Addressing Maternal Health Disparities: Building a Novel Two-Generation Approach to Comprehensive Postpartum Care.

The United States is facing a maternal health crisis with increasing rates of severe maternal morbidity and mortality. To improve maternal health and promote health equity, the authors developed a novel 2-generation model of postpartum and pediatric care. This article describes the Two-Generation Clinic (Two-Gen) and model of care. The model combines a dyadic strategy for simultaneous maternal and pediatric care with the collaborative care model in which seamless primary and behavioral health care are delivered to address the physical health, behavioral health, and social service needs of families. The transdisciplinary team includes primary care physicians, nurse practitioners, psychiatrists, obstetrician-gynecologists, social workers, care navigators, and lactation specialists. Dyad clinic visits are coscheduled (at the same time) and colocated (in the same examination room) with the same primary care provider. In the Two-Gen, the majority (89%) of the mothers self-identify as racial and ethnic minorities. More than 40% have a mental health diagnosis. Almost all mothers (97.8%) completed mental health screenings, >50.0% have received counseling from a social worker, 17.2% had a visit with a psychiatrist, and 50.0% received lactation counseling. Over 80% of the children were up to date with their well-child visits and immunizations. The Two-Gen is a promising model of care that has the potential to inform the design of postpartum care models and promote health equity in communities with the highest maternal health disparities.

Prevalencia de uropatógenos y sensibilidad antimicrobiana en lactantes menores de 2 años provenientes de la comunidad con diagnóstico de infección de vías urinarias / Prevalence of uropathogens and antimicrobial susceptibility in infants younger than 2 years of age from the community with a diagnosis of urinary tract infection

RESUMEN Introducción: la infección urinaria (IU) es una patología frecuente en los niños. La prevalencia de los uropatógenos varía de acuerdo a las regiones geográficas e incluso entre los diferentes centros asistenciales. El conocimiento de dicha prevalencia y de la sensibilidad a los antimicrobianos ayuda a la elección de la antibioticoterapia empírica inicial, permitiendo de esa manera, el control del cuadro agudo y evitando la resistencia bacteriana. Objetivo determinar la sensibilidad de los uropatógenos a los antimicrobianos obtenidos de urocultivos de niños menores de 24 meses con diagnóstico de IU provenientes de la comunidad. Material y métodos: estudio observacional, descriptivo, retrospectivo, de corte transverso. Se analizaron los expedientes clínicos y resultados de urocultivos de lactantes menores de 24 meses internados en el Departamento de Pediatría del Hospital Nacional en el período comprendido entre enero de 2012 a diciembre de 2014 , con diagnóstico de IU. Resultados: los uropatógenos más frecuentemente obtenidos fueron: Escherichia coli (67,6%) seguido de Klebsiella pneumoniae (18,3%), Enterobacter cloacae (8,4%), Pseudomonas aeruginosa (2,8%) y otros en 2,9%. La sensibilidad de la E. coli a la ciprofloxacina, las cefalosporinas y aminoglucósidos fue alta. El 14,6% de Escherichia coli fue productora de betalactamasa de espectro extendido (BLEE). El 100% de las cepas de Klebsiella pneumoniae fuer sensible a amikacina, ciprofloxacina y acidonalidíxico. Conclusiones: el germen más frecuentemente encontrado fue E. coli, seguido de la Klebsiella pneumoniae. El tratamiento de elección recomendado es la combinación de cefalospinas de primera generación asociado a aminoglucósidos, ya que con este esquema se cubrirá más del 95% de los uropatógenos causantes de infección de vías urinarias de la comunidad. Los gérmenes productores de infección urinaria atípica, deberán ser investigados.

ABSTRACT Introduction Urinary tract infection (UTI) is a common pathology in children. The prevalence of uropathogens varies according to geographic regions and even between different care centers. Knowledge of this prevalence and antimicrobial susceptibility helps to choose the initial empirical antibiotic therapy, thus allowing the control of the acute condition and avoiding bacterial resistance. Objective to determine the sensitivity of uropathogens to antimicrobials obtained from urine cultures of children younger than 24 months with diagnosis of UTI from the community. Material and methods: observational, descriptive, retrospective, cross-sectional study. We analyzed the clinical records and results of urine cultures of infants under 24 months admitted to the Department of Pediatrics of the National Hospital in the period between January 2012 and December 2014, diagnosed as UI. Results: the most frequent uropathogen was Escherichia coli (67.6%) followed by Klebsiella pneumoniae (18.3%), Enterobacter cloacae (8.4%), Pseudomonas aeruginosa (2.8%) and others in 2, 9%. The sensitivity of E. coli to ciprofloxacin, cephalosporins and aminoglycosides was high. 14.6% of Escherichia coli was a producers of extended spectrum betalactamase (ESBL). 100% of Klebsiella pneumoniae strains was a sensitive to amikacin, ciprofloxacin and acidonaldehyde. Conclusions: the more frequent germ found was E. coli, followed by Klebsiella pneumoniae. The recommended treatment of choice is the combination of first-generation cephalosporins associated with aminoglycosides, as this scheme will cover more than 95% of the uropathogens that cause urinary tract infection in the community. Germs producing atypical urinary infection should be investigated.

Use of adult day care service centers in an ethnically diverse sample of older adults.

Our nation is aging and unprepared to meet the needs of community-dwelling seniors and their caregivers. This study explored the perceived need for and use of adult day care services (ADS) in a low-income population. A random sample of 537 patient-caregiver dyads were recruited in home care agencies, and separate in-home surveys were conducted. Patients and caregivers were primarily women and 50.2% were of Hispanic origin. Although half (n = 267/537, 49.7%) of the caregivers had a perceived need for using ADS, only 19.1% of these caregivers used these services, mostly in the context of severe patient cognitive impairment. There were no racial or ethnic differences among ADS users and nonusers. The overall low use of ADS in a growing ethnically diverse senior population with a perceived need for services warrants further investigation and action as states seek to decrease nursing home placement and find solutions for our looming caregiving crisis.

Isolated limb infusion with hyperthermia and chemotherapy for advanced limb malignancy: factors influencing toxicity.

BACKGROUND: The isolated limb infusion (ILI) technique is a simpler and less invasive alternative to isolated limb perfusion, which allows regional administration of high-dose chemotherapy to patients with advanced melanoma and other malignancies restricted to a limb. METHODS: Patients from two institutions, treated by ILI between 1998 and 2009 for extensive disease restricted to a limb, were included. The cohort included 31 patients with melanoma who presented with in-transit metastases or an extensive primary lesion, one patient with squamous cell carcinoma and another with epithelioid sarcoma not suitable for local surgical treatment. RESULTS: A complete response was achieved in 26.3% of patients and a partial response in 52.6%. Toxicity was assessed according to the Wieberdink limb toxicity scale. Grade II toxicity was noted in 39.5% of patients, grade III in 50% and grade IV in 10.5%. Toxicity was correlated with the results of a number of clinical and laboratory tests. The toxicity of melphalan and actinomycin D was dose-dependent. For melphalan, the relationship between toxicity and mean dose was as follows: grade II--34.7 mg; grades III and IV--47.5 mg (P = 0.012). The relationship between toxicity and maximum serum creatine phosphokinase (CPK) was as follows: grade II--431.5 U/L; grades III and IV--3228 U/L (P = 0.010). CONCLUSION: Toxicity after ILI is dose-dependent and serum CPK correlates with toxicity.

Family history of dilated cardiomyopathy among patients with heart failure from the HF-ACTION genetic ancillary study.

BACKGROUND: The value of family history (FH) is well established, but its sensitivity to detect familial dilated cardiomyopathy (FDC) has been infrequently examined. METHODS: A genetic ancillary study was created as a component of the HF-ACTION trial, a multicenter, prospective, randomized clinical trial of exercise in patients with heart failure and an ejection fraction <35%. A FH-based study using a structured questionnaire mailed to all consenting individuals was incorporated into the genetic ancillary. FH responses were analyzed for dilated cardiomyopathy (DCM) in family members. RESULTS: Of the 741 individuals with data available, 358 (48.3%) had nonischemic and 383 (51.6%) had ischemic etiology, and of these 164 (45.8%) and 201 (52.4%), respectively, returned evaluable questionnaires. Of those with nonischemic etiology, 14/164 (8.5%) reported at least one first-degree family member with DCM or an enlarged heart; another 21/164 (12.8%) reported a FH of "cardiomyopathy," a less specific term to indicate DCM. CONCLUSION: At least 8.5% of patients with nonischemic etiology in the HF-ACTION genetic ancillary study provided FH indicating familial DCM, information important to inform further genetic analyses of this cohort and to plan other studies.

Patterns of caregiving of Cuban, other Hispanic, Caribbean Black, and White elders in South Florida.

Caregivers in Miami, Florida (185 Cubans, 108 other Hispanics, 229 non-Hispanic Whites, and 73 Caribbean Blacks) were described and compared along demographic and health variables, cultural attitudes, and caregiving behaviors. Participants were recruited at random through Home Health Services (61 %) and convenience sampling in the community (39 %), and interviewed at their home. Standardized instruments and measures constructed for this study were pretested. Multivariate analyses showed that the ethnic groups differed in age, education, income, and number of persons giving care, while caregiver health and patient functioning were similar. Controlling for demographics, differences in cultural variables were small. The sense of obligation, emotional attachment, openness about who should give care, spirituality, use of family help or community services were comparable in all groups. Commitment to caregiving was high, driven mainly by patient needs. Cubans had the greatest family stability, and worked the hardest, with the lowest sense of burden. Caribbean Black caregivers lived in bigger families, were youngest, and their patients had the lowest cognitive status. Burden was felt most by White caregivers who were older than the others. Professionals need to understand complex belief systems and behavior patterns to assist caregivers in mobilizing appropriate resources.

Return of genetic results in the familial dilated cardiomyopathy research project.

The goal of the Familial Dilated Cardiomyopathy (FDC) Research Project, initiated in 1993, has been to identify and characterize FDC genetic cause. All participating individuals have been consented for the return of genetic results, an important but challenging undertaking. Since the inception of the Project we have enrolled 606 probands, and 269 of these had 1670 family members also enrolled. Each subject was evaluated for idiopathic dilated cardiomyopathy (IDC) and pedigrees were categorized as familial or sporadic. The coding regions of 14 genes were resequenced in 311 to 324 probands in five studies. Ninety-two probands were found to carry nonsynonymous rare variants absent in controls, and with Clinical Laboratory Improvement Amendment of 1988 (CLIA) compliant protocols, relevant genetic results were returned to these probands and their consented relatives by study genetic counselors and physicians in 353 letters. In 10 of the 51 families that received results >1 year ago, at least 23 individuals underwent CLIA confirmation testing for their family's rare variant. Return of genetic results has been successfully undertaken in the FDC Research Project. This report describes the methods utilized in the process of returning research results. We use this information as a springboard for providing guidance to other genetic research groups and proposing future directions in this arena.

Qualidade protéica de multimisturas distribuídas em Alfenas, Minas Gerais, Brasil / Protein quality from multimixture distributed in Alfenas, Minas Gerais, Brazil

OBJETIVOS: O propósito do estudo foi avaliar a qualidade protéica de quatro multimisturas distribuídas para combater a desnutrição em comunidades do Município de Alfenas-MG. MÉTODOS: Foram utilizados ratos da raça Wistar, machos, distribuídos ao acaso em 6 grupos (n=6) em gaiolas individuais de aço inox, com temperatura controlada (25°C, desvio padrão= 2°C), durante 14 dias. O grupo padrão recebeu dieta à base de caseína, o grupo controle dieta livre de nitrogênio e os outros quatro grupos experimentais receberam dietas à base de multimistura. Para avaliação da qualidade protéica foram utilizados os métodos biológicos Quociente de Eficiência Protéica, Razão Protéica Líquida, Utilização Protéica Líquida e Digestibilidade Verdadeira. RESULTADOS: O quociente de eficiência protéica, a razão protéica líquida e a digestibilidade dos grupos recebendo multimistura foram inferiores (p<0,05) ao da caseína. A utilização protéica líquida promovida pelas dietas à base de multimisturas foi inferior à dieta à base de caseína em todos os grupos experimentais, exceto no grupo cuja multimistura apresentava maior proporção de leite em pó e não era adicionada de pó de sementes, de folha de mandioca e de casca de ovo. A digestibilidade das multimisturas foi em torno de 89 por cento, entretanto a utilização protéica foi de, aproximadamente, 27 por cento. CONCLUSÃO: Conclui-se que as multimisturas apresentaram baixa retenção protéica, não sendo adequadas para o crescimento dos animais ou até mesmo para a manutenção do peso corporal em um dos grupos teste.

OBJECTIVE: The study was developed to evaluate the protein quality of four multimixtures distributed in communities in Alfenas, MG, Brazil, to combat malnutrition. METHODS: Male Wistar rats were randomaly assigned to one of six groups (n=6) and individually housed in stainless steel cages on controlled temperature (25°C, standard deviation 2°C) for 14 days. The standard group was fed a casein diet, control group was fed a free nitrogen diet and four-test groups were fed different multimixture diets. A biological assay was carried out to determine the protein quality by Protein Efficiency Ratio, Net Protein Ratio, Net Protein Utilization and True Protein Digestibility. RESULTS: The Multimixture test groups showed lower (p<0.05) Protein Efficiency Ratio, Net Protein Ratio and digestibility than casein group. The net retention protein from multimixture test groups was lower (p<0.05) than casein group, except the group fed with multimixture contained a higher powdered milk proportion and was not added with powdered seeds, leaf cassava and egg shell powders in their formula. The multimixture digestibility was roughty 89 percent however the protein retention was approximately 27 percent. CONCLUSION: In conclusion, the multimixture showed low protein retention, did not promote adequate animal growth and was not capable of maintaining body weight in one multimixture test-group.