives were chosen for inclusion in the DVD. Pilot testing showed viewers reported high level of transportation into the narrative. The authors found that some behavioral constructs were rare and difficult to solicit in this population but that the final product was engaging to the viewers. Lessons learned may be useful for other video-based behavioral interventions that incorporate personal narratives.

Patient complexity and diabetes quality of care in rural settings

PURPOSE

Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States.

BASIC PROCEDURES

Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c<or=7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories.

MAIN FINDINGS

Rural primary care practices (n=135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p<.05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (kappa=0.47; 95% confidence interval, 0.32-0.56; p<001).

PRINCIPAL CONCLUSIONS

Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.

Pathology and immunohistochemistry of papillomavirus-associated cutaneous lesions in Cape mountain zebra, giraffe, sable antelope and African buffalo in South Africa

Skin lesions associated with papillomaviruses have been reported in many animal species and man. Bovine papillomavirus (BVP) affects mainly the epidermis, but also the dermis in several species including bovine, the best-known example being equine sarcoid, which is associated with BVP types 1 and 2. This publication describes and illustrates the macroscopic and histological appearance of BPV-associated papillomatous, fibropapillomatous or sarcoid-like lesions in Cape mountain zebra (Equus zebra zebra) from the Gariep Dam Nature Reserve, 2 giraffes (Giraffa camelopardalis) from the Kruger National Park, and a sable antelope (Hippotragus niger) from the Kimberley area of South Africa. An African buffalo (Syncerus caffer) cow from Kruger National Park also had papillomatous lesions but molecular characterisation of lesional virus was not done. Immunohistochemical staining using polyclonal rabbit antiserum to chemically disrupted BPV-1, which cross-reacts with the L1 capsid of most known papillomaviruses, was positive in cells of the stratum granulosum of lesions in Giraffe 1, the sable and the buffalo and negative in those of the zebra and Giraffe 2. Fibropapillomatous and sarcoid-like lesions from an adult bovine were used as positive control for the immunohistochemistry and are described and the immunohistochemistry illustrated for comparison. Macroscopically, both adult female giraffe had severely thickened multifocal to coalescing nodular and occasionally ulcerated lesions of the head, neck and trunk with local poorly-circumscribed invasion into the subcutis. Necropsy performed on the 2nd giraffe revealed neither internal metastases nor serious underlying disease. Giraffe 1 had scattered, and Giraffe 2 numerous, large, anaplastic, at times indistinctly multinucleated dermal fibroblasts with bizarre nuclei within the sarcoid-like lesions, which were BPV-1 positive in Giraffe 1 and BPV-1 and -2 positive in Giraffe 2 by RT-PCR. The sable antelope presented with a solitary large lesion just proximal to the right hind hoof, which recurred after excision, and was BPV-1 positive by RT-PCR. Other wart-like growths were present elsewhere on the body. The Cape mountain zebra either succumbed from their massive lesions or were euthanased or removed from the herd because of them. The lesions were BPV-1 and/or -2 positive by RT-PCR. The buffalo lesions were wart-like papillomatous projections in the inguinal and udder region. Stratum granulosum cells that stained immunohistochemically positive in the various species appeared koilocyte-like, as described in human papillomaviral lesions.

Infiltrative angiolipoma of the parotid salivary gland in a dog

Solitary benign angiolipoma and infiltrative angiolipoma are rare tumours in dogs. Angiolipomata can be distinguished histologically from lipomata by the large number of tightly packed blood vessels seen between the adipocytes with multiple fibrin thrombi occupying some of the vessels' lumens. The dog presented with a solitary slow-growing mass in the cervical region. Histopathology revealed multifocal to coalescing single or clusters of blood-filled vessels lined by flattened endothelial cells with narrow, elongated, basophilic nuclei. These regions were embedded in adipose tissue with multifocal areas of intervascular remnants of differentiated serous salivary glandular tissue with multifocal small ducts. Fibrin thrombi occupied a few of the vessel lumens. A histological diagnosis of infiltrative angiolipoma was made. On computed tomography, the mass was bilobed with a suspected primary component involving the right parotid gland which was grossly enlarged. The mass had a slightly hypoattenuating mottled to lobulated appearance with a few hyperattenuating mineralised specks throughout. Hounsfield units of the mass ranged between 40 and 45, which was less than the 60-65 of the contralateral salivary glands and cranial musculature. Post contrast images showed no contrast enhancement of 90% of the mass with only a band of peripheral contrast uptake of the affected lateral lobe.

Cognitive mapping tobacco control advice for dentistry: a dental PBRN study

OBJECTIVE

To identify facilitative strategies that could be used in developing a tobacco cessation program for community dental practices.

METHODS

Nominal group technique (NGT) meetings and a card-sort task were used to obtain formative data. A cognitive mapping approach involving multidimensional scaling and hierarchical cluster analysis was used for data analysis.

RESULTS

Three NGT meetings conducted with 23 dental professionals yielded 27 nonredundant facilitative strategies. A 2-dimensional 4-cluster cognitive map provided an organizational framework for understanding these strategies.

CONCLUSION

Views of the target population solicited in a structured format provided clear direction for designing a tobacco cessation intervention.

Recruitment of rural physicians in a diabetes internet intervention study: overcoming challenges and barriers

PURPOSE

This paper highlights a descriptive study of the challenges and lessons learned in the recruitment of rural primary care physicians into a randomized clinical trial using an Internet-based approach.

METHODS

A multidisciplinary/multi-institutional research team used a multilayered recruitment approach, including generalized mailings and personalized strategies such as personal office visits, letters, and faxes to specific contacts. Continuous assessment of recruitment strategies was used throughout study in order to readjust strategies that were not successful.

RESULTS

We recruited 205 primary care physicians from 11 states. The 205 lead physicians who enrolled in the study were randomized, and the overall recruitment yield was 1.8% (205/11231). In addition, 8 physicians from the same practices participated and 12 nonphysicians participated. The earlier participants logged on to the study Web site, the greater yield of participation. Most of the study participants had logged on within 10 weeks of the study.

CONCLUSION

Despite successful recruitment, the 2 major challenges in recruitment in this study included defining a standardized definition of rurality and the high cost of chart abstractions. Because many of the patients of study recruits were African American, the potential implications of this study on the field of health disparities in diabetes are important.

Aflatoxin-albumin adducts and correlation with decreased serum levels of vitamins A and E in an adult Ghanaian population

A study of aflatoxin (AF) exposure and the levels of vitamins A and E was carried out with a group of 507 Ghanaian participants. AFB(1)-albumin adducts (AFB-AA) were measured by radioimmunoassay and vitamins A and E were measured by high-performance liquid chromatography (HPLC). The average level of serum AFB-AA was 0.94 +/- 0.64 (range = 0.1-4.44) pmol mg(-1) albumin. Mean levels of vitamins A and E were 1.32 +/- 0.48 (range = 0.41-4.85) micromol l(-1) and 15.68 +/- 4.12 (range = 6.35-30.40) micromol l(-1), respectively. A significantly negative correlation was found between serum AFB-AA and vitamin A levels (r = -0.110, p = 0.013). An even stronger, significant negative, correlation was found between serum AFB-AA and vitamin E levels (r = -0.149, p < 0.001). Serum AFB-AA levels were statistically higher (median = 0.985 pmol mg(-1) albumin) in subjects who had low levels of both vitamins A and E as compared with the levels (median = 0.741 pmol mg(-1) albumin) subjects who had high vitamins A and E levels (p(trend) = 0.001). To verify these findings, blood samples were again collected from 165 of the 507 people 3 months after the initial collection. Significantly negative correlations were confirmed between levels of serum AFB-AA and both vitamins A (r = -0.232, p = 0.003) and E (r = -0.178, p = 0.023). Again, high serum AFB-AA concentrations (median = 1.578 pmol mg(-1) albumin) were found in subjects with low levels of vitamins A and E compared with the concentrations (median = 1.381 pmol mg(-1) albumin) in subjects with high levels of vitamins A and E (p(trend) = 0.002). These data show that AF exposure was associated with decreased levels of serum vitamins A and E in high-risk human populations, which may significantly influence the incidence of AF-related adverse health effects.

Impact of content-specific email reminders on provider participation in an online intervention: a dental PBRN study

Engaging busy healthcare providers in online continuing education interventions is challenging. In an Internet-delivered intervention for dental providers, we tested a series of email-delivered reminders - cues to action. The intervention included case-based education and downloadable practice tools designed to encourage providers to increase delivery of smoking cessation advice to patients. We compared the impact of email reminders focused on 1) general project announcements, 2) intervention related content (smoking cessation), and 3) unrelated content (oral cancer prevention focused content). We found that email reminders dramatically increased participation. The content of the message had little impact on the participation, but day of the week was important - messages sent at the end of the week had less impact, likely due to absence from clinic on the weekend. Email contact, such as day of week an email is sent and notice of new content post-ing, is critical to longitudinal engagement. Further research is needed to understand which messages and how frequently, will maximize participation.

Relative age effect in youth soccer: analysis of the FIFA U17 World Cup competition

This investigation sought to determine if a relative age effect exists in the FIFA U17 World Cup competition. Birthdates of players competing in the most recent six competitions, from 1997 to 2007 were examined. For all competitions, the distributions of birth months were significantly different than expected with more players born in the early months of the year compared with the later months. For the entire cohort of players, 40% were born in the first quarter of the year while only 16% were born in the last 3 months. A small portion of this effect seems to be due to physical stature of the players. This relative age effect held for all FIFA-designated geographical zones except for Africa. The African region displayed a reverse relative age effect with a relatively large portion of players born in the later part of the year, particularly in December of the age appropriate year. The results of this investigation show that at the highest level of youth soccer, there is a strong bias toward inclusion of players born early in the selection year.

NovaSil clay intervention in Ghanaians at high risk for aflatoxicosis: II. Reduction in biomarkers of aflatoxin exposure in blood and urine

The efficacy of NovaSil clay (NS) to reduce aflatoxin (AF) biomarkers of exposure was evaluated in 656 blood samples and 624 urine samples collected from study participants during a 3-month phase IIa clinical intervention trial in Ghana. NS was delivered before meals via capsules. Serum AFB (1)-albumin adduct was measured by radioimmunoassay and urinary AFM (1) metabolites were quantified by immunoaffinity-high-performance liquid chromatography (HPLC)-fluorescence methods. Levels of AFB (1) -albumin adduct in serum samples collected at baseline and at 1 month were similar (p = 0.2354 and p = 0.3645, respectively) among the placebo (PL), low dose (LD, 1.5 g NS day (-1)), and high dose (HD, 3.0 g NS day (-1)) groups. However, the levels of AFB (1)-albumin adduct at 3 months were significantly decreased in both the LD group (p < 0.0001) and the HD group (p < 0.0001) compared with levels in the PL group. Levels of AFM(1) in urine samples collected at baseline and at 1 month were not statistically different among the three study groups. However, a significant decrease (up to 58%) in the median level of AFM (1) in samples collected at 3 months was found in the HD group when compared with the median level in the PL group (p < 0.0391). In addition, significant effects were found for dose, time, and dose-time interaction with serum AFB(1)-albumin adduct and dose-time interaction with urinary AFM (1) metabolites. The results suggest that capsules containing NS clay can be used to reduce effectively the bioavailability of dietary AF based on a reduction of AF-specific biomarkers.

Reasons for not intensifying medications: differentiating "clinical inertia" from appropriate care

BACKGROUND

"Clinical inertia" has been defined as inaction by physicians caring for patients with uncontrolled risk factors such as blood pressure. Some have proposed that it accounts for up to 80% of cardiovascular events, potentially an important quality problem. However, reasons for so-called clinical inertia are poorly understood.

OBJECTIVE

To derive an empiric conceptual model of clinical inertia as a subset of all clinical inactions from the physician perspective.

METHODS

We used Nominal Group panels of practicing physicians to identify reasons why they do not intensify medications when seeing an established patient with uncontrolled blood pressure.

MEASUREMENTS AND MAIN RESULTS

We stopped at 2 groups (N = 6 and 7, respectively) because of the high degree of agreement on reasons for not intensifying, indicating saturation. A third group of clinicians (N = 9) independently sorted the reasons generated by the Nominal Groups. Using multidimensional scaling and hierarchical cluster analysis, we translated the sorting results into a cognitive map that represents an empirically derived model of clinical inaction from the physician's perspective. The model shows that much inaction may in fact be clinically appropriate care.

CONCLUSIONS/RECOMMENDATIONS

Many reasons offered by physicians for not intensifying medications suggest that low rates of intensification do not necessarily reflect poor quality of care. The empirically derived model of clinical inaction can be used as a guide to construct performance measures for monitoring clinical inertia that better focus on true quality problems.

NovaSil clay intervention in Ghanaians at high risk for aflatoxicosis. I. Study design and clinical outcomes

A 3-month double-blind and placebo-controlled, phase IIa clinical trial was conducted in Ghana to investigate the safety, tolerance and aflatoxin-sorption efficacy of dietary NovaSil (NS). Volunteers (507 subjects) were clinically screened to evaluate their general health, pregnancy status and blood AFB(1)-albumin adduct levels. Of these subjects, 177 were randomly assigned to three groups: high-dose (HD), low-dose (LD) and placebo-control (PL) groups receiving 3.0, 1.5 and 0 g NS day(-1) in capsules. Trained study-monitors supervised NS capsule administration to participants and recorded side-effects daily. Physical examinations were performed monthly. Blood and urine samples were collected for laboratory analysis. Approximately 92% of the participants (162 of 177) completed the study and compliance rate was over 97%. Overall, 99.5% of person x time reported no side-effects throughout the study. Mild to moderate health events ( approximately 0.5% of person x time) were recorded in some participants. Symptoms included nausea, diarrhea, heartburn and dizziness. These side-effects were statistically similar among all three groups. No significant differences were shown in hematology, liver and kidney function or electrolytes in the three groups. These findings demonstrate that NS clay is apparently safe and practical for the protection of humans against aflatoxins in populations at high risk for aflatoxicosis.

APOE alleles predict the rate of cognitive decline in Alzheimer disease: a nonlinear model

BACKGROUND

The APOE genotype predicts the age at onset of Alzheimer disease (AD) and neuropathologic progression. However, studies relating APOE alleles to the rate of cognitive decline have been inconclusive. This may stem from their use of linear statistical analyses.

OBJECTIVE

To model relations of APOE alleles to the rate of cognitive decline in AD, nonlinearly.

METHODS

Serial measures of cognitive ability were obtained using the cognitive scale of the Cambridge Examination for Mental Disorders of the Elderly in 218 patients with AD. The relations of these serial scores to APOE alleles were tested using nonlinear and linear mixed-effects models.

RESULTS

In the non-linear model, possession of an APOE epsilon4 allele related to earlier and faster cognitive decline, but possession of an APOE epsilon2 related to slower decline. Patients homozygous for APOE epsilon4 showed faster cognitive decline than heterozygotes. The linear model was less sensitive and did not detect differences between APOE epsilon4 homo- and heterozygotes.

CONCLUSIONS

APOE genotype strongly predicts the rate of cognitive decline in Alzheimer disease. The decline shows a dose-response relation with the APOE epsilon4 allele, but the APOE epsilon2 allele is protective. The nonlinear model yielded larger estimates of the maximal rate of decline than the linear.

Lymphangiosarcoma of dogs: a review

Lymphangiosarcoma in dogs, an extremely rare tumour with only 16 cases reported in the literature, is reviewed. Lymphangiosarcoma in humans, also very rare, and known in post-mastectomy, chronically-lymphoedematous patients as 'Stewart-Treves' syndrome, is briefly outlined, as well as the various other causes of lymphoedema, both primary and secondary, which usually precede malignancy. Comparisons between human and canine lymphoedema are made when such references were found. The genetic links to primary lymphoedema and the manifestation thereof in humans are mentioned. Lymphangiosarcoma in the majority of human and canine patients is an aggressively malignant tumour with few patients surviving despite various attempted treatments. The tumour most commonly arises in the subcutaneous tissues and rapidly invades underlying tissues and may spread widely internally via haematogenous and lymphatic routes, with frequent pleural and chest involvement. The tumour has been reported mostly in medium- to large-breed dogs, in slightly more males than females, and in an age-range of 8 weeks to 13 years, with more cases aged 5 years and older. Methods of diagnosis, with the variations encountered, including routine histopathology, immunohistochemistry, electron microscopy, tissue culture characteristics and endothelial expression of glycocongugates, are discussed.

Vertical cross contamination of trichloroethylene in a borehole in fractured sandstone

Boreholes drilled through contaminated zones in fractured rock create the potential for vertical movement of contaminated ground water between fractures. The usual assumption is that purging eliminates cross contamination; however, the results of a field study conducted in a trichloroethylene (TCE) plume in fractured sandstone with a mean matrix porosity of 13% demonstrates that matrix-diffusion effects can be strong and persistent. A deep borehole was drilled to 110 m below ground surface (mbgs) near a shallow bedrock well containing high TCE concentrations. The borehole was cored continuously to collect closely spaced samples of rock for analysis of TCE concentrations. Geophysical logging and flowmetering were conducted in the open borehole, and a removable multilevel monitoring system was installed to provide hydraulic-head and ground water samples from discrete fracture zones. The borehole was later reamed to complete a well screened from 89 to 100 mbgs; persistent TCE concentrations at this depth ranged from 2100 to 33,000 microg/L. Rock-core analyses, combined with the other types of borehole information, show that nearly all of this deep contamination was due to the lingering effects of the downward flow of dissolved TCE from shallower depths during the few days of open-hole conditions that existed prior to installation of the multilevel system. This study demonstrates that transfer of contaminant mass to the matrix by diffusion can cause severe cross contamination effects in sedimentary rocks, but these effects generally are not identified from information normally obtained in fractured-rock investigations, resulting in potential misinterpretation of site conditions.

Lymphangiosarcoma in a 3.5-year-old Bullmastiff bitch with vaginal prolapse, primary lymph node fibrosis and other congenital defects : clinical communication

Lymphangiosarcoma is an extremely rare tumour in dogs with only 16 cases reported in the literature. Lymphoedema, whichmaybe primary due to defects in the lymphatic system, or secondary to various other pathologies, often precedes malignancy. Of the 16 canine reports, only 1 dog was confirmed as having had prior primary lymphoedema due to aplasia of the popliteal lymph nodes. A case of lymphangiosarcoma is described in a 3.5-year-old purebred, Bullmastiff bitch which presented with vaginal blood 'spotting' for 3 weeks after cessation of oestrus, during which intromission by the male had been unsuccessful. During ovariohysterectomy a large multicystic, proliferative, spongy, fluid-filled, brownish-red mass surrounding the cervix and projecting into the abdominal space was removed with the cervix, and a diagnosis of lymphangiosarcoma made on histological and electron microscopic examination of the tissue. Ultrastructurally, no basement membrane or pericytes were found, only some of the neoplastic endothelial cells were linked by tight junctions while there were gaps between others, and neither micropinocytotic vesicles nor Weibel-Palade bodies occurred in the cells examined.Very few of the endothelial cells lining the many interlinking, tortuous maze of channels, stained slightly positive immunohistochemically for factor VIII-related antigen. The channels were filled mostly with serous fluid, and occasionally mixed leucocytes and some erythrocytes. The endothelium was often associated with underlying blocks of collagenous material, as well as looselyarranged aggregates of lymphocytes, other mononuclear cells and occasional neutrophils in the connective tissue septae and more prominently perivascularly. The bitch was discharged on antibiotic treatment but returned 2 weeks later with apparent prolapsed vagina which failed to reduce over the next week. Laparotomy revealed the tumour to have spread extensively in the caudal abdomen to involve the broad ligament and the ventral rectal serosa, and the 'prolapsed' tissue was found to be expanded vaginal wall. The bitch was euthanased and necropsied, Histological examination confirmed lymphangiosarcomatous invasion of the submucosal and muscular layers of the retroperitoneal, traumatised, prolapsed part of the vagina, the urethra and the ventral rectal wall. The broad ligament was diffusely invaded with tumour which had proliferated into the caudal abdominal space, and 3 small intra-trabecular foci of tumour were found in the right popliteal lymph node near the hilus. Mitotic figures were generally scarce. There was mild subcutaneous oedema of the ventral trunk extending from the axillae to the inner proximal thighs, which had not been evident clinically, and the lymph nodes (peripheral more so than internal) microscopically showed marked trabecular and perivascular fibrosis especially in hilar regions. Other congenital defects were hepatic capsular and central venous fibrosis with lymphatic duplication and dilatation in all areas of connective tissue, ventrally-incongruous half-circular tracheal rings, and multifocal renal dysplasia affecting the right kidney. There was locally-extensive subacute pyelonephritis of the left kidney.

Renal medullary AA amyloidosis, hepatocyte dissociation and multinucleated hepatocytes in a 14-year-old free-ranging lioness (Panthera leo)

A 14-year-old lioness, originating from Etosha in Namibia, and a member of a pride in Pilanesberg National Park since translocation in 1994, was euthanased due to fight-related vertebral fracture and spinal injury, incurred approximately 6-8 weeks previously. Blood specimens collected at the time of death showed mild anaemia and a leukogram reflecting stress and chronic infection. Necropsy conducted within 2 hours of death was on a dehydrated, emaciated animal with hindquarter wasting and chronic traumatic friction injuries from dragging her hindlegs. There was cellulitis in the region of bite-wounds adjacent to the thoraco-lumbar vertebral fracture, at which site there was spinal cord compression, and there was marked intestinal helminthiasis. The outer renal medullae appeared pale and waxy and the liver was macroscopically unremarkable. Histopathology and electron microscopy of the kidneys revealed multifocal to coalescing deposits of proximal medullary interstitial amyloid, which fluoresced strongly with thioflavine T, and was sensitive to potassium permanganate treatment prior to Congo Red staining, thus indicating inflammatory (AA) origin. There was diffuse hepatocyte dissociation, as well as numerous binucleated and scattered multinucleated (up to 8 nuclei/cell) hepatocytes, with swollen hepatocyte mitochondria, in liver examined light microscopically. Ultrastructurally, the mono-, bi- and multinucleated hepatocytes contained multifocal irregular membrane-bound accumulations of finely-granular, amorphous material both intra-cytoplasmically and intra-nuclearly, as well as evidence of irreversible mitochondrial injury. The incidence and relevance in cats and other species of amyloidosis, particularly with renal medullary distribution, as well as of hepatocyte dissociation and multinucleation, as reported in selected literature, is briefly overviewed and their occurrence in this lioness is discussed.

Glycogen debranching enzyme is associated with rat skeletal muscle sarcoplasmic reticulum

AIMS

Gel electrophoresis revealed a band of molecular weight approximately 160 000 Da associated with the skeletal muscle sarcoplasmic reticulum (SR) vesicle preparations. This investigation sought to examine glycogen debranching enzyme associated with skeletal muscle SR.

METHODS

Sarcoplasmic reticulum samples were also taken from muscle whose glycogen content had been reduced either via stimulation of the sciatic nerve or alpha-amylase treatment of muscle homogenates.

RESULTS

The stimulation protocol reduced whole muscle glycogen by 86% (7.4 +/- 0.4 vs. 1.0 +/- 0.3 microg mg(-1) wet mass, P < or = 0.05). Glycogen associated with the SR was reduced by 82% in the stimulation protocol (533 +/- 82 vs. 96 +/- 7 microg mg(-1) protein) and by 94% in alpha-amylase treatment (493 +/- 11 vs. 29 +/- 2 microg mg(-1) protein), respectively. Gel electrophoresis and Western blots revealed that the content of glycogen debranching enzyme was reduced by approximately 53% as a result of muscle stimulation and by approximately 46% in alpha-amylase treatment (P < or = 0.05). In addition, glycogen debranching enzyme activity was reduced by 61% in stimulated samples compared with control (20.3 +/- 1.0 vs. 8.0 +/- 1.2 nmol mg(-1) min(-1), respectively), a value consistent with reductions observed from gel electrophoresis and Western blots.

CONCLUSION

These results confirm that similar to glycogen phosphorylase, glycogen debranching enzyme is associated with the skeletal muscle SR and is dissociated under exercise conditions.

Effects of fatigue on depolarization- and caffeine-induced contractures of skinned fibres

AIMS

Fatigue has been shown to cause intrinsic alterations in sarcoplasmic reticulum (SR) Ca2+ release.

METHODS

In this investigation, frog semitendinosus muscles were stimulated to fatigue, in vitro (80 Hz, 100 ms, 1 train s-1, 5 min). Immediately after stimulation, single fibres were removed and skinned using either chemically or mechanically skinning. Contralateral muscle were treated similarly but were not stimulated.

RESULTS

In fatigued, saponin skinned fibres, contracture responses to low [caffeine] (4-8 mm) were depressed compared with control. However, responses to high concentrations (10-15 mm) were not different between conditions. In the fatigued, mechanically skinned fibres, responses to chloride depolarization were depressed at all [chloride] (20-100 mm) compared with control.

CONCLUSIONS

These results suggest that fatigue causes intrinsic alterations in both the SR Ca2+ release channel as well as communication between the transverse-tubule and the SR.

Comparison of formation and fluid-column logs in a heterogeneous basalt aquifer

Deep observation boreholes in the vicinity of active production wells in Honolulu, Hawaii, exhibit the anomalous condition that fluid-column electrical conductivity logs and apparent profiles of pore-water electrical conductivity derived from induction conductivity logs are nearly identical if a formation factor of 12.5 is assumed. This condition is documented in three boreholes where fluid-column logs clearly indicate the presence of strong borehole flow induced by withdrawal from partially penetrating water-supply wells. This result appears to contradict the basic principles of conductivity-log interpretation. Flow conditions in one of these boreholes was investigated in detail by obtaining flow profiles under two water production conditions using the electromagnetic flowmeter. The flow-log interpretation demonstrates that the fluid-column log resembles the induction log because the amount of inflow to the borehole increases systematically upward through the transition zone between deeper salt water and shallower fresh water. This condition allows the properties of the fluid column to approximate the properties of water entering the borehole as soon as the upflow stream encounters that producing zone. Because this condition occurs in all three boreholes investigated, the similarity of induction and fluid-column logs is probably not a coincidence, and may relate to aquifer response under the influence of pumping from production wells.

Neosporosis in a white rhinoceros (Ceratotherium simum) calf

A 16-day-old white rhinoceros calf died suddenly while in excellent condition and showing no obvious previous clinical signs. It was the 9th calf of a mature female kept free-ranging with 11 other rhinoceros as well as various other game species on a 2000 hectare game breeding centre adjacent to the town of Lichtenburg and outlying cattle farmlands in the Northern Province. At post mortem examination, death was ascribed to heart failure. There was marked multifocal to coalescing subacute parasitic myocarditis with numerous protozoan bradyzoite cysts and free tachyzoites present amongst the predominantly round cell inflammatory infiltrate. The coccidian was positively identified as Neospora sp. using both polyclonal and murine monoclonal Neospora caninum antibody immunohistochemistry in the avidin-biotin technique. The parasites stained poorly with Toxoplasma gondii-specific immunoperoxidase staining. Ultrastructurally, a section of a bradyzoite-containing cyst, as well as tachyzoites, were largely but not totally consistent with those described for Neospora caninum. The dam showed no sign of illness. Neosporosis affecting white rhinoceros (Ceratotherium simum) has not previously been reported. A summarised overview of neosporosis from selected publications and a recent review is given.

Action of deferoxamine against Pneumocystis carinii

We found earlier that deferoxamine (DFO), a drug used for treatment of iron overload, is active against a rat model of Pneumocystis carinii pneumonia (PCP). We had assumed a mode of action by deprivation of nutritional iron; however, data here show that DFO penetrates P. carinii, causing irreversible damage, thus indicating a different mode of action. Penetration was demonstrated by showing DFO uptake by high-pressure liquid chromatography analysis. By using calcein-AM as an indicator, exposure to DFO was shown to cause a reduction in P. carinii cytoplasmic free iron. Exposure to >or=100 microM DFO for >or=8 h in vitro caused growth to cease and cell numbers to decline over several days. This direct and irreversible damage to P. carinii led to the prediction that infrequent delivery of DFO to the lungs via an aerosol would be an effective treatment in the animal model of PCP. This prediction was confirmed by demonstrating that a once-a-week aerosol treatment of rats was 100% effective both as a prophylactic and as a curative treatment in a rat model of PCP.

The first reported case of equine nocardioform placentitis in South Africa

Since the late 1980s a distinct form of focally-extensive mucoid to mucopurulent uterine body chronic placentitis,caused by nocardioform organisms, hasbeen recognised in horses in the USA state of Kentucky and possibly in other areas. This disease has led to increasing numbers of foal losses from late abortions, still-births, prematurity, or early neonatal deaths. The foals are usually not infected, but may be small or emaciated. Modes of infection and transmission are as yet unknown. Nocardia spp. and related nocardioform bacteria as causes of equine infertility, endometritis and foal death are briefly reviewed. A case of near full-term abortion involving a Friesian mare in the Pretoria district of Gauteng Province in South Africa during February 2000, with the same placental lesion as described in the Kentucky cases, is presented. Nocardioform organisms were visualised on impression smears and histological sections of affected foetal membranes, and were also cultured. The organism has been identified at the Livestock Disease Diagnostic Center of the University of Kentucky as an Amycolatopsis sp. of the less-commonly diagnosed group of nocardioforms causing placentitis in the USA. The organism was cultured from the uterus of the mare 18 days post-foaling, but after a 2-week course of oral trimethoprim and sulphamethoxazole, based on antibiogram sensitivity testing, a uterine flush yielded no growth. A semen sample from the sire of the aborted foal did not yield any Gram-positive filamentous branching bacteria. The mare subsequently conceived to a single insemination.

Reproductive processes in two oak (Quercus) contact zones with different levels of hybridization

Patterns of reproductive isolation between two sympatric species of oaks, Quercus gambelii and Q. grisea, that exhibit strong ecological differentiation were examined. A full diallel cross using four trees of each species (i.e. all possible pollinations among eight trees) was performed. This design was repeated at two sites that represent different outcomes of sympatry: (1) a xeric mountain ridge where many hybrids are established (HZ); and (2) a mesic valley bottom where virtually no hybrids are established (MOCYN). By measuring fruit survival at several developmental stages, both the timing and strength of reproductive barriers within and between sites, species, cross types, and pollen dosage levels were examined. In three of four cases, heterospecific fruit set was significantly reduced compared to conspecific fruit set. This reduction occurred after the time of fertilization, but before the onset of embryo growth. Increasing the dose of pollen from an average of 9-194 grains/stigma did not affect this result. Thus, early postfertilization processes play a strong role in species fidelity in these oaks. Quercus gambelii experienced a five-fold decrease in conspecific fruit set at HZ relative to MOCYN. In contrast, heterospecific fruit set of Q. gambelii was the same at both sites. Poor Q. gambelii pollen performance is implicated as playing the major role in this result. One Q. gambelii individual at HZ was highly fecund, and had higher heterospecific than conspecific fruit set; slight introgression in this tree was detected uisng RAPD markers. The Environmental Emasculation Hypothesis that posits that environmental stress can increase the probability of hybrid formation by reducing the competitive ability of male gametes of one species is proposed.

Thyroid hormone receptor-interacting protein 1 modulates cytokine and nuclear hormone signaling in erythroid cells

Erythropoietin (Epo) and thyroid hormone (T(3)) are key molecules in the development of red blood cells. We have shown previously that the tyrosine kinase Lyn is involved in differentiation signals emanating from an activated erythropoietin receptor. Here we demonstrate that Lyn interacts with thyroid hormone receptor-interacting protein 1 (Trip-1), a transcriptional regulator associated with the T(3) receptor, providing a link between the Epo and T(3) signaling pathways. Trip-1 co-localized with Lyn and the T(3) receptor alpha in the cytoplasm/plasma membrane of erythroid cells but translocated to discrete nuclear foci shortly after Epo-induced differentiation. Our data reveal that T(3) stimulated the proliferation of immature erythroid cells, and inhibited maturation promoted by erythropoietin. Removal of T(3) reduced cell division and enhanced terminal differentiation. This was accompanied by large increases in the cell cycle inhibitor p27(Kip1) and by increasing expression of erythroid transcription factors GATA-1, EKLF, and NF-E2. Strikingly, a truncated Trip-1 inhibited both erythropoietin-induced maturation and T(3)-initiated cell division. This mutant Trip-1 acted in a dominant negative fashion by eliminating endogenous Lyn, elevating p27(Kip1), and blocking T(3) response elements. These data demonstrate that Trip-1 can simultaneously modulate responses involving both cytokine and nuclear receptors.

Glycogen and glycogen phosphorylase associated with sarcoplasmic reticulum: effects of fatiguing activity

The purpose of the present study was to investigate the effects of fatiguing muscular activity on glycogen, glycogen phosphorylase (GP), and Ca(2+) uptake associated with the sarcoplasmic reticulum (SR). Tetanic contractions (100 ms, 75 Hz) of the gastrocnemius and plantaris muscles, elicited once per second for 15 min, significantly reduced force to 26.5 +/- 4.0% and whole muscle glycogen to 23% of rested levels. SR glycogen levels were 415.4 +/- 76.6 and 20.4 +/- 2.1 microg/mg SR protein in rested and fatigued samples, respectively. The optical density of GP from SDS-PAGE was reduced to 21% of control, whereas pyridoxal 5'-phosphate concentration, a quantitative indicator of GP content, was significantly reduced to 3% of control. GP activity after exercise, in the direction of glycogen breakdown, was reduced to 4% of control. Maximum SR Ca(2+) uptake rate was also significantly reduced to 81% of control. These data demonstrate that glycogen and GP associated with skeletal muscle SR are reduced after fatiguing activity.