Fresh Bucks: A Process Approach for Improving Supplemental Nutrition Assistance Program (SNAP) Matching Programs at Farmers' Markets.

Supplemental Nutrition Assistance Program (SNAP) matching programs at farmers' markets have been shown to increase access to fresh fruits and vegetables (FV) as well as improve food security among participants. Implementing SNAP matching programs in an efficient way is vital for sustainability and increasing access to fresh FV for SNAP participants. The Fresh Bucks SNAP matching program in Marion County, Indiana transitioned from using wooden tokens as incentive scrips to checks. This innovative approach streamlined administrative processes and reduced the wait time for vendors to be reimbursed. Surveys results indicated that the new form of incentive was positively received by vendors and participants. Implications for practice are provided.

Digital Technologies for Children and Parents Sharing Self-Management in Childhood Chronic or Long-Term Conditions: A Scoping Review.

Worldwide, the prevalence of chronic (or long-term) conditions in children and young people from birth to 18 years (children) is increasing. Promoting competent and effective self-management skills early in the trajectory is important to improve adherence to treatment and optimise quality of life. Successful self-management, therefore, requires parents and children who are developmentally able to develop a range of complex skills, including the use of digital technologies. This scoping review aimed to identify primary research investigating digital technologies for children and parents sharing self-management in childhood chronic illnesses. A comprehensive search of electronic databases was conducted. Nineteen papers were included, assessed for quality and methodological rigour using the Hawker tool and thematically analysed. Three themes were identified: (i) the feasibility and acceptability of using technology, (ii) the usability of technologies and (iii) the effect of technologies on adherence and self-management skills. The results indicate that technologies such as mobile apps and websites can assist the management of long-term conditions, are an acceptable method of delivering information and can promote the development of effective self-management skills by parents and children. However, future technology design must include children and parents in all stages of development.

National Pediatric Experience With Virtual Interviews: Lessons Learned and Future Recommendations.

The coronavirus disease 2019 pandemic significantly impacted undergraduate and graduate medical education and created challenges that prevented a traditional approach to residency and fellowship recruitment and interviews. Early in the pandemic, the pediatric education community came together to support applicants and training programs and to foster an equitable recruitment process. We describe many of our community's innovations, including the use of virtual cafés to educate programs and highlight best practices for virtual recruitment and the use of regional webinars to highlight residency programs and provide information to applicants. Surveys of applicants and programs suggest that the virtual interview process worked well overall, with applicants and programs saving both time and money and programs maintaining a high rate of filling their positions. On the basis of this experience, we highlight the strengths and weaknesses of 3 potential models for future interview seasons. We close with a series of questions that need further investigation to create an effective and equitable recruitment process for the future.

Creating a learning environment in your practice or facility.

Family physicians are expected to build the capacity of the primary care team and to provide clinical training to students, but often lack the educational expertise and a supportive learning environment. This article aims to outline the competencies needed to fulfil these expectations and to assist with professional development in this area. The organisational environment has a profound effect on the success of learning and issues such as adequate infrastructure, optimal staff numbers and mix, appropriate patient mix, quality of care, supportive management and organisational culture are all important. Within this organisational culture learning is often dependent on an effective clinical trainer. Clinical trainers impact learning through role modelling, facilitation of learning and providing up to date information. They need educational competencies to embed brief and effective training into clinical practice, to provide effective feedback and to engage with small group teaching and assessment. The family physician can lead the entire team and practice through developing themselves as a clinical trainer, creating supportive relationships and transforming policies and processes to support innovation and learning.

Training of workplace-based clinical trainers in family medicine, South Africa: Before-and-after evaluation.

BACKGROUND: The training of family physicians is a relatively new phenomenon in the district health services of South Africa. There are concerns about the quality of clinical training and the low pass rate in the national examination. AIM: To assess the effect of a five-day course to train clinical trainers in family medicine on the participants' subsequent capability in the workplace. SETTING: Family physician clinical trainers from training programmes mainly in South Africa, but also from Ghana, Uganda, Kenya, Malawi and Botswana. METHODS: A before-and-after study using self-reported change at 6 weeks (N = 18) and a 360-degree evaluation of clinical trainers by trainees after 3 months (N = 33). Quantitative data were analysed using the Statistical Package for Social Sciences, and qualitative data wereanalysed thematically. RESULTS: Significant change (p < 0.05) was found at 6 weeks in terms of ensuring safe and effective patient care through training, establishing and maintaining an environment for learning, teaching and facilitating learning, enhancing learning through assessment, and supporting and monitoring educational progress. Family physicians reported that they were better at giving feedback, more aware of different learning styles, more facilitative and less authoritarian in their educational approach, more reflective and critical of their educational capabilities and more aware of principles in assessment. Despite this, the trainees did notreport any noticeable change in the trainers' capability after 3 months. CONCLUSION: The results support a short-term improvement in the capability of clinical trainers following the course. This change needs to be supported by ongoing formative assessment and supportive visits, which are reported on elsewhere.

Using GP trainees as role players as a teaching/training tool for established GP trainers.

This work aimed to evaluate the effectiveness of using GP trainees in place of professional actors, to role-play trainees with 'difficulties' or various challenging characteristics, as an educational tool for skills development of experienced GP trainers. The context was a residential experienced GP trainers' course and the role players were local ST3 GP trainees. Professional actors have been used for this purpose for many years in medical education at all levels, particularly in teaching communication and consultation skills in the Thames Valley area of the UK. We wanted to trial and evaluate whether using GP trainees themselves, with their own more authentic 'hinterland' of experience, (but no acting training) would be as, or more, effective than using actors. The exercise was successful and showed, through post-course feedback (immediate written feedback and later on-line questionnaire), that the use of trainees was considered by the delegates to be an effective, adaptable and realistic training tool, and more so than using professional actors. The trainees also reported educational benefit from the experience.

Training the trainers: beyond providing a well-received course.

CONTEXT: The Royal College of General Practitioners in partnership with the South African Academy of Family Physicians obtained funding to run a series of 'Training the Trainers' courses for trainers of family medicine registrars, with a view to strengthening clinical supervision of postgraduate registrars. The authors wanted to establish whether it was worthwhile for the course to be provided on an ongoing basis after the funded project was completed. INTERVENTION: Development of a pilot tool for evaluation visits after a faculty development course. METHODS: The authors developed a pre-visit pack and conducted five site visits to registrar trainers who had been on the course between 12 and 24 months earlier. Before the series of visits and after each visit we debriefed and modified our approach. RESULTS: Optimising the use of the pre-visit pack will require greater orientation of the trainer. Administrative support for the visits will be vital. The visits were experienced very positively. However, in a context in which these visits are not the norm, the trainers need support and encouragement to participate in an activity which made them feel quite vulnerable. CONCLUSIONS: The tool enabled course participants to show evidence of their behaviour change, enabled their colleagues to report on the impact on their own teaching practices, and enabled registrars to voice their opinions of their trainer's supervision skills. A post-course formative evaluation visit has the potential to catalyse the impact of the training course. It will be necessary to train the family physicians who conduct these visits.

Adults with cystic fibrosis - responding to a new ageing population.

Worldwide, the life expectancy of adults with cystic fibrosis has increased substantially over the last two decades and cystic fibrosis can no longer be regarded as a paediatric condition. Adults with cystic fibrosis are becoming a new ageing population and are working, having families of their own and are likely to retire due to old age rather than ill health. Despite this progress, little is known about how people with cystic fibrosis are experiencing ageing with this long-term condition and how prepared they are for older age. This paper highlights the implications that ageing with cystic fibrosis may have for specialist health services and in particular the individual with cystic fibrosis, as well as providing pointers for future research.

The effects of external quality management on workplace-based assessment.

BACKGROUND: In 2007 all medical specialty training curricula in the uK changed to become competence based, and Annual Review of Competence Progression (ARCP) panels became the mechanism for progression through training. The RCGP also developed an internet-based electronic portfolio to record trainees' learning and development. The operational instructions for the new specialty training curricula included the requirement for quality management of the decisions made by the ARCP panels. METHODS: The Royal College of General Practitioners (RCGP) developed criteria to measure the quality of the decisions made by Deanery ARCP panels and the educational and clinical supervisors' reports that informed them. A team of external advisors (EAs) was appointed and trained to undertake this external scrutiny work. RESULTS: For the past four years there has been a consistency in agreement between the decisions made by the Deanery ARCP teams and the EAs. The quality of both the educational and clinical supervisor reports has improved over the same time period. CONCLUSION: An internet-based electronic portfolio is an essential component of competency-based curricula using programmes of assessment. Quality management is an effective strategy to ensure the dependability of high-stakes decisions. Feedback from the RCGP quality management process has provided a stimulus to promote change within deaneries.

Care home staff can detect the difference between delirium, dementia and depression.

Prevention of delirium is an important part of looking after care home residents, however, it can be difficult to detect, especially in those who have dementia. This article explores the perceptions and experiences of care home staff integrating delirium prevention activity in their everyday work. As part of the Stop delirium! feasibility study interviews were carried out and when they were analysed five themes were identified: triggers and knowledge; detection and observation; effect of closest contact; changes in management of care; and communication and teamwork to overcome difficulties. Together these provide insight into how carers identified a potential episode of delirium and indicated the steps that might be taken to manage residents' care. Communication and teamwork were identified as important in delirium prevention and appropriate management.

Stop Delirium! A complex intervention to prevent delirium in care homes: a mixed-methods feasibility study.

BACKGROUND: delirium is likely to be particularly common in care homes, given the clustering of known risk factors in these settings. Preventing delirium should result in significant benefits, including better quality of care and improved outcomes for residents. OBJECTIVE: to test the feasibility of 'Stop Delirium!', an intervention to prevent delirium in care homes for older people, and to optimise parameters to inform the design of a future trial evaluation. METHOD: we delivered Stop Delirium! to six care homes over 10 months, in a mixed methods before and after study. RESULTS: Stop Delirium! was successfully implemented in the study homes. We found evidence supporting positive changes in staff attitudes and practice after the intervention. Although qualitative data suggested it was too early to expect changes in resident outcomes, we also found preliminary evidence suggesting potential improvements in a range of outcomes, including a reduction in the number of falls and prescribed medications. CONCLUSION: a complex intervention for delirium prevention in care homes is feasible and has the potential to improve staff practice and outcomes for residents. This work provides the basis for the next phase of the evaluation to establish its effectiveness and cost-effectiveness.

Respiratory control stability and upper airway collapsibility in men and women with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is two to three times more common in men as in women. The mechanisms leading to this difference are currently unclear but could include gender differences in respiratory stability [loop gain (LG)] or upper airway collapsibility [pharyngeal critical closing pressure (Pcrit)]. The aim of this study was to compare LG and Pcrit between men and women with OSA to determine whether the factors contributing to apnea are similar between genders. The first group of 11 men and 11 women were matched for OSA severity (mean +/- SE apnea-hypopnea index = 43.8 +/- 6.1 and 44.1 +/- 6.6 events/h). The second group of 12 men and 12 women were matched for body mass index (BMI; 31.6 +/- 1.9 and 31.3 +/- 1.8 kg/m2, respectively). All measurements were made during stable supine non-rapid eye movement sleep. LG was determined using a proportional assist ventilator. Pcrit was measured by progressively dropping the continuous positive airway pressure level for three to five breaths until airway collapse. Apnea-hypopnea index-matched women had a higher BMI than men (38.0 +/- 2.4 vs. 30.0 +/- 1.9 kg/m2; P = 0.03), but LG and Pcrit were similar between men and women (LG: 0.37 +/- 0.02 and 0.37 +/- 0.02, respectively, P = 0.92; Pcrit: 0.35 +/- 0.62 and -0.18 +/- 0.87, respectively, P = 0.63). In the BMI-matched subgroup, women had less severe OSA during non-rapid eye movement sleep (30.9 +/- 7.4 vs. 52.5 +/- 8.1 events/h; P = 0.04) and lower Pcrit (-2.01 +/- 0.62 vs. 1.16 +/- 0.83 cmH2O; P = 0.005). However, LG was not significantly different between genders (0.38 +/- 0.02 vs. 0.33 +/- 0.03; P = 0.14). These results suggest that women may be protected from developing OSA by having a less collapsible upper airway for any given degree of obesity.

Ventilatory control and airway anatomy in obstructive sleep apnea.

Ventilatory instability may play an important role in the pathogenesis of obstructive sleep apnea. We hypothesized that the influence of ventilatory instability in this disorder would vary depending on the underlying collapsibility of the upper airway. To test this hypothesis, we correlated loop gain with apnea-hypopnea index during supine, nonrapid eye movement sleep in three groups of patients with obstructive sleep apnea based on pharyngeal closing pressure: negative pressure group (pharyngeal closing pressure less than -1 cm H(2)O), atmospheric pressure group (between -1 and +1 cm H(2)O), and positive pressure group (greater than +1 cm H(2)O). Loop gain was measured by sequentially increasing proportional assist ventilation until periodic breathing developed, which occurred in 24 of 25 subjects. Mean loop gain for all three groups was 0.37 +/- 0.11. A significant correlation was found between loop gain and apnea-hypopnea index in the atmospheric group only (r = 0.88, p = 0.0016). We conclude that loop gain has a substantial impact on apnea severity in certain patients with sleep apnea, particularly those with a pharyngeal closing pressure near atmospheric.

The influence of gender and upper airway resistance on the ventilatory response to arousal in obstructive sleep apnoea in humans.

The termination of obstructive respiratory events is typically associated with arousal from sleep. The ventilatory response to arousal may be an important determinant of subsequent respiratory stability/instability and therefore may be involved in perpetuating obstructive respiratory events. In healthy subjects arousal is associated with brief hyperventilation followed by more prolonged hypoventilation on return to sleep. This study was designed to assess whether elevated sleeping upper airway resistance (R(UA)) alters the ventilatory response to arousal and subsequent breathing on return to sleep in patients with obstructive sleep apnoea (OSA). Inspired minute ventilation (V(I)), R(UA) and end-tidal CO(2) pressure (P(ET,CO(2))) were measured in 22 patients (11 men, 11 women) with OSA (mean +/-s.e.m., apnoea-hypopnoea index (AHI) 48.9 +/- 5.9 events h(-1)) during non-rapid eye movement (NREM) sleep with low R(UA) (2.8 +/- 0.3 cmH(2)O l(-1) s; optimal continuous positive airway pressure (CPAP) = 11.3 +/- 0.7 cmH(2)O) and with elevated R(UA) (17.6 +/- 2.8 cmH(2)O l(-1) s; sub-optimal CPAP = 8.4 +/- 0.8 cmH(2)O). A single observer, unaware of respiratory data, identified spontaneous and tone-induced arousals of 3-15 s duration preceded and followed by stable NREM sleep. V(I) was compared between CPAP levels before and after spontaneous arousal in 16 subjects with tone-induced arousals in both conditions. During stable NREM sleep at sub-optimal CPAP, P(ET,CO(2)) was mildly elevated (43.5 +/- 0.8 versus 42.5 +/- 0.8 Torr). However, baseline V(I) (7.8 +/- 0.3 versus 8.0 +/- 0.3 l min(-1)) was unchanged between CPAP conditions. For the first three breaths following arousal, V(I) was higher for sub-optimal than optimal CPAP (first breath: 11.2 +/- 0.9 versus 9.3 +/- 0.6 l min(-1)). The magnitude of hypoventilation on return to sleep was not affected by the level of CPAP and both obstructive and central respiratory events were rare following arousal. Similar results occurred after tone-induced arousals which led to larger responses than spontaneous arousals. V(I) for the first breath following arousal under optimal CPAP was greater in men than women (11.0 +/- 0.4 versus 7.6 +/- 0.6 l min(-1)). These results demonstrate that the ventilatory response to arousal is influenced by pre-arousal airway resistance and gender. Whether this contributes to the perpetuation of respiratory events and the pathogenesis of OSA is unclear.

An exploration of patients' experiences of anti-TNF therapy.

OBJECTIVE: To explore the experience of rheumatoid arthritis patients receiving anti-tumour necrosis factor (anti-TNF) therapy on physical, psychological and social well-being. METHOD: Seven patients with rheumatoid arthritis (RA) who received six months of infliximab were interviewed in depth by one researcher to identify their experiences of this treatment. The interviews were tape-recorded and analysed using Colaizzi's procedural steps. RESULTS: Four main categories were identified from the interview relating to the patient's experience of anti-TNF therapy. These included: The impact of living with RA on physical, psychological and social function. The influence of anti-TNF therapy on physical, psychological and social function. The experience of attending for treatment. The impact of discontinuing anti-TNF treatment. CONCLUSION: All seven patients experienced benefits from receiving anti-TNF therapy. These benefits were not maintained once the treatment period was completed.

The influence of lung volume on pharyngeal mechanics, collapsibility, and genioglossus muscle activation during sleep.

STUDY OBJECTIVES: Previous studies in both awake and sleeping humans have demonstrated that lung-volume changes substantially affect upper-airway size and pharyngeal resistance and, thus, may influence pharyngeal patency. We sought to systematically investigate the isolated effects of lung-volume changes on pharyngeal collapsibility and mechanics and genioglossus muscle activation during stable non-rapid eye movement sleep. We hypothesized that lower lung volumes would lead to increased pharyngeal collapsibility, airflow resistance, and, in compensation, augmented genioglossus muscle activation. DESIGN: Nineteen normal individuals (age, 30.4 +/- 0.5 years; body mass index: 24.5 +/- 0.4 kg/m2) were studied during stable non-rapid eye movement sleep in a rigid head-out shell equipped with a variable positive/negative pressure attachment for manipulations of extrathoracic pressure and, thus, lung volume. SETTING: Sleep physiology laboratory. PARTICIPANTS: Normal healthy volunteers. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We measured change in end-expiratory lung volume (EELV) (magnetometers), genioglossus electromyogram (GGEMG) (intramuscular electrodes), pharyngeal pressure, and collapsibility of the pharynx in response to a brief pulse of negative pressure (-8 to -15 cm H2O) under the following conditions: (1) baseline, (2) increased EELV (+1 liter), and (3) decreased EELV (-0.6 liter). Reduced lung volumes led to increased inspiratory airflow resistance (7.54 +/- 2.80 cm H2O x L(-1) x s(-1) vs 4.53 +/- 1.05 cm H2O x L(-1) x s(-1), mean +/- SEM, P = 0.02) and increased genioglossus muscle activation (GGEMG peak 14.6% +/- 1.5% of maximum vs 8.6% +/- 1.5% of maximum, maximum P = 0.001) compared to baseline. The pharynx was also more collapsible at low lung volumes (4.3 +/- 0.5 cm H2O vs 5.4 +/- 0.6 cm H2O, P = 0.04). CONCLUSIONS: We conclude that upper-airway muscles respond to changes in lung volumes but not adequately to prevent increased collapsibility. These results suggest that lung volume has an important influence on pharyngeal patency during non-rapid eye movement sleep in normal individuals.

Gap junctions in the inner ear: comparison of distribution patterns in different vertebrates and assessement of connexin composition in mammals.

The distribution and size of gap junctions (GJ) in the sensory epithelia of the inner ear have been examined in a reptile (gecko), birds (chicken and owl), and mammals (mouse, guinea pig, gerbil, and bat), and the connexin composition of GJs in the mammalian inner ear has been assessed. Freeze fracture revealed a common pattern of GJ distribution in auditory and vestibular sensory epithelia in the different vertebrate classes. In all these tissues, GJs are numerous, often occupying more than 25% of the plasma membrane area of supporting cells and sometimes composed of more than 100,000 channels. Screening for 12 members of the connexin family in the mammalian inner ear by RT-PCR, Western blotting, and immunohistochemistry revealed four connexin isotypes, cx26, cx30, cx31, and cx43, in the cochlea and three, cx26, cx30, and cx43, in the vestibular organs. With antibodies characterised for their specificity, cx26 and cx30 colocalised in supporting cells of the organ of Corti, in the basal cell region of the stria vascularis, and in type 1 fibrocytes of the spiral ligament. No other connexin was detected in these regions. Cx31 was localised among type 2 fibrocytes below the spiral prominence, a region where cx30 was not expressed and cx26 expression appeared to be low. Cx43 was detected only in the region of "tension fibrocytes" lining the inner aspect of the otic capsule. This suggests separate functional compartments in the cochlea. In addition to cx26 and cx30, cx43 was detected in supporting cells of the vestibular sensory epithelia. Where cx26 and cx30 were colocalised, double immunogold labelling of thin sections showed both cx26 and cx30 evenly distributed in individual GJ plaques, a pattern consistent with the presence of heteromeric connexons. Coimmunoprecipitation of cochlear membrane proteins solubilised with a procedure that preserves the oligomeric structure of connexons confirmed the presence of heteromeric cx26/cx30 connexons. Heteromeric cx26/cx30 connexons may be unique to the inner ear, which could be one factor underlying the non-syndromic character of the deafness caused by mutations in cx26.

Control of upper airway muscle activity in younger versus older men during sleep onset.

Pharyngeal dilator muscles are clearly important in the pathophysiology of obstructive sleep apnoea syndrome (OSA). We have previously shown that the activity of both the genioglossus (GGEMG) and tensor palatini (TPEMG) are decreased at sleep onset, and that this decrement in muscle activity is greater in the apnoea patient than in healthy controls. We have also previously shown this decrement to be greater in older men when compared with younger ones. In order to explore the mechanisms responsible for this decrement in muscle activity nasal continuous positive airway pressure (CPAP) was applied to reduce negative pressure mediated muscle activation. We then investigated the effect of sleep onset (transition from predominantly alpha to predominantly theta EEG activity) on ventilation, upper airway muscle activation and upper airway resistance (UAR) in middle-aged and younger healthy men. We found that both GGEMG and TPEMG were reduced by the application of nasal CPAP during wakefulness, but that CPAP did not alter the decrement in activity in either muscle seen in the first two breaths following an alpha to theta transition. However, CPAP prevented both the rise in UAR at sleep onset that occurred on the control night, and the recruitment in GGEMG seen in the third to fifth breaths following the alpha to theta transition. Further, GGEMG was higher in the middle-aged men than in the younger men during wakefulness and was decreased more in the middle-aged men with the application of nasal CPAP. No differences were seen in TPEMG between the two age groups. These data suggest that the initial sleep onset reduction in upper airway muscle activity is due to loss of a 'wakefulness' stimulus, rather than to loss of responsiveness to negative pressure. In addition, it suggests that in older men, higher wakeful muscle activity is due to an anatomically more collapsible upper airway with more negative pressure driven muscle activation. Sleep onset per se does not appear to have a greater effect on upper airway muscle activity as one ages.

Within-breath control of genioglossal muscle activation in humans: effect of sleep-wake state.

Pharyngeal dilator muscles are clearly important in the pathogenesis of obstructive sleep apnoea syndrome. Substantial data support the role of a local negative pressure reflex in modifying genioglossal activation across inspiration during wakefulness. Using a model of passive negative pressure ventilation, we have previously reported a tight relationship between varying intrapharyngeal negative pressures and genioglossal muscle activation (GGEMG) during wakefulness. In this study, we used this model to examine the slope of the relationship between epiglottic pressure (Pepi) and GGEMG, during stable NREM sleep and the transition from wakefulness to sleep. We found that there was a constant relationship between negative epiglottic pressure and GGEMG during both basal breathing (BB) and negative pressure ventilation (NPV) during wakefulness (slope GGEMG/Pepi 1.86+/-0.3 vs. 1.79+/-0.3 arbitrary units (a.u.) cmH2O(-1)). However, while this relationship remained stable during NREM sleep during BB, it was markedly reduced during NPV during sleep (2.27+/-0.4 vs. 0.58+/-0.1 a.u. cmH2O(-1)). This was associated with a markedly higher pharyngeal airflow resistance during sleep during NPV. At the transition from wakefulness to sleep there was also a greater reduction in peak GGEMG seen during NPV than during BB. These data suggest that while the negative pressure reflex is able to maintain GGEMG during passive NPV during wakefulness, this reflex is unable to do so during sleep. The loss of this protective mechanism during sleep suggests that an airway dependent upon such mechanisms (as in the patient with sleep apnoea) will be prone to collapse during sleep.