The Puerto Rico Young Adults' Stress, Contextual, Behavioral & Cardiometabolic Risk (PR-OUTLOOK) Study: Design and Methods.

The Puerto Rico (PR) Young Adults' Stress, Contextual, Behavioral & Cardiometabolic Risk Study (PR-OUTLOOK) is investigating overall and component-specific cardiovascular health (CVH) and cardiovascular disease (CVD) risk factors in a sample of young (age 18-29) Puerto Rican adults in PR (target n=3,000) and examining relationships between individual-, family/social- and neighborhood-level stress and resilience factors and CVH and CVD risk factors. The study is conducting standardized measurements of CVH and CVD risk factors and demographic, behavioral, psychosocial, neighborhood, and contextual variables and establishing a biorepository of blood, saliva, urine, stool, and hair samples. The assessment methods are aligned with other National Heart, Lung, and Blood Institute funded studies: the Puerto Rico Observational Study of Psychosocial, Environmental, and Chronic Disease Trends (PROSPECT) of adults 30-75 years, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), the Boston Puerto Rican Health Study (BPRHS), and the Coronary Artery Risk Development in Young Adults (CARDIA). PR-OUTLOOK data and its biorepository will facilitate future longitudinal studies of the temporality of associations between stress and resilient factors and CVH and CVD risk factors among young Puerto Ricans, with remarkable potential for advancing the scientific understanding of these conditions in a high-risk but understudied young population.

Racial and ethnic disparities in utilization of total knee arthroplasty among older women.

OBJECTIVE: To evaluate racial and ethnic disparities in utilization of total knee arthroplasty (TKA) in relation to demographic, health, and socioeconomic status variables. DESIGN: Prospective study of 102,767 Women's Health Initiative postmenopausal women initially aged 50-79, examining utilization rates of primary TKA between non-Hispanic Black/African American, non-Hispanic White, and Hispanic/Latina women (hereafter referred to as Black, White, and Hispanic). A total of 8,942 Black, 3,405 Hispanic, and 90,420 White women with linked Medicare claims data were followed until time of TKA, death, or transition from fee-for-service coverage. Absolute disparities were determined using utilization rates by racial/ethnic group and relative disparities quantified using multivariable hazards models in adjusting for age, arthritis, joint pain, mobility disability, body mass index, number of comorbidities, income, education, neighborhood socioeconomic status (SES), and geographic region. RESULTS: TKA utilization was higher among White women (10.7/1,000 person-years) compared to Black (8.5/1,000 person-years) and Hispanic women (7.6/1,000 person-years). Among women with health indicators for TKA including diagnosis of arthritis, moderate to severe joint pain, and mobility disability, Black and Hispanic women were significantly less likely to undergo TKA after adjusting for age [Black: HR (95% confidence interval) = 0.70 (0.63-0.79); Hispanic: HR = 0.58 (0.44-0.77)]. Adjustment for SES modestly attenuated the measured disparity, but significant differences remained [Black: HR = 0.75 (0.67-0.89); Hispanic: HR = 0.65 (0.47-0.89)]. CONCLUSIONS: Compared to White women, Black and Hispanic women were significantly less likely to undergo TKA after considering need and appropriateness for TKA and SES. Further investigation into personal-level and provider-level factors that may explain these disparities is warranted.

Expression of inflammatory markers in women with perinatal depressive symptoms.

Perinatal depression affects 10-20% of women and is associated with poor outcomes for mother and child. Inflammation is associated with depression in non-pregnant adults. Perinatal depression and inflammation in pregnancy are independently associated with morbidities including obesity, gestational diabetes, preeclampsia, and preterm birth. The role of inflammation in perinatal depression has received little attention. We hypothesized an association between self-reported perinatal depressive symptoms and serum inflammatory biomarkers TNF-α, IL-6, IL-1ß, and CRP. 110 healthy gravidas were recruited in third trimester from an academic medical center, with a baseline study visit at a mean of 32.5 (SD ± 1.8) weeks gestational age. Sixty-three participants completed the Edinburgh Postnatal Depression Scale (EPDS) and provided demographic information and serum samples upon enrollment and at 3 and 6 months postpartum. Serum inflammatory markers were quantified by multiplex array. Multiple linear mixed effects models were used to evaluate trends of biomarkers with the EPDS score in the third trimester of pregnancy and the postpartum period. Elevated serum TNF-α was associated with lower EPDS total score (ß = - 0.90, p = 0.046) after adjusting for demographics and medication use. In contrast, IL-6, CRP, and IL-1ß did not demonstrate statistically significant associations with depressive symptoms by the EPDS in either crude or adjusted models. Study findings showed no association or an inverse (TNF-α) association between inflammatory markers and perinatal depressive symptoms. Relevant literature evaluating a role for inflammation in depression in the unique context of pregnancy is both limited and inconsistent, and further exploration is merited.

A pregnancy lifestyle intervention to prevent gestational diabetes risk factors in overweight Hispanic women: a feasibility randomized controlled trial.

AIMS: To pilot the feasibility of a prenatal lifestyle intervention to modify physical activity and diet among pregnant overweight and obese Hispanic women, with the aim of reducing risk factors for gestational diabetes mellitus. METHODS: Women were randomized either to a lifestyle intervention (n = 33, 48.5%), consisting of a culturally and linguistically modified, motivationally targeted, individually tailored 6-month prenatal programme, or to standard care (n = 35, 51.5%). Bilingual and bicultural health educators encouraged women to achieve guidelines for physical activity, decrease saturated fat and increase dietary fibre. Outcomes included gestational weight gain, infant birth weight and biomarkers associated with insulin resistance. RESULTS: Patient retention up to delivery was 97% in both study groups. The lifestyle intervention attenuated the pregnancy-associated decline in moderate-intensity physical activity, but differences between groups were not significant (mean ± se -23.4 ± 16.6 vs -27.0 ± 16.2 metabolic equivalent of task h/week; P = 0.88). Vigorous-intensity activity increased during the course of pregnancy in the lifestyle intervention group (mean ± se 1.6 ± 0.8 metabolic equivalent of task h/week) and declined in the standard care group (-0.8 ± 0.8 metabolic equivalent of task h/week; P = 0.04). The lifestyle intervention group also had slightly lower gestational weight gain and infant birth weights compared with the standard care group; however, these differences were not statistically significant. There were no statistically significant differences in biomarkers of insulin resistance between groups. CONCLUSIONS: Findings suggest that a motivationally matched lifestyle intervention is feasible and may help attenuate pregnancy-related decreases in vigorous physical activity in a population of overweight and obese Hispanic women. The intervention protocol can readily be translated into clinical practice in underserved and minority populations.

[Design and development of a dietary intervention in children with prediabetes]. / Diseño y desarrollo de una intervención dietética en niños con prediabetes.

INTRODUCTION: Prediabetes is a pathological condition where the blood glucose concentration is higher than normal concentrations, but lower than those considered in the diagnosis of type 2 diabetes mellitus (DM2). Until a few years ago, the prediabetes condition occurred in adults with associated risk factors such as overweight or obesity, sedentary lifestyle, poor eating habits, cardiovascular problems, etc. In recent years it has begun to be detected in children, with the family habits that these children have established becoming increasingly important. MATERIAL AND METHODS: In our study, 29 pre-diabetic children from Pedro Abad, Córdoba, have been evaluated. For this, we have carried out a randomized crossover trial with an intervention group (IG) and a control group (CG), using a dietary intervention with nutritional reinforcement. The main objective of the present study was to determine if the eating habits of pre-diabetic children improved with a dietary intervention based on nutritional education. RESULTS: Through a nutritional evaluation through different tests and visits made to the children, the results corresponding to the first phase of the study, relate an improvement in eating habits and adherence to the Mediterranean Diet by the intervened children. CONCLUSIONS: The eating habits of pre-diabetic children improve with a dietary intervention based on nutritional education, since by providing them with knowledge of the different foods and the contribution of nutrients that they provide us, they can make a better selection of foods.

Tsukamurella: a cause of catheter-related bloodstream infections.

Tsukamurellae are strictly aerobic Gram-positive rods that can be easily misidentified as Corynebacterium species, Rhodococcus species, Nocardia species, Mycobacterium species, or other Gram-positive aerobic rods. They have been uncommonly reported as a cause of different human infections, including bloodstream infections. We describe 2 new cases of catheter-related bloodstream infections (CR-BSI) caused by Tsukamurella species and review 12 similar cases reported in the literature. Conventional procedures have often misidentified Tsukamurella species as other aerobic Gram-positive rods. This misidentification could be avoided using genotyping. All cases ultimately required the withdrawal of the infected line. The literature provides no firm conclusions regarding ideal choice or duration of antimicrobial therapy for this infection. Tsukamurella species should be added to the list of agents able to produce CR-BSI. Genotypic methods such as PCR 16S rRNA can allow a reliable identification at the genus level of Tsukamurella strains faster than a combination of conventional phenotypic methods.

Comparison of three vascular endothelial markers in the evaluation of microvessel density in breast cancer.

PURPOSE: To evaluate the microvessel density by comparing the performance of anti-factor VIII-related antigen, anti-CD31 and anti-CD34 monoclonal antibodies in breast cancer. METHODS: Twenty-three postmenopausal women diagnosed with Stage II breast cancer submitted to definitive surgical treatment were evaluated. The monoclonal antibodies used were anti-factor VIII, anti-CD31 and anti-CD34. Microvessels were counted in the areas of highest microvessel density in ten random fields (200 x). The data were analyzed using the Kruskal-Wallis nonparametric test (p < 0.05). RESULTS: Mean microvessel densities with anti-factor VIII, anti-CD31 and anti-CD34 were 4.16 +/- 0.38, 4.09 +/- 0.23 and 6.59 +/- 0.42, respectively. Microvessel density as assessed by anti-CD34 was significantly greater than that detected by anti-CD31 or anti-factor VIII (p < 0.0001). There was no statistically significant difference between anti-CD31 and anti-factor VIII (p = 0.4889). CONCLUSION: The density of stained microvessels was greater and staining was more intense with anti-CD34 compared to anti-CD31 and anti-factor VIII-related antigen.

Predictors of adherence in the Women's Health Initiative Calcium and Vitamin D Trial.

The authors analyzed data from the Women's Health Initiative (WHI) Calcium and Vitamin D Supplementation Trial (CaD) to learn more about factors affecting adherence to clinical trial study pills (both active and placebo). Most participants (36,282 postmenopausal women aged 50-79 years) enrolled in CaD 1 year after joining either a hormone trial or the dietary modification trial of WHI. The WHI researchers measured adherence to study pills by weighing the amount of remaining pills at an annual study visit; adherence was primarily defined as taking > or = 80% of the pills. The authors in this study examined a number of behavioral, demographic, procedural, and treatment variables for association with study pill adherence. They found that relatively simple procedures (ie, phone contact early in the study [4 weeks post randomization] and direct social contact) later in the trial may improve adherence. Also, at baseline, past pill-use experiences, personal supplement use, and relevant symptoms may be predictive of adherence in a supplement trial.

Ectopic breast cancer in the anterior chest wall: a case report and literature review.

Ectopic breast cancer is rare and when situated in the chest wall, it is even rarer. This report describes the case of an 86-year old Brazilian woman with a palpable carcinoma, located in the right inframammary fold, and right axillary adenopathy. The patient was submitted to excision of the accessory breast and to right axillary lymphadenectomy. All 28 resected lymph nodes contained metastatic cells. Diagnosis and treatment of ectopic breast cancer should be carried out early in view of its aggressivity.

PDA-assisted low glycemic index dietary intervention for type II diabetes: a pilot study.

BACKGROUND: Epidemiological and dietary intervention studies suggest that a low-glycemic index (GI) diet is beneficial for blood glucose control; however, long-term clinical utility of the low GI diet has not been fully investigated. OBJECTIVES: To evaluate the feasibility and efficacy of a nutritionist-delivered low-GI dietary intervention, with the support of a personal digital assistant (PDA), for adult patients with poorly controlled type II diabetes. METHOD: The low-GI intervention consisted of six counseling sessions and the use of a PDA-based food database with GI scores for 6 months. Study outcomes included feasibility measures, glycosylated hemoglobin levels (HbA1c), GI and glycemic load (GL) score of self-reported dietary intake, body weight, depression and quality of life (QOL). Measures were obtained at baseline, 3 and 6 months. RESULTS: Of 31 adult patients approached, 15 met study eligibility criteria and were enrolled in the study. Thirteen patients (87%) completed all study assessments. Findings included decreases in average HbA1c (-0.5% P = 0.02), body weight, hip circumference, blood pressure, dietary GI and daily caloric intake. Diabetes impact scores also decreased. All but one participant completed all components of the intervention. There were mixed reports regarding the usefulness of the PDAs; however, participants offered helpful suggestions for further development. CONCLUSIONS: Results of this pilot study support the feasibility of implementing a nutritionist-delivered, PDA-assisted low-GI dietary intervention for patients with poorly controlled type II diabetes. Encouraging initial efficacy data require further testing in the context of a randomized clinical trial.

Women in Control: Pioneering Diabetes Self-Management Medical Group Visits in the Virtual World.

Background: The current state of diabetes self-management (DSM) education and support for diabetic patients is inadequate, especially for minority women who experience disproportionately high rates of diabetes mellitus (DM) in the US. While DSM education and support enables individuals with diabetes to make positive lifestyle choices and achieve clinical goals, this type of support is difficult to deliver in medical practice settings. Virtual reality can assist DM patients and their clinical teams by providing effective educational tools in an engaging, learner-centered environment that fosters self-efficacy and skill proficiency. Methods: Our prior research demonstrated that virtual worlds are suitable for supporting DSM education. Building upon this success, we are now investigating whether DSM virtual world medical group visits lead to similarly effective health and educational outcomes compared to face-to-face medical group visits. Currently in year one of a five year randomized controlled trial, we aim to compare the effectiveness of a virtual world DSM medical group visit format versus a face-to-face DSM medical group visit format to increase physical activity and improve glucose control (HbA1c) among Black/African American and Hispanic women with uncontrolled DM. We will also conduct a qualitative study of participant engagement with the virtual world platform to characterize learners' interactions with the technology and assess its correlation with DSM behaviors and diabetes control. Discussion: Novel methods to promote diabetes self-management are critically needed, and the use of virtual world technology to conduct medical group visits offers a unique approach to such issue. If successful, our intervention will increase access to culturally-sensitive diabetes care and improve patient engagement in online DSM learning, leading to higher uptake of DSM behaviors and better diabetes control. Importantly, the program can be easily expanded to other chronic disease areas and scaled for widespread use.

Seasonal variation of blood cholesterol levels: study methodology.

This manuscript provides a description of the methodology used in the Seasonal Variation of Blood Cholesterol Levels (SEASON) study, with the intent of informing the scientific community of the available data sets and to invite a dialogue with scientists in complementary fields. The primary aim of the SEASON study is to describe and delineate the causes of seasonal variation of blood lipid levels in the general population. This research project is designed specifically to systematically collect and analyze a number of important variables necessary to study the role of seasonality in blood lipids and relevant covariates.

Seasonal variation of depression and other moods: a longitudinal approach.

The present study examined the effect of season of the year on depression and other moods. Previous work, primarily cross sectional or retrospective in design and involving clinically depressed or seasonally affective disordered samples, has suggested that mood changes as a function of season. However, the literature also shows conflicting and/or inconsistent findings about the extent and nature of this relationship. Importantly, these prior studies have not adequately answered the question of whether there is a seasonal effect in nondepressed people. The present study employed a longitudinal design and a large sample drawn from a normal population. The results, based on those participants for whom mood measures were collected in each season, demonstrated strong seasonal effects. Beck Depression Inventory (BDI) scores were highest in winter and lowest in summer. Ratings on scales of hostility, anger, irritability, and anxiety also showed very strong seasonal effects. Further analyses revealed that seasonal variation in BDI scores differed for females and males. Females had higher BDI scores that showed strong seasonal variation, whereas males had lower BDI scores that did not vary significantly across season of the year.

Coronary Artery Smoking Intervention Study (CASIS): 5-year follow-up.

The authors compared the effect of a behavioral multicomponent smoking cessation special intervention (SI) to an advice-only intervention (AO) on smoking status at 5 years for smokers with coronary disease (n = 160). Regression analyses revealed an interaction between intervention type and disease severity such that patients in the SI group with greater degrees of coronary artery disease showed significantly higher cessation rates (odds ratio = 344 for 3-vessel disease in the SI vs. AO, p = .01). Factors predicting maintained abstinence included having 12 or more years of education, contemplating quitting smoking or being ready to begin action to quit at baseline, and having a higher self-efficacy score.

A longitudinal study of students' depression at one medical school.

PURPOSE: Using a standardized measure of depression at three assessment points, to examine depression in medical students during their training. METHOD: Students entering the University of Massachusetts Medical School in the fall in 1987, 1988, and 1989 were mailed a recruitment letter and baseline questionnaire four weeks prior to the start of classes. Subsequent assessments took place in the middles of year 2 and year 4 and included only the students who had participated in the baseline assessment. The baseline assessment included the Center for Epidemiological Studies Depression (CES-D) scale, the Bortner Type A Behavior scale, the Spielberger Trait Anger scale, and the Spielberger Anger Expression scale. In addition, the baseline package included a rating of perceived stress, a demographics questionnaire, and a social-life survey. The follow-up assessments included the CES-D scale, the rating of perceived stress level, and the social-life survey. Analytic methods used were univariate descriptive statistics, correlation, and multiple-linear-regression analyses, two-sample t-tests, analysis of variance, and chi-square tests. RESULTS: Of the initial pool of 300 students, 264 responded at the baseline assessment (88% response rate; 53% men); 171 of these participated in the year-2 assessment (65% response rate; 51% men), and 126 participated in the year-4 assessment (48% response rate; 48% men); a total of 99 students participated in all three assessments. CES-D scores > or =80th percentile were obtained for 18% of the entering students. This rose to 39% at year 2 and 31% at year 4 (p = .0001). No gender difference was found at baseline; however, the women experienced higher depression levels than did the men at year 2 (p = .004) and at year 4 (p = .04). Overall, gender and increases in perceived stress (from baseline to year 2) were significant predictors of increased CES-D scores (from baseline to year 2; p = .01 and p = .0001, respectively). For the women, increased perceived stress, angerin, and frequency of social contacts outside work/school were significant predictors of the magnitude of increases in CES-D scores (baseline to year 2; p = .0001, p = .02, and p = .03, respectively). CONCLUSION: These preliminary data support the view that, upon entering medical school, students' emotional status resembles that of the general population. However, the rise in depression scores and their persistence over time suggest that emotional distress during medical school is chronic and persistent rather than episodic. Also, the women had more significant increases in depression scores than did the men.

Facilitating dietary change: the patient-centered counseling model.

Recent data indicate that the patient-centered counseling model enhances long-term dietary adherence. This model facilitates change by assessing patient needs and subsequently tailoring the intervention to the patient's stage in the process of change, personal goals, and unique challenges. This article describes this model, including its theoretical foundations, a 4-step counseling process, and applications. This behavioral counseling model can help nutrition professionals enhance patient adherence to nutrition care plans and dietary guidelines.

Sexual functioning post-myocardial infarction: effects of beta-blockers, psychological status and safety information.

Impaired sexual functioning limits the quality of life of 34-75% of post-myocardial infarction (MI) patients. This study examined the effects of three factors: (a) beta-blocker intake, (b) psychological distress, and (c) information about safety of sexual activity, on post-MI decreased sexual functioning. Sixty-three male post-MI, post-cardiac rehabilitation patients and their spouses participated in the study. Analyses of partial variance were conducted to test for the effect of each factor on sexual functioning. Controlling for age, results revealed that patients' psychological distress explained uniquely 24% of the variance on decreased post-MI sexual activity (p < 0.002). Beta-blocker intake and message received with regard to sexual activity safety were not significant predictors of observed changes. Interdisciplinary assessments and interventions are recommended.

Sequence and seasonal effects of salivary cortisol.

Assessments of cortisol levels in saliva have been widely used by both researchers and clinicians as an index of adrenal functioning. Quarterly measurements of morning and evening cortisol levels were determined in a longitudinal study of 147 participants (72 women and 75 men) followed for 1 year each. The analysis of salivary cortisol revealed no significant gender or age differences in the sample. There was a sequence effect in quarterly cortisol values with a progressive decrease in serial measurements, especially notable in the morning values; as well as a seasonal variation in cortisol levels with significantly higher levels found in winter and fall, compared with spring and summer. The findings in this study suggest that repeated saliva sampling and seasonal variation in cortisol levels may independently affect adrenal response and, therefore, need to be accounted for in longitudinal studies.