Enhancing hypertension education of community health extension workers in Nigeria's federal capital territory: the impact of the extension for community healthcare outcomes model on primary care, a quasi-experimental study.

BACKGROUND: Healthcare workers (HCWs) including community health extension workers (CHEWs) in the Federal Capital Territory, Nigeria participated in a hypertension training series following the Extension for Community Healthcare Outcomes (ECHO) model which leverages technology and a practical peer-to-peer learning framework to virtually train healthcare practitioners. We sought to evaluate the patient-level effects of the hypertension ECHO series. METHODS: HCWs from 12 of 33 eligible primary healthcare centers (PHCs) in the Hypertension Treatment in Nigeria Program (NCT04158154) were selected to participate in a seven-part hypertension ECHO series from August 2022 to April 2023. Concurrent Hypertension Treatment in Nigeria Program patient data were used to evaluate changes in hypertension treatment and control rates, and adherence to Nigeria's hypertension treatment protocol. Outcomes were compared between the 12 PHCs in the ECHO program and the 21 which were not. RESULTS: Between July 2022 and June 2023, 16,691 PHC visits were documented among 4340 individuals (ECHO: n = 1428 [33%], non-ECHO: n = 2912 [67%]). Patients were on average (SD) 51.5 (12.0) years old, and one-third were male (n = 1372, 32%) with no differences between cohorts in either characteristic (p ≥ 0.05 for both). Blood pressures at enrollment were higher in the ECHO cohort compared to the non-ECHO cohort (systolic p < 0.0001 and diastolic p = 0.0001), and patients were less likely to be treated with multiple medications (p < 0.0001). Treatment rates were similar at baseline (ECHO: 94.0% and Non-ECHO: 94.7%) and increased at a higher rate (interaction p = 0.045) in the ECHO cohort over time. After adjustment for baseline and within site variation, the difference was attenuated (interaction p = 0.37). Over time, control rates increased and medication protocol adherence decreased, with no differences between cohorts. Staffing levels, adult patient visits, and rates of hypertension screening and empanelment were similar between ECHO and non-ECHO cohorts (p ≥ 0.05 for all). CONCLUSIONS: The ECHO series was associated with moderately increased hypertension treatment rates and did not adversely affect staffing or clinical capacity among PHCs in the Federal Capital Territory, Nigeria. These results may be used to inform strategies to support scaling hypertension education among frontline HCWs throughout Nigeria, and use of the ECHO model for CHEWs. TRIAL REGISTRATION: The Hypertension Treatment in Nigeria Program was prospectively registered on November 8, 2019 at www. CLINICALTRIALS: gov (NCT04158154; https://clinicaltrials.gov/ct2/show/NCT04158154 ).

Response to Hypoglossal Nerve Stimulation Changes With Body Mass Index and Supine Sleep.

Importance: Hypoglossal nerve stimulation (HGNS) is a potential alternative therapy for obstructive sleep apnea (OSA), but its efficacy in a clinical setting and the impact of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) on treatment response remain unclear. Objective: To investigate whether HGNS therapy is effective for patients with OSA, whether HGNS can treat supine OSA, and whether there are associations between BMI and treatment response. Design, Setting, and Participants: In this cohort study, adult patients with OSA implanted with HGNS at the Washington University Medical Center in St Louis from April 2019 to January 2023 were included. Data were analyzed from January 2023 to January 2024. Exposure: HGNS. Main Outcomes and Measures: Multivariable logistic regression was performed to assess associations between HGNS treatment response and both BMI and supine sleep. Treatment response was defined as 50% reduction or greater in preimplantation Apnea-Hypopnea Index (AHI) score and postimplantation AHI of less than 15 events per hour. Results: Of 76 included patients, 57 (75%) were male, and the median (IQR) age was 61 (51-68) years. A total of 59 patients (78%) achieved a treatment response. There was a clinically meaningful reduction in median (IQR) AHI, from 29.3 (23.1-42.8) events per hour preimplantation to 5.3 (2.6-12.3) events per hour postimplantation (Hodges-Lehman difference of 23.0; 95% CI, 22.6-23.4). In adjusted analyses, patients with BMI of 32 to 35 had 75% lower odds of responding to HGNS compared with those with a BMI of 32 or less (odds ratio, 0.25; 95% CI, 0.07-0.94). Of 44 patients who slept in a supine position, 17 (39%) achieved a treatment response, with a clinically meaningful reduction in median (IQR) supine AHI from 46.3 (33.6-63.2) events per hour preimplantation to 21.8 (4.30-42.6) events per hour postimplantation (Hodges-Lehman difference of 24.6; 95% CI, 23.1-26.5). In adjusted analysis, BMI was associated with lower odds of responding to HGNS with supine AHI treatment response (odds ratio, 0.39; 95% CI, 0.04-2.59), but the imprecision of the estimate prevents making a definitive conclusion. Conclusions and Relevance: This study adds to the growing body of literature supporting the use of HGNS for OSA treatment. Sleep medicine clinicians should consider informing patients that higher BMI and supine sleeping position may decrease therapeutic response to HGNS. Future research is needed to replicate these findings in larger, more diverse cohorts, which would facilitate the optimization of treatment strategies and patient counseling for HGNS therapy.

Maternal Food and Beverage Consumption Behaviors and Discrepant Phthalate Exposure by Race.

Background: Differential exposure to endocrine-disrupting chemicals, including phthalate diesters, may contribute to persistent racial/ethnic disparities in women's reproductive health outcomes. We sought to characterize sources of gestational exposure to these agents that may differ according to maternal race. Methods: We enrolled pregnant Black (n = 198), including African American, and White (n = 197) women during the second trimester, and measured eight phthalate monoester metabolites in urine. We assessed confounder-adjusted associations between multiple food and beverage consumption habits, summarized using a principal component analysis, as predictors of maternal urinary phthalate metabolite levels, stratified by race. Results: Whites reported significantly greater unprocessed food consumption (42.5% vs. 32.0%; p < 0.001) and storage of food in clear unbreakable plastic containers (66.5% vs. 49.3%; p < 0.001) than Blacks, while Blacks consumed more canned fruits and vegetables (23.5% vs. 12.2%; p < 0.001) than Whites. Using plastics for food storage, microwaving in plastic containers, and using hard plastic water bottles was associated with urinary phthalate concentrations, especially DEHP metabolites (e.g., mean difference = 5.13%; 95% CI: 3.05, 7.25). These associations were driven primarily by Black pregnant women. Conclusions: Targeted interventions to reduce maternal exposure to phthalates need to be designed with specific attention to differences in food and beverage consumption behaviors among Black and White women.

Preconception serum lipids and lipophilic micronutrient levels are associated with live birth rates after IVF.

RESEARCH QUESTION: Is a mixture of preconception serum lipids and lipophilic micronutrients associated with clinical pregnancy and live births? DESIGN: In this prospective cohort study, blood serum was collected on the day of oocyte retrieval for 180 women undergoing IVF at an academic reproductive health centre. Concentrations of lipids (phospholipids, total cholesterol, high- and low-density lipoproteins, and triglycerides) and lipophilic micronutrients (α-, δ-, and γ-tocopherols, retinol, ß- and α-carotenes, ß-cryptoxanthin, lutein and lycopene) were determined using diagnostic reagent kits and high-performance liquid chromatography. Poisson regression was used with robust variance estimation to evaluate changes in Z-scores for the mixture of serum lipid and lipophilic micronutrient concentrations as predictors of embryo implantation, clinical pregnancy and live birth, adjusted for age, body mass index (BMI), race, smoking status, infertility diagnosis, ovarian stimulation protocol and other measured lipid and lipophilic micronutrient concentrations. RESULTS: Each SD higher serum triglyceride concentration was associated with a lower chance of live birth (RR 0.54; 95% CI 0.33 to 0.90) whereas a 1 SD higher serum α-tocopherol concentration, as part of a mixture of serum lipids and lipophilic micronutrients, was associated with a higher likelihood for a live birth (RR 1.61; 95% CI 1.11 to 2.36). Serum ß-carotene concentrations were associated with live birth in a non-linear fashion; low ß-carotene was associated with a lower chance of live birth and high ß-carotene with a higher chance of live birth. CONCLUSION: Although components of a mixture of lipids and lipophilic micronutrients were associated with live birth outcomes after IVF, a larger investigation is necessary to fully evaluate the potential clinical implications.