Causes of death in infants admitted to Australian neonatal intensive care units between 1995 and 2006.

AIM: To compare causes and rates of mortality among infants admitted to 10 Australian neonatal intensive care units (NICUs) between 1995 and 2006. METHODS: De-identified perinatal data from the Neonatal Intensive Care Units' (NICUS) Data Collection for 24 131 infants were examined for causes and rates of death. The study period was divided into two epochs: I (1995-2000, n = 11 185 infants) and II (2001-2006, n = 12 946 infants). RESULTS: A total of 2224 (9.2%) infants died in hospital. Mortality decreased from 10.3% (1152/11 185) in epoch I to 8.3% (1072/12 946) in epoch II (p < 0.001) due to improved survival in term infants. Extreme prematurity also decreased as a primary cause of death (118 (10.2%) vs 76 (7.1%), p = 0.008). No infant >42-week gestation was admitted in epoch II. Congenital abnormalities were the most common cause of death (>20%) in both epochs, mostly in term rather than preterm infants (40.7% vs 13.9%, p < 0.001). Age of death was unchanged between the two epochs (median 4, 1st, 3rd quartiles: 1,16 days). CONCLUSION: Mortality rates have continued to decrease but improvement is predominantly due to improved survival of term infants and prevention of postdate deliveries. Congenital abnormalities continue to be the most common cause of death.

Emergency physician and stroke specialist beliefs and expectations regarding telestroke.

BACKGROUND AND PURPOSE: Telestroke has been effective in the management of acute ischemic stroke. This study characterizes and compares stroke specialist (SS) and emergency physician (EP) perceptions of telestroke and identifies barriers preventing increased implementation. METHODS: A survey was developed and distributed nationwide to 382 SSs through an online survey system and in paper form to 226 EPs attending the 2008 American College of Emergency Physicians national conference. RESULTS: Stroke specialists perceived themselves to be more knowledgeable about telemedicine and telestroke (P<0.001 and P=0.010, respectively). A large majority of physicians in both specialties either strongly agreed or agreed that telestroke will reduce geographical differences in stroke management and that it is superior to telephone consultation. EPs perceived patient preference (P<0.001), recombinant tissue plasminogen activator side effects (P<0.001), level of technology (P=0.005), and recombinant tissue plasminogen activator not the standard of care (P<0.001) to be more significant obstacles to increased implementation of telestroke than SSs. However, SSs found increased personal work to be a greater barrier than EPs (P<0.001). CONCLUSIONS: SSs and EPs report positive beliefs regarding telestroke; however, perceived obstacles exist to implementation. Differences between barriers perceived by EPs and SSs need to be addressed to enhance acute ischemic stroke treatment.

Transient ischemic attack overview: defining the challenges for improving outcomes.

Transient ischemic attacks are reversible neurologic events that herald potentially catastrophic strokes. Well designed studies have documented that approximately 10% of patients who have a transient ischemic attack will have a stroke within the succeeding 90 days; half of these strokes occur within 48 hours of the transient ischemic attack. Improved outcomes from transient ischemic attacks require a heightened awareness of the clinical features of transient ischemic attacks on the part of both patients and physicians. The significant potential for stroke in the immediate days after the transient ischemic attack imposes an urgency in the diagnostic evaluation of these patients. A review of the literature suggests that there is a need for pathways to promote facilitated evaluations of transient ischemic attack patients in order to identify underlying correctable pathologies, and to direct medical and surgical management strategies.

From smartphone to EHR: a case report on integrating patient-generated health data.

Patient-generated health data (PGHD), collected from mobile apps and devices, represents an opportunity for remote patient monitoring and timely interventions to prevent acute exacerbations of chronic illness-if data are seen and shared by care teams. This case report describes the technical aspects of integrating data from a popular smartphone platform to a commonly used EHR vendor and explores the challenges and potential of this approach for disease management. Consented subjects using the Asthma Health app (built on Apple's ResearchKit platform) were able to share data on inhaler usage and peak expiratory flow rate (PEFR) with a local pulmonologist who ordered this data on Epic's EHR. For users who had installed and activated Epic's patient portal (MyChart) on their iPhone and enabled sharing of health data between apps via HealthKit, the pulmonologist could review PGHD and, if necessary, make recommendations. Four patients agreed to share data with their pulmonologist, though only two patients submitted more than one data point across the 4.5-month trial period. One of these patients submitted 101 PEFR readings across 65 days; another submitted 24 PEFR and inhaler usage readings across 66 days. PEFR for both patients fell within predefined physiologic parameters, except once where a low threshold notification was sent to the pulmonologist, who responded with a telephone discussion and new e-prescription to address symptoms. This research describes the technical considerations and implementation challenges of using commonly available frameworks for sharing PGHD, for the purpose of remote monitoring to support timely care interventions.

The asthma mobile health study, smartphone data collected using ResearchKit.

Widespread adoption of smart mobile platforms coupled with a growing ecosystem of sensors including passive location tracking and the ability to leverage external data sources create an opportunity to generate an unprecedented depth of data on individuals. Mobile health technologies could be utilized for chronic disease management as well as research to advance our understanding of common diseases, such as asthma. We conducted a prospective observational asthma study to assess the feasibility of this type of approach, clinical characteristics of cohorts recruited via a mobile platform, the validity of data collected, user retention patterns, and user data sharing preferences. We describe data and descriptive statistics from the Asthma Mobile Health Study, whereby participants engaged with an iPhone application built using Apple's ResearchKit framework. Data from 6346 U.S. participants, who agreed to share their data broadly, have been made available for further research. These resources have the potential to enable the research community to work collaboratively towards improving our understanding of asthma as well as mobile health research best practices.

Depressed mood in informal caregivers of individuals with mild cognitive impairment.

This study estimates the prevalence of depressed mood in caregivers of individuals with mild cognitive impairment (MCI) and assesses whether demographics, stressors, intrapsychic strain, and gain are associated with depressed mood. A secondary analysis of baseline data from the Alzheimer's Disease Cooperative Study MCI trial was conducted using a cross-sectional, correlational design. Descriptive statistics to estimate the prevalence of caregiver depressed mood and univariate and block-wise logistic regression analyses were used. The prevalence of depressed mood in 769 caregivers was 24.6% (95% confidence interval, 21.5-27.7). The odds of being depressed were significantly higher in younger, nonspousal caregivers with less education, who cared for MCI patients with lower activities of daily living functioning, and who perceived greater relational deprivation, higher levels of self-loss, and personal gain. Controlling for relevant variables, relational deprivation and caregiver education continued to be significantly associated with depressed mood. Relational deprivation may be important for future interventions.

Relationships between caregiver stress and self-care behaviors in response to symptoms.

The specific aims of this study were to (a) identify relationships among care-giving stress, caregivers' functional ability, and number of self-care behavior responses to physical and psychological symptoms in caregivers of persons with dementia and (b) examine the mediating function of functional ability in the relationship between caregiving stress and self-care behavior response to symptoms. A correlational, cross-sectional design was used, and a survey was mailed to 99 caregivers. The survey questionnaire contained items about demographics, caregiving stress, functional ability, and self-care behavior. The results indicate that caregivers who reported higher levels of caregiving stress had poorer self-rated health, poorer physical function, more symptoms, high levels of depressed mood, and more self-care behaviors. Caregiving stress was indirectly related to self-care behavior response to symptoms through functional ability, which suggests a need for developing early interventions to enhance the functional ability and self-care behaviors in response to some caregivers' symptoms.

The Asthma Mobile Health Study, a large-scale clinical observational study using ResearchKit.

The feasibility of using mobile health applications to conduct observational clinical studies requires rigorous validation. Here, we report initial findings from the Asthma Mobile Health Study, a research study, including recruitment, consent, and enrollment, conducted entirely remotely by smartphone. We achieved secure bidirectional data flow between investigators and 7,593 participants from across the United States, including many with severe asthma. Our platform enabled prospective collection of longitudinal, multidimensional data (e.g., surveys, devices, geolocation, and air quality) in a subset of users over the 6-month study period. Consistent trending and correlation of interrelated variables support the quality of data obtained via this method. We detected increased reporting of asthma symptoms in regions affected by heat, pollen, and wildfires. Potential challenges with this technology include selection bias, low retention rates, reporting bias, and data security. These issues require attention to realize the full potential of mobile platforms in research and patient care.

Stroke education in an emergency department waiting room: a comparison of methods.

BACKGROUND: Since the emergency department (ED) waiting room hosts a large, captive audience of patients and visitors, it may be an ideal location for conducting focused stroke education. The aim of this study was to assess the effectiveness of various stroke education methods. METHODS: Patients and visitors of an urban ED waiting room were randomized into one of the following groups: video, brochure, one-to-one teaching, combination of these three methods, or control group. We administered a 13-question multiple-choice test to assess stroke knowledge prior to, immediately after, and at 1 month post-education to patients and visitors in the ED waiting room. RESULTS: Of 4 groups receiving education, all significantly improved their test scores immediately post intervention (test scores 9.4±2.5-10.3±2.0, P<0.01). At 1 month, the combination group retained the most knowledge (9.4±2.4) exceeding pre-intervention and control scores (both 6.7±2.6, P<0.01). CONCLUSION: Among the various stroke education methods delivered in the ED waiting room, the combination method resulted in the highest knowledge retention at 1-month post intervention.

Gender differences in community services knowledge, needs, and use among older African-Americans.

The primary purpose of this study was to compare knowledge of use of and need for community services between older (60 years of age and older) African-American men and women. A secondary purpose was to determine whether predisposing, enabling, and health-status factors could predict knowledge of need for, and use of specific community services among African-American women and men, 60 years of age and older Data were gleaned from a community-based random telephone survey of African-Americans (77 female and 23 male), 60 years of age and older, living in northeastern Ohio. Data generated from this study were analyzed using chi-square, and independent samples t-test, and multiple regression. Findings from this study suggested that women had higher levels of knowledge of use of and need for community-specific services than their male counterparts. Another finding from this study suggested that none of the identified predisposing, enabling, and health-status factors found in this study could plausibly explain knowledge of need for, or use of community-specific services.

Supplemental oxygen delivery to suspected stroke patients in pre hospital and emergency department settings.

BACKGROUND: Recent data suggests that high-flow oxygen started promptly after stroke symptom onset salvages ischemic brain tissue. We investigated the consistency of oxygen delivery to suspected stroke patients in the pre-hospital (PH) and Emergency Department (ED) settings, and associated adverse events (AEs). METHODS: We retrospectively reviewed pre-hospital call reports of suspected stroke patients transported by our institution's paramedics. We extracted data on oxygen delivery in the PH and ED settings, demographics, Glasgow Coma Scale score (GCS), final diagnosis, and selected AEs (mortality, seizures, worsening neurological status, new infarction, and post-ischemic hemorrhage). Patients were grouped according to ED oxygen delivery: none, low-flow (2-4 L/min), and high-flow (10-15 L/min). RESULTS: Oxygen delivery was documented in 84% of 366 stroke transports, with 98% receiving 10-15 L/min. Our hospital received 164 patients. Oxygen delivery in the ED was documented in 150 patients, with 38% receiving none, 47% low-flow, and 15% high-flow oxygen. There were no instances of oxygen refusal, premature termination, or technical difficulties. Advanced age and low GCS predicted the use of higher flow rates. High-flow oxygen was more frequently administered to patients with symptom onset < 3 hours, and those with intracerebral hemorrhage (ICH), hypoxic-ischemic encephalopathy (HIE) or seizures (p < 0.001). More patients receiving high-flow oxygen were documented to have an AE (p = 0.02), however the low- and no-oxygen groups more frequently had multiple AEs (p = 0.01). The occurrence of AEs was predicted by the diagnosis of ICH/HIE/seizures (p = 0.013) and acute ischemic stroke (AIS)/transient ischemic attack (TIA) (p = 0.009), but not by the amount of oxygen. CONCLUSIONS: Suspected stroke patients routinely receive 10-15 L/min oxygen in the ambulance however in the ED there is wide variability due to factors such as clinical severity. Oxygen delivery appears safe in the PH and ED settings.

Experience and perspectives of caregivers of spouse with mild cognitive impairment.

The purpose of this paper is to describe commonalities of the lived experience of being a spouse caregiver of a person with mild cognitive impairment (MCI). The Colaizzi method of empirical phenomenology was used for inter-viewing and analyzing data obtained from 10 spouse caregivers of persons with MCI. Four major themes were found and labeled: (a) Putting the Puzzle Pieces Together-There Really is Something Wrong; (b) A Downward Spiral into a World of Silence; (c) Consequences to Caregivers of Living in a World of Silence; (d) Taking Charge of Care. The findings of this study provided rich data to guide interventions to help caregivers to improve their awareness of MCI, gain new information and skills to deal more effectively with and adjust to the caregiving of their spouse with MCI over the long-term.

Impact of workplace sociocultural attributes on participation in health assessments.

OBJECTIVE: To investigate the impact of sociocultural workplace attributes on participation in employer sponsored health assessments. METHODS: Medical center employees were encouraged to participate in free, voluntary, and confidential biometric screening and on-line health risk appraisal. A job satisfaction database, aggregated by job type and work area, was used to identify workplace sociocultural attributes correlated with participation. RESULTS: : Thirty-seven percent of the population engaged in the health assessments; however, participation varied widely by work area (10% to 83%) and by job type (17% to 56%). Participation was significantly correlated with selected aspects of job satisfaction. CONCLUSIONS: Overall participation rates in employee population health assessments can disguise large variation in employee engagement. This variation is associated with work sociocultural characteristics. Attention to these attributes may be essential to improving involvement in employer sponsored health promotion.