Visioning an Effective Health Encounter: Indigenous Healthcare Experiences and Recommendations for Health Professionals

PURPOSE

Indigenous patients experience challenges while accessing and utilizing healthcare services that relate to worsened health experiences. Bias towards Indigenous patients is prevalent in healthcare settings and leads to poor health outcomes. The purpose of this study was to learn about the healthcare experiences, both positive and negative, of Indigenous patients and solicit subsequent recommendations to improve care delivered to this population.

METHODS

This study sampled Indigenous patients (n = 20) from an Indigenous-serving health clinic to discuss participants' health experiences and elicit recommendations for improved care. Four focus groups were conducted, and template analysis was employed to analyze the data.

RESULTS

A total of 15 themes were developed under the category of an effective health encounter. Highlighted themes include healthcare that is free of stigma, quality care, respecting trauma experiences, expanded integrated care and the patient-provider relationship. Based on participant recommendations, a checklist was created for healthcare professionals to improve care delivery to Indigenous patients. Results indicated that bias in healthcare settings may masquerade as poor clinical care but is really founded in biased beliefs and healthcare delivery. Alternatively, when patients received good quality care, their healthcare outcomes improved. Further, effective healthcare incorporates culture, family, tribe, and community and addresses these aspects of health in both clinical and systemic settings.

CONCLUSIONS

With some of the largest proportions of health disparities and bias experiences in the US, it is critical that healthcare delivered to Indigenous patients incorporate culturally safe care to regain dignity and improve health outcomes for this population.

Conceptualizing Indigenous strengths-based health and wellness research using group concept mapping

BACKGROUND

In recent years public health research has shifted to more strengths or asset-based approaches to health research but there is little understanding of what this concept means to Indigenous researchers. Therefore our purpose was to define an Indigenous strengths-based approach to health and well-being research.

METHODS

Using Group Concept Mapping, Indigenous health researchers (N = 27) participated in three-phases. Phase 1: Participants provided 218 unique responses to the focus prompt "Indigenous Strengths-Based Health and Wellness Research…" Redundancies and irrelevant statements were removed using content analysis, resulting in a final set of 94 statements. Phase 2: Participants sorted statements into groupings and named these groupings. Participants rated each statement based on importance using a 4-point scale. Hierarchical cluster analysis was used to create clusters based on how statements were grouped by participants. Phase 3: Two virtual meetings were held to share and invite researchers to collaboratively interpret results.

RESULTS

A six-cluster map representing the meaning of Indigenous strengths-based health and wellness research was created. Results of mean rating analysis showed all six clusters were rated on average as moderately important.

CONCLUSIONS

The definition of Indigenous strengths-based health research, created through collaboration with leading AI/AN health researchers, centers Indigenous knowledges and cultures while shifting the research narrative from one of illness to one of flourishing and relationality. This framework offers actionable steps to researchers, public health practitioners, funders, and institutions to promote relational, strengths-based research that has the potential to promote Indigenous health and wellness at individual, family, community, and population levels.

Effects of a Decolonizing Training on Mental Health Professionals' Indigenous Knowledge and Beliefs and Ethnocultural Empathy

Indigenous communities suffer from the highest rates of mental health disparities of any ethnic group in the United States, as well as experience significant amounts of historical and contemporary trauma including violence, racism, and childhood abuse. Unfortunately, the mental health workforce is unprepared to effectively work with this population due to the influence of stereotypes, bias, and lack of training. A 90-minute training for mental health agency employees using decolonizing methods was delivered to improve knowledge of and empathy for Indigenous patient populations (N = 166). Results indicated that the training increased participants' Indigenous knowledge and beliefs across demographic variables and may increase aspects of empathy including awareness. This training was feasible for a wide variety of mental health employees and resulted in increased learning about Indigenous people, which is a critical starting point for mental health professionals working with this population. Suggestions are offered to train mental health providers to deliver culturally responsive care to Indigenous clients and families and for decolonizing mental health professions.

Health effects of Indigenous language use and revitalization: a realist review

Background

Indigenous populations across the world are more likely to suffer from poor health outcomes when compared to other racial and ethnic groups. Although these disparities have many sources, one protective factor that has become increasingly apparent is the continued use and/or revitalization of traditional Indigenous lifeways: Indigenous language in particular. This realist review is aimed at bringing together the literature that addresses effects of language use and revitalization on mental and physical health.

Methods

Purposive bibliographic searches on Scopus were conducted to identify relevant publications, further augmented by forward citation chaining. Included publications (qualitative and quantitative) described health outcomes for groups of Indigenous people who either did or did not learn and/or use their ancestral language. The geographical area studied was restricted to the Americas, Australia or New Zealand. Publications that were not written in English, Spanish, French, Portuguese or German were excluded. A realist approach was followed to identify positive, neutral or negative effects of language use and/or acquisition on health, with both qualitative and quantitative measures considered.

Results

The bibliographic search yielded a total of 3508 possible publications of which 130 publications were included in the realist analysis. The largest proportion of the outcomes addressed in the studies (62.1%) reported positive effects. Neutral outcomes accounted for 16.6% of the reported effects. Negative effects (21.4%) were often qualified by such issues as possible cultural use of tobacco, testing educational outcomes in a student’s second language, and correlation with socioeconomic status (SES), health access, or social determinants of health; it is of note that the positive correlations with language use just as frequently occurred with these issues as the negative correlations did.

Conclusions

Language use and revitalization emerge as protective factors in the health of Indigenous populations. Benefits of language programs in tribal and other settings should be considered a cost-effective way of improving outcomes in multiple domains.

The potential for over diagnosis of Paget's disease of bone using macroscopic analysis

OBJECTIVE

This study explores the validity of Paget's disease of bone (PDB) reported in unpublished skeletal reports, based on macroscopic analysis alone.

MATERIALS

The high prevalence of 'suspected' Paget's disease (10.7%) in an early modern sample from St John's the Evangelist Church in Redhill, Surrey is reassessed.

METHODS

Signs of PDB were examined in 53 well-preserved adults aged 35 + years using macroscopic, radiographic and histological techniques.

RESULTS

Macroscopic features of PDB were identified in 8 individuals (15%), with 5 individuals later rejected using radiography. Two individuals showed classic radiographic features of PDB, with a third presenting possible features in radiography (5.7%). These three cases were confirmed by histological analysis.

CONCLUSIONS

PDB should not be suggested as a single diagnosis in cases of bone hypertrophy without confirmation using radiography.

SIGNIFICANCE

The growing popularity of 'big data' projects and limited collections access means that unpublished cases of PDB are often included in large scale analyses, impacting our understanding of the evolution of this disease. Using macroscopic analysis alone leads to overdiagnosis. Histological analysis is unnecessary when radiographic features are present, but provides a useful diagnostic step in long bones in advanced cases of PBD.

LIMITATIONS

The radiographic sample in this study was limited to three individuals.

SUGGESTIONS FOR FURTHER RESEARCH

The conclusion that radiography alone can be used to identify PDB in archaeological cases merits further research on a larger number of cases.

The Health Effects of a Cherokee Grounded Culture and Leadership Program

Introduction: Indigenous youth and young adults endure some of the highest rates of physical and mental health problems in the United States compared to their non-Indigenous counterparts. Colonization, oppression, and discrimination play a substantial role in these inequitable disease rates. However, culture (e.g., identity, participation, and connection) relates to the prevention of and recovery from illness in Indigenous populations. The Remember the Removal program aims to teach Indigenous youth and young adults tribally specific culture, history, and language to put them on a trajectory to become informed and culturally connected community leaders. We examined the program’s effects on health. Method: Thirty Remember the Removal program participants, mainly young adults, completed surveys four times: before the program’s start, at the end of the training period, at the program’s end, and at a six-month follow-up. Various indicators of physical, mental, spiritual, and cultural health and well-being were measured at each time period. Paired t-tests were completed to compare baseline scores to each subsequent time interval. Results: At program completion, and as indicated with an asterisk at the six month follow-up, participants had statistically significantly improved diet and exercise measures (e.g., reduced sugary, salty, and fatty foods, reduced soda consumption, increased fruit consumption, and improved self-efficacy for exercise), improved mental health indicators (e.g., reduced stress, anxiety, depression*, anger*, post-traumatic stress disorder, and microaggressions*, and improved positive mental health) and improved social and cultural connection (e.g., social support, Cherokee identity*, Cherokee values). Discussion: This is one of the first quantitative studies to demonstrate the profound effects that cultural learning and connection have on the health and well-being of Indigenous people and practices. It also demonstrates the specificity and effectiveness of a program created by and for tribal citizens. Future programs with Indigenous populations should work to center cultural connection and ensure that programs are created and directed by tribal community members.

V3-Loop genotypes do not predict maraviroc susceptibility of CCR5-tropic virus or clinical response through week 48 in HIV-1-infected, treatment-experienced persons receiving optimized background regimens

Viruses from 15 of 35 maraviroc-treated participants with virologic failure and CCR5-tropic (R5) virus in the MOTIVATE studies at Week 24 had reduced maraviroc susceptibility. On-treatment amino acid changes were observed in the viral envelope glycoprotein 120 third variable (V3)-loop stems and tips and differed between viruses. No amino acid change reliably predicted reduced susceptibility, indicating that resistance was genetic context-dependent. Through Week 24, poor adherence was associated with maraviroc-susceptible virologic failure, whereas reduced maraviroc susceptibility was associated with suboptimal background regimen activity, highlighting the importance of overall regimen activity and good adherence. Predictive values of pretreatment V3-loop sequences containing these Week 24 mutations or other variants present at >3% in pretreatment viruses of participants with virologic failure at Week 48 were retrospectively assessed. Week 48 clinical outcomes were evaluated for correlates with pretreatment V3-loop CCR5-tropic sequences from 704 participants (366 responders; 338 virologic failures [83 with R5 virus with maraviroc susceptibility assessment]). Seventy-five amino acid variants with >3% prevalence were identified among 23 V3-loop residues. Previously identified variants associated with resistance in individual isolates were represented, but none were associated reliably with virologic failure alone or in combination. Univariate analysis showed virologic-failure associations with variants 4L, 11R, and 19S (P < 0.05). However, 11R is a marker for CXCR4 tropism, whereas neither 4L nor 19S was reliably associated with reduced maraviroc susceptibility in R5 failure. These findings from a large study of V3-loop sequences confirm lack of correlation between V3-loop genotype and clinical outcome in participants treated with maraviroc.Clinical trial registration numbers (ClinicalTrials.gov): NCT00098306 and NCT00098722.

Adipokines and Subclinical Cardiovascular Disease in Post-Menopausal Women: Study of Women's Health Across the Nation

Background The menopausal transition is characterized by increased cardiovascular risk, weight gain, and increased adiposity for many women. The adipose-derived secretory proteins adiponectin and leptin are associated with insulin resistance, metabolic syndrome, and cardiovascular disease but their role in subclinical atherosclerotic disease is unclear. This cross-sectional study evaluated the associations of adiponectin and leptin with carotid artery intima-media thickness, adventitial diameter, presence of carotid plaques, and brachial-ankle pulse wave velocity (baPWV) in women aged 54 to 65 years. Methods and Results Participants were 1399 women from SWAN (Study of Women's Health Across the Nation), a community-based study of women transitioning through menopause. Carotid ultrasound and baPWV measures were obtained at SWAN follow-up visits 12 or 13, when 97% of participants were post-menopausal. Adipokines were assayed from serum specimens obtained concurrently at these visits. Linear and logistic regression models were used to evaluate adiponectin or leptin, both log-transformed attributable to skewness, in relationship to carotid artery intima-media thickness, adventitial diameter, baPWV, and presence of carotid plaque. Covariates included age, race, study site, smoking, alcohol use, obesity, cardiovascular disease risk factors, and menopausal status. Lower levels of adiponectin were related to greater carotid artery intima-media thickness, wider adventitial diameter, and faster baPWV; associations were attenuated after adjusting for cardiovascular disease risk factors. Higher levels of leptin were associated with greater carotid artery intima-media thickness and wider adventitial diameter in minimally and fully adjusted models, and contrary to expectation, with slower baPWV, particularly among women with diabetes mellitus or obesity. Conclusions Adiponectin and leptin are 2 important inflammatory pathways that may contribute to adverse subclinical cardiovascular disease risk profiles in women at midlife.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan

BACKGROUND

Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here.

METHODS

This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed.

RESULTS

Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities.

CONCLUSIONS

There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Highly prevalent Russian HIV-1 V3-loop sequence variants are susceptible to maraviroc

INTRODUCTION

Maraviroc inhibits CCR5-tropic HIV-1 across different subtypes in vitro and has demonstrated efficacy in clinical trials. V3-loop amino acid variants observed in individual maraviroc-resistant viruses have not been found to be predictive of reduced susceptibility. Sequence-database searches have demonstrated that approximately 7.3% of viruses naturally encode these variants, raising concerns regarding potential pre-existing resistance. A study from Russia reported that combinations of these same amino acids are present in the V3 loops of the Russian variant subtype A (IDU-A, now A6) with a much greater prevalence (range: 74.4%-92.3%) depending on the combination. However, these studies and database searches did not include phenotypic evaluation.

METHODS

Sixteen Russian HIV-1 isolates (including sub-subtype A6 viruses) were assessed for V3 loop sequence and phenotypic susceptibility to maraviroc.

RESULTS

All 12 of the A6 viruses and 2/4 subtype B isolates encoded V3-loop variants that have previously been identified in individual virus isolates with reduced susceptibility to maraviroc. However, despite the prevalence of these V3-loop amino acid variants among the tested viruses, phenotypic sensitivity to maraviroc was observed in all instances. Similarly, reduced susceptibility to maraviroc was not found in virus from participants who experienced virologic failure in a clinical study of maraviroc in Russia (A4001101, [NCT01275625]).

DISCUSSION

Altogether, these data confirm that the presence of individual or combinations of V3-loop amino acid residues in sub-subtype A6 viruses alone does not predict natural resistance to maraviroc and that V3-loop genotype analysis of R5 virus prior to treatment is not helpful in predicting clinical outcome.

The Effects of an Indigenous Health Curriculum for Medical Students

PURPOSE

Indigenous patients experience a variety of healthcare challenges including accessing and receiving needed healthcare services, as well as experiencing disproportionate amounts of bias and discrimination within the healthcare system. In an effort to improve patient-provider interactions and reduce bias towards Indigenous patients, a curriculum was developed to improve first-year medical students' Indigenous health knowledge.

METHOD

Two cohorts of students were assessed for their Indigenous health knowledge, cultural intelligence, ethnocultural empathy, and social justice beliefs before the lecture series, directly after, and 6 months later.

RESULTS

Results of paired t test analysis revealed that Indigenous health knowledge significantly improved after the training and 6 months later. Some improvements were noted in the areas of cultural intelligence and ethnocultural empathy in the second cohort.

CONCLUSIONS

It is feasible to teach and improve Indigenous-specific health knowledge of medical students using a brief intervention of lectures. However, other critical components of culturally appropriate care including social justice beliefs and actions, ethnocultural empathy, and cultural humility may require increased and immersed cultural training.

Evaluation of a Native Youth Leadership Program Grounded in Cherokee Culture: The Remember the Removal Program

Indigenous youth suffer from high rates of comorbid mental and physical health disease. The purpose of this research was to evaluate an existing intervention aimed at empowering Indigenous youth, using a qualitative, community-based participatory research method. We completed focus groups with 23 program participants, and analysis revealed positive improvements in physical, emotional, social, and cultural domains. Participants noted that key social, familial, and cultural aspects of the intervention were most impactful for them. Informed by the participants' experiences, these findings offer guidance for developing interventions to reduce and/or prevent mental and physical health disparities for Indigenous youth and young adults.

Integrated Care with Indigenous Populations: Considering the Role of Health Care Systems in Health Disparities

INTRODUCTION

There is increased evidence for the effectiveness of integrated behavioral health care, however, it is unknown if integrated care is effective or culturally appropriate for Indigenous populations-the population with the largest health disparities in the nation.

METHODS

We conducted a literature review to analyze the state of Indigenous health care focusing specifically on the appropriateness of integrated care in this population.

RESULTS

Integrated care could improve access to comprehensive care, quality of care, and may be a promising model to reduce health disparities for Indigenous people.

DISCUSSION

Indigenous people experience significant barriers to effective health care services that require strategic, systemic, and collaborative interventions to close these gaps. Integrated care appears to be an appropriate solution but additional research is needed to determine this. Further, any health intervention must be carried out in collaboration with tribal communities and nations to ensure success.

Decolonizing Mental Health Services for Indigenous Clients: A Training Program for Mental Health Professionals

Culturally appropriate mental health services are essential for Indigenous people who suffer the greatest mental health disparities of any ethnic group in the U.S. However, few mental health professionals receive training to work with this population. To fill this gap, a 90-minute training was created to increase knowledge of and empathy for Indigenous people and culture and therefore, improve mental health services for Indigenous patients. This training is grounded in cultural competency, cultural humility, and decolonialism. The training is presented here for mental health professionals, agencies, and administrators to use as a guide. The training aims to increase knowledge, awareness, and skills and has been implemented in a variety of settings receiving positive feedback from participants and administrators.

Integrated Care with Indigenous Populations: A Systematic Review of the Literature

INTRODUCTION

The integration of behavioral health into medical care is related to positive results including improved patient health outcomes, provider satisfaction, and cost-offset. Indigenous people suffer from the highest health disparities in the nation and disproportionately experience barriers to health care; yet it is unknown if integrated care is effective for this population.

METHODS

A systematic literature review was completed on the state of integrated care at Indigenous-serving health care sites in 2014 and was updated in 2016. Three databases were selected (Eric, Medline, and PsycInfo) and keywords pertaining to an Indigenous population and integrated care services (e.g., Native American, American Indian, or First Nations with integrated care, primary care, or family medicine) were used. After inclusion and exclusion criteria were applied, nine articles were selected out of the 2,889 articles found. Five additional articles were added in the 2016-update search. The selected articles were then evaluated using standards of integrated care.

RESULTS

The selected articles demonstrated wide-ranging and positive results including improved physical and mental health symptoms, reduced substance use, improvements in education and employment status, as well as a decreased involvement with the criminal justice system. It appears that interventions that additionally integrated culturally relevant health beliefs and practices experienced the largest gains in health outcomes.

DISCUSSION

Integrated care appears to be an intervention that can ameliorate these disparities by reducing stigma for those seeking care and providing coordinated care to prevent or reduce health care disparities in this population. While integrated care appears to be an effective system of care for Indigenous people, it must be noted that integration of local Indigenous health beliefs and practices is equally necessary.

Not all drinking events are the same: Exploring 21st birthday and typical alcohol expectancies as a risk factor for high-risk drinking and alcohol problems

Alcohol expectancies are a central construct in understanding college student typical alcohol use. However, to our knowledge, there is no research addressing how alcohol expectancies for specific events (i.e. 21st birthday) are different from expectancies regarding typical drinking. We examine the extent to which 21st birthday alcohol expectancies differ from general alcohol expectancies and how 21st birthday expectancies are associated with actual alcohol use and consequences experienced on 21st birthdays, above and beyond expectancies for typical drinking. Participants were college students (N=585; 54% women) who were turning 21 within a week, and intended to drink 4/5 (female/male) drinks on their birthday. All negative expectancies (impairment, risk and aggression, negative self-perception) and positive expectancies (social, liquid courage, sex) except tension reduction were significantly greater for 21st birthday drinking than for typical drinking. While 21st birthday expectancies were not uniquely related to actual birthday drinking, several positive and negative 21st birthday expectancy subscales were associated with 21st birthday drinking-related consequences, even when controlling for typical drinking expectancies. Expectancy challenge interventions aimed specifically at these subscales may be effective at attenuating alcohol-related consequences that result from 21st birthday drinking.

Myocardial contusion

Myocardial contusion can be a difficult diagnosis to make. There is currently no gold standard of investigation that allows its accurate diagnosis in the clinical setting. Trauma surgeons need to have a high degree of clinical suspicion when dealing with patients who have received blunt thoracic injuries in order that the diagnosis of myocardial contusion may be made. In this article we discuss the diagnosis, potential complications and investigation of patients with suspected myocardial contusion and also present a fl ow diagram for the possible management of patients with trauma who may have suspected myocardial contusion.

RFLP linkage map of asparagus

A population resulting from a double pseudotestcross of two outbred-derived asparagus (Asparagus officinalis L.) clones was evaluated by RFLP (restriction fragment length polymorphism) analysis to produce individual maps of the male and female parents. An asparagus PstI genomic library was created and used as the source of probes. Scoring of bands was done by examining SDRFs (single dose restriction fragments) that are present in one parent and absent in the other and segregate 1:1 in the progeny. The data were analyzed as a backcross population; inversion or recoding allowed for the detection of repulsion phase linkage. The male parent map consisted of 33 loci in 10 groups, while the female parent map had 48 loci arranged in 14 groups. Segregation distortion was minimal (5%), and 17% of the markers were found to be unlinked. Loci of the configuration a/b x a/b and a/c x b/c were used to bridge seven homologous linkage groups between the two parents. The sex locus was not found to be associated with any linkage group. Key words : RFLP, bridge loci, repulsion phase linkage, double pseudotestcross.

Combined RAPD and RFLP molecular linkage map of asparagus

Two linkage maps of asparagus (Asparagus officinalis L.) were constructed using a double pseudotestcross mapping strategy with restriction fragment length polymorphisms (RFLPs), random amplified polymorphic DNAs (RAPDs), and allozymes as markers in a population generated from crossing MW25 x A19, two heterozygous parents. All data were inverted and combined with the natural data to detect linkages in repulsion phase. Two sets of data, one for each parent, were formed according to the inheritance patterns of the markers. The maternal MW25 map has a total of 163 marker loci placed in 13 linkage groups covering 1281 cM, with an average and a maximum distance between adjacent loci of 7.9 and 29 cM, respectively. The paternal A19 map has 183 marker loci covering 1324 cM in 9 linkage groups, with an average and a maximum distance between two adjacent loci of 7.7 and 29 cM, respectively. Six multiallelic RFLPs segregating in the pattern a/c x b/c and eight heterozygous loci (four RAPDs, and four RFLPs segregating in the pattern a/b x a/b (HZ loci)) were common to both maps. These 14 loci were used as bridges to align homologous groups between the two maps. In this case, RFLPs were more frequent and informative than RAPDs. Nine linkage groups in the MW25 map were homologous to six groups in the A19 map. In two cases, two or more bridge loci were common to a group; thus, the orientation of homologous linkage groups was also determined. In four other cases, only one locus was common to the two homologous groups and the orientation was unknown. Mdh, four RFLPs, and 14 RAPDs were assigned to chromosome L5, which also has the sex locus M.

Correlates of age at diagnosis of autism spectrum disorders in six Canadian regions

INTRODUCTION

Early identification of autism spectrum disorders (ASD) is important, since earlier exposure to behavioural intervention programs may result in better outcomes for the child. Moreover, it allows families timely access to other treatments and supports.

METHODS

Using generalized linear modeling, we examined the association between child and family characteristics and the age at which 2180 children were diagnosed with ASD between 1997 and 2005 in six Canadian regions.

RESULTS

A diagnosis of pervasive developmental disorder-not otherwise specified (PDD-NOS) or Asperger syndrome, rural residence, diagnosis in more recent years, and foreign birthplace were associated with a later age at diagnosis. Children who are visible minorities or who have siblings with ASD were more likely to be diagnosed earlier. Collectively, these factors explained little of the variation in age at diagnosis, however.

CONCLUSION

While it is encouraging that ethnocultural identity, neighbourhood income, urban or rural residence, and sex of the child were not major contributors to disparities in the age when children were identified with ASD, more work is needed to determine what does account for the differences observed. Regional variations in the impact of several factors suggest that aggregating data may not be an optimal strategy if the findings are meant to inform policy and clinical practice at the local level.

It's good to talk! Changes in coronary revascularisation practice in PCI centres without onsite surgical cover and the impact of an angiography video conferencing system

INTRODUCTION

Percutaneous coronary intervention (PCI) activity has increased more than 6 fold in the last 15 years. Increased demand has been met by PCI centres without on-site surgical facilities. To improve communication between cardiologists and surgeons at a remote centre, we have developed a video conferencing system using standard internet links. The effect of this video data link (VDL) on referral pattern and patient selection for revascularisation was assessed prospectively after introduction of a joint cardiology conference (JCC) using the system.

METHODS

Between 1st October 2005 and 31st March 2007, 1346 patients underwent diagnostic coronary angiography (CA). Of these, 114 patients were discussed at a cardiology conference (CC) attended by three consultant cardiologists (pre-VDL). In April 2007, the VDL system was introduced. Between 1st April 2007 and 30th September 2008, 1428 patients underwent diagnostic CA. Of these, 120 patients were discussed at a JCC attended by four consultant cardiologists and two consultant cardiothoracic surgeons (post-VDL). Following case-matching for patient demographics and coronary artery disease (CAD) severity and distribution, we assessed the effect upon management decisions arising from both the pre- and post-VDL JCC meetings.

RESULTS

When comparing decision-making outcomes of post-VDL JCC with pre-VDL CC, significantly fewer patients were recommended for PCI (36.8% vs. 17.2% respectively, p = 0.001) and significantly more patients were recommended for surgery (21.1% vs. 48.4% respectively, p < 0.001). There were no significant differences in waiting times for PCI following JCC discussion; however, waiting times for surgical revascularisation were significantly reduced (140.9 ± 71.8 days vs. 99.4 ± 56.6 days respectively, p = 0.045).

CONCLUSIONS

  The VDL system provides a highly practical method for PCI centres without onsite surgical cover to discuss complex patients requiring coronary revascularisation and significantly increases the number of patients referred for surgical revascularisation rather than PCI.

Corticotropin and beta-endorphin-like materials are native to unicellular organisms

Multiple molecular forms of immunoreactive corticotropin (ACTH) and beta-endorphin were present in extracts of a unicellular eukaryote (Tetrahymena pyriformis). One form of immunoreactive ACTH reacted similarly with two different ACTH antisera (one specific for the 11-24 sequence and the other with determinants within sequences 1-14 and 17-39) and migrated with synthetic hACTH-(1-39) in a gel filtration system. This form also exhibited ACTH bioactivity in a dispersed rat adrenal cell bioassay system, with a mean immunoassay/bioassay ratio of 1.5. Gel filtration revealed multiple size classes of immunoreactive beta-endorphin; a major peak of radioreceptor activity was detected which exhibited a K(av) similar to that of authentic beta-endorphin. A major portion of immunoreactive beta-endorphin-sized material exhibited retention times similar to those of synthetic human and camel beta-endorphin upon reverse-phase high-pressure liquid chromatography. These distinctive properties and specificities would seem to exclude the presence of limited homologies with sequences present in other proteins. High molecular weight material containing both ACTH and beta-endorphin antigenic determinants was also demonstrated, suggesting, but not proving, the presence of a common precursor molecule.

Nerve growth factor increases activity of ornithine decarboxylase in rat brain

Intraventricular administration of nanogram quantities of nerve growth factor to adult rats results in a marked increase in the activity of ornithine decarboxylase (L-ornithine carboxy-lyase, EC 4.1.1.17) in the brain. The increase occurs in all major brain regions and the activity is maximal by 7.5 hr after administration. The enzyme response to nerve growth factor increases in magnitude during maturation; the relative increase in ornithine decarboxylase activity in adult animals is much greater than that in young. Neither insulin nor bovine growth hormone was able to increase ornithine decarboxylase activity to the same extent as did nerve growth factor. When brain was separated into neuronal- and glial-enriched fractions, induction of ornithine decarboxylase was found in both, but a greater increase was observed in the glial fraction.

Prawns masquerading as endobronchial tumours

This report details the events surrounding the case of an 89-year-old woman referred for surgery with a suspected endobronchial tumour. At rigid bronchoscopy she was found to have inspissated sputum within which the remains of organic foreign bodies (king prawns) were found obstructing the left main and left upper lobe bronchi. We outline her presentation, initial diagnosis and eventual outcome, and re-emphasise the importance of bronchoscopy as a vital tool in the assessment of any endoluminal lesion of the airway.

Comparison of child morbidity in two contrasting medieval cemeteries from Denmark

This study compares associations between demographic profiles, long bone lengths, bone mineral content, and frequencies of stress indicators in the preadult populations of two medieval skeletal assemblages from Denmark. One is from a leprosarium, and thus probably represents a disadvantaged group (Naestved). The other comes from a normal, and in comparison rather privileged, medieval community (AEbelholt). Previous studies of the adult population indicated differences between the two skeletal collections with regard to mortality, dental size, and metabolic and specific infectious disease. The two samples were analyzed against the view known as the "osteological paradox" (Wood et al. [1992] Curr. Anthropol. 33:343-370), according to which skeletons displaying pathological modification are likely to represent the healthier individuals of a population, whereas those without lesions would have died without acquiring modifications as a result of a depressed immune response. Results reveal that older age groups among the preadults from Naestved are shorter and have less bone mineral content than their peers from AEbelholt. On average, the Naestved children have a higher prevalence of stress indicators, and in some cases display skeletal signs of leprosy. This is likely a result of the combination of compromised health and social disadvantage, thus supporting a more traditional interpretation. The study provides insights into the health of children from two different biocultural settings of medieval Danish society and illustrates the importance of comparing samples of single age groups.

Surgical repair of ruptured thoracic and thoracoabdominal aortic aneurysms

BACKGROUND

Rupture is the single most common cause of death in patients with thoracic aortic and thoracoabdominal aneurysm (TAA/TAAA) and is almost uniformly fatal.

METHODS

This was a retrospective review of patients admitted to a single practice with rupture of a TAA/TAAA between 1993 and 2000.

RESULTS

Twenty-two consecutive patients with a leaking TAA/TAAA were identified. The aetiology of rupture was either secondary to a degenerative TAAA or a type B dissection. Seventeen patients underwent surgery; one had a Crawford extent I, seven an extent II, one an extent III and two an extent IV TAAA. Six patients had an acute type B dissection with rupture in the upper descending thoracic aorta. The 30-day survival rate was 88 per cent (15 of 17 patients). Actuarial survival at 1 year in patients who had surgery was 65 per cent. Survival at 1 year for all presenting patients who consented to surgery was 40 per cent. Median survival was greater than 36 months.

CONCLUSION

As a result of improving medical care, more patients with a contained rupture of a TAA/TAAA may present for treatment. Surgery is complex and requires specialist teams for optimal care.

Spinal injuries caused by the acceleration of ejection

The speed and altitude at which modern military aircraft operate are such that escape can only be achieved by some means of forcibly propelling the aircrew clear of the aircraft. The most common method of doing this is by use of an ejection seat. The use of such seats, whilst generally life saving, exposes aircrew to forces that may be at the limits of human tolerance. Each phase of the ejection sequence is associated with characteristic injury patterns and of particular concern is the occurrence of spinal compression fractures, which are caused by the upward acceleration of the ejection seat. Thorough investigation of aircrew who eject is necessary and magnetic resonance imaging of the spines of these aircrew is now becoming mandatory. Aircrew who sustain stable anterior wedge compression fractures usually require no invasive treatment, but are prevented from flying aircraft fitted with ejection seats for 3-4 months.

Serum creatine kinase levels parallel the clinical course for rhabdomyomatous Wilms tumor

A right-sided renal mass in an 11-month-old girl was diagnosed by percutaneous needle biopsy as Wilms tumor, which on histologic examination was found to be predominantly rhabdomyomatous. As part of the examination, serum creatine kinase (CK) and CK-MB levels were measured and were significantly elevated at 994 U/L (reference range, 42-180 U/L) and 40 U/L (reference range, 0-3 U/L), respectively. Subsequently, an 8-month-old girl was admitted to the hospital with septicemia and was found to have an abdominal mass. A diagnosis of bilateral Wilms tumor was made following percutaneous biopsy of both kidneys; histologic examination confirmed that the tumor was predominantly rhabdomyomatous. Serum CK and CK-MB levels also were measured and were significantly elevated at 685 U/L and 84.4 U/L, respectively. In both cases, the serum CK and CK-MB levels reflected the clinical course; elevation in serum levels was associated with tumor recurrence, infarction, or chemotherapy-related necrosis. We conclude that these enzymes have clinical usefulness as markers for Wilms tumor showing rhabdomyomatous morphologic features.

Incremental shuttle walk test in the assessment of patients for heart transplantation

OBJECTIVE

To compare the incremental shuttle walk test (ISWT) with treadmill exercise testing (TT) derived measurement of peak oxygen consumption (peak VO(2)) in patients undergoing assessment for cardiac transplantation.

DESIGN

Prospective comparison. All investigations occurred during a single period of admission for transplant assessment.

SETTING

Single UK cardiothoracic transplantation unit.

PATIENTS

25 patients recruited (21 men). Mean age was 53 years.

INTERVENTIONS

Patients underwent two TT of peak VO(2) using the modified Naughton protocol and three (one practice) ISWT. Investigations were performed on consecutive days.

MAIN OUTCOME MEASURES

Main outcome measures were repeatability of TT and ISWT assessments; relation between peak VO(2) and distance walked in the ISWT; and receiver operating characteristic (ROC) analysis to establish a distance walked in the ISWT that predicted which patients would have a peak VO(2) greater than 14 ml/min/kg.

RESULTS

Both the ISWT and the TT were highly reproducible. Following the first practice walk, mean (SD) ISWT distances were 400.0 (146) m (ISWT2) and 401.3 (129) m (ISWT3), r = 0.90, p < 0.0001. Mean peak VO(2) by TT was 15.2 (4.4) ml/kg/min (TT1) and 15.0 (4.4) ml/kg/min (TT2), r = 0.83, p < 0.0001. The results revealed a strong correlation between distance covered in the ISWT and peak VO(2) obtained during TT (r = 0.73, p = 0.0001). ROC analysis showed that a distance walked of 450 m allowed the selection of patients with a peak VO(2) of over 14 ml/min/kg.

CONCLUSIONS

This work confirms the utility of the ISWT in the assessment of exercise capacity in patients with severe heart failure undergoing assessment for cardiac transplantation. ISWT may provide a widely applicable surrogate measure for peak VO(2) estimation in this population. Shuttle distance walked may therefore allow the convenient, serial assessment of patients with heart failure before referral for transplantation.

Incremental shuttle walk test in the assessment of patients for heart transplantation

OBJECTIVE

To compare the incremental shuttle walk test (ISWT) with treadmill exercise testing (TT) derived measurement of peak oxygen consumption (peak Vo2) in patients undergoing assessment for cardiac transplantation.

DESIGN

Prospective comparison. All investigations occurred during a single period of admission for transplant assessment.

SETTING

Single UK cardiothoracic transplantation unit.

PATIENTS

25 patients recruited (21 men). Mean age was 53 years.

INTERVENTIONS

Patients underwent two TT of peak Vo2 using the modified Naughton protocol and three (one practice) ISWT. Investigations were performed on consecutive days.

MAIN OUTCOME MEASURES

Main outcome measures were repeatability of TT and ISWT assessments; relation between peak Vo2 and distance walked in the ISWT; and receiver operating characteristic (ROC) analysis to establish a distance walked in the ISWT that predicted which patients would have a peak Vo2 greater than 14 ml/min/kg.

RESULTS

Both the ISWT and the TT were highly reproducible. Following the first practice walk, mean (SD) ISWT distances were 400.0 (146) m (ISWT2) and 401.3 (129) m (ISWT3),r = 0.90, p < 0.0001. Mean peak Vo2 by TT was 15.2 (4.4) ml/kg/min (TT1) and 15.0 (4.4) ml/kg/min (TT2), r = 0.83, p < 0.0001. The results revealed a strong correlation between distance covered in the ISWT and peak Vo2obtained during TT (r = 0.73, p = 0.0001). ROC analysis showed that a distance walked of 450 m allowed the selection of patients with a peak Vo2 of over 14 ml/min/kg.

CONCLUSIONS

This work confirms the utility of the ISWT in the assessment of exercise capacity in patients with severe heart failure undergoing assessment for cardiac transplantation. ISWT may provide a widely applicable surrogate measure for peak Vo2 estimation in this population. Shuttle distance walked may therefore allow the convenient, serial assessment of patients with heart failure before referral for transplantation.

Vagus nerve stimulation decreases left ventricular contractility in vivo in the human and pig heart

1. Studies of the effect of vagus nerve stimulation on ventricular myocardial function in mammals are limited, particularly in the human. 2. The present study was designed to determine the effect of direct electrical stimulation of the left vagus nerve on left ventricular contractile state in hearts paced at 10 % above the natural rate, in anaesthetised pigs and anaesthetised human subjects undergoing open chest surgery for coronary artery bypass grafting. 3. Contractility of the left ventricle was determined from a series of pressure-volume loops obtained from a combined pressure and conductance (volume) catheter placed in the left ventricle. From the measurements a regression slope of the end-systolic pressure-volume relationship was determined to give end-systolic elastance (Ees), a load-independent measure of contractility. 4. In six anaesthetised open chest pigs, stimulation of the peripheral cut end of the left cervical vagus nerve induced a significant decrease in Ees of 26 +/- 14 %. 5. In nine patients electrical stimulation of the left thoracic vagus nerve close to its cardiac branch resulted in a significant drop in Ees of 38 +/- 16 %. 6. The effects of vagal stimulation were blocked by the muscarinic antagonist glycopyrronium (5 mg kg(-1)). 7. Administration of the beta-adrenoreceptor antagonist esmolol (1 mg kg(-1)) also attenuated the effect of vagal stimulation, indicating a degree of interaction of vagal and sympathetic influences on contractility. 8. These studies show that in the human and pig heart the left vagus nerve can profoundly decrease the inotropic state of the left ventricular myocardium independent of its bradycardic effect.

Structure of the RGS-like domain from PDZ-RhoGEF: linking heterotrimeric g protein-coupled signaling to Rho GTPases

BACKGROUND

The multidomain PDZ-RhoGEF is one of many known guanine nucleotide exchange factors that upregulate Rho GTPases. PDZ-RhoGEF and related family members play a critical role in a molecular signaling pathway from heterotrimeric G protein-coupled receptors to Rho proteins. A approximately 200 residue RGS-like (RGSL) domain in PDZ-RhoGEF and its homologs is responsible for the direct association with Galpha12/13 proteins. To better understand structure-function relationships, we initiated crystallographic studies of the RGSL domain from human PDZ-RhoGEF.

RESULTS

A recombinant construct of the RGSL domain was expressed in Escherichia coli and purified, but it did not crystallize. Alternative constructs were designed based on a novel strategy of targeting lysine and glutamic acid residues for mutagenesis to alanine. A triple-point mutant functionally identical to the wild-type protein was crystallized, and its structure was determined by the MAD method using Se-methionine (Se-Met) incorporation. A molecular model of the RGSL domain was refined at 2.2 A resolution, revealing an all-helical tertiary fold with the mutations located at intermolecular lattice contacts.

CONCLUSIONS

The first nine helices adopt a fold similar to that observed for RGS proteins, although the sequence identity with other such known structures is below 20%. The last three helices are an integral extension of the RGS fold, packing tightly against helices 3 and 4 with multiple hydrophobic interactions. Comparison with RGS proteins suggests features that are likely relevant for interaction with G proteins. Finally, we conclude that the strategy used to produce crystals was beneficial and might be applicable to other proteins resistant to crystallization.

A novel and simple technique to allow detection of the position of the R-waves from intraventricular pressure waveforms: application to the conductance catheter method

A simple and novel technique that utilizes the zero-crossing points of the first time derivative of intra-ventricular pressure (dP/dt) to mark systole, is proposed. Discrete differentiation of the sampled pressure waveform is calculated using a difference equation. Filtration of high-frequency noise in dP/dt is achieved using a low-pass Butterworth filter of order 4 and a cutoff frequency of 10 Hz. The filter is realized digitally using infinite impulse response filter stages. Double filtering of discrete dP/dt is used to eliminate time shifts. The methods are evaluated on data obtained from six large, white, anaesthetised and open chest pigs, instrumented with a conductance catheter. The zero-crossing points of the filtered dP/dt compare very well with the R-waves of the electrocardiogram (ECG) as markers of systole. The mean error is 1.3% of the duration of the heartcycle. Significantly, our results provide a solution to a problem often encountered with multiuse pressure-volume catheters when an ECG signal cannot be obtained. In this situation, the zero-crossing points of dP/dt, rather than the R-waves of the ECG, can be used as a marker of systole, thus enabling the construction of end-systolic pressure-volume relations to assess cardiac contractility.

Expression, purification, and crystallization of the RGS-like domain from the Rho nucleotide exchange factor, PDZ-RhoGEF, using the surface entropy reduction approach

Lsc-homology domains are found in several eukaryotic nucleotide exchange factors which act on Rho-family GTPases. They show limited amino acid sequence similarity to RGS proteins, which down-regulate the cellular signaling by the alpha-subunits of trimeric G-proteins and have been shown to interact with Galpha12 and Galpha13. It is believed that the RGS-like (RGSL) domain constitutes the functional link between G-protein-coupled receptors and cytosolic Rho-GTPases. We report here the expression, purification, and crystallization of the RGSL domain from the PDZ-RhoGEF. To obtain X-ray-grade crystals we have used the recently proposed approach of crystallization by mutational surface entropy reduction, in which selected Lys --> Ala, Glu --> Ala, and/or combined point mutations are introduced into the target protein to reduce the cumulative conformational entropy of surface residues. Of the five mutants that were designed and prepared, the second one tried (K463A, E465A, E466A) yielded crystals suitable for further analysis and diffracted X-rays to 2.8 A resolution on a home source. The crystals exhibit hexagonal symmetry, space group P6(1) 22 or P6(5) 22, with unit cell parameters a = b = 63.1 A, c = 202.1 A, and contain one molecule in the asymmetric unit.

Coronary artery surgery for ischemic heart failure: risks, benefits, and the importance of assessment of myocardial viability

Heart failure and left ventricular dysfunction are common and are most often caused by myocardial ischemia/infarction secondary to occlusive coronary artery disease. Although recent refinements in medical therapy have resulted in improved survival, morbidity and mortality remain high in patients with advanced heart failure. Heart transplantation remains an option for selected patients, and implantable left ventricular assist devices may soon provide another treatment strategy for such patients. However, patients with established postischemic heart failure, significant myocardial viability, and coronary artery anatomy amenable to surgical revascularization can derive significant functional and survival benefit after coronary artery surgery, albeit with an increased perioperative risk. We discuss the role of coronary artery surgery in ischemic heart failure and review the evidence for such an approach.

Conservation of small-airway function by tacrolimus/cyclosporine conversion in the management of bronchiolitis obliterans following lung transplantation

We studied serial lung function in 11 patients with bronchiolitis obliterans syndrome who were treated with tacrolimus conversion following lung or heart-lung transplantation. Our results show that tacrolimus conversion slows the decline of lung function in bronchiolitis obliterans syndrome. The attenuation continues for at least 1 year following conversion.

Clinical and patho-anatomical factors affecting expansion of thoracic aortic aneurysms

OBJECTIVE

To examine the expansion of aneurysmal aortic segments (> or = 35 mm) and to assess the impact of clinical and patho-anatomical factors on aneurysm expansion.

DESIGN

87 consecutive patients (mean age 63.6 years, range 22-84 years) were studied using serial (six month intervals) computed tomographic or magnetic resonance imaging to monitor progression of thoracic aortic aneurysms. Aortic diameter was measured at seven predetermined segments and at the site of maximum aortic dilatation (MAX).

RESULTS

780 segment intervals were identified. The median overall aneurysm expansion rate was 1.43 mm/year. This increased exponentially with incremental aortic diameter (p < 0.01) and varied by anatomical segment (p < 0.05). The presence of intraluminal thrombus (p < 0.01) but not dissection or calcification was associated with accelerated growth. Univariate analysis identified thrombus (p < 0.001), previous stroke (p < 0.002), smoking (p < 0. 01), and peripheral vascular disease (p < 0.05) as factors associated with accelerated growth in MAX. Dissection, wall calcification, and history of hypertension did not affect expansion. beta Blocker treatment was not associated with protection. Multivariate analysis confirmed the positive effect of intraluminal thrombus and previous cerebral ischaemia, and the negative effect of previous aortic surgery on aneurysm growth. These findings translated into a mathematical equation describing exponential aneurysm expansion.

CONCLUSIONS

Aneurysmal thoracic aortic segments expand exponentially according to their initial size and their anatomical position within the aorta. The presence of intraluminal thrombus, atherosclerosis, and smoking history is associated with accelerated growth and may identify a high risk patient group for close surveillance.

Phenotypic correction of feline lipoprotein lipase deficiency by adenoviral gene transfer

Previous studies have revealed that adenovirus-mediated ectopic liver expression of human LPL (huLPL) can efficiently mediate plasma triacylglycerol (TG) catabolism in mice despite its native expression in adipose and muscle tissue. We aimed to explore the feasibility of liver-directed gene transfer and enzyme replacement for human LPL deficiency in a larger, naturally occurring feline animal model of complete LPL deficiency that is remarkably similar in phenotype to the human disorder. A cohort of LPL-deficient (LPL -/-) cats was given an intravenous injection of 8 x 10(9) PFU/kg of a CMV promoter/enhancer-driven, E1/E3-deleted adenoviral (Ad) vector containing a 1.36-kb huLPL cDNA (Ad-LPL) or reporter alkaline phosphatase gene (Ad-AP). After Ad-LPL administration, active, heparin-releasable huLPL was readily detected along with a 10-fold reduction in plasma TGs, disappearance of plasma TG-rich lipoproteins up to day 14, and enhanced clearance of an excess intravenous fat load on day 9. However, antibody against the huLPL protein was detected on day 14 in cats receiving Ad-LPL and adenovirus-specific neutralizing antibody was present 7 days after gene transfer in both cat cohorts. Tissue-specific expression of the huLPL transgene relative to controls was confirmed by RT-PCR. While huLPL expression was evident in the liver, other tissues including spleen and lung expressed huLPL message, in direct correlation with histological evidence of increased Oil red O (ORO)-positive neutral lipid influx. In contrast, intravenous LPL enzyme replacement therapy (ERT) led to rapid disappearance of 9000 mU/kg of active bovine LPL enzyme from the circulation, with t1/2 occurring at <10 min in two LPL-/- cats. Heparin injection 1 hr later released <10% of the original bovine LPL, further indicating its rapid systemic clearance, inactivation, or degradation as well as its ineffectiveness as a viable therapeutic alternative for complete LPL deficiency. Although LPL gene transfer and expression via this first-generation Ad vector was limited by the immune response against both the human LPL protein and adenovirus our results clearly provide a key advance supporting further development of LPL gene therapy as a viable therapeutic option for clinical LPL deficiency.

Replacement of the proximal aorta and aortic valve using a composite bileaflet prosthesis and gelatin-impregnated polyester graft (Carbo-Seal): early results in 143 patients

OBJECTIVE

We report the combined early results from two centers in the United Kingdom using a composite conduit consisting of a bileaflet mechanical valve incorporated into a gelatin-impregnated, ultra-low porosity, woven polyester graft (Carbo-Seal; Sulzer Carbomedics, Inc, Austin, Tex).

METHODS

Between August 1992 and March 1997, 143 patients underwent aortic root replacement with the Carbo-Seal composite prosthesis. The indication for surgery was acute type A dissection in 31 (22%), chronic type A dissection in 9 (6%), ascending aortic aneurysm without dissection in 100 (70%), and false aneurysm of the ascending aorta in 3 (2%). Twenty-seven patients (19%) had undergone previous sternotomy, and 40 (28%) were seen as emergencies. Concomitant procedures were performed in 38 (27%), including 18 aortic arch or hemiarch replacements. Total follow-up is 270 patient-years. Follow-up is 100% complete.

RESULTS

The early (30-day) mortality was 7% (10 patients). Permanent neurologic events occurred in 2%. At a mean follow-up of 23 months, 94% of survivors were in New York Heart Association functional class I. Freedom from reoperation was 97.2% +/- 1.6% (1 standard error [1 SE]) at 12 months and 95.7% +/- 2.2% at 48 months. Including early mortality, survival was 90.1% +/- 2.6% at 12 months and 83.1% +/- 3. 5% at 48 months.

CONCLUSIONS

Aortic root replacement with use of the Carbo-Seal prosthesis can be undertaken with a relatively low early mortality and morbidity. A low reoperation rate and high intermediate-term survival can be expected, but continued follow-up is needed to determine the long-term efficacy of this prosthesis.