Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial.

BACKGROUND: Early in medical education, physicians must develop competencies needed for tobacco dependence treatment. OBJECTIVE: To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills. DESIGN: A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE). SETTING/PARTICIPANTS: Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys. INTERVENTIONS: The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students. MEASUREMENTS: The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling. RESULTS: Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05). LIMITATIONS: Inclusion of only ten schools limits generalizability. CONCLUSIONS: Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

Tobacco counseling experience prior to starting medical school, tobacco treatment self-efficacy and knowledge among first-year medical students in the United States.

OBJECTIVE: To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States. METHOD: In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments. RESULTS: Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences. CONCLUSIONS: Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students.

OBJECTIVE: Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students. METHODS: Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models. RESULTS: Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors. CONCLUSIONS: Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Assessing Medical Students' Tobacco Dependence Treatment Skills Using a Detailed Behavioral Checklist.

UNLABELLED: CONSTRUCT: This article describes the development and implementation of an assessment intended to provide objective scores that would be valid indications of medical students' abilities to counsel patients about tobacco dependence. BACKGROUND: Assessing medical students' advanced communication skills, particularly in the context of providing tobacco-dependence treatment, consistently and accurately is challenging; doing so across multiple medical schools is even more difficult. APPROACH: Ten medical schools implemented a tobacco-dependence treatment case as part of an Objective Structured Clinical Examination for 3rd-year medical students. A 33-item checklist with detailed criteria and examples was developed for scoring students' performances. Trained coders viewed and coded 660 videotaped encounters; approximately 10% also were coded by the coding supervisor to check accuracy. RESULTS: Average time required to code an encounter was approximately 31 minutes; accuracy (i.e., agreement with the gold standard coder) was excellent. Overall, students performed an average of 1 in 4 of the 33 behaviors included on the checklist, and only 1 in 10 discussed setting a quit date. Most students (almost 9 in 10) asked how much the patient smoked in a day, and just over 7 in 10 informed the patient that the cough was due to smoking. CONCLUSIONS: The authors developed and implemented a rigorous assessment that will be used to evaluate medical students' tobacco-dependence treatment skills. Operationalizing the specific counseling behaviors, training coders to accurately capture students' performances using a structured checklist, and conducting the coding all required substantial time commitments but will provide confidence in the objectivity of the assessment results. In addition, this assessment can be used to provide formative information on medical students' tobacco-dependence treatment skills and to tailor ongoing training for medical students in this area.

Tobacco dependence treatment teaching by medical school clerkship preceptors: survey responses from more than 1,000 US medical students.

OBJECTIVE: To determine factors associated with tobacco cessation counseling in medical school clerkships. METHODS: Third-year medical students at 10 medical schools across the United States completed a 100-item survey, measuring the frequency with which they experienced their preceptors providing clinical teaching components: clear instruction, feedback, modeling behavior, setting clear objectives, and responding to questions about tobacco dependence counseling as well as frequency of use of tobacco prompts and office systems. Our primary dependent measure was student self-reported skill level for items of tobacco dependence treatment (e.g. "5As"). RESULTS: Surveys were completed by 1213 students. For both family medicine and internal medicine clerkships, modeling and providing clear instruction on ways to provide tobacco counseling were reported most commonly. In contrast, providing feedback and clear objectives for tobacco dependence treatment lagged behind. Overall, students who reported preceptors' provision of optimal clinical teaching components and office system prompts in both family medicine and internal medicine clerkships had higher self-reported skill (P<0.001) than students with no exposure or exposure during only one of the clerkships. CONCLUSIONS: Future educational interventions intended to help students adopt effective tobacco dependence treatment techniques should be engineered to facilitate these critical precepting components.

Associations among living alone, social support and social activity in older adults.

OBJECTIVES: We examined cross-sectional associations of living alone with social isolation among community-dwelling older adults in Worcester County, Massachusetts, USA. METHODS: Four hundred participants 65 years old and older were recruited in community group settings or by direct mail. Participants were queried for living status, social support, frequency of social activity, sociodemographic and lifestyle factors, and health conditions. Social isolation was assessed by lack of social support and decreased frequency of social activity. Physical activity (PA) was measured via an accelerometer and global positioning system (GPS), which was worn by the participant, for at least 7 consecutive days. RESULTS: Participants living alone (N = 110) had less social support than those living with others (N = 290) (p < 0.001) but did not differ significantly in the frequency of their social activities. Group-setting recruitment was strongly associated with greater social activity (p < 0.001). Less social support was independently associated with a less-than-high-school education (p = 0.001), higher CES-D depression score (p < 0.001) and lower PA (p = 0.003). Less social activity was independently associated with a less-than-high-school education (p = 0.007) and annual income less than $50,000 (p = 0.01). DISCUSSION: Older adults who are socioeconomically disadvantaged, have less social support, and who live alone are more likely to be socially isolated and may benefit from continuation of low-cost social activities and increased social support inside the home. Identifying correlates of social isolation may inform future interventions.

Matrix extracellular phosphoglycoprotein inhibits phosphate transport.

The role of putative humoral factors, known as phosphatonins, in phosphate homeostasis and the relationship between phosphate handling by the kidney and gastrointestinal tract are incompletely understood. Matrix extracellular phosphoglycoprotein (MEPE), one of several candidate phosphatonins, promotes phosphaturia, but whether it also affects intestinal phosphate absorption is unknown. Here, using the in situ intestinal loop technique, we demonstrated that short-term infusion of MEPE inhibits phosphate absorption in the jejunum but not the duodenum. Simultaneous measurement of urinary phosphate excretion suggests that the phosphaturic action of MEPE correlates with a significant reduction in the protein levels of the renal sodium-phosphate co-transporter NaPi-IIa in the proximal convoluted tubules of the outer renal cortex, assessed by Western blotting and immunohistochemistry. This short-term inhibitory effect of MEPE on renal and intestinal phosphate handling occurred without any changes in circulating levels of parathyroid hormone, 1,25-dihydroxyvitamin D(3), or fibroblast growth factor 23. Taken together, these findings suggest that MEPE is a candidate phosphatonin involved in phosphate homeostasis, acting in both the kidney and the gastrointestinal tract.

A nonrestrictive, weight loss diet focused on fiber and lean protein increase.

OBJECTIVE: We examined the feasibility and acceptability of a non-restrictive diet that was focused on increasing dietary fiber and lean protein intake for weight loss. METHODS: Dietary intake was assessed using three randomly selected 24-h dietary recalls. Fifteen obese adults enrolled in a 12-wk study that included six biweekly individual dietary counseling sessions to attain a daily goal of higher fiber (35 g/d) and lean protein (0.8 g/kg/d of individual's ideal body weight) intake. Feasibility was determined by retention and attendance and dietary adherence was measured. RESULTS: One participant dropped out of the study before the 12-wk assessment visit. Fourteen participants completed all six counseling sessions and one participant completed five sessions. At week 12, 93% of participants approved of the diet and 92% of participants did not feel hungry while on the diet. Mean fiber intake increased by 6.8 g/d (95% confidence interval [CI], 3.2 to 10.5 g/d) and total protein intake increased by 5.7 g/d (95% CI, -3.7 to 15.0 g/d). The mean change in energy intake was -265.5 kcal/d (95% CI, -454.8 to -76.2 kcal/d). The dietary quality score as measured by the Alternative Healthy Eating Index increased by 6.1 (95% CI, 1.5 to 10.7). The mean change in weight was -2.2% (95% CI, -3.6 to -0.7%). CONCLUSIONS: A diet that promotes increased fiber and lean protein intake demonstrates feasibility and high acceptability ratings, which resulted in calorie and weight reductions and an improvement of the dietary quality.

Students' Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools.

INTRODUCTION: Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling. METHODS: Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018. RESULTS: Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback. CONCLUSIONS: Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial.

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.

Comparison of Dietary Quality Assessment Using Food Frequency Questionnaire and 24-hour-recalls in Older Men and Women.

OBJECTIVES: To examine the agreement in nutrient intake and alternative healthy eating indices (AHEI) between a self-administered Food Frequency Questionnaire (FFQ) and 24-hour recall (24HR) measurements of diet by gender, among older adults. MATERIAL AND METHODS: This is a cross-sectional observational study of 105 men and 99 women aged 65 and older living in urban and rural neighborhoods in Worcester County, Massachusetts, USA. Participants were queried on diet using both FFQ and 24HR. The healthy eating classification was compared between the two instruments by gender. RESULTS: For men, the mean ± SD of AHEI total score was 48.2 ± 12.3 based on FFQ versus 34.7 ± 10.2 based on 24HR. For women, the mean ± SD was 47.9 ± 10.1 based on FFQ versus 36.1 ± 10.0 based on 24HR. Using 32 as the cutoff (40% of maximum AHEI score), 9% of men and 7% of women were classified as eating unhealthy based on the FFQ, versus 47% of men and 38% of women based on 24HR. Compared to women, men had larger 24HR to FFQ discrepancies in the nuts and vegetable protein subscore and white/red meat ratio, and smaller discrepancy in alcohol beverages subscore. CONCLUSION: Agreements between FFQ and 24HR-based measures of diet quality were roughly comparable between men and women, though slightly better for women than men. Compared to 24HR, the FFQ tended to underestimate the proportions of older men and women classified as eating unhealthy and misclassified more men than women. Such limitations should be considered when the FFQ is used to study healthy eating in older age.

Racial Differences in Neighborhood Perceptions and their Influences on Physical Activity among Urban Older Women.

BACKGROUND: Proper levels of physical activity (PA) are important to healthy aging. Little is known about racial differences in influences of neighborhood perceptions (NP) on PA and use of neighborhood resources among community-dwelling older women. MATERIALS AND METHODS: In 2014 and 2015, 49 white and 44 black women of age 65 and older living in Washington, DC were queried about their PA, NP, use of neighborhood resources and sociodemographic characteristics. They wore an accelerometer and a Global Positioning System device concurrently for 7 consecutive days. Data were analyzed by race. RESULTS: Compared to Whites, Blacks had lower NP scores (71% positive vs. 77%, p = 0.01), lower mean daily step counts (mean (SD): 3256 (1918) vs. 5457 (2989), p < 0.001), and lower frequencies of all exercise activities combined (19.7 (8.7) vs. 25.2 (11.8) per week, p = 0.01). For both Whites and Blacks, better NPs were associated with more frequent PA both at (p = 0.05) and away from home (p = 0.01). However, better NPs were associated with higher frequencies of exercise activities, moderate-to-high intensity activities, and utilitarian walking for Whites but not Blacks (p < 0.05 for race-perception interaction terms). CONCLUSIONS: In an urban setting, older Black women were more likely than older White women to have poor NPs, less PA, and weaker or no association of positive NPs with higher levels of certain PAs. Such substantial racial differences warrant further investigation and consideration in health promotion programs.

A pilot study of mindfulness-based stress reduction for hot flashes.

OBJECTIVE: A variety of results from both population and laboratory studies suggest that stress and hot flashes (HFs) are correlated and that HFs are more severe in women with lower coping abilities. The objective of this pilot study was to obtain information on the feasibility and effect of participation in a mindfulness-based stress reduction (MBSR) program on HF severity and menopause-related quality of life. DESIGN: Fifteen women volunteers reporting a minimum of seven moderate to severe HFs per day at study intake attended the eight weekly MBSR classes at the University of Massachusetts Medical School. Participants were assessed for menopause-related quality of life before beginning and at the conclusion of the MBSR program. Women also kept a daily log of their HFs through the course of the 7 weeks of the MBSR program and for 4 weeks after it. RESULTS: Women's scores on quality-of-life measures increased significantly, and the median reported HF severity, calculated as the weekly average of a daily HF severity score, decreased 40% over the course of the 11 weeks of the assessment period. The women were individually interviewed at the completion of their participation, and the results of the interviews were consistent with the results from daily diaries. CONCLUSIONS: These results provide preliminary positive evidence of the feasibility and efficacy of MBSR in supporting women who are experiencing severe HFs, and it warrants further investigation.

Teaching tobacco dependence treatment and counseling skills during medical school: rationale and design of the Medical Students helping patients Quit tobacco (MSQuit) group randomized controlled trial.

INTRODUCTION: Physician-delivered tobacco treatment using the 5As is clinically recommended, yet its use has been limited. Lack of adequate training and confidence to provide tobacco treatment is cited as leading reasons for limited 5A use. Tobacco dependence treatment training while in medical school is recommended, but is minimally provided. The MSQuit trial (Medical Students helping patients Quit tobacco) aims to determine if a multi-modal and theoretically-guided tobacco educational intervention will improve tobacco dependence treatment skills (i.e. 5As) among medical students. METHODS/DESIGN: 10 U.S. medical schools were pair-matched and randomized in a group-randomized controlled trial to evaluate whether a multi-modal educational (MME) intervention compared to traditional education (TE) will improve observed tobacco treatment skills. MME is primarily composed of TE approaches (i.e. didactics) plus a 1st year web-based course and preceptor-facilitated training during a 3rd year clerkship rotation. The primary outcome measure is an objective score on an Objective Structured Clinical Examination (OSCE) tobacco-counseling smoking case among 3rd year medical students from schools who implemented the MME or TE. DISCUSSION: MSQuit is the first randomized to evaluate whether a tobacco treatment educational intervention implemented during medical school will improve medical students' tobacco treatment skills. We hypothesize that the MME intervention will better prepare students in tobacco dependence treatment as measured by the OSCE. If a comprehensive tobacco treatment educational learning approach is effective, while also feasible and acceptable to implement, then medical schools may substantially influence skill development and use of the 5As among future physicians.

Impact of dose, frequency of administration, and equol production on efficacy of isoflavones for menopausal hot flashes: a pilot randomized trial.

OBJECTIVE: The relatively modest benefit of vasomotor symptom relief in clinical trials of isoflavones may reflect once-daily dosing and low percentages of participants who are able to metabolize daidzein into equol, a potentially more biologically active isoflavone. This pilot study examined whether symptom reduction was greater with more frequent administration and with higher daily doses. In addition, we explored possible effect modification by equol producer status. METHODS: We randomized 130 perimenopausal (no menses in the past 3 mo) and postmenopausal (≥12 mo of amenorrhea) women with a mean of five or more moderate/severe hot flashes per day to treatment arms with varying total daily isoflavone doses and dosing frequency, separately for equol producers and nonproducers. Participants recorded the daily frequency and severity of hot flashes. Analyses compared mean daily hot flash intensity scores (sum of hot flashes weighted by severity) by total daily dose and by dosing frequency. Dose- and frequency-related differences were also compared for equol producers and nonproducers. RESULTS: Hot flash intensity scores were lowest in women randomized to the highest total daily dose (100-200 mg) and in women randomized to the highest dosing frequency (twice daily to thrice daily), with greater benefits on nighttime scores than on daytime scores. Dose- and frequency-related differences were somewhat larger in equol producers than in nonproducers. CONCLUSIONS: These results suggest that a twice-daily to thrice-daily dosing frequency may improve the benefit of isoflavones for vasomotor symptom relief, particularly in equol producers and for nighttime symptoms. Larger studies are needed to confirm these findings.

Mindfulness training for coping with hot flashes: results of a randomized trial.

OBJECTIVE: The aim of this study was to analyze the effect of participation in a mindfulness training program (mindfulness-based stress reduction, [MBSR]) on the degree of bother from hot flashes and night sweats. METHODS: This study was a randomized trial of 110 late perimenopausal and early postmenopausal women experiencing an average of 5 or more moderate or severe hot flashes (including night sweats)/day. A wait-list control (WLC) was used with 3-month postintervention follow-up. The main outcome was the degree of bother from hot flashes and night sweats in the previous 24 hours. Secondary measures were hot flash intensity, quality of life, insomnia, anxiety, and perceived stress. RESULTS: Baseline average (SD) hot flash frequency was 7.87 (3.44) and 2.81 (1.76) night sweats/day. Mean (SD) bothersomeness score was 3.18 (0.55; "moderately bothered/extremely bothered"). All analyses were intention to treat and were controlled for baseline values. Within-woman changes in bother from hot flashes differed significantly by treatment arm (week × treatment arm interaction, P = 0.042). At completion of the intervention, bother in the MBSR arm decreased on average by 14.77% versus 6.79% for WLC. At 20 weeks, total reduction in bother for MBSR was 21.62% and 10.50% for WLC. Baseline-adjusted changes in hot flash intensity did not differ between treatment arms (week × treatment arm interaction, P = 0.692). The MBSR arm made clinically significant improvements in quality of life (P = 0.022), subjective sleep quality (P = 0.009), anxiety (P = 0.005), and perceived stress (P = 0.001). Improvements were maintained 3 months postintervention. CONCLUSIONS: Our data suggest that MBSR may be a clinically significant resource in reducing the degree of bother and distress women experience from hot flashes and night sweats.

Vulnerability-based spatial sampling stratification for the National Children's Study, Worcester County, Massachusetts: capturing health-relevant environmental and sociodemographic variability.

BACKGROUND: The National Children's Study is the most ambitious study ever attempted in the United States to assess how environmental factors impact child health and development. It aims to follow 100,000 children from gestation until 21 years of age. Success requires breaking new interdisciplinary ground, starting with how to select the sample of > 1,000 children in each of 105 study sites; no standardized protocol exists for stratification of the target population by factoring in the diverse environments it inhabits. Worcester County, Massachusetts, like other sites, stratifies according to local conditions and local knowledge, subject to probability sampling rules. OBJECTIVES: We answer the following questions: How do we divide Worcester County into viable strata that represent its health-relevant environmental and sociodemographic heterogeneity, subject to sampling rules? What potential does our approach have to inform stratification at other sites? RESULTS: We developed a multivariable, vulnerability-based method for spatial sampling consisting of two descriptive indices: a hazards/stressors exposure index (comprising three proxy variables), and an adaptive capacity/sociodemographic character index (five variables). Multivariable, health-relevant stratification at the start of the study may improve detection power for environment-child health associations down the line. Eighteen strata capture countywide heterogeneity in the indices and have optimal relative homogeneity within each. They achieve comparable expected birth counts and conform to local concepts of space. CONCLUSION: The approach offers moderate to high potential to inform other sites, limited by intersite differences in data availability, geodemographics, and technical capacity. Energetic community engagement from the start promotes local stratification coherence, plus vital researcher-community trust and co-ownership for sustainability.

beta1-Adrenoceptor distribution in the rat brain: an immunohistochemical study.

Current knowledge of the central nervous system distribution of the beta(1)-adrenergic receptors (beta(1)-AR) is incomplete. Here we present a general map of the beta(1)-AR distribution in the rat brain. beta(1)-AR-immunoreactivity was detected throughout the entire rat brain, but particularly dense staining was observed in the cerebellar cortex and basal ganglia. Brainstem areas displaying significant beta(1)-AR-immunoreactivity include the ventrolateral medulla, nucleus ambiguus and the nucleus of the solitary tract. Within the hypothalamus, only the paraventricular nucleus and the median eminence (ME) showed beta(1)-AR immunostaining. Numerous beta(1)-AR-immunoreactive cells were also found in the hippocampus, basal ganglia and cerebral cortex. These results extend our knowledge of the expression profile of beta(1)-AR in the central nervous system. The identification of several distinct beta(1)-AR immunoreactive substrates linked with neuropathophysiological roles in cardiovascular disease supports the hypothesis that the therapeutic benefit of beta(1)-AR blockade may be conferred at least in part through central nervous system mechanisms.

Regulatory interdependence of cloned epithelial Na+ channels and P2X receptors.

Epithelial Na+ channels (ENaC) coexist with a family of ATP-gated ion channels known as P2X receptors in the renal collecting duct. Although ENaC is itself insensitive to extracellular ATP, tubular perfusion of ATP can modify the activity of ENaC. To investigate a possible regulatory relationship between P2X receptors and ENaC, coexpression studies were performed in Xenopus oocytes. ENaC generated a persistent inward Na+ current that was sensitive to the channel blocker amiloride (I(am-s)). Exogenous ATP transiently activated all cloned isoforms of P2X receptors, which in some cases irreversibly inhibited I(am-s). The degree of inhibition depended on the P2X receptor subtype present. Activation of P2X2, P2X(2/6), P2X4, and P2X(4/6) receptor subtypes inhibited I(am-s), whereas activation of P2X1, P2X3, and P2X5 receptors had no significant effect. The degree of inhibition of I(am-s) correlated positively with the amount of ionic charge conducted by P2X receptor subtypes. ENaC inhibition required Na+ influx through I(am-s)-inhibiting P2X ion channels but also Ca2+ influx through P2X4 and P2X(4/6) ion channels. P2X-mediated inhibition of I(am-s) was found to be due to retrieval of ENaC from the plasma membrane. Maximum amplitudes of ATP-evoked P2X-mediated currents (I(ATP)) were significantly increased for P2X2, P2X(2/6), and P2X5 receptor subtypes after coexpression of ENaC. The increase in I(ATP) was due to increased levels of plasma membrane-bound P2X receptor protein, suggesting that ENaC modulates protein trafficking. In summary, ENaC was downregulated by the activation of P2X2, P2X(2/6), P2X4, and P2X(4/6) receptors. Conversely, ENaC increased the plasma membrane expression of P2X2, P2X(2/6), and P2X5 receptors.

Influences on older women's adherence to a low-fat diet in the Women's Health Initiative.

OBJECTIVE: Most studies of dietary change during aging have focused on maintaining adequate intake by impaired elderly, and little is known about factors affecting dietary change for preventive purposes in older individuals. The purpose of this exploratory study was to determine the major behavioral influences on older women's adherence to a dietary fat reduction intervention. METHOD: A diverse sample of 92 women aged 55 to 80 was recruited from two East Coast sites of the Women's Health Initiative. All the women were participating in the dietary modification arm of WHI, had received the same dietary instruction, and were in the maintenance phase of the intervention. The women were classified by nutritionists as adherent or nonadherent to a diet limiting fat intake to <20% of total calories. Focus groups and telephone interviews were conducted, and textual data were coded and sorted using content analysis techniques within the four categories of the Stimuli-Organismic Factors-Response Repertoire-Consequences (SORC) behavioral model. Frequencies of responses within categories were tabulated and compared qualitatively. RESULTS: Adherent women were more likely to report assertiveness, a lifelong commitment to reduced dietary fat, satisfaction with their lifestyle changes, and having applicable knowledge and skills. Nonadherent women reported more difficulty resisting negative emotions and prior food preferences and habits; they were also more concerned about negative responses from others. CONCLUSIONS: Enhancing adherence of older women to a dietary fat reduction program will require shifting priorities away from conforming to social pressure and using high-fat foods for personal satisfaction and moving toward enhancing motivation and commitment to long-term health.