on behalf of the American Heart Association Council on Cardiovascular Nursing V arious forms of smokeless tobacco (ST) products (snuff, chewing tobacco) are used by individuals of all ages. Over the past several years, US tobacco companies have expanded marketing and promotion of ST products. A major aim of this statement is to review and summarize the scientific evidence regarding ST product use and the potential cardiovascular risks associated with ST product use that can be used to inform policy related to tobacco control and strategies related to tobacco harm reduction. A specific policy question is whether ST products should be recommended to smokers instead of cigarettes to reduce the morbidity and mortality associated with smoking and/or as an approach to enhance smoking cessation. Although evidence is consistent with the suggestion that the cardiovascular risks are lower with ST products compared with cigarette smoking, ST products are not without harm. As reviewed in this statement, there is evidence that long-term ST product use may be associated with a modest risk of fatal myocardial infarction (MI) and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke. In addition, there is inadequate evidence to support the use of ST products as a smoking cessation strategy. Based on the findings reviewed in this statement, clinicians should continue to discourage use of all tobacco products and emphasize prevention of smoking initiation and smoking cessation as primary goals for tobacco control.In the United States, various forms of ST products (snuff, chewing tobacco) are used by individuals of all ages, including adolescents and young adults.

Rationale: Bioactive lipid mediators, derived from membrane lipid precursors, are released into the airway and airspace where they bind high-affinity cognate receptors and may mediate asthma pathogenesis. Lysophosphatidic acid (LPA), a bioactive lipid mediator generated by the enzymatic activity of extracellular autotaxin (ATX), binds LPA receptors, resulting in an array of biological actions on cell proliferation, migration, survival, differentiation, and motility, and therefore could mediate asthma pathogenesis.Objectives: To define a role for the ATX-LPA pathway in human asthma pathogenesis and a murine model of allergic lung inflammation. Methods: We investigated the profiles of LPA molecular species and the level of ATX exoenzyme in bronchoalveolar lavage fluids of human patients with asthma subjected to subsegmental bronchoprovocation with allergen. We interrogated the role of the ATX-LPA pathway in allergic lung inflammation using a murine allergic asthma model in ATX-LPA pathway-specific genetically modified mice. Measurements and Main Results: Subsegmental bronchoprovocation with allergen in patients with mild asthma resulted in a remarkable increase in bronchoalveolar lavage fluid levels of LPA enriched in polyunsaturated 22:5 and 22:6 fatty acids in association with increased concentrations of ATX protein. Using a triple-allergen mouse asthma model, we showed that ATX-overexpressing transgenic mice had a more severe asthmatic phenotype, whereas blocking ATX activity and knockdown of the LPA 2 receptor in mice produced a marked attenuation of Th2 cytokines and allergic lung inflammation. Conclusions: The ATX-LPA pathway plays a critical role in the pathogenesis of asthma. These preclinical data indicate that targeting the ATX-LPA pathway could be an effective antiasthma treatment strategy.Keywords: asthma; lysophosphatidic acid; autotaxin; allergic airway inflammation supplied the ATX inhibitor, GWJ-23. V.A., E.K., and I.N. were involved in discussions related to animal dosage. A.J.M. and S.S.S. provided breeding pairs of ATX-Tg and ATX 1/2 mice. S.J.A. managed the inflammatory cell purification core lab for the SBP-AG protocol, designed experiments, interpreted data, coordinated regular scientific research meetings for the project, and edited the manuscript. V.N. conceptualized the study, designed mouse experiments, interpreted data, provided genetically modified mice, and wrote part of and edited the manuscript. J.W.C. obtained the SBP-AG IRB and IND approval, supervised mouse experiments and performance of the human SBP-AG protocol, designed experiments, interpreted and analyzed data, and edited the manuscript. All authors contributed to data discussion and review of the manuscript.Correspondence and requests for reprints should be addressed to John W. What This Study Adds to the FieldThe enzyme autotaxin (ATX) and two of its LPA products, LPA 22:5 and LPA 22:6, are markedly and selectively increased in the bronchoalveolar lavage fluid of human patients with asthma in response to airway allergen ch...

Recommendation 3.1: Population-based payment models should use outcomebased population health measures and risk adjustment systems that are designed to support population-specific and community-specific priorities for prevention and health promotion.Recommendation 3.2: If a payment model is based on measures of value that use annual measures of spending, high-value preventive services with multi-year benefits should be paid for through a separate payment mechanism or budget in order to facilitate patient access to the services, to protect against underuse of services, and to enable flexibility in the way preventive services are delivered. 7 Recommendation 6.1: A clinician or other healthcare provider who is taking accountability under an alternative payment model for improving the quality of care for a patient and for controlling the cost of the patient's care should have the flexibility to design or redesign cost-sharing requirements for the patient where necessary to enable and encourage the patient to adhere to a care plan developed through a shared decision-making process.Recommendation 6.2: Providers should be transparent about the quality of care they deliver so that patients can be assured that they are receiving high-quality care under value-based payment systems and benefit designs. Data and Analyses Needed to Develop and Implement Successful Payment ModelsRecommendation 7.1: Data on all of the important clinical and non-clinical factors that can have a significant impact on patient needs and outcomes must be accessible in order to support development and use of valid and reliable risk stratification methodologies in performance measures and alternative payment models.Recommendation 7.2: Linkages must be developed between the information in claims data, the information in electronic health records and registries, and information on patient-reported outcomes in order to provide the analyses needed to improve care and measure performance. Funding should be provided to enable Qualified Entities (which have multi-payer claims data), Qualified Clinical Data Registries (which collect clinical information relating to patient care), and Patient-8 Reported Outcome databases to link their data for specific uses that will benefit patients, payers, and providers and that incorporate appropriate protections to ensure responsible use.Recommendation 7.3: All Electronic Health Record systems should be required to support (a) the creation of custom fields and (b) data retrieval and analysis. Incentives should be created to encourage the development of infrastructure for linking data and there should be penalties for vendors that block data.Recommendation 7.4: Payers and provider organizations should be required to give clinicians access to information on the amounts payers and patients pay for services. Facilitating the Transition to Improved Payment SystemsRecommendation 8.1: Alternative payment models should be implemented using multi-year contracts and/or multi-year performance measures that allow for a shortterm peri...

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Patient simulation is increasingly used in the education of healthcare providers, yet few studies have compared simulation to other teaching modalities. The purpose of this study was to determine differences in knowledge acquisition and student satisfaction between two methods of teaching the principles of mechanical ventilation to advanced practice nursing (APN) students: high-fidelity patient simulation (including face-to-face instruction) versus an online, narrated PowerPoint presentation. Twenty APN students were randomized to either the simulation or online teaching method in this pre/posttest study. Measures included a 12-item knowledge questionnaire and a 5-item satisfaction survey. Both groups had significant improvement in knowledge scores from pretest to posttest, but knowledge scores were not significantly different at posttest between groups. Student satisfaction with their learning method was significantly higher in the simulation group. Students choosing to participate in the alternative teaching method after study completion preferred the simulation to the online method.