Prevalence and Perception of Childhood Obesity in California's Farmworker Communities.

In California's central valley, childhood obesity rates are above the national average. The majority of families living in the rural, agricultural communities of this region are immigrant of Mexican heritage, and face numerous social and environmental challenges. Demographic and anthropometric data were collected from a population of Mexican-heritage children 3-8 years (N = 609) and families (N = 466) living in two central valley communities. Overall, 45 % of children and 82 % of mothers were classified as overweight or obese. Multivariable analyses indicated that mother's BMI and acculturation level were positively associated with child BMI z-score. Most children classified as overweight or obese (92 % and 53 %, respectively) were perceived as having 'normal' weight by their mothers. Childhood obesity remains a major public health issue in Mexican-heritage, central valley communities. Our model indicates that mother's BMI is predictor of child obesity, and parents tend to underestimate their child's weight status. These findings highlight a need for family-targeted and culturally-tailored approaches to address relevant perceptions of obesity and risk factors in these communities.

Social and Environmental Determinants of Child Physical Activity in a Rural Mexican-Origin Community.

California's rural agricultural communities face an increased burden of obesity and metabolic disease. The present objective is to define the social and environmental influences to child obesity and physical activity within Mexican-origin communities in California's Central Valley. A range of data (anthropometric, socioeconomic, demographic, cultural and environmental) were collected on more than 650 children enrolled in Niños Sanos, Familia Sana. Physical activity data were gathered from a subsample of children 4-7 years of age (n = 148) via accelerometer. Cross sectional analyses explored the relationship between BMI and physical activity and the influence of numerous social and environmental variables. In this sample 45 % of children were determined to be overweight or obese. Boys had a higher daily average moderate-to-vigorous physical activity than girls (p = 0.008). Chi square analyses showed weight status was associated with activity level in girls (p = 0.03) but not boys. Multivariate regression revealed several social and environmental indicators influenced BMI and physical activity (p = 0.004). In this population of school-age children of Mexican-origin, girls may benefit more from targeted efforts to increase MVPA. Family and community support systems may also boost child participation in physical activities.

Pre-Younger Dryas megafaunal extirpation at Rancho La Brea linked to fire-driven state shift.

The cause, or causes, of the Pleistocene megafaunal extinctions have been difficult to establish, in part because poor spatiotemporal resolution in the fossil record hinders alignment of species disappearances with archeological and environmental data. We obtained 172 new radiocarbon dates on megafauna from Rancho La Brea in California spanning 15.6 to 10.0 thousand calendar years before present (ka). Seven species of extinct megafauna disappeared by 12.9 ka, before the onset of the Younger Dryas. Comparison with high-resolution regional datasets revealed that these disappearances coincided with an ecological state shift that followed aridification and vegetation changes during the Bølling-Allerød (14.69 to 12.89 ka). Time-series modeling implicates large-scale fires as the primary cause of the extirpations, and the catalyst of this state shift may have been mounting human impacts in a drying, warming, and increasingly fire-prone ecosystem.

Interviewing Teen Parents: Simulated Patient Experience for Clinical Education and Outreach.

INTRODUCTION:  Many medical students' initial experience obtaining a history from a pediatric patient happens in their clerkship years. There is a shift in medical education to provide early clinical experiences to train physicians. To increase the exposure to pediatric history in the pre-clinical years, we developed this simulation-based session involving students in their second year of medical school. They are tasked with eliciting a history from a baby provided by a teenager who functions both as a standardized patient (SP) and the parent of the infant. Our goal was to have second-year medical students learn and practice interviewing an adolescent while obtaining history about an infant to assist in the transition to Year three Pediatric clerkship. APPROACH:  Collaborating with the Office of Diversity at our medical school, we recruited students registered in medical academies in public middle and high schools in our county and asked them to be part of this simulation-based activity. A majority of these medical academy students are underrepresented in medicine (URiM). The students functioned as SPs for pre-clerkship medical students while gaining exposure to a career in medicine and the medical school environment. The medical students obtained a history, with faculty providing formative feedback, followed by documentation of the encounter. OUTCOMES:  Medical students felt they gained skills to communicate with caregivers of pediatric patients. They also practiced the skill of eliciting a pediatric history from an infant whose parent is a teenager. The middle and high school students that functioned as SPs gained a better appreciation for the medical education system and felt that the experience was valuable for all parties involved. DISCUSSION:  This session exposed pre-clerkship medical students to the nuances of eliciting a pediatric history from pediatric caregivers while also engaging URiM from middle and high school in the medical education process. This session could be used at other institutions to expand diversity in the medical field while also providing pre-clerkship medical students with pediatric experiences.  This article was previously presented as an oral presentation at the AAMC Group on Education Affairs (GEA) Virtual Regional Spring Meeting on April 21, 2021.

Alarming Trends: Mortality from Alcoholic Cirrhosis in the United States.

BACKGROUND: Alcoholic cirrhosis is an advanced form of alcohol-related liver disease. In the United States, between 2010 and 2016, alcohol-related liver disease was the primary cause of nearly 1 in 3 liver transplants, surpassing hepatitis C. METHODS: We utilized the US Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database to compare trends in mortality from alcoholic cirrhosis in the United States in 1999 and 2019. We defined mortality from alcoholic cirrhosis as International Classification of Diseases code K70.3 (alcoholic cirrhosis of liver). We calculated mortality rates and mortality rate ratios (MRRs) per 100,000 from alcoholic cirrhosis in 10-year age groups from 25 to 85+ as measures of effect and 95% confidence intervals to test for significance. RESULTS: In 1999, there were 6007 deaths from alcoholic cirrhosis among 180,408,769 aged 25-85+ years, yielding a mortality rate of 3.3 per 100,000. In 2019, there were 23,780 deaths from alcoholic cirrhosis among 224,981,167 aged 25-85+ years, yielding a mortality rate of 10.6 per 100,000. The overall MRR of 3.2 was statistically significant. (P < .001), and was apparent in each 10-year age group. CONCLUSIONS: These alarming trends in mortality from alcoholic cirrhosis in the United States contribute to the formulation of many hypotheses. These require testing in analytic studies designed a priori to do so. Meanwhile, clinical and public health efforts are necessary to curb the epidemics of heavy alcohol consumption and overweight and obesity in the United States that may be contributing to these alarming trends.

Training Preclerkship Medical Students on History Taking in Transgender and Gender Nonconforming Patients.

The purpose of the study is to introduce a standardized patient (SP) activity focusing on communication with transgender and gender nonconforming (TGNC) individuals. Using an SP script, preclerkship medical students obtained medical histories from TGNC SPs, followed by a panel discussion. In total, 126 students participated in the SP encounter for a period of 2 years. After completion, 92.2% of students felt more confident using patient's pronouns and 95.4% indicated improved confidence with the overall experience of taking a history from a transgender patient. This study demonstrated that partnering with local LGBTQ+ community partners can create authentic simulated clinical experiences for preclerkship medical students, improving their confidence in communication and interpersonal skills with TGNC patients.

Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit-risk ratio, not age.

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

Use of a structured approach and virtual simulation practice to improve diagnostic reasoning.

OBJECTIVES: In 2015, the National Academy of Medicine IOM estimated that 12 million patients were misdiagnosed annually. This suggests that despite prolonged training in medical school and residency there remains a need to improve diagnostic reasoning education. This study evaluates a new approach. METHODS: A total of 285 medical students were enrolled in this 8 center, IRB approved trial. Students were randomized to receive training in either abdominal pain (AP) or loss of consciousness (LOC). Baseline diagnostic accuracy of the two different symptoms was assessed by completing a multiple-choice question (MCQ) examination and virtual patient encounters. Following a structured educational intervention, including a lecture on the diagnostic approach to that symptom and three virtual patient practice cases, each student was re-assessed. RESULTS: The change in diagnostic accuracy on virtual patient encounters was compared between (1) baseline and post intervention and (2) post intervention students trained in the prescribed symptom vs. the alternate symptom (controls). The completeness of the student's differential diagnosis was also compared. Comparison of proportions were conducted using χ2-tests. Mixed-effects regressions were used to examine differences accounting for case and repeated measures. Compared with baseline, both the AP and LOC groups had marked post-intervention improvements in obtaining a correct final diagnosis; a 27% absolute improvement in the AP group (p<0.001) and a 32% absolute improvement in the LOC group (p<0.001). Compared with controls (the groups trained in the alternate symptoms), the rate of correct diagnoses increased by 13% but was not statistically significant (p=0.132). The completeness and efficiency of the differential diagnoses increased by 16% (ß=0.37, p<0.001) and 17% respectively (ß=0.45, p<0.001). CONCLUSIONS: The study showed that a virtual patient platform combined with a diagnostic reasoning framework could be used for education and diagnostic assessment and improved correct diagnosis compared with baseline performance in a simulated platform.

Addressing the Rapidly Increasing Need for Telemedicine Education for Future Physicians.

INTRODUCTION: As the COVID-19 pandemic affected the ability to conduct in-person sessions to teach clinical skills, our medical school developed a curriculum to introduce first-year medical students to telemedicine visits, while also reinforcing their history-taking and clinical reasoning skills. METHODS: All first-year medical students at Florida Atlantic University went through three sessions on telemedicine that began with a lecture, followed by a standardized patient interaction, then a small group meeting with clinical faculty. We assessed the sessions using survey questions on a 5-point Likert scale and additional narrative feedback. We also assessed students on a telemedicine objective structured clinical examination (OSCE) at the end of the semester and compared results to the previous year's same case done in person. RESULTS: Students overall found the sessions helpful for refining their history-taking skills and that the knowledge gained would be helpful in their future practices. They felt the online platform was a useful way to interact with patients, but had frustrations with technical difficulties. They also expressed a greater appreciation for the ability to perform an in-person physical examination. Students performed similarly on the OSCE station in person compared to virtual visits (mean score 93% vs 93.75%). CONCLUSION: Introducing telemedicine during a first-year medical school clinical skills course provides students with opportunities to refine their clinical skills while introducing a skill that will be commonplace in the postpandemic environment. This curriculum could be adopted not only during a time of necessary distance learning, but also continued as in-person education resumes.

Approach to Electrolyte Abnormalities, Prerenal Azotemia, and Fluid Balance.

Volume and electrolyte evaluation and management is seen frequently in primary care practices. Some of the most common abnormalities encountered in outpatient practices are prerenal azotemia, dysnatremias, and altered potassium levels. Perturbations in volume or electrolyte concentrations can lead to serious organ dysfunction as well as hemodynamic collapse. This review focuses on the maintenance and regulation of intravascular volume and electrolytes, specifically sodium and potassium.

Hatching of Globodera pallida Induced by Root Exudates Is Not Influenced by Soil Microbiota Composition.

Plant-parasitic nematodes are among the most harmful pests of cultivated crops causing important economic losses. The ban of chemical nematicides requires the development of alternative agroecological approaches to protect crops against nematodes. For cyst nematodes, egg hatching is stimulated by host plant root exudates. Inducing "suicide hatching" of nematode second-stage juveniles (J2), using root exudates in the absence of the host plant, may constitute an effective and innovative biocontrol method to control cyst nematodes. However, before considering the development of this approach, understanding the effect of soil biotic component on cyst nematode hatching by root exudates is a major issue. The effectiveness of this approach could be modulated by other soil organisms consuming root exudates for growth as soil microbiota, and this must be evaluated. To do that, four different native agricultural soils were selected based on their physicochemical properties and their microbiota composition were characterized by rDNA metabarcoding. To disentangle the effect of microbiota from that of soil on hatching, four recolonized artificial soils were obtained by inoculating a common sterile soil matrix with the microbiota proceeding from each agricultural soil. Each soil was then inoculated with cysts of the potato cyst nematode, Globodera pallida, and low or high doses of potato root exudates (PREs) were applied. After 40 days, viable J2 remaining in cysts were counted to determine the efficiency of root exudates to stimulate hatching in different soils. Results showed that (i) when physicochemical and microbiota compositions varied among native soils, the hatching rates remained very high albeit small differences were measured and no dose effect was detected and (ii) when only microbiota composition varied among recolonized soils, the hatching rates were also high at the highest dose of PREs, but a strong dose effect was highlighted. This study shows that abiotic and biotic factors may not compromise the development of methods based on suicide hatching of cyst nematodes, using root exudates, molecules inducing J2 hatch, or trap crops.

The Screening and Prevention of Diabetes Mellitus.

Type 2 diabetes mellitus is among the most common diseases seen in primary care practices and can lead to significant complications. Furthermore, more than 7 million Americans are unaware that they even have the disease. This article reviews the screening guidelines and prevention strategies for type 2 diabetes mellitus and discusses the risks and benefits of screening.

Prospects for the Primary Prevention of Myocardial Infarction and Stroke.

Cardiovascular disease (CVD), principally myocardial infarction (MI) and stroke, is the leading clinical and public health problem in the United States and is rapidly becoming so worldwide. Their primary prevention is promising, in theory, but difficult to achieve in practice. The principal modalities that have demonstrated efficacy include therapeutic lifestyle changes (TLCs) and adjunctive drug therapies under the guidance of the health-care provider and tailored to the individual patient. The prevention and treatment of the pandemic of overweight and obesity and lack of regular physical activity, both of which are alarmingly common in the United States, prevention and treatment of hypertension, avoidance and cessation of cigarette smoking, adoption and maintenance of a healthy diet, and avoidance of heavy alcohol consumption all have proven benefits in decreasing the risks of a first MI and stroke as well as other clinical manifestations of CVD. Although adoption of TLCs would avoid the need for adjunctive drug therapies in many primary prevention subjects, this strategy is difficult to achieve or maintain for most and may be insufficient for many, especially those at high risk with metabolic syndrome. The criteria for metabolic syndrome, affecting over 40% of the adult population older than 40 in the United States, include overweight or obesity, dyslipidemia, hypertension, and insulin resistance, a precursor of diabetes. The adjunctive therapies of proven benefit in the primary prevention of MI and stroke include statins, blood pressure medications, aspirin, and drugs to treat insulin resistance and hyperglycemia. Fortunately, even for patients who prefer prescription of pills to proscription of harmful lifestyles, these drug therapies still have net benefits. The adoption and maintenance of TLCs and adjunctive drug therapies into clinical practice will reduce both the incidence of and mortality from a first MI and stroke as well as other major clinical manifestations of CVD.

Attitudes and Social Norms Are Related to Attendance at Childhood Obesity Prevention Classes in a Rural Mexican-Heritage Community.

OBJECTIVE: To examine factors related to attendance of Mexican-heritage parents at community-based nutrition classes to prevent childhood obesity. METHODS: Starting in 2011, interviewers collected baseline data from Niños Sanos Familia Sana (Healthy Children, Healthy Families) participants in rural California. Educators maintained attendance logs from 2012 to 2014. Informed by the Theory of Planned Behavior, interviewers administered an exit survey in 2015 to collect data on attitudes, subjective norms, health motivations, and perceived control related to attendance. Multivariable ordinal logistic regression analysis examined the correlates of attendance (n = 194, intervention group only). RESULTS: Controlling for mother's age, marital status, acculturation, and employment, attitudes and subjective norms were significantly related to attendance (odds ratio = 1.27; 95% confidence interval [CI], 1.18-1.37; P < .001). CONCLUSIONS AND IMPLICATIONS: In these Mexican-heritage participants, attitudes and subjective norms were significant correlates of attendance. The Theory of Planned Behavior may shed light on attendance of high-risk groups but further testing of instruments is needed.

Development and Application of a High Throughput Protein Unfolding Kinetic Assay.

The kinetics of folding and unfolding underlie protein stability and quantification of these rates provides important insights into the folding process. Here, we present a simple high throughput protein unfolding kinetic assay using a plate reader that is applicable to the studies of the majority of 2-state folding proteins. We validate the assay by measuring kinetic unfolding data for the SH3 (Src Homology 3) domain from Actin Binding Protein 1 (AbpSH3) and its stabilized mutants. The results of our approach are in excellent agreement with published values. We further combine our kinetic assay with a plate reader equilibrium assay, to obtain indirect estimates of folding rates and use these approaches to characterize an AbpSH3-peptide hybrid. Our high throughput protein unfolding kinetic assays allow accurate screening of libraries of mutants by providing both kinetic and equilibrium measurements and provide a means for in-depth ϕ-value analyses.

Breast cancer molecular subtypes and survival in a hospital-based sample in Puerto Rico.

Information on the impact of hormone receptor status subtypes in breast cancer (BC) prognosis is still limited for Hispanics. We aimed to evaluate the association of BC molecular subtypes and other clinical factors with survival in a hospital-based female population of BC cases in Puerto Rico. We analyzed 663 cases of invasive BC diagnosed between 2002 and 2005. Information on HER-2/neu (HER-2) overexpression, estrogen (ER), and progesterone (PR) receptor status and clinical characteristics were retrieved from hospitals cancer registries and record review. Survival probabilities by covariates of interest were described using the Kaplan-Meier estimators. Cox proportional hazards models were employed to assess factors associated with risk of BC death. Overall, 17.3% of BC cases were triple-negative (TN), 61.8% were Luminal-A, 13.3% were Luminal-B, and 7.5% were HER-2 overexpressed. In the multivariate Cox model, among patients with localized stage, women with TN BC had higher risk of death (adjusted hazard ratio [HR]: 2.57, 95% confidence interval [CI]: 1.29-5.12) as compared to those with Luminal-A status, after adjusting for age at diagnosis. In addition, among women with regional/distant stage at diagnosis, those with TN BC (HR: 5.48, 95% CI: 2.63-11.47) and those HER-2+, including HER-2 overexpressed and Luminal-B, (HR: 2.73, 95% CI:1.30-5.75) had a higher mortality. This is the most comprehensive epidemiological study to date on the impact of hormone receptor expression subtypes in BC survival in Puerto Rico. Consistent to results in other populations, the TN subtype and HER-2+ tumors were associated with decreased survival.