Mistrust of Researchers Correlates with Stroke Knowledge among Minority Seniors in a Community Intervention Trial.

BACKGROUND: Medical mistrust influences patients' treatment seeking, adherence, health behaviors, and minority participation in research studies. However, medical mistrust remains understudied within neurological diseases like stroke despite disproportionately affecting minority populations. OBJECTIVE: This study examines the relationship of medical mistrust with stroke knowledge among Black, Latino, Korean, and Chinese-Americans. METHODS: Subjects greater than 60 years were enrolled from senior centers to test a culturally-tailored educational curriculum around stroke risk reduction in a randomized controlled trial. A Trust Physician Scale and a modified Trust of Medical Researchers Scale measured medical mistrust. The Stroke Action Test instrument measured stroke knowledge, focusing on intent to call 911 appropriately when presented with stroke symptoms. RESULTS: Of 225 subjects, 69.5% were female (n = 157) with an average age of 73.7 years (standard deviation 6.7). Blacks had highest trust scores of physicians relative to Latino/a, Korean or Chinese subjects (P< .05). In multivariable analysis, decreased stroke knowledge was associated with decreased researcher trust at baseline (<.05), but not physician trust, when controlling for covariates. Among Latino/a, Korean, and Chinese groups, mainstream acculturation reduced the association between researcher trust and stroke knowledge. A mediation model showed no evidence of physician trust mediating researcher trust. CONCLUSIONS: Among minority seniors participating in a randomized controlled trial, decreased trust of researchers, not physicians, was associated with low baseline knowledge of stroke symptoms. Those least acculturated to US culture may be a particular focus for trust building intervention. Future studies should examine whether researcher mistrust is disproportionately preventing those with the largest knowledge gaps from participating in trials.

Associations of objective versus subjective social isolation with sleep disturbance, depression, and fatigue in community-dwelling older adults.

Objective: Older adults are at higher risk of experiencing social isolation, which has been linked to impaired physical and mental health. The link between social isolation and health might be due to objective deprivation of social network and/or subjective experience of loneliness. This community-based cross-sectional study examined whether the associations between social isolation and behavioral symptoms including sleep disturbance, depression, and fatigue are mostly explained by its subjective component. Methods: Randomly selected 2541 community-dwelling individuals in Los Angeles aged ≥60 years were telephone-interviewed regarding their objective and subjective social isolation (respectively social network size and loneliness), sleep disturbance, depression, and fatigue. Results: When objective and subjective social isolation were separately included in multivariate regression models, both were significantly associated with behavioral symptoms. However, once they were simultaneously included in the same multivariate models, while subjective social isolation remained strongly associated (adjusted beta 0.24 for sleep disturbance [P < 0.001], 0.44 for depression [P < 0.001], 0.17 for fatigue [P < 0.001]), objective social isolation was weakly or non-significantly associated (-0.04 for sleep disturbance [P = 0.03], -0.01 for depression [P = 0.48], -0.003 for fatigue [P = 0.89]). Additionally, those with objective social isolation were found to have worse symptoms mostly when they also experienced subjective social isolation. Conclusions: Older adults with objective social isolation may experience sleep disturbance, depression, and fatigue because they feel socially isolated, not just because they are deprived of social networks. Interventions that target social isolation might serve as potential treatments for improving behavioral health of older adults, especially by targeting its subjective component.

Varicella zoster virus-specific immune responses to a herpes zoster vaccine in elderly recipients with major depression and the impact of antidepressant medications.

BACKGROUND: The Depression Substudy of the Shingles Prevention Study (SPS) was designed to evaluate the association between major depression and immune responses to a high-titer live attenuated varicella zoster virus (VZV) vaccine (zoster vaccine), which boosts cell-mediated immunity (CMI) to VZV and decreases the incidence and severity of herpes zoster (HZ). The Depression Substudy was a 2-year longitudinal cohort study in 92 community-dwelling adults≥60 years of age who were enrolled in the SPS, a large, double-blind, placebo-controlled Veterans Affairs Cooperative zoster vaccine efficacy study. METHODS: Forty subjects with major depressive disorder, stratified by use of antidepressant medications, and 52 age- and sex-matched controls with no history of depression or other mental illness had their VZV-CMI measured prior to vaccination with zoster vaccine or placebo and at 6 weeks, 1 year, and 2 years postvaccination. RESULTS: Depressed subjects who were not treated with antidepressant medications had lower levels of VZV-CMI following administration of zoster vaccine than nondepressed controls or depressed subjects receiving antidepressants even when antidepressant medications failed to alter depressive symptom severity (P<.005). Similar results were obtained taking into account the time-varying status of depression and use of antidepressant medications, as well as changes in depressive symptoms, during the postvaccination period. CONCLUSIONS: Depressed patients have diminished VZV-CMI responses to zoster vaccine, and treatment with antidepressant medication is associated with normalization of these responses. Because higher levels of VZV-CMI correlate with lower risk and severity of HZ, untreated depression may increase the risk and severity of HZ and reduce the efficacy of zoster vaccine.

Choosing Wisely interventions to reduce antibiotic overuse in the safety net.

OBJECTIVES: Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs). STUDY DESIGN: Interrupted time series. METHODS: A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics. RESULTS: Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences. CONCLUSIONS: These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

Prevention of Incident and Recurrent Major Depression in Older Adults With Insomnia: A Randomized Clinical Trial.

Importance: Older adults with insomnia have a high risk of incident and recurrent depression. Depression prevention is urgently needed, and such efforts have been neglected for older adults. Objective: To examine whether treatment of insomnia disorder with cognitive behavioral therapy for insomnia (CBT-I) compared with an active comparator condition, sleep education therapy (SET), prevents major depressive disorder in older adults. Design, Setting, and Participants: This assessor-blinded, parallel-group, single-site randomized clinical trial assessed a community-based sample of 431 people and enrolled 291 adults 60 years or older with insomnia disorder who had no major depression or major health events in past year. Study recruitment was performed from July 1, 2012, to April 30, 2015. The trial protocol was modified to extend follow-up from 24 to 36 months, with follow-up completion in July 2018. Data analysis was performed from March 1, 2019, to March 30, 2020. Interventions: Participants were randomized to 2 months of CBT-I (n = 156) or SET (n = 135). Main Outcomes and Measures: The primary outcome was time to incident major depressive disorder as diagnosed by interview and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria. Secondary outcome was sustained remission of insomnia disorder before depression event or duration of follow-up. Results: Among 291 randomized participants (mean [SD] age, 70.1 [6.7] years; 168 [57.7%] female; 7 [2.4%] Asian, 32 [11.0%] Black, 3 [1.0%] Pacific Islander, 241 [82.8%] White, 6 [2.1%] multiracial, and 2 [0.7%] unknown), 156 were randomized to CBT-I and 135 to SET. A total of 140 participants (89.7%) completed CBT-I and 130 (96.3%) participants completed SET (χ2 = 4.9, P = .03), with 114 (73.1%) completing 24 months of follow-up in the CBT-I group and 117 (86.7%) in the SET group (χ2 = 8.4, P = .004). After protocol modification, 92 (59.0%) of the CBT-I participants and 86 (63.7%) of the SET participants agreed to extended follow-up (χ2 = 0.7, P = .41), with 81 (51.9%) of the CBT-I participants and 77 (57.0%) of the SET group completing 36 months of follow-up (χ2 = 0.8; P = .39). Incident or recurrent major depression occurred in 19 participants (12.2%) in the CBT-I group and in 35 participants (25.9%) in the SET group, with an overall benefit (hazard ratio, 0.51; 95%, CI 0.29-0.88; P = .02) consistent across subgroups. Remission of insomnia disorder continuously sustained before depression event or during follow-up was more likely in CBT-I participants (41 [26.3%]) compared with the SET participants (26 [19.3%], P = .03). Those in the CBT-I group with sustained remission of insomnia disorder had an 82.6% decreased likelihood of depression (hazard ratio, 0.17; 95%, CI 0.04-0.73; P = .02) compared with those in the SET group without sustained remission of insomnia disorder. Conclusions and Relevance: The findings of this randomized clinical trial indicate that treatment of insomnia with CBT-I has an overall benefit in the prevention of incident and recurrent major depression in older adults with insomnia disorder. Community-level screening for insomnia concerns in older adults and wide delivery of CBT-I-based treatment for insomnia could substantially advance public health efforts to treat insomnia and prevent depression in this vulnerable older adult population. Trial Registration: ClinicalTrials.gov Identifier: NCT01641263.

West Mexico Berries Modulate α-Amylase, α-Glucosidase and Pancreatic Lipase Using In Vitro and In Silico Approaches.

The objective was to evaluate the antioxidant and biological potential of eight freeze-dried berry varieties of southern Jalisco using in silico and in vitro approaches. Fourteen tentative phenolic compounds were identified in berries by ESI-QToF, including anthocyanins, phenolic acids, flavanols and flavonols. In silico assays of phytochemicals in the berry inhibiting enzymes related to obesity and diabetes showed predicted binding energy interactions (ranging from -5.4 to -9.3 kcal/mol). Among the cultivars, antioxidant potential for DPPH IC50 ranged from 1.27 to 3.40 mg/mL, ABTS IC50 from 2.26 to 7.32 mg/mL and nitric oxide (NO) inhibition IC50 from 4.26 to 11.07 mg/mL. The potential to inhibit α-amylase IC50 ranged from 4.02 to 7.66 mg/mL, α-glucosidase IC50 from 0.27 to 4.09 mg/mL, lipase IC50 from 1.30 to 4.82 mg/mL and DPP-IV IC50 from 1.36 to 3.31 mg/mL. Blackberry cultivars from the southern Jalisco region showed outstanding biological potential compared to other evaluated berries and could be used in the formulation of functional foods in the prevention of noncommunicable diseases.

Major depressive disorder and immunity to varicella-zoster virus in the elderly.

Major depressive disorder has been associated with activation of inflammatory processes as well as with reductions in innate, adaptive and non-specific immune responses. The objective of this study was to evaluate the association between major depression and a disease-relevant immunologic response, namely varicella-zoster virus (VZV)-specific immunity, in elderly adults. A cross-sectional cohort study was conducted in 104 elderly community dwelling adults ≥ 60years of age who were enrolled in the depression substudy of the shingles prevention study, a double blind, placebo-controlled vaccine efficacy trial. Fifty-two subjects had a current major depressive disorder, and 52 age- and sex-matched controls had no history of depression or any mental illness. VZV-specific cell-mediated immunity (VZV-CMI) was measured by VZV responder cell frequency (VZV-RCF) and interferon-γ enzyme-linked immunospot (ELISPOT) assays, and antibody to VZV was measured by an enzyme-linked immunosorbent assay against affinity-purified VZV glycoproteins (gpELISA). VZV-CMI, measured by VZV-RCF, was significantly lower in the depressed group than in the controls (p<0.001), and VZV-RCF was inversely correlated with the severity of depressive symptoms in the depressed patients. In addition, an age-related reduction in VZV-RCF was observed in the depressed patients, but not in the controls. Furthermore, there was a trend for depressive symptom severity to be associated with lower ELISPOT counts. Finally, VZV-RCF was higher in depressed patients treated with antidepressant medications as compared to untreated depressed patients. Since lower levels of VZV-RCF appear to explain the increased risk and severity of herpes zoster observed in older adults, these findings suggest that, in addition to increasing age, depression may increase the risk and severity of herpes zoster.

The Effects of Avocado Waste and Its Functional Compounds in Animal Models on Dyslipidemia Parameters.

Ischemic heart disease and stroke are two main causes of death that have prevailed for more than 15 years. Dyslipidemia and its parameters like hypercholesterolemia, hypertriglyceridemia, increase in low-density cholesterol, and a reduction of high-density cholesterol have been related with heart disease and risk of stroke. Approaches to improve the health and specifically reduce the risk of heart disease, such as medications and dietary interventions have been effective, but there are other potential sources of biological compounds that could have an effect due to their antioxidant properties. Avocado is a commonly consumed fruit especially its pulp, while the peel, seed, and leaf are usually discarded as waste. Some researchers have reported antioxidant, hepatoprotective, gastroprotective, lipid-lowering, and hypoglycemic effects in these wastes. In this review article, we have summarized the current evidence on the effect of biological compounds from avocado waste on dyslipidemia parameters in preclinical models. Also, we have included the compound extracted and the extraction method from the selected articles.

Feeding pattern, biochemical, anthropometric and histological effects of prolonged ad libitum access to sucrose, honey and glucose-fructose solutions in Wistar rats.

BACKGROUND/OBJECTIVES: The exposure to sucrose in rats has mimic abnormalities attributed to metabolic syndrome (MetS). The effects of honey bee and "free" glucose and fructose, have not been explored in this context. The aim was to expose Wistar rodents to sucrose solution (SS), honey solution (HS) and fructose/glucose solution (GFS) at 30% to assess their effects. SUBJECTS/METHODS: HS (n = 10), SS (n = 10) and GFS (n = 10) groups were formed. Solutions were ad libitum along 14-weeks. RESULTS: Between solutions consumptions, honey was significantly 42% higher (P = 0.000), while similar consumption was observed among GFS and SS. The feeding pattern of HS consumption was irregular along experiment; while the food intake pattern showed the similar trend among groups along time. Non statistical differences were obtained in any biochemical and anthropometric measure, however, a higher concentration of leptin (721 ± 507 pg/mL), lower concentration of total cholesterol (TC; 48.87 ± 2.41 mg/100 mL), very low density lipoprotein (VLDL; 16.47 ± 6.55 mg/100 mL) and triglycerides (82.37 ± 32.77 mg/100 mL) was obtained in SS group. For anthropometric values, HS showed less total adipose tissue (AT; average 26 vs. 31-33 g) and adiposity index (average 6.11 vs. 7.6). Due to sugar-sweetened beverages consumption increases the risk for the development of chronic diseases; correlations between fluid intake and anthropometric and biochemical parameters were assessed. A moderate correlation was obtained in groups with the weight of total AT and solution intake; for the weight gain in GFS group and for triglycerides in HS and GFS. The highest hepatic tissue damage was observed in SS group with multiple intracytoplasmic vacuoles, atypia changes, moderate pleomorphism and hepatocellular necrosis. CONCLUSIONS: In spite of the significantly higher consumption of HS, biochemical, anthropometrical and histological effects were not remarkably different in comparision to other sweeteners.

Diagnostic Criteria for Metabolic Syndrome in Diet-Induced Rodent Models: A Systematic Review.

BACKGROUND: Thousands of publications in recent years have addressed the induction of metabolic syndrome (MetS) in rodents. However, the criteria and the reference values for diagnosing this disease have not been defined. OBJECTIVE: Our main objective was to carry out a systematic review to gather evidence about the criteria for biochemical and anthropometric parameters in which scientific studies have relied on to report that rats developed MetS from a previous dietary manipulation. METHODS: We compiled characteristics and findings of diet-induced MetS with high-fat, high-carbohydrate, high-fat/high-carbohydrates, and cafeteria diet from PubMed and Science Direct databases published in the last 5 years. RESULTS: The results on the principal determinants for the syndrome, published in the reviewed articles, were chosen to propose reference values in the rat models of food induction. CONCLUSION: The values obtained will serve as reference cut-of points in the development of the disease; in addition, the compilation of data will be useful in planning and executing research protocols in animal models.

Sleep loss activates cellular markers of inflammation: sex differences.

Sleep disturbance is associated with inflammation and related disorders including cardiovascular disease, arthritis, and diabetes mellitus. Given sex differences in the prevalence of inflammatory disorders with stronger associations in females, this study was undertaken to test the effects of sleep loss on cellular mechanisms that contribute to proinflammatory cytokine activity. In 26 healthy adults (11 females; 15 males), monocyte intracellular proinflammatory cytokine production was repeatedly assessed at 08:00, 12:00, 16:00, 20:00, and 23:00h during a baseline period and after partial sleep deprivation (awake from 23:00 to 3.00h). In the morning after a night of sleep loss, monocyte production of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) differentially changed between the two sexes. Whereas both females and males showed a marked increase in the lipopolysaccharide (LPS) - stimulated production of IL-6 and TNF-alpha in the morning immediately after PSD, production of these cytokines during the early- and late evening was increased in the females as compared to decreases in the males. Sleep loss induces a functional alteration of monocyte proinflammatory cytokine responses with females showing greater cellular immune activation as compared to changes in males. These results have implications for understanding the role of sleep disturbance in the differential risk profile for inflammatory disorders between the sexes.

Evaluation of Recruitment of Older Adults of Color into a Community-Based Chronic Disease Self-Management Wellness Pathway Program in Los Angeles County.

Background: Established relationships between researchers, stakeholders and potential participants are integral for recruitment of potential older adult participants and Evidence-Based Programs (EBPs) for chronic disease management have empirically been shown to help improve health and maintain healthy and active lives. To accelerate recruitment in EBPs and potential future research, we propose a Wellness Pathway allowing for delivery within multipurpose senior centers (MPCs) linked with medical facilities among lower-income urban older adults. The study aims were to: 1) assess the effectiveness of three MPC-delivered EBPs on disease management skills, health outcomes, and self-efficacy; and 2) assess the feasibility of the proposed Wellness Pathway for lower-income urban-dwelling older adults of color. Methods: We administered surveys and conducted a pre-post analysis among participants enrolled in any 1 of 3 MPC-based EBPs (n=53). To assess feasibility of the pathway, we analyzed survey data and interviews (EBP participants, MPC staff, physicians, n=10). Results: EBP participation was associated with greater disease management skills (increased time spent stretching and aerobic activity) but not improvements in self-efficacy or other health outcomes. Interviews revealed: 1) older adults valued EBPs and felt the Wellness Pathway feasible; 2) staff felt it feasible given adequate growth management; 3) physicians felt it feasible provided adequate medical facility integration. Conclusions: MPC-based EBPs were associated with improvements in disease management skills among older adults; a proposed Wellness Pathway shows early evidence of feasibility and warrants further investigation. Future efforts to implement this model of recruiting older adults of color into EBPs should address barriers for implementation and sustainability.

Community-Partnered Evaluation of the Aging Mastery Program in Los Angeles Area Senior Centers.

Background. The National Council on Aging's Aging Mastery Program (AMP) aims to help older adults implement health behavior and lifestyle changes to promote healthy aging and social engagement. The purpose of the present community-partnered evaluation was to test the effectiveness of AMP implementation in Los Angeles County to improve participants' quality of life, global physical and mental health, and patient activation. Method. A modified randomized wait-list controlled trial design was used to examine experimental, quasi-experimental, and dose-response evidence in five senior centers. Participants completed questionnaires at baseline and after the 10-week intervention, self-reporting their overall quality of life, physical health, mental health, and patient activation. Results. Experimental, intention-to-treat analyses found AMP assignment did not affect any measured outcomes (n = 71). Quasi-experimental, "as treated" analyses (n = 106) controlling for study site and sociodemographic characteristics indicated that participants who attended AMP reported more positive changes in global mental health than the control group. Attending AMP was not associated with changes in quality of life, physical health, or patient activation. Dose-response analyses among AMP participants who attended at least one class (n = 75) found that attending more classes was not significantly associated with greater improvements in mental health. Conclusions. Experimental, intention-to-treat analyses did not support effectiveness of AMP on quality of life, physical or mental health, or patient activation; quasi-experimental analyses found attending AMP was associated with improvements in mental health. Recruitment challenges and participants' nonadherence with condition assignment decreased our ability to detect effects. https://clinicaltrials.gov/ct2/show/NCT03342729?term=Aging+Mastery+Program&rank=1 .

Potential Hypoglycemic Effect of Pomegranate Juice and Its Mechanism of Action: A Systematic Review.

Pomegranate juice (PJ) has gained popularity attributed to its phenolic compounds and their medicinal properties. Its potential hypoglycemic effect has been related to enzymatic inhibition, insulin release, and the protection of pancreatic tissue. These effects depend on several aspects, such as the content and composition of phenols in pomegranate and characteristics of the organism that consumes the juice. The objective of this study was to systematically review scientific evidence investigating the hypoglycemic effect of PJ; the factors that affect bioactive compounds; and the mechanisms of action attributed to this effect. Human and rodent in vivo and in vitro studies were retrieved from PubMed, Scopus, and ScienceDirect databases. After reviewing the articles, it was identified that the methodologies and results among the scientific evidence were quite heterogeneous. Despite these limitations, many of the in vivo and in vitro studies found important hypoglycemic effects from PJ, as well as an increase in the function of ß-cell, insulin secretion, a significantly lower activity of α-amylase enzyme, an inhibition of the enzyme α-glucosidase and dipeptidyl peptidase-4 (DPP-4), and the protection against DNA damage. Determining the potential health benefits of polyphenols contained in the pomegranate is limited for multiple factors that could affect the efficacy of PJ. Overall, the results of this review suggest the need for further experimentation, using controlled variable factors and testing the effect of PJ under similar experimental conditions.

Host plants and Wolbachia shape the population genetics of sympatric herbivore populations.

Changing climate and land-use practices have the potential to bring previously isolated populations of pest insects into new sympatry. This heightens the need to better understand how differing patterns of host-plant association, and unique endosymbionts, serve to promote genetic isolation or integration. We addressed these factors in populations of potato psyllid, Bactericera cockerelli (Sulc), a generalist herbivore that vectors a bacterial pathogen (Candidatus Liberibacter solanacearum, causal pathogen of zebra chip disease) of potato (Solanum tuberosum L.). Genome-wide SNP data revealed two major genetic clusters-psyllids collected from potato crops were genetically similar to psyllids found on a common weed, Lycium spp., but dissimilar from those found on another common non-crop host, Solanum dulcamara L. Most psyllids found on Lycium spp. and potato represented a single mitochondrial cytochrome oxidase I (COI) haplotype that has been suggested to not be native to the region, and whose arrival may have been concurrent with zebra chip disease first emerging. The putatively introduced COI haplotype usually co-occurred with endosymbiotic Wolbachia, while the putatively resident COI haplotype generally did not. Genetic intermediates between the two genetic populations of insects were rare, consistent with recent sympatry or reproductive isolation, although admixture patterns of apparent hybrids were consistent with introgression of genes from introduced into resident populations. Our results suggest that both host-plant associations and endosymbionts are shaping the population genetic structure of sympatric psyllid populations associated with different non-crop hosts. It is of future interest to explicitly examine vectorial capacity of the two populations and their potential hybrids, as population structure and hybridization might alter regional vector capacity and disease outbreaks.

"Worth the Walk": Culturally Tailored Stroke Risk Factor Reduction Intervention in Community Senior Centers.

Background Racial/ethnic minority older adults have worse stroke burden than non-Hispanic white and younger counterparts. Our academic-community partner team tested a culturally tailored 1-month (8-session) intervention to increase walking and stroke knowledge among Latino, Korean, Chinese, and black seniors. Methods and Results We conducted a randomized wait-list controlled trial of 233 adults aged 60 years and older, with a history of hypertension, recruited from senior centers. Outcomes were measured at baseline (T0), immediately after the 1-month intervention (T1), and 2 months later (T2). The primary outcome was pedometer-measured change in steps. Secondary outcomes included stroke knowledge (eg, intention to call 911 for stroke symptoms) and other self-reported and clinical measures of health. Mean age of participants was 74 years; 90% completed T2. Intervention participants had better daily walking change scores than control participants at T1 (489 versus -398 steps; mean difference in change=887; 97.5% CI, 137-1636), but not T2 after adjusting for multiple comparisons (233 versus -714; mean difference in change=947; 97.5% CI, -108 to 2002). The intervention increased the percent of stroke symptoms for which participants would call 911 (from 49% to 68%); the control group did not change (mean difference in change T0-T1=22%; 99.9% CI, 9-34%). This effect persisted at T2. The intervention did not affect measures of health (eg, blood pressure). Conclusions This community-partnered intervention did not succeed in increasing and sustaining meaningful improvements in walking levels among minority seniors, but it caused large, sustained improvements in stroke preparedness. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02181062.

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System.

Importance: Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. Objective: To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. Design, Setting, and Participants: This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Interventions: Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Main Outcomes and Measures: Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Results: Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. Conclusions and Relevance: This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

[Severe gastric dysplasia with intramucosal carcinoma in a 16-year-old male]. / Displasia gástrica severa con carcinoma intramucoso en un hombre de 16 años.

Gastric dysplasia is a rare adult condition affecting a small area near polyps, ulcers or is an inflammatory process. Adenocarcinoma develops in severe gastric dysplasia, and this process may take 1 year. Mild and moderate dysplasias regress and only a small proportion progresses to severe dysplasia. We report a severe dysplasia in a 16-year-old male with no clinical history of gastric disease with acute and severe upper gastrointestinal bleeding that lowered hemoglobin levels to 2.8 g/dL. Bleeding persisted and subtotal gastrectomy was performed on an emergency basis. At gross examination, bleeding and congestion were found with superficial ulcers. Microscopically, severe dysplasia was observed with intramucosal areas of carcinoma limited to foveolar mucosa. The ulcers were congested and there was no inflammation, no polyps or other alterations in the mucosal layer. Ki-67 and P53 markers were positive, p16 with sporadic positivity. The purpose here is to report an exceptional case because of the young age and extensive and severe dysplasia with areas of intramucosal carcinoma and no previous clinical history. No similar cases of severe dysplasia with carcinoma in situ are reported in the literature.

Tai Chi Chih Compared With Cognitive Behavioral Therapy for the Treatment of Insomnia in Survivors of Breast Cancer: A Randomized, Partially Blinded, Noninferiority Trial.

Purpose Cognitive behavioral therapy for insomnia (CBT-I) and Tai Chi Chih (TCC), a movement meditation, improve insomnia symptoms. Here, we evaluated whether TCC is noninferior to CBT-I for the treatment of insomnia in survivors of breast cancer. Patients and Methods This was a randomized, partially blinded, noninferiority trial that involved survivors of breast cancer with insomnia who were recruited from the Los Angeles community from April 2008 to July 2012. After a 2-month phase-in period with repeated baseline assessment, participants were randomly assigned to 3 months of CBT-I or TCC and evaluated at months 2, 3 (post-treatment), 6, and 15 (follow-up). Primary outcome was insomnia treatment response-that is, marked clinical improvement of symptoms by the Pittsburgh Sleep Quality Index-at 15 months. Secondary outcomes were clinician-assessed remission of insomnia; sleep quality; total sleep time, sleep onset latency, sleep efficiency, and awake after sleep onset, derived from sleep diaries; polysomnography; and symptoms of fatigue, sleepiness, and depression. Results Of 145 participants who were screened, 90 were randomly assigned (CBT-I: n = 45; TCC: n = 45). The proportion of participants who showed insomnia treatment response at 15 months was 43.7% and 46.7% in CBT-I and TCC, respectively. Tests of noninferiority showed that TCC was noninferior to CBT-I at 15 months ( P = .02) and at months 3 ( P = .02) and 6 ( P < .01). For secondary outcomes, insomnia remission was 46.2% and 37.9% in CBT-I and TCC, respectively. CBT-I and TCC groups showed robust improvements in sleep quality, sleep diary measures, and related symptoms (all P < .01), but not polysomnography, with similar improvements in both groups. Conclusion CBT-I and TCC produce clinically meaningful improvements in insomnia. TCC, a mindful movement meditation, was found to be statistically noninferior to CBT-I, the gold standard for behavioral treatment of insomnia.

Using NextRAD sequencing to infer movement of herbivores among host plants.

Herbivores often move among spatially interspersed host plants, tracking high-quality resources through space and time. This dispersal is of particular interest for vectors of plant pathogens. Existing molecular tools to track such movement have yielded important insights, but often provide insufficient genetic resolution to infer spread at finer spatiotemporal scales. Here, we explore the use of Nextera-tagmented reductively-amplified DNA (NextRAD) sequencing to infer movement of a highly-mobile winged insect, the potato psyllid (Bactericera cockerelli), among host plants. The psyllid vectors the pathogen that causes zebra chip disease in potato (Solanum tuberosum), but understanding and managing the spread of this pathogen is limited by uncertainty about the insect's host plant(s) outside of the growing season. We identified 1,978 polymorphic loci among psyllids separated spatiotemporally on potato or in patches of bittersweet nightshade (S. dulcumara), a weedy plant proposed to be the source of potato-colonizing psyllids. A subset of the psyllids on potato exhibited genetic similarity to insects on nightshade, consistent with regular movement between these two host plants. However, a second subset of potato-collected psyllids was genetically distinct from those collected on bittersweet nightshade; this suggests that a currently unrecognized source, i.e., other nightshade patches or a third host-plant species, could be contributing to psyllid populations in potato. Oftentimes, dispersal of vectors of pathogens must be tracked at a fine scale in order to understand, predict, and manage disease spread. We demonstrate that emerging sequencing technologies that detect genome-wide SNPs of a vector can be used to infer such localized movement.