Interviews with parents of adolescents with intellectual and developmental disabilities in a weight management study.

BACKGROUND: Adolescents and young adults with intellectual and developmental disabilities are at risk of obesity. Parents influence their diet and physical activity behaviours and therefore, can play important roles in weight management. The aims of this qualitative study were to explore parents' experiences assisting their son or daughter to participate in a weight management study. METHODS: Interviews were completed at 6 months with 27 parents whose adolescent or young adult had completed the weight loss portion of an 18-month weight management study. Interviews were recorded, transcribed and thematic analysis performed. RESULTS: Parents shared insights about how well program components worked with their family, and what strategies worked best to adopt healthier dietary choices and become more physically active. The importance of meeting regularly with someone outside the family to encourage healthier habits was stressed. CONCLUSIONS: Future weight management studies should involve parents and their adolescents to help tailor strategies and adapt intervention approaches.

Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center.

OBJECTIVES: Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting. METHODS: We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ2 tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically. RESULTS: Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism. CONCLUSIONS: Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.

Weight management in adults with intellectual and developmental disabilities: A randomized controlled trial of two dietary approaches.

BACKGROUND: The prevalence of obesity among individuals with intellectual and developmental disabilities (IDD) is equal to or greater than the general population. METHODS: Overweight/obese adults (BMI ≥25 kg/m2 ) with mild-to-moderate intellectual and developmental disabilities were randomized to an enhanced stop light diet (eSLD = SLD + portion-controlled meals, n = 78) or a conventional diet (CD, n = 72) for an 18 months trial (6 months weight loss, 12 months maintenance). Participants were asked to increase physical activity (150 min/week), self-monitor diet and physical activity and attend counselling/educational sessions during monthly home visits. RESULTS: Weight loss (6 months) was significantly greater in the eSLD (-7.0% ± 5.0%) compared with the CD group (-3.8% ± 5.1%, p < .001). However, at 18 months, weight loss between groups did not differ significantly (eSLD = -6.7% ± 8.3%; CD = 6.4% ± 8.6%; p = .82). CONCLUSION: The eSLD and CD provided clinically meaningful weight loss over 18 months in adults with intellectual and developmental disabilities.

Physical activity and academic achievement across the curriculum: Results from a 3-year cluster-randomized trial.

We compared changes in academic achievement across 3years between children in elementary schools receiving the Academic Achievement and Physical Activity Across the Curriculum intervention (A+PAAC), in which classroom teachers were trained to deliver academic lessons using moderate-to-vigorous physical activity (MVPA) compared to a non-intervention control. Elementary schools in eastern Kansas (n=17) were cluster randomized to A+PAAC (N=9, target ≥100min/week) or control (N=8). Academic achievement (math, reading, spelling) was assessed using the Wechsler Individual Achievement Test-Third Edition (WIAT-III) in a sample of children (A+PAAC=316, Control=268) in grades 2 and 3 at baseline (Fall 2011) and repeated each spring across 3years. On average 55min/week of A+PACC lessons were delivered each week across the intervention. Baseline WIAT-III scores (math, reading, spelling) were significantly higher in students in A+PAAC compared with control schools and improved in both groups across 3years. However, linear mixed modeling, accounting for baseline between group differences in WIAT-III scores, ethnicity, family income, and cardiovascular fitness, found no significant impact of A+PAAC on any of the academic achievement outcomes as determined by non-significant group by time interactions. A+PAAC neither diminished or improved academic achievement across 3-years in elementary school children compared with controls. Our target of 100min/week of active lessons was not achieved; however, students attending A+PAAC schools received an additional 55min/week of MVPA which may be associated with both physical and mental health benefits, without a reduction in time devoted to academic instruction.

Statin-Associated Diabetes Mellitus: Review and Clinical Guide.

A small but significant link between new-onset diabetes mellitus (NOD) and statin therapy was noted with rosuvastatin users in the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin study. Since then multiple analyses have further confirmed this association, with most studies demonstrating a modest increase in NOD with statin therapy, especially among individuals with risk factors for developing diabetes mellitus. More recent observational analyses suggest a stronger correlation between statin use and NOD, however. A definitive mechanism confirming causation between statins and glucose impairment remains elusive, but many have been proposed. Although considered a class effect by the US Food and Drug Administration, most data indicate NOD is dependent upon the dose and potency of the statin, with certain agents appearing to be less diabetogenic. The consensus is that the benefits of statin therapy far outweigh the risk of NOD, especially among patients with high cardiovascular risk. Nonetheless, more studies are needed to better understand this association and long-term clinical implications. In the meantime, we provide clinicians with a practical guide to assist with clinical decision making when prescribing statin therapy. Overall, this article serves to provide the primary care physician with a timely review of the most clinically relevant data regarding statins and NOD, with hopes to ultimately optimize statin prescribing and limit any potential drug-induced glucose impairment.

Weight management in rural health clinics: Results from the randomized midwest diet and exercise trial.

Introduction: Rural living adults have higher rates of obesity compared with their urban counterparts and less access to weight management programs. Previous research studies have demonstrated clinically relevant weight loss in rural living adults who complete weight management programs delivered by university affiliated interventionists. However, this approach limits the potential reach, adoption, implementation, and maintenance of weight management programs for rural residents. Weight management delivered through rural health clinics by non-physician clinic associated staff, for example, nurses, registered dieticians, allied health professionals, etc. has the potential to improve access to weight management for rural living adults. This trial compared the effectiveness of a 6-month multicomponent weight management intervention for rural living adults delivered using group phone calls (GP), individual phone calls (IP) or an enhanced usual care control (EUC) by rural clinic associated staff trained by our research team. Methods: Rural living adults with overweight/obesity (n = 187, age âˆ¼ 50 years 82% female, body mass index ∼35 kg/m2) were randomized (2:2:1) to 1 of 3 intervention arms: GP, which included weekly âˆ¼ 45 min sessions with 7-14 participants (n = 71), IP, which included weekly âˆ¼ 15 min individual sessions (n = 80), or EUC, which included one-45 min in-person session at baseline. Results: Weight loss at 6 months was clinically relevant, that is, ≥5% in the GP (-11.4 kg, 11.7%) and the IP arms (-9.1 kg, 9.2%) but not in the EUC arm (-2.6%, -2.5% kg). Specifically, 6 month weight loss was significantly greater in the IP versus EUC arms (-6.5 kg. p ≤ 0.025) but did not differ between the GP and IP arms (-2.4 kg, p > 0.025). The per participant cost per kg. weight loss for implementing the intervention was $93 and $60 for the IP and GP arms, respectively. Conclusions: Weight management delivered by interventionists associated with rural health clinics using both group and IP calls results in clinically relevant 6 months weight loss in rural dwelling adults with overweight/obesity with the group format offering the most cost-effective strategy. Clinical trial registration: ClinicalTrials.gov (NCT02932748).

Physical activity and academic achievement across the curriculum (A + PAAC): rationale and design of a 3-year, cluster-randomized trial.

BACKGROUND: Improving academic achievement and reducing the rates of obesity in elementary school students are both of considerable interest. Increased physical activity during academic instruction time during school offers a potential intervention to address both issues. A program titled "Physical Activity Across the Curriculum" (PAAC) was developed in which classroom teachers in 22 elementary schools were trained to deliver academic instruction using physical activity with a primary aim of preventing increased BMI. A secondary analysis of data assessed the impact of PAAC on academic achievement using the Weschler Individual Achievement Test-II and significant improvements were shown for reading, math and spelling in students who participated in PAAC. Based on the results from PAAC, an adequately powered trial will be conducted to assess differences in academic achievement between intervention and control schools called, "Academic Achievement and Physical Activity Across the Curriculum (A + PAAC)." METHODS/DESIGN: Seventeen elementary schools were cluster randomized to A + PAAC or control for a 3-year trial. Classroom teachers were trained to deliver academic instruction through moderate-to-vigorous physical activity with a target of 100+ minutes of A + PAAC activities per week. The primary outcome measure is academic achievement measured by the Weschler Individual Achievement Test-III, which was administered at baseline (Fall 2011) and will be repeated in the spring of each year by assessors blinded to condition. Potential mediators of any association between A + PAAC and academic achievement will be examined on the same schedule and include changes in cognitive function, cardiovascular fitness, daily physical activity, BMI, and attention-to-task. An extensive process analysis will be conducted to document the fidelity of the intervention. School and student recruitment/randomization, teacher training, and baseline testing for A + PAAC have been completed. Nine schools were randomized to the intervention and 8 to control. A random sample of students in each school, stratified by gender and grade (A + PAAC = 370, Control = 317), was selected for outcome assessments from those who provided parental consent/child assent. Baseline data by intervention group are presented. DISCUSSION: If successful, the A + PAAC approach could be easily and inexpensively scaled and disseminated across elementary schools to improve both educational quality and health. FUNDING SOURCE: R01- DK85317. TRIAL REGISTRATION: US NIH Clinical Trials, http://NCT01699295.

Controlled aerobic exercise training reduces resting blood pressure in sedentary older adults.

The results of existing controlled clinical trials were synthesized to determine effects of aerobic exercise training on resting systolic (SBP) and diastolic blood pressure (DBP) among previously sedentary older adults, to quantify the magnitude of observed changes, and to examine the influence of the associated interventional variables on these changes. Studies were identified via a systematic computer database search, hand searching, and cross-referencing of previously located articles. All potentially eligible articles were carefully reviewed and examined with the established inclusion criteria. Twenty-three studies, representing a total of 1226 older subjects, were included in the final analysis. Robust statistically significant effects were found in terms of the pooled standardized effect size of - 0.33 ± 0.06 (p < 0.0001) in SBP and - 0.39 ± 0.09 (p < 0.0001) in DBP. When compared with the control group, net decreases in both SBP (- 5.39 ± 1.21 mmHg, p < 0.0001) and DBP (-3.68 ± 0.83 mmHg, p < 0.0001) were observed in older exercisers, representing a 3.9% and a 4.5% reduction, respectively. This meta-analytic study provides robust quantitative data to support the efficacy and effectiveness of controlled endurance exercise training in decreasing resting SBP and DBP among previously sedentary older adults.

A 6-month trial of resistance training with milk supplementation in adolescents: effects on body composition.

Fluid milk consumed in conjunction with resistance training (RT) provides additional protein and calcium, which may enhance the effect of RT on body composition. However, the literature on this topic is inconsistent with limited data in adolescents. Therefore, we examined the effects of a supervised RT program (6 mo, 3 d/ wk, 7 exercises, 40-85% 1-repetition maximum) with daily milk supplementation (24 oz/day, one 16-oz dose immediately post-RT) on weight, fat mass (FM), and fat-free mass (FFM) assessed via dual-energy X-ray absorptiometry (baseline, 3 mo, 6 mo) in a sample of middle-school students who were randomly assigned to 1 of 3 supplement groups: milk, isocaloric carbohydrate (100% fruit juice), or water (control). Thirty-nine boys and 69 girls (mean age = 13.6 yr, mean BMI percentile = 85th) completed the study: milk n = 36, juice n = 34, water n = 38. The results showed no significant differences between groups for change in body weight (milk = 3.4 ± 3.7 kg, juice = 4.2 ± 3.1 kg, water = 2.3 ±2.9 kg), FM (milk = 1.1 ±2.8 kg, juice = 1.6 ± 2.5 kg, water = 0.4 ±3.6 kg), or FFM (milk = 2.2 ± 1.9 kg, juice = 2.7 ± 1.9 kg, water = 1.7 ± 2.9 kg) over 6 mo. FFM accounted for a high proportion of the increased weight (milk = 62%, juice = 64%, water = 74%). These results from a sample of predominantly overweight adolescents do not support the hypothesis that RT with milk supplementation enhances changes in body composition compared with RT alone.

The impact of pulmonary cachexia on inpatient outcomes: A national study.

BACKGROUND: Cachexia has been associated with chronic lung disease (pulmonary cachexia syndrome), which is associated with increased mortality. However, studies that looked into this association was relatively small, and national level data are lacking. Herein, we aim to study the association between chronic obstructive lung disease (COPD) and cachexia. RESEARCH QUESTION: Do patients with COPD and cachexia has worse inpatient outcomes in comparison to those with no cachexia? STUDY DESIGN AND METHODS: We used the Nationwide Readmissions Database from 2016 to 2019, extracting adult patients with a primary diagnosis of COPD who were admitted between January and November of each year studied. We excluded patients with missing data on event time or length of stay. Furthermore, we excluded all cases with cormobidities associated with cachexia. We used SAS 9.4 for data exploration and analysis. RESULTS: We included 1,446,431 COPD-related weighted hospitalizations for which 115,276 cases (7.9%) had a concurrent diagnosis of cachexia (or cachexia-related diagnoses). Overall, patients with cachexia (COPD-C), compared to patients with COPD and no cachexia (COPD-NC), were older (mean age 69 vs. 66 years, respectively, P < 0.001) with similar gender distribution (58%). COPD-C patients had more inpatient complications including cardiac arrest, and use of mechanical ventilation (P < 0.001). Furthermore, they had longer mean lengths of stay (5.2 days vs. 3.8 days, P < 0.001). In-hospital mortality during index, admission was significantly higher in these patients at 2.2% compared to 0.5% for COPD-NC (P < 0.001). CONCLUSION: COPD-related cachexia is associated with increased inpatient mortality, resource utilization, and prolonged hospitalization.

Atherosclerotic Cardiovascular Disease in Women: Providing Protection With Lipid-altering Agents.

PURPOSE: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in women, yet it remains underdiagnosed, undertreated, and understudied in women compared with men. Although estrogen has provided observational evidence of cardioprotection, randomized controlled trials using hormone replacement therapy have generally produced unfavorable results. METHODS: For this narrative review, a literature search was performed using the key words cardiovascular disease, women, and dyslipidemia in PubMed and Google Scholar with no date limitations. References within each article were also reviewed for additional relevant articles. FINDINGS: Sex-specific risk factors and underrecognized conditions more predominant in women elevate ASCVD risk, creating further clinical challenges, such as the need for accurate risk stratification, compared with in men. Dyslipidemia frequently manifests or worsens during the menopausal transition. Therefore, identification during midlife and implementing lipid-lowering strategies to reduce ASCVD risk is imperative. Women have historically been poorly represented in cardiovascular (CV) outcome trials. However, more recent studies and meta-analyses have indicated that lipid-lowering therapies are equally effective in women and produce similar reductions in CV events and total mortality. Major cholesterol guidelines address many of the challenges that clinicians face when assessing ASCVD risk in women. Key points specific to women include obtaining a detailed history of pregnancy-related conditions, identification of common autoimmune disorders associated with systemic inflammation, and use of 10-year ASCVD risk calculators and imaging modalities (coronary artery calcium) to optimize ASCVD assessment. In terms of treatment, similar to men, women with existing ASCVD or high-risk primary prevention patients should be treated aggressively to achieve ≥50% LDL-C reductions and/or LDL-C goals as low as <55 mg/dL. Appropriate lipid-lowering therapies include high-intensity statins with or without ezetimibe and proprotein convertase subtilisin kexin/type 9 inhibitors. Women with lower ASCVD risk may be considered for low- to moderate-intensity statin therapy (approximately 30%-50% LDL-C reduction). All women, regardless of ASCVD risk category, should implement therapeutic lifestyle changes, which improve many common age-related cardiometabolic conditions. IMPLICATIONS: Although ASCVD and current risk factor trends in women are concerning, numerous evidence-based approaches are available to protect women with ASCVD risk from life-changing CV events.

Inpatient Outcomes for Myocarditis-Related Heart Failure.

Background Heart failure (HF) is one of the leading causes of hospitalizations among adults, accounting for high rates of morbidity and mortality in the United States. Myocarditis is a less common etiology of HF, and its outcomes are less well understood. Methods We used the Nationwide Readmissions Database from 2016 to 2019, extracting adult patients with a primary diagnosis of HF who were admitted between January and November of each year studied. We excluded patients with missing data on event time or length of stay. Inpatient outcomes were compared between cases of HF without myocarditis and myocarditis-associated HF (MAHF). Survey procedures were applied. Propensity scores as covariates were used in survey-weighted models to estimate the population average treatment effect on the treated using SAS 9.4. Results We included 4,454,272 HF-related weighted admissions for which 4,605 patients (0.1%) had a concurrent diagnosis of myocarditis. Overall, patients with MAHF, compared with HF without myocarditis, were younger (mean age: 53 years vs. 72 years, p < 0.001) with fewer women (45 vs. 48%), respectively. Patients with MAHF had more inpatient complications including cardiac arrest, cardiogenic shock, and use of mechanical circulatory support ( p < 0.001) despite having fewer comorbidities such as diabetes, hypertension, and renal disease. Patients with MAHF had longer mean lengths of stay (9.2 vs. 5.5 days, p < 0.001). In-hospital mortality during index admission was significantly higher in MAHF at 3.9% compared with 2.8% for HF without myocarditis ( p < 0.001). Myocarditis was a key predictor of inpatient mortality adjusting for risk factors. Conclusion Myocarditis-related HF is associated with increased inpatient mortality, resource utilization, and prolonged hospitalization.

Cachexia Is Associated With Adverse Outcomes in Patients Admitted With Heart Failure.

Cachexia is often seen in patients with heart failure (HF). This study aimed to examine the association between cachexia and clinical outcomes in patients hospitalized for HF. We extracted all adult cases with a primary diagnosis of HF that were discharged between January and November, identified in the Nationwide Readmissions Database for 2016 through 2019. Exclusion criteria included cases with missing data or a diagnosis of acquired immunodeficiency syndrome, advanced liver disease, end-stage renal disease, chronic lung disease, or malignancy. Appropriate weighting was used to obtain national estimates. Primary outcomes were inpatient mortality, length of stay, and 30-day readmission in patients with HF with cachexia compared with patients with no cachexia. Multivariable logistic regression was used to estimate the association between cachexia and clinical outcomes. Survey procedures were applied using Statistical Analysis Software 9.4. The final analysis included 2,360,307 HF-related hospitalizations. Cachexia was present in about 7% of the study population. A greater percentage of patients with cachexia were female and older than patients without cachexia (52% vs 47% female, the mean age of 77 vs 72 years, respectively). However, after adjusting for demographics and co-morbidities, including coronary artery disease and atrial fibrillation, patients with cardiac cachexia had higher inpatient mortality (odds ratio 3.01, 95% confidence interval 2.88 to 3.15, p <0.001), prolonged hospital stays (9 vs 5 days, p <0.0001), and greater all-cause 30-day readmissions (23% vs 21%, p <0.0001). HF-related cachexia is associated with increased inpatient mortality, greater resource use, and additional healthcare costs.

Developing a Healthy Lifestyle Program for Recent Kidney Transplant Recipients.

INTRODUCTION: Many kidney transplant recipients experience weight gain in the first year after transplantation. RESEARCH QUESTION: The objective of this research study was to assess the desires of recent kidney transplant patients about the design features of a healthy lifestyle program to counter unnecessary weight gain. DESIGN: In this descriptive study, recent recipients at 2 transplant centers were invited to participate in an online survey. Survey items included sociodemographic information, current medications, health conditions, weight change posttransplant, diet behaviors, physical activity participation, and desired features of a lifestyle program. RESULTS: Fifty-three participants, mean age 60.5 (11.2) years, primarily males, completed surveys. Forty percent gained weight posttransplantation with many indicating struggling with their diet. Physical activity levels stayed the same (17%) or decreased (40%) posttransplantation. Eighty-seven percent of participants indicated they would participate in an online lifestyle program and 76% wanted online physical activity and nutrition sessions to meet at least once weekly. Suggestions about the type of information and activities, included eating strategies (eg, how to eat healthfully at restaurants, grocery shopping tips, and recipes), resources for at-home physical activities, access to cooking classes, and apps to track both activity and food intake. CONCLUSION: Recent kidney transplant recipients would benefit from and desired to join a lifestyle program featuring tailored nutrition education and physical activity coaching. Gathered information will be used to inform and tailor a lifestyle program. Identifying features for the prevention of unnecessary weight gain with patients' input is essential for promoting and sustaining healthy behaviors.

Assessing the Immunization Information System and electronic health record interface accuracy for COVID-19 vaccinations.

Objective: Our objective is to assess the accuracy of the COVID-19 vaccination status within the electronic health record (EHR) for a panel of patients in a primary care practice when manual queries of the state immunization databases are required to access outside immunization records. Materials and Methods: This study evaluated COVID-19 vaccination status of adult primary care patients within a university-based health system EHR by manually querying the Kansas and Missouri Immunization Information Systems. Results: A manual query of the local Immunization Information Systems for 4114 adult patients with "unknown" vaccination status showed 44% of the patients were previously vaccinated. Attempts to assess the comprehensiveness of the Immunization Information Systems were hampered by incomplete documentation in the chart and poor response to patient outreach. Conclusions: When the interface between the patient chart and the local Immunization Information System depends on a manual query for the transfer of data, the COVID-19 vaccination status for a panel of patients is often inaccurate.

A randomized trial comparing diet and delivery strategies for weight management in adolescents with intellectual disabilities.

BACKGROUND: The literature evaluating multi-component interventions for long-term weight loss in adolescents with intellectual disabilities (ID) is extremely limited. OBJECTIVES: To compare the effectiveness of two delivery strategies, face-to-face (FTF) or remote delivery (RD), and two diets, enhanced Stop Light diet (eSLD) or conventional diet (CD) on weight change across 12 and 18 months. in response to an 18 months. weight management intervention (6 months Weight loss/12 months. Weight maintenance) in adolescents with ID. METHODS: Adolescents with ID were randomized to one of three arms: FTF /CD, RD/CD, RD/eSLD and asked to attend individual education sessions with a health educator which were delivered during FTF home visits or remotely using video conferencing. The CD followed the US dietary guidelines. The eSLD utilized the Stop Light guide and was enhanced with portion-controlled meals. Participants were also asked to increase their physical activity (PA) and to self-monitor diet, PA and body weight across the 18-month. RESULTS: Weight was obtained from 92(84%) and 89(81%) randomized adolescents at 12 and 18 months, respectively. Weight change across 12 months. Differed significantly by diet (RD/eSLD: -7.0% vs. RD/CD: -1.1%, p = 0.002) but not by delivery strategy (FTF/CD: +1.1% vs. RD/CD: -1.1%, p = 0.21). Weight change across 18 months. Was minimal in all intervention arms and did not differ by diet (RD/eSLD: -2.6% vs. RD/CD: -0.5%; p = 0.28) or delivery strategy (FTF/CD: +1.6% vs. RD/CD: -0.5%; p = 0.47). CONCLUSIONS: Additional research is required to identify effective strategies to improve long-term weight loss in adolescents with ID.

Clinical outcomes of coronavirus disease 2019 in liver transplant recipients.

BACKGROUND: Liver transplant patients are at higher risk of infection due to immunosuppression. Whether liver transplant recipients are also more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and will have worse outcomes than the general population if they develop coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 is a topic of ongoing studies, including ours. AIM: To assess the clinical outcomes of COVID-19 in liver transplant recipients. METHODS: This was a case-control study, with a database search performed (at the study site) from March 1, 2020 through February 28, 2021. Patients 18 years or older who tested positive for SARS-CoV-2 via polymerase chain reaction (PCR) were included in the study. Patients with infection other than pneumonia at the time of admission were excluded. After selection, patients who had been the recipient of liver transplant were considered cases and those without as controls. After being matched by age, sex, and obesity, two controls were randomly selected for each case. Death and hospitalization due to COVID-19 infection were the primary outcomes. Secondary outcomes were pertinent only to patients who were hospitalized, and they included duration of hospital stay, need for supplemental oxygen, presence of at least one type of end-organ damage, effects on liver enzymes, incidence of acute liver failure, effect on d-dimer levels, and incidence of venous thromboembolism (VTE). Chi-square or Fisher's exact test was used to compare all primary and secondary outcomes with the exception of duration of hospital stay and d-dimer levels, which were compared using the Wilcoxon signed-rank test. Alpha criterion was set at 0.05. Logistic regression was performed for each primary outcome (as the dependent variable). Statistical analyses were performed using R software. RESULTS: Of the 470 Liver transplant recipients who were tested for COVID-19 via the PCR test, 39 patients tested positive (8.3%). There was no significant difference between cases and controls regarding death [odds ratio (OR): 2.04, 95% confidence interval (CI): 0.14-29.17; P = 0.60] and hospitalization rates (OR: 1.38, 95%CI: 0.59-3.24; P = 0.46). There also was no significant difference between cases and controls with respect to all secondary outcomes. Among all patients who had elevated liver enzymes, their levels were either normalized, improving, or remained stable at the time of discharge. No patient developed acute liver failure. Of the 31 hospitalized patients, 27 received a prophylactic anticoagulation dose and no patient developed VTE in either group. Among cases who were hospitalized, immunosuppression was decreased in 5 patients and there was no change in immunosuppression among the remaining 7 patients. One patient died in each of these two subgroups. Logistic regression analysis was done, but all of the models had poor model predictions as well as insignificant predictors (independent variables). Therefore, they could not be used for either prediction or inference. CONCLUSION: Clinical outcomes of COVID-19 in liver transplant recipients are not different than those without transplantation. COVID-19 should not impact timely health care access and immunosuppression continuation among these patients.

Risk stratification of patients who present with chest pain and have normal troponins using a machine learning model.

BACKGROUND: Risk stratification tools exist for patients presenting with chest pain to the emergency room and have achieved the recommended negative predictive value (NPV) of 99%. However, due to low positive predictive value (PPV), current stratification tools result in unwarranted investigations such as serial laboratory tests and cardiac stress tests (CSTs). AIM: To create a machine learning model (MLM) for risk stratification of chest pain with a better PPV. METHODS: This retrospective cohort study used de-identified hospital data from January 2016 until November 2021. Inclusion criteria were patients aged > 21 years who presented to the ER, had at least two serum troponins measured, were subsequently admitted to the hospital, and had a CST within 4 d of presentation. Exclusion criteria were elevated troponin value (> 0.05 ng/mL) and missing values for body mass index. The primary outcome was abnormal CST. Demographics, coronary artery disease (CAD) history, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, obesity, and smoking were evaluated as potential risk factors for abnormal CST. Patients were also categorized into a high-risk group (CAD history or more than two risk factors) and a low-risk group (all other patients) for comparison. Bivariate analysis was performed using a χ 2 test or Fisher's exact test. Age was compared by t test. Binomial regression (BR), random forest, and XGBoost MLMs were used for prediction. Bootstrapping was used for the internal validation of prediction models. BR was also used for inference. Alpha criterion was set at 0.05 for all statistical tests. R software was used for statistical analysis. RESULTS: The final cohort of the study included 2328 patients, of which 245 (10.52%) patients had abnormal CST. When adjusted for covariates in the BR model, male sex [risk ratio (RR) = 1.52, 95% confidence interval (CI): 1.2-1.94, P < 0.001)], CAD history (RR = 4.46, 95%CI: 3.08-6.72, P < 0.001), and hyperlipidemia (RR = 3.87, 95%CI: 2.12-8.12, P < 0.001) remained statistically significant. Incidence of abnormal CST was 12.2% in the high-risk group and 2.3% in the low-risk group (RR = 5.31, 95%CI: 2.75-10.24, P < 0.001). The XGBoost model had the best PPV of 24.33%, with an NPV of 91.34% for abnormal CST. CONCLUSION: The XGBoost MLM achieved a PPV of 24.33% for an abnormal CST, which is better than current stratification tools (13.00%-17.50%). This highlights the beneficial potential of MLMs in clinical decision-making.

Millennials Seeking Healthcare: Examining the Degree to Which Patients Utilize Online Resources.

Introduction: According to the 2020 U.S. Census, a Silver Tsunami is looming, with more than 75.4 million persons aged 57 to 75 expected to need more costly medical care. However, a larger wave of 83.1 million Millennials nearing adulthood is approaching rapidly. Therefore, it is important to understand how this population finds their physician and what may influence this decision. Methods: Paper-based surveys were administered to adult patients at primary care and geriatric clinics located at the University of Kansas Medical Center in Kansas City, Kansas. Questions included demographic information, utilization and influence of online reviews, and the effects negative and positive reviews have on a patient's choice of physician. Descriptive statistics were calculated for respondent characteristics and survey responses. Chi-square and McNemar's tests were performed to evaluate differences between age and gender groups, and to determine how influential review ratings are in choosing a physician for medical care. Statistical significance was determined at the 0.05 level. Results: A sample of 284 patients completed the survey (44.35 ± 17.54 years old [range = 18-90], 60.6% female, 57.4% white). Of Millennials, 67.2% read online reviews before choosing a physician. Millennials were significantly more likely to read online reviews before choosing a physician (p = 0.004) and utilize online resources to search for a new physician (p < 0.001) than older patients. Conclusions: Millennials were more likely to research online reviews before choosing a physician. Therefore, an online review presence will be beneficial to one's practice to acquire this new wave of patients.

Identifying patient perceptions and attitudes regarding statin-associated diabetes mellitus: a mixed-methods study.

Aim: The aims of this study were to explore factors that influence initiation and continuation of statin therapy. Patients & methods: Mixed-method design employed with 73 patients completing surveys and 14 patients participating in semi-structured interviews. Results: When lower total cholesterol is achieved, patients' views are favorable while views of statin therapy diminish among those with higher total cholesterol values. All patients are concerned with adverse events including the potential for developing diabetes. However, overall patients believe the benefits of statins outweigh the risk of diabetes. Conclusion: Barriers remain that prevent patients from achieving cholesterol goals and maintaining or initiating statin therapy. Effective strategies to provide accurate information about the risks and benefits of statin therapy, and implementation of shared decision-making to improve medication adherence and persistence are needed.

The statin medications are commonly prescribed agents used to lower cholesterol and prevent cardiovascular events, such as heart attacks. Although these medications are prescribed often, researchers and clinicians have limited understanding regarding the influences involving patients' decision to start or stop a statin. This study was conducted to gain insight on patients' beliefs and attitudes involving statin therapy. We observed that when patients' had lower cholesterol values, favorable views of statins were more common, while views became less favorable when cholesterol levels were higher. All patients were concerned about statin-associated side effects; but overall believed that the benefits of statins outweighed the risks. It is essential that patients' are provided accurate information from their healthcare team regarding the advantages and disadvantages of statin therapy. Such discussions may allow patients to make more informed decisions and help with continuing a statin long term.