A systematic review of lifestyle counseling for diverse patients in primary care

Prior research and systematic reviews have examined strategies related to weight management, less is known about lifestyle and behavioral counseling interventions optimally suited for implementation in primary care practices generally, and among racial and ethnic patient populations. Primary care practitioners may find it difficult to access and use available research findings on effective behavioral and lifestyle counseling strategies and to assess their effects on health behaviors among their patients. This systematic review compiled existing evidence from randomized trials to inform primary care providers about which lifestyle and behavioral change interventions are shown to be effective for changing patients' diet, physical activity and weight outcomes. Searches identified 444 abstracts from all sources (01/01/2004-05/15/2014). Duplicate abstracts were removed, selection criteria applied and dual abstractions conducted for 106 full text articles. As of June 12, 2015, 29 articles were retained for inclusion in the body of evidence. Randomized trials tested heterogeneous multi-component behavioral interventions for an equally wide array of outcomes in three population groups: diverse patient populations (23 studies), African American patients only (4 studies), and Hispanic/Mexican American/Latino patients only (2 studies). Significant and consistent findings among diverse populations showed that weight and physical activity related outcomes were more amenable to change via lifestyle and behavioral counseling interventions than those associated with diet modification. Evidence to support specific interventions for racial and ethnic minorities was promising, but insufficient based on the small number of studies.

Diffusional Kurtosis Imaging and Motor Outcome in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Motor impairment is the most common deficit after stroke. Our aim was to evaluate whether diffusional kurtosis imaging can detect corticospinal tract microstructural changes in the acute phase for patients with first-ever ischemic stroke and motor impairment and to assess the correlations between diffusional kurtosis imaging-derived diffusion metrics for the corticospinal tract and motor impairment 3 months poststroke.

MATERIALS AND METHODS

We evaluated 17 patients with stroke who underwent brain MR imaging including diffusional kurtosis imaging within 4 days after the onset of symptoms. Neurologic evaluation included the Fugl-Meyer Upper Extremity Motor scale in the acute phase and 3 months poststroke. For the corticospinal tract in the lesioned and contralateral hemispheres, we estimated with diffusional kurtosis imaging both pure diffusion metrics, such as the mean diffusivity and mean kurtosis, and model-dependent quantities, such as the axonal water fraction. We evaluated the correlations between corticospinal tract diffusion metrics and the Fugl-Meyer Upper Extremity Motor scale at 3 months.

RESULTS

Among all the diffusion metrics, the largest percentage signal changes of the lesioned hemisphere corticospinal tract were observed with axial kurtosis, with an average 12% increase compared with the contralateral corticospinal tract. The strongest associations between the 3-month Fugl-Meyer Upper Extremity Motor scale score and diffusion metrics were found for the lesioned/contralateral hemisphere corticospinal tract mean kurtosis (ρ = -0.85) and axial kurtosis (ρ = -0.78) ratios.

CONCLUSIONS

This study was designed to be one of hypothesis generation. Diffusion metrics related to kurtosis were found to be more sensitive than conventional diffusivity metrics to early poststroke corticospinal tract microstructural changes and may have potential value in the prediction of motor impairment at 3 months.

Characteristics of Biostatistics, Epidemiology, and Research Design Programs in Institutions With Clinical and Translational Science Awards

PURPOSE

To learn the size, composition, and scholarly output of biostatistics, epidemiology, and research design (BERD) units in U.S. academic health centers (AHCs).

METHOD

Each year for four years, the authors surveyed all BERD units in U.S. AHCs that were members of the Clinical and Translational Science Award (CTSA) Consortium. In 2010, 46 BERD units were surveyed; in 2011, 55; in 2012, 60; and in 2013, 61.

RESULTS

Response rates to the 2010, 2011, 2012, and 2013 surveys were 93.5%, 98.2%, 98.3%, and 86.9%, respectively. Overall, the size of BERD units ranged from 3 to 86 individuals. The median FTE in BERD units remained similar and ranged from 3.0 to 3.5 FTEs over the years. BERD units reported more availability of doctoral-level biostatisticians than doctoral-level epidemiologists. In 2011, 2012, and 2013, more than a third of BERD units provided consulting support on 101 to 200 projects. A majority of BERD units reported that between 25% and 75% (in 2011) and 31% to 70% (in 2012) of their consulting was to junior investigators. More than two-thirds of BERD units reported their contributions to the submission of 20 or more non-BERD grant or contract applications annually. Nearly half of BERD units reported 1 to 10 manuscripts submitted annually with a BERD practitioner as the first or corresponding author.

CONCLUSIONS

The findings regarding BERD units provide a benchmark against which to compare BERD resources and may be particularly useful for institutions planning to develop new units to support programs such as the CTSA.

Length of Interdialytic Intervals Affects Morbidity and Mortality in Chronic Haemodialysis Patients

Background

Chronic in-center hemodialysis (HD) patients may experience more morbidity and mortality after the weekend. Since our Veterans Administration Hospital HD unit is closed on the weekend, non-traditional HD schedules were created. Some schedules contained a 4-day weekend compared to the usual 3-day weekend. We hypothesized that there are more frequent cardiovascular events (CVEs) and higher mortality after longer interdialytic intervals.

Methods

Patients (n=85) were placed on HD schedules as they became available. The usual interdialytic interval group consisted of patients dialyzing on Mon-Wed-Fri or Mon-Tue-Fri (longest interdialytic gap 3 days, n=29), and the long interdialytic interval group consisted of patients dialyzing on Mon-Wed-Thu, Mon-Tue-Thu, Tue-Wed-Fri, or Tue-Thu-Fri (longest interdialytic gap 4 days, n=56).

Results

All-cause mortality was not different between groups, and CVEs occurred more frequently in the usual interdialytic interval group (maybe due to higher mean potassium and phosphorus concentrations). However, within each group, a similar pattern of CVE occurrence as a function of time after dialysis was observed. Compared to CVEs occurring during the 2 days after HD (the lowest frequency), CVEs occurred 2–3 times more frequently during and immediately after HD and 5–7 times more frequently during the third and fourth days after HD. The greatest risk of CVE occurred during the fourth day after HD, which exists only in the long interdialytic interval group.

Conclusion

In chronic HD patients, CVEs are most likely to occur after the longest interdialytic intervals.

Assessing the Correlation Between Physical Activity and Quality of Life in Advanced Lung Cancer

BACKGROUND AND OBJECTIVE

Increasing physical activity (PA) is safe and beneficial in lung cancer (LC) patients. Advanced-stage LC patients are under-studied and have worse symptoms and quality of life (QoL). We evaluated the feasibility of monitoring step count in advanced LC as well as potential correlations between PA and QoL.

METHODS

This is a prospective, observational study of 39 consecutive patients with advanced-stage LC. Daily step count over 1 week (via Fitbit Zip), QoL, dyspnea, and depression scores were collected. Spearman rank testing was used to assess correlations. Correlation coefficients (ρ) >0.3 or <-0.3 (more and less correlated, respectively) were considered potentially clinically significant.

RESULTS

Most (83%) of the patients were interested in participating, and 67% of those enrolled were adherent with the device. Of those using the device (n = 30), the average daily step count was 4877 (range = 504-12 118) steps/d. Higher average daily step count correlated with higher QoL (ρ = 0.46), physical (ρ = 0.61), role (ρ = 0.48), and emotional functioning (ρ = 0.40) scores as well as lower depression (ρ = -0.40), dyspnea (ρ = -0.54), and pain (ρ = -0.37) scores.

CONCLUSION

Remote PA monitoring (Fitbit Zip) is feasible in advanced-stage LC patients. Interest in participating in this PA study was high with comparable adherence to other PA studies. In those utilizing the device, higher step count correlates with higher QoL as well as lower dyspnea, pain, and depression scores. PA monitoring with wearable devices in advanced-stage LC deserves further study.

Genetic markers of immunoglobulin G and immunity to cytomegalovirus in patients with breast cancer

Human cytomegalovirus (CMV), a ubiquitous herpesvirus, has been implicated in the etiology of breast cancer. It is clear that not all people exposed to CMV are equally likely to develop this malignancy, implying the presence of host genetic factors that might modulate the cancer-spurring properties of the virus. CMV has evolved sophisticated strategies for evading host immunosurveillance. One strategy involves encoding decoy Fcγ receptors (FcγR) that thwart the Fcγ-mediated effector functions, such as antibody-dependent cellular cytotoxicity. In this investigation, using an enzyme-linked immunosorbent assay (ELISA), we aimed to determine whether the decoy FcγR encoded by the CMV gene RL13 binds differentially to anti-CMV antibodies expressing different immunoglobulin GM (γ marker) allotypes, genetic markers of immunoglobulin G (IgG). Results of our ELISA binding studies showed that the absorbance values for the binding of the viral FcγR to the GM 17-expressing IgG antibodies were significantly higher than for the GM 3-expressing antibodies (0.60 vs. 0.36; p=0.0019). These findings provide mechanistic insights into the modulating role played by the genetic variants of IgG in the generation of immunity to CMV in patients with breast cancer.

Assessment Tools for Use During Anesthesia-Centric Pediatric Advanced Life Support Training and Evaluation

BACKGROUND

Pediatric perioperative cardiac arrests are rare events that require rapid, skilled and coordinated efforts to optimize outcomes. We developed an assessment tool for assessing clinician performance during perioperative critical events termed Anesthesia-centric Pediatric Advanced Life Support (A-PALS). Here, we describe the development and evaluation of the A-PALS scoring instrument.

METHODS

A group of raters scored videos of a perioperative team managing simulated events representing a range of scenarios and competency. We assessed agreement with the reference standard grading, as well as interrater and intrarater reliability.

RESULTS

Overall, raters agreed with the reference standard 86.2% of the time. Rater scores concerning scenarios that depicted highly competent performance correlated better with the reference standard than scores from scenarios that depicted low clinical competence (P < 0.0001). Agreement with the reference standard was significantly (P < 0.0001) associated with scenario type, item category, level of competency displayed in the scenario, correct versus incorrect actions and whether the action was performed versus not performed. Kappa values were significantly (P < 0.0001) higher for highly competent performances as compared to lesser competent performances (good: mean = 0.83 [standard deviation = 0.07] versus poor: mean = 0.61 [standard deviation = 0.14]). The intraclass correlation coefficient (interrater reliability) was 0.97 for the raters' composite scores on correct actions and 0.98 for their composite scores on incorrect actions.

CONCLUSIONS

This study provides evidence for the validity of the A-PALS scoring instrument and demonstrates that the scoring instrument can provide reliable scores, although clinician performance affects reliability.

The accuracy of pleural ultrasonography in diagnosing complicated parapneumonic pleural effusions

We compared the accuracy of pleural ultrasound versus chest CT versus chest radiograph (CXR) to determine radiographic complexity in predicting a complicated parapneumonic effusion (CPPE) defined by pleural fluid analysis. 66 patients with parapneumonic effusions were identified with complete data. Pleural ultrasound had a sensitivity of 69.2% (95% CI 48.2% to 85.7%) and specificity of 90.0% (95% CI 76.3% to 97.2%). Chest CT had a sensitivity of 76.9% (95% CI 56.3% to 91.0%) and specificity of 65.0% (95% CI 48.3% to 79.4%). CXR had a sensitivity of 61.5% (95% CI 40.6% to 79.8%) and specificity of 60.0% (95% CI 43.3% to 75.1%). Pleural ultrasound appears to be a superior modality to rule in a CPPE when compared with chest CT and CXR.

Pediatric Patients Demonstrate Progressive T1-Weighted Hyperintensity in the Dentate Nucleus following Multiple Doses of Gadolinium-Based Contrast Agent

BACKGROUND AND PURPOSE

While there have been recent reports of brain retention of gadolinium following gadolinium-based contrast agent administration in adults, a retrospective series of pediatric patients has not previously been reported, to our knowledge. We investigated the relationship between the number of prior gadolinium-based contrast agent doses and increasing T1 signal in the dentate nucleus on unenhanced T1-weighted MR imaging. We hypothesized that despite differences in pediatric physiology and the smaller gadolinium-based contrast agent doses that pediatric patients are typically administered based on weighted-adjusted dosing, the pediatric brain would also demonstrate dose-dependent increasing T1 signal in the dentate nucleus.

MATERIALS AND METHODS

We included children with multiple gadolinium-based contrast agent administrations at our institution. A blinded reader placed ROIs within the dentate nucleus and adjacent cerebellar white matter. To eliminate reader bias, we also performed automated ROI delineation of the dentate nucleus, cerebellar white matter, and pons. Dentate-to-cerebellar white matter and dentate-to pons ratios were compared with the number of gadolinium-based contrast agent administrations.

RESULTS

During 20 years at our institution, 280 patients received at least 5 gadolinium-based contrast agent doses, with 1 patient receiving 38 doses. Sixteen patients met the inclusion/exclusion criteria for ROI analysis. Blinded reader dentate-to-cerebellar white matter ratios were significantly associated with gadolinium-based contrast agent doses (r_s = 0.77, P = .001). The dentate-to-pons ratio and dentate-to-cerebellar white matter ratios based on automated ROI placement were also significantly correlated with gadolinium-based contrast agent doses (t = 4.98, P < .0001 and t = 2.73, P < .02, respectively).

CONCLUSIONS

In pediatric patients, the number of prior gadolinium-based contrast agent doses is significantly correlated with progressive T1-weighted dentate hyperintensity. Definitive confirmation of gadolinium deposition requires tissue analysis. Any potential clinical sequelae of gadolinium retention in the developing brain are unknown. Given this uncertainty, we suggest taking a cautious stance, including the use, in pediatric patients, of higher stability, macrocyclic agents, which in both human and animal studies have been shown to be associated with lower levels of gadolinium deposition, and detailed documentation of dosing. Most important, a patient should not be deprived of a well-indicated contrasted MR examination.

The Logic Behind a Multimethod Intervention to Improve Adherence to Clinical Practice Guidelines in a Nationwide Network of Primary Care Practices

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Biologic effects of stress and bonding in mother-infant pairs

OBJECTIVE

Maternal stress in humans influences behavior of children and can be assessed using biological markers. Mothers and their one-month-old infants were recruited from an existing study to examine baseline maternal serum oxytocin and hypothalamic-pituitary-adrenal axis response to infant blood heel stick stress as measured by salivary cortisol in the dyads. Objectives were to explore (1) relationships between mother and infant cortisol levels, (2) gender differences in infant biologic cortisol response, and (3) the association of cortisol levels in the dyads and maternal oxytocin levels

METHODS

Forty-two mother-infant dyads provided biologic samples and self-report data. Maternal oxytocin samples were obtained. Initial salivary cortisol was assessed in both the mother and infant, followed by a heel stick blood draw. Twenty minutes later, salivary cortisol was collected again from dyads.

RESULTS

Self-report measures were negative for depression and risk for childhood neglect. Although oxytocin and baseline cortisol in the infants was higher in mothers that did some breast-feeding, there was no statistically significant difference (p = 0.2 and p = 0.1, respectively). Analyses showed (a) higher baseline cortisol in mothers was related to higher baseline cortisol in infants (p ≤ 0.0001), (b) following the stressor, female infants had a larger positive change in cortisol, after adjusting for baseline cortisol (p = 0.045), and (c) there was no relationship between dyad cortisol levels and maternal oxytocin.

CONCLUSIONS

Maternal and infant biologic stress measures are related. Female infants have a larger hypothalamic-pituitary-adrenal response to a blood draw stressor as measured by salivary cortisol than male infants.

Systemic Sclerosis and Perceptions of Quality in Primary Care

BACKGROUND

Among patients with systemic sclerosis (SSc), early recognition of potentially life-threatening organ involvement is critical. Because prompt recognition of early signs of organ involvement can dramatically alter a patient׳s outcome, it is crucial that patients and primary care providers (PCPs) recognize these symptoms. We conducted a survey of patients with SSc regarding their perceptions of the quality of their primary care, and whether or not they perceive the quality of their primary care to be impaired by their scleroderma diagnosis.

MATERIALS AND METHODS

A mail survey was sent to 525 patients with SSc seen at the Medical University of South Carolina. Questionnaire items addressed demographics and perceptions of their quality of their primary care.

RESULTS

Of n = 140 respondents, most (74.5%) did not feel as though their diagnosis of SSc has resulted in barriers to appropriate or satisfactory care, and most (81.3%) answered that they had not ever felt as though their medical concerns were not being addressed because they had SSc. Perceptions of barriers were significantly (P < 0.05) associated with female sex and younger age, along with poorer overall quality of care and satisfaction with their primary care.

CONCLUSIONS

Most patients with SSc value the quality of their primary care. However, some patients with SSc feel that their PCPs do not adequately monitor their blood pressure, reflux symptoms or shortness of breath. These results highlight the importance of PCPs in the overall care of patients with SSc and the need for continued education regarding close monitoring of signs and symptoms suggestive of possible life-threatening internal organ involvement.

Initial Assessment of Stewards of Children Program Effects on Child Sexual Abuse Reporting Rates in Selected South Carolina Counties

Child sexual abuse (CSA) prevention programs often include a focus on increased reporting of suspected abuse, in addition to other prevention components such as helping trainees recognize suspected abusive situations. This study aimed to determine whether the Stewards of Children prevention program is associated with increased CSA reporting. Analyses examined whether rates of CSA allegations increased over time in three counties in South Carolina (SC) targeted with program dissemination efforts and whether CSA reporting trends differed between the three targeted counties and three comparison counties that did not experience substantial program dissemination. CSA allegation data were obtained by county and year for predissemination and postdissemination periods from the SC Department of Social Services. Results indicated that, for the targeted counties but not the nontargeted counties, estimated allegation rates increased significantly over time, corresponding with the onset of significant program dissemination efforts. Results also indicated significant between-groups differences in allegation trends for targeted versus nontargeted counties. These findings suggest that the Stewards prevention intervention may be associated with increased CSA allegations. However, results require replication with randomization of counties. Moreover, whether increased reporting is associated with decreased CSA incidence remains unknown.

Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

BACKGROUND

The efficacy of vasoconstrictors in hepatorenal syndrome (HRS) is variable. We hypothesized that the effectiveness of vasoconstrictor therapy in improving kidney function ultimately relates to the magnitude of the achieved mean arterial pressure (MAP) increase.

METHODS

A retrospective study was conducted to identify cirrhotic individuals treated with vasoconstrictors for acute kidney injury (AKI) presumably caused by HRS to examine the relationship between change in MAP and change in serum creatinine (sCr) using multivariate mixed linear regression.

RESULTS

Among 73 patients treated with midodrine/octreotide, change in MAP inversely correlated with change in sCr (p = 0.0005). The quartile with the greatest increase in MAP (+15.9 to +29.4 mm Hg) was associated with a subsequent absolute decrease in sCr. The strength of the correlation increased when the analysis was restricted to those who met the HRS criteria (n = 27, p = 0.002), where the third (+5.3 to +15.6 mm Hg) and fourth (+15.9 to +20.9 mm Hg) quartiles of MAP change were associated with a decrease in sCr. A similar but stronger correlation was found among 14 patients treated with norepinephrine either after failing midodrine/octreotide (n = 10) or de novo (n = 4; p = 0.002), where a rise in MAP of +19.2 to 25 mm Hg was associated with a larger reduction in sCr. Associations remained significant after adjustment for baseline parameters.

CONCLUSIONS

The magnitude of MAP rise during HRS therapy with midodrine/octreotide or norepinephrine correlated with a reduction in sCr concentration. Our results suggest that achieving a pre-specified target of MAP increase might improve renal outcomes in hepatorenal AKI.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED

BACKGROUND

Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes.

OBJECTIVES

We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets.

METHODS

We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates.

RESULTS

There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates.

CONCLUSIONS

An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Association of Cardiometabolic Multimorbidity With Mortality

IMPORTANCE

The prevalence of cardiometabolic multimorbidity is increasing.

OBJECTIVE

To estimate reductions in life expectancy associated with cardiometabolic multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates.

EXPOSURES

A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI).

MAIN OUTCOMES AND MEASURES

All-cause mortality and estimated reductions in life expectancy.

RESULTS

In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy.

CONCLUSIONS AND RELEVANCE

Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Randomized Clinical Trial of Preoperative Feeding to Evaluate Intestinal Barrier Function in Neonates Requiring Cardiac Surgery

OBJECTIVES

To evaluate intestinal barrier function in neonates undergoing cardiac surgery using lactulose/mannitol (L/M) ratio measurements, and to determine correlations with early breast milk feeding.

STUDY DESIGN

This was a single-center, prospective, randomized pilot study of 27 term-born neonates (≥ 37 weeks gestation) requiring cardiac surgery who were randomized to 1 of 2 preoperative feeding groups: nil per os (NPO) or trophic (10 mL/kg/day) breast milk feeds. At 3 time points (preoperative [preop], postoperative [postop] day 7, and postop day 14), subjects were administered an oral L/M solution, after which urine L/M ratios were measured using gas chromatography, with higher ratios indicative of increased intestinal permeability. Trends over time in the mean urine L/M ratios for each group were estimated using a general linear mixed model.

RESULTS

There were no adverse events related to preoperative trophic feeding. In the NPO group (n = 13), the mean urine L/M ratio was 0.06 at preop, 0.12 at postop day 7, and 0.17 at postop day 14. In the trophic breast milk feeds group (n = 14), the mean urine L/M ratio was 0.09 at preop, 0.19 at postop day 7, and 0.15 at postop day 14. In both groups, L/M ratios were significantly higher at postop day 7 and postop day 14 compared with preop (P < .05).

CONCLUSION

Neonates have increased intestinal permeability after cardiac surgery extending to at least postop day 14. This pilot study was not powered to detect differences in benefit or adverse events comparing the NPO and trophic breast milk feeds groups. Further studies to identify mechanisms of intestinal injury and therapeutic interventions are warranted.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov: NCT01475357.

D-cycloserine combined with cue exposure therapy fails to attenuate subjective and physiological craving in cocaine dependence

BACKGROUND

Based on preclinical studies showing that the partial N-methyl-D-aspartate (NMDA) agonist D-cycloserine (DCS) facilitates extinction of cocaine self-administration and cocaine-induced conditioned place preference, we evaluated whether 50 mg of DCS would reduce craving to cocaine cues when combined with cue exposure (CE) in cocaine dependent humans.

METHODS

In this double-blind placebo-controlled pilot study, 47 cocaine dependent participants were randomized to DCS or placebo (PBO), plus CE. Participants received DCS or PBO 30 minutes prior to two CE sessions, conducted one day apart. Craving and heart rate was assessed prior to CE sessions, during CE trials, and after CE trials. These measures were assessed again at a 1-week follow-up (session 3) after the second CE session.

RESULTS

DCS failed to significantly attenuate cocaine cue reactivity based on subjective craving and physiological reactivity (heart rate) compared to PBO. The CE protocol, consisting of repeated exposure to drug cues combined with skills training, resulted in extinction to cocaine cues as suggested by decreased craving within and between sessions in both treatment conditions. All participants exhibited elevated heart rate with repeated exposures, demonstrating a potentiation in heart rate between sessions.

CONCLUSIONS

50 mg of DCS may not be effective for extinguishing reactivity to drug cues for individuals with cocaine dependence.

SCIENTIFIC SIGNIFICANCE

Future studies examining the effect of DCS on facilitating extinction to drug cues should examine variations in cue exposure length, number of CE presentations, and timing of DCS dose administration prior to cue exposures, which may differentially impact drug cue reactivity.

Raynaud phenomenon and mortality: 20+ years of follow-up of the Charleston Heart Study cohort

BACKGROUND

Raynaud phenomenon (RP) is a temporary vasoconstrictive condition that often manifests itself in the fingers in response to cold or stress. It often co-occurs with certain chronic diseases that impact mortality. Our objective was to determine whether RP has any independent association with survival.

METHODS

From 1987-1989, a total of 830 participants of the Charleston Heart Study cohort completed an in-person RP screening questionnaire. Two definitions of RP were used: a broad definition that included both blanching (pallor) and cyanotic color changes and a narrow definition that included only blanching. All-cause and cardiovascular disease (CVD) mortality were compared between subjects with and without RP using race-specific survival models that adjusted for age, sex, baseline CVD, and 10-year risk of coronary heart disease.

RESULTS

Using the narrow RP definition, we identified a significant interaction between older age and the presence of RP on all-cause mortality. In the broad RP definition model, the presence of RP was not associated with CVD mortality among blacks; however, among whites, the presence of RP was associated with a 1.6-fold increase in the hazard associated with CVD-related death (hazard ratio: 1.55, 95% confidence interval: 1.10-2.20, P=0.013).

CONCLUSION

RP was independently associated with mortality among older adults in our cohort. Among whites, RP was associated with increased CVD-related death. It is possible that RP may be a sign of undiagnosed vascular disease.

Myocardial stiffness in patients with heart failure and a preserved ejection fraction: contributions of collagen and titin

BACKGROUND

The purpose of this study was to determine whether patients with heart failure and a preserved ejection fraction (HFpEF) have an increase in passive myocardial stiffness and the extent to which discovered changes depend on changes in extracellular matrix fibrillar collagen and cardiomyocyte titin.

METHODS AND RESULTS

Seventy patients undergoing coronary artery bypass grafting underwent an echocardiogram, plasma biomarker determination, and intraoperative left ventricular epicardial anterior wall biopsy. Patients were divided into 3 groups: referent control (n=17, no hypertension or diabetes mellitus), hypertension (HTN) without (-) HFpEF (n=31), and HTN with (+) HFpEF (n=22). One or more of the following studies were performed on the biopsies: passive stiffness measurements to determine total, collagen-dependent and titin-dependent stiffness (differential extraction assay), collagen assays (biochemistry or histology), or titin isoform and phosphorylation assays. In comparison with controls, patients with HTN(-)HFpEF had no change in left ventricular end-diastolic pressure, myocardial passive stiffness, collagen, or titin phosphorylation but had an increase in biomarkers of inflammation (C-reactive protein, soluble ST2, tissue inhibitor of metalloproteinase 1). In comparison with both control and HTN(-)HFpEF, patients with HTN(+)HFpEF had increased left ventricular end-diastolic pressure, left atrial volume, N-terminal propeptide of brain natriuretic peptide, total, collagen-dependent, and titin-dependent stiffness, insoluble collagen, increased titin phosphorylation on PEVK S11878(S26), reduced phosphorylation on N2B S4185(S469), and increased biomarkers of inflammation.

CONCLUSIONS

Hypertension in the absence of HFpEF did not alter passive myocardial stiffness. Patients with HTN(+)HFpEF had a significant increase in passive myocardial stiffness; collagen-dependent and titin-dependent stiffness were increased. These data suggest that the development of HFpEF depends on changes in both collagen and titin homeostasis.

Master Settlement Agreement (MSA) spending and tobacco control efforts

We investigate whether the distributions to the states from the Tobacco Master Settlement Agreement (MSA) in 1998 is associated with stronger tobacco control efforts. We use state level data from 50 states and the District of Columbia from four time periods post MSA (1999, 2002, 2004, and 2006) for the analysis. Using fixed effect regression models, we estimate the relationship between MSA disbursements and a new aggregate measure of strength of state tobacco control known as the Strength of Tobacco Control (SoTC) Index. Results show an increase of $1 in the annual per capita MSA disbursement to a state is associated with a decrease of −0.316 in the SoTC mean value, indicating higher MSA payments were associated with weaker tobacco control measures within states. In order to achieve the initial objectives of the MSA payments, policy makers should focus on utilizing MSA payments strictly on tobacco control activities across states.

Identification of asthma phenotypes in a tertiary care medical center

BACKGROUND

Asthma affects 5% to 10% of the population and its severity is assessed using 4 parameters: lung function, symptom frequency, rescue inhaler use, and number of asthma exacerbations. Asthma is increasingly recognized as a clinical syndrome rather than a single disease. However, the current classification system fails to reflect the heterogeneous characteristics of the disease.

METHODS

A retrospective chart review of 139 patients with mild, moderate, and severe persistent asthma was performed. Variables including baseline and maximal forced expiratory volume over first second (percent predicted), and age of asthma onset were used to classify patients.

RESULTS

This yielded 5 clusters similar to Severe Asthma Research Program (SARP). Subjects in cluster 1 (n = 32) and cluster 2 (n = 47) had early-onset atopic asthma and reduced lung function but differed in medication requirement and health care utilization. Cluster 3 (n = 32) consisted of older obese women with late-onset asthma, less atopy, and mildly reduced forced expiratory volume over first second. Members of cluster 4 (n = 20) and cluster 5 (n = 8) had atopic asthma with severe obstruction but differed in bronchodilator response, age of onset, and oral corticosteroid use. Compared with SARP, our subjects were older, had a higher percentage of African Americans and obesity, and less severe asthma (P < 0.05). The observed clusters differed from SARP clusters in the following: (1) more frequent asthma exacerbations and medication use among cluster 1 and cluster 2; (2) lower medication use in cluster 3 and cluster 4; (3) although total health care utilization was similar, there were fewer emergency department visits in cluster 3 (P < 0.05).

CONCLUSIONS

The SARP algorithm may be used to classify diverse asthmatic populations into a clinically reproducible phenotypic cluster.

Placental Nkx2-5 and target gene expression in early-onset and severe preeclampsia

OBJECTIVE

Preeclampsia (PE) affects 2-8% of pregnancies worldwide and is a significant source of maternal and neonatal morbidity and mortality. However, the mechanisms underlying PE are poorly understood and major questions regarding etiology and risk factors remain to be addressed. Our objective was to examine whether abnormal expression of the cardiovascular developmental transcription factor, Nkx2-5, was associated with early onset and severe preeclampsia (EOSPE).

METHODS

Using qPCR and immunohistochemical assay, we examined expression of Nkx2-5 and target gene expression in EOSPE and control placental tissue. We tested resulting mechanistic hypotheses in cultured cells using shRNA knockdown, qPCR, and western blot.

RESULTS

Nkx2-5 is highly expressed in racially disparate fashion (Caucasians > African Americans) in a subset of early EOSPE placentae. Nkx2-5 mRNA expression is highly correlated (Caucasians > African Americans) to mRNA expression of the preeclampsia marker sFlt-1, and of the Nkx2-5 target and RNA splicing factor, Sam68. Knockdown of Sam68 expression in cultured cells significantly impacts sFlt-1 mRNA isoform generation in vitro, supporting a mechanistic hypothesis that Nkx2-5 impacts EOSPE severity in a subset of patients via upregulation of Sam68 to increase sFlt-1 expression. Expression of additional Nkx2-5 targets potentially regulating metabolic stress response is also elevated in a racially disparate fashion in EOSPE.

CONCLUSIONS

Expression of Nkx2-5 and its target genes may directly influence the genesis and racially disparate severity, and define a mechanistically distinct subclass of EOSPE.

Outcome of patients with negative and unsatisfactory cytologic specimens obtained by endobronchial ultrasound-guided transbronchial fine-needle aspiration of mediastinal lymph nodes

BACKGROUND

Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-FNA) has gained acceptance as the diagnostic procedure of choice with which to sample hilar and mediastinal lymph nodes (LNs) for diagnosing and staging patients with lung cancer. Studies have shown that EBUS has a high positive predictive value; however, its negative predictive value (NPV) varies significantly. The aim of the current study was to evaluate the clinical outcome surrounding negative and nondiagnostic EBUS-FNA of mediastinal LNs.

METHODS

A retrospective chart review of cases of EBUS-FNA performed between 2008 and the middle of 2011 was conducted. Mediastinal LNs with cytologic diagnoses of negative for malignant cells and unsatisfactory were selected for the study. Each LN was followed for up to 1 year with imaging or biopsy/surgical resection. A true-negative result was defined as a LN that did not enlarge on repeat imaging or was negative for malignancy on repeat biopsy or surgery during the follow-up period.

RESULTS

Among 1418 LNs sampled, 479 from 228 patients met the search criteria, including 394 LN (82.3%) with the cytologic diagnosis of negative for malignant cells and 85 (17.8%) with a diagnosis of unsatisfactory. A total of 104 patients (45.6%) were followed with imaging, and 124 patients (54.3%) underwent repeat biopsy/surgery. A total of 445 LNs met the definition of a true-negative finding, resulting in an overall NPV of 92.9% (95% confidence interval [95% CI], 90.6%-95.2%). The NPVs of a negative and unsatisfactory diagnosis were 93.9% (95% CI, 91.6%-96.3%) and 88.2% (95% CI, 81.4%-95.1%), respectively.

CONCLUSIONS

The vast majority of LNs with a cytologic diagnosis of negative and unsatisfactory were likely to be true-negative findings. In these patients, a more conservative approach to follow-up may be appropriate.