Association of neighborhood gentrification and residential moves with hypertension and diabetes control in Los Angeles County, 2014-2019: A retrospective cohort study.

OBJECTIVE: To examine whether gentrification exposure is associated with future hypertension and diabetes control. METHODS: Linking records from an integrated health care system to census-tract characteristics, we identified adults with hypertension and/or diabetes residing in stably low-SES census tracts in 2014 (n = 69,524). We tested associations of census tract gentrification occurring between 2015 and 2019 with participants' disease control in 2019. Secondary analyses considered the role of residential moves (possible displacement), race and ethnicity, and age. RESULTS: Gentrification exposure was associated with improved odds of hypertension control (aOR: 1.08; 95% CI: 1.00, 1.17), especially among non-Hispanic Whites and adults >65 years. Gentrification was not associated with diabetes control overall, but control improved in the Hispanic subgroup. Disease control was similar regardless of residential moves in the overall sample, but disparate associations emerged in models stratified by race and ethnicity. CONCLUSIONS: Residents of newly gentrifying neighborhoods may experience modestly improved odds of hypertension and/or diabetes control, but associations may differ across population subgroups. POLICY IMPLICATIONS: Gentrification may support-or at least not harm-cardiometabolic health for some residents. City leaders and health systems could partner with impacted communities to ensure that neighborhood development meets the goals and health needs of all residents and does not exacerbate health disparities.

Academic, clinical and personal experiences of undergraduate healthcare students during the COVID-19 pandemic: A prospective cohort study.

BACKGROUND: Coronavirus disease 2019 has impacted upon the role and safety of healthcare workers, with the potential to have a lasting effect on their wellbeing. Limited research has been conducted during previous pandemics exploring how student healthcare workers are impacted as they study and train for their professional careers. OBJECTIVE: The aim of the current study was to examine the specific impact of COVID-19 on the academic, clinical and personal experiences of healthcare students. METHOD: Undergraduate students across three year groups within the School of Health Sciences at Ulster University completed online Qualtrics surveys at three timepoints during one academic year (2020/2021). Quantitative survey data was downloaded from Qualtrics into SPSS Version 25 for descriptive analysis of each cross-sectional sample. Qualitative survey data was downloaded into text format, which was thematically analysed using content analysis. RESULTS: 412 students completed the survey at Time 1 (October 2020), n = 309 at Time 2 (December 2020) and n = 259 at Time 3 (April 2021). Academically, the pandemic had mostly a negative impact on the learning environment, the development of practical skills, the assessment process and opportunities for peer learning and support. Students reported increased stress and challenges managing their workload and maintaining a sense of motivation and routine. Clinically, they felt unprepared by the university for placement where the pandemic had an increasingly negative impact over time on learning and skill development. In terms of personal experiences, despite the majority of students taking steps to keep physically and mentally well, negative impacts on friendships, mental wellbeing and concerns for family were reported. The pandemic had not impacted upon career choice for most students. CONCLUSION: Consideration must be given to the development of practical skills so students feel prepared for their professional careers given the practical nature of their roles. Programme coordinators should adopt a holistic approach to student wellbeing.

Older Adult Suicides: What You Should Know and What You Can Do.

Suicide among most age groups has been on the rise in the United States for the past 20 years. Suicide is currently the 10th leading cause of death in the United States, but suicide completion and suicide attempts may be underreported. Suicide is a very personal act often predicated on a sense of hopelessness and despair, but often prompted by very addressable factors such as pain and social isolation. This article will use a case narrative to illustrate life circumstances that may influence suicidal thinking. In addition, risk factors are addressed. Lastly, the article addresses some useful assessment tools to gauge suicide risk among older adult clients and provides resources for home care clinicians.

The Integration of Clinical and Research Training: How and Why MD-PhD Programs Work.

For over 60 years, MD-PhD programs have provided integrated clinical and research training to produce graduates primed for physician-scientist careers. Yet the nature of this integrated training is poorly characterized, with no program theory of MD-PhD training to guide program development or evaluation. The authors address this gap by proposing a program theory of integrated MD-PhD training applying constructs from cognitive psychology and medical education. The authors argue that integrated physician-scientist training requires development of at least three elements in trainees: cognitive synergy, sense of self, and professional capacity. First, integrated programs need to foster the cognitive ability to synergize and transfer knowledge between the clinical and research realms. Second, integrated programs need to facilitate development of a unique and emergent identity as a physician-scientist that is more than the sum of the individual roles of physician and scientist. Third, integrated programs should develop core competencies unique to physician-scientists in addition to those required of each independently. The authors describe how programs can promote development of these elements in trainees, summarized in a logic model. Activities and process measures are provided to assist institutions in enhancing integration. Specifically, programs can enact the proposed theory by providing tailored MD-PhD curricula, personal development planning, and a supportive community of practice. It is high time to establish a theory behind integrated MD-PhD training as the basis for designing interventions and evaluations to develop the foundations of physician-scientist expertise.

Efficacy of a Chronic Care-Based Intervention on Secondary Stroke Prevention Among Vulnerable Stroke Survivors: A Randomized Controlled Trial.

BACKGROUND: Disparities of care among stroke survivors are well documented. Effective interventions to improve recurrent stroke preventative care in vulnerable populations are lacking. METHODS AND RESULTS: In a randomized controlled trial, we tested the efficacy of components of a chronic care model-based intervention versus usual care among 404 subjects having an ischemic stroke or transient ischemic attack within 90 days of enrollment and receiving care within the Los Angeles public healthcare system. Subjects had baseline systolic blood pressure (SBP) ≥120 mm Hg. The intervention included a nurse practitioner/physician assistant care manager, group clinics, self-management support, report cards, decision support, and ongoing care coordination. Outcomes were collected at 3, 8, and 12 months, analyzed as intention-to-treat, and used repeated-measures mixed-effects models. Change in SBP was the primary outcome. Low-density lipoprotein reduction, antithrombotic medication use, smoking cessation, and physical activity were secondary outcomes. Average age was 57 years; 18% were of black race; 69% were of Hispanic ethnicity. Mean baseline SBP was 150 mm Hg in both arms. SBP decreased to 17 mm Hg in the intervention arm and 14 mm Hg in the usual care arm; the between-arm difference was not significant (-3.6 mm Hg; 95% confidence interval, -9.2 to 2.2). Among secondary outcomes, the only significant difference was that persons in the intervention arm were more likely to lower their low-density lipoprotein <100 md/dL (2.0 odds ratio; 95% confidence interval, 1.1-3.5). CONCLUSIONS: This intervention did not improve SBP control beyond that attained in usual care among vulnerable stroke survivors. A community-centered component could strengthen the intervention impact. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT00861081.

A 10-year estimate of the incidence of decompression illness in a discrete group of recreational cave divers in Australia.

INTRODUCTION: The vast majority of freshwater cave diving in Australia occurs within the limestone caves of the Gambier karst in the south-east of South Australia. The incidence of decompression illness (DCI) in cave divers is presumed to be higher than open-water recreational divers because of the greater depths involved, but has not previously been reported. Our aim was to determine the incidence of DCI in cave divers, the patterns of diving and the outcome of hyperbaric treatment. METHODS: This was a retrospective cohort study of cave divers with DCI presenting to the Royal Adelaide Hospital or The Alfred Hospital over a 10-year period between 2002 and 2012. We reviewed case notes of cave divers who were treated for DCI after diving in the Mt Gambier karst. As there are no records of the number of dives performed during the study period we generated a denominator for the incidence of DCI by extrapolating available data and making a number of assumptions about the number of dives per dive permit issued. RESULTS: Sixteen patients were treated for DCI during the study period. The precipitating dive was a single deep decompression dive in seven cases, multiday repetitive dive sequences in eight and a non-decompression dive in one. Three of the 16 cases of DCI involved dives in excess of 90 metres' fresh water (mfw) using trimix. As the total estimated number of dives in the study period was approximately 57,000 the incidence of DCI in Australian cave divers was estimated to be 2.8:10,000 (0.028%). It is possible that the overall incidence of DCI is as high as 0.05%, and even higher when dives to depths greater than 90 mfw are involved. CONCLUSIONS: The estimated incidence of DCS in this series is lower than expected but consistent with other series describing DCI in cold-water recreational diving.

The effect of physician workload on an educational intervention to increase vitamin D screening.

RATIONALE, AIMS AND OBJECTIVE: Changes in physician behavior are difficult to accomplish. We hypothesized measuring physicians' vitamin D levels would increase measurement of their patients' levels. METHODS: We recruited faculty via e-mail. We measured physicians' serum 25(OH)D levels and asked them to complete a questionnaire created to assess the risk of vitamin D deficiency. Physicians received their vitamin D test results by mail. We monitored physicians' vitamin D testing rate per 100 patient visits in the 12 weeks before and after receipt of their own vitamin D test result. RESULTS: Twenty-eight (22%) of 126 primary care physicians participated in the study; all were Caucasian and 17 (61%) were women. Gender, practic type, and year of graduation from medical school were similar in participants and non-participants. Over half of participants took a multivitamin and a third took a vitamin D supplement. Although 6 (21%) reported a recent fracture, only 1 physician carried a diagnosis of osteopenia or osteoporosis. At baseline, geriatricians ordered 14 vitamin D tests per 100 patient visits, while internists and family practitioners ordered substantially fewer tests (2 and <1 tests per 100 visits, respectively). After study participation, vitamin D testing rates increased significantly among family practitioners (rate ratio 3.27, 95% CI 1.29-8.33) and internists (rate ratio 3.19, 95% CI 1.12-9.07). Physicians with heavier clinic workloads were half as likely (rate ratio 0.50, 95% CI 0.32-0.76) as those with lighter clinic workloads to increase vitamin D testing rates. Surprisingly, physicians with hypovitaminosis D demonstrated no change in vitamin D testing rates. CONCLUSIONS: Physicians with low vitamin D testing rates were receptive to a personal intervention involving measurement of their own vitamin D levels. High workload appeared to attenuate this effect. These novel but preliminary observations require confirmation in future studies.

Vitamin D repletion does not alter urinary calcium excretion in healthy postmenopausal women.

OBJECTIVE: To evaluate, in a posthoc analysis of a previous study, whether vitamin D repletion in postmenopausal women with insufficient vitamin D increases urinary calcium excretion, as vitamin D therapy might contribute to hypercalciuria and calcium stones in susceptible individuals, and the effect of vitamin D on the risk of urolithiasis warrants attention. SUBJECTS AND METHODS: We recruited 18 women at > or =5 years after menopause who had vitamin D insufficiency (serum 25(OH)-vitamin D, 16-24 mg/dL). We excluded women with a history of urolithiasis and kidney disease. Women had one calcium absorption study when vitamin D-insufficient, received vitamin D therapy, and completed a second calcium absorption study when vitamin D-replete. We fed subjects meals that mirrored the nutrient composition from self-reported 7-day diet diaries. To measure calcium absorption, we collected urine for 24 h during both visits. RESULTS: We achieved vitamin D repletion in all women (25(OH)-vitamin D before and after treatment, 22 and 63 mg/dL, respectively; P < 0.001). The mean calcium intake was 832 mg/day. Residual urine specimens were available for 16 women, allowing a measurement of 24-h urinary calcium. Calcium excretion did not change after vitamin D therapy (212 before vs 195 mg/day after; P = 0.60). Of four women with hypercalciuria (>247 mg/day), calcium excretion decreased in three (377-312 mg/day, not significant). CONCLUSION: Vitamin D supplementation did not increase the urinary calcium excretion in healthy postmenopausal women. Many stone formers are at risk of premature bone loss, vitamin D insufficiency, or both. Based on the present results we suggest a study of patients with hypercalciuria and nephrolithiasis to determine the risks of vitamin D therapy.

Vitamin D and musculoskeletal health.

Vitamin D is critical for calcium homeostasis. Following cutaneous synthesis or ingestion, vitamin D is metabolized to 25(OH)D and then to the active form 1,25(OH)2D. Low serum vitamin D levels are common in the general population and cause a decline in calcium absorption, leading to low serum levels of ionized calcium, which in turn trigger the release of parathyroid hormone, promoting skeletal resorption and, eventually, bone loss or osteomalacia. Vitamin D deficiency is generally defined as a serum 25(OH)D concentration <25-37 nmol/l (<10-15 ng/ml), but the definition of the milder state of vitamin D insufficiency is controversial. Three recent meta-analyses concluded that vitamin D must be administered in combination with calcium in order to substantially reduce the risk of nonvertebral fracture in adults over the age of 50 years. Fracture protection is optimal when patient adherence to medication exceeds 80% and vitamin D doses exceed 700 IU/day. In addition to disordered calcium homeostasis, low vitamin D levels might have effects on cell proliferation and differentiation and immune function. Randomized, double-blind, placebo-controlled trials are needed to clarify whether vitamin D supplementation is beneficial in cancer, autoimmune disease and infection. This Review focuses on the pathophysiology, clinical correlates, evaluation and treatment of hypovitaminosis D.

Research into EPRs: how midwives really feel.

This article describes some of the findings of a two-year research project entitled The use of electronic patient records (EPRs) in maternity services: professional and public acceptability, commissioned by the Department of Health (DH). The main methods used were: --Literature review. --A national telephone survey of heads of midwifery (HOMs) in England (2001). --Case studies of maternity services in four NHS Trusts (2002). One of the findings of the research was that midwives and HOMs considered they had little knowledge of what EPRs are, and most were confused about whether their existing maternity information system (MIS) constituted an EPR system. The exact nature of EPRs was also contested among information technology (IT) professionals and NHS Trusts' EPR development strategies varied. Each Trust was, and still is, developing their own response to Information for health (NHS executive, 1998). Broadly speaking, these fell into one of two main categories of approach to EPR development. First, a 'best of breed' approach meant that departmental information systems, such as MISs were to be part of future EPR systems, and these specialist systems would become part of an inter-connected EPR system by being gradually connected with other departmental and Trust-wide information systems. Second, a 'big bang' or 'one-system' approach meant all departmental systems were in the process of being replaced by a single supplier's system for the whole Trust, and specialist departments were expected to meet their information needs by using specialist modules within this system. The relative merits of each approach were hotly debated both locally and nationally during the course of the research project. Another finding was that midwives had little interest in EPRs, although the views expressed were contradictory. While midwives were not interested in being involved in EPR developments, they did want to see midwifery interests represented. Nearly all midwives and midwifery managers expected their perspective to be provided by the 'IT midwife'. The definition of this role varied in different services. Also, the research found that not all IT midwives were accepted by colleagues as appropriate representatives of their needs. At a time when there are increasing pressures on midwives to expand their role, (Department of Health, 1999: RCM, 2002b) we argue that midwives should play a more proactive role in the development of EPRs. The example is given of the claim that EPR systems save practitioners time (NHS executive, 1998). The research showed that maternity EPR systems consumed more time for midwives than they saved, although where midwives could see the clinical value of having the system this burden was considered more acceptable. Midwives should ask more questions about the value of the information systems they use and the new EPR systems that are being rolled out, and this needs to be encouraged by midwifery educators.