Advance Care Planning for Children With Rare Diseases: A Pilot RCT.

BACKGROUND AND OBJECTIVE: Pediatric rare diseases are often life-limiting conditions and/or require constant caregiving. Investigators assessed the initial efficacy of the FAmily CEntered (FACE) pediatric advance care planning (pACP), FACE-Rare, intervention on families' quality of life. METHODS: A pilot-phase, single-blinded, intent-to-treat, randomized controlled clinical trial enrolled families from 1 pediatric quaternary hospital between 2021 and 2023. Intervention families received 3 weekly 60-minute (FACE-Rare pACP) sessions: (1) Carer Support Needs Assessment Tool or Action Plan, (2) Carer Support Needs Assessment Tol Action Plan Review, and (3) Pediatric Next Steps: Respecting Choices pACP. Controls received treatment as usual (TAU). Outcome measures were Beck Anxiety Inventory, Family Appraisal of Caregiving, Functional Assessment of Chronic Illness Therapy (FACIT)-Spirituality, and health care utilization. Generalized mixed effect models with γ response assessed the intervention effect at 3-month follow-up. RESULTS: Children (n = 21) were aged 1 to 10 years, 48% male, 24% Black; and 100% technology dependent. Primary family caregivers (n = 21) were aged 30 to 43 years, 19% male, 19% Black; and 27% household income below the Federal poverty level. Dyads underwent 1:1 randomization: 9 to FACE-Rare and 12 to TAU. TAU caregivers reported statistically lower meaning and peace than FACE-Rare caregivers (0.9, P = .03, confidence interval [CI]: 0.75-0.99). Black caregivers reported significantly less caregiver distress (0.7, P = .04, CI: 0.47-0.98) than non-Black caregivers. Poor families reported more anxiety (3.5, P = .002, CI: 1.62-7.94), more caregiver strain (1.2, P = .006, CI: 1.07-1.42); and less family well-being (0.8, P = .02, CI: 0.64-0.95). CONCLUSIONS: FACE®-Rare was feasible, acceptable, safe, and demonstrated initial efficacy, providing greater feelings of meaning and peace to caregivers. Poverty impacted well-being. A multisite trial is needed to determine generalizability.

Chronic Disease Management through Clinical Video Telehealth on Health Care Utilization, and Mortality in the Veterans Health Administration: A Retrospective Cohort Study.

Background: Chronic health diseases such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) affect 6 in 10 Americans and contribute to 90% of the $4.1 trillion health care expenditures. The objective of this study was to measure the effect of clinical video telehealth (CVT) on health care utilization and mortality. A retrospective cohort study of Veterans ≥65 years with CHF, COPD, or DM was conducted. Measures: Veterans using CVT were matched 1:3 on demographic characteristics to Veterans who did not use CVT. Outcomes included 1-year incidence of ED visits, inpatient admissions, and mortality, reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Results: Final analytical cohorts included 22,280 Veterans with CHF, 51,872 Veterans with COPD, and 170,605 Veterans with DM. CVT utilization was associated with increased ED visits for CHF (aOR: 1.24; 95% CI: 1.15-1.34), COPD (aOR: 1.20; 95% CI: 1.14-1.26), and DM (aOR: 1.07; 95% CI: 1.00-1.10). For CHF, there was no difference between CVT utilization and inpatient admissions (aOR: 0.98; 95% CI 0.91-1.05) or mortality (aOR: 1.03; 95% CI: 0.93-1.15). For COPD, CVT was associated with increased inpatient admissions (aOR: 1.08; 95% CI: 1.02-1.13) and mortality (aOR: 1.36; 95% CI: 1.25-1.48). For DM, CVT utilization was associated with lower risk of inpatient admissions (aOR: 0.83; 95% CI: 0.80-0.86) and mortality (aOR: 0.89; 95% CI: 0.84-0.95). Conclusions: CVT use as an alternative care site might serve as an early warning system, such that this mechanism may indicate when an in-person assessment is needed for potential exacerbation of conditions. Although inpatient and mortality varied, ED utilization was higher with CVT. Exploring pathways accessing clinical care through CVT, and how CVT is directly or indirectly associated with immediate and long-term clinical outcomes would be valuable.

Effect of Chronic Disease Home Telehealth Monitoring in the Veterans Health Administration on Healthcare Utilization and Mortality.

BACKGROUND: The high prevalence of chronic diseases, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM), accounts for a large burden of cost and poor health outcomes in US hospitals, and home telehealth (HT) monitoring has been proposed to improve outcomes. OBJECTIVE: To measure the association between HT initiation and 12-month inpatient hospitalizations, emergency department (ED) visits, and mortality in veterans with CHF, COPD, or DM. DESIGN: Comparative effectiveness matched cohort study. PATIENTS: Veterans aged 65 years and older treated for CHF, COPD, or DM. MAIN MEASURES: We matched veterans initiating HT with veterans with similar demographics who did not use HT (1:3). Our outcome measures included a 12-month risk of inpatient hospitalization, ED visits, and all-cause mortality. KEY RESULTS: A total of 139,790 veterans with CHF, 65,966 with COPD, and 192,633 with DM were included in this study. In the year after HT initiation, the risk of hospitalization was not different in those with CHF (adjusted odds ratio [aOR] 1.01, 95% confidence interval [95%CI] 0.98-1.05) or DM (aOR 1.00, 95%CI 0.97-1.03), but it was higher in those with COPD (aOR 1.15, 95%CI 1.09-1.21). The risk of ED visits was higher among HT users with CHF (aOR 1.09, 95%CI 1.05-1.13), COPD (1.24, 95%CI 1.18-1.31), and DM (aOR 1.03, 95%CI 1.00-1.06). All-cause 12-month mortality was lower in those initiating HT monitoring with CHF (aOR 0.70, 95%CI 0.67-0.73) and DM (aOR 0.79, 95%CI 0.75-0.83), but higher in COPD (aOR 1.08, 95%CI 1.00-1.16). CONCLUSIONS: The initiation of HT was associated with increased ED visits, no change in hospitalizations, and lower all-cause mortality in patients with CHF or DM, while those with COPD had both higher healthcare utilization and all-cause mortality.

US Military Dietetic Internship and Graduate Program: Retrospective Analysis of Selection Criteria and Student Success.

BACKGROUND: The US Military-Baylor Graduate Program in Nutrition (GPN) has a 10% 7-year attrition rate representing wasted military resources. Evidence-based selection criteria for dietetics masters of science (MS) programs do not exist, nor does descriptive information of successful students. OBJECTIVE: Identify GPN student characteristics predicting program success in the didactic and internship phases. DESIGN: Retrospective study using demographic, academic, and nonacademic data extracted from existing files. PARTICIPANTS AND SETTING: There were 72 GPN students enrolled from 2006 to 2013 in San Antonio, TX. MAIN OUTCOME MEASURES: Categorization by optimal performance (no course grade <3.0, no internship rotation delays, first attempt pass registered dietitian nutritionist examination) and GPN completion. RESULTS: The average GPN student was female (65%), in the US Army (94%), and single (64%), with a mean age of 26 years. Mean Quantitative, Verbal Reasoning, and Analytical Writing Graduate Record Examination (GRE) scores were 149, 153, and 4.2 points, respectively. Odds of GPN failure increased 1.3 times with each year increase in age at GPN program start (95% CI=1.089 to 1.612; P=0.005). Odds of attaining optimal performance decreased 4.5 times with each additional year increase between GRE completion and GPN start (95% CI=1.623 to 16.236; P=0.005) and 0.157 times with each grade point average point decrease in Biochemistry (95% CI=0.49 to 0.430; P=0.002). CONCLUSIONS: Modification of selection criteria based on time between GRE and GPN start and undergraduate Biochemistry grades could improve GPN success. However, identification and mitigation of potential student weaknesses is a more realistic approach to promote student success. Intentional development of students with optimal characteristics will strengthen the dietetics profession during the transition to an MS degree requirement.

Misperceptions of Weight Status in Military Men and Women.

OBJECTIVE: Military members may be in a unique position to misperceive their weight status because of the expectations of military service-specific body composition standards and sex-specific ideals of body image. Two-thirds of military service members are overweight or obese, costing the Department of Defense over $1 billion/year. This study assessed accuracy of perceived weight status. MATERIALS AND METHODS: A cross-sectional, descriptive study of active duty service members (n = 295). Participants were predominantly white (57%), Army (91%), male (71%), with a mean age of 30.1 ± 8.6 years. Thirty-six percent were normal body mass index (BMI) (22.7 ± 1.6 kg/m2) and 64% were overweight/obese BMI (29.3 ± 3.3 kg/m2). Subject BMI (m/kg2) was dichotomized as normal (18.5-24.9 kg/m2) or overweight (≥25 kg/m2); BMI status was contrasted to perceived weight. The study was approved by the Institutional Review Boards at Madigan and Brook Army Medical Centers. Inferential statistics between groups compared differences between accurate and inaccurate weight status perception. Binary logistic regression was performed to identify if significant independent variables contributed to predicting weight status accuracy. Data were analyzed using SPSS Predictive Analytic Software version 21 with statistical significance set at p < 0.05. RESULTS: A higher education is associated with a 2.6 higher odds of accurately perceiving weight status. Trying to lose weight is associated with a 0.31 lower odds of accurate perception of weight status. Normal BMI: no men and 29% of women perceived they were overweight; 81% of normal weight women with inaccurate weight perceptions were attempting weight loss (p = 0.005). Overweight BMI: 66% of men and 63% of women were not dieting and 42% of men and 6% of women perceived being at the right weight (p < 0.001). Accurate weight perceivers: The majority of overweight/obese females (94%) and males (85%) with an accurate weight perception were trying to lose weight, compared to 30% of those who had inaccurate weight perceptions (p = 0.002 and p < 0.001, respectively). CONCLUSIONS: Weight misperception may result in underestimation of personal health risk associated with weight gain and may lead to undesirable weight-related outcomes. Aspects of the military culture, such as weight and body composition standards, as well as an emphasis on physical fitness, may influence weight perception in military members differently than that observed in civilian populations, and may influence military men and women differently. Incongruence between actual and perceived weight status and lifestyle behaviors reveals a need for tailored interventions and inclusion of public health campaigns.

Normal Weight Status in Military Service Members Was Associated With Intuitive Eating Characteristic.

The purpose of this study was to determine the relationship between individual weight status and intuitive eating or motivation for eating characteristics. Participants were predominantly white (57%), Army (91%), enlisted (72%), males (71%), with a mean age of 30 ± 9 years and mean body mass index (BMI) of 27.0 ± 4.2 kg/m(2). The cross-sectional, descriptive study included active duty service members (n = 295) recruited from Texas and Washington. Validated Motivation for Eating Scale (MFES) and Intuitive Eating Scale were administered and BMI (m/kg(2)) was dichotomized at <25 or ≥25 kg/m(2). Descriptive, correlation, t-test, and logistic regression analysis were conducted for BMI category with demographic, lifestyle, and MFES/Intuitive Eating Scale scores (α = 0.05; 80% power). Thirty-six percent were normal BMI (22.7 ± 1.6 kg/m(2)) and 64% were overweight/obese BMI (29.3 ± 3.3 kg/m(2)). Mean BMI was 27.8 ± 4.2 kg/m(2) (males) and 24.8 ± 3.4 kg/m(2) (females) (p < 0.001). Physical MFES type was predominant (77% normal BMI vs. 66% overweight; p = 0.001). Males ate for physical rather than emotional reasons (p = 0.014). Each 1-point increase in Reliance on Internal Hunger Satiety Score was associated with 34% lower odds of being overweight. Disparity existed between sex and intuitive eating characteristic. Increasing awareness of eating influences may improve weight-related dietary behaviors.

Provision of nutrition support therapies in the recent Iraq and Afghanistan conflicts.

This article describes the experience of nutrition support practitioners, specifically dietitians, providing care to combat casualties. It provides a brief overview of dietitians' induction into armed service but focuses primarily on their role in providing nutrition support during the most recent conflicts in Iraq and Afghanistan. The current system of combat casualty care is discussed with specific emphasis on providing early and adequate nutrition support to U.S. combat casualties from injury, care in theater combat support hospitals (CSHs)/expeditionary medical support (EMEDs), and en route care during critical care air transport (CCAT) up to arrival at treatment facilities in the United States. The article also examines practices and challenges faced in the CSHs/EMEDs providing nutrition support to non-U.S. or coalition patients. Over the past decade in armed conflicts, dietitians, physicians, nurses, and other medical professionals have risen to challenges, have implemented systems, and continue working to optimize treatment across the spectrum of combat casualty care.

Estimating direct and episodic atmospheric nitrogen deposition to a coastal waterbody.

Direct deposition of atmospheric nitrogen to shallow coastal embayments is usually estimated, since insufficient field measurements are available. Using Waquoit Bay (Cape Cod, MA. USA) as a case study, and a recent review of literature, we determined reasonable bounds on wet and dry inputs of inorganic and organic N. Since precipitation and wind vary daily, we explored the potential of episodic events to stimulate phytoplankton blooms. Many coastal waterbodies like Waquoit Bay are small relative to their watersheds. Nevertheless, direct deposition of NH(3), NO(3)(-), and HNO(3) is significant in the loading budget. For Waquoit Bay, direct deposition was calculated to be 7-15.5 kg total N ha(-1)yr(-1), representing 70-150% of the atmospheric N reported to reach the bay via the watershed, and 20-45% of the total N reaching the bay from all land-based sources. Episodic events were estimated to deliver up to 65 mg N m(-2)day(-1), representing a phytoplankton stock of 12.3 mg Chl m(-2), an amount unlikely to stimulate dense blooms in shallow coastal waters in the northeastern United States.