Droplet Size and Distribution of Nebulized 3% Sodium Chloride, Albuterol, and Epoprostenol by Phase Doppler Particle Analyzer.

BACKGROUND: Aerosolized drug therapy administered to mechanically ventilated patients is a standard part of pulmonary critical care medicine. Aerosol particle size and distribution are important factors in the optimal delivery of aerosolized drugs to ventilated patients. OBJECTIVE: The objective of this study was to characterize aerosol droplet size and distribution with laser diffraction for nebulized 3% sodium chloride, albuterol, and epoprostenol sodium (containing glycine) delivered via Aeroneb Solo Mesh Nebulizers (Aerogen, Mountain View, California). METHODS: A series of functional flow tests were run on each of 8 Solo mesh nebulizers before the study to verify accuracy of flow rates in milliliters per minute. Aerosolized droplets exiting the nebulizer heads were then measured using a phase Doppler particle analyzer. Data collected during delivery of 3% sodium chloride, albuterol, and epoprostenol sodium included aerosol droplet size distribution, mass median aerodynamic diameter (MMAD), and geometric standard deviation. For each Solo nebulizer, droplet size measurements were taken 2 cm away from the nebulizer head and 2 cm away from the wye of a heated, humidified adult ventilator circuit. For measurements taken at the wye, 4 distinct, continuous flow rates (2, 10, 20, and 40 L/min) were generated by an air pump to simulate inspiratory flows delivered with mechanical ventilation. The expiratory limb was capped, and the nebulizer head was inserted into the breathing circuit upstream of the humidifier. RESULTS: Each Solo nebulizer met Aerogen's recommended minimum flow rate of 0.2 mL/min, ranging from 0.23 to 0.31 mL/min. The MMAD of the 3 tested aerosols was several times smaller when measured at the wye outlet of the heated/humidified breathing circuit (0.82-2.73 µm) compared with droplets measured directly at the nebulizer outlet (MMAD, 4.6-7.3 µm). There was also significant variability across Solo heads with some ventilator flow rates. The mean MMAD at the wye for the 3% sodium chloride solution, albuterol, and epoprostenol test solutions was 1.62 µm, 1.09 µm, and 1.18 µm, respectively. The mean MMAD at the nebulizer for the 3% sodium chloride solution, albuterol, and epoprostenol test solutions was 5.37 µm, 5.73 µm, and 6.73 µm, respectively. CONCLUSIONS: Results from this study suggest that particle size of aerosolized drugs administered via a commonly used setup for delivery of in-line aerosols to mechanically ventilated patients may be several times smaller than expected and may result in less drug being delivered to the patient than previously realized.(Curr Ther Res Clin Exp. 2021; 82:XXX-XXX)© 2021 Elsevier HS Journals, Inc.

Prevalence and correlates of 25-hydroxyvitamin D deficiency in the Chronic Kidney Disease in Children (CKiD) cohort.

BACKGROUND: Vitamin D plays an important role in the mineral and bone disorder seen in chronic kidney disease (CKD). Deficiency of 25-hydroxyvitamin D (25OHD) is highly prevalent in the adult CKD population. METHODS: The prevalence and determinants of 25OHD deficiency (defined as a level <20 ng/ml) were examined longitudinally in 506 children in the CKiD cohort. Predictors of secondary hyperparathyroidism and the determinants of 1,25-dihydroxyvitamin D (1,25(OH)2D) levels were also evaluated. RESULTS: Deficiency of 25OHD was observed in 28 % of the cohort at enrollment. Significant predictors of 25OHD deficiency were older age, non-white race, higher body mass index, assessment during winter, less often than daily milk intake, non-use of nutritional vitamin D supplement and proteinuria. Lower values of glomerular filtration rate (GFR), serum 25OHD, calcium and higher levels of FGF23 were significant determinants of secondary hyperparathyroidism. Lower GFR, low serum 25OHD, nephrotic-range proteinuria, and high FGF23 levels were significant determinants of serum 1,25(OH)2 D levels. CONCLUSIONS: Deficiency of 25OHD is prevalent in children with CKD and is associated with potentially modifiable risk factors such as milk intake, nutritional vitamin D supplement use, and proteinuria. 25OHD deficiency is a risk factor for secondary hyperparathyroidism and decreased serum 1,25(OH)2D in children with CKD.

Appropriateness and acceptability of a Tele-Yoga intervention for people with heart failure and chronic obstructive pulmonary disease: qualitative findings from a controlled pilot study.

BACKGROUND: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are highly prevalent and associated with a large symptom burden, that is compounded in a dual HF-COPD diagnosis. Yoga has potential benefit for symptom relief; however functional impairment hinders access to usual yoga classes. We developed a Tele-Yoga intervention and evaluated it in a controlled pilot trial. This paper reports on the appropriateness and acceptability of the intervention and the evaluation design. METHODS: A controlled, non-randomised trial was conducted of an 8-week Tele-Yoga intervention versus an educational control (information leaflets mailed to participants with one phone call a week). Biweekly one-hour Tele-Yoga classes were implemented via multipoint videoconferencing that connected participants to live classes via an Internet connection to their televisions. Semi-structured qualitative interviews were conducted with participants post study exit to explore reasons for and experiences of participating, including views of study outcome measures and physiological tests. Transcribed interviews were analysed using thematic content analysis. RESULTS: Fifteen people participated in the pilot study (7 in the intervention group, 8 in the control). Of these, 12 participants were interviewed, 6 in each group, mean age 71.2 years (SD 10.09); 3 were male. Themes are reported in the following categories: acceptability and appropriateness of the intervention, potential active ingredients of the intervention, acceptability and appropriateness of the control, participation in the research, and acceptability of the testing procedures. The intervention was acceptable and appropriate: the intervention group reported enjoying yoga and valuing the home-based aspect and participants described a high symptom burden and social isolation. However, technological problems resulted in poor video-streaming quality for some participants. Potential active ingredients included physical postures, breathing exercises and guidance in relaxation and meditation. The educational control intervention was acceptable and appropriate, with participants reporting little effect on their well-being and no impact on mechanisms hypothesised to explain yoga's effectiveness. The questionnaires and home physiological testing were acceptable to participants. CONCLUSIONS: Tele-Yoga is an acceptable and appropriate intervention in people with HF and COPD and further research is warranted to refine the technology used in its delivery. Findings provide guidance for researchers working in tele-interventions, yoga, and similar populations. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02078739 (4 March 2014).

Training in ChiRunning to reduce blood pressure: a randomized controlled pilot study.

BACKGROUND: People with prehypertension (120-130/80-90 mmHg) are at increased risk of progressing to hypertension. Recommendations for prehypertension include engaging in regular physical activity. We aimed to assess feasibility and acceptability and collect preliminary outcome data on ChiRunning for people with elevated blood pressure. ChiRunning is a commercially available running program based on the mindful movements of Tai Chi, which is aimed at decreasing injury by both increasing body awareness and modifying running form. METHODS: We enrolled adults with elevated systolic (130-150 mmHg) or diastolic (80-100 mmHg) blood pressure in a 12-week pilot trial. Participants were randomized 2:1:1 to 8 weeks of: 1) intervention-a trainer-led ChiRunning group (n = 10); 2) active control-a trainer-led running group (n = 6); or 3) educational control-a self-directed running group (n = 6) and followed for 4 more weeks. The active control and educational control groups were combined for analysis. RESULTS: This study was feasible, meeting recruitment, retention and adherence goals, and acceptable to participants. Systolic and diastolic blood pressure did not change significantly over the study for either the ChiRunning or control groups. Changes in BMI over time were significantly different from zero in the ChiRunning group (p = 0.04) but not in the control group (slope for ChiRunning -0.05 [-0.1 to -0.002] vs. control -0.01 [-0.06 to 0.04], between slope difference, p = 0.22). Self-reported running-related injury (i.e. discomfort leading to a decrease in running) was similar between groups (ChiRunning, 4 [1.2 to 8.4] vs. control, 3 [0.7 to 7.1] injuries per 100 h of running, p = 0.72) although self-reported running-related discomfort (i.e. discomfort that does not lead to changes in running) trended higher in the ChiRunning group (ChiRunning, 10 [5.4 to 16.8] vs. control, 4 [1.5 to 9] reports of discomfort per 100 h of running, p = 0.06). CONCLUSION: ChiRunning appears to be a feasible and acceptable exercise program for people with elevated blood pressure. We did not find that ChiRunning had a significant impact on blood pressure or self reported injury, but did see a positive change in BMI over time. ChiRunning warrants further investigation in a larger trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01587183.

Pelvic pain and mode of delivery.

OBJECTIVE: We sought to determine the long-term effect of mode of delivery on the prevalence and severity of pelvic pain. STUDY DESIGN: Six to eleven years after a first delivery, pelvic pain (dysmenorrhea, dyspareunia, and pelvic pain not related to menses or intercourse) was measured using the Oxfordshire Women's Health Study Questionnaire. Obstetrical exposures were assessed by review of the hospital delivery record. The prevalence of moderate to severe pelvic pain was compared between the 577 women who delivered via cesarean for all births and the 538 who delivered at least 1 child vaginally. Other obstetrical exposures were also studied. RESULTS: Prevalence of pelvic pain was similar between women who delivered vaginally and by cesarean. Among women who delivered vaginally, those who experienced at least 1 forceps delivery and women who delivered at least 1 baby ≥4 kg vaginally reported a higher rate of dyspareunia. Perineal trauma was not associated with dyspareunia. CONCLUSION: Forceps delivery and a vaginal delivery of a baby ≥4 kg are associated with dyspareunia 6-11 years after vaginal birth. Vaginal birth is not associated with a higher rate of pelvic pain when compared to cesarean delivery.

Growth in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children Study.

BACKGROUND: Growth failure is common among children with chronic kidney disease (CKD). We examined the relationship of growth parameters with glomerular filtration rate (GFR), CKD diagnosis, sex and laboratory results in children with CKD. METHODS: Baseline data from 799 children (median age 11.0 years, median GFR 49.9 mL/min/1.73 m(2)) participating in the Chronic Kidney Disease in Children Study were examined. Growth was quantified by age-sex-specific height, weight, body mass index (BMI-age), and height-age-sex-specific BMI (BMI-height-age) standard deviation scores (SDS). RESULTS: Median height and weight SDS were -0.55 [interquartile range (IQR) -1.35 to 0.19] and 0.03 (IQR -0.82 to 0.97), respectively. Girls with non-glomerular CKD were the shortest (median height SDS -0.83; IQR -1.62 to -0.02). Compared to those with a serum bicarbonate (CO2) level of ≥ 22 mEq/L, children with CO2 of <18 mEq/L had a height SDS that was on average 0.67 lower [95 % confidence interval (CI) -0.31 to -1.03]. Only 23 % of children with a height SDS of ≤-1.88 were prescribed growth hormone therapy. Forty-six percent of children with glomerular CKD were overweight or obese (BMI-height-age ≥ 85th percentile). CONCLUSIONS: Growth outcomes in a contemporary cohort of children with CKD remain suboptimal. Interventions targeting metabolic acidosis and overcoming barriers to recombinant human growth hormone usage may improve growth in this population.

A yoga intervention for type 2 diabetes risk reduction: a pilot randomized controlled trial.

BACKGROUND: Type 2 diabetes is a major health problem in many countries including India. Yoga may be an effective type 2 diabetes prevention strategy in India, particularly given its cultural familiarity. METHODS: This was a parallel, randomized controlled pilot study to collect feasibility and preliminary efficacy data on yoga for diabetes risk factors among people at high risk of diabetes. Primary outcomes included: changes in BMI, waist circumference, fasting blood glucose, postprandial blood glucose, insulin, insulin resistance, blood pressure, and cholesterol. We also looked at measures of psychological well-being including changes in depression, anxiety, positive and negative affect and perceived stress. Forty-one participants with elevated fasting blood glucose in Bangalore, India were randomized to either yoga (n = 21) or a walking control (n = 20). Participants were asked to either attend yoga classes or complete monitored walking 3-6 days per week for eight weeks. Randomization and allocation was performed using computer-generated random numbers and group assignments delivered in sealed, opaque envelopes generated by off-site study staff. Data were analyzed based on intention to treat. RESULTS: This study was feasible in terms of recruitment, retention and adherence. In addition, yoga participants had significantly greater reductions in weight, waist circumference and BMI versus control (weight -0.8 ± 2.1 vs. 1.4 ± 3.6, p = 0.02; waist circumference -4.2 ± 4.8 vs. 0.7 ± 4.2, p < 0.01; BMI -0.2 ± 0.8 vs. 0.6 ± 1.6, p = 0.05). There were no between group differences in fasting blood glucose, postprandial blood glucose, insulin resistance or any other factors related to diabetes risk or psychological well-being. There were significant reductions in systolic and diastolic blood pressure, total cholesterol, anxiety, depression, negative affect and perceived stress in both the yoga intervention and walking control over the course of the study. CONCLUSION: Among Indians with elevated fasting blood glucose, we found that participation in an 8-week yoga intervention was feasible and resulted in greater weight loss and reduction in waist circumference when compared to a walking control. Yoga offers a promising lifestyle intervention for decreasing weight-related type 2 diabetes risk factors and potentially increasing psychological well-being. TRIAL REGISTRATION: ClinicalTrials.gov Identified NCT00090506.

Joint hypermobility, obstetrical outcomes, and pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: Benign joint hypermobility syndrome may be a risk factor for pelvic floor disorders. It is unknown whether hypermobility impacts the progress of childbirth, a known risk factor for pelvic floor disorders. Our objective was to investigate the association between joint hypermobility syndrome, obstetrical outcomes, and pelvic floor disorders. Our hypotheses were: (1) women with joint hypermobility are less likely to experience operative delivery and prolonged second-stage labor; and (2) pelvic floor disorders are associated with benign hypermobility syndrome, controlling for obstetrical history. METHODS: Joint hypermobility was measured in 587 parous women (participants in a longitudinal cohort study of pelvic floor disorders after childbirth). Their obstetrical histories were obtained from review of hospital records. Pelvic floor disorders were assessed using validated questionnaires and a structured examination for prolapse. Joint hypermobility and pelvic floor disorders were evaluated at enrollment (5-10 years after first delivery). We compared obstetrical outcomes and pelvic floor disorders between women with and without joint hypermobility, defined as a Beighton score ≥ 4. RESULTS: Hypermobility was diagnosed in 46 women (7.8 %) and was associated with decreased odds of cesarean after complete cervical dilation or operative vaginal delivery [odds ratio (OR)=0.51; 95 % confidence interval (CI):0.27-0.95]. Anal sphincter laceration was unlikely to occur in women with hypermobility (OR=0.19; 95 % CI 0.04-0.80). However, hypermobility was not associated with any pelvic floor disorder considered. CONCLUSIONS: Benign joint hypermobility syndrome may facilitate spontaneous vaginal birth but does not appear to be a risk factor for pelvic floor disorders in the first decade after childbirth.

Chronic kidney disease is associated with adverse outcomes among elderly patients taking clopidogrel after hospitalization for acute coronary syndrome.

BACKGROUND: Chronic kidney disease (CKD) is associated with worse outcomes among patients with acute coronary syndrome (ACS). Less is known about the impact of CKD on longitudinal outcomes among clopidogrel treated patients following ACS. METHODS: Using a retrospective cohort design, we identified patients hospitalized with ACS between 10/1/2005 and 1/10/10 at Department of Veterans Affairs (VA) facilities and who were discharged on clopidogrel. Using outpatient serum creatinine values, estimated glomerular filtration rate [eGFR (1.73 ml/min/m2)] was calculated using the CKD-EPI equation. The association between eGFR and mortality, hospitalization for acute myocardial infarction (AMI), and major bleeding were examined using Cox proportional hazards models. RESULTS: Among 7413 patients hospitalized with ACS and discharged taking clopidogrel, 34.5% had eGFR 30-60 and 11.6% had eGFR < 30. During 1-year follow-up after hospital discharge, 10% of the cohort died, 18% were hospitalized for AMI, and 4% had a major bleeding event. Compared to those with eGFR > =60, individuals with eGFR 30-60 (HR 1.45; 95% CI: 1.18-1.76) and < 30 (HR 2.48; 95% CI: 1.97-3.13) had a significantly higher risk of death. A progressive increased risk of AMI hospitalization was associated with declining eGFR: HR 1.20; 95% CI: 1.04-1.37 for eGFR 30-60 and HR 1.47; 95% CI: 1.22-1.78 for eGFR < 30. eGFR < 30 was independently associated with over a 2-fold increased risk in major bleeding (HR 2.09; 95% CI: 1.40-3.12) compared with eGFR > = 60. CONCLUSION: Lower levels of kidney function were associated with higher rates of death, AMI hospitalization, and major bleeding among patients taking clopidogrel after hospitalization for ACS.

Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study.

OBJECTIVE: To assess outcomes associated with Mindfulness-Based Stress Reduction (MBSR) for veterans with PTSD. METHODS: Forty-seven veterans with posttraumatic stress disorder (PTSD; 37 male, 32 Caucasian) were randomized to treatment as usual (TAU; n = 22), or MBSR plus TAU (n = 25). PTSD, depression, and mental health-related quality of life (HRQOL) were assessed at baseline, posttreatment, and 4-month follow-up. Standardized effect sizes and the proportion with clinically meaningful changes in outcomes were calculated. RESULTS: Intention-to-treat analyses found no reliable effects of MBSR on PTSD or depression. Mental HRQOL improved posttreatment but there was no reliable effect at 4 months. At 4-month follow-up, more veterans randomized to MBSR had clinically meaningful change in mental HRQOL, and in both mental HRQOL and PTSD symptoms. Completer analyses (≥ 4 classes attended) showed medium to large between group effect sizes for depression, mental HRQOL, and mindfulness skills. CONCLUSIONS: Additional studies are warranted to assess MBSR for veterans with PTSD.

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth.

OBJECTIVE: The purpose of this study was to investigate the long-term impact of anal sphincter laceration on anal incontinence. STUDY DESIGN: Five to 10 years after first delivery, anal incontinence and other bowel symptoms were measured with the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetric exposures were assessed with review of hospital records. Symptoms and quality-of-life impact were compared among 90 women with at least 1 anal sphincter laceration, 320 women who delivered vaginally without sphincter laceration, and 527 women who delivered by cesarean delivery. RESULTS: Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio, 2.32; 95% confidence interval, 1.27-4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality-of-life scores were similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration. CONCLUSION: Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery.

Factors associated with presenting >12 hours after symptom onset of acute myocardial infarction among Veteran men.

BACKGROUND: Approximately 2/3 of Veterans admitting to Veterans Health Administration (VHA) facilities present >12 hours after symptom onset of acute myocardial infarction (AMI) ("late presenters"). Veterans admitted to VHA facilities with AMI may delay hospital presentation for different reasons compared to their general population counter parts. Despite the large descriptive literature on factors associated with delayed presentation in the general population, the literature describing these factors among the Veteran AMI population is limited. The purpose of this analysis is to identify predictors of late presentation in the Veteran population presenting with AMI to VHA facilities. Identifying predictors will help inform and target interventions for Veterans at a high risk of late presentation. METHODS: In our cross-sectional study, we analyzed a cohort of 335 male Veterans from nine VHA facilities with physician diagnosed AMI between April 2005 and December 2006. We compared demographics, presentation characteristics, medical history, perceptions of health, and access to health care between early and late presenting Veterans. We used standard descriptive statistics for bivariate comparisons and multivariate logistic regression to identify independent predictors of late presentation. RESULTS: Our cohort was an average of 64 ± 10 years old and was 88% white. Sixty-eight percent of our cohort were late presenters. Bivariate comparisons found that fewer late presenters had attended at least some college or vocational school (late 53% vs. early 66%, p = 0.02). Multivariate analysis showed that presentation with ST-elevation myocardial infarction (STEMI) was associated with early presentation (OR = 0.4 95%CI [0.2, 0.9]) and ≥2 angina episodes in the prior 24 hours (versus 0-1 episode) was associated with late presentation (OR = 7.5 95%CI [3.6,15.6]). CONCLUSIONS: A significant majority of Veterans presenting to VHA facilities with AMI were late presenters. We found few differences between early and late presenters. Having a STEMI was independently associated with early presentation and reporting ≥2 angina episodes in the 24 hours prior to hospital admission was independently associated with late presentation. These independent predictors of early and late presentation are similar to what has been reported for the general population. Despite these similarities to the general population, there may be untapped opportunities for patient education within the VHA to decrease late presentation.

Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample.

OBJECTIVES: To assess outcomes of veterans who participated in mindfulness-based stress reduction (MBSR). DESIGN: Posttraumatic stress disorder (PTSD) symptoms, depression, functional status, behavioral activation, experiential avoidance, and mindfulness were assessed at baseline, and 2 and 6 months after enrollment. RESULTS: At 6 months, there were significant improvements in PTSD symptoms (standardized effect size, d = -0.64, p< 0.001); depression (d = -0.70, p<0.001); behavioral activation (d = 0.62, p<0.001); mental component summary score of the Short Form-8 (d = 0.72, p<0.001); acceptance (d = 0.67, p<0.001); and mindfulness (d = 0.78, p<0.001), and 47.7% of veterans had clinically significant improvements in PTSD symptoms. CONCLUSIONS: MBSR shows promise as an intervention for PTSD and warrants further study in randomized controlled trials.

What is the long-term relevance of clinically detected postoperative anastomotic urine leakage after robotic-assisted laparoscopic prostatectomy?

OBJECTIVE: • To determine whether patients with postoperative clinically detected anastomotic urine leaks are at increased risk for poorer erectile function, urinary incontinence and bladder neck contracture (BNC) after robotic-assisted laparoscopic radical prostatectomy. PATIENTS AND METHODS: • A retrospective review of all patients undergoing RALRP from October 2005 until December 2009 by a single surgeon (R.B.N.) was conducted. Clinically detected anastomotic urine leak was defined as drain output consistent with urine at more than 24 h postoperatively. The presence of BNC was identified on cystoscopy. • Erectile function was measured with the Sexual Healthy Inventory for Men (SHIM) questionnaire. Incontinence was measured by patient-reported daily pad use. • Univariate and multivariate analyses were performed. Outcomes were assessed at the most recent follow-up. RESULTS: • Among 213 patients eligible for inclusion, 27 experienced an anastomotic urine leak (12.7%). • At a mean long-term follow-up of 24.2 months, there was no difference in SHIM scores (7.0 vs 13.1; P= 0.101), continence rates (87.5% vs 85.2%; P= 0.999) or risk of BNC (7.4% vs 3.2%; P= 0.268) between patients with and without postoperative anastomotic urine leaks, respectively. • The results did not change after controlling for covariates in a multivariate analysis. CONCLUSION: • The present study suggests that patients with clinically detected postoperative anastomotic urine leaks do not necessarily have worse long-term outcomes of erectile function, continence and risk of BNC.

A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction.

OBJECTIVE: Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI). DATA SOURCE: Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry. INTERVENTIONS: We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy. MEASUREMENTS AND MAIN RESULTS: We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13-64% for door to balloon. CONCLUSIONS: We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.

Evaluation of the Feasibility of a Home-Based TeleYoga Intervention in Participants with Both Chronic Obstructive Pulmonary Disease and Heart Failure.

OBJECTIVE: Test the feasibility and clinical outcomes of a home-based videoconferencing yoga intervention in participants diagnosed with both Chronic Obstructive Pulmonary Disease (COPD) and heart failure (HF). BACKGROUND: Yoga has potential benefit for symptom relief in participants with COPD and with HF; however, functional impairment and transportation issues can hinder access to typical yoga classes. METHODS: A controlled, nonrandomized trial was conducted of an 8-week TeleYoga intervention versus an educational control (information leaflets mailed to participants with one weekly phone call). One-hour TeleYoga classes were implemented twice weekly via multipoint videoconferencing, which connected participants to live classes via an Internet connection to their televisions. RESULTS: Fourteen participants with COPD and HF took part in the pilot study (7 in the intervention group and 8 in the control). Intervention participants were adherent to classes, able to safely participate, and found the classes enjoyable after the 8-week program. Dyspnea after exercise improved in the intervention group. CONCLUSIONS: Despite their frailty, patients diagnosed with both COPD and HF were able to perform yoga safely in the home setting. TeleYoga was acceptable and adherence was good; however, technical issues were an important hindrance to participation.

Engagement and outcomes in a digital Diabetes Prevention Program: 3-year update.

OBJECTIVE: Translations of the Diabetes Prevention Program (DPP) have proliferated in recent years, with increasing expansion to digital formats. Although these DPP translations have consistently shown favorable clinical outcomes, long-term data for digital formats are limited. This study's objective was to examine clinical outcomes up to 3 years post-baseline and the relationship between program engagement and clinical outcomes in a digital DPP. RESEARCH DESIGN AND METHODS: In a single-arm, non-randomized trial, 220 patients previously diagnosed with prediabetes were enrolled in the Omada Health Program, a commercially available, 16-week DPP-based weight loss intervention followed by an ongoing weight maintenance intervention. Changes in body weight and A1c were assessed annually. Relationships between program engagement during the first year and clinical outcomes across 3 years were examined. RESULTS: Participants were socioeconomically diverse (62% women, 50.2% non-Hispanic white, 51.7% college educated or higher). From baseline to 3 years, those participants who completed four or more lessons and nine or more lessons achieved significant sustained weight loss (-3.0% and -2.9%, respectively) and an absolute reduction in A1c (-0.31 and -0.33, respectively) with an average remission from the prediabetes range to the normal glycemic range. Factor analysis of engagement metrics during the first year revealed two underlying dimensions, one comprising lesson completion and health behavior tracking consistency, and the other comprising website logins and group participation. When these two factors were used to predict weight loss, only the logins and group participation factor was a significant predictor of weight loss at 16 weeks and 1 year. CONCLUSIONS: This study demonstrates significant long-term reductions in body weight and A1c in a digital DPP and identifies patterns of program engagement that predict weight loss.

Gender differences across racial and ethnic groups in the quality of care for diabetes.

High-quality care for diabetes is based on proper prevention, coordination of care among a multidisciplinary team of health care professionals, enhanced patient-provider relationships, and patient self-management skills. This paper discusses gender differences across racial and ethnic groups in the quality of care for type 2 diabetes according to 10 measures defined by the National Healthcare Quality Report and the National Healthcare Disparities Report. These measures include 5 process measures and one composite measure derived from the Medical Expenditure Panel Survey and 4 outcome measures derived from the Healthcare Cost and Utilization Project. National rates for 2 process measures--measurement of HbA1c (women 89.70% versus men 90.10%) and lipid profile (women 92.9% versus men 95.3%)--are high, but only 28.9% of women and 33.9% of men with diabetes received all 5 recommended process measures (HbA1c, lipid profile, eye exam, foot exam, and influenza immunization). Screening rates for retinal and foot exams and influenza immunization should be improved for all, but the need is particularly urgent for Hispanics and non-Hispanic blacks. Women and men have similar rates of hospital admissions for uncontrolled diabetes, but rates for lower extremity amputations were higher for men, particularly non-Hispanic blacks and Hispanics. Avoidable hospitalizations for diabetes decreased as income increased across racial/ethnic groups, but other factors (e.g., quality of primary care, age, relationship with providers, patients' self-management skills) may influence such rates. Moreover, any improvements in the diabetes outcomes measures may lag many years behind any measurable improvements in quality of care. Well-designed interventions that reallocate resources for diabetes self-care should be developed to ensure that gender differences are addressed across racial/ethnic groups. Because much of this care involves the management of risk factors, self-management education should be tailored to the lifestyles and beliefs specific to gender and racial/ethnic groups.

Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities.

This paper provides important insights on gender differences across racial and ethnic groups in a Medicare population in terms of the quality of care received for acute myocardial infarction (AMI) and congestive heart failure (CHF) in association with diabetes or hypertension/end-stage renal disease (ESRD). Both race/ethnicity and gender are associated with differences in the diagnostic evaluation and treatment of Medicare recipients with these conditions. In the AMI group, non-Hispanic Black and Hispanic patients of both genders were less likely to receive aspirin or beta-blockers than non-Hispanic Whites. These differences persisted for Hispanic women and men even when they presented with ESRD or diabetes. Rates for smoking cessation counseling were among the lowest among non-Hispanic Blacks and Hispanics with AMI-diabetes and non-Hispanic blacks with AMI-hypertension/ESRD. Gender comparisons within racial groups for the AMI and AMI-diabetes groups show that among non-Hispanic Whites, women were less likely to receive aspirin and beta-blockers. No gender differences were noted among non-Hispanic Black and Hispanic Medicare recipients. In the CHF group, Hispanics were the racial/ethnic group least likely to have an assessment of left ventricular function (LVF), even if they had diabetes and had lower rates of angiotensin-converting enzyme inhibitor therapy or even if they had combined CHF-hypertension/ESRD. Gender comparisons in both the CHF and CHF-hypertension/ESRD groups show that non-Hispanic White women were less likely to have an LVF assessment than non-Hispanic White men. Among all subjects, having comorbidities with AMI was not associated with higher markers of quality cardiovascular care. Closing the many gaps in cardiovascular care must target the specific needs of women and men across racial and ethnic groups.

Adaptation and Feasibility Study of a Digital Health Program to Prevent Diabetes among Low-Income Patients: Results from a Partnership between a Digital Health Company and an Academic Research Team.

Background. The feasibility of digital health programs to prevent and manage diabetes in low-income patients has not been adequately explored. Methods. Researchers collaborated with a digital health company to adapt a diabetes prevention program for low-income prediabetes patients at a large safety net clinic. We conducted focus groups to assess patient perspectives, revised lessons for improved readability and cultural relevance to low-income and Hispanic patients, conducted a feasibility study of the adapted program in English and Spanish speaking cohorts, and implemented real-time adaptations to the program for commercial use and for a larger trial of in multiple safety net clinics. Results. The majority of focus group participants were receptive to the program. We modified the curriculum to a 5th-grade reading level and adapted content based on patient feedback. In the feasibility study, 54% of eligible contacted patients expressed interest in enrolling (n = 23). Although some participants' computer access and literacy made registration challenging, they were highly satisfied and engaged (80% logged in at least once/week). Conclusions. Underserved prediabetic patients displayed high engagement and satisfaction with a digital diabetes prevention program despite lower digital literacy skills. The collaboration between researchers and a digital health company enabled iterative improvements in technology implementation to address challenges in low-income populations.