Evaluation of the Effectiveness of Remote Foot Temperature Monitoring for Prevention of Amputation in a Large Integrated Health Care System.

OBJECTIVE: We evaluated the effectiveness of remote foot temperature monitoring (RTM) in the Veterans Affairs health care system. RESEARCH DESIGN AND METHODS: We conducted a retrospective cohort study that included 924 eligible patients enrolled in RTM between 2019 and 2021 who were matched up to 3:1 to 2,757 nonenrolled comparison patients. We used conditional Cox regression to estimate adjusted cause-specific hazard ratios (aHRs) and corresponding 95% CIs for lower-extremity amputation (LEA) as the primary outcome and all-cause hospitalization and death as secondary outcomes. RESULTS: RTM was not associated with LEA incidence (aHR 0.92, 95% CI 0.62-1.37) or all-cause hospitalization (aHR 0.97, 95% CI 0.82-1.14) but was inversely associated (reduced risk) with death (aHR 0.63, 95% CI 0.49-0.82). CONCLUSIONS: This study does not provide support that RTM reduces the risk of LEA or all-cause hospitalization in individuals with a history of diabetic foot ulcer. Randomized controlled trials can overcome important limitations.

Association of Antidepressant Continuation in Pregnancy and Infant Birth Weight.

PURPOSE: The aim of the study was to evaluate the association of antidepressant continuation in pregnancy with infant birth weight among women using antidepressants before pregnancy. METHODS: This retrospective cohort study used electronic health data linked with state birth records. We identified singleton live births (2001-2014) to enrolled women with 1 or more antidepressant prescriptions filled 6 months or less before pregnancy, including "continuers" (≥1 antidepressant fills during pregnancy, n = 1775) and "discontinuers" (no fill during pregnancy, n = 1249). We compared birth weight, small or large for gestational age (SGA or LGA), low birth weight (LBW; <2500 g), and macrosomia (>4500 g) between the 2 groups, using inverse probability of treatment weighting to account for pre-pregnancy characteristics, including mental health conditions. RESULTS: After weighting, infants born to antidepressant continuers weighed 71.9 g less than discontinuers' infants (95% confidence interval [CI], -115.5 to -28.3 g), with a larger difference for female infants (-106.4 g; 95% CI, -164.6 to -48.1) than male infants (-48.5 g; 95% CI, -107.2 to 10.3). For female infants, SGA risk was greater in continuers than discontinuers (relative risk [RR],1.54; 95% CI, 1.02 to 2.32). Low birth weight risk was greater in continuers with 50% or more of days covered (RR, 1.69; 95% CI, 1.11 to 2.58) and exposure in the second trimester (RR, 1.53; 95% CI, 1.02 to 2.29), as compared with discontinuers. CONCLUSIONS: Depending on infant sex, as well as duration and timing of use, continuation of antidepressant use during pregnancy may be associated with lower infant birth weight, with corresponding increases in LBW and SGA.

Antidepressant continuation in pregnancy and risk of gestational diabetes.

PURPOSE: Previous studies observed modestly higher risk of gestational diabetes (GDM) associated with antidepressant use in pregnancy, potentially due to confounding by indication. We assessed the association of antidepressant continuation in pregnancy with GDM, as well as blood glucose levels, after accounting for confounding. METHODS: We conducted a retrospective cohort study of singleton live births from 2001 to 2014 to women enrolled in Kaiser Permanente Washington, an integrated health care delivery system, utilizing electronic health data and linked Washington State birth records. We required that women have ≥1 antidepressant prescription fills ≤6 months before pregnancy. Women with an antidepressant fill during pregnancy were categorized as "continuers" (n = 1634); those without a fill were "discontinuers" (n = 1211). We calculated relative risks (RRs) for GDM and mean differences in screening blood glucose levels using generalized estimating equations with inverse probability of treatment weighting to account for baseline characteristics, including mental health conditions and indicators of mental health severity. RESULTS: Compared with discontinuers, antidepressant continuers had comparable risk of GDM (RR: 1.10; 95% confidence interval [CI], 0.84-1.44) and blood glucose levels (mean difference: 2.3 mg/dL; 95% CI, -1.5 to 6.1 mg/dL). We observed generally similar results for specific antidepressants, with the potential exceptions of risk of GDM associated with sertraline (RR: 1.30; 95% CI, 0.90-1.88) and venlafaxine (RR: 1.52; 95% CI, 0.87-2.68), but neither association was statistically significant. CONCLUSIONS: Our study suggests that overall, women who continue antidepressants in pregnancy are not at increased risk for GDM or higher blood glucose, although further study may be warranted for sertraline and venlafaxine.

Patterns of Alcohol Use Among Patients Living With HIV in Urban, Large Rural, and Small Rural Areas.

BACKGROUND: For people living with HIV (PLWH), alcohol use is harmful and may be influenced by unique challenges faced by PLWH living in rural areas. We describe patterns of alcohol use across rurality among PLWH. METHODS: Veterans Aging Cohort Study electronic health record data were used to identify patients with HIV (ICD-9 codes for HIV or AIDS) who completed AUDIT-C alcohol screening between February 1, 2008, and September 30, 2014. Regression models estimated and compared 4 alcohol use outcomes (any use [AUDIT-C > 0] and alcohol use disorder [AUD; ICD-9 codes for abuse or dependence] diagnoses among all PLWH, and AUDIT-C risk categories: lower- [1-3 men/1-2 women], moderate- [4-5 men/3-5 women], higher- 6-7]), and severe-risk [8-12], and heavy episodic drinking (HED; ≥1 past-year occasion) among PLWH reporting use) across rurality (urban, large rural, small rural) and census-defined region. FINDINGS: Among 32,699 PLWH (29,540 urban, 1,301 large rural, and 1,828 small rural), both any alcohol use and AUD were highest in urban areas, although this varied across region. Predicted prevalence of any alcohol use was 54.1% (53.5%-54.7%) in urban, 49.6% (46.9%-52.3%) in large rural, and 50.6% (48.3%-52.9%) in small rural areas (P < .01). Predicted prevalence of AUD was 14.4% (14.0%-14.8%) in urban, 11.8% (10.0%-13.5%) in large rural, and 12.3% (10.8%-13.8%) in small rural areas (P < .01). Approximately 12% and 25% had higher- or severe-risk drinking and HED, respectively, but neither differed across rurality. CONCLUSION: Though some variation across rurality and region was observed, alcohol-related interventions are needed for PLWH across all geographic locations.

Maternal sedentary behavior during pre-pregnancy and early pregnancy and mean offspring birth size: a cohort study.

BACKGROUND: Sedentary behavior is associated with adverse health outcomes in the general population. Whether sedentary behavior during pregnancy is associated with newborn outcomes, such as birth size, is not established, and previous studies have been inconsistent. While previous research suggests that male and female fetuses respond differently to maternal behaviors, such as physical activity, the role of infant sex in sedentary behavior-birth size associations has not been examined. METHODS: Participants in the Omega study, a cohort in Washington State (1996-2008), reported leisure time sedentary behavior (non-work time spent sitting), light intensity physical activity, and moderate/vigorous leisure time physical activity duration in the year before pregnancy (N = 1373) and in early pregnancy (N = 1535, mean 15 weeks). Offspring birth size was abstracted from delivery records. Non-parametric calibration weighting was used to assign adjustment weight (matching the distribution of sociodemographic and medical characteristics of the full cohort (N = 4128)) to participants with available sedentary behavior data. Weighted linear regression models were used to estimate mean differences in offspring birthweight, head circumference, and ponderal index (birthweight/length3) associated with leisure time sedentary behavior. Regression models were run overall and stratified by offspring sex. Isotemporal substitution modeling was used to determine mean differences in birthweight associated with replacing sedentary behavior with light or moderate/vigorous physical activity. RESULTS: On average, women spent 2.3 and 2.6 h/day in leisure time sedentary behavior during pre- and early pregnancy, respectively. There were no associations of pre-pregnancy leisure time sedentary behavior with mean birthweight, head circumference, or ponderal index (adjusted ß = - 12, 95% CI: -28, 4.1; ß = 0.0, 95% CI: -0.04, 0.1; and ß = 0.1, 95% CI: -0.2, 0.4, respectively). Early pregnancy sedentary behavior was not associated with mean birth size. Associations of sedentary behavior with mean birth size did not differ by offspring sex. Replacing sedentary time with light or moderate/vigorous physical activity was not associated with mean birthweight. CONCLUSIONS: We did not observe associations of maternal sedentary behavior during pre- or early pregnancy with mean offspring birth size. Pre-pregnancy and early pregnancy sedentary behavior may have important adverse effects on maternal health, but our results do not support associations with mean offspring birth size.

Readiness to Change Over Time: Change Commitment and Change Efficacy in a Workplace Health-Promotion Trial.

INTRODUCTION: Organizational readiness to change may be a key determinant of implementation success and a mediator of the effectiveness of implementation interventions. If organizational readiness can be reliably and validly assessed at the outset of a change initiative, it could be used to assess the effectiveness of implementation-support activities by measuring changes in readiness factors over time. METHODS: We analyzed two waves of readiness-to-change survey data collected as part of a three-arm, randomized controlled trial to implement evidence-based health promotion practices in small worksites in low-wage industries. We measured five readiness factors: context (favorable broader conditions); change valence (valuing health promotion); information assessment (demands and resources to implement health promotion); change commitment (an intention to implement health promotion); and change efficacy (a belief in shared ability to implement health promotion). We expected commitment and efficacy to increase at intervention sites along with their self-reported effort to implement health promotion practices, termed wellness-program effort. We compared means between baseline and 15 months, and between intervention and control sites. We used linear regression to test whether intervention and control sites differed in their change-readiness scores over time. RESULTS: Only context and change commitment met reliability thresholds. Change commitment declined significantly for both control (-0.39) and interventions sites (-0.29) from baseline to 15 months, while context did not change for either. Only wellness program effort at 15 months, but not at baseline, differed significantly between control and intervention sites (1.20 controls, 2.02 intervention). Regression analyses resulted in two significant differences between intervention and control sites in changes from baseline to 15 months: (1) intervention sites exhibited significantly smaller change in context scores relative to control sites over time and (2) intervention sites exhibited significantly higher changes in wellness program effort relative to control sites. DISCUSSION: Contrary to our hypothesis, change commitment declined significantly at both Healthlinks and control sites, even as wellness-program effort increased significantly at HealthLinks sites. Regression to the mean may explain the decline in change commitment. Future research needs to assess whether baseline commitment is an independent predictor of wellness-program effort or an effect modifier of the HealthLinks intervention.

Associations of Maternal Light/Moderate Leisure-Time Walking and Yoga With Offspring Birth Size.

BACKGROUND: Although perinatal walking and yoga have been associated with decreased risks of pregnancy complications, associations with offspring birth size have been inconsistent. We investigated associations of prepregnancy and early pregnancy leisure-time light/moderate walking and yoga practice with birth size. METHODS: Study participants (N = 3687) reported leisure-time physical activity duration (hours per week) in the year before pregnancy and early pregnancy. Birth size was abstracted from medical records. Regression was used to determine mean differences in birth weight, head circumference, and ponderal index. Interaction terms were used to assess effect modification by offspring sex. RESULTS: About one-third of women reported light/moderate leisure-time walking and about 10% reported yoga practice. Women in the highest tertile for prepregnancy (mean: 2.9 h/wk; range: 1.4-20 h/wk) or early pregnancy (mean: 5.9 h/wk; range: 3.1-24 h/wk) light/moderate walking had offspring with 0.9 and 1.5 kg/m3 greater ponderal index (95% confidence interval, 0.3 to 1.4 and 0.7 to 2.4, respectively) compared with women who reported no light/moderate walking in the same time period. Light/moderate walking was not associated with birth weight or head circumference. Yoga practice was not associated with birth size. Associations were similar by offspring sex. CONCLUSION: Light/moderate leisure-time walking may be associated with greater offspring ponderal index.

Racial/ethnic differences in the association between alcohol use and mortality among men living with HIV.

BACKGROUND: Increasing alcohol use is associated with increased risk of mortality among patients living with HIV (PLWH). This association varies by race/ethnicity among general outpatients, but racial/ethnic variation has not been investigated among PLWH, among whom racial/ethnic minorities are disproportionately represented. METHODS: VA electronic health record data from the Veterans Aging Cohort Study (2008-2012) were used to describe and compare mortality rates across race/ethnicity and levels of alcohol use defined by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire. Within each racial/ethnic group, Cox proportional hazards models, adjusted for age, disease severity, and comorbidities, compared mortality risk for moderate-risk (AUDIT-C = 4-7) and high-risk (AUDIT-C ≥ 8) relative to lower-risk (AUDIT-C = 1-3) alcohol use. RESULTS: Mean follow-up time among black (n = 8518), Hispanic (n = 1353), and white (n = 7368) male PLWH with documented AUDIT-C screening (n = 17,239) was 4.3 years. Black PLWH had the highest mortality rate among patients reporting lower-risk alcohol use (2.9/100 person-years) relative to Hispanic and white PLWH (1.8 and 2.3, respectively) (p value for overall comparison = 0.011). Mortality risk was increased for patients reporting high-risk relative to lower-risk alcohol use in all racial/ethnic groups [black adjusted hazard ratio (AHR) = 1.36, 95% confidence interval (CI) 1.12-1.66; Hispanic AHR = 2.18, 95% CI 1.30-3.64; and white AHR = 2.04, 95% CI 1.61-2.58]. For only white PLWH, mortality risk was increased for patients reporting moderate-relative to lower-risk alcohol use (black AHR = 1.09, 95% CI 0.93-1.27; Hispanic AHR = 1.36, 95% CI 0.89-2.09; white AHR = 1.51, 95% CI 1.28-1.77). CONCLUSION: Among all PLWH, mortality risk was increased among patients reporting high-risk alcohol use across all racial/ethnic groups, but mortality risk was only increased among patients reporting moderate-risk relative to lower-risk alcohol use among white PLWH, and black patients appeared to have higher mortality risk relative to white patients at lower-risk levels of alcohol use. Findings of the present study further underscore the need to address unhealthy alcohol use among PLWH, and future research is needed to understand mechanisms underlying observed differences.

A concordance-based study to assess doctors' and nurses' mental models in Internal Medicine.

Interprofessional collaboration between doctors and nurses is based on team mental models, in particular for each professional's roles. Our objective was to identify factors influencing concordance on the expectations of doctors' and nurses' roles and responsibilities in an Internal Medicine ward. Using a dataset of 196 doctor-nurse pairs (14x14 = 196), we analyzed choices and prioritized management actions of 14 doctors and 14 nurses in six clinical nurse role scenarios, and in five doctor role scenarios (6 options per scenario). In logistic regression models with a non-nested correlation structure, we evaluated concordance among doctors and nurses, and adjusted for potential confounders (including prior experience in Internal Medicine, acuteness of case and gender). Concordance was associated with number of female professionals (adjusted OR 1.32, 95% CI 1.02 to 1.73), for acute situations (adjusted OR 2.02, 95% CI 1.13 to 3.62), and in doctor role scenarios (adjusted OR 2.19, 95% CI 1.32 to 3.65). Prior experience and country of training were not significant predictors of concordance. In conclusion, our concordance-based approach helped us identify areas of lower concordance in expected doctor-nurse roles and responsibilities, particularly in non-acute situations, which can be targeted by future interprofessional, educational interventions.

Neighborhood Crime-Related Safety and Its Relation to Children's Physical Activity.

Crime is both a societal safety and public health issue. Examining different measures and aspects of crime-related safety and their correlations may provide insight into the unclear relationship between crime and children's physical activity. We evaluated five neighborhood crime-related safety measures to determine how they were interrelated. We then explored which crime-related safety measures were associated with children's total moderate-to-vigorous physical activity (MVPA) and MVPA in their neighborhoods. Significant positive correlations between observed neighborhood incivilities and parents' perceptions of general crime and disorder were found (r = 0.30, p = 0.0002), as were associations between parents' perceptions of general crime and disorder and perceptions of stranger danger (r = 0.30, p = 0.0002). Parent report of prior crime victimization in their neighborhood was associated with observed neighborhood incivilities (r = 0.22, p = 0.007) and their perceptions of both stranger danger (r = 0.24, p = 0.003) and general crime and disorder (r = 0.37, p < 0.0001). After accounting for covariates, police-reported crime within the census block group in which children lived was associated with less physical activity, both total and in their neighborhood (beta = -0.09, p = 0.005, beta = -0.01, p = 0.02, respectively). Neighborhood-active children living in the lowest crime-quartile neighborhoods based on police reports had 40 min more of total MVPA on average compared to neighborhood-active children living in the highest crime-quartile neighborhoods. Findings suggest that police reports of neighborhood crime may be contributing to lower children's physical activity.

Children's objective physical activity by location: why the neighborhood matters.

Knowledge of where children are active may lead to more informed policies about how and where to intervene and improve physical activity. This study examined where children aged 6-11 were physically active using time-stamped accelerometer data and parent-reported place logs and assessed the association of physical-activity location variation with demographic factors. Children spent most time and did most physical activity at home and school. Although neighborhood time was limited, this time was more proportionally active than time in other locations (e.g., active 42.1% of time in neighborhood vs. 18.1% of time at home). Children with any neighborhood-based physical activity had higher average total physical activity. Policies and environments that encourage children to spend time outdoors in their neighborhoods could result in higher overall physical activity.