Dysregulation of Glucocorticoid Receptor Homeostasis and Glucocorticoid-Associated Genes in Umbilical Cord Endothelial Cells of Diet-Induced Obese Pregnant Sheep.

Maternal obesity (MO) is associated with offspring cardiometabolic diseases that are hypothesized to be partly mediated by glucocorticoids. Therefore, we aimed to study fetal endothelial glucocorticoid sensitivity in an ovine model of MO. Rambouillet/Columbia ewes were fed either 100% (control) or 150% (MO) National Research Council recommendations from 60 d before mating until near-term (135 days gestation). Sheep umbilical vein and artery endothelial cells (ShUVECs and ShUAECs) were used to study glucocorticoid receptor (GR) expression and function in vitro. Dexamethasone dose-response studies of gene expression, activation of a glucocorticoid response element (GRE)-dependent luciferase reporter vector, and cytosolic/nuclear GR translocation were used to assess GR homeostasis. MO significantly increased basal GR protein levels in both ShUVECs and ShUAECs. Increased GR protein levels did not result in increased dexamethasone sensitivity in the regulation of key endothelial gene expression such as endothelial nitric oxide synthase, plasminogen activator inhibitor 1, vascular endothelial growth factor, or intercellular adhesion molecule 1. In ShUVECs, MO increased GRE-dependent transactivation and FKBP prolyl isomerase 5 (FKBP5) expression. ShUAECs showed generalized glucocorticoid resistance in both dietary groups. Finally, we found that ShUVECs were less sensitive to dexamethasone-induced activation of GR than human umbilical vein endothelial cells (HUVECs). These findings suggest that MO-mediated effects in the offspring endothelium could be further mediated by dysregulation of GR homeostasis in humans as compared with sheep.

Effectiveness of an Assertive Community Treatment program for people with severe schizophrenia in mainland China - a 12-month randomized controlled trial.

BACKGROUND: Assertive Community Treatment (ACT) is an evidence-based treatment program for people with severe mental illness developed in high-income countries. We report the first randomized controlled trial of ACT in mainland China. METHODS: Sixty outpatients with schizophrenia with severe functional impairments or frequent hospitalizations were randomly assigned to ACT (n = 30) or standard community treatment (n = 30). The severity of symptoms and level of social functioning were assessed at baseline and every 3 months during the 1-year study. The primary outcome was the duration of hospital readmission. Secondary outcomes included a pre-post change in symptom severity, the rates of symptom relapse and gainful employment, social and occupational functioning, and quality of life of family caregivers. RESULTS: Based on a modified intention-to-treat analysis, the outcomes for ACT were significantly better than those of standard community treatment. ACT patients were less likely to be readmitted [3.3% (1/30) v. 25.0% (7/28), Fisher's exact test p = 0.023], had a shorter mean readmission time [2.4 (13.3) v. 30.7 (66.9) days], were less likely to relapse [6.7% (2/30) v. 28.6% (8/28), Fisher's exact test p = 0.038], and had shorter mean time in relapse [3.5 (14.6) v. 34.4 (70.6) days]. The ACT group also had significantly longer times re-employed and greater symptomatic improvement and their caregivers experienced a greater improvement in their quality of life. CONCLUSION: Our results show that culturally adapted ACT is both feasible and effective for individuals with severe schizophrenia in urban China. Replication studies with larger samples and longer duration of follow up are warranted.

Food Access and Its Relationship to Perceived Walkability, Safety, and Social Cohesion.

Understanding social inequalities in terms of neighborhood characteristics and the context to which individuals belong is important for reducing disparities. This article describes how perceptions of food access are related to three physical and social environmental factors: perceived neighborhood walkability, safety, and social cohesion. A cross-sectional survey was conducted with a random sample of 1,500 households in Springfield, Missouri. The main outcome measures were ease of purchase; availability of a large selection and quality; and affordability of fresh fruits and vegetables (FVs) and low-fat products (LFPs). Overall, 63% of respondents reported consuming <5 servings of FVs daily in the past month. Most agreed it was easy to purchase FVs (70%) and LFPs (76%) in their neighborhood and felt there was a large selection available (70% and 71%, respectively). High walkability (odds ratio [OR]: 1.8), low crime (OR: 1.6), and high social cohesion (OR: 1.7) were significantly associated with having greater selection of FVs. High walkability (OR: 1.6) and low crime (OR: 1.6) were associated with greater access to FVs. Given that healthy food access is an important component to improving health outcomes, understanding how to alter environmental features that influence behaviors like eating is important.

Use of life jackets and other types of flotation for in-water recreation in designated swim areas in Washington State.

Most fatal drownings worldwide occur in open water. Flotation devices may protect swimmers. Their use by those recreating in water has not been described. METHODS: Observational survey of swimmers and waders at designated swim sites at lakes and rivers evaluated them by age group, sex, type of flotation used (life jacket vs substandard flotation, eg, water wings, noodles, inflatables) and, for children <6 years, being within arm's reach of an adult. RESULTS: Of 1967 swimmers/waders observed, 37% used some type of flotation device. Use rates, especially of life jackets, decreased with increasing age. Children <6 years had the highest use of some type of flotation (140/212, 66%) and the highest use of life jackets (50.5%). Children <13 years were more likely to use flotation devices and life jackets than teens (RR 6.78, 3.62 to 12.71); boys were more likely than girls to wear life jackets (RR 1.47, 1.18 to 1.83). While teenagers and adults used flotation (29.5% and 23.5%), they rarely used life jackets (2-3%). Boys <6 years who were further than arm's length of an adult were more likely to wear life jackets than girls. Substandard flotation use did not differ among age groups (15.5-26.5%) but their use was greater among females in most age groups. CONCLUSIONS: Flotation devices were frequently used for recreational wading and swimming in open water by all age groups. Life jacket use was limited to children. Promoting use of flotation devices with safety standards that provide protection as well as fun could potentially decrease open water drowning rates.

The Value of Experiential Sexually Transmitted Disease Clinical Training in the Digital Age.

BACKGROUND: The translation of evidence-based guidelines for sexually transmitted disease (STD) care into clinical practice is crucial for the prevention and control of STDs. METHODS: Participants in a hands-on, multifaceted, small-group STD Clinical Intensive Course from 2006 to 2013 were asked to complete a survey regarding course content and value compared with other continuing education courses. Survey respondents with demographic and professional information were compared with all other course participants. χ Statistics were used to test for differences in proportions; the Cochran-Armitage trend test was used to evaluate for trends in response rate by year of training. RESULTS: Of 113 respondents (35.9% response rate), 92.9% felt that clinical knowledge stayed longer, 84.1% changed clinical practice more, and 90.3% recommended the course more, compared with other continuing education programs in which they had participated previously. Respondents' average suggested registration fee should the course no longer be free was $188.90. Physician assistants and advanced practice nurses were overrepresented among respondents (69.4% vs. 58.1%, P = 0.04); more recent course participants were more likely to respond (P < 0.01). CONCLUSIONS: These findings suggest that this STD experiential clinical training program is still relevant to participants in the digital age and is valued more highly than other continuing education experiences. A significant disconnect was identified between what participants are willing/able to pay versus actual course costs, indicating that cost is likely to become a barrier to participation should the course no longer be free.

Healthy Futures Program and Adolescent Sexual Behaviors in 3 Massachusetts Cities: A Randomized Controlled Trial.

OBJECTIVES: We evaluated the impact of the 3-year Healthy Futures program on reducing sexual behaviors among middle school students. METHODS: Fifteen public middle schools in Haverhill, Lowell, and Lynn, Massachusetts, participated in this longitudinal school-cluster randomized controlled trial (2011-2015), which included 1344 boys and girls. We collected student survey data at baseline, immediately after each Nu-CULTURE curriculum (classroom component of Healthy Futures) in the sixth, seventh, and eighth grades, and at a 1-year follow-up in the ninth grade (cohort 1 students only). RESULTS: Healthy Futures did not reduce the overall prevalence of eighth-grade students who reported ever having vaginal sex. In the eighth-grade follow-up, fewer girls in the treatment group than in the control group reported ever having vaginal sex (P = .04), and fewer Hispanic treatment students than Hispanic control students reported ever having vaginal sex (P = .002). CONCLUSIONS: There was some evidence of delaying sexual initiation by the end of Nu-CULTURE, for girls and Hispanics, but not for boys. Future research should focus on improving implementation of the supplemental components intended to foster interpersonal and environmental protective factors associated with sustained delays in sexual activity.

A Leg to Stand On: Working With Marginal Decision-making Capacity in a Patient With a Severe Leg Infection and Schizophrenia.

Assessment of a patient's capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Experiences of Family Burden in Caring for the Severely Mentally Ill in a Foreign Land: A Qualitative Study of Chinese Immigrant Families in Toronto, Canada.

There is a relative dearth of qualitative studies on the actual experiences of families caring for members suffering from serious mental illness, and even less is known about disadvantaged ethnic minority immigrant families. This explorative qualitative study examines the burden experienced by 15 family members of Chinese immigrant background in Toronto, Canada. Six common themes emerged from the study: 1) significant worries about not being able to take care of ill members in the future; 2) on-going strain and changed family life; 3) pervasive social stigma, discrimination and lack of resources; 4) general appreciation of Canadian health and welfare systems and opportunities; 5) cultural factors and beliefs uniquely shape families' support and caring commitment; and 6) families find various ways to cope and help themselves. Opportunities for improved care delivery based on these understandings are discussed.

Multi-family psycho-education group for assertive community treatment clients and families of culturally diverse background: a pilot study.

This study evaluates the incorporation of Multi-Family Psycho-education Group (MFPG) to an Assertive Community Treatment Team developed to serve culturally diverse clients who suffers from severe mental illness. Participants included Chinese and Tamil clients and their family members. Family members' well-being, perceived burden, and acceptance of clients were assessed before and after the intervention. Focus group interviews with clinicians were conducted to qualitatively examine MFPG. Family members' acceptance increased after MFPG. Regular attendance was associated with reduction in perceived family burden. Culturally competent delivery of MFPG enhanced family members' understanding of mental illness and reduced stress levels and negative feelings towards clients.

Vinorelbine Augments Radiotherapy in Hepatocellular Carcinoma.

There is a need to improve the effectiveness of radiotherapy (RT) in hepatocellular carcinoma (HCC). Therefore, the purpose of this study was to explore the efficacy and toxicity of the anti-microtubule agent Vinorelbine as a radiosensitizer in HCC. The radio sensitivity of 16 HCC patient-derived xenograft (PDX) models was determined by quantifying the survival fraction following irradiation in vitro, and Vinorelbine radio sensitization was determined by clonogenic assay. Ectopic HCC xenografts were treated with a single dose of 8 Gy irradiation and twice-weekly 3 mg/kg Vinorelbine. Tumor growth and changes in the proteins involved in DNA repair, angiogenesis, tumor cell proliferation, and survival were assessed, and the 3/16 (18.75%), 7/16 (43.75%), and 6/16 (37.5%) HCC lines were classified as sensitive, moderately sensitive, and resistant, respectively. The combination of RT and Vinorelbine significantly inhibited tumor growth, DNA repair proteins, angiogenesis, and cell proliferation, and promoted more apoptosis compared with RT or Vinorelbine treatment alone. Vinorelbine improved HCC tumor response to standard irradiation with no increase in toxicity. HCC is prevalent in less developed parts of the world and is mostly unresectable on presentation. Vinorelbine and conventional radiotherapy are cost-effective, well-established modalities of cancer treatment that are readily available. Therefore, this strategy can potentially address an unmet clinical need, warranting further investigation in early-phase clinical trials.

Risk factors associated with life jacket wear among adult canoeists and kayakers in the United States, 1999-2017.

Drowning is the most common cause of death in recreational boating. Life jackets prevent drowning, yet adult wear rates remain relatively low on most types of boats. Canoes and kayaks are among the least used boat types, yet maintain the third and first highest annual boating-related drowning rates in 2012, respectively. This 1999-2017 study collected data from 124 study sites across the US. Life jacket wear was calculated for 13 dichotomized risky and non-risky variables, using Chi-square tests. A count variable based on number of risks was created, and Cochran-Armitage trend tests examined linearity in life jacket use. Three illustrative variables for each boat type were represented in tree diagrams. Kayakers had higher wear rates than canoeists among all variables observed. For both boats, the majority of risky conditions had higher life jacket wear rates than their non-risky alternatives. As the number of risks increased, life jacket wear rate increased. Boaters seemingly conduct a mental assessment of risk to determine whether to wear a life jacket.

Factors associated with life jacket use among cabin sailboat and day sailor boaters in the United States.

INTRODUCTION: In 2015, drowning accounted for 68% of the 626 recreational boating related deaths in the United States. Although life jackets are estimated to prevent between 50% to 80% of boating deaths, approximately 83% of sailboat-related drowning victims were reported to not be wearing life jackets. Life jacket use among adult boaters has remained consistently low across most boat types and may vary by boater, boating, and environmental conditions. Although many risky environmental and boating factors may be associated with a higher risk of boating death, drowning occurs in all situations and it is useful to understand adult life jacket wearing behaviors in differing boating situations. METHODS: This study uses observational survey data from 61318 adult sailors collected during the summer months of 1999 - 2017 from 124 selected study sites across 30 states in the US. Life jacket use was compared for day sailors and cabin sailboats by multiple boating, boater, and environmental conditions using Chi-square tests for equality of proportions. Results of these tests led to a choice of 3 informative and scientifically compelling variables to summarize variation in life jacket use for each sailboat type. Odds ratios were calculated comparing life jacket use from each boating situation to the lowest risk situation as determined by the 3 selected variables. These variables were represented in a tree diagram, detailing the additive impact of each factor. Following these analyses, all boating conditions were categorized to be risky or non-risky and a count variable was created for each observation based on the number of risks present. Cochran-Armitage trend tests were conducted to test for linearity in life jacket use for both boat types. RESULTS: The overall life jacket wear rate was higher among adults in day sailor sailboats (51.6%) compared to cabin sailboats (13.8%) and in all measured demographic, boating, and environmental circumstances. Comparing high-risk cabin sailboat conditions of low water temperatures, small boat size, and high wind speed to the lowest-risk situation accounted for a 23.3% range in life jacket wear rate (OR=4.7). Comparing high-risk day sailor sailboat conditions of small boat size, one boater on board, and choppy/rough wave height to the lowest-risk situation accounted for a 39.3% range in life jacket wear rate (OR=5.9). For both boat types, the number of risks present and life jacket wear rate exhibited a statistically significant positive linear relationship at p<0.0001. CONCLUSION: Study results suggest that boaters are aware of the connection between life jacket use and drowning prevention and are more likely to wear life jackets when boating in conditions perceived to be risky. PRACTICAL APPLICATIONS: Boating safety promotion efforts should recommend adult life jacket use in all boating situations, as seemingly non-risky conditions may still result in drownings.

First adaptation of a family-based ACT model in mainland China: a pilot project.

OBJECTIVE: This study reports findings from a preliminary evaluation of the first implementation of the assertive community treatment (ACT) model in mainland China. METHODS: Over six months, the pilot study compared a group of patients (N=15) and family caregivers who received ACT services with a control group (N=16) who received standard community services. Data on hospitalization days, relapse frequency, psychiatric symptoms, social and vocational functioning, general mental health status, family burden, and level of social support for family caregivers were examined. RESULTS: ACT patients had no admissions, compared with two in the control group; they also had significantly lower psychopathology and higher social functioning scores. No significant differences in outcome measures for family caregivers were found. CONCLUSIONS: The study found preliminary support for implementing ACT in mainland China. Implementation could contribute to reducing admission and psychopathology and improving social functioning. Further research on ways to enhance family caregivers' experience is warranted.

Long-term care: a health promotion challenge.

There is a lack of health promotion for the elderly residing in long-term care facilities. It becomes imperative therefore for the nursing profession to readjust its thinking and practice to include health promotion strategies and interventions for institutionalized elderly in the long-term care sector. From using the empowerment theory in the discussion it is clear that nurses can help the elderly receive health promotion strategies and interventions to help the older person make informed choices about their lifestyle, health and treatment. The elderly population continues to grow and more than likely will spend some part of their life in a long-term care setting. Evidence from studies performed by Robertson (1991), Caserta (1995), Phillips (1994) and McBride (2000) suggests that health promotion efforts positively correlate with improved physical and psychological elements of health for the elderly. Nurses largely determine the kind of care that is given and thus can influence the quality of life that elderly client's experience. By advocating for health promotion interventions and strategies for their elderly clients, nurses are demonstrating to the community, their patients, and institution that nurses do have the power to make and influence change for the better. Nurses advocating for health promotion for their elderly patients not only empower choice, but also create an active and involved elderly population. Health promotion exists at all stages of life and does not cease when one is admitted to a long-term care facility (Hutchings, 1999; McBride, 2000).

Changing life jacket wearing behavior: an evaluation of two approaches.

In the United States during 1999-2012, about 4 per cent of adults wore life jackets while engaged in recreation on powerboats. Educational campaigns have promoted life jacket use. Mandatory use regulations target primarily children or boaters on personal watercrafts or water skiing. We describe findings from two interventions - 'Wear It California!', a targeted marketing campaign in the California Delta region and mandatory wear regulations at four US Army Corps of Engineers (USACE) lakes in the state of Mississippi. Before the campaign in the Delta, adult wear was 8.5 per cent, increasing to 12.1 per cent during the first year, dipping to 9.4 per cent during the second year, and rising slightly to 10.5 per cent 3 plus years after the campaign. Before mandatory regulations at USACE lakes, adult wear was 13.7 per cent, increasing to 75.6 per cent during the first year, 70.1 per cent during the second year, and remaining high at 68.1 per cent in the third year. Policymakers should consider these findings when choosing how to increase life jacket use.

Barriers to cervical cancer screening and follow-up care among Black Women in Massachusetts.

OBJECTIVE: To explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts. DESIGN: Qualitative using focus groups. SETTING: Hospitals, health centers, and community-based organizations in Boston, Massachusetts. PARTICIPANTS: Sixty-four participants including Black, non-Hispanic women from the general population and cervical cancer survivors, community leaders in women's health, and health care providers. METHODS: Six focus groups. Data were analyzed using methods based on grounded theory. RESULTS: Findings from interviews revealed that inadequate information and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Fear, cultural beliefs, and compounding factors related to poverty, gender roles, and health system barriers create delays to screening and follow-up care. Also, unconscious bias, therapeutic delays, and miscommunication are important factors affecting continuity of care. CONCLUSION: These results suggest a need for comprehensive, culturally specific cervical cancer prevention education initiatives and interventions for Black women and strategies to improve patient-provider relationships.

Trends in life jacket wear among recreational boaters: a dozen years (1999-2010) of US observational data.

We report results from 12 years of US observational data on life jacket use among recreational boaters based on more than 480,000 boaters in 175,000 boats between 1999 and 2010. The overall wear rate was 21.7 per cent, with sharp differences by age and boat types. We found strong increasing trends in wear rates among youth boaters, but among adults, the only increase was on sailboats. The increasing trend among youth is probably due to a combination of expanding laws for mandatory life jacket use among this age group, and targeted educational campaigns promoting life jacket use for children. Future efforts to increase the prevalence of life jacket wear should target groups with low wear rates and boaters on boats most likely to capsize. Policymakers should give serious consideration to regulations requiring adult boaters to wear life jackets while boating.

Improved quality of HIV care over time among participants in a national quality improvement initiative.

Ensuring comprehensive quality HIV and primary care is critical for effective HIV management. This study evaluates the impact of long-term engagement in a quality management (QM) initiative on performance measures. HIVQUAL-US is a federally-funded program to build clinic QM capacity to improve care for people living with HIV/AIDS. Forty-five facilities with four or more years of HIVQUAL-US performance measurement between 2002 and 2009 were included. Composite quality scores were constructed for HIV care, primary care and overall quality. Unadjusted analyses showed significant improvements in HIV care (76.2% to 88.8%, p<.0001), primary care (65.7% to 71.4%, p<.05) and overall (70.6% to 79.6%, p<.0001). Improvement was higher among clinics performing in the lowest quartile. Adjusting for clinic factors, the probability of improvement increased with each additional year of data submission for all scores. Engagement in a QM capacity building program was associated with continuing improvement in quality of HIV and primary care.

Adapting ACT to serve culturally diverse communities: a comparison of a Japanese and a Canadian ACT team.

OBJECTIVE: The assertive community treatment (ACT) teams of Mount Sinai Hospital in Toronto and the KUINA Center, Hitachinaka, Japan, were compared with regard to ACT fidelity, organizational structure, populations served, and treatment outcomes. Ethnocultural adaptations to the ACT model made by both teams included enhanced family support and intervention, culturally and linguistically matched staff and patients when possible, culturally informed therapy, routine cultural assessments, culturally matched housing and community support, and flexible funding models. METHODS: Data were gathered by chart reviews (66 patients in Toronto and 40 patients in Japan), a satisfaction measure, a standard measure of ACT fidelity, and a pre-post measure of treatment outcomes (the Brief Psychiatric Rating Scale), and hospitalization days. RESULTS: Both teams achieved good fidelity to ACT and reductions in hospitalization and symptom severity. Family satisfaction scores were high. CONCLUSIONS: With culturally informed adaptations, ACT can be effective in a Canadian mixed ethnocultural population and a homogeneous Japanese population.