Neighborhood Disadvantage, Quality of Life, and Symptom Burden in Children with Mild Sleep-disordered Breathing.

Rationale: Neighborhood disadvantage (ND) has been associated with sleep-disordered breathing (SDB) in children. However, the association between ND and SDB symptom burden and quality of life (QOL) has not yet been studied.Objectives: To evaluate associations between ND with SDB symptom burden and QOL.Methods: Cross-sectional analyses were performed on 453 children, ages 3-12.9 years, with mild SDB (habitual snoring and apnea-hypopnea index < 3/h) enrolled in the PATS (Pediatric Adenotonsillectomy Trial for Snoring) multicenter study. The primary exposure, neighborhood disadvantage, was characterized by the Child Opportunity Index (COI) (range, 0-100), in which lower values (specifically COI ⩽ 40) signify less advantageous neighborhoods. The primary outcomes were QOL assessed by the obstructive sleep apnea (OSA)-18 questionnaire (range, 18-126) and SDB symptom burden assessed by the Pediatric Sleep Questionnaire-Sleep-related Breathing Disorder (PSQ-SRBD) scale (range, 0-1). The primary model was adjusted for age, sex, race, ethnicity, maternal education, recruitment site, and season. In addition, we explored the role of body mass index (BMI) percentile, environmental tobacco smoke (ETS), and asthma in these associations.Results: The sample included 453 children (16% Hispanic, 26% Black or African American, 52% White, and 6% other). COI mean (standard deviation [SD]) was 50.3 (29.4), and 37% (n = 169) of participants lived in disadvantaged neighborhoods. Poor SDB-related QOL (OSA-18 ⩾ 60) and high symptom burden (PSQ-SRBD ⩾ 0.33) were found in 30% (n = 134) and 75% (n = 341) of participants, respectively. In adjusted models, a COI increase by 1 SD (i.e., more advantageous neighborhood) was associated with an improvement in OSA-18 score by 2.5 points (95% confidence interval [CI], -4.34 to -0.62) and in PSQ-SRBD score by 0.03 points (95% CI, -0.05 to -0.01). These associations remained significant after adjusting for BMI percentile, ETS, or asthma; however, associations between COI and SDB-related QOL attenuated by 23% and 10% after adjusting for ETS or asthma, respectively.Conclusions: Neighborhood disadvantage was associated with poorer SDB-related QOL and greater SDB symptoms. Associations were partially attenuated after considering the effects of ETS or asthma. The findings support efforts to reduce ETS and neighborhood-level asthma-related risk factors and identify other neighborhood-level factors that contribute to SDB symptom burden as strategies to address sleep-health disparities.Clinical trial registered with www.clinicaltrials.gov (NCT02562040).

The effectiveness and cost-effectiveness of a group domestic abuse perpetrator programme: protocol for a randomised controlled trial.

BACKGROUND: In contrast to evidence for interventions supporting victim/survivors of domestic violence and abuse (DVA), the effectiveness of perpetrator programmes for reduction of abuse is uncertain. This study aims to estimate the effectiveness and cost-effectiveness of a perpetrator programme for men. METHODS: Pragmatic two-group individually randomised controlled trial (RCT) with embedded process and economic evaluation. Five centres in southwest England and South Wales aim to recruit 316 (reduced from original target of 366) male domestic abuse perpetrators. These will be randomised 2:1 to a community-based domestic abuse perpetrator programme (DAPP) or usual care comparator with 12-month follow-up. Female partners/ex-partners will be invited to join the study. The intervention for men comprises 23 weekly sessions of a group programme delivered in voluntary sector domestic abuse services. The intervention for female partners/ex-partners is one-to-one support from a safety worker. Men allocated to usual care receive no intervention; however, they are free to access other services. Their partners/ex-partners will be signposted to support services. Data is collected at baseline, and 4, 8 and 12 months' follow-up. The primary outcome is men's self-reported abusive behaviour measured by the Abusive Behaviour Inventory (ABI-29) at 12 months. Secondary measures include physical and mental health status and resource use alongside the abuse measure ABI (ABI-R) for partners/ex-partners and criminal justice contact for men. A mixed methods process evaluation and qualitative study will explore mechanisms of effectiveness, judge fidelity to the intervention model using interviews and group observations. The economic evaluation, over a 1-year time horizon from three perspectives (health and social care, public sector and society), will employ a cost-consequences framework reporting costs alongside economic outcomes (Quality-Adjusted Life Years derived from EQ-5D-5L, SF-12 and CHU-9D, and ICECAP-A) as well as the primary and other secondary outcomes. DISCUSSION: This trial will provide evidence of the (cost)effectiveness of a DAPP. The embedded process evaluation will further insights in the experiences and contexts of participants and their journey through a perpetrator programme, and the study will seek to address the omission in other studies of economic evaluations. TRIAL REGISTRATION: ISRCTN15804282, April 1, 2019.

Asthma outcomes in pediatric patients with 30-day follow-up after an asthma hospitalization in a Medicaid-managed care program.

BACKGROUND: National asthma guidelines recommend an outpatient follow-up after hospitalization for asthma. Our aim is determine if a follow-up visit within 30 days after an asthma hospitalization impacts risk for re-hospitalization and emergency department visits for asthma within the following year. METHODS: This was a retrospective cohort study of claims data of Texas Children's Health Plan (a Medicaid managed care program) members age 1 to <18 years and hospitalized for asthma between January 1, 2012, and December 31, 2018. Primary outcomes were days to re-hospitalization and emergency department visit between 30 days and 365 days following the index hospitalization. RESULTS: We identified 1,485 children age 1 to <18 years hospitalized for asthma. Comparing those with a 30 day follow-up to those without, there was no difference in days to re-hospitalization (adjusted hazard ratio 1.23, 95% Confidence Interval (CI) 0.74-2.06) or emergency department visit for asthma (aHR 1.08, 95% CI 0.88-1.33). Inhaled corticosteroid and short acting beta agonist dispensing were greater in the group completing the 30 day follow-up (means of 2.8 and 4.8 respectively for those with follow-up, 1.6 and 3.5 respectively for those without, p < 0.0001). CONCLUSION: Having a follow-up outpatient visit within 30 days of an asthma hospitalization is not associated with a decrease in asthma re-hospitalization or emergency department visit in the 30-365 day period following the index hospitalization. Non-adherence to regular use of inhaled corticosteroid medication was high in both groups. These findings suggest need for improvement in the quality and quantity of post hospital asthma follow-up.

Remote Patient Monitoring During COVID-19: An Unexpected Patient Safety Benefit.

This Viewpoint explains how some hospitals used home monitoring of pulse oximetry during the COVID-19 pandemic to avoid patient overcrowding and control high patient to staff ratios and how increased use of home monitoring for other vital signs could potentially improve patient safety and decrease costs.

Promoting adherence to bone-loading exercises in postmenopausal women with low bone mass.

BACKGROUND: We recently completed a parent study (Bone Loading Exercises versus Risedronate on Bone Health in Post-menopausal Women [NIH# R01NR015029]) examining bone-loading exercises to prevent bone loss in postmenopausal women with low bone mass. Forty-three million US women have low bone mass and increased risk for fractures. Bone-loading exercises (weight-bearing and resistance training) can preserve bone mass and decrease risk of fractures. However, multiple barriers prevent women from exercising and adherence rates are low. PURPOSE: This secondary analysis of the parent study (a) examined barriers specific to women participating in bone-loading exercises; (b) described effectiveness of self-efficacy strategies used in the parent study for increasing confidence in knowledge and reducing barriers; and (c) applied study findings and principles of self-efficacy and self-regulation in development of guidelines for promoting adherence to exercises. METHODS: Seventy-two women were randomized to the exercise group and completed 12 months of exercises. Instruments for self-efficacy were completed at 2 weeks and barriers interference at 6 months. Percent adherence was measured as the number of exercise sessions attended divided by the number prescribed. RESULTS: In the 12-month study, average adherence to exercises was 58.9%. Lower adherers reported lack of self-regulation skills such as "lack of time" as the most frequent barriers to exercise. IMPLICATIONS FOR PRACTICE: Guidelines developed included promotion of skills for self-regulation (such as regulation of time) as well as self-efficacy to improve adherence rates. Nurse practitioners may be the most motivated of all providers to use guidelines promoting exercise for women in their clinical practice.

Revision Lingual Frenotomy Improves Patient-Reported Breastfeeding Outcomes: A Prospective Cohort Study.

BACKGROUND: Lingual frenotomy improves patient-reported outcome measures, including infant reflux and maternal nipple pain, and prolongs the nursing relationship; however, many mother-infant dyads continue to experience breastfeeding difficulty despite having had a frenotomy. Research aim: The aim of this study was to determine how incomplete release of the tethered lingual frenulum may result in persistent breastfeeding difficulties. METHODS: A one-group, observational, prospective cohort study was conducted. The sample consisted of breastfeeding mother-infant (0-9 months of age) dyads ( N = 54) after the mothers self-elected completion lingual frenotomy and/or maxillary labial frenectomy following prior lingual frenotomy performed elsewhere. Participants completed surveys preoperatively, 1-week postoperatively, and 1-month postoperatively consisting of the Breastfeeding Self-Efficacy Scale-Short-Form (BSES-SF), Visual Analog Scale (VAS) for nipple pain severity, and the Revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). RESULTS: Significant postoperative improvements were reported between mean preoperative scores compared with 1-week and 1-month scores of the BSES-SF, F(2) = 41.2, p < .001; the I-GERQ-R, F(2) = 22.7, p < .001; and VAS pain scale, F(2) = 46.1, p < .001. CONCLUSION: We demonstrated that besides nipple pain, measures of infant reflux symptoms and maternal breastfeeding self-confidence can improve following full release of the lingual frenulum. Additionally, a patient population was identified that could benefit from increased scrutiny of infant tongue function when initial frenotomy fails to improve breastfeeding symptoms.

Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study.

OBJECTIVES/HYPOTHESIS: Numerous symptoms may arise that prevent mother-infant dyads from maintaining desired breastfeeding intervals. Investigations into treatments that positively influence breastfeeding outcomes allow for improved patient counseling for treatment decisions to optimize breastfeeding quality. This investigation aimed to determine the impact of surgical tongue-tie/lip-tie release on breastfeeding impairment. STUDY DESIGN: Prospective, cohort study from June 2014 to April 2015 in a private practice setting. METHODS: Study participants consisted of breastfeeding mother-infant (0-12 weeks of age) dyads with untreated ankyloglossia and/or tethered maxillary labial frenula who completed preoperative, 1 week, and 1 month postoperative surveys consisting of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), visual analog scale (VAS) for nipple pain severity, and the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R). Breastmilk intake was measured preoperatively and 1 week postoperatively. RESULTS: A total of 237 dyads were enrolled after self-electing laser lingual frenotomy and/or maxillary labial frenectomy. Isolated posterior tongue-tie was identified in 78% of infants. Significant postoperative improvements were reported between mean preoperative scores compared to 1 week and 1 month scores of the BSES-SF (F(2) = 212.3; P < .001), the I-GERQ-R (F(2) = 85.3; P < .001), and VAS pain scale (F(2) = 259.8; P < .001). Average breastmilk intake improved 155% from 3.0 (2.9) to 4.9 (4.5) mL/min (P < .001). CONCLUSIONS: Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes. Improvements occur early (1 week postoperatively) and continue to improve through 1 month postoperatively. Improvements were demonstrated in both infants with classic anterior tongue-tie and less obvious posterior tongue-tie. This study identifies a previously under-recognized patient population that may benefit from surgical intervention if abnormal breastfeeding symptoms exist. LEVEL OF EVIDENCE: 2c Laryngoscope, 127:1217-1223, 2017.

Coronary artery fenestration prior to stenting in spontaneous coronary artery dissection.

Percutaneous coronary intervention (PCI) in patients with spontaneous coronary artery dissection is associated with high rates of complications and suboptimal long-term outcomes. Coronary artery fenestration with cutting balloon angioplasty prior to stenting can prevent the expansion of intramural hematoma and optimize PCI outcomes in this patient population. © 2015 Wiley Periodicals, Inc.

Gender and ethnic differences in hand hygiene practices among college students.

BACKGROUND: Poor hand hygiene on college campuses can be improved by promoting handwashing behavior. This observational study was conducted to evaluate gender and race/ethnic differences in hand hygiene practices among college students. METHODS: Hand hygiene practices in college students were evaluated in 4 settings (soap and water; soap and water and visual prompts; soap and water and hand sanitizers; and soap and water, hand sanitizers, and visual prompts). The degree of hand hygiene (ie, adequate handwashing time, use of hand sanitizer, and hand-drying method) also was evaluated at various locations on campus. RESULTS: Overall, 72.9% of students washed their hands, 58.3% practiced hand hygiene (using either soap or hand sanitizer), and 26.1% washed their hands adequately. Hand sanitizer use was low when students were given the option, and paper towel was the most common hand-drying method. In general, hand hygiene practices were better in academic buildings than in the student recreation center. Visual prompts improved handwashing behavior only among students in the "other" ethnic category, but not by gender. CONCLUSIONS: Handwashing is the most effective way of preventing the spread of infectious diseases, and our findings have implications for the design of effective hand hygiene education programs in college students.

Improving emergency obstetric care in a context of very high maternal mortality: the Nepal Safer Motherhood Project 1997-2004.

The Nepal Safer Motherhood Project (1997-2004) was one of the first large-scale projects to focus on access to emergency obstetric care, covering 15% of Nepal. Six factors for success in reducing maternal mortality are applied to assess the project. There was an average annual increase of 1.3% per year in met need for emergency obstetric care, reaching 14% in public sector facilities in project districts in 2004. Infrastructure and equipment to achieve comprehensive-level care were improved, but sustained functioning, availability of a skilled doctor, blood and anaesthesia, were greater challenges. In three districts, 70% of emergency procedures were managed by nurses, with additional training. However, major shortages of skilled professionals remain. Enhancement of the weak referral system was beyond the project's scope. Instead, it worked to increase information in the community about danger signs in pregnancy and delivery and taking prompt action. A key initiative was establishing community emergency funds for obstetric complications. Efforts were also made to develop a positive shift in attitudes towards patient-centred care. Supply-side interventions are insufficient for reducing the high level of maternal deaths. In Nepal, this situation is complicated by social norms that leave women undervalued and disempowered, especially those from lower castes and certain ethnic groups, a pattern reflected in use of maternity services. Programming also needs to address the social environment.

Sweat production during global heating and during isometric exercise in people with diabetes.

BACKGROUND: While sweat production in response to heat is impaired in people with diabetes, sweat production has not been examined during isometric exercise. MATERIAL/METHODS: Eight subjects with type 2 diabetes and 9 control subjects exerted a fatiguing isometric contraction of the handgrip muscles at a tension of 40% of the maximum voluntary strength (MVC) after exposure to a 32 deg C environment for 30 min. compared to 10 controls and 10 subjects with diabetes exposed to a 39 deg C environment. RESULTS: Sweat was impaired to all areas of the body during heat exposure in patients with diabetes under both environmental conditions. For example, on the chest, the average sweat rates after exposure to the 32 deg environment was 259.2 +/- 55.2 nanoliters/min in control subjects and 198.3 +/- 46.2 nanoliters/min for subjects with diabetes. Compared to the 32 deg C environment, control subjects increased sweat in all 4 areas proportionally more than subjects with diabetes. Sudomotor rhythm was present in sweat in control subjects at a rate of repetition of 11 and 50 seconds but almost absent in subjects with diabetes. During exercise, sweat rates slowly increased from the beginning to the end of the exercise. But the head of the subjects with diabetes showed hypersweating while the other areas showed diminished sweating compared to control subjects. CONCLUSIONS: Thus some of the impairment in sweating may be due to central mechanisms associated with heat sensitivity or in the hypothalamus and not to the sweat glands themselves.

Cardiovascular responses and endurance during isometric exercise in patients with Type 2 diabetes compared to control subjects.

BACKGROUND: While it is well documented that diabetes impairs the microcirculation, its effect on isometric exercise has not been determined. MATERIAL/METHODS: Isometric strength and endurance of the handgrip muscles for a series of 2 fatiguing isometric contractions at a tension of 40% of the maximum strength were assessed in 10 subjects with Type 2 diabetes compared to 10 control subjects; 5 minutes were allowed between the contractions. Blood pressure (BP), heart rate (HR), blood flow (BF) of the whole arm and of the skin on the chest and foot were measured. RESULTS: Strength and endurance for the first contraction was the same in control subjects compared to subjects with Type 2 diabetes (p>0.05), but endurance of the second contraction was significantly less in subjects with diabetes (p<0.01). HR increased significantly (p<0.01) by over three fold during exercise in control subjects compared to subjects with diabetes. Resting and peak blood pressures were greater in subjects with type 2 diabetes compared to control subjects (p<0.01). Forearm blood flow was significantly lower at rest, during exercise and post exercise in subjects with diabetes compared to control subjects (p<0.01). CONCLUSIONS: The results are probably explained by the damage to the microcirculation seen in subjects with diabetes.

Convulsive syncope associated with acupuncture.

Syncope is a rare but known reaction to acupuncture; however, convulsive syncope has never been previously documented as a reaction to acupuncture. This case report describes an episode of convulsive syncope, characterized by irregular clonic-tonic movements while the patient was unconscious. The episode occurred immediately after the insertion of acupuncture needles into the bilateral ST-36 acupuncture point. Here we discuss the presentation, possible causes, and prevention of convulsive syncope.

Use of complementary/alternative therapies by women with advanced-stage breast cancer.

BACKGROUND: This study sought to describe the pattern of complementary/alternative medicine (CAM) use among a group of patients with advanced breast cancer, to examine the main reasons for their CAM use, to identify patient's information sources and their communication pattern with their physicians. METHODS: Face-to-face structured interviews of patients with advanced-stage breast cancer at a comprehensive oncology center. RESULTS: Seventy three percent of patients used CAM; relaxation/meditative techniques and herbal medicine were the most common. The most commonly cited primary reason for CAM use was to boost the immune system, the second, to treat cancer; however these reasons varied depending on specific CAM therapy. Friends or family members and mass media were common primary information source's about CAM. CONCLUSIONS: A high proportion of advanced-stage breast cancer patients used CAM. Discussion with doctors was high for ingested products. Mass media was a prominent source of patient information. Credible sources of CAM information for patients and physicians are needed.