Sleep Quality in Individuals with and without Persistent Postpartum Hypertension.

OBJECTIVE: This study aimed to compare sleep quality at 1 year postpartum following a hypertensive disorder of pregnancy (HDP) among individuals with persistent postpartum hypertension (HTN) compared with those with normal blood pressures (BPs). STUDY DESIGN: We combined data from the Heart Health 4 New Moms pilot randomized trial (n = 118) and the Pathways prospective cohort study (n = 36). Individuals with a singleton pregnancy complicated by gestational HTN or preeclampsia underwent a research study visit at a mean 48.7 ± 9.5 weeks postpartum with standardized BP measurement and assessment of subjective sleep quality with the Pittsburgh Sleep Quality Index (PSQI). Persistent postpartum HTN was defined as Stage 1 HTN or greater (mean systolic BP ≥ 130 mm Hg or mean diastolic BP ≥ 80 mm Hg over three measurements at rest) or requiring antihypertensive medication. Statistical analysis was performed using univariate and multivariable logistic regression analyses. RESULTS: Of 154 individuals with an HDP included in the analysis, 84 (55%) were normotensive at 1 year postpartum and 70 (45%) had persistent postpartum HTN. Individuals with persistent postpartum HTN were more likely to be older, self-identify as Black race, have higher prepregnancy and 1-year postpartum body mass index (BMI), be multiparous, and deliver at an earlier gestational age. The mean global PSQI score was 8.7 ± 3.7, with 81% reporting poor sleep (PSQI > 5), and scores were higher among individuals who were persistently hypertensive (9.6 ± 3.5) compared with those who were normotensive at 1 year postpartum (7.9 ± 3.6), p < 0.01. Findings were unchanged in a multivariable model adjusting for age, self-reported race, prepregnancy BMI, and parity. CONCLUSION: Following an HDP, individuals reported poor sleep quality at 1 year postpartum. Individuals with persistent postpartum HTN reported lower sleep quality, suggesting that sleep behavior may be a target for intervention to improve maternal cardiovascular health following an HDP. KEY POINTS: · After an HDP, poor sleep quality was common at 1 year postpartum.. · Those with persistent postpartum HTN reported worse sleep quality at 1 year postpartum.. · Sleep behavior may be a target for intervention to improve maternal cardiovascular health..

Vaccination during pregnancy: first line of defense for expecting mothers and vulnerable young infants.

PURPOSE OF REVIEW: Maternal vaccination is a well-tolerated and effective way to protect mothers, their developing fetuses, and their young infants from infectious diseases. Although influenza vaccine and diphtheria, tetanus, and acellular pertussis (Tdap) vaccine are recommended for all pregnant women, uptake rates in the United States remain low. This review will focus on the rationale, scientific evidence, and perceptions of vaccination during pregnancy. RECENT FINDINGS: Recent studies show that administration of influenza and Tdap vaccines during pregnancy is well tolerated and provides protection to the pregnant woman, her fetus, and young infant. Studies have shown that many pregnant women look to their obstetricians to guide their prenatal care. A strong provider recommendation remains the greatest impetus to increase vaccine uptake. Both healthcare providers and expectant mothers should continue to be educated on the importance and safety of the influenza and Tdap vaccines during pregnancy. SUMMARY: Providers play a central role in advising patients and their families about the importance of maternal vaccination. The strong recommendation of providers and the availability of maternal vaccines in OB/GYN offices are keys to improve vaccine uptake. Attention must be paid to further development of intervention techniques that address unique barriers such as vaccine cost, storage concerns, and misinformation about vaccine safety.

Mandatory influenza vaccination for all healthcare personnel: a review on justification, implementation and effectiveness.

PURPOSE OF REVIEW: As healthcare-associated influenza is a serious public health concern, this review examines legal and ethical arguments supporting mandatory influenza vaccination policies for healthcare personnel, implementation issues and evidence of effectiveness. RECENT FINDINGS: Spread of influenza from healthcare personnel to patients can result in severe harm or death. Although most healthcare personnel believe that they should be vaccinated against seasonal influenza, the Centers for Disease Control and Prevention (CDC) report that only 79% of personnel were vaccinated during the 2015-2016 season. Vaccination rates were as low as 44.9% in institutions that did not promote or offer the vaccine, compared with rates of more than 90% in institutions with mandatory vaccination policies. Policies that mandate influenza vaccination for healthcare personnel have legal and ethical justifications. Implementing such policies require multipronged approaches that include education efforts, easy access to vaccines, vaccine promotion, leadership support and consistent communication emphasizing patient safety. SUMMARY: Mandatory influenza vaccination for healthcare personnel is a necessary step in protecting patients. Patients who interact with healthcare personnel are often at an elevated risk of complications from influenza. Vaccination is the best available strategy for protecting against influenza and evidence shows that institutional policies and state laws can effectively increase healthcare personnel vaccination rates, decreasing the risk of transmission in healthcare settings. There are legal and ethical precedents for institutional mandatory influenza policies and state laws, although successful implementation requires addressing both administrative and attitudinal barriers.

Epigenetic and pharmacological regulation of 5HT3 receptors controls compulsive ethanol seeking in mice.

Factors underlying individual vulnerability to develop alcoholism are largely unknown. In humans, the risk for alcoholism is associated with elevated cue reactivity. Recent evidence suggests that in animal models, reactivity to reward-paired cues is predictive of addictive behaviors. To model cue reactivity in mice, we used a Pavlovian approach (PA) paradigm in which mice were trained to associate a cue with delivery of a food reinforcer. We then investigated the relationship between PA status with habitual and compulsive-like ethanol seeking. After training mice to respond for 10% ethanol, habitual behavior was investigated using both an outcome devaluation paradigm, in which ethanol was devalued via association with lithium chloride-induced malaise, and a contingency degradation paradigm in which the relationship between action and outcome was disrupted. Compulsive-like behavior was investigated in a modified conditioned place preference paradigm in which footshock was paired with the reward-paired chamber. PA was found to be predictive of habitual and compulsive-like ethanol seeking. Additionally, innate risk status was related to epigenetic changes in the gene encoding the requisite subunit of the 5HT3 receptor, Htr3a, as well as 5HT3A protein expression in the amygdala. We then used pharmacological tools to demonstrate that risk status determines the ability of a 5HT3 antagonist to reduce compulsive ethanol seeking. These data indicate that risk status can be identified prior to any alcohol exposure by assessment of cue reactivity, and further that this endophenotype may be predictive of response to pharmacological treatment for components of alcoholism.

The effect of a neonatal sleep intervention on maternal postpartum hypertension: a randomized trial.

BACKGROUND: In nonpregnant adults, poor sleep is associated with higher blood pressure. Poor sleep is common in the postpartum period and is often attributed to infant caretaking needs. However, its effects on cardiovascular health in individuals with a hypertensive disorder of pregnancy are unknown. OBJECTIVE: This study aimed to determine the effect of a neonatal sleep intervention on maternal postpartum blood pressure in individuals with a hypertensive disorder of pregnancy. STUDY DESIGN: In this single-institution pilot randomized controlled trial from July 2021 to March 2022, 110 individuals with a hypertensive disorder of pregnancy were randomized to receive a neonatal sleep intervention (SNOO responsive bassinet) plus usual care of safe sleep education (n=54) or usual care alone (n=56). Remote follow-up visits were conducted at 1 week, 6 weeks, and 4 months after delivery and involved blood pressure and weights, sleep and mood questionnaires, and self-reported infant and maternal sleep logs. Based on institutional data, the sample size had 80% power to detect a 4.5-mm Hg difference in the primary outcome of mean arterial pressure at 6 weeks after delivery. RESULTS: Baseline characteristics were similar between the arms. At 1 week after delivery, the intervention arm had lower mean arterial pressure and less antihypertensive medication use than the control arm (99±10 vs 103±7 mm Hg [P=.04] and 23% vs 35% [P=.15], respectively). At 6 weeks after delivery, mean arterial pressure was similar between arms (93±8 vs 94±8 mm Hg; P=.54), but there was a lower rate of antihypertensive use in the intervention arm (15% vs 26%; P=.19). Scores from maternal sleep and mood questionnaires at 6 weeks after delivery and self-reported infant and maternal sleep duration at 6 weeks and 4 months after delivery were similar between arms (P>.05). CONCLUSION: The SNOO responsive bassinet as a neonatal sleep intervention did not result in improved mean arterial pressure at 6 weeks after delivery after hypertensive disorders of pregnancy.

Interaction Between CRIPT and PSD-95 Is Required for Proper Dendritic Arborization in Hippocampal Neurons.

CRIPT, the cysteine-rich PDZ-binding protein, binds to the third PDZ domain of PSD-95 (postsynaptic density protein 95) family proteins and directly binds microtubules, linking PSD-95 family proteins to the neuronal cytoskeleton. Here, we show that overexpression of a full-length CRIPT leads to a modest decrease, and knockdown of CRIPT leads to an increase in dendritic branching in cultured rat hippocampal neurons. Overexpression of truncated CRIPT lacking the PDZ domain-binding motif, which does not bind to PSD-95, significantly decreases dendritic arborization. Conversely, overexpression of a full-length CRIPT significantly increases the number of immature and mature dendritic spines, and this effect is not observed when CRIPT∆PDZ is overexpressed. Competitive inhibition of CRIPT binding to the third PDZ domain of PSD-95 with PDZ3-binding peptides resulted in differential effects on dendritic arborization based on the origin of respective peptide sequence. These results highlight multifunctional roles of CRIPT during development and underscore the significance of the interaction between CRIPT and the third PDZ domain of PSD-95.

Increasing antepartum Tdap vaccine administration: A quality improvement initiative.

The Centers for Disease Control and Prevention (CDC) recommends antepartum Tdap vaccination for women with each pregnancy to protect themselves and their vulnerable infants through transplacental transfer of maternal antibodies. Our aim was to increase the rate of antepartum Tdap vaccine administration by 20%. Obstetricians were surveyed to identify their present approaches and barriers to antepartum Tdap vaccine administration to help guide the development of our intervention. Limited staff training, lack of vaccine on site, and cost were the most commonly identified barriers. Using these survey responses, existing literature, and brainstorming conversations with colleagues, an interdisciplinary workgroup then created a fishbone analysis and developed a 5-step intervention to address these barriers: (1) educate providers and patients on Tdap and pertussis; (2) increase Tdap availability to all pregnant women; (3) remind staff of the established Tdap standing order to facilitate administration; (4) encourage obstetricians to offer Tdap; (5) transfer documentation of Tdap administration from office to hospital. To monitor changes in the process over 15 months of pre- and post-intervention, data were collected from monthly chart audits and a two-phase control chart was created. The main outcome measure was proportion of eligible women who received Tdap during current pregnancy. In the pre-intervention period, 362 of 636 eligible women (56.9%) received Tdap during their current pregnancy; in the post-intervention period, 457 of 708 eligible women (64.5%) received Tdap during their current pregnancy. This absolute difference of 7.6% (64.5% vs. 56.9%, p < 0.01) represents a 13.4% relative increase (64.5%/56.9%) in the proportion of clinically eligible pregnant women who received Tdap. This represents a clinically and statistically significant increase in the rate of antepartum Tdap immunization. More research is needed to further understand obstetric barriers and maternal refusal of antepartum Tdap administration.

A Role for Prefrontal Cortical NMDA Receptors in Murine Alcohol-Heightened Aggression.

Alcohol is associated with nearly half of all violent crimes committed in the United States; yet, a potential neural basis for this type of pathological aggression remains elusive. Alcohol may act on N-methyl-d-aspartate receptors (NMDARs) within cortical circuits to impede processing and to promote aggression. Here, male mice were characterized as alcohol-heightened (AHAs) or alcohol non-heightened aggressors (ANAs) during resident-intruder confrontations after self-administering 1.0 g/kg alcohol (6% w/v) or water. Alcohol produced a pathological-like pattern of aggression in AHAs; these mice shifted their bites to more vulnerable locations on the body of a submissive animal, including the anterior back and ventrum after consuming alcohol. In addition, through immunoblotting, we found that AHAs overexpressed the NMDAR GluN2D subunit in the prefrontal cortex (PFC) as compared to ANAs while the two phenotypes expressed similar levels of GluN1, GluN2A and GluN2B. After identifying several behavioral and molecular characteristics that distinguish AHAs from ANAs, we tested additional mice for their aggression following preferential antagonism of GluN2D-containing NMDARs. In these experiments, groups of AHAs and ANAs self-administered 1.0 g/kg alcohol (6% w/v) or water before receiving intraperitoneal (i.p.) doses of ketamine or memantine, or infusions of memantine directly into the prelimbic (PLmPFC) or infralimbic medial PFC (ILmPFC). Moderate doses of IP ketamine, IP memantine, or intra-PLmPFC memantine increased aggression in AHAs, but only in the absence of alcohol. Prior alcohol intake blocked the pro-aggressive effects of ketamine or memantine. In contrast, only memantine, administered systemically or intra-PLmPFC, interacted with prior alcohol intake to escalate aggression in ANAs. Intra-ILmPFC memantine had no effect on aggression in either AHAs or ANAs. In sum, this work illustrates a potential role of GluN2D-containing NMDARs in the PLmPFC in alcohol-heightened aggression. GluN2D-containing NMDARs are highly expressed on cortical parvalbumin-containing interneurons, suggesting that, in a subset of individuals, alcohol may functionally alter signal integration within cortical microcircuits to dysregulate threat reactivity and promote aggression. This work suggests that targeting GluN2D-NMDARs may be of use in reducing the impact of alcohol-related violence in the human population.

Clinical assessment tools identify functional deficits in fragility fracture patients.

PURPOSE: To identify inexpensive, noninvasive, portable, clinical assessment tools that can be used to assess functional performance measures that may put older patients at risk for falls such as balance, handgrip strength, and lumbopelvic control. PATIENTS AND METHODS: Twenty fragility fracture patients and 21 healthy control subjects were evaluated using clinical assessment tools (Nintendo Wii Balance Board [WBB], a handheld dynamometer, and an application for the Apple iPod Touch, the Level Belt) that measure functional performance during activity of daily living tasks. The main outcome measurements were balance (WBB), handgrip strength (handheld dynamometer), and lumbopelvic control (iPod Touch Level Belt), which were compared between fragility fracture patients and healthy controls. RESULTS: Fragility fracture patients had lower scores on the vertical component of the WBB Torso Twist task (P=0.042) and greater medial-lateral lumbopelvic sway during a 40 m walk (P=0.026) when compared to healthy controls. Unexpectedly, the fracture patients had significantly higher scores on the left leg (P=0.020) and total components (P=0.010) of the WBB Single Leg Stand task as well as less faults during the left Single Leg Stand task (P=0.003). CONCLUSION: The clinical assessment tools utilized in this study are relatively inexpensive and portable tools of performance measures capable of detecting differences in postural sway between fragility fracture patients and controls.

Commercially available gaming systems as clinical assessment tools to improve value in the orthopaedic setting: a systematic review.

INTRODUCTION: Commercially available gaming systems (CAGS) such as the Wii Balance Board (WBB) and Microsoft Xbox with Kinect (Xbox Kinect) are increasingly used as balance training and rehabilitation tools. The purpose of this review was to answer the question, "Are commercially available gaming systems valid and reliable instruments for use as clinical diagnostic and functional assessment tools in orthopaedic settings?" and provide a summary of relevant studies, identify their strengths and weaknesses, and generate conclusions regarding general validity/reliability of WBB and Xbox Kinect in orthopaedics. MATERIALS AND METHODS: A systematic search was performed using MEDLINE (1996-2013) and Scopus (1996-2013). Inclusion criteria were minimum of 5 subjects, full manuscript provided in English or translated, and studies incorporating investigation of CAG measurement properties. Exclusion criteria included reviews, systematic reviews, summary/clinical commentaries, or case studies; conference proceedings/presentations; cadaveric studies; studies of non-reversible, non-orthopaedic-related musculoskeletal disease; non-human trials; and therapeutic studies not reporting comparative evaluation to already established functional assessment criteria. All studies meeting inclusion and exclusion criteria were appraised for quality by two independent reviewers. Evidence levels (I-V) were assigned to each study based on established methodological criteria. RESULTS: 3 Level II, 7 level III, and 1 Level IV studies met inclusion criteria and provided information related to the use of the WBB and Xbox Kinect as clinical assessment tools in the field of orthopaedics. Studies have used the WBB in a variety of clinical applications, including the measurement of center of pressure (COP), measurement of medial-to-lateral (M/L) or anterior-to-posterior (A/P) symmetry, assessment anatomic landmark positioning, and assessment of fall risk. However, no uniform protocols or outcomes were used to evaluate the quality of the WBB as a clinical assessment tool; therefore a wide range of sensitivities, specificities, accuracies, and validities were reported. CONCLUSION: Currently it is not possible to make a universal generalization about the clinical utility of CAGS in the field of orthopaedics. However, there is evidence to support using the WBB and the Xbox Kinect as tools to obtain reliable and valid COP measurements. The Wii Fit Game may specifically provide reliable and valid measurements for predicting fall risk.

Training Advanced Practice Providers to Collect Functional Outcomes After Fragility Fractures.

OBJECTIVE: The objective of this study was to determine whether advanced practice providers could learn to collect objective functional assessment data accurately and efficiently with commercially available devices that measure kinematics and kinetics (Nintendo Wii Balance Board [WBB] and Level Belt [LB]) to aid in the assessment of fall risk and outcomes after fragility fractures. METHODS: Nine advanced practice providers participated in a 1-hour clinical assessment tools (CATs) training session on equipment use, providing standardized instructions, and practice of the testing procedures. Afterward, they participated in a skills demonstration evaluation and completed a postsession survey. RESULTS: Participants successfully achieved a mean of 18.22 (standard deviation 1.56) of 20 performance measures. Of the incomplete or omitted tasks, the majority (10 of 16) occurred within the first of 3 CATs activities. Postsession survey results revealed that 9 of 9 participants reported that the 1 hour provided for training on the CATs was sufficient. All participants reported that after the training, they felt confident they could reliably carry out the tasks to test patients on both the WBB and the LB. The majority of participants reported that they believed that the WBB (7 of 9) and LB (8 out of 9) would be good assets to clinics in assessing patient functionality after fragility fractures. CONCLUSION: These results indicate that advanced practice providers can confidently learn and effectively test patients with the WBB and LB within 1 hour of training. In the future, adoption of CATs in the clinical setting may allow for objective, easy-to-use, portable, noninvasive, and relatively inexpensive measures to assess functional outcomes in patients with fragility fracture.