The case for screening for diabetes distress, depression, and anxiety.

Our goal was to determine the prevalence of anxiety and depression in a sample of U.S. military veterans with type 2 diabetes and elevated diabetes distress (DD). Cross-sectional analyses were conducted. The association between DD and anxiety and depression was assessed with logistic regression. Almost 80% of persons with elevated DD had clinically significant anxiety or depression symptoms. The odds of depression and anxiety increased with DD severity. Given the large overlap of depression and anxiety with elevated DD, we recommend providers screen for all three conditions and, if positive, connect to resources for diabetes self-management and/or clinical treatment.

The impact of veteran support and resources for diabetes (iNSPiRED) on diabetes distress: Results from a randomized, parallel-group trial.

OBJECTIVE: The primary objective of this research was to assess the impact of a novel, peer-directed intervention (iNSPiRED) on diabetes distress (DD) among veterans with type 2 diabetes and DD. Secondary objectives were to assess iNSPiRED's impact on anxiety, depression, and diabetes self-management behaviors. METHOD: A single-blinded, randomized, parallel-group trial was conducted. Participants (n = 218) were recruited through a Veterans Affairs medical center and community agencies in a major metropolitan area from September 2019 through January 2022. Certified mental health peer specialists delivered iNSPiRED, a three-month goal-setting and resource navigation intervention. Outcomes were assessed at baseline, postintervention, and month six. Multilevel random-intercept linear regression models with treatment x time interaction terms were used to assess treatment effects. RESULTS: Frequency of following a healthy eating plan was higher for iNSPiRED vs usual care at month three relative to baseline (B = 0.58; p = 0.03) after adjusting for race and socioeconomic status. No other treatment effects differed significantly from zero (ps ≥ 0.05). CONCLUSION: Peer-directed interventions have the potential to deliver low-cost, highly scalable care. However, based on the largely negative findings of the current study, it is likely that more intense, multimodal interventions are needed to address DD.

Unmet Needs and Coping Strategies of Older Underserved Veterans During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has had profound impacts on people with diabetes, a group with high morbidity and mortality. Factors like race, age, income, Veteran-status, and limited or interrupted resources early in the COVID-19 pandemic compounded risks for negative health outcomes. Our objective was to characterize the experiences and needs of under-resourced Veterans with type 2 diabetes during the COVID-19 pandemic. METHODS: We conducted semi-structured qualitative interviews (March through September 2021) with U.S. military Veterans with diabetes. Transcripts were analyzed using a team-based, iterative process of summarizing and coding to identify key themes. Participants included Veterans (n = 25) who were mostly men (84%), Black or African American (76%), older (mean age = 62.6), and low-income (<$20 000/year; 56%). Most participants self-reported moderate (36%) or severe (56%) diabetes-related distress. RESULTS: Shutdowns and social distancing negatively impacted Veterans' social, mental, and physical health. Veterans reported feeling increased isolation, depression, stress, and unmet mental health needs. Their physical health was also negatively affected. Despite pandemic-related challenges, Veterans adapted with new technological skills, appreciating their families, staying active, and relying on their religious faith. CONCLUSIONS: Veterans' experiences during the pandemic revealed the importance of social support and access to technology. For those without social support, peer support could protect against negative health outcomes. Emergency-preparedness efforts for vulnerable patients with type 2 diabetes should include raising awareness about and increasing access to technological resources (eg, Zoom or telehealth platforms). Findings from this study will help tailor support programs for specific populations' needs in future health crises.

Validation of a Brief Screen to Identify Persons With Dementia at Risk for Behavioral Problems.

OBJECTIVES: Clinical assessment of persons with dementia should include potential causes of behavioral problems, including pain, depression, and caregiver-patient relationship quality. Many validated assessment tools are available; however, a brief screening tool is needed, as administering a battery of instruments is impractical in most clinical settings. We evaluated (a) the construct validity of brief screens for pain, depression, and relationship strain by examining their associations with validated measures and medication use and (b) the predictive validity of each screen and the screens as a set by examining their associations with frequency of disruptive behaviors. METHODS: Patient-caregiver dyads (n = 228) in Aggression Prevention Training for Caregivers were examined. RESULTS: There was evidence of good construct validity for each screen. The relationship screen and total number of screens endorsed were significantly associated with frequency of disruptive behaviors. CONCLUSION: The brief screens show potential for use in clinical practice.

Genetic differences and longevity-related phenotypes influence lifespan and lifespan variation in a sex-specific manner in mice.

Epidemiological studies of human longevity found two interesting features, robust advantage of female lifespan and consistent reduction of lifespan variation. To help understand the genetic aspects of these phenomena, the current study examined sex differences and variation of longevity using previously published mouse data sets including data on lifespan, age of puberty, and circulating insulin-like growth factor 1 (IGF1) levels in 31 inbred strains, data from colonies of nuclear-receptor-interacting protein 1 (Nrip1) knockout mice, and a congenic strain, B6.C3H-Igf1. Looking at the overall data for all inbred strains, the results show no significant difference in lifespan and lifespan variation between sexes; however, considerable differences were found among and within strains. Across strains, lifespan variations of female and male mice are significantly correlated. Strikingly, between sexes, IGF1 levels correlate with the lifespan variation and maximum lifespan in different directions. Female mice with low IGF1 levels have higher variation and extended maximum lifespan. The opposite is detected in males. Compared to domesticated inbred strains, wild-derived inbred strains have elevated lifespan variation due to increased early deaths in both sexes and extended maximum lifespan in female mice. Intriguingly, the sex differences in survival curves of inbred strains negatively associated with age of female puberty, which is significantly accelerated in domesticated inbred strains compared to wild-derived strains. In conclusion, this study suggests that genetic factors are involved in the regulation of sexual disparities in lifespan and lifespan variation, and dissecting the mouse genome may provide novel insight into the underlying genetic mechanisms.

Aggression Prevention Training for Individuals With Dementia and Their Caregivers: A Randomized Controlled Trial.

OBJECTIVE: International appeals call for interventions to prevent aggression and other behavioral problems in individuals with dementia (IWD). Aggression Prevention Training (APT), based on intervening in three contributors to development of aggression (IWD pain, IWD depression, and caregiver-IWD relationship problems) aims to reduce incidence of aggression in IWD over 1 year. DESIGN: Randomized, controlled trial. SETTING: Three clinics that assess, diagnose, and treat dementia. PARTICIPANTS: Two hundred twenty-eight caregiver-IWD dyads who screened positive for IWD pain, IWD depression, or caregiver-IWD relationship problems randomized to APT or Enhanced Usual Primary Care (EU-PC). INTERVENTION: APT, a skills-based intervention delivered over 3 months to address pain/depression/caregiver-IWD relationship issues. EU-PC included printed material on dementia and community resources; and eight brief, weekly support calls. MEASUREMENTS: The primary outcome was incidence of aggression over 1 year, determined by the Cohen Mansfield Agitation Inventory-Aggression Subscale. Secondary outcomes included pain, depression, caregiver-IWD relationship, caregiver burden, positive caregiving, behavior problems, and anxiety. RESULTS: Aggression incidence and secondary outcomes did not differ between groups. However, in those screening positive for IWD depression or caregiver-IWD relationship problems, those receiving EU-PC had significant increases in depression and significant decreases in quality of the caregiver-IWD relationship, whereas those receiving APT showed no changes in these outcomes over time. CONCLUSION: The cost to patients, family, and society of behavioral problems in IWD, along with modest efficacy of most pharmacologic and nonpharmacologic interventions, calls for more study of novel preventive approaches.

Anti-aging interventions affect lifespan variability in sex, strain, diet and drug dependent fashion.

It was recently reported that socio-economic factors related differences in human life expectancy are associated with differences in the variance of age at death. To determine whether anti-aging interventions also alter the variance of longevity, we have analyzed data from mice subjected to treatment with drugs that affect aging or to calorie restriction and from long-lived mutant mice. The relationship of changes in longevity and in longevity variance was found to depend on sex and treatment and apparently also on strain. Increased longevity of male mice treated with effective anti-aging drugs was accompanied by reduced variance of age at death and apparent reduction of early life mortality. Life extension induced by growth-hormone related mutations and calorie restriction tended to increase longevity variance in females only. We conclude that impact of anti-aging interventions on the variance of age at death and distribution of individual lifespans in laboratory mice is treatment-dependent and sexually dimorphic.

The Impact of Landscape Complexity on Invertebrate Diversity in Edges and Fields in an Agricultural Area.

Invertebrate diversity is important for a multitude of ecosystem services and as a component of the larger ecological food web. A better understanding of the factors influencing invertebrate taxonomic richness and diversity at both local and landscape scales is important for conserving biodiversity within the agricultural landscape. The aim of this study was to determine if invertebrate richness and diversity in agricultural field interiors and edges in central Illinois, USA, were related to the complexity of the surrounding landscape. Our results show taxonomic richness and diversity in field edges is positively related to large scale landscape complexity, but the relationship is negative for field interiors. These unexpected results need further study.

An Innovative Approach for Decreasing Fall Trauma Admissions from Geriatric Living Facilities: Preliminary Investigation.

Geriatric living facilities have been associated with a high rate of falls. We sought to develop an innovative intervention approach targeting geriatric living facilities that would reduce geriatric fall admissions to our Level II trauma center. In 2011, a Trauma Prevention Taskforce visited 5 of 28 local geriatric living facilities to present a fall prevention protocol composed of three sections: fall education, risk factor identification, and fall prevention strategies. To determine the impact of the intervention, the trauma registry was queried for all geriatric fall admissions attributed to patients living at local geriatric living facilities. The fall admission rate (total fall admissions/total beds) of the pre-intervention period (2010-2011) was compared with that of the postintervention period (2012-2013) at the 5 intervention and 23 control facilities. A P value < 0.05 was considered statistically significant. From 2010 to 2013, there were 487 fall admissions attributed to local geriatric living facilities (intervention: 179 fall admissions; control: 308 fall admissions). The unadjusted fall rate decreased at intervention facilities from 8.9 fall admissions/bed pre-intervention to 8.1 fall admissions/bed postintervention, whereas fall admission rates increased at control sites from 5.9 to 7.7 fall admissions/bed during the same period [control/intervention odds ratio (OR), 95% confidence interval (CI) = 1.32, 1.05-1.67; period OR, 95%CI = 1.55, 1.18-2.04, P = 0.002; interaction of control/intervention group and period OR 95% CI = 0.68, 0.46-1.00, P = 0.047]. An aggressive intervention program targeting high-risk geriatric living facilities resulted in a statistically significant decrease in geriatric fall admissions to our Level II trauma center.

Magnet hospitals are a magnet for higher survival rates at adult trauma centers.

BACKGROUND: Little is known about nursing care's impact on trauma outcomes. The Magnet Recognition Program recognizes hospitals for quality patient care and nursing excellence based on objective standards. We hypothesized that Magnet-designated trauma centers would have improved survival over their non-Magnet counterparts. METHODS: All 2009 to 2011 admissions to Pennsylvania's Level I and II trauma centers with more than 500 admissions during the study period (10 Magnet and 17 non-Magnet hospitals) were extracted from the Pennsylvania Trauma Systems Foundation State Registry. A logistic regression model with mortality as the dependent variable included the following variables: Magnet status, age, sex, admitting temperature, logit transformation of mortality probability predicted by the Trauma Mortality Prediction Model (TMPM-ais), systolic blood pressure, mechanism of injury, paralytic drug use, and Glasgow Coma Scale motor (GCSm) score. RESULTS: A total of 73,830 patients from the Pennsylvania Trauma Outcome Study database met inclusion criteria for this study. The Magnet and non-Magnet hospital groups were statistically indistinguishable with respect to level of designation, medical school association, surgical residency programs, in-house surgeons, and urban locations. Patients admitted to a Magnet hospital had a significantly decreased odds of mortality when compared with their non-Magnet counterparts (odds ratio, 0.83; 95% confidence interval, 0.70-0.99; p = 0.033), when controlling for numerous factors. Overall, the model has outstanding discrimination with a receiver operating characteristic curve of 0.93. CONCLUSION: Admission to a Magnet-designated hospital is associated with a 20% reduction in mortality. We believe that the Magnet program's attention to nursing competence has important consequences for trauma patients, as reflected in the improved survival rates in trauma patients admitted to Magnet-designated hospitals. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III. Care management study, level IV.

Checklist-styled daily sign-out rounds improve hospital throughput in a major trauma center.

The checklist concept has received much attention as a result of its ability to improve patient care by minimizing complications. We hypothesized daily sign-out rounds using a checklist, by improving team communication and consistency of clinical care, could lead to expedited throughput for patients at a major trauma center. A retrospective study examined patients admitted to a mature trauma center. Two time periods, PRE (September 2008 to January 2009) and POST (September 2009 to January 2010), were selected to match for seasonal variation in admission diagnosis. An organ system-based checklist was used during daily sign-out for all admitted trauma patients in the POST period. We examined discharge status, complications and rates, and intensive care unit (ICU) and overall hospital length of stay for differences. There were similar numbers of patients (824 PRE vs 798 POST) admitted in these two cohorts. We found no statistical differences in the incidence of complications or mortality rate. We did discover statistically significant differences in the median ICU days (2 PRE vs 1 POST, P = 0.007) as well as median hospital length of stay (2 days, interquartile differences Q1 to Q3 PRE [1 to 5] and POST [1 to 4] P = 0.000). These trends remained valid even among the severely injured (Injury Severity Score 16 or greater) with a hospital length of stay of 5 (PRE) versus 3 days (POST; P = 0.021). A simple, organ system-based checklist can be successfully adopted for daily sign-out round on a busy, multiprovider trauma service. We were able to expedite trauma patient throughput in both ICU and overall hospital stays with a trend toward decreasing mortality. This improved throughput may potentially translate into a cost saving for the hospital.

Investigating short-term exposure to electromagnetic fields on reproductive capacity of invertebrates in the field situation.

Organisms are exposed to electromagnetic fields from the introduction of wireless networks that send information all over the world. In this study we examined the impact of exposure to the fields from mobile phone base stations (GSM 900 MHz) on the reproductive capacity of small, virgin, invertebrates. A field experiment was performed exposing four different invertebrate species at different distances from a radiofrequency electromagnetic fields (RF EMF) transmitter for a 48-h period. The control groups were isolated from EMF exposure by use of Faraday cages. The response variables as measured in the laboratory were fecundity and number of offspring. Results showed that distance was not an adequate proxy to explain dose-response regressions. No significant impact of the exposure matrices, measures of central tendency and temporal variability of EMF, on reproductive endpoints was found. Finding no impact on reproductive capacity does not fully exclude the existence of EMF impact, since mechanistically models hypothesizing non-thermal-induced biological effects from RF exposure are still to be developed. The exposure to RF EMF is ubiquitous and is still increasing rapidly over large areas. We plea for more attention toward the possible impacts of EMF on biodiversity.

Breaking down the barriers! Factors contributing to barrier days in a mature trauma center.

BACKGROUND: As we enter the brave new world of the Patient Protection and Affordable Care Act of 2010, it is imperative that trauma centers provide not only excellent but also cost-effective trauma care. To that end, we sought to determine those factors that contribute significantly to barrier days (BDs), when a patient is medically cleared for discharge but unable to leave the hospital. We hypothesized that there would be significant demographic and payor factors associated with BDs. METHODS: All trauma admissions to a Level II trauma center discharged alive from 2010 to 2012 were queried from the trauma registry. BDs were identified and recorded at daily sign-out. Patients with a hospital length of stay of 24 hours or less or transferred to another hospital were excluded. Univariate logistic regression was used to analyze which factors were significant (p ≤ 0.05) for BDs. Significant variables were then included in a multivariate logistic regression model. RESULTS: A total of 3,056 patients were included in the study, 105 (3.44%) of whom had at least one BD. Multivariate analysis revealed that patients awaiting nursing home placement and rehabilitation placement were at 6.39 and 2.79 times higher odds of having significant barriers to discharge, respectively, compared with patients who were discharged home. The multivariate model also showed that Medicaid coverage, one or more comorbidities, Injury Severity Score of 9 or greater, and one or more ventilation days had a significant correlation with the incidence of BDs. CONCLUSION: This study suggests that discharge destination is a significant factor associated with BDs. Understanding what type of patient is prone to develop barriers to discharge will allow case managers and social workers to intervene with discharge planning early in that patient's hospital course to secure placement and possibly reduce health care costs and improve functional outcome. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Acute care and trauma surgeons: we can't get no satisfaction--what do satisfaction surveys measure?

Patient satisfaction surveys are increasingly being used as a measure of physician performance in a hospital setting. We sought to determine what role the clinical condition the physician is treating has on overall patient satisfaction scores. Patient satisfaction scores were calculated for elective and emergent general surgery and trauma patients for eight surgeons taking care of all three types of patients. Both physician satisfaction (PP) and hospital satisfaction (GP) scores were calculated. Mean scores (± standard deviation) between groups were compared with P < 0.05 significance. Of 1521 trauma patients and 3779 general surgery patients, there was 14.8 and 15.1 per cent response rate, respectively, to the survey. Trauma patients had a significantly lower PP than general surgery patients (81.0 ± 19.4 vs 85.7 ± 16.4; P < 0.001). However, the GP between trauma and general surgery was not significant (84.0 ± 13 vs 84.0 ± 12.3; nonsignificant) When general surgery patients were divided into emergent versus elective, the PP was significantly higher for elective than emergent (87.9 ± 14.6 vs 82.7 ± 18; P < 0.001). A patient's underlying clinical condition may influence response to patient satisfaction surveys. Further research needs to be performed before patient satisfaction surveys can be adopted as a overall measure of physician competency.

Does prehospital prolonged extrication (entrapment) place trauma patients at higher risk for venous thromboembolism?

BACKGROUND: The aim of this study was to determine if prolonged immobility and tissue injury from a prehospital entrapment would place patients at higher risk for in-hospital venous thromboembolism (VTE) complications. It was hypothesized that entrapment would increase in-hospital VTE. METHODS: All consecutive trauma admissions over a 10-year period were retrospectively reviewed. Patients were divided into those who were entrapped according to defined prehospital criteria for entrapment and those who were not entrapped. The complications of deep vein thrombosis and pulmonary embolism were noted. RESULTS: There were 15,159 patients admitted between 1999 and 2008. Of these, 1,176 met the criteria for prehospital entrapment. Those patients who met the criteria for entrapment had a significant risk for developing both deep vein thrombosis (P < .001, χ(2) test) and pulmonary embolism (P = .005, Fisher's exact test). Multiple logistic regression analysis revealed entrapment to be a significant contributing risk factor to the development of VTE (odds ratio, 1.54; P = .04). CONCLUSIONS: Patients with prehospital entrapment are at higher risk for VTE. These results mandate aggressive VTE prophylaxis in patients with histories of prehospital entrapment.

In a mature trauma system, there is no difference in outcome (survival) between Level I and Level II trauma centers.

BACKGROUND: The state of Pennsylvania (PA) has one of the oldest, most well-established trauma systems in the country. The requirements for verification for Level I versus Level II trauma centers within PA differ minimally (only in the requirement for patient volume, residency, and research). We hypothesized that there would be no difference in outcome at Level I versus Level II trauma centers. METHODS: Odds of mortality for 16 Level I and 11 Level II hospitals in PA over a 5-year period (2004-2008) was computed using a random effects logistic regression model. Overall adjusted mortality rates at Level I versus Level II hospitals were compared using the nonparametric Wilcoxon's rank sum test. The crude mortality rates for 140,691 patients over the 5-year period were similar (5.07% Level II vs. 5.48% Level I), but statistically significant (odds ratio mortality at Level I = 1.084, p = 0.002 Fisher's exact test). RESULTS: Although Level I centers had on average crude mortality rates that were higher than those of Level II centers, median adjusted mortality rates were not different for the two types of centers (Wilcoxon's rank sum test). Performance of Level I versus Level II shows considerable variability among centers (basic random effects model, age, blunt/penetrating, and Injury Severity Score [ISS]). However, Level II centers seem no different from Level I. CONCLUSION: As trauma systems mature, the distinction between Level I and Level II trauma centers blurs. The hierarchal descriptors "Level I" or "Level II" in a mature trauma system is pejorative and implies in those hospitals labeled "Level II" as inferior, and as such should be replaced with nonhierarchal descriptors.

Peptide YY attenuates transcription factor activity in tumor necrosis factor-alpha-induced pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a disease characterized by inflammation. Nuclear factor (NF)-kappaB, Smad proteins, and the steroid hormone family peroxisome proliferator-activated receptors (PPARs) are involved in regulation of gene transcription during the disease process. Peptide YY (PYY), a gastrointestinal hormone, inhibits NF-kappaB translocation to acinar nuclei in tumor necrosis factor (TNF)-alpha-induced AP. We investigated TNF-alpha induction of Smad proteins, PPARalpha/gamma, and NF-kappaB by TNF-alpha, and hypothesized that PYY would attenuate this effect. STUDY DESIGN: Rat acinar cells were treated with recombinant TNF-alpha (200 ng/mL). PYY (3 to 36) was added at 500 pM at 30 minutes after TNF-alpha treatment until cell harvest at 2 hours. Western blot analysis and intracellular staining of the p65 subunit of NF-kappaB were performed. NF-kappaB, Smad3/4, and PPARalpha/gamma binding activities were determined by protein/DNA array analysis and verified by electrophoretic-mobility shift assay and densitometry. RESULTS: Cellular localization of NF-kappaB p65 showed nuclear staining within 2 hours, with controls stained in the cytoplasm. With PYY, p65 stained in the cytoplasm. Nuclear p65 was increased significantly (p < 0.05) by TNF-alpha at 2 hours and PYY reduced it. Array analysis revealed upregulation of NF-kappaB, PPARalpha/gamma, and Smad3/4 with TNF-alpha. TNF-alpha stimulated NF-kappaB activation sevenfold, and binding was enhanced (p < 0.05). PYY reduced NF-kappaB binding to control levels. PPAR binding increased 51% after TNF-alpha treatment and was reduced to 33% with PYY. Smad3/4 binding was increased (p < 0.05) above controls with TNF-alpha and PYY reduced it by 40%. CONCLUSIONS: TNF-alpha increases early nuclear translocation of the p65 subunit of NF-kappaB in acinar cells. Exposure to TNF-alpha activates transcription factors NF-kappaB, Smad3/4, and PPARalpha/gamma. PYY reduces this activation. Treatment with PYY may have therapeutic potential in improving AP.