Background Studies suggest that 30% to 40% of asthmatic women report significant perimenstrual (late luteal phase) exacerbations of asthma are primarily retrospective, rely on subjective findings and do not demonstrate a consistent association between asthma and the menstrual cycle. Objective In this exploratory analysis, women with and without self-reported perimenstrual exacerbations of asthma (PMA) were examined prospectively to determine the association between asthma and the menstrual cycle and to characterize associated clinical factors. Methods Thirty-two adult asthmatic women with regular menstrual periods recorded daily asthma symptoms, medication use, and peak expiratory flow rate (PEFR) over six consecutive menstrual cycles, and underwent spirometry and methacholine bronchoprovocation during the luteal and follicular phases of 2 cycles. Results Nine of 32 subjects (28.2%) reported PMA. Daily means of rescue medication use and AM peak flow computed for each perimenstrual day demonstrated significant non-parallelism of group profiles; subjects with PMA had increasing inhaled short acting beta2-agonist use an decreasing AM peak flow rates during the perimenstrual interval. Luteal-follicular phase differences in FEV1 or methacholine bronchoprovocation between the groups were not detected. Subjects with PMA were older (P = .007), had longer duration of asthma (P = .039), and increased baseline asthma severity (P = .076) compared with subjects wihtout PMA. Conclusion The findings of this study suggest that women with self-reported perimenstrual asthma demonstrate perimenstrual differences in rescue bronchodilator use and AM peak flow and appear to constitute a distinct subset of women with asthma who are older, have longer duration of asthma, and increased severity of asthma compared with women without self-reported perimenstrual asthma. These factors identify women who require close monitoring of their asthma during their menstrual cycles. Studies suggest that 30% to 40% of asthmatic women report significant perimenstrual (late luteal phase) exacerbations of asthma are primarily retrospective, rely on subjective findings and do not demonstrate a consistent association between asthma and the menstrual cycle. In this exploratory analysis, women with and without self-reported perimenstrual exacerbations of asthma (PMA) were examined prospectively to determine the association between asthma and the menstrual cycle and to characterize associated clinical factors. Thirty-two adult asthmatic women with regular menstrual periods recorded daily asthma symptoms, medication use, and peak expiratory flow rate (PEFR) over six consecutive menstrual cycles, and underwent spirometry and methacholine bronchoprovocation during the luteal and follicular phases of 2 cycles. Nine of 32 subjects (28.2%) reported PMA. Daily means of rescue medication use and AM peak flow computed for each perimenstrual day demonstrated significant non-parallelism of group profiles; subjects with PMA had increasing inhaled short acting beta2-agonist use an decreasing AM peak flow rates during the perimenstrual interval. Luteal-follicular phase differences in FEV1 or methacholine bronchoprovocation between the groups were not detected. Subjects with PMA were older (P = .007), had longer duration of asthma (P = .039), and increased baseline asthma severity (P = .076) compared with subjects wihtout PMA. The findings of this study suggest that women with self-reported perimenstrual asthma demonstrate perimenstrual differences in rescue bronchodilator use and AM peak flow and appear to constitute a distinct subset of women with asthma who are older, have longer duration of asthma, and increased severity of asthma compared with women without self-reported perimenstrual asthma. These factors identify women who require close monitoring of their asthma during their menstrual cycles.
Many outpatient clinics where health professionals train will transition to a team-based medical home model over the next several years. Therefore, training programs need innovative approaches to prepare and incorporate trainees into team-based delivery systems. To address this need, educators at the San Francisco Veterans Affairs (VA) Medical Center included trainees in preclinic team "huddles," or briefing meetings to facilitate care coordination, and developed an interprofessional huddle-coaching program for nurse practitioner students and internal medicine residents who function as primary providers for patient panels in VA outpatient primary care clinics. The program aimed to support trainees' partnerships with staff and full participation in the VA's Patient Aligned Care Teams. The huddle-coaching program focuses on structuring the huddle process via scheduling, checklists, and designated huddle coaches; building relationships among team members through team-building activities; and teaching core skills to support collaborative practice. A multifaceted evaluation of the program showed positive results. Participants rated training sessions and team-building activities favorably. In interviews, trainees valued their team members and identified improvements in efficiency and quality of patient care as a result of the team-based approach. Huddle checklists and scores on the Team Development Measure indicated progress in team processes and relationships as the year progressed. These findings suggest that the huddle-coaching program was a worthwhile investment in trainee development that also supported the clinic's larger mission to deliver team-based, patient-aligned care. As more training sites shift to team-based care, the huddle-coaching program offers a strategy for successfully incorporating trainees.
Abstract Current molecular classification of colorectal cancer (CRC), the Consensus Molecular Subtypes (CMS), has highlighted the biological heterogeneity of CRC and enables patient stratification based on the molecular subtype of their tumor. The CMS4 subtype shows the worst prognosis and is linked to the highest occurrence of hepatic metastasis but the underlying molecular mechanisms remain unclear. In this study, we show that the molecular features that largely define CMS4 classification, i.e. abundance of cancer-associated fibroblasts (CAFs) in the tumor microenvironment (TME) and active TGFβ signaling, converge to promote liver metastasis. Studying TGFβ signaling in CRC patient-derived CAFs from the primary tumor revealed that all three TGFβ isoforms induce expression of different IL-6 cytokine family members, particularly IL-6 and IL-11. This primary tumor-derived IL-6 and IL-11 in turn induce upregulation of myeloid chemoattractants, including SAA1, in hepatocytes. Chemical inhibition and genetic ablation experiments revealed that gp130, the IL-6 family of cytokine co-receptor, through JAK/STAT signaling is crucial for the induction of neutrophil chemoattractants by hepatocytes and mediates the migration of potential pro-metastatic neutrophils towards the liver. This IL-6 family-JAK/STAT stromal signaling axis is active in both a murine model of CMS4 as well as in human CRC patients in vivo . Combined, our data reveal that TGFβ signaling in CAFs actively contributes to the formation of a neutrophil-dependent, pre-metastatic hepatic niche and that this mechanism might play a role in the metastatic phenotype of CMS4 subtype CRC.
Purpose The purpose of the study was to describe perception of risk for developing diabetes among foreign-born Spanish-speaking US Latinos. Methods Participants (N = 146), recruited at food-pantry distribution events and free clinics, were surveyed using the Risk Perception Survey for Developing Diabetes in Spanish. Type 2 diabetes risk factors measured included body mass index, physical activity, and A1C. Results Sample characteristics were mean (SD) age of 39.5 (9.9) years, 58% with less than a high school graduate-level education, and 65% with a family income less than $15,000/year. Prevalence of risk factors was 81% overweight or obese, 47% less than 150 minutes/week moderate/vigorous-intensity physical activity, and 12% A1C consistent with prediabetes. Of the 135 participants with complete data, 31% perceived a high/moderate risk for developing diabetes. In univariate logistic regression analyses, 9 of 18 potential variables were significant ( P < .05) predictors of perception of risk. When these 9 variables were entered into a multiple logistic regression model, 5 were significant predictors of perception of risk: history of gestational diabetes, high school graduate or above, optimistic bias, worry, and perceived personal disease risk. Conclusions Use of the Spanish-language translation of the Risk Perception Survey for Developing Diabetes revealed factors influencing perception of risk for developing diabetes. Results can be used to promote culturally acceptable type 2 diabetes primary prevention strategies and provide a useful comparison to other populations.
An educational dialog founded on open communication between clinician and patient is necessary for a successful partnership in asthma care. Educating patients in self-management of asthma has become a major challenge in primary care practice. The process should begin at the time of diagnosis and should be integrated into every step of medical care during office visits and any other clinician-patient interaction. Identifying patients' expectations and concerns about their disease at each office visit helps the clinician focus care. The educational effort should include a discussion of basic asthma facts, and the types and uses of medications, and a demonstration of the skills involved in the proper use of metered-dose inhalers, spacers and peak flow meters. A written asthma self-management plan developed jointly by the clinician and the patient includes recommended daily medications and the specific steps the patient should take to control asthma and achieve the goals of asthma care.
