Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain

Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.

Predictors of Sustained Response to Functional Restoration in a Military Population

INTRODUCTION

The purpose of this study was to determine if improvement in pain impact and functional performance following a functional restoration (FR) program was sustained up to 6 months posttreatment and to identify predictors of sustained improvement.

MATERIALS AND METHODS

Secondary analysis of data collected during randomized clinical trial. Study population included 108 US active duty service members who completed an FR program, as well as 3- and/or 6-month follow-up assessments. Primary outcome measure was the NIH Research Task Force (pain) impact score (PIS). Secondary outcome was a composite functional performance measure of treadmill, lifting, and carrying tolerances. Variables analyzed to determine their predictive value included demographics; treatment hours; measures of pain intensity, function, mood, sleep, social satisfaction, pain catastrophizing, kinesiophobia, self-efficacy, pain acceptance, patient activation, functional performance, and neuropathic pain.

RESULTS

Mean PIS and functional performance improved significantly immediately following FR, but after 6 months, only improvement in functional performance sustained. Responder analysis showed that 6 months after FR, 42% of participants reported improvement that exceeded the minimal clinically important difference in PIS or functional performance. Predictors of sustained PIS improvement included younger age, absence of neuropathic pain features, less self-rated disability, better baseline functional performance, and worse baseline PIS. Predictors of sustained functional performance improvement included more treatment hours, lower baseline pain catastrophizing, and lower baseline functional performance.

CONCLUSIONS

This study supports the investment of treatment time in FR to yield sustained clinically meaningful improvement, as observed in over 40% of this study's military participants. Pretreatment predictors of sustained response included lower pain catastrophizing and absence of neuropathic pain. Further research is needed to determine if treatments that improve pain catastrophizing and neuropathic pain will result in sustained improvement in pain impact and functional performance following FR program participation.

Hybrid effectiveness-implementation trial of guided relaxation and acupuncture for chronic sickle cell disease pain (GRACE): A protocol

Background

People with sickle cell disease frequently use complementary and integrative therapies to cope with their pain, yet few studies have evaluated their effectiveness. The 3-arm, 3-site pragmatic Hybrid Effectiveness-implementation Trial of Guided Relaxation and Acupuncture for Chronic Sickle Cell Disease Pain (GRACE) has 3 priorities: (1) evaluate guided relaxation and acupuncture to improve pain control; (2) determine the most appropriate and effective treatment sequence for any given patient based on their unique characteristics; and (3) describe the processes and structures required to implement guided relaxation and acupuncture within health care systems.

Methods

Participants (N = 366) are being recruited and randomized 1:1:1 to one of 2 intervention groups or usual care. The acupuncture intervention group receives 10 sessions over approximately 5 weeks. The guided relaxation intervention group receives access to video sessions ranging from 2 to 20 min each viewed daily over 5 weeks. The usual care group receives the standard of clinical care for sickle cell disease. Participants are re-randomized at 6 weeks depending on their pain impact score. Assessments occur at 6 weeks, 12 weeks, and 24 weeks. The primary outcome is the change in pain impact score and secondary measures include opioid use, anxiety, depression, sleep, pain catastrophizing, substance use, global impression of change, constipation, and hospitalizations. The GRACE study uses the Consolidated Framework for Implementation Research to plan, execute, and evaluate the associated implementation processes.

Conclusion

The results from GRACE will represent a critical step toward improving management of pain affecting patients with sickle cell disease.ClinicalTrials.gov Identifier: NCT04906447.

A Systematic Review and Meta-analysis of the Initial Literature Regarding COVID-19 Symptoms in Children in the United States

INTRODUCTION

COVID-19 symptom presentation among adults is mostly understood. However, understanding COVID-19 symptom presentation in children lags.

METHOD

A literature search was conducted in three electronic databases. Twenty-three initial publications addressing COVID-19 symptom presentation among hospitalized children in the United States met the criteria for review and meta-analysis.

RESULTS

Fever, the most common symptom, was present in nearly all cases. Gastrointestinal, respiratory, oral symptoms, and rash occurred in over half of the cases. Disease severity assessment showed that comorbidities were present in one-third of patients; intensive care was needed for half of the patients, and supplemental oxygen and mechanical ventilation were needed by 13.3% and 7.1%, respectively.

DISCUSSION

The magnitude and significance of COVID-19 symptoms in children compared with those in adults and three common childhood viral illnesses: influenza, respiratory syncytial virus, and gastroenteritis, are discussed. Important clinical differences were found that may help clinicians distinguish COVID-19 from other illnesses.

Pattern of Cumulative Treatment Hours on Pain Impact and PROMIS Outcomes

INTRODUCTION

Participation in interdisciplinary treatments is associated with improvement in pain intensity, physical function, and additional pain-related outcome domains. However, the effect of cumulative treatment hours on outcomes remains unknown among military patients. The present analysis examined the relationship between cumulative interdisciplinary treatment hours and pain management outcomes at a single interdisciplinary pain management center (IPMC).

MATERIALS AND METHODS

This is a retrospective observational study of data previously collected as standard of care at the Madigan Army Medical Center, approved by the Institutional Review Board. We included patients who received treatment at the IPMC and completed at least two self-report assessment batteries: one at baseline and at least one between 90 and 180 days after baseline (n = 882). The primary outcome was pain impact. Secondary outcomes included fatigue, depression, anxiety, and sleep-related impairment.

RESULTS

Generalized additive models indicated that cumulative treatment hours were significantly associated with improvement in pain impact, fatigue, and depression. Patients who had higher baseline pain impact, who had mild or no depressive symptoms, and who were >40 years of age had greater improvements in pain impact following treatment, relative to those with lower pain impact, moderate-to-severe depressive symptoms, and were 40 years of age or younger, respectively. Additional research is needed to elucidate the effect of different therapies and additional patient factors in understanding the "therapeutic dose" of interdisciplinary pain management.

CONCLUSIONS

A higher number of cumulative treatment hours was associated with improvement of pain impact, fatigue, and depression among military personnel receiving interdisciplinary pain treatment. At least 30 hours of sustained interdisciplinary treatment appears to be the threshold for improvement in pain impact and related outcomes.

Associations in Cigarette Smoking and Health Conditions by Race/Ethnicity Among a Diverse Sample of Patients Receiving Treatment in a Federally Qualified Health Care Setting in Chicago

Purpose

To examine the association of cigarette use and smoking-related health conditions by race/ethnicity among diverse and low-income patients at a federally qualified health center (FQHC).

Methods

Demographics, smoking status, health conditions, death, and health service use were extracted from electronic medical data for patients seen between September 1, 2018, and August 31, 2020 (n=51,670). Smoking categories included everyday/heavy smoker, someday/light smoker, former smoker, or never smoker.

Results

Current and former smoking rates were 20.1% and 15.2%, respectively. Males, Black, White, non-partnered, older, and Medicaid/Medicare patients were more likely to smoke. Compared with never smokers, former and heavy smokers had higher odds for all health conditions except respiratory failure, and light smokers had higher odds of asthma, chronic obstructive pulmonary disease, emphysema, and peripheral vascular disease. All smoking categories had more emergency department visits and hospitalizations than never smokers. The associations between smoking status and health conditions differed by race/ethnicity. White patients who smoked had a greater increase in odds of stroke and other cardiovascular diseases compared with Hispanic and Black patients. Black patients who smoked had a greater increase in odds of emphysema and respiratory failure compared with Hispanic patients. Black and Hispanic patients who smoked had a greater increase in emergency care use compared with White patients.

Conclusion

Smoking was associated with disease burden and emergency care and differed by race/ethnicity.

Health Equity Implications

Resources to document smoking status and offer cessation services should be increased in FQHCs to promote health equity for lower income populations.

Women's Experience of Living with Vulvodynia Pain: Why They Participated in a Randomized Controlled Trial of Acupuncture

Introduction: Vulvodynia is vulvar pain lasting at least 3-months without clear identifiable cause that may have other associated factors. The aim, to explore motivations of women participating in a double-blind randomized controlled trial of acupuncture for vulvodynia. Methods: Responses to the question: "Tell me about why you decided to participate in this study" were analyzed using conceptual content analysis to identify patterns in motivation for study participation. Results: Four patterns emerged: 1) desire to address uncontrolled pain, 2) desire for understanding, 3) wish to contribute to knowledge generation, and 4) need to remove cost barriers. Conclusion: Motivations indicate vulvodynia-specific aspects of acceptability of acupuncture. Clinical Trial Registration: NCT03364127.

Protocol for double-blind RCT of acupuncture for vulvodynia

Background

Vulvodynia, vulvar pain of unknown origin lasting at least 3 months, affects 7% of American women. Dyspareunia, its frequent companion, renders sexual intercourse virtually impossible. Although few therapies are efficacious and rapid pain relief is rarely possible, there have been no sham/placebo-controlled studies of acupuncture for vulvodynia. Aims are to: 1) determine efficacy of acupuncture for vulvodynia, 2) explore duration of the acupuncture effect.

Methods

In a pretest/posttest randomized controlled, double-blind (practitioner-patient) efficacy trial of a standardized acupuncture protocol, we will randomize 80 participants 1:1 to either penetrating needle or skin-touch placebo needle groups. Both types of needles are designed to blind both the acupuncturist and participant. Participants with vulvodynia will insert and remove a tampon as a standardized stimulus and complete primary measures of vulvar pain (pain intensity) and secondary measures of dyspareunia (Female Sexual Function Index, FSFI dyspareunia subscale score) and sexual function (FSFI total score) pretreatment, after the 10th acupuncture session, and pain measures weekly until return to pretest levels. Upon study completion control group participants will be offered 10 free real acupuncture sessions.

Discussion

This is the first multi-needle multi-session RCT using double-blind acupuncture needles as a reliable sham. We hypothesize that controlling for baseline, at posttest there will be statistically significant less vulvar pain and dyspareunia and more sexual function over five weeks in the penetrating needle group compared to the skin touch placebo group.

Conclusion

This study is responsive to the need for efficacious pain management for women with vulvodynia.ClinicalTrials.gov Identifier: NCT03364127.

Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756)

BACKGROUND

Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery.

METHODS

A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group.

DISCUSSION

If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.

Abstract PO-010: Increased risk of smoking-related health conditions for current and former smokers in the Chicago metro area

PURPOSE: Smoking is a main cause of lung cancer and COPD and is also a cause of coronary heart disease, stroke and a host of other cancers and diseases. The purpose of this study was to investigate rates of smoking-related health conditions in the Chicago metro area and to assess how cigarette use and demographic factors correlate with increased risk for these conditions. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS) is a national system of health-related telephone surveys that collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions, and use of preventive services. A subsample of the 2019 BRFSS data from the Chicago metro-area was used (n=4,838). Analysis was conducted with STATA survey analysis tools to account for the complex sampling design of BRFSS data. Logistic regression models predicting increased risk for each health condition for 3 categories of smokers (current, quit in past 10 years, quit >10 years ago) compared to non-smokers and including age, sex, race, income, and BMI as covariates were run. RESULTS: Rates of health problems of Chicago area residents were: 5.9% non-skin cancer, 5.1% COPD, 8.4% asthma, 5.0% coronary heart disease/myocardial infarction (MI/CHD), 2.8% stroke, 30.2% hypertension, 10.4% diabetes, and 7.5% poor/fair health. Current smoking was associated with increased odds of COPD (7.3 [4.7, 11.4]), asthma (1.8 [1.2, 2.6]), hypertension (1.6 [1.2, 2.1]), diabetes (1.5 [1.0, 2.3]), and poor/fair health (1.8 [1.3, 2.5]). Those that quit smoking in the past 10 years had increased odds of COPD (2.9 [1.7, 5.1]), stroke (2.6 [1.3, 5.4]), diabetes (1.9 [1.2, 2.9]), and poor/fair health (1.5 [1.1, 2.2]). Those that quit more than 10 years ago had increased odds of non-skin cancer (1.6 [1.1, 2.3]), COPD (2.3 [1.5, 3.6]), and MI/CHD (2.2 [1.4, 3.2]). Demographic factors also predicted greater risk of smoking-related health conditions after controlling for smoking status including greater risk for Black residents of stroke (2.0 (1.1, 3.7)], hypertension (1.7 [1.3, 2.2]), diabetes (1.7 [1.2, 2.4]), and poor/fair health (1.7 [1.3, 2.4]) and increased risk for Hispanic residents of diabetes (2.4 [1.6, 3.4]) and poor/fair health (2.5 [1.8, 3.3]). Lower income predicted greater risk for MI/CHD (1.9 [1.3, 2.9]), stroke (2.2 [1.2, 4.2]), hypertension (1.5 [1.2, 1.9]), diabetes (1.5 [1.1, 2.1]) and poor/fair health (3.0 [2.3, 3.8]). CONCLUSION: Risks for smoking-related health conditions varied for current and former cigarette users and also by different demographic factors for Chicago metro-area residents. These findings can inform clinical work by revealing the continued health risks even for those who quit smoking and how risks my be exacerbated for different racial groups and for those with lower income.

Citation Format: Larisa A. Burke, Alana D. Steffen, Cherdsak Duangchan, Karriem S. Watson, Alicia K. Matthews. Increased risk of smoking-related health conditions for current and former smokers in the Chicago metro area [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-010.

Abstract PO-013: Racial differences in smoking rates among low-income adults living in a large urban area

PURPOSE While smoking rates have decreased nationally, they remain elevated in underserved communities. The purpose of this study was to investigate smoking rates among race/ethnic groups in Chicago and for lower income levels across segregated neighborhoods served by a network of 6 federally qualified health center clinics. METHODS The Healthy Chicago Survey, an annual telephone survey of adults conducted by the Chicago Department of Public Health (2014-2018), was used to obtain rates and correlates of smoking using weighted analyses and linearized standard errors to account for the complex survey design and differential nonresponse. We examined city-wide estimates as well as a subsample composed of lower income (defined as <200% of the poverty level) residents of 3 geographic areas which represent roughly a quarter of Chicago adults (n=3,544 weighted to represent 517,271). RESULTS City-wide Chicago adults are 36% non-Hispanic (NH) White, 29% NH Black, and 26% Hispanic/Latino and have a smoking rate of 18.6% with 60% being daily smokers. The subsample results were 7% NH White, 49% NH Black, and 39% Hispanic Latino; smoking rate 26.8%. Background characteristics most associated with smoking include middle age (30-64 years), male sex, lesbian/gay/bisexual orientation, unmarried/no partner, NH Black, some college or less education, has no personal doctor, and experiences psychological distress. These relationships were consistent citywide and within the subsample except race/ethnic differences were less pronounced for those with lower income. NH Blacks, nearly half our low-income subsample, had the highest smoking rate (35.9%; 95% CI [33.1, 38.7]), followed by NH Whites (31.0 [23.6, 39.4]) with lower rates among Hispanic/Latinos (16.0 [13.4, 19.0]). The subsample comprised three distinct regions within the city with varying levels of race/ethnic diversity. CONCLUSION While tobacco use has declined over recent years there are significant disparities based on race and income. Among lower-income adults, NH Blacks, middle-aged, and males are at greater risk for smoking-related health conditions. Our findings demonstrate the higher rates of smoking among Black, medically underserved adults in low-income communities that contribute to health disparities.

Citation Format: Alana D. Steffen, Larisa A. Burke, Cherdsak Duangchan, Karriem S. Watson, Alicia K. Watson. Racial differences in smoking rates among low-income adults living in a large urban area [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-013.

Womb to womb: Maternal litter size and birth weight but not adult characteristics predict early neonatal death of offspring in the common marmoset monkey

A singular focus on maternal health at the time of a pregnancy leaves much about perinatal mortality unexplained, especially when there is growing evidence for maternal early life effects. Further, lumping stillbirth and early neonatal death into a single category of perinatal mortality may obscure different causes and thus different avenues of screening and prevention. The common marmoset monkey (Callithrix jacchus), a litter-bearing nonhuman primate, is an ideal species in which to study the independent effects of a mother’s early life and adult phenotypes on pregnancy outcomes. We tested two hypotheses in 59 marmoset pregnancies at the Southwest National Primate Research Center and the Barshop Institute for Longevity and Aging Studies. We explored 1) whether pregnancy outcomes were predicted independently by maternal adult weight versus maternal litter size and birth weight, and 2) whether stillbirth and early neonatal death were differentially predicted by maternal variables. No maternal characteristics predicted stillbirth and no maternal adult characteristics predicted early neonatal death. In univariate Poisson models, triplet-born females had a significantly increased rate of early neonatal death (IRR[se] = 3.00[1.29], p = 0.011), while higher birth weight females had a decreased rate (IRR[se] = 0.89[0.05], p = 0.039). In multivariate Poisson models, maternal litter size remained an independent predictor, explaining 13% of the variance in early neonatal death. We found that the later in the first week those neonates died, the more weight they lost. Together these findings suggest that triplet-born and low birth weight females have distinct developmental trajectories underlying greater rates of infant loss, losses that we suggest may be attributable to developmental disruption of infant feeding and carrying. Our findings of early life contributions to adult pregnancy outcomes in the common marmoset disrupt mother-blaming narratives of pregnancy outcomes in humans. These narratives hold that the pregnant person is solely responsible for pregnancy outcomes and the health of their children, independent of socioecological factors, a moralistic framing that has shaped clinical pregnancy management. It is necessary to differentiate temporal trajectories and causes of perinatal loss and view them as embedded in external processes to develop screening, diagnostic, and treatment tools that consider the full arc of a mother’s lived experience, from womb to womb and beyond.

Lesioning of the pedunculopontine nucleus reduces rapid eye movement sleep, but does not alter cardiorespiratory activities during sleep, under hypoxic conditions in rats

To determine how partial lesioning of the pedunculopontine nucleus (PPT) affects sleep, breathing, and blood pressure in rats, ibotenic acid (IBO) was injected bilaterally into the PPT. Sham-injected (saline) and IBO-lesioned rats were first studied under normoxic conditions (40 recordings were obtained from 15 rats, with each recording lasting for 6 daytime hours). Rats were then exposed to intermittent hypoxia for 4 ± 2 days (51 recordings from 12 rats, each lasting 6 daytime hours). The intermittent hypoxia protocol involved an oxygen decline lasting 35 s (to a nadir of 10 %) followed by a 50 s increase to normoxia. The IBO caused an estimated 53 % reduction in PPT neurons. When normoxic, IBO-lesioned rats had remarkedly normal sleep architecture, respiratory rates, and mean arterial pressure. The exposure to intermittent hypoxia evoked tachypnea in both the IBO-lesioned and sham-injected rats. When intermittently hypoxic, IBO-lesioned rats demonstrated a significant reduction in the duration of rapid eye movement (REM) sleep. We conclude that partial lesions of the PPT do not disrupt cardiorespiratory activities, but a reduction in PPT neurons impairs the ability to sustain REM sleep under hypoxic conditions.

Double-blinding of an acupuncture randomized controlled trial optimized with clinical translational science award resources

BACKGROUND

Clinical trial articles often lack detailed descriptions of the methods used to randomize participants, conceal allocation, and blind subjects and investigators to group assignment. We describe our systematic approach to implement and measure blinding success in a double-blind phase 2 randomized controlled trial testing the efficacy of acupuncture for the treatment of vulvodynia.

METHODS

Randomization stratified by vulvodynia subtype is managed by Research Electronic Data Capture software's randomization module adapted to achieve complete masking of group allocation. Subject and acupuncturist blinding assessments are conducted multiple times to identify possible correlates of unblinding.

RESULTS

At present, 48 subjects have been randomized and completed the protocol resulting in 87 subject and 206 acupuncturist blinding assessments.

DISCUSSION

Our approach to blinding and blinding assessment has the potential to improve our understanding of unblinding over time in the presence of possible clinical improvement.

Sleep fragmentation increases blood pressure and is associated with alterations in the gut microbiome and fecal metabolome in rats

The gut microbiota, via the production of metabolites entering the circulation, plays a role in blood pressure regulation. Blood pressure is also affected by the characteristics of sleep. To date, no studies have examined relationships among the gut microbiota/metabolites, blood pressure, and sleep. We hypothesized that fragmented sleep is associated with elevated mean arterial pressure, an altered and dysbiotic gut microbial community, and changes in fecal metabolites. In our model system, rats were randomized to 8 h of sleep fragmentation during the rest phase (light phase) or were undisturbed (controls) for 28 consecutive days. Rats underwent sleep and blood pressure recordings, and fecal samples were analyzed during: baseline (days -4 to -1), early sleep fragmentation (days 0-3), midsleep fragmentation (days 6-13), late sleep fragmentation (days 20-27), and recovery/rest (days 28-34). Less sleep per hour during the sleep fragmentation period was associated with increased mean arterial pressure. Analyses of gut microbial communities and metabolites revealed that putative short chain fatty acid-producing bacteria were differentially abundant between control and intervention animals during mid-/late sleep fragmentation and recovery. Midsleep fragmentation was also characterized by lower alpha diversity, lower Firmicutes:Bacteroidetes ratio, and higher Proteobacteria in intervention rats. Elevated putative succinate-producing bacteria and acetate-producing bacteria were associated with lower and higher mean arterial pressure, respectively, and untargeted metabolomics analysis demonstrates that certain fecal metabolites are significantly correlated with blood pressure. These data reveal associations between sleep fragmentation, mean arterial pressure, and the gut microbiome/fecal metabolome and provide insight to links between disrupted sleep and cardiovascular pathology.

Evaluation of a Randomized Clinical Trial Comparing the Effectiveness of a Culturally Targeted and Nontargeted Smoking Cessation Intervention for Lesbian, Gay, Bisexual, and Transgender Smokers

PURPOSE

To examine the benefits of a culturally targeted compared with a nontargeted smoking cessation intervention on smoking cessation outcomes among lesbian, gay, bisexual, and transgender (LGBT) smokers.

METHODS

A prospective randomized design was used to evaluate the added benefits of an LGBT culturally targeted Courage to Quit (CTQ-CT) smoking cessation treatment (N = 172) compared with the standard intervention (CTQ; N = 173). The smoking cessation program consisted of six treatment sessions combined with 8 weeks of nicotine replacement therapy. The primary smoking cessation outcome was 7-day point prevalence quit rates. Secondary outcomes examined included changes in nicotine dependence, nicotine withdrawal, cigarettes per day, smoking urges, self-efficacy, and readiness to quit.

RESULTS

Overall quit rates were 31.9% at 1 month, 21.1% at 3 months, 25.8% at 6 months, and 22.3% at 12 months. Quit rates did not differ between treatment groups [1 month OR = 0.81 (0.32, 2.09), 3 months OR = 0.65 (0.23, 1.78), 6 months OR = 0.45 (0.17, 1.21), 12 months OR = 0.70 (0.26, 1.91)]. Compared with baseline levels, all secondary smoking cessation outcomes measured were improved at 1 month and were maintained at 12-month follow-up. Compared with the CTQ, the CTQ-CT intervention was more highly rated on program effectiveness (d = 0.2, p = .011), intervention techniques (d = 0.2, p = .014), the treatment manual (d = 0.3, p < .001), and being targeted to the needs of LGBT smokers (d = 0.5, p < .0001).

CONCLUSIONS

LGBT smokers receiving the CTQ intervention achieved smoking cessation outcomes in the range reported for other demographic groups. Cultural targeting improved the acceptability of the intervention but did not confer any additional benefit for smoking cessation outcomes.

IMPLICATIONS

Study results have implications for understanding the benefits of culturally targeted compared with nontargeted smoking cessation interventions for improving smoking cessation outcomes among LGBT smokers. Shorter and longer term 7-day point prevalence quit rates associated with the targeted and nontargeted interventions were modest but comparable with other group-based interventions delivered in a community setting. Although cultural targeting improved the overall acceptability of the intervention, no added benefits were observed for the culturally targeted intervention on either the primary or secondary outcomes.

Assessing condition and ecological role of deep-water biogenic habitats: Glass sponge reefs in the Salish Sea

Biogenic habitats play important roles in shallow-water ecosystems, but their roles in deeper waters are less well-studied. We quantitatively assessed 19 glass sponge reefs in the Salish Sea for live reef-building sponge cover and biodiversity, explored potential drivers behind variation observed among reefs, and quantified individual and collective roles the reefs play in filtration and carbon removal. The reefs support diverse and abundant communities of invertebrates and fish, with 115 unique taxonomic groups observed. Sponge cover varied widely between reefs: percent live reef-building sponge cover ranged from 0.2 to 17.5% and proportion of live reef habitat category ranged from 0.2 to 92%. These differences were predominantly driven by the seabed terrain characteristics such as seafloor rugosity, curvature, and depth; human pressure measures explored in this study - density of anthropogenic objects and fishing footprint over the past 17 years - did not mask the natural influence of seabed terrain. The difference in sponge cover between the reefs led to wide variation in ecosystem function with individual reefs processing between 465 and 47,300 L/m² per day. Collectively, each day the 19 reefs filter 1.04 × 10¹¹ L of water which corresponds to 1% of the total water volume in Strait of Georgia and Howe Sound combined. The reefs remove up to 1 g of carbon per m² per day, comparable to carbon sequestration rates reported for terrestrial old growth forests and to "blue carbon" sequestration rates by marine vegetation. Implications for sponge reef conservation and monitoring are discussed.

What's the Risk? Older Women Report Fewer Symptoms for Suspected Acute Coronary Syndrome than Younger Women

The purpose of the study was to determine whether older (≥65 years) and younger (<65 years) women presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome (ACS) varied on risk factors, comorbid conditions, functional status, and symptoms that have implications for emergent cardiac care. Women admitted to five EDs were enrolled. The ACS Symptom Checklist was used to measure symptoms. Comorbid conditions and functional status were measured with the Charlson Comorbidity Index and Duke Activity Status Index. Logistic regression models were used to evaluate symptom differences in older and younger women adjusting for ACS diagnosis, functional status, body mass index (BMI), and comorbid conditions. Analyses were stratified by age, and interaction of symptom by age was tested. Four hundred women were enrolled. Mean age was 61.3 years (range 21–98). Older women (n = 163) were more likely to have hypertension, hypercholesterolemia, never smoked, lower BMI, more comorbid conditions, and lower functional status. Younger women (n = 237) were more likely to be members of minority groups, be college-educated, and have a non-ACS discharge diagnosis. Younger women had higher odds of experiencing chest discomfort, chest pain, chest pressure, shortness of breath, nausea, sweating, and palpitations. Lack of chest symptoms and shortness of breath (key symptoms triggering a decision to seek emergency care) may cause older women to delay seeking treatment, placing them at risk for poorer outcomes. Younger African American women may require more comprehensive risk reduction strategies and symptom management.

Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department

Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.

Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department

BACKGROUND

It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions.

AIMS

Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis.

METHODS

A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis.

RESULTS

The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS.

CONCLUSIONS

Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.

Bullying victimization among college students: negative consequences for alcohol use

This study reports the prevalence of bullying victimization at school and work among college freshmen and the relationships between victimization and changes in alcohol consumption and alcohol problems. Web survey data at 2 time points from a sample of 2118 freshmen from 8 colleges and universities in the Midwestern United States indicated that 43% of students experienced bullying at school and that 33% of students experienced bullying at work. Bullying, particularly at school, consistently predicted alcohol consumption and problematic drinking, after controlling for baseline drinking and other school and work stressors.

Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White

OBJECTIVES

To explore disparities between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential acute coronary syndrome (ACS).

BACKGROUND

Individuals with fewer resources have worse health outcomes and these individuals are disproportionately those of color.

METHODS

This prospective study enrolled 663 patients in four EDs. Clinical presentation, treatment, and patient-reported outcome variables were measured at baseline, 1, and 6 months.

RESULTS

Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms 1 month following discharge.

CONCLUSIONS

Significant racial disparities remain in clinical presentation and outcomes for Blacks compared to Whites presenting to the ED with symptoms suggestive of ACS.

Intraoperative tissue expansion: a review

Tissue expansion is used to facilitate reconstruction procedures following trauma and cosmetic breast augmentation. This article describes tissue expansion, reviews intraoperative expansion techniques, and discusses the nurse's role in the procedure.

Identification of the major activity derived from cultured human peripheral blood mononuclear cells, which enhances eosinophil viability, as granulocyte macrophage colony-stimulating factor (GM-CSF)

Eosinophils (EOSs) cultured in the presence of 50% peripheral blood mononuclear cell (PBMC)-derived culture supernatants remained 67% +/- 7% (mean +/- SEM; n = 5) viable for 7 days. In the absence of PBMC supernatant, only 15% +/- 7% of cells remained viable for 7 days. PBMC supernatants from six atopic individuals, with eosinophilia, and six normal subjects, with no eosinophilia, were compared for EOS viability-enhancing activity with the same target EOSs. Optimal conditions for the production of viability-enhancing activity by mononuclear cells were established as a 24-hour culture period, with a concentration of 2 x 10(6) cells per milliliter. Comparison of monocyte-enriched and lymphocyte-enriched culture supernatants for the production of the EOS viability-enhancing activity indicated that both cell types released the factor. C-18 Sep-Pak separation of the PBMC culture supernatant yielded a major EOS viability-enhancing activity in the aqueous eluent, suggesting a hydrophilic molecule. This major activity was neutralized by a specific antibody to granulocyte/macrophage colony-stimulating factor but was unaffected by specific antibodies to interleukin-3 and interleukin-5. A second, minor viability-enhancing activity was observed in the 100% methanol fraction, indicating the presence of a more hydrophobic molecule. The supernatants from the PBMCs of the atopic individuals consistently enhanced EOS survival to a greater extent than supernatants from the PBMCs of the normal, nonatopic individuals.

Interactions of macrophages and monocytes with granulocytes in asthma

The pathology of bronchial asthma demonstrates a multicellular process. The airway mucosa is infiltrated with both mononuclear cells and granulocytes, of which the eosinophil is particularly prominent. In an attempt to further the understanding of the interactions between different cells, we have elected to study the effects of monocyte/macrophage-derived cell products on granulocytes, because of the evidence for monocyte/macrophage activation in bronchial asthma.

Comparison of the generation of platelet-activating factor and leukotriene C4 in human eosinophils stimulated by unopsonized zymosan and by the calcium ionophore A23187: the effects of nedocromil sodium

The generation of platelet-activating factor (PAF) and leukotriene C4 (LTC4) from normodense human eosinophils (EOSs), stimulated with unopsonized zymosan or calcium ionophore A23187, has been studied. There was a zymosan time- and dose-dependent increase in both PAF and LTC4 production. A plateau of 0.11 +/- 0.04 ng of PAF per 10(6) EOSs (mean +/- SEM; n = 7) and of 1.38 +/- 0.58 ng of LTC4 per 10(6) EOSs (n = 5) was reached at 5 x 10(8) zymosan particles at 37 degrees C for 30 minutes. Under optimal conditions, 91 +/- 1% of the PAF and 66 +/- 13% of the LTC4 remained cell associated. Calcium ionophore A23187 induced a time- and dose-dependent increase in the quantities of PAF and of LTC4 generated by EOSs. A plateau of 31 +/- 13 ng of LTC4 per 10(6) EOSs (n = 5) was reached at 1 mumol/L of calcium ionophore A23187 at 37 degrees C for 15 minutes. The dose response for PAF generation reached 4.2 +/- 0.8 ng/10(6) EOSs (n = 8) at 10 mumols/L of calcium ionophore A23187 at 37 degrees C for 15 minutes and had not plateaued; 90 +/- 5% of the generated PAF was cell associated. In vitro preincubation of EOSs with 10(-8) to 10(-4) mol/L of nedocromil sodium for 15 minutes did not change the subsequent generation or cellular distribution of PAF or LTC4 in EOSs optimally stimulated with either zymosan or calcium ionophore A23187.

Amoxicillin and diaper dermatitis

Multiple skin sites and the gastrointestinal tract of 57 infants with otitis media were cultured quantitatively for Candida albicans before and after antibiotic therapy. Ten days of systemic therapy with amoxicillin was associated with a twofold increase in the recovery of C. albicans from the rectum and skin. Infants who developed diaper dermatitis had a significant increase in the number of C. albicans organisms recovered from these sites. We conclude that the use of amoxicillin increases the risk for developing diaper dermatitis.