Bereaved Informal Caregivers Rarely Recall a Relationship Between Transfusions and Hospice in Acute Myeloid Leukemia.

AIMS: The inability to prescribe blood transfusions is a potential barrier to timely hospice enrollment for patients with blood cancers. The benefits and harms of transfusions near the end of life (EOL), however, are poorly characterized and patients' preferences are unknown. We sought to characterize the recollections of bereaved caregivers about the relationships between transfusions and hospice enrollment decisions. METHODS: We recruited 18 bereaved caregivers of 15 decedents who died within 6-18 months of the interview. Interviews focused on caregivers' recollections of transfusion and hospice enrollment decisions. Transcripts were analyzed for themes. RESULTS: We identified 2 themes. First, caregivers described that transfusions were necessary and the decisions to receive transfusions or not were deferred to the clinicians. Second, only 1 caregiver recalled transfusions as relevant to hospice decisions. In that instance there was a delay. Caregivers identified difficulties recognizing death was imminent, hope for miracles, and the necessity of accepting life was ending as more relevant barriers. CONCLUSIONS: The results indicate clinicians' beliefs in transfusion at EOL may be a more relevant barrier to hospice enrollment than patients' preferences. Strategies to evaluate accurately and discuss the actual benefits and harms of transfusions at the EOL are necessary to advise patients and integrate their preferences into decisions.

Current Evidence on the Effects of Intensive Early Reading Interventions.

Many students at risk for or identified with reading disabilities need intensive reading interventions. This meta-analysis provides an update to the Wanzek and Vaughn synthesis on intensive early reading interventions. Effects from 25 reading intervention studies are analyzed to examine the overall effect of intensive early reading interventions as well as relationships between intervention and student characteristics related to outcomes. The weighted mean effect size (ES) estimate (ES = 0.39), with a mean effect size adjusted for publication bias (ES = 0.28), both significantly different from zero, suggested intensive early reading interventions resulted in positive outcomes for early struggling readers in kindergarten through third grades. There was no statistically significant or meaningful heterogeneity in the study-wise effect sizes. Exploratory examination of time in intervention, instructional group size, initial reading achievement, and date of publication are provided.

Creating an environmental justice framework for policy change in childhood asthma: a grassroots to treetops approach.

OBJECTIVES: The Community Action to Fight Asthma Initiative, a network of coalitions and technical assistance providers in California, employed an environmental justice approach to reduce risk factors for asthma in school-aged children. Policy advocacy focused on housing, schools, and outdoor air quality. Technical assistance partners from environmental science, policy advocacy, asthma prevention, and media assisted in advocacy. An evaluation team assessed progress and outcomes. METHODS: A theory of change and corresponding logic model were used to document coalition development and successes. Site visits, surveys, policymaker interviews, and participation in meetings documented the processes and outcomes. Quantitative and qualitative data were analyzed to assess strategies, successes, and challenges. RESULTS: Coalitions, working with community residents and technical assistance experts, successfully advocated for policies to reduce children's exposures to environmental triggers, particularly in low-income communities and communities of color. Policies were implemented at various levels. CONCLUSIONS: Environmental justice approaches to policy advocacy could be an effective strategy to address inequities across communities. Strong technical assistance, close community involvement, and multilevel strategies were all essential to effective policies to reduce environmental inequities.

Lipid-induced insulin resistance mediated by the proinflammatory receptor TLR4 requires saturated fatty acid-induced ceramide biosynthesis in mice.

Obesity is associated with an enhanced inflammatory response that exacerbates insulin resistance and contributes to diabetes, atherosclerosis, and cardiovascular disease. One mechanism accounting for the increased inflammation associated with obesity is activation of the innate immune signaling pathway triggered by TLR4 recognition of saturated fatty acids, an event that is essential for lipid-induced insulin resistance. Using in vitro and in vivo systems to model lipid induction of TLR4-dependent inflammatory events in rodents, we show here that TLR4 is an upstream signaling component required for saturated fatty acid-induced ceramide biosynthesis. This increase in ceramide production was associated with the upregulation of genes driving ceramide biosynthesis, an event dependent of the activity of the proinflammatory kinase IKKß. Importantly, increased ceramide production was not required for TLR4-dependent induction of inflammatory cytokines, but it was essential for TLR4-dependent insulin resistance. These findings suggest that sphingolipids such as ceramide might be key components of the signaling networks that link lipid-induced inflammatory pathways to the antagonism of insulin action that contributes to diabetes.

Universal health insurance for children.

Large and increasing numbers of Americans lack health insurance. While children have recently fared better than adults, millions still lack coverage, and thus experience difficulty obtaining acute and preventive care during a critical period of growth and development. This situation has both short and long-term social and economic implications, including higher health care costs for episodic and end-stage treatment, loss of productivity, and rising-insurance costs to businesses. This paper describes past and current efforts to extend health insurance to children and explores options for achieving universal coverage among children. Specifically, it describes the challenges associated with the financing and delivery of the American health care system, outlines public policy approaches to covering children historically, presents the current status of health insurance for low-income children, and offers options for achieving universal health insurance for children.

Inhibition of ceramide synthesis ameliorates glucocorticoid-, saturated-fat-, and obesity-induced insulin resistance.

Insulin resistance occurs in 20%-25% of the human population, and the condition is a chief component of type 2 diabetes mellitus and a risk factor for cardiovascular disease and certain forms of cancer. Herein, we demonstrate that the sphingolipid ceramide is a common molecular intermediate linking several different pathological metabolic stresses (i.e., glucocorticoids and saturated fats, but not unsaturated fats) to the induction of insulin resistance. Moreover, inhibition of ceramide synthesis markedly improves glucose tolerance and prevents the onset of frank diabetes in obese rodents. Collectively, these data have two important implications. First, they indicate that different fatty acids induce insulin resistance by distinct mechanisms discerned by their reliance on sphingolipid synthesis. Second, they identify enzymes required for ceramide synthesis as therapeutic targets for combating insulin resistance caused by nutrient excess or glucocorticoid therapy.