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Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers’ experiences treating people with diabetes in this region. This study explored providers’ perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.
We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).
Qualitative analysis revealed four themes: (1) patients’ diabetes fatalism and helplessness: providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers’ cultural understanding and recommendations: providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.
Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio.
We examined whether change in added sugar intake is associated with change in δ13C, a novel sugar biomarker, in thirty-nine children aged 5–10 years selected from a Colorado (USA) prospective cohort of children at increased risk for type 1 diabetes. Reported added sugar intake via FFQ and δ13C in erythrocytes were measured at two time points a median of 2 years apart. Change in added sugar intake was associated with change in the δ13C biomarker, where for every 1-g increase in added sugar intake between the two time points, there was an increase in δ13C of 0⋅0082 (P = 0⋅0053), independent of change in HbA1c and δ15N. The δ13C biomarker may be used as a measure of compliance in an intervention study of children under the age of 10 years who are at increased risk for type 1 diabetes, in which the goal was to reduce dietary sugar intake.
We analyzed antibiotic use data from 29 southeastern US hospitals over a 5-year period to determine changes in antibiotic use after the fluoroquinolone US Food and Drug Administration (FDA) advisory update in 2016. Fluoroquinolone use declined both before and after the FDA announcement, and the use of select, alternative antibiotics increased after the announcement.
Fluoroquinolones are among the 4 most commonly prescribed antibiotic classes.1,2 Postmarketing reports of serious adverse events linked to fluoroquinolones include tendonitis, neuropathy, hypoglycemia, psychiatric side effects, and possible aortic vessel rupture, leading to safety label changes in July 2008 and August 2013.3 In July 2016, the US Food and Drug Administration (FDA) strengthened the “black box” warning following an initial safety announcement in May 2016, recommending avoidance of fluoroquinolones for uncomplicated infections such as acute exacerbation of chronic bronchitis, uncomplicated urinary tract infections, and acute bacterial sinusitis.4 Concerns over safety and the association with Clostridiodes difficile infection have led inpatient antimicrobial stewardship programs (ASPs) to develop initiatives to promote avoidance of quinolones. The objective of this study was to quantify the effect of the 2016 FDA “black box” update on inpatient antibiotic use among a cohort of southeastern US hospitals.
To examine the relationship between protein intake and the risk of incident premenstrual syndrome (PMS).
Nested case–control study. FFQ were completed every 4 years during follow-up. Our main analysis assessed protein intake 2–4 years before PMS diagnosis (for cases) or reference year (for controls). Baseline (1991) protein intake was also assessed.
Nurses’ Health Study II (NHS2), a large prospective cohort study of registered female nurses in the USA.
Participants were premenopausal women between the ages of 27 and 44 years (mean: 34 years), without diagnosis of PMS at baseline, without a history of cancer, endometriosis, infertility, irregular menstrual cycles or hysterectomy. Incident cases of PMS (n 1234) were identified by self-reported diagnosis during 14 years of follow-up and validated by questionnaire. Controls (n 2426) were women who did not report a diagnosis of PMS during follow-up and confirmed experiencing minimal premenstrual symptoms.
In logistic regression models adjusting for smoking, BMI, B-vitamins and other factors, total protein intake was not associated with PMS development. For example, the OR for women with the highest intake of total protein 2–4 years before their reference year (median: 103·6 g/d) v. those with the lowest (median: 66·6 g/d) was 0·94 (95 % CI 0·70, 1·27). Additionally, intakes of specific protein sources and amino acids were not associated with PMS. Furthermore, results substituting carbohydrates and fats for protein were also null.
Overall, protein consumption was not associated with risk of developing PMS.
In 2018, the Clostridium difficile LabID event methodology changed so that hospitals doing 2-step tests, nucleic acid amplification test (NAAT) plus enzyme immunofluorescence assay (EIA), had their adjustment modified to EIA-based tests, and only positive final tests (eg, EIA) were counted in the numerator. We report the immediate impact of this methodological change at 3 Milwaukee hospitals.
Coastal ecosystems have been degraded by human activity over centuries, with loss of memory about past states resulting in shifted baselines. More recently conservation efforts have resulted in localized recoveries of species and ecosystems. Given the dynamism of ecosystem degradation and recovery, understanding how communities perceive long-term and recent changes is important for developing and implementing conservation measures. We interviewed stakeholders on three Caribbean islands and identified a shifted baseline with respect to the extent and degree of long-term declines in marine animal populations; stakeholders with more experience identified more species as depleted and key species as less abundant than those with less experience. Notably, the average respondent with < 15 years of experience listed no species as depleted despite clear evidence of declines. We also identified a phenomenon we call the policy placebo effect, in which interviewees perceived some animal populations as recently recovering following passage of new conservation legislation but in the absence of evidence for actual recovery. Although shifted baselines have a negative effect on conservation as they can lower recovery goals, the outcomes of a policy placebo effect are unclear. If the public prematurely perceives recovery, motivation for continued conservation could decline. Alternatively, perception of rapid success could lead communities to set more ambitious conservation goals.
Scarce research has examined stress responsivity among Latino youths, and no studies have focused on the role of acculturation in shaping cortisol stress response in this population. This study assessed Mexican American adolescents’ Mexican and Anglo cultural orientations and examined prospective associations between their patterns of bicultural orientation and hypothalamic–pituitary–adrenal cortisol reactivity to an adapted Trier Social Stress Test. The sample included 264 youths from a longitudinal birth cohort study who completed the Trier Social Stress Test and provided saliva samples at age 14. The youths completed assessments of cultural orientation at age 12, and family conflict and familism at age 14. Analyses testing the interactive effects of Anglo and Mexican orientation showed significant associations with cortisol responsivity, including the reactivity slope, peak levels, and recovery, but these associations were not mediated by family conflict nor familism values. Findings revealed that bicultural youth (high on both Anglo and Mexican orientations) showed an expected pattern of high cortisol responsivity, which may be adaptive in the context of a strong acute stressor, whereas individuals endorsing only high levels of Anglo orientation had a blunted cortisol response. Findings are discussed in relation to research on biculturalism and the trade-offs and potential recalibration of a contextually responsive hypothalamic–pituitary–adrenal axis for acculturating adolescents.
The prevalence and incidence of obesity are high in people with severe mental illness (SMI). In England, around 6000 people with SMI access care from secure mental health units. There is currently no specific guidance on how to reduce the risk of obesity-related morbidity and mortality in this population.
To identify international evidence that addresses the issue of obesity in mental health secure units.
A mixed method review of evidence (published 2000–2015) was carried out to assess obesity prevalence, intervention and policy change, as well as barriers to change.
Evidence from 22 mainly small, non-comparator studies (reported in 21 papers) using a range of methods was reviewed. Dietary, physical activity and cultural interventions being implemented within secure units to address the problem of obesity showed some promising outcomes for physical health and health education. These were facilitated by adequate organisational resources, staff training and motivated staff. Holistic interventions that included a social and/or competitive element were more likely to be taken up. Involving patients in decision-making mediated the tension between facilitating behaviour change and imposing control. Barriers to successful outcomes included patient movement in and out of units, severity of mental health condition and resistance to change by patients and staff.
Despite the promising outcomes reported, further assessment is needed of the feasibility, acceptability and effectiveness of interventions and policies targeting the obesogenic environment, using robust research methods.
Volume 34 of Arthurian Literature presents essays that revisit the familiar and introduce the unfamiliar, ranging from Chrétien's Erec et Enide, Sir Gawain and the Green Knight and Malory to a hitherto unpublished Middle English poem on Arthur's drawing of the sword from the stone and a little-known Irish Arthurian text, plus a re-evaluation of the cross supposedly found in Arthur's grave at Glastonbury.
Rebecca Newby's examination of the ending of Chrétien's Erec et Enide constitutes a case study in which she explores the extent to which Chrétien's endings conform to medieval theories of poetic composition, with an eye to discovering whether ‘they do in fact contain a nucleus of poetic truth or not’. She studies the structure of Chrétien's poem, paying special attention to endings – both ‘illusory’ and ‘actual’ – and argues that Erec and Enide are also ‘symbolic figures’, or ‘allegorical apotheoses of chivalric matière and beautiful poetic, form respectively’. Neil Cartlidge asks several questions of the opening frame of Sir Gawain and the Green Knight, most notably regarding the identity of the knight who is said by the narrator to have committed an act of treason. Can he be identified? The poem's earliest editors decided on either Aeneas or Antenor, but Cartlidge argues for a new approach to this question, and comes to the striking conclusion that the person who best fits the profile within the context of the Fall of Troy narrative is in fact Paris. Nicole Clifton reads Sir Gawain's deathbed scene in Malory's Morte Darthur, offering an answer to the question of how Gawain knows the exact hour of his death. His prediction, according to Clifton, is neither prophetic nor symbolic, as other critics have argued, but simply a matter of factual observation. Furthermore, she argues that Arthur's subsequent dream of Gawain need not necessarily amount to prophecy on Gawain's part either, as some would have it, but has instead a pragmatic explanation as well. Clifton concludes that such passages point to Malory being ‘a hard-headed knight-prisoner whose real-life experience inflects his reading of assorted French books’, rather than ‘a nostalgic writer in love with “olde romaunce” ’.
To determine the feasibility and value of developing a regional antibiogram for community hospitals.
Multicenter retrospective analysis of antibiograms.
SETTING AND PARTICIPANTS
A total of 20 community hospitals in central and eastern North Carolina and south central Virginia participated in this study.
We combined antibiogram data from participating hospitals for 13 clinically relevant gram-negative pathogen–antibiotic combinations. From this combined antibiogram, we developed a regional antibiogram based on the mean susceptibilities of the combined data.
We combined a total of 69,778 bacterial isolates across 13 clinically relevant gram-negative pathogen–antibiotic combinations (median for each combination, 1100; range, 174–27,428). Across all pathogen–antibiotic combinations, 69% of local susceptibility rates fell within 1 SD of the regional mean susceptibility rate, and 97% of local susceptibilities fell within 2 SD of the regional mean susceptibility rate. No individual hospital had >1 pathogen–antibiotic combination with a local susceptibility rate >2 SD of the regional mean susceptibility rate. All hospitals’ local susceptibility rates were within 2 SD of the regional mean susceptibility rate for low-prevalence pathogens (<500 isolates cumulative for the region).
Small community hospitals frequently cannot develop an accurate antibiogram due to a paucity of local data. A regional antibiogram is likely to provide clinically useful information to community hospitals for low-prevalence pathogens.