Pilot implementation of an electronic patient-reported outcome measure for planning and monitoring participation-focused care in early intervention.

BACKGROUND: Family-centered care is a valued approach to improving child and family outcomes in early intervention (EI), yet there is need to implement interventions that support information exchange for shared decision-making when planning and monitoring EI care. This study aims at estimating the feasibility, acceptability, and value of implementing the Young Children's Participation and Environment Measure (YC-PEM), a valid electronic patient-reported outcome (e-PRO) that is designed to support family engagement when planning care and monitoring outcomes of care. METHODS: Data were gathered from caregivers (N = 139) that were enrolled in a Phase 1 trial of the YC-PEM e-PRO as implemented within 1 month of their child's next EI evaluation of progress. YC-PEM e-PRO feasibility was estimated according to enrollment and completion rates, and mean completion time. Chi-square tests were used to examine parent perceptions of YC-PEM e-PRO acceptability by caregiver education and family income. Caregiver feedback via open-ended responses were content coded to inform intervention and protocol optimizations. YC-PEM e-PRO value was estimated via composite and item-level scores to capture the extent of participation difficulty in home and community activities, and common areas of need regarding caregivers desired change in their child's participation. RESULTS: Feasibility of implementing the YC-PEM e-PRO in routine EI care was mixed, as evidenced by low enrollment rates (21.0-29.2%), a high completion rate (85.3%), and limited missing data (80.6% of completed cases contained no missing data). More than half of the participants reported that the completion of the YC-PEM e-PRO was at least somewhat helpful, regardless of family income or caregiver education, providing support for its acceptability. As for its value, the YC-PEM e-PRO results were viewed by 64% of caregivers, whose desire for change most often pertained to the child's participation in non-discretionary activities at home and structured activities in the community. CONCLUSIONS: Results may support the implementation of YC-PEM e-PRO as a feasible, acceptable, and valued option for engaging families in planning the child's EI care. Results also inform select intervention and protocol optimizations prior to undertaking a multi-site pragmatic trial of its effectiveness on family engagement and shared decision-making within an EI clinical workflow. TRIAL REGISTRATION: Trial number: NCT03904797 . Trial registered at Clinicaltrials.gov . Registered 22 March 2019. Retrospectively registered.

Human papillomavirus (HPV) types among Alaska native women attending a colposcopy clinic in Anchorage, Alaska, 2009-2011.

BACKGROUND: The first HPV vaccines licensed targeted two HPV types responsible for most cervical cancers. A 9-valent vaccine (9vHPV), targeting 5 additional types, was introduced in 2016 and is currently the only HPV vaccine available in the United States. Previous studies demonstrated high rates of HPV infection in Alaska Native (AN) women. We sought to measure prevalence of high risk HPV types in AN women undergoing colposcopy and to determine those preventable by vaccination. METHODS: For this cross-sectional study, we recruited women who were undergoing colposcopy for clinical indications at Alaska Native Medical Center to obtain cervical brush biopsy samples. Specimens were shipped to Atlanta, Georgia for DNA extraction, HPV detection, and typing using L1 PCR with type-specific hybridization to detect 37 HPV types. RESULTS: Four hundred eighty eight specimens from 489 women were tested. At least one HPV type was found in 458 (94%) specimens. Of 458 participants who were HPV positive, 332 (72%) had two or more types. At least one type targeted by 9vHPV was detected in 95% of participants with CIN 3 (21/22), 82% with CIN 2 (37/45), and 65% with CIN 1 (119/184). (p < 0.001) HPV 16 or 18 were detected in 77% (17/22) with CIN 3, 53% (24/45) with CIN 2, and 36% (67/184) with CIN 1. (p < 0.001). CONCLUSIONS: A substantial proportion of AN women attending colposcopy clinic had evidence of HPV 16/18 infection, as well as other high risk types targeted by 9vHPV. At least one 9vHPV type was detected in 62% of the participants overall, and 95% of participants with CIN3. AN women are expected to benefit from vaccination against HPV 16/18, and will have greater benefit from 9vHPV. Information from this study could be used to develop public health strategies to increase vaccine uptake, or to track HPV genotype prevalence over time.

Diabetes among Alaska Natives: a review.

This review summarizes the published information on diabetes mellitus and gestational diabetes among Alaska Natives. The most recently published age-adjusted prevalence was 28.3/1000 in 1998. There is evidence of a steadily increasing prevalence, documented both by cross sectional screening studies and patient registry methods. The overall incidence rates in 1986-1998 of lower extremity amputation (6.1/1000) and renal replacement therapy (2.1/1000) appear to be lower than those in other Native American populations in the United States. Incidence of stroke and MI in 1986-1998 varied widely by ethnic group and gender with Eskimo women having the highest rate of stroke (19.6/1000), and Aleut men the highest rate of MI (14/1000). The overall mortality among diabetic Alaska Native people in 1986-1993 (43.2/1000) was somewhat lower than that in other US diabetic populations, with heart disease being the most common cause of death. A high rate of gestational diabetes (6.7%) was reported in one region in 1987-88, but this appeared to decline following nutritional education intervention. In screening studies, the prevalence of abnormal glucose tolerance has been found to be positively associated with body mass index and negatively associated with daily seal oil or salmon consumption and higher levels of physical activity. Observations on the prevalence and relationships among other factors in the insulin resistance syndrome are summarized. Suggestions for prevention of diabetes and further studies are presented.

Alaska's obstetrical delivery systems: a descriptive epidemiologic study.

Delivery of obstetrical care in rural Alaska can be very challenging, due to remoteness, lack of medical resources and transportation difficulties. This descriptive study looks at what the current delivery systems for obstetrical care in Alaska are. Alaska's obstetrical delivery systems can be divided into three basic systems. 1) Full comprehensive obstetrical care limited only by lack of neonatal ICU capability. 2) Cesarean delivery capable, but with limited resources. 3) Low risk vaginal deliveries with no cesarean delivery capability except by transports approaching 6 hours. This study raises questions about which system is most effective for which communities. Further studies need to be undertaken to better understand how to provide effective obstetrical care in rural and bush Alaska at an acceptable risk, and at reasonable cost.

Hypertension in Alaska Natives: association with overweight, glucose intolerance, diet and mechanized activity.

OBJECTIVE: Determine the prevalence of hypertension in Alaska Natives and evaluate risk factors. DESIGN: Population-based univariate and multivariate analysis of blood pressure in 1124 Alaska Natives over 20 years of age. RESULTS: The sample had mean: age 45 years, body mass index 27, systolic pressure 123 mmHg and diastolic pressure 73 mmHg. The age-adjusted rate of hypertension > or = 160/95 mmHg was 9.1% and 6.8% among Athabascan Indians and Yup'ik Eskimos, respectively. After controlling for age and sex there was significantly more hypertension among Athabascan Indians (OR = 1.53, CI = 1.07-2.2, p = 0.019) compared to Yup'ik Eskimos. Race was significantly associated with blood pressure > or = 140/90 when controlled for age and overweight (p = 0.01, OR = 0.78, CI = 0.69-0.95). The presence of hypertension was significantly associated with the following: intake of non-indigenous food (p = 0.01); mechanized activities (p = 0.01); and glucose intolerance in both women (p = 0.043) and men (p = 0.001). Multiple regression analysis revealed age (OR = 1.06, CI = 1.05-1.08) and overweight in both men (OR = 3.02, CI = 1.85-4.93) and women (OR = 2.76, CI = 1.81-4.19) to be significantly associated with BP > or = 140/90. CONCLUSION: Hypertension is no longer rare in Alaska Natives and is associated with overweight, non-indigenous diet, mechanized activities, and glucose intolerance.

The negative association between traditional physical activities and the prevalence of glucose intolerance in Alaska Natives.

The once low prevalence of non-insulin-dependent (Type 2) diabetes (NIDDM) in Eskimos and Indians has risen approximately fourfold over the past 30 years, suggesting the presence of a non-genetic factor affecting NIDDM prevalence. At the same time, traditional physical activities required of a subsistence (self-sufficiency) lifestyle have diminished. Since physical activity has been shown to prevent NIDDM in other populations, we performed a case-control study of physical activity and glucose intolerance in 666 Yup'ik Eskimos and Athabaskan Indians > or = 40 years old in 15 villages in the Yukon Kuskokwim Delta in Alaska. Self-administered questionnaires were used to determine whether subjects participated in a number of traditional activities and/or their modern counterpart (for example, dog sledding and riding motorized vehicles). Intensity values and a score were defined for the activities. Cases included known or newly discovered impaired glucose tolerance or NIDDM. Newly discovered cases were defined by oral glucose tolerance testing of those individuals were screening blood glucose values > or = 6.7 mmol l-1 by random capillary blood glucose testing. Cases included 11 newly discovered (1 with a history of IGT) and 26 known cases of NIDDM, and 17 newly discovered and 1 known cases of IGT. The results showed that, compared to a reference group with low-level physical activity, moderate level physical activity (odds ratio, OR, 0.7, 95% confidence interval [CI] 0.4-1.3) and high level activity (OR 0.2, CI 0.1-0.6) were associated with a lower prevalence of glucose intolerance, adjusted for age, ethnicity, body mass index, and sex.

Tobacco erases 30 years of progress: preliminary analysis of the effect of tobacco smoking on Alaska Native birth weight.

OBJECTIVE: Investigate the relationship between tobacco and/or alcohol use and Alaska Native birth weight. METHODS: Data on weight, tobacco smoking and alcohol use among Alaska Natives were abstracted from 1989-91 Indian Health Service natality records based on birth certificates. RESULTS: Birth certificate data were available for 9,175 live births. Single live births were analyzed for 8,994 Alaska Natives. In women with no tobacco smoking the mean birth weight of their infants was 3,571 g; 1-5 cigarettes/day 3,429 g; 6-10 cigarettes/day 3,332 g (p < .05); and > 10 cigarettes/day 3,260 g (p < .05). Infants of Alaska Natives who reported no alcohol and no tobacco use had a mean birth weight of 3,579 g; alcohol use but no tobacco use 3,452 g; no alcohol but tobacco use 3,388 g; and both alcohol and tobacco use 3,281 g. (p < .001). CONCLUSIONS: The mean birth weight of infants born to Alaska Native women with the highest use of tobacco were reduced by over 300 g compared to non-smoking Alaska Native women. Mean infant birth weight of tobacco smoking Yup'ik women in 1989-91 were reduced by over 400 g, comparable to weights reported in the 1960s.

Dietary change and obesity associated with glucose intolerance in Alaska Natives.

OBJECTIVE: To investigate frequency of food intake, body weight, and glucose intolerance in Alaska Natives. DESIGN: Height, weight, and random blood glucose levels were measured and a frequency-of-food-intake questionnaire was obtained. This questionnaire classified persons as consumers of indigenous foods or nonindigenous foods within three food groups. Those with a random blood glucose measurement > or = 6.72 mmol/L received an oral glucose tolerance test. SETTING: Community screening in 15 villages in Alaska. SUBJECTS: Nutrition screenings were done for 1,124 Alaska Native residents aged 20 years or older. An oral glucose tolerance test was done for 202 subjects. OUTCOMES MEASURED: Subjects were classified as consumers of indigenous or nonindigenous foods within three food groups. A diagnosis of non-insulin-dependent diabetes mellitus (NIDDM) was made on the basis of World Health Organization criteria. A determination of overweight was made on the basis of National Center for Health Statistics criteria. STATISTICAL ANALYSIS: A chi 2 test with Yates correction, t test, and linear regression, with two-sided P values. RESULTS: Athabascan Indians had twice the rate of NIDDM as Yup'ik Eskimos with significantly higher frequency of nonindigenous food intake, plus lower frequency of indigenous carbohydrate and fat intake. Subjects < or = 30 years old consumed significantly more nonindigenous protein and fat and low-nutrient-density carbohydrates than those > or = 60 years old. Persons who had glucose intolerance reported significantly greater consumption of nonindigenous protein and less seal oil. Incidence of overweight was significantly higher than was found 25 years ago. Participants with glucose intolerance were significantly more overweight than others. CONCLUSION: A pattern of increased frequency of nonindigenous protein, low-nutrient-density carbohydrate, and fat intake with less indigenous carbohydrate and fat consumption was found in subjects < or = 30 years old and in association with the higher rate of NIDDM found in the Athabascan Indians. Persons with glucose intolerance were significantly more overweight than others. APPLICATIONS: Although the nutritional value of indigenous foods for reducing disease risk should be promoted, nutrition education, especially among young adults, should also include building skills to select and prepare nonindigenous foods to attain a healthful diet. Although snacking is a concern, dietary fat was the most significant factor in obesity and NIDDM.

Lower prevalence of impaired glucose tolerance and diabetes associated with daily seal oil or salmon consumption among Alaska Natives.

OBJECTIVE: To examine the association of seal oil and salmon consumption with impaired glucose tolerance (IGT) and non-insulin-dependent diabetes mellitus (NIDDM) among Alaska Natives. RESEARCH DESIGN AND METHODS: Screening was performed on 666 Yup'ik Eskimos and Athabaskan Indians > or = 40 years old in 15 villages. Self-administered questionnaires were used to obtain partial food frequency data. A case was defined as IGT or NIDDM, either newly discovered or known. Newly discovered cases (11 patients with NIDDM and 17 with IGT) were determined by random blood glucose testing followed by a 2-h 75-g oral glucose tolerance test (OGTT) for those with values > or = 6.72 mmol/l or for subjects with unconfirmed histories of glucose intolerance. Known cases included 26 patients with NIDDM and 1 with IGT. Control subjects had random blood glucoses < 6.72 or normal OGTT results. RESULTS: Compared with less-than-daily consumption, both daily seal oil (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.1-0.8) and daily salmon consumption (OR 0.5, CI 0.2-1.1) were associated with a lower prevalence of glucose intolerance, controlling for age, ethnicity, body mass index, and sex. The effects were similar when limited to newly discovered cases: OR 0.3, CI 0.1-1.3 for seal oil and OR 0.4, CI 0.1-1.3 for salmon. Consumption of seal oil at least five times per week was required to reduce risk. CONCLUSIONS: Consumption of seal oil and salmon, high in omega-3 fatty acids, appears to lower the risk of glucose intolerance and is a potentially modifiable risk factor for NIDDM in Alaska Natives.

Carbohydrate sources for gestational diabetes mellitus screening. A comparison.

One hundred eight patients were prospectively randomized to receive 50 g of a glucose polymer, d-glucose or a candy bar during a one-hour gestational diabetes mellitus (GDM) screening. The polymer had a mean serum glucose similar to that of d-glucose, with significantly fewer side effects, allowing an increased rate of examination completion. The candy bar produced a significantly lower mean serum glucose but had the highest rating for flavor. The polymer was an inexpensive and well-tolerated alternative for GDM screening, while the use of a candy bar needs more study.

Screening for gestational diabetes mellitus with a reflectance photometer: accuracy and precision of the single-operator model.

OBJECTIVE: To investigate the accuracy and precision of a recent-generation reflectance photometer, Accu-Chek III, for gestational diabetes mellitus screening with a single operator. METHODS: Four hundred ten paired capillary and serum glucose samples collected prospectively were evaluated by a reflectance photometer and a glucose oxidase method (Beckman), respectively, during routine gestational diabetes mellitus screening with a single operator. RESULTS: The mean Accu-Chek III result was 12% greater than serum glucose oxidase (115.5 +/- 1.4 and 103.4 +/- 1.3 mg/dL, respectively). A serum glucose level of at least 135 mg/dL by glucose oxidase produced sensitivity and specificity of 0.81 and 0.68, respectively. At 155 mg/dL, the Accu-Chek III sensitivity was 0.81 and specificity 0.74, and the method produced fewer false-positive results (37 of 410 [9.0%] versus 41 of 410 [10%]) than a 135-mg/dL serum cutoff. Adjusting the Accu-Chek III threshold by two times the coefficient of variation resulted in the same number of false positives as the Beckman technique at 135 mg/dL. The receiver operating characteristic curve cutoff for the venous value of 135 mg/dL was an Accu-Chek III value of 141 mg/dL. Linear regression analysis predicted y = 20.6 + 0.919x, r = 0.838. The mean coefficient of variation was 3.9%. CONCLUSIONS: The Accu-Chek III produced accurate and precise gestational diabetes mellitus screening results with a single operator. Because capillary blood is a combination of arterial and venous blood, an Accu-Chek III cutoff of 155 mg/dL may be more appropriate for screening, considering the 10-15% higher capillary glucose level in the fed state. An Accu-Chek III cutoff of 155 mg/dL produced a higher specificity than venous serum at 135 mg/dL, with no decrease in sensitivity.

Use of a reflectance photometer as a diabetes mellitus screening tool under field conditions.

OBJECTIVE: Investigate the Accu-Chek II and visual Chemstrip bG methods for non-insulin dependent diabetes mellitus (NIDDM) screening under field conditions with the aid of local providers. METHODS: Compare simultaneous random Chemstrip bG, Accu-Chek II and plasma glucose levels using a 6.7 mM cut-off, followed by a 75 gram 2 hour oral glucose tolerance test while screening 1124 people in 15 Alaskan villages with the aid of local personnel during winter field conditions. RESULTS: The Accu-Chek II and visual Chemstrip bG methods detected 92% and 96%, respectively, of those newly diagnosed with NIDDM whose plasma screen was > or = 6.7 mM. The Accu-Chek II provided correlations of 0.774, 0.850, 0.923, and 0.946 with random, fasting, 1 and 2 hour plasma glucose. The mean Accu-Chek II, Chemstrip bG and plasma levels at which NIDDM was diagnosed were not statistically different. Receiver operator characteristic (ROC) curve analysis revealed optimum screening cut-off values for subsequent new diagnosis of NIDDM to be 8.3, 7.7, and 8.0 mM for visual, Accu-Chek II and hexokinase methods (p = NS). CONCLUSION: The Accu-Chek II and Chemstrip bG provided accurate glucose data in random NIDDM screening under field conditions with multiple local providers.

An upstream approach to health care: the education of nurses for policy change.

Working within the social context of well-being, therefore, enables nurses to respond holistically to clients. Central to the accomplishment of this vision, however, is a reformation of policies, starting with the educational foundation of nursing students. Equipped with a liberal education, an internalization of the values that uphold human dignity and sense of self, and professional knowledge, nurses can become leaders in the process of policy change. With associate health professionals, nurses can assist in forming interventive policies that lay the foundation for community-based programs aimed at the preventive nature of an upstream approach.

Gonadotropin releasing hormone (GnRH) agonist therapy for reduction of leiomyoma volume.

A patient with menorrhagia, dysmenorrhea, and an enlarged uterus was treated with a GnRH agonist for leiomyoma volume reduction. A laser-assisted myomectomy yielded five tumors that did not appear to be well demarcated and had a combined weight of only 30 g. Postoperative pathologic evaluation revealed leiomyosarcoma with 22 mitoses per 10 high-power fields. The 8-month delay in therapy was associated with Stage IV, grade 3 disease at diagnosis. In rare cases GnRH agonist therapy may palliate symptoms and delay definitive surgical therapy of leiomyosarcoma, resulting in more advanced disease at diagnosis.

Menometrorrhagia in an oral contraceptive user.

Endometrial carcinoma is the most frequent malignancy of the female reproductive tract, and irregular vaginal bleeding is the most common presenting symptom. Endometrial carcinoma is found most commonly among postmenopausal women and is associated with obesity, nulliparity, and anovulation. Oral contraceptive (OC) use and tobacco smoking have been reported to protect against endometrial carcinoma. Irregular vaginal bleeding is a common side effect of OC therapy. We report the case of an obese, premenopausal nulliparous woman with normal menses who developed menometrorrhagia and was then found to have endometrial carcinoma despite her youth and her use of both tobacco and combination OC.

PIP: Endometrial carcinoma is the most frequent malignancy of the female reproductive tract, and irregular vaginal bleeding is its most common symptom. It is most common among postmenopausal women and is associated with obesity, nulliparity, and anovulation. Oral contraceptive (OC) use and tobacco smoking have been reported to protect against it. A 30-year-old nulligravida nulliparous woman presented with menometrorrhagia. She had had normal menses since age 11, she had smoked a pack of cigarettes a day for 15 years, and had been obese since age 15 (weighing 302 pounds). At age 26, she started taking a combination OC containing .1 mg ethynodiol diacetate and 35 mcg ethynyl estradiol (EE). 4 years later she gradually developed menorrhagia which improved upon changing the OC to .3 mg norgestrel and 30 mcg EE. Subsequently she developed early cycle metrorrhagia and was placed on .5 mg norgestrel and 50 mcg EE. She continued having early and midcycle breakthrough bleeding with clots. Physical examination and test results including a PAP smear were normal. She was taken to the emergency department because of continued bleeding. The uterus sounded to 14 cm. Curettings were consistent with grade 1-2, well-differentiated adenocarcinoma of the endometrium. 3 weeks later, she had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and peritoneal biopsy for cytological examination. The pelvis and the abdomen were free of metastasis. Histological examination revealed a superficially invasive, well-differentiated adenocarcinoma consistent with stage IB, grade 1%. Ploidy analysis uncovered 12.5% tetraploid, with 0% aneuploid or hyperploid cells with 8.5% of the cells in S phase and 21% in the proliferative phase. Both estrogen and progesterone receptors were positive. The ploidy analysis and receptor status were consistent with the low-grade nature of the lesions. Postoperative radiation was not recommended, and the patient was well 6 months postoperatively.

Diabetes prevalence, incidence, and complications among Alaska Natives, 1987.

OBJECTIVE: To provide descriptive epidemiological data on diabetes mellitus among Alaska Natives, including incidence, updated prevalence, and incidence rates of ESRD, LEA, MI, and stroke in the diabetic population. RESEARCH DESIGN AND METHODS: In IHS and tribal contract hospitals and clinics throughout Alaska, Alaskan Indians, Eskimos, and Aleuts living in Alaska with documented diabetes mellitus were studied from 1986 to 1987. RESULTS: The number of diabetic patients increased from 610 to 708, and the prevalence changed from 15.7 to 17.4/1000 (not a statistically significant increase). Incidence rates per 10,000 diabetic person-yr for complications were 38 for ESRD, 69 for LEA, 92 for MI, and 92 for stroke. CONCLUSIONS: The prevalence of diabetes mellitus increased during the period of observation, but not to a statistically significant degree. Incidence rates for diabetes are lower than for the U.S. general population, but complications rates are as high as those in other diabetic populations.

Prevalence of diabetes mellitus in pregnancy among Yup'ik Eskimos, 1987-1988.

OBJECTIVE: To evaluate the prevalence of diabetes mellitus in pregnancy in Yup'ik Eskimos. RESEARCH DESIGN AND METHODS: A retrospective review of consecutive birth-log data and medical records was conducted. Records were taken from the primary care and tertiary referral facilities in Alaska Area Native Health Service. Some 630 consecutive deliveries were reviewed from 1 March 1987 to 29 February 1988, with 25 excluded for ancestry other than Alaska Native. Another 605 Alaska Native patient charts were reviewed, with 545 Alaska Native patients screened for diabetes in pregnancy. The study population had a mean age of 25.6 yr, mean gravidity of 3.4, mean parity of 1.9, and mean birth weight of 3567 +/- 493 g. RESULTS: Patients were screened with a 50-g glucose oral load with a plasma glucose 1 h later. 156 of 605 (25.7%) patients, with a screen > or = 7.8 mM received a 100-g OGTT. Of 605, 35 (5.8%) patients met O'Sullivan criteria, and 2 of 605 (0.3%) patients met WHO criteria for previous diabetes mellitus, for a total 37 of 605 (6.7% [corrected]) women with diabetes in pregnancy. The subjects who met O'Sullivan criteria had statistically greater mean age (29.9 yr), gravidity (4.9), parity (2.9), and birth weight of their infants (3678 +/- 389 g), compared with women with a screen < 7.8 mM. CONCLUSIONS: The prevalence of diabetes in pregnancy among Yup'ik Eskimos is twice the rate for the U.S. for all races, despite the Yup'ik having the lowest rate of diabetes mellitus among Alaska Natives. This may represent a large number of undiagnosed patients with impaired glucose tolerance, and may reflect the wide-spread dietary and life-style changes that have occurred in the Yup'ik in the last 30 yr. The Yup'ik present a unique opportunity to apply prevention techniques in a population with an emerging problem with glucose tolerance.