Engagement With Remote Delivery Channels in a Physical Activity Intervention for Senior Women in the US

PURPOSE

Identify the effects of engagement with different intervention delivery channels on physical activity (PA), and the participant subgroups engaging with the different channels, among Women's Health Initiative Strong and Healthy (WHISH) PA trial participants.

DESIGN

Secondary analysis of data from WHISH, a pragmatic trial that used passive randomized consent.

SETTING

United States (remote intervention in all 50 states).

SAMPLE

18,080 U.S. women, aged 68-99 years, assigned to the WHISH PA intervention arm.

MEASURES

6 dichotomous variables operationalized engagement: Engagement with Targeted Inserts, Email (opened), Email (clicked links), Website (logging in), Website (tracking), Interactive Voice Response (IVR). PA was measured using the CHAMPS PA questionnaire.

ANALYSIS

Linear regressions evaluated effects of engagement on PA. Conditional Inference Trees identified subgroups of participants engaging with different channels based on demographic and psychosocial variables.

RESULTS

Engagement with each channel, except IVR, was associated with significantly more hours/week of PA (square root coefficients .29 - .13, P values <.001). Consistently across channels, features that identified subgroups of participants with higher engagement included younger age, and higher levels of PA and physical function. Subgroups with the highest engagement differed from those with the lowest in most participant characteristics.

CONCLUSIONS

For equitable population-level impact via large-scale remotely-delivered PA programs, it may be necessary to identify strategies to engage and target harder to reach subgroups more precisely.

CLINICAL TRIAL REGISTRATION

The WHISH trial is registered at ClinicalTrials.gov (No. NCT02425345).

Prevalence and predictors for postpartum sleep disorders: a nationwide analysis

OBJECTIVE

To describe the prevalence and predictors of postpartum sleep disorders.

DESIGN

A retrospective cohort study.

SETTING

Postpartum.

POPULATION

Commercially insured women delivering in California (USA) between 2011 and 2014.

METHODS

Using the Optum Clinformatics Datamart Database.

MAIN OUTCOME MEASURES

Prevalence of a postpartum sleep disorder diagnosis with and without a depression diagnosis up to 12 months following hospital discharge for inpatient delivery. We also identified predictors of a postpartum sleep disorder diagnosis using multivariable logistic regression.

RESULTS

We identified 3535 (1.9%) women with a postpartum sleep disorder diagnosis. The prevalence of sleep disorder diagnoses was insomnia (1.3%), sleep apnea (0.25%), and other sleep disorder (0.25%). The odds of a postpartum sleep disorder were highest among women with a history of drug abuse (adjusted odds ratio (aOR): 2.70, 95% confidence interval (CI): 1.79-4.09); a stillbirth delivery (aOR: 2.15, 95% CI: 1.53-3.01); and chronic hypertension (aOR: 1.82; 95% CI: 1.57-2.11). A comorbid diagnosis of a postpartum sleep disorder and depression occurred in 1182 women (0.6%). These women accounted for 33.4% of all women with a postpartum sleep disorder. The strongest predictors of a comorbid diagnosis were a history of drug abuse (aOR: 4.13; 95% CI: 2.37-7.21) and a stillbirth delivery (aOR: 2.93; 95% CI: 1.74-4.92).

CONCLUSIONS

Postpartum sleep disorders are underdiagnosed conditions, with only 2% of postpartum women in this cohort receiving a sleep diagnosis using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Insomnia was the most common disorder and one-third of women diagnosed with a postpartum sleep disorder had a co-morbid diagnosis of depression. Future studies are needed to improve the screening and diagnostic accuracy of postpartum sleep disorders.

Physical activity, well-being, and priorities of older women during the COVID-19 pandemic: a survey of Women's Health Initiative Strong and Healthy (WHISH) intervention participants

Sheltering-in-place, social distancing, and other strategies to minimize COVID-19 transmission may impact physical activity (PA) and well-being in older adults. To assess self-reported PA changes, well-being, and priorities of older women across the USA early in the COVID-19 pandemic. In May 2020, a 10-question survey was emailed to 5,822 women, aged over 70 years, who had been assigned to the Women’s Health Initiative (WHI) Strong and Healthy (WHISH) trial PA intervention and had provided email addresses. The survey assessed general and physical well-being, current priorities, and PA levels before and during the COVID-19 pandemic. Demographic and physical function data were collected previously. Descriptive analyses characterized participants’ priorities and PA changes from before the pandemic to the time of data collection during the pandemic. Differences in PA change by age, physical function, and geographic region were assessed by Kruskal-Wallis and post hoc Dunn tests. Among 2,876 survey respondents, 89% perceived their general well-being as good, very good, or excellent, despite 90% reporting at least moderate (to extreme) concern about the pandemic, with 18.2% reporting increased PA levels, 27.1% reporting no changes, and 54.7% reporting decreased PA levels. Top priorities “in the midst of the COVID-19 outbreak” were staying in touch with family/friends (21%) and taking care of one’s body (20%). Among priorities related to physical well-being, staying active was selected most frequently (33%). Support for maintaining PA in older populations should be a priority during a pandemic and similarly disruptive events.

Baseline brain function in the preadolescents of the ABCD Study

The Adolescent Brain Cognitive Development (ABCD) Study® is a 10-year longitudinal study of children recruited at ages 9 and 10. A battery of neuroimaging tasks are administered biennially to track neurodevelopment and identify individual differences in brain function. This study reports activation patterns from functional MRI (fMRI) tasks completed at baseline, which were designed to measure cognitive impulse control with a stop signal task (SST; N = 5,547), reward anticipation and receipt with a monetary incentive delay (MID) task (N = 6,657) and working memory and emotion reactivity with an emotional N-back (EN-back) task (N = 6,009). Further, we report the spatial reproducibility of activation patterns by assessing between-group vertex/voxelwise correlations of blood oxygen level-dependent (BOLD) activation. Analyses reveal robust brain activations that are consistent with the published literature, vary across fMRI tasks/contrasts and slightly correlate with individual behavioral performance on the tasks. These results establish the preadolescent brain function baseline, guide interpretation of cross-sectional analyses and will enable the investigation of longitudinal changes during adolescent development.

What moves you? Physical activity strategies in older women

Physical activity improves quality of life and extends independence in older adults. Yet, how to motivate older adults to engage in physical activity is unclear. In the present study, 4108 older women, aged 70-99, reported how they motivated themselves to move when they did not feel like it, and their hours of physical activity and walking each week. Findings indicated that participants who endorsed more strategies had more hours of physical activity and walking. Strategic categories that correlated with more physical activity include focusing on the benefits and utilizing the surrounding environment to help motivate movement.

Women's Health Initiative Strong and Healthy Pragmatic Physical Activity Intervention Trial for Cardiovascular Disease Prevention: Design and Baseline Characteristics

BACKGROUND

National guidelines promote physical activity to prevent cardiovascular disease (CVD), yet no randomized controlled trial has tested whether physical activity reduces CVD.

METHODS

The Women's Health Initiative (WHI) Strong and Healthy (WHISH) pragmatic trial used a randomized consent design to assign women for whom cardiovascular outcomes were available through WHI data collection (N = 18 985) or linkage to the Centers for Medicare and Medicaid Services (N30 346), to a physical activity intervention or "usual activity" comparison, stratified by ages 68-99 years (in tertiles), U.S. geographic region, and outcomes data source. Women assigned to the intervention could "opt out" after receiving initial physical activity materials. Intervention materials applied evidence-based behavioral science principles to promote current national recommendations for older Americans. The intervention was adapted to participant input regarding preferences, resources, barriers, and motivational drivers and was targeted for 3 categories of women at lower, middle, or higher levels of self-reported physical functioning and physical activity. Physical activity was assessed in both arms through annual questionnaires. The primary outcome is major cardiovascular events, specifically myocardial infarction, stroke, or CVD death; primary safety outcomes are hip fracture and non-CVD death. The trial is monitored annually by an independent Data Safety and Monitoring Board. Final analyses will be based on intention to treat in all randomized participants, regardless of intervention engagement.

RESULTS

The 49 331 randomized participants had a mean baseline age of 79.7 years; 84.3% were White, 9.2% Black, 3.3% Hispanic, 1.9% Asian/Pacific Islander, 0.3% Native American, and 1% were of unknown race/ethnicity. The mean baseline RAND-36 physical function score was 71.6 (± 25.2 SD). There were no differences between Intervention (N = 24 657) and Control (N = 24 674) at baseline for age, race/ethnicity, current smoking (2.5%), use of blood pressure or lipid-lowering medications, body mass index, physical function, physical activity, or prior CVD (10.1%).

CONCLUSION

The WHISH trial is rigorously testing whether a physical activity intervention reduces major CV events in a large, diverse cohort of older women. Clinical Trials Registration Number: NCT02425345.

The relation between the flexion relaxation phenomenon onset angle and lumbar spine muscle reflex onset time in response to 30 min of slumped sitting

Viscoelastic creep of spine tissue, induced by submaximal spine flexion in sitting, can delay the onset of the flexion-relaxation phenomenon (FRP) and low back reflexes (LBR). Theoretically, these two outcome measures should be correlated; however, no studies have investigated this. This study aims to determine whether 30 min of near-maximal spine flexion will affect the onset of FRP and LBR in the lumbar erector spinae (LS) and lumbar multifidus (LM), and to examine the relation between these parameters. 15 participants were recruited (9F, 6M). Spine angle (between L1 and S2) was monitored synchronously with bilateral muscle activity in the LS (L1) and the LM (L4). FRP onset and LBR were measured in a randomized order before and after 30 min of slouched sitting. No significant difference was found for any muscle LBR onset time between pre and post-sitting (p > 0.05). A significant increase in FRP onset was found in the RLM (p = 0.016) following sitting. No significant correlation was found between the FRP and the LBR for any muscle. These results suggest that the LBR onset might not be as sensitive as an outcome measure to investigate shorter exposures of sitting as FRP.

Diversification of the antigen-specific T cell receptor repertoire after varicella zoster vaccination

Diversity and size of the antigen-specific T cell receptor (TCR) repertoire are two critical determinants for successful control of chronic infection. Varicella zoster virus (VZV) that establishes latency during childhood can escape control mechanisms, in particular with increasing age. We examined the TCR diversity of VZV-reactive CD4 T cells in individuals older than 50 years by studying three identical twin pairs and three unrelated individuals before and after vaccination with live attenuated VZV. Although all individuals had a small number of dominant T cell clones, the breadth of the VZV-specific repertoire differed markedly. A genetic influence was seen for the sharing of individual TCR sequences from antigen-reactive cells but not for repertoire richness or the selection of dominant clones. VZV vaccination favored the expansion of infrequent VZV antigen-reactive TCRs, including those from naïve T cells with lesser boosting of dominant T cell clones. Thus, vaccination does not reinforce the in vivo selection that occurred during chronic infection but leads to a diversification of the VZV-reactive T cell repertoire. However, a single-booster immunization seems insufficient to establish new clonal dominance. Our results suggest that repertoire analysis of antigen-specific TCRs can be an important readout to assess whether a vaccination was able to generate memory cells in clonal sizes that are necessary for immune protection.

Defective T Memory Cell Differentiation after Varicella Zoster Vaccination in Older Individuals

Vaccination with attenuated live varicella zoster virus (VZV) can prevent zoster reactivation, but protection is incomplete especially in an older population. To decipher the molecular mechanisms underlying variable vaccine responses, T- and B-cell responses to VZV vaccination were examined in individuals of different ages including identical twin pairs. Contrary to the induction of VZV-specific antibodies, antigen-specific T cell responses were significantly influenced by inherited factors. Diminished generation of long-lived memory T cells in older individuals was mainly caused by increased T cell loss after the peak response while the expansion of antigen-specific T cells was not affected by age. Gene expression in activated CD4 T cells at the time of the peak response identified gene modules related to cell cycle regulation and DNA repair that correlated with the contraction phase of the T cell response and consequently the generation of long-lived memory cells. These data identify cell cycle regulatory mechanisms as targets to reduce T cell attrition in a vaccine response and to improve the generation of antigen-specific T cell memory, in particular in an older population.

Defective Signaling in the JAK-STAT Pathway Tracks with Chronic Inflammation and Cardiovascular Risk in Aging Humans

Chronic inflammation, a decline in immune responsiveness, and reduced cardiovascular function are all associated with aging, but the relationships among these phenomena remain unclear. Here, we longitudinally profiled a total of 84 signaling conditions in 91 young and older adults and observed an age-related reduction in cytokine responsiveness within four immune cell lineages, most prominently T cells. The phenotype can be partially explained by elevated baseline levels of phosphorylated STAT (pSTAT) proteins and a different response capacity of naive versus memory T cell subsets to interleukin 6 (IL-6), interferon α (IFN-α), and, to a lesser extent, IL-21 and IFN-γ. Baseline pSTAT levels tracked with circulating levels of C-reactive protein (CRP), and we derived a cytokine response score that negatively correlates with measures of cardiovascular disease, specifically diastolic dysfunction and atherosclerotic burden, outperforming CRP. Thus, we identified an immunological link between inflammation, decreased cell responsiveness in the JAK-STAT pathway, and cardiovascular aging. Targeting chronic inflammation may ameliorate this deficiency in cellular responsiveness and improve cardiovascular function.

Longitudinal Kinetics of Cytomegalovirus-Specific T-Cell Immunity and Viral Replication in Infants With Congenital Cytomegalovirus Infection

BACKGROUND

Congenital cytomegalovirus (CMV) is reported to affect up to 1% of all live births in the United States. T-cell immunity may be important for controlling CMV replication in congenital CMV-infected infants. We describe the natural history of CMV-specific T-cell evolution and CMV replication in infants with congenital CMV infection.

METHODS

Cytomegalovirus viral load, CMV urine culture, and CMV-specific CD4 and CD8 T-cell responses were assessed in a prospective longitudinal cohort of 51 infants with congenital CMV infection who were observed from birth to 3 years of age.

RESULTS

We found a kinetic pattern of decreasing urinary CMV replication and increasing CMV-specific CD4 and CD8 T-cell responses during the first 3 years of life. We also found higher CMV-specific CD8 T-cell responses were associated with subsequent reduction of urine CMV viral load.

CONCLUSION

For infants with congenital CMV infection, our data suggest an age-related maturation of both CMV-specific CD4 and CD8 T-cell immunity that is associated with an age-related decline in urinary CMV replication.

Pregnancy Does Not Attenuate the Antibody or Plasmablast Response to Inactivated Influenza Vaccine

BACKGROUND

Inactivated influenza vaccine (IIV) is recommended during pregnancy to prevent influenza infection and its complications in pregnant women and their infants. However, the extent to which pregnancy modifies the antibody response to vaccination remains unclear, and prior studies have focused primarily on hemagglutinin inhibition (HI) titers. A more comprehensive understanding of how pregnancy modifies the humoral immune response to influenza vaccination will aid in maximizing vaccine efficacy.

METHODS

Healthy pregnant women and control women were studied prior to, 7 days after, and 28 days after vaccination with IIV. HI titers, microneutralization (MN) titers, and the frequency of circulating plasmablasts were evaluated in pregnant versus control women.

RESULTS

Pregnant women and control women mount similarly robust serologic immune responses to IIV, with no significant differences for any influenza strain in postvaccination geometric mean HI or MN titers. HI and MN titers correlate, though MN titers demonstrate more robust changes pre- versus postvaccination. The induction of circulating plasmablasts is increased in pregnant women versus controls (median fold-change 2.60 vs 1.49 [interquartile range, 0.94-7.53 vs 0.63-2.67]; P = .03).

CONCLUSIONS

Pregnant women do not have impaired humoral immune responses to IIV and may have increased circulating plasmablast production compared to control women.

Mapping epitopes of U1-70K autoantibodies at single-amino acid resolution

The mechanisms underlying development of ribonucleoprotein (RNP) autoantibodies are unclear. The U1-70K protein is the predominant target of RNP autoantibodies, and the RNA binding domain has been shown to be the immunodominant autoantigenic region of U1-70K, although the specific epitopes are not known. To precisely map U1-70K epitopes, we developed silicon-based peptide microarrays with >5700 features, corresponding to 843 unique peptides derived from the U1-70K protein. The microarrays feature overlapping peptides, with single-amino acid resolution in length and location, spanning amino acids 110-170 within the U1-70K RNA binding domain. We evaluated the serum IgG of a cohort of patients with systemic lupus erythematosus (SLE; n = 26) using the microarrays, and identified multiple reactive epitopes, including peptides 116-121 and 143-148. Indirect peptide ELISA analysis of the sera of patients with SLE (n = 88) revealed that ∼14% of patients had serum IgG reactivity to 116-121, while reactivity to 143-148 appeared to be limited to a single patient. SLE patients with serum reactivity to 116-121 had significantly lower SLE Disease Activity Index (SLEDAI) scores at the time of sampling, compared to non-reactive patients. Minimal reactivity to the peptides was observed in the sera of healthy controls (n = 92). Competitive ELISA showed antibodies to 116-121 bind a common epitope in U1-70K (68-72) and the matrix protein M1 of human influenza B viruses. Institutional Review Boards approved this study. Knowledge of the precise epitopes of U1-70K autoantibodies may provide insight into the mechanisms of development of anti-RNP, identify potential clinical biomarkers and inform ongoing clinical trails of peptide-based therapeutics.

Pregnancy does not attenuate the antibody or plasmablast response to inactivated influenza vaccine (HUM6P.247)

Background. Inactivated influenza vaccine (IIV) is recommended during pregnancy to prevent influenza infection and its complications in pregnant women and their infants. However, the extent to which pregnancy modifies the antibody response to vaccination remains unclear, and prior studies have focused primarily on hemagglutinin inhibition (HI) titers. A more comprehensive understanding of how pregnancy modifies the humoral immune response to influenza vaccination will aid in maximizing vaccine efficacy. Methods. Healthy pregnant women and control women were studied prior to, 7 days after and 28 days after vaccination with IIV. HI titers, microneutralization (MN) titers and the frequency of circulating plasmablasts were evaluated in pregnant vs. control women. Results. Pregnant women and control women mount similarly robust serologic immune responses to IIV, with no significant differences for any influenza strain in post-vaccination geometric mean HI or MN titers. HI and MN titers correlate, though MN titers demonstrate more robust changes pre- vs. post-vaccination. The induction of circulating plasmablasts is increased in pregnant women vs. controls (median fold-change 2.60 vs. 1.49 [Interquartile Range 0.94-7.53 vs. 0.63-2.67]; p = 0.03). Conclusion. Pregnant women do not have impaired humoral immune responses to IIV, and may have increased circulating plasmablast production compared to control women.

Optimizing real time fMRI neurofeedback for therapeutic discovery and development

While reducing the burden of brain disorders remains a top priority of organizations like the World Health Organization and National Institutes of Health, the development of novel, safe and effective treatments for brain disorders has been slow. In this paper, we describe the state of the science for an emerging technology, real time functional magnetic resonance imaging (rtfMRI) neurofeedback, in clinical neurotherapeutics. We review the scientific potential of rtfMRI and outline research strategies to optimize the development and application of rtfMRI neurofeedback as a next generation therapeutic tool. We propose that rtfMRI can be used to address a broad range of clinical problems by improving our understanding of brain–behavior relationships in order to develop more specific and effective interventions for individuals with brain disorders. We focus on the use of rtfMRI neurofeedback as a clinical neurotherapeutic tool to drive plasticity in brain function, cognition, and behavior. Our overall goal is for rtfMRI to advance personalized assessment and intervention approaches to enhance resilience and reduce morbidity by correcting maladaptive patterns of brain function in those with brain disorders.

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Guidelines are proposed for studies of rtfMRI neurofeedback for clinical therapeutics.

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Evidence-based guidelines are needed for clinical trials of rtfMRI neurofeedback.

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These guidelines will shape the design of future clinical trials.

Genetic and environmental determinants of human NK cell diversity revealed by mass cytometry

Natural killer (NK) cells play critical roles in immune defense and reproduction, yet remain the most poorly understood major lymphocyte population. Because their activation is controlled by a variety of combinatorially expressed activating and inhibitory receptors, NK cell diversity and function are closely linked. To provide an unprecedented understanding of NK cell repertoire diversity, we used mass cytometry to simultaneously analyze 37 parameters, including 28 NK cell receptors, on peripheral blood NK cells from 5 sets of monozygotic twins and 12 unrelated donors of defined human leukocyte antigen (HLA) and killer cell immunoglobulin-like receptor (KIR) genotype. This analysis revealed a remarkable degree of NK cell diversity, with an estimated 6000 to 30,000 phenotypic populations within an individual and >100,000 phenotypes in the donor panel. Genetics largely determined inhibitory receptor expression, whereas activation receptor expression was heavily environmentally influenced. Therefore, NK cells may maintain self-tolerance through strictly regulated expression of inhibitory receptors while using adaptable expression patterns of activating and costimulatory receptors to respond to pathogens and tumors. These findings further suggest the possibility that discrete NK cell subpopulations could be harnessed for immunotherapeutic strategies in the settings of infection, reproduction, and transplantation.

Randomized, placebo-controlled trial to assess the safety and immunogenicity of an adenovirus type 35-based circumsporozoite malaria vaccine in healthy adults

Malaria results in over 650,000 deaths each year; thus, there is an urgent need for an effective vaccine. Pre-clinical studies and recently reported human trials suggest that pre-erythrocytic stage vaccines can provide protection against infection. A Phase 1, randomized, placebo-controlled, dose-escalation study was conducted with a vaccine composed of a replication-deficient adenovirus-35 backbone with P. falciparum circumsporozoite (CS) surface antigen (Ad35.CS.01). Healthy adult subjects received three doses of 10 (8), 10 (9), 10 (10), or 10 (11) vp/mL Ad35.CS.01 vaccine or saline placebo intramuscularly at 0, 1, and 6-mo intervals. Adverse events were assessed and anti-CS antibody responses were determined by ELISA. Seventy-two individuals were enrolled, with age, gender, and ethnicity similar across each study arm. While the vaccine was generally well tolerated, adverse events were more frequent in the highest dose groups (10 (10) and 10 (11) vp/mL). More robust humoral responses were also noted at the highest doses, with 73% developing a positive ELISA response after the three dose series of 10 (11) vp/mL. The Ad35.CS.01 vaccine was most immunogenic at the highest dosages (10 (10) and 10 (11) vp/mL). Reactogenicity findings were more common after the 10 (11) vp/mL dose, although most were mild or moderate in nature and resolved without therapy.

Discovering the determinants of diversity in the human NK cell repertoire by mass cytometry (P3018)

NK cells respond to infected and transformed cells using germline-encoded NK receptors (NKRs). Collectively, these NKRs combine to form distinct repertoires that tune the NK cell response. To provide a framework for understanding how perturbations in expression of NKRs influence disease pathogenesis, we defined the phenotypic heterogeneity of NK cells in 22 healthy individuals (ages 21-62; M=10, F=12), including 5 sets of monozygotic twins. Using mass cytometry, surface expression of 38 markers specific for NKRs and lineage markers to identify B cells, T cells and myeloid cells were examined. KIR and HLA class I genotypes were determined by Luminex, and KIR gene content was further assessed using pyrosequencing. NK cell populations, as defined by inhibitory NKRs, were highly concordant between twins (R2 = 0.90) in comparison to unrelated individuals (R2 = 0.66), indicating that the inhibitory repertoire is highly genetically determined. However, when analyzing all twenty-five NKRs, including activating receptors, the concordance in twins (R2=0.34) and in unrelated individuals (R2=0.11) was greatly decreased, indicating significant environmental influence in determining the overall NK cell repertoire. Overall, these analyses reveal tremendous diversity within the NK repertoire that is both genetically and environmentally determined, and offer the ability to examine the functional capacity of NK cells with far greater resolution.

Quantifying the unanticipated diversity of the human NK cell repertoire (P1456)

Like their T and B lymphocyte counterparts, natural killer (NK) cells exist in small and specialized subpopulations. However, while T and B cell repertoire diversity is generated primarily through DNA rearrangement to produce a single antigen-specific receptor, the diversity of the NK cell repertoire is determined by the expression of a spectrum of activating and inhibitory receptors. To evaluate the human NK cell repertoire on a single-cell basis, we simultaneously measured more than 25 NK cell receptors in the peripheral blood of 22 healthy individuals via mass cytometry. We used Boolean gating to classify cellular phenotypes. Based on the Simpson index, an ecological measure designed to quantify population diversity, we found that total NK cell repertoire diversity was approximately normally distributed across individuals. Using rarefaction curves and non-parametric species estimators, we calculate the expansiveness of the NK cell repertoire at a minimum of 100,000 unique phenotypes. Furthermore, within an individual, the ex vivo addition of the homeostatic cytokine IL-15 biased the repertoire toward highly common and uncommon phenotypes, increasing the total population richness but decreasing the overall diversity. These data show, for the first time, that the receptor-based NK cell repertoire is exquisitely diverse. They further suggest an optimal baseline diversity that is highly sensitive to optimization by exogenous factors.

Predictors of referral uptake in children with disabilities in Bangladesh--exploring barriers as a first step to improving referral provision

PURPOSE

Making services available to children with disabilities in low- and middle-income countries does not guarantee their use. This study aims to identify factors associated with the uptake of referrals in order to investigate barriers to service use.

METHODS

Children with impairments identified in two districts of Bangladesh were invited to attend screening camps where their condition was confirmed; they were provided with referrals for rehabilitation and treatment services. Predictors of referral uptake were identified using logistic regression.

RESULTS

Overall referral uptake was 47%, 32% in Sirajganj and 61% in Natore. There was no association between age or gender and referral uptake. Factors predictive of referral uptake were higher income in Sirajganj (OR=2.6 95%CI 1.4-5.0), and the districts combined (OR=1.6 95%CI 1.1-2.1); maternal literacy in Natore (OR=1.6 95%CI 1.0-2.5); and epilepsy in all three models (Sirajganj: OR=2.6 95%CI 1.7-4.0; Natore: OR=13.5 95%CI 6.5-28.3; Combined: OR=4.6 95%CI 3.3-6.5). Physical impairment was associated with increased odds of uptake in Sirajganj and in the combined model (OR=2.7 95%CI 1.8-4.1; OR=3.34 95%CI 2.2-5.2).

CONCLUSIONS

Even when some logistical and financial assistance is available, children with impairment from low-income families may require additional support to take up referrals. There may be greater willingness to accept treatment that is locally provided, such as medication for epilepsy or therapy at village level.

Functional clinical placements: a driver for change

The aim of the project was to create a supervised professional experience placement model involving undergraduate nursing students, families of children with intellectual disabilities and nursing lecturers. Action research provided the methodological framework for developing a new placement model. Five families with children with disabilities, nine nursing students and two nurse academics worked together through the cycles of the action research process to develop a family health promotion intervention to improve the health and wellness of the family members and reduce risk for illness. Awareness, valuing and understanding were key themes derived from the qualitative data. Findings of this project indicate that this model of university-initiated, community-focused professional experience placement is effective in achieving the competency-based learning outcomes required of undergraduate nursing students and is worthy of ongoing exploration.

Architectonic mapping of the medial region of the human orbitofrontal cortex by density profiles

The study of architectonic differentiation in the cortex is advanced by the articulation of objective definitions based on clear features of the cortical architecture. We adopted areal density profiles as a means of sampling the cortex. On the profiles, we isolated and quantified the density of individual cortical layers. These features may serve as criteria in objective definitions in a way that builds on qualitative observations found in the classical literature. A preprocessing procedure was introduced to overcome artefacts in the density profiles caused by the partial overlap of neighboring neuronal layers and cortical folding. We applied this method to the medial half of the orbital frontal cortex in specimens drawn from 10 human postmortem brain hemispheres. The measurements successfully confirmed the existence of several qualitatively observed areas (architectonic areas 14c, 14r, 11m, 11 and 13). The selection of specific sampling parameters was justified on the basis of simultaneous measurements of the cortical morphology which demonstrate its influence on the appearance of the cortical layers. We also examined the robustness of the measuring procedure by analyzing the outcome of varying systematically the sampling parameters. We describe here a novel method of sampling the cortex for architectonic analysis and demonstrate its application on histological sections obtained from the medial half of the human orbitofrontal cortex.

Psychiatric health service areas in the southeast

Analysis of small areas in psychiatric health services research is sensitive to the choice of geographic units. To partially overcome the arbitrary aspects of political boundaries, service areas can be synthesized from empirical data on consumer migration patterns. Using patient flow data from 1991 Medicare discharges, we completed an agglomerative cluster analysis to generate psychiatric health service areas (PHSAs) and found that the optimal solution contained 75 PHSAs. Solutions greater than 75 clusters had high rates of area fragmentation and small single-county clusters. Psychiatric resource supply and health status indicators should be analyzed using expanded geographic units.

Towards a definition of wellness

The term 'wellness' is widely referred to in the nursing literature, yet its meaning remains elusive. Definitions vary widely, if they are provided. Lack of consensus regarding the definition of wellness contributes to fragmentation of access to research findings and limits understanding and action in wellness practice. This paper looks beyond individual definitions of the terms 'wellness' and 'health' to examine some conceptual similarities which may contribute to the debate.

Therapeutic massage: an education program for rural and remote workers in the palliative care field

This paper, drawing upon data from a Rural Health, Support, Education and Training (RHSET) funded project, focuses on the evaluation of a massage education program developed specifically for rural and remote palliative care workers. An 8 week pilot massage education course was run for palliative care workers in the Albury-Wodonga area and, from this course, an instructional video education package on massage has been developed. The program was evaluated by using a questionnaire, journals and focus group interviews. Feedback from participants was incorporated into both the pilot course and final education package, which was consistent with the action research framework. The major findings of the project were that skill development in the therapeutic use of massage was attained and that job satisfaction was indeed achieved by palliative care workers.

Effects of diet and exercise in men and postmenopausal women with low levels of HDL cholesterol and high levels of LDL cholesterol

BACKGROUND

Guidelines established by the National Cholesterol Education Program (NCEP) promote exercise and weight loss for the treatment of abnormal lipoprotein levels. Little is known, however, about the effects of exercise or the NCEP diet, which is moderately low in fat and cholesterol, in persons with lipoprotein levels that place them at high risk for coronary heart disease.

METHODS

We studied plasma lipoprotein levels in 180 postmenopausal women, 45 through 64 years of age, and 197 men, 30 through 64 years of age, who had low high-density lipoprotein (HDL) cholesterol levels (< or =59 mg per deciliter in women and < or =44 mg per deciliter in men) and moderately elevated levels of low-density lipoprotein (LDL) cholesterol (>125 mg per deciliter but <210 mg per deciliter in women and >125 mg per deciliter but <190 mg per deciliter in men). The subjects were randomly assigned to aerobic exercise, the NCEP Step 2 diet, or diet plus exercise, or to a control group, which received no intervention.

RESULTS

Dietary intake of fat and cholesterol decreased during the one-year study (P<0.001), as did body weight, in women and men in either the diet group or the diet-plus-exercise group, as compared with the controls (P<0.001) and the exercise group (P<0.05), in which dietary intake and body weight were unchanged. Changes in HDL cholesterol and triglyceride levels and the ratio of total to HDL cholesterol did not differ significantly among the treatment groups, for subjects of either sex. The serum level of LDL cholesterol was significantly reduced among women (a decrease of 14.5+/-22.2 mg per deciliter) and men (a decrease of 20.0+/-17.3 mg per deciliter) in the diet-plus-exercise group, as compared with the control group (women had a decrease of 2.5+/-16.6 mg per deciliter, P<0.05; men had a decrease of 4.6+/-21.1 mg per deciliter, P<0.001). The reduction in LDL cholesterol in men in the diet-plus-exercise group was also significant as compared with that among the men in the exercise group (3.6+/-18.8 mg per deciliter, P<0.001). In contrast, changes in LDL cholesterol levels were not significant among the women (a decrease of 7.3+/-18.9 mg per deciliter) or the men (10.8+/-18.8 mg per deciliter) in the diet group, as compared with the controls.

CONCLUSIONS

The NCEP Step 2 diet failed to lower LDL cholesterol levels in men or women with high-risk lipoprotein levels who did not engage in aerobic exercise. This finding highlights the importance of physical activity in the treatment of elevated LDL cholesterol levels.