Team-based comanagement of diabetes in rural primary care.

OBJECTIVE: To explore clinical indicators among patients with diabetes in southern Alberta and assess changes over time, and to compare patients with diabetes attending a reference clinic (RC), which had adapted its service model to address the specific needs of the patient population, with patients with diabetes attending comparison clinics (CCs) in the same region. DESIGN: Analysis of longitudinal data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). SETTING: Rural southern Alberta. PARTICIPANTS: A community-based family medicine clinic and the 6 other CPCSSN clinics in the same region at the time of the study. MAIN OUTCOME MEASURES: A range of data elements from patients with diabetes within the RC, as well as from patients with diabetes from the CCs, were analyzed by CPCSSN to compare rates of comorbidity and mean body mass index, hemoglobin A1c levels, and blood pressure, as well as service use and measurement frequency. Rate of change per year was modeled longitudinally for each of the outcomes. RESULTS: The RC had higher proportions of patients with comorbid conditions and a consistently higher mean body mass index. Mean HbA1c levels varied minimally between the RC and CCs, with both sets worsening slightly. However, the rate of worsening among patients with diabetes in the RC was found to be significantly greater (P < .05) than for those in the CCs. Blood pressure also varied minimally between the RC and the CCs, with both sets improving; however, the RC had a significantly greater (P < .001) rate of improvement than the CCs did. Finally, a greater proportion of patients in the RC had complete data for these 3 outcome measures, and RC patients made a greater number of clinic visits compared with the CC patients (P < .001). CONCLUSION: This study describes a team-based comanagement organizational model and might provide useful commentary about organizational effectiveness in primary care. Although improvement in health outcomes cannot be directly attributed to any specific change in clinic organization, some statistically and likely clinically significant benefit was found associated with the service model of the RC in a relatively medically and socially challenged patient population and in a conservative evaluative design.

Childbearing Decisions in Residency: A Multicenter Survey of Female Residents.

PURPOSE: To characterize how female residents make decisions about childbearing, factors associated with the decision to delay childbearing, and satisfaction with these decisions. METHOD: In 2017, the authors sent a voluntary, anonymous survey to 1,537 female residents enrolled across 78 graduate medical education programs, consisting of 25 unique specialties, at 6 U.S. academic medical centers. Survey items included personal, partner, and institutional characteristics, whether the respondent was delaying childbearing during residency, and the respondent's satisfaction with this decision. RESULTS: The survey response rate was 52% (n = 804). Among the 447 (56%) respondents who were married or partnered, 274 (61%) were delaying childbearing. Residents delaying childbearing were significantly more likely to be younger (P < .001), not currently a parent (P < .001), in a specialty with an uncontrollable lifestyle (P = .001), or in a large program (P = .004). Among self-reported reasons for delaying childbearing, which were not mutually exclusive, the majority cited a busy work schedule (n = 255; 93%) and desire not to extend residency training (n = 145; 53%). Many cited lack of access to childcare (n = 126; 46%), financial concerns (n = 116; 42%), fear of burdening colleagues (n = 96; 35%), and concern for pregnancy complications (n = 74; 27%). Only 38% (n = 103) of respondents delaying childbearing were satisfied with this decision, with satisfaction decreasing with increasing age. CONCLUSIONS: Decisions to delay childbearing are more common in certain specialties, and many residents who delay childbearing are not satisfied with that decision. These findings suggest that greater attention is needed overall, and particularly in certain specialties, to promote policies and cultures that both anticipate and normalize parenthood in residency, thus minimizing the conflict between biological and professional choices for female residents.

Maternity Leave in Residency: A Multicenter Study of Determinants and Wellness Outcomes.

PURPOSE: To characterize determinants of resident maternity leave and the effect of length of leave on maternal well-being. METHOD: In 2017, the authors sent a voluntary, anonymous survey to female residents at 78 programs, in 25 unique specialties, at 6 institutions. Survey items included personal, partner, and child demographics, and logistics of leave, including whether leave was paid or vacation or sick leave was used. Outcomes were maternity leave length; duration of breastfeeding; burnout and postpartum depression screens; perceptions of support; and satisfaction with length of leave, breastfeeding, and childbearing during residency. RESULTS: Fifty-two percent (804/1,537) of residents responded. Among 16% (126) of respondents who were mothers, 50% (63) had their first child during residency. Seventy-seven maternity leaves were reported (range, 2-40 weeks), with most taking 6 weeks (32% of leaves; 25) and including vacation (81%; 62) or sick leave (64%; 49). Length of leave was associated with institution, use of sick leave or vacation, and amount of paid leave. The most frequently self-reported determinant of leave was the desire not to extend residency training (27%; 59). Training was not extended for 53% (41) of mothers; 9% (7) were unsure. Longer breastfeeding duration and perceptions of logistical support from program administration were associated with longer maternity leaves. Burnout affected approximately 50% (38) of mothers regardless of leave length. CONCLUSIONS: This study illustrates variability in administration of resident maternity leaves. Targets for intervention include policy clarification, improving program support, and consideration of parent wellness upon return to work.

An N-terminal fragment of mouse DGAT1 binds different acyl-CoAs with varying affinity.

A histidine-tagged recombinant N-terminal fragment of type-1 mouse liver diacylglycerol acyltransferase (DGAT; EC 2.3.1.20), MmDGAT1(1-95)His6, was expressed in Escherichia coli, and used to investigate possible acyl-CoA-binding properties. Analysis of the purified fragment by MALDI-TOF mass spectrometry revealed a polypeptide with molecular mass of about 11 kDa which was consistent with the calculated molecular mass based on the deduced amino acid sequence. Lipidex-1000 binding assays indicated that MmDGAT1(1-95)His(6) interacted with long chain fatty acyl-CoAs similar to observations on DGAT1 from oilseed rape (Brassica napus). Binding, as a function of acyl-CoA concentration, differed for palmitoyl (16:0), stearoyl (18:0), and erucoyl (cisDelta(13)22:1)-CoA. Binding of stearoyl- or erucoyl-CoA to MmDGAT1(1-95)His(6) as a function of acyl-CoA concentration, however, was sigmoid and displayed positive cooperativity suggesting that MmDGAT1 may be subject to allosteric modulation by acyl-CoAs. An intra-polypeptide segment within the N-terminal region of MmDGAT1 contained remnants of an acyl-CoA-binding signature initially identified in plant DGAT1. The acyl-CoA-binding site in mammalian DGAT1 could represent a potential target for therapeutic interventions for disorders such as type-2 diabetes and obesity.

Acyl-CoA-binding and self-associating properties of a recombinant 13.3 kDa N-terminal fragment of diacylglycerol acyltransferase-1 from oilseed rape.

BACKGROUND: Diacylglycerol acyltransferase (DGAT, EC 2.3.1.20) catalyzes the acyl-CoA-dependent acylation of sn-1, 2-diacylglycerol to generate triacylglycerol and CoA. The deduced amino acid sequence of cDNAs encoding DGAT1 from plants and mammals exhibit a hydrophilic N-terminal region followed by a number of potential membrane-spanning segments, which is consistent with the membrane-bound nature of this enzyme family. In order to gain insight into the structure/function properties of DGAT1 from Brassica napus (BnDGAT1), we produced and partially characterized a recombinant polyHis-tagged N-terminal fragment of the enzyme, BnDGAT1(1-116)His6, with calculated molecular mass of 13,278 Da. RESULTS: BnDGAT1(1-116)His6 was highly purified from bacterial lysate and plate-like monoclinic crystals were grown using this preparation. Lipidex-1000 binding assays and gel electrophoresis indicated that BnDGAT1(1-116)His6 interacts with long chain acyl-CoA. The enzyme fragment displayed enhanced affinity for erucoyl (22:1cisDelta13)-CoA over oleoyl (18:1cisDelta9)-CoA, and the binding process displayed positive cooperativity. Gel filtration chromatography and cross-linking studies indicated that BnDGAT1(1-116)His6 self-associated to form a tetramer. Polyclonal antibodies raised against a peptide of 15 amino acid residues representing a segment of BnDGAT1(1-116)His6 failed to react with protein in microsomal vesicles following treatment with proteinase K, suggesting that the N-terminal fragment of BnDGAT1 was localized to the cytosolic side of the ER. CONCLUSION: Collectively, these results suggest that BnDGAT1 may be allosterically modulated by acyl-CoA through the N-terminal region and that the enzyme self-associates via interactions on the cytosolic side of the ER.

Pollen competition as a unilateral reproductive barrier between sympatric diploid and tetraploid Chamerion angustifolium.

Speciation requires the evolution of barriers to gene exchange between descendant and progenitor populations. Cryptic reproductive barriers in plants arise after pollination but before fertilization as a result of pollen competition and interactions between male gametophytes and female reproductive tissues. We tested for such gametic isolation between the polyploid Chamerion angustifolium and its diploid progenitor by conducting single (diploid or tetraploid) and mixed ploidy (1 : 1 diploid and tetraploid) pollinations on both cytotypes and inferring siring success from paternity analysis and pollen-tube counts. In mixed pollinations, polyploids sired most (79%) of their own seeds as well as those of diploids (61%) (correcting for triploid block, siring success was 70% and 83%, respectively). In single donor pollinations, pollen tubes from tetraploids were more numerous than those from diploids at four different positions in each style and for both diploid and tetraploid pollen recipients. The lack of a pollen donor x recipient interaction indicates that the tetraploid siring advantage is a result of pollen competition rather than pollen-pistil interactions. Such unilateral pollen precedence results in an asymmetrical pattern of isolation, with tetraploids experiencing less gene flow than diploids. It also enhances tetraploid establishment in sympatric populations, by maximizing tetraploid success and simultaneously diminishing that of diploids through the production of inviable triploid offspring.

Stress-induced somatization in spouses of deployed and nondeployed servicemen.

PURPOSE: To compare the level of perceived stress and somatization experienced by spouses of deployed versus nondeployed servicemen, and to determine the relationship between stress and somatization. DATA SOURCES: Using Lazarus and Folkman's theory of Stress and Coping, a descriptive correlational design was used with 130 participants; 68 spouses of nondeployed servicemen and 62 spouses of servicemen deployed to a combat zone. Participants completed a Perceived Stress Scale-10 and Patient Heath Questionnaire-15. An independent t-test was used to determine the level of perceived stress and somatization in each sample. The Pearson's correlation was used to determine the relationship between perceived stress score and level of somatization in the total sample. CONCLUSIONS: Spouses of deployed servicemen had significantly higher perceived stress scores than spouses of nondeployed service members (p <.001). Somatization scores were also significantly higher in spouses of deployed versus nondeployed servicemen (p <.001). A significant positive correlation was found between level of perceived stress and level of somatization (r = .878, p <.001). IMPLICATIONS FOR PRACTICE: Providers should be familiar with common somatic symptoms, treatments used for somatization and adjunct community resources available to patients with stress-related somatization.