Assessment of Exercise Capacity in Home Healthcare: Differences in Three Self-Paced Tests.

Submaximal functional tests of endurance are ubiquitous in clinical practice. This investigation compared cardiovascular responses, perceived exertion, and performance measures following the completion of three self-paced, 2-minute, functional tests of endurance. A pilot prospective, observational, cross-sectional design with 16 community-dwelling older participants compared heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), rating of perceived exertion (RPE), and performance measures following the completion of three randomly allocated self-paced activities. The three activities included 2 minutes of stepping in standing (2MSTD), 2 minutes of seated stepping (2MSIT), and a 2-minute walk test (2MWT). A within-subjects repeated measures ANOVA analyzed differences in change scores for cardiovascular and RPE responses. Pearson's correlations assessed associations in performance measures between the three tests. Standing stepping compared to seated stepping produced statistically higher change scores in HR, SBP, DBP, and RPE (p < .05). Further, 2MSTD revealed statistically higher SBP and RPE scores compared to 2MWT (p < .05). Large and moderate correlations were observed between number of steps completed in sitting and standing (r = 0.83, p < .01) and between standing steps and distance walked (r = 0.56, p = .02), respectively. This pilot investigation informs home care physical therapists that 2 minutes of self-paced stepping in standing produced the greatest change scores in all cardiovascular and perceived exertion responses. No significant differences were noted in HR between self-paced walking and standing stepping, and between standing and seated stepping. For patients unable to walk or step in standing, self-paced seated stepping may be a viable alternative.

A Pilot Survey on the Perceptions of Pediatric Subspecialty Fellows and Program Directors on Virtual Compared with In-Person Interview Experiences.

Pediatric fellowship programs have conducted virtual interviews since the start of the COVID-19 pandemic in 2020. In this national survey of fellowship program directors and fellows interviewed in-person and virtually, fellowship program directors and fellows formed accurate impressions, regardless of format, but our data did not clearly support one interview format over another.

Introduction: Student Experiences of COVID-19 Around the Globe: Insights from the Pandemic Journaling Project.

The COVID-19 crisis has taken a significant toll on the mental health of many students around the globe. In addition to the traumatic effects of loss of life and livelihood within students' families, students have faced other challenges, including disruptions to learning and work; decreased access to health care services; emotional struggles associated with loneliness and social isolation; and difficulties exercising essential rights, such as rights to civic engagement, housing, and protection from violence. Such disruptions negatively impact students' developmental, emotional, and behavioral health and wellbeing and also become overlaid upon existing inequities to generate intersectional effects. With these findings in mind, this special issue investigates how COVID-19 has affected the mental health and wellbeing of high school and college students in diverse locations around the world, including the United States, Mexico, Brazil, China, and South Africa. The contributions collected here analyze data collected through the Pandemic Journaling Project, a combined research study and online journaling platform that ran on a weekly basis from May 2020 through May 2022, along with complementary projects and using additional research methods, such as semi-structured interviews and autobiographical writing by students. The collection offers a nuanced, comparative window onto the diverse struggles that students and educators experienced at the height of the pandemic and considers potential solutions for addressing the long-term impacts of COVID-19. It also suggests a potential role for journaling in promoting mental wellbeing among youth, particularly in the Global South.

Seesaw Precarity: Journaling Anxious Hope on a Chinese University Campus During Covid-19.

In this article, we examine the Covid-19 experiences of a group of Chinese university students studying in the city of Guangzhou. We draw on journal entries that Chinese students submitted to the Pandemic Journaling Project between March and May 2022, along with follow-up responses in July and December 2022, to argue that these students spent most of their undergraduate years living in a state of "seesaw precarity." We define seesaw precarity as a protracted period during which many Chinese were unable to predict from one day to the next whether they would be free to engage in the quotidian activities of everyday life. We trace student reactions and adaptations as they struggled to attend class, buy food, and see friends and family in the midst of unpredictable swings between openness and closedness. The seesaw nature of restrictions spurred considerable anxiety among the students we followed, but also produced an optimistic mindset we refer to as "anxious hope." Participants accepted the necessity of Covid controls and felt it was incumbent upon them as individuals to adjust to this reality. They saw themselves as responsible for actively cultivating a positive mindset. Our findings suggest that the promotion of emotional self-care and anxious hope during the pandemic may have supported the viability of long-term controls as well as the acceptability of their sudden abandonment, while muting the possibility of resistance.

Unintentional Cannabis Ingestions and Supervisory Neglect.

Unintentional pediatric ingestions of substances can lead to serious and even fatal consequences in children1 and raises concern for supervisory neglect. Supervisory neglect occurs when a caregiver's supervisory decisions or behaviors place a child in their care at significant risk for physical, emotional or psychological harm.2 A caregiver who is taking prescription medication or who uses recreational or therapeutic substances, such as cannabis, must protect children in their care from accessing these potentially harmful drugs. Studies have demonstrated that unintentional cannabis ingestions by children has increased in states that have legalized medical and recreational cannabis.3 Given the changing laws surrounding cannabis in Rhode Island, this study aims to provide a conceptual framework to diagnose, manage and understand supervisory neglect when children present to care with a cannabis ingestion. Additionally, this paper provides guidance for providers to help prevent unintentional cannabis ingestions.

"You would think she would hug me": Micropractices of Care Between First-Generation College Students and Their Parents During Covid-19.

The Covid-19 pandemic has greatly disrupted the education of first-generation college students (first-gens)-those whose parents did not complete a college degree. With campuses closed, activities canceled, and support services curtailed, many first-gens have increasingly relied on their parents for mental, emotional, and logistical support. At the same time, their parents face compounding stresses and challenges stemming from the prolonged effects of the Covid pandemic. We examined the role that relational dynamics between first-gens and their parents played in how they weathered the first 2 years of the Covid pandemic together. We draw upon journals submitted by self-identified first-gens and parents of first-gens to the Pandemic Journaling Project between October 2021 and May 2022 as part of a pilot study of first-gen family experiences of Covid-19, along with a series of interviews conducted with three student-parent dyads. We argue that what we term the micropractices of care-the "little things," like a kind word, small gift, or car ride, that were regularly exchanged between parents and students-played a key role in mental wellness and educational persistence. We find that when there is synchrony between practices offered by one dyad member and their reception by the other, mental wellbeing is preserved. When there is asynchrony, mental health is destabilized. These findings reflect the strategies on which first-gen families have creatively relied to maintain shared mental wellness and student success during a time of crisis. We show how everyday mental wellness is forged in the intersubjective space between two people engaged in achieving shared life goals.

"It's Overwhelming With the Grief" A Qualitative Study of Families' Experiences When a Young Relative Dies of Sudden Cardiac Death.

BACKGROUND: Sudden cardiac death (SCD) in younger individuals is frequently caused by heritable cardiac conditions. The unexpected nature of SCD leaves families with many unanswered questions and an insufficient understanding of the cause of death and their own risk for heritable disease. We explored the experiences of families of young SCD victims upon learning about their relative's cause of death and how they perceive their own risk for heritable cardiac conditions. METHODS: We conducted a qualitative descriptive study, by interviewing families of young (ages 12-45) SCD victims, who died between 2014 and 2018 from a heritable cardiac condition and were investigated by the Office of the Chief Coroner of Ontario, Canada. We used thematic analysis to analyze the transcripts. RESULTS: Between 2018 and 2020, we interviewed 19 family members, of which 10 were males and 9 were females, ages ranging from 21 to 65 (average 46.2±13.1). Four main themes were revealed, each representing a distinct time period that families experience along a trajectory: (1) interactions between bereaved family and others, in particular coroners, shaped their search for answers about their relative's cause of death, with the types, formats, and timing of communication varying by case; (2) searching for answers and processing the cause of death; (3) incidental implications of the SCD event, such as financial strain and lifestyle changes contributed to cumulative stress; (4) receiving answers (or not) and moving forward. CONCLUSIONS: Families rely on communication with others, yet the type, formats, and timing of information received varies, which can influence families' experiences of processing the death (and its cause), their perceived risk and their decision to pursue cascade screening. These results may provide key insights for the interprofessional health care team responsible for the delivery and communication of the cause of death to families of SCD victims.

Blenders, Hammers, and Knives: Postpartum Intrusive Thoughts and Unthinkable Motherhood.

"Intrusive thoughts" are common symptoms of perinatal mood and anxiety disorders such as postpartum obsessive-compulsive disorder. These thoughts can include horrific flashes of violence involving one's baby and frequently lead to shame and fear on the mother's part, but rarely result in real-world violence. Clinicians tend to downplay the importance of these images' content and calm women by reminding them that they will not act on their impulses. This article leans into the dark nature of intrusive thoughts. I intersperse theoretical and ethnographic reflections with vivid fragments of narratives about intrusive thoughts collected from several years of ethnographic research conducted with postpartum women in the United States. I explore the fear, rage, and repulsion that characterize the thoughts themselves and the racism, classism, and sexism involved in clinical, institutional, and interpersonal responses to them. I suggest that dwelling on the "unthinkable" images contained within intrusive thoughts may be important for understanding and accepting the realities of mother love.

Why they willingly complied: Ordinary people, the big environment, and the control of COVID-19 in China.

During the first two years of the COVID-19 pandemic, the Chinese public consistently demonstrated a high level of compliance with some of the most restrictive infection control measures in the world. As a result, as of early 2022 China achieved remarkable control of a virus that had devastating effects in other parts of the world. In this article we take seriously the complexities of a simple question: Why did most urban Chinese citizens so willingly comply with the state's COVID-19 control measures for so long? Based on two years of ethnographic research conducted primarily in Shanghai, China between June 2020 and May 2022, we argue that the strong support the Chinese government enjoyed among China's self-described laobaixing ("ordinary people") in implementing its COVID-19 control measures emerged from a combination of self-interest, nationalistic pride, and "conscious indifference to transparency," rooted in ongoing critical evaluations of governmental competence. With these evaluations changing in the wake of new outbreaks in 2022, the future of China's zero-COVID policy is in jeopardy.

New life, new feelings of loss: Journaling new motherhood during Covid-19.

In this article we analyze the longitudinal journals of 32 Pandemic Journaling Project (PJP) participants who were pregnant, planned a pregnancy, or gave birth between January 2020 and July 2021. Employing a grounded theory approach, we coded journals in NVivo for emerging themes related to the influence of the Covid-19 pandemic on perinatal experiences in North America and Europe. In the paper we first provide some brief background on perinatal mental health and on the particular conditions for pregnancy and birth during Covid-19, before introducing major themes that emerged from the data, along with three in-depth case studies. We argue that the new mothers and prospective mothers in our sample associated new life with new feelings of loss during Covid-19. New motherhood during Covid-19 has meant for PJP participants a loss of seemingly irretrievable opportunities and moments that they see as necessary for establishing themselves as mothers and integrating their babies into their families through a process of "kinning" (Howell, 2003). Feelings of loss associated with disruptions to kinning may be partially responsible for the increase in perinatal mental distress observed during the pandemic.

Delays in Presentation of New Onset Diabetes at the Start of the COVID-19 Pandemic.

OBJECTIVE: To compare the frequency, severity of presentation and initial presentations of new onset diabetes mellitus (DM) in youth in Rhode Island during the early phase of the COVID-19 pandemic compared to the same time frame in 2018 and 2019. METHODS: A retrospective cohort study of youth treated for new onset DM at Hasbro Children's Hospital between March 1 and May 15, 2020, compared to those diagnosed in the same period in 2018 and 2019. RESULTS: Fewer youth were diagnosed with new onset DM in Spring 2020 and the percentage of youth with DKA at time of DM diagnosis was higher in Spring 2020 compared to prior years (p=0.048). Age, gender, and DKA complications did not differ by year. CONCLUSION: Nearly 50% fewer youth were diagnosed with DM at the start of the COVID-19 pandemic compared to years prior, and those diagnosed with new onset DM in Spring 2020 were more likely to present with DKA. Delays in both initial health care evaluation and the recognition of DM symptoms may have contributed to the decline in overall DM diagnoses and the more severe presentations. Identification of DM symptoms is essential, especially during future surges of COVID-19 or other events that impact the healthcare system, to reduce the risk of DM complications including DKA.

Multidisciplinary Health Care Professionals' Perceptions About Pediatric End of Life Discussions: A Cross-Sectional Survey and Needs Analysis.

BACKGROUND: Pediatric end of life (EOL) care involves complex coordination of providers from multiple disciplines. Many of these providers' experiences have not been completely described. AIM: This study aims to explicate the alignment and divergence of health care professionals' perceptions of the training, timelines, comfort, and effectiveness of pediatric EOL discussions as well as identify methods to improve medical education training. DESIGN: A cross-sectional survey was conducted. Analyses included Fisher's exact and post-hoc tests for all pairwise comparisons. SETTING/PARTICIPANTS: A total of 160 of 508 eligible participants at a single academic Department of Pediatrics completed the survey (response rate 31%). Participants included attending physicians, fellows, residents, mid-level providers, nurses, and social workers. RESULTS: Sixty percent thought EOL discussions occurred late and 70% thought discussions should occur earlier. Attending physicians were more likely to think discussions occurred late and should occur earlier (P <.01). Residents and fellows were more likely to think participating in and leading discussions was stressful (P <.02 and P <.01, respectively). Respondents that were female, younger than forty years old, had been in their provider role less than five years, or were residents and fellows were more likely to agree that these discussions led to changes in plan of patient care (P <.05). CONCLUSIONS: The majority of multidisciplinary pediatric health care professionals believe pediatric EOL discussions are stressful, occur too late, and should occur earlier. Future efforts in medical education should prioritize curriculum development focusing on workshops and simulations.

Best Practices in Medical Documentation: A Curricular Module.

OBJECTIVE: To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation. METHODS: Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment RESULTS: 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed CONCLUSIONS: This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.

Introduction: Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project.

In this article, we introduce the SSM-MH Special Issue "Journaling and Mental Health during COVID-19: Insights from the Pandemic Journaling Project," which presents findings from the Pandemic Journaling Project (PJP). PJP is an online journaling platform and mixed-methods research study created in May 2020 to provide ordinary people around the world an opportunity to chronicle the impact of the COVID-19 pandemic in their lives-for themselves and for posterity. The essays in this collection demonstrate how journaling via an online platform can help illuminate experiences of mental wellbeing and distress, with important implications for both research and clinical practice. We begin by introducing the Pandemic Journaling Project and describing our procedures for generating the data subsets analyzed in the papers collected here. We then outline the principal interventions of the special issue as a whole, introduce the papers, and identify a number of cross-cutting themes and broader contributions. Finally, we point toward key questions for future research and therapeutic practice by highlighting the three-fold value of online journaling as a research method, a therapeutic strategy, and a tool for advancing social justice. We focus in particular on how this innovative methodological approach holds promise as both a modality for psychotherapeutic intervention and a form of grassroots collaborative ethnography. We suggest that our methods create new opportunities for confronting the impact of pandemics and other large-scale events that generate radical social change and affect population-level mental health.

Combined Medicine-Pediatrics Fellowships: A Guide for Fellowship Directors and Residents.

Dual training in Internal Medicine-Pediatrics (MedPeds) was recognized by the American Board of Medical Specialties in 1967. Residents complete 24 months each in Internal Medicine and Pediatrics and are board-eligible for both at the conclusion of training. Graduates are eligible for fellowships in either or both fields. Many graduates pursue fellowship training. A small absolute number of graduates apply for dual training in adult and pediatric subspecialties, but those that do bring direct, in-depth clinical experience across the lifespan, and familiarity with care in both pediatric and adult settings. As such, they contribute unique perspectives and capabilities to their fellowship and future practice. This includes the ability to provide subspecialty care in settings with limited resources, where they are able to address needs without age restrictions, and in the transition of subspecialty care for emerging adults with childhood-onset conditions. Due to the small number of applicants pursuing joint adult and pediatric fellowships, many fellowship directors may have limited experience with dual fellowships but may want to create opportunities for these unique trainees. This summary was developed jointly by residents, fellows, MedPeds program directors, and fellowship directors in Pediatrics and Internal Medicine subspecialties, and approved by their respective leadership councils to offer some key points on common questions, suggest additional resources, and share best practices, with a goal of facilitating this process for fellowship programs and residents alike.

A mixed methods study of perinatal sleep and breastfeeding outcomes in women at risk for postpartum depression.

INTRODUCTION: Pregnant and postpartum women experience significant sleep disruption, but the role of perinatal sleep disturbances in breastfeeding is understudied. METHODS: In this observational cohort study, we used mixed methods to examine associations between perinatal sleep and breastfeeding. Forty-eight women (mean age 28.2 ± 4.9 years) who were euthymic at enrollment but had a history of major depression (n = 43) or bipolar disorder (n = 5) had sleep recorded with wrist actigraphy. We determined feeding status through daily diaries and used semi-structured interviews to identify themes regarding participants' experiences, breastfeeding decisions, and behaviors. To examine whether sleep disturbance during pregnancy predicted breastfeeding (BF) rates, we defined "lower sleep efficiency" (LSE) and "higher sleep efficiency" (HSE) groups based on the median split of actigraphic SE at 33 weeks' gestation (cutoff SE = 84.9%) and classified mothers as No-BF, Mixed-BF (BF + formula), and Exclusive-BF at 2 weeks postpartum. RESULTS: Percentages of women who did any breastfeeding were: Week 2 = 72.3%, Week 6 = 62.5%, Week 16 = 50%. LSE mothers were less likely than HSE mothers to initiate breastfeeding (percent No-BF: LSE = 45.8%, HSE = 16.7%, P < .05). Average actigraphic sleep onset, sleep offset, time in bed, sleep duration, and SE did not differ based on breastfeeding status at any time point. Qualitative themes included insufficient preparation for the demands of breastfeeding, interrupted and nonrestorative sleep, and unrelenting daytime tiredness. CONCLUSIONS: In our sample, preserved actigraphic SE during pregnancy was associated with initiation and continuation of breastfeeding. Future work should examine whether improving sleep in pregnancy improves mothers' feeding experiences.

Postpartum Maternal Tethering: A Bioethics of Early Motherhood.

This article proposes a new way of conceptualizing the ethical relationship between postpartum mothers and their newborn babies. I suggest that the intertwinement of mother and baby - and the tensions that this intertwinement produces - do not disappear with birth, but rather persist throughout the postpartum period in the form of postpartum maternal tethering. I draw upon three years of ethnographic fieldwork and training in the US and China to argue that the dependency associated with postpartum maternal tethering makes it extremely difficult for postpartum mothers to act autonomously, even in the relational sense. I then examine how breaches in the postpartum maternal tether can open up new possibilities for thinking about the bioethics of vulnerability, dependency and care, by denaturalizing and de-sanctifying the mother-baby relationship and diversifying newborn care.

Epidemiologizing Culture: Scaling Chineseness through Narratives of Stigma in New York City.

Drawing on 18 months of participation on an epidemiological research team and close analysis of in-depth interviews the team conducted with 30 Chinese immigrants to New York City, this article traces a process I call epidemiologizing culture. In producing qualitative interview data from Chinese immigrants at risk for HIV, team members smoothed over individual variation to extract elements thought to be relevant to population-level experiences of "Chinese culture." Relevance was determined based on how closely the experiences of participants mirrored the behavior of a Chinese ideal type. Interviewer and interviewee collaborated in articulating and reproducing homophobic and HIV-phobic discourses associated with Chinese culture while erasing details of lived experience, and conflating race and culture. I conclude that differing epistemic virtues make an epidemiological embrace of contemporary anthropological understandings of culture difficult. A model of "parallel play" may be an alternative approach to interdisciplinary synthesis.