Primary care renewal: regional faculty development and organizational change

BACKGROUND: Many reports, including the Future of Family Medicine, have called for change in primary care, but few have defined, implemented, and evaluated mechanisms to address such change. The regional, interdisciplinary Primary Care Renewal Project was designed to address problems in primary care practice and teaching related to practice management, compensation, increasing responsibility for teaching, and faculty development. METHODS: Twelve northeastern US medical schools assembled a conference attended by teams of key stakeholders representing both clinical and educational missions. Teams developed and implemented an institutional plan to address identified needs. Outcome data was collected during, and for 1 year after, the conference. RESULTS: Findings demonstrate novel ways of improving learning experiences, coordinating and centralizing planning efforts, and addressing faculty needs. The magnitude of organizational change ranged from establishing new administrative units with significant institutional authority (eg, restructuring dean\u27s office) to enhancing the strategic planning process and refining mission statements to reflect emphasis on primary care. CONCLUSIONS: A well-planned, regional interdisciplinary effort that fosters the development of concrete plans can be associated with significant change in medical education. A central theme emerged--that primary care medicine will survive only if institutions align their educational and clinical missions and foster system-wide change

Genome-by-Trauma Exposure Interactions in Adults With Depression in the UK Biobank

IMPORTANCE: Self-reported trauma exposure has consistently been found to be a risk factor for major depressive disorder (MDD), and several studies have reported interactions with genetic liability. To date, most studies have examined gene-environment interactions with trauma exposure using genome-wide variants (single-nucleotide variations [SNVs]) or polygenic scores, both typically capturing less than 3% of phenotypic risk variance. OBJECTIVE: To reexamine genome-by-trauma interaction associations using genetic measures using all available genotyped data and thus, maximizing accounted variance. DESIGN, SETTING, AND PARTICIPANTS: The UK Biobank study was conducted from April 2007 to May 1, 2016 (follow-up mental health questionnaire). The current study used available cross-sectional genomic and trauma exposure data from UK Biobank. Participants who completed the mental health questionnaire and had available genetic, trauma experience, depressive symptoms, and/or neuroticism information were included. Data were analyzed from April 1 to August 30, 2021. EXPOSURES: Trauma and genome-by-trauma exposure interactions. MAIN OUTCOMES AND MEASURES: Measures of self-reported depression, neuroticism, and trauma exposure with whole-genome SNV data are available from the UK Biobank study. Here, a mixed-model statistical approach using genetic, trauma exposure, and genome-by-trauma exposure interaction similarity matrices was used to explore sources of variation in depression and neuroticism. RESULTS: Analyses were conducted on 148 129 participants (mean [SD] age, 56 [7] years) of which 76 995 were female (52.0%). The study approach estimated the heritability (SE) of MDD to be approximately 0.160 (0.016). Subtypes of self-reported trauma exposure (catastrophic, adult, childhood, and full trauma) accounted for a significant proportion of the variance of MDD, with heritability (SE) ranging from 0.056 (0.013) to 0.176 (0.025). The proportion of MDD risk variance accounted for by significant genome-by-trauma interaction revealed estimates (SD) ranging from 0.074 (0.006) to 0.201 (0.009). Results from sex-specific analyses found genome-by-trauma interaction variance estimates approximately 5-fold greater for MDD in male participants (0.441 [0.018]) than in female participants (0.086 [0.009]). CONCLUSIONS AND RELEVANCE: This cross-sectional study used an approach combining all genome-wide SNV data when exploring genome-by-trauma interactions in individuals with MDD; findings suggest that such interactions were associated with depression manifestation. Genome-by-trauma interaction accounts for greater trait variance in male individuals, which points to potential differences in depression etiology between the sexes. The methodology used in this study can be extrapolated to other environmental factors to identify modifiable risk environments and at-risk groups to target with interventions

Examination of Curcumin and Fenugreek Soluble Fiber Supplementation on Submaximal and Maximal Aerobic Performance Indices

This study examined the effects of curcumin and fenugreek soluble fiber supplementation on the ventilatory threshold (VT) and peak oxygen consumption (VO2 peak). Methods: Forty-five untrained men and women were randomly assigned to one of three supplementation groups: placebo (PLA, n = 13), 500 mg·day−1 CurQfen® (CUR, n = 14), or 300 mg·day−1 fenugreek soluble fiber (FEN, n = 18). Participants completed a maximal graded exercise test on a cycle ergometer to determine the VT and VO2 peak before (PRE) and after (POST) 28 days of daily supplementation. Separate, one-way analyses of covariance (ANCOVAs) were used to examine the between-group differences for adjusted POST VT and VO2 peak values, covaried for the respective PRE-test values. Results: The adjusted POST VT VO2 values for the CUR (mean SD = 1.593 0.157 L·min−1) and FEN (1.597 0.157 L·min−1) groups were greater than (p = 0.039 and p = 0.025, respectively) the PLA (1.465 0.155 L·min−1) group, but the FEN and CUR groups were not different (p = 0.943). There were no differences in the adjusted VO2 peak values (F = 0.613, p = 0.547) among groups. Conclusion: These findings indicated that fenugreek soluble fiber was responsible for the improvements in the submaximal performance index for both CUR and FEN groups

Unilateral Handgrip Holds to Failure Result in Sex-Dependent Contralateral Facilitation

There can be differences in fatigue characteristics between men and women. In some cases, these differences may be manifested in unique strength responses in the fatigued and non-fatigued limbs following a unilateral fatiguing task. PURPOSE: This study examined changes in maximal voluntary isometric contraction (MVIC) force following dominant (Dm) and nondominant (NDm) unilateral, isometric handgrip holds to failure (HTF) for the exercised ipsilateral (IPS) and non-exercised contralateral (CT) limbs. Sex- and hand- (Dm vs NDm) dependent responses in HTF time, performance fatiguability (PF, %D in MVIC) for the exercised IPS limb, as well as changes in MVIC force for the CT limb following the HTF were examined. METHODS: Ten men and 10 women (Age = 22.2 yrs) performed an isometric, HTF at 50% MVIC for the Dm and NDm hand on separate days. Prior to, and immediately after the HTF, a MVIC was performed on the IPS and CT limbs, in a randomized order. A 2 (hand [Dm, NDm]) x 2 (limb [IPS, CON]) x 2 (time [pre-HTF, post-HTF]) x 2 (sex [men, women]) mixed-model ANOVA was used to examine the MVIC force (kg) and a 2 (hand [Dm, NDm]) x 2 (sex [men, women]) mixed-model ANOVA was used to examine time for the HTF. RESULTS: The Dm (130.3 ± 36.8s) HTF (collapsed across sex) was significantly longer (p = 0.002) than the NDm (112.1 ± 34.3s). The men (collapsed across hand) demonstrated IPS (%Δ= 22.9 ± 10.8%) PF and CT facilitation (%Δ= -6.1 ±6.9%) following the HTF, while the women demonstrated differences in PF between the Dm and NDm hands for the IPS (%Δ Dm = 28.0 ± 9.4%; NDm = 32.3% ± 10.1%; p = 0.027), but not the CT limb (%Δ Dm= -1.6 ± 5.7%; NDm = 1.7 ± 5.9%). CONCLUSIONS: Despite the greater fatigue resistance for the Dm compared to the NDm hand, there were no differences in PF for the IPS side for the men, but lesser IPS PF for Dm compared to NDm hand for the women. The cross-over facilitation of the CT limb for men, but not women, following a unilateral, isometric handgrip HTF may be related to post-activation potentiation

Distribution of \u3ci\u3eBaylisascaris procyonis\u3c/i\u3e in Raccoons (\u3ci\u3eProcyon lotor\u3c/i\u3e) in Florida, USA

Baylisascaris procyonis, or raccoon roundworm, is an intestinal nematode parasite of raccoons (Procyon lotor) that is important to public and wildlife health. Historically, the parasite was uncommon in the southeastern US; however, the range of B. procyonis has expanded to include Florida, US. From 2010 to 2016, we opportunistically sampled 1,030 raccoons statewide. The overall prevalence was 3.7% (95% confidence interval=2.5–4.8%) of sampled individuals, and infection intensity ranged from 1 to 48 (mean±standard deviation 9.9±4.0). We found raccoon roundworm in 9/56 (16%) counties sampled, and the percent positive ranged from 1.1% to 13.3% of specimens collected per county. Including previously published data, B. procyonis was detected in 11 Florida counties. We used logistic regression to estimate the contribution of raccoon demographic variables and the presence of the endoparasite Macracanthorhynchus ingens to B. procyonis detection in Florida. Following the model selection process we found housing density, M. ingens presence, and urbanicity to be predictive of raccoon roundworm presence. We also found substantial among-county variation. Raccoon sex and age were not useful predictors. Public health officials, wildlife rehabilitators, wildlife managers, and others should consider any Florida raccoon to be potentially infected with B. procyonis, particularly in areas where housing density is high

Cardiac rehabilitation to improve health-related quality of life following trans-catheter aortic valve implantation: a randomised controlled feasibility study: RECOVER-TAVI Pilot, ORCA 4, for the Optimal Restoration of Cardiac Activity Group

Objectives: Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population. Design: We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT). Participants: We screened patients undergoing TAVI at a single institution between June 2016 and February 2017. Interventions: Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group). Outcomes: We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population. Results: Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6). Conclusions: We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-related quality of life outcomes in this vulnerable population. Retrospectively registered 3rd October 2016 clinicaltrials.gov NCT02921880. Trial registration: Clinicaltrials.Gov identifier NCT0292188

Lifestyle and Genetic Factors Modify Parent-of-Origin Effects on the Human Methylome

BACKGROUND: parent-of-origin effects (POE) play important roles in complex disease and thus understanding their regulation and associated molecular and phenotypic variation are warranted. Previous studies mainly focused on the detection of genomic regions or phenotypes regulated by POE. Understanding whether POE may be modified by environmental or genetic exposures is important for understanding of the source of POE-associated variation, but only a few case studies addressing modifiable POE exist. METHODS: in order to understand this high order of POE regulation, we screened 101 genetic and environmental factors such as ‘predicted mRNA expression levels’ of DNA methylation/imprinting machinery genes and environmental exposures. POE-mQTL-modifier interaction models were proposed to test the potential of these factors to modify POE at DNA methylation using data from Generation Scotland: The Scottish Family Health Study(N=2315). FINDINGS: a set of vulnerable/modifiable POE-CpGs were identified (modifiable-POE-regulated CpGs, N=3). Four factors, ‘lifetime smoking status’ and ‘predicted mRNA expression levels’ of TET2, SIRT1 and KDM1A, were found to significantly modify the POE on the three CpGs in both discovery and replication datasets. We further identified plasma protein and health-related phenotypes associated with the methylation level of one of the identified CpGs. INTERPRETATION: the modifiable POE identified here revealed an important yet indirect path through which genetic background and environmental exposures introduce their effect on DNA methylation, motivating future comprehensive evaluation of the role of these modifiers in complex diseases. FUNDING: NSFC (81971270),H2020-MSCA-ITN(721815), Wellcome (204979/Z/16/Z,104036/Z/14/Z), MRC (MC_UU_00007/10, MC_PC_U127592696), CSO (CZD/16/6,CZB/4/276, CZB/4/710), SFC (HR03006), EUROSPAN (LSHG-CT-2006-018947), BBSRC (BBS/E/D/30002276), SYSU, Arthritis Research UK, NHLBI, NIH

Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations

Abstract Health care-associated infections (HAI) are a major public health problem with a significant impact on morbidity, mortality and quality of life. They represent also an important economic burden to health systems worldwide. However, a large proportion of HAI are preventable through effective infection prevention and control (IPC) measures. Improvements in IPC at the national and facility level are critical for the successful containment of antimicrobial resistance and the prevention of HAI, including outbreaks of highly transmissible diseases through high quality care within the context of universal health coverage. Given the limited availability of IPC evidence-based guidance and standards, the World Health Organization (WHO) decided to prioritize the development of global recommendations on the core components of effective IPC programmes both at the national and acute health care facility level, based on systematic literature reviews and expert consensus. The aim of the guideline development process was to identify the evidence and evaluate its quality, consider patient values and preferences, resource implications, and the feasibility and acceptability of the recommendations. As a result, 11 recommendations and three good practice statements are presented here, including a summary of the supporting evidence, and form the substance of a new WHO IPC guideline

Stigma of Seeking Psychological Services: Examining College Students Across Ten Countries/Regions

© Division of Counseling Psychology of the American Psychological Association. Stigma is an important barrier to seeking psychological services worldwide. Two types of stigma exist: public stigma and self-stigma. Scholars have argued that public stigma leads to self-stigma, and then self-stigma is the primary predictor of attitudes toward seeking psychological services. However, this assertion is largely limited to U.S. samples. The goal of this research was to provide a first step in understanding the relationship between public stigma, self-stigma, and attitudes toward seeking psychological services in international contexts (N = 3,276; Australia, Brazil, Canada, Hong Kong, Portugal, Romania, Taiwan, Turkey, United Arab Emirates, and United States). Using structural equation modeling, we found that self-stigma mediated the relationship between public stigma and attitudes toward seeking services among college students in each country and region. However, differences in path strengths emphasize the need to pay attention to the role of public and self-stigma on attitudes toward seeking psychological services throughout the world

Haplotype-based association analysis of general cognitive ability in Generation Scotland, the English Longitudinal Study of Ageing, and UK Biobank

Background: Cognitive ability is a heritable trait with a polygenic architecture, for which several associated variants have been identified using genotype-based and candidate gene approaches. Haplotype-based analyses are a complementary technique that take phased genotype data into account, and potentially provide greater statistical power to detect lower frequency variants. Methods: In the present analysis, three cohort studies (ntotal = 48,002) were utilised: Generation Scotland: Scottish Family Health Study (GS:SFHS), the English Longitudinal Study of Ageing (ELSA), and the UK Biobank. A genome-wide haplotype-based meta-analysis of cognitive ability was performed, as well as a targeted meta-analysis of several gene coding regions. Results: None of the assessed haplotypes provided evidence of a statistically significant association with cognitive ability in either the individual cohorts or the meta-analysis. Within the meta-analysis, the haplotype with the lowest observed P-value overlapped with the D-amino acid oxidase activator (DAOA) gene coding region. This coding region has previously been associated with bipolar disorder, schizophrenia and Alzheimer’s disease, which have all been shown to impact upon cognitive ability. Another potentially interesting region highlighted within the current genome-wide association analysis (GS:SFHS: P = 4.09 x 10-7), was the butyrylcholinesterase (BCHE) gene coding region. The protein encoded by BCHE has been shown to influence the progression of Alzheimer’s disease and its role in cognitive ability merits further investigation. Conclusions: Although no evidence was found for any haplotypes with a statistically significant association with cognitive ability, our results did provide further evidence that the genetic variants contributing to the variance of cognitive ability are likely to be of small effect