Outcome evaluation of the p drivers Program: Randomised controlled trial of a program to improve safe driving among novice drivers

BACKGROUND

Globally, road traffic crashes are the leading cause of death for young adults. The P Drivers Project was a trial of a behavioural change program developed for, and targeted at, young Australian drivers in their initial months of solo driving when crash risk is at its highest.

METHODS

In a parallel group randomised controlled trial, drivers (N = 35,109) were recruited within 100 days of obtaining their probationary licence (allowing them to drive unaccompanied) and randomised to an intervention or control group. The intervention was a 3 to 6-week multi-stage driving behaviour change program (P Drivers Program). Surveys were administered at three time points (pre-Program, approximately one month post-Program and at 12 months after). The outcome evaluation employed an on-treatment analysis comprising the 2,419 intervention and 2,810 control participants who completed all required activities, comparing self-reported crashes and police-reported casualty crashes (primary outcome), infringements, self-reported attitudes and behaviours (secondary outcomes) between groups.

RESULTS

The P Drivers Program improved awareness of crash risk factors and intentions to drive more safely, relative to the controls; effects were maintained after 12-months. However, the Program did not reduce self-reported crashes or police-reported casualty crashes. In addition, self-reported violations, errors and risky driving behaviours increased in the intervention group compared to the control group as did recorded traffic infringements. This suggests that despite the Program increasing awareness of risky behaviour in novice drivers, behaviour did not improve. This reinforces the need to collect objective measures to accompany self-reported behaviour and intentions.

CONCLUSIONS

The P Drivers Program was successful in improving attitudes toward driving safety but the negative impact on behaviour, lack of effect on crashes, and the large loss to follow-up fail to support the use of a post-licensing behaviour change program to improve novice driver behaviour and reduce crashes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: 363,293 (ANZCTR, 2012).

Lay health worker research personnel for home-based data collection in clinical and translational research: Qualitative and quantitative findings from two trials in hard-to-reach populations

Aims

The role of lay health workers in data collection for clinical and translational research studies is not well described. We explored lay health workers as data collectors in clinical and translational research studies. We also present several methods for examining their work, i.e., qualitative interviews, fidelity checklists, and rates of unusable/missing data.

Methods

We conducted 2 randomized, controlled trials that employed lay health research personnel (LHR) who were employed by community-based organizations. In one study, n = 3 Latina LHRs worked with n = 107 Latino diabetic participants. In another study, n = 6 LHR worked with n = 188 Cambodian American refugees with depression. We investigated proficiency in biological, behavioral, and psychosocial home-based data collection conducted by LHR. We also conducted in-depth interviews with lay LHR to explore their experience in this research role. Finally, we described the training, supervision, and collaboration for LHR to be successful in their research role.

Results

Independent observers reported a very high degree of fidelity to technical data collection protocols (>95%) and low rates of missing/unusable data (1.5%-11%). Qualitative results show that trust, training, communication, and supervision are key and that LHR report feeling empowered by their role. LHR training included various content areas over several weeks with special attention to LHR and participant safety. Training and supervision from both the academic researchers and the staff at the community-based organizations were necessary and had to be well-coordinated.

Conclusions

Carefully selected, trained, and supervised LHRs can collect sophisticated data for community-based clinical and translational research.

A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies

The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.

Social comparisons on social media: online appearance-related activity and body dissatisfaction in adolescent girls

INTRODUCTION

Adolescents' engagement with online social networking platforms is advancing at an exponential rate and research is needed to investigate any impact on young users' mental health. This study examined appearance-related activity (e.g. looking at photos of friends) on social media and body dissatisfaction among adolescent girls.

METHODS

Self-report measures of online appearance-related activity, social comparisons to female target groups, internalization of the thin ideal, body dissatisfaction, and self-esteem were administered to 210 girls (mean age = 15.16 years).

RESULTS

Body dissatisfaction was significantly related to (i) time spent engaged in social comparisons and (ii) upward social comparisons with various female targets while online. Evaluating oneself less favorably than the target group of close friends was most strongly associated with poorer body image appraisals. Serial multiple mediation analysis revealed that even after controlling for age and self-esteem, time spent engaged in social comparisons significantly mediated the relationship between online appearance-related activity and body dissatisfaction. This association was then further partially mediated by internalization of the thin ideal, which significantly mediated the relationship between time engaged in social comparisons and body dissatisfaction.

DISCUSSION

Results are discussed in terms of online social media platforms representing an additional appearance culture environment for adolescent girls. The effects of this on the mental health of vulnerable users and how future research should investigate protective factors that may buffer young girls from the adverse effects of social media are considered.

Self-reported outcomes of a randomized trial comparing three community health worker interventions for diabetes prevention among Cambodian Americans with depression

OBJECTIVE

Cambodian Americans have complex, interrelated and persistent medical and mental health problems stemming from genocide and the social determinants of health. We examined changes in multiple domains of self-reported health outcomes from a diabetes prevention trial.

METHODS

Cambodian Americans with depression and high risk for diabetes (n = 188) were randomized to one of three community health worker interventions: lifestyle vs lifestyle plus medication therapy management vs social services. Assessments were at baseline, 12- and 15-months.

RESULTS

The typical participant was 55 years old, female, earned below $20,000 annually, and had 7 years of education. About one-third were taking antidepressant medication and over half had elevated depressive symptoms. Relative to social services, lifestyle and lifestyle plus medication therapy management were both similarly effective at increasing diabetes knowledge, nutrition habits, sleep quality and decreasing pain; 2) lifestyle alone was superior to social services for self-reported health; and, 3) all three groups showed improved anxiety and insomnia. There were no effects on physical activity or physical functioning.

CONCLUSION

Community health worker interventions have multiple benefits beyond delaying diabetes.

PRACTICE IMPLICATIONS

Health promotion programs that are designed and delivered appropriately can impact even hard to reach and hard to treat groups.

SNAP participation moderates the association between household food insecurity and HbA1c among Cambodian Americans with depression

OBJECTIVES

We tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) moderated the relation between household food insecurity and HbA1c among Cambodian Americans with depression enrolled in a diabetes prevention trial.

METHODS

Community health workers assessed household food insecurity and SNAP participation. HbA1c was ascertained using direct enzymatic assay.

RESULTS

Among the n = 189 respondents, 19% were food insecure, 41% received SNAP benefits, and mean HbA1c = 5.5%. There was a significant interaction between SNAP and food insecurity. HbA1c was highest among participants without SNAP who were food insecure. Simple effects analysis revealed a significant difference within the no SNAP group [Mean (SD): Secure = 5.38 (0.38), Insecure = 5.78 (0.36)] and no difference within the SNAP group [Secure = 5.61(0.44), Insecure = 5.61(0.55)]. Differences remained significant after controlling for demographic, socioeconomic, and clinical indicators.

CONCLUSIONS

SNAP may protect against the deleterious association between household food insecurity and HbA1c.

Self-reported pain among Cambodian Americans with depression: patient-provider communication as an overlooked social determinant

Objectives

Pain is common among torture survivors and refugees. Clear communication about one’s pain is vital to timely and precise diagnosis and treatment but is rarely recognized as a social determinant of health. We examined whether self-reported difficulty communicating with their health care provider, along with standard social determinants, is associated with self-reported pain in Cambodian American refugees.

Methods

Secondary data analysis was conducted on n = 186 baseline assessments from a diabetes prevention trial of Cambodian Americans with depression. Bilingual, bicultural community health workers (CHWs) conducted surveys including social determinants of health and past week pain occurrence and interference.

Results

The sample was 78% female, modal household income = $25,000, mean age = 55 years, and mean education = 6.9 years. About one-third had private insurance and two-thirds could not speak English conversationally. The average pain score was 2.8 on a scale from 0–8 with 37% reporting no pain at all. In bivariate analyses, predictors of higher pain scores were higher difficulty understanding healthcare provider, depressive symptoms, trauma symptoms, food insecurity, and social isolation; predictors of lower pain scores were higher years of education, income, English language proficiency, social support, working, and having private insurance. In the multivariate backward elimination model only two predictors were retained: difficulty understanding healthcare provider and depressive symptoms.

Discussion

We propose that healthcare communication is a modifiable social determinant of health. Healthcare institutions should receive the resources necessary to secure patients’ rights to clear communication including trained community health workers.

Psychological distress and health behaviours among Cambodian Americans at risk for developing diabetes

This paper reports secondary data analysis of associations between psychological distress and health behaviours among Cambodian Americans. Data are from baseline assessments from a diabetes prevention trial. All participants met stucriteria for depression and were free of diabetes. Participants (n = 191) completed surveys, a food frequency assessment, and wore sleep and physical activity actigraphy devices for 7 days. A factor analysis of symptoms of post-traumatic stress, baksbat (a Cambodian culture-bound syndrome), depression, and anxiety yielded a single factor named 'psychological distress'. Multivariate models controlling for psychotropic medications were run for the following outcomes: sleep actigraphy, self-reported sleep, physical activity actigraphy, self-reported physical activity, nutrition, and substance use. For actigraphy, higher distress was associated with lower moderate/vigorous physical activity and higher mean variability of 24 h total sleep time. Higher distress was also associated with worse self-reported sleep quality as indicated by standard, and culturally-specific, sleep indicators. Higher distress was also associated with lower use of food labels, lower carbohydrate consumption, and higher alcohol consumption as a coping mechanism. Interventions to mitigate diabetes risk in high-distress populations may benefit from strategies to decrease psychological distress. The sequelae of complex trauma may transcend discrete psychiatric diagnoses.

Exposure to Starvation: Associations with HbA1c, Anthropometrics, and Trauma Symptoms Four Decades Later Among Cambodians Resettled in the USA

BACKGROUND

Epidemiological data suggest that populations exposed to starvation show increased incidence of type 2 diabetes but these studies are limited by lack of person-level data. Cambodians resettled in the USA survived severe malnutrition during distinct historical eras. We examined the relationship of individual exposure to starvation with current HbA1c, anthropometrics, and trauma symptoms among Cambodian Americans.

METHODS

Participants were excluded for extant diabetes but all had elevated risk factors for type 2 diabetes and depression. Participants identified images on a 5-point scale that best depicted their body size during four distinct periods: before 1970 (peacetime), 1970-1975 (USA bombing campaign, widespread hunger), 1975-1979 (Pol Pot regime, mass starvation), and "now" (2016-2019, resettled in the USA). They reported trauma symptoms and provided anthropometrics and a blood sample.

RESULTS

The n = 189 participants were mean = 55 years old and had glycosylated hemoglobin (HbA1c) mean = 5.5%. Self-reported body size showed excellent validity by strong correlations between body thinness "now" and objectively measured waist circumference (r =  -0.35), weight (r =  -0.50), and body mass index (r =  -0.50). Whereas there was some variability, modal self-reported body size started as normal during peacetime, became thinner during the USA bombing campaign, became emaciated during the Pol Pot regime, and rebounded to normal/slightly heavy "now." Body size during Pol Pot showed the strongest associations with long-term outcomes; thinner body size (greater starvation) was associated with higher trauma symptoms and higher HbA1c even after controlling for age, current waist circumference, and current body mass index.

CONCLUSION

Greater degree of starvation was associated with higher HbA1c and trauma symptoms four decades later.

0239 A Latent Profile Analysis of actigraphic sleep and physical activity measures among Cambodian-Americans: Relationship with specific trauma symptoms

Introduction

Sleep and physical activity are related to psychological trauma. Less is known about how individuals with distinct sleep and activity profiles differ on specific clusters of trauma symptoms. Cambodian-Americans who survived the Pol Pot genocide experienced severe collective trauma. This analysis explored group differences between sleep/activity profiles on specific trauma symptoms among Cambodian-Americans.

Methods

Participants in a diabetes prevention trial for Cambodian-Americans (NCT02502929) met inclusion criteria for depression and high diabetes risk (but did not have diabetes). They wore wrist actigraphy (sleep) and hip actigraphy (physical activity) for 7 days (≥3 days to be included) and completed the 16-item trauma symptom scale of the Harvard Trauma Questionnaire (HTQ; N=166). Latent Profile Analyses identified profiles using 3 mean actigraphic sleep and activity variables: total nightly sleep time, sleep maintenance efficiency, and minutes in moderate-vigorous physical activity. ANOVAs explored differences between sleep/activity profiles on the HTQ, specifically total scores and the “Avoidance/Numbing” and “Re-experiencing/Hyperarousal” subscales. Models were adjusted for psychotropic medication use.

Results

Participants were predominantly women (79%), mean age 55.3, with elevated trauma symptoms (17% were higher than 2.5 cutpoint; mean±SD= 1.90±0.61). Sleep and physical activity patterns yielded a BIC best fit with 3 sleep/activity profiles: Inactive Poor Sleepers (n=30, 18%), Highly Active Short Sleepers (n=35, 21%), and Moderately Active Good Sleepers (n=101, 61%). Differences were observed between profiles on the HTQ total score (p=0.03). Tukey’s post hoc test revealed that Inactive Poor Sleepers exhibited greater HTQ scores than Highly Active Short Sleepers (p<0.05), but did not differ from Moderately Active Good Sleepers. There was also a significant difference between profiles in the Avoidance/Numbing subscale (p=0.01); Inactive Poor Sleepers had higher Avoidance/Numbing than Highly Active Short Sleepers (p<0.05, Cohen’s d: 0.47). There were no differences between profiles on the Re-experiencing/Hyperarousal subscale (p=.09).

Conclusion

Individuals with contrasting actigraphic sleep/activity profiles differed on trauma symptoms. Inactive Poor Sleepers may benefit from specific interventions for Avoidance/Numbing symptoms. Future analyses will evaluate how changes in sleep/activity profiles are longitudinally related to psychological health and diabetes risk following interventions.

Support (If Any)

5R01DK103663

Risk factors for drug therapy problems among Cambodian Americans with complex needs: a cross-sectional, observational study

Background

Pharmaceutical drug therapy problems (DTPs) are a major public health problem. We examined patient-level risk factors for DTPs among Cambodian Americans.

Methods

Community health workers (CHWs) verbally administered surveys and completed a detailed medication review form with participants. A doctoral-level pharmacist reviewed the form with the patient and CHW to determine DTP number and type (appropriateness, effectiveness, safety, and adherence).

Results

Participants (n = 63) averaged 55 years old, 6 years of education, 52% were married, 87% spoke Khmer at home, with modal household income <$20,000 (41%). The percentage of participants with DTPs was: 45% appropriateness, 25% effectiveness, 64% safety, and 30% adherence, averaging 3.7 DTPs per patient. In multiple regressions, patient characteristics uniquely predicted each type of DTP. In a multiple regression controlling for number of medications, being married reduced total DTPs (IRR = 0.70) and being depressed increased total DTPs (IRR = 1.26).

Conclusions

Vulnerable patients should be prioritized for pharmacist/CHW teams to identify DTPs.

Trial registration:ClinicalTrials.gov identifier: NCT02502929.

Relationship of alcohol use and facial flushing to blood pressure and HbA1c among Cambodian populations with dysglycemia in the U.S. and in Cambodia

BACKGROUND AND AIMS

Facial flushing after drinking alcohol, common among Asians, is a phenotype for genes involved in alcohol metabolism.

METHODS

We investigated cross-sectional associations between flushing, alcohol use, blood pressure (BP) and HbA1c among (n = 287) Cambodians with dysglycemia in Cambodia and in the U.S. Participants were categorized as Abstainers, Flushers who drink, or Non-flushers who drink.

RESULTS

Flushers and Non-flushers had similar alcohol use. Flushers had higher BP than Non-flushers and Abstainers, even after controlling for confounders. Findings were similar across countries. Drinkers had higher HbA1c than Abstainers.

CONCLUSIONS

Future research should examine whether reducing alcohol improves cardiometabolic outcomes.

The largest prison outbreak of TB in Western Europe investigated using whole-genome sequencing

BACKGROUND: In March 2011, the Department of Public Health East in Ireland were notified of two cases of TB in two prisoners sharing a cell. We define the resulting outbreak and highlight the role of public health and laboratory-based molecular epidemiology in mapping and control of a prison outbreak.METHODS: Cases were identified through clinical presentation, contact tracing, case-finding exercise or enhanced laboratory surveillance. Mycobacterium tuberculosis isolates were genotyped and underwent whole-genome sequencing (WGS).RESULTS: Of the 34 cases of TB linked to the outbreak, 27 were prisoners (79%), 4 prison officers (12%) and 3 community cases (9%). M. tuberculosis was isolated from 31 cases (culture positivity: 91%). A maximum of six single-nucleotide polymorphisms separated the isolates, with 22 being identical, suggestive of a highly infectious 'super-spreader´ within the prison. Isolates belonged to the Beijing sub-lineage, and were susceptible to first-line anti-TB agents. A case-finding exercise incidentally detected a prisoner with multidrug-resistant TB. Of the 143 prison officers screened, 52% had latent TB infection. Litigation costs exceeded five million euros.CONCLUSION: This constitutes the largest prison outbreak of TB in Western Europe investigated using WGS. A robust prison entry TB screening and education programme is required to effect better TB control, and prevent future outbreaks and attendant litigation.

SNAP Participation Moderates the Association Between Household Food Insecurity and A1c Among Cambodian Americans With Depression

Objectives

We tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) moderated the relation between household food security status and HbA1c, the gold standard measure of glycemic control, among Cambodian Americans with depression enrolled in a diabetes prevention trial.

Methods

Participants had elevated risk factors for type 2 diabetes and elevated depressive symptoms; recruits were excluded for extant diabetes. Community health workers assessed household food security status and SNAP participation via in-person interview. HbA1c levels from venous blood samples were ascertained using direct enzymatic assay.

Results

Among respondents (n = 189), 19% were food insecure, 41% received SNAP benefits, and mean HbA1c = 5.5%. There was a significant interaction between SNAP and food insecurity. HbA1c was highest among participants without SNAP who were food insecure. Simple effects analysis revealed a significant difference within the no SNAP group [Mean (SD) HbA1c: Secure = 5.38 (0.38), Insecure = 5.78 (0.36)] and no difference within the SNAP group [Secure = 5.61(0.44), Insecure = 5.61(0.55)]. Differences remained significant after controlling for demographic, socioeconomic, and clinical indicators.

Conclusions

SNAP may protect against the deleterious association between household food insecurity and elevated HbA1c.

Funding Sources

R01-DK103663 to Dr. Julie Wagner.

A randomized trial to decrease risk for diabetes among Cambodian Americans with depression: Intervention development, baseline characteristics and process outcomes

Background:

Depression and antidepressant medications are associated with increased risk for type 2 diabetes. It is not known if diabetes can be prevented in the setting of depression. Cambodian Americans have high rates of both depression and diabetes. This paper reports intervention development, experimental design, baseline characteristics, and process outcomes of diabetes prevention interventions for Cambodian Americans with depression, “Diabetes Risk Reduction through Eat, Walk, Sleep and Medication Therapy Management” (DREAM).

Methods:

Participants were aged 35–75, Khmer speaking, at high risk for developing diabetes, and met criteria for likely depression by either a) antidepressant medication and/or b) elevated depressive symptoms at two time-points during a study eligibility period. Treatment arms were: 1) community health educator (CHE) delivered lifestyle intervention called Eat, Walk, Sleep (EWS), 2) EWS plus pharmacist/CHE-delivered medication therapy management (EWS + MTM), and, 3) social services (SS; control).

Results:

188 participants were randomized. Treatment fidelity was high (98% checklist adherence) and on a scale from 0 to 3, participants reported high EWS treatment satisfaction (M = 2.9, SD = 0.2), group cohesion (M = 2.9, SD = 0.3), and therapeutic alliance to CHEs (M = 2.9, SD = 0.2) and to pharmacists (2.9, SD = 0.3). Attendance was challenging but highly successful; in EWS, 99% attended ≥ one session and 86% completed ≥ 24 sessions, M = 27.3 (SD = 3.7) sessions. Of those randomized to EWS + MTM, 98% attended at least one MTM session and 77%) completed ≥ 4 sessions. Retention was high, 95% at 12-month and 96% at 15-month assessments.

Conclusions:

The interventions were successfully implemented. Lessons learned and suggestions for future trials are offered.

ClinicalTrials.gov identifier: NCT02502929

Social disconnection and metabolic syndrome score among Cambodian Americans with depression

AIMS

Migrants experience social disconnection and also have high risk for metabolic syndrome (MetS). This study explored associations of social alienation, social isolation, and social support with MetS among Cambodian Americans.

METHODS

We conducted secondary data analysis on baseline assessments from a diabetes prevention trial for Cambodian Americans with depression and high risk for diabetes. Participants were aged 35-75, Cambodian or Cambodian-American, Khmer speaking, lived in Cambodia during the Pol Pot regime, lived in the northeastern U.S. at the time of study, endorsed elevated risk factors for diabetes and met criteria for depression by medication for depression and/or elevated depressive symptoms. They completed surveys and provided anthropometric and blood pressure measurements and fasting blood samples.

RESULTS

In multiple linear regressions, greater social alienation was associated with increased risk for MetS. The social alienation-MetS association was stronger in men than women. Associations were not better accounted for by crude indicators of social isolation such as marital status, living alone, and number of people in the household. Social support was not associated with MetS and did not buffer the deleterious association between social alienation and MetS.

CONCLUSIONS

Decreasing social alienation may mitigate risk for MetS among migrant populations.

Laboratory biomarkers associated with COVID-19 severity and management

The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care.

From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66.

Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.

Social Disconnection as a Risk Factor for Health among Cambodian Refugees and Their Offspring in the United States

Studies of relatively recently resettled refugees have noted social disconnection, linked to various physical and mental health outcomes, as a concern. Limited studies have examined whether social disconnection and its effects persists within refugee populations resettled more than 3 decades prior. The relationship between social disconnection and self-reported health was explored in a secondary analysis of a cross-sectional needs assessment survey with a snowball sample of 100 Cambodian refugees residing in Connecticut. Social disconnectedness and comorbid health conditions were prevalent. Lack of religious and community engagement were associated with poor health outcomes, while individuals with a lack of ethnic engagement reported better overall health. This study underscores the importance of understanding the specific risks that social disconnection poses to refugees who have resettled many years before and their offspring that may assist in better serving currently settling refugees within the United States.

Using technology and cross-cultural teams to deliver trauma-informed medication management

Issue/Problem

Cambodian Americans have high rates of mental health conditions, diabetes and cardiovascular disease. Unique risk factors include history of malnutrition, torture, social isolation, and poor social determinants of health. Community CARES is a trauma-informed model applicable to any trauma community with complex chronic health and mental health problems.

Description of the problem

High-touch, high-tech approaches can improve access to culturally and linguistically appropriate medication therapy management (MTM) services. Over 12 months, pharmacists teamed with community health workers (CHWs) to provide MTM services in Connecticut and California. Face-to-face consultations occurred in Connecticut, while patients and CHWs in California used teleconferencing with the pharmacist in Connecticut. Project goals: improve drug therapy outcomes, reduce inappropriate medication use, improve medication adherence, display cost savings.

Results

96 patients, average age 69, completed the project. Patients averaged 6.6 medical conditions and 10.3 medications. Pharmacists identified 604 medication-related problems, resolving 93%. Drug therapy outcomes increased 35%, medication adherence improved 23%, inappropriate medication use decreased 35%, and depression screening scores improved 25%. Return on investment ratio was 6:1, a savings of $3032/patient/year. Health improvements from face-to-face and telehealth MTM consultations were similar.

Lessons

Healthcare workforce is optimized by linking CHWs with pharmacists and technology to deliver cost-effective MTM services. The approach is generalizable to populations challenged by distance, disability, language, or culture. Public health care policies need to reflect team approaches and value-based payment models.

Main messages: The virtual cross-cultural team MTM model for underserved populations has the potential to meet the triple aim goals of better care, better health, and lower costs in multiple settings.

Key messages

Virtual cross-cultural team MTM model for underserved populations. Meets the triple aim goals of better care, better health, and lower costs in multiple settings.

Pharmacokinetics of plasma infusion in congenital thrombotic thrombocytopenic purpura

Essentials Congenital thrombotic thrombocytopenic purpura (TTP) is primarily treated with plasma infusion. We present a pharmacokinetic analysis of ADAMTS-13 in six patients following plasma infusion. A median half-life of 130 h was demonstrated, ranging between 82.6 and 189.5 h. Investigation of interindividual clearance of ADAMTS-13 is necessary to optimize treatment. SUMMARY: Background Congenital thrombotic thrombocytopenic purpura (TTP) is defined by persistent severe deficiency of ADAMTS-13 in the absence of anti-ADAMTS-13 inhibitory antibodies, confirmed by mutational analysis. Replacement of the missing protease prevents disease relapse, primarily using plasma infusion (PI). Objectives, patients and methods There is scant evidence regarding optimal dose and frequency of treatment, which tends to be empirically guided. We present a pharmacokinetic analysis of ADAMTS-13 in six patients with congenital TTP on established regimes following PI. Results We found a median clearance of 25.41 mL h-1 and half-life of 130 h, ranging between 82.6 and 189.5 h (3.4-7.9 days, respectively). All patients reached baseline ADAMTS-13 level within 7-10 days post-plasma. Median ADAMTS-13 activity peak post-PI was 24.05 IU dL-1 . Variation was related to elimination rate, which, in turn, was affected by weight and metabolism, but not to von Willebrand factor antigen or activity levels. Using the pharmacokinetic parameters, we simulated individualized protocols based on PI dose or frequency to target hypothetical optimal plasma levels of ADAMTS-13 of 10 and 50 IU dL-1 , respectively. Results suggest a target trough ADAMTS-13 of 10 IU dL-1 is feasible but 50 IU dL-1 would not be achievable taking into account volume required. Conclusions Further work is needed to compare treatment of congenital TTP with PI vs. recombinant ADAMTS-13. PI may provide longer duration of ADAMTS-13 effect, but is limited by plasma volume required, whereas recombinant therapy can provide a higher ADAMTS-13 peak. We propose that investigation of interindividual clearance of ADAMTS-13 is necessary to optimize treatment and provide the rationale for dose and frequency of prophylaxis.

Magnetism in semiconducting molybdenum dichalcogenides

Transition metal dichalcogenides (TMDs) are interesting for understanding the fundamental physics of two-dimensional (2D) materials as well as for applications to many emerging technologies, including spin electronics. Here, we report the discovery of long-range magnetic order below T _M = 40 and 100 K in bulk semiconducting TMDs 2H-MoTe₂ and 2H-MoSe₂, respectively, by means of muon spin rotation (μSR), scanning tunneling microscopy (STM), and density functional theory (DFT) calculations. The μSR measurements show the presence of large and homogeneous internal magnetic fields at low temperatures in both compounds indicative of long-range magnetic order. DFT calculations show that this magnetism is promoted by the presence of defects in the crystal. The STM measurements show that the vast majority of defects in these materials are metal vacancies and chalcogen-metal antisites, which are randomly distributed in the lattice at the subpercent level. DFT indicates that the antisite defects are magnetic with a magnetic moment in the range of 0.9 to 2.8 μ_B. Further, we find that the magnetic order stabilized in 2H-MoTe₂ and 2H-MoSe₂ is highly sensitive to hydrostatic pressure. These observations establish 2H-MoTe₂ and 2H-MoSe₂ as a new class of magnetic semiconductors and open a path to studying the interplay of 2D physics and magnetism in these interesting semiconductors.

Honouring the role of community in community health work with Cambodian Americans

Despite surviving extreme forms of violence, torture and other traumas during the Khmer Rouge genocide and forced migration, Cambodian Americans experience devastating health inequities and barriers to health access in the United States (U.S.). From the perspective of Cambodian American community health workers (CHWs), we explored three aims in this community-based participatory research (CBPR), qualitative study: Cambodian Americans' understanding of health, community health work strategies that improve health access of Cambodian Americans, and action steps that improve health access for Cambodian Americans. From 2014 to 2016, our two-phased study spanned seven U.S. states, which included a focus group (n = 5) and 16 semistructured interviews. Participants identified an indigenous concept of health, and micro-level (e.g. service navigation, peer education) and mezzo-level interventions (e.g. community building, coalition work) to improve health access. Finally, Khmer Health Advocates, a community-based health advocacy organisation, served as a vital study partner in this CBPR study.

Chrono-Pharmacological Study of Once Daily Curative Dose of a Low Molecular Weight Heparin (200IU antiXa/kg of Dalteparin) in Ten Healthy Volunteers

Low molecular weight heparin (LMWH) is currently prescribed for the treatment of deep vein thrombosis at the dose of 100 IU antiXa/kg twice daily or at a dose of 175 IU antiXa/kg once daily with a similar efficacy. We decided to study the chrono-pharmacology of curative dose of LMWH once daily administrated according to the one previously described with unfractionated heparin (UFH).

Ten healthy volunteers participated in an open three-period crossover study according to three 24 h cycles, separated by a wash-out interval lasting 7 days: one control cycle without injection, two cycles with subcutaneous injection of 200 IU antiXa/kg of Dalteparin (Fragmin®) at 8 a.m. or at 8 p.m. Parameters of heparin activity were analysed as maximal values and area under the curve.

Activated partial thromboplastin time (APTT), thrombin time (TT), prothrombin time (PT) and tissue factor pathway inhibitor (TFPI) were higher after 8 p.m. injection than after 8 a.m. injection (p <0.05) while no chrono-pharmacological variation of anti factor Xa (AXa) activity was observed. Thus the biological anticoagulant effect of 200 IU antiXa/kg of Dalteparin seems to be higher after an evening injection than after a morning injection.

A chrono-therapeutic approach with LMWH, as prescribed once daily, deserves further investigation since our results suggest that a preferential injection time may optimise the clinical efficacy of these LMWH.

The role of ADAMTS-13 in the coagulopathy of sepsis

The interaction between platelets and the vessel wall is mediated by various receptors and adhesive proteins, of which von Willebrand factor (VWF) is the most prominent. The multimeric size of VWF is an important determinant of a more intense platelet-vessel wall interaction, and is regulated by the VWF-cleaving protease ADAMTS-13. A deficiency in ADAMTS-13 leads to higher concentrations of ultralarge VWF multimers and pathological platelet-vessel wall interactions, in its most typical and extreme form leading to thrombocytopenic thrombotic purpura, a thrombotic microangiopathy characterized by thrombocytopenia, non-immune hemolysis, and organ dysfunction. Thrombotic microangiopathy associated with low levels of ADAMTS-13 may be a component of the coagulopathy observed in patients with sepsis. Here, we review the potential role of ADAMTS-13 deficiency and ultralarge VWF multimers in sepsis, and their relationship with sepsis severity and prognosis. In addition, we discuss the possible benefit of restoring ADAMTS-13 levels or reducing the effect of ultralarge VWF as an adjunctive treatment in patients with sepsis.

Combating Health Disparities in Cambodian American Communities: A CBPR Approach to Building Community Capacity

BACKGROUND

Cambodian Americans have higher rates of health problems compared with the general U.S.

POPULATION

A relatively modest community capacity for collecting data contributes to these disparities.

OBJECTIVES

To (1) further develop the Cambodian American community's capacity to design and conduct health research meaningful to their community via a community-based participatory research (CBPR) approach, (2) train and deploy bilingual community health workers (CHWs) to gather health-related data from their communities using mobile technology, and (3) measure the feasibility and effectiveness of our efforts.

METHODS

A CBPR approach was used to engage leaders of Cambodian American communities in six states to identify their research needs, develop a short community health survey administered by CHWs, and conduct the survey using iPads programmed in Khmer spoken-language format. Administrative logs and surveys of CHWs and leaders measured feasibility and effectiveness of the project.

RESULTS

CHWs, leaders, and community members reported largely positive experiences with the community health survey, despite poor/inconsistent Internet connectivity. The institutional capacity of Cambodian American community-based organizations to collect health-related data in their own communities was strengthened. Our efforts proved to be both feasible and effective.

CONCLUSIONS

The use of mobile technology with spoken format can be a valuable tool in accessing input from vulnerable community members, including persons who may not be literate in any language. Trained CHWs, backed by dedicated and experienced community leaders, are an asset to their communities. Together, they are uniquely placed to make important contributions to the well-being of their community.

Caplacizumab reduces the frequency of major thromboembolic events, exacerbations and death in patients with acquired thrombotic thrombocytopenic purpura

Essentials Acquired thrombotic thrombocytopenic purpura (aTTP) is linked with significant morbidity/mortality. Caplacizumab's effect on major thromboembolic (TE) events, exacerbations and death was studied. Fewer caplacizumab-treated patients had a major TE event, an exacerbation, or died versus placebo. Caplacizumab has the potential to reduce the acute morbidity and mortality associated with aTTP.

SUMMARY

Background Acquired thrombotic thrombocytopenic purpura (aTTP) is a life-threatening autoimmune thrombotic microangiopathy. In spite of treatment with plasma exchange and immunosuppression, patients remain at risk for thrombotic complications, exacerbations, and death. In the phase II TITAN study, treatment with caplacizumab, an anti-von Willebrand factor Nanobody® was shown to reduce the time to confirmed platelet count normalization and exacerbations during treatment. Objective The clinical benefit of caplacizumab was further investigated in a post hoc analysis of the incidence of major thromboembolic events and exacerbations during the study drug treatment period and thrombotic thrombocytopenic purpura-related death during the study. Methods The Standardized Medical Dictionary for Regulatory Activities (MedDRA) Query (SMQ) for 'embolic and thrombotic events' was run to investigate the occurrence of major thromboembolic events and exacerbations in the safety population of the TITAN study, which consisted of 72 patients, of whom 35 received caplacizumab and 37 received placebo. Results Four events (one pulmonary embolism and three aTTP exacerbations) were reported in four patients in the caplacizumab group, and 20 such events were reported in 14 patients in the placebo group (two acute myocardial infarctions, one ischemic stroke, one hemorrhagic stroke, one pulmonary embolism, one deep vein thrombosis, one venous thrombosis, and 13 aTTP exacerbations). Two of the placebo-treated patients died from aTTP during the study. Conclusion In total, 11.4% of caplacizumab-treated patients and 43.2% of placebo-treated patients experienced one or more major thromboembolic events, experienced an exacerbation, or died. This analysis shows the potential for caplacizumab to reduce the risk of major thromboembolic morbidities and mortality associated with aTTP.

Consensus on the standardization of terminology in thrombotic thrombocytopenic purpura and related thrombotic microangiopathies

Essentials An international collaboration provides a consensus for clinical definitions. This concerns thrombotic microangiopathies and thrombotic thrombocytopenic purpura (TTP). The consensus defines diagnosis, disease monitoring and response to treatment. Requirements for ADAMTS-13 are given.

SUMMARY

Background Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) are two important acute conditions to diagnose. Thrombotic microangiopathy (TMA) is a broad pathophysiologic process that leads to microangiopathic hemolytic anemia and thrombocytopenia, and involves capillary and small-vessel platelet aggregates. The most common cause is disseminated intravascular coagulation, which may be differentiated by abnormal coagulation. Clinically, a number of conditions present with microangiopathic hemolytic anemia and thrombocytopenia, including cancer, infection, transplantation, drug use, autoimmune disease, and pre-eclampsia and hemolysis, elevated liver enzymes and low platelet count syndrome in pregnancy. Despite overlapping clinical presentations, TTP and HUS have distinct pathophysiologies and treatment pathways. Objectives To present a consensus document from an International Working Group on TTP and associated thrombotic microangiopathies (TMAs). Methods The International Working Group has proposed definitions and terminology based on published information and consensus-based recommendations. Conclusion The consensus aims to aid clinical decisions, but also future studies and trials, utilizing standardized definitions. It presents a classification of the causes of TMA, and criteria for clinical response, remission and relapse of congenital and immune-mediated TTP.

Retrospective comparative analysis of cardiovascular implantable electronic device infections with and without the use of antibacterial envelopes

BACKGROUND

Cardiovascular implantable electronic device (CIED) infections are associated with morbidity and mortality. Peri-operative systemic intravenous antibiotic prophylaxis reduces the rate of CIED infections. AIGIS_Rx, a polymer envelope implanted with the CIED, releases minocycline and rifampin, and has been introduced to reduce infections.

METHODS

Retrospective review of 184 patients who underwent CIED implantation was conducted. Ninety-two patients were implanted with an AIGIS_Rx envelope (AIGIS_Rx group) and 92 patients were not implanted with an AIGIS_Rx envelope (control group). Data were collected on demographics and risk factors for CIED infections (i.e. congestive heart failure, renal insufficiency, chronic kidney disease, oral anticoagulant use, chronic steroid use, need for lead replacement or revision, temporary pacing, early re-intervention, and having more than two leads in place). Rates of implantation success, major infections and mortality were compared between the AIGIS_Rx group and the control group.

RESULTS

The AIGIS_Rx group had longer hospitalizations (6.8±10.7 days vs 3.1±5.2 days; P=0.001), higher chronic corticosteroid use, higher rates of replacement or revision (51.1% vs 8.7%; P=0.001), and a greater proportion of devices with more than two intracardiac leads (42.4% vs 29.3%; P=0.03) than the control group. Successful implantation occurred in 97% of patients in both groups. Major infection was seen in 5.4% of cases in the AIGIS_Rx group and 1.1% of cases in the control group (P=0.048). Device removal was conducted in 3.3% of cases in the AIGIS_Rx group compared with 1.1% of cases in the control group (P=0.16). There were two deaths in the AIGIS_Rx group. Organisms cultured were meticillin-resistant Staphylococcus aureus, meticillin-susceptible S. aureus and Enterococcus faecalis.

CONCLUSION

The AIGIS_Rx group had higher rates of major infection but also higher risk factors compared with the control group. The rate of device extraction and CIED-related mortality was higher in the AIGIS_Rx group than in the control group.

Diabetes among refugee populations: what newly arriving refugees can learn from resettled Cambodians

A growing body of literature suggests that cardiometabolic disease generally and type 2 diabetes specifically are problems among refugee groups. This paper reviews rates of cardiometabolic disease and type 2 diabetes among refugees and highlights their unique risk factors including history of malnutrition, psychiatric disorders, psychiatric medications, lifestyle changes toward urbanization and industrialization, social isolation, and a poor profile on the social determinants of health. Promising interventions are presented for preventing and treating diabetes in these groups. Such interventions emphasize well-coordinated medical and mental health care delivered by cross-cultural and multidisciplinary teams including community health workers that are well integrated into the community. Finally, recommendations for service, policy, and research are made. The authors draw on local data and clinical experience of our collective work with Cambodian American refugees whose 30-year trajectory illustrates the consequences of ignoring diabetes and its risk factors in more recent, and soon to be arriving, refugee cohorts.

The National Cambodian American Town Hall Meeting: a community dialogue on "eat, walk, sleep" for health

BACKGROUND

The 2009 National Cambodian American Town Hall Meeting was a public-private partnership convened to address long-term health issues related the Cambodian holocaust. Goals for participants were to dispel myths about diabetes; goals for the partnership were to build research capacity and to strengthen relationships.

METHODS

Partners collaborated on all aspects of the meeting which was held in Khmer by bridged videoconferencing in 10 sites and webinar at 5 sites across the United States over a 3-hour period. EAT, WALK, SLEEP for Health (EWS), the National Cambodian American Diabetes Project program, provided the framework for the meeting.

RESULTS

Pre and post surveys were completed by 323 participants. Modest improvements were seen in participants' belief that they could improve their own and their community's health, although significant barriers remained. Participants and community partners evaluated the meeting positively.

CONCLUSIONS

The meeting is a model for other populations, and results inform future work.

Trauma, healthcare access, and health outcomes among Southeast Asian refugees in Connecticut

Mental health problems among Southeast Asian refugees have been documented. However, longer term health consequences of mass violence as re-settled refugees age are less well described. This study investigated relationships among trauma symptoms, self-reported health outcomes, and barriers to healthcare among Cambodian and Vietnamese persons in Connecticut. An internet phone directory was used to generate a list of names that was compared to 2000 census data to estimate the proportion of the population in each group. From these lists, 190 telephone listings were selected at random. Interviewers telephoned selected listings to screen for eligible participants and obtain an appointment for interview. Surveys were administered through face-to-face interviews during home visits conducted in Khmer or Vietnamese. The Harvard Trauma Questionnaire assessed trauma symptoms. Questions regarding the presence of physician diagnosed heart disease, hypertension, diabetes, and chronic pain were adapted as written from the Health Interview Survey. Healthcare access and occurrence were measured with questions regarding cost and access, patient-provider understanding, and interpretive services. Hierarchical modeling was used to account for respondent nesting within family. Analyses controlled for age, sex, and country of origin. Individuals who reported greater trauma symptoms were more likely to report heart disease by a factor of 1.82, hypertension by a factor of 1.41, and total count of diseases by a factor of 1.22, as well as lower levels of subjective health. Greater trauma symptoms were also associated with greater lack of understanding, cost and access problems, and the need for an interpreter. Although the majority of Southeast Asian immigrants came to the United States as refugees approximately 20-30 years ago, there continues to be high levels of trauma symptoms among this population which are associated with increased risk for disease and decreased access to healthcare services.

Pulse pressure in cambodian americans: relationships to weight and mental health

Few studies have explored interrelationships among mental health and health status in refugees using objective, clinical data. Pulse pressure (PP) has recently emerged as an easily obtained, strong, independent determinant of mortality. We conducted a chart review of electronic records for 24 consecutive months to investigate PP among Cambodian refugees receiving services at a community clinic in Connecticut, USA. 301 patients charts were retrieved, 41 contained complete data for all variables. We found high rates of cardiovascular, anthropometric, and mental health problems. Among women, higher weight was related to higher PP. Among men, higher mental health symptom scores were marginally related to higher PP. Findings held after controlling for age.

DISCUSSION

Adiposity and mental health symptoms, which are known to be related to trauma history, contribute to elevated PP in this resettled refugee population. Given that PP may be modifiable through lifestyle intervention, further investigation of these problems in this needy population is warranted.

Effects of nutrient content claims, sports celebrity endorsements and premium offers on pre-adolescent children's food preferences: experimental research

OBJECTIVES

To assess pre-adolescent children's responses to common child-oriented front-of-pack food promotions.

METHODS

Between-subjects, web-based experiment with four front-of-pack promotion conditions on energy-dense and nutrient-poor (EDNP) foods: no promotion [control]; nutrient content claims; sports celebrity endorsements (male athletes) and premium offers. Participants were 1302 grade 5 and 6 children (mean age 11 years) from Melbourne, Australia. Participants chose their preferred product from a randomly assigned EDNP food pack and comparable healthier food pack then completed detailed product ratings. Child-oriented pack designs with colourful, cartooned graphics, fonts and promotions were used.

RESULTS

Compared to the control condition, children were more likely to choose EDNP products featuring nutrient content claims (both genders) and sports celebrity endorsements (boys only). Perceptions of nutritional content were enhanced by nutrient content claims. Effects of promotions on some product ratings (but not choice) were negated when children referred to the nutrition information panel. Premium offers did not enhance children's product ratings or choice.

CONCLUSIONS

Nutrient content claims and sports celebrity endorsements influence pre-adolescent children's preferences towards EDNP food products displaying them. Policy interventions to reduce the impact of unhealthy food marketing to children should limit the use of these promotions.

Characterization of the complications associated with plasma exchange for thrombotic thrombocytopaenic purpura and related thrombotic microangiopathic anaemias: a single institution experience

Background

Plasma exchange (PEX) is a life-saving therapeutic procedure in patients with thrombotic thrombocytopaenic purpura (TTP) and other thrombotic microangiopathic anaemias (TMAs). However, it may be associated with significant complications, exacerbating the morbidity and mortality in this patient group.

Study Design and Methods

We reviewed all PEX procedures over a 72-month period, following the exclusive introduction of solvent–detergent double viral-inactivated plasma in high-volume users, such as TTP, in the United Kingdom (UK). We documented allergic reactions to plasma, citrate reactions, complications relating to central venous access insertion and venous thrombotic events (VTE) in 155 patient episodes and >2000 PEX procedures.

Results

The overall complication rate was low. Allergic plasma reactions occurred in 6·45% of the cohort with only one episode of acute anaphylaxis. Similarly, VTEs were 6·45%, not significantly greater than in medical patients receiving thromboprophylaxis, despite added potential risk factors in TTP. Citrate reactions were the most frequent complication documented, but toxicity was significantly reduced by administration of further calcium infusions during the PEX procedure. There were no serious central line infections and no catheter thrombosis.

Conclusion

Our data confirms that PEX continues to be a life-saving procedure in the acute TTP setting and, the procedure was not associated with an increased mortality and limited morbidity.

Rituximab for thrombotic thrombocytopenic purpura: benefit of early administration during acute episodes and use of prophylaxis to prevent relapse

BACKGROUND

Rituximab has been documented in the treatment of acute (≤ 3 days from admission), relapsed/refractory thrombotic thrombocytopenic purpura (TTP) and given as prophylaxis in selected cases to prevent acute relapse. The precise timing of rituximab in acute TTP has not been determined.

OBJECTIVE

To perform a retrospective analysis of rituximab use in a large TTP referral center over an 8-year period.

PATIENTS/METHODS

We assessed response to treatment and outcome for all patients treated with rituximab, including 91 patients presenting with 104 episodes of acute TTP and 15 patients given rituximab as prophylaxis to prevent relapse. In the acute TTP group we assessed the benefit of giving early (≤ 3 days from admission) vs. later (> 3 days) rituximab.

RESULTS

In acute de novo TTP, previously untreated with rituximab, rituximab was given ≤ 3 days from admission to 54 patients and > 3 days from admission to 32 patients. Earlier administration (≤ 3 days) was associated with faster attainment of remission (12 vs. 20 days, P < 0.001), fewer plasma exchanges (16 vs. 24, P = 0.03) and shorter hospital stay (16 vs. 23 days, P = 0.01). Eighty-two patients (95%) achieved complete remission within 14 days (4-52 days); four patients died acutely. Eleven out of 82 (13.4%) relapsed at a median of 24 months (4-49 months). Rituximab prophylaxis was associated with normalization of ADAMTS13 levels within 3 months in all but one case, with only one acute relapse at follow-up.

CONCLUSIONS

Although limited by being retrospective and non-randomized, this study demonstrates the potential benefit of early administration of rituximab in acute TTP, and prophylactic use to prevent acute relapse.