Beyond Access: Characteristics of the Food Environment and Risk of Diabetes.

Characteristics of the built environment, including access to unhealthy food outlets, are hypothesized to contribute to type 2 diabetes mellitus (T2D). Swedish nationwide registry data on 4,718,583 adults aged 35-80 years living in 9,353 neighborhoods, each with at least 1 food outlet, were geocoded and linked to commercial registers (e.g., restaurants and grocery stores). Multilevel logistic regression was used to examine the prospective relationship between characteristics of the food environment and T2D from 2005 to 2010. Relative access to health-harming food outlets was associated with greater likelihood of both prevalent and incident T2D in a curvilinear manner, with the highest risk being observed for environments in which one-third of outlets were health-harming. Relative to individuals whose food environment did not change, those who moved into areas with more health-harming food outlets had higher odds of developing T2D (odds ratio = 3.67, 95% confidence interval: 2.14, 6.30). Among those who did not move, living in an area that gained relative access to health-harming food outlets was also associated with higher odds of T2D (odds ratio = 1.72, 95% confidence interval: 1.27, 2.33). These results suggest that local food environment, including changes that result in greater access to unhealthy food outlets, is associated with T2D.

Immigrant enclaves and risk of diabetes: a prospective study.

BACKGROUND: The diversity of the Swedish population has increased substantially over the past three decades. The aim of this study was to assess whether living in an ethnic enclave is associated with risk of diabetes mellitus (DM) among first and second-generation immigrants and native Swedes. METHODS: Cumulative incidence of DM in three urban municipalities was assessed from 2006-2010 by linking records from the national census, multi-generational family register, and prescription drug register. Immigrant enclaves were identified using Moran's Index. Multi-level logistic regression was used to assess the relationship between enclave residence and risk of DM for three groups: Iraqi immigrants, non-Iraqi immigrants, and native Swedes (N = 887,603). RESULTS: The cumulative incidence of DM was greater in Iraqi enclaves compared to other neighborhoods (4.7% vs. 2.3%). Among Iraqi immigrants, enclave residence was not associated with odds of DM (Odds ratio (OR): 1.03, 95% Confidence Interval (CI): 0.86 - 1.24). Among other immigrants, enclave residence was not associated with DM after accounting for neighborhood deprivation. Among native Swedes, enclave residence was associated with elevated risk of DM even after accounting for neighborhood deprivation and individual-level characteristics (OR: 1.23, 95% CI: 1.11 - 1.36). CONCLUSIONS: Residential ethnic composition is associated with DM but this relationship differs across ethnic group. Enclave residence is not associated with increased odds of DM for immigrants, regardless of their nation of origin, but it is associated with increased likelihood of DM for native Swedes.

Stability of patch test allergens.

Patch testing is widely used in evaluating suspected contact dermatitis. One major component of a quality patch test result is a dependable, predictable allergen supply. The allergen needs to be present at a sufficient concentration to elicit a reaction in an allergic patient. To better understand the stability of patch-test allergens, we completed a systematic review of the literature. We found that there is variability in stability among patch-test allergens and that although a few have been shown to be stable, many degrade when in storage. In most cases, expiration dates should be honored. In addition, allergen panels should be prepared as close to the time of patch test application as is possible.

ER vs. ED: a comparison of televised and real-life emergency medicine.

BACKGROUND: Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation. OBJECTIVE: The purpose of this study was to compare sociodemographic and medical characteristics of patients depicted on television vs. actual United States (US) Emergency Department (ED) patients. METHODS: Two independently working coders analyzed all 22 programs in one complete year of the popular "emergency room" drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey from the same year. Chi-squared goodness-of-fit tests were used to compare televised vs. real distribution across key sociodemographic and medical variables. RESULTS: Ages at the extremes of age (i.e., ≤ 4 and ≥ 45 years) were less commonly represented on television compared with reality. Characters on television vs. reality were less commonly women (31.2% vs. 52.9%, respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories "non-urgent" and "emergent," whereas the two most common categories for reality were the middle categories "semi-urgent" and "urgent." Televised visits compared with reality were most commonly due to injury (63.5% vs. 37.0%, respectively), and televised injuries were less commonly work-related (4.2% vs. 14.8%, respectively). CONCLUSIONS: Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist, as well as what types of interventions may be beneficial in correcting that potential misinformation.

U.S. hookah tobacco smoking establishments advertised on the internet.

BACKGROUND: Establishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities. PURPOSE: To conduct a comprehensive, qualitative assessment of websites promoting these establishments. METHODS: In June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009-2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohen's κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used. RESULTS: The search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common. CONCLUSIONS: Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.

Alcohol brand appearances in US popular music.

AIMS: The average US adolescent is exposed to 34 references to alcohol in popular music daily. Although brand recognition is an independent, potent risk factor for alcohol outcomes among adolescents, alcohol brand appearances in popular music have not been assessed systematically. We aimed to determine the prevalence of and contextual elements associated with alcohol brand appearances in US popular music. DESIGN: Qualitative content analysis. SETTING: We used Billboard Magazine to identify songs to which US adolescents were most exposed in 2005-07. For each of the 793 songs, two trained coders analyzed independently the lyrics of each song for references to alcohol and alcohol brand appearances. Subsequent in-depth assessments utilized Atlas.ti to determine contextual factors associated with each of the alcohol brand appearances. MEASUREMENTS: Our final code book contained 27 relevant codes representing six categories: alcohol types, consequences, emotional states, activities, status and objects. FINDINGS: Average inter-rater reliability was high (κ = 0.80), and all differences were easily adjudicated. Of the 793 songs in our sample, 169 (21.3%) referred explicitly to alcohol, and of those, 41 (24.3%) contained an alcohol brand appearance. Consequences associated with alcohol were more often positive than negative (41.5% versus 17.1%, P < 0.001). Alcohol brand appearances were associated commonly with wealth (63.4%), sex (58.5%), luxury objects (51.2%), partying (48.8%), other drugs (43.9%) and vehicles (39.0%). CONCLUSIONS: One in five songs sampled from US popular music had explicit references to alcohol, and one-quarter of these mentioned a specific alcohol brand. These alcohol brand appearances are associated commonly with a luxury life-style characterized by wealth, sex, partying and other drugs.

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods.

BACKGROUND: Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration. OBJECTIVE: To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration. METHODS: A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification. RESULTS: On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential. CONCLUSIONS: The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.

Molecular pathways to CML stem cells.

Imatinib has revolutionized the treatment of chronic myeloid leukemia (CML), but it does not cure the disease. Many patients never achieve significant cytogenetic or molecular responses. Some develop resistance to the drug, while others are simply unable to tolerate it. Unfortunately, most will relapse if the drug is discontinued. This is particularly true in patients with advanced disease, who tend to develop resistance rapidly and are unlikely to achieve durable remission with single-agent tyrosine kinase inhibitor therapy. A growing body of evidence suggests that the reason imatinib does not cure CML is that it is unable to eradicate the leukemic stem cells (LSC). LSC are a tiny population of cancer cells with the capacity to recapitulate the disease. These quiescent cells have subverted properties of normal hematopoietic stem cells, allowing them to avoid apoptosis, evade innate immunity, renew themselves, and survive long term. Here, we review the studies that have identified the deregulated molecular pathways responsible for the generation of CML stem cells and discuss implications for therapy.

Waterpipe and cigarette smoking among college athletes in the United States.

PURPOSE: Tobacco use using a waterpipe is an emerging trend among college students. Although cigarette smoking is low among college athletes, waterpipe tobacco smoking may appeal to this population. The purpose of this study was to compare cigarette and waterpipe tobacco smoking in terms of their associations with organized sport participation. METHODS: In the spring of 2008, we conducted an online survey of 8,745 college students at eight institutions as part of the revised National College Health Assessment. We used multivariable regression models to assess the associations between tobacco use (cigarette and waterpipe) and organized sports participation. RESULTS: Participants reported participation in varsity (5.2%), club (11.9%), and intramural (24.9%) athletics. Varsity athletes and individuals who were not varsity athletes had similar rates of waterpipe tobacco smoking (27.6% vs. 29.5%, p=.41). However, other types of athletes were more likely than their counterparts to have smoked waterpipe tobacco (35.1% vs. 28.7%, p < .001 for club sports and 34.8% vs. 27.7%, p < .001 for intramural sports). In fully-adjusted multivariable models, sports participants of any type had lower odds of having smoked cigarettes, whereas participants who played intramural sports (odds ratio=1.15, 95% confidence interval=1.03, 1.29) or club sports (odds ratio=1.15, 95% confidence interval=1.001, 1.33) had significantly higher odds of having smoked waterpipe tobacco. CONCLUSIONS: College athletes are susceptible to waterpipe tobacco use. In fact, compared with their nonathletic counterparts, club sports participants and intramural sports participants generally had higher odds of waterpipe tobacco smoking. Allure for waterpipe tobacco smoking may exist even for individuals who are traditionally considered at low risk for tobacco use.

Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture.

The objective of this study was to investigate safety climates within a cohort of regional hospitals to assess health care workers' perceptions of their hospitals' safety reporting, feedback, and problem-solving systems, and to examine how regional initiatives and health care organizations use safety climate information to improve patient safety outcomes. A purposive sample of staff at 25 western Pennsylvania hospitals was surveyed using Likert scale questions. The instrument studied provided foci on which regional efforts and hospitals could base interventions to improve patient safety culture. Significant differences in perceived patient safety climate existed between hospitals, respondents, and departments. The differences in responses suggest that such instruments may be useful to identify and reinforce aspects of safety, culture, and organizational characteristics, which may need to be targeted to improve patient safety outcomes across and within hospitals. Due to the complex nature of safety culture within health care systems, determining how these surveys can be used will require further investigation.

Interstitial norepinephrine concentrations in skeletal muscle of ischemic heart failure.

During exercise, sympathetic nerve responses are accentuated in heart failure (HF), and this enhances norepinephrine (NE) release and evokes vasoconstriction. Two key pathophysiological responses could contribute to the greater NE release: 1) increased sympathetic nerve discharge and 2) increased NE in the neurovascular junction for a given level of sympathetic discharge. In this report, we focus on the second of these two general issues and test the following hypotheses: 1) in HF for a given level of sympathetic nerve stimulation, NE concentration in the interstitium (an index of neurovascular NE) would be greater, and 2) the greater interstitial NE concentration would be linked to reduced NE uptake. Studies were performed in rats 8-10 wk after induction of myocardial infarction (MI). Interstitial NE samples were collected from microdialysis probes inserted into the hindlimb muscle. Dialysate concentration of NE was determined by the HPLC method. First, interstitial NE concentration increased during electrical stimulation of the lumbar sympathetic nerves in eight control rats. An increase in interstitial NE concentration was significantly greater in 10 rats with severe MI. Additionally, an NE uptake-1 inhibitor (desipramine, 1 microM) was injected into the arterial blood supply of the muscle in six control and eight MI rats. Desipramine increased interstitial NE concentration by 24% in control and by only 3% (P < 0.05 vs. control) in MI rats. In conclusion, given levels of electrical stimulation of the lumbar sympathetic nerve lead to higher interstitial NE concentration in HF. This effect is due, in part, to reduced NE uptake-1 in HF.

Factors influencing models of end-of-life care in nursing homes: results of a survey of nursing home administrators.

Approximately 20% of deaths in the United States occur in nursing homes. Dying nursing home residents have unique care needs, which historically have been inadequately addressed. The goal of this study was to determine what factors influence nursing home administrators' choice of model for end-of-life care in their facilities. Thirty nursing home administrators in the Denver, Colorado, metropolitan area were interviewed. The interview used open-ended questions about: facilities' end-of-life care programming and factors that influenced which model was used; scalar questions measuring administrators' attitudes about aspects of end-of-life care; and questions that assessed key demographic characteristics of participants. Twenty-nine of the 30 facilities included in this study reported contracting with hospice. Five were also in the process of creating in-house palliative care teams, and an additional five were negotiating with hospice agencies to dedicate beds for use as hospice units. For profit status, larger facility size, and shorter duration of administrator tenure were found to be associated with greater likelihood of considering implementation of a facility-based end-of-life care model. When asked about obstacles to providing quality end-of-life care, the majority of participants (n = 16) cited an educational deficit among physicians, staff, or the public as the most significant, while an additional seven cited staff shortages and turnover. These results suggest at least two potential avenues for change to improve end-of-life care in nursing homes: (1) educational efforts on the topics of end-of-life and palliative care among both practitioners, residents, and their families, and (2) creating incentives to improve staff recruitment and retention.