Adoption of a Portal for the Primary Care Management of Pediatric Asthma: A Mixed-Methods Implementation Study.

BACKGROUND: Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established. OBJECTIVE: We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success. METHODS: We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework. RESULTS: We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success. CONCLUSIONS: Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children. CLINICALTRIAL: Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3).

Charge and temperature dependence of biomolecule conformations: K+ tryptamine(H2O)(n=0-1)Ar(m=0-1) cluster ions.

The impact of temperature and charge on the conformation of tryptamine (Tryp) is examined in the gas phase by infrared laser-vibrational predissociation spectroscopy in the 2800-3800 cm(-1) region. Previous studies of neutral Tryp(H(2)O)(n) clusters showed preferential stabilization of specific tryptamine conformers through hydrogen bonding. When complexed with the biologically significant potassium ion, the only conformers found to form under these experimental conditions are built on hitherto unobserved neutral Tryp conformers. The electrostatic interaction between K(+), the tryptamine NH(2) lone pair, and the indole ring in K(+)(Tryp) favors the formation of these new conformers. The observed K(+)(Tryp)(H(2)O) conformers vary significantly from the previously reported neutral Tryp(H(2)O) structure. Using the argon tagging method, we show how variations in temperature impact the observed infrared spectra, demonstrating that different conformers are populated under the different experimental conditions. In addition, the presence of a high-energy conformer of K(+)(Tryp)(H(2)O), trapped by the argon evaporative cooling process, was identified. Exploring the conformational landscape of hydrated cluster ions bearing flexible biomolecules is now possible.

Medication-associated diethylene glycol mass poisoning: a review and discussion on the origin of contamination.

Diethylene glycol (DEG), an extremely toxic chemical, has been implicated as the etiologic agent in at least 12 medication-associated mass poisonings over the last 70 years. Why DEG mass poisonings occur remains unclear. Most reports do not contain detailed reports of trace-back investigations into the etiology. The authors, therefore, conducted a systematic literature review on potential etiologies of these mass poisonings. The current available evidence suggests that substitution of DEG or DEG-containing compounds for pharmaceutical ingredients results from: (1) deception as to the true nature of certain ingredients by persons at some point in the pharmaceutical manufacturing process, and (2) failure to adhere to standardized quality control procedures in manufacturing pharmaceutical products intended for consumers. We discuss existing guidelines and new recommendations for prevention of these incidents.

Entropic effects on hydrated alkali-metal cations: infrared spectroscopy and ab initio calculations of M+(H2O)(x=2-5) cluster ions for M = Li, Na, K, and Cs.

A delicate balance between competing and cooperating noncovalent interactions determines the three-dimensional structure of hydrated alkali-metal ion clusters. A critical factor influencing the balance reached is the internal energy content (or effective temperature) of the ion cluster. Cold cluster ions (approximately 50-150 K) have little internal energy, and enthalpic contributions have a greater influence on the relative population of low-lying minima. In clusters whose internal energy distributions correspond to temperatures approximately 250-500 K, entropic effects are expected to influence which structural isomers are present, favoring those where free energy has been minimized. Infrared photodissociation spectra of M(+)(H2O)(x=2-5) (approximately 250-500 K) are reported for M = Li, Na, K, and Cs to explore ion dependencies and entropic effects on the observed three-dimensional structure.

Hydrated alkali-metal cations: infrared spectroscopy and ab initio calculations of M+(H2O)(x=2-5)Ar cluster ions for M = Li, Na, K, and Cs.

A delicate balance between competing and cooperating noncovalent interactions determines the three-dimensional structure of hydrated alkali-metal ion clusters. With a single water molecule hydrating an ion, the electrostatic ion...water interaction dominates. With more than one water molecule, however, water...water hydrogen-bonding interactions compete with the ion...water interactions to influence the three-dimensional structure. Infrared photodissociation spectra of M(+)(H2O)(x=2-5)Ar (with effective temperatures of approximately 50-150 K, depending on size and composition) are reported for M = Li, Na, K, and Cs, and dependencies on ion size and hydration number are explored.

Negative Additive Manufacturing of Complex Shaped Boron Carbides.

Boron carbide (B4C) is one of the hardest materials in existence. However, this attractive property also limits its machineability into complex shapes for high wear, high hardness, and lightweight material applications such as armors. To overcome this challenge, negative additive manufacturing (AM) is employed to produce complex geometries of boron carbides at various length scales. Negative AM first involves gelcasting a suspension into a 3D-printed plastic mold. The mold is then dissolved away, leaving behind a green body as a negative copy. Resorcinol-formaldehyde (RF) is used as a novel gelling agent because unlike traditional hydrogels, there is little to no shrinkage, which allows for extremely complex molds to be used. Furthermore, this gelling agent can be pyrolyzed to leave behind ~50 wt% carbon, which is a highly effective sintering aid for B4C. Due to this highly homogenous distribution of in situ carbon within the B4C matrix, less than 2% porosity can be achieved after sintering. This protocol highlights in detail the methodology for creating near fully dense boron carbide parts with highly complex geometries.

Tizanidine is effective in the treatment of myofascial pain syndrome.

Myofascial pain syndrome (MPS) is difficult to treat. The efficacy and safety of tizanidine, an alpha2-adrenergic agent with effects on spasticity and pain, in treating MPS was evaluated. Female subjects (n = 29) with MPS of 9 to > 52 weeks' duration and mean age 37.5 (range 20-51) years, who also had reduced pressure thresholds, were enrolled. Subjects were titrated up to 12 mg of tizanidine over 3 weeks and maintained for 2 weeks. Sleep was assessed via visual analog scale (VAS), pain intensity via short form McGill questionnaire including VAS, disability/level of function, and pressure threshold (tested by algometry) at baseline, weeks 3 and 5, and 1 week after tizanidine was discontinued. Patient and physician global assessments of treatment were reported at week 5. Twenty-four subjects completed the study. Pain intensity and disability decreased significantly from baseline at weeks 3 and 5 and after washout (P < .001). Pressure threshold and sleep improved for all study periods (P < .001). Tizanidine was rated as good to excellent in relieving pain by 89% of subjects and 79% of physicians. No serious adverse events occurred. Tizanidine was effective in the treatment of MPS.

The ACA's pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with exclusions.

The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. "Pediatric services" is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans-the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules-address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.

Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health.

OBJECTIVE: Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures. METHODS: Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates. RESULTS: With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics. CONCLUSIONS: Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.

Eclampsia characteristics and outcomes: a comparison of two eras.

OBJECTIVE: To describe the trends in incidence, characteristics, and outcomes of women with eclampsia. METHODS: We reviewed and abstracted data from medical records of all women diagnosed with eclampsia in our institution from August 1998 to April 2011. In addition to overall characteristics and outcomes, the cases were stratified by onset: antenatal versus postnatal and early (<32 weeks of gestation) versus late antenatal cases (≥32 weeks of gestation). Comparisons were made using chi-square, Fisher's exact, Mann-Whitney U, and t-tests. A two-sided P < 0.05 was considered statistically significant. RESULTS: We identified 87 eclampsia cases out of 59,388 deliveries; 62 cases were diagnosed before delivery, and 25 had a postnatal onset. Among the 62 antenatal cases, 41 were diagnosed before 32 weeks and 21 at or after 32 weeks of gestation. Antenatal cases had higher systolic (P = 0.03) and diastolic (P = 0.01) blood pressures, more abnormal dipstick-test proteinuria (P = 0.002), and lower platelet counts (P ≤ 0.001) than postnatal cases. Early eclampsia cases were complicated more often with HELLP syndrome than late eclampsia cases (P = 0.007). CONCLUSION: The occurrence of eclampsia has decreased over time. The earlier the onset is, the worse the outcome appears to be.

A procurement-based pathway for promoting public health: innovative purchasing approaches for state and local government agencies.

Through their purchasing powers, government agencies can play a critical role in leveraging markets to create healthier foods. In the United States, state and local governments are implementing creative approaches to procuring healthier foods, moving beyond the traditional regulatory relationship between government and vendors. They are forging new partnerships between government, non-profits, and researchers to increase healthier purchasing. On the basis of case examples, this article proposes a pathway in which state and local government agencies can use the procurement cycle to improve healthy eating.

Modeling competitive interactions in proteins: vibrational spectroscopy of M+(n-methylacetamide)1(H2O)n=0-3, M=Na and K, in the 3 microm region.

To properly understand the preferred structures and biological properties of proteins, it is important to understand how they are influenced by their immediate environment. Competitive intrapeptide, peptide...water, ion...water, and ion...peptide interactions, such as hydrogen bonding, play a key role in determining the structures, properties, and functionality of proteins. The primary types of hydrogen bonding involving proteins are intramolecular amide...amide (N-H...O=C) and intermolecular amide...water (O-H...O=C and H-O...H-N). n-Methylacetamide (NMA) is a convenient model for investigating these competitive interactions. An analysis of the IR photodissociation (IRPD) spectra of M+(n-methylacetamide)1(H2O)n=0-3 (M=Na and K) in the O-H and N-H spectral regions is presented. Ab initio calculations (MP2/cc-pVDZ) are used as a guide in identifying both the type and location of hydrogen bonds present. In larger clusters, where several structural isomers may be present in the molecular beam, ab initio calculations are also used to suggest assignments for the observed spectral features. The results presented offer insight to the nature of ion...NMA interactions in an aqueous environment and reveal how different ion...ligand pairwise interactions direct the extent of water...water and water...NMA hydrogen bonding observed.

Structures, energetics, and spectra of aqua-cesium (I) complexes: an ab initio and experimental study.

The design of cesium-selective ionophores must include the nature of cesium-water interactions. The authors have carried out extensive ab initio and density functional theory calculations of hydrated cesium cations to obtain reasonably accurate energetics, thermodynamic quantities, and IR spectra. An extensive search was made to find the most stable structures. Since water...water interactions are important in the aqua-Cs+ clusters, the authors investigated the vibrational frequency shifts as a function of the number of water molecules and the frequency characteristics with and without the presence of outer-shell water molecules. The predicted vibrational frequencies were then compared with the infrared photodissociation spectra of argon-tagged hydrated cesium cluster ions. This comparison allowed the identification of specific hydrogen-bonding structures present in the experimental spectra.

Mimicking solvent shells in the gas phase. II. Solvation of K+.

The observed gas-phase coordination number of K+ in K+(H2O)m clusters is smaller than that observed in bulk solution, where the coordination number has been reported to be between 6 and 8. Both theoretical and gas-phase studies of K+(H2O)m cluster ions point to a coordination number closer to 4. In the gas phase, the coordination number is determined by a variety of factors-the most critical being the magnitude of the K+...ligand pairwise interaction. Decreasing the magnitude of the ion...ligand interaction allows more ligands to directly interact with the cation. One method for decreasing the ion...ligand interaction in K+(H2O)m clusters is to systematically substitute weakly bound ligands for the more strongly bound water molecules. The systematic introduction of para-difluorobenzene (DFB) to K+(H2O)m clusters was monitored using infrared photodissociation spectroscopy in the OH stretching region. By varying the ratio of DFB molecules to water molecules present in K+(H2O)m(DFB)n clusters, the observed coordination number of gas-phase K+ was increased to 8, similar to that reported for bulk solution.

Hydration of ion-biomolecule complexes: ab initio calculations and gas-phase vibrational spectroscopy of K+ (indole)m(H2O)n.

In recent years neutral indole(H2O)n clusters have been used to model the hydration of biomolecules containing an indole moiety. Both experimental and theoretical studies of the binary indole...OH2 system show NH...OH sigma hydrogen-bonding. By introducing a cation to the indole...OH2 model, cation...pi and ion...dipole electrostatic interactions are placed in direct competition with conventional indole...OH2 hydrogen-bonding. The effects, arising from a monovalent potassium cation on (indole)m(H2O)n clusters, were investigated using infrared photodissociation spectroscopy in the OH and NH stretching regions. In K+ (indole)1(H2O)(n < or = 4) and K+ (indole)2(H2O)(m < or = 3) clusters, the electrostatic ion...ligand interaction inhibits the formation of an indole NH...OH2 sigma hydrogen-bond. However, indole...H2O pi hydrogen-bonding via the five-membered indole ring is observed with three or more ligands around the ion.