Preventing severe hypoglycemia in adults with type 2 diabetes (PHT2): Design, delivery and evaluation framework for a randomized controlled trial

BACKGROUND

Severe hypoglycemia is a common and feared complication of medications used to lower blood glucose levels in individuals with diabetes. Psychoeducational interventions can prevent severe hypoglycemia in individuals with type 1 diabetes (T1D). We aim to determine the effectiveness of this approach among adults with type 2 diabetes (T2D) at elevated risk for severe hypoglycemia.

METHODS

Preventing Hypoglycemia in Type 2 diabetes (PHT2) is a two-arm, parallel, randomized controlled trial. Participants are eligible if they are adults with T2D receiving care at an integrated group practice in Washington state and have experienced one or more episodes of severe hypoglycemia in the prior 12 months or have impaired awareness of hypoglycemia (Gold score ≥ 4). Participants are randomized to proactive nurse care management with or without my hypo compass, an evidence-based, psychoeducational intervention combining group and individual self-management training. For this study, my hypo compass was adapted to be suitable for adults with T2D and from an in-person to a virtual intervention over videoconference and telephone. The primary outcome is any self-reported severe hypoglycemia in the 12 months following the start of the intervention. Secondary outcomes include biochemical measures of hypoglycemia, self-reported hypoglycemia awareness, fear of hypoglycemia, and emergency department visits and hospitalizations for severe hypoglycemia. The study includes a process evaluation to assess implementation fidelity and clarify the causal pathway.

CONCLUSION

The PHT2 trial will compare the effectiveness of two approaches for reducing severe hypoglycemia in adults with T2D.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT04863872.

Young Women's Perspectives on Being Screened for Hereditary Breast and Ovarian Cancer Risk During Routine Primary Care

PURPOSE

The U.S. Preventive Services Task Force recommends screening women to identify individuals eligible for genetic counseling based on a priori hereditary breast and ovarian cancer (HBOC) risk (i.e., risk assessment). However, risk assessment has not been widely integrated into primary care. This qualitative study explored young women's views on implementing routine HBOC risk assessment with a focus on equity and patient-centeredness.

METHODS

We conducted group discussions with young women (aged 21-40 years) receiving care in an integrated health care system. Discussion groups occurred in two phases and used a modified deliberative approach that included a didactic component and prioritized developing consensus. Twenty women participated in one of three initial small group discussions (phase one). All 20 were invited to participate in a subsequent large group discussion (phase two), and 15 of them attended.

FINDINGS

Key themes and recommendations were as follows. Risk assessment should be accessible, contextualized, and destigmatized to encourage participation and reduce anxiety, particularly for women who do not know their family history. Providers conducting risk assessments must be equipped to address women's informational needs, relieve emotionality, and plan next steps after positive screens. Finally, to minimize differential screening uptake, health care systems must prioritize equity in program design and contribute to external educational and outreach efforts.

CONCLUSION

Young women see pragmatic opportunities for health systems to optimize HBOC screening implementation.

Relationship of Blood Pressure, Health Behaviors, and New Diagnosis and Control of Hypertension in the BP-CHECK Study

BACKGROUND

Undiagnosed hypertension and uncontrolled blood pressure (BP) are common and contribute to excess cardiovascular morbidity and mortality. We examined whether BP control, changes in BP, and patient behaviors and attitudes were associated with a new hypertension diagnosis.

METHODS

We performed a post hoc analysis of 323 participants from BP-CHECK (Blood Pressure Checks for Diagnosing Hypertension), a randomized diagnostic study of BP measuring methods in adults without diagnosed hypertension with elevated BP recruited from 12 primary care clinics of an integrated health care system in Washington State during 2017 to 2019. All 323 participants returned a positive diagnostic test for hypertension based on 24-hour ambulatory BP monitoring and were followed for 6 months. We used linear regression to examine the relationships between a new hypertension diagnosis (primary independent variable) and differences in the change in study outcomes from baseline to 6-month.

RESULTS

Mean age of study participants was 58.3 years (SD, 13.1), 147 (45%) were women, and 253 (80%) were of non-Hispanic White race. At 6 months, 154 of 323 (48%) participants had a new hypertension diagnosis of whom 88 achieved target BP control. Participants with a new hypertension diagnosis experienced significantly larger declines from baseline in BP (adjusted mean difference: systolic BP, -7.6 mm Hg [95% CI, -10.3 to -4.8]; diastolic BP, -3.8 mm Hg [95% CI, -5.6 to -2.0]) compared with undiagnosed peers. They were also significantly more likely to achieve BP control by 6 months compared with undiagnosed participants (adjusted relative risk, 1.5 [95% CI, 1.1 to 2.0]). At 6 months, 101 of 323 participants (31%) with a positive ambulatory BP monitoring diagnostic test remained with undiagnosed hypertension, uncontrolled BP, and no antihypertensive medications.

CONCLUSIONS

Approximately one-third of participants with high BP on screening and ambulatory BP monitoring diagnostic testing remained with undiagnosed hypertension, uncontrolled BP, and no antihypertensive medications after 6 months. New strategies are needed to enhance integration of BP diagnostic testing into clinical practice.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03130257.

Is Hypertension Diagnostic Testing and Diagnosis Associated With Psychological Distress?

BACKGROUND

Psychological impacts of hypertension diagnostic testing and new hypertension diagnoses are unclear.

METHODS

BP-CHECK was a randomized diagnostic study conducted in 2017-2019 in an integrated healthcare system. Participants with no hypertension diagnosis or medications and elevated blood pressure (BP) were randomized to one of three diagnostic regimens: (i) Clinic, (ii) Home, or (iii) Kiosk. Participants completed questionnaires at baseline, after completion of the diagnostic regimens, and at 6 months. Outcomes included changes from baseline in health-related quality of life (HRQOL), BP-related worry, and thoughts about having a stroke or heart attack.

RESULTS

Participants (n = 482) were mostly over age 50 (77.0%), and White race (80.3%). HRQOL did not significantly change from baseline to 3 weeks or 6 months. Among all participants, BP-related worry and concerns about having a heart attack or stroke increased significantly from baseline to 3 weeks, with heart attack and stroke concerns significantly higher in the Kiosk compared Clinic and Home groups. At 6 months, thoughts about having a heart attack or stroke returned to baseline overall and in the Kiosk group, however BP-related worry was significantly higher among those with, compared to those without, a new hypertension diagnosis.

CONCLUSIONS

The hypertension diagnostic process did not lead to short-term or intermediate-term changes in self-reported HRQOL. However, BP-related worry increased short-term and persisted at 6 months among individuals with a new hypertension diagnosis. Results warrant validation in more representative populations and additional exploration of the impacts of this worry on psychological well-being and hypertension control.

CLINICALTRIALS.GOV IDENTIFIER

NCT03130257.

Acceptability and Adherence to Home, Kiosk, and Clinic Blood Pressure Measurement Compared to 24-H Ambulatory Monitoring

BACKGROUND

The US Preventive Services Task Force recommends measuring blood pressure (BP) outside of clinic/office settings. While various options are available, including home devices, BP kiosks, and 24-h ambulatory BP monitoring (ABPM), understanding patient acceptability and adherence is a critical factor for implementation.

OBJECTIVE

To compare the acceptability and adherence of clinic, home, kiosk, and ABPM measurement.

DESIGN

Comparative diagnostic accuracy study which randomized adults to one of three BP measurement arms: clinic, home, and kiosk. ABPM was conducted on all participants.

PARTICIPANTS

Adults (18-85 years) receiving care at 12 Kaiser Permanente Washington primary care clinics (Washington State, USA) with a high BP (≥ 138 mmHg systolic or ≥ 88 mmHg diastolic) in the electronic health record with no hypertension diagnosis and on no hypertensive medications and with high BP at a research screening visit.

MEASURES

Patient acceptability was measured using a validated survey which was used to calculate an overall acceptability score (range 1-7) at baseline, after completing their assigned BP measurement intervention, and after completing ABPM. Adherence was defined based on the pre-specified number of BP measurements completed.

KEY RESULTS

Five hundred ten participants were randomized (mean age 59 years), with mean BP of 150/88. Overall acceptability score was highest (i.e. most acceptable) for Home BP (mean 6.2, SD 0.7) and lowest (least acceptable) for ABPM (mean 5.0, SD 1.0); scores were intermediate for Clinic (5.5, SD 1.1) and Kiosk (5.4, SD 1.0). Adherence was higher for Home (154/170, 90.6%) and Clinic (150/172, 87.2%) than for Kiosk (114/168, 67.9%)). The majority of participants (467/510, 91.6%) were adherent to ABPM.

CONCLUSIONS

Participants found home BP measurement most acceptable followed by clinic, BP kiosks, and ABPM. Our findings, coupled with recent evidence regarding the accuracy of home BP measurement, further support the routine use of home-based BP measurement in primary care practice in the US.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03130257 https://clinicaltrials.gov/ct2/show/NCT03130257.

Using Protection Motivation Theory to Predict Intentions for Breast Cancer Risk Management: Intervention Mechanisms from a Randomized Controlled Trial

The purpose of this study is to evaluate the direct and indirect effects of a web-based, Protection Motivation Theory (PMT)-informed breast cancer education and decision support tool on intentions for risk-reducing medication and breast MRI among high-risk women. Women with ≥ 1.67% 5-year breast cancer risk (N = 995) were randomized to (1) control or (2) the PMT-informed intervention. Six weeks post-intervention, 924 (93% retention) self-reported PMT constructs and behavioral intentions. Bootstrapped mediations evaluated the direct effect of the intervention on behavioral intentions and the mediating role of PMT constructs. There was no direct intervention effect on intentions for risk-reducing medication or MRI (p's ≥ 0.12). There were significant indirect effects on risk-reducing medication intentions via perceived risk, self-efficacy, and response efficacy, and on MRI intentions via perceived risk and response efficacy (p's ≤ 0.04). The PMT-informed intervention effected behavioral intentions via perceived breast cancer risk, self-efficacy, and response efficacy. Future research should extend these findings from intentions to behavior. ClinicalTrials.gov Identifier: NCT03029286 (date of registration: January 24, 2017).

Primary care physician beliefs and practices regarding blood pressure measurement: results from BP-CHECK qualitative interviews

BACKGROUND

Early identification and control of hypertension is critical to reducing cardiovascular disease events and death. U.S. Preventive Services Task Force guidelines recommend health care professionals screen all adults for hypertension, yet 1 in 4 adults with hypertension are unaware of their condition. This gap between guidelines and clinical practices highlights an important opportunity to improve blood pressure (BP) screening and hypertension diagnosis, including measurement outside of clinic settings. To identify targets for future diagnostic interventions, we sought to understand primary care physicians' (PCPs) beliefs and practices regarding use of common forms of BP measurement.

METHODS

Study participants were PCPs (N = 27) who had patients enrolled in the BP-CHECK trial. The trial compared the accuracy of 24-h ambulatory BP monitoring (ABPM) to: 1) clinic-based monitoring, 2) home BP monitoring (HBPM), or 3) use of a BP kiosk in clinics or pharmacies. Physicians were interviewed by phone and compensated for their participation. Interviews were recorded, transcribed, and analyzed using a template analysis approach.

RESULTS

Overall, PCPs preferred and trusted clinic BP measurement for diagnosing hypertension, particularly when measured with a manual sphygmomanometer. Concerns with HBPM included the belief that patients did not follow protocols for rest and body positioning at home, that home machines were not accurate, that home BPs could not be entered into the medical record, and that HBPM would make some patients anxious. Issues regarding kiosk measurement included beliefs that the public setting created stress for patients, that patients did not follow resting protocols when using kiosks, and concerns about the maintenance of these machines. ABPM was recognized as highly accurate but was not perceived as accessible. Additionally, some PCPs found it challenging to interpret the multiple readings generated by ABPM and HBPM, especially when these readings differed from clinic BPs.

CONCLUSIONS

Our findings suggest that both additional physician education and training and investments in equipment and system-level processes are needed to increase the acceptance and utilization of out of office BP measurement for identification and treatment of hypertension. These changes are needed to improve ensure everyone in the U.S receive optimal care for hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03130257 . Initial registration date: 4/21/2017.

Clinic, Home, and Kiosk Blood Pressure Measurements for Diagnosing Hypertension: a Randomized Diagnostic Study

BACKGROUND

The US Preventive Services Task Force recommends blood pressure (BP) measurements using 24-h ambulatory monitoring (ABPM) or home BP monitoring before making a new hypertension diagnosis.

OBJECTIVE

Compare clinic-, home-, and kiosk-based BP measurement to ABPM for diagnosing hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Diagnostic study in 12 Washington State primary care centers, with participants aged 18-85 years without diagnosed hypertension or prescribed antihypertensive medications, with elevated BP in clinic.

INTERVENTIONS

Randomization into one of three diagnostic regimens: (1) clinic (usual care follow-up BPs); (2) home (duplicate BPs twice daily for 5 days); or (3) kiosk (triplicate BPs on 3 days). All participants completed ABPM at 3 weeks.

MAIN MEASURES

Primary outcome was difference between ABPM daytime and clinic, home, and kiosk mean systolic BP. Differences in diastolic BP, sensitivity, and specificity were secondary outcomes.

KEY RESULTS

Five hundred ten participants (mean age 58.7 years, 80.2% white) with 434 (85.1%) included in primary analyses. Compared to daytime ABPM, adjusted mean differences in systolic BP were clinic (-4.7mmHg [95% confidence interval -7.3, -2.2]; P<.001); home (-0.1mmHg [-1.6, 1.5];P=.92); and kiosk (9.5mmHg [7.5, 11.6];P<.001). Differences for diastolic BP were clinic (-7.2mmHg [-8.8, -5.5]; P<.001); home (-0.4mmHg [-1.4, 0.7];P=.52); and kiosk (5.0mmHg [3.8, 6.2]; P<.001). Sensitivities for clinic, home, and kiosk compared to ABPM were 31.1% (95% confidence interval, 22.9, 40.6), 82.2% (73.8, 88.4), and 96.0% (90.0, 98.5), and specificities 79.5% (64.0, 89.4), 53.3% (38.9, 67.2), and 28.2% (16.4, 44.1), respectively.

LIMITATIONS

Single health care organization and limited race/ethnicity representation.

CONCLUSIONS

Compared to ABPM, mean BP was significantly lower for clinic, significantly higher for kiosk, and without significant differences for home. Clinic BP measurements had low sensitivity for detecting hypertension. Findings support utility of home BP monitoring for making a new diagnosis of hypertension.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03130257 https://clinicaltrials.gov/ct2/show/NCT03130257.

Automated Office Blood Pressure and the Impact of Attendance and Rest on Diagnostic Accuracy

BACKGROUND

Automated office blood pressure (AOBP) using 3-5 measurements taken with an oscillometric device with or without an attendant in the room may decrease "white coat" effect. We evaluated the impact of the presence or absence of the attendant and rest on BP and diagnosis of hypertension.

METHODS

We randomly assigned 133 adults aged 18-85 with high BP at baseline (≥140/90 mm Hg), no hypertensive diagnosis and no antihypertensive medications to either attended AOBP first, unattended second, or unattended AOBP first, attended second. Outcomes included within-person BP difference for attended vs. unattended measurements; 5 vs. 15 minutes of rest; and the diagnostic performance of AOBP compared with daytime automated blood pressure measurement (ABPM).

RESULTS

We found no significant differences between attended and unattended AOBP (mean difference attended - unattended [95% confidence interval, CI], systolic 0.14 mm Hg [-0.78, 1.06]; diastolic 0.16 mm Hg [-0.45, 0.78]) or by rest time (mean difference 15 - 5 minutes [95% CI], systolic -0.45 mm Hg [-1.36, 0.47]; diastolic 0.61 mm Hg [-1.23, 0.003]). AOBP was lower than mean daytime ABPM, regardless of attendance or rest (after 5 minutes rest systolic -3.6 and diastolic -2.55 mm Hg, P = 0.001 for both comparisons). Using daytime ABPM of ≥135/85 mm Hg as the diagnostic threshold, AOBP sensitivity and specificity after 5 minutes of rest were 71.0% and 54.1%, respectively.

CONCLUSIONS

The presence or absence of a clinic attendant during AOBP measurement and the amount of rest time before AOBP measurements had no effects on BP. AOBP measurements have low sensitivity and specificity for making a new diagnosis of hypertension.

Endogenous Cushings syndrome is associated with impaired myocardial work efficiency

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Ministry of Research and Education within the Comprehensive Heart Failure Center, Würzburg

OnBehalf

STAAB Cohort Study and CV-CORT-EX Study

Background

Endogenous Cushing’s syndrome (CS) is associated with increased cardiovascular morbidity and mortality. Long-term remission (LTR) after successful treatment is considered to positively affect the cardiovascular system including the heart. Left ventricular (LV) myocardial work (MyW) based on pressure-strain loops is a novel tool to non-invasively assess LV performance and is considered less load-dependent than LV ejection fraction (LVEF) and global longitudinal strain (GLS). We analyzed LV function in patients with overt CS and CS in LTR in comparison to healthy individuals derived from a local population-based cohort.

Methods/Results: In a cross-sectional analysis, we compared n = 31 comprehensively characterized patients with overt CS (mean age 48 ± 12 years, 71% women) and 49 patients with CS in LTR (53 ± 12 years, 77% women) with a control group who underwent transthoracic echocardiography. As control group, we analyzed a population-based sample of apparently healthy individuals (in sinus rhythm, free from CV risk factors, and no significant valve disease) from a population-based cohort: n = 439, 49 ± 11 years, 56% women. MyW assessment was performed off-line using EchoPAC (GE, version 202).

Systolic and diastolic blood pressure, HbA1c, and body mass index were significantly higher in patients with either overt CS or CS in LTR when compared to healthy participants (without significant differences between both patient groups). LVEF was equal between all three groups, but GLS was significantly lower in healthy participants and tended to be lower in LTR when compared to patients with CS. Global work index was equal between all three groups, but global wasted work was significantly higher in CS patients when compared to healthy participants, resulting in lower global work efficiency (Table).

Conclusion

In contrast to LVEF as established parameter of cardiac function, myocardial work analysis revealed functional alterations in patients with current and previous cortisol excess when compared to healthy individuals derived from a population-based sample. CS patients´ hearts appear to perform larger amounts of wasted work even during long-term remission. Abstract Figure.

Effect of a Randomized Trial of a Web-Based Intervention on Patient-Provider Communication About Breast Density

Background: Breast density increases breast cancer risk and decreases mammographic detection. We evaluated a personalized web-based intervention designed to improve breast cancer risk communication between women and their providers. Materials and Methods: This was a secondary outcome analysis of an online randomized trial. Women aged 40-69 years were randomized, February 2017-May 2018, to a control (n = 503) versus intervention website (n = 492). The intervention website included information about breast density, personalized breast cancer risk, chemoprevention, and magnetic resonance imaging. Participants self-reported communication about density with providers (yes/no) at 6 weeks and 12 months. We used logistic regression with generalized estimating equations to evaluate the association of study arm with density communication. In secondary analyses, we tested if the intervention was associated with indicators of patient activation (breast cancer worry, perceived risk, or health care use). Results: Women (mean age 62 years) in the intervention versus control arm were 2.39 times (95% confidence interval [CI] = 1.37-4.18) more likely to report density communication at 6 weeks; this effect persisted at 12 months (odds ratio [OR] = 1.71, 95% CI = 1.25-2.35). At 6 weeks, this effect was only significant among women who reported (OR = 3.23, 95% CI = 1.24-8.40) versus did not report any previous density discussions (OR = 1.64, 95% CI = 0.83-3.26). A quarter of women in each arm never had a density conversation at any time during the study. Conclusions: Despite providing personalized density and risk information, the intervention did not promote density discussions between women and their providers who had not had them previously. This intervention is unlikely to be used clinically to motivate density conversations in women who have not had them before. Clinical trial registration number NCT03029286.

Abstract 50: Acceptability And Adherence To Home, Kiosk, Office Blood Pressure Measurement Compared To 24- Hour Ambulatory Monitoring In Primary Care

Introduction: Despite recommendations to use out of office blood pressure (BP) to confirm diagnosis of hypertension, there is little robust evidence on the acceptability of different methods for confirming hypertension. Most evaluations have involved small observational studies and have not compared measurement methods. The Blood Pressure Checks for Diagnosing Hypertension trial (BP-CHECK) trial compared the acceptability and adherence of clinic, home, kiosk and 24-hour ambulatory monitoring (ABPM) among adults with elevated BP who had not been diagnosed with hypertension.

Methods: Adults presenting to Kaiser Permanente Washington primary care clinics with elevated BP but who did not have a hypertension diagnosis, were randomized to one of three arms: office, home and kiosk. ABPM was also conducted on all participants. Acceptability of each method to patients was measured using a validated questionnaire to calculate an overall score. Differences in mean acceptability by randomization arms and ABPM were calculated using linear regression models and Generalized Estimating Equations. Adherence was calculated as the proportion of participants completing their BP testing protocols and compared using chi-square tests.

Results: A total of 510 individuals were randomized, with mean age 59 years, 80% white, 51% male, with mean BP of 150/88. The overall acceptability score was highest (i.e. most acceptable) for home (mean 6.2, SD 0.7) and lowest (i.e. least acceptable) for ABPM (mean 5.0, SD 1.0). Scores were intermediate for clinic (5.5, SD 1.1) and kiosk (5.4, SD 1.0) groups. Acceptability was significantly higher for all three intervention arms compared to ABPM. Adherence to the minimum number of BP readings pre-specified in the study protocol was higher for home (90.6%) and clinic (87.2%) groups than for the kiosk group (67.9%).

Conclusions: Home BP measurement was the most acceptable method for diagnosing hypertension followed by measurement in the clinic or at kiosks, with ABPM the least acceptable, due to its discomfort, disturbance to sleep and to everyday activities. Although ABPM is considered the gold standard for confirming elevated BP, patients find home BP more acceptable.

Effect of Personalized Breast Cancer Risk Tool on Chemoprevention and Breast Imaging: ENGAGED-2 Trial

Background

Limited evidence exists about how to communicate breast density-informed breast cancer risk to women at elevated risk to motivate cancer prevention.

Methods

We conducted a randomized controlled trial evaluating a web-based intervention incorporating personalized breast cancer risk, information on chemoprevention, and values clarification on chemoprevention uptake vs active control. Eligible women aged 40-69 years with normal mammograms and elevated 5-year breast cancer risk were recruited from Kaiser Permanente Washington from February 2017 to May 2018. Chemoprevention uptake was measured as any prescription for raloxifene or tamoxifen within 12 months from baseline in electronic health record pharmacy data. Secondary outcomes included breast magnetic resonance imaging (MRI), mammography use, self-reported distress, and communication with providers. We calculated unadjusted odds ratios (ORs) using logistic regression models and mean differences using analysis of covariance models with 95% confidence intervals (CIs) with generalized estimating equations.

Results

We randomly assigned 995 women to the intervention arm (n = 492) or control arm (n = 503). The intervention (vs control) had no effect on chemoprevention uptake (OR = 1.04, 95% CI = 0.07 to 16.62). The intervention increased breast MRI use (OR = 5.65, 95% CI = 1.61 to 19.74) while maintaining annual mammography (OR = 0.98, 95% CI = 0.75 to 1.28). Women in the intervention (vs control) arm had 5.67-times higher odds of having discussed chemoprevention or breast MRI with provider by 6 weeks (OR = 5.67, 95% CI = 2.47 to 13.03) and 2.36-times higher odds by 12 months (OR = 2.36, 95% CI = 1.65 to 3.37). No measurable differences in distress were detected.

Conclusions

A web-based, patient-level intervention activated women at elevated 5-year breast cancer risk to engage in clinical discussions about chemoprevention, but uptake remained low.

Characteristics Associated with Participation in ENGAGED 2 - A Web-based Breast Cancer Risk Communication and Decision Support Trial

PURPOSE

We evaluated demographic and clinical characteristics associated with participation in a clinical trial testing the efficacy of an online tool to support breast cancer risk communication and decision support for risk mitigation to determine the generalizability of trial results.

METHODS

Eligible women were members of Kaiser Permanente Washington aged 40-69 years with a recent normal screening mammogram, heterogeneously or extremely dense breasts and a calculated risk of > 1.67% based on the Breast Cancer Surveillance Consortium 5-year breast cancer risk model. Trial outcomes were chemoprevention and breast magnetic resonance imaging by 12-months post-baseline. Women were recruited via mail with phone follow-up using plain language materials notifying them of their density status and higher than average breast cancer risk. Multivariable logistic regression calculated independent odds ratios (ORs) for associations between demographic and clinical characteristics with trial participation.

RESULTS

Of 2,569 eligible women contacted, 995 (38.7%) participated. Women with some college (OR = 1.99, 95% confidence interval [CI] 1.34-2.96) or college degree (OR = 3.35, 95% CI 2.29-4.90) were more likely to participate than high school-educated women. Race/ethnicity also was associated with participation (African-American OR = 0.50, 95% CI 0.29-0.87; Asian OR = 0.22, 95% CI 0.12-0.41). Multivariate adjusted ORs for family history of breast/ovarian cancer were not associated with trial participation.

DISCUSSION

Use of plain language and potential access to a website providing personal breast cancer risk information and education were insufficient in achieving representative participation in a breast cancer prevention trial. Additional methods of targeting and tailoring, potentially facilitated by clinical and community outreach, are needed to facilitate equitable engagement for all women.

Abstract MP35: Automated Office Blood Pressures For Making A Diagnosis Of Hypertension And The Effect Of Attendance And Rest Time

Context: Automated office blood pressure (AOBP) where three to five blood pressures (BP) are taken using an oscillometric device without an attendant in the room may decrease white coat effect.

Objective: We evaluated the presence/absence of the attendant and varying amounts of rest time on BP; and the diagnostic performance of AOBP in making a new diagnosis of hypertension compared to daytime ambulatory blood pressure monitoring (ABPM).

Methods: Participants included 130 adults aged 18-84 with no hypertension diagnosis or treatment and high BP ( > 140/90) prior to the study. Participants completing ABPM testing in the prior 24-hours were randomized either to Attended AOBP first, unattended second or; Unattended AOBP first, attended second . AOBP was subsequently performed twice, once after 5 minutes of rest and again after 15 minutes. Outcomes included within person difference between attended versus unattended BPs , and between 5 and 15 minutes of rest. Sensitivity and specificity of AOBP for making a new diagnosis of HTN was evaluated.

Results: AOBP was significantly lower than mean daytime ABPM regardless of rest or attendance (systolic BP between -3.9 mmHg and diastolic BP -2.9 mm Hg lower). There were no significant within-person differences between AOBPs that were attended versus unattended (mean difference systolic 0.1 mmHg, CI -0.8, 1.1; diastolic 0.2 mmHg, CI -0.5, 0.8) or after five versus 15-minutes of rest (mean difference systolic -0.5 mmHg, CI -1.4, 0.5, diastolic 0.2 mmHg, CI -1.2, 0.0). Using daytime mean ABPM threshold of > 135/85, the sensitivity and specificity of AOBP for making a new diagnosis of hypertension was 71.0% and 54.1%.

Conclusion: Neither the presence/absence of an attendant nor rest time significantly impacted AOBP measurement. A single set of AOBP measurements may be insufficient for making a new diagnosis of hypertension.

Abstract P163: Blood Pressure Checks And Diagnosing Hypertension: Provider Knowledge, Beliefs, And Practices

Context: The US Preventive Services Task Force recommends out-of-office blood pressure (BP) measurement before making a new diagnosis of hypertension, using 24-hour ambulatory (ABPM) or home BP monitoring. However, this approach is not common in routine practice.

Objective: To evaluate provider knowledge, beliefs, and practices about BP diagnostic tests

Methods: The setting was 10 primary care medical centers in a single health care system. E-mails with a link to a survey were sent to 420 providers, with 282 (67%) responding, including 102 medical assistants (MA), 28 licensed practical nurses (LPN), 33 registered nurses (RN), 86 primary care physicians (physician), and 33 advanced practitioners (AP). Outcomes were a descriptive analysis of provider BP measurement and hypertension diagnosis knowledge, beliefs, and practices.

Results: Most providers (78.8%) believed that BP measured manually with a stethoscope and ABPM as very or highly accurate way to measure BP when making a new diagnosis of hypertension. In contrast, most providers did not believe that automated clinic BPs, home BP, or kiosk BP measurements were very or highly accurate. Almost all providers reported that they always or almost always relied on clinic BP measurements in making a new diagnosis of hypertension (95.7%), but the majority of physician/APs would prefer using ABPM (60.5%) if it was readily available. Providers were mixed as to whether patients received home BP training and whether home BP monitors were checked for accuracy. Physician/APs reported varying home BP schedules with no schedule the most common response (37.3%), followed by 14 days (19.1%), and 7 days (10.9%). Almost all physicians/APs reported using a clinic BP threshold of 140/90 mmHg for making a new diagnosis of, but a few reported 130/80 mmHg. Very few physician/APs reported guideline concordant home or ABPM diagnostic thresholds, with 140/90 mmHg the most common response.

Conclusion: In our study providers did not report following evidence-based guidelines for making a new diagnosis of hypertension, and appeared to have substantial gaps in knowledge, beliefs, and use of recommended practices. Interventions to increase use of evidence-based practices for diagnosing hypertension are needed.

Knowledge and Perception of Breast Density, Screening Mammography, and Supplemental Screening: in Search of "Informed"

BACKGROUND

As of 2019, 37 US states have breast density notification laws. No qualitative study to date has examined women's perspectives about breast density in general or by states with and without notification laws.

OBJECTIVE

Explore women's knowledge and perceptions of breast density and experiences of breast cancer screening across three states with and without notification laws.

DESIGN

Qualitative research design using four focus groups conducted in 2017.

PARTICIPANTS

Forty-seven women who had a recent normal mammogram and dense breasts in registry data obtained through the Breast Cancer Surveillance Consortium.

APPROACH

Focus groups were 90 min, audio recorded, and transcribed for analysis. Data were analyzed using mixed deductive and inductive coding.

KEY RESULTS

Women reported variable knowledge levels of personal breast density and breast density in general, even among women living in states with a notification law. A number of women were aware of the difficulty of detecting cancer with dense breasts, but only one knew that density increased breast cancer risk. Across all states, very few women reported receiving information about breast density during healthcare visits beyond being encouraged to get supplemental imaging or to pay for new mammography technology (i.e., breast tomosynthesis). Women offered more imaging or different technology held strong convictions that these were "better," even though knowledge of differences, effectiveness, or harms across technologies seemed limited. Women from all states expressed a strong desire for more information about breast density.

CONCLUSIONS

More research needs to be done to understand how the medical community can best assist women in making informed decisions related to breast density, mammography, and supplemental screening. Options to explore include improved breast density notifications and education materials about breast density, continued development of personalized risk information tools, strategies for providers to discuss evidence and options based on risk stratification, and shared decision-making.

CO-DESIGNING CANCER SCREENING INTERVENTIONS WITH PEOPLE OVER 55 YEARS OLD AT RISK FOR LUNG CANCER

In 2014, the US Preventive Task Force recommended annual lung cancer screening with low dose CT (LDCT) for adults aged 55 to 80 years old with significant smoking history. Although screening reduces lung cancer mortality, the leading cause of cancer mortality in the US, adherence to screening follow-up remains low. In a human-centered design qualitative study, health services researchers and eight adults over 55 years old from Kaiser Permanente Washington who had recently had an LDCT participated in two co-design sessions. We elicited barriers, facilitators and design principles to develop multilevel interventions that aim to improve adherence to ongoing LDCT. In the initial discussion, participants identified four key areas for improvements to adherence: a) reminders for scheduling and appointments, b) knowledge about tests and follow-up, c) convenience in location and scheduling, and d) financial and non-financial incentives. In a second session, participants referenced patient personas and sketched storyboards, a comic strip-like format showing steps in a journey, to describe different ways to help patients return for LDCTs. Through qualitative analysis, we identified ten elements to consider incorporating in multilevel interventions: versatility (e.g., multiple reminder options), social support (e.g., families, peers), individualization (e.g., tailoring to patient needs), feelings (e.g., fear, relief), knowledge (e.g., harms/benefits, expectations), responsibility (e.g., who is accountable for reminders), continuity (e.g., clear pathway to adherence), consistency (e.g., same messages), cadence (e.g., rhythm of messages), and acknowledgment (e.g., recognition of screening completion). Next steps are to incorporate feedback from clinical stakeholders and develop multilevel interventions for further testing.

Blood pressure checks and diagnosing hypertension (BP-CHECK): Design and methods of a randomized controlled diagnostic study comparing clinic, home, kiosk, and 24-hour ambulatory BP monitoring

BACKGROUND

The US Preventive Services Task Force recommends out-of-office blood pressure (BPs) before making a new diagnosis of hypertension, using 24-h ambulatory (ABPM) or home BP monitoring (HBPM), however this is not common in routine clinical practice. Blood Pressure Checks and Diagnosing Hypertension (BP-CHECK) is a randomized controlled diagnostic study assessing the comparability and acceptability of clinic, home, and kiosk-based BP monitoring to ABPM for diagnosing hypertension. Stakeholders including patients, providers, policy makers, and researchers informed the study design and protocols.

METHODS

Adults aged 18-85 without diagnosed hypertension and on no hypertension medication with elevated BPs in clinic and at the baseline research visit are randomized to one of 3 regimens for diagnosing hypertension: (1) clinic BPs, (2) home BPs, or (3) kiosk BPs; all participants subsequently complete ABPM. The primary outcomes are the comparability (with daytime ABPM mean systolic and diastolic BP as the reference standard) and acceptability (e.g., adherence to, patient-reported outcomes) of each method compared to ABPM. Longer-term outcomes are assessed at 6-months including: patient-reported outcomes, primary care providers' diagnosis of hypertension; and BP control. We report challenges experienced and our response to these.

RESULTS

Enrollment began in May of 2017 with a target of randomizing 510 participants. BP thresholds for diagnosing hypertension in the US changed after the trial started. We discuss the stakeholder process used to assess and respond to these changes.

CONCLUSION AND PUBLIC HEALTH IMPACT

BP-CHECK will inform which hypertension diagnostic methods are most accurate, acceptable, and feasible to implement in primary care.

Actions and processes that patients, family members, and physicians associate with patient- and family-centered care

Background

Patient- and family-centered care (PFCC) is increasingly linked to improved communication, care quality, and patient decision making. However, in order to consistently implement and study PFCC, health care systems and researchers need a solid evidentiary base. Most current definitions and models of PFCC are broad and conceptual, and difficult to translate into measurable behaviors and actions. This paper provides a brief overview of all actions that focus group respondents associated with PFCC in ambulatory (outpatient) care settings and then explores actions associated with the concept of “dignity and respect” in greater detail.

Methods

We conducted nine focus groups with patients, family members, and physicians in three metropolitan regions across the United States. Group discussions were transcribed and analyzed using a thematic analysis approach.

Results

We identified 14 domains and 47 specific actions that patients, family members, and physicians associate with PFCC. In addition to providing a detailed matrix of these domains and actions, this paper details the actions associated with the “dignity and respect” concept. Key domains identified under “dignity and respect” include: 1) building relationships, 2) providing individualized care, and 3) respecting patients’ time. Within these domains we identified specific actions that break down these abstract ideas into explicit and measurable units such as taking time, listening, including family, and minimizing wait times. We identified 9, 6, and 3 specific actions associated, respectively, with building relationships, providing individualized care, and respecting patients’ time.

Conclusions

Our work fills a critical gap in our ability to understand and measure PFCC in ambulatory care settings by breaking down abstract concepts about PFCC into specific measurable actions. Our findings can be used to support research on how PFCC affects clinical outcomes and develop innovative tools and policies to support PFCC.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0918-7) contains supplementary material, which is available to authorized users.

Evaluation of the Learning to Integrate Neighborhoods and Clinical Care Project: Findings from Implementing a New Lay Role into Primary Care Teams to Address Social Determinants of Health

INTRODUCTION

Health systems increasingly recognize the impact of social determinants of health such as access to housing, transportation, and nutritious food. Lay health workers have been used to address patients' social determinants of health through resource referral and goal setting in targeted populations, such as individuals with diabetes. However, we know of no studies that evaluate this type of role for a general primary care population.

OBJECTIVE

To assess the implementation and impact of the Community Resource Specialist (CRS) role in Kaiser Permanente Washington.

METHODS

We analyzed data from staff interviews, patient focus groups, clinic site visits, patient surveys, the electronic health record, and administrative sources.

RESULTS

Satisfaction with CRSs was high, with 92% of survey respondents choosing "very satisfied" or "somewhat satisfied." Of patients with a resource referral and follow-up encounter, 45% reported using the resource (n = 229) and 86% who set a goal and had a follow-up encounter (n = 218) progressed toward their goal. Primary care teams reported workload easing. Patients who used CRSs and participated in focus groups reported behavior changes and improved health, although no changes were detected from electronic health records or patient survey data. Key learnings include the need to clearly define the CRS role, ensure high visibility to clinical staff, and facilitate personal introductions of patients (warm handoffs).

CONCLUSION

Adding an individual to the primary care team with expertise in community resources can increase patient satisfaction, support clinicians, and improve patients' perceptions of their health and well-being.

pH sensing through a single optical fibre using SERS and CMOS SPAD line arrays

Full exploitation of fibre Raman probes has been limited by the obstruction of weak Raman signals by background fluorescence of the sample and the intrinsic Raman signal of the delivery fibre. Here we utilised functionalised gold nanoshells (NS) to take advantage of the surface-enhanced Raman spectroscopy (SERS) effect to enhance the pH responsive spectrum of 4-mercaptobenzoic acid (MBA). However, the fibre background is still dominant. Using the photon arrival time-resolving capability of a CMOS single-photon avalanche diode (SPAD) based line sensor, we recover the SERS spectrum without a fibre background in a 10 s measurement. In this manner, pH sensing through a multimode fibre at a low excitation power that is safe for future in vivo applications, with short acquisition times (10 or 60 s), is demonstrated. A measurement precision of ± 0.07 pH units is thus achieved.

Time-resolved spectroscopy at 19,000 lines per second using a CMOS SPAD line array enables advanced biophotonics applications

A SPAD-based line sensor fabricated in 130 nm CMOS technology capable of acquiring time-resolved fluorescence spectra (TRFS) in 8.3 milliseconds is presented. To the best of our knowledge, this is the fastest time correlated single photon counting (TCSPC) TRFS acquisition reported to date. The line sensor is an upgrade to our prior work and incorporates: i) parallelized interface from sensor to surrounding circuitry enabling high line rate to the PC (19,000 lines/s) and ii) novel time-gating architecture where detected photons in the OFF region are rejected digitally after the output stage of the SPAD. The time-gating architecture was chosen to avoid electrical transients on the SPAD high voltage supplies when gating is achieved by excess bias modulation. The time-gate has an adjustable location and time window width allowing the user to focus on time-events of interest. On-chip integrated center-of-mass (CMM) calculations provide efficient acquisition of photon arrivals and direct lifetime estimation of fluorescence decays. Furthermore, any of the SPC, TCSPC and on-chip CMM modes can be used in conjunction with the time-gating. The higher readout rate and versatile architecture greatly empower the user and will allow widespread applications across many techniques and disciplines. Here we focused on 3 examples of TRFS and time-gated Raman spectroscopy: i) kinetics of chlorophyll A fluorescence from an intact leaf; ii) kinetics of a thrombin biosensor FRET probe from quenched to fluorescence states; iii) ex vivo mouse lung tissue autofluorescence TRFS; iv) time-gated Raman spectroscopy of toluene at 3056 cm^-1 peak. To the best of our knowledge, we detect spectrally for the first time the fast rise in fluorescence lifetime of chlorophyll A in a measurement over single fluorescent transient.

A web-based personalized risk communication and decision-making tool for women with dense breasts: Design and methods of a randomized controlled trial within an integrated health care system

BACKGROUND

Mammographic breast density is one of the strongest risk factors for breast cancer after age and family history. Mandatory breast density disclosure policies are increasing nationally without clear guidance on how to communicate density status to women. Coupling density disclosure with personalized risk counseling and decision support through a web-based tool may be an effective way to allow women to make informed, values-consistent risk management decisions without increasing distress.

METHODS/DESIGN

This paper describes the design and methods of Engaged, a prospective, randomized controlled trial examining the effect of online personalized risk counseling and decision support on risk management decisions in women with dense breasts and increased breast cancer risk. The trial is embedded in a large integrated health care system in the Pacific Northwest. A total of 1250 female health plan members aged 40-69 with a recent negative screening mammogram who are at increased risk for interval cancer based on their 5-year breast cancer risk and BI-RADS® breast density will be randomly assigned to access either a personalized web-based counseling and decision support tool or standard educational content. Primary outcomes will be assessed using electronic health record data (i.e., chemoprevention and breast MRI utilization) and telephone surveys (i.e., distress) at baseline, six weeks, and twelve months.

DISCUSSION

Engaged will provide evidence about whether a web-based personalized risk counseling and decision support tool is an effective method for communicating with women about breast density and risk management. An effective intervention could be disseminated with minimal clinical burden to align with density disclosure mandates. Clinical Trials Registration Number:NCT03029286.

The effects of different antioxidants on the activity of cerebrocortical MnSOD and Na,K-ATPase from post mortem Alzheimer's disease and age-matched normal brains

Among the markers and targets of the early phase of Alzheimer's disease (AD) pathogenesis MnSOD (mitochondrial dysfunction) and Na-pump (disturbances in function/regulation) are often highlighted. This paper focused on comparison of the effects of three antioxidants on the activity of cerebrocortical MnSOD and Na,K-ATPase from post mortem Alzheimer's disease and age-matched normal brains. Antioxidant compounds with different origins: natural glutathione, synthetic UPF peptides (glutathione analogues) and phytoestrogen genistein were investigated. Firstly, MnSOD and Na,K-ATPase activities were found to be decreased in the post mortem AD brains compared with age-matched controls. Secondly, GSH had no effect on MnSOD activity, but decreased Na,K-ATPase activity both in the control and AD brains. Thirdly, UPF1 and UPF17 increased MnSOD activity, and UPF17 suppressed Na,K-ATPase activity. Further studies are needed to clarify, if the inhibitory effect of UPF17 on Na,K-ATPase could abolish the beneficial effect gained from MnSOD activation. Both the antioxidative potential of genistein and its potency to up-regulate Na,K-ATPase activity make it an attractive candidate substance to suppress the early phase of the pathogenesis of AD.

Factors associated with successful discontinuation of hormone therapy

BACKGROUND

Careful management of symptoms, particularly sleep and mood disturbances, may assist women in discontinuing hormone therapy (HT). We sought to describe characteristics associated with successful HT cessation in women who attempted to discontinue estrogen pills/patches with or without progestin.

METHODS

We invited 2,328 women, aged 45-70, enrolled January 1, 2005, to May 31, 2006, at Group Health in Washington State and Harvard Vanguard Medical Associates in Massachusetts, to participate in a telephone survey about HT practices. For the sample, we selected 2,090 women with estrogen dispensings (pharmacy data) during the study period, 200 women without HT dispensing after January 2005, and 240 women with no estrogen dispensings; 1,358 (58.3%) completed the survey. These analyses are based on survey responses.

RESULTS

Among 802 women who attempted HT discontinuation, the mean age was 50 years, 93% were postmenopausal, 90% were white, 30% had had a hysterectomy, and 75% experienced hot flashes after discontinuation. Those who did not succeed had greater trouble sleeping (74% vs. 57%) and mood disturbances (51% vs. 34%) than those who succeeded. In multivariable analyses, factors associated with successful discontinuation included doctor advice (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.68-4.08), lack of symptom improvement (OR 4.21, CI 1.50-12.17), vaginal bleeding (OR 5.96, CI 1.44-24.6), and learning to cope with symptoms (OR 3.36, CI 2.21-5.11). Factors associated with unsuccessful HT discontinuation included trouble sleeping (OR 0.40, CI 0.26-0.61) and mood swings or depression (OR 0.63, CI 0.42-0.92).

CONCLUSIONS

Doctor advice is strongly associated with successful HT discontinuation. Symptom management, particularly sleep and mood disturbances, may help women discontinue HT.

Enhancing the power of genetic association studies through the use of silver standard cases derived from electronic medical records

The feasibility of using imperfectly phenotyped "silver standard" samples identified from electronic medical record diagnoses is considered in genetic association studies when these samples might be combined with an existing set of samples phenotyped with a gold standard technique. An analytic expression is derived for the power of a chi-square test of independence using either research-quality case/control samples alone, or augmented with silver standard data. The subset of the parameter space where inclusion of silver standard samples increases statistical power is identified. A case study of dementia subjects identified from electronic medical records from the Electronic Medical Records and Genomics (eMERGE) network, combined with subjects from two studies specifically targeting dementia, verifies these results.

Spreading a medical home redesign: effects on emergency department use and hospital admissions

PURPOSE

The patient-centered medical home (PCMH) is being rapidly deployed in many settings to strengthen US primary care, improve quality, and control costs; however, evidence supporting this transformation is still lacking. We describe the Group Health experience in attempting to replicate the effects on health care use seen in a PCMH prototype clinic via a systemwide spread using Lean as the change strategy.

METHODS

We used an interrupted time series analysis with a patient-month unit of analysis over a 4-year period that included baseline, implementation, and stabilization periods for 412,943 patients. To account for secular trends across these periods, we compared changes in use of face-to-face primary care visits, emergency department visits, and inpatient admissions with those of a nonequivalent comparison group of patients served by community network practices.

RESULTS

After accounting for secular trends among network patients, patients empaneled to the PCMH clinics had 5.1% and 6.7% declines in primary care office visits in early and later stabilization years, respectively, after the implementation year. This trend was accompanied by a 123% increase in the use of secure electronic message threads and a 20% increase in telephone encounters. Declines were also seen in emergency department visits at 1 and 2 years (13.7% and 18.5%) compared with what would be expected based on secular trends in network practices. No statistically significant changes were found for hospital admissions.

CONCLUSIONS

The Group Health experience shows it is possible to reduce emergency department use with PCMH transformation across a diverse set of clinics using a clear change strategy (Lean) and sufficient resources and supports.

Confirmation of the reported association of clonal chromosomal mosaicism with an increased risk of incident hematologic cancer

Chromosomal abnormalities provide clinical utility in the diagnosis and treatment of hematologic malignancies, and may be predictive of malignant transformation in individuals without apparent clinical presentation of a hematologic cancer. In an effort to confirm previous reports of an association between clonal mosaicism and incident hematologic cancer, we applied the anomDetectBAF algorithm to call chromosomal anomalies in genotype data from previously conducted Genome Wide Association Studies (GWAS). The genotypes were initially collected from DNA derived from peripheral blood of 12,176 participants in the Group Health electronic Medical Records and Genomics study (eMERGE) and the Women’s Health Initiative (WHI). We detected clonal mosaicism in 169 individuals (1.4%) and large clonal mosaic events (>2 mb) in 117 (1.0%) individuals. Though only 9.5% of clonal mosaic carriers had an incident diagnosis of hematologic cancer (multiple myeloma, myelodysplastic syndrome, lymphoma, or leukemia), the carriers had a 5.5-fold increased risk (95% CI: 3.3–9.3; p-value = 7.5×10⁻¹¹) of developing these cancers subsequently. Carriers of large mosaic anomalies showed particularly pronounced risk of subsequent leukemia (HR = 19.2, 95% CI: 8.9–41.6; p-value = 7.3×10⁻¹⁴). Thus we independently confirm the association between detectable clonal mosaicism and hematologic cancer found previously in two recent publications.

A hypothesis to explain how LaeA specifically regulates certain secondary metabolite biosynthesis gene clusters

Biosynthesis of mycotoxins involves transcriptional co-regulation of sets of clustered genes. We hypothesise that specific control of transcription of genes in these clusters by LaeA, a global regulator of secondary metabolite production and development in many filamentous fungi, results from its interaction with a Cys6Zn2 DNA-binding protein unique to the gene cluster.

Increased sensitivity of Aspergillus flavus and Aspergillus parasiticus aflatoxin biosynthesis polyketide synthase mutants to UVB light

One strategy to reduce aflatoxin contamination of maize and cottonseed is to introduce spores of non-aflatoxigenic strains as competitors. Using isogenic mutants we show that, upon 5 or 20 min exposure to 302 nm (UVB) light, the viability of conidia of Aspergillus flavus and Aspergillus parasiticus mutants lacking the ability to accumulate any aflatoxin precursor metabolite is reduced five-fold compared to that of aflatoxin-producing strains or pigmented mutants that accumulate aflatoxin precursors. This result suggests that the long-term viability of introduced non-aflatoxigenic competitor strains may be lower than that of natural aflatoxin-producing isolates when exposed to sunlight.

Depressive symptoms and menopausal burden in the midlife

OBJECTIVE

The goal of this study was to assess whether menopausal symptoms were more common and/or more severe among women with depressive symptoms.

METHODS

A cross-sectional survey of 1358 women, ages 45-70, at two large integrated health plans (Seattle; Boston) was performed. Information on demographics, medical and reproductive history, medication use, menopausal experience and depressive symptoms (PHQ-8) were collected. Women taking HT were excluded. Logistic regression models adjusted for age and body mass index tested the associations between menopausal symptoms (hot flushes, night sweats, vaginal dryness and dyspareunia) and presence of moderate/severe depressive symptoms.

RESULTS

770 women were included; 98 (12.7%) had moderate/severe depressive symptoms and 672 (87.3%) had no/mild depressive symptoms. Women with moderate/severe depressive symptoms were almost twice as likely to report recent vasomotor symptoms (hot flashes and or night sweats) vs. women with no/mild depressive symptoms (adjusted odds ratio (aOR) 1.67, 95%CI 1.04-2.68), and to report them as severe (aOR 1.63, 95%CI 0.95-2.83). A higher symptom burden was observed despite the fact that 20% of women with moderate/severe depressive symptoms (vs. 4.6% no/mild depressive symptoms) were using an SSRI or SNRI, medications known to improve vasomotor symptoms. The percentage of women with menopausal symptoms, and the percentage with severe vasomotor symptoms were linearly associated with the depressive symptom score.

CONCLUSIONS

Depressive symptoms "amplified" the menopausal experience, or alternatively, severe vasomotor symptoms worsened depressive symptoms.

Vaginal, endometrial, and reproductive hormone findings: randomized, placebo-controlled trial of black cohosh, multibotanical herbs, and dietary soy for vasomotor symptoms: the Herbal Alternatives for Menopause (HALT) Study

OBJECTIVE

To evaluate vaginal, endometrial, and reproductive hormone effects of three herbal regimens compared with placebo and hormone therapy (HT).

DESIGN

This was a 1-year, randomized, double-blind, placebo-controlled trial of 351 women, ages 45 to 55, with two or more vasomotor symptoms per day. Women were randomly assigned to (1) black cohosh, (2) a multibotanical containing black cohosh, (3) the same multibotanical plus dietary soy counseling, (4) HT, or (5) placebo. Women were ineligible if they had used HT in the previous 3 months or menopausal herbal therapies in the previous month. Data on vaginal cytology and dryness were collected (at baseline and 3 and 12 mo). Daily menstrual diaries were maintained by 313 women with a uterus, and abnormal bleeding was evaluated. Serum estradiol, follicle-stimulating hormone, luteinizing hormone, and steroid hormone-binding globulin were assessed (baseline and 12 mo) among 133 postmenopausal women. Gynecologic outcomes of the five groups were compared.

RESULTS

The five groups did not vary in baseline vaginal cytology profiles, vaginal dryness, menstrual cyclicity, or hormone profiles. The HT group had a lower percentage of parabasal cells and vaginal dryness than the placebo group at 3 and 12 months (P < 0.05). Abnormal bleeding occurred in 53 of 313 (16.9%) women. There were no differences in frequency of abnormal bleeding between any of the herbal and placebo groups, whereas women in the HT group had a greater risk than those in the placebo group (P < 0.001). Among postmenopausal women, HT significantly decreased follicle-stimulating hormone and increased estradiol; none of the herbal interventions showed significant effects on any outcomes at any time point.

CONCLUSION

Black cohosh, used alone or as part of a multibotanical product with or without soy dietary changes, had no effects on vaginal epithelium, endometrium, or reproductive hormones.

The effects of black cohosh therapies on lipids, fibrinogen, glucose and insulin

OBJECTIVE

Black cohosh (Actaea racemosa) is an herb commonly used to treat menopausal symptoms. Little is known about its effect on other physiologic parameters that could result in untoward events. This study examines the effect of black cohosh on lipids, fibrinogen, glucose and insulin.

METHODS

Three hundred and fifty-one, 45-55 years old, peri or post-menopausal women experiencing vasomotor symptoms participated in a 3-month, double blind trial with randomization to: (1) black cohosh (160 mg daily); (2) multibotanical including black cohosh (200 mg daily); (3) multibotanical plus soy diet counseling; (4) conjugated equine estrogen .625 mg, with or without medroxyprogesterone acetate 2.5mg daily, for women with or without a uterus, respectively; (5) placebo. Baseline and month 3 total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol (calculated), triglyceride, insulin, glucose, and fibrinogen serum concentrations were measured in 310 women. Baseline information was also collected on medical history, demographic characteristics, and diet.

RESULTS

There were no statistically significant differences in the adjusted mean change from baseline to 3 months between the herbal groups and placebo in total cholesterol, LDL, HDL, triglycerides, glucose, and insulin. Adjusted fibrinogen levels appear to increase in the multibotanical treatment group in comparison with the other herbal groups and placebo overall (P = .02), but there was no statistically significant difference in the pairwise test against placebo (P = .11).

CONCLUSIONS

Black cohosh containing therapies had no demonstrable effects on lipids, glucose, insulin or fibrinogen.

Night sweats, sleep disturbance, and depression associated with diminished libido in late menopausal transition and early postmenopause: baseline data from the Herbal Alternatives for Menopause Trial (HALT)

OBJECTIVE

The objective of the study was to evaluate the association of depression, sleep disturbance, and menopausal symptoms with diminished libido.

STUDY DESIGN

Data from a 2001-2002 baseline survey of 341 peri- and postmenopausal women, aged 45-55 years, participating in a randomized trial, was analyzed. Eligibility included at least 2 hot flashes and/or night sweats per day and no hormone therapy for at least the prior 3 months. The survey evaluated sexual function, depression, sleep, and vasomotor symptoms. We examined the association between these factors, using multivariate regression models.

RESULTS

Of 341 women, 64% had diminished libido, 18% had moderate to severe depression, and 43% had poor sleep quality. Women averaged 4.6 hot flashes and 1.9 night sweats per day. Depressive symptoms (P = .003), poor sleep (P = .02), and night sweats (P = .04) were significantly associated with diminished libido.

CONCLUSION

Factors associated with diminished libido in midlife are complex but include depression, disturbed sleep, and night sweats, all common symptoms of the menopausal transition and early menopause.

Secondary metabolite profiling, growth profiles and other tools for species recognition and important Aspergillus mycotoxins

Species in the genus Aspergillus have been classified primarily based on morphological features. Sequencing of house-hold genes has also been used in Aspergillus taxonomy and phylogeny, while extrolites and physiological features have been used less frequently. Three independent ways of classifying and identifying aspergilli appear to be applicable: Morphology combined with physiology and nutritional features, secondary metabolite profiling and DNA sequencing. These three ways of identifying Aspergillus species often point to the same species. This consensus approach can be used initially, but if consensus is achieved it is recommended to combine at least two of these independent ways of characterising aspergilli in a polyphasic taxonomy. The chemical combination of secondary metabolites and DNA sequence features has not been explored in taxonomy yet, however. Examples of these different taxonomic approaches will be given for Aspergillus section Nigri.

Biodiversity of Aspergillus species in some important agricultural products

The genus Aspergillus is one of the most important filamentous fungal genera. Aspergillus species are used in the fermentation industry, but they are also responsible of various plant and food secondary rot, with the consequence of possible accumulation of mycotoxins. The aflatoxin producing A. flavus and A. parasiticus, and ochratoxinogenic A. niger, A. ochraceus and A. carbonarius species are frequently encountered in agricultural products. Studies on the biodiversity of toxigenic Aspergillus species is useful to clarify molecular, ecological and biochemical characteristics of the different species in relation to their different adaptation to environmental and geographical conditions, and to their potential toxigenicity. Here we analyzed the biodiversity of ochratoxin producing species occurring on two important crops: grapes and coffee, and the genetic diversity of A. flavus populations occurring in agricultural fields. Altogether nine different black Aspergillus species can be found on grapes which are often difficult to identify with classical methods. The polyphasic approach used in our studies led to the identification of three new species occurring on grapes: A. brasiliensis, A. ibericus, and A. uvarum. Similar studies on the Aspergillus species occurring on coffee beans have evidenced in the last five years that A. carbonarius is an important source of ochratoxin A in coffee. Four new species within the black aspergilli were also identified in coffee beans: A. sclerotioniger, A. lacticoffeatus, A. sclerotiicarbonarius, and A. aculeatinus. The genetic diversity within A. flavus populations has been widely studied in relation to their potential aflatoxigenicity and morphological variants L- and S-strains. Within A. flavus and other Aspergillus species capable of aflatoxin production, considerable diversity is found. We summarise the main recent achievements in the diversity of the aflatoxin gene cluster in A. flavus populations, A. parasiticus and the non-toxigenic A. oryzae. Studies are needed in order to characterise the aflatoxin biosynthetic genes in the new related taxa A. minisclerotigenes and A. arachidicola.

Treatment of vasomotor symptoms of menopause with black cohosh, multibotanicals, soy, hormone therapy, or placebo: a randomized trial

BACKGROUND

Herbal supplements are widely used for vasomotor symptoms.

OBJECTIVE

To test the efficacy of 3 herbal regimens and hormone therapy for relief of vasomotor symptoms compared with placebo.

DESIGN

1-year randomized, double-blind, placebo-controlled trial conducted from May 2001 to September 2004.

SETTING

Group Health, Washington State.

PARTICIPANTS

351 women age 45 to 55 years with 2 or more vasomotor symptoms per day; 52% of the women were in menopausal transition and 48% were postmenopausal.

MEASUREMENTS

Rate and intensity of vasomotor symptoms (1 = mild to 3 = severe), and Wiklund Vasomotor Symptom Subscale.

INTERVENTIONS

1) Black cohosh, 160 mg daily; 2) multibotanical with black cohosh, 200 mg daily, and 9 other ingredients; 3) multibotanical plus dietary soy counseling; 4) conjugated equine estrogen, 0.625 mg daily, with or without medroxyprogesterone acetate, 2.5 mg daily; or 5) placebo.

RESULTS

Vasomotor symptoms per day, symptom intensity, Wiklund Vasomotor Symptom Subscale score did not differ between the herbal interventions and placebo at 3, 6, or 12 months or for the average over all the follow-up time points (P > 0.05 for all comparisons) with 1 exception: At 12 months, symptom intensity was significantly worse with the multibotanical plus soy intervention than with placebo (P = 0.016). The difference in vasomotor symptoms per day between placebo and any of the herbal treatments at any time point was less than 1 symptom per day; for the average over all the follow-up time points, the difference was less than 0.55 symptom per day. The difference for hormone therapy versus placebo was -4.06 vasomotor symptoms per day for the average over all the follow-up time points (95% CI, -5.93 to -2.19 symptoms per day; P < 0.001).

LIMITATIONS

The trial did not simulate the whole-person approach used by naturopathic physicians. Differences between treatment groups smaller than 1.5 Vasomotor symptoms per day cannot be ruled out.

CONCLUSION

Black cohosh used in isolation, or as part of a multibotanical regimen, shows little potential as an important therapy for relief of vasomotor symptoms.

CLINICAL TRIALS REGISTRATION NUMBER

NCT00169299.

The Herbal Alternatives for Menopause (HALT) Study: background and study design

We designed a randomized double-blind randomized trial to examine the short and long-term effects of alternative approaches commonly used to manage menopause symptoms. Women were randomly assigned to: (1) black cohosh 160 mg daily; (2) multibotanical (50 mg black cohosh, alfalfa, chaste tree, dong quai, false unicorn, licorice, oats, pomegranate, Siberian ginseng, boron) four capsules daily; (3) multibotanical plus telephone counseling to increase dietary soy; (4) conjugated equine estrogen 0.625 mg +/- 2.5 mg medroxyprogesterone acetate; or (5) placebo. Working with a skilled CAM provider helped us choose interventions that reflected naturopathic practices worthy of study. Mass mailing, with careful tracking and rapid responses to recruitment rates, was an effective and cost-effective recruitment strategy. Creativity was necessary to construct methods for blinding capsules and the dietary soy intervention. Independent testing of herbal products was vital to confirming their constituents. The Data and Safety and Monitoring Committee, and project officers at the funding agency, were critical partners in designing responses to unanticipated Women's Health Initiative findings published during the HALT trial. Careful monitoring of adverse events may provide much needed information about side effects of herbal products and supplements. Despite inherent challenges, the study of alternative therapies for menopause symptoms is a rewarding and important area deserving of further inquiry.

Pluraflavins, potent antitumor antibiotics from Saccharothrix sp. DSM 12931

The new pluramycin-type antibiotics pluraflavin A, C43H54N2O14, pluraflavin B, C43H56N2O15, and pluraflavin E, C36H41NO14 were isolated from cultures of the Saccharothrix species DSM 12931. The structures of the novel compounds were elucidated with the aid of 2D NMR and mass spectrometric investigations. The characteristic structural element of pluraflavins A and B is an additional 4-epi-vancosamine unit at position 13 of the anthraquinone-gamma-pyrone ring system. Pluraflavin E has a carboxyl group in this position. Pluraflavin A has a reactive dimethyl epoxide side chain at position 2 of the anthraquinone-gamma-pyrone aglycon, which may explain the high activity of the antibiotic. The outstanding biological characteristic of pluraflavin A is its powerful, organ-dependent cytostatic action: the IC50 in the colon carcinoma proliferation assay is in the subnanomolar range.