Feasibility of the flipped classroom approach for health education in a clinical weight loss program.

Aim: To assess the feasibility of the flipped classroom pedagogy in a clinical weight loss program and its impact on 6-month weight change. Methods: Adults with overweight/obesity enrolled in a 6-month program with a structured diet (portion-controlled meals and fruits/vegetables) and exercise plan (≥150mins/week), plus weekly, 1-h group education sessions. Sessions used a flipped classroom approach: educational content was delivered beforehand via podcast/video and book readings and session time involved application-based activities (e.g., case studies, games). Satisfaction surveys were completed at 3 months. Weight change was assessed using paired t-tests (SAS 9.4, significance 0.05). Results: Eighteen participants completed 6 months (retention 94%). Participants maintained diet adherence and exercise at 3 months (∼84% diet adherence, ∼153mins exercise/week) and 6 months (∼83% diet adherence, ∼158mins exercise/week), as well as attendance to behavioral sessions (3 months: 77%; 6mo: 71%). Satisfaction surveys showed high program enjoyment (∼8.1/10). Mean weight change at 3 and 6 months was -6.5 ± 4.2% and - 9.3 ± 5.0% (both p < 0.01), respectively. Conclusion: The flipped classroom pedagogy was feasible for delivery in a clinical weight loss program and supported significant 6-month weight loss. Innovation: This is the first evaluation of the flipped classroom in a clinical setting and supports the investigation of this pedagogy in weight management.

Diet Quality of Midwest Adolescents and Young Adults With Intellectual Disabilities and Overweight/Obesity Differs by Diagnosis but Not by Weight Category.

BACKGROUND: Poor diet may contribute to high rates of overweight/obesity (OW/OB) in adolescents and young adults with intellectual disabilities (IDs). OBJECTIVE: The purpose of this study was to examine diet quality as assessed by Healthy Eating Index 2015 (HEI-2015) scores in adolescents and young adults with IDs and OW/OB and to compare diet quality by ID diagnosis and weight. DESIGN: Three-day image-assisted food records from baseline assessments in an 18-month weight-loss trial for adolescents and young adults with IDs and OW/OB were used to calculate HEI-2015 scores, which were compared between ID diagnoses and weight categories. PARTICIPANTS/SETTING: A total of 102 adolescents and young adults (aged 13 to 21 years) with IDs (48 with Down syndrome [DS], 40 with autism, and 14 with other/unspecified IDs) and OW/OB at a Midwestern academic medical center completed valid food records from November 2015 to November 2019. MAIN OUTCOME MEASURES: Outcome measures included HEI-2015 scores, energy intake (kcal/d), macronutrient intake as percentage of energy, energy intake per kilogram body weight, and grams protein per kilogram body weight. STATISTICAL ANALYSES PERFORMED: Differences in HEI-2015 scores and additional dietary measures by weight category and ID diagnosis were examined with analysis of variance or Kruskal-Wallis tests. RESULTS: Participants with DS had a significantly higher mean ± SD HEI-2015 score (53.9 ± 8.4) compared with participants with autism (49.1 ± 9.6; P = .047). Compared with those with autism, participants with DS had a higher percentage of energy from protein, higher energy intake per kilogram body weight, and higher grams of protein intake per kilogram body weight. For HEI-2015 components, participants with DS had higher scores than participants with autism for total fruits, whole fruits, total vegetables, greens and beans, and total protein foods, but lower scores for sodium. Diet quality was not observed to differ by weight classification. CONCLUSIONS: Adolescents and young adults with autism had lower overall diet quality scores compared with those with DS. Diet quality was not found to be related to OW/OB. Understanding dietary differences by ID diagnosis may inform intervention strategies.

Two-year mortality and seizure recurrence following status epilepticus in Auckland, New Zealand: A prospective cohort study.

PURPOSE: To document the 2-year mortality and seizure recurrence rate of a prospective cohort of patients identified with status epilepticus (SE). METHODS: Patients presenting to any hospital in the Auckland region between April 6 2015, and April 5 2016, with a seizure lasting 10 min or longer were identified. Follow up was at 2 years post index SE episode via telephone calls and detailed review of clinical notes. RESULTS: We identified 367 patients with SE over the course of one year. 335/367 (91.3 %) were successfully followed up at the 2-year mark. Two-year all-cause mortality was 50/335 (14.9 %), and 49/267 (18.4 %) when febrile SE was excluded. Two-year seizure recurrence was 197/335 (58.8 %). On univariate analyses, children (preschoolers 2 to < 5 years and children 5 to < 15 years), Asian ethnicity, SE duration <30 mins and acute (febrile) aetiology were associated with lower mortality, while older age >60 and progressive causes were associated with higher mortality on both univariate and multivariate analyses. Age < 2 years and acute aetiology were associated with lower seizure recurrence, while non convulsive status epilepticus (NCSE) with coma and a history of epilepsy were associated with higher seizure recurrence. On multivariate analyses, a history of epilepsy, as well as having both acute and remote causes were associated with higher seizure recurrence. CONCLUSIONS: All-cause mortality in both the paediatric and adult populations at 2 years was lower than most previous reports. Older age, SE duration ≥30 mins and progressive aetiologies were associated with the highest 2-year mortality, while febrile SE had the lowest mortality. A history of epilepsy, NCSE with coma, and having both acute and remote causes were associated with higher seizure recurrence at 2 years. Future studies should focus on functional measures of outcome and long-term quality of life.

An Individual vs Parent Supported Physical Activity Intervention in Adolescents with Intellectual Disabilities.

INTRODUCTION: Moderate-to-vigorous physical activity (MVPA) is inadequate in adolescents with intellectual and developmental disabilities (IDD). This report describes the results of an 18-mo. clinical trial in adolescents with IDD which compared changes in accelerometer assessed daily MVPA, gross motor quotient and leg press strength between participants randomized to an exercise intervention delivered to adolescents only (AO) or to the adolescent and a parent (A + P). METHODS: The 18-mo. trial included a 6-mo. active intervention, 6-mo. maintenance interventions, and a 6-mo. no-contact follow-up. Adolescents in both arms were asked to attend 40 min. remotely delivered group video exercise sessions (0-6 mos. =3 sessions·wk-1., 7-12 mos. =1 session·wk-1). In the A + P arm, one parent/guardian was asked to attend all group remote video exercise sessions and a monthly remotely delivered 30-min. educations/support session with their adolescent across the 12-mo. intervention. RESULTS: Adolescents (n = 116) with IDD (age ~ 16 yrs., 52% female) were randomized to the AO (n = 59) or A + P (n = 57) arms. Mixed modeling, controlling for baseline MVPA and season, indicated minimal but statistically significant changes in MVPA across 6 (p = 0.006), 12 (p < 0.001), and 18 mos. (p < 0.001). However, the change in MVPA in the two intervention arms did not differ significantly at any time point (all p > 0.05). Similarly, gross motor quotient and leg press strength improved significantly over time (p < 0.001) and these changes did not differ between intervention arms (all p > 0.05). CONCLUSIONS: Parental involvement had no impact on changes in daily MVPA, gross motor quotient or leg press strength in response to a remotely delivered exercise intervention in adolescents with IDD.

Days Alive and Out of Hospital as an Outcome Measure in Patients Receiving Hyperacute Stroke Intervention.

BACKGROUND: Patient outcome after stroke is frequently assessed with clinical scales such as the modified Rankin Scale score (mRS). Days alive and out of hospital at 90 days (DAOH-90), which measures survival, time spent in hospital or rehabilitation settings, readmission and institutionalization, is an objective outcome measure that can be obtained from large administrative data sets without the need for patient contact. We aimed to assess the comparability of DAOH with mRS and its relationship with other prognostic variables after acute stroke reperfusion therapy. METHODS AND RESULTS: Consecutive patients with ischemic stroke treated with intravenous thrombolysis or endovascular thrombectomy were analyzed. DAOH-90 was calculated from a national minimum data set, a mandatory nationwide administrative database. mRS score at day 90 (mRS-90) was assessed with in-person or telephone interviews. The study included 1278 patients with ischemic stroke (714 male, median age 70 [59-79], median National Institutes of Health Stroke Scale score 14 [9-20]). Median DAOH-90 was 71 [29-84] and median mRS-90 score was 3 [2-5]. DAOH-90 was correlated with admission National Institutes of Health Stroke Scale score (Spearman rho -0.44, P<0.001) and Alberta Stroke Program Early CT [Computed Tomography] Score (Spearman rho 0.24, P<0.001). There was a strong association between mRS-90 and DAOH-90 (Spearman rho correlation -0.79, P<0.001). Area under receiver operating curve for predicting mRS score >0 was 0.86 (95% CI, 0.84-0.88), mRS score >1 was 0.88 (95% CI, 0.86-0.90) and mRS score >2 was 0.90 (95% CI, 0.89-0.92). CONCLUSIONS: In patients with stroke treated with reperfusion therapies, DAOH-90 shows reasonable comparability to the more established outcome measure of mRS-90. DAOH-90 can be readily obtained from administrative databases and therefore has the potential to be used in large-scale clinical trials and comparative effectiveness studies.

Weight management in rural health clinics: Results from the randomized midwest diet and exercise trial.

Introduction: Rural living adults have higher rates of obesity compared with their urban counterparts and less access to weight management programs. Previous research studies have demonstrated clinically relevant weight loss in rural living adults who complete weight management programs delivered by university affiliated interventionists. However, this approach limits the potential reach, adoption, implementation, and maintenance of weight management programs for rural residents. Weight management delivered through rural health clinics by non-physician clinic associated staff, for example, nurses, registered dieticians, allied health professionals, etc. has the potential to improve access to weight management for rural living adults. This trial compared the effectiveness of a 6-month multicomponent weight management intervention for rural living adults delivered using group phone calls (GP), individual phone calls (IP) or an enhanced usual care control (EUC) by rural clinic associated staff trained by our research team. Methods: Rural living adults with overweight/obesity (n = 187, age âˆ¼ 50 years 82% female, body mass index ∼35 kg/m2) were randomized (2:2:1) to 1 of 3 intervention arms: GP, which included weekly âˆ¼ 45 min sessions with 7-14 participants (n = 71), IP, which included weekly âˆ¼ 15 min individual sessions (n = 80), or EUC, which included one-45 min in-person session at baseline. Results: Weight loss at 6 months was clinically relevant, that is, ≥5% in the GP (-11.4 kg, 11.7%) and the IP arms (-9.1 kg, 9.2%) but not in the EUC arm (-2.6%, -2.5% kg). Specifically, 6 month weight loss was significantly greater in the IP versus EUC arms (-6.5 kg. p ≤ 0.025) but did not differ between the GP and IP arms (-2.4 kg, p > 0.025). The per participant cost per kg. weight loss for implementing the intervention was $93 and $60 for the IP and GP arms, respectively. Conclusions: Weight management delivered by interventionists associated with rural health clinics using both group and IP calls results in clinically relevant 6 months weight loss in rural dwelling adults with overweight/obesity with the group format offering the most cost-effective strategy. Clinical trial registration: ClinicalTrials.gov (NCT02932748).

Exploration of uncertainty of PRx time trends.

Introduction: PRx can be used as surrogate measure of Cerebral Autoregulation (CA) in traumatic brain injury (TBI) patients. PRx can provide means for individualising cerebral perfusion pressure (CPP) targets, such as CPPopt. However, a recent Delphi consensus of clinicians concluded that consensus could not be reached on the accuracy, reliability, and validation of any current CA assessment method. Research question: We aimed to quantify the short-term uncertainty of PRx time-trends and to relate this to other physiological measurements. Material and methods: Intracranial pressure (ICP), arterial blood pressure (ABP), end-tidal CO2 (EtCO2) high-resolution recordings of 911 TBI patients were processed with ICM + software. Hourly values of metrics that describe the variability within modalities derived from ABP, ICP and EtCO2, were calculated for the first 24h of neuromonitoring. Generalized additive models were used to describe the time trend of the variability in PRx. Linear correlations were studied for describing the relationship between PRx variability and the other physiological modalities. Results: The time profile of variability of PRx decreases over the first 12h and was higher for average PRx ∼0. Increased variability of PRx was not linearly linked with average ABP, ICP, or CPP. For coherence between slow waves of ABP and ICP >0.7, the variability in PRx decreased (R = -0.47, p < 0.001). Discussion and conclusion: PRx is a highly variable parameter. PRx short-term dispersion was not related to average ICP, ABP or CPP. The determinants of uncertainty of PRx should be investigated to improve reliability of individualised CA assessment in TBI patients.

Visualization of Cerebral Pressure Autoregulatory Insults in Traumatic Brain Injury.

OBJECTIVES: The first aim was to investigate the combined effect of insult intensity and duration of the pressure reactivity index (PRx) and deviation from the autoregulatory cerebral perfusion pressure target (∆CPPopt = actual CPP - optimal CPP [CPPopt]) on outcome in traumatic brain injury. The second aim was to determine if PRx influenced the association between intracranial pressure (ICP), CPP, and ∆CPPopt with outcome. DESIGN: Observational cohort study. SETTING: Neurocritical care unit, Cambridge, United Kingdom. PATIENTS: Five hundred fifty-three traumatic brain injury patients with ICP and arterial blood pressure monitoring and 6-month outcome data (Glasgow Outcome Scale [GOS]). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The insult intensity (mm Hg or PRx coefficient) and duration (minutes) of ICP, PRx, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In these plots, there was a transition from favorable to unfavorable outcome when PRx remained positive for 30 minutes and this was also the case for shorter durations when the intensity was higher. In a similar plot of ∆CPPopt, there was a gradual transition from favorable to unfavorable outcome when ∆CPPopt went below -5 mm Hg for 30-minute episodes of time and for shorter durations for more negative ∆CPPopt. Furthermore, the percentage of monitoring time with certain combinations of PRx with ICP, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In the combined PRx/ICP heatmap, ICP above 20 mm Hg together with PRx above 0 correlated with unfavorable outcome. In a PRx/CPP heatmap, CPP below 70 mm Hg together with PRx above 0.2-0.4 correlated with unfavorable outcome. In the PRx-/∆CPPopt heatmap, ∆CPPopt below 0 together with PRx above 0.2-0.4 correlated with unfavorable outcome. CONCLUSIONS: Higher intensities for longer durations of positive PRx and negative ∆CPPopt correlated with worse outcome. Elevated ICP, low CPP, and negative ∆CPPopt were particularly associated with worse outcomes when the cerebral pressure autoregulation was concurrently impaired.