Perspectives of individuals with sickle cell disease on barriers to care.

INTRODUCTION: Sickle cell disease (SCD) is an inherited hemoglobinopathy that predominantly affects African Americans in the United States. The disease is associated with complications leading to high healthcare utilization rates, including emergency department (ED) visits and hospitalizations. Optimal SCD care requires a multidisciplinary approach involving SCD specialists to ensure preventive care, minimize complications and prevent unnecessary ED visits and hospitalizations. However, most individuals with SCD receive sub-optimal care or are unaffiliated with care (have not seen an SCD specialist). We aimed to identify barriers to care from the perspective of individuals with SCD in a multi-state sample. METHODS: We performed a multiple methods study consisting of surveys and interviews in three comprehensive SCD centers from March to June 2018. Interviews were transcribed and coded, exploring themes around barriers to care. Survey questions on the specific themes identified in the interviews were analyzed using summary statistics. RESULTS: We administered surveys to 208 individuals and conducted 44 in-depth interviews. Barriers to care were identified and classified according to ecological level (i.e., individual, family/interpersonal, provider, and socio-environmental/organizational level). Individual-level barriers included lack of knowledge in self-management and disease severity. Family/interpersonal level barriers were inadequate caregiver support and competing life demands. Provider level barriers were limited provider knowledge, provider inexperience, poor provider-patient relationship, being treated differently, and the provider's lack of appreciation of the patient's SCD knowledge. Socio-environmental/organizational level barriers included limited transportation, lack of insurance, administrative barriers, poor care coordination, and reduced access to care due to limited clinic availability, services provided or clinic refusal to provide SCD care. CONCLUSION: Participants reported several multilevel barriers to SCD care. Strategies tailored towards reducing these barriers are warranted. Our findings may also inform interventions aiming to locate and link unaffiliated individuals to care.

Feasibility of an mHealth self-management intervention for children and adolescents with sickle cell disease and their families.

Sickle cell disease (SCD) is an inherited hemoglobinopathy that leads to blood vessel occlusion and multiorgan complications, including pain, that may be experienced daily. Symptom management often begins at home, and tools are needed to support self-management strategies that can be implemented by children with SCD and families. The purpose of this study was to assess the feasibility of the mHealth self-management intervention (application) Voice Crisis Alert V2 for children with SCD and families. Feasibility assessment was guided by the Reach, Efficacy, Adoption, Implementation, and Maintenance framework. Data were collected with 60 dyads (children with SCD/caregivers) at four time points. Self-management data were collected via application use, and postintervention interviews were conducted. Analyses included descriptive statistics and constant comparison with directed content analysis. Recruitment was completed in 28 weeks, with 82% retention at end-of-intervention. Mobile Application Rating Scale scores and interview data indicated high satisfaction. From baseline to mid-intervention, 94% of dyads used the application (75% of total use); 45% used the application from mid-intervention to the end-of-intervention. Dyads made 2,384 actions in the application; the most commonly used features were recording health history and recording and tracking symptoms. Few reported issues with the application; most issues occurred early in the study and were corrected. After the intervention period was completed, 37% continued to use the application. Feasibility was confirmed by meeting recruitment and retention goals, high adoption of the application, and high reported satisfaction with the application. Challenges with sustained use were encountered, and areas for improvement were identified.

The Impact in the United States of the Baby-Friendly Hospital Initiative on Early Infant Health and Breastfeeding Outcomes.

UNLABELLED: Studies were examined to evaluate the impact of the Baby-Friendly Hospital Initiative (BFHI) on breastfeeding and early infant health outcomes in U.S. POPULATIONS: Using the Social Ecological Model as a guiding theoretical framework, results were categorized into four interrelated multilevel factors: (1) maternal/infant dyad factors, (2) provider factors, (3) hospital organizational factors, and (4) policy/systems factors. Results from the review support the BFHI's success in facilitating successful breastfeeding initiation and exclusivity. Breastfeeding duration also appears to increase when mothers have increased exposure to Baby-Friendly practices, but deficiencies in breastfeeding tracking mechanisms have limited reliable breastfeeding duration data. Of the 10 steps of the BFHI, step 3, prenatal education and step 10, postnatal breastfeeding support are the most difficult steps to implement; however, those steps have the potential to significantly impact maternal breastfeeding decisions. The underlying mechanisms by which Baby-Friendly practices contribute to maternal breastfeeding decisions remain unclear; thus, studies are needed to examine mothers' experiences and perceptions of Baby-Friendly practices. Additionally, studies are needed to investigate the impact of the BFHI for women living in rural areas and in southeastern regions of the United States. Finally, studies are needed to examine early infant health outcomes related to the BFHI, especially for late premature infants (34-36 weeks) who are most vulnerable to poor outcomes and are in need of specialized breastfeeding support. Results from future qualitative and quantitative explorations could clarify how the delivery of Baby-Friendly practices leads to successful breastfeeding and infant health outcomes.

Assessment of protein synthesis in highly aerobic canine species at the onset and during exercise training.

Canis lupus familiaris, the domesticated dog, is capable of extreme endurance performance. The ability to perform sustained aerobic exercise is dependent on a well-developed mitochondrial reticulum. In this study we examined the cumulative muscle protein and DNA synthesis in groups of athletic dogs at the onset of an exercise training program and following a strenuous exercise training program. We hypothesized that both at the onset and during an exercise training program there would be greater mitochondrial protein synthesis rates compared with sedentary control with no difference in mixed or cytoplasmic protein synthesis rates. Protein synthetic rates of three protein fractions and DNA synthesis were determined over 1 wk using (2)H2O in competitive Alaskan Huskies and Labrador Retrievers trained for explosive device detection. Both groups of dogs had very high rates of skeletal muscle protein synthesis in the sedentary state [Alaskan Huskies: Mixed = 2.28 ± 0.12, cytoplasmic (Cyto) = 2.91 ± 0.10, and mitochondrial (Mito) = 2.62 ± 0.07; Labrador Retrievers: Mixed = 3.88 ± 0.37, Cyto = 3.85 ± 0.06, and Mito = 2.92 ± 0.20%/day]. Mitochondrial (Mito) protein synthesis rates did not increase at the onset of an exercise training program. Exercise-trained dogs maintained Mito protein synthesis during exercise training when mixed (Mixed) and cytosolic (Cyto) fractions decreased, and this coincided with a decrease in p-RpS6 but also a decrease in p-ACC signaling. Contrary to our hypothesis, canines did not have large increases in mitochondrial protein synthesis at the onset or during an exercise training program. However, dogs have a high rate of protein synthesis compared with humans that perhaps does not necessitate an extra increase in protein synthesis at the onset of aerobic exercise training.

Comparison among the euglycemic-hyperinsulinemic clamp, insulin-modified frequently sampled intravenous glucose tolerance test, and oral glucose tolerance test for assessment of insulin sensitivity in healthy Standardbreds.

OBJECTIVE: To compare, in horses, estimates of insulin sensitivity obtained from minimal model analysis (MMA) of a frequently sampled IV glucose tolerance test (FSIGTT) with estimates from the euglycemic-hyperinsulinemic clamp (EHC) and to evaluate the validity of surrogate estimates of insulin sensitivity derived from an oral glucose tolerance test (OGTT). ANIMALS: 18 mature Standardbreds (mean ± SD body weight, 428.9 ± 35.9 kg; mean ± SD body condition score, 4.4 ± 1.0 [on a scale of 1 to 9]). PROCEDURES: All horses underwent at least 2 of the 3 procedures (EHC [n = 15], insulin-modified FSIGTT [18], and OGTT [18]) within a 10-day time frame to evaluate insulin sensitivity. RESULTS: Insulin sensitivity variables derived from the EHC and FSIGTT were strongly correlated (r = 0.88). When standardized to the same units of measure, these measures were still strongly correlated (r = 0.86) but were not equivalent. Area under the curve, peak insulin concentration, insulin concentration at 120 minutes, and 2 calculated indices from glucose and insulin data from the OGTT were significantly correlated with the EHC- and FSIGTT-derived estimates of insulin sensitivity. CONCLUSIONS AND CLINICAL RELEVANCE: In healthy Standardbreds with moderate body condition score, insulin sensitivities from the EHC and FSIGTT were strongly correlated but not equivalent. Estimates derived from an OGTT also may be useful to estimate insulin sensitivity.

Hospital-acquired anemia: prevalence, outcomes, and healthcare implications.

BACKGROUND: Evidence suggests that patients with normal hemoglobin (Hgb) levels on hospital admission who subsequently develop hospital-acquired anemia (HAA) may be at risk for adverse outcomes. Our objectives were to (1) determine the prevalence of HAA and (2) examine whether HAA is associated with increased mortality, length of stay (LOS), and total hospital charges. METHODS: The population consisted of 417,301 adult hospitalizations from January 1, 2009 to August 31, 2011, in an academic medical center and 9 community hospitals. Patients with anemia on admission, and hospitals in the health system without available laboratory data were excluded; 188,447 hospitalizations were included in the analysis. Demographics, comorbidities, and outcomes were retrieved from administrative data; Hgb values were taken from the electronic medical record. Regression modeling was used to examine the association between demographics, comorbidity, hospitalization type, and HAA variables (mild: Hgb >11 and <12 g/dL for women, and >11 and <13 g/dL for men; moderate: Hgb 9.1 to ≤ 11.0 g/dL; severe: Hgb ≤ 9.0 g/dL) on mortality, LOS, and hospital charges. RESULTS: Among 188,447 hospitalizations, 139,807 patients (74%) developed HAA: mild, 40,828 (29%); moderate, 57,184 (41%); and severe, 41,795 (30%). Risk-adjusted odds ratios and 95% confidence intervals for in-hospital mortality with HAA were: mild, 1.0 (0.88-1.17; P = 0.8); moderate, 1.51 (1.33-1.71, P < 0.001); and severe, 3.28 (2.90-3.72, P < 0.001). Risk-adjusted relative mean LOS and hospital charges relative to no HAA were higher with HAA: LOS: mild, 1.08 (1.08-1.10, P < 0.001); moderate, 1.28 (1.26-1.29, P < 0.001); severe, 1.88 (1.86-1.89, P < 0.001). Hospital charges: mild, 1.06 (1.06-1.07, P < 0.001); moderate, 1.18 (1.17-1.19, P < 0.001); severe, 1.80 (1.79-1.82, P < 0.001). CONCLUSIONS: HAA is common and associated with increased mortality and resource utilization. Factors related to its development necessitate further study.

Evaluating conservation program success with Landsat and SWAT.

In the United States, many state and federally funded conservation programs are required to quantify the water quality benefits resulting from their efforts. The objective of this research was to evaluate the impact of conservation practices subsidized by the Oklahoma Conservation Commission on phosphorus and sediment loads to Lake Wister. Conservation practices designed to increase vegetative cover in grazed pastures were evaluated using Landsat imagery and the Soil and Water Assessment Tool (SWAT). Several vegetative indices were derived from Landsat imagery captured before and after the implementation of conservation practices. Collectively, these indicators provided an estimate of the change in vegetative soil cover attributable to conservation practices in treated fields. Field characteristics, management, and changes in vegetative cover were used in the SWAT model to simulate sediment and phosphorus losses before and after practice implementation. Overall, these conservation practices yielded a 1.9% improvement in vegetative cover and a predicted sediment load reduction of 3.5%. Changes in phosphorus load ranged from a 1.0% improvement to a 3.5% increase, depending upon initial vegetative conditions. The use of fertilizers containing phosphorus as a conservation practice in low-productivity pastures was predicted by SWAT to increase net phosphorus losses despite any improvement in vegetative cover. This combination of vegetative cover analysis and hydrologic simulation was a useful tool for evaluating the effects of conservation practices at the basin scale and may provide guidance for the selection of conservation measures subsidized in future conservation programs.

Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children.

OBJECTIVES: We sought to determine if the prevalence of depression and anxiety in mothers and the prevalence of behavior problems in preschool-aged children are more common when mothers report being food insecure. METHODS: A cross-sectional survey of 2870 mothers of 3-year-old children was conducted in 2001-2003 in 18 large US cities. On the basis of the adult food-security scale calculated from the US Household Food Security Survey Module, mothers were categorized into 3 levels: fully food secure, marginally food secure, and food insecure. The 12-month prevalence in mothers of a major depressive episode and generalized anxiety disorder was assessed by the Composite International Diagnostic Interview-Short Form. A child behavior problem in > or = 1 of 3 domains (aggressive, anxious/depressed, or inattention/hyperactivity) was based on the Child Behavior Checklist. RESULTS: Seventy-one percent of the respondents were fully food secure, 17% were marginally food secure, and 12% were food insecure. After adjustment for sociodemographic factors plus maternal physical health, alcohol use, drug use, prenatal smoking, and prenatal physical domestic violence, the percentage of mothers with either major depressive episode or generalized anxiety disorder increased with increasing food insecurity: 16.9%, 21.0%, and 30.3% across the 3 levels. Among children, after further adjustment for maternal major depressive episode and generalized anxiety disorder, the percentage with a behavior problem also increased with increasing food insecurity: 22.7%, 31.1%, and 36.7%. CONCLUSIONS: Mental health problems in mothers and children are more common when mothers are food insecure, a stressor that can potentially be addressed by social policy.