Decreasing Intraoperative Skin Damage in Prone-Position Surgeries.

OBJECTIVE: To determine if subepidermal moisture (SEM) measures help detect and prevent intraoperative acquired pressure injuries (IAPIs) for prone-position surgery. METHODS: In this clinical trial of patients (n = 39 preintervention, n = 48 intervention, 100 historical control) undergoing prone-position surgery, researchers examined the use of multidimensionally flexible silicone foam (MFSF) dressings applied preoperatively to patients' face, chest, and iliac crests. Visual skin assessments and SEM measures were obtained preoperatively, postoperatively, and daily for up to 5 days or until discharge. Electronic health record review included demographic, medical, and surgery data. RESULTS: Of the 187 total participants, 76 (41%) were women. Participants' mean age was 61.0 ± 15.0 years, and 9.6% were Hispanic (n = 18), 9.6% were Asian (n = 18), 6.9% were Black or African American (n = 13), and 73.8% were White (n = 138). Participants had a mean Scott-Triggers IAPI risk score of 1.5 ± 1.1. Among those with no erythema preoperatively, fewer intervention participants exhibited postoperative erythema on their face and chest than did preintervention participants. Further, fewer intervention participants had SEM-defined IAPIs at all locations in comparison with preintervention participants. The MFSF dressings overcame IAPI risk factors of surgery length, skin tone, and body mass index with fewer IAPIs in intervention participants. CONCLUSIONS: Patients undergoing prone-position surgeries developed fewer IAPIs, and SEM measures indicated no damage when MFSF dressings were applied to sites preoperatively. The SEM measures detected more damage than visual assessment.

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.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BACKGROUND: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population. METHODS/DESIGN: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care. DISCUSSION: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01763203 .

Validation of blood-based assays using dried blood spots for use in large population studies.

Assessment of health in large population studies has increasingly incorporated measures of blood-based biomarkers based on the use of dried blood spots (DBS). The validity of DBS assessments made by labs used by large studies is addressed by comparing assay values from DBS collected using conditions similar to those used in the field with values from whole blood samples. The DBS approach generates values that are strongly related to whole blood levels of HbA1c, cystatin C, and C-reactive protein. Assessing lipid levels reliably with DBS appears to be a greater challenge. However, even when DBS values and values from venous blood are highly correlated, they are often on a different scale, and using conventional cutoffs may be misleading.

RR interval variability is inversely related to inflammatory markers: the CARDIA study.

Recent evidence reveals that the immune system is under the direct control of the vagus nerve via the "cholinergic anti-inflammatory pathway." Stimulation of vagus nerve activity significantly inhibits cytokine levels in animal models, and cholinergic agents inhibit cytokine release by human macrophages. Moreover, when vagus nerve activity is decreased or absent, cytokines are overproduced. Atherosclerosis is an inflammatory disease characterized by elevated levels of CRP and IL-6, but the relationship between cardiac vagal activity and cytokine levels in healthy humans is not well understood. Here we measured RR interval variability, an index of cardiac vagal modulation, and CRP and IL-6 in 757 subjects participating in a subset of the year 15 data collection in the CARDIA study of the evolution of risk factors in young adults. Univariate analysis revealed that all indices of RRV were strongly and inversely related to IL-6 (log pg/mL b=-0.08 and -0.17 for HF and LF power, P<0.001 respectively) and CRP (log mg/L b=-0.14 and -0.26 for HF and LF power, P<0.001 respectively) levels. In the multivariate model including gender, race, age, smoking, physical activity, SBP, BMI, and disease, the inverse relationship between RRV and inflammatory markers, although slightly attenuated, remained significant. These findings are consistent with the hypothesis that diminished descending vagal anti-inflammatory signals can allow cytokine overproduction in humans.

Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: the CARDIA Study.

OBJECTIVES: We examined the effects of self-reported experiences of racial discrimination on Black-White differences in preterm (less than 37 weeks gestation) and low-birthweight (less than 2500 g) deliveries. METHODS: Using logistic regression models, we analyzed data on 352 births among women enrolled in the Coronary Artery Risk Development in Young Adults Study. RESULTS: Among Black women, 50% of those with preterm deliveries and 61% of those with low-birthweight infants reported having experienced racial discrimination in at least 3 situations; among White women, the corresponding percentages were 5% and 0%. The unadjusted odds ratio for preterm delivery among Black versus White women was 2.54 (95% confidence interval [CI]=1.33, 4.85), but this value decreased to 1.88 (95% CI=0.85, 4.12) after adjustment for experiences of racial discrimination and to 1.11 (95% CI=0.51, 2.41) after additional adjustment for alcohol and tobacco use, depression, education, and income. The corresponding odds ratios for low birthweight were 4.24 (95% CI=1.31, 13.67), 2.11 (95% CI=0.75, 5.93), and 2.43 (95% CI=0.79, 7.42). CONCLUSIONS: Self-reported experiences of racial discrimination were associated with preterm and low-birthweight deliveries, and such experiences may contribute to Black-White disparities in perinatal outcomes.

Absence of risk factor change in young adults after family heart attack or stroke: the CARDIA Study.

BACKGROUND: Health behavior theories suggest that occurrence of heart attack or stroke in an immediate family member should increase one's perceived susceptibility to these conditions, which might lead to improved risk factor behavior and control. METHODS: Changes in measures of smoking, physical activity, lipids/lipoproteins, body weight, and blood pressure were investigated over two consecutive 5-year follow-up periods among 3950 participants (aged 18 to 30 years) in the Coronary Artery Risk Development in Young Adults (CARDIA) study, who either did or did not have an immediate family member experience a heart attack or stroke. Recruitment and examinations for Years 0, 5, and 10 took place in 1985-1986, 1990-1991, and 1995-1996, respectively. RESULTS: After adjustment for baseline demographics and risk factors, young adults who experienced a change in family history of heart attack or stroke over a 5-year period were no more likely than those who did not to quit smoking, or to experience more positive changes in weight, physical activity, LDL cholesterol, HDL cholesterol, triglycerides, or systolic or diastolic blood pressure. These findings persisted among the few study participants with one or more established risk factors at baseline. CONCLUSIONS: The occurrence of a heart attack or stroke in an immediate family member does not appear to lead to self-initiated, sustained change in modifiable risk factors in young adults. Since family history of heart attack and stroke is associated with known risk factors and is an independent risk factor for incident development of these conditions, interventions should be developed and tested to motivate sustained risk-factor control following occurrence of a severe vascular event in a family member.