Everyday discrimination, emotion, and daily interactions during adolescence.

The present study examined whether everyday discrimination relates to the frequency of adolescents' positive and negative daily social interactions and whether these associations are driven by anger and positive emotion. Adolescents (N = 334) participated in a three-wave longitudinal study, in which they completed surveys regarding everyday discrimination, anger, and positive emotion, as well as 15 daily reports of conflict and getting along with friends and family. Higher everyday discrimination was related to more daily conflicts and fewer experiences of getting along with other people. Longitudinal models also provided preliminary evidence that everyday discrimination was associated with daily conflicts 4 years later indirectly through anger. Overall, results suggest everyday discrimination relates to adolescents' daily experiences, potentially through differences in emotion.

Decreasing Intraoperative Skin Damage in Prone-Position Surgeries.

OBJECTIVE: To determine if subepidermal moisture (SEM) measures help detect and prevent intraoperative acquired pressure injuries (IAPIs) for prone-position surgery. METHODS: In this clinical trial of patients (n = 39 preintervention, n = 48 intervention, 100 historical control) undergoing prone-position surgery, researchers examined the use of multidimensionally flexible silicone foam (MFSF) dressings applied preoperatively to patients' face, chest, and iliac crests. Visual skin assessments and SEM measures were obtained preoperatively, postoperatively, and daily for up to 5 days or until discharge. Electronic health record review included demographic, medical, and surgery data. RESULTS: Of the 187 total participants, 76 (41%) were women. Participants' mean age was 61.0 ± 15.0 years, and 9.6% were Hispanic (n = 18), 9.6% were Asian (n = 18), 6.9% were Black or African American (n = 13), and 73.8% were White (n = 138). Participants had a mean Scott-Triggers IAPI risk score of 1.5 ± 1.1. Among those with no erythema preoperatively, fewer intervention participants exhibited postoperative erythema on their face and chest than did preintervention participants. Further, fewer intervention participants had SEM-defined IAPIs at all locations in comparison with preintervention participants. The MFSF dressings overcame IAPI risk factors of surgery length, skin tone, and body mass index with fewer IAPIs in intervention participants. CONCLUSIONS: Patients undergoing prone-position surgeries developed fewer IAPIs, and SEM measures indicated no damage when MFSF dressings were applied to sites preoperatively. The SEM measures detected more damage than visual assessment.

Harmonization of four biomarkers across nine nationally representative studies of older persons.

INTRODUCTION: A growing number of international population surveys have included measurement of biomarkers, but differ in the type of specimens collected, sample processing procedures, shipment protocols, and laboratory assay platforms. The purpose of this study is to harmonize biomarker data from nine nationally representative studies of people 50 years of age and over by adjusting for assay platforms and type of specimens for total cholesterol (total-C), high-density lipoprotein cholesterol (HDL-C), glycosylated hemoglobin (HbA1c), and C-reactive protein (CRP). METHODS: Sets of 24 identical serum, plasma, whole blood, and dried blood spot harmonization samples with known analyte levels were generated at a reference laboratory, shipped at -80°C to the respective study laboratories, and subsequently assayed following the study laboratory's protocol. Both original and harmonized study data were used to calculate mean values and at-risk prevalence. RESULTS: The correlation coefficients between the biomarker values of the harmonization samples obtained by the study laboratories and the reference laboratory were 0.99 or above for all analytes and laboratories, indicating the high quality of assays at all laboratories. However, using the harmonized data from each study, there were significant differences in the mean values and country ranking of the prevalence of at-risk levels of these four biomarkers. CONCLUSIONS: While the biomarker data from the different study laboratories were highly correlated, indicating very high correlation of rank order of specimens, absolute values did vary significantly. This can have a major impact on assessment of international differences in estimates of risks for chronic morbidity and mortality.

Low subjective social status is associated with daily selection of fewer healthy foods and more high-fat/high sugar foods.

Socioeconomic status has been related to poorer eating behaviors, potentially due to feeling of lower status relative to peers. Despite experimental evidence that temporarily feeling of lower status can contribute to greater caloric intake, it remains unclear how feeling of lower social status relate to eating behavior in daily life. This study aimed to test whether lower subjective social status (SSS)-the feeling of having relatively lower social status-in American society and relative to college peers were related to daily food selection. A sample of 131 young adults (Mage = 20.3, SD = 0.8; 60% female; 46% Latinos; 34% European American; 15% Asian American; 5% of other ethnicities) reported their SSS in society and in college and completed 15 daily reports regarding the number of daily servings they had of fruits, vegetables, fried foods, fast foods, desserts, and sugary drinks. Multilevel models with days nested within individuals were used to test whether low SSS in society or college related to daily food intake. Next, we examined whether associations were driven by young adults' perceived stress and daily stressors. Analyses controlled for age, gender, ethnicity, family and personal income, and parents' education to test the unique associations between subjective status and food intake. Whereas SSS in society was not related to food intake, young adults with lower SSS in their college consumed fewer daily servings of healthy foods and more daily servings of high-fat/high-sugar foods. Although lower college SSS was related to greater perceived stress, perceived stress and daily stressors were consistently unrelated to daily food intake. Findings suggested that lower SSS in local environments (e.g., college) may impact young adults' daily food choices through processes beyond heightened stress.

Sleep-Wake Timings in Adolescence: Chronotype Development and Associations with Adjustment.

Adolescent sleep research has focused heavily on duration and quality with less work examining chronotype, defined as individual differences in sleep-wake timings driven by the circadian rhythm. This study filled a gap in the literature by utilizing actigraphy-based sleep estimates in an accelerated longitudinal design in order to better understand the developmental trajectory and individual stability of chronotype during adolescence, as well as the associations between chronotype with risky behaviors, substance use, and depressive symptoms. A total of 329 adolescents (57% female; 21% Asian American, 31% European American, 41% Latino, 7% other ethnicity) provided actigraphy-based estimates of sleep and completed questionnaires at up to three time points, two years apart, beginning at 14-17 years of age. Multilevel modeling revealed a non-linear developmental trend in chronotype whereby eveningness increased from 14 to 19 years of age followed by a trend toward morningness. Individual differences in chronotype exhibited modest stability during adolescent development. Furthermore, greater evening chronotype was associated with more risky behaviors and substance use among males, and more substance use among older adolescents, whereas depressive symptoms were not associated with chronotype. The findings from this study may have practical implications for adolescent behavioral health interventions targeted at reducing risky behaviors and substance use among youth.

Natural History of Pressure Injury Among Ethnically/Racially Diverse Nursing Home Residents: The Pressure Ulcer Detection Study.

The current observational study provides descriptive data on 270 pressure injuries (PrIs) among 142 racially/ethnically diverse nursing home (NH) residents over 16 weeks. Weekly assessments were conducted with the Bates-Jensen Wound Assessment Tool. NH data were obtained from public government websites. NH, resident, and PrI characteristics across race/ethnicity groups were compared using analysis of variance and chi-square. Participants were 62% female and 89% functionally dependent. More Black and Asian individuals had peripheral vascular disease. More Black individuals had persistent trunk and Stage 4 PrIs. Black and Hispanic individuals had normal skin color surrounding PrIs. More Asian individuals had PrIs surrounded by purple/red discolored skin. More Black individuals' heel PrIs were unstageable, necrotic, and showed no granulation. Black and Hispanic individuals exhibited more deep tissue injury. No NH or prevention differences existed. Health disparities found validate administrative data results. Differences in PrI characteristics should be further examined among diverse NH residents. [Journal of Gerontological Nursing, 47(3), 37-46.].

Sleep problems in adolescence are prospectively linked to later depressive symptoms via the cortisol awakening response.

Sleep disturbance is a symptom of and a well-known risk factor for depression. Further, atypical functioning of the HPA axis has been linked to the pathogenesis of depression. The purpose of this study was to examine the role of adolescent HPA axis functioning in the link between adolescent sleep problems and later depressive symptoms. Methods: A sample of 157 17-18 year old adolescents (61.8% female) completed the Pittsburgh Sleep Quality Inventory (PSQI) and provided salivary cortisol samples throughout the day for three consecutive days. Two years later, adolescents reported their depressive symptoms via the Center for Epidemiological Studies Depression Scale (CES-D). Results: Individuals (age 17-18) with greater sleep disturbance reported greater depressive symptoms two years later (age 19-20). This association occurred through the indirect effect of sleep disturbance on the cortisol awakening response (CAR) (indirect effect = 0.14, 95%CI [.02 -.39]). Conclusions: One pathway through which sleep problems may lead to depressive symptoms is by up-regulating components of the body's physiological stress response system that can be measured through the cortisol awakening response. Behavioral interventions that target sleep disturbance in adolescents may mitigate this neurobiological pathway to depression during this high-risk developmental phase.

Reliability of the Bates-Jensen wound assessment tool for pressure injury assessment: The pressure ulcer detection study.

The Bates-Jensen Wound Assessment Tool (BWAT) is used to assess wound healing in clinical practice. The purpose of this study was to evaluate BWAT use among nursing home residents with pressure injury. Findings and reliability estimates from the BWAT related to pressure injury characteristics (stage, anatomic location) and natural history (resolved, persisted) among 142 ethnically and racially diverse residents are reported. In this prospective 16-week study, 305 pressure injuries among 142 participants (34% prevalence) are described by stage, anatomic location, and BWAT scores. Visual and subepidermal moisture assessments were obtained from sacrum, buttock, ischial, and heel ulcers weekly. Participants were 14% Asian, 28% Black, 18% Hispanic, 40% White with a mean age of 78 ± 14 years, and were 62% female; 80% functionally dependent (bed mobility extensive/total assistance) and at risk (Braden Scale score 14 ± 2.7). The reliability coefficient for BWAT score (all participants, all anatomic locations) was high (r = 0.90; p < 0.0001; n = 1,161 observations). Weighted Kappas for characteristics ranging from 0.46 (skin color surrounding wound) to 0.79 (undermining) were consistent for all participants. BWAT scores showed strongest agreement coefficients for stage 4 pressure injury (r = 0.69), pressure injuries among Asian and White ethnicity/racial groups (r = 0.89, and r = 0.91, respectively), and sacrum anatomic location (r = 0.92) indicating scores are better correlated to fair skin tones. Lower agreement coefficients were demonstrated for stage 2 pressure injury (r = 0.38) and pressure injuries among African American and Hispanic ethnicity/racial groups (r = 0.88 and 0.87, respectively). BWAT scores were significantly different by pressure injury stage (F = 496.7, df = 6, p < 0.001) and anatomic location (F = 33.76, df = 8, p < 0.001). BWAT score correlated with pressure injury natural history (ulcer resolved 18.4 ± 7.4, ulcer persisted 24.9 ± 10.0; F = 70.11, df = 2, p < 0.001), but not with comorbidities. The BWAT provides reliable, objective data for assessing pressure injury healing progress.

Psychological resilience and the gene regulatory impact of posttraumatic stress in Nepali child soldiers.

Adverse social conditions in early life have been linked to increased expression of proinflammatory genes and reduced expression of antiviral genes in circulating immune cells-the conserved transcriptional response to adversity (CTRA). However, it remains unclear whether such effects are specific to the Western, educated, industrialized, rich, and democratic (WEIRD) cultural environments in which previous research has been conducted. To assess the roles of early adversity and individual psychological resilience in immune system gene regulation within a non-WEIRD population, we evaluated CTRA gene-expression profiles in 254 former child soldiers and matched noncombatant civilians 5 y after the People's War in Nepal. CTRA gene expression was up-regulated in former child soldiers. These effects were linked to the degree of experienced trauma and associated distress-that is, posttraumatic stress disorder (PTSD) severity-more than to child soldier status per se. Self-perceived psychological resilience was associated with marked buffering of CTRA activation such that PTSD-affected former child soldiers with high levels of personal resilience showed molecular profiles comparable to those of PTSD-free civilians. These results suggest that CTRA responses to early life adversity are not restricted to WEIRD cultural contexts and they underscore the key role of resilience in determining the molecular impact of adverse environments.

The Roles of Parental Support and Family Stress in Adolescent Sleep.

The current study examines the association between parental support and adolescent sleep under varying levels of family stress. Participants included 316 adolescents (Mage  = 16.40 years, 43% male) and their parents (Mage  = 45.67 years, 91% mothers) from diverse ethnic backgrounds. Both adolescents and parents completed questionnaires and adolescents wore wrist actigraphs and completed self-reports on their sleep for 7 consecutive days. Results indicated that under contexts of family stress, more parental support was linked to longer sleep duration, less sleep variability, and less time spent awake during the night. Findings suggest that under contexts of family stress, cohesive family relationships may provide a sense of stability and security that is necessary for healthful sleep.

Discrimination and Sleep Difficulties during Adolescence: The Mediating Roles of Loneliness and Perceived Stress.

Irregular and insufficient sleep place youth at risk for adverse psychological and physical health outcomes. Recent research indicates that discrimination constitutes a type of stressor that interferes with adolescent sleep; however, the mechanisms through which discrimination affects sleep are not well understood. This study examined whether ethnic and non-ethnic (i.e., gender, age, and height/weight) discrimination were associated with adolescents' sleep duration, variability, and quality, and whether loneliness and perceived stress mediated these associations. An ethnically-diverse sample (42% Latino, 29% European American, 23% Asian) of adolescents (N = 316; M age = 16.40 years, 57% girls) reported on their experiences of discrimination, perceived stress, and loneliness. Sleep duration and variability were assessed by actigraphy and sleep quality through self-reports. Ethnic discrimination was related to shorter sleep duration and both ethnic and non-ethnic discrimination were associated with worse sleep quality. Loneliness and perceived stress partially mediated the relation between discrimination and sleep quality. Discriminatory experiences can heighten feelings of loneliness and stress, which, in turn, may contribute to diminished sleep quality during adolescence.

Subepidermal moisture detection of heel pressure injury: The pressure ulcer detection study outcomes.

We examined subepidermal moisture (SEM) and visual skin assessment of heel pressure injury (PrI) among 417 nursing home residents in 19 facilities over 16 weeks. Participants were older (mean age 77 years), 58% were female, over half were ethnic minorities (29% African American, 12% Asian American, 21% Hispanic), and at risk for PrI (mean Braden Scale Risk score = 15.6). Blinded concurrent visual assessments and SEM measurements were obtained at heels weekly. Visual skin damage was categorised as normal, erythema, stage 1 PrI, deep tissue injury (DTI) or stage 2 or greater PrI. PrI incidence was 76%. Off-loading occurred with pillows (76% of residents) rather than heel boots (21%) and often for those with DTI (91%). Subepidermal moisture was measured with a device where higher readings indicate greater moisture (range: 0-70 tissue dielectric constant), with normal skin values significantly different from values in the presence of skin damage. Subepidermal moisture was associated with concurrent damage and damage 1 week later in generalised multinomial logistic models adjusting for age, diabetes and function. Subepidermal moisture detected DTI and differentiated those that resolved, remained and deteriorated over 16 weeks. Subepidermal moisture may be an objective method for detecting PrI.

Subepidermal moisture detection of pressure induced tissue damage on the trunk: The pressure ulcer detection study outcomes.

We examined the relationship between subepidermal moisture measured using surface electrical capacitance and visual skin assessment of pressure ulcers at the trunk location (sacral, ischial tuberosities) in 417 nursing home residents residing in 19 facilities. Participants were on average older (mean age of 77 years), 58% were female, over half were ethnic minorities (29% African American, 12% Asian American, and 21% Hispanic), and at risk for pressure ulcers (mean score for Braden Scale for Predicting Pressure Ulcer Risk of 15.6). Concurrent visual assessments and subepidermal moisture were obtained at the sacrum and right and left ischium weekly for 16 weeks. Visual assessment was categorized as normal, erythema, stage 1 pressure ulcer, Deep Tissue Injury or stage 2+ pressure ulcer using the National Pressure Ulcer Advisory Panel 2009 classification system. Incidence of any skin damage was 52%. Subepidermal moisture was measured with a dermal phase meter where higher readings indicate greater moisture (range: 0-70 tissue dielectric constant), with values increasing significantly with the presence of skin damage. Elevated subepidermal moisture values co-occurred with concurrent skin damage in generalized multinomial logistic models (to control for repeated observations) at the sacrum, adjusting for age and risk. Higher subepidermal moisture values were associated with visual damage 1 week later using similar models. Threshold values for subepidermal moisture were compared to visual ratings to predict skin damage 1 week later. Subepidermal moisture of 39 tissue dielectric constant units predicted 41% of future skin damage while visual ratings predicted 27%. Thus, this method of detecting early skin damage holds promise for clinicians, especially as it is objective and equally valid for all groups of patients.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED).

BACKGROUND: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population. METHODS/DESIGN: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care. DISCUSSION: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01763203 .

Sleep and Inflammation During Adolescence.

OBJECTIVE: To investigate the associations between objective and subjective dimensions of adolescent sleep and C-reactive protein (CRP), a key biomarker of inflammation that predicts chronic health problems in adulthood, and whether the associations vary as a function of adolescents' age. METHODS: A total of 315 adolescents (14.5-18.4 years) wore wrist actigraphs at night to objectively estimate their sleep duration and variability across nights, and completed the Pittsburgh Sleep Quality Index to assess their subjective sleep quality. CRP levels were assayed from dried blood spots obtained from finger pricks. To control for adiposity, age- and sex-specific body mass index percentiles were obtained from height and weight measurements. RESULTS: Nightly variability in sleep duration was associated with higher levels of CRP (b = 0.13, p = .045). Shorter average sleep duration was associated with higher CRP, but only among younger adolescents (b = -0.11, p = .041). Subjective sleep quality was not associated with CRP. CONCLUSIONS: The association of sleep with inflammation during adolescence seems more evident in objective dimensions of sleep duration and variability than in the subjective dimensions of sleep quality. Insufficient sleep may be particularly consequential for younger adolescents.

Everyday discrimination and diurnal cortisol during adolescence.

PURPOSE: To examine the associations of the frequency and type of everyday discrimination with diurnal cortisol and whether those associations depend upon adolescents' ethnicity and gender. METHODS: Adolescents (N=292, Mage=16. 39years, SD=0.74; 58% female) reported the frequency of perceived everyday discrimination and whether they attributed that discrimination to race, gender, age, or height and weight. Five saliva samples were collected per day across 3days and assayed for cortisol. RESULTS: Higher frequency of everyday discrimination was associated with greater total daily cortisol output (area under the curve; AUC), lower wake and bedtime levels of cortisol, and less of a decline in cortisol across the day. These associations generally did not depend upon ethnicity or gender and attributions for the discrimination were not as consequential as the actual frequency of any type of unfair treatment. CONCLUSION: Everyday discrimination, regardless of its type, may contribute to heightened HPA activity among adolescents of different ethnic backgrounds and genders.

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development.

AIMS: To assess the feasibility of classifying skin tone using Munsell color chart values and to compare Munsell-based skin tone categories to ethnicity/race to predict pressure ulcer risk. BACKGROUND: Pressure ulcer classification uses level of visible tissue damage, including skin discoloration over bony prominences. Prevention begins with early detection of damage. Skin discoloration in those with dark skin tones can be difficult to observe, hindering early detection. DESIGN: Observational cohort of 417 nursing home residents from 19 nursing homes collected between 2009-2014, with weekly skin assessments for up to 16 weeks. METHODS: Assessment included forearm and buttocks skin tone based on Munsell values (Dark, Medium, Light) at three time points, ethnicity/race medical record documentation, and weekly skin assessment on trunk and heels. RESULTS: Inter-rater reliability was high for forearm and buttock values and skin tone. Mean Munsell buttocks values differed significantly by ethnicity/race. Across ethnicity/race, Munsell value ranges overlapped, with the greatest range among African Americans. Trunk pressure ulcer incidence varied by skin tone, regardless of ethnicity/race. In multinomial regression, skin tone was more predictive of skin damage than ethnicity/race for trunk locations but ethnicity/race was more predictive for heels. CONCLUSIONS: Given the overlap of Munsell values across ethnicity/race, color charts provide more objective measurement of skin tone than demographic categories. An objective measure of skin tone can improve pressure ulcer risk assessment among patients for whom current clinical guidelines are less effective.

A Strategy for Identifying and Disseminating Best Practice Innovations in the Care of Patients with Multiple Chronic Conditions or End-of-Life Care Needs.

Patients with multiple chronic conditions and those with end-of-life care needs experience high health care costs and needs for skilled coordination and well-trained staff. Focusing on these populations presents an opportunity to improve the patient experience toward the goal of more patient-centered care and reduced costs. Although innovative programs that provide better care to these patient populations have been developed, these innovations are often localized and not actively disseminated to other settings. This paper describes a quality-improvement project aimed at developing a process to identify best practices implemented in community-based clinical settings, develop a platform to share and disseminate these best practices, and facilitate the adoption of successful practices across other similar settings. The facilitation process involved structured coaching by clinicians and researchers experienced with practice change and quality improvement. The coaching component ensured that implementation teams receive guidance in the planning and adoption process, stay on track with implementation, and have access to timely support in addressing unanticipated barriers.

Study protocol of "Worth the Walk": a randomized controlled trial of a stroke risk reduction walking intervention among racial/ethnic minority older adults with hypertension in community senior centers.

BACKGROUND: Stroke disproportionately kills and disables ethnic minority seniors. Up to 30 % of ischemic strokes in the U.S. can be attributed to physical inactivity, yet most Americans, especially older racial/ethnic minorities, fail to participate in regular physical activity. We are conducting a randomized controlled trial (RCT) to test a culturally-tailored community-based walking intervention designed to reduce stroke risk by increasing physical activity among African American, Latino, Chinese, and Korean seniors with hypertension. We hypothesize that the intervention will yield meaningful changes in seniors' walking levels and stroke risk with feasibility to sustain and scale up across the aging services network. METHODS/DESIGN: In this randomized single-blind wait-list control study, high-risk ethnic minority seniors are enrolled at senior centers, complete baseline data collection, and are randomly assigned to receive the intervention "Worth the Walk" immediately (N = 120, intervention group) or in 90 days upon completion of follow-up data collection (N = 120, control group). Trained case managers employed by the senior centers implement hour-long intervention sessions twice weekly for four consecutive weeks to the intervention group. Research staff blinded to participants' group assignment collect outcome data from both intervention and wait-list control participants 1 and 3-months after baseline data collection. Primary outcome measures are mean steps/day over 7 days, stroke knowledge, and self-efficacy for reducing stroke risk. Secondary and exploratory outcome measures include selected biological markers of health, healthcare seeking, and health-related quality of life. Outcomes will be compared between the two groups using standard analytic methods for randomized trials. We will conduct a formal process evaluation to assess barriers and facilitators to successful integration of Worth the Walk into the aging services network and to calculate estimated costs to sustain and scale up the intervention. Data collection is scheduled to be completed in December 2016. DISCUSSION: If this RCT demonstrates superior improvements in physical activity and stroke knowledge in the intervention group compared to the control group and is found to be sustainable and scalable, Worth the Walk could serve as a primary stroke prevention model for racial/ethnic communities across the nation. TRIAL REGISTRATION: ClinicalTrials.gov NCT02181062 ; registered on June 30, 2014.

Randomized clinical trial of an emergency department observation syncope protocol versus routine inpatient admission.

STUDY OBJECTIVE: Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. METHODS: This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. RESULTS: Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were $629 (95% CI difference -$1,376 to -$56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. CONCLUSION: An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.