Cardiac Troponin I-Interacting Kinase Affects Cardiomyocyte S-Phase Activity but Not Cardiomyocyte Proliferation.

BACKGROUND: Identifying genetic variants that affect the level of cell cycle reentry and establishing the degree of cell cycle progression in those variants could help guide development of therapeutic interventions aimed at effecting cardiac regeneration. We observed that C57Bl6/NCR (B6N) mice have a marked increase in cardiomyocyte S-phase activity after permanent coronary artery ligation compared with infarcted DBA/2J (D2J) mice. METHODS: Cardiomyocyte cell cycle activity after infarction was monitored in D2J, (D2J×B6N)-F1, and (D2J×B6N)-F1×D2J backcross mice by means of bromodeoxyuridine or 5-ethynyl-2'-deoxyuridine incorporation using a nuclear-localized transgenic reporter to identify cardiomyocyte nuclei. Genome-wide quantitative trait locus analysis, fine scale genetic mapping, whole exome sequencing, and RNA sequencing analyses of the backcross mice were performed to identify the gene responsible for the elevated cardiomyocyte S-phase phenotype. RESULTS: (D2J×B6N)-F1 mice exhibited a 14-fold increase in cardiomyocyte S-phase activity in ventricular regions remote from infarct scar compared with D2J mice (0.798±0.09% versus 0.056±0.004%; P<0.001). Quantitative trait locus analysis of (D2J×B6N)-F1×D2J backcross mice revealed that the gene responsible for differential S-phase activity was located on the distal arm of chromosome 3 (logarithm of the odds score=6.38; P<0.001). Additional genetic and molecular analyses identified 3 potential candidates. Of these, Tnni3k (troponin I-interacting kinase) is expressed in B6N hearts but not in D2J hearts. Transgenic expression of TNNI3K in a D2J genetic background results in elevated cardiomyocyte S-phase activity after injury. Cardiomyocyte S-phase activity in both Tnni3k-expressing and Tnni3k-nonexpressing mice results in the formation of polyploid nuclei. CONCLUSIONS: These data indicate that Tnni3k expression increases the level of cardiomyocyte S-phase activity after injury.

Substance Use Disorder Education: A Statewide Assessment of Core Content in Nursing Schools.

Of individuals who need treatment for substance use disorder (SUD), 12.6% do not receive it. One reason for this failure to treat is an inadequately prepared health care workforce, including nurses. To establish a state-wide baseline of SUD curricular content, we collected information about topics taught and barriers to teaching important topics using an anonymous survey sent to all 55 nursing programs in Indiana. Topics deemed important were taught more frequently, such as opioid withdrawal (60.6%). Lack of expertise was more commonly reported as a barrier than lack of time (25.3% vs. 7.1%). Findings suggest that nursing students in Indiana are not taught requisite content related to SUD. We have provided pragmatic recommendations to enhance content in schools of nursing and address lack of expertise among faculty. Leaders need to actively evaluate and augment the content of their curriculums to include SUD. [Journal of Psychosocial Nursing and Mental Health Services, 61(9), 15-23.].

Retention in care and viral suppression in the PMTCT continuum at a large referral facility in western Kenya.

Medical records of pregnant and postpartum women living with HIV and their infants attending a large referral facility in Kenya from 2015 to 2019 were analyzed to identify characteristics associated with retention in care and viral suppression. Women were stratified based on the timing of HIV care enrollment: known HIV-positive (KHP; enrolled pre-pregnancy) and newly HIV-positive (NHP; enrolled during pregnancy). Associations with retention at 18 months postpartum and viral suppression (< 1000 copies/mL) were determined. Among 856 women (20% NHP), retention was 83% for KHPs and 53% for NHPs. Viral suppression was 88% for KHPs and 93% for NHPs, but 19% of women were missing viral load results. In a competing risk model, viral suppression increased by 18% for each additional year of age but was not associated with other factors. Overall, 1.9% of 698 infants with ≥ 1 HIV test result were HIV-positive. Tailored interventions are needed to promote retention and viral load testing, particularly for NHPs, in the PMTCT continuum.

Hyperglycemia, symptoms, and symptom clusters in colorectal cancer survivors with type 2 diabetes.

PURPOSE: The purpose of the study was to compare the individual and total number of symptoms and explore symptom clusters by hyperglycemia status in colorectal cancer survivors (CRCS) with diabetes (type 2). METHODS: A retrospective cohort study was conducted, whereby symptom data were extracted from clinical notes in electronic health records. CRCS (stage II or III) diagnosed between 2007 and 2017 who had diabetes and at least one HbA1c within 8 months of initial chemotherapy were included. Zero-inflated negative binomial regression analysis was used to examine total symptoms by hyperglycemia status (hyperglycemia versus no hyperglycemia). Exploratory factor analysis was conducted to identify symptom clusters. RESULTS: Two hundred forty-three CRCS met inclusion criteria. CRCS with hyperglycemia (HbA1c ≥ 6.5%) had greater individual symptoms (fatigue and depression) and total number of symptoms than those with no hyperglycemia. Two distinct symptom clusters, with five (nausea, vomiting, constipation, fatigue, and peripheral neuropathy) and two symptoms (anxiety and depression), were identified among CRCS with hyperglycemia. CONCLUSION: These findings indicate that CRCS with diabetes and hyperglycemia had more symptoms and two distinct symptom clusters compared to those with no hyperglycemia. Prospective research studies are needed to examine the role of hyperglycemia in symptoms among CRCS with diabetes. Understanding hyperglycemia's influence is important as it is a modifiable risk factor towards which prevention and intervention can be directed, potentially mitigating symptoms and symptom clusters and improving outcomes for CRCS with diabetes.

Randomized double-masked controlled trial of cognitive training in breast cancer survivors: a preliminary study.

PURPOSE: To evaluate the acceptability, satisfaction, and preliminary efficacy of cognitive training for improving cognitive function and health outcomes in breast cancer survivors (BCS). PATIENTS AND METHODS: BCS enrolled in this 2-group randomized, double-masked controlled trial of cognitive training. Primary outcomes included the acceptability and satisfaction of the interventions. Secondary outcomes included examining the effect size and reliable improvement of perceived cognitive function and health outcomes, including work ability, health perception (status and change), and quality of life. Exploratory outcomes were performance on neuropsychological tests and plasma levels of brain-derived neurotropic factor (BDNF). Data were collected at baseline and immediately post-intervention. Using ANCOVA models, the intervention was compared to attention control while adjusting for covariates and baseline values. The effect sizes for differences in means and the reliable improvement percentage were reported. RESULTS: Thirty-six BCS completed the study and were on average 57.6 (SD = 8.0) years old, 59.4% Caucasian, and had some college education (74.5%). Both programs were reported to be satisfactory and acceptable. Non-significant small effect sizes were noted for the intervention on cognitive abilities (d = 0.26) and cognitive concerns (d = - 0.32), with reliable improvement noted in 32% and 28% of BCS, respectively. Small to medium effect sizes were noted in improvement in work ability (d = 0.37) and health perception status (d = 0.30) and change (d = 0.60, p < 0.05). CONCLUSIONS: Cognitive training was acceptable to BCS and resulted in improvement in perceived cognitive function and perceptions of "real-world" health benefits. A larger randomized controlled trial is warranted to determine its effectiveness for objective cognitive performance.

Exploring the Relationships Among Social Support, Patient Activation, and Pain-Related Outcomes.

OBJECTIVE: Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain. METHODS: Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes. RESULTS: Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation = 0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes. CONCLUSIONS: These findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain.

Reasons for and associated characteristics with early study termination: Analysis of ClinicalTrials.gov data on pregnancy topics.

BACKGROUND: Prematurely terminated studies are unlikely to provide data for evidence-based practice. There has been no systematic review on premature study termination on pregnancy-related research. PURPOSE: This study investigated the reasons why studies on pregnancy topics are terminated and the associated characteristics with early termination. METHODS: A total of 3,623 studies (332 terminated and 3,291 completed) were retrieved from ClinicalTrials.gov registry. Reasons for termination were grouped into four categories, including accrual difficulty, research operation issues, data-related recommendations, and external factors. Study characteristics were statistically compared between terminated and completed studies. FINDINGS: Accrual difficulty (44.6%) and research operation issues (21.4%) were most frequently cited reasons for termination. Study design characteristics of intervention, randomization, masking, treatment and drug trial, and low funding from federal agencies were significantly associated with early termination. DISCUSSION: Population tailored subject recruitment strategies, scientifically sound research protocols, and well-planned research operations may mitigate premature study termination.

Provider Communication and Telepresence Enhance Veteran Satisfaction With Telestroke Consultations.

BACKGROUND AND PURPOSE: Telestroke has been demonstrated to be a cost-effective means to expand access to care and improve outcomes in stroke; however, information on patient perceptions of this system of care delivery are limited. This study seeks to examine patient feedback of a national telestroke system within the Veterans Health Administration. METHODS: Patients who received a telestroke consultation were eligible for a phone interview 2 weeks later, including questions about technology quality, telepresence, and telestroke provider communication. Satisfaction scores ranged from 1 to 7 (higher=more satisfied) and for analyses were dichotomized as 6 to 7 indicating high satisfaction versus <6. Patient variables including stroke severity (measured by the National Institutes of Health Stroke Scale) were obtained from study records. Generalized estimating equation models were used to determine what factors were associated with patient satisfaction. RESULTS: Over 18 months, 186 interviews were completed, and 142 (76%) reported high satisfaction with telestroke. Patients with more severe stroke were less likely to recall the consultation. Factors significantly associated with patient satisfaction were higher ratings of the technology (P<0.0001), telepresence (P<0.0001), provider communication ratings (P<0.0001), and overall Veterans Affairs satisfaction (P=0.02). In the multivariate model, telepresence (odds ratio, 3.10 [95% CI, 1.81-5.31]) and provider ratings (odds ratio, 2.37 [95% CI, 1.20-4.68]) were independently associated with satisfaction. Veterans who were satisfied were more likely to recommend the technology (P<0.0001). CONCLUSIONS: Provider qualities, including telepresence and provider ratings, were associated with overall Veteran satisfaction with the telestroke consultation. Technology quality may be necessary but not sufficient to impact patient experience. Training providers to improve telepresence could improve patient experience with telestroke consultation.

Dysmenorrhea Symptom-Based Phenotypes: A Replication and Extension Study.

BACKGROUND: Dysmenorrhea is a prevalent pain condition among women and a risk factor for other chronic pain conditions. Individuals vary in dysmenorrhea pain severity, the number of painful sites, and co-occurring gastrointestinal symptoms. Three dysmenorrhea symptom-based phenotypes were previously identified using latent class analysis; however, there is a need to validate these in an independent sample, so they can be used in mechanistic and interventional research. There is also a need to further characterize dysmenorrhea symptom-based phenotypes in terms of demographic, clinical, and psychobehavioral characteristics so they can be used to inform precision dysmenorrhea treatment. OBJECTIVES: The study objectives were to (a) determine whether the same dysmenorrhea symptom-based phenotypes would be found in a new sample; (b) determine whether including demographic, clinical, and psychobehavioral covariates in latent class analyses would change individuals' phenotype memberships; and (c) investigate relationships between dysmenorrhea symptom-based phenotypes and demographic, clinical, and psychobehavioral characteristics. METHODS: This cross-sectional survey study included 678 women (aged 14-42 years) with dysmenorrhea. Participants reported dysmenorrhea symptom severity, demographic, clinical (comorbid chronic pain and gynecological conditions), and psychobehavioral characteristics (perceived stress, anxiety, depression, sleep disturbance, and pain catastrophizing). We used latent class analysis to identify symptom-based phenotypes. We compared analyses with and without covariates (i.e., demographic, clinical, and psychobehavioral characteristics) to determine if individuals' phenotype memberships changed. We then examined associations between phenotypes and demographic, clinical, and psychobehavioral characteristics. RESULTS: We reproduced three dysmenorrhea symptom-based phenotypes: the "mild localized pain" phenotype (characterized by mild abdominal cramps), the "severe localized pain" phenotype (characterized by severe abdominal cramps), and the "multiple severe symptoms" phenotype (characterized by severe pain at multiple locations and gastrointestinal symptoms). Analyses with and without covariates had little effect on individuals' phenotype membership. Race, comorbid chronic pain condition, endometriosis, and pain catastrophizing were significantly associated with the dysmenorrhea phenotypes. DISCUSSION: Findings provide a foundation to further study mechanisms of dysmenorrhea symptom heterogeneity and develop dysmenorrhea precision treatments. The three dysmenorrhea symptom-based phenotypes were validated in a second sample. Demographic, clinical, and psychobehavioral factors were associated with dysmenorrhea symptom-based phenotypes.

Developing interprofessional collaborative practice competencies in rural primary health care teams.

BACKGROUND: Leaders from a university, Area Health Education Center, and primary care centers (PCCs) collaborated to integrate Interprofessional Collaborative Practice (IPCP) in PCCs. PURPOSE: Describe the facilitators and barriers of IPCP implementation in rural clinics and the impact on decision-making and safety culture. METHODS: The implementation team used engagement strategies to support the development of IPCP. PCC team participants completed surveys measuring collaboration and satisfaction with care decisions and safety culture. Qualitative data were analyzed to describe facilitators and barriers to IPCP. FINDINGS: Significant improvement (p < .035) in the Global Amount of Collaboration made over time. Barriers to IPCP included high turnover, hierarchical culture, lack of role clarity, competing time demands, limited readiness for change, and physical space limitations. Facilitators included structured huddles, alignment of IPCP with organizational goals, and academic-practice partnership. DISCUSSION: Partnering with academic-practice partnerships may facilitate collaboration and team learning as PCCs incorporate IPCP into practice.

Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial.

BACKGROUND: Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources. OBJECTIVE: To test a peer coach-delivered pain self-management program for chronic pain. DESIGN: Randomized controlled trial. PARTICIPANTS: Veterans with chronic musculoskeletal pain. INTERVENTION: Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class. MAIN MEASURES: The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months. KEY RESULTS: Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, - 0.40, p = 0.018; control, - 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons. CONCLUSIONS: Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02380690.

Global nurse/midwife workforce and reproductive health through social ecology lens.

OBJECTIVE: To explore how community social ecology factors may be associated with country registered nurse/registered midwife (RN/RM) workforce supply and reproductive health globally. DESIGN: A cross-sectional design using a social ecology framework was employed. SAMPLE: Data were retrieved from publicly available websites for 107 countries. MEASUREMENTS: Dependent variables included RN/RM density, maternal mortality ratios (MMR), and adolescent birth rates (ABR). Independent variables included gender inequality, region, country income classification, education, gross domestic product per capita, government expenditure of spending on education and health, life expectancy, percent of female seats in legislature, and labor force participation factors. RESULTS: The best fit multivariable model of RN/RM density showed that after adjustment for region, country income and the GII, the percent of females with some secondary education explained most of variation in RN/RM density. The best fit models of MMR and ABR showed that gender inequality explained most of the variation. Other factors in the models were the percent of female seats in legislatures, region, country income class, and mean years of schooling. CONCLUSIONS: Employing a social ecology model can useful in RN/RM workforce planning and development as countries seek multisectoral strategies for increasing the RN/RM supply and improving reproductive health outcomes.

A Multisite Health System Survey to Assess Organizational Context to Support Evidence-Based Practice.

BACKGROUND: Implementation and sustainability of a culture of evidence-based practice (EBP) require a systematic approach. A baseline assessment of the organizational context can inform implementation efforts. AIMS: To examine organizational hospital context and provider characteristics associated with EBP readiness and to describe EBP context across hospitals. METHODS: A nonexperimental descriptive correlational design was used to conduct a web-based survey of direct-care registered nurses (N = 701) and nurse managers (N = 94) across a large Midwestern multisite healthcare system using the Alberta Context Tool (ACT). RESULTS: Many significant relationships existed among nurse characteristics and ACT domains, including age (lower age had higher Leadership, Evaluation, and Formal Interactions), education (graduate education had lower Social Capital than a bachelor's or associate degree), role (direct-care nurses had lower Culture than managers and lower Social Capital), and work status (full-time employees had lower Evaluation and Social Capital). EBP context across type of hospitals is similar, with marginal differences in Social Capital and Organizational Slack (higher in critical access hospitals). LINKING EVIDENCE TO ACTION: Assessing organizational context to support EBP is the first step in developing and enhancing a sustainable culture of inquiry. The ACT has been tested across countries, settings, and healthcare disciplines to measure perception of readiness of the practice environment toward EBP. Optimal organizational context is essential to support EBP and sustain the use of evidence in professional nursing practice. Nursing leaders can use baseline assessment information to identify strengths and opportunities to enhance EBP implementation. Enhancing organizational context across nurse characteristics (e.g., age, role, and work status) to acknowledge nurses' contributions, balance nurses' personal and work life, enhance connectedness, and support work culture is beneficial. Fostering development of Social Capital in nurses is needed to influence EBP readiness. A systematic and standardized approach to foster EBP across health systems is key to successful implementation.

Fostering interprofessional collaborative practice in acute care through an academic-practice partnership.

An interprofessional collaborative practice (IPCP) environment was implemented in four inpatient acute care unit accountable care teams (ACT) through an academic-practice partnership. An action research methodology was implemented to empower healthcare professionals and promote ownership and sustainment of the IPCP strategies. Healthcare professionals on the ACT units, students, and faculty engaged in the multi-year project. Interventions included staff engagement exercises and coaching and support of individual ACT unit IPCP strategies and education. Healthcare professional outcome data were collected in the form of participant surveys, measuring collaboration about care decisions and the extent to which professionals engaged in a culture of safety, collected at baseline and 6-month intervals. Healthcare outcome measures of the ACT units were also collected at baseline and 6-month intervals. Students had clinical learning experiences in the IPCP settings and completed post clinical surveys. Implementation of the interventions resulted in a positive trend in the healthcare professionals, although statistical significance was not observed. Student outcome data demonstrated statistically significant positive learning outcomes. Healthcare outcome measures demonstrated a significant decrease in readmissions and an overall decrease in catheter-associated urinary tract infections over time. Other measures were not significantly impacted. In conclusion, an academic - practice partnership can strengthen and support an IPCP environment by allowing healthcare clinicians to be directly involved in the selection and implementation of IPCP strategies and contribute to improved professional, healthcare and student outcomes.

Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy.

BACKGROUND: Obstructive sleep apnea is common and associated with poor outcomes after stroke or transient ischemic attack (TIA). We sought to determine whether the intervention strategy improved sleep apnea detection, obstructive sleep apnea (OSA) treatment, and hypertension control among patients with chronic cerebrovascular disease and hypertension. METHODS: In this randomized controlled strategy trial intervention, patients received unattended polysomnography at baseline, and patients with OSA (apnea-hypopnea index ≥5 events/h) received auto-titrating continuous positive airway pressure (CPAP) for up to 1 year. Control patients received usual care and unattended polysomnography at the end of the study, to identify undiagnosed OSA. Both groups received 24-h blood pressure assessments at baseline and end of the study. "Excellent" CPAP adherence was defined as cumulative use of ≥4 h/night for ≥70% of the nights. RESULTS: Among 225 randomized patients (115 control; 110 intervention), 61.9% (120/194) had sleep apnea. The strategy successfully diagnosed sleep apnea with 97.1% (102/105) valid studies; 90.6% (48/53, 95% CI 82.7-98.4%) of sleep apnea was undiagnosed among control patients. The intervention improved long-term excellent CPAP use: 38.6% (22/57) intervention versus 0% (0/2) control (p < 0.0001). The intervention did not improve hypertension control in this population with well-controlled baseline blood pressure: intervention, 132.7 mmHg (±standard deviation, 14.1) versus control, 133.8 mmHg (±14.0) (adjusted difference, -1.1 mmHg, 95% CI (-4.2, 2.0)), p = 0.48). CONCLUSIONS: Patients with cerebrovascular disease and hypertension have a high prevalence of OSA. The use of portable polysomnography, and auto-titrating CPAP in the patients' homes, improved both the diagnosis and the treatment for sleep apnea compared with usual care but did not lower blood pressure.

Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea.

BACKGROUND: Screening instruments for obstructive sleep apnea (OSA), as used routinely to guide clinicians regarding patient referral for polysomnography (PSG), rely heavily on symptomatology. We sought to develop and validate a cerebrovascular disease-specific OSA prediction model less reliant on symptomatology, and to compare its performance with commonly used screening instruments within a population with ischemic stroke or transient ischemic attack (TIA). METHODS: Using data on demographic factors, anthropometric measurements, medical history, stroke severity, sleep questionnaires, and PSG from 2 independently derived, multisite, randomized trials that enrolled patients with stroke or TIA, we developed and validated a model to predict the presence of OSA (i.e., Apnea-Hypopnea Index ≥5 events per hour). Model performance was compared with that of the Berlin Questionnaire, Epworth Sleepiness Scale (ESS), the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender instrument, and the Sleep Apnea Clinical Score. RESULTS: The new SLEEP Inventory (Sex, Left heart failure, ESS, Enlarged neck, weight [in Pounds], Insulin resistance/diabetes, and National Institutes of Health Stroke Scale) performed modestly better than other instruments in identifying patients with OSA, showing reasonable discrimination in the development (c-statistic .732) and validation (c-statistic .731) study populations, and having the highest negative predictive value of all in struments. CONCLUSIONS: Clinicians should be aware of these limitations in OSA screening instruments when making decisions about referral for PSG. The high negative predictive value of the SLEEP INventory may be useful in determining and prioritizing patients with stroke or TIA least in need of overnight PSG.

Sensitivity analysis of methods for active surveillance of acute myocardial infarction using electronic databases.

BACKGROUND: The validity of conclusions from observational studies depends on decisions regarding design, analysis, data quality, and implementation. Through sensitivity analyses, we explored the impact of such decisions on balance control and risk estimates. METHODS: Using as a template the Mini-Sentinel protocol for the active surveillance of acute myocardial infarction (MI) in association with use of antidiabetic agents, we defined cohorts of new users of metformin and second-generation sulfonylureas, baseline covariates and acute MI events using three combinations of washout and baseline periods. Using propensity-score matching, we assessed balance control and risk estimates using cumulative data for matching all patients compared with not rematching prior matches in quarterly analyses over the follow-up period. RESULTS: A longer washout period increased the confidence in new-user status, but at the expense of sample size; a longer baseline period improved capture of covariates related to pre-existing chronic conditions. When all patients were matched each quarter, balance was improved and risk estimates were more robust, especially in the later quarters. CONCLUSIONS: Durations of washout and baseline periods influence the likelihood of new-user status and sample size. Matching all patients tends to result in better covariate balance than matching only new patients. Decisions regarding the durations of washout and baseline periods depend on the specific research question and availability of longitudinal patient data within the database. This paper demonstrates the importance and utility of sensitivity analysis of methods for evaluating the robustness of results in observational studies.

Duration of polymerase chain reaction-detectable DNA after treatment of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infections in women.

BACKGROUND: To avoid positive results attributable to residual DNA, the Centers for Disease Control and Prevention recommends avoiding repeat testing with nucleic-acid based tests within 3 weeks after treatment of chlamydial (Chlamydia trachomatis [CT]) or gonococcal (Neisseria gonorrhoeae [GC]) infection. We retrospectively analyzed the duration of detectable DNA from a longitudinal cohort of adolescent women after diagnosis and treatment of infection with CT, GC, or Trichomonas vaginalis (TV). METHODS: Vaginal swabs were obtained weekly from young women for up to 12 weeks (observation period) after treatment of CT, GC and TV infections. Swabs were tested using a commercially available first generation nucleic acid amplification test (NAAT) for CT and GC, and a laboratory developed NAAT for TV. Kaplan-Meier statistics were used to estimate median time to the first negative DNA-based polymerase chain reaction (PCR) result. RESULTS: Observation periods were available for analysis for 195, 82 and 102 treatments for CT, GC, and TV infection, respectively. Median time to a first negative PCR result for CT, GC, and TV was 9 (range 0-84), 6 (0-76), and 7 (0-84) days, and by day 21, 89%, 95%, and 85% were negative, respectively. CONCLUSIONS: Data from this retrospective analysis indicate that greater than 85% of these young women did not have detectable CT, GC, or TV DNA by day 21 post-treatment. This data may be useful to clinicians for patient management and post-treatment testing purposes.

Weight Variability, Weight Gain Goals, and Biopsychosocial Factors Among Pregnant Women.

This study investigated the pattern of weight variability over 8 weeks and its associations with achieving weight gain goals and five biopsychosocial factors among pregnant women. We conducted a secondary analysis of 117 weeks of data from 16 pregnant women with a body mass index (BMI) ≥25. Weight variability was calculated from the difference of ending and beginning and maximum and minimum weights in a week and percent of each difference from baseline weight. Loess smoother, repeated measures model, and compound symmetric covariance matrix were used for analysis. The variability measure of maximum-minimum weight (overall mean: 2.1 ± 0.4 lbs.) was greater than the ending-beginning weight measure (overall mean: 0.7 ± 0.6 lbs.). Weight variability was negatively associated with achieving weight gain goals but not with biopsychosocial factors. Assessing weight variability is important during pregnancy so that preventive measures or lifestyle counseling can be instituted immediately to prevent excessive weight gain.

Patient accessibility and utilization of behavioral sleep medicine referrals in an academic center.

STUDY OBJECTIVES: Behavioral sleep medicine (BSM) is a subspecialty that combines behavioral psychology and sleep medicine specialties. The objective of this study was to analyze referral patterns to a BSM clinic. The three specific aims were: (1) describe factors that predict referral acceptance, (2) identify barriers to attending initial appointment, and (3) describe variables associated with the number of visits attended. METHODS: Retrospective chart reviews were conducted as part of a quality improvement project by this study team's clinical setting. Adults over 21 years of age who were referred to a behavioral sleep medicine clinic in an urban Midwestern academic healthcare system between 2014-2019 were included in this study. RESULTS: Sleep medicine was the main referral source for BSM patients (74.2%), followed by internal medicine (9.3%) and neurology/psychiatry (7.3%). Thirty-eight percent of patients did not schedule an appointment after a referral for BSM was initiated. Younger age, longer distance from clinic, commercial insurance and out of network insurance were all significantly greater for non-schedulers. Eighty-three percent of patients did attend the initial intake session with BSM providers. Older age was associated with lower likelihood of not attending scheduled BSM appointments. CONCLUSIONS: Patient characteristics of older age, closer distance from clinic, and in network insurance coverage were found to significantly increase the likelihood of BSM scheduling, while younger age, Black race and not getting a primary sleep disorder diagnosis (versus a diagnosis of Insomnia Disorder) and shorter days from referral to appointment were associated with an increased likelihood of not attending the scheduled BSM treatment engagement.