Machine Learned Cellular Phenotypes in Cardiomyopathy Predict Sudden Death

RATIONALE

Susceptibility to VT/VF (ventricular tachycardia/fibrillation) is difficult to predict in patients with ischemic cardiomyopathy either by clinical tools or by attempting to translate cellular mechanisms to the bedside.

OBJECTIVE

To develop computational phenotypes of patients with ischemic cardiomyopathy, by training then interpreting machine learning of ventricular monophasic action potentials (MAPs) to reveal phenotypes that predict long-term outcomes.

METHODS AND RESULTS

We recorded 5706 ventricular MAPs in 42 patients with coronary artery disease and left ventricular ejection fraction ≤40% during steady-state pacing. Patients were randomly allocated to independent training and testing cohorts in a 70:30 ratio, repeated K=10-fold. Support vector machines and convolutional neural networks were trained to 2 end points: (1) sustained VT/VF or (2) mortality at 3 years. Support vector machines provided superior classification. For patient-level predictions, we computed personalized MAP scores as the proportion of MAP beats predicting each end point. Patient-level predictions in independent test cohorts yielded c-statistics of 0.90 for sustained VT/VF (95% CI, 0.76-1.00) and 0.91 for mortality (95% CI, 0.83-1.00) and were the most significant multivariate predictors. Interpreting trained support vector machine revealed MAP morphologies that, using in silico modeling, revealed higher L-type calcium current or sodium-calcium exchanger as predominant phenotypes for VT/VF.

CONCLUSIONS

Machine learning of action potential recordings in patients revealed novel phenotypes for long-term outcomes in ischemic cardiomyopathy. Such computational phenotypes provide an approach which may reveal cellular mechanisms for clinical outcomes and could be applied to other conditions.

A Statement of Commitment to Zero Tolerance of Harassment and Discrimination in Schools and Programs of Public Health

The Association of Schools and Programs of Public Health convened a Task Force on Zero Tolerance of Harassment and Discrimination in 2019 to develop a policy statement and strategies for addressing harassment of all types in institutions offering public health education. We outline the premises and scholarly foundation for the development of the Statement of Commitment to Zero Tolerance of Harassment and Discrimination, the statement itself, and future plans for realizing the aspiration established in the statement. The development of this living document is predicated on the belief that it is the core responsibility of academic institutions to build the knowledge and that it is the responsibility of leaders, namely deans of schools of public health and directors of public health programs, to lead in building the shared knowledge and insist on the practices that create institutions for a better future free of harassment and discrimination. Our statement is informed by the knowledge that aggressions in the form of harassment and discrimination undermine the health and well-being of individuals, the public, and populations.

Hypoxic stress upregulates Kir2.1 expression by a pathway including hypoxic-inducible factor-1α and dynamin2 in brain capillary endothelial cells

Brain capillary endothelial cells (BCECs) play a central role in maintenance of blood-brain barrier (BBB) function and, therefore, are essential for central nervous system homeostasis and integrity. Although brain ischemia damages BCECs and causes disruption of BBB, the related influence of hypoxia on BCECs is not well understood. Hypoxic stress can upregulate functional expression of specific K+ currents in endothelial cells, e.g., Kir2.1 channels without any alterations in the mRNA level, in t-BBEC117, a cell line derived from bovine BCECs. The hyperpolarization of membrane potential due to Kir2.1 channel upregulation significantly facilitates cell proliferation. In the present study, the mechanisms underlying the hypoxia-induced Kir2.1 upregulation was examined. We emphasize the involvement of dynamin2, a protein known to be involved in a number of surface expression pathways. Hypoxic culture upregulated dynamin2 expression in t-BBEC117 cells. The inhibition of dynamin2 by Dynasore canceled hypoxia-induced upregulation of Kir2.1 currents by reducing surface expression. On the contrary, Kir2.1 currents and proteins in t-BBEC117 cultured under normoxia were increased by overexpression of dynamin2, but not by dominant-negative dynamin2. Molecular imaging based on bimolecular fluorescence complementation, double-immunostaining, and coimmunoprecipitation assays revealed that dynamin2 can directly bind to the Kir2.1 channel. Moreover, hypoxic culture downregulated hypoxic-inducible factor-1α (HIF-1α) expression. Knockdown of HIF-1α increased dynamin2 expression in t-BBEC117 cells, in both normoxic and hypoxic culture conditions. In summary, our results demonstrated that hypoxia downregulates HIF-1α, increases dynamin2 expression, and facilitates Kir2.1 surface expression, resulting in hyperpolarization of membrane potential and subsequent increase in Ca2+ influx in BCECs.

Cardiac action potential repolarization revisited: early repolarization shows all-or-none behaviour

In healthy mammalian hearts the action potential (AP) waveform initiates and modulates each contraction, or heartbeat. As a result, AP height and duration are key physiological variables. In addition, rate-dependent changes in ventricular AP duration (APD), and variations in APD at a fixed heart rate are both reliable biomarkers of electrophysiological stability. Present guidelines for the likelihood that candidate drugs will increase arrhythmias rely on small changes in APD and Q-T intervals as criteria for safety pharmacology decisions. However, both of these measurements correspond to the final repolarization of the AP. Emerging clinical evidence draws attention to the early repolarization phase of the action potential (and the J-wave of the ECG) as an additional important biomarker for arrhythmogenesis. Here we provide a mechanistic background to this early repolarization syndrome by summarizing the evidence that both the initial depolarization and repolarization phases of the cardiac action potential can exhibit distinct time- and voltage-dependent thresholds, and also demonstrating that both can show regenerative all-or-none behaviour. An important consequence of this is that not all of the dynamics of action potential repolarization in human ventricle can be captured by data from single myocytes when these results are expressed as 'repolarization reserve'. For example, the complex pattern of cell-to-cell current flow that is responsible for AP conduction (propagation) within the mammalian myocardium can change APD and the Q-T interval of the electrocardiogram alter APD stability, and modulate responsiveness to pharmacological agents (such as Class III anti-arrhythmic drugs).

The Whole School, Whole Community, Whole Child model: a new approach for improving educational attainment and healthy development for students

BACKGROUND

The Whole Child approach and the coordinated school health (CSH) approach both address the physical and emotional needs of students. However, a unified approach acceptable to both the health and education communities is needed to assure that students are healthy and ready to learn.

METHODS

During spring 2013, the ASCD (formerly known as the Association for Supervision and Curriculum Development) and the US Centers for Disease Control and Prevention (CDC) convened experts from the field of education and health to discuss lessons learned from implementation of the CSH and Whole Child approaches and to explore the development of a new model that would incorporate the knowledge gained through implementation to date.

RESULTS

As a result of multiple discussions and review, the Whole School, Whole Community, Whole Child (WSCC) approach was developed. The WSCC approach builds upon the traditional CSH model and ASCD's Whole Child approach to learning and promotes greater alignment between health and educational outcomes.

CONCLUSION

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities that will improve educational attainment and healthy development for students.

Evaluation of the effect of respiratory and anatomical variables on a Fourier technique for markerless, self-sorted 4D-CBCT

A novel technique based on Fourier transform theory has been developed that directly extracts respiratory information from projections without the use of external surrogates. While the feasibility has been demonstrated with three patients, a more extensive validation is necessary. Therefore, the purpose of this work is to investigate the effects of a variety of respiratory and anatomical scenarios on the performance of the technique with the 4D digital extended cardiac torso phantom. FT-phase and FT-magnitude methods were each applied to identify peak-inspiration projections and quantitatively compared to the gold standard of visual identification. Both methods proved to be robust across the studied scenarios with average differences in respiratory phase <10% and percentage of projections assigned within 10% of the gold standard >90%, when incorporating minor modifications to region-of-interest (ROI) selection and/or low-frequency location for select cases of DA and lung percentage in the field of view of the projection. Nevertheless, in the instance where one method initially faltered, the other method prevailed and successfully identified peak-inspiration projections. This is promising because it suggests that the two methods provide complementary information to each other. To ensure appropriate clinical adaptation of markerless, self-sorted four-dimensional cone-beam CT (4D-CBCT), perhaps an optimal integration of the two methods can be developed.

Training the workforce in evidence-based public health: an evaluation of impact among US and international practitioners

INTRODUCTION

The Prevention Research Center in St. Louis developed a course on evidence-based public health in 1997 to train the public health workforce in implementation of evidence-based public health. The objective of this study was to assess use and benefits of the course and identify barriers to using evidence-based public health skills as well as ways to improve the course.

METHODS

We used a mixed-method design incorporating on-site pre- and post-evaluations among US and international course participants who attended from 2008 through 2011 and web-based follow-up surveys among course participants who attended from 2005 through 2011 (n = 626). Respondents included managers, specialists, and academics at state health departments, local health departments, universities, and national/regional health departments.

RESULTS

We found significant improvement from pre- to post-evaluation for 11 measures of knowledge, skill, and ability. Follow-up survey results showed at least quarterly use of course skills in most categories, majority endorsement of most course benefits, and lack of funding and coworkers who do not have evidence-based public health training as the most significant barriers to implementation of evidence-based public health. Respondents suggested ways to increase evidence-based decision making at their organization, focusing on organizational support and continued access to training.

CONCLUSION

Although the evidence-based public health course is effective in improving self-reported measures of knowledge, skill, and ability, barriers remain to the implementation of evidence-based decision making, demonstrating the importance of continuing to offer and expand training in evidence-based public health.

Electrophysiological mapping of embryonic mouse hearts: mechanisms for developmental pacemaker switch and internodal conduction pathway

INTRODUCTION

Understanding sinoatrial node (SAN) development could help in developing therapies for SAN dysfunction. However, electrophysiological investigation of SAN development remains difficult because mutant mice with SAN dysfunctions are frequently embryonically lethal. Most research on SAN development is therefore limited to immunocytochemical observations without comparable functional studies.

METHODS AND RESULTS

We applied a multielectrode array (MEA) recording system to study SAN development in mouse hearts acutely isolated at embryonic ages (E) 8.5-12.5 days. Physiological heart rates were routinely restored, enabling accurate functional assessment of SAN development. We found that dominant pacemaking activity originated from the left inflow tract (LIFT) region at E8.5, but switched to the right SAN by E12.5. Combining MEA recordings and pharmacological agents, we show that intracellular calcium (Ca(2+))-mediated automaticity develops early and is the major mechanism of pulse generation in the LIFT of E8.5 hearts. Later in development at E12.5, sarcolemmal ion channels develop in the SAN at a time when pacemaker channels are down-regulated in the LIFT, leading to a switch in the dominant pacemaker location. Additionally, low micromolar concentrations of tetrodotoxin (TTX), a sodium channel blocker, minimally affect pacemaker rhythm at E8.5-E12.5, but suppress atrial activation and reveal a TTX-resistant SAN-atrioventricular node (internodal) pathway that mediates internodal conduction in E12.5 hearts.

CONCLUSIONS

Using a physiological mapping method, we demonstrate that differential mechanistic development of automaticity between the left and right inflow tract regions confers the pacemaker location switch. Moreover, a TTX-resistant pathway mediates preferential internodal conduction in E12.5 mouse hearts. 

Surveillance of health status in minority communities - Racial and Ethnic Approaches to Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009

PROBLEM

Substantial racial/ethnic health disparities exist in the United States. Although the populations of racial and ethnic minorities are growing at a rapid pace, large-scale community-based surveys and surveillance systems designed to monitor the health status of minority populations are limited. CDC conducts the Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Risk Factor Survey annually in minority communities. The survey focuses on black, Hispanic, Asian (including Native Hawaiian and Other Pacific Islander), and American Indian (AI) populations.

REPORTING PERIOD COVERED

2009.

DESCRIPTION OF SYSTEM

An address-based sampling design was used in the survey in 28 communities located in 17 states (Arizona, California, Georgia, Hawaii, Illinois, Massachusetts, Michigan, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Virginia, West Virginia, and Washington). Self-reported data were collected through telephone, questionnaire mailing, and in-person interviews from an average of 900 residents aged ≥ 18 years in each community. Data from the community were compared with data derived from the Behavioral Risk Factor Surveillance System (BRFSS) for the metropolitan and micropolitan statistical area (MMSA), county, or state in which the community was located and also compared with national estimates.

RESULTS

Reported education level and household income were markedly lower in black, Hispanic, and AI communities than that among the general population living in the comparison MMSA, county, or state. More residents in these minority populations did not have health-care coverage and did not see a doctor because of the cost. Substantial variations were identified in self-perceived health status and prevalence of selected chronic conditions among minority populations and among communities within the same racial/ethnic population. In 2009, the median percentage of men who reported fair or poor health was 15.8% (range: 8.3%-29.3%) among A/PI communities and 26.3% (range: 22.3%-30.8%) among AI communities. The median percentage of women who reported fair or poor health was 20.1% (range: 13.3%-37.2%) among A/PI communities, whereas it was 31.3% (range: 19.4%-44.2%) among Hispanic communities. AI and black communities had a high prevalence of self-reported hypertension, cardiovascular disease, and diabetes. For most communities, prevalence was much higher than that in the corresponding MMSA, county, or state in which the community was located. The median percentages of persons who knew the signs and symptoms of a heart attack and stroke were consistently lower in all four minority communities than the national median. Variations were identified among racial/ethnic populations in the use of preventive services. Hispanics had the lowest percentages of persons who had their cholesterol checked, of those with high blood pressure who were taking antihypertensive medication, and of those with diabetes who had a glycosylated hemoglobin (HbA1C) test in the past year. AIs had the lowest mammography screening rate within 2 years among women aged ≥40 years (median: 72.7%; range: 69.4%-76.2%). A/PIs had the lowest Pap smear screening rate within 3 years (median: 74.4%; range: 60.3%-80.8%). The median influenza vaccination rates in adults aged ≥65 years were much lower among black (57.3%) and Hispanic communities (63.3%) than the national median (70.1%) among the 50 states and DC. Pneumococcal vaccination rates also were lower in black (60.5%), Hispanic (58.5%), and A/PI (59.7%) communities than the national median (68.5%).

INTERPRETATIONS

Data from the REACH U.S. Risk Factor Survey demonstrate that residents in most of the minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for and burden of disease compared with the general populations living in the same MMSA, county, or state. Substantial variations in prevalence of risk factors, chronic conditions, and use of preventive services among different minority populations and different communities within the same racial/ethnic population provide opportunities for public health intervention. These variations also indicate that different priorities are needed to eliminate health disparities for different communities.

PUBLIC HEALTH ACTION

These community-level survey data are being used by CDC and community coalitions to implement, monitor, and evaluate intervention programs in each community. Continuous surveillance of health status in minority communities is necessary so that community-specific, culturally sensitive strategies that include system, environmental, and individual-level changes can be tailored to these communities.

Ionic mechanisms of electrophysiological properties and repolarization abnormalities in rabbit Purkinje fibers

Purkinje cells play an important role in drug-induced arrhythmogenesis and are widely used in preclinical drug safety assessments. Repolarization abnormalities such as action potential (AP) prolongation and early afterdeploarizations (EAD) are often observed in vitro upon pharmacological interventions. However, because drugs do not act on only one defined target, it is often difficult to fully explain the mechanisms of action and their potential arrhythmogenicity. Computational models, when appropriately detailed and validated, can be used to gain mechanistic insights into the mechanisms of action of certain drugs. Nevertheless, no model of Purkinje electrophysiology that is able to reproduce characteristic Purkinje responses to drug-induced changes in ionic current conductances such as AP prolongation and EAD generation currently exists. In this study, a novel biophysically detailed model of rabbit Purkinje electrophysiology was developed by integration of data from voltage-clamp and AP experimental recordings. Upon validation, we demonstrate that the model reproduces many key electrophysiological properties of rabbit Purkinje cells. These include: AP morphology and duration, both input resistance and rate dependence properties as well as response to hyperkalemia. Pharmacological interventions such as inward rectifier K(+) current and rapid delayed rectifier K(+) current block as well as late Na(+) current increase result in significant AP changes. However, enhanced L-type Ca(2+) current (i(CaL)) dominates in EAD genesis in Purkinje fibers. In addition, i(CaL) inactivation dynamics and intercellular coupling in tissue strongly modulate EAD formation. We conclude that EAD generation in Purkinje cells is mediated by an increase in i(CaL) and modulated by its inactivation kinetics.

Recurrence of breech presentation in consecutive pregnancies

Objective

To investigate the recurrence risk of breech presentation at term, and to assess the risk factors that contribute to its recurrence.

Design

Cohort study.

Setting

New South Wales, Australia.

Population

Women with their first two (n = 113 854) and first three (n = 21 690) consecutive singleton term pregnancies, in the period 1994–2002.

Methods

Descriptive statistics including rates, relative risks and adjusted relative risks, as determined from logistic regression and Poisson analyses.

Main outcome measures

Rates and risks of occurrence and recurrence of breech presentation at birth in each pregnancy, and maternal and infant risk factors associated with breech recurrence.

Results

First-time breech presentation at term occurred in 4.2% of first pregnancy deliveries, 2.2% of second pregnancies and 1.9% of third pregnancies. The rate of breech recurrence in a second consecutive pregnancy was 9.9%, and in a third consecutive pregnancy (after two prior breech deliveries) was 27.5%. The relative risk of breech recurrence in a second pregnancy was 3.2 (95% CI 2.8–3.6), and in a third consecutive breech pregnancy was 13.9 (95% CI 8.8–22.1). First pregnancy factors associated with recurrence included placenta praevia [adjusted relative risk (aRR) 2.2; 95% CI 1.3–3.7], maternal diabetes (aRR 1.4; 95% CI 1.0–2.1) and a maternal age of ≥35 years (aRR 1.2; 95% CI 0.9–1.6). Second pregnancy factors included birth defects (aRR 2.5; 95% CI 1.4–4.2), placenta praevia (aRR 2.5; 95% CI 1.5–4.1) and a female infant (aRR 1.2; 95% CI 1.0–1.5).

Conclusions

The increased recurrence risk of breech presentations suggests that women with a history of breech delivery should be closely monitored in the latter stages of pregnancy.

Accelerated Ca2+ entry by membrane hyperpolarization due to Ca2+-activated K+ channel activation in response to histamine in chondrocytes

In articular cartilage inflammation, histamine release from mast cells is a key event. It can enhance cytokine production and matrix synthesis and also promote cell proliferation by stimulating chondrocytes. In this study, the functional impact of Ca2+-activated K+ (KCa) channels in the regulation of intracellular Ca2+ concentration ([Ca2+]i) in chondrocytes in response to histamine was examined using OUMS-27 cells, as a model of chondrocytes derived from human chondrosarcoma. Application of histamine induced a significant [Ca2+]i rise and also membrane hyperpolarization, and both effects were mediated by the stimulation of H1 receptors. The histamine-induced membrane hyperpolarization was attenuated to ∼50% by large-conductance KCa (BK) channel blockers, and further reduced by intermediate (IK) and small conductance KCa (SK) channel blockers. The tonic component of histamine-induced [Ca2+]i rise strongly depended on the presence of extracellular Ca2+ ([Ca2+]o) and was markedly reduced by La3+ or Gd3+ but not by nifedipine. It was significantly attenuated by BK channel blockers, and further blocked by the cocktail of BK, IK, and SK channel blockers. The KCa blocker cocktail also significantly reduced the store-operated Ca2+ entry (SOCE), which was induced by Ca2+ addition after store-depletion by thapsigargin in [Ca2+]o free solution. Our results demonstrate that the histamine-induced membrane hyperpolarization in chondrocytes due to KCa channel activation contributes to sustained Ca2+ entry mainly through SOCE channels in OUMS-27 cells. Thus, KCa channels appear to play an important role in the positive feedback mechanism of [Ca2+]i regulation in chondrocytes in the presence of articular cartilage inflammation.

Surveillance of certain health behaviors and conditions among states and selected local areas - Behavioral Risk Factor Surveillance System, United States, 2007

PROBLEM

Chronic diseases (e.g., heart disease, cancer, stroke, and diabetes) are the leading causes of death in the United States. Controlling health risk behaviors (e.g., smoking, physical inactivity, poor diet, and excessive drinking) and using preventive health-care services (e.g., cancer, hypertension, and cholesterol screenings) can reduce morbidity and mortality from chronic diseases. Monitoring health-risk behaviors, chronic health conditions, and preventive care practices is essential to develop health promotion activities, intervention programs, and health policies at the state, city, and county levels.

REPORTING PERIOD COVERED

January 2007-December 2007.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based, on-going, random--digit-dialed household telephone survey of noninstitutionalized adults aged >or=18 years residing in the United States. BRFSS collects data on health-risk behaviors and use of preventative health services related to the leading causes of death and disability in the United States. This report presents results for 2007 for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Virgin Islands, 184 metropolitan and micropolitan statistical areas (MMSAs), and 298 counties.

RESULTS

In 2007, prevalence estimates of risk behaviors, chronic conditions, and the use of preventive services varied substantially by state and territory, MMSA, and county. The following is a summary of results listed by BRFSS question topic. Each set of proportions refers to the range of estimated prevalence for the disease, condition, or behavior, as reported by the survey subject. Adults who reported fair or poor health: 11% to 32% for states and territories and 6% to 31% for MMSAs and counties. Adults with health-care coverage: 71% to 94% for states and territories and 51% to 97% for MMSAs and counties. Annual influenza vaccination among adults aged >or=65 years: 32% to 80% for states and territories, 48% to 83% for MMSAs, and 44% to 88% for counties. Pneumococcal vaccination among adults aged >/=65 years: 26% to 74% for states and territories, 44% to 83% for MMSAs, and 39% to 87% for counties. Adults who had their cholesterol checked within the preceding 5 years: 66% to 85% for states and territories and 58% to 90% for MMSAs and counties. Adults who consumed at least 5 servings of fruits and vegetables per day: 14% to 33% for states and territories, 16% to 34% for MMSAs and 14% to 37% for counties. Adults who reported no leisure-time physical activity: 17% to 44% for states and territories and 9% to 38% for MMSAs and counties. Adults who engaged in moderate or vigorous physical activity: 31% to 61% for states and territories and 36% to 67% for MMSAs and counties. Adults who engaged in only vigorous physical activity: 19% to 40% for states and territories and 15% to 45% for MMSAs and counties. Cigarette smoking among adults: 9% to 31% for states and territories, 7% to 34% for MMSAs, and 7% to 30% for counties. Binge drinking among adults: 3% to 8% for states and territories. Adults classified as overweight: 33% to 40% for states and territories and 26% to 47% for MMSAs and counties. Adults aged >or=20 years who were obese: 20% to 34% for states and territories and 14% to 38% for MMSAs and counties. Adults who were told of a diabetes diagnosis: 5% to 13% for states and territories and 2% to 17% for MMSAs and counties. Adults with high blood pressure diagnosis: 21% to 35% for states and territories and 16% to 38% for MMSAs and counties. Adults who had high blood cholesterol: 28% to 43% for states and territories, 29% to 49% for MMSAs, and 26% to 51% for counties. Adults with a history of coronary heart disease: 2% to 14% for states and territories, MMSAs, and counties. Adults who were told of a stroke diagnosis: 1% to 7% for states and territories, MMSAs, and counties. Adults who were diagnosed with arthritis: 14% to 36% for states and territories and 16% to 40% for MMSAs and counties. Adults who had asthma: 5% to 10% for states and territories and 3% to 13% for MMSAs and counties. Adults with activity limitation associated with physical, mental, or emotional problems: 10% to 26% for states and territories. Adults who required special equipment because of health problems: 3% to 10% for states and territories and 3% to 14% for MMSAs and counties.

INTERPRETATION

The findings in this report indicate substantial variation in self-reported health status, health-care coverage, use of preventive health-care services, health behaviors leading to chronic health conditions, and disability among U.S. adults at the state and territory, MMSA, and county levels. The findings underscore the continued need for surveillance of health-risk behaviors, chronic diseases and conditions, and the use of preventive services.

PUBLIC HEALTH ACTIONS

Healthy People 2010 (HP 2010) objectives have been established to monitor health behaviors and the use of preventive health services. Local and state health departments and federal agencies use BRFSS data to identify populations at high risk for certain health behaviors, chronic diseases and conditions and to evaluate the use of preventive services. In addition, BRFSS data are used to direct, implement, monitor, and evaluate public health programs and policies that can lead to a reduction in morbidity and mortality.

Surveillance of certain health behaviors and conditions among states and selected local areas--Behavioral Risk Factor Surveillance System (BRFSS), United States, 2006

PROBLEM

Behavioral risk factors such as smoking, poor diet, physical inactivity, and excessive drinking are linked to the leading causes of death in the United States. Controlling these behavioral risk factors and using preventive health services (e.g., influenza vaccinations and cholesterol screenings) can reduce morbidity and mortality in the U.S. population substantially. Continuous monitoring both of health behaviors and of the use of preventive services is essential for developing health promotion activities, intervention programs, and health policies at the state, city, and county level.

REPORTING PERIOD COVERED

January--December 2006.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. population aged >/=18 years. BRFSS collects data on health-risk behaviors and use of preventive health services related to the leading causes of death and disability in the United States. This report presents results for 2006 for all 50 states, DC, Puerto Rico, the U.S. Virgin Islands, 145 selected metropolitan and micropolitan statistical areas (MMSAs), and 234 corresponding counties.

RESULTS

Prevalence estimates of risk behaviors, chronic conditions, and the use of preventive services varied substantially by state and territory, MMSA, and county. In 2006, the estimated prevalence of fair or poor health ranged from 11% to 33% for states and territories, from 8% to 24% for MMSAs, and from 5% to 24% for counties. The estimated prevalence of health-care coverage ranged from 61% to 96% for states and territories, MMSAs, and counties. The estimated prevalence of teeth extraction among adults aged >/=65 years was lowest in Hawaii (10%) and highest in Kentucky (39%) and West Virginia (41%). The estimated prevalence of activity limitation as a result of physical, mental, or emotional problems ranged from 10% to 28% for states and territories, from 13% to 36% for MMSAs, and from 11% to 29% for counties. The estimated prevalence of adults who had a recent routine checkup ranged from 45% to 81% for states and territories, MMSAs, and counties. The estimated prevalence of annual influenza vaccination among adults aged >/=65 years was lowest in Puerto Rico (33%) and highest in Colorado (76%). The estimated prevalence of pneumococcal vaccination among older adults ranged from 30% to 75% for states and territories, from 52% to 80% for MMSAs, and from 42% to 82% for counties. The estimated prevalence of sigmoidoscopy/colonoscopy among adults aged >/=50 years ranged from 38% to 84% for states and territories, MMSAs, and counties. The estimated prevalence among adults aged >/=50 years who had a blood stool test during the preceding 2 years was lowest in Puerto Rico (5%) and highest in DC and Maine (33%). The estimated prevalence among women having a Papanicolaou (Pap) test during the preceding 3 years ranged from 72% to 89% for states and territories, from 75% to 94% for MMSAs, and from 75% to 95% in counties. The estimated prevalence among women aged >/=40 years having a mammogram during the preceding 2 years ranged from 60% to 89% for states and territories, MMSAs, and counties. The estimated prevalence among men aged >/=40 years who had a prostate-specific antigen (PSA) test during the preceding 2 years was lowest in Hawaii (40%) and highest in Puerto Rico (66%). The estimated prevalence of cigarette smoking ranged from 9% to 29% for states and territories and from 6% to 31% for MMSAs and counties. The estimated prevalence of binge drinking was lowest in Kentucky and Tennessee (9%) and highest in Wisconsin (24%). The estimated prevalence of leisure-time physical inactivity ranged from 11% to 41% for states and territories, MMSAs, and counties. Seat belt use was lowest in North and South Dakota (58%) and highest in California, Hawaii, and Washington (92%). The estimated prevalence among adults who were overweight ranged from 32% to 40% for states and territories, from 31% to 45% for MMSAs, and from 24% to 49% for counties. The estimated prevalence of obesity ranged from 10% to 46% for states and territories, MMSAs, and counties. The estimated current asthma prevalence ranged from 3% to 14% for states and territories, MMSAs, and counties. The estimated prevalence of diabetes ranged from 2% to 13% for states and territories, MMSAs, and counties. The estimated prevalence of coronary heart disease among adults aged >/=45 years ranged from 5% to 20% for states and territories. The estimated prevalence of a history of stroke history among adults aged >/=45 years ranged from 2% to 10% for states and territories, MMSAs, and counties.

INTERPRETATION

This report indicates that substantial variations in health-risk behaviors, chronic diseases and conditions, and the use of preventive health services exist among adults from state to state and within states and underscores the continued need for prevention and health promotion activities at the local, state, and federal levels.

PUBLIC HEALTH ACTION

Healthy People 2010 objectives have been established to monitor health behaviors and the use of preventive health services. Local and state health departments and federal agencies use BRFSS data to measure progress toward achieving national and local health objectives. Continued surveillance is needed to design, implement, and evaluate public health policies and programs that can lead to a reduction in morbidity and mortality from the effects of health-risk behaviors and subsequent chronic conditions.

Association of C-reactive protein with surrogate measures of insulin resistance among nondiabetic US from National Health and Nutrition Examination Survey 1999-2002

BACKGROUND

Increased C-reactive protein (CRP) concentration and insulin resistance (IR) are associated with increased rates of adverse cardiovascular events. We sought to examine the relationship of CRP with surrogate measures of IR among nondiabetic adults in the US.

METHODS

We conducted analyses using data from the National Health and Nutrition Examination Survey 1999-2002. We analyzed a nationally representative sample of 2514 men and nonpregnant women age > or = 20 years who were non-Hispanic white, non-Hispanic black, or Mexican American.

RESULTS

After adjustment for age, sex, race/ethnicity, smoking status, systolic blood pressure, and serum concentrations of HDL cholesterol, LDL cholesterol, and triglyceride, CRP was significantly associated with 10 IR measures (all P values <0.01). The strength of the association attenuated after further adjustment for waist circumference (change in adjusted regression coefficients ranging from 60.0% to 75.1%). The association of CRP with each IR surrogate was similar (standardized regression coefficient ranges from 0.06 to 0.09). The association of CRP (>3 vs <1 mg/L) with the homeostasis model for assessment of IR (> or = 75th vs <75th percentile) was statistically significant among people with a body mass index > or = 30 kg/m(2) (odds ratio, 2.6; 95% CI, 1.3-5.1) or with a body mass index <25 kg/m(2) (odds ratio, 2.5; 95% CI, 1.5-4.2).

CONCLUSIONS

CRP was significantly associated with the surrogate measures of IR among nondiabetic adults. Obesity may play an important role in the association of CRP with IR in this nationally representative sample.

Probable Migraine With Visual Aura and Risk of Ischemic Stroke

Background and Purpose— Migraine with aura is associated with ischemic stroke, but few studies have investigated the clinical and anatomic features of this association. We assessed the association of probable migraine with and without visual aura with ischemic stroke within subgroups defined by stroke subtype, vascular territory, probable migraine characteristics, and other clinical features.

Methods— Using data from a population-based, case-control study, we studied 386 women ages 15 to 49 years with first ischemic stroke and 614 age- and ethnicity-matched controls. Based on their responses to a questionnaire on headache symptoms, subjects were classified as having no migraine, probable migraine without visual aura, or probable migraine with visual aura (PMVA).

Results— Women with PMVA had 1.5 greater odds of ischemic stroke (95% CI, 1.1 to 2.0); the risk was highest in those with no history of hypertension, diabetes, or myocardial infarction compared to women with no migraine. Women with PMVA who were current cigarette smokers and current users of oral contraceptives had 7.0-fold higher odds of stroke (95% CI, 1.3 to 22.8) than did women with PMVA who were nonsmokers and non–oral contraceptive users. Women with onset of PMVA within the previous year had 6.9-fold higher adjusted odds of stroke (95% CI, 2.3 to 21.2) compared to women with no history of migraine.

Conclusions— PMVA was associated with an increased risk of stroke, particularly among women without other medical conditions associated with stroke. Behavioral risk factors, specifically smoking and oral contraceptive use, markedly increased the risk of PMVA, as did recent onset of PMVA.

ERRgamma directs and maintains the transition to oxidative metabolism in the postnatal heart

At birth, the heart undergoes a critical metabolic switch from a predominant dependence on carbohydrates during fetal life to a greater dependence on postnatal oxidative metabolism. This remains the principle metabolic state throughout life, although pathologic conditions such as heart failure and cardiac hypertrophy reactivate components of the fetal genetic program to increase carbohydrate utilization. Disruption of the ERRgamma gene (Esrrg), which is expressed at high levels in the fetal and postnatal mouse heart, blocks this switch, resulting in lactatemia, electrocardiographic abnormalities, and death during the first week of life. Genomic ChIP-on-chip and expression analysis identifies ERRgamma as both a direct and an indirect regulator of a nuclear-encoded mitochondrial genetic network that coordinates the postnatal metabolic transition. These findings reveal an unexpected and essential molecular genetic component of the oxidative metabolic gene program in the heart and highlight ERRgamma in the study of cardiac hypertrophy and failure.

Surveillance of certain health behaviors among states and selected local areas--United States, 2005

PROBLEM

Behavioral risk factors such as smoking, poor diet, physical inactivity, and excessive drinking are linked to the leading causes of death in the United States. Controlling these behavioral risk factors and using preventive health services (e.g., influenza and pneumococcal vaccination of adults aged > or =65 years and hypertension and cholesterol screenings) can substantially reduce the morbidity and mortality in the U.S. population. Continuous monitoring of these behaviors and preventive services are essential for developing health promotion, intervention programs, and health policies at the state, city, and county level.

REPORTING PERIOD COVERED

Data collected in 2005 are presented for states/territories, selected metropolitan and micropolitan statistical areas (MMSAs), metropolitan divisions, and selected counties.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. population aged > or =18 years. BRFSS collects information on health risk behaviors and preventive health services related to leading causes of death. All 50 states, the District of Columbia (DC), the Commonwealth of Puerto Rico, and the U.S. Virgin Islands participated in BRFSS during 2005. Within these states and territories, 153 MMSAs and 232 counties that reported data for at least 500 respondents or a minimum sample size of 19 per weighting class were included in the analyses.

RESULTS

Prevalence of health-risk behaviors, awareness of specific medical conditions, and use of preventive services varied substantially by state/territory, MMSA, and county. In 2005, prevalence of health insurance ranged from 60% to 95% for states/territories, MMSAs, and counties. Prevalence of leisure-time physical inactivity ranged from 16% to 49% for states/territories, 14% to 36% for MMSAs, and 12% to 41% for counties. Prevalence of adults who engaged in at least moderate physical activity ranged from 33% to 62%, and prevalence of vigorous physical activity ranged from 15% to 42% for states/territories, MMSAs, and counties. Prevalence of adults who currently smoke cigarettes ranged from 6% to 35% for states/territories, MMSAs, and counties. The prevalence of binge drinking was substantially higher than the prevalence of heavy drinking across all the states/territories, MMSAs, and counties. Prevalence of adults who were overweight ranged from 53% to 67 % for states/territories, 49% to 70% for MMSAs, and 44% to 71% for counties. Prevalence of current asthma ranged from 4% to 14% for states/territories, MMSAs, and counties. Prevalence of diabetes ranged from 4% to 14% for states/territories and MMSAs and from 3% to 14% for counties. Proportion of respondents with high blood pressure ranged from 13% to 39% for states/territories, MMSAs and counties. Prevalence of respondents with high cholesterol ranged from 31% to 41% for states/territories and 26% to 47% for MMSAs and counties. The prevalence estimates for respondents who reported being limited in any way in any activities because of physical, mental, or emotional problems ranged from 10% to 27% for states/territories, 12% to 31% for MMSAs, and 10% to 27% for counties. The percentage of respondents who required use of special equipment ranged from 4% to 10% for the states/territories, 3% to 15% for MMSAs, and 3% to 11% for counties. Prevalence of fair or poor health ranged from 11% to 34% for states/territories and 6% to 26% for MMSAs and counties. The prevalence of adults who checked their cholesterol during the preceding 5 years ranged from 55% to 86% for states/territories, MMSAs, and counties. Prevalence of annual influenza vaccination among adults aged > or =65 years ranged from 32% to 78% for states/territories, 48% to 83% for MMSAs, and 41% to 84% for counties. The estimated prevalence of pneumococcal vaccination among adults aged > or =65 years ranged from 28% to 72% for states/territories, 52% to 82% for MMSAs, and 35% to 83% for counties.

INTERPRETATION

The findings in this report indicate a wide variation in health-risk behaviors, chronic conditions, and use of preventive services among U.S. adults at the state/territory, MMSA, and county level. The findings underscore a need for continuous efforts to evaluate public health intervention programs and policies designed to reduce morbidity and mortality caused by chronic disease and injury.

PUBLIC HEALTH ACTION

The 2005 BRFSS data indicate a need for continued monitoring of health-risk behaviors, specific disease conditions, and use of preventive services to identify high-risk populations and to implement and monitor health-promotion programs and health policies at the state/territory, MMSA, and county level.

KCNQ potassium channel mutations cause cardiac arrhythmias in Drosophila that mimic the effects of aging

Population profiles of industrialized countries show dramatic increases in cardiovascular disease with age, but the molecular and genetic basis of disease progression has been difficult to study because of the lack of suitable model systems. Our studies of Drosophila show a markedly elevated incidence of cardiac dysfunction and arrhythmias in aging fruit fly hearts and a concomitant decrease in the expression of the Drosophila homolog of human KCNQ1-encoded K(+) channel alpha subunits. In humans, this channel is involved in myocardial repolarization, and alterations in the function of this channel are associated with an increased risk for Torsades des Pointes arrhythmias and sudden death. Hearts from young KCNQ1 mutant fruit flies exhibit prolonged contractions and fibrillations reminiscent of Torsades des Pointes arrhythmias, and they exhibit severely increased susceptibility to pacing-induced cardiac dysfunction at young ages, characteristics that are observed only at advanced ages in WT flies. The fibrillations observed in mutant flies correlate with delayed relaxation of the myocardium, as revealed by increases in the duration of phasic contractions, extracellular field potentials, and in the baseline diastolic tension. These results suggest that K(+) currents, mediated by a KCNQ channel, contribute to the repolarization reserve of fly hearts, ensuring normal excitation-contraction coupling and rhythmical contraction. That arrhythmias in both WT and KCNQ1 mutants become worse as flies age suggests that additional factors are also involved.

Cardiac fibroblasts: friend or foe?

Cardiac function is determined by the dynamic interaction of various cell types and the extracellular matrix that composes the heart. This interaction varies with the stage of development and the degree and duration of mechanical, chemical, and electrical signals between the various cell types and the ECM. Understanding how these complex signals interact at the molecular, cellular, and organ levels is critical to understanding the function of the heart under a variety of physiological and pathophysiological conditions. Quantitative approaches, both in vivo and in vitro, are essential to understand the dynamic interaction of mechanical, chemical, and electrical stimuli that govern cardiac function. The fibroblast can thus be a friend in normal function or a foe in pathophysiological conditions.

Surveillance for certain health behaviors among states and selected local areas--behavioral risk factor surveillance system, United States, 2004

PROBLEM

Continuous monitoring of behaviors that increase the risk for chronic diseases and use of preventive practices are essential for the development, implementation, and evaluation of health promotion programs and policies, and other intervention strategies to prevent morbidity and mortality. Data from states/territories, selected metropolitan and micropolitan statistical areas (MMSAs), and counties provide the impetus for policymakers and other stakeholders to develop and promote the improvement of their community's overall health status.

REPORTING PERIOD COVERED

Data in this report were collected during January 1-December 31, 2004, from states/territories, MMSAs, and counties that participated in the 2004 Behavioral Risk Factor Surveillance System (BRFSS).

DESCRIPTION OF THE SYSTEM

BRFSS is an ongoing, state-based, random-digit--dialed telephone survey that employs a multistage cluster design. BRFSS collects information on health risk behaviors and preventive health practices related to the leading causes of death from the U.S. civilian, noninstitutionalized population aged > or =18 years. During 2004, a total of 49 states, the District of Columbia (DC), Puerto Rico, and the U.S. Virgin Islands participated in BRFSS. Among these states and territories, completed surveys were collected from a selection of 134 MMSAs and 199 counties.

RESULTS

Prevalence of high-risk behaviors for chronic diseases, awareness of specific medical conditions, screening for certain cancers, and use of preventive health services varied substantially by state/territory, MMSA, and county. The proportion of the population that achieved Healthy People 2010 (HP 2010) objectives also varied by state/territory, MMSA, and county. In 2004, HP 2010 objectives for 100% health-care coverage and vaccination for pneumonia and influenza among persons aged > or =65 years were not achieved by any state/territory, MMSA, or county. Twelve states/territories, 47 MMSAs, and 74 counties achieved the HP 2010 objective of < or =20% of adults engaged in no leisure-time physical activity or exercise. The HP 2010 objective to reduce the proportion of adults who currently smoke cigarettes to < or =12% was achieved by two states/territories, four MMSAs, and six counties. One MMSA and one county achieved the HP 2010 target of < or =6% who engage in binge drinking during the month preceding the survey. The HP 2010 target of < or =15% of adults who are obese was obtained by one MMSA and eight counties. The HP 2010 objective to reduce the proportion to <20% for older adults who have had all of their natural teeth extracted was achieved by 23 states/territories, 51 MMSAs, and 45 counties. The HP 2010 target for adults aged > or =50 years who have ever received a sigmoidoscopy is 50%. BRFSS measured both sigmoidoscopy and colonoscopy. Using this measure, 38 states, 110 MMSAs, and 154 counties achieved the 50% goal. Four counties achieved the HP 2010 objective of 50% for adults who received a blood stool test within the previous 2 years. The HP 2010 objective to increase the proportion of women aged > or =18 years who had a Papanicolaou (Pap) test within the preceding 3 years is 90%. Twenty-four MMSAs and 49 counties achieved this objective. The HP 2010 objective for women aged > or =40 years who have received a mammogram within the preceding 2 years is 70%. Thirty-nine states, 112 MMSAs, and 168 counties achieved the objective. This report includes several risk behaviors and conditions that, although not included in HP 2010 goals, are important public health problems. These include self-reported fair-to-poor health status, heavy alcohol consumption, asthma, diabetes, and prostate cancer screening. The 2004 BRFSS data indicate great variability in the prevalence of self-reported fair-to-poor health status (5.7%-34.8%) and use of prostate cancer screening (34.7%-65.2%) by states/territories, MMSAs, and counties. Among these areas, the prevalence of current asthma ranged from 4.1% to 12.4%, and the prevalence of diabetes ranged from 3.2% to 12.5%.

INTERPRETATION

The findings in this report indicate variations in health risk behaviors and use of preventive health screenings and health services among adults at the state, local, and county levels. These variations substantiate the continued need for public health surveillance in designing, implementing, monitoring, and evaluating public health policies and health-care use programs to reduce morbidity and mortality from the effect of high-risk health behaviors and subsequent chronic disease outcomes.

PUBLIC HEALTH ACTION

Data from BRFSS are essential for monitoring prevalence of high-risk health behaviors, specific diseases, and use of preventive health services; dictating the design, focus, implementation, and evaluation of prevention health programs and strategies; and monitoring progress toward obtaining local, state, and national health objectives. Data from the 2004 BRFSS indicate a continual necessity to initiate and implement health promotion strategies for identifying specific health risk behaviors and practices and for assessing progress toward achieving disease prevention and health promotion objectives at state and local levels throughout the United States.

ATX-II Effects on the Apparent Location of M Cells in a Computational Model of a Human Left Ventricular Wedge

INTRODUCTION

The apparent location of the myocytes (M cells) with the longest action potential duration (APD) in a canine left ventricular (LV) wedge have been reported to shift after application of a sea anemone toxin, ATX-II. This toxin slows inactivation of I(Na) and thus prolongs APD. Thus, M cells may exhibit dynamic functional states, rather than being a static, anatomically discrete, myocyte population. In this study, we attempted to further define and understand this phenomenon using a mathematical model of the human ventricular myocyte action potential incorporated into an in silico "wedge" preparation. Our simulations demonstrate that even under conditions of a fixed population and ratio of epicardial, M, and endocardial myocytes, the apparent anatomical position (transmural location) of the myocytes with the longest APD can shift following ATX-II treatment. This arises because the ATX-II effect, modeled as a small increase in the late or persistent Na(+) current, and consequent prolongation of APD significantly changes the electrotonic interactions between ventricular myocytes in this LV wedge preparation.

METHODS AND RESULTS

This LV wedge model is based on bidomain equations. It corresponds to a rectangular tissue immersed in a passive and isotropic medium that represents the superfusion bath. In this theoretical work, the three known different and discrete populations of myocytes in the human left ventricle have been included: the epicardial, M, and endocardial cells. The effects of ATX-II on I(Na) were simulated by altering the voltage-dependent steady-state inactivation of the parameters h (fast gate) and j (slow gate). As a result, in these ATX-II simulations a persistent late Na(+) current was generated in all three types of ventricular myocytes. However, the APDs were prolonged in a heterogeneous pattern. Our simulations demonstrate that after the ATX-II effects develop, alterations in transmural electrotonic interactions can produce changes in the transmural location of myocytes with the longest APD.

CONCLUSIONS

The combination of intercellular electrotonic interactions, which tend to reduce and smooth out the discrete transmural APD variations, and the heterogeneous effects of ATX-II, which preferentially prolong the APD of M cells, can shift the location of the ventricular myocytes. This shift results in significantly altered transmural patterns of action potential durations, which would be expected to change localized refractory period and excitability. These cellular changes give rise to alterations in the corresponding surface electrograms and may change the overall substrates for conduction and rhythm disturbances.

Surveillance for certain health behaviors among states and selected local areas--Behavioral Risk Factor Surveillance System, United States, 2003

PROBLEM

Data on health risk behaviors (e.g., cigarette smoking, binge drinking, and physical inactivity) for chronic diseases and use of preventive practices (e.g., influenza and pneumococcal vaccination for adults aged > or =65 years and cholesterol screening) are essential for developing effective health education and intervention programs and policies to prevent morbidity and mortality from chronic diseases. Continuous monitoring of these behaviors and practices at the state, city, and county levels can help public health programs in evaluating progress toward improving their community's health.

REPORTING PERIOD COVERED

Data collected in 2003 are presented for states, selected metropolitan and micropolitan statistical areas (MMSAs), and their counties.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized U.S. population aged > or =18 years. All 50 states, the District of Columbia, Guam, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands participated in BRFSS during 2003. Within these states and territories, 105 MMSAs and 153 counties that reported data for at least 500 respondents or a minimum sample size of 19 per weighting class were included in the analyses.

RESULTS

Prevalence of high-risk behaviors for chronic diseases, awareness of certain medical conditions, and use of preventive health-care services varied substantially by state/territory, MMSA, and county. The proportion of the population that achieved Healthy People 2010 (HP 2010) objectives also varied by state/territory, MMSA, and county. Twelve states, 39 MMSAs, and 65 counties achieved the HP 2010 objective to reduce the proportion of adults who engage in no leisure-time physical activity to 20%. Twenty states, 41 MMSAs, and 63 counties achieved the HP 2010 goal of 50% of adults engaging in moderate physical activity for at least 30 minutes per day. The HP 2010 goal of 30% of adults who engage in vigorous physical activity was achieved by 17 states, 33 MMSAs, and 57 counties. Two states, one MMSA, and one county achieved the HP 2010 current cigarette smoking goal of 12% prevalence. One county achieved the HP 2010 binge drinking goal of 6% prevalence among adults. One MMSA and eight counties achieved the HP 2010 goal of 15% for obesity prevalence. The HP 2010 goal for influenza and pneumococcal vaccination coverage of 90% was not achieved by any state, MMSA, or county. No state, MMSA, or county achieved the HP 2010 objective of 17% prevalence of high cholesterol among adults.

INTERPRETATION

The findings in this report indicate substantial variation in health risk behaviors and use of preventative services among adults at state and local levels, indicating a need for appropriate public health interventions and continued efforts to evaluate public health programs and policies and health-care-related efforts designed to reduce morbidity and mortality.

PUBLIC HEALTH ACTION

Data from BRFSS are useful for assessing national health objectives, for identifying and characterizing at risk populations, and for designing and evaluating health promotion and disease prevention programs and policies. The 2003 BRFSS data indicate a continued need to develop and implement health promotion programs for targeting specific behaviors and practices and provides information for measuring progress towards achieving disease prevention and health promotion goals at state and local levels.