Association of Traditional and Nontraditional Risk Factors in the Development of Strokes Among Young Adults by Sex and Age Group: A Retrospective Case-Control Study.

BACKGROUND: Despite women having fewer traditional risk factors (eg, hypertension, diabetes), strokes are more common in women than men aged ≤45 years. This study examined the contributions of traditional and nontraditional risk factors (eg, migraine, thrombophilia) in the development of strokes among young adults. METHODS: This retrospective case-control study used Colorado's All Payer Claims Database (2012-2019). We identified index stroke events in young adults (aged 18-55 years), matched 1:3 to stroke-free controls, by (1) sex, (2) age±2 years, (3) insurance type, and (4) prestroke period. All traditional and nontraditional risk factors were identified from enrollment until a stroke or proxy-stroke date (defined as the prestroke period). Conditional logistic regression models stratified by sex and age group first assessed the association of stroke with counts of risk factors by type and then computed their individual and aggregated population attributable risks. RESULTS: We included 2618 cases (52% women; 73.3% ischemic strokes) and 7827 controls. Each additional traditional and nontraditional risk factors were associated with an increased risk of stroke in all sex and age groups. In adults aged 18 to 34 years, more strokes were associated with nontraditional (population attributable risk: 31.4% men and 42.7% women) than traditional risk factors (25.3% men and 33.3% women). The contribution of nontraditional risk factors declined with age (19.4% men and 27.9% women aged 45-55 years). The contribution of traditional risk factors peaked among patients aged 35 to 44 years (32.8% men and 39.7% women). Hypertension was the most important traditional risk factor and increased in contribution with age (population attributable risk: 27.8% men and 26.7% women aged 45 to 55 years). Migraine was the most important nontraditional risk factor and decreased in contribution with age (population attributable risk: 20.1% men and 34.5% women aged 18-35 years). CONCLUSIONS: Nontraditional risk factors were as important as traditional risk factors in the development of strokes for both young men and women and have a stronger association with the development of strokes in adults younger than 35 years of age.

New Frontier: The First Year of an Adult Neurodevelopmental Disabilities Clinic.

BACKGROUND: As patients with neurodevelopmental disorders (NDDs) transition from pediatric to adult health care systems, they often have difficulty finding physicians to address their NDD-related needs. In response to this care gap, we established a new consultation clinic within a behavioral neurology clinic in an adult neurology department to address the neurodevelopmental concerns of these adult patients. OBJECTIVE: To characterize the population of adult patients with NDDs seen in the adult NDD clinic in its first year. METHOD: Data were obtained by a retrospective chart review of all patients with NDDs seen in the adult NDD clinic from September 2020 through December 2021. RESULTS: Of the 86 patients who were seen in the adult NDD clinic, the average age was 34 years (SD = 15, range = 18-74 years). Developmental diagnoses included intellectual disability (63%), autism spectrum disorder (47%), Down syndrome (15%), cerebral palsy (9%), and other genetic disorders (26%). Comorbidities addressed included behavioral concerns (34%), anxiety (29%), seizure disorders (22%), and depression (15%). Behavioral and/or mental health concerns prompted 65% of the initial clinic visits. The most common recommendation made was to begin or increase exercise (59%), followed by facilitating connection to community, social, and employment resources. CONCLUSION: Adults with NDDs have diagnoses, comorbidities, and concerns that are similar to, but also distinct from, those addressed in other adult neurology clinics. This study addresses the need for, and feasibility of, caring for the diverse population of adults with NDDs in an adult neurology setting.

Trainee educational curriculum to standardize central venous catheter repair.

INTRODUCTION: Children may require durable central venous catheters (CVCs) for various reasons. CVC-related integrity complications are common and can often be repaired at the bedside to increase lifetime. Variability in repair techniques can lead to complications, including the need for repeat repair and Central Line Associated Blood Stream Infection (CLABSI). METHODS: The impact of an educational curriculum to standardize tunneled CVC repairs for trainees on a pediatric surgery service was studied, focusing on comfort level with tunneled CVC repair and to determine the impact on complication rates. Rotating trainees studied a dedicated audiovisual educational curriculum comprised of a video, educational slides, and a practical component from November 2020 through January 2022. Experience and comfort level with tunneled CVC repairs were assessed before and after the rotation. CVCs repaired during the duration of the study were evaluated and compared to the period prior. RESULTS: Forty-nine individuals completed the pre- and post-training survey. Respondents (34.7%, n = 17) most commonly reported one year of surgical experience, and (79.6%, n = 39) had never observed or assisted in a repair previously. Following training, respondents felt more comfortable with all aspects of the CVC repair process (p < 0.001). There were no statistically significant differences in re-repair rates or CLABSI rates following the implementation of the curriculum. CONCLUSIONS: Tunneled CVC procedural repair variability can be standardized with a dedicated educational curriculum for rotating trainees, which improves knowledge and comfort with such procedures.

Hyperglycemia and Other Glycemic Measures Throughout Therapy for Pediatric Acute Lymphoblastic Leukemia and Lymphoma.

Transient hyperglycemia during induction chemotherapy is associated with increased morbidity and mortality in patients with acute lymphoblastic leukemia (ALL). Treatment with glucocorticoids, asparaginase, and stress are the proposed causal factors. Although these risks are not exclusive to induction, glycemic control throughout the remainder of ALL/lymphoma (ALL/ALLy) therapy has not been described. Furthermore, prior research has been limited to transient hyperglycemia. This study aimed to characterize glycemic control throughout ALL/ALLy and to evaluate risk factors and outcomes associated with increased mean glucose and glucose coefficient of variation (glucose CV) during induction chemotherapy. The records for 220 pediatric/young adult patients, age 1 to 26 years, who underwent treatment for ALL/ALLy from 2010 to 2014 at Children's Hospital Colorado were retrospectively reviewed. Measures of glycemic control were calculated for each cycle. For the cycle with the highest mean glucose, induction (n=208), multivariable models were performed to identify potential risk factors and consequences of increased glucose. Highest mean glucose by cycle were induction 116 mg/dL, pretreatment 108 mg/dL, delayed intensification 96 mg/dL, and maintenance 93 mg/dL; these cycles also had the most glycemic variability. During induction, patients with Down syndrome, or who were ≥12 years and overweight/obese, had higher mean glucoses; age and overweight/obese status were each associated with increased glucose CV. In multivariable analysis, neither induction mean glucose nor glucose CV were associated with increased hazard of infection, relapse, or death.

Delivery of home-based post-partum contraception in rural Guatemalan women: feasibility, recruitment and retention in a cluster-randomized trial.

BACKGROUND: Few cluster-randomized trials have been performed in rural Guatemala. Our objective was to describe the feasibility, recruitment and retention in our cluster-randomized trial. METHODS: In our cluster-randomized trial, a range of contraceptives were brought to mothers' homes in rural Guatemala. RESULTS: Of 173 women approached, 33 were excluded. Of the 140 eligible women, 127 (91%) consented to participate. Of the 87 women who should have been assessed for the primary outcome, three were lost to follow-up, which represents a retention rate of 97%. CONCLUSIONS: Nurses who are both clinical providers and study staff can feasibly conduct research, which leads to high enrollment and retention rates.

Outcomes of a Multi-Component School-Based Nutrition Program.

BACKGROUND: This paper presents the effectiveness of a multi-component elementary school-based nutrition education program, the Integrated Nutrition Education Program (INEP), which has been in existence for over 25 years. INEP includes components to address multiple layers of influence: hands-on nutrition education lessons in the classroom (student-level), parent education, and outreach (home-level), and facilitation of a planning process to implement policy, system, and environmental (PSE) school changes (school-level). METHODS: Three evaluation tools assessed the effectiveness of the program: (1) classroom plate waste measurement in intervention (N = 149 students) and demographically-matched comparison schools (N = 131 students), (2) pre/post classroom surveys completed by students who participated in INEP (N = 204), and (3) PSE change data from participating schools (N = 47 schools). RESULTS: Students who participated in the nutrition education program were more likely to consume vegetable-based recipes and vegetables included in classroom nutrition lessons compared to students in comparison classrooms (Chinese vegetable salad: p < .001; couscous salad: p < .001; snap peas: p = .001). Classroom survey analyses showed improvements in student self-efficacy (p < .001), preference for vegetables (p = .005), and knowledge (p < .001). In addition, through a wellness planning process, schools implemented an average of 3.7 PSE changes per school. CONCLUSIONS: Results demonstrate a multi-component school-based nutrition education program improves student nutrition-related outcomes.

Body Composition and Markers of Cardiometabolic Health in Transgender Youth on Gonadotropin-Releasing Hormone Agonists.

Purpose: Up to 1.8% of youth identify as transgender; many will be treated with a gonadotropin-releasing hormone agonist (GnRHa). The impact of GnRHa on insulin sensitivity and body composition in transgender youth is understudied. We aimed to evaluate differences in insulin sensitivity and body composition in transgender youth on GnRHa therapy compared with cisgender youth. Methods: Transgender participants were matched to cisgender participants on age, body mass index, and sex assigned at birth. Transgender males (n=9, ages 10.1-16.0 years) on GnRHa (mean±standard deviation duration of exposure: 20.9±19.8 months) were compared with cisgender females (n=14, ages 10.6-16.2). Transgender females (n=8, ages 12.6-16.1) on GnRHa (11.3±7 months) were compared with cisgender males (n=17, ages 12.5-15.5). Differences in insulin sensitivity (1/[fasting insulin], homeostatic model of insulin resistance [HOMA-IR]), glycemia (hemoglobin A1C [HbA1c], fasting glucose), and body composition (dual-energy X-ray absorptiometry) were evaluated using a mixed linear regression model. Results: Transgender males had lower 1/fasting insulin and higher HOMA-IR (p=0.031, p=0.01, respectively), fasting glucose (89±4 vs. 79±13 mg/dL, p=0.012), HbA1c (5.4±0.2 vs. 5.2±0.2%, p=0.039), and percent body fat (36±7 vs. 32±5%, p=0.042) than matched cisgender females. Transgender females had lower 1/fasting insulin and higher HOMA-IR (p=0.028, p=0.035), HbA1c (5.4±0.1% vs. 5.1±0.2%, p=0.007), percent body fat (31±9 vs. 24±10%, p=0.002), and lower percent lean mass (66±8 vs. 74±10%, p<0.001) than matched cisgender males. Conclusion: Transgender youth on a GnRHa have lower estimated insulin sensitivity and higher glycemic markers and body fat than cisgender controls with similar characteristics. Longitudinal studies are needed to understand the significance of these changes. Clinical Trial.gov ID: NCT02550431.

Impact of a nutrition education programme on preschool children's willingness to consume fruits and vegetables.

OBJECTIVE: To evaluate the impact of a preschool-based nutrition education programme consisting of twelve 'hands on' nutrition education lessons delivered during the school year on young children's willingness to consume fruits and vegetables. DESIGN: Quasi-experimental, pre-post design including the collection of plate waste evaluation data at the start and end of the 2015-2016 school year within two groups: (1) randomly selected classrooms receiving the intervention and (2) within conveniently sampled preschool classrooms not receiving the intervention serving as a comparison group. SETTING: Centre-based preschool programmes serving low-income families in the Denver metro area. PARTICIPANTS: Three- to five-year-old children in preschool classrooms participating in the intervention during the 2015-2016 school year (n 308) and children enrolled in comparison classrooms (n 215). RESULTS: Repeated-measures logit models assessed whether increases in the odds of consuming small samples of fruits and vegetables between Time 1 (pre-intervention) and Time 2 (post-intervention) were different for children within the intervention group compared with the comparison group. Analyses showed that the change over time in consumption of the three vegetable samples varied by intervention status with greater change occurring among children within the intervention group (edamame: P = 0·001; cauliflower: P ≤ 0·0001 and red pepper: P ≤ 0·0001). Unlike vegetables, the change over time in consumption of the two fruit samples was not different between children within the intervention and comparison groups. CONCLUSIONS: An experiential-learning nutrition education programme can positively influence eating behaviours of low-income preschoolers in a centre-based setting by increasing willingness to consume vegetables.

Postpartum Contraceptive Use Among Denver-Based Adolescents and Young Adults: Association with Subsequent Repeat Delivery.

STUDY OBJECTIVE: To determine the association of postpartum contraceptive use with repeat deliveries among adolescents and youth. DESIGN: Retrospective, observational analysis of electronic health record data. SETTING: Single, urban facility in Denver, Colorado, United States. PARTICIPANTS: Women aged 10-24 years who gave birth between January 1, 2011 and December 31, 2015. INTERVENTIONS AND MAIN OUTCOME MEASURES: Postpartum contraceptive use and time to subsequent delivery. RESULTS: Among 4068 women, 1735 (43%) used postpartum contraception. In adjusted analyses, characteristics associated with contraceptive use included Hispanic ethnicity (relative risk [RR], 1.1; P = .03), incremental prenatal visits (RR, 1.01; P = .047), and attendance at postpartum care (RR, 1.60; P < .001). Long-acting reversible contraceptive (LARC) use was higher among women younger than 15 years (reference: 20-24 years; RR, 1.12; P < .001) and lower among women aged 18-19 years (RR, 0.93; P = .009). Hispanic women had higher rates of LARC use than non-Hispanic women (RR, 1.07; P = .02). Compared with inpatient LARC placement, outpatient placement (1-4 weeks and 5 or more weeks) rates were lower (RR, 0.77 and RR, 0.89, respectively; P < .001). Time to subsequent delivery was shorter in non-LARC users (median, 659 days) and contraception nonusers (median, 624 days) compared with LARC users (median, 790 days; P < .001); non-LARC postpartum contraceptive use did not significantly alter time to repeat delivery compared with that in women who used no method (P = .24). CONCLUSION: Postpartum LARC use reduced the risk of repeat pregnancy with a significant increase in time to the next delivery. Non-LARC use was not different from no contraceptive use in terms of time to repeat delivery.

Body Composition and Markers of Cardiometabolic Health in Transgender Youth Compared With Cisgender Youth.

CONTEXT: As many as 1.8% of adolescents identify as transgender and many more seek care, yet the impact of gender-affirming hormone therapy (GAHT) on cardiometabolic health is unknown. OBJECTIVE: To determine insulin sensitivity and body composition among transgender females (TF) and males (TM) on estradiol or testosterone, compared with cisgender females (CF) and males (CM). DESIGN: Pilot, cross-sectional study conducted from 2016-2018. SETTING: Academic regional transgender referral center. PARTICIPANTS: Transgender adolescents on either testosterone or estradiol for at least 3 months were recruited. Nineteen TM were matched to 19 CM and 42 CF on pubertal stage and body mass index (BMI). Eleven TF were matched to 23 CF and 13 TF to 24 CM on age and BMI. MAIN OUTCOME MEASURES: 1/[fasting insulin] and body composition (dual-energy x-ray absorptiometry). RESULTS: Total body fat was lower in TM than CF mean ± SD: (29% ± 7% vs 33% ± 7%; P = 0.002) and higher than in CM (28% ± 7% vs 24% ± 9%; P = 0.047). TM had higher lean mass than CF (68% ± 7% vs 64% ± 7%, P = 0.002) and lower than CM (69% ± 7% vs 73% ± 8%; P = 0.029). Insulin sensitivity was not different between the groups.TF had lower body fat than CF (31% ± 7% vs 35% ± 8%; P = 0.033) and higher than CM (28% ± 6% vs 20% ± 10%; P = 0.001). TF had higher lean mass than CF (66% ± 6% vs 62% ± 7%; P = 0.032) and lower than CM (69% ± 5% vs 77% ± 9%; P = 0.001). TF were more insulin resistant than CM (0.078 ± 0.025 vs 0.142 ± 0.064 mL/µU; P = 0.011). CONCLUSIONS: Transgender adolescents on GAHT have significant differences in body composition compared with cisgender controls, with a body composition intermediate between BMI-matched CMs and CFs. These changes in body composition may have consequences for the cardiometabolic health of transgender adolescents. CLINICALTRIALS.GOV: NCT02550431.

Delivery of home-based postpartum contraception in rural Guatemalan women: a cluster-randomized trial protocol.

BACKGROUND: Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth. METHODS: This study is a cluster-randomized trial of communities in rural Guatemala where women receive ante- and postnatal care through a community-based nursing program. When nurses visit women for their postpartum visit in the intervention clusters, instead of providing only routine care that includes postpartum contraceptive education and counseling, the nurses will also bring a range of barrier, short-acting, and long-acting contraceptives that will be offered and administered in the home setting, after routine clinical care is provided. DISCUSSION: A barrier to postpartum contraception is access to medications and devices. Our study removes some access barriers (distance, time, cost) by providing contraception in the home. We also trained community nurses to place implants, which are a type of long-acting reversible contraceptive method that was previously only available in the closest town which is about an hour away by vehicular travel. Therefore, our study examines how home-based delivery of routinely available contraceptives and the less routinely available implant may be associated with increased uptake of postpartum contraception within 3 months of childbirth. The potential implications of this study include that nurses may be able to be trained to safely provide contraceptives, including placing implants, in the home setting, and provision of home-based contraception may be an effective way of delivering an evidence-based intervention for preventing unintended and closely spaced pregnancies in the postpartum period. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04005391. Retrospectively registered on 1 July 2019.

Trends in the Mode of Delivery of Pregnant Women in Rural Guatemala from a Quality Improvement Database.

Purpose To evaluate trends and factors associated with mode of delivery in the rural Southwest Trifinio region of Guatemala. Description We conducted a retrospective analysis of self-reported antepartum factors and postpartum outcomes recorded in a quality improvement database among 430 women enrolled in a home-based maternal healthcare program between June 1, 2015 and August 1, 2017. Assessment Over the study period, the rates of cesarean delivery (CD) increased (from 30 to 45%) and rates of vaginal delivery (VD) decreased (70-55%) while facility-based delivery attendance remained stable around 70%. Younger age (23.5 years for VD vs. 21.6 years for CD, p < 0.001), nulliparity (25.1% for VD vs. 45.0% for CD, p < 0.001), prolonged/obstructed labor (2.4% for VD vs. 55.6% for CD, p < 0.001), and fetal malpresentation (0% for VD vs. 16.3% CD, p < 0.001) significantly influenced mode of delivery in univariate analysis. The leading indications for CD were labor dysfunction (47.5%), malpresentation (14.5%), and prior cesarean delivery (19.8%). The CD rate among the subpopulation of term, nulliparous women with singleton pregnancies in vertex presentation also increased from 20% of all CD in 2015, to 38% in 2017. Conclusion Among low-income women from rural Guatemala, the CD rate has increased above the World Health Organization (WHO) recommendations in a period of 3 years. Additional research on the factors affecting this trend are essential to guide interventions that might improve the appropriateness of CD, and to determine if reducing or stabilizing rates is necessary.

Clinical outcomes in U.S. infants with cystic fibrosis from 2001 to 2012.

BACKGROUND: All 50 United States implemented newborn screening (NBS) for cystic fibrosis (CF) by 2010. The purpose of this study was to evaluate trends over the decade when NBS became universal to determine current rates of malnutrition, stunting, and infection rates in U.S. infants with CF. METHODS: Annual data were obtained on infants with CF up to 24 months of age diagnosed between 2001 and 2010 in the CF Foundation Patient Registry (CFFPR), in both the years of and after diagnosis, including method of diagnosis, demographics, and growth parameters and microbiology. RESULTS: Data were obtained on 8178 infants diagnosed with CF. The percentage of infants diagnosed by NBS increased from 15% in 2001-83% in 2012 (P < 0.001). Mean weight, length, and weight-for-length z-scores in the year of diagnosis increased from 2001 to 2012 (Wt z-score 2001: -1.32 (SD 1.41), 2012: -0.72 (SD 1.12); Ht z-score 2001: -1.32 (SD 1.57), 2012 -0.60 (SD 1.21); Wt/Ht Z score 2001: -0.54 (SD 1.18), 2012: 0.06 (SD 1.05); P < 0.001 for each). The proportion of infants on pancreatic enzymes decreased from 94% in 2001-83% in 2012 (P < 0.0001). Pseudomonas aeruginosa culture positivity in the diagnosis year decreased significantly (27% in 2001, 15% in 2012, P < 0.001). CONCLUSIONS: Nationwide implementation of CF NBS is temporally associated with significant improvements in growth outcomes and reductions in P. aeruginosa infections. Current rates of malnutrition, stunting, and airway infection present a target for early intervention and quality improvement efforts.

Health and Cardiometabolic Disease in Transgender Adults in the United States: Behavioral Risk Factor Surveillance System 2015.

CONTEXT: Little is known about the health of transgender adults in the United States, a growing population. There have been no large reports examining differences in health status and cardiometabolic disease in subgroups of transgender adults [female-to-male (FTM), male-to-female (MTF), and gender nonconforming (GNC)] in the United States. OBJECTIVE: Compare the health status and prevalence of cardiometabolic disease among specific subgroups of transgender adults (FTM, MTF, GNC) with those of cisgender adults in the United States. DESIGN: Secondary data analysis based on the 2015 Behavioral Risk Factor Surveillance System survey. SETTING: The 22 states in the United States that asked about transgender identity. PARTICIPANTS: Noninstitutionalized adults age ≥18 years who reside in the United States, identified through telephone-based methods. MAIN OUTCOME MEASURES: Data were extracted for respondents who answered the transgender identity question. Weighted percentages are given for all measures. Adjusted odds ratios (ORs) are reported for health status and cardiometabolic disease measures. RESULTS: FTM adults have a higher odds of being uninsured than both cisgender women [OR 3.8; 95% confidence interval (CI), 2.1 to 7.1] and cisgender men (OR 2.5; 95% CI, 1.4 to 4.7). MTF adults have a higher odds of reporting myocardial infarction than cisgender women (OR 2.9; 95% CI, 1.6 to 5.3) but not cisgender men. CONCLUSIONS: There are significant differences in health status measures and cardiometabolic health between subgroups of transgender adults and cisgender adults. There is a need for additional research to understand the societal and medical (e.g., hormone therapy) effects on these outcomes.

Growth and endocrine function in children with Dravet syndrome.

PURPOSE: Dravet syndrome is an intractable childhood epilepsy syndrome most often associated with an SCN1A mutation. In our clinical practice, several patients with Dravet syndrome were noted to have short stature and endocrine dysfunction. This has not been reported in the literature. Our study aim was to describe growth measurements and endocrine abnormalities in children with Dravet syndrome. METHOD: A retrospective chart review was performed at a single institution. Eligibility criteria included clinical and genetic (SCN1A) diagnosis of Dravet syndrome. Records were reviewed for height and weight measurements and serologic evidence of endocrine abnormality, as well as patient demographics, anti-seizure medication, and family history. Age and gender specific trend of height and weight measurements, using z-scores, were compared to CDC growth curves (Centers for Disease Control and Prevention [1]). RESULTS: Sixty-eight children were identified, 46% male, age 1-21 years, taking an average of 2.9 anti-seizure medications per patient. Mean growth parameter measurements were significant for decrease in height z-score of 0.10 (p=<0.001) and decrease in weight z-score of 0.09 (p=<0.01) for every year increase in age, such that with increasing age the cohort moved farther away from the mean. The average group height and weight z-score, at age 8, was -0.45 and -0.09, respectively. After adjusting for age, neither gender, family history, or anti-seizure medication was associated with height or weight z-score. Serologic endocrine results were available for 26 children (38%). This identified low insulin-like growth factor 1 (IGF-1) in 7/15 and low testosterone in 2/10. Two children received growth hormone supplementation. TSH testing was abnormal <10% of the time. CONCLUSIONS: Comorbidities in children with Dravet syndrome may involve more systems than previously reported. We report a cohort of children with Dravet syndrome with reduced height and weight growth trend, as well as a subset with endocrine dysfunction evidenced by low IGF-1 and testosterone levels. Additional prospective research is needed to further define the significance of this relationship.

Parental Perception of Comorbidities in Children With Dravet Syndrome.

BACKGROUND: We hypothesized that children with Dravet syndrome may have additional common features beyond seizures and cognitive impairment. To address this gap in knowledge, we conducted a survey of caregivers of children with Dravet syndrome to identify and quantify their perception of associated symptoms in this population. METHODS: An electronic survey was developed in REDcap (Research Electronic Data Capture) and sent via e-mail to the participants on the Dravet Syndrome Foundation e-mail list. Questions focused on eating, sleep, behavior, and other symptoms that might be related to Dravet syndrome. The questions were assessed using a four-point Likert scale (e.g., strongly agree to strongly disagree). Results were later dichotomized for analysis. Logistic regression was used to calculate odds ratios of various demographic factors potentially associated with symptoms. Multivariable models were constructed using backward elimination to assess the relationship among a variety of symptoms. RESULTS: There were 202 respondents, 96% were parents of a child with Dravet syndrome (the remainder were grandparents or guardians); 90.5% were female. The median age of the affected child was eight years (interquartile range five to 14), 50% were male, and 90.5% were reported to have a known SCN1A mutation. At least one symptom associated with appetite was reported in 99% of respondents, 82% reported a disturbance of sleep, one third reported autonomic symptoms, and 75% reported problems with gait. Inattention and perseveration were reported more commonly than other behavioral disturbances. SIGNIFICANCE: Caregivers have the perception of many symptoms in children with Dravet syndrome in addition to those that have been previously reported, including appetite, sleep, gait, and behavior. Many of these can significantly affect quality of life for both the child and the caregiver.

A Community-Engaged Approach to Collecting Rural Health Surveillance Data.

PURPOSE: In order for communities to make health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities, they need an accurate picture of the health status of residents. While state and national health surveillance systems exist to help local communities make data-driven health decisions, rural communities face unique challenges including: (1) limited county-level data; (2) underrepresented segments of the population; and (3) a lack of survey items to address local health concerns. The purpose of this study was to take a community-engaged approach to collecting population-based health status data in a rural area in an effort to address some of these unique challenges. METHODS: Using a community-based participatory research (CBPR) approach, over 1,500 residents from 6 rural and frontier counties were randomly selected with a stratified, multistage cluster study design. Surveys were primarily completed over the phone. FINDINGS: Response rates by county ranged from 59% to 80% (overall = 66%). Males and younger adults (18-24 year olds) were underrepresented in the sample, but Hispanics, low-income residents, and cell phone-only users were adequately represented. Prevalence rates for chronic disease and health behavior varied by county. CONCLUSIONS: The implications of this project are that engaging stakeholders in community surveillance efforts increases the quality, relevance and utility of the information collected and can help reach otherwise difficult-to-reach populations. This can result in a more accurate picture of the health status of residents, which can lead to making health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities.

Disseminating Evidence-Based Physical Education Practices in Rural Schools: The San Luis Valley Physical Education Academy.

BACKGROUND: To address childhood obesity, strategies are needed to maximize physical activity during the school day. The San Luis Valley Physical Education Academy was a public health intervention designed to increase the quality of physical education and quantity of moderate to vigorous physical activity (MVPA) during physical education class. METHODS: Elementary school physical education teachers from 17 schools participated in the intervention. They received SPARK curriculum and equipment, workshops, and site coordinator support for 2 years. A pre/post/post within physical education teacher design was used to measure intervention effectiveness. System for Observing Fitness Instruction Time (SOFIT) and a physical education teacher survey were collected 3 times. RESULTS: MVPA increased from 51.1% to 67.3% over the 2-year intervention resulting in approximately 14.6 additional hours of physical activity over a school year and 4662 kcal or 1.33 lbs. of weight gain prevention. More time was spent on skill drills and less time on classroom management and free play. CONCLUSIONS: The San Luis Valley Physical Education Academy succeeded in increasing rural, low-income students' physical activity. The multicomponent intervention contributed to the program's success. However, cost-effective approaches are needed to disseminate and implement evidencebased practices aimed at increasing students' physical activity during the school day.

Factors Associated with Tooth Loss in Older Adults in Rural Colorado.

The purpose of this paper is to examine factors that are associated with tooth loss in older adults living in the San Luis Valley (SLV), Colorado, which is a rural and large geographical area (roughly the size of Connecticut) that has a large population age 60 years or older. Data used in this manuscript were collected as a part of the SLV Community Health Survey. The analyzed sample included 308 adults over the age of 65 years who completed the survey. Basic descriptive statistics and a series of step-wise binary logistic regression analyses were conducted; the dependent variable was the number of permanent teeth removed because of tooth decay or gum disease. Fifty-two percent of the participants were male, Hispanic participants made up 40 % of the sample and 76 % of the participants had at least a high school education. Tooth loss was significantly associated with older age (OR = 1.09; p = 0.02), lower income (OR = 0.01; p = 0.00), less than high school education (OR = 0.32; p = 0.01), being Hispanic (OR = 2.15; p = 0.05), self-reported fair-poor health status (OR 2.94; p = 0.02), consumption of one or more than one sweet beverage per day (OR = 4.52; p = 0.00), no dental insurance (OR = 4.70; p = 0.01) and length of time since last dental visit (OR = 0.21; p = 0.01). The findings of the present study suggest possible causes for tooth loss in rural adults and underscore the need for in-depth research to study the overall oral health of rural older adults living in SLV.

Local Wellness Policy 5 years later: is it making a difference for students in low-income, rural Colorado elementary schools?

INTRODUCTION: The federally mandated Local Wellness Policy (LWP) was intended to promote student health in schools. This study assesses the 5-year effects of the LWP on the health practices of rural elementary schools in Colorado. METHODS: One year before and 5 years after the LWP mandate, a survey was administered to a random sample of principals, physical education (PE) teachers, and food-service managers in 45 rural, low-income elementary schools in Colorado. Response rates were 71% in 2005 and 89% in 2011. RESULTS: Minutes for PE and recess did not increase, nor did offerings of fresh fruits and vegetables. More schools adopted policies prohibiting teachers from taking recess away as punishment (9.7% in 2005 vs 38.5% in 2011, P = .02) or for making up missed instructional time, class work, or tests in other subjects (3.2% in 2005 vs 28.2% in 2011, P = .03). More schools scheduled recess before lunch (22.6% in 2005 vs 46.2% in 2011, P = .04) and developed policies for vending machines (42.9% in 2005 vs 85.7% in 2011, P = .01) and parties (21.4% in 2005 vs 57.9% in 2011, P = .004). CONCLUSION: Changes in school practices are modest, and arguably the important school practices such as increased PE and recess time and increased offerings of fruits and vegetables in the lunch line have not changed in the 5 years since the mandate went into effect. Further investigation is needed to identify the knowledge, skills, and attitudes as well as financial and physical resources required for school administrators to make changes in school practices.