Social Determinants of Health among Older Adults with Dementia in Urban and Rural Areas.

BACKGROUND: Social determinants of health (SDOH) may influence health in people living with dementia. Little is known about SDOH differences in urban compared to rural dwelling people living with dementia. OBJECTIVES: To explore urban-rural differences in SDOH in people living with mild cognitive impairment (MCI) and dementia. DESIGN: Descriptive study. SETTING/PARTICIPANTS: People ≥55 years with MCI or dementia empaneled to Community Internal Medicine at Mayo Clinic (Rochester, MN, USA) who completed SDOH questions between June 1, 2019 and June 30, 2021 were included. MEASUREMENTS: SDOH questions addressed education, depression, alcohol use, financial strain, food insecurity, physical activity, social connections, stress and transportation. SDOH data were compared by location based on Rural-Urban Commuting Areas Codes. RESULTS: Of 3552 persons with MCI (n=1495) or dementia (n=2057), 62% lived in urban areas, 19% in large rural, 10% in small rural and 9% in isolated areas. Approximately 60% were physically inactive, 20% socially isolated and 30% had stress concerns. Rural patients experienced greater financial strain (p=0.003). CONCLUSION: Social isolation, stress and physical inactivity are common in people living with MCI and dementia across urban and rural areas. Targeted interventions to improve physical and psychosocial health could have great impact in this population.

The effect of varying levels of population control on the prevalence of tuberculosis in badgers in Ireland.

We examined the effect of varying levels of badger population control on the prevalence of Mycobacterium bovis infection in badgers in four counties of Ireland. In the 'Removal' and 'Buffer' areas, proactive culling was conducted to substantially reduce and subsequently maintain badger populations at a low level for five years. In the 'Reference' areas, localised reactive culling was conducted in association with herd breakdowns. The infection status of badgers was determined using bacteriology. A total of 2696 badgers were recruited into the study, and 19.0% were found to be infected with M. bovis. The two population control strategies had differing effects on the subsequent prevalence of tuberculosis in badger populations. Proactive culling led to a long term decrease in the prevalence of tuberculosis in the re-emergent populations. Although there was an overall decline in the disease prevalence, no consistent trend in disease prevalence as a result of reactive culling was observed.

The impact of badger removal on the control of tuberculosis in cattle herds in Ireland.

In Ireland, the herd prevalence of bovine tuberculosis has remained stable for several decades, and in common with several other countries, progress towards eradication has stalled. There is evidence in support of the potential role of infected badgers (Meles meles, a protected species) in bovine tuberculosis in Ireland and Britain. However, this evidence on its own has not been sufficient to prove disease causation. Field trials are likely to offer the best opportunity to define this role. Building on the earlier East Offaly project, our objectives were to assess the impact of badger removal on the control of tuberculosis in cattle herds in Ireland. The study was conducted from September 1997 to August 2002 in matched removal and reference areas (average area of 245.1km(2)) in four counties: Cork, Donegal, Kilkenny and Monaghan. Badger removal was intensive and proactive throughout the study period in the removal areas, but reactive (in response to severe tuberculosis outbreaks in cattle) in the reference areas. Removal intensity in the removal and reference areas during the first 2 years of the study averaged 0.57 and 0.07 badgers/km(2)/year, respectively. The outcome of interest was restriction of cattle herds due to confirmed tuberculosis, where tuberculous lesions were detected in one or more animals. Data were analysed using logistic regression (modelling the probability of a confirmed herd restriction) and survival analysis (modelling time to a confirmed herd restriction). During the study period, there was a significant difference between the removal and reference areas in all four counties in both the probability of and the time to a confirmed herd restriction due to tuberculosis. In the final year of the study, the odds of a confirmed herd restriction in the removal (as compared to the reference areas) were 0.25 in Cork, 0.04 in Donegal, 0.26 in Kilkenny and 0.43 in Monaghan. Further, the hazard ratios (removal over reference) ranged from 0.4 to 0.04 (a 60-96% decrease in the rate at which herds were becoming the subject of a confirmed restriction).

Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.

The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.

Prevalence of excess lead absorption and associated risk factors in children enrolled in a midwestern health maintenance organization.

OBJECTIVE: To assess the prevalence of lead intoxication in children in a defined low-risk population at the new levels recommended by the Centers for Disease Control and Prevention. DESIGN: During an 11-month period, whole blood lead tests were performed on 4678 children at routine well-child visits at 9 months and 2 years of age. For the last 8 months of the study, parents were asked to complete a prescreening risk factor questionnaire at these visits. The questionnaire and blood lead results were then matched. Data were collected from October 1, 1991 through August 31, 1992. SETTING: The study subjects were all enrolled in Group Health, Inc, a large health maintenance organization. Its 17 staff model clinics serve urban and suburban populations in the Minneapolis-St. Paul area. More than 95% of the population had coverage based on employment, not Medicaid. RESULTS: Results indicated that 2.5% (n = 119) of the children had BPb levels > or = 10 micrograms/dL. Urban clinics had rates of elevated BPb levels three to eight times those of suburban clinics (P < .00001), but the number of elevated BPb levels at the suburban clinics was greater than expected. BPb levels were significantly higher in summer and fall (P < .00001). The prescreening questionnaire addressed five areas potentially associated with risk according to the literature: housing, siblings with lead poisoning, parental hobbies or work involving lead, proximity to highways, and use of cultural medicines. Positive correlations were found between elevated BPb levels and residences built before 1950 (P < .00001). For children living in housing built before 1950, positive correlations were found between elevated blood lead levels and peeling paint (P < .01) or remodeling (P < .0001). CONCLUSIONS: Children who are at low socioeconomic risk but who live in housing built before 1950 are at increased risk for lead poisoning. The risk is greater if the house has peeling paint and especially if there is recent or ongoing renovation. Recommendations based on these results and the Centers for Disease Control and Prevention guidelines are made for screening programs in similar populations, and for the need to increase community awareness concerning this issue.

Clinical pharmacokinetics of contraceptive steroids. An update.

The present article should be read in conjunction with the original review published in the Journal in 1983. There is no new information of major significance about the pharmacokinetics of levonorgestrel, norethisterone (norethindrone) or ethinylestradiol, although it has been shown that the concentrations of these hormones secreted in breast milk are small and mothers taking combined oral contraceptive steroids may breast-feed safely. Both levonorgestrel and ethinylestradiol can be successfully administered from appropriate vaginal formulations, but no clear advantages over oral administration have been demonstrated. Several new progestogens have been investigated. Desogestrel is a prodrug for its active metabolite 3-keto-desogestrel, gestodene is itself an active progestogen and norgestimate is a prodrug acting by conversion to norgestrel and its metabolites. All 3 compounds have good bioavailability with wide intersubject variation. The newer progestogens, like norethisterone and levonorgestrel, are bound to sex hormone binding globulin (SHBG). This causes their plasma concentrations to increase with time, since SHBG is induced by ethinylestradiol even in doses of 30 micrograms daily. The binding capacity and affinity of SHBG do not increase in direct proportion to its concentration. Further drug interactions with oral contraceptive steroids have been described. Contraceptive steroids may inhibit hepatic microsomal enzyme metabolism and increase the plasma concentration and effect of some tricyclic antidepressants, the hydroxylated benzodiazepines, some beta-blocking drugs, methylxanthines, prednisolone and cyclosporin. There are no significant effects on vitamins. Oral contraceptive steroids induce glucuronidation and hence decrease plasma concentrations of some benzodiazepines, clofibric acid, paracetamol (acetaminophen) and possibly morphine. The plasma concentration of ethinylestradiol may be increased by competitive sulphation with paracetamol. Plasma concentrations of contraceptive steroids are decreased by griseofulvin, which induces their hepatic metabolism. The role of other antibiotics remains controversial but there is probably a group of susceptible women who have lower plasma contraceptive hormone concentrations and experience breakthrough bleeding or pregnancy when given broad spectrum antibiotics. This may relate to interruption of the enterohepatic recirculation of ethinylestradiol. Anticonvulsants, other than valproic acid, all induce contraceptive steroid metabolism and therefore lower plasma hormone concentrations, thus reducing contraceptive effectiveness.

Inhibition of CYP2E1 reverses CD4+ T-cell alterations in trichloroethylene-treated MRL+/+ mice.

Trichloroethylene is an organic solvent that is primarily used as a degreasing agent for metals. There is increasing evidence in both humans and animal models that trichloroethylene promotes the development of autoimmunity, but little is known about the mechanisms that mediate the effect of trichloroethylene on the immune system. Metabolic activation of trichloroethylene is considered an obligatory pathway for other known toxicities such as hepatotoxicity, nephrotoxicity, and carcinogenicity. Trichloroethylene is metabolized by the cytochromes P450, primarily cytochrome P450 2E1 (CYP2E1). To investigate whether metabolism by CYP2E1 is required for immunomodulation, we treated autoimmune prone MRL+/+ mice with trichloroethylene in the drinking water for 4 weeks, in the presence or absence of diallyl sulfide, a specific inhibitor of CYP2E1. Using an antibody that recognizes proteins covalently modified by a reactive metabolite of trichloroethylene; two immunoreactive proteins were detected in liver microsomes from trichloroethylene-treated mice. Formation of these trichloroethylene-protein adducts, an indicator of metabolic activation, was completely inhibited in animals that were concomitantly treated with trichloroethylene and diallyl sulfide. The level of CYP2E1 apoprotein in liver microsomes was significantly reduced in the presence of diallyl sulfide. The enhanced mitogen-induced proliferative capacity of T cells from trichloroethylene-treated MRL+/+ mice was inhibited if the mice were also treated with diallyl sulfide. In addition, the reduction in interleukin-4 levels secreted by activated CD4+ T cells from trichloroethylene-treated mice was reversed if the mice were also treated with diallyl sulfide. Taken collectively, metabolism of trichloroethylene by CYP2E1 is responsible, at least in part, for the CD4+ T cell alterations associated with exposure to this environmental toxicant.

CD4(+) T-cell activation and induction of autoimmune hepatitis following trichloroethylene treatment in MRL+/+ mice.

Exposure to relatively high levels of trichloroethylene has recently been shown to accelerate the development of an autoimmune response in the autoimmune prone MRL+/+ mice. The trichloroethylene-induced autoimmune response was associated with an increase in activated CD4(+) T cells, producing Th(1)-like cytokines. The present study was conducted to determine whether lower, more occupationally relevant doses of trichloroethylene could also promote autoimmunity, in MRL+/+ mice, and if so, to investigate the mechanism of this accelerated autoimmune response. In addition, histological studies were performed to determine if trichloroethylene was capable of producing pathological markers consistent with an autoimmune disease. Trichloroethylene was administered to mice in the drinking water at 0, 0.1, 0.5, and 2.5 mg/ml for 4 and 32 weeks. There was a significant increase above controls in serum antinuclear antibody (ANA) levels following 4 weeks of both 0.1 and 0.5 mg/kg/day of trichloroethylene. After 32 weeks of treatment, ANA levels were elevated and equal in all groups. The kinetics of the ANA response indicated that trichloroethylene accelerated the innate autoimmune response in the MRL+/+ mice. There was a dose-related increase in the percentage of activated CD4(+) T cells in both the spleens and lymph nodes of mice treated for 32 weeks with trichloroethylene when compared to controls. CD4(+) T cells isolated from MRL+/+ mice after either 4 or 32 weeks of treatment with trichloroethylene secreted inflammatory or Th(1)-like cytokines. Following 32 weeks of trichloroethylene treatment, there was a significant increase in hepatic mononuclear infiltration localized to the portal region, a type of hepatic infiltration consistent with autoimmune hepatitis. Taken collectively, these data suggest that exposure to occupationally relevant concentrations of trichloroethylene can accelerate an autoimmune response and can lead to autoimmune disease. The mechanism of this autoimmunity appears to involve, at least in part, activated CD4(+) T cells that then produced inflammatory cytokines.

Covalent binding of trichloroethylene to proteins in human and rat hepatocytes.

The environmental contaminant and occupational solvent trichloroethylene is metabolized to a reactive intermediate that covalently binds to specific hepatic proteins in exposed mice and rats. In order to compare covalent binding between humans and rodents, primary hepatocyte cultures were exposed to vaporized trichloroethylene at 0-10,000 parts per million for up to 2 h. Immunochemical detection of three major dose- and time-dependent trichloroethylene protein adducts at 50, 52 and 100 kDa was demonstrated in the rat hepatocytes, while a single, distinctively different 47 kDa adduct was detected in human hepatocytes. The 50 kDa adduct in rat hepatocytes was found to comigrate on SDS-PAGE with cytochrome P450 2E1 (CYP2E1), while the adduct found in humans did not comigrate with CYP2E1. These data show that reactive metabolites of trichloroethylene can be formed in human and rat hepatocytes and bind covalently to discrete hepatic proteins, and suggests that in rats, but not humans, that one of the targets is CYP2E1.

Bovine tuberculosis in badgers in four areas in Ireland: does tuberculosis cluster?

We described the distribution of badger populations in four different areas in the Republic of Ireland. The data came from periodic targeted badger-removal and subsequent post-mortem examinations conducted between 1989 and September 1997, and from a formal badger-removal project in the same areas from 1997 through 1999. Records were complete for 2292 badgers regarding the date of capture, tuberculosis status, geographical area and specific sett from where the badgers were snared. Of 3187 setts, 2290 had no badgers recorded against them (i.e. were inactive). The badger-level prevalence of tuberculosis differed among areas (range 13-29%). Badger populations were highly clustered by sett, and this result was similar over the four study areas. The median number of badgers per active sett was 2. Tuberculous badgers also clustered within a sett. The third quartile of tuberculous badgers was 1 per active sett. The prevalence of tuberculous badgers within a sett was not related to the total number of badgers. There was little evidence of spatial clustering with only one local cluster of tuberculous setts in each of three areas, and none in the fourth area. After adjusting for the number of badgers per sett, only one area had spatial clusters identified.

The effect of a badger removal programme on the incidence of tuberculosis in an Irish cattle population.

The risk of a confirmed tuberculous herd restriction was examined using a logistic model for herds involved in the East Offaly Badger Research Project, Ireland, from 1988-1995. Cattle herds present in the badger-removal area had a significantly lower proportion of new confirmed tuberculous herd restrictions compared with cattle from an area where no systematic badger removal was attempted.

Locus of control and achievement in child psychiatric inpatients.

The relationship between the Nowicki-Strickland Locus of Control Scale for Children (Nowicki & Strickland, 1973) and academic achievement was examined in a sample of 66 child psychiatric inpatients. Previous studies had suggested that this measure correlated with achievement in normal samples (Nowicki & Strickland, 1973) but not in populations of male juvenile offenders (Little & Kendall, 1978). The product-moment correlation between the Nowicki-Strickland Scale and the Peabody Individual Achievement Test was significant. However, when the effect of IQ was controlled for in a partial correlation, there was no significant correlation. Discussion focuses on the relationship between these results and other findings in the area of locus of control, intelligence, and achievement.

The association between the bovine tuberculosis status of herds in the East Offaly Project Area, and the distance to badger setts, 1988-1993.

The proximity of farms to badger setts was compared between farms that had experienced a tuberculosis breakdown and those that had not, over the 6 year period from 1988 to 1993. The data were derived from a badger removal study conducted in East Offaly County in the Republic of Ireland. Badger removal began in 1989 and continued through 1993; by the end of 1990, approximately 80% of all badgers caught in the 6 year period had been removed. All badgers were examined, grossly, for evidence of tuberculosis. Tuberculosis status of the approximately 900 study herds was based on the results of the single intradermal comparative skin test and/or lesions of bovine tuberculosis. All herds were tested at least once annually. The number of herds experiencing bovine tuberculosis declined over the period, particularly in the years 1992 and 1993. The data on farm and badger sett location were stored and analysed, initially, in a geographical information system. Owing to the badger removal programme, the distance between the barn yard of a typical farm and the nearest occupied badger sett increased, by about 300 m year-1, and by about 600 m year-1 to the closest infected sett. In bivariate analyses, in the years 1988 and 1989, the risk of tuberculosis declined with increasing distance to a badger sett containing one or more tuberculous badgers. In multivariable logistic regression analyses, year and the average number of cattle tested per farm per year were controlled. A second identical analysis was conducted to control for the repeated observations on the same herds using generalised estimating equations. In both analyses, the risk of a multiple reactor tuberculosis breakdown decreased for herds at least 1000 m away from an infected badger sett, and increased as the number of infected badgers per infected sett increased. Despite the significantly reduced risk of a breakdown with increasing distance to infected badger setts, the relationship was not strong (sensitivity and specificity of the model in the low 70% range) and explained only 9-19% of tuberculosis breakdowns.

Congenital arteriovenous malformations of the upper extremity.

The embryology and the clinical management of congenital AV fistulas of the upper extremity are discussed. Early excisional surgery of asymptomatic lesions should be confined to ones of a very limited extent. Excisional surgery on extensive lesions should be limited to those which are symptomatic and have decreasing hand function. Possibly of limited effectiveness in some lesions may be the selective occlusion of vascular feeders by injecting cyanoacrylate glue through a catheter.

Subcutaneous mastectomy. The excess skin problem.

Subcantaneous mastectomy through a lateral approach, with preservation of the nipple and areola on a dermal pedicle, removing the excess skin at the time of aubautaneous mastectomy, is a safe procedure which results in esthetically acceptable breasts. The surgical approach greatly facilitates the removal of the entire glandular portion of the breast. The need for a second surgical procedure is eliminated. Lateral biopsy scars can be reinforced by the dermal sling support, thereby decreasing the chances of exposure of the implant. The implant is also successfully and easily held in position by the use of the dermal-fat sling support. The nipple and areola survive quite well on the dermal pedicle, with preservation of contractility and sensation, as well as of blood supply.

Race, clinical factors and pre-term birth in a low-income urban setting.

UNLABELLED: While infant mortality rates have declined for both White and African-American populations, the perennial two-fold excess in risk for African Americans remains unchanged, and indeed, may have increased since 1985. One potential explanation for the excess risk in African Americans might be racial differences in maternal clinical risk factors, such as prior pregnancy history and pregnancy complications. This paper examines the contributions of such clinical indicators to racial differences in pre-term delivery in a study sample of urban, low-income women, aged 18 to 43 years. METHODS: Study participants were enrolled during their first prenatal care visit at one of four hospital-based, prenatal care clinics in Baltimore City. Medical history and pregnancy outcome data were abstracted from clinical records. Multiple logistic regression models were used to assess the independent relationship between race and pre-term birth, after controlling for clinical factors. RESULTS: Without adjustment for clinical risk factors, African-American women were 1.8 times more likely than White women to have a pre-term birth outcome (95% confidence interval 1.20-2.78). After statistical adjustment for the clinical variables, however, the association between race and pre-term birth was diminished (OR = 1.64, 95% confidence interval: 0.99-2.72). Moreover, the associations between certain clinical risks and pre-term birth were stronger for African-American than White women. CONCLUSION: These results suggest that attention to clinical risk factors among African-American women may be an important avenue for reducing Black/White racial disparities in pre-term birth.

Epidemiology and control of an outbreak of foot-and-mouth disease in the Republic of Ireland in 2001.

An outbreak of foot-and-mouth disease was confirmed in a flock of sheep on a farm in the Cooley peninsula, County Louth, on March 22, 2001. The virus was similar to other viruses of the serotype O PanAsian strain and virtually indistinguishable from other isolates from Northern Ireland and Great Britain. The epidemiological evidence suggested that infected sheep brought from Great Britain on February 19, 2001, were the source of the infection. The disease was eradicated by epidemiological investigation, serological testing and extensive culling.

Undiagnosed shrapnel of the tongue.

A case of a large metal fragment in the tongue is reported in a soldier injured in Operation Desert Storm. The fragment was not diagnosed for 57 days as the patient was evacuated through multiple U.S. Army medical facilities for other injuries. Diagnosis and treatment of the case are discussed.

James B. Connolly, First modern Olympic champion. The Georgia Connection, Circa 1896.

As the centennial Olympic Games come to Atlanta in 1996, and the sailing venue to Savannah, it is only fitting that the first modern Olympic champion had some connection to the state of Georgia, the city of Savannah, and the art of sailing. James Brendan Connolly was not only a terrific athlete, but a noted writer and adventurer. Moreover, he was the type of man who impressed even the President of the United States with his sterling qualities. The latter serve as a shining example a century after his initial Olympic exploits.

In situ simulation training for paediatric cardiorespiratory arrest: initial observations and identification of latent errors.

In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.