[Influence of Fetomaternal Risk Factors on Mortality and Morbidity in Extremely Preterm Infants]. / Einfluss von fetomaternalen Risikofaktoren auf die Mortalität und Morbidität von Extremfrühgeborenen.

INTRODUCTION: The management of pregnant women at risk of preterm delivery poses a challenge to the interdisciplinary team. At the edge of viability, it is crucial to take into consideration maternal and fetal risk factors when determining individual counseling and therapeutic approaches. METHODS: At a level 4 perinatal center, all preterm infants (PI) born in the years 2017 to 2020 who had a gestational age between 230/7 and 246/7 weeks and were cared for with a curative therapeutic approach were enrolled in a retrospective observational study. Divided into two groups (230/7-236/7 and 240/7-246/7 weeks of gestation), the PI were compared in terms of mortality and morbidity based on maternal and fetal risk factors. Thirteen risk factors and their prognostic relevance for survival were analyzed. RESULTS: 41 mothers with 48 PI were included. 9 neonates received primary palliative treatment and were excluded from the analyses. The survival rates between the two groups (n=21, n=27) showed no significant difference (66.7% versus 74.1%, p=0.750). A significantly higher mortality was observed in PI with an increased number of risk factors (p=0.004), the most severe of which were hypertensive disorders of pregnancy and preterm premature rupture of membranes. Data regarding morbidity showed no significant difference. CONCLUSION: Data regarding mortality correlate with national findings. Observed morbidity in the study population was recorded. The prediction of probability of survival is more precise when risk factors are taken into consideration.

Health-related quality of life and social determinants of health following COVID-19 infection in a predominantly Latino population.

BACKGROUND: As the COVID-19 pandemic evolves, more information is needed on its long-term impacts on health-related quality of life (HRQoL) and social determinants of health (SDoH). The aim of the study was to assess HRQoL and SDoH among a predominantly Latino population of COVID-19 survivors and to compare effects in Latinos versus non-Latinos. METHODS: This cross-sectional study consisted of a survey (in English and Spanish) of COVID-19 survivors from December 2020 to July 2021. The study assessed sociodemographic data, clinical characteristics, and SDoH, consisting of 10 COVID-19-related concerns. The PROMIS-29 + 2 (PROPr) measure, which captures 8 HRQoL domains and a preference-based health utility, was used to assess HRQoL. Bivariate analyses included chi-square tests and t-tests. Generalized linear models were conducted for multivariable analyses. RESULTS: Of 230 respondents (6.3% response rate), the mean [SD] age was 43.1 [14.3] years; 83.0% were Latino; the mean [SD] time since diagnosis was 8.1 [3.2] months; and 12.6% had a history of hospitalization with COVID-19. HRQoL scores were slightly worse than population norms on all domains, especially anxiety; the mean [SD] PROPr health utility was 0.36 [0.25]. Domain scores were similar by ethnicity except for cognitive function-abilities, where scores were lower in Latinos. Multivariable analyses revealed that: (1) financial concerns were associated with worse health utility, as well as worse scores on all 8 PROMIS domains; (2) interpersonal conflict was associated with worse health utility and worse scores on 6 of the 8 PROMIS domains (anxiety, depression, fatigue, sleep disturbance, social function, and pain interference); and (3) Latino ethnicity was only associated with 1 PROMIS domain (cognitive function-abilities) after controlling for covariates. CONCLUSION: COVID-19 infection is associated with HRQoL decrements long after the acute infection, and financial concerns and interpersonal conflict are particularly associated with worse HRQoL.

Impacts on patient-centered outcomes of a chronic pain self-management program in a rural community: A feasibility study.

This study explored if a self-management training program was feasible for a predominantly older rural Latino adults with chronic pain who had limited access to non-pharmacologically based pain treatment. Physical therapy doctoral students delivered the six-week low-literacy low-cost patient-centered program. The intervention was feasible to the participants (n=38) who showed improvement in a majority of the eight outcome measures at 6-week posttest and three measures at 18-week followup. The changes in pain severity, pain interference and pain-related physical functions reached minimally clinically important difference at follow-up. A randomized controlled trial with long-term follow-up is needed to test the program effectiveness in partnership with community health centers to increase access to pain management in rural communities.

Development of an E-Cigarettes Education and Cessation Program: A South Texas Oral Health Network Study.

Electronic cigarette (e-cigarette) use, or vaping, among youth and young adults has become a major public health concern. The prevalence of vaping has grown an astounding 900% among high school students from 2011 to 2015, and e-cigarette use among high school students has increased by 78% from 2017 to 2018, largely due to the rise in popularity of the high-dose nicotine product, JUUL. To date, there are few evidence-based e-cigarette cessation programs. To address this need, the South Texas Oral Health Network collaborated with dental practitioners and community members to conduct focus groups assessing knowledge and awareness of e-cigarette use. Based on this feedback, we developed a dental practitioner-based e-cigarette cessation program. The next step will be to utilize this program in a practice-based research network, a "real-world" practice setting that has the potential to increase the number of dental practitioners who counsel their patients about ecigarettes.

The Overlap Between Rural Hospital Needs and Medical Student Goals in Texas.

INTRODUCTION: The rural health workforce in the United States is difficult to maintain and harder to increase. This may contribute to worse health outcomes in rural areas and threaten the sustainability of rural hospitals. Previous studies have attempted to identify medical student characteristics and strategies to help grow this workforce. In this study, we aimed to understand the needs of medical students and hospital administrators to identify potential strategies to improve the rural health workforce. METHODS: We conducted medical student and hospital administrator focus groups. We analyzed focus group data separately to identify themes, and reviewed these themes for overlap between groups and potential actionable areas. We calculated Cohen κ statistics. RESULTS: We identified 26 themes in the medical student focus groups, and 14 themes in the hospital administrator focus group. Of these themes, three were identical between groups (scope of practice, loan repayment and financial concerns, and exposure to rural health in training), and two were similar between the groups (family and leadership). CONCLUSION: The identification of two themes that are similar but not identical between medical students and hospital administrators may serve as part of future strategies to improving rural physician recruitment. Future studies should determine if a shift in language or focus in these areas specifically help to improve the rural health workforce.

Allopregnanolone augments epileptiform activity of an in-vitro mouse hippocampal preparation in the first postnatal week.

In the immature brain the neurotransmitter γ-amino butyric acid (GABA) mediates a membrane depolarization and can contribute to both, inhibition and excitation. Therefore the consequences of a positive modulation of GABA(A) receptors by neurosteroids on epileptiform activity are hard to predict. In order to analyze whether neurosteroids attenuate or exaggerate epileptiform activity in the immature brain, we investigated the effect of the neurosteroid allopregnanolone on epileptiform activity in an in-toto hippocampus preparation of early postnatal mice (postnatal days 4-7) using field potential recordings. These in-vitro experiments revealed that 0.5 µmol/L allopregnanolone had no effect on ictal-like epileptiform activity, but increased the occurrence of interictal epileptiform events. The allopregnanolone-induced enhancement of interictal epileptiform activity could be blocked by a selective inhibition of synaptic GABAA receptors. In contrast, allopregnanolone had no effect on interictal epileptiform activity upon enhanced extrasynaptic GABAergic activity. Patch-clamp experiments demonstrated that allopregnanolone prolonged the decay of GABAergic postsynaptic currents, but had no effect on tonic GABAergic currents. We conclude from these results that allopregnanolone can enhance excitability in the immature hippocampus viaprolonged synaptic GABAergic currents. This potential effect of neurosteroids on brain excitability should be considered if they are applied as anticonvulsants to premature or early postnatal babies.

Taurine potentiates the anticonvulsive effect of the GABAA agonist muscimol and pentobarbital in the immature mouse hippocampus.

OBJECTIVE: The high incidence of epileptic seizures in neonates and their frequent refractoriness to pharmacologic therapies require identification of new therapeutical options. Therefore, we investigated whether the modulatory effect of taurine on γ-aminobutyric acid (GABA)A receptors can enhance the anticonvulsive potential of the GABAA receptor agonist muscimol and of the barbiturate pentobarbital. METHODS: We performed field potential recordings in in toto hippocampus preparations of immature (postnatal days 4-7) C57Bl/6 mouse pups. Spontaneous epileptiform activity was induced by the continuous presence of the potassium channel blocker 4-aminopyridine and the glycinergic antagonist strychnine in Mg2+ -free solutions. RESULTS: Bath application of 0.1 µmol/L muscimol increases the occurrence of recurrent epileptiform discharges, whereas they are significantly attenuated in a dose-dependent manner by muscimol in concentrations between 0.5 and 5 µmol/L. Taurine at concentrations between 0.1 and 0.5 mmol/L induces a proconvulsive effect, but upon coapplication, it significantly augments the anticonvulsive effect of moderate muscimol doses (0.5-1 µmol/L). In addition, the anticonvulsive effect of 100 and 200 µmol/L pentobarbital is increased significantly in the presence of 0.5 µmol/L taurine. SIGNIFICANCE: These observations demonstrate that taurine can indeed enhance the anticonvulsive effects of muscimol and pentobarbital, suggesting that taurine may act as a positive modulator on GABAA receptors. Thus, interfering with the modulatory taurine binding site of GABAA receptors or the interstitial taurine concentration may provide new therapeutical options for anticonvulsive therapies in neonates.

Early Antibiotics and Childhood Obesity: Do Future Risks Matter to Parents and Physicians?

To understand how parents and physicians make decisions regarding antibiotics and whether a potential associated risk of obesity would alter decisions, we conducted a qualitative study of parents and physicians who care for children. Parent focus groups and physician interviews used a guide focused on experience with antibiotics and perceptions of risks and benefits, including obesity. Content analysis was used to understand how a risk of obesity would influence antibiotic decisions. Most parents (n = 59) and physicians (n = 22) reported limited discussion about any risks at the time of antibiotic prescriptions. With an acute illness, most parents prioritized symptomatic improvement and chose to start antibiotics. Physicians' treatment preferences were varied. An obesity risk did not change most parents' or physicians' preferences. Given that parent-physician discussion at the time of acute illness is unlikely to change preferences, public health messaging may be a more successful approach to counter obesity and antibiotics overuse.

Developing a patient-centered outcome for targeting early childhood obesity across multiple stakeholders.

BACKGROUND: Patient-centered outcome measures for childhood obesity are limited. Identifying outcomes that patients and families consider important could be a viable avenue for better engagement of patients and interventions that are efficacious and acceptable to patients. Latino children experience high rates of obesity, and under-recognition of obesity in preschool aged children is common. METHODS: We used growth chart data to identify low-income, Latino children 2-5 years of age with obesity who decreased their adiposity (positive deviants) and a set of controls. We used qualitative interview data to identify themes around goals parents used in addressing weight. Then, we applied a modified Delphi approach across groups of caregivers and providers to identify common goals. We conducted focus groups to explore conflicts and congruency between caregivers and providers related to goals. Using the focus group data, we developed a decision tool for use between patients and providers relevant for early childhood obesity. RESULTS: We identified 257 children who successfully reduced adiposity (positive deviants) from 1621 eligible growth charts. From interviews with 44 parents (21 positive deviants and 23 controls), we coded and categorized outcomes such as increased happiness, clothing size and improved activity. We recruited 81 parents, grandparents and health care providers to participate in the modified Delphi process of ranking outcomes by importance and feasibility. Focus groups (2, total n = 24) suggested potential methods for a common framework to discuss goals, including a modified growth chart. We created a decision-tool that incorporated a growth chart and a section for discussion of patient-centered goals. A final focus group (1, n = 10) provided feedback on the tool as acceptable and potentially useful. CONCLUSIONS: The development of a patient-centered tool around achieving a healthy weight in early childhood identified common goals between providers and parents. While the tool has been developed, prospective testing of this patient-centered tool and its effects on engagement, parent motivation, and behavior change would be a useful next step.

Less Exercise and More Drugs: How a Low-Income Population Manages Chronic Pain.

OBJECTIVES: To evaluate chronic pain management in a multistate, low-income Hispanic population, and to examine predictors of exercising and prescription pain medication (PPM) use. DESIGN: Online survey administered to a representative sample of Hispanic adults in June 2015. SETTING: Five southwestern states. PARTICIPANTS: Among all online panel members who were Hispanic (N=1007), aged 35 to 75 years from 5 states, representing 11,016,135 persons, the survey was completed by 516 members (51%). Among these, 102 participants were identified with chronic noncancer pain representing 1,140,170 persons. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Exercising or using PPM for chronic pain in past year. RESULTS: Most participants reported using PPM (58%) and exercise (54%) to manage pain. Compared with annual household incomes >$75,000, adjusted odds ratios [AORs] for exercising were .20 for <$10,000 (P=.12); .40 for $10,000 to $34,999 (P=.22); and .15 for $35,000 to $74,999 (P=.015). Conversely, AORs for PPM were over 4-fold higher for lower-income groups as follows: 14.2, 4.79, and 4.85, respectively (all P<.065). PPM users rated the importance of accessing a gym to manage pain lower (P=.01), while exercisers rated the feasibility of gym access to manage pain higher (P=.001). CONCLUSIONS: In a Hispanic population-based sample with chronic pain, lower-income groups tended to exercise less but use PPM more. Barriers to gym access and use may play a role in these disparities.

Gaps in the Public's Knowledge About Chronic Pain: Representative Sample of Hispanic Residents From 5 States.

Educating the general public about chronic pain and its care is a national health priority. We evaluated knowledge, attitudes, and beliefs (KAB) of a 5-state, population-based sample of Hispanic individuals aged 35 to 75 years without chronic pain, representing more than 8.8 million persons. A Web-based survey assessed KAB using an adapted version of the Survey of Pain Attitudes-Brief and self-reported knowledge about chronic pain (nothing, a little, a lot). In unweighted analyses of participants (N = 349), the mean age was 52.0 (±10.6) years, 54% were women, 53% preferred Spanish, and 39% did not graduate from high school. More participants reported knowing nothing about chronic pain (24%) than a lot (12%). In weighted logistic models with knowing nothing as the reference, knowing a lot was associated with greater KAB for chronic pain-related emotions, functioning, and cure (all P < .01) but poorer KAB about pain medications (P < .001). Associations were similar for those knowing a little. Men and women preferring Spanish had poorer KAB about pain medications than men preferring English (both P < .001). In view of Hispanic individuals' disparities in chronic pain care, these data underscore the need for effective public educational campaigns about chronic pain. PERSPECTIVE: In this 5-state representative sample of Hispanic individuals without chronic pain, one-quarter reported knowing nothing about chronic pain and had poorer KAB about multiple aspects of this disease. This study reinforces the need to evaluate and address gaps in the general public's knowledge about chronic pain.

Comparing two sampling methods to engage hard-to-reach communities in research priority setting.

BACKGROUND: Effective community-partnered and patient-centered outcomes research needs to address community priorities. However, optimal sampling methods to engage stakeholders from hard-to-reach, vulnerable communities to generate research priorities have not been identified. METHODS: In two similar rural, largely Hispanic communities, a community advisory board guided recruitment of stakeholders affected by chronic pain using a different method in each community: 1) snowball sampling, a chain- referral method or 2) purposive sampling to recruit diverse stakeholders. In both communities, three groups of stakeholders attended a series of three facilitated meetings to orient, brainstorm, and prioritize ideas (9 meetings/community). Using mixed methods analysis, we compared stakeholder recruitment and retention as well as priorities from both communities' stakeholders on mean ratings of their ideas based on importance and feasibility for implementation in their community. RESULTS: Of 65 eligible stakeholders in one community recruited by snowball sampling, 55 (85 %) consented, 52 (95 %) attended the first meeting, and 36 (65 %) attended all 3 meetings. In the second community, the purposive sampling method was supplemented by convenience sampling to increase recruitment. Of 69 stakeholders recruited by this combined strategy, 62 (90 %) consented, 36 (58 %) attended the first meeting, and 26 (42 %) attended all 3 meetings. Snowball sampling recruited more Hispanics and disabled persons (all P < 0.05). Despite differing recruitment strategies, stakeholders from the two communities identified largely similar ideas for research, focusing on non-pharmacologic interventions for management of chronic pain. Ratings on importance and feasibility for community implementation differed only on the importance of massage services (P = 0.045) which was higher for the purposive/convenience sampling group and for city improvements/transportation services (P = 0.004) which was higher for the snowball sampling group. CONCLUSIONS: In each of the two similar hard-to-reach communities, a community advisory board partnered with researchers to implement a different sampling method to recruit stakeholders. The snowball sampling method achieved greater participation with more Hispanics but also more individuals with disabilities than a purposive-convenience sampling method. However, priorities for research on chronic pain from both stakeholder groups were similar. Although utilizing a snowball sampling method appears to be superior, further research is needed on implementation costs and resources.

The citizen scientist: Community-academic partnerships through Translational Advisory Boards.

OBJECTIVE: To describe the effectiveness of engaging patient partners as "citizen scientists" in the research process to boost patient centered outcomes research in underrepresented populations. METHODS: Translational Advisory Boards in South Texas have effectively collaborated with University researchers to develop community-based patient centered research. Here we describe innovative approaches in research to engage patients and offer practical methods to enhance partnerships between patients and researchers to facilitate patient engagement. RESULTS: Three health issues identified by the TABs were diabetes, obesity and teen pregnancy Examples of other community inspired research topics include air and water quality, methicillin-resistant staphylococcus aureus, intimate partner violence, chronic pain, and human papilloma virus and hepatitis C vaccinations. CONCLUSION: Patient engagement of underrepresented populations is inverse to the vast disparities they experience. In order to adequately address our nation's deficits in providing equitable healthcare, we must fully integrate disparate partners into the research process. By engaging community champions, academic health centers can fully integrate meaningful interventions on topics of interest to the catchment area in which they serve. PRACTICE IMPLICATIONS: These lessons can be used in developing local and regional collaborations across the country to boost active participation of patient stakeholder in PCOR to reduce healthcare disparities and improve our healthcare systems.

A qualitative study of family healthy lifestyle behaviors of Mexican-American and Mexican immigrant fathers and mothers.

This study qualitatively examines contrasting parental decision-making styles about family food choices and physical activities as well as willingness to change behaviors among Mexican-American and Mexican immigrant mothers and fathers of school-aged children. Twelve sex-specific focus groups were held in English or Spanish in 2012. Qualitative analysis informed by grounded theory examined parenting styles (ie, authoritative, authoritarian, or permissive), barriers to healthy lifestyle, and parents' stage of change about healthy lifestyles. One third of the 33 participating couples were born in Mexico. The majority of mothers and fathers described being permissive and allowing unhealthy food choices, and a minority of mothers reported more authoritarian approaches to promoting a healthier diet for their children. Mothers were more permissive than fathers about family physical activities and less engaged in these activities. Most mothers and fathers described only contemplating a healthier diet and more physical activity, while wanting their children to have a healthier lifestyle. These data suggest that clinicians need to assess and address differential parental roles when promoting a healthy lifestyle for children. Clinicians should also adopt culturally competent approaches to overcome barriers to parental engagement in diverse aspects of a healthy family lifestyle.

El psicoanálisis como envés de la ley / Psychoanalysis as the underside of the law / La psychanalyse comme envers de la loi

El psicoanálisis se ocupa del sujeto. El restituir al sujeto en su decir verdad a partir del inconsciente (y de la palabra) aparece, desde el inicio, episte-mológicamente, como el envés de la ley. La ley se debe a lo público y aquél a lo privado. La dis-tinción entre “público” y “privado” deviene, regla-da, desde el Derecho Romano —primer Digesto jurídico—. Pero la praxis analítica, como política institucional, al recomponer el lazo social y pre-sentificar la tensión entre el sujeto y el derecho, permite que el sujeto aborde lo real “haciendo uso” de la norma y que se ubique, además así, en la dimensión simbólica social de la ley...

Psychoanalysis deals with the subject. The return to the subject in saying truth as from the uncon-scious (and the word) appears, from the begin-ning, as the epistemological reverse of the law. This latter is due to the public whereas psychoa-nalysis is due to the private. The distinction be-tween "public" and "private" becomes, regulated, from the Roman law - first-Legal Digest. Yet, the analytical practice as an institutional policy, while rebuilding the social ties and materializing ten-sion between the subject and the rule of law, allows the subject to dwell into the the real thing "making use" of the rule of law and placing it also in the social/ symbolic dimension of the law...

La psychanalyse s’occupe du sujet. Le fait de rétablir le sujet à son dire vrai à partir de l’inconscient (et de la parole) apparait, dès le début et épistémologiquement, en tant que l’envers de la loi. La loi se doit au public, le sujet, au privé. La différence entre ® public ¼ et ® privé ¼ existe —réglée— depuis le Droit Roman, depuis le premier Digeste juridique. Mais en recompo-sant le lien social et en présentifiant la tension entre le sujet et le droit, la praxis analytique-en tant que politique institutionnelle- permet au sujet d’aborder le réel ® en faisant appel ¼ à la norme, et de se placer, ainsi aussi, dans la dimension symbolique et sociale de la loi...