Protocol for the "Implementation, adoption, and utility of family history in diverse care settings" study.

BACKGROUND: Risk assessment with a thorough family health history is recommended by numerous organizations and is now a required component of the annual physical for Medicare beneficiaries under the Affordable Care Act. However, there are several barriers to incorporating robust risk assessments into routine care. MeTree, a web-based patient-facing health risk assessment tool, was developed with the aim of overcoming these barriers. In order to better understand what factors will be instrumental for broader adoption of risk assessment programs like MeTree in clinical settings, we obtained funding to perform a type III hybrid implementation-effectiveness study in primary care clinics at five diverse healthcare systems. Here, we describe the study's protocol. METHODS/DESIGN: MeTree collects personal medical information and a three-generation family health history from patients on 98 conditions. Using algorithms built entirely from current clinical guidelines, it provides clinical decision support to providers and patients on 30 conditions. All adult patients with an upcoming well-visit appointment at one of the 20 intervention clinics are eligible to participate. Patient-oriented risk reports are provided in real time. Provider-oriented risk reports are uploaded to the electronic medical record for review at the time of the appointment. Implementation outcomes are enrollment rate of clinics, providers, and patients (enrolled vs approached) and their representativeness compared to the underlying population. Primary effectiveness outcomes are the percent of participants newly identified as being at increased risk for one of the clinical decision support conditions and the percent with appropriate risk-based screening. Secondary outcomes include percent change in those meeting goals for a healthy lifestyle (diet, exercise, and smoking). Outcomes are measured through electronic medical record data abstraction, patient surveys, and surveys/qualitative interviews of clinical staff. DISCUSSION: This study evaluates factors that are critical to successful implementation of a web-based risk assessment tool into routine clinical care in a variety of healthcare settings. The result will identify resource needs and potential barriers and solutions to implementation in each setting as well as an understanding potential effectiveness. TRIAL REGISTRATION: NCT01956773.

Surface contamination artificially elevates initial sweat mineral concentrations.

Several sweat mineral element concentrations decline with serial sampling. Possible causes include reduced dermal mineral concentrations or flushing of surface contamination. The purpose of this study was to simultaneously sample mineral concentrations in transdermal fluid (TDF), sweat, and serum during extended exercise-heat stress to determine if these compartments show the same serial changes during repeat sampling. Sixteen heat-acclimated individuals walked on a treadmill (1.56 m/s, 3.0% grade) in a 35°C, 20% relative humidity (RH), 1 m/s wind environment 50 min each hour for 3 h. Mineral concentrations of Ca, Cu, Fe, K, Mg, Na, and Zn were measured each hour from serum, sweat from upper back (sweat pouch) and arm (bag), and TDF from the upper back. Sites were meticulously cleaned to minimize surface contamination. Mineral concentrations were determined by spectrometry. TDF remained stable over time, with exception of a modest increase in TDF [Fe] (15%) and decrease in TDF [Zn] (-18%). Likewise, serum and pouch sweat samples were stable over time. In contrast, the initial arm bag sweat mineral concentrations were greater than those in the sweat pouch, and [Ca], [Cu], [Mg], and [Zn] declined 26-76% from initial to the subsequent samples, becoming similar to sweat pouch. Nominal TDF mineral shifts do not affect sweat mineral concentrations. Arm bag sweat mineral concentrations are initially elevated due to skin surface contaminants that are not removed despite meticulous cleaning (e.g., under fingernails, on arm hair), then decrease with extended sweating and approach those measured from the scapular region.

Serum S-100beta response to exercise-heat strain before and after acclimation.

UNLABELLED: Exercise alone or in combination with environmental heat stress can elevate blood S-100beta protein concentrations. However, the explanatory power of exercise with marked environmental heat stress on the appearance of S-100beta is questionable. It is possible that the process of heat acclimation might afford additional insight. PURPOSE: Determine the S-100beta response to moderate-intensity exercise with heat strain before and after heat acclimation. METHODS: Nine healthy male volunteers completed 10 consecutive days of heat acclimation consisting of up to 100 min of treadmill walking (1.56 m x s(-1), 4% grade) in the heat (45 degrees C, 20% relative humidity). Changes in HR, rectal temperature (T(re)), and sweat rate (SR) were examined to determine successful acclimation. Area under the curve (AUC) for T(re) greater than 38.5 degrees C was calculated to assess cumulative hyperthermia. Blood samples were taken before and after exercise on days 1 and 10 and were analyzed for serum osmolality and S-100beta concentration. RESULTS: All subjects displayed physiological adaptations to heat acclimation including a significant (P < 0.05) reduction in final HR (161 to 145 bpm) and T(re) (39.0 to 38.4 degrees C), as well as a modest (approximately 10%) increase in SR (1.10 to 1.20 L x h(-1); P = 0.09). No differences were observed in pre- to postexercise serum S-100beta concentrations on day 1 or 10, and no differences were observed in S-100beta values between days 1 and 10. No significant correlations were found between S-100beta values and any variable of interest. CONCLUSIONS: S-100beta concentrations do not necessarily increase in response to exercise-heat strain, and no effect of heat acclimation on S-100beta could be observed despite other quantifiable physiological adaptations.

Effect of heat acclimation on sweat minerals.

PURPOSE: This study examined the impact of 10 d of exercise-heat acclimation on sweat mineral concentrations. METHODS: Eight male subjects walked on a treadmill at 3.5 mph, 4% grade for 100 continuous minutes or until rectal temperature reached 39.5 degrees C on 10 consecutive days in an environmental chamber set at 45 degrees C, 20% relative humidity. Arm sweat samples were collected during the first 30 min of exercise-heat stress on days 1 and 10 using a polyethylene arm glove. RESULTS: Final core temperature and HR values were significantly lower (P < 0.05) on day 10 versus day 1. Whole-body sweating rates increased by approximately 6% (P = 0.12). Sweat sodium concentration on day 10 (36.22 +/- 7.22 mM) was significantly lower than day 1 (54.49 +/- 16.18 mM) (P < 0.05). Sweat mineral concentrations of calcium (approximately 29%), copper (approximately 50%), and magnesium (approximately 43%) were also significantly lower on day 10 versus day 1 of heat acclimation (P < 0.05). A trend for lower sweat iron (approximately 75%; P = 0.07) and zinc (approximately 23%; P = 0.10) concentrations were observed from day 1 to day 10. The estimated hourly sweat mineral losses (arm concentration x whole-body sweat rate) were reduced for calcium (approximately 27%), copper (approximately 46%), and magnesium (approximately 42%) (P < 0.05), but not iron (75%) or zinc (approximately 16%) (P > 0.05), from day 1 to day 10. CONCLUSION: Exercise-heat acclimation conserves arm sweat mineral concentrations and possibly whole-body sweat losses of calcium, copper, and magnesium, and may reduce sweat iron and zinc concentrations.

Efficacy of body ventilation system for reducing strain in warm and hot climates.

This study determined whether a torso-vest forced ambient air body ventilation system (BVS) reduced physiological strain during exercise-heat stress. Seven heat-acclimated volunteers attempted nine, 2-h treadmill walks at 200 W m(-2) in three environments, -40 degrees C, 20% rh (HD), 35 degrees C, 75% rh (HW), and 30 degrees C, 50% rh, (WW) wearing the Army Combat Uniform, interceptor body armor (IBA) and Kevlar helmet. Three trials in each environment were BVS turned on (BVS(On)), BVS turned off (BVS(Off)), and no BVS (IBA). In HD, BVS(On) significantly lowered core temperature (T (re)), heart rate (HR), mean skin temperature (T (sk)), mean torso skin temperature (T (torso)), thermal sensation (TS), heat storage (S), and physiological strain index (PSI), versus BVS(Off) and IBA (P < 0.05). For HW (n = 6), analyses were possible only through 60 min. Exercise tolerance time (min) during HW was significantly longer for BVS(On) (116 +/- 10 min) versus BVS(Off) (95 +/- 22 min) and IBA (96 +/- 18 min) (P < 0.05). During HW, BVS(On) lowered HR at 60 min versus IBA, T (sk) from 30 to 60 min versus BVS(Off) and IBA, and PSI from 45 to 60 min versus BVS(Off) and at 60 min versus IBA (P < 0.05). BVS(On) changes in T (re) and HR were lower in HD and HW. During WW, BVS(On) significantly lowered HR, T (sk), and T (torso) versus BVS(Off) and IBA (P < 0.05) during late exercise. Sweating rates were significantly lower for BVS(On) versus BVS(Off) and IBA in both HD and WW (P < 0.05), but not HW. These results indicate that BVS(On) reduces physiological strain in all three environments by a similar amount; however, in hot-dry conditions the BVS(Off) increases physiological strain.

Prevalence of glucose-6-phosphate dehydrogenase deficiency in U.S. Army personnel.

The U.S. Army recently mandated that soldiers undergo glucose-6-phosphate dehydrogenase (G6PD) testing before deployment to malarious regions. We retrospectively characterize the presence and degree of G6PD deficiency in U.S. military personnel by sex, self-reported ethnicity, and World Health Organization deficiency classification through test results obtained October 1, 2004 through January 17, 2005. Data were available for 63,302 (54,874 males and 8,428 females) subjects; 2.5% of males and 1.6% of females were deficient, with most having only moderate enzyme deficiency. African American males (12.2%) and females (4.1%), along with Asian males (4.3%), had the highest rates of G6PD deficiency. Most males were found to have class III variants while most females were class IV variants. The most severely deficient were Asian males (class II). These results suggest that universal screening for G6PD deficiency is clinically warranted, and particularly essential for those male service members who self-report ethnicity as African American, Asian, or Hispanic.

Effects of L-tyrosine and carbohydrate ingestion on endurance exercise performance.

To test the effects of tyrosine ingestion with or without carbohydrate supplementation on endurance performance, nine competitive cyclists cycled at 70% peak oxygen uptake for 90 min under four different feeding conditions followed immediately by a time trial. At 30-min intervals, beginning 60 min before exercise, each subject consumed either 5 ml/kg body wt of water sweetened with aspartame [placebo (Pla)], polydextrose (70 g/l) (CHO), L-tyrosine (25 mg/kg body wt) (Tyr), or polydextrose (70 g/l) and L-tyrosine (25 mg/kg body wt) (CHO+Tyr). The experimental trials were given in random order and were carried out by using a counterbalanced double-blind design. No differences were found between treatments for oxygen uptake, heart rate, or rating of perceived exertion at any time during the 90-min ride. Plasma tyrosine rose significantly from 60 min before exercise to test termination (TT) in Tyr (means +/- SE) (480 +/- 26 micromol) and CHO+Tyr (463 +/- 34 micromol) and was significantly higher in these groups from 30 min before exercise to TT vs. CHO (90 +/- 3 micromol) and Pla (111 +/- 7 micromol) (P < 0.05). Plasma free tryptophan was higher after 90 min of exercise, 15 min into the endurance time trial, and at TT in Tyr (10.1 +/- 0.9, 10.4 +/- 0.8, and 12.0 +/- 0.9 micromol, respectively) and Pla (9.7 +/- 0.5, 10.0 +/- 0.3, and 11.7 +/- 0.5 micromol, respectively) vs. CHO (7.8 +/- 0.5, 8.6 +/- 0.5, and 9.3 +/- 0.6 micromol, respectively) and CHO+Tyr (7.8 +/- 0.5, 8.5 +/- 0.5, 9.4 +/- 0.5 micromol, respectively) (P < 0.05). The plasma tyrosine-to-free tryptophan ratio was significantly higher in Tyr and CHO+Tyr vs. CHO and Pla from 30 min before exercise to TT (P < 0.05). CHO (27.1 +/- 0.9 min) and CHO+Tyr (26.1 +/- 1.1 min) treatments resulted in a reduced time to complete the endurance time trial compared with Pla (34.4 +/- 2.9 min) and Tyr (32.6 +/- 3.0 min) (P < 0.05). These findings demonstrate that tyrosine ingestion did not enhance performance during a cycling time trial after 90 min of steady-state exercise.

Minimum rest period for strength recovery during a common isokinetic testing protocol.

PURPOSE: The intent of this investigation was to determine the minimal time for a between sets rest period during a common isokinetic knee extension strength-testing protocol. Based on a review of the literature, a set was considered a group of four maximal coupled contractions at a specific velocity. METHODS: Eleven normal, healthy college-age men underwent unilateral knee extension testing to determine their individual isokinetic peak torque at 60, 120, 180, 240, and 300 degrees.s-1. Velocities were administered in ascending order. Between sets, rest periods of 15, 60, 180, and 300 s were assigned to subjects in a counterbalanced fashion. RESULTS: There were no differences in peak torque at the beginning velocity of 60 degrees.s-1 among any of the rest periods. At 120 degrees.s-1, peak torque production during the 15-s rest period trial was similar to 60 s but lower than 180 and 300 s. Peak torques at 180, 240, and 300 degrees.s-1 produced during the 15-s rest period test were significantly lower than measured torques at the same velocities during the 60, 180, and 300-s rest period tests (P < 0.05). There were no differences in peak torque production between the 60, 180, and 300-s rest period tests. CONCLUSION: These data demonstrate that during a common isokinetic strength testing protocol a between set rest period of at least 60 s is sufficient for recovery before the next test set.