Patient loneliness in an urban, underserved family medicine residency clinic: prevalence and relationship to health care utilization.

BACKGROUND: Mounting evidence suggests that loneliness increases the risk of poor health outcomes, including cardiovascular disease and premature mortality.Objective: This study examined the prevalence of loneliness in an urban, underserved family medicine residency clinic and the association of loneliness with health care utilization. METHODS: Adult patients (N = 330; M age = 42.1 years, SD = 14.9; 63% female; 58% African American) completed the 3-item UCLA Loneliness screener at their primary care visits between November 2018 and January 2019. A retrospective case-control study design was used to compare health care utilization [hospitalizations, emergency department (ED) visits, primary care visits, no-shows and referrals] in the prior 2 years between patients who identified as lonely versus those who did not. Covariates included demographics and clinical characteristics. RESULTS: Nearly half (44%) of patients exceeded the cut-off for loneliness. Patients who were lonely were more likely to identify as African American, have depression and have a substance use disorder. Patients in the lonely group had significantly longer hospital stays and more primary care visits, no-shows and referrals than patients in the non-lonely group; there were no differences in number of hospitalizations or ED visits. CONCLUSIONS: The prevalence of loneliness in an urban, underserved primary care clinic was much higher than prior prevalence estimates in primary care. Patients who are lonely may use more health care resources than patients who are not lonely. Primary care may be an ideal setting in which to identify patients who are lonely to further understand the impact of loneliness on health care outcomes.

sdf1 Expression reveals a source of perivascular-derived mesenchymal stem cells in zebrafish.

There is accumulating evidence that mesenchymal stem cells (MSCs) have their origin as perivascular cells (PVCs) in vivo, but precisely identifying them has been a challenge, as they have no single definitive marker and are rare. We have developed a fluorescent transgenic vertebrate model in which PVC can be visualized in vivo based upon sdf1 expression in the zebrafish. Prospective isolation and culture of sdf1(DsRed) PVC demonstrated properties consistent with MSC including prototypical cell surface marker expression; mesodermal differentiation into adipogenic, osteogenic, and chondrogenic lineages; and the ability to support hematopoietic cells. Global proteomic studies performed by two-dimensional liquid chromatography and tandem mass spectrometry revealed a high degree of similarity to human MSC (hMSC) and discovery of novel markers (CD99, CD151, and MYOF) that were previously unknown to be expressed by hMSC. Dynamic in vivo imaging during fin regeneration showed that PVC may arise from undifferentiated mesenchyme providing evidence of a PVC-MSC relationship. This is the first model, established in zebrafish, in which MSC can be visualized in vivo and will allow us to better understand their function in a native environment.

Depression Outcomes in Smokers and Nonsmokers: Comparison of Collaborative Care Management Versus Usual Care.

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire-9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.

An Examination of Screening Tools for Collaborative Care of Adolescent Depression.

OBJECTIVE: Collaborative care models for treatment of adolescent depression are rapidly evolving. However, a dearth of information exists regarding patient characteristics associated with positive outcomes. We explored the association between baseline scores on routine screening tools for substance abuse, mood disorders, and anxiety with depression remission and graduation from a collaborative care program in an outpatient pediatric practice. METHODS: Adolescents (aged 12-17 years) with Patient Health Questionnaire-9 Modified for Adolescents (PHQ-9A) score ≥ 10 and a diagnosis of depressive disorder based on DSM-IV criteria between July 2011 and August 2015 were eligible for enrollment in a collaborative care model and inclusion in this study. Remission was defined as a single PHQ-9A score < 5; the criterion for graduation was 3 consecutive months with PHQ-9A score < 5. Analyses compared baseline assessment scores with those at remission and graduation. RESULTS: Of the 182 patients included in the analysis, the overall remission rate was 55%; program graduation rate was 27%. There was no association between scores on baseline screening tools and remission. Graduation was associated with lower scores on a screening tool for substance abuse (unit odds ratio [OR] = 1.62; P = .01) and anxiety (unit OR = 1.03; P = .02). When the scores were examined as categorical variables, graduation was associated with negative assessments on screening tools for substance abuse (OR = 3.21; P = .003) and anxiety (OR = 2.35; P = .02). CONCLUSIONS: Baseline substance abuse and anxiety assessments may have utility in identifying depressed adolescents who are less likely to maintain remission and graduate from a collaborative care program, suggesting that these patients may need additional intervention to achieve sustained remission.

Markers of oxidative stress in umbilical cord blood from G6PD deficient African newborns.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked disorder that affects as many as 400 million people worldwide, making it the most common enzymatic defect. Subjects with G6PD deficiency are more likely to develop neonatal hyperbilirubinemia potentially leading to kernicterus and are at increased risk for acute hemolytic anemia when exposed to pro-oxidant compounds such as anti-malarial drugs. We collected umbilical cord blood from 300 males born in Uganda to assess for novel markers of systemic oxidative stress. We determined that 10.7% of the samples collected were G6PD A- deficient (G202A/A376G) and when these were compared with unaffected controls, there was significantly higher 8-hydroxy-2'-deoxyguanosine (8-OHdG) concentration, elevated ferritin, increased leukocyte count and higher small molecule antioxidant capacity. These data suggest increased baseline oxidative stress and an elevated antioxidant response in umbilical cord blood of patients with G6PD deficiency.

Elevated cerebral spinal fluid cytokine levels in boys with cerebral adrenoleukodystrophy correlates with MRI severity.

BACKGROUND: X-linked adrenoleukodystrophy (ALD) is a metabolic, peroxisomal disease that results from a mutation in the ABCD1 gene. The most severe course of ALD progression is the cerebral inflammatory and demyelinating form of the disease, cALD. To date there is very little information on the cytokine mediators in the cerebral spinal fluid (CSF) of these boys. METHODOLOGY/PRINCIPAL FINDINGS: Measurement of 23 different cytokines was performed on CSF and serum of boys with cerebral ALD and patients without ALD. Significant elevations in CSF IL-8 (29.3±2.2 vs 12.8±1.1 pg/ml, p = 0.0001), IL-1ra (166±30 vs 8.6±6.5 pg/ml, p = 0.005), MCP-1 (610±47 vs 328±34 pg/ml, p = 0.002), and MIP-1b (14.2±1.3 vs 2.0±1.4 pg/ml, p<0.0001) were found in boys with cALD versus the control group. The only serum cytokine showing an elevation in the ALD group was SDF-1 (2124±155 vs 1175±125 pg/ml, p = 0.0001). The CSF cytokines of IL-8 and MCP-1b correlated with the Loes MRI severity score (p = 0.04 and p = 0.008 respectively), as well as the serum SDF-1 level (p = 0.002). Finally, CSF total protein was also significantly elevated in boys with cALD and correlated with both IL-8, MCP-1b (p = 0.0001 for both), as well as Loes MRI severity score (p = 0.0007). CONCLUSIONS/SIGNIFICANCE: IL-8, IL-1ra, MCP-1, MIP-1b and CSF total protein were significantly elevated in patients with cALD; IL-8, MCP-1b, and CSF total protein levels correlated with disease severity determined by MRI. This is the largest report of CSF cytokine levels in cALD to date, and identification of these key cytokines will provide further insight into disease progression and perhaps lead to improved targeted therapies.