Factors impacting medication adherence in a birth cohort at higher risk for Hepatitis C infection

Due to the high prevalence of Hepatitis C virus (HCV) infection among individuals born between 1945 and 1965, in 2012 the Centers for Disease Control and Prevention began recommending HCV screening for this birth cohort. As adherence to HCV treatment is essential for sustained virologic response, identifying factors influencing medication adherence is important. The validated Adherence to Refills and Medications Scale (ARMS) is used to study recent medication adherence in those with chronic disease. This cross-sectional pilot study assesses factors associated with reduced adherence, indicated by higher ARMS scores, among individuals in this birth cohort. To elucidate factors associated with medication adherence, measured by the ARMS score, among a birth cohort at higher risk for HCV to guide future treatment and improve adherence. Patients born between 1945 and 1965, accessing care at an academic family medicine clinic, were recruited between April and June 2019. Demographics, prior HCV diagnosis, HCV risk factors (prior imprisonment, tattoos, and intravenous drug use), depression assessment (Patient Health Questionnaire-9), adverse childhood experiences (ACEs), and ARMS scores were collected. Mean ARMS scores were compared using t tests and analysis of variance (α = 0.05), while multiple variable models were performed using linear regression. Women comprised 58% of participants (n = 76), 52% reported depression and 37% 4 or more ACEs. The mean ARMS score was 16.3 (SD = 3.43) and 10% reported prior diagnosis of HCV. In the final multiple variable model, ARMS scores were 2.3 points higher in those with mild depression (95% CI: 0.63, 4.04), 2.0 in those with at least 4 ACEs (95% CI: 0.55, 3.49), and 1.8 in those with tattoos (95% CI: 0.30, 3.28). ACEs and food insecurity were identified as confounding variables in those with moderate to severe depression. This study found medication adherence was related to depression, ACEs, tattoos, and food insecurity among patients in this birth cohort at higher risk for HCV.

Unpacking determinants and consequences of food insecurity for insulin resistance among people living with HIV: Conceptual framework and protocol for the NOURISH-OK study

Background:

Over the past four decades, advances in HIV treatment have contributed to a longer life expectancy for people living with HIV (PLWH). With these gains, the prevention and management of chronic co-morbidities, such as diabetes, are now central medical care goals for this population. In the United States, food insecurity disproportionately impacts PLWH and may play a role in the development of insulin resistance through direct and indirect pathways. The Nutrition to Optimize, Understand, and Restore Insulin Sensitivity in HIV for Oklahoma (NOURISH-OK) will use a novel, multi-level, integrated framework to explore how food insecurity contributes to insulin resistance among PLWH. Specifically, it will explore how food insecurity may operate as an intermediary risk factor for insulin resistance, including potential linkages between upstream determinants of health and downstream consequences of poor diet, other behavioral risk factors, and chronic inflammation.

Methods/design:

This paper summarizes the protocol for the first aim of the NOURISH-OK study, which involves purposeful cross-sectional sampling of PLWH (n=500) across four levels of food insecurity to test our conceptual framework. Developed in collaboration with community stakeholders, this initial phase involves the collection of anthropometrics, fasting blood samples, non-blood biomarkers, 24-hour food recall to estimate the Dietary Inflammatory Index (DII^®) score, and survey data. A 1-month, prospective observational sub-study (total n=100; n=25 for each food security group) involves weekly 24-hour food recalls and stool samples to identify temporal associations between food insecurity, diet, and gut microbiome composition. Using structural equation modeling, we will explore how upstream risk factors, including early life events, current discrimination, and community food access, may influence food insecurity and its potential downstream impacts, including diet, other lifestyle risk behaviors, and chronic inflammation, with insulin resistance as the ultimate outcome variable. Findings from these analyses of observational data will inform the subsequent study aims, which involve qualitative exploration of significant pathways, followed by development and testing of a low-DII^® food as medicine intervention to reverse insulin resistance among PLWH (ClinicalTrials.gov Identifier: NCT05208671).

Discussion:

The NOURISH-OK study will address important research gaps to inform the development of food as medicine interventions to support healthy aging for PLWH.

Design and Methods of a Participatory Healthy Eating Intervention for Indigenous Children: The FRESH Study

Objective

To increase vegetable and fruit intake, reduce body mass index (BMI), and improve parental blood pressure among American Indian families.

Design

Randomized, wait-list controlled trial testing a multi-level (environmental, community, family, and individual) multi-component intervention with data collection at baseline and 6 months post-intervention.

Setting

Tribally owned and operated Early Childhood Education (ECE) programs in the Osage Nation in Oklahoma.

Participants

American Indian families (at least one adult and one child in a ECE program). A sample size of 168 per group will provide power to detect differences in fruit and vegetable intake.

Intervention

The 6-month intervention consisted of a (1) ECE-based nutrition and gardening curriculum; (2) nutrition education and food sovereignty curriculum for adults; and (3) ECE program menu modifications.

Main Outcome Measures

The primary outcome is increase in fruit and vegetable intake, assessed with a 24-h recall for adults and plate weight assessments for children. Secondary outcomes included objective measures of BMI among adults and children and blood pressure among adults.

Development and Implementation of a Hybrid Online and In-Person Food Sovereignty and Nutrition Education Curriculum for Native American Parents: The FRESH Study

The Food Resource Equity and Sustainability for Health ("FRESH") study is an Indigenous-led intervention to increase vegetable and fruit intake among Native American children. As part of this study, we developed a hybrid (online and in-person) food sovereignty and nutrition education curriculum for the parents of these children. This 16-week curriculum was developed to promote household- and community-level healthy eating and food sovereignty practices to parents of preschool-aged children residing in Osage Nation, Oklahoma. A total of 81 parent/caregivers participated in the curriculum component of the FRESH study, with a median age of 34 years (range: 23-54 years). Most study participants were female (88.9%) and less than half (45.7%) had an annual household income of more than US$50,000. Most were married or had a significant other (76.5%) and worked full-time (65.4%). The median total number of children in the home <18 years of age was three (range: 1-8). Participation among the 94 parents was 56% during the first week and was 12% in the final week. Having some college or technical training (vs. having a college degree) and having an annual household income of US$20,000-US$50,000 (vs. more than US$50,000) were associated with fewer sessions attended (p = 0.004 and 0.02, respectively) Being married (vs. not) was associated with higher attendance (p < .0001). Participation in a hybrid food sovereignty and nutrition education curriculum for parents was generally low, but income, education, and marital status were associated with curriculum participation. Our research adds to the literature by describing the development and implementation of this curriculum and recommendations for future research incorporating Indigenous approaches to health.

Methods for Assessing Willingness to Try and Vegetable Consumption among Children in Indigenous Early Childcare Settings: The FRESH Study

Food preferences begin in early childhood, and a child's willingness to try (WTT) new vegetables is an important determinant of vegetable intake. Young children living in rural communities are at increased risk for food insecurity, which may limit exposure to and consumption opportunities for vegetables. This manuscript describes the validation of the Farfan-Ramirez WTT (FR-WTT) measure using baseline data from the FRESH study, a gardening intervention for Native American families with preschool-aged children in Osage Nation, Oklahoma. Individually weighed vegetable containers were prepared with six types of vegetables and ranch dip. Researchers presented children (n = 164; M = 4.3 years, SD = 0.8) with these vegetables preceding a snack- or lunch time and recorded the child's FR-WTT for each vegetable using a 5-point scale, ranging from "did not remove food (0)" to "put food in mouth and swallowed (4)". After the presentation period, contents were re-weighed to calculate vegetable consumption. Household parents/guardians completed the Child Food Neophobia Scale (CFNS) for their child. FR-WTT scores were positively correlated with consumption weights of all vegetables (r = 0.7613, p < 0.0001) and each vegetable individually (r = 0.2016-0.7664). The total FR-WTT score was inversely correlated with the CFNS score (r = 0.3268, p < 0.0001). Sensitivity analyses demonstrated similar relationships by BMI, food security, and age. In conclusion, the FR-WTT is a valid method for assessing young children's vegetable eating behavior and intake.

Beyond Groceries: An Analysis of Referral Needs to Address Underlying Causes of Child Hunger among Households Accessing Food Pantries

Very low food security among children (VLFS-C), often referred to as child hunger, can profoundly hinder child development, family well-being, and community health. Food pantries are important community resources that routinely serve at-risk families. This study investigated the influence of various candidate risk factors for VLFS-C within a food pantry population to inform the development of the "Pantry Assessment Tool against Child Hunger (PATCH)." We collected standardized surveys among a representative sample of households with children accessing food pantry services in Oklahoma (n = 188). Weighted analyses revealed a large majority of households experienced child-level food insecurity (70.6%), with nearly half reporting low food security and nearly one-quarter reporting VLFS-C. We then used logistic regression to identify factors associated with VLFS-C, followed by chi-square automatic interaction detection (CHAID) to assess if, and in what progression, significant risk factors predicted VLFS-C. In unadjusted models, annual household income <$15,000, non-urban residence, lack of health insurance, unstable housing, heavier food pantry reliance, fair or poor adult health, adult anxiety, and adult smoking to reduce hunger pangs were all positively associated with VLFS-C. Receipt of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and higher social support were protective against VLFS-C. However, in adjusted models, only receipt of WIC remained significant. CHAID analysis revealed that access to insurance best differentiated groups with and without VLFS-C. Informed by these analyses, the PATCH tool may be useful for the development of screening programs to identify and address potential root causes of VLFS-C in pantry settings.

Misclassification Error-Adjusted Prevalence of Injection Drug Use Among Infective Endocarditis Hospitalizations in the United States: A Serial Cross-Sectional Analysis of the 2007-2016 National Inpatient Sample

Administrative health databases have been used to monitor trends in infective endocarditis hospitalization related to nonprescription injection drug use (IDU) using International Classification of Diseases (ICD) code algorithms. Because no ICD code for IDU exists, drug dependence and hepatitis C virus (HCV) have been used as surrogate measures for IDU, making misclassification error (ME) a threat to the accuracy of existing estimates. In a serial cross-sectional analysis, we compared the unadjusted and ME-adjusted prevalences of IDU among 70,899 unweighted endocarditis hospitalizations in the 2007-2016 National Inpatient Sample. The unadjusted prevalence of IDU was estimated with a drug algorithm, an HCV algorithm, and a combination algorithm (drug and HCV). Bayesian latent class models were used to estimate the median IDU prevalence and 95% Bayesian credible intervals and ICD algorithm sensitivity and specificity. Sex- and age group-stratified IDU prevalences were also estimated. Compared with the misclassification-adjusted prevalence, unadjusted estimates were lower using the drug algorithm and higher using the combination algorithm. The median ME-adjusted IDU prevalence increased from 9.7% (95% Bayesian credible interval (BCI): 6.3, 14.8) in 2008 to 32.5% (95% BCI: 26.5, 38.2) in 2016. Among persons aged 18-34 years, IDU prevalence was higher in females than in males. ME adjustment in ICD-based studies of injection-related endocarditis is recommended.

Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation

Importance

In 2019, hepatitis C virus (HCV) infection contributed to more deaths in the US than 60 other notifiable infectious diseases combined. The incidence of and mortality associated with HCV infection are highest among American Indian and Alaska Native individuals.

Objective

To evaluate the association of the Cherokee Nation (CN) HCV elimination program with each element of the cascade of care: HCV screening, linkage to care, treatment, and cure.

Design, Setting, and Participants

This cohort study used data from the CN Health Services (CNHS), which serves approximately 132 000 American Indian and Alaska Native individuals residing in the 14-county CN reservation in rural northeastern Oklahoma. Data from the first 22 months of implementation (November 1, 2015, to August 31, 2017) of an HCV elimination program were compared with those from the pre-elimination program period (October 1, 2012, to October 31, 2015). The analysis included American Indian and Alaska Native individuals aged 20 to 69 years who accessed care through the CNHS between October 1, 2012, and August 31, 2017. Cure data were recorded through April 15, 2018.

Exposure

The CN HCV elimination program.

Main Outcomes and Measures

The main outcomes were the proportions of the population screened for HCV, diagnosed with current HCV infection, linked to care, treated, and cured during the initial 22 months of the elimination program period and the pre-elimination program period. Data from electronic health records and an HCV treatment database were analyzed. The cumulative incidence of HCV infection in this population was estimated using bayesian analyses.

Results

Among the 74 039 eligible individuals accessing care during the elimination program period, the mean (SD) age was 36.0 (13.5) years and 55.9% were women. From the pre-elimination program period to the elimination program period, first-time HCV screening coverage increased from 20.9% to 38.2%, and identification of current HCV infection and treatment in newly screened individuals increased from a mean (SD) of 170 (40) per year to 244 (4) per year and a mean of 95 (133) per year to 215 (9) per year, respectively. During the implementation period, of the 793 individuals with current HCV infection accessing the CNHS, 664 were evaluated (83.7%), 394 (59.3%) initiated treatment, and 335 (85.0%) had documented cure. In less than 2 years, the 85% 3-year goal was reached for cure (85.0%), and the goal for linkage to care was nearly reached (83.7%), whereas screening (44.1%) and treatment initiation (59.3%) required more time and resources.

Conclusions and Relevance

This cohort study found that after 22 months of implementation, the CNHS community-based HCV elimination program was associated with an improved cascade of care. The facilitators and lessons learned in this program may be useful to other organizations planning similar programs.

Impact of a Healthy Retail Intervention on Fruits and Vegetables and Total Sales in Tribally Owned Convenience Stores: Findings From the THRIVE Study

BACKGROUND

Healthy retail interventions are a recommended intervention strategy to address diet-related diseases, such as obesity and diabetes; however, retail managers are concerned about their bottom line. This study's aim was to assess the impact of a healthy retail intervention on fruits and vegetables (FV) sales, as well as total sales, in tribally owned convenience stores where grocery stores are scarce.

METHOD

We analyzed weekly sales data over the first 6 months of a healthy retail intervention. We assessed the proportion of sales from two FV baskets. The FV basket included all fresh, canned, and dried FV sold at stores; while the fruits, vegetables, and salads (FVS) basket included all FV items as well as all salads sold. We compared mean weekly sales rates in intervention and control stores over the 6-month period using generalized estimating equations models to account for repeated measures.

RESULTS

Mean weekly FV basket sales rates were higher in intervention stores than control stores in both Nations. Mean weekly FVS baskets sales were significantly higher in intervention stores than control stores in one Nation and were higher, but not statistically significant, in intervention stores in the other Nation. Total sales remained steady throughout the intervention period.

CONCLUSIONS

The THRIVE (Tribal Health and Resilience in Vulnerable Environments) intervention increased FV sales without negatively affecting total sales. Policy and Practice Implications. Healthy retail interventions in tribal convenience stores, where many Native Americans living in rural areas shop due to scarcity of grocery stores, could improve diet-related disparities without reducing total sales.

Validity of International Classification of Diseases codes in identifying illicit drug use target conditions using medical record data as a reference standard: A systematic review

BACKGROUND

The twenty-first century opioid crisis has spurred interest in using International Classification of Diseases (ICD) code algorithms to identify patients using illicit drugs from administrative healthcare data. We conducted a systematic review of studies that validated ICD code algorithms for illicit drug use against a reference standard of medical record data.

METHODS

Systematic searches of MEDLINE, EMBASE, PsycINFO, and Web of Science were conducted for studies published between 1980 and 2018 in English, French, Italian, or Spanish. We included validation studies of ICD-9 or ICD-10 code algorithms for an illicit drug use target condition (e.g., illicit drug use, abuse, or dependence (UAD), illicit drug use-related complications) given the sensitivity or specificity was reported or could be calculated. Bias was assessed with the Quality Assessment of Diagnostic Accuracy Studies Version 2 (QUADAS-2) tool.

RESULTS

Six of the 1210 articles identified met the inclusion criteria. For validation studies of broad UAD (n = 4), the specificity was nearly perfect, but the sensitivity ranged from 47% to 83%, with higher sensitivities tending to occur in higher prevalence populations. For validation studies of injection drug use (IDU)-associated infective endocarditis (n = 2), sensitivity and specificity were poor due to the lack of an ICD code for IDU. For all six studies, the risk of bias for the QUADAS-2 "reference standard" and "flow/timing domains" was scored as "unclear" due to insufficient reporting.

CONCLUSIONS

Few studies have validated ICD code algorithms for illicit drug use target conditions, and available evidence is challenging to interpret due to inadequate reporting. PROSPERO Registration: CRD42019118401.

Process Evaluation Tool Development and Fidelity of Healthy Retail Interventions in American Indian Tribally Owned Convenience Stores: the Tribal Health Resilience in Vulnerable Environments (THRIVE) Study

BACKGROUND

The Tribal Health Resilience in Vulnerable Environments (THRIVE) study aimed to increase healthy food access in 2 rural American Indian communities. The intervention sought to increase fruit and vegetable availability, variety, and convenience through placement, promotion, and pricing of healthy foods and beverages in tribal convenience stores.

OBJECTIVE

The aim of this study was to describe the development and implementation of the study process evaluation tool to assess intervention fidelity as part of this cluster-controlled trial.

METHODS

Eight stores (2 intervention and 2 control stores per Nation) participated in the study, implemented from May 2016 to May 2017. A web-based survey tailored to store layouts and intervention components assessed how often intervention items were available, approximate quantity available, and whether placement of healthier food items and promotional materials were implemented as designed. After pilot testing the survey, tribal staff members implemented it to collect process evaluation data in the 8 stores during a period of 9-12 mo, assessing study implementation and potential changes in control stores.

RESULTS

Promotional materials were available ≥75% of the time for most intervention locations. Fruit availability was similar in Nation A and Nation B intervention stores (79-100% compared with 70-100%), whereas fresh vegetable availability was higher in Nation B compared with Nation A (95-96% compared with 55-75%). Both control stores in Nation A and 1 control store in Nation B had moderate fruit and vegetable availability, ranging from 45% to 52%. No control stores in either Nation used intervention promotional materials.

CONCLUSIONS

Process evaluation data indicate that the study was implemented with moderate to high fidelity. The development and implementation of the tool can inform future healthy retail interventions that aim to improve rural and tribal food environments.

The Impact of Responsive Feeding Practice Training on Teacher Feeding Behaviors in Tribal Early Care and Education: The Food Resource Equity and Sustainability for Health (FRESH) Study

BACKGROUND

Establishing healthy eating habits early affects lifelong dietary intake, which has implications for many health outcomes. With children spending time in early care and education (ECE) programs, teachers establish the daytime meal environment through their feeding practices.

OBJECTIVE

We aimed to determine the effect of a teacher-focused intervention to increase responsive feeding practices in 2 interventions, 1 focused exclusively on the teacher's feeding practices and the other focused on both the teacher's feeding practices and a nutrition classroom curriculum, in ECE teachers in a Native American (NA) community in Oklahoma.

METHODS

Nine tribally affiliated ECE programs were randomly assigned to 1 of 2 interventions: 1) a 1.5-h teacher-focused responsive feeding practice training (TEACHER; n = 4) and 2) TEACHER plus an additional 3-h training to implement a 15-wk classroom nutrition curriculum (TEACHER + CLASS; n = 5). Feeding practice observations were conducted during lunch at 1 table in 1 classroom for 2- to 5-y-olds at each program before and 1 mo after the intervention. The Mealtime Observation in Child Care (MOCC) organizes teacher behaviors into 8 subsections. Descriptive statistics and the Shapiro-Wilk test for normality were calculated. Paired t tests were calculated to determine change in each group.

RESULTS

A mean ± SD of 5.2 ± 2.0 (total n = 47) children and 1.7 ± 0.5 (total n = 14) teachers/center were observed at baseline, and 5.6 ± 1.7 (total n = 50) children and 1.7 ± 0.7 teachers (total n = 14) were observed/center postintervention. Total MOCC scores (max possible = 10) improved for TEACHER (6.1 ± 0.9 compared with 7.5 ± 0.3, t = 4.12, P = 0.026) but not for TEACHER + CLASS (6.5 ± 0.8 compared with 6.4 ± 1.0, t = -0.11, P = 0.915). No other changes were observed.

CONCLUSIONS

Teacher intervention-only programs demonstrated improvements in responsive feeding practices, whereas the programs receiving teacher and classroom training did not. Greater burden likely decreased capacity to make changes in multiple domains. We demonstrated the ability to implement interventions in NA ECE. Further research with larger communities is necessary. This trial was registered at clinicaltrials.gov as NCT03251950.

Diabetes and Obesity Associated with Poor Food Environments in American Indian Communities: the Tribal Health and Resilience in Vulnerable Environments (THRIVE) Study

BACKGROUND

American Indians (AIs) have significantly higher rates of diet-related chronic diseases than other racial/ethnic groups, and many live in environments with limited access to healthy food.

OBJECTIVE

As part of the Tribal Resilience in Vulnerable Environments (THRIVE) study, we examined the relations between the perceived food environment, utilization of food retailers, fruit and vegetable intake, and chronic diseases, including obesity, hypertension, and type 2 diabetes among AI adults.

METHODS

Through a community-based participatory research partnership, we surveyed a cross-sectional sample of 513 AIs living within the Chickasaw Nation and the Choctaw Nation of Oklahoma.

RESULTS

Only 57% of participants reported that it was easy to purchase fruits and vegetables in their town, and fewer (35%) reported that available fruits and vegetables were of high quality. Additionally, over half (56%) reported traveling ≥20 miles round trip to shop for food. Few participants met the recommended daily intake for fruit (44%) or vegetables (25%). Obesity (55%), hypertension (49%), and diabetes (25%) were commonly reported. Obesity was significantly higher among participants who reported that the price of fruits and vegetables were cost-prohibitive (prevalence proportion ratio (PPR): 1.24; 95% CI: 1.02, 1.50) and those who shopped frequently for food at nontraditional food retailers, such as Dollar Stores (PPR: 1.35; 95% CI: 1.08, 1.69) and small markets (PPR: 1.38; 95% CI: 1.02, 1.86). Diabetes was significantly higher among participants who frequently shopped at convenience stores/gas stations (PPR: 2.26; 95% CI: 1.22, 4.19).

CONCLUSIONS

Our study found that the use of nontraditional food retailers, including convenience stores, gas stations, and Dollar Stores, as a regular source of food was associated with obesity and diabetes. These results underscore the importance of interventions to improve rural Tribal food environments. Healthy retail interventions in nontraditional retail settings, such as those implemented through the THRIVE study, may contribute to reducing AI health disparities.

Characteristics of Households of People With Diabetes Accessing US Food Pantries: Implications for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to explore the associations between food insecurity (FI) and coping strategies of relevance to diabetes self-management among households of people with diabetes (HHDM) who access US food pantry programs.

METHODS

The authors conducted a secondary data analysis of HHDM accessing US food pantry programs from the Hunger in America 2014 study (n = 16 826). Weighted analyses included descriptive statistics for household sociodemographics, food pantry service utilization, FI, and coping behaviors. The authors used chi-square and logistic regression to estimate the relationship between FI and coping behaviors.

RESULTS

Nearly one-half of HHDM reported visiting food pantries at least 6 times in the past year. Most HHDM were FI, with the majority experiencing the most severe form of FI. Over one-fifth of households reported lacking health insurance. The majority of HHDM reported purchasing inexpensive unhealthy foods to ensure household food adequacy, and many reported watering down food and beverages. The odds of reporting these behaviors significantly increased as FI worsened.

CONCLUSION

Food pantries represent an opportunity for the delivery of community-based diabetes self-management education and support programs. These programs should be adapted to address population barriers to self-management and to support access to healthful foods and medical care.

Social Support and Physical Activity Among American Indians in Oklahoma: Results From a Community-based Participatory Research Study

PURPOSE

Little is known about the contribution of social support to physical activity (PA) behavior among American Indians (AIs). This community-based participatory research study examined the prevalence of and associations between different types of PA social support and PA among AIs in rural Oklahoma.

METHODS

Our tribal-academic partnership surveyed AI adults (N = 513) living within the tribal jurisdictional areas of 2 tribal nations. We used the Physical Activity Social Support (PASS) scale to assess 3 types of PA social support and Poisson regression to investigate associations between PASS types and self-reported PA behavior.

FINDINGS

Over a third of participants perceived high levels of PA social support from friends (37%), family (35%), and overall (34%), yet only 29% reported regular PA (ie, 150 minutes or more weekly). Participants who exercised with pets/other were significantly more likely to achieve regular PA than those who exercised alone (PR 2.0, 95% CI: 1.4-2.9). Although not significant, compared with those reporting no/low support, participants with high friend PASS (PR 1.2, 95%: CI 0.9-1.6), medium family PASS (PR 1.2, 95% CI: 0.9-1.7), and overall PASS (PR 1.1, 95% CI: 0.8-1.6) were more likely to report regular PA.

CONCLUSIONS

The majority of participants did not meet current recommendations for PA behavior, which underscores the ongoing need for PA effective interventions among AIs living in rural areas. Results suggest that exercising with pets/other could be an important factor for future intervention. Further research is needed to elucidate determinants of PA and test interventions to increase PA among AIs.

Development and Evaluation of a Nutrition-Centered Lifestyle Medicine Curriculum for Physician Assistant Students

BACKGROUND

US medical schools are increasingly integrating lifestyle medicine competencies into their academic programs. Yet, physician assistant (PA) academic programs have been slower to respond.

METHODS

We developed, implemented, and evaluated a nutrition-centered lifestyle medicine curriculum for 2nd-year PA students (n = 24). The 4-week hybrid, 2-credit hour course activities aligned with the American College of Lifestyle Medicine competencies for primary care providers and reinforced four of the Accreditation Standards for PA Education. We combined didactic lectures with weekly hands-on cooking modules from the "Health meets Food" courseware for medical students. We employed a pre-post evaluation design including a comparison group of 2nd-year PA students in a separate program. We assessed changes in personal nutrition behaviors and knowledge and confidence for counseling in nutrition, exercise/physical activity, weight, smoking, and alcohol, using the modified 5A's framework (assess, advise, agree, assist, and arrange) for lifestyle counseling.

RESULTS

Students receiving the intervention demonstrated significantly higher gains in both knowledge and confidence for the 5A's of nutrition counseling compared to the control group. Self-reported knowledge and confidence for the 5A's of counseling for the other lifestyle behaviors similarly improved among the intervention group compared to the control group, but to a lesser extent.

CONCLUSION

A nutrition-centered lifestyle medicine course can demonstrate PA academic program adherence to accreditation standards, while also introducing students to nutrition and lifestyle medicine competencies. Hands-on experiences that reinforce didactic instruction may maximize student knowledge and self-efficacy for implementing lifestyle medicine into their practice.

Quitline treatment dose predicts cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect

The efficacy of tobacco treatment delivered by state quitlines in diverse populations is well-supported, yet little is known about associations between treatment dose and cessation outcomes following the implementation of Ask-Advise-Connect (AAC), an electronic health record-based systematic referral process that generates a high volume of proactive calls from the state quitline to smokers. The current study is a secondary analysis of a 34-month implementation trial evaluating ACC in 13 safety-net clinics in Houston, TX. Treatment was delivered by a quitline and comprised up to five proactive, telephone-delivered multi-component cognitive-behavioral treatment sessions. Associations between treatment dose and abstinence were examined. Abstinence was assessed by phone six months after treatment enrollment, and biochemically confirmed via mailed saliva cotinine. Among smokers who enrolled in treatment and agreed to follow-up (n = 3704), 29.2% completed no treatment sessions, 35.5% completed one session, 16.4% completed two sessions, and 19.0% completed ≥three sessions. Those who completed one (vs. no) sessions were no more likely to report abstinence (OR: 0.98). Those who completed two (vs. no) sessions were nearly twice as likely to report abstinence (OR: 1.83). Those who completed ≥three (vs. no) sessions were nearly four times as likely to report abstinence (OR: 3.70). Biochemically-confirmed cessation outcomes were similar. Most smokers received minimal or no treatment, and treatment dose had a large impact on abstinence. Results highlight the importance of improving engagement in evidence-based treatment protocols following enrollment. Given that motivation to quit fluctuates, systematically offering enrollment to all smokers at all visits is important.

•

The majority of smokers received minimal or no evidence-based tobacco treatment.

•

Smokers who completed 0 or 1 treatment sessions were unlikely to achieve abstinence.

•

Completion of 2 calls doubled the likelihood of abstinence at 6 months.

•

Completion of ≥3 calls was associated with a near quadrupling of abstinence rates.

•

Improving engagement in evidence-based treatment protocols is a research priority.

A Nutrition Environment Measure to Assess Tribal Convenience Stores: The THRIVE Study

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment-food availability, pricing, quality, and placement-and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

SNAP-Based Incentive Programs at Farmers' Markets: Adaptation Considerations for Temporary Assistance for Needy Families (TANF) Recipients

OBJECTIVE

To describe the design, implementation, and consumer response to a coupon-style intervention aimed to increase Supplemental Nutrition Assistance Program (SNAP) use at a farmers' market (FM) among Temporary Assistance for Needy Families (TANF) participants.

DESIGN

A quasi-experimental trial to evaluate redemption response to 2 coupon interventions; baseline surveys characterized coupon redeemers and non-redeemers.

SETTING

Urban.

PARTICIPANTS

The TANF recipients were assigned to either a plain (n = 124) or targeted marketing coupon intervention (n = 130).

INTERVENTION(S)

Both groups received 10 $2 coupons to double fruit and vegetable SNAP purchases at the FM. The targeted marketing group also received an oral presentation designed to reduce perceived barriers to FM use.

MAIN OUTCOME MEASURE

Coupon redemption.

ANALYSIS

The researchers used t tests and chi-square/Fisher exact tests to examine associations between redeemers and non-redeemers; logistic regression was used to adjust for the intervention.

RESULTS

No male and few female participants redeemed coupons (6.3%). Among women, those with knowledge of vegetable preparation were 3 times more likely to redeem coupons than were those with little or no knowledge (odds ratio = 3.77; 95% confidence interval, 1.03-13.77).

CONCLUSIONS AND IMPLICATIONS

Stand-alone coupon incentive programs may not be a high-reach strategy for encouraging FM use among the population using TANF. Complementary strategies to build vegetable preparation knowledge and skills are needed.

State-Level Correlates of Unassisted Quit Attempts and Success

BACKGROUND

Although the majority of smokers attempting to quit do so without assistance, research in the area of unassisted quit behaviors is limited. The aim of this study was to investigate whether population-level policies and programs, such as smoke-free air policies and tobacco control programs, contribute to unassisted quit attempts and cessation.

METHODS

The current study used the 2003 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) special Cessation Supplement (CS) to estimate unassisted quit attempt and success rates by state. Linear regression was used to examine whether state-level unassisted quit attempt and success rates were related to state-level policies and social norms. State-level factors investigated were tobacco control program funding, tobacco taxes, smoke-free air policies, state anti-smoking sentiment and recent change in smoking prevalence.

RESULTS

Consistent with previous studies, this study found the majority of smokers who attempted to quit did so without assistance. This study also found unassisted quit attempt rates were higher than assisted attempt rates in every state and DC. Additionally, unassisted quit success rates were higher than assisted quit success rates in most states; however, some states had higher assisted quit success rates. State-level factors associated with unassisted quit attempt rates included anti-smoking sentiment and tobacco taxes; however, no significant relationships were uncovered between unassisted quit success rates and state-level factors.

CONCLUSIONS

These results suggest that state-level factors may be more important in motivating smokers to attempt quitting, and other individual factors or unmeasured state factors may be related to quit success.

Communities of excellence in tobacco control: changes in local policy and key outcomes

BACKGROUND

The Oklahoma Communities of Excellence in Tobacco Control (CX) program was established in 2004. Thirty-three CX grants have been funded to implement comprehensive tobacco control programs in 50 counties and one tribal nation.

PURPOSE

To describe local tobacco policy gains within CX counties and short-term and intermediate outcomes such as Oklahoma Tobacco Helpline registration and awareness, quit attempts, and home smoking bans among adults.

METHODS

A before-and-after study design examined outcomes within CX counties and among CX urban and rural counties. Comparisons were made with non-funded counties when possible. Local policy tracking databases were reviewed for the number of policies implemented from 2004 to 2013 in CX counties. Population-level tobacco indicators, using Helpline registration and 2004-2010 Behavioral Risk Factor Surveillance System data, quantified changes over time. Data were collected in 2003-2013 and analyzed in 2013.

RESULTS

Eight hundred thirty-one legislated and voluntary policies were implemented in CX counties and high levels of Helpline registration were maintained. Statistically significant increases were observed in CX counties for the proportion of smokers making a quit attempt, Helpline awareness, and home smoking bans among smokers. These observed increases were greater in rural CX counties than urban. Non-CX counties only experienced a statistically significant increase in Helpline awareness.

CONCLUSIONS

Using community-based best practices in tobacco control while focusing on social norm change, CX counties experienced positive changes in smoking-related attitudes and behaviors. This study expands the evidence base for statewide tobacco control programming and underscores the value of community-based tobacco control programs.

Phantom evaluations of a dedicated dual-head scintimammography system

Results of aboratory evaluations are presented of the dual-head scintimammography system using two opposed and co-registered compact gamma heads. The system is intended for clinical studies imaging suspicious lesions in a compressed breast. The studies were performed using 5 cm and 6 cm compressed breast phantoms with lesion sizes from 6 to 10 mm and lesion to breast tissue activity ratios from 6 to 10. Two imagers with a field-of-view (FOV) of 15 cmx20 cm were placed on the opposite sides of the breast phartoms. In some studies anthropomorphic torso phantom was used to simulate realistic scatter gamma radiation field. Two types of parallel-hole lead collimators were employed. Combining the co-registered images from both detector heads resulted in an over two-fold increase in lesioin contrast in the central plane of the phantom and substantially increased detection sensitivity over the whole breast volume, especially of asymmetrically placed small lesions. The results confirm the important advantage of a co-registoed two-head scintimammography system over a single head system in lesion detection and localization.

Experimental and theoretical studies of the reaction of the OH radical with alkyl sulfides: 2. Kinetics and mechanism of the OH initiated oxidation of methylethyl and diethyl sulfides; observations of a two channel oxidation mechanism

A pulsed laser photolysis-pulsed laser induced fluorescence technique has been employed to measure rate coefficients for the OH initiated oxidation of methylethyl sulfide (MES) and diethylsulfide (DES). In the absence of oxygen and at low sulfide concentrations we measure rate coefficients that are independent of pressure and temperature. At high sulfide concentrations and a temperature of 245 K, we observed the equilibration of MESOH and DESOH adducts over the pressure range 100-600 Torr. In the presence of O(2) the observed rate coefficients show a dependence on the O(2) partial pressure. We measured the dependence of the overall rates of oxidation on the partial pressure of O(2) over the temperature range 240-295 K and at 200 and 600 Torr total pressures. All observations are consistent with oxidation proceeding via a two channel oxidation mechanism involving abstraction and addition channels, analogous to that observed in the OH initiated oxidation of dimethylsulfide (DMS). Structures and thermochemistry of the MESOH and DESOH adducts were calculated and all results compared to those for DMS. Calculated bond strengths of adducts increase with alkyl substitution but are comparable to that of the DMSOH adduct and are consistent with experimental observations.

Experimental and Theoretical Studies of the Reaction of the OH Radical with Alkyl Sulfides: 1. Direct Observations of the Formation of the OH−DMS Adduct−Pressure Dependence of the Forward Rate of Addition and Development of a Predictive Expression at Low Temperature

A pulsed laser photolysis-pulsed laser-induced fluorescence (PLP-PLIF) system was employed to study the kinetics and mechanisms of reactions (1) OH + h6-DMS --> products and (2) OH + d6-DMS --> products. We report direct observations of the rate coefficients for the formation and dissociation of the h6-OHDMS and d6-OHDMS adducts over the pressure range 50-650 Torr and between 240 and 245 K, together with measurements of the oxygen dependence of the effective rate coefficients for reactions 1 and 2 under similar conditions. The effective rate coefficients increased as a function of O2 concentration reaching their limiting values in each case. The values of the adduct formation rate, obtained from the O2 dependencies, were in excellent agreement with values determined from direct observation of adduct equilibration in N2. OH regeneration is insignificant. The rate coefficients for the formation of the adduct isotopomers showed slight differences in their falloff behavior and do not approach the high-pressure limit in either case. The equilibrium constants obtained show no dependence on isotopomer and are in good agreement with previous work. A "second-law" analysis of the temperature dependence of the equilibrium constant gives an adduct bond strength (DeltaH degrees =-10.9 +/- 1.0 kcal mol(-1)), also in good agreement with previously reported values. Using the entropy calculated from the ab initio vibrational frequencies, we obtain a "third-law" value for the reaction enthalpy at 240 K, DeltaH(240K) degrees = -10.5 kcal mol(-1) in good agreement with the other approach. The rate coefficient for the reactions of the adducts with O2 was obtained from an analysis of the O2 dependence and was determined to be 6.3 +/- 1.2 x 10(-13) cm3 molecule(-1) s(-1), with no dependence on pressure or isotopomer. The pressure and temperature dependence for all of the elementary processes in the initial steps of the dimethylsulfide (DMS) oxidation mechanism have been characterized in the range 238-245 K, allowing the formulation of an expression which can be used to calculate the effective rate coefficient for reaction 1 at any pressure and oxygen concentration. The expression can calculate the effective rate coefficient for reaction 1 to +/- 40% over the range 220-260 K, with the largest errors at the extremes of this range. Gaussian 03 has been used to calculate the structure of the OH-DMS adduct and its deuterated isotopomer. We find similar bound structures for both isotopomers. The calculated enthalpies of formation of the adducts are lower than the experimentally determined values.

Same-day discharge is preferred by the majority of the patients undergoing radial PCI

There is limited data on patient preference for same-day discharge PCI. We contacted 953 patients who had same-day discharge radial PCI between 1998 and 2001 and checked whether they were satisfied with same-day discharge and whether they had any complications within 30 days post-PCI (vascular, repeat angiogram/PCI). Complications and health status were also verified by checking hospital records, our province-wide cath lab database and provincial vital statistics, as well as by contacting the referring doctor. A total of 811 patients responded. Of this total, 88.6% of the patients were satisfied with same-day discharge PCI, and 11.4% were not. Patients were significantly more satisfied with same-day discharge when they did not experience vascular complications (83.4% versus 91.5% satisfied with and without vascular complications at 24 hours, and 74.3% versus 90.9% at 30 days, p < 0.01). Patient preference on same-day discharge was the same regardless of whether they needed a repeat PCI within 30 days (p > 0.05). Patients for whom early discharge was important were significantly more satisfied with same-day discharge (97.9% versus 79.7% when early discharge was not important, p < 0.01). Patients who were reluctant to be discharged on the same day of the procedure were significantly less satisfied compared to those who were not (71.9% vs. 96.4% respectively, p < 0.01). A few patients (8.6%) had difficulty finding transportation home and were significantly less satisfied (70.0% vs. 90.3% when they found transportation easily, p < 0.01). In conclusion, same-day discharge is preferred by the majority of the patients undergoing radial PCI.

Comparison of the radial and femoral approaches in left main PCI: a retrospective study

Transradial percutaneous coronary intervention (PCI) is a safe and effective method of percutaneous revascularization. However, there are no data on the efficacy of the transradial approach in left main (LM) PCI. We studied 80 patients (pts) who underwent LM PCI between February 1994 and January 2002, and compared the radial (27 pts) and femoral (53 pts) approaches. Patients were considered free of restenosis if they were free of angina and had a negative treadmill or nuclear imaging study 6 months post-PCI. Mean follow-up time was 27.4+/-23.0 months. Reason for PCI (stable angina, unstable angina, acute myocardial infarction) and lesion location (ostial, mid, distal) were similar in both groups (p>0.05), whereas mean ejection fraction was higher in the radial group (56.5+/-11.1% versus 49.2+/-14.7%, respectively; p<0.05). Sheath size (7 or 8 French; 44.4% radial versus 77.3% femoral) and amount of heparin used (9,192+/-3,645 IU versus 11,468+/-5,083 IU) were significantly larger in the femoral group (p<0.05), and the use of intra-aortic balloon pump was significantly more frequent (3.7% versus 22.6%). Mean fluoroscopy time (21.3+/-12.8 minutes versus 16.7+/-8.5 minutes), amount of contrast used (227+/-92 ml versus 225+/-85 ml), mean procedural time (67.0+/-27.6 minutes versus 73.4+/-32.7 minutes), procedure success (96.3% versus 98.1%), in-hospital major adverse cardiac events (MACE; 7.4% versus 5.6%) and 6-month MACE (14.8% versus 25.5%) were similar in the 2 groups (p>0.05). However, major vascular complications occurred only in the femoral group (5.7%). Radial LM PCI is as fast and successful as the femoral approach and results in fewer vascular complications.

Alcohol and suicide death among American Indians of New Mexico: 1980-1998

The relationship between alcohol use prior to suicide was explored among American Indian decedents in New Mexico for the years 1980 through 1998. The suicide data were collected from New Mexico Vital Statistics and toxicology reports from the New Mexico Office of the Medical Investigator and matched on a case-by-case basis. Detailed analyses were undertaken for all cases of resident New Mexico Indians from the Navajo, Pueblo, and Apache cultures. Alcohol was detected in 69% of all suicides of American Indians with some variance by major tribal cultural groups (range = 62.1% to 84.4%). This is higher than in suicides among the overall New Mexico population (44.3%). The mean blood alcohol concentration (BAC) of the drinking Indian decedents at suicide was 0.198 (+/- SD of .088). Mean BACs were high for both males (0.199) and females (0.180) who had been drinking. Over 90% of the Indian decedents who had been drinking had BACs greater than the legal intoxication level of 0.08. The Navajo had the lowest percentage of cases that were alcohol involved, and their mean BAC was lower than the other two cultural groups. Alcohol use for completed suicides also varied somewhat by age, sex, method of suicide, and place of occurrence, but very little by whether the decedent was an on or off reservation resident. Analyses indicated that alcohol use prior to suicide was significantly more associated with male suicides than for females, and it was negatively correlated for those who died by overdose and also those using other drugs at suicide. Otherwise, alcohol use did not significantly differentiate American Indian suicides by age, use of firearms, hanging, use of other methods, or residence, for the presence of alcohol was a factor very commonly associated with all of these variables. Heavy alcohol consumption is, therefore, an important factor in over two thirds of all completed suicides among the Indians of New Mexico.

Radiologists' preferences for digital mammographic display. The International Digital Mammography Development Group

PURPOSE

To determine the preferences of radiologists among eight different image processing algorithms applied to digital mammograms obtained for screening and diagnostic imaging tasks.

MATERIALS AND METHODS

Twenty-eight images representing histologically proved masses or calcifications were obtained by using three clinically available digital mammographic units. Images were processed and printed on film by using manual intensity windowing, histogram-based intensity windowing, mixture model intensity windowing, peripheral equalization, multiscale image contrast amplification (MUSICA), contrast-limited adaptive histogram equalization, Trex processing, and unsharp masking. Twelve radiologists compared the processed digital images with screen-film mammograms obtained in the same patient for breast cancer screening and breast lesion diagnosis.

RESULTS

For the screening task, screen-film mammograms were preferred to all digital presentations, but the acceptability of images processed with Trex and MUSICA algorithms were not significantly different. All printed digital images were preferred to screen-film radiographs in the diagnosis of masses; mammograms processed with unsharp masking were significantly preferred. For the diagnosis of calcifications, no processed digital mammogram was preferred to screen-film mammograms.

CONCLUSION

When digital mammograms were preferred to screen-film mammograms, radiologists selected different digital processing algorithms for each of three mammographic reading tasks and for different lesion types. Soft-copy display will eventually allow radiologists to select among these options more easily.

Image processing algorithms for digital mammography: a pictorial essay

Digital mammography systems allow manipulation of fine differences in image contrast by means of image processing algorithms. Different display algorithms have advantages and disadvantages for the specific tasks required in breast imaging-diagnosis and screening. Manual intensity windowing can produce digital mammograms very similar to standard screen-film mammograms but is limited by its operator dependence. Histogram-based intensity windowing improves the conspicuity of the lesion edge, but there is loss of detail outside the dense parts of the image. Mixture-model intensity windowing enhances the visibility of lesion borders against the fatty background, but the mixed parenchymal densities abutting the lesion may be lost. Contrast-limited adaptive histogram equalization can also provide subtle edge information but might degrade performance in the screening setting by enhancing the visibility of nuisance information. Unsharp masking enhances the sharpness of the borders of mass lesions, but this algorithm may make even an indistinct mass appear more circumscribed. Peripheral equalization displays lesion details well and preserves the peripheral information in the surrounding breast, but there may be flattening of image contrast in the nonperipheral portions of the image. Trex processing allows visualization of both lesion detail and breast edge information but reduces image contrast.

Application and maintenance habits do make a difference in adhesion of Alora transdermal systems

OBJECTIVES

To explore and evaluate Alora placebo patch application and maintenance habits of women in order to identify the factors that influence adhesion success.

METHODS

This single-center, open-label, placebo, randomized, multiple-application, parallel-group study involved 99 healthy naïve users of transdermal patches. Participants applied and wore an Alora placebo patch for ten consecutive applications of approximately 3.5 days each and evaluated adhesion of the patches twice-daily. Three subgroups comprising participants achieving low, moderate or high adhesion success took part in focus groups to discuss their wear habits, practices and attitudes regarding transdermal patches.

RESULTS

There was a significant behavioral component involved in patch adhesion. The habits, practices and attitudes of high achievers were clearly different from the other two subgroups. The three most important issues identified to improve adhesion were: mastering the removal of the patch liner, identifying the best site of application, and developing and implementing techniques to maintain patch adhesion. The Alora placebo patch was well tolerated throughout the study.

CONCLUSION

The data showed that there is a learning curve involved in achieving maximal adhesion with a transdermal patch. During the study, a novel patch application method ('press, fold and slide') was demonstrated for the participants. This method was very well received by all participants and was more easily executed than the previous method. An adaptation of this method was incorporated into the Alora patient information leaflet, together with several other changes to help improve adhesion success.

Performance of a PSPMT based detector for scintimammography

In breast scintigraphy, compact detectors with high intrinsic spatial resolution and small inactive peripheries can provide improvements in extrinsic spatial resolution, efficiency and contrast for small lesions relative to larger conventional cameras. We are developing a pixelated small field-of-view gamma camera for scintimammography. Extensive measurements of the imaging properties of a prototype system have been made, including spatial resolution, sensitivity, uniformity of response, geometric linearity and energy resolution. An anthropomorphic torso phantom providing a realistic breast exit gamma spectrum has been used in a qualitative study of lesion detectability. A new type of breast imaging system that combines scintimammography and digital mammography in a single upright unit has also been developed. The system provides automatic co-registration between the scintigram and the digital mammogram, obtained with the breast in a single configuration. Intrinsic spatial resolution was evaluated via calculation of the phase-dependent modulation transfer function (MTF). Measurements of extrinsic spatial resolution, sensitivity and uniformity of response were made for two types of parallel hole collimator using NEMA (National Electrical Manufacturers Association) protocols. Geometric linearity was quantified using a line input and least squares analysis of the measured line shape. Energy resolution was measured for seven different crystal types, and the effectiveness of optical grease coupling was assessed. Exit gamma spectra were obtained using a cadmium zinc telluride based spectrometer. These were used to identify appropriate radioisotope concentrations for the various regions of an anthropomorphic torso phantom, such that realistic scatter conditions could be obtained during phantom measurements. For prone scintimammography, a special imaging table was constructed that permits simultaneous imaging of both breasts, as well as craniocaudal views. A dedicated breast imaging system was also developed that permits simultaneous acquisition and superposition of planar gamma images and digital x-ray images. The intrinsic MTF is nonstationary, and is dependent on the phase relationship between the signal and the crystal array matrix. Averaged over all phases, the MTF is approximately 0.75, 0.57 and 0.40 at spatial frequencies of 1.0, 1.5 and 2.0 cycles per cm, respectively. The phase averaged line spread function (LSF) has a FWHM value of 2.6 mm. Following uniformity corrections, the RMS deviations in flood images are only slightly greater than is predicted from counting statistics. Across an 80 mm section of the active area, the differential linearity is 0.83 mm and the absolute linearity 2.0 mm. Using an anthropomorphic torso phantom with detachable breasts, scatter radiation similar to that observed exiting the breast of scintimammography patients was observed. It was observed that scattered gamma rays can constitute the majority of the radiation incident on the detector, but that the scatter-to-primary ratio varies significantly across the field of view, being greatest in the caudal portion of the breast, where scatter from the liver is high. Using a lesion-to-breast concentration ratio of 6:1, a 1.0 cm3 simulated breast lesion was detectable in lateral images obtained with both the developmental camera and with a clinical camera, while a 0.35 cm3 lesion was detectable in neither. Utilization of the dual x-ray transmission, gamma emission breast imaging system greatly increases the conspicuity of scintimammographic lesions relative to prone imaging, as well as greatly facilitating the localization and identification of structures in the gamma image. The prototype imaging gamma detector exhibits spatial resolution superior to that of conventional cameras, and comparable uniformity of response and geometric linearity. Because of light losses in the crystals, the energy resolution is inferior to that of single crystal NaI(Tl) came

Detection of regional pulmonary perfusion deficit of the occluded lung using arterial spin labeling in magnetic resonance imaging

Detection of regional perfusion deficit in the lung has been demonstrated using an arterial spin labeling technique called flow-sensitive alternating inversion recovery with an extra radiofrequency pulse (FAIRER). A pulmonary artery was occluded using a nondetachable balloon catheter to simulate an acute pulmonary embolism in 3 of 10 rabbits. Inflating the balloon occludes the artery, and deflating the balloon allows for reperfusion. Perfusion imaging was performed pre-occlusion, during occlusion, and after reperfusion. Signal enhancement due to perfusion of the pulmonary parenchyma was observed in the perfusion images with negligible artifacts. The perfusion deficit of the pulmonary parenchyma was detected distal to the site of occlusion in all three rabbits. Return of the pulmonary parenchymal perfusion was observed after reperfusion. Magnetic resonance imaging using FAIRER can detect signal loss due to absence of perfusion caused by pulmonary embolism.

Analysis of the detective quantum efficiency of a developmental detector for digital mammography

We are developing a modular detector for applications in full field digital mammography and for diagnostic breast imaging. The detector is based on a design that has been refined over the past decade for applications in x-ray crystallography [Kalata et al., Proc. SPIE 1345, 270-279 (1990); Phillips et al. ibid. 2009, 133-138 (1993), Phillips et al., Nucl. Instrum. Methods Phys. Rev. A 334, 621-630 (1993)]. The full field mammographic detector, currently undergoing clinical evaluation, is formed from a 19 cm x 28 cm phosphor screen, read out by a 2 x 3 array of butted charge-coupled device (CCD) modules. Each 2k x 2k CCD is optically coupled to the phosphor via a fiber optic taper with dimensions of 9.4 cm x 9.4cm at the phosphor. This paper describes the imaging performance of a two-module prototype, built using a similar design. In this paper we use cascaded linear systems analysis to develop a model for calculating the spatial frequency dependent noise power spectrum (NPS) and detective quantum efficiency (DQE) of the detector using the measured modulation transfer function (MTF). We compare results of the calculation with the measured NPS and DQE of the prototype. Calculated and measured DQEs are compared over a range of clinically relevant x-ray exposures and kVps. We find that for x-ray photon energies between 10 and 28 keV, the detector gain ranges between 2.5 and 3.7 CCD electrons per incident x-ray, or approximately 5-8 electrons per absorbed x ray. Using a Mo/Mo beam and acrylic phantom, over a detector entrance exposure range of approximately 10 to 80 mR, the volume under the measured 2-d NPS of the prototype detector is proportional to the x-ray exposure, indicating quantum limited performance. Substantial agreement between the calculated and measured values was obtained for the frequency and exposure dependent NPS and DQE over a range of tube voltage from 25 to 30 kVp.

Treatment planning considerations and quality assurance for CT-guided transischiorectal implantation of the prostate

A CT-guided technique for prostate brachytherapy has been developed which can be performed on patients with large prostates and which allows real time evaluation and modification of implant geometry. The patient is positioned prone and radioactive Pd 103 or I 125 seeds are implanted through the transischiorectal space. Needles are inserted through a template whose plane is oriented at a nominal angle of 26 degrees away from the horizontal to facilitate needle penetration through the ischiorectal space. The CT gantry is tilted 26 degrees, so that its plane is orthogonal to that of the template. The oblique geometry between the CT gantry and direction of couch translation must be considered during source position planning, implantation, and post-treatment evaluation. This consideration is presented along with discussion of relevant quality assurance procedures and recommended tolerances. The mechanical and radiological tolerances of the CT scanner must be consistent with the high level of precision required in radiation therapy. Special emphasis was placed on gantry laser and image plane alignment, sensitivity and radiation profiles, and spatial accuracy of image reconstruction, table translation, and gantry tilt.

Noise power spectra of images from digital mammography detectors

Noise characterization through estimation of the noise power spectrum (NPS) is a central component of the evaluation of digital x-ray systems. We begin with a brief review of the fundamentals of NPS theory and measurement, derive explicit expressions for calculation of the one- and two-dimensional (1D and 2D) NPS, and discuss some of the considerations and tradeoffs when these concepts are applied to digital systems. Measurements of the NPS of two detectors for digital mammography are presented to illustrate some of the implications of the choices available. For both systems, two-dimensional noise power spectra obtained over a range of input fluence exhibit pronounced asymmetry between the orthogonal frequency dimensions. The 2D spectra of both systems also demonstrate dominant structures both on and off the primary frequency axes indicative of periodic noise components. Although the two systems share many common noise characteristics, there are significant differences, including markedly different dark-noise magnitudes, differences in NPS shape as a function of both spatial frequency and exposure, and differences in the natures of the residual fixed pattern noise following flat fielding corrections. For low x-ray exposures, quantum noise-limited operation may be possible only at low spatial frequency. Depending on the method of obtaining the 1D NPS (i.e., synthetic slit scanning or slice extraction from the 2D NPS), on-axis periodic structures can be misleadingly smoothed or missed entirely. Our measurements indicate that for these systems, 1D spectra useful for the purpose of detective quantum efficiency calculation may be obtained from thin cuts through the central portion of the calculated 2D NPS. On the other hand, low-frequency spectral values do not converge to an asymptotic value with increasing slit length when 1D spectra are generated using the scanned synthetic slit method. Aliasing can contribute significantly to the digital NPS, especially near the Nyquist frequency. Calculation of the theoretical presampling NPS and explicit inclusion of aliased noise power shows good agreement with measured values.

Establishing minimum performance standards, calibration intervals, and optimal exposure values for a whole breast digital mammography unit

Methods are developed to establish minimum performance standards, calibration intervals, and criteria for exposure control for a whole breast digital mammography system. A prototype phantom was designed, and an automatic method programmed, to analyze CNR, resolution, and dynamic range between CCD components in the image receptor and over time. The phantom was imaged over a 5 month period and the results are analyzed to predict future performance. White field recalibration was analyzed by subtracting white fields obtained at different intervals. Exposure effects were compared by imaging the prototype phantom at different kVp, filtration (Mo vs Rh) and mAs. Calcification detection tests showed that phantom images, obtained at 28 kVp with a Mo/Mo anode/filter and low mAs technique, often could not depict Al2O3 specks 0.24 mm in diameter, while a 28 kVp Mo/Rh, higher mAs technique usually could. Stability of the system tested suggests that monthly phantom imaging may suffice. Differences in CCD performance are greater (12%) than differences in a single CCD over time (6%). White field recalibration is needed weekly because of pixel variations in sensitivity which occur if longer intervals between recalibration occur. When mean glandular dose is matched, Rh filtration gives better phantom performance at 28 kVp than Mo filtration at 26 kVp and is recommended for clinical exposures. An aluminum step wedge shows markedly increased dynamic range when exit exposure is increased by using a higher energy spectrum beam. Phantoms for digital mammography units should cover the entire image receptor, should test intersections between components of the receptor, and should be automatically analyzed.

The memory B cell subset responsible for the secretory IgA response and protective humoral immunity to rotavirus expresses the intestinal homing receptor, alpha4beta7

Infection of mice with murine rotaviruses induces life-long immunity, characterized by high levels of IgA in the intestine and large numbers of rotavirus (RV)-specific Ab-secreting cells in gut-associated lymphoid tissues. Lymphocyte trafficking into gut-associated lymphoid tissues is mediated by interaction of the alpha4beta7 integrin on lymphocytes with the vascular mucosal addressin cell adhesion molecule-1. To determine whether B cell memory for RV correlates with alpha4beta7 expression, we transferred sorted B220+ phenotypically defined memory (IgD- alpha4beta7(high) and IgD- alpha4beta7-) and naive (IgD+ alpha4beta7+) splenocytes into recombination-activating gene-2 knockout mice (B and T cell-deficient) that were chronically infected with RV. Only mice receiving alpha4beta7(high) memory (IgD-) B cells produced RV-specific IgA in the stool, cleared the virus, and were immune to reinfection. Alpha4beta7(high) (but not alpha4beta7-) memory B cells from donors boosted as much as 7 mo previously also cleared the virus, indicating that alpha4beta7(high) memory B cells maintain long term functional immunity to RV. Although only alpha4beta7(high) memory cells provided mucosal immunity, alpha4beta7- cells from recently boosted donor animals could generate RV-specific serum IgG, but, like naive (IgD+) B cells, were unable to induce viral clearance even 60 days after cell transfer. These data indicate that protective immunity for an intestinal pathogen, RV, resides in memory phenotype B cells expressing the intestinal homing receptor, alpha4beta7.

Future directions in imaging of breast diseases

In the near future, investigation and refinement of emerging anatomic and functional breast imaging techniques will enable clinical trials that will evaluate their utility and potential for improving the survival and quality of life for patients with breast cancer. In the longer term, strategic research collaborations among investigators in the fields of functional imaging, molecular biology, and pathology are needed to merge existing science and advance the development of biomarker and genetic techniques focused on detecting and characterizing disease at the cellular and molecular levels. This research could create clinical tools for (a) detecting breast cancer earlier, (b) more accurately quantifying the extent of disease, (c) noninvasively evaluating lymph node involvement, (d) identifying micrometastases and residual microscopic disease, and (e) enhancing therapy by means of imaging-guided biomarker or tumor-specific delivery of pharmacologic, chemosensitizing, or radiosensitizing agents to tumors.

Expression of the mucosal homing receptor alpha4beta7 correlates with the ability of CD8+ memory T cells to clear rotavirus infection

The integrin alpha4beta7 plays an important role in lymphocyte homing to mucosal lymphoid tissues and has been shown to define a subpopulation of memory T cells capable of homing to intestinal sites. Here we have used a well-characterized intestinal virus, murine rotavirus, to investigate whether memory/effector function for an intestinal pathogen is associated with alpha4beta7 expression. Alpha4beta7(hi) memory phenotype (CD44hi), alpha4beta7- memory phenotype, and presumptively naive (CD44(lo)) CD8+ T lymphocytes from rotavirus-infected mice were sorted and transferred into Rag-2 (T- and B-cell-deficient) recipients that were chronically infected with murine rotavirus. Alpha4beta7(hi) memory phenotype CD8+ cells were highly efficient at clearing rotavirus infection, alpha4beta7- memory cells were inefficient or ineffective, depending on the cell numbers transferred, and CD44(lo) cells were completely unable to clear chronic rotavirus infection. These data demonstrate that functional memory for rotavirus resides primarily in memory phenotype cells that display the mucosal homing receptor alpha4beta7.

Expression of mucosal homing receptor alpha4beta7 by circulating CD4+ cells with memory for intestinal rotavirus

The integrin alpha4beta7 mediates lymphocyte binding to mucosal addressin cell adhesion molecule-1, and its expression defines lymphocytes capable of trafficking through the intestines and the intestinal lymphoid tissues. We examined the ability of discrete alpha4beta7(hi) and alpha4beta7- subsets of circulating memory phenotype (CD45RA-) CD4+ T cells to proliferate in response to rotavirus, a ubiquitous intestinal pathogen. alpha4beta7(hi) memory (CD45RA-) CD4+ T cells displayed much greater reactivity to rotavirus than alpha4beta7- memory or naive (CD45RA+) CD4+ T cells. In contrast, alpha4beta7- memory cells were the predominant population responsive to mumps antigen after intramuscular vaccination. Our results are consistent with the conclusion that natural rotavirus infection, an enteric pathogen, results in a specific circulating memory CD4+ response that is largely limited to the gut-homing alpha4beta7+ subpopulation. This phenotype is not shared with memory cells elicited by intramuscular immunization (shown here) or by skin contact allergens. The results support the hypothesis that gut trafficking memory CD4+ T cells comprise cellular memory for intestinal antigens and suggest that regulated expression of alpha4beta7 helps target and segregate intestinal versus systemic immune response.

Homing of naive and memory T lymphocyte subsets to Peyer's patches, lymph nodes, and spleen

The specificity and efficiency of extravasation of subsets of memory and naive lymphocytes into organized lymphoid tissues has been the subject of recent controversy, but has not been directly assessed in physiologic systems. Here, we compare the lymphoid organ homing of naive and phenotypically defined memory T cells, focusing on memory subsets differentially expressing the integrin receptor alpha4beta7, which is implicated in homing to mucosal sites. Naive T cells (CD44(low), Thy1+) home to all secondary lymphoid organs. Alpha4beta7(high) memory-phenotype (CD44(high)) T cells home to Peyer's patches as efficiently as naive lymphocytes, whereas alpha4beta7- memory-phenotype T cells are essentially excluded from entry into these mucosal lymphoid organs. In contrast, alpha4beta7- memory-phenotype cells home approximately twice as efficiently as alpha4beta7(high) T cells to peripheral lymph nodes, but only approximately 20% as well as naive T cells. Interestingly, the spleen recruits all three identified subsets with nearly equal efficiency. The relative subset localization is similar 2.5 h after injection and after overnight trafficking, suggesting that memory cells can directly extravasate from blood into Peyer's Patches and lymph nodes. We conclude that subsets of memory T cells defined by patterns of homing receptor expression display differential homing to organized lymphoid tissues, an ability that may facilitate homeostatic interactions and target contributions to specialized regional immune responses.

Homing of naive and memory T lymphocyte subsets to Peyer's patches, lymph nodes, and spleen

The specificity and efficiency of extravasation of subsets of memory and naive lymphocytes into organized lymphoid tissues has been the subject of recent controversy, but has not been directly assessed in physiologic systems. Here, we compare the lymphoid organ homing of naive and phenotypically defined memory T cells, focusing on memory subsets differentially expressing the integrin receptor alpha4beta7, which is implicated in homing to mucosal sites. Naive T cells (CD44(low), Thy1+) home to all secondary lymphoid organs. Alpha4beta7(high) memory-phenotype (CD44(high)) T cells home to Peyer's patches as efficiently as naive lymphocytes, whereas alpha4beta7- memory-phenotype T cells are essentially excluded from entry into these mucosal lymphoid organs. In contrast, alpha4beta7- memory-phenotype cells home approximately twice as efficiently as alpha4beta7(high) T cells to peripheral lymph nodes, but only approximately 20% as well as naive T cells. Interestingly, the spleen recruits all three identified subsets with nearly equal efficiency. The relative subset localization is similar 2.5 h after injection and after overnight trafficking, suggesting that memory cells can directly extravasate from blood into Peyer's Patches and lymph nodes. We conclude that subsets of memory T cells defined by patterns of homing receptor expression display differential homing to organized lymphoid tissues, an ability that may facilitate homeostatic interactions and target contributions to specialized regional immune responses.

Factor-derived subsyndromes of schizophrenia and familial morbid risks

Factor analysis was performed on OPCRIT checklist ratings from 66 patients with RDC schizophrenia. Eight substantive factors were found, characterised respectively by: positive formal thought disorder; first rank delusions; first rank hallucinations; inappropriate affect/bizarre behaviour; negative symptoms; grandiose/bizarre delusions; delusions of influence/persecution; and other hallucinations. A history of schizophrenia and other non-affective psychoses was ascertained in the probands' first-degree relatives using a family history approach. Illness in relatives was best predicted by probands' scores on subsyndromes derived from the inappropriate affect/bizarre behaviour and positive formal thought disorder factors.

Circadian variation in rat brain AP-1 DNA binding activity after cholinergic stimulation: modulation by lithium

The potential influence of a circadian rhythm and its modulation by lithium on the stimulation of AP-1 DNA binding activity by the cholinergic agonist pilocarpine was investigated in rat cerebral cortex. Stimulation of AP-1 binding after pilocarpine (30 mg/kg) was evident within 1 h and was maximally stimulated by 200% at 2 h. Pilocarpine-stimulated AP-1 binding exhibited a circadian rhythm in AP-1 binding measured at 0800, 1200, and 1600 hours, 2 h after pilocarpine. Pilocarpine-stimulated AP-1 binding at 0800 hours was approximately twice the level measured at 1600 hours. After acute lithium treatment, pilocarpine administration induced generalized seizures after about 20 min and stimulated AP-1 binding which increased continuously for 4.5 h, at which time the stimulation was 900% above control. A circadian variation was apparent in AP-1 binding stimulated by acute lithium plus pilocarpine, with stimulation at 0800 hours being 1.5 times that at 1600 hours. After chronic lithium and pilocarpine, which also produced seizures, there was no circadian variation in pilocarpine-stimulated AP-1 binding. Thus pilocarpine-induced AP-1 binding in rat cerebral cortex was influenced by a circadian rhythm, but this was abolished by chronic lithium administration.

Modulation by inositol of cholinergic- and serotonergic-induced seizures in lithium-treated rats

Hippocampal and cortical EEG recordings in rats were used to monitor the in vivo modulation by lithium of responses to agonists for 5HT2/5HT1c serotonergic (DOI) and cholinergic (pilocarpine) receptors and the influence of inositol administration. Administration of DOI (8 mg/kg) or pilocarpine (30 mg/kg) to rats pretreated with lithium acutely (3 mmol/kg) or chronically (dietary, 4 weeks) resulted in seizures, whereas these doses did not cause seizures without lithium pretreatment. This indicated that lithium most likely affects a signal transduction process common to both systems, which is the phosphoinositide second messenger system. To examine the potential influence of altered inositol levels on these responses, we tested the effects of infusions (10 mg, i.c.v.) of myo-inositol, a precursor of phosphoinositide synthesis, and of epi-inositol, an isomer not used for phosphoinositide synthesis. Administration of myo-inositol (10 mg) slightly reduced the incidence of seizures induced by acute lithium plus DOI but almost completely blocked seizures induced by acute lithium plus pilocarpine. This was surprising since seizures induced by acute lithium plus DOI were less severe than those after acute lithium plus pilocarpine, but myo-inositol was more effective in blocking the latter. Epi-inositol also blocked seizures under both conditions but it was less effective than myo-inositol after treatment with acute lithium plus pilocarpine. The latencies to seizures and/or severity of seizures were potentiated more by chronic than acute lithium pretreatment with both DOI and pilocarpine, but attenuation by myo-inositol was less with each agonist after chronic lithium compared with acute lithium treatment. Peripheral administration of a high dose of myo-inositol blocked seizures induced by acute lithium plus pilocarpine, but the inositol treatment itself was toxic and caused seizures prior to pilocarpine administration, so the mechanism of action cannot simply be attributed to increased brain inositol levels. These results demonstrate that lithium modulates the in vivo responses to DOI and pilocarpine, most probably through an effect on the phosphoinositide signal transduction system. They also show that centrally administered myo-inositol modifies responses to these agents, but the effectiveness of epi-inositol and other results leave unclear the mechanistic basis of its actions.