Pre-pandemic circadian phase predicts pandemic alcohol use among adolescents.

Later circadian timing during adolescence is linked to worse sleep, more severe depression and greater alcohol involvement, perhaps due to circadian misalignment imposed by early school schedules. School schedules shifted later during the COVID-19 pandemic, ostensibly reducing circadian misalignment and potentially mitigating problems with depression and alcohol. We used the pandemic as a natural experiment to test whether adolescent drinkers with later circadian timing showed improvements in sleep, depression and alcohol involvement. Participants were 42 adolescents reporting alcohol use. We assessed circadian phase via dim light melatonin onset prior to the pandemic, then conducted remote assessments of sleep, depressive symptoms and alcohol use during the pandemic. Mixed-effects models were used to test for pandemic effects, covarying for age, sex, time since baseline evaluation, and current school/work status. Adolescents with later circadian timing reported less sleep than other teens on school nights, both before and during the pandemic. Although school night sleep increased during the pandemic (F = 28.36, p < 0.001), those increases were not greater for individuals with later circadian timing. Individuals with later circadian timing reported larger increases in alcohol use than other teens during the pandemic (X2 = 36.03, p < 0.001). Depressive symptoms increased during the pandemic (X2 = 46.51, p < 0.001) but did not differ based on circadian timing. Consistent with prior reports, adolescents with later circadian timing obtained less sleep, and later school schedules facilitated increased sleep duration. Nonetheless, individuals with later circadian timing reported the sharpest increases in alcohol use, suggesting that circadian timing contributes to risk for alcohol use beyond the effects of insufficient sleep.

Racism and Quality of Neonatal Intensive Care: Voices of Black Mothers.

BACKGROUND AND OBJECTIVES: Black preterm infants are more likely to die than White preterm infants within the same NICU. Racism may lead to disparate quality of NICU care contributing to disparities in preterm infant health outcomes. The objective of our study was to understand Black mothers' perspectives of the impact of racism on the quality of care for Black preterm infants in the NICU and what might be done to address it. METHODS: Using qualitative research methods, we conducted in-depth, semistructured interviews with 20 Black mothers of preterm infants in a single Level IV NICU 6 to 18 months after hospital discharge regarding experiences with disparate quality of NICU care. We developed themes iteratively and conducted interviews until thematic saturation was reached. RESULTS: The majority of mothers believed that racism impacted the quality of NICU care and described examples of racism in the NICU at structural, institutional, and interpersonal levels. Mothers also provided ideas for interventions that would decrease racism and improve quality of NICU care for Black families, including increased Black representation, increased peer support, and improved staff education and training. CONCLUSIONS: Black mothers of preterm infants experienced racism during NICU hospitalization that impacted the quality of care they received. Interventional studies directed toward mitigating these racial disparities may focus on addressing racism during the NICU period and should include input from Black stakeholders at all stages of design, implementation, and analysis.

Lived experiences of stress of Black and Hispanic mothers during hospitalization of preterm infants in neonatal intensive care units.

OBJECTIVE: To characterize the lived experiences of stress associated with having a preterm infant hospitalized in the NICU among Black and Hispanic mothers. METHODS: We performed a qualitative content analysis of secondary data from two prior studies that included 39 in-depth interviews with Black and Hispanic mothers of preterm infants at 3 U.S. NICUs. We used a constant comparative method to select important concepts and to develop codes and subsequent themes. RESULTS: Black and Hispanic mothers described stressors in the following domains and categories: Individual (feeling overwhelmed, postpartum medical complications, previous stressful life events, competing priorities); Hospital (perceived poor quality of care, provider communication issues, logistical issues); Community (lack of social supports, lack of financial resources, work challenges). CONCLUSIONS: The findings of this study suggest that stressors both inside and outside of the hospital affect the lived experiences of stress by Black and Hispanic mothers during NICU hospitalization.

Video-assisted Thoracoscopic Resection of a Congenital Tracheobiliary Fistula in a Neonate: Technical Report and Review of the Literature.

BACKGROUND: Congenital tracheobiliary or bronchobiliary fistulae are rare developmental malformations associated with high morbidity and mortality primarily because of concomitant anomalies as well as delays in diagnosis. TECHNICAL REPORT: We report a case of a neonate who presented with bilious emesis and progressive respiratory failure requiring bronchoscopy and fluoroscopic bronchography for diagnosis with successful management through video-assisted thoracoscopic surgery. We also review the published literature on tracheobiliary fistula. CONCLUSION: Use of video-assisted thoracoscopic surgery for fistula resection has been reported in only one other neonate and provides a clinically less invasive option compared with open surgical ligation and resection. To our knowledge, this is the first English language report of thoracoscopic resection in a neonate with congenital tracheobiliary fistula.

Team-Based Breastfeeding Support at a Federally Qualified Health Center: Efficacy, Utilization, and Patient Satisfaction.

Background: A team-based, integrated lactation consultant (LC) and primary care provider (PCP) program improves breastfeeding rates in some outpatient settings, but only a limited number of studies have assessed efficacy in socioeconomically and racially diverse communities. Objectives: Following implementation of team-based LC/PCP care at a Federally Qualified Health Center (FQHC), quality improvement efforts assessed utilization, breastfeeding rates, and patient satisfaction. Method: A retrospective chart review examined feeding status pre- and postimplementation. Analysis compared feeding rates at the 2-week, 2-month, 4-month, and 6-month well visits (well child care). Subanalysis of patients who initiated breastfeeding postimplementation examined feeding status and LC support. Patient survey evaluated satisfaction. Results: Among patients who initiated breastfeeding, those who received a LC/PCP visit were significantly more likely to be breastfeeding at 2 weeks (94% versus 80%, p = 0.004) and 4 months (68% versus 45%, p = 0.01). However, breastfeeding rates for the whole practice were not significantly different before and after implementation. Seventy-two percent of breastfeeding families saw a LC (n = 204). Median LC visit per breastfeeding patient was 1.18 (standard deviation [SD] +1.2). Patient survey reported that the three most commonly helpful aspects of the visit were "latch instruction" (60%), "breastfeeding questions answered" (80%) and "learning about massage and hand expression" (50%). Discussion: Team-based LC/PCP care is feasible at a FQHC. Patients found it helpful. Among families who initiated breastfeeding, receiving LC/PCP care was associated with increased breastfeeding duration through 4 months.

Translating Team-Based Breastfeeding Support into Primary Care Practice.

BACKGROUND: Team-based care facilitates efficient, evidence-based, patient-centered practice. An outpatient, integrated lactation consultant (LC) and primary care provider (PCP) model improves breastfeeding support, yet practices need assistance with implementation. METHOD: Based on experience with team-based breastfeeding support at a suburban practice serving mainly well-educated and privately insured families, we constructed and piloted a 6-step needs assessment that informed implementation of the model at a federally qualified health center (FQHC). Practice assessment included baseline data collection of practice newborn volume, breastfeeding intent, breastfeeding rates, provider survey, and financial variables. Postimplementation outcome measurements included provider satisfaction and visit volume. RESULTS: Analysis using newborn volume, breastfeeding intent, and average insurance reimbursement enabled business calculation, which estimated additional 400 visits per year and revenue to cover staff training costs. The baseline provider survey (n = 20) assessed knowledge, practice resources, and barriers. The main barriers identified to providing lactation support were "not enough time" (80%) and patients "not receiving adequate help" (80%) with 58% noting "inadequate LC staffing at the clinic." After team-based LC/PCP implementation, monthly lactation visit volume doubled. Provider postintervention assessment surveys (n = 20) demonstrated a positive response with providers reporting a perception of "providing better breastfeeding support" (100%) and that "patients had a positive breastfeeding support experience" (84%). CONCLUSION: Team-based LC and PCP health care is a promising approach for delivering efficient, patient-centered, face-to-face counseling and support. Practice assessment informs financial feasibility and confirms provider interest in change. An integrated LC/PCP model can be implemented in a FQHC while enhancing patient breastfeeding support and provider satisfaction.

The role of tablets in accessing information throughout undergraduate medical education in Botswana.

BACKGROUND: Mobile learning (mLearning) uses wireless networks and mobile devices to expand physician trainees' and healthcare providers' access to and exchange of medical information. Opportunities to increase implementation and expand use of mobile devices to support health care information access and delivery in Africa are vast, but the rapid growth of mLearning has caused project implementation to outpace objective measurement of impact. This study makes a contribution to the existing body of literature regarding mLearning implementation in Africa through its focus on the use of smart devices (tablets) in undergraduate medical education and medical students' perceptions of the effects on their learning environment. MATERIALS AND METHODS: The population of this prospective mixed-methods study consisted of 82 undergraduate medical students (45 third year and 37 fourth year) at the University of Botswana Faculty of Medicine. They received tablets in the earliest phase of the mLearning project implementation (between November 2012 and January 2013), when they were in the third and fourth year of their medical training. Usage of the tablets was assessed both quantitatively and qualitatively, through both application usage tracking and focus groups. RESULTS: Based on application usage data and coding and analysis of focus group discussions, undergraduate medical students indicated that tablets were useful in their medical education, allowing them continual access to information and opportunities for communication. Participants noted that the primary barrier to use of tablets was the lack of mobile cellular Internet beyond the Wi-Fi zones at the training sites. Moreover, participants offered suggestions for improvements to the implementation process. CONCLUSIONS: Even in resource-limited settings where Internet access can be unreliable and intermittent, the adoption of tablets can have benefits to medical education by providing consistent access to extensive and current medical information resources. This study highlights the value of clinical resources with offline functionality, with or without consistent access to the Internet. There is also the potential for optimizing the use of tablets through improved training and technical support.

Clinician adherence to recommendations for screening of adolescents for sexual activity and sexually transmitted infection/human immunodeficiency virus.

OBJECTIVES: To evaluate clinician adherence to guidelines for documentation of sexual history and screening for sexually transmitted infection (STI)/HIV infection during routine adolescent well visits. Secondary objectives were to determine patient and clinician factors associated with sexual history documentation and STI/HIV testing. STUDY DESIGN: Retrospective, cross-sectional study of 1000 randomly selected 13- to 19-year-old routine well visits at all 29 pediatric primary care practices affiliated with a children's hospital. We evaluated frequency of documentation of sexual history and testing for gonorrhea (GC)/chlamydia (CT) and HIV testing. Multivariable logistic regression was performed to identify factors associated with documentation and testing. RESULTS: Of the 1000 patient visits reviewed, 212 (21.2%; 95% CI, 18.7-23.7) had a documented sexual history, of which 45 adolescents' (21.2%; 95% CI, 15.7-26.8) encounters were documented as being sexually active. Overall, 26 (2.6%; 95% CI, 1.6-3.6) patients were tested for GC/CT and 16 (1.6%; 95% CI, 0.8-2.4) were tested for HIV infection. In multivariable analyses, factors associated with sexual history documentation included older patient age, non-Hispanic black race/ethnicity, nonprivate insurance status, and care by female clinician. Factors associated with GC/CT testing included male gender, non-Hispanic black race/ethnicity, and nonprivate insurance. HIV testing was more likely to be performed on older adolescents, those of non-Hispanic black race/ethnicity, and those with nonprivate insurance. CONCLUSIONS: Pediatric primary care clinicians infrequently document sexual histories and perform STI and HIV testing on adolescent patients. Future studies should investigate provider beliefs, clinical decision-making principles, and perceived barriers to improve the sexual health care of adolescents and evaluate interventions to increase rates of adolescent sexual health screening.

Effects of surface dehydration on mucosal wave amplitude and frequency in excised canine larynges.

OBJECTIVE: Evaluate the effect of vocal fold surface dehydration on mucosal wave amplitude and frequency. STUDY DESIGN: Controlled test-retest. SETTING: Larynges were mounted on an excised larynx phonation system and attached to a pseudolung in a triple-walled sound-attenuated room that eliminated background noise and maintained a stabilized room temperature and humidity level. SUBJECTS AND METHODS: High-speed video was recorded for 8 excised canine larynges during exposure to dehumidified air at 20 cm H(2)O. Control trials consisted of high-speed videos recorded for 2 excised canine larynges during exposure to humidified air at the same pressure. RESULTS: In the majority of larynges, increased levels of dehydration were correlated with decreased amplitude and frequency. The slope of the linear regression fitted to the change in amplitude (P = .003) and the percent change (P < .001) between the initial and final trials were significantly decreased in dehydrated larynges. These measurements with respect to the change in frequency were also significantly decreased in dehydrated larynges (P < .001; P = .027). CONCLUSION: Vocal fold surface dehydration caused a decrease in mucosal wave amplitude and frequency. This study provides objective, quantitative support for the mechanism of voice deterioration observed after extreme surface dehydration.

Preliminary investigation of adjustable balloon implant for type I thyroplasty.

OBJECTIVE: We present the adjustable balloon implant (ABI), a novel implant to be used in type I thyroplasty for the treatment of vocal fold paralysis. The ABI offers the same medialization provided by other implants, but can easily be catered to individual patient anatomy as well as modified postoperatively without the need for a revision thyroplasty. STUDY DESIGN: Repeated measures with each larynx serving as its own control. METHODS: Medialization thyroplasty (MT) with the ABI was performed on five excised canine larynges. Mucosal wave, aerodynamic, and acoustic parameters were measured for three conditions: normal; right vocal fold paralysis; and paralysis with the ABI. RESULTS: Insertion of the ABI resulted in significant decreases in both phonation threshold pressure and phonation threshold flow. Perturbation parameters of percent jitter and percent shimmer were also significantly decreased and restored to normal levels. Signal-to-noise ratio was significantly increased to the normal level as well. The mucosal wave was preserved after implant insertion. CONCLUSIONS: This preliminary experiment showing significant improvements in aerodynamic and acoustic parameters demonstrates the potential of the ABI as a thyroplasty implant. Effective medialization and preservation of the mucosal wave combined with postoperative adjustability makes it a potentially valuable clinical device.

Optimal arytenoid adduction based on quantitative real-time voice analysis.

HYPOTHESIS: The optimal degree of arytenoid rotation for arytenoid adduction (AA) can be determined using quantitative real-time voice analysis. STUDY DESIGN: Repeated measures with each larynx serving as its own control. METHODS: Unilateral vocal fold paralysis (VFP) was modeled in five excised canine larynges. Medialization laryngoplasty (ML) was performed, followed by AA. The optimal degree of arytenoid rotation was determined using real-time measurements of vocal efficiency (V(E) ), percent jitter, and percent shimmer. After the optimal degree of rotation was determined, the arytenoid was hypo- and hyperrotated 10% ± 2% of the optimal angle to mimic hypoadducted and hyperadducted states. Aerodynamic, acoustic, and mucosal wave measurements were recorded. RESULTS: Mean optimal angle of arytenoid adduction was 151.4 ± 2.5°. V(E) differed significantly across experimental conditions (P = .003). Optimal AA produced the highest V(E) of any treatment, but this value did not reach that produced in the normal condition. Percent jitter (P < .001) and percent shimmer (P < .001) differed across groups and were lowest for optimal AA. Mucosal wave amplitude of the normal (P = .001) and paralyzed fold (P = .043) differed across treatments. Amplitude of both folds was highest for optimal AA. CONCLUSIONS: V(E) and perturbation parameters were sensitive to the degree of arytenoid rotation. Using real-time voice analysis may aid surgeons in determining the optimal degree of arytenoid rotation when performing AA. Testing this method in patients and determining if optimal vocal outcomes are associated with optimal respiratory and swallowing outcomes will be essential to establishing clinical viability.

Effects of the Voice over Internet Protocol on perturbation analysis of normal and pathological phonation.

OBJECTIVE: In this study, a Voice over Internet Protocol (VoIP) communication based on G.729 protocol was simulated to determine the effects of this system on acoustic perturbation parameters of normal and pathological voice signals. PATIENTS AND METHODS: Fifty recordings of normal voice and 48 recordings of pathological voice affected by laryngeal paralysis were transmitted through a VoIP communication system. The acoustic analysis programs of CSpeech and MDVP were used to determine the percent jitter and percent shimmer from the voice samples before and after VoIP transmission. The effects of three frequently used audio compression protocols (MP3, WMA, and FLAC) on the perturbation measures were also studied. RESULTS: It was found that VoIP transmission disrupts the waveform and increases the percent jitter and percent shimmer of voice samples. However, after VoIP transmission, significant discrimination between normal and pathological voices affected by laryngeal paralysis was still possible. It was found that the lossless compression method FLAC does not exert any influence on the perturbation measures. The lossy compression methods MP3 and WMA increase percent jitter and percent shimmer values. CONCLUSION: This study validates the feasibility of these transmission and compression protocols in developing remote voice signal data collection and assessment systems.

Comparative study of the retinal vessel anatomy of rhesus monkeys and humans.

OBJECTIVES: This study aims to compare retinal vessel anatomy of normal rhesus monkeys and humans and to provide a basis from a structural perspective for the use of rhesus monkey as an experimental model in future studies of retinal vessels. METHODS: The retinas of six normal rhesus monkey eyes and eight human eyecups following corneal transplantation were obtained and stained using adenosine diphosphatase methods. The distributions, orders, layers of the retinal vessels and the perifoveal vascular ring were compared. RESULTS: With adenosine diphosphatase staining, distinct retinal vessels were fully discernable from the first order surrounding the optic disc to the fifth order. There were no statistically significant differences between rhesus monkeys and humans in the percentages of vessels surrounding the optic disc at the equator and the peripheral region. Vascular networks in both species were arranged in several layers around the optic disc, two anastomotic layers at the equator and one sparse layer peripherally. Capillaries at the macular area were quite dense and an intact perifoveal vascular ring was observed. No differences were observed between rhesus monkeys and humans in the percentage area of the vessels and the area, perimeter and diameter of the perifoveal vascular ring. CONCLUSIONS: The distributions, orders, layers and the perifoveal vascular ring of the retinal vessels of rhesus monkey are quite similar to those of humans. The data suggest that from an anatomical perspective, the rhesus monkey is a good animal model for the study of human retinal vessels, particularly the macular capillaries.

Regional macular light sensitivity changes in myopic Chinese adults: an MP1 study.

PURPOSE: To investigate the variation of macular light sensitivity (MLS) in myopic Chinese adults by using microperimetry. METHODS: MLS was recorded with the MP1 microperimeter (Nidek Technologies, Padova, Italy) in eyes affected by various degrees of myopia. Subjects were divided into group A (18-30 years) and group B (31-60 years). Subjects in both age groups were further divided based on refractive status: (1) high myopia (spherical equivalent, SE<-6.00 D); (2) low to moderate myopia (-6.00 D

Multiparameter comparison of injection laryngoplasty, medialization laryngoplasty, and arytenoid adduction in an excised larynx model.

OBJECTIVES/HYPOTHESIS: Evaluate the effect of injection laryngoplasty (IL), medialization laryngoplasty (ML), and ML combined with arytenoid adduction (ML-AA) on acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup. STUDY DESIGN: Comparative case study using ex vivo canine larynges. METHODS: Measurements were recorded for eight excised canine larynges with simulated unilateral vocal fold paralysis before and after vocal fold injection with Cymetra. A second set of eight larynges was used to evaluate medialization laryngoplasty using a Silastic implant without and with arytenoid adduction. RESULTS: IL and ML led to comparable decreases in phonation threshold flow (PTF), phonation threshold pressure (PTP), and phonation threshold power (PTW). ML-AA led to significant decreases in PTF (P = .008), PTP (P = .008), and PTW (P = .008). IL and ML led to approximately equal decreases in percent jitter and percent shimmer. ML-AA caused the greatest increase in signal-to-noise ratio. ML-AA discernibly decreased frequency (P = 0.059); a clear trend was not observed for IL or ML. IL significantly reduced mucosal wave amplitude (P = 0.002), whereas both ML and ML-AA increased it. All procedures significantly decreased glottal gap, with the most dramatic effects observed after ML-AA (P = 0.004). CONCLUSIONS: ML-AA led to the greatest improvements in phonatory parameters. IL was comparable to ML aerodynamically and acoustically, but caused detrimental changes to the mucosal wave. Incremental improvements in parameters recorded from the same larynx were observed after ML and ML-AA. To ensure optimal acoustic outcome, the arytenoid must be correctly rotated. This study provides objective support for the combined ML-AA procedure in tolerant patients.

Multiparameter analysis of titanium vocal fold medializing implant in an excised larynx model.

OBJECTIVES: We evaluated the efficacy of the titanium vocal fold medializing implant (TVFMI) for the treatment of unilateral vocal fold paralysis (UVFP) on the basis of acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup. METHODS: Measurements were recorded on 8 excised canine larynges with simulated UVFP before and after medialization with a TVFMI. RESULTS: The phonation threshold flow (p < 0.001) and phonation threshold power (p = 0.008) decreased significantly after medialization. The phonation threshold pressure also decreased, but this difference was not significant (p = 0.081). Jitter (p = 0.005) and shimmer (p = 0.034) decreased significantly after medialization. The signal-to-noise ratio increased significantly (p = 0.05). Differences in mucosal wave characteristics were discernible but not significant. The phase difference between the normal and paralyzed vocal folds (p = 0.15) and the amplitude of the paralyzed vocal fold (p = 0.78) decreased. The glottal gap decreased significantly (p = 0.004). CONCLUSIONS: The TVFMI was effective in achieving vocal fold medialization, improving vocal aerodynamic and acoustic characteristics of phonation significantly and mucosal wave characteristics discernibly. This study provides objective, quantitative support for the use of the TVFMI in improving vocal function in patients with UVFP.

High-salt loading exacerbates increased retinal content of aquaporins AQP1 and AQP4 in rats with diabetic retinopathy.

In the neural retina, glial cells control formation of ionic gradients by mediating transmembrane water fluxes through aquaporin (AQP) water channels. Retinal content and immunolocalization of two water channels, AQP1 and AQP4, in the diabetic rat retinas during high-salt loading were examined in this study. Diabetes was induced by an intraperitoneal injection of streptozotocin. Diabetic and control animals were observed after varying lengths of exposure to normal- and high-salt conditions. Ultrathin sections of retinal tissue, stained with uranyl acetate and lead citrate, were photographed using a transmission electron microscope (TEM). Retinal wholemounts were immunostained with AQP1 and AQP4 antibody to detect the immunolocalization changes by confocal microscopy. AQP1 and AQP4 content were evaluated by Western blot analysis. In the retinas of high-salt loading diabetic animals, obviously increased intracellular edema was observed by TEM in ganglion cells and mitochondrial swelling was observed in glial cells. Immunolocalization of AQP1 increased from the posterior to peripheral retina. Western blot results indicated that a high-salt diet may cause increased retinal content of AQP4 and may exacerbate increased retinal content of AQP1 caused by diabetic retinopathy. High-salt loading may increase neural retinal edema in rats with diabetic retinopathy, and altered glial cell mediated water transport via AQP channels in the retina may play an important role in the neural retinal edema formation and resolution.

Effect of dehydration on phonation threshold flow in excised canine larynges.

OBJECTIVES: The minimum airflow necessary to initiate stable vocal fold vibration--phonation threshold flow (PTF)--may increase as exposure to dry air increases. A critical period of dehydration may exist after which phonation can no longer be initiated. METHODS: We collected PTF data for 11 excised canine larynges mounted on a bench apparatus. Trials consisted of cycles of 10 seconds of phonation followed by 3 seconds of rest. During the experimental trials, subglottal flow of comparatively dry air was increased until phonation was initiated, and phonation was sustained for the remainder of the 10-second period. The subglottal flow was then decreased until phonation ceased. No saline solution was applied during the dehydration trials. During the control trials, subglottal airflow was humidified and saline solution was applied frequently to the vocal folds. RESULTS: The PTF increased as exposure to dry air increased during the experimental trials (p = 0.010); this relationship was not statistically significant in control trials. A point existed after which phonation could not be initiated. CONCLUSIONS: Knowledge of the effect of exposure to dry air on PTF could be useful in the clinical assessment and prevention of dehydration. Further exploration of this relationship in vivo could be used to evaluate the effectiveness of current hydration therapies and provide theoretical support for the development of new ones.