"I can't provide what my child needs": Early feeding experiences of caregivers of children with craniofacial microsomia.

PURPOSE: Craniofacial microsomia (CFM) is a congenital condition that can be associated with feeding challenges in infants. As part of the larger 'Craniofacial microsomia: Accelerating Research and Education (CARE)' program, this study described caregivers' early feeding experiences. DESIGN AND MATERIALS: US-based caregivers of 34 children with CFM participated in remote narrative interviews. Two authors completed inductive thematic analysis in an iterative process until consensus was reached. RESULTS: Caregivers' narratives outlined the inherent challenges of feeding an infant with special healthcare needs. The first theme 'Navigating Challenges and Managing Expectations' describes the distress participants experienced when they were unable to breastfeed and the negative emotional effect of switching to formula. The second theme 'Making Adaptations' outlines the methods participants tried, including breast pumps and feeding tubes. The third theme 'Accessing Support' describes participants' interactions with healthcare providers and challenges accessing feeding support. The final theme 'Growing from Adversity' recounts participants' relief once their child established a feeding pattern and the personal growth gained from their experiences. CONCLUSIONS: Caregivers reported several feeding related challenges associated with CFM, many of which negatively affected their wellbeing. Negative consequences were particularly pronounced in cases where caregivers' feeding experiences differed from their expectations. Participants identified challenges in accessing reliable feeding information and support. Despite difficult experiences, caregivers cited some positive outcomes, including increased confidence and resilience. PRACTICE IMPLICATIONS: Holistic feeding information and support for families affected by CFM should be inclusive of several feeding methods to improve care delivery, child health, and the caregiver experience.

Maternal Metabolic Status and Orofacial Cleft Risk: A Case-Control Study in Thailand.

OBJECTIVES: Metabolic syndrome (MetS) has been suggested to play a role in congenital defects. This study investigated the association of MetS and its components with orofacial clefts (OFCs). METHODS: We conducted a case-control study in Northeast Thailand. Ninety-four cases with cleft lip, with or without cleft palate, were frequency matched with 94 controls on the infant's age and mother's education. We administered a mother's health questionnaire and collected anthropometric measurements and blood samples. Multiple logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were performed among infants without a family history of OFCs, mothers who were not currently breastfeeding, and mothers who were >6 months postpartum. RESULTS: When compared to mothers of normal weight, the OR associated with OFCs were 2.44 (95% CI, 1.04-5.76, P = .04) in overweight mothers, and 3.30 (95% CI, 1.14-9.57, P = .03) in obese mothers. Low HDL-C raised the risk of OFCs 2.95 times (95% CI, 1.41-6.14, P = .004) compared to normal HDL-C levels. Mothers with 4 or 5 features of MetS were 2.77 times as likely to have the affected child than those who did not (95% CI, 0.43-17.76), but this difference was not statistically significant (P = .28). Subgroup analyses showed similar results, uncovering an additional significant association between underweight mothers and OFCs. CONCLUSIONS: The results indicate a robust association between underweight and overweight/obese maternal body mass index and increased OFC risk. Additionally, low HDL-C in mothers is linked to an elevated risk of OFCs. Further research is needed to evaluate if promoting strategies to maintain optimal body weight and enhance HDL-C levels in reproductive-age and pregnant women icould contribute to a reduction of the risk of OFCs in their progeny.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state.

INTRODUCTION: There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children. MATERIALS AND METHODS: Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects. RESULTS: Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33). CONCLUSIONS: Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program.

OBJECTIVE: Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision. DESIGN: The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community. RESULTS: Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community. CONCLUSIONS: The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

Observations by Caregivers Using the Infant with Clefts Observation Outcomes Instrument (iCOO): A Comparison of Three Versus Seven-day Daily Diaries.

OBJECTIVE: Our goal was to compare data collected from 3- and 7-day Infant with Clefts Observation Outcomes (iCOO) diaries. DESIGN: Secondary data analysis of an observational longitudinal cohort study. Caregivers completed the daily iCOO for 7 days before cleft lip surgery (T0) and for 7 days after cleft lip repair (T1). We compared 3- and 7-day diaries collected at T0 and 3- and 7-day diaries collected at T1. SETTING: United States. PARTICIPANTS: Primary caregivers of infants with cleft lip with and without cleft palate (N = 131) planning lip repair and enrolled in original iCOO study. MAIN OUTCOMES MEASURE(S): Mean differences and Pearson correlation coefficients. RESULTS: Correlation coefficients were high for global impressions (>0.90) and scaled scores (0.80-0.98). Mean differences were small across iCOO domains at T0. T1 comparisons reflected the same pattern. CONCLUSIONS: Three-day diary data is comparable to 7-day diaries for measuring caregiver observations using iCOO across T0 and T1.

Changes in children's dental fear after restorative treatment under different sedation types: Associations with parents' experiences and dental health.

BACKGROUND: Dentists often use sedative medications such as nitrous oxide inhaled sedation and general anesthesia (GA) to help decrease patient fear and manage paediatric patients' behavior during treatment. AIM: The goal of this study was to examine factors associated with dental fear changes after restorative dental treatment under nitrous oxide or GA in children 4-12 years old. DESIGN: A prospective cohort study of 124 children examined changes in dental fear, number of treatment visits, and parental factors among children receiving restorative dental treatment under nitrous oxide (n = 68) or GA (n = 56) sedation. Data were collected at pretreatment (T1), 16 weeks post-treatment (T2), and at 29-month follow-up (T3). RESULTS: Dental fear increased slightly, but not significantly, under both forms of sedation between T1 and T3. Children's dental fear was associated with parents' poor dental experiences and oral health, but not with number of treatment visits. CONCLUSIONS: Progression of children's dental fear seems not dependent solely on the type of sedation used but is likely predicted by factors including pretreatment dental fear and dental needs. Dentists recommending sedation for children's dental care may consider pretreatment dental need, fear levels, and parental factors when determining which type of sedation to use.

Nonsurgical periodontal treatment during pregnancy and rates of preterm birth.

BACKGROUND: Periodontitis during pregnancy is associated with an increased risk of preterm birth (<37 weeks of gestation) or low birthweight (<2500 g) offspring. Beyond periodontal disease, the risk of preterm birth varies both by previous history of preterm birth and in association with social determinants prevalent among vulnerable and marginalized populations. This study hypothesized that the timing of periodontal treatment during pregnancy and/or social vulnerability measures modified the response to dental scaling and root planing for the treatment of periodontitis and prevention of preterm birth. OBJECTIVE: This study aimed to determine the association of timing of dental scaling and root planing for gravidae with a diagnosed periodontal disease on the rates of preterm birth or low birthweight offspring among subgroups or strata of gravidae as part of the Maternal Oral Therapy to Reduce Obstetric Risk randomized controlled trial. All participants in the study had clinically diagnosed periodontal disease and differed by the timing of the periodontal treatment (dental scaling and root planing at <24 weeks [per protocol] or after delivery) or by baseline characteristics. Although all participants met the well-accepted clinical criteria for periodontitis, not all participants acknowledged a priori that they had periodontal disease. STUDY DESIGN: This was a per-protocol analysis of data from 1455 participants of the Maternal Oral Therapy to Reduce Obstetric Risk trial evaluating dental scaling and root planing on the risk of preterm birth or low birthweight offspring. Adjusted multiple logistic regression to control for confounders was used to estimate associations comparing the timing of periodontal treatment in pregnancy to receiving treatment after pregnancy (referent control) on rates of preterm birth or low birthweight among subgroups of gravidae with known periodontal disease. Study analyses were stratified, and the associations with the following characteristics-body mass index, self-described race and ethnicity, household income, maternal education, recency of immigration, and self-acknowledgment of poor oral health, were explored. RESULTS: Dental scaling and root planing during the second or third trimester of pregnancy were associated with an increased adjusted odds ratio of preterm birth among those at the lower body mass index strata (18.5 to <25.0 kg/m2) (adjusted odds ratio, 2.21; 95% confidence interval, 1.07-4.98), but not among individuals who were overweight (body mass index of 25.0 to <30.0 kg/m2; adjusted odds ratio, 0.68; 95% confidence interval, 0.29-1.59) or obese (body mass index of ≥30 kg/m2; adjusted odds ratio, 1.26; 95% confidence interval, 0.65-2.49). There was no significant difference in pregnancy outcomes related to the other evaluated variables: self-described race and ethnicity, household income, maternal education, immigration status, or self-acknowledgment of poor oral health. CONCLUSION: In this per-protocol analysis of the Maternal Oral Therapy to Reduce Obstetric Risk trial, dental scaling and root planing had no preventive benefit against adverse obstetrical outcomes and were associated with increased odds of preterm birth among individuals at lower body mass index strata. There was no significant difference in the occurrence of preterm birth or low birthweight after dental scaling and root planing periodontitis treatment concerning other analyzed social determinants of preterm birth.

A Cross-Sectional Study of the Nutritional Status of Infants with Orofacial Clefts in the First 6 Months of Life.

OBJECTIVE(S): To estimate nutritional status in a large cohort of infants with orofacial clefts in the US, overall and by cleft type from birth to 6 months of age. STUDY DESIGN: We conducted a cross-sectional study in infants with orofacial clefts by examining growth by month between birth and 6 months of age. Infants with at least one weight measurement at a single US regional tertiary care pediatric hospital with an interdisciplinary cleft team between 2010 and 2020 were included. We calculated the average weight-for-age z scores and weight-for-length z scores. We calculated the proportion of infants underweight and wasting with z scores below -2 SDs monthly from birth to 6 months of age. We used t tests to compare the distribution of weight for age z-score and weight for length z-score among children with orofacial clefts to a normal distribution. RESULTS: We included 883 infants with orofacial clefts. Compared with expected proportion of underweight infants (2.3%), a larger proportion of infants with orofacial clefts were underweight between birth and 1 month (10.6%), peaking between 2 and 3 months (27.1%), and remaining high between 5 and 6 months (16.3%). Compared with the expected proportion of infants with wasting (2.3%), a higher proportion of infants with orofacial clefts experienced wasting between birth and 1 month (7.3%), peaking between 2 and 3 months (12.8%), and remaining high between 5 and 6 months (5.3%). Similar findings were observed for all cleft types and regardless of comorbidities. CONCLUSION(S): A substantial proportion of infants with orofacial clefts compared with normative peers have malnutrition in the first 6 months of life in the US.

Longitudinal Analysis of Children's Oral Health-Related Quality of Life After Restorative Dental Treatment.

Purpose: To document mid- and long-term changes in oral health-related quality of life (OHRQoL) following dental intervention in a sample of restorative treatment-naïve children receiving different levels of care, with and without general anesthesia (GA). Methods: This prospective cohort study followed 132 children. Parents completed the pediatric OHRQoL instrument (POQL) before, 16 weeks after (i.e., posttreatment), and 18 to 45 (mean equals 29.5) months after (i.e., follow-up) child receipt of treatment. Parents provided child demographic and oral health information. The number of restored surfaces and anesthesia type were abstracted from dental records. The mean differences in POQL scores were compared across groups. Results: The sample was 49 percent female (age range equals four to 12 years; mean±standard deviation equals 5.8±1.8). Overall, from pretreatment to posttreatment, mean POQL scores decreased by 4.5 points (P<0.001), representing improved OHRQoL. Only among children with 10 or more surfaces restored or who received GA did follow-up POQL scores remain significantly lower than pretreatment scores (mean difference equals -7.4 and -8.0, respectively, P<0.01). Overall, follow-up scores were significantly higher than posttreatment scores, representing a decline from the initial improvement. Conclusions: Regardless of disease severity, children experience an immediate improvement in OHRQoL following restorative treatment. Improvements in OHRQoL are sustained over the long-term only among children with more extensive pretreatment needs.

Income-Based Disparities in a Yearly Dental Visit in United States Adults and Children: Trend Analysis 1997 to 2016.

OBJECTIVE: To determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults. METHODS: We analyzed Medical Expenditure Panel Survey 1997 to 2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality and the Relative Index of Inequality and examined trends in yearly dental visit, Slope Index of Inequality, and Relative Index of Inequality using joinpoint regression. RESULTS: Income-based disparities, absolute and relative, narrowed over time for children. Steady upward trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act. CONCLUSIONS: In 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income-based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.

Children with Autism Spectrum Disorder Are Able to Maintain Dental Skills: A Two-Year Case Review of Desensitization Treatment.

Purpose: The purposes of this study of children with autism spectrum disorder (ASD), who had successfully accepted a dental examination seated in a dental chair following desensitization interventions, were to: (1) determine if ability to accept an examination was maintained two years following initial success; (2) quantify new dental skills acquired; and (3) analyze the use of advanced behavior guidance techniques. Methods: This retrospective two-year case series included 138 ASD children. Data were obtained from dental records. Descriptive statistics were calculated, and Fisher's exact test was used for comparisons of interest. Results: Most children (92 percent) maintained the ability to receive minimum threshold examinations once the initial exam had been achieved. New basic dental skills attained by most children included receiving toothbrush prophylaxis (83 percent) and accepting fluoride varnish (77 percent). Few children required oral sedation or protective stabilization, but 22 percent received general anesthesia. Conclusions: Most children with autism spectrum disorder who learned to accept an examination maintained that skill over time, and many accepted toothbrush prophylaxis and fluoride varnish. Sensory-invasive skills, such as radiographs and rubber cup prophylaxis, were acquired with lower frequency. Therefore, when treating ASD patients, it is important to consider that some will require advanced behavior guidance techniques. (Pediatr Dent 2019;41(5):397-403).

A randomized crossover trial comparing the Nifty cup to a medicine cup in preterm infants who have difficulty breastfeeding at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana.

INTRODUCTION: Preterm infants make up the majority of the 9 million babies born in Africa and South Asia requiring supplemental feedings as they transition to exclusive breastfeeding. The World Health Organization recommends the use of a cup to feed newborns with breastfeeding difficulties in low-resource settings. We set out to evaluate the Nifty cup, a new feeding cup designed specifically for infants with breastfeeding difficulties. MATERIALS AND METHODS: We conducted a randomized clinical trial in Ghana. We hypothesized infants would prefer the Nifty cup and that it would have less spillage as compared to a medicine cup. We enrolled mothers and preterm infants with breastfeeding difficulties indicated to cup feed at Komfo Anokye Teaching Hospital. Each mother-infant pair used the Nifty cup and a standard medicine cup; and two feeding assessments with each cup were conducted. We employed an intent-to-treat analysis comparing cup preference using a Wilcoxon signed rank test and spillage using generalized estimating equations. RESULTS: We enrolled 200 mothers and 237 infants. Many infants were very low birth weight (62%), less than two weeks old (62%), and multiple birth (29%). In response to separate questions about each cup, more mothers reported liking the Nifty cup a lot as compared to the medicine cup (85% versus 57%, p<0.001). When asked to choose between the two cups, more than 75% preferred the Nifty cup (p < 0.001). There was slightly less spillage with the Nifty cup (8.9%) versus the medicine cup (9.3%), which was not statistically significant (p = 0.35). Mothers reported greater confidence and ease of using the Nifty cup and greater use one-month post-discharge compared to the medicine cup (p-values <0.001). Nearly all mothers were breastfeeding and cup feeding their infants at study initiation and at one-month post-discharge. DISCUSSION: This is the first randomized clinical trial of cup feeding in sub-Saharan Africa. Mothers prefer the Nifty cup to a medicine cup for supplemental feeds to their preterm infant. The Nifty cup was used with greater ease and confidence. The Nifty cup can offer an improved feeding experience for the mother-infant pair.

An Academic Research Coach: An Innovative Approach to Increasing Scholarly Productivity in Medicine.

BACKGROUND: Academic faculty who devote most of their time to clinical work often struggle to engage in meaningful scholarly work. They may be disadvantaged by limited research training and limited time. Simply providing senior mentors and biostatistical support has limited effectiveness. OBJECTIVE: We aimed to increase productivity in scholarly work of hospitalists and internal medicine physicians by integrating an Academic Research Coach into a robust faculty development program. DESIGN: This was a pre-post quality improvement evaluation. SETTING: This was conducted at the University of Washington in faculty across three academic-affiliated hospitals and 10 academic-affiliated clinics. PARTICIPANTS: Participants were hospitalists and internists on faculty in the Division of General Internal Medicine at the University of Washington. INTERVENTION: The coach was a 0.50 full time equivalent health services researcher with strong research methods, project implementation, and interpersonal skills. The coach consulted on research, quality improvement, and other scholarship. MEASUREMENTS: We assessed the number of faculty supported, types of services provided, and numbers of grants, papers, and abstracts submitted and accepted. RESULTS: The coach consulted with 49 general internal medicine faculty including 30 hospitalists who conducted 63 projects. The coach supported 13 publications, 11 abstracts, four grant submissions, and seven manuscript reviews. Forty-eight faculty in other departments benefited as co-authors. CONCLUSION: Employing a dedicated health services researcher as part of a faculty development program is an effective way to engage clinically oriented faculty in meaningful scholarship. Key aspects of the program included an accessible and knowledgeable coach and an ongoing marketing strategy.

Childbearing and maternity leave in residency: determinants and well-being outcomes.

PURPOSE: To characterise determinants of resident maternity leave and their effect on maternal and infant well-being. Among non-parents, to identify factors that influence the decision to delay childbearing STUDY DESIGN: In 2016, a survey was sent to female residents at a large academic medical centre on their experiences with maternity leave, the impact of personal and programme factors on length of leave, reasons for delaying childbearing and measures of well-being. RESULTS: Forty-four percent (214/481) of residents responded. Fifty (23%) residents were parents, and 25 (12%) took maternity leave during training. The average maternity leave length was 8.4 weeks and did not differ across programme type, size or programme director gender but was longer for programmes with fewer women than men. The most common self-reported determinant of leave was financial. Residents with >8 weeks of leave were less likely to have postpartum depression or burnout and more likely to breastfeed longer, perceive support from colleagues and programme directors, and be satisfied with resident parenthood. Among 104 non-parents who were married or partnered, 84 (81%) were delaying childbearing, citing busy work schedules, concern for burdening colleagues and finances. CONCLUSIONS: This study suggests that multiple aspects of resident wellbeing are associated with longer maternity leaves, yet finances and professional relationships hinder length of leave and lead to delayed childbearing. These issues could be addressed at a programme level with clear policies describing how work is redistributed during parental leave and at an institutional and state level through provision of paid family leave.

Maternal exposures and risk of oral clefts in South Vietnam.

BACKGROUND: Oral clefts are among the most common congenital anomalies. Most studies on risk factors of oral clefts have been carried out in developed countries. We investigated the associations between maternal exposures in the first trimester and oral clefts in South Vietnam. METHODS: We conducted a hospital-based case-control study during October 2014-November 2015. Cases included 170 patients with nonsyndromic cleft lip with or without cleft palate and those with cleft palate only. Controls were 170 children without oral clefts, matched to each case by age and gender. Mothers were interviewed using structured questionnaire. We performed conditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Passive smoking was associated with increased risk of oral clefts in univariate analysis, but not in multivariable analysis (adjusted OR [aOR] = 1.68; 95% CI, 0.53-5.37). No association was observed between liver intake and oral clefts. Compared with nondrinkers, mothers who reported consumption of caffeine-containing beverages were more likely to have an infant with oral cleft (aOR = 5.89; 95% CI, 1.08-32.00). Periconceptional use of folic acid and multivitamins supplementation was associated with reduced risk of oral clefts (aOR = 0.01; 95% CI, 0.00-0.09 and aOR = 0.03; 95% CI, 0.01-0.13, respectively). CONCLUSIONS: The results suggest no associations of maternal passive smoking or liver intake with oral clefts. Periconceptional use of folic acid or multivitamins may protect against oral clefts. Further studies are warranted to examine the roles of caffeine consumption in pregnant mothers on occurrence of oral clefts in offspring.

Primary care provider approaches to preventive health delivery: a qualitative study.

AimThe objective of this study was to seek decision-making insights on the provider level to gain understanding of the values that shape how providers deliver preventive health in the primary care setting. BACKGROUND: The primary care clinic is a core site for preventive health delivery. While many studies have identified barriers to preventive health, less is known regarding how primary care providers (PCPs) make preventive health decisions such as what services to provide, under what circumstances, and why they might choose one over another. METHODS: Qualitative methods were chosen to deeply explore these issues. We conducted semi-structured, one-on-one interviews with 21 PCPs at clinics affiliated with an academic medical center. Interviews with providers were recorded and transcribed. We conducted a qualitative analysis to identify themes and develop a theoretical framework using Grounded Theory methods.FindingsThe following themes were revealed: longitudinal care with an established PCP-patient relationship is perceived as integral to preventive health; conflict and doubt accompany non-preventive visits; PCPs defer preventive health for pragmatic reasons; when preventive health is addressed, providers use multiple contextual factors to decide which interventions are discussed; and PCPs desired team-based preventive health delivery, but wish to maintain their role when shared decision-making is required. We present a conceptual framework called Pragmatic Deferral.

Factors That Influence Treatment Completion for Latent Tuberculosis Infection.

INTRODUCTION: The aim of this study is to describe factors associated with noncompletion of latent tuberculosis infection (LTBI) therapy. METHODS: We conducted a retrospective cohort study of adults who initiated LTBI treatment with isoniazid, rifampin, or isoniazid-rifapentine at 5 clinics. Demographic, treatment, and monitoring characteristics were abstracted. We estimated descriptive statistics and compared differences between completers and noncompleters using t tests and χ2 tests. RESULTS: The rate of completion across LTBI regimens was 66% (n = 393). A greater proportion of noncompleters were unmarried, used tobacco and/or alcohol, and had more medical problems than completers (all P < .05). A larger proportion of noncompleters received charity care compared with completers (P < .001). The most common reason for treatment discontinuation was loss to follow-up; the majority of these participants were treated with the longest isoniazid-only regimen. CONCLUSIONS: Patients at risk of progression to active tuberculosis with factors associated with noncompletion may benefit from interventions that enhance adherence to LTBI therapy. These interventions could include enhanced outreach, incentive programs, or home visits.

Predicting successful dental examinations for children with autism spectrum disorder in the context of a dental desensitization program.

BACKGROUND: The authors evaluated the effectiveness of a dental desensitization program for children with autism spectrum disorder (ASD) and determined characteristics associated with a successful dental examination. METHODS: The authors performed a retrospective review of clinical behavioral data and previsit questionnaires for 168 children with ASD who attended a university-based dental desensitization program. Data elements included demographic, treatment, and behavioral characteristics. The primary outcome was receiving a minimal threshold examination (MTE) while seated in a dental chair. RESULTS: An MTE was achieved for 77.4% of all children within 1 to 2 visits and 87.5% in 5 visits or less. Several factors predicted a successful dental examination: ability to be involved in group activities (relative risk [RR], 1.18; P = .02), ability to communicate verbally (RR, 1.17; P < .01), understanding of most language (RR, 1.14; P = .02), moderate versus severe caregiver-rated ASD severity (RR, 1.24; P = .04), and ability to dress self (RR, 1.27; P = .04). CONCLUSIONS: Desensitization was effective in achieving an MTE for most children. Those with characteristics consistent of a milder presentation of ASD were more likely to be successful. PRACTICAL IMPLICATIONS: Desensitization can be a successful approach to providing dental care for children with ASD.

Observing bedside rounds for faculty development.

BACKGROUND: Bedside rounds are an ideal opportunity for clinical teaching. We previously offered faculty development on balancing learner autonomy, patient care and teaching. We noticed that participants often asked whether attending physicians and learners shared the same perceptions of the key elements (patient-centredness, efficiency and educational value) of bedside rounds. Understanding these perceptions and identifying areas of discordance would inform faculty development for optimal bedside rounds. METHODS: At a university hospital we observed 16 attending physicians and 47 learners over 112 patient encounters. We noted the length of rounds and the number of interruptions. Participants were surveyed on their perception of the attending physicians' efficacy in preparing the team for rounds, and the efficiency and educational value of the rounds. Bedside rounds are an ideal opportunity for clinical teaching FINDINGS: After the same rounds, compared with the attending physicians, learners perceived the patient-centredness, efficiency and educational value of the rounds to be significantly higher. Learners rated attending physicians higher than attending physicians did themselves on learner autonomy, appropriate supervision, conferring responsibility for the care plan to learners and not interrupting. There was no correlation between interruptions and length of the rounds, or learner or attending physician perception of key elements of the rounds. Learners tended to attribute greater efficacy to attending physicians for team preparation than attending physicians did themselves. CONCLUSION: We identified salient beliefs and practices on bedside teaching. Our findings suggest that identifying shared goals and expectations, and creating metrics to define successful rounds, may help attending physicians to better synergize with learners. Interruptions need not be eschewed completely for the purpose of achieving efficient rounds. Integrating these measures into faculty development may bolster the quality of bedside rounds.

Treatment completion for latent tuberculosis infection: a retrospective cohort study comparing 9 months of isoniazid, 4 months of rifampin and 3 months of isoniazid and rifapentine.

BACKGROUND: The U.S. Centers for Disease Control and Prevention (CDC) recommended a new regimen for treatment of latent tuberculosis (three months of weekly isoniazid and rifapentine) in late 2011. While completion rates of this regimen were reported to be higher than nine months of isoniazid, little is known about the completion rates of three months of isoniazid and rifapentine compared to nine months of isoniazid or four months of rifampin in actual use scenarios. METHODS: We conducted a retrospective cohort study comparing treatment completion for latent tuberculosis (TB) infection in patients treated with nine months of isoniazid, three months of isoniazid and rifapentine or four months of rifampin in outpatient clinics and a public health TB clinic in Seattle, Washington. The primary outcome of treatment completion was defined as 270 doses of isoniazid within 12 months, 120 doses of rifampin within six months and 12 doses of isoniazid and rifapentine within four months. RESULTS: Three hundred ninety-three patients were included in the study. Patients were equally likely to complete three months of weekly isoniazid and rifapentine or four months of rifampin (85% completion rate of both regimens), as compared to 52% in the nine months of isoniazid group (p < 0.001). These associations remained statistically significant even after adjusting for clinic location and type of monitoring. Monitoring type (weekly versus monthly versus less often than monthly) had less impact on treatment completion than the type of treatment offered. CONCLUSIONS: Patients were equally as likely to complete the three months of isoniazid and rifapentine as four months of rifampin. Four months of rifampin is similar in efficacy compared to placebo as isoniazid and rifapentine but does not require directly observed therapy (DOT), and is less expensive compared to combination therapy with isoniazid and rifapentine, and thus can be the optimal treatment regimen to achieve the maximal efficacy in a community setting.