Shared decision making between older people with multimorbidity and GPs: a qualitative study.

BACKGROUND: Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice. AIM: To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care. DESIGN AND SETTING: Qualitative study. General practices (rural and urban) in Devon, England. METHOD: Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis. RESULTS: Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators. CONCLUSION: Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Nonfreezing Cold Injuries Among Long-Distance Polar Rowers.

INTRODUCTION: Nonfreezing cold injury (NFCI) is a peripheral cold injury that occurs when the extremities are exposed to cold temperatures, at or near the freezing point, for sustained periods of time (48-96 h at temperatures of usually around 0 to 6°C with associated wind chill). Although NFCI often goes unreported and may be underdiagnosed, it is a cause of significant morbidity in those working in cold conditions, particularly those in the military. Thus, further research into the prevention, recognition, and treatment of NFCI is warranted. METHODS: The height, body weight, and body composition of 6 rowers taking part in 1 or 2 legs of the 2017 Polar Row expedition were measured. The weather conditions of the 2 legs of the journey were recorded, and symptoms relating to NFCI were documented. RESULTS: All incidences of NFCI occurred during Leg 2 of the expedition, which was colder and wetter. Of the Leg 2 rowers, those who developed NFCI had a trend toward higher pre-row body weight and body mass index and a trends toward losing more weight and body water relative to those who did not. CONCLUSIONS: The main factor contributing to the incidence of NFCI appeared to be weather; NFCI only occurred during the colder and wetter leg of the expedition. We also tentatively suggest that nutrition and dehydration may be linked to the incidence of NFCI as predisposing factors. More work, with sample sizes greater than those reported here, is required to investigate these associations to further characterize risk factors.

A Dietary Intervention in Urban African Americans: Results of the "Five Plus Nuts and Beans" Randomized Trial.

INTRODUCTION: Unhealthy diets, often low in potassium, likely contribute to racial disparities in blood pressure. We tested the effectiveness of providing weekly dietary advice, assistance with selection of higher potassium grocery items, and a $30 per week food allowance on blood pressure and other outcomes in African American adults with hypertension. DESIGN: We conducted an 8-week RCT with two parallel arms between May 2012 and November 2013. SETTING/PARTICIPANTS: We randomized 123 African Americans with controlled hypertension from an urban primary care clinic in Baltimore, Maryland, and implemented the trial in partnership with a community supermarket and the Baltimore City Health Department. Mean (SD) age was 58.6 (9.5) years; 71% were female; blood pressure was 131.3 (14.7)/77.2 (10.5) mmHg; BMI was 34.5 (8.2); and 28% had diabetes. INTERVENTION: Participants randomized to the active intervention group (Dietary Approaches to Stop Hypertension [DASH]-Plus) received coach-directed dietary advice and assistance with weekly online ordering and purchasing of high-potassium foods ($30/week) delivered by a community supermarket to a neighborhood library. Participants in the control group received a printed DASH diet brochure along with a debit account of equivalent value to that of the DASH-Plus group. MAIN OUTCOME MEASURES: The primary outcome was blood pressure change. Analyses were conducted in January to October 2014. RESULTS: Compared with the control group, the DASH-Plus group increased self-reported consumption of fruits and vegetables (mean=1.4, 95% CI=0.7, 2.1 servings/day); estimated intake of potassium (mean=0.4, 95% CI=0.1, 0.7 grams/day); and urine potassium excretion (mean=19%, 95% CI=1%, 38%). There was no significant effect on blood pressure. CONCLUSIONS: A program providing dietary advice, assistance with grocery ordering, and $30/week of high-potassium foods in African American patients with controlled hypertension in a community-based clinic did not reduce BP. However, the intervention increased consumption of fruits, vegetables, and urinary excretion of potassium.

Seroprevalence of Trypanosoma cruzi among eleven potential reservoir species from six states across the southern United States.

Trypanosoma cruzi, the causative agent of Chagas' disease, is a substantial public health concern in Latin America. Although rare in humans and domestic animals in the United States, T. cruzi is commonly detected in some wildlife species, most commonly raccoons (Procyon lotor) and Virginia opossums (Didelphis virginiana). To increase our understanding of the reservoir host species range and geographic distribution, 11 species of mammals from six states spanning the known range of T. cruzi (Arizona, California, Florida, Georgia, Missouri, and Virginia) were tested for antibodies to T. cruzi using indirect immunofluorescent antibody testing. In addition, culture isolation attempts were conducted on a limited number of animals from Georgia and Florida. Evidence of T. cruzi was found in every state except California; however, low numbers of known reservoirs were tested in California. In general, the highest seroprevalence rates were found in raccoons (0-68%) and opossums (17-52%), but antibodies to T. cruzi were also detected in small numbers of striped skunks (Mephitis mephitis) from Arizona and Georgia, bobcats (Lynx rufus) from Georgia, two coyotes (Canis latrans) from Georgia and Virginia, and a ringtail (Bassariscus astutus) from Arizona. Culture-based prevalence rates for raccoons were significantly greater than those for opossums; however, seroprevalences of raccoons and opossums from several geographic locations in Georgia and Florida were not different, indicating that exposure rates of these two species are similar within these areas. For both raccoons and opossums, seroprevalence was significantly higher in females than in males. No difference was detected in seroprevalence between adults and juveniles and between animals caught in urban and rural locations. Our results indicate that T. cruzi prevalence varies by host species, host characteristics, and geographic region and provides data to guide future studies on the natural history of T. cruzi in the United States.

Evaluation of the Chagas Stat-Pak assay for detection of Trypanosoma cruzi antibodies in wildlife reservoirs.

An immunochromatographic assay (Chagas Stat-Pak) was evaluated for the detection of Trypanosoma cruzi antibodies in 4 species of wildlife reservoirs. Antibodies to T. cruzi were detected in raccoons (Procyon lotor) (naturally and experimentally infected) and degus (Octodon degu) (experimentally-infected) using the Chagas Stat-Pak. In naturally exposed wild raccoons, the Chagas Stat-Pak had a sensitivity and specificity of 66.7-80.0% and 96.3%, respectively. Compared with indirect immunofluorescent antibody assay results, seroconversion as determined by Chagas Stat-Pak was delayed for experimentally infected raccoons, but occurred sooner in experimentally infected degus. The Chagas Stat-Pak did not detect antibodies in naturally or experimentally infected Virginia opossums (Didelphis virginiana) or in experimentally infected short-tailed opossums (Monodelphis domestica). These data suggest that the Chagas Stat-Pak might be useful in field studies of raccoons and degus when samples would not be available for more-conventional serologic assays. Because this assay did not work on either species of marsupial, the applicability of the assay should be examined before it is used in other wild species.

Molecular typing of Trypanosoma cruzi isolates, United States.

Studies have characterized Trypanosoma cruzi from parasite-endemic regions. With new human cases, increasing numbers of veterinary cases, and influx of potentially infected immigrants, understanding the ecology of this organism in the United States is imperative. We used a classic typing scheme to determine the lineage of 107 isolates from various hosts.

Acrophobia and pathological height vertigo: indications for vestibular physical therapy?

BACKGROUND AND PURPOSE: Acrophobia (fear of heights) may be related to a high degree of height vertigo caused by visual dependence in the maintenance of standing balance. The purpose of this case report is to describe the use of vestibular physical therapy intervention following behavioral therapy to reduce a patient's visual dependence and height vertigo. CASE DESCRIPTION: Mr N was a 37-year-old man with agoraphobia (fear of open spaces) that included symptoms of height phobia. Exposure to heights triggered symptoms of dizziness. Intervention. Mr N underwent 8 sessions of behavioral therapy that involved exposure to heights using a head-mounted virtual reality device. Subsequently, he underwent 8 weeks of physical therapy for an individualized vestibular physical therapy exercise program. OUTCOMES: After behavioral therapy, the patient demonstrated improvements on the behavioral avoidance test and the Illness Intrusiveness Rating Scale, but dizziness and body sway responses to moving visual scenes did not decrease. After physical therapy, his dizziness and sway responses decreased and his balance confidence increased. DISCUSSION: Symptoms of acrophobia and sway responses to full-field visual motion appeared to respond to vestibular physical therapy administered after completion of a course of behavioral therapy. Vestibular physical therapy may have a role in the management of height phobia related to excessive height vertigo.