Integrating harm reduction into acute care: A single center's experience.

Objective: Injection drug use (IDU) is prevalent in North America and is associated with presentations with infective endocarditis. Supporting patients who present with infective endocarditis related to IDU through harm reduction, a pragmatic approach to reduce secondary harms of a health behavior, helps address the underlying IDU. We share a case exemplar of how one acute care facility integrated harm-reduction practices into daily patient care. Methods: We took a 3-stage approach to integrate harm-reduction practices into daily patient care. In stage 1, we raised awareness and knowledge of harm reduction through education. In stage 2, we provided explicit support for harm reduction. In stage 3, we provided tangible tools to support harm reduction. Results: More than 300 staff attended education sessions and reported increased knowledge related to substances, harm reduction, and engaging patients who use substances in conversations. Staff requested the hospital explicitly support harm reduction, which led to stage 2. The creation of a harm-reduction philosophy statement provided permission to engage in harm-reduction practices. Stage 3 included the creation of a harm-reduction supply distribution program and consultations with Addictions Medicine and treatment programs. The implementation of harm-reduction supply distribution was successful and is being spread across the facility. Conclusions: Engaging in harm-reduction practices within an acute care facility is possible through a multistage process focused on education, explicit support, and tangible tools. Spreading harm-reduction integration and working with patients who used substances to evaluate effectiveness are key next steps.

Napping in high-performance athletes: Sleepiness or sleepability?

Daytime napping is a common practice in high-performance athletes, and is widely assumed to reflect sleepiness arising from sports-related sleep debt. The possibility that athlete naps may also be indicative of 'sleepability', a capacity to nap on demand that is only weakly related to homeostatic sleep pressure, has not previously been tested. The present study compared daytime sleep latencies in high-performance athletes and non-athlete controls using a single nap opportunity model. Elite (n = 10), and sub-elite (n = 10) athletes, and non-athlete controls (n = 10) attended the laboratory for a first adaption trial, and a subsequent experimental trial. Subjective sleepiness was assessed using the Karolinska Sleepiness Scale (KSS) at 14:00, 14:30 and immediately prior to a 20-minute nap opportunity at 15:00. Sleep latencies were measured using polysomnography, and defined as the time from lights out to the first epoch of any stage of sleep (N1, N2, N3, REM). In unadjusted comparisons with non-athlete controls, elite athletes showed significantly shorter sleep latencies in both the adaptation (p < 0.05) and experimental trials (p < 0.05). These significant differences were maintained in models controlling for pre-trial KSS scores and pre-trial total sleep time (all p < 0.05). Sleep latency scores for sub-elite athletes showed similar trends, but were more labile. These results are consistent with a conclusion that, among elite athletes, napping behaviour can reflect sleepability and may not necessarily result from nocturnal sleep disruption and daytime sleepiness.

Phase II randomised control feasibility trial of a nutrition and physical activity intervention after radical prostatectomy for prostate cancer.

OBJECTIVE: Dietary factors and physical activity may alter prostate cancer progression. We explored the feasibility of lifestyle interventions following radical prostatectomy for localised prostate cancer. DESIGN: Patients were recruited into a presurgical observational cohort; following radical prostatectomy, they were offered randomisation into a 2×3 factorial randomised controlled trial (RCT). SETTING: A single National Health Service trust in the South West of England, UK. PARTICIPANTS: Those with localised prostate cancer and listed for radical prostatectomy were invited to participate. RANDOMISATION: Random allocation was performed by the Bristol Randomised Trial Collaboration via an online system. INTERVENTIONS: Men were randomised into both a modified nutrition group (either increased vegetable and fruit, and reduced dairy milk; or lycopene supplementation; or control) and a physical activity group (brisk walking or control) for 6 months. BLINDING: Only the trial statistician was blind to allocations. PRIMARY OUTCOME MEASURES: Primary outcomes were measures of feasibility: randomisation rates and intervention adherence at 6 months. Collected at trial baseline, three and six months, with daily adherence reported throughout. Our intended adherence rate was 75% or above, the threshold for acceptable adherence was 90%. RESULTS: 108 men entered the presurgical cohort, and 81 were randomised into the postsurgical RCT (randomisation rate: 93.1%) and 75 completed the trial. Of 25 men in the nutrition intervention, 10 (40.0%; 95% CI 23.4% to 59.3%) adhered to the fruit and vegetable recommendations and 18 (72.0%; 95% CI 52.4% to 85.7%) to reduced dairy intake. Adherence to lycopene (n=28), was 78.6% (95% CI 60.5% to 89.8%), while 21/39 adhered to the walking intervention (53.8%; 95% CI 38.6% to 68.4%). Most men were followed up at 6 months (75/81; 92.6%). Three 'possibly related' adverse events were indigestion, abdominal bloating and knee pain. CONCLUSIONS: Interventions were deemed feasible, with high randomisation rates and generally good adherence. A definitive RCT is proposed. TRIAL REGISTRATION NUMBER: ISRCTN 99048944.

Does Elite Sport Degrade Sleep Quality? A Systematic Review.

BACKGROUND: Information on sleep quality and insomnia symptomatology among elite athletes remains poorly systematised in the sports science and medicine literature. The extent to which performance in elite sport represents a risk for chronic insomnia is unknown. OBJECTIVES: The purpose of this systematic review was to profile the objective and experienced characteristics of sleep among elite athletes, and to consider relationships between elite sport and insomnia symptomatology. METHODS: Studies relating to sleep involving participants described on a pre-defined continuum of 'eliteness' were located through a systematic search of four research databases: SPORTDiscus, PubMed, Science Direct and Google Scholar, up to April 2016. Once extracted, studies were categorised as (1) those mainly describing sleep structure/patterns, (2) those mainly describing sleep quality and insomnia symptomatology and (3) those exploring associations between aspects of elite sport and sleep outcomes. RESULTS: The search returned 1676 records. Following screening against set criteria, a total of 37 studies were identified. The quality of evidence reviewed was generally low. Pooled sleep quality data revealed high levels of sleep complaints in elite athletes. Three risk factors for sleep disturbance were broadly identified: (1) training, (2) travel and (3) competition. CONCLUSION: While acknowledging the limited number of high-quality evidence reviewed, athletes show a high overall prevalence of insomnia symptoms characterised by longer sleep latencies, greater sleep fragmentation, non-restorative sleep, and excessive daytime fatigue. These symptoms show marked inter-sport differences. Two underlying mechanisms are implicated in the mediation of sport-related insomnia symptoms: pre-sleep cognitive arousal and sleep restriction.

Effect of increased fruit and vegetable consumption on physical function and muscle strength in older adults.

Fruit and vegetable (FV) intake, which is often low in older people, may be associated with improved muscle strength and physical function. However, there is a shortage of intervention trial evidence to support this. The current study examined the effect of increased FV consumption on measures of muscle strength and physical function among healthy, free-living older adults. A randomized controlled intervention study was undertaken. Eighty-three participants aged 65-85 years, habitually consuming ≤ 2 portions of FV/day, were randomised to continue their normal diet (≤ 2 portions/day), or to consume ≥ 5 portions of FV/day for 16 weeks. FV were delivered to all participants each week, free of charge. Compliance was monitored at baseline, 6, 12 and 16 weeks by diet history and by measuring biomarkers of micronutrient status. Grip strength was measured by a hand-held dynamometer, while lower-extremity physical function was assessed by performance-based measures. Eighty-two participants completed the intervention. The 5 portions/day group showed greater change in daily FV consumption compared to the 2 portions/day group (P < 0.001). This was reflected in significant increases in biomarkers of micronutrient status. No significant differences were evident in change in physical function between the two groups. However, there was a trend towards a greater change in grip strength in the 5 portions/day compared to the 2 portions/day group (mean change at 16 weeks ± SD, 2.04 ± 5.16 and 0.11 ± 3.26 kg, respectively, P = 0.06). Increased FV consumption may modestly increase grip strength but has no effect on physical function in healthy older adults.

Effect of fruit and vegetable consumption on immune function in older people: a randomized controlled trial.

BACKGROUND: Fruit and vegetable (FV) intake, which is often low in older people, is associated with reduced chronic disease risk. OBJECTIVE: We determined whether increased FV intake improves measures of immune function. DESIGN: We conducted a randomized controlled trial (The Ageing and Dietary Intervention Trial) in 83 healthy volunteers aged 65-85 y with low FV intakes (≤2 portions/d); 82 subjects completed the intervention. Participants were assigned to continue their normal diets or to consume ≥5 FV portions/d for 16 wk. At 12 wk, tetanus toxoid (0.5 mL intramuscular) and Pneumovax II vaccine (0.5 mL intramuscular; both vaccines from Sanofi Pasteur) were administered. FV intake was monitored by using diet histories, and biomarkers of nutritional status were assessed. The primary endpoint was the antibody response to vaccination. Specific antibodies binding to tetanus toxoid (total IgG) and pneumococcal capsular polysaccharide (total IgG and IgG2) were assessed at baseline and 16 wk. Participants were recruited between October 2006 and June 2008. RESULTS: The change in FV consumption differed significantly between groups [mean change in number of portions (95% CI): in the 2-portion/d group, 0.4 portions/d (0.2, 0.7 portions/d); in the 5-portion/d group, 4.6 portions/d (4.1, 5.0 portions/d); P < 0.001)] and also in micronutrient status. Antibody binding to pneumococcal capsular polysaccharide (total IgG) increased more in the 5-portion/d group than in the 2-portion/d group [geometric mean (95% CI) of the week 16:baseline ratio: 3.1 (2.1, 4.4) and 1.7 (1.3, 2.1), respectively; P = 0.005)]. There was no significant difference in the increases in antibody binding to tetanus toxoid. CONCLUSION: Increased FV intake improves the Pneumovax II vaccination antibody response in older people, which links an achievable dietary goal with improved immune function.

Effect of supplementation with B vitamins and antioxidants on levels of asymmetric dimethylarginine (ADMA) and C-reactive protein (CRP): a double-blind, randomised, factorial design, placebo-controlled trial.

PURPOSE: Cardiovascular risk factors such as elevated levels of asymmetric dimethylarginine (ADMA)/C-reactive protein (CRP) and homocysteine are potentially related to essential micronutrients such as certain B vitamins and antioxidant vitamins. The aim of the present study was to investigate whether supplementation with moderate doses of B vitamins and/or antioxidants could alter either ADMA and/or CRP concentrations in middle-aged, apparently healthy men with mildly elevated homocysteine levels. METHODS: A randomised, double-blind, factorial design, intervention study was carried out on 132 men with mildly elevated homocysteine levels, allocated to four groups (a) B vitamins alone--1 mg folic acid, 7.2 mg pyridoxine, 0.02 mg cyanocobalamin daily, (b) antioxidants alone--150 mg ascorbic acid, 67 mg vitamin E, 9 mg ß-carotene daily, (c) B vitamins with antioxidant vitamins, or (d) placebo. A total of 101 men completed the study to 8 weeks. RESULTS: When the percentage of baseline ADMA and CRP was examined at 8 weeks, no statistically significant differences were observed between the four groups (p = 0.21 and p = 0.90, respectively). Similar non-significant results were observed when analysis was stratified based on baseline CRP levels (<1.0 mg/L, p = 0.10; ≥1.0 mg/L, p = 0.64) and smoking status (all p ≥ 0.05). CONCLUSIONS: Supplementation with moderate doses of B vitamins and/or antioxidants did not alter either ADMA or CRP concentrations in these middle-aged, apparently healthy men with mildly elevated homocysteine levels.

Cardiovascular disease and hypertension are strong risk factors for choroidal neovascularization.

PURPOSE: To investigate the association of cardiovascular risk factors and inflammatory markers with neovascular age-related macular degeneration (AMD). DESIGN: Cross-sectional case-control study. PARTICIPANTS: Of the 410 of the >/=65-year-old community sample invited to attend, 205 participated (50% response rate). Of the 215 clinic attendees who were invited to participate, 212 agreed to take part (98% response rate). A diagnosis of neovascular AMD in at least one eye was made in 193 clinic attendees and 2 of the community sample. METHODS: Clinic and community participants underwent a detailed ophthalmic examination with fundus imaging, were interviewed for assessment of putative risk factors, and provided a blood sample. Analysis included levels of serum lipids, intercellular adhesion molecule 1 (ICAM), vascular cellular adhesion molecule (VCAM), and C-reactive protein (CRP). All participants were classified by fundus image grading on the basis of the eye with more severe AMD features. MAIN OUTCOME MEASURE: Neovascular AMD. RESULTS: There were 195 participants with choroidal neovascularization in at least one eye, 97 nonneovascular AMD participants, and 115 controls (no drusen or pigmentary irregularities in either eye). In confounder-adjusted logistic regression, a history of cardiovascular disease was strongly associated with neovascular AMD (odds ratio [OR], 7.53; 95% confidence interval [CI], 2.78-20.41). Cigarette smoking (OR, 3.71; 95% CI, 1.25-11.06), being in the highest quartile of body mass index (OR, 3.82; 95% CI, 1.22-12.01), stage 2 hypertension (OR, 3.21; 95% CI, 1.14-8.98), and being in the highest quartile of serum cholesterol (OR, 4.66; 95% CI, 1.35-16.13) were positively associated with neovascular AMD. There was no association between AMD status and serum CRP, ICAM, or VCAM. CONCLUSIONS: Our results suggest that cardiovascular disease plays an etiological role in the development of choroidal neovascularization in a proportion of older adults and highlight the importance of control of blood pressure and cholesterol, avoidance of smoking, and maintenance of a normal body weight.

The use of Raman microscopy to determine and localize vitamin E in biological samples.

Alpha-tocopherol (aT), the predominant form of vitamin E in mammals, is thought to prevent oxidation of polyunsaturated fatty acids. In the lung, aT is perceived to be accumulated in alveolar type II cells and secreted together with surfactant into the epithelial lining fluid. Conventionally, determination of aT and related compounds requires extraction with organic solvents. This study describes a new method to determine and image the distribution of aT and related compounds within cells and tissue sections using the light-scattering technique of Raman microscopy to enable high spatial as well as spectral resolution. This study compared the nondestructive analysis by Raman microscopy of vitamin E, in particular aT, in biological samples with data obtained using conventional HPLC analysis. Raman spectra were acquired at spatial resolutions of 2-0.8 microm. Multivariate analysis techniques were used for analyses and construction of corresponding maps showing the distribution of aT, alpha-tocopherol quinone (aTQ), and other constituents (hemes, proteins, DNA, and surfactant lipids). A combination of images enabled identification of colocalized constituents (heme/aTQ and aT/surfactant lipids). Our data demonstrate the ability of Raman microscopy to discriminate between different tocopherols and oxidation products in biological specimens without sample destruction. By enabling the visualization of lipid-protein interactions, Raman microscopy offers a novel method of investigating biological characterization of lipid-soluble compounds, including those that may be embedded in biological membranes such as aT.

Retinal vein occlusion, homocysteine, and methylene tetrahydrofolate reductase genotype.

PURPOSE: The aim of this case-control study was to investigate the relationship between homocysteine (tHcy), 5,10 methylene tetrahydrofolate reductase (MTHFR) C677T genotype, folate and vitamin B12 status, and retinal vein occlusion (RVO). METHODS: Subjects with RVO (n = 106) were recruited from outpatient and inpatient sources. Controls (n = 98) were selected to achieve a similar age and sex distribution. Full ocular examination was performed and medical history was taken for each study participant. Plasma and serum samples were analyzed for tHcy level and folate and vitamin B12 status, and extracted DNA was assessed for the MTHFR C677T genotype. RESULTS: There was no significant difference in plasma tHcy level or thermolabile MTHFR allele frequency between subjects and controls. Similarly, there was no significant difference in folate or vitamin B12 status between subjects and controls. MTHFR genotype did not affect folate or vitamin B12 concentrations in subjects or controls. However, tHcy was significantly higher in thermolabile homozygotes than in nonthermolabile homozygotes (ratio of geometric means, 1.35; 95% confidence interval [CI], 1.04-1.74; P = 0.024). CONCLUSIONS: Hyperhomocysteinemia, the MTHFR C677T mutation, and folate and vitamin B12 status are not important risk factors for RVO in this population.