Sports: An underutilized tool for patients with disabilities.

Sport activities promote health and well-being in this population, which is disproportionately affected by obesity, sedentary lifestyle, and social isolation.

Addressing Social Determinants of Health in a Free Clinic Setting: A Student-Run Free Clinic and Community Resource Navigator Program.

Background: Social determinants of health (SDOH) disproportionately affect medically-underserved populations such as those cared for in student-run free clinics (SRFCs). Community resource programs which address SDOH play an important role in reducing health disparities. The Southside MEDiC Clinic (SMC), a SRFC at the University of Wisconsin School of Medicine and Public Health, partnered with the Community Resource Navigator Program (CRNP), a community resource program focused on addressing SDOH, to remove barriers that prevent positive health outcomes for SMC patients. Aim: Our objective is to describe the partnership between the SMC and the CRNP. We hope this design may be used as a model for addressing SDOH in other SRFCs. Discussion: Partnership goals include improved patient perception of health, increased communication between patients and the clinic, and enhanced opportunities for volunteer action learning. Challenges discussed include adaptation to unique clinics. Future directions and potential advancements in this partnership are also addressed.

Effect of Husbandry Practices on the Fecal Microbiota of C57BL/6J Breeding Colonies Housed in 2 Different Barrier Facilities in the Same Institution.

Evidence showing a relationship between the mouse gut microbiome and properties such as phenotype and reaction to therapeutic agents and other treatments has increased significantly over the past 20 to 30 y. Recent concerns regarding the reproducibility of animal experiments have underscored the importance of understanding this relationship and how differences in husbandry practices can affect the gut microbiome. The current study focuses on effects of different barrier practices in 2 barrier facilities at the same institution on the fecal microbiome of breeding C57Bl/6J mice. Ten female and 10 male C57Bl/6J mice were obtained in one shipment from Jackson Laboratories and were housed under different barrier conditions upon arrival. Fecal samples were collected on arrival and periodically thereafter and were sent to TransnetYX for microbiome analysis. Mice used for collection of feces were housed as breeding pairs, with a total of 5 breeding pairs per barrier. An additional fecal sample was collected from these mice at 8 wk after arrival. One F1 female and one F1 male from each breeding cage were housed as brother-sister breeding pairs and a fecal sample was collected from them at 8 wk of age. Brother-sister breeding colonies were continued through F3, with fecal samples for microbiome analysis were collected from each generation at 8 wk of age. Breeding colonies in the 2 barriers showed differences in relative abundance, α -diversity, and ß -diversity. Our data indicate that differences in barrier husbandry practices, including the use of autoclaved cages, the degree of restricted access, feed treatment practices, and water provision practices, can affect fecal microbiome divergence in both the parental and filial generations of different breeding colonies. To our knowledge, this is the first study to examine the effect of barrier husbandry practices on the microbiome of breeding colonies through the F3 generation.

A computerized, self-administered questionnaire to evaluate posttraumatic stress among firefighters after the World Trade Center collapse.

OBJECTIVES: We sought to determine the frequency of psychological symptoms and elevated posttraumatic stress disorder (PTSD) risk among New York City firefighters after the World Trade Center (WTC) attack and whether these measures were associated with Counseling Services Unit (CSU) use or mental health-related medical leave over the first 2.5 years after the attack. METHODS: Shortly after the WTC attack, a computerized, binary-response screening questionnaire was administered. Exposure assessment included WTC arrival time and "loss of a co-worker while working at the collapse." We determined elevated PTSD risk using thresholds derived from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and a sensitivity-specificity analysis. RESULTS: Of 8487 participants, 76% reported at least 1 symptom, 1016 (12%) met criteria for elevated PTSD risk, and 2389 (28%) self-referred to the CSU, a 5-fold increase from before the attack. Higher scores were associated with CSU use, functional job impairment, and mental health-related medical leave. Exposure-response gradients were significant for all outcomes. CONCLUSIONS: This screening tool effectively identified elevated PTSD risk, higher CSU use, and functional impairment among firefighters and therefore may be useful in allocating scarce postdisaster mental health resources.

Diabetes and cardiovascular risk factors in Native Hawaiians.

OBJECTIVE: Diabetes is an increasing health problem among Native Hawaiians. Diabetes is a risk factor for cardiovascular disease (CVD), the leading cause of death among Native Hawaiians. In this article, the prevalence of diabetes is reported and associations with CVD risk factors are examined. DESIGN AND METHODS: Cross-section of 862 Native Hawaiians, ages 19-88. Physical exam included anthropometric measures, blood pressure, glucose and lipid measures, and personal interview. RESULTS: Age-adjusted prevalences of diabetes (25.1% in men vs. 22.6% in women) and impaired fasting glucose (IFG) (47.8% vs. 39.3%) increased with age and were higher in men. Fasting glucose was higher in diabetic men than women (209 mg/dL vs. 179, p = .0117). BMI, waist circumference, systolic blood pressure, triglycerides, and low-density lipoprotein cholesterol were higher in diabetic participants (all p < .01), and high-density lipoprotein cholesterol was lower (p < .005). CONCLUSIONS: Diabetes prevalence in Native Hawaiians is high. The high proportion with IFG and the increase in CVD risk factors with diabetes suggest that community-based programs are needed to focus on diabetes and diabetes-related CVD.

Coronary heart disease risk equivalence in diabetes depends on concomitant risk factors.

OBJECTIVE: Diabetes has been defined as a coronary heart disease (CHD) risk equivalent, and more aggressive treatment goals have been proposed for diabetic patients. RESEARCH DESIGN AND METHODS: We studied the influence of single and multiple risk factors on the 10-year cumulative incidence of fatal and nonfatal CHD and cardiovascular disease (CVD) in diabetic and nondiabetic men and women, with and without baseline CHD or CVD, in a population (n = 4,549) with a high prevalence of diabetes. RESULTS: In both sexes, diabetes increased the risk for CHD (hazard ratio 1.99 and 2.93 for men and women, respectively). Diabetic men and women had a 10-year cumulative incidence of CHD of 25.9 and 19.1%, respectively, compared with 57.4 and 58.4% for nondiabetic men and women with previous CHD. The pattern was similar when only fatal events were considered. Diabetic individuals with one or two risk factors had a 10-year cumulative incidence of CHD that was only 1.4 times higher than that of nondiabetic individuals (14%). However, the 10-year incidence of CHD in diabetic subjects with multiple risk factors was >40%, and the incidence of fatal CHD was higher in these subjects than in nondiabetic subjects with previous CHD. Data for CVD showed similar patterns, as did separate analyses by sex. CONCLUSIONS: Our results and comparisons with other available data show wide variation in the rate of CHD in diabetes, depending on the population and existing risk factors. Most individuals had a 10-year cumulative incidence >20%, but only those with multiple risk factors had a 10-year cumulative incidence that was equivalent to that of patients with CHD. Until more data are available, it may be prudent to consider targets based on the entire risk factor profile rather than just the presence of diabetes.

A mental health program for ground zero rescue and recovery workers: cases and observations.

Clinical vignettes from the World Trade Center Worker and Volunteer Mental Health Monitoring and Treatment Program at the Mount Sinai Medical Center in New York City are presented. The hospital-based program pairs mental health screenings with federally funded occupational medical screenings to identify persons with mental health problems related to their rescue and recovery roles. The program also provides on-site mental health treatment. The cases illustrate the diverse mental health needs of the rescue and recovery workers, some of whom initially sought treatment years after September 11, 2001. The cases show that in addition to symptoms of posttraumatic stress disorder, workers experienced survivor guilt, distressing memories of childhood trauma, shame associated with intense feelings, substance abuse relapse, psychosis, and problems with family relationships.

Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study.

BACKGROUND: The associations of low (<0.90) and high (>1.40) ankle brachial index (ABI) with risk of all-cause and cardiovascular disease (CVD) mortality have not been examined in a population-based setting. METHODS AND RESULTS: We examined all-cause and CVD mortality in relation to low and high ABI in 4393 American Indians in the Strong Heart Study. Participants had bilateral ABI measurements at baseline and were followed up for 8.3+/-2.2 years (36 589 person-years). Cox regression was used to quantify mortality rates among participants with high and low ABI relative to those with normal ABI (0.90 < or =ABI < or =1.40). Death from all causes occurred in 1022 participants (23.3%; 27.9 deaths per 1000 person-years), and of these, 272 (26.6%; 7.4 deaths per 1000 person-years) were attributable to CVD. Low ABI was present in 216 participants (4.9%), and high ABI occurred in 404 (9.2%). Diabetes, albuminuria, and hypertension occurred with greater frequency among persons with low (60.2%, 44.4%, and 50.1%) and high (67.8%, 49.9%, and 45.1%) ABI compared with those with normal ABI (44.4%, 26.9%, and 36.5%), respectively (P<0.0001). Adjusted risk estimates for all-cause mortality were 1.69 (1.34 to 2.14) for low and 1.77 (1.48 to 2.13) for high ABI, and estimates for CVD mortality were 2.52 (1.74 to 3.64) for low and 2.09 (1.49 to 2.94) for high ABI. CONCLUSIONS: The association between high ABI and mortality was similar to that of low ABI and mortality, highlighting a U-shaped association between this noninvasive measure of peripheral arterial disease and mortality risk. Our data suggest that the upper limit of normal ABI should not exceed 1.40.

Insulin resistance, the metabolic syndrome, and risk of incident cardiovascular disease in nondiabetic american indians: the Strong Heart Study.

OBJECTIVE: Insulin resistance (IR) and the metabolic syndrome (MS) are associated with type 2 diabetes and adverse cardiovascular disease (CVD) risk factor profiles. Whether IR and MS predict CVD independently of diabetes and other CVD risk factors is not known. This study examines whether IR and/or presence of MS are independently associated with CVD in nondiabetic American Indians (AI). RESEARCH DESIGN AND METHODS: We examined 2283 nondiabetic AI who were free of CVD at the baseline examination of the Strong Heart Study (SHS). CVD risk factors were measured, IR was quantified using the homeostasis model assessment (HOMA), and MS as defined by the National Cholesterol Education Program Adult Treatment Panel (ATP III) was assessed for each participant. Incident CVD and diabetes were ascertained during follow-up. RESULTS: MS was present in 798 individuals (35%), and 181 participants (7.9%) developed CVD over 7.6 +/- 1.8 years of follow-up. Age, BMI, waist circumference, and triglyceride levels increased and HDL cholesterol decreased across tertiles of HOMA-IR. Risk of diabetes increased as a function of baseline HOMA-IR (6.3, 14.6, and 30.1%; P < 0.001) and MS (12.8 vs. 24.5%). In Cox models adjusted for CVD risk factors, risk of CVD did not increase either as a function of baseline HOMA-IR or MS, but individual CVD risk factors predicted subsequent CVD. CONCLUSIONS: Among nondiabetic AI in the SHS, HOMA-IR and MS both predict diabetes, but neither predicts CVD independently of other established CVD risk factors.

Non-HDL cholesterol as a predictor of cardiovascular disease in type 2 diabetes: the strong heart study.

OBJECTIVE: To determine whether non-HDL cholesterol, a measure of total cholesterol minus HDL cholesterol, is a predictor of CVD in patients with diabetes. RESEARCH DESIGN AND METHODS: The Strong Heart Study, a population-based study of CVD and its risk factors in 13 American Indian communities in three geographic areas in the U.S. The baseline examination, conducted between July 1989 and January 1992, consisted of a personal interview, a physical examination, and laboratory tests. Of the 4,549 women and men aged 45-74 years participating in the study, 2,108 had diabetes but no CVD at baseline. Data on fatal and nonfatal CVD were collected during the follow-up period through 31 December 1998 (average 9 years). RESULTS: Multivariable analyses indicated that non-HDL cholesterol is a strong predictor of CVD in men and women with diabetes and is particularly indicative of coronary events. Hazard ratios for the highest tertile of non-HDL cholesterol in men and women with diabetes (2.23 and 1.80, respectively) were higher than those for either LDL cholesterol or triglycerides alone in both men and women and were higher than the ratio of total/HDL cholesterol in women. The utility of non-HDL cholesterol in predicting CVD extended over a wide range of triglyceride concentrations. CONCLUSIONS: This study suggests that non-HDL cholesterol index may be particularly useful in predicting CVD risk in patients with diabetes.

Crystal methamphetamine, its analogues, and HIV infection: medical and psychiatric aspects of a new epidemic.

The use of the recreational drug crystal methamphetamine among younger homosexual men is expanding, and with it, unsafe sex behaviors that increase the transmission of human immunodeficiency virus (HIV). This article reviews available literature on the medical and psychiatric morbidities associated with methamphetamine abuse in HIV-infected patients. Medical complications include hypertension, hyperthermia, rhabdoymyolysis, and stroke. One fatal case of ingestion of methamphetamine with HIV medication has been documented. Two fatal cases of ingestion of HIV medication with the amphetamine analogue n-methyl-3,4 methylenedioxymethamphetamine (MDMA, or "ecstasy") have also been reported. Some molecular researchers suggest that dopaminergic systems are vulnerable to the combined neurotoxicity of HIV infection and methamphetamine. Population surveys indicate high rates of HIV infection among methamphetamine abusers and high rates of unprotected anal intercourse during drug intoxication. Intoxication can sometimes produce paranoia, auditory hallucinations, and, occasionally, violent behavior. Amphetamine withdrawal commonly results in symptoms of depression. Methamphetamine is a new challenge related to treatment and prevention of HIV infection.

Alcohol intake and glycemia in American Indians: the strong heart study.

The goal of this study was to explore the relationship between alcohol intake and glycemia and type 2 diabetes in American Indians aged 45 to 74 years. Data were obtained from participants in the Strong Heart Study, a longitudinal study of 13 American Indian communities in 3 geographic areas in the United States. Alcohol consumption was determined by self-reported alcohol intake history. Participants previously diagnosed with diabetes were excluded from the analysis. Analysis of covariance (ANCOVA) was used to estimate the adjusted means of blood glucose for alcohol intake categories. Logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) to estimate the association between alcohol intake and type 2 diabetes in the cross-sectional analysis and between alcohol intake and glucose intolerance using longitudinal data. Fasting and 2-hour plasma glucose concentrations showed an inverse J-shaped curve across categories of alcohol intake. Using never drinkers as the referent group in cross-sectional analysis, light drinkers had a significantly lower risk of having diabetes (OR, 0.66; 95% CI, 0.44 to 0.99); among drinkers, heavy drinkers had a higher, although not significant, prevalence of diabetes. Longitudinal analysis showed no significant worsening of glucose tolerance across levels of alcohol intake. Subanalyses stratified by body mass index (BMI) did not show differences between obese and non-obese participants in the relationship between alcohol intake and glucose tolerance. Although plasma glucose concentration showed a shallow, inverse J-shaped association across levels of increasing alcohol intake in American Indians aged 45 to 74 years, alcohol intake did not appear to significantly increase the risk for worsening glucose tolerance. Thus, alcohol intake does not appear to be a determinant of diabetes risk in this population.

A trade-off between the frequency and duration of bumblebee visits to flowers.

Pollinator behavior influences plant reproduction in many ways. A traditional measure of pollination, the number of visits received, may be a poor predictor of plant reproductive success, particularly when there are trade-offs between visit quantity and components of visit quality. For example, the duration of pollinator visits may be negatively correlated with the number of visits received by a flower. We tested for a trade-off between the number of bumblebee visits and the duration of those visits in an experimental population of snapdragons (Antirrhinummajus: Scrophulariaceae). The duration of a bumblebee visit to a flower increased significantly with the time interval since the flower had last been visited. Over the lifetime of a flower the correlation between the total number and average duration of visits received by a flower was weakly negative. However, at the whole-plant level the correlation was positive: plants whose flowers received more visits also received visits of longer duration. Factors affecting the relationship between quantity and duration of pollinator visits to flowers also were investigated. Two factors weakened the negative dependence of average visit duration on number of visits received by individual snapdragon flowers: (1) the correlation between the total number of visits to a flower and the average interval between visits was only -0.53, as visits to individual flowers were not very evenly spaced over time, and (2) newly opened flowers received fewer and shorter visits than older flowers. Comparing whole plants, nectar production per flower varied dramatically across individuals, a probable explanation for the positive correlation between visit number and average duration per flower observed at the plant level. The potential for a trade-off between these two components of pollinator service exists when visit duration depends on reward quantity; whether the trade-off is realized will depend on variation in nectar production and on whether pollinators forage systematically.

What do physician recommendations of health plans mean?

OBJECTIVE: To examine what determines physician recommendations of health plans and whether their recommendations reflect experiences with specific plans. STUDY DESIGN: Cross-sectional mail and telephone survey. PARTICIPANTS AND METHODS: A sample of 11453 physicians was surveyed from November 2000 to early 2001, and 3798 (2105 generalists, 1693 specialists) responded. After adjusting for ineligibles and duplicates, the response rate was estimated to be between 41% and 45%. Physician respondents were from 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Plans included those serving commercial, Medicare and Medicaid populations and represented group/staff type HMOs, independent practice associations, and preferred provider organizations. Measurements included self-reported experience with 9 health plan care management strategies and ratings of managed care beliefs and satisfaction with pay. Physicians were asked about their willingness to recommend the health plan to a family member or friend, to people with serious illnesses, or to other physicians. RESULTS: Physician recommendations of a health plan were associated with the health plan's care management activities and with the physician's generalized beliefs about managed care and satisfaction with pay. CONCLUSION: Physician health plan recommendations can reasonably be interpreted as partially reflecting physician experiences with specific plans. Therefore, they can play a role in helping purchasers and consumers compare health plans.

S-adenosylmethionine (SAM-e) for the treatment of depression in people living with HIV/AIDS.

BACKGROUND: This study reports on clinical data from an 8-week open-label study of 20 HIV-seropositive individuals, diagnosed with Major Depressive Disorder (DSM-IV), who were treated with SAM-e (S-Adenosylmethionine). SAM-e may be a treatment alternative for the management of depression in a population reluctant to add another "pill" or another set of related side effects to an already complex highly active antiretroviral therapy (HAART) regimen. METHODS: The Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI) were used to assess depressive symptomatology from 1,2,4,6 and 8 weeks after initiation of treatment with SAM-e. RESULTS: Data show a significant acute reduction in depressive symptomatology, as measured by both the HAM-D and the BDI instruments. CONCLUSIONS: SAM-e has a rapid effect evident as soon as week 1 (p < .001), with progressive decreases in depression symptom rating scores throughout the 8 week study.

Establishing a culturally sensitive palliative care program in rural Alaska Native American communities.

End-of-life programs that provide an option for patients to die at home are available in most U.S. communities. However, Alaska Natives living in remote Alaska villages often die alone in hospitals and nursing homes hundreds of miles away from home. The Bristol Bay Area Health Corporation (BBAHC), a tribal organization, is the sole provider of comprehensive primary care services to 34 Alaska Native villages located within a 46,000 square mile area in southwest Alaska. The closest tertiary care hospital is 329 air miles away in Anchorage. Because of the high cost of, and difficulties encountered in trying to deliver end-of-life care services to remote communities, a village-focused, culturally sensitive, volunteer and primary care program combined with a regionally based physician and home health nurse to deliver multi-disciplinary palliative care was developed. The Helping Hands Program blends cultural practices with contemporary palliative care medicine to allow Alaska Natives and others living in remote communities to be cared for at home through the end of life. Since the program was implemented in 1999, the percentage of home deaths for selected causes has changed from 33% in 1997 to 77% in 2001. The Anchorage-based Alaska Native Tribal Health Consortium (ANTHC) and the Alaska Native Medical Center (ANMC) have recognized the importance and success of the BBAHC program and are investigating expanding the program to other parts of Alaska. Centralizing the program in Anchorage will allow staff trained in palliative care to travel to regional Alaska Native hospitals to help train health care professionals.

Drinking drivers and drug use on weekend nights in the United States.

BACKGROUND: Studies of drinking drivers in alcohol-related crashes have shown that high breath-alcohol concentrations (BrACs) are associated with illegal drug use. Until the 2007 National Roadside Survey (NRS), the prevalence of drugs among drinking drivers on U.S. roads was unknown. Using NRS data, we explore how many drivers with positive BrACs may also be using drugs and their significance to current drinking-driving enforcement procedures. METHODS: Based on a stratified, random sample covering the 48 U.S. contiguous states, we conducted surveys on weekend nights from July-November 2007. Of the 8384 eligible motorists contacted, 85.4% provided a breath sample; 70.0%, an oral fluid sample; and 39.1%, a blood sample. We conducted regression analyses on 5912 participants with a breath test and an oral fluid or blood test. The dependent variables of interest were illegal drugs (cocaine, cannabinoids, street drugs, street amphetamines, and opiates) and medicinal drugs (prescription and over-the-counter). RESULTS: 10.5% of nondrinking drivers were using illegal drugs, and 26 to 33% of drivers with illegal BrACs (≥ 0.08 g/dL) were using illegal drugs. Medicinal drug use was more common among nondrinking drivers (4.0%) than among drivers with illegal BrACs (2.4%). CONCLUSIONS: The significant relationship between an illegal BrAC and the prevalence of an illegal drug suggests as many as 350,000 illegal drug-using drivers are arrested each year for DWI by U.S. alcohol-impaired driving enforcement. These drug-using drivers need to be identified and appropriate sanctions/treatment programs implemented for them in efforts to extend per se laws to unapprehended drug users.

An evaluation of graduated driver licensing effects on fatal crash involvements of young drivers in the United States.

OBJECTIVE: Graduated driver licensing (GDL) systems are designed to reduce the high crash risk of young novice drivers. Almost all states in the United States have some form of a 3-phase GDL system with various restrictions in the intermediate phase. Studies of the effects of GDL in various states show significant reductions in fatal crash involvements of 16- and 17-year-old drivers; however, only a few national studies of GDL effects have been published. The objective of this national panel study was to evaluate the effect of GDL laws on the fatal crash involvements of novice drivers while controlling for possible confounding factors not accounted for in prior studies. METHODS: The Fatality Analysis Reporting System (FARS) was used to examine 16- and 17-year-old driver involvement in fatal crashes (where GDL laws are applied) relative to 2 young driver age groups (19-20, 21-25) where GDL would not be expected to have an effect. Dates when various GDL laws were adopted in the states between 1990 and 2007 were coded from a variety of sources. Covariates in the longitudinal panel regression analyses conducted included 4 laws that could have an effect on 16- and 17-year-old drivers: primary enforcement seat belt laws, zero-tolerance (ZT) alcohol laws for drivers younger than age 21, lowering the blood alcohol concentration limit for driving to 0.08, and so-called use and lose laws where drivers aged 20 and younger lose their licenses for underage drinking violations. RESULTS: The adoption of a GDL law of average strength was associated with a significant decrease in fatal crash involvements of 16- and 17-year-old drivers relative to fatal crash involvements of one of the 2 comparison groups. GDL laws rated as "good" showed stronger relationships to fatal crash reductions, and laws rated as "less than good" showed no reductions in crash involvements relative to the older driver comparison groups. CONCLUSIONS: States that adopt a basic GDL law can expect a decrease of 8 to 14 percent in the proportion of 16- and 17-year-old drivers involved in fatal crashes (relative to 21- to 25-year-old drivers), depending upon their other existing laws that affect novice drivers, such as those used in these analyses. This finding is consistent with recent national studies that used different outcome measures and covariates. The results of this study provide additional support for states to adopt, maintain, and upgrade GDL systems to reduce youthful traffic crash fatalities.