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RESEARCH OBJECTIVE: Department of Veterans Affairs (VA) Home‐Based Primary Care (HBPC) employing mobile interdisciplinary teams (IDT: physician/nurse practitioner, nurse, therapist, social worker, dietician, pharmacist, and psychologist) has been reported to be effective at improving care and lowering cost for frail, high‐risk Veterans. The full IDT represents a significant investment in care for complex Veterans. Some VA Medical Centers (VAMCs) employ HBPC without providing mobile primary care but use an enhanced home health team. The Program for All Inclusive Care for the Elderly (PACE) employs a similar IDT to care for frail older adults. The updated Centers for Medicare & Medicaid Services (CMS) PACE addresses the cost of a full IDT by regulating a “core” team (primary care, nursing, social work, and therapy), with additional team members as needed. We examined the variability of IDT care by frailty of HBPC Veterans. STUDY DESIGN: Using discipline‐specific visit codes, we classified staffing patterns by IDT involvement: full IDT (all 7 members), core (primary care, nursing, social work, and therapy), core+ (core and one or more noncore disciplines), home health (nursing, social work, and therapy), home health + (home health and one or more noncore disciplines), and housecalls (mobile primary care). We clustered the 13 domains of frailty identified from diagnoses codes in the JEN Frailty Index domains (JFI=sum of domains, range 0‐13) to identify clusters of high and low frailty. Chi‐square goodness of fit tested the association of HBPC service teams with the frailty profiles among all HBPC Veterans and the subset with high frailty (JFI > 6). POPULATION STUDIED: Veterans enrolled in HBPC in fiscal year 2018 across 139 VA Medical Centers (VAMCs) (N = 55 197) of whom 35 876 (65%) were high frailty (JFI > 6). PRINCIPAL FINDINGS: Forty‐one percent of all HBPC Veterans received care from a full IDT, 22% received care from a Core IDT, 16% received care from a Core+ IDT, 4% received care from a Home Health IDT, while 16% received care from a Home Health+ IDT and 1% received housecalls. Ten clusters of teams were identified ranging from high risk to low risk and an “Other” risk formed the 11th cluster. Among high frailty Veterans, 71% were in the top 2 high‐risk clusters, among whom 62% received Full IDT or Core+ IDT. Among lower risk Veterans, 74% were in clusters 1‐10, among whom 28% were in the 3 lowest risk clusters, and 38.9% received HH/HH+ IDT. The 15 VAMCs with the greatest share of a HH or HH+ teams had between 34 and 100% of Veterans receiving mobile primary care. The chi‐square with 66 degrees of freedom (11 clusters * 6 IDT models) of the global association of care patterns and Veteran frailty was 1487 (P

IntroductionHome health agencies have been tasked to improve their patients’ disaster preparedness. Few studies have evaluated the robustness of tools to support preparedness in home health. Through evaluation of the Home-Based Primary Care (HBPC) Patient Assessment Tool, we conducted a survey to identify strengths and challenges in supporting the preparedness of patients served by home health programs such as the Veterans Health Administration’s HBPC program.MethodsPractitioners from 10 HBPC programs fielded the Patient Assessment Tool with all patients during a 3-week period. Logistic regression and bivariate analyses were used to identify patient characteristics associated with the delivery of preparedness education.ResultsA total of 754 Patient Assessment Tools were returned. The educational item most likely to be covered was how to activate 911 services (87%). The item least likely to be discussed was information on emergency shelter registration and emergency specialty transportation (44%). When compared to the low risk group, HBPC patients in the high/medium risk group were more likely to receive preparedness education materials for 6 of the 9 educational preparedness items (P values less than 0.05).DiscussionPractitioners are relaying preparedness education to their most vulnerable patients, suggesting that home health agencies can provide disaster preparedness in the home. Nonetheless, there is room for improvement. (Disaster Med Public Health Preparedness. 2019;13:547-554)

OBJECTIVE To investigate ethnic differences in adiponectin and leptin concentration and to determine whether these adipokines and a high–glycemic index diet account for ethnic variation in insulin resistance. RESEARCH DESIGN AND METHODS In 1,176 South Asian, Chinese, Aboriginal, and European Canadians, fasting blood samples were drawn, and clinical history and dietary habits including glycemic index/glycemic load were recorded using standardized questionnaires. Insulin resistance was defined using homeostasis model assessment–insulin resistance (HOMA-IR). RESULTS Adiponectin concentrations were significantly higher in Europeans (adjusted mean 12.94 [95% CI 2.27–13.64]) and Aboriginal people (11.87 [11.19–12.59]) than in South Asians (9.35 [8.82–9.92]) and Chinese (8.52 [8.03–9.03]) (overall P < 0.001). Serum leptin was significantly higher in South Asians (11.82 [10.72–13.04]) and Aboriginal people (11.13 [10.13–12.23]) than in Europeans (9.21 [8.38–10.12]) and Chinese (8.25 [7.48–9.10]). BMI and waist circumference were inversely associated with adiponectin in every group except the South Asians (P < 0.001 for interaction). Adiponectin was inversely and leptin was positively associated with HOMA-IR (P < 0.001). The increase in HOMA-IR for each given decrease in adiponectin was larger among South Asians (P = 0.01) and Aboriginal people (P < 0.001) than among Europeans. A high glycemic index was associated with a larger decrease in adiponectin among South Asians (P = 0.03) and Aboriginal people (P < 0.001) and a larger increase in HOMA-IR among South Asians (P < 0.05) relative to that in other groups. CONCLUSIONS South Asians have the least favorable adipokine profile and, like the Aboriginal people, display a greater increase in insulin resistance with decreasing levels of adiponectin. Differences in adipokines and responses to glycemic foods parallel the ethnic differences in insulin resistance.

Background Adiponectin, a secretagogue exclusively produced by adipocytes, has been associated with metabolic features, but its role in the development of the metabolic syndrome remains unclear. Objectives We investigated the association between serum adiponectin level and metabolic traits, using both observational and genetic epidemiologic approaches in a multiethnic population assembled in Canada. Methods Clinical data and serum adiponectin level were collected in 1,157 participants of the SHARE/SHARE-AP studies. Participants were genotyped for the functional rs266729 and rs1260326 SNPs in ADIPOQ and GCKR genes. Results Adiponectin level was positively associated with HDL cholesterol and negatively associated with body mass index, waist-to-hip ratio, triglycerides, fasting glucose, fasting insulin, systolic and diastolic pressure (all P

Background Germline mutations of BRCA1/2 are associated with hereditary breast and ovarian cancer. Recent data suggests excess mortality in mutation carriers beyond that conferred by neoplasia, and recent in vivo and in vitro studies suggest a modulatory role for BRCA proteins in endothelial and cardiomyocyte function. We therefore tested the association of BRCA2 variants with clinical cardiovascular disease (CVD). Methods Using data from 1,170 individuals included in two multi-ethnic population-based studies (SHARE and SHARE-AP), the association between BRCA2 variants and CVD was evaluated. 15 SNPs in BRCA2 with minor allele frequencies (MAF) > 0.01 had been previously genotyped using the cardiovascular gene-centric 50 k SNP array. 115 individuals (9.8%) reported a CVD event, defined as myocardial infarction (MI), angina, silent MI, stroke, and angioplasty or coronary artery bypass surgery. Analyses were adjusted for age and sex. The SNPs rs11571836 and rs1799943 were subsequently genotyped using the MassARRAY platform in 1,045 cases of incident MI and 1,135 controls from the South Asian subset of an international case-control study of acute MI (INTERHEART), and rs11571836 was imputed in 4,686 cases and 4500 controls from the Pakistan Risk of Myocardial Infarction Study (PROMIS). Results Two BRCA2 SNPs, rs11571836 and rs1799943, both located in untranslated regions, were associated with lower risk of CVD (OR 0.47 p = 0.01 and OR 0.56 p = 0.03 respectively) in the SHARE studies. Analysis by specific ethnicities demonstrated an association with CVD for both SNPs in Aboriginal People, and for rs11571836 only in South Asians. No association was observed in the European and Chinese subgroups. A non-significant trend towards an association between rs11571836 and lower risk of MI was observed in South Asians from INTERHEART [OR = 0.87 (95% CI: 0.75-1.01) p = 0.068], but was not evident in PROMIS [OR = 0.96 (95% CI: 0.90-1.03) p = 0.230]. Meta-analysis of both case-control studies resulted in a combined OR of 0.94 (95% CI: 0.89-1.004, p = 0.06). Conclusions Although there was an association between two SNPs in BRCA2 and CVD in a multi-ethnic population, these results were not replicated in two South Asian case-control studies of incident MI. Future studies exploring the association between BRCA variants and cardiovascular disorders are needed to clarify the role, if any, for BRCA variants in CVD pathogenesis.

OBJECTIVE: To study how clinical preceptors select patients for medical student teaching in ambulatory care and to explore key factors they consider in the selection process. DESIGN: Qualitative analysis of transcribed interviews. SETTING: Harvard Medical School, Boston, Mass. PARTICIPANTS: Nineteen physicians (14 general internists and 5 general pediatricians) who serve as clinical preceptors. MEASUREMENTS: Responses to in-depth open-ended interview regarding selection of patients for participation in medical student teaching. MAIN RESULTS: Preceptors consider the competing needs of the patient, the student, and the practice the most important factors in selecting patients for medical student teaching. Three dominant themes emerged: time and efficiency, educational value, and the influence of teaching on the doctor-patient relationship. These physicians consciously attempt to select patients whose participation in medical student teaching maximizes the efficiency of the clinical practice and optimizes the students’ educational experiences, while minimizing any potential for harming the relationship between preceptor and patient. CONCLUSIONS: These findings may help validate the frustration preceptors frequently feel in their efforts to teach in the outpatient setting. Becoming more cognizant of the competing interests—the needs of the patient, the student, and the practice—may help physicians to select patients to enhance the educational experience without compromising efficiency or the doctor-patient relationship. For educators, this study suggests an opportunity for faculty development programs to assist the clinical preceptor both in selecting patients for medical student teaching and in finding ways to maximize the efficiency and educational quality of the outpatient teaching environment.

The spatial arrangement of a cell's contents, and its ability to redistribute them, is fundamental to its survival. In all animal and plant cells, kinesins fill a large part of this need, hauling chromosomes and vital cargo-containing sacks to their required destinations. Many kinesins operate as a homodimer in which the two subunits coordinate their movement along microtubules and perform a single cellular function. However, a few kinesins in certain species mix-and-match different molecules in ways that allow the motor to perform multiple functions. Certain types of pathogenic fungi harbor an unusual group of kinesins that form heterodimeric complexes with one or more non-catalytic kinesin-like proteins that regulate the function and cellular localization of their catalytic partner. A challenge in the motor protein field is to provide a mechanistic view of how these asymmetric motors move using this unconventional form of motor subunit arrangement. Our recent determination of the X-ray crystal structures of the motor domain region of both the catalytic and non-catalytic subunits of a heterodimeric kinesin from Candida glabrata revealed that certain regions of the latter subunit are highly dynamic. Specifically, our crystals of CgVik1 (the non-catalytic subunit) exhibit three very different conformations of an alpha-helical segment that is analogous to the force-producing ‘neck’ element of kinesins. The intramolecular interactions of the CgVik1 neck and its motor core differ in each conformation and are accompanied by movements in elements that are analogous to the nucleotide binding ‘P-loop’ and part of the microtubule binding surface of catalytic kinesins. This suggests a functional link between CgVik1 neck orientation and microtubule interactions and motility of the motor complex, and sheds light on how this kinesin works at the atomic level as an asymmetric motor complex.