Accumulation of saturated intramyocellular lipid is associated with insulin resistance.

Intramyocellular lipid (IMCL) accumulation has been linked to both insulin-resistant and insulin-sensitive (athletes) states. Biochemical analysis of intramuscular triglyceride composition is confounded by extramyocellular triglycerides in biopsy samples, and hence the specific composition of IMCLs is unknown in these states. 1H magnetic resonance spectroscopy (MRS) can be used to overcome this problem. Thus, we used a recently validated 1H MRS method to compare the compositional saturation index (CH2:CH3) and concentration independent of the composition (CH3) of IMCLs in the soleus and tibialis anterior muscles of 16 female insulin-resistant lipodystrophic subjects with that of age- and gender-matched athletes (n = 14) and healthy controls (n = 41). The IMCL CH2:CH3 ratio was significantly higher in both muscles of the lipodystrophic subjects compared with controls but was similar in athletes and controls. IMCL CH2:CH3 was dependent on the IMCL concentration in the controls and, after adjusting the compositional index for quantity (CH2:CH3adj), could distinguish lipodystrophics from athletes. This CH2:CH3adj marker had a stronger relationship with insulin resistance than IMCL concentration alone and was inversely related to VO2max The association of insulin resistance with the accumulation of saturated IMCLs is consistent with a potential pathogenic role for saturated fat and the reported benefits of exercise and diet in insulin-resistant states.

"We're Onto Something Here!": Clinician Perspectives of a Pilot Program to Increase Palliative Care Access in an Urban Skilled Nursing Facility.

Many adults cycle between the hospital and skilled nursing facilities (SNFs) near the end of life. However, palliative care services, which can provide specialized support for patients with serious illness, are often limited at SNFs. The "3C's Palliative Care Program," a 5-month pilot, aimed to improve palliative care access for patients admitted to subacute rehabilitation at an SNF affiliated with an urban academic medical center. This manuscript focuses on the pilot's feasibility, acceptability based on SNF clinician feedback from interviews, and lessons learned. The 3C's Program featured primary palliative care skill coaching, virtual palliative care consultations, and continuity via referrals to home-based palliative care at discharge. Ninety percent of SNF clinicians surveyed recommended the continuation of the pilot. SNF clinicians felt the program improved their ability to identify patients for PC consultation, to understand the role and value of palliative care, and to appreciate their patients' illness trajectories. Lessons learned from this pilot suggest SNF-Palliative Care clinician relationship building and simple patient identification mechanisms for palliative care are key to the success of palliative care at SNF integration.

Effects of enforcement intensity on alcohol impaired driving crashes.

BACKGROUND: Research measuring levels of enforcement has investigated whether increases in police activities (e.g., checkpoints, driving-while-intoxicated [DWI] special patrols) above some baseline level are associated with reduced crashes and fatalities. Little research, however, has attempted to quantitatively measure enforcement efforts and relate different enforcement levels to specific levels of the prevalence of alcohol-impaired driving. OBJECTIVE: The objective of this study was to investigate the effects of law-enforcement intensity in a sample of communities on the rate of crashes involving a drinking driver. We analyzed the influence of different enforcement strategies and measures: (1) specific deterrence - annual number of driving-under-the-influence (DUI) arrests per capita; (2) general deterrence - frequency of sobriety checkpoint operations; (3) highly visible traffic enforcement - annual number of traffic stops per capita; (4) enforcement presence - number of sworn officers per capita; and (5) overall traffic enforcement - the number of other traffic enforcement citations per capita (i.e., seat belt citations, speeding tickets, and other moving violations and warnings) in each community. METHODS: We took advantage of nationwide data on the local prevalence of impaired driving from the 2007 National Roadside Survey (NRS), measures of DUI enforcement activity provided by the police departments that participated in the 2007 NRS, and crashes from the General Estimates System (GES) in the same locations as the 2007 NRS. We analyzed the relationship between the intensity of enforcement and the prevalence of impaired driving crashes in 22-26 communities with complete data. Log-linear regressions were used throughout the study. RESULTS: A higher number of DUI arrests per 10,000 driving-aged population was associated with a lower ratio of drinking-driver crashes to non-drinking-driver crashes (p=0.035) when controlling for the percentage of legally intoxicated drivers on the roads surveyed in the community from the 2007 NRS. Results indicate that a 10% increase in the DUI arrest rate is associated with a 1% reduction in the drinking driver crash rate. Similar results were obtained for an increase in the number of sworn officers per 10,000 driving-age population. DISCUSSION: While a higher DUI arrest rate was associated with a lower drinking-driver crash rate, sobriety checkpoints did not have a significant relationship to drinking-driver crashes. This appeared to be due to the fact that only 3% of the on-the-road drivers were exposed to frequent sobriety checkpoints (only 1 of 36 police agencies where we received enforcement data conducted checkpoints weekly). This low-use strategy is symptomatic of the general decline in checkpoint use in the U.S. since the 1980s and 1990s when the greatest declines in alcohol-impaired-driving fatal crashes occurred. The overall findings in this study may help law enforcement agencies around the country adjust their traffic enforcement intensity in order to reduce impaired driving in their community.