The impact of fear of hypoglycaemia on sleep in adolescents with type 1 diabetes.

AIMS: Fear of hypoglycaemia (FOH) can contribute to impaired sleep for adults with type 1 diabetes (T1D) and parents of children with T1D, although it is unknown how FOH may affect sleep for adolescents with T1D. This study examines the relationship between adolescent FOH and sleep and assessed the influences of continuous glucose monitor (CGM) and insulin pump use. METHODS: Adolescents ages 14-18 years with T1D completed questionnaires evaluating FOH (Child Hypoglycemia Fear Survey) and sleep (Pittsburgh Sleep Quality Index, PSQI). Analyses included linear and logistic regression, t-tests and Fisher's exact tests. RESULTS: Participants included 95 adolescents (52 female) with a median (IQR) age of 16.5 (15.3-17.7) years and a T1D duration of 5.7 (2.5-9.6) years. Analyses showed increased FOH-Worry subscale scores were associated with reduced sleep duration (ß = -0.03, p = 0.042, adjusting for BMI z-score, race and ethnicity) and increased sleep disturbances (OR = 1.1, p = 0.038, adjusting for race and ethnicity). Frequent CGM users had longer sleep duration (average 7.5 h) compared with infrequent or non-CGM users (average = 6.8 h; p = 0.029), and pump users had overall improved sleep health as determined by PSQI score (p = 0.019). Technology use did not have significant interactions in the relationships between FOH and sleep duration or sleep disturbances. CONCLUSIONS: Worrying about hypoglycaemia was associated with impaired sleep for adolescents with T1D. Diabetes technology users have some sleep improvements, but CGM and pump use do little to alter the relationship between FOH and sleep outcomes.

Chronic Intravenous Inotropic Support as Palliative Therapy and Bridge Therapy for Patients With Advanced Heart Failure: A Single-Center Experience.

BACKGROUND: Many patients with American College of Cardiology/American Heart Association Stage D (advanced) heart failure are discharged home on chronic intravenous inotropic support (CIIS) as bridge to surgical therapy or as palliative therapy. This study analyzed the clinical trajectory of patients with advanced heart failure who were on home CIIS. METHODS: We conducted a single-institution, retrospective cohort study of patients on CIIS between 2010 and 2016 (n = 373), stratified by indication for initiation of inotropic support. Study outcomes were time from initiation of CIIS to cessation of therapy, time to death for patients who did not receive surgical therapy and rates of involvement with palliative care. RESULTS: Overall, patients received CIIS therapy for an average of 5.9 months (standard deviation [SD] 7.3). Patients on CIIS as palliative therapy died in an average of 6.2 months (SD 6.6) from the time of initiation of CIIS, and those on CIIS as bridge therapy who did not ultimately receive surgical therapy died after an average of 8.6 months (SD 9.3). Patients who received CIIS as bridge therapy were significantly less likely to receive palliative-care consultation than those on inotropes as palliative therapy, whether or not they underwent surgery. CONCLUSIONS: In this large cohort of patients with advanced HF, patients who on CIIS as palliative therapy survived for 6.2 months, on average, with wide variation among patients. Patients who were on CIIS as bridge therapy but did not ultimately receive surgical therapy received less palliative care despite the high mortality rate in this subgroup.

Virtual reality for pain management in advanced heart failure: A randomized controlled study.

BACKGROUND: Hospitalized patients with advanced heart failure often experience acute and/or chronic pain. While virtual reality has been extensively studied across a wide range of clinical settings, no studies have yet evaluated potential impact on pain management on this patient population. AIM: To investigate the impact of a virtual reality experience on self-reported pain, quality-of-life, general distress, and satisfaction compared to a two-dimensional guided imagery active control. DESIGN: Single-center prospective randomized controlled study. The primary outcome was the difference in pre- versus post-intervention self-reported pain scores on a numerical rating scale from 0 to 10. Secondary outcomes included changes in quality-of-life scores, general distress, and satisfaction with the intervention. SETTING/PARTICIPANTS: Between October 2018 and March 2020, 88 participants hospitalized with advanced heart failure were recruited from an urban tertiary academic medical center. RESULTS: Participants experienced significant improvement in pain score after either 10 minutes of virtual reality (change from pre- to post -2.9 ± 2.6, p < 0.0001) or 10 minutes of guided imagery (change from pre- to post -1.3 ± 1.8, p = 0.0001); the virtual reality arm experienced a 1.5 unit comparatively greater reduction in pain score compared to guided imagery (p = 0.0011). Total quality-of-life and general distress scores did not significantly change for either arm. Seventy-eight participants (89%) responded that they would be willing to use the assigned intervention again. CONCLUSION: Virtual reality may be an effective nonpharmacologic adjuvant pain management intervention in hospitalized patients with heart failure. TRIAL REGISTRATION: ClinicalTrials.gov database (NCT04572425).

Short communication: Long-term -20°C survival of Listeria monocytogenes in artificially and process-contaminated ice cream involved in an outbreak of listeriosis.

Listeria monocytogenes was linked to an outbreak of foodborne illness associated with in-process contaminated ice cream in the United States from 2010 to 2015 that sickened 10 individuals and led to 3 deaths. Ice cream obtained from the outbreak was used in this study to examine the population dynamics of L. monocytogenes as in-process contaminants compared with artificially inoculated cells. Because challenge studies of food products generally use artificial contamination, it is necessary to understand the differences in survival, if any, between these 2 types of contaminants. We hypothesized that laboratory-grown cultures of the pathogen that were not exposed to the environmental stresses of the manufacturing facility would show different population dynamics in an ice cream challenge study compared with in-process contaminants. In this study, half of the outbreak-associated ice cream samples were artificially inoculated with a 10 cfu/g cocktail of L. monocytogenes; the other half contained only the in-process contaminants. All samples were stored at -20°C and tested for pathogen levels (n = 10 for each contaminant type at each time point) by the most probable number method at 3-mo intervals for 36 mo. Generally, population levels between the 2 contamination states in the ice cream were not significantly different and L. monocytogenes survived for at least 36 mo, regardless of contamination state. Overall, our results suggest that the use of L. monocytogenes as an artificial contaminant in challenge studies and risk assessment of ice cream during frozen storage give results similar to those shown by in-process contaminants.

Efficacy of quality improvement and patient safety workshops for students: a pilot study.

BACKGROUND: While the Association of American Medical Colleges encourages medical schools to incorporate quality improvement and patient safety (QI/PS) into their curriculum, medical students continue to have limited QI/PS exposure. To prepare medical students for careers that involve QI/PS, the Institute for Healthcare Improvement chapter at an allopathic medical school and school of allied health professions initiated self-directed learning by offering student-led workshops to equip learners with skills to improve the quality and safety of healthcare processes. METHODS: In this prospective cohort study, workshops were hosted for medical students between 2015 and 2018 on five QI/PS topics: Process Mapping, Root-Cause Analysis (RCA), Plan-Do-Study-Act (PDSA) Cycles, Evidence Based Medicine (EBM), and Patient Handoffs. Each workshop included a hands-on component to engage learners in practical applications of QI/PS skills in their careers. Change in knowledge, attitudes, and behaviors was assessed via pre- and post-surveys using 5-point Likert scales, and analyzed using either the McNemar test or non-parametric Wilcoxon signed-rank test. Surveys also gathered qualitative feedback regarding strengths, future areas for improvement, and reasons for attending the workshops. RESULTS: Data was collected from 88.5% of learners (n = 185/209); 19.5% of learners reported prior formal instruction in these topics. Statistically significant improvements in learners' confidence were observed for each workshop. Additionally, after attending workshops, learners felt comfortable teaching the learned QI/PS skill to colleagues (mean pre/post difference 1.96, p < 0.0001, n = 139) and were more likely to pursue QI/PS projects in their careers (mean pre/post difference 0.45, p < 0.0001, n = 139). Lastly, learners demonstrated a statistically significant increase in knowledge in four out of five skills workshop topics. CONCLUSION: Few medical students have formal instruction in QI/PS tools. This pilot study highlights advantages of incorporating an innovative, student-directed modified 'flipped classroom' methodology, with a focus on active experiential learning and minimal didactic instruction.

Quantitation of viable Coxiella burnetii in milk products using a liquid medium-based MPN-PCR assay.

This Technical Research Communication describes a new method by which thermally treated Coxiella in milk products may be grown in a liquid growth medium and quantitated using an MPN-PCR assay. Coxiella is generally not used in studies on thermal and non-thermal processing of milk due to the need for specialized and highly laborious techniques such as animal assays and tissue culture for determining viability. Recently, a liquid growth medium (ACCM-2) and modified atmosphere were used to grow Coxiella from pure cultures, infected mouse tissues, and clinical samples, however, the ability to grow Coxiella from a food such as milk has not been shown. The potential ability to enrich Coxiella directly from contaminated milk presents a new avenue for conducting pasteurization research in which the viability of heat-treated or injured cultures could be more easily determined through direct enrichment of Coxiella in ACCM-2. ACCM-2 medium allowed enrichment of Coxiella from bovine whole milk and cream, whole goat, and whole camel milks but not whole water buffalo milk. Enrichment was possible from whole bovine milk containing as few as 6 Coxiella ge/ml of milk. The applicability of this ACCM-2 enrichment method was shown when using an MPN-PCR assay to quantitate the number of viable Coxiella remaining in whole bovine milk after 64 °C thermal treatment for up to 10 min.

Symptom management challenges in heart failure: pharmacotherapy considerations.

Heart failure is a chronic, progressive illness that is increasing in prevalence in the USA. Patients with advanced heart failure experience a high symptom burden that is comparable to patients with advanced cancer. Palliative care, however, is underutilized in patients with heart failure, and symptoms may go untreated as the disease progresses. A combination of pharmacologic and non-pharmacologic interventions should be used to address symptoms and maintain quality of life. While there have been significant advances in evidence-based heart failure treatments in recent years, selection of appropriate palliative medications as symptoms progress is challenging due to limited clinical studies in this patient population. Medications that are commonly used for symptom management in other life-limiting illnesses may have little to no evidence in heart failure, or have undesirable cardiac effects that preclude use. Clinicians must extrapolate available clinical evidence and prescribing considerations relevant to heart failure to palliate symptoms as well as possible. The objectives of this paper are to review the most common and distressing symptoms in heart failure, analyze evidence, or lack thereof, for pharmacologic management of symptoms, and provide prescribing considerations based on side effect profiles and comorbid conditions.

A human factors approach to improving electronic performance measurement of venous thromboembolism prophylaxis.

OBJECTIVE: In 2011, our institution developed a venous thromboembolism (VTE) prophylaxis order set to monitor prophylaxis management through physician-generated risk assessment orders. Prophylaxis rates obtained using the risk assessment orders were falsely low compared with chart review. Our goal was to redesign the order set to increase the percentage of VTE risk assessments ordered, both to improve care and to better reflect performance. DESIGN: Quality Improvement Project. SETTING: Veterans Health Administration. PARTICIPANTS: Patients admitted to acute care and intensive care medical units. INTERVENTIONS: Process analysis was used to identify systems failures limiting use of the original order set. The order set was redesigned using a human factors approach. MAIN OUTCOME MEASURE: VTE risk assessment orders. RESULTS: The order set was redesigned to reduce complexity and improve integration into provider workflow. The rate of risk assessment orders placed within 24 h increased from 48.6 to 80.4% (P < 0.001). There was no difference in the actual use of prophylaxis. However, for patients on prophylaxis, the rates of having a documented 'moderate' or 'high' risk assessment within 24 h increased from 66.7 to 95.7% (P < 0.001). CONCLUSIONS: Using human factor principles to redesign an order set led to a significant increase in the percentage of patients with a risk assessment order placed within 24 h of admission. Although the risk assessments using the redesigned order set better reflected physician performance, it remained an imperfect measure for VTE prophylaxis. New technology used to measure human performance must be evaluated following implementation to assess accuracy.

Quantitation of viable Coxiella burnetii in milk using an integrated cell culture-polymerase chain reaction (ICC-PCR) assay.

The obligate intracellular pathogen Coxiella burnetii has long been considered the most heat resistant pathogen in raw milk, making it the reference pathogen for determining pasteurisation conditions for milk products. New milk formulations and novel non-thermal processes require validation of effectiveness which requires a more practical method for analysis than using the currently used animal model for assessing Coxiella survival. Also, there is an interest in better characterising thermal inactivation of Coxiella in various milk formulations. To avoid the use of the guinea pig model for evaluating Coxiella survival, an Integrated Cell Culture-PCR (ICC-PCR) method was developed for determining Coxiella viability in milk. Vero cell cultures were directly infected from Coxiella-contaminated milk in duplicate 24-well plates. Viability of the Coxiella in milk was shown by a ≥ 0.5 log genome equivalent (ge)/ml increase in the quantity of IS111a gene from the baseline post-infection (day 0) level after 9-11 d propagation. Coxiella in skim, 2%, and whole milk, and half and half successfully infected Vero cells and increased in number by at least 2 logs using a 48-h infection period followed by 9-d propagation time. As few as 125 Coxiella ge/ml in whole milk was shown to infect and propagate at least 2 logs in the optimised ICC-PCR assay, though variable confirmation of propagation was shown for as low as 25 Coxiella ge/ml. Applicability of the ICC-PCR method was further proven in an MPN format to quantitate the number of viable Coxiella remaining in whole milk after 60 °C thermal treatment at 0, 20, 40, 60 and 90 min.

Lower health literacy predicts smoking relapse among racially/ethnically diverse smokers with low socioeconomic status.

BACKGROUND: Nearly half of U.S. adults have difficulties with health literacy (HL), which is defined as the ability to adequately obtain, process, and understand basic health information. Lower HL is associated with negative health behaviors and poor health outcomes. Racial/ethnic minorities and those with low socioeconomic status (SES) are disproportionately affected by poor HL. They also have higher smoking prevalence and more difficulty quitting smoking. Thus, lower HL may be uniquely associated with poorer cessation outcomes in this population. METHODS: This study investigated the association between HL and smoking cessation outcomes among 200, low-SES, racially/ethnically diverse smokers enrolled in smoking cessation treatment. Logistic regression analyses adjusted for demographics (i.e., age, gender, race/ethnicity, relationship status), SES-related characteristics (i.e., education, income), and nicotine dependence were conducted to investigate associations between HL and smoking relapse at the end of treatment (3 weeks post quit day). RESULTS: Results indicated that smokers with lower HL (score of < 64.5 on the Rapid Estimate of Adult Literacy in Medicine [REALM]) were significantly more likely than those with higher HL (score of ≥ 64.5 on the REALM) to relapse by the end of treatment, even after controlling for established predictors of cessation including demographics, SES, and nicotine dependence (OR = 3.26; 95% CI = 1.14, 9.26). CONCLUSIONS: Findings suggest that lower HL may serve as an independent risk factor for smoking relapse among low-SES, racially/ethnically diverse smokers enrolled in treatment. Future research is needed to investigate longitudinal relations between HL and cessation outcomes and potential mechanisms of this relationship.

The association of depression and anxiety with glycemic control among Mexican Americans with diabetes living near the U.S.-Mexico border.

BACKGROUND: The prevalence of diabetes is alarmingly high among Mexican American adults residing near the U.S.-Mexico border. Depression is also common among Mexican Americans with diabetes, and may have a negative influence on diabetes management. Thus, the purpose of the current study was to evaluate the associations of depression and anxiety with the behavioral management of diabetes and glycemic control among Mexican American adults living near the border. METHODS: The characteristics of Mexican Americans with diabetes living in Brownsville, TX (N = 492) were compared by depression/anxiety status. Linear regression models were conducted to evaluate the associations of depression and anxiety with BMI, waist circumference, physical activity, fasting glucose, and glycated hemoglobin (HbA1c). RESULTS: Participants with clinically significant depression and/or anxiety were of greater age, predominantly female, less educated, more likely to have been diagnosed with diabetes, and more likely to be taking diabetes medications than those without depression or anxiety. In addition, anxious participants were more likely than those without anxiety to have been born in Mexico and to prefer study assessments in Spanish rather than English. Greater depression and anxiety were associated with poorer behavioral management of diabetes (i.e., greater BMI and waist circumference; engaging in less physical activity) and poorer glycemic control (i.e., higher fasting glucose, HbA1c). CONCLUSIONS: Overall, depression and anxiety appear to be linked with poorer behavioral management of diabetes and glycemic control. Findings highlight the need for comprehensive interventions along the border which target depression and anxiety in conjunction with diabetes management.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status.

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Psychosocial predictors of weight regain in the weight loss maintenance trial.

This study's purpose was to identify psychosocial predictors of weight loss maintenance in a multi-site clinical trial, following a group-based weight loss program. Participants (N = 1025) were predominately women (63%) and 38% were Black (mean age = 55.6 years; SD = 8.7). At 12 months, higher SF-36 mental health composite scores were associated with less weight regain (p < .01). For Black participants, an interaction existed between race and friends' encouragement for exercise, where higher exercise encouragement was related to more weight regain (p < .05). At 30 months, friends' encouragement for healthy eating was associated with more weight regain (p < .05), whereas higher SF-36 mental health composite scores were related to less weight regain (p < .0001). Perceived stress and select health-related quality of life indices were associated with weight regain; this relationship varied across gender, race, and treatment conditions. Temporal changes in these variables should be investigated for their impact on weight maintenance.

Survival of Listeria monocytogenes on Frozen Vegetables during Long-term Storage at -18 and -10°C.

Two recent listeriosis outbreaks have occurred in the United States and Europe due to contaminated individually quick-frozen (IQF) vegetables. While one of the outbreaks was due to frozen vegetables considered ready-to-eat (RTE), the other was linked to frozen corn whose packaging contained cooking instructions and was considered not-ready-to-eat (NRTE). However, consumers may thaw certain frozen vegetables and consume without cooking. Since no data is available on the survivability of L. monocytogenes on IQF vegetables during frozen storage, this study examined the population of six different strains (comprising lineages 1/2a, 1/2b, and 4b) on IQF vegetables during long-term storage. Individual strains were inoculated onto an IQF vegetable mix at 4 log CFU/g and stored at -18 or -10°C for 360 days. Although fluctuations in populations of all strains were observed on the vegetables during storage, no significant differences based on strain, lineages, or temperature were observed. Overall, L. monocytogenes populations were only reduced by up to 0.47 and 0.59 log CFU/g after 360 days at -18 and -10°C, respectively. Results from this study suggest that L. monocytogenes is able to persist on IQF vegetables for extended time periods with no significant reduction in population. Future studies could evaluate the survival and growth of L. monocytogenes on IQF vegetables during thawing and storage.

Comparative growth kinetics of Listeria monocytogenes and Salmonella enterica on dehydrated enoki and wood ear mushrooms during rehydration and storage.

Specialty mushrooms have been implicated in foodborne illness outbreaks in the U.S. in recent years. These mushrooms are available to consumers in both their fresh and dried states. Dehydrating mushrooms is a convenient way to increase shelf life. The dehydration process results in a lowered water activity (aw) of the commodity, creating an environment where both spoilage and pathogenic bacteria cannot proliferate. Prior to food preparation and consumption, these mushrooms are typically rehydrated and possibly stored for later use which could lead to increased levels of pathogens. This study examined the survival and growth of Listeria monocytogenes and Salmonella enterica on dehydrated enoki and wood ear mushrooms during rehydration and subsequent storage. Mushrooms were heat dehydrated, inoculated at 3 log CFU/g, and rehydrated at either 5 or 25°C for 2 h. Rehydrated mushrooms were stored at 5, 10, or 25°C for up to 14 d. L. monocytogenes and S. enterica survived on enoki and wood ear mushroom types during rehydration at 5 and 25°C, with populations often <2.39 log CFU/g. During subsequent storage, no growth was observed on wood ear mushrooms, regardless of the rehydration or storage temperature, with populations remaining <2.39 log CFU/g for both pathogens. When stored at 5°C, no growth was observed for either pathogen on enoki mushrooms. During storage at 10 and 25°C, pathogen growth rates and populations after 14 d were generally significantly higher on the enoki mushrooms rehydrated at 25°C; the highest growth rate (3.56 ± 0.75 log CFU/g/d) and population (9.48 ± 0.62 log CFU/g) after 14 d for either pathogen was observed by S. enterica at 25°C storage temperature. Results indicate a marked difference in pathogen survival and proliferation on the two specialty mushrooms examined in this study and highlight the need for individual product assessments. Data can be used to assist in informing guidelines for time and temperature control for the safety of rehydrated mushrooms.

Method of Inoculation Influences the Survival of Salmonella enterica on Retail and Orchard Peaches.

Challenge studies associated with fruits and vegetables generally utilize wet bacterial inoculation methods. However, a recent salmonellosis outbreak in the U.S. was linked to peaches plausibly contaminated via fugitive dust from a nearby animal operation. This outbreak has highlighted the need for a suitable inert carrier which can be used for the dry transfer of Salmonella enterica to produce. The purpose of this study was 1) to examine the population stability of S. enterica and its surrogate, Enterococcus faecium, in different dry matrices during extended storage to identify suitable carriers and 2) to evaluate the survival of S. enterica on peaches based on the mode of contamination (i.e., wet vs. dry). S. enterica and E. faecium were cultivated on tryptic soy agar (TSA) and inoculated into corn-cob small animal litter, sand, or silica at 10-11 log CFU/g. Matrices were mixed by hand and stored at 25°C and 33% relative humidity for up to 120 d. S. enterica remained relatively stable in the silica and litter, with no significant decrease in population after 14 and 28 d, respectively. E. faecium significantly reduced in all matrices, with the greatest reduction observed in silica (2.86 log CFU/g after 120 d). Additional carriers would need to be assessed for E. faecium which could maintain its population stability. Silica was ultimately selected for the dry carrier of S. enterica. Peaches available at retail or from orchards were inoculated with S. enterica using the silica carrier or by spot or dip inoculation methods at 5 log CFU/peach and stored at 5°C and 80% relative humidity for up to 28 d. The population of S. enterica significantly reduced on all peaches except for the dry inoculated orchard peaches, where the population remained stable (4.62 ± 0.35 log CFU/peach after 28 d). Results from this study determined that the mode of contamination influences the survival of S. enterica on peaches and that dry inoculation methods should be considered for produce in some instances.

Associations between health literacy and established predictors of smoking cessation.

OBJECTIVES: We examined associations between health literacy and predictors of smoking cessation among 402 low-socioeconomic status (SES), racially/ethnically diverse smokers. METHODS: Data were collected as part of a larger study evaluating smoking health risk messages. We conducted multiple linear regression analyses to examine relations between health literacy and predictors of smoking cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking risk perceptions and knowledge, self-efficacy, intentions to quit or reduce smoking). RESULTS: Lower health literacy was associated with higher nicotine dependence, more positive and less negative smoking outcome expectancies, less knowledge about smoking health risks, and lower risk perceptions. Associations remained significant (P < .05) after controlling for demographics and SES-related factors. CONCLUSIONS: These results provide the first evidence that low health literacy may serve as a critical and independent risk factor for poor cessation outcomes among low-socioeconomic status, racially/ethnically diverse smokers. Research is needed to investigate potential mechanisms underlying this relationship.

Race moderates the effect of menthol cigarette use on short-term smoking abstinence.

INTRODUCTION: The Food and Drug Administration is in the process of reviewing evidence of the impact of mentholated cigarettes on smoking behaviors and smoking cessation in order to determine if these products should be removed from the market. More empirical research is needed to inform those decisions. The goal of this study was to examine associations of menthol cigarette use with biochemically verified continuous short-term smoking abstinence, and potential moderation by race, among adult current smokers enrolled in a cohort study (N = 183; 57.4% female; 48.1% non-Hispanic Black, 51.9% non-Hispanic White). METHODS: Continuation ratio logit models, adjusted for age, race, gender, total annual household income, educational level, employment status, and partner status, were used to examine associations of menthol use with smoking abstinence with and without an interaction term for race. RESULTS: Menthol cigarette use was not significantly associated with smoking abstinence in the sample as a whole; however, there was a significant interaction of menthol use with race (p = .03). Follow-up analyses stratified by race indicated that among White participants, menthol users had significantly lower odds of maintaining continuous abstinence than nonmenthol users (p = .05). Exploratory analyses suggested that tobacco dependence may lie along the causal pathway and partially explain this effect. CONCLUSIONS: White menthol smokers in this sample were at increased risk of smoking relapse relative to White nonmenthol smokers, at least partially due to greater tobacco dependence. Results should be replicated among other treatment-seeking samples with a greater representation of White menthol and Black nonmenthol smokers.

Long-Term Survival of Listeria monocytogenes in Nut, Seed, and Legume Butters.

Nut, seed, and legume butters have become increasingly popular with consumers. Listeria monocytogenes contamination of a variety of butters has resulted in several recalls, although no known outbreaks have been identified. L. monocytogenes has been shown to survive on a variety of seeds for up to 6 months, legumes and nuts for over 12 months, and in peanut butter and peanut-chocolate spreads for 21 to 60 weeks depending on formulation; however, long-term survival in other butters has not yet been characterized. In this study, the survival of L. monocytogenes in various nut, seed, legume, and chocolate-containing butters (n = 10) based on inoculation level, storage temperature, and the pH, aw, and nutrient contents of the butters was examined. First, butters were inoculated with L. monocytogenes at 4 log CFU/g and stored at either 5 or 25°C with enumeration and/or enrichment at intervals over 12 months. L. monocytogenes survived in all butters examined with no significant change in population after storage at 5°C, whereas the population was reduced to <1.70 log CFU/g in as little as 3 months at 25°C; the only exception was for sunflower butter, where L. monocytogenes decreased approximately 1 log CFU/g. Subsequently, all butters were inoculated at 1 log CFU/g and stored at 25°C for 6 months with enrichment during storage. L. monocytogenes was detected in all butters, except pecan butter, after 6-month storage. Butters containing chocolate did not inhibit L. monocytogenes survival, regardless of the inoculation level. Results indicate there may be an association between high-fat and carbohydrate level and survivability of L. monocytogenes in various types of butters. This work highlights the need to mitigate the potential for cross-contamination of L. monocytogenes into nut, seed, and legume butters due to the potential for long-term survival.