Effect of a Coordinated Community and Chronic Care Model Team Intervention vs Usual Care on Systolic Blood Pressure in Patients With Stroke or Transient Ischemic Attack: The SUCCEED Randomized Clinical Trial.

Importance: Few stroke survivors meet recommended cardiovascular goals, particularly among racial/ethnic minority populations, such as Black or Hispanic individuals, or socioeconomically disadvantaged populations. Objective: To determine if a chronic care model-based, community health worker (CHW), advanced practice clinician (APC; including nurse practitioners or physician assistants), and physician team intervention improves risk factor control after stroke in a safety-net setting (ie, health care setting where all individuals receive care, regardless of health insurance status or ability to pay). Design, Setting, and Participants: This randomized clinical trial included participants recruited from 5 hospitals serving low-income populations in Los Angeles County, California, as part of the Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) clinical trial. Inclusion criteria were age 40 years or older; experience of ischemic or hemorrhagic stroke or transient ischemic attack (TIA) no more than 90 days prior; systolic blood pressure (BP) of 130 mm Hg or greater or 120 to 130 mm Hg with history of hypertension or using hypertensive medications; and English or Spanish language proficiency. The exclusion criterion was inability to consent. Among 887 individuals screened for eligibility, 542 individuals were eligible, and 487 individuals were enrolled and randomized, stratified by stroke type (ischemic or TIA vs hemorrhagic), language (English vs Spanish), and site to usual care vs intervention in a 1:1 fashion. The study was conducted from February 2014 to September 2018, and data were analyzed from October 2018 to November 2020. Interventions: Participants randomized to intervention were offered a multimodal coordinated care intervention, including hypothesized core components (ie, ≥3 APC clinic visits, ≥3 CHW home visits, and Chronic Disease Self-Management Program workshops), and additional telephone visits, protocol-driven risk factor management, culturally and linguistically tailored education materials, and self-management tools. Participants randomized to the control group received usual care, which varied by site but frequently included a free BP monitor, self-management tools, and linguistically tailored information materials. Main Outcomes and Measures: The primary outcome was change in systolic BP at 12 months. Secondary outcomes were non-high density lipoprotein cholesterol, hemoglobin A1c, and C-reactive protein (CRP) levels, body mass index, antithrombotic adherence, physical activity level, diet, and smoking status at 12 months. Potential mediators assessed included access to care, health and stroke literacy, self-efficacy, perceptions of care, and BP monitor use. Results: Among 487 participants included, the mean (SD) age was 57.1 (8.9) years; 317 (65.1%) were men, and 347 participants (71.3%) were Hispanic, 87 participants (18.3%) were Black, and 30 participants (6.3%) were Asian. A total of 246 participants were randomized to usual care, and 241 participants were randomized to the intervention. Mean (SD) systolic BP improved from 143 (17) mm Hg at baseline to 133 (20) mm Hg at 12 months in the intervention group and from 146 (19) mm Hg at baseline to 137 (22) mm Hg at 12 months in the usual care group, with no significant differences in the change between groups. Compared with the control group, participants in the intervention group had greater improvements in self-reported salt intake (difference, 15.4 [95% CI, 4.4 to 26.0]; P = .004) and serum CRP level (difference in log CRP, -0.4 [95% CI, -0.7 to -0.1] mg/dL; P = .003); there were no differences in other secondary outcomes. Although 216 participants (89.6%) in the intervention group received some of the 3 core components, only 35 participants (14.5%) received the intended full dose. Conclusions and Relevance: This randomized clinical trial of a complex multilevel, multimodal intervention did not find vascular risk factor improvements beyond that of usual care; however, further studies may consider testing the SUCCEED intervention with modifications to enhance implementation and participant engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT01763203.

Perineal injuries at a large urban trauma center: injury patterns and outcomes.

The purpose of this study was to describe the characteristics of this unique patient population, their clinical presentations, and outcomes. The Los Angeles County and University of Southern California Medical Center Trauma Registry was used to retrospectively identify patients who sustained perineal injuries. Information included gender, age, vital signs, trauma scores, mechanisms of injury, studies performed, surgeries performed, and outcomes. Pediatric patients and injuries related to obstetric trauma were not included. Sixty-nine patients were identified between February 1, 1992 and October 31, 2005. One patient died on arrival; 85 per cent (58 of 68) were males, mean age was 30 +/- 12 years, and there was a penetrating mechanism in 56 per cent. Vital signs on admission were systolic blood pressure 119 +/- 33 mmHg, heart rate 94 +/- 27 beats/minute, and respiratory rate 20 +/- 6 breaths/min. Glasgow Coma Scale (GCS) was 13 +/- 3, Revised Trauma Score (RTS) was 7.2 +/- 1.5, and Injury Severity Score (ISS) was 11 +/- 12. CT scan was obtained for 23 (33%) patients. Lower extremity fractures were 35 per cent and pelvic fractures 32 per cent. The most common surgery was débridement and drainage, diversion with colostomy in five patients (7%). Overall mortality was 10 per cent. Mortality group mean scores were: GCS, 6; RTS, 5.74; and ISS, 34. The survival group mean scores were: GCS, 14; RTS, 7.7; and ISS, 8. There was a statistically significant association between mortality and GCS, RTS, and ISS scores (P < 0.001). Most patients with perineal injuries (93%) can be managed without colostomy. Associated injuries are not uncommon, particularly bony fractures. Mortality is mostly the result of exsanguination related to associated injuries.

Anfibios y reptiles del departamento de Ica con comentarios sobre su distribución

En este trabajo se presenta el listado actualizado de anfibios y reptiles de Ica. Las especies son comentadas, acompañadas de mapas de distribución y claves de identificación para reptiles y anfibios. Se recopiló información de registros en colecciones científicas, artículos científicos, informes de agencias gubernamentales de vida silvestre y bases de datos taxonómicas especializadas. Adicionalmente, entre los años 2019 y 2020 se realizaron evaluaciones de campo en zonas con vacíos de información. Se encontraron un total de 22 especies (anfibios 3 y reptiles 19). Los nuevos registros de reptiles para Ica incluyen la lagartija Liolaemus evaristoi y la serpiente Incaspis tachymenoides en la provincia de Chincha a 4200 y 3200 m de altitud respectivamente, la lagartija Stenocercus ornatissimus y la serpiente ciega Epictia tesselata en la provincia de Pisco a 3500 y 2800 m respectivamente. Los nuevos registros de anfibios incluyen a Pleurodema marmoratum en la provincia de Chincha (3900 m) y Telmatobius rimac en las provincias de Chincha y Palpa a 3900 y 2350 m respectivamente. La mayor riqueza y endemismos locales se encontraron en el desierto costero, mientras que, las ampliaciones de distribución y endemismos regionales se registraron en la vertiente occidental de los Andes. También, se observa que las familias Leptotyphlopidae y Viperidae, y los géneros Dicrodon, Stenocercus y Oxyrophus terminan su distribución en la vertiente occidental y la zona costera de los departamentos de Ica y Arequipa sin representantes en el extremo sur del Perú y Chile.

This paper presents the updated list of amphibians and reptiles of Ica. Species are commented, accompanied by distribution maps and identification keys for reptiles and amphibians. Information was collected from scientific collections, scientific articles, governmental wildlife agency reports, and specialized taxonomic database. Additionally, between 2019 and 2020, field surveys were carried out in areas with information gaps. A total of 22 species were found (amphibians 3 and reptiles 19). The new records of reptiles include the Liolaemus evaristoi lizard and the Incaspis tachymenoides snake from Chincha province at 4200 and 3200 m altitude respectively, the Stenocercus ornatissimus lizard and the blind snake Epictia tesselata from Pisco province at 3500 and 2800 m respectively. New amphibian records include Pleurodema marmoratum in Chincha province (3900 m) and Telmatobius rimac in Chincha and Palpa provinces at 3900 and 2350 m respectively. The greatest richness and local endemism were found in the coastal desert, while the expansion of distribution and regional endemism were recorded on the western slope of the Andes. Also, it is observed that the families Leptotyphlopidae and Viperidae, and the genera Dicrodon, Stenocercus and Oxyrophus are finishing their distribution in the western slope and the coastal zone of the departments of Ica and Arequipa without representatives in the extreme south of Peru and Chile.

The environmental and intrinsic yeast diversity of Cuban cocoa bean heap fermentations.

The environmental yeast diversity of spontaneous cocoa bean fermentations in east Cuba was investigated. Seven fermentations, 25 equipment- and handling-related samples, and 115 environmental samples, such as flowers, leaf and cocoa pod surfaces, as well as drosophilid insects, were analysed. The basic fermentation parameters temperature and pH were recorded during five fermentations for at least six days. A total of 435 yeast isolates were identified by a combination of PCR-fingerprinting of genomic DNA with the M13 primer and sequence analysis of DNA from representative isolates, using the internal transcribed spacer region, the D1/D2 region of the large subunit rRNA gene, and an actin gene-encoding fragment, as required. Among 65 yeast species detected, Pichia manshurica and Hanseniaspora opuntiae were the most frequently isolated species, obtained from five and four fermentations, followed in frequency by Pichia kudriavzevii from two fermentations. Saccharomyces cerevisiae was isolated only occasionally. Cocoa fermentation yeast species were also present on processing equipment. The repeated isolation of a preliminarily as Yamadazyma sp. classified species, a group of strains similar to Saccharomycopsis crataegensis from fermentations and equipment, and the isolation of fifteen other potentially novel yeast species in low numbers provides material for further studies. Environmental samples showed higher yeast diversity compared to the fermentations, included the most frequent fermentation species, whereas the most frequently isolated environmental species were Candida carpophila, Candida conglobata, and Candida quercitrusa. Potential selective advantages of the most frequently isolated species were only partly explained by the physiological traits tested. For instance, tolerance to higher ethanol concentrations was more frequent in strains of Pichia spp. and S. cerevisiae compared to Hanseniaspora spp.; the ability to also assimilate ethanol might have conferred a selective advantage to Pichia spp. In contrast, high glucose tolerance was common among strains of Hanseniaspora spp., Torulaspora delbrueckii, and Candida tropicalis, among which only Hanseniaspora spp. were frequently isolated.

Small intestinal bacterial overgrowth in patients with lower gastrointestinal symptoms and a history of previous abdominal surgery.

BACKGROUND: The small intestinal bacterial overgrowth (SIBO) breath test has had positive results in 84% of patients with irritable bowel syndrome vs 20% of controls. We hypothesized that SIBO would be more prevalent in patients with symptoms consistent with irritable bowel syndrome who have undergone previous abdominal surgery. OBJECTIVE: To identify causative factors for SIBO. DESIGN: Retrospective review. SETTING: Tertiary colorectal surgery clinic. MAIN OUTCOME MEASURE: Result of SIBO breath test. RESULTS: We identified 77 patients whose differential diagnosis included SIBO from January 1, 2005, to December 31, 2007; 18 were excluded because of noncompliance with testing and 2 because of a decision to treat SIBO without formal testing. Symptoms were chronic abdominal pain in 30 patients (53%), bloating in 25 (44%), constipation in 37 (65%), and diarrhea in 7 (12%). Mean (SD) symptom duration was 45 (22) months. Of the 57 patients enrolled in this study, 45 (79%) tested positive for SIBO and 37 (82%) of those had a history of surgery, whereas 12 (21%) tested negative for SIBO and 9 (75%) of those had a history of surgery. Of the 36 SIBO-positive patients with a history of abdominal surgery (mean number of procedures, 2), the surgery locations were as follows: female reproductive organs, 23 (64%); hindgut, 15 (42%); foregut, 8 (22%); and midgut, 6 (17%). Open surgery alone was performed in 32 patients (56%) vs laparoscopic surgery in 7 (12%). Both open and laparoscopic procedures had been performed in 6 patients (11%). Four patients (7%) had a history of small intestinal obstruction. The mean age of SIBO-positive patients was higher than that of SIBO-negative patients (57 vs 44 years; P < .01). Analysis did not reveal any clinically significant independent factor associated with SIBO. CONCLUSION: Physicians should consider SIBO in the differential diagnosis of patients with normal anatomic findings and chronic lower gastrointestinal complaints.

Efectos de la técnica de instrumentación escalonada y la técnica convencional en la limpieza de los conductos radiculares / Effects of the scallionate instrumental technique and the conventional technique in the cleane of the denture

Se realizó un estudio en 47 conductos pertenecientes a premolares extraídos con el fin de probar la eficiencia de dos técnicas de instrumentación: 26 de dichos conductos fueron instrumentados con la técnica convencional y el resto fue instrumentado con la técnica escalonada. La comparación entre ambas técnicas, para establecer con cual de las dos, los conductos radiculares quedan más libres de restos pulpares, se realizó en base al análisis histológico de los cortes que se hicieron a 1mm., a 3mm. y a 5mm. Del análisis de los resultados se probó que la técnica de instrumentación escalonada, fue más adecuada para lograr una limpieza efectiva de los conductos radiculares que la técnica de instrumentación convencional; la cantidad de restos pulpares dejados fue superior a medida que se está más cerca del ápice de la raíz cuando se realiza la técnica de instrumentación escalonada, no así cuando se aplica la instrumentación convencional donde la cantidad de restos pulpares dejados fue igual a cualquiera de los niveles estudiados; también se aprobó que los istmos presentes en los conductos quedaron más limpios al aplicar la instrumentación escalonada a unos conductos, que cuando se aplicó la instrumentación convencional a otros, y se concluyó además que ninguna de las dos técnicas de instrumentación testificadas deja los conductos totalmente limpios.