Macronutrient analysis of human milk and factors associated with its composition in mothers of preterm infants ≤ 32 weeks.

We conducted an exploratory longitudinal study to evaluate the macronutrient composition of human milk in mothers delivering very preterm infants ≤ 32 weeks over the first 4 weeks of lactation and the association of human milk composition with maternal and neonatal factors A total of 213 human milk samples collected in the morning between 8 am and 12 pm from 60 eligible mothers were analyzed on 7 (n = 60), 14 (n = 60), 21 (n = 52), and 28 (n = 41) days of lactation by infrared transmission spectroscopy. The true protein content decreased significantly over 4 weeks (mean difference (95% confidence interval)) (MD (95% CI)) week 1 and week 4 = 0.2 g (0.037 to 0.363, P = 0.009)). On the contrary, the mean fat and calorie content showed significant increase over time (MD (95% CI)) = - 1.03 g (- 1.719 to - 0.343, P = 0.001) and - 9.0 kcal/dl (- 15.170 to - 2.830, P = 0.001), respectively). There was no difference in the carbohydrate content of human milk over 4 weeks. Macronutrient composition was independent of maternal parity, mode of delivery, pre-pregnancy body mass index, umbilical artery Doppler flows, previous breast feeding experience, neonatal centile status, gestation, and infant's weight at birth. Multiple regression analysis of human milk composition with mother's dietary components showed no significant association. CONCLUSION : We conclude that in mothers who deliver very preterm infants ≤ 32 weeks, true protein content decreased, fat and calorie content increased, and carbohydrate content remained stable in human milk during first 4 weeks of lactation. Human milk macronutrient composition was independent of various maternal and neonatal factors including maternal body mass index and dietary intake. TRIAL REGISTRATION : CTRI/2017/02/007895 What is Known: • Preterm human milk has high temporal and inter-individual variation in the macronutrient composition. What is New: • In mothers who deliver very preterm infants < 32 weeks, true protein content decreases, fat and calorie content increases, and carbohydrate content remains stable in human milk during first 4 weeks of lactation. • Human milk macronutrient composition is independent of various maternal and neonatal factors including maternal body mass index and dietary intake.

Risk perception, adaptation, and resilience during the COVID-19 pandemic in Southeast Alaska Natives.

Indigenous communities worldwide are at higher risk of negative pandemic outcomes, and communities Indigenous to the Arctic are disproportionately affected compared to national majorities. Despite this, their experiences have scarcely been investigated qualitatively and from their own perspectives. We collected and analyzed 22 structured interviews in three Southeast Alaska island communities (Sitka, Hoonah, and Kake) to learn about their perceptions of and experiences with the COVID-19 pandemic. Interviews were analyzed with thematic qualitative analysis in Dedoose. Four primary categories were identified within which to discuss risk and resilience in Southeast Alaska: (1) risk perception, (2) socioeconomic impacts, (3) reactions to public health guidelines, and (4) coping. Primary findings indicate that Southeast Alaska Native communities display considerable resilience and adaptive flexibility despite the significant adversity imposed by the COVID-19 pandemic. Southeast Alaska Native people use historical and traditional knowledge to culturally ground adaptive behaviors to cope with the threat of COVID-19. Interviewees expressed that adaptive, community-centered, and non-individualistic behaviors strongly tied to Native culture minimized the negative epidemiological impacts of the pandemic. Future research can more deeply explore the root causes of the need for adaptiveness and resilience, such as histories of colonialism and marginalization, to emergency situations in Indigenous communities.

Improving Pain Care for Service Members: Administrator, Provider, and Patient Perspectives on Treatment, Policies, and Opportunities for Change.

Acute and chronic pain are common among service members, with musculoskeletal pain and injuries being the leading cause of nondeployability among active-duty service members. Given the significant implications for individual health and force readiness, providing high-quality pain care to service members is a priority of the Military Health System (MHS). Prior RAND research used administrative data to assess the quality and safety of pain care and opioid prescribing in the MHS, generated a set of quality measures that the MHS could adopt going forward, and identified strengths and opportunities for improvement in care provided to service members with pain conditions. In this study, authors document findings from interviews with MHS administrators, providers, and patients, providing valuable detail and context for those findings, along with on-the-ground perspectives on MHS pain care policies and guidance in practice. Staff and patients recommended prioritizing increases in treatment access and availability to improve pain care, and patients emphasized effective treatment and patient-centered care as the most important facilitators of high-quality pain care.

The U.S. Equity-First Vaccination Initiative: Impacts and Lessons Learned.

The one-year U.S. Equity-First Vaccination Initiative (EVI), launched in April 2021, aimed to reduce racial inequities in coronavirus disease 2019 (COVID-19) vaccination across five demonstration cities (Baltimore, Chicago, Houston, Newark, and Oakland) and over the longer term strengthen the United States' public health system to achieve more-equitable outcomes. This initiative comprised nearly 100 community-based organizations (CBOs), who led hyper-local work to increase vaccination access and confidence in communities of individuals who identify as Black, Indigenous, and People of Color. In this study, the second of two on the initiative, the authors examine the results of the EVI. They look at the initiative's activities, effects, and challenges, and provide recommendations for how to support and sustain this hyper-local community-led approach and strengthen the public health system in the United States.

Community and Healthcare Perspectives on Implementing Hypertension Interventions for a Multiethnic Safety-Net Population.

Objective: To synthesize community and healthcare informants' perspectives on contextual considerations and tailoring recommendations for high-quality, sustainable implementation of evidence-based practices (EBPs) for managing hypertension (HTN) in a multiethnic safety-net population. Design: Structured focus-group discussions and semistructured qualitative interviews. Background: High-quality, sustainable implementation of HTN-related EBPs can promote equitable care. Implementation challenges extend beyond individual patients to span multiple levels of context. Few studies have systematically engaged community and healthcare perspectives to inform the design of HTN intervention trials. Setting: A large safety-net healthcare system. Participants/Methods: We conducted four structured discussions with each of five race- or ethnicity-specific community action boards (CABs) to understand community members' HTN-related norms, assets, needs, and experiences across local healthcare systems. We interviewed 41 personnel with diverse roles in our partnered healthcare system to understand the system's HTN-related strengths and needs. We solicited EBP tailoring recommendations from both groups. We summarized the findings using rapid content analysis. Results: Participants identified contextual considerations spanning seven themes: social determinants, healthcare engagement, clinical interaction, system operations, standardization, patient education, and partnerships and funding. They offered tailoring recommendations spanning nine themes: addressing complex contexts, addressing social needs, system operations, healthcare system training and resources, linguistic and cultural tailoring, behavioral engagement, relational engagement, illness-course engagement, and community partnerships. Conclusions: Engaging community and healthcare informants can ground implementation in the policy, community, healthcare system, clinical, and interpersonal contexts surrounding diverse patients at risk for disparities. Such grounding can reframe inequitable implementation as a multilevel social problem facing communities and healthcare systems, rather than individuals.

A qualitative study of COVID-19 vaccine intentions and mistrust in Black Americans: Recommendations for vaccine dissemination and uptake.

BACKGROUND: COVID-19 vaccination rates among Black Americans have been lower than White Americans and are disproportionate to their population size and COVID-19 impact. This study examined reasons for low vaccination intentions and preferred strategies to promote COVID-19 vaccination. METHODS: Between November 2020 and March 2021, we conducted semi-structured interviews with 24 participants who expressed low vaccination intentions in a RAND American Life Panel survey; we also interviewed five stakeholders who represent organizations or subgroups in Black communities that have been highly affected by COVID-19. RESULTS: Many interviewees discussed the "wait-and-see" approach, citing that more time and evidence for vaccine side effects and efficacy are needed. Perceived barriers to COVID-19 vaccination included structural barriers to access (e.g., transportation, technology) and medical mistrust (e.g., towards the vaccines themselves, the government, healthcare providers and healthcare systems, and pharmaceutical companies) stemming from historical and contemporary systematic racism against Black communities. Interviewees also discussed strategies to promote COVID-19 vaccines, including acknowledging systemic racism as the root cause for mistrust, preferred messaging content (e.g., transparent messages about side effects), modes, and access points (e.g., a variety of medical and non-medical sites), and trusted information sources (e.g., trusted leaders, Black doctors and researchers). CONCLUSIONS: These insights can inform ways to improve initial and booster vaccination uptake as the COVID-19 pandemic progresses.

COVID-19 Vaccine Intentions and Mistrust in a National Sample of Black Americans.

BACKGROUND: National data indicate low intentions for COVID-19 vaccination among a substantial minority of Black Americans, and disproportionately lower vaccination rates among Black Americans than White Americans. METHODS: A total of 207 of the 318 Black participants (65%) in the RAND American Life Panel, a nationally representative internet panel, were surveyed about COVID-19 vaccine intentions in November-December 2020. Participants' census tracts were geocoded using the Centers for Disease Control and Prevention's Social Vulnerability Index. RESULTS: Overall, 35% agreed or strongly agreed that they would not get a COVID-19 vaccine, 40% agreed or strongly agreed that they would get vaccinated, and 25% reported "don't know." Significant multivariable predictors of not wanting to get vaccinated included high mistrust of the vaccine itself (e.g., concerns about harm and side effects), OR (95% CI) = 2.2 (1.2-3.9), p = .007, and weak subjective norms for vaccination in one's close social network, OR (95% CI) = 0.6 (0.4-0.7), p < .001. Residence in an area of higher socioeconomic vulnerability was a marginally significant predictor, OR (95% CI) = 3.1 (0.9-11.0), p = .08. CONCLUSIONS: High mistrust around COVID-19 vaccines may lower vaccine confidence. Social network members' attitudes can be influential in encouraging vaccination. Public health communications could use transparent and clear messaging on safety and efficacy, and acknowledge historical and ongoing discrimination and racism as understandable reasons for low confidence in COVID-19 vaccines. Future research is needed to consider vaccine access challenges in tandem with mistrust as contributing to low vaccination rates across health conditions.

Impact of Quality Improvement Program on Expressed Breastmilk Usage in Very Low Birth Weight Infants.

OBJECTIVE: To improve the usage of expressed breast milk in very low birth weight infants admitted in the neonatal intensive care unit of a tertiary centre in India. METHODS: Between April 2015 and August 2016, various Plan-do-act-study cycles were conducted to test change ideas like antenatal counselling including help of brochure and video, post-natal telephonic reminders within 4-6 hours of birth, standardization of Kangaroo mother care, and non-nutritive sucking protocol. Data was analyzed using statistical process control charts. RESULTS: 156 very low birth weight infants were delivered during the study period, of which 31 were excluded due to various reasons. Within 6 months of implementation, the proportion of very low birth weight infants who received expressed breast milk within 48 hours improved to 100% from 38.7% and this was sustained at 100% for next 8 months. The mean time of availability and volume of expressed breast milk within 48 hours, improved gradually from 73.3 h to 20.9 h and 4.7 mL to 15.8 mL, respectively. The mean proportion of expressed breast milk once infant reached a feed volume of 100 mL/kg/day also improved from 61.3% to 82.3%. CONCLUSIONS: Quality improvement interventions showed promising results of increased expressed breast milk usage in very low birth weight infants.

Durability and correlates of vaccine protection against Zika virus in rhesus monkeys.

An effective Zika virus (ZIKV) vaccine will require long-term durable protection. Several ZIKV vaccine candidates have demonstrated protective efficacy in nonhuman primates, but these studies have typically involved ZIKV challenge shortly after vaccination at peak immunity. We show that a single immunization with an adenovirus vector-based vaccine, as well as two immunizations with a purified inactivated virus vaccine, afforded robust protection against ZIKV challenge in rhesus monkeys at 1 year after vaccination. In contrast, two immunizations with an optimized DNA vaccine, which provided complete protection at peak immunity, resulted in reduced protective efficacy at 1 year that was associated with declining neutralizing antibody titers to subprotective levels. These data define a microneutralization log titer of 2.0 to 2.1 as the threshold required for durable protection against ZIKV challenge in this model. Moreover, our findings demonstrate that protection against ZIKV challenge in rhesus monkeys is possible for at least 1 year with a single-shot vaccine.

Delusion or obsession: clinical dilemma.

BACKGROUND: A 52-year old lady presented for admission with severe depression characterised by suicidal ideation and delusional belief. CASE PRESENTATION: Her treatment regime was reviewed and modified. The dilemma was whether she suffered from a psychotic depression with delusion or an obsessional disorder. She responded well to change of antipsychotic medication. CONCLUSIONS: Her depression went in remission and her delusional belief decreased in intensity. She also gained reasonable insight into her problem. She is currently being followed up in the psychiatric outpatient clinic.

Psychosis in temporal lobe epilepsy: atypical presentation.

A 55-year-old lady was admitted following a concern raised by family members who had noticed a change in behaviour in terms of declining mood, paranoia with expression of belief that she was being bugged, also reported smelling perfume and after shave lotion. She had a prior diagnosis of bipolar mood disorder and was on lithium but remained no-compliant with her prescribed medication in the 10 weeks before admission. Upon admission, necessary investigations were performed including CT scan and EEG. Her CT was normal but EEG was grossly abnormal. Neurology consultation was sought and a sleep deprived EEG and MRI was ordered. Meanwhile, carbamezipine was commenced in view of the change in diagnosis to that of temporal lobe epilepsy. The patient responded very well to this regime and improved in all spheres. She was finally discharged with follow-up appointments with both neurology and psychiatry clinics.