In Silico Research of New Therapeutics Rotenoids Derivatives against Leishmania amazonensis Infection.

Yearly, 1,500,000 cases of leishmaniasis are diagnosed, causing thousands of deaths. To advance in its therapy, we present an interdisciplinary protocol that unifies ethnobotanical knowledge of natural compounds and the latest bioinformatics advances to respond to an orphan disease such as leishmaniasis and specifically the one caused by Leishmania amazonensis. The use of ethnobotanical information serves as a basis for the development of new drugs, a field in which computer-aided drug design (CADD) has been a revolution. Taking this information from Amazonian communities, located in the area with a high prevalence of this disease, a protocol has been designed to verify new leads. Moreover, a method has been developed that allows the evaluation of lead molecules, and the improvement of their affinity and specificity against therapeutic targets. Through this approach, deguelin has been identified as a good lead to treat the infection due to its potential as an ornithine decarboxylase (ODC) inhibitor, a key enzyme in Leishmania development. Using an in silico-generated combinatorial library followed by docking approaches, we have found deguelin derivatives with better affinity and specificity against ODC than the original compound, suggesting that this approach could be adapted for developing new drugs against leishmaniasis.

Searching for Scientific Explanations for the Uses of Spanish Folk Medicine: A Review on the Case of Mullein (Verbascum, Scrophulariaceae).

Verbascum species (common mullein) have been widely used in Spanish folk medicine to treat pathologies related to the musculature, skeleton, and circulatory, digestive, and respiratory systems, as well as to treat infectious diseases and organ-sense illnesses. These applications support the potential anti-inflammatory action of Verbascum phytochemicals. Based on the aforementioned facts, and following a deep bibliographic review of the chemical composition of the 10 species of Verbascum catalogued by the Spanish Inventory of Traditional Knowledge related to Biodiversity, we look for scientific evidences to correlate the traditional medical uses with the chemical components of these plants. To support these findings, in silico simulations were performed to investigate molecular interactions between Verbascum phytochemicals and cellular components. Most of common mullein traditional uses could rely on the anti-inflammatory action of phytochemicals, such as quercetin, and it could explain the employment of these plants to treat a wide range of diseases mediated by inflammatory processes such as respiratory diseases, otitis, arthrosis, and rheumatism among others.

Piper aduncum essential oil: a promising insecticide, acaricide and antiparasitic. A review.

Several studies have assessed the potential of essential oils as substitutes for synthetic pesticides, in order to counter insect resistance to commercial pesticides. Piper aduncum L. is a very common shrub in the Amazon Rainforest and in other subtropical areas. The objective of this review was to analyse the existing information on P. aduncum essential oil as a raw material for new bioproducts for sustainable pest disease management. With this review, we collected and critically analysed 59 papers, representing all the studies that aimed to evaluate the essential oil properties of this species as an insecticide, acaricide and antiparasitic. The chemical composition differs depending on the origin, although phenylpropanoid dillapiole is the most cited component, followed by myristicin, 1,8-cineole and ß-ocimene. Between the acaricidal, antiparasitic and synergistic activities, the insecticidal effects are highly promising, with optimal results against the malaria vector Aedes aegypti, with an LC50 that ranges between 57 and 200µg/mL. Acaricidal activity has mainly been reported against Tetranychus urticae, showing an LC50 that ranges between 5.83 and 7.17µg/mL. Antiparasitic activity has predominately been found on Leishmania amazonensis, and antipromastigote activity has been found to be between 23.8 and 25.9µg/mL. Concerning the synergistic effect between dillapiole and synthetic insecticides, four studies on Spodoptera frugiperda found promising results with cypermethrin. In this review, we highlighted the potential of P. aduncum essential oil as a biopesticide, also focusing on the lack of information about applied research. We also provide suggestions for future investigations.

TITLE: L'huile essentielle de Piper aduncum: un insecticide, acaricide et antiparasitaire prometteur. Une synthèse. ABSTRACT: Plusieurs études ont abordé le potentiel des huiles essentielles comme substitut aux pesticides de synthèse, afin de lutter contre la résistance des insectes aux pesticides commerciaux. Piper aduncum L. est un arbuste très commun dans la forêt amazonienne et dans d'autres zones subtropicales. L'objectif de ce travail est d'analyser les informations existantes sur l'huile essentielle de P. aduncum comme matière première de nouveaux bioproduits pour une gestion durable des maladies nuisibles. Dans cette synthèse, nous avons collecté et analysé de manière critique 59 articles, représentant toutes les études qui visaient à prouver les propriétés des huiles essentielles de cette espèce en tant qu'insecticide, acaricide et antiparasitaire. La composition chimique diffère selon la provenance, bien que le phénylpropanoïde dillapiole soit le composant le plus cité, suivi de la myristicine, du 1,8-cinéole et du ß-ocimène. À côté des activités acaricide, antiparasitaire et de synergie avec les autres composants, les effets insecticides sont les plus prometteurs, avec des résultats optimaux contre le vecteur du paludisme Aedes aegypti, avec une CL50 comprise entre 57 et 200µg/mL. Une activité acaricide a été principalement rapportée contre Tetranychus urticae avec une CL50 comprise entre 5,83 et 7,17µg/mL. L'activité antiparasitaire a été montrée principalement sur Leishmania amazonensis et l'activité antipromastigote s'est avérée être comprise entre 23,8 et 25,9µg/mL. Concernant l'effet synergique entre le dillapiole et les insecticides synthétiques, quatre études sur Spodoptera frugiperda ont mis l'accent sur des résultats prometteurs avec la cyperméthrine. Avec cette étude, nous avons mis en évidence le potentiel de l'huile essentielle de P. aduncum en tant que biopesticide, en insistant sur le manque d'informations de la recherche appliquée et sur certaines propositions pour de futures recherches.

Three Alkaloids from an Apocynaceae Species, Aspidosperma spruceanum as Antileishmaniasis Agents by In Silico Demo-case Studies.

This paper is focused on demonstrating with a real case that Ethnobotany added to Bioinformatics is a promising tool for new drugs search. It encourages the in silico investigation of "challua kaspi", a medicinal kichwa Amazonian plant (Aspidosperma spruceanum) against a Neglected Tropical Disease, leishmaniasis. The illness affects over 150 million people especially in subtropical regions, there is no vaccination and conventional treatments are unsatisfactory. In attempts to find potent and safe inhibitors of its etiological agent, Leishmania, we recovered the published traditional knowledge on kichwa antimalarials and selected three A. spruceanum alkaloids, (aspidoalbine, aspidocarpine and tubotaiwine), to evaluate by molecular docking their activity upon five Leishmania targets: DHFR-TS, PTR1, PK, HGPRT and SQS enzymes. Our simulation results suggest that aspidoalbine interacts competitively with the five targets, with a greater affinity for the active site of PTR1 than some physiological ligands. Our virtual data also point to the demonstration of few side effects. The predicted binding free energy has a greater affinity to Leishmania proteins than to their homologous in humans (TS, DHR, PKLR, HGPRT and SQS), and there is no match with binding pockets of physiological importance. Keys for the in silico protocols applied are included in order to offer a standardized method replicable in other cases. Apocynaceae having ethnobotanical use can be virtually tested as molecular antileishmaniasis new drugs.

Food Identities, Biocultural Knowledge and Gender Differences in the Protected Area "Sierra Grande de Hornachos" (Extremadura, Spain).

A food tradition not only corresponds to the vital need to be nourished every day, but is part of the particularity of a territory as a consequence of its history, traditions, natural heritage, and capacity for ecological and social resilience. In the search for culinary identity, a valorization of a rural territory of high identity potential is carried out, such as in the environmental protection area "Sierra Grande de Hornachos" (Extremadura, Spain), and specifically the town of Hornachos. For this purpose, a series of workshops and interviews were held for men and women who had lived most of their lives in Hornachos and who were older than 70. Information on the food uses of wild and cultivated plants, as determined by the Cultural Significance Index (CSI) for 79 species, was extracted from the interpretation of the data collected. In addition, new uses were collected in Extremadura for 16 plants and in Spain for 3, with some of these data being of particular significance in the culinary culture of Hornachega. We conclude that the area "Sierra Grande de Hornachos" forms an environment of great culinary identity that must be preserved, not only for its heritage interests but also for its agroecological ones, which could be translated into measures of wealth creation and development.

Promising Potential of Lonchocarpus utilis against South American Myasis.

Traditional medicine is especially important in the treatment of neglected tropical diseases because it is the way the majority of populations of affected countries manage primary healthcare. We present a case study that can serve as an example that can be replicated by others in the same situation. It is about the validation of a local remedy for myasis in Amazonian Ecuador, which is contrasted by bibliographic chemical reviews and in silico activity tests. We look for scientific arguments to demonstrate the reason for using extracts of Lonchocarpus utilis against south American myasis (tupe). We provide a summary of the isoflavonoids, prenylated flavonoids, chalcones, and stilbenes that justify the action. We make modeling predictions on the affinity of eight chemical components and enzyme targets using Swiss Target Prediction software. We conclude that the effects of this extract can be reasonably attributed to an effect of the parasite that causes the disease, similar to the one produced by synthetic drugs used by conventional medicine (e.g., Ivermectine).

In Silico Molecular Studies of Antiophidic Properties of the Amazonian Tree Cordia nodosa Lam.

We carried out surveys on the use of Cordia nodosa Lam. in the jungles of Bobonaza (Ecuador). We documented this knowledge to prevent its loss under the Framework of the Convention on Biological Diversity and the Nagoya Protocol. We conducted bibliographic research and identified quercetrin as a significant bioactive molecule. We studied its in silico biological activity. The selected methodology was virtual docking experiments with the proteins responsible for the venomous action of snakes. The molecular structures of quercetrin and 21 selected toxins underwent corresponding tests with SwissDock and Chimera software. The results point to support its antiophidic use. They show reasonable geometries and a binding free energy of -7 to -10.03 kcal/mol. The most favorable values were obtained for the venom of the Asian snake Naja atra (5Z2G, -10.03 kcal/mol). Good results were also obtained from the venom of the Latin American Bothrops pirajai (3CYL, -9.71 kcal/mol) and that of Ecuadorian Bothrops asper snakes (5TFV, -9.47 kcal/mol) and Bothrops atrox (5TS5, -9.49 kcal/mol). In the 5Z2G and 5TS5 L-amino acid oxidases, quercetrin binds in a pocket adjacent to the FAD cofactor, while in the myotoxic homologues of PLA2, 3CYL and 5TFV, it joins in the hydrophobic channel formed when oligomerizing, in the first one similar to α-tocopherol. This study presents a case demonstration of the potential of bioinformatic tools in the validation process of ethnobotanical phytopharmaceuticals and how in silico methods are becoming increasingly useful for sustainable drug discovery.

Bioactive Phytochemicals from Mercurialis spp. Used in Traditional Spanish Medicine.

Plants from the genus Mercurialis have a long history of use as herbal remedies in traditional Spanish medicine. The growing interest in the conservation of knowledge related to biodiversity has encouraged us to review the bioactive phytochemicals from the four most widespread Mercurialis species in the Iberian Peninsula (M. annua L., M. ambigua L., M. perennis L., and M. tomentosa L.). First, the medicinal uses of these four species throughout Spain were compiled, and then a bibliographical search on their chemical composition was conducted in an attempt to justify their reported traditional uses. We found that most of the medicinal uses of Mercurialis spp. are supported by scientific evidence. This includes its antidiabetic and antihypertensive properties attributable to the flavonoid rutin and narcissin, respectively; its benefits in the treatment of skin dark spots, attributable to mequinol; and its anti-inflammatory activity, attributable to scopoletin, kaempferol, squalene, and cycloartenol. This review contributes to the validation of the medicinal uses of Mercurialis spp. in Spain and provides some new avenues for further investigations on the biological activity of this interesting medicinal plant.

Microstructural and Thermo-Physical Characterization of a Water Hyacinth Petiole for Thermal Insulation Particle Board Manufacture.

Water Hyacinth (Eichhornia crassipes) is a dangerous and invasive aquatic species, of which global concern has sharply risen due to its rapid growth. Despite ample research on its possible applications in the construction field, there are no clear references on the optimal use of the plant in finding the most efficient-use building material. In this paper, a microstructural and chemical characterization of the Water Hyacinth petiole was performed, in order to find the most efficient use as a construction material. Subsequently, two types of binder-less insulation panels were developed, with two types of particle size (pulp and staple). A physical, mechanical, and thermal characterization of the boards was performed. These results demonstrated that it is possible to manufacture self-supporting Water Hyacinth petiole panels without an artificial polymer matrix for thermal insulation. The boards showed good thermal conductivity values, ranging from 0.047⁻0.065 W/mK. In addition, clear differences were found in the properties of the boards, depending on the type of Water Hyacinth petiole particle size, due to the differences in the microstructure.

Providing added value to local uses of paparahua (Artocarpus altilis) in Amazonian Ecuador by phytochemical data review

Abstract Artocarpus altilis (Parkinson ex F.A.Zorn.) Fosberg, Moraceae, is a native tree of Southeast Asia introduced to South America at the beginning of the 19th century. It has been used by several indigenous communities. This paper aims to preserve the traditional knowledge at risk of loss and to validate some of the applications found. Current ancestral practices were documented, by interviews in a scarcely contacted Amazonic Kichwa community from the Bobonaza River (Ecuador). The findings were compared with bibliographic citations from other Amazonian cultures. A bioinformatics literature survey of articles that report experiments on the chemical constituents was executed. The major findings are that some uses given in this population may be considered surprising, but the molecular profile of this species justifies its local value. It has cycloartenol (terpenoid), artoindonesianin F (stilbenoid), and different groups of flavonoids (chalcones, prenylflavones, oxepinoflavones, pyrano-flavones, xanthones). This information can prove effective in a search for novel drugs, focused to merge potential innovative uses of the plant.

On the Possible Chemical Justification of the Ethnobotanical Use of Hyptis obtusiflora in Amazonian Ecuador.

In rural areas of Latin America, Hyptis infusions are very popular. Hyptis obtusiflora extends from Mexico throughout Central America to Bolivia and Peru. It has added value in Ecuador where it has been used by different ethnic groups. We aimed to learn about the traditional knowledge of ancient Kichwa cultures about this plant, and to contrast this knowledge with the published information organized in occidental databases. We proposed to use traditional knowledge as a source of innovation for social development. Our specific objectives were to catalogue the uses of H. obtusiflora in the community, to prospect on the bibliography on a possible chemical justification for its medicinal use, to propose new products for development, and to give arguments for biodiversity conservation. An ethnobotanical survey was made and a Prisma 2009 Flow Diagram was then followed for scientific validation. We rescued data that are novel contributions for the ethnobotany at the national level. The catalogued main activity of anti-inflammation can be related to the terpene composition and the inhibition of xanthine oxidase. This opens the possibility of researching the extract of this plant as an alternative to allopurinol or uricosuric drugs. This is a concrete example of an argument for biodiversity conservation.

Chiricaspi (Brunfelsia grandiflora, Solanaceae), a Pharmacologically Promising Plant.

This study's objective was to evaluate the rescued traditional knowledge about the chiricaspi (Brunfelsia grandiflora s.l.), obtained in an isolated Canelo-Kichwa Amazonian community in the Pastaza province (Ecuador). This approach demonstrates well the value of biodiversity conservation in an endangered ecoregion. The authors describe the ancestral practices that remain in force today. They validated them through bibliographic revisions in data megabases, which presented activity and chemical components. The authors also propose possible routes for the development of new bioproducts based on the plant. In silico research about new drug design based on traditional knowledge about this species can produce significant progress in specific areas of childbirth, anesthesiology, and neurology.

Designing audience-centered interactive voice response messages to promote cancer screenings among low-income Latinas.

INTRODUCTION: Cancer screening rates among Latinas are suboptimal. The objective of this study was to explore how Latinas perceive cancer screening and the use and design of interactive voice response (IVR) messages to prompt scheduling of 1 or more needed screenings. METHODS: Seven focus groups were conducted with Latina community health center patients (n = 40) in need of 1 or more cancer screenings: 5 groups were of women in need of 1 cancer screening (breast, cervical, or colorectal), and 2 groups were of women in need of multiple screenings. A bilingual researcher conducted all focus groups in Spanish using a semistructured guide. Focus groups were recorded, transcribed, and translated into English for analysis. Emergent themes were identified by using thematic content analysis. RESULTS: Participants were familiar with cancer screening and viewed it positively, although barriers to screening were identified (unaware overdue for screening, lack of physician referral, lack of insurance or insufficient insurance coverage, embarrassment or fear of screening procedures, fear of screening outcomes). Women needing multiple screenings voiced more concern about screening procedures, whereas women in need of a single screening expressed greater worry about the screening outcome. Participants were receptive to receiving IVR messages and believed that culturally appropriate messages that specified needed screenings while emphasizing the benefit of preventive screening would motivate them to schedule needed screenings. CONCLUSION: Participants' receptiveness to IVR messages suggests that these messages may be an acceptable strategy to promote cancer screening among underserved Latina patients. Additional research is needed to determine the effectiveness of IVR messages in promoting completion of cancer screening.

Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project.

OBJECTIVES: We tested the effectiveness of a community-based, literacy-sensitive, and culturally tailored lifestyle intervention on weight loss and diabetes risk reduction among low-income, Spanish-speaking Latinos at increased diabetes risk. METHODS: Three hundred twelve participants from Lawrence, Massachusetts, were randomly assigned to lifestyle intervention care (IC) or usual care (UC) between 2004 and 2007. The intervention was implemented by trained Spanish-speaking individuals from the community. Each participant was followed for 1 year. RESULTS: The participants' mean age was 52 years; 59% had less than a high school education. The 1-year retention rate was 94%. Compared with the UC group, the IC group had a modest but significant weight reduction (-2.5 vs 0.63 lb; P = .04) and a clinically meaningful reduction in hemoglobin A1c (-0.10% vs -0.04%; P = .009). Likewise, insulin resistance improved significantly in the IC compared with the UC group. The IC group also had greater reductions in percentage of calories from total and saturated fat. CONCLUSIONS: We developed an inexpensive, culturally sensitive diabetes prevention program that resulted in weight loss, improved HbA1c, and improved insulin resistance in a high-risk Latino population.

Prevalence and implications of multiple cancer screening needs among Hispanic community health center patients.

OBJECTIVES: To examine adherence rates for multiple cancer screening tests, which will inform prevention efforts in community health centers (CHCs). METHODS: We report on the prevalence of screening for multiple cancers (cervical, breast and colorectal) among 43,000 patients who are predominantly Hispanic, in four CHC sites that share an integrated electronic medical record. RESULTS: Among the 20,057 patients eligible for at least one test, 43% of the population was current on all screening targets; 15,887 additional screening tests were needed among 11,526 individuals. CONCLUSIONS: Expanding use of health information technology in community health centers provides an opportunity to create an electronic infrastructure for addressing multiple screening needs from a patient-centered perspective.

Awareness of diabetes risk factors and prevention strategies among a sample of low-income Latinos with no known diagnosis of diabetes.

PURPOSE: This study assessed awareness of type 2 diabetes risk and severity, perceived risk factors, knowledge of diabetes prevention strategies, and challenges of and opportunities for prevention among low-income Latinos in Lawrence, Massachusetts. METHODS: Qualitative research design. Latinos with no known diagnosis of diabetes participated in 4 focus groups, conducted in Spanish, which were recorded and transcribed for systematic analysis. RESULTS: The sample, (N = 41) was largely female (85%) with a wide age range (22-76 years), most (71%) had an educational level of high school or less, and less than half (46%) were employed. Participants had basic knowledge of diabetes, but gaps were apparent. Many perceived family history of diabetes, poor diet, emotional distress, and stress associated with the United States as risk factors for diabetes. There was little or no awareness of risk associated with Latino ethnicity, gestational diabetes, hypertension, lipid abnormalities, or obesity. Few cited physical activity or weight loss as diabetes prevention strategies. More than half the participants perceived themselves at low risk for diabetes. CONCLUSIONS: This Latino sample had limited knowledge of diabetes risk factors and lifestyle changes that can prevent or delay diabetes onset. Insights for intervening for diabetes prevention are offered.

Association of depressive symptoms and lifestyle behaviors among Latinos at risk of type 2 diabetes.

Little is known about depression among Latinos at risk for type 2 diabetes. The purpose of this cross-sectional study was to determine the rate of depression in Latinos at risk for type 2 diabetes and to examine the associations between depressive symptoms, diet, physical activity, and body mass index (BMI; calculated as kg/m(2)). Latinos at risk for type 2 diabetes (n=210) were surveyed from July 2007 to August 2008. Depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D). Three 24-hour recalls were used to assess diet and physical activity. Linear regression analyses were used to examine the association between depression, BMI, and lifestyle factors. The sample (78% female) was largely of Caribbean origin (83%) and mean age was 52 years (standard deviation [SD]=11 years). Mean BMI was 34.2 (SD=5.9) and 77% were obese. Average CES-D score was 16.3 (SD=11.3; range=0-45) and 50% had CES-D score > or =16, suggesting clinical depression. Higher CES-D scores were associated with lower diet quality (P<0.05), but were not associated with BMI or physical activity. Depression and lower dietary quality can contribute to risk for type 2 diabetes among Latinos.

Methodology of a diabetes prevention translational research project utilizing a community-academic partnership for implementation in an underserved Latino community.

BACKGROUND: Latinos comprise the largest racial/ethnic group in the United States and have 2-3 times the prevalence of type 2 diabetes mellitus as Caucasians. METHODS AND DESIGN: The Lawrence Latino Diabetes Prevention Project (LLDPP) is a community-based translational research study which aims to reduce the risk of diabetes among Latinos who have a >/= 30% probability of developing diabetes in the next 7.5 years per a predictive equation. The project was conducted in Lawrence, Massachusetts, a predominantly Caribbean-origin urban Latino community. Individuals were identified primarily from a community health center's patient panel, screened for study eligibility, randomized to either a usual care or a lifestyle intervention condition, and followed for one year. Like the efficacious Diabetes Prevention Program (DPP), the LLDPP intervention targeted weight loss through dietary change and increased physical activity. However, unlike the DPP, the LLDPP intervention was less intensive, tailored to literacy needs and cultural preferences, and delivered in Spanish. The group format of the intervention (13 group sessions over 1 year) was complemented by 3 individual home visits and was implemented by individuals from the community with training and supervision by a clinical research nutritionist and a behavioral psychologist. Study measures included demographics, Stern predictive equation components (age, gender, ethnicity, fasting glucose, systolic blood pressure, HDL-cholesterol, body mass index, and family history of diabetes), glycosylated hemoglobin, dietary intake, physical activity, depressive symptoms, social support, quality of life, and medication use. Body weight was measured at baseline, 6-months, and one-year; all other measures were assessed at baseline and one-year. All surveys were orally administered in Spanish. RESULTS: A community-academic partnership enabled the successful recruitment, intervention, and assessment of Latinos at risk of diabetes with a one-year study retention rate of 93%. TRIAL REGISTRATION: NCT00810290.

Creating community-based participatory research in a diverse community: a case study.

Communities struggle to create research guidelines for ethical collaborative research within their locale. In Lawrence, Massachusetts (USA) a collaborative group of community members and academic researchers, known as the Mayor's Health Task Force Research Initiative Working Group, took on the challenge of creating guidelines for ethical community-based research. This case study of the Task Force's work addresses questions of research ethics in a diverse community where families struggle with few resources and face many health disparities, under the often-intrusive and unhelpful scrutiny of researchers from the many nearby major research universities. Representatives from the city, community organizations, and research universities developed a set of core ethical principles for research partnerships, a list of criteria for agreements between partners, and a model to help guide researchers and community members toward equitable and mutually beneficial research. This model can be generalized to similar other communities.

Practice-based interventions to improve health care for Latinos with diabetes.

This study examined diabetes-related health disparities in a Latino population in terms of prevalence of the disease, and the extent to which practice-based interventions improve health care and health for the Latinos who have diabetes. Previous research has shown that Latinos, overall, are at greater risk for diabetes, but less is known for those of Puerto Rican and Dominican origin. Two interventions were implemented in a large primary care practice: an ADA-recognized Diabetes Self Management Education program, and clinical information feedback loops to providers regarding adherence to the Massachusetts Guidelines for the Care of Diabetes. The study identified the prevalence of diabetes to be 13.7% among Puerto Ricans, and 9.1% among Dominicans, rates 2-to-3 times that for the general population. Latino patients (N=567) who participated in a Diabetes Self Management Education Program maintained lower Hb A1c values than did a comparison group (N=432). For a random sample of Latinos with diabetes (N=98) in this study, 6 measures of health care improved significantly from 2001 to 2003. Areas of improvement among healthcare providers were: ordering a microalbumin level measurement when appropriate, prescribing ACE inhibitors as needed, providing pneumococcal and influenza vaccines, reviewing activity status and exercise, identifying smoking status, and prescribing lipid-lowering agents, as appropriate. Body mass index (BMI) for the 98 patients remained the same for both measurement periods at 32.8. Although this initial study spanned only 2 years, improvements in health care and health indices for the population are encouraging. Further study is underway to expand on these gains.