Harvest for health in survivors of chronic disease: A demonstration project in the Alabama Black Belt and Mississippi Delta Region.

This demonstration project expands upon the Harvest for Health vegetable gardening intervention for cancer survivors by: (i) including survivors of other chronic diseases (i.e. heart disease and diabetes); and (ii) targeting an area with known health inequities (Alabama Black Belt and Mississippi Delta Region). To assess: (i) gardening acceptability (engagement, satisfaction, sustainability, and safety); and (ii) changes over time in health behaviors (fruit and vegetable [F&V] intake, and physical activity) and outcomes (physical performance and anthropometrics). Chronic disease survivors (CDS) were recruited across 15 counties in Alabama and Mississippi and provided with gardening supplies and paired with a master gardener (MG). MGs mentored participants in planning, planting, and maintaining a vegetable garden over a 3-month period. Data collection consisted of an electronic survey (baseline, post-intervention, 6-month follow-up) and community-based physical assessments (baseline and post-intervention). Participants (n = 137; 92% African American; Mage = 65) included individuals with a history of diabetes (56%), heart disease (29%), and cancer (26%). Seventy-five percent of participants engaged in gardening ≥3 times a week. Significant improvements in F&V intake (+0.73, P = .04), physical activity (+49.6, P < .01), and 4 of 7 physical performance measures were observed, while positive trends were seen in others. Eighteen participants withdrew (13% attrition rate). No adverse events occurred. Participants were satisfied with their gardening experience (90%) and were still gardening at 6-month follow-up (85%). Seventy-two percent of participants expanded, or planned on expanding, their garden at 6-month follow-up. Harvest for Health was acceptable and associated with improved health behaviors and outcomes.

In the Alabama Black Belt and Mississippi Delta region of the USA, incidence and mortality rates of high-burden chronic diseases (cancer, cardiovascular disease, and diabetes) are among the highest in the nation. Behavioral risk factors associated with chronic disease include low fruit and vegetable intake and physical inactivity. Vegetable gardening is a holistic approach to improving these health behaviors. Harvest for Health, a mentored home-based vegetable gardening intervention, pairs cancer survivors with master gardener (MG) mentors to guide survivors in planning, planting, and maintaining a vegetable garden. The current demonstration project expands upon Harvest for Health by: (i) including survivors of cardiovascular disease and diabetes (in addition to cancer); and (ii) targeting an area with known health inequities (Alabama Black Belt and Mississippi Delta). One hundred thirty-seven chronic disease survivors (CDS) enrolled in the 3-month demonstration project. Participants were provided gardening supplies for a summer garden and MG mentorship over a 3-month period. Participants engaged in gardening several times a week, reported satisfaction with their gardening experience, and were still gardening at 6-month follow-up. Improvements among CDS were seen in health behaviors (fruit and vegetable intake and physical activity) and physical well-being (physical function battery and weight).

Long-term missing role of small colloids and nanoparticles on the loading and speciation of phosphorus in catfish aquaculture ponds in west Alabama.

Increasing loading of phosphorus (P) into freshwater systems is deemed as one of the key drivers triggering harmful algal blooms (HABs). However, conventional water quality monitoring of P normally uses the operational cutoff (e.g., 450-nm filter membrane) to separate particulate and dissolved phases (entities passing through the 450-nm membrane are regarded as dissolved phase), which completely neglects the roles of small colloids (450-100 nm) and nanoparticles (100-1 nm). Herein, a new particle size separation approach was used to separate water samples collected from catfish aquaculture ponds in west Alabama into six size fractions: large particles (>1000 nm), large colloids (1000-450 nm), small colloids (450-100 nm), large nanoparticles (100-50 nm), small nanoparticles (50-1 nm), and the truly dissolved phase (<1 nm). The speciation and concentration of P in these six size fractions were then investigated using Hedley's sequential extraction method. The new particle size separation results showed that particle loading (mass) followed the order: >1000 nm, 450-100 nm, 1000-450 nm, 100-50 nm, and 50-1 nm. This is mainly due to the abundance of large-sized (>1000 nm) zooplankton and phytoplankton such as algae and cyanobacteria in the catfish aquaculture ponds. Importantly, the small colloid (450-100 nm) and nanoparticle (100-1 nm) size fractions, which were previously regarded as the dissolved phase using the 450-nm membrane filtration operation, accounted for ∼41.8% of the total particle mass. The Hedley's sequential extraction results showed that sodium hydroxide (NaOH)-extracted P represented the largest P pool, followed by water (H2O)- and sodium bicarbonate (NaHCO3)-extracted P pools. Smaller particles exhibited a higher loading of P due to their large surface areas. These new findings suggest that the new particle size separation approach needs to be adopted for future water quality monitoring and mitigation of HABs in freshwater ecosystems.

What has changed in pediatric neurosurgical care in spina bifida? A 30-year UAB/Children's of Alabama observational overview.

Spina bifida (SB) remains the most serious and most common congenital anomaly of the human nervous system that is compatible with life. The open myelomeningocele on the back is perhaps the most obvious initial problem, but the collective impact of dysraphism upon the entirety of the nervous system and innervated organs is an equal or greater longitudinal threat. As such, patients with myelomeningocele (MMC) are best managed in a multi-disciplinary clinic that brings together experienced medical, nursing, and therapy teams that provide high standards of care while studying outcomes and sharing insights and experiences. Since its inception 30 years ago, the spina bifida program at UAB/Children's of Alabama has remained dedicated to providing exemplary multi-disciplinary care for affected children and their families. During this time, there has been great change in the care landscape, but many of the neurosurgical principles and primary issues have remained the same. In utero myelomeningocele closure (IUMC) has revolutionized initial care and has favorable impact on several important co-morbidities of SB including hydrocephalus, the Chiari II malformation, and the functional level of the neurologic deficit. Hydrocephalus however is not solved by IUMC, and hydrocephalus management remains at the center of neurosurgical care in SB. Ventricular shunts were long the cornerstone of treatment for hydrocephalus, but we came to assess and incorporate endoscopic third ventriculostomy with choroid plexus coagulation (ETV-CPC). Educated and nurtured by an experienced senior mentor, we dedicated ourselves to fundamental concepts but persistently evaluated our care outcomes and evolved our protocols and paradigms for improvement. Active conversations amidst networks of treasured colleagues were central to this development and growth. While hydrocephalus support and treatment of tethered spinal cord remained our principal neurosurgical charges, we evolved to embrace a holistic perspective and approach that is reflected and captured in the Lifetime Care Plan. Our team engaged actively in important workshops and guideline initiatives and was central to the development and support of the National Spina Bifida Patient Registry. We started and developed an adult SB clinic to support our patients who aged out of pediatric care. Lessons there taught us the importance of a model of transition that emphasized personal responsibility and awareness of health and the crucial role of dedicated support over time. Support for sleep, bowel health, and personal intimate cares are important contributors to overall health and care. This paper details our growth, learning, and evolution of care provision over the past 30 years.

Legacy phosphorus in Alabama Hartsells soil after long-term amendment with broiler litter.

Numerous studies have investigated effects of long-term manure application on total phosphorus (P) and inorganic P (Pi ), but few have evaluated soil organic P (Po ). Little is known about crop management effects on Po in soils with varying minerology. In this study, sequential fractionation was used to characterize specific P forms after 25 years of broiler litter (BL) or ammonium nitrate (Con) applications to an Alabama Hartsells soil. Crops (corn [Zea mays L.], soybean [Glycine Willd.], and corn or soybean with a wheat [Triticum aestivum L.] cover crop) were under conventional tillage (CT) or no-tillage (NT). Regardless of crop, tillage, or fertilizer type, the proportion of extractable Pi was relatively stable at 21%-49% at 0-5 cm and 25%-45% at 5-10 cm. Extractable Pi ranged from 0.69 to 2.4 mg g-1 . BL increased total extractable Pi (p ≤ 0.001) at 0-5 cm and 5-10 cm. Total extractable P was influenced at 0-5 cm (p ≤ 0.006) by both tillage and fertilization type, but not at 5-10 cm or at either depth in soybean plots. Long-term BL application increased total extractable soil P at 0-5 cm. In corn systems, CT did not reduce P loading to topsoil or result in P leaching to lower soil depths, compared to NT. Soybean and soybean-wheat reduced P loading in BL plots, compared to corn and corn-wheat. Soil Po was classed in the order of monoesters > phytate and polyphosphates, where most was extractable with NaOH. BL increased extractable Po in all fractions. Care should be taken when applying BL to highly weathered soils to avoid legacy Po accumulation. Soybean rotations and cover crops could help remediate P-laden soils after repeated BL application.

Prospective feasibility study of a mindfulness-based program for breast cancer patients in the southeastern US.

BACKGROUND: Mindfulness interventions can improve psychological distress and quality of life (QoL) in cancer survivors. Few mindfulness programs for cancer recovery exist in Southeastern U.S. The primary objective of this study was to assess the feasibility of a modified mindfulness-based stress reduction (MBSR) program for breast cancer patients in Birmingham, Alabama. The secondary objective was to explore potential program effects on mindfulness skills and QoL. METHODS: This study was a prospective, quasi-experimental feasibility study conducted over 10 months at a university hospital. Feasibility was achieved if 80% of eligible patients screened enrolled in the study and 70% of enrolled patients attended all 8 program sessions. Effectiveness was estimated by changes in mindfulness and QoL indicators measured with validated scales administered at 3 time points and assessed with a non-parametric Friedman test. Sessions included meditation, yoga, and an attention practice called body scan. There were 3 groups of 2-5 patients. RESULTS: The sample totaled 12 patients. Forty-four percent (12/27) of eligible patients enrolled in the study, and two out of 12 enrolled patients completed 8 program sessions, resulting in 16.7% (2/12) retention. However, more than half (66.7%) of participants completed at least 7 sessions. Between baseline and 8-week follow-up, patients demonstrated statistically significant improvements in distress, general wellbeing, and fatigue-related QoL. CONCLUSIONS: Feasibility objectives were not achieved. However, a majority of participants (66.7%) completed 7 of 8 program sessions. Program effects were promising for distress, fatigue, and wellbeing. Results warrant further research on MBSR-like programs for breast cancer patients in Alabama.

Nature-Based Therapies for Sleep Disorders in People Living with Human Immunodeficiency Virus.

Following diagnosis of human immunodeficiency virus (HIV), getting adequate sleep may be the farthest thing from the mind of patients or providers. Even further from mind are the potential benefits on both sleep and HIV from nature-based therapy. In developing and developed countries, access to high-quality natural spaces has the potential to support physical and mental health. This article provides a review of sleep disorders, conventional and nature-based therapies, and the potential of nature-based therapy to support the health of people living with HIV through increased restorative sleep and immune function.

Racial differences in dietary choices and their relationship to inflammatory potential in childbearing age women at risk for exposure to COVID-19.

Since the ongoing coronavirus disease 2019 (COVID-19) pandemic is linked to chronic inflammation, people with initial lower inflammatory status could have better outcomes from exposure to this disease. Because dietary habits are one of the most important modifiable risk factors for inflammation, identification of dietary components associated with inflammation could play a significant role in controlling or reducing the risk of COVID-19. We investigated the inflammatory potential of diets consumed by African American (AA) and Caucasian American (CA) women of childbearing age (n = 509) who are at high risk for exposure to COVID-19 by being residents of Birmingham, Alabama, a city severely affected by this pandemic. The overall pro- and anti- inflammatory scores were calculated using dietary intake data gathered using Block food frequency questionnaire. The proinflammatory potential of diets consumed by AAs was significantly higher compared to CAs. Several anti- and proinflammatory nutrients and food groups consumed differed by race. With consumption of a greater number of antioxidants and B-vitamins, CAs switched toward an anti-inflammatory score more effectively than AAs while AAs performed better than CAs in improving the anti-inflammatory score with the consumption of a greater number of minerals and vitamin D. Effective race-specific dietary modifications or supplementation with nutrients identified will be useful to improve proinflammatory diets toward anti-inflammatory. This approach could aid in controlling the current COVID-19 pandemic and future pandemics of a similar nature in women at risk for exposure.

Pediatric ingestions with gummy formulated medications: a retrospective study.

CONTEXT: Gummy formulations are widely available with estimated 65% marketed for children. Currently, there are few studies describing children ingesting gummy formulated medications. The aim of this study was to quantify and identify the type of ingestions due to gummy formulated medications, evaluate their clinical significance as defined by adverse outcomes: associated symptoms, emergency department (ED) visits, and hospitalizations. METHODS: Retrospective study in children aged 0-19 exposed to gummy formulated medications from 2015 to 2017 as identified by calls made to the Regional Poison Control Center (RPCC). A list of potentially toxic gummy formulated medications was compiled and reviewed by medical and clinical toxicologists. We categorized medications into vitamins, minerals and supplements, melatonin, and other. Data collected included: medication name, number of units, age, sex, symptoms described, ED visit, hospitalization, and unintentional or intentional ingestion. DISCUSSION: Of the 66,059 pediatric exposures received by RPCC, 1143 (1.7%) involved gummy formulated medications of which 1098 were analyzed. Median age was 3 years, 57.7% were males and 7% were symptomatic. Seventy-four percent exposures involved vitamins and 24% melatonin. In comparison to other gummy exposures, those who ingested melatonin had 8.4 times higher odds of being symptomatic (OR: 8.4, 95% CI: 5.1, 14) and 4.8 times higher odds of visiting ED (OR: 4.8, 95% CI: 2.5, 9). The predominant symptoms reported were drowsiness, gastrointestinal upset, and hyperactivity. Two patients were hospitalized who ingested multiple medications, one was unintentional, and one was intentional as a suicide attempt thus admitted for psychiatric stabilization. CONCLUSIONS: Gummy formulated medications comprised <2% of the total pediatric calls to the RPCC. Although, the occurrence of symptoms is rare, these medications especially those containing melatonin should be safely stored.

Community-Level Factors and HIV Health Among Older People Living With HIV (PLWH) in Alabama, United States: A Qualitative Analysis.

ABSTRACT: As the number of older people living with HIV (PLWH) is increasing, there is an urgent need for research on community-level factors to better understand the health care needs of this population. In-depth interview transcripts of 20 older PLWH who participated in a community-based participatory research study conducted in Alabama, in the United States, were analyzed through a phenomenological research approach. Results suggest that crime, lack of resources, and social isolation experienced at the community levels were found to be associated with the wellbeing of older PLWH. Moreover, community characteristics may confound older PLWH's comorbid conditions and resultant polypharmacy. An increased understanding of the impact of contextual factors on HIV health can inform more holistic individual- and community-level interventions aimed at addressing barriers to retention or re-engagement in HIV medical care and viral suppression among older PLWH.

MYONECROSIS AND DEATH DUE TO PRESUMED MICROCYSTIN TOXICOSIS IN AMERICAN WHITE PELICANS (PELECANUS ERYTHRORHYNCOS).

Over a period of 5 mo, seven out of eight American white pelicans (Pelecanus erythrorhynchos) housed on a spring-fed pond at a zoo died or were euthanized. Clinical signs included inability to stand, anorexia, and weight loss. Clinicopathologic findings included heterophilic leukocytosis and elevated creatine kinase and aspartate aminotransferase. Histopathologic findings on all pelicans demonstrated severe, chronic, diffuse rhabdomyofiber degeneration and necrosis, making vitamin E deficiency a differential diagnosis despite routine supplementation. Based on tissue and pond water assays for the cyanobacterial toxin, microcystin, toxicosis is suspected as the inciting cause of death in these cases. We hypothesize that vitamin E exhaustion and resultant rhabdomyodegeneration and cardiomyopathy were sequelae to this toxicosis.

Understanding Preferences for Addressing Spirituality Among Adults Seeking Outpatient Mental Health Care.

Focusing on 472 religiously heterogenous adult patients seeking psychotherapy at a university-based outpatient clinic, this brief report examined (1) these patients' preferences about clinicians appreciating their religion and/or spirituality (R/S) backgrounds (spiritually affirming) and addressing spiritual concerns in treatment (spiritually integrated) and (2) role of demographic factors and psychological functioning in predicting preferences for R/S integration. Analyses revealed that more than half of patients reported moderate or greater importance for spiritually affirming care and one-third hoped to address spiritual issues. Furthermore, these factors emerged as indicators of stronger preferences for R/S integration: female sex, racial minority status (African American, Native American), history of marriage (past and present), affiliation to organized religion (Christianity, Islam), and importance placed on R/S. In general, findings suggest that most patients seeking psychotherapy in a university-based clinic in southern Alabama might desire a spiritually affirming approach, and a smaller subset prefer an approach in which R/S is integrated into treatment.

Early and prehospital trauma deaths: Who might benefit from advanced resuscitative care?

BACKGROUND: Recent civilian and military data from the United States and the United Kingdom suggest that further reductions in mortality will require prehospital or preoperating room hemorrhage control and blood product resuscitation. The aims of this study were to examine the potential preventability of prehospital and early in-hospital fatalities, and to consider the geographical location of such incidents, to contextualize how the use of advanced resuscitative techniques could be operationalized. METHODS: Retrospective analysis of prehospital and early in-hospital trauma deaths from January to December 2017. Data were obtained from the Coroner/ME's Office. Each death was reviewed by a panel of two trauma surgeons and a forensic pathologist. Anatomical and physiological survivabilities were evaluated separately, and then combined, leading to a holistic assessment of preventability. Incident locations were mapped and analyzed using ArcGIS. RESULTS: Three hundred sixteen trauma deaths were identified. Two hundred thirty-one (73%) were deemed anatomically not survivable; 29 (9%) anatomically survivable, but only with hospital care; 43 (14%) anatomically survivable with advanced prehospital care; and 13 (4%) anatomically survivable with basic prehospital care. Physiologically, 114 (36%) of the patients had been dead for some time when found; 137 (43%) had no cardiorespiratory effort on arrival of Emergency Medical Services (EMS) at the scene; 24 (8%) had cardiorespiratory effort at the scene, but not on arrival at the emergency department; and 41 (13%) had cardiorespiratory effort on arrival at the emergency department, but died shortly after. Combining the assessments, 10 (3%) deaths were deemed probably not preventable, 38 (12%) possibly preventable, and the remaining 278 (85%) not preventable. CONCLUSION: Twelve percent of trauma deaths were potentially preventable and might be amenable to advanced resuscitative interventions. Operationalizing this type of care will be challenging and will require either prehospital doctors, or very highly trained paramedics, nurses, or physician assistants. LEVEL OF EVIDENCE: Epidemiological, level III.

Petroleum hydrocarbons in semipermeable membrane devices deployed in the Northern Gulf of Mexico and Florida keys following the Deepwater Horizon incident.

The Deepwater Horizon (DWH) oil spill from April to July of 2010 contaminated Gulf of Mexico waters through release of an estimated 4.1 × 106 barrels of oil. Beginning in June of 2010, semipermeable membrane devices (SPMDs) were deployed near areas with sensitive marine habitats (Alabama Alps and Western Shelf) potentially exposed to that oil. Elevated TPAH50 concentrations, flux rates and similarity of histograms and diagnostic ratios for polycyclic aromatic hydrocarbons (PAH) from SPMDs to weathered floating oil collected during the DWH spill indicates the Alabama Alps habitats were affected. While not affected by oil from the DWH spill, the temporal pattern of PAH contamination of SPMDs deployed near the Western Shelf between July 2010 and March 2011 could indicate prevailing currents affected contaminant transport to the Western Shelf Area (East and West Flower Garden, Sonnier, and Stetson Banks) from non-DWH sources, including oil and gas exploration, shipping, and Mississippi River effluent.

Implementation of a Shared Medical Appointment as a Holistic Approach to CHF Management.

Congestive heart failure is a costly chronic disease within the United States. The purpose of this study was to examine the effect of a holistic shared medical appointment (SMA) approach to congestive heart failure. Findings suggest the SMA approach improves depression, quality of life (QOL), and health-promoting behaviors. This study implemented congestive heart failure self-management education in primary care using a holistic multidisciplinary approach with SMA to provide evidence-based interventions to improve depression, QOL, and health promotion outcomes. Patients participating in the holistic multidisciplinary SMA experienced improvement in depression, QOL, and health promotion behaviors. A comparison of the means between preintervention and postintervention showed an overall reduction in systolic blood pressure, weight, depression scores, QOL scores, and several indicators of health promotion lifestyle.

A rapid UHPLC-MS/MS method for quantitation of phytoestrogens and the distribution of enterolactone in an Alabama estuary.

Endocrine disrupting chemicals (EDCs) are natural or synthetic compounds that can interfere with the endocrine systems of humans and wildlife. EDCs can pass through wastewater treatment systems, or run off from urban areas or agricultural operations, into natural water bodies, exposing resident and migratory organisms to complex EDC mixtures. Some phytoestrogenic polyphenolics (PEPP) are known or suspected EDCs; however, their contribution to total EDC burden in natural surface water systems is largely unknown. We describe a rapid, sensitive, and reproducible quantitative method for analysis of 15 PEPP in estuarine sediment and water, using ultra-high performance liquid chromatography-triple quadrupole mass spectrometry (UHPLC-MS/MS). The method provides excellent peak resolution, peak separation, and rapid run times (method separation/total run time: 8/12.5 min). With two exceptions, spiking experiments demonstrated that the percent recoveries for target PEPP in sediment and water samples were within acceptable analytical validation limits. LOD and LOQ values ranged from 0.004 to 0.010 ng/injection and 0.013-0.032 ng/injection, respectively. The validated method was used for PEPP analysis of sediment and water samples collected from 11 locations within the Perdido Bay estuary in coastal Alabama. No PEPP above the LOD were detected in sediment samples. The mammalian-derived lignin enterolactone was observed at low concentrations in water throughout the estuary, and significantly, at elevated concentrations at two locations associated with small-scale septic systems (3.66 ±â€¯0.27 ng L-1 and 4.01 ±â€¯0.33 ng L-1) and a large wastewater treatment system (4.56 ±â€¯0.24 ng L-1 and 5.69 ±â€¯0.43 ng L-1).

Program Evaluation of Camp V.I.P: Promoting Self-confidence and Independence for Patients with Spina Bifida.

PURPOSE: Camp V.I·P (Victory, Independence, Possibilities) was established by the Spina Bifida Association of Alabama in 2012. The goal is to provide children with spina bifida (SB) and their families a traditional-style summer camp focusing on self-empowerment and fostering independence in medical self-management. DESIGN AND METHODS: Part 1 of this study describes Camp V.I·P. structure. Part 2 describes an online survey to caregivers of campers gauging camp effectiveness and value and evaluating perceptions of confidence/independence and family connections. Camper characteristics were compared to the overall SB clinic population. RESULTS: 63 children with SB, 81 siblings, and over 100 caregivers have attended camp. Campers are similar to the overall clinic population in race, gender, and ambulation status. At camp, there are significantly more children with myelomeningocele (versus other spinal dysraphism) and lumbar functional level (versus thoracic). Survey results show that confidence grew in 93% of campers, and 86% gained greater independence. Parents stated that they created lifelong friendships. The majority of caregivers (91%) indicated "certainty" that they would attend camp again. CONCLUSION: Camp V.I·P is a family-centered environment that emphasizes respite, nurture, and the continuum between family and clinic. Our research shows that camp can be a useful tool to aid in independence, confidence, and social adaption. PRACTICE IMPLICATIONS: Camp has become an integral part of our comprehensive care of children with SB and has been shown to reinforce what is taught through the clinic by creating trust between the care team and campers.

Hurricane Isaac brings more than oil ashore: Characteristics of beach deposits following the Deepwater Horizon spill.

Prior to Hurricane Isaac making landfall along the Gulf of Mexico coast in August 2012, local and state officials were concerned that the hurricane would mobilize submerged oiled-materials from the Deepwater Horizon (DWH) spill. In this study, we investigated materials washed ashore following the hurricane to determine if it affected the chemical composition or density of oil-containing sand patties regularly found on Gulf Coast beaches. While small changes in sand patty density were observed in samples collected before and after the hurricane, these variations appear to have been driven by differences in sampling location and not linked to the passing of Hurricane Isaac. Visual and chemical analysis of sand patties confirmed that the contents was consistent with oil from the Macondo well. Petroleum hydrocarbon signatures of samples collected before and after the hurricane showed no notable changes. In the days following Hurricane Isaac, dark-colored mats were also found on the beach in Fort Morgan, AL, and community reports speculated that these mats contained oil from the DWH spill. Chemical analysis of these mat samples identified n-alkanes but no other petroleum hydrocarbons. Bulk and δ13C organic carbon analyses indicated mat samples were comprised of marshland peat and not related to the DWH spill. This research indicates that Hurricane Isaac did not result in a notable change the composition of oil delivered to beaches at the investigated field sites. This study underscores the need for improved communications with interested stakeholders regarding how to differentiate oiled from non-oiled materials. This is especially important given the high cost of removing oiled debris and the increasing likelihood of false positives as oiled-materials washing ashore from a spill become less abundant over time.

Diabetes Self-Management Education and Medical Nutrition Therapy: A Multisite Study Documenting the Efficacy of Registered Dietitian Nutritionist Interventions in the Management of Glycemic Control and Diabetic Dyslipidemia through Retrospective Chart Review.

BACKGROUND: Diabetes self-management education (DSME) and medical nutrition therapy (MNT) improve glycemic control and reduce risk of chronic comorbid disease. OBJECTIVE: Document outcomes for patients with type 2 diabetes (T2D) completing DSME and MNT through American Diabetes Association-recognized programs. DESIGN: Descriptive, retrospective chart review. PARTICIPANTS/SETTING: Four random samples of 100 records of patients with T2D completing DSME and MNT at each of four regional centers in Alabama, June 2013 to 2014, were chosen for review; after exclusions, 392 records were retained. OUTCOME MEASURES: Weight, body mass index (BMI), hemoglobin A1c (HbA1c), total cholesterol, low-density lipoprotein, high-density lipoproteins (HDL), triglycerides (TG), and TG-to-HDL ratio. ANALYSIS: Mixed-model analysis of variance was used to determine differences between continuous variables. McNemar test was used to assess frequency of patients reaching glycemic targets. Paired t tests were used to determine significance of lipid parameters. RESULTS: Significant reductions were observed at end of program and 1 year in weight (2.67±5.54 kg, P<0.001; 2.25±5.45 kg, P=0.001), BMI (0.93±1.91, P<0.001; 0.76±1.93, P=0.001), and HbA1c (1.82%±2.23%, P<0.001; 1.22%±2.15%, P<0.001). Patients managed by diet alone had a mean baseline HbA1c of 6.95% and exhibited a 0.8% reduction in HbA1c (P<0.001) at end of program. Those managed with diet plus drug therapy had a baseline HbA1c of 9% and exhibited a 2.09% reduction in HbA1c (P<0.001). Following DSME and MNT, 62% of patients reached glycemic targets (HcA1c≤7%), as compared with 32% at baseline (P<0.001). Significant reductions in TG were observed from baseline (162±74 mg/dL [4.19±1.91 mmol/L]) to follow-up (109±36 mg/dL [2.82±0.92 mmol/L]) (P<0.001). HDL increased from baseline (45±13 mg/dL [1.16±0.34 mmol/L]) to follow-up (48±11 mg/dL [1.24±0.28 mmol/L]) (P=0.05). The TG-to-HDL ratio improved from a baseline of 4.07±2.41 to 2.48±1.26 at follow-up (P<0.001). CONCLUSIONS: Reductions were observed in weight, BMI, HbA1c, TG, and TG-to-HDL ratio. Improved patient outcomes were achieved in the clinical setting and support universal coverage to increase patient access to DSME and MNT.

Factors Associated With Marijuana Use Among Treatment-seeking Adult Cigarette Smokers in the Criminal Justice Population.

OBJECTIVES: Due to the elevated rates of cigarette use and marijuana use within the criminal justice system, it is critical to develop a stronger understanding of tobacco and marijuana co-use among this population to inform future interventions. METHODS: This study is a secondary analysis of baseline data from a smoking cessation randomized clinical trial of adults (n = 500) in a community correction program. Participants were classified as using cigarettes only or both cigarettes and marijuana through either self-report or positive urine drug screening. Demographics and measures regarding legal, drug use, smoking, mental health, and interpersonal histories were assessed. Logistic regression analyses were conducted to assess factors associated with co-use. RESULTS: Among adults who smoked cigarettes, 25% reported current marijuana use. Individuals who used both cigarettes and marijuana were more likely than those who only used cigarettes to be African American (80%), male (73.6%), and younger (M = 32.4 [SD = 11.0]). Increasing difficulties with last quit attempt was associated with a reduction in the likelihood of co-use (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.60-0.94, P < 0.05), and benzodiazepine (OR 9.09, 95% CI 1.25-65.94, P < 0.05) and opioid (OR 8.17, 95% CI 2.03-32.93, P < 0.01) use was significantly associated with an increased likelihood of co-use. CONCLUSIONS: This study identified several factors that are associated with an increased risk of cigarette and marijuana co-use among a community correction population. These findings will be valuable for informing targeted prevention and treatment interventions.

Treatment of apixaban- and rivaroxaban-associated major bleeding using 4-factor prothrombin complex concentrate.

There is limited clinical experience with the use of coagulation concentrates to reverse the effect of direct oral anticoagulants. We assess the achievement of effective clinical hemostasis with the use of 4-factor prothrombin complex concentrate (PCC) in patients on apixaban or rivaroxaban presenting with major bleeding. A retrospective chart review was conducted at a tertiary referral medical center in the USA. We assess the achievement of clinical hemostasis using 4-factor PCC in patients on chronic apixaban or rivaroxaban therapy presenting with major bleeding. Clinical hemostasis was assessed by the International Society of Thrombosis and Hemostasis Scientific and Standardization Subcommittee criteria. A total of 29 patients are included in the study. The most common site of bleeding was intracranial hemorrhage (ICH) (72.4%), followed by gastrointestinal bleed (13.8%). Clinical hemostasis was achieved in 21 (72.4%) patients. Patients who did not achieve clinical hemostasis (27.6%) suffered from ICH, and all of them died during hospitalization except for two patients who were discharged with neurologic deterioration. One patient developed multiple brain infarctions after receiving 4-factor PCC. Sixteen patients (55.2%) were receiving concomitant medications that interact with apixaban and rivaroxaban and increase the risk of bleeding. Four-factor PCC appears to be effective in achieving clinical hemostasis in patients on apixaban or rivaroxaban presenting with major bleeding. It may be an alternative to patients who need anticoagulation reversal if the specific antidote, andexanet alfa, is not available.