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ABSTRACT BACKGROUND The Healthy, Hunger-Free Kids Act of 2010 ( HHKA) required schools to make changes to meals provided to children. Rural school districts have limited resources, with increased obesity rates and local food insecurity. In this study we sought to understand the perceptions of rural food service directors and the barriers to implementing the changes. METHODS Food service directors from rural school districts were invited to complete a semistructured telephone interview and online survey. A total of 51 respondents completed both, 6 completed only the online survey, and 16 completed only the telephone interview. Qualitative interview data were analyzed through open thematic coding; descriptive statistics were calculated for the quantitative data. RESULTS Food service directors mostly perceived the changes as negative, challenging, and burdensome. They believed that the changes resulted from concern about childhood obesity, which they did not view as a problem for their students. Diverse challenges were reported related to cost, preparation, and student preference. CONCLUSIONS Food service directors in isolated, rural areas need support to enhance understanding of HHKA requirements, build professional networks to learn from one another, and communicate with students, families, and other stakeholders. Future efforts should focus on changing perceptions and supporting directors in order to make implementation a success. [ABSTRACT FROM AUTHOR]

Information and communication technology for development (ICT4D) research sporadically leverages information science scholarship. Our qualitative study employs the "information grounds" (IG) lens to investigate the consequences of information exchanges by pregnant women on Facebook, who are vulnerable in the doctor‐centric birth culture in rural America. The thematic analysis of in‐depth interviews with members and administrators of the Vaginal Birth After Cesarean (VBAC) group shows that positive consequences outweigh negative consequences of information exchanges and lead to the following progression of outcomes: (a) VBAC group as an information ground, (b) social capital (e.g., cognitive, structural, and relational capital) built on the information ground, (c) seven emergent properties of the information ground, and (d) value co‐created (e.g., local, affordable, timely, enduring, and reliable support) by VBAC group members. The IG lens reveals the following roles of Facebook, an ICT, in development: (a) a linker that lets people with similar needs and interests convene and shapes their interactions, (b) a prerequisite to building an online, "third place" for social interactions, and (c) an apparatus for ubiquitously seeking, searching, sharing, and storing information in multiple formats and controlling its flow on the VBAC group. This paper fills in six gaps in the ICT4D research. [ABSTRACT FROM AUTHOR]

Background: Children with medical complexity (CMC) often face significant barriers to accessing care, obtaining appropriate insurance coverage for medical devices, technology, supplies, home nursing and social services. These challenges, when viewed through the lens of social determinants of health, highlight concerns about healthcare inequity. These inequities can impact CMC by limiting access to follow‐up appointments, leading to disproportionate use of emergency department services, restricting support services, reducing the quality of medical products and increasing the likelihood of adverse events. Addressing these concerns requires comprehensive policy changes at both state and federal levels. Achieving successful collaborations between states and federal agencies is particularly challenging and may take months or even years to accomplish. Objectives: Through an exploratory qualitative approach, this study facilitates a nuanced inquiry into the experiences and systemic challenges encountered by medical professionals and primary caregivers managing CMC who require a paediatric tracheostomy. Methods: Qualitative interviews were conducted with 17 health professionals and primary caregivers residing in the United States. A thematic analysis was used to analyse the transcribed interview data. Results: Using exploratory thematic analysis, we identified challenges and opportunities for improvement regarding (a) access to health insurance, (b) procurement of essential medical supplies, (c) logistical constraints and (d) identifying interim solutions. Conclusion: Building on our findings, we discuss how socioecological factors impact health and quality of life of CMC and families. Additionally, we address the growing gap in quality of care through a comprehensive approach that considers patient needs, regulatory frameworks and affordability. Patient or Public Contribution: Medical practitioners and healthcare professionals were actively involved in the development, production and implementation of the research project. These individuals were given the opportunity to review their statements and review the manuscript before publishing. While caregivers did not engage in member checking, each provided their consent before data collection. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND Behavioral support may be effective in increasing physical activity (PA) in school settings. However, there are no data collection systems to concurrently record PA and behavioral support. This paper describes the development and validation of the System for Observing Behavioral Ecology for Youth in Schools (SOBEYS)-an instrument used with existing observation systems to record PA within a behavioral ecological context. METHODS In 2013, experts created a set of behavioral categories to record prompting and reinforcement of PA during a recreational school activity program. The school provided supervision and equipment for lunchtime PA, making it possible to assess both PA and behavioral support. The system was implemented in spring semester 2014 at 1 suburban junior high school (N = 1452; 48% girls, 74% Caucasian) in the western Unites States. RESULTS Following multiple field trials, the SOBEYS instrument recorded behavioral categories of visual and verbal prompting, verbal, and nonreinforcement by adults and peers, and token reinforcement. Construct validity and acceptable interobserver agreement (>90%; kappa between 0.22 and 0.94) resulted. CONCLUSION Trained SOBEYS users can accurately and reliably record the presence of behavioral support aimed at prompting and reinforcing PA in conjunction with established systematic observation instruments to record PA context and quantity. [ABSTRACT FROM AUTHOR]

Background/aim The successful development and maintenance of professional identity is associated with professional development and retention in the health workforce. This paper explores students' perspectives on the ways pre-entry experiences and curricula content shape professional identity. Methods An online cross-sectional survey was sent to students enrolled in the final year of entry-level programmes in five countries. Descriptive statistical analyses of data were completed. Results The results reflect the perceptions of 319 respondents from five countries. Respondents identified professional education (98%) and professional socialisation during placement (92%) as curricula components with the greatest influence on professional identity formation. Discipline-specific knowledge such as, occupation-focussed models and occupational science were ranked lower than these aspects of practice. The students' length of programme and level of entry-level programme did not impact on these results. Conclusion When designing curricula educators need to be mindful that students perceive practice education and professional socialisation have the greatest affect on professional identity formation. The findings reinforce the need for curricula to provide students with a range of practice experiences, which allow the observation and application of occupation-based practices. It highlights a need for educators to provide university-based curricula activities, which better prepare students for a potential dissonance between explicit occupation-based curricula and observed practice education experiences. The study indicates the need for further research into the role curricula content, and in particular practice education, plays in the multidimensional formation of professional development within entry-level programmes. [ABSTRACT FROM AUTHOR]

Background Alcohol-related blackouts are periods of amnesia that reflect the failure of the brain to record memories of what transpires while drinking. This paper examined the incidence, predictors, and behavioral correlates of blackouts among emerging adults and examined whether questions about blackouts could serve as better markers of risk for other alcohol related harms than questions about levels of consumption. Methods In 2012 to 2013, 1,463 (68%) of 2,140 respondents 1-year past high school reported having consumed alcohol. They were asked whether, in the past 6 months because of drinking, they forgot where they were or what they did. The survey also explored demographics, substance use behaviors, and other alcohol-related problems in the past 6 months. Chi-square and logistic regression analyses explored bivariate and multivariate predictors of blackouts and other alcohol-related problems. Results Twenty percent of respondents who ever drank alcohol reported a blackout in the past 6 months. Blackouts were more prevalent among females and those who, in the past 30 days, used multiple drugs, more frequently binged, were drunk, smoked, had lower body weight, and lived in college dorms. After controlling for drinking levels, having a blackout was the strongest independent predictor of most other alcohol problems examined, including in the past 6 months because of drinking, missing class or work, getting behind in work or school, doing something respondents later regretted, arguing with friends, experiencing an overdose, and total number of alcohol problems reported. It was also an independent predictor of hangovers, damaging property, getting hurt, and trouble with police. Conclusions Because blackouts indicate drinking at levels that result in significant cognitive and behavioral impairment, questions about blackouts could serve as important, simple screeners for the risk of experiencing other alcohol related harms. Additional work on this subject is warranted. [ABSTRACT FROM AUTHOR]

The 31‐item Practice Environment Scale of the Nursing Work Index (PES‐NWI) has been frequently used globally to measure the nurse work environment. However, due to its length and subsequent respondent burden, a more parsimonious version of the PES‐NWI may be desirable. Item response theory (IRT) is a statistical technique that assists in decreasing the number of items in an instrument without sacrificing reliability and validity. Two separate samples of nurses in the United States (one called the "internal data source" and the other called "external data source"; sample sizes = 843 and 722, respectively) were analyzed. The internal data source was randomly split into training (n = 531) and validating data sets (n = 312), while a separate whole external data source was used as the final validating data set. Using IRT with training data, we removed nine items; two additional items were removed based on recommendations from a previous study. Confirmatory factor analyses supported the validity of the measurement model with the 20‐item of PES‐NWI in both internal and external validation data sources. The correlations among subscales between 31‐ and 20‐item versions were high magnitude for five subscales in both validation data sets (τ = 0.84–0.89). Ultimately, we identified a 20‐item version of the PES‐NWI which demonstrated adequate validity and reliability properties while decreasing data collection burden yet maintaining a similar factor structure to the original instrument. Additional research may be necessary to update the items themselves on the PES‐NWI. NO PATIENT OR PUBLIC CONTRIBUTION: Patients were not involved in setting the research question, the outcome measures, the design, or implementation of the study. [ABSTRACT FROM AUTHOR]

The article focuses on the variation in firearm screening and access based on LGBT status among Veterans with the risk of firearm-related suicide in both LGBT individuals and Veterans. It mentions that the study aims to fill this gap by examining LGBTQI+ status, emergency department visits, and firearm screening and access using natural language processing and machine learning algorithms applied to clinical notes in the Veterans Affairs (VA) electronic health records.

BACKGROUND: As COVID‐19 has let many students into remote learning environments and exacerbated inequality among marginalized individuals, there is a growing concern about Bias‐Based Bullying (BBB) in online spaces among school‐aged youths. Learning modality and perceived school fairness may affect youth's likelihood of reporting BBB. METHODS: Data were collected as part of "No Place For Hate" (NPFH) project, which was conducted by an equity office of a school district. A sample of middle and high school students (N = 1117) in the school district was used as an analytic sample. We conducted a series of independent samples t tests and calculated a hierarchical stepwise multivariate regression model to examine the proposition. RESULTS: Results demonstrated that students in fully remote modality reported slightly higher levels of witnessing BBB (t = 2.29, p <.05), lower perceived school fairness (t = −2.94, p <.01), and higher levels of likelihood of reporting BBB (t = 2.31, p <.05). Results of the regression model showed that perceived school fairness was positively associated with likelihood of reporting BBB, even when considering the influences of sociodemographic characteristics, learning modality, and experience of witnessing BBB. CONCLUSIONS: Findings of this study suggest that learning modality and perceived school fairness can meaningfully explain witnesses' likelihood of reporting BBB. Additional research should continue investigating how schools can encourage students to increase their likelihood of reporting and adopt the bystander response of reporting against BBB at school to ensure school health and safety. [ABSTRACT FROM AUTHOR]

Purpose: Nurses are on the forefront of delivering care to patients hospitalized with COVID‐19. Nurses' impact on patient care can be discerned through assessment and documentation strategies, including structured and unstructured narratives, clinical pathways, flowsheets, and problem‐based approaches. To date, there are no published reports regarding nursing assessment and documentation during the COVID‐19 pandemic using an assessment framework to capture clinical decision making, nursing diagnoses, and key social determinant of health (SDoH) data. Hence, the purpose of this investigation was to conduct an exploratory nursing documentation audit of patients hospitalized with COVID‐19 during the first surge to identify types and frequency of nurse‐sensitive indicators, including SDoH. Method: This pilot study utilized a retrospective chart review design at a single academic medical center, utilizing Gordon's Eleven Functional Health Patterns (FHP) framework to extract clinical, social, and nursing assessment data for patients hospitalized with COVID‐19. Descriptive statistics were computed for continuous variables and counts/percentages for categorical variables. Findings: Data from 94 patient records were analyzed. Most patients were male (59.6%), with a mean age of 58 years. Nearly 15% of patients were Black and 12.8% were Hispanic, most residing in four geographic areas. Nine of the 11 FHPs were reflected in nurse‐sensitive indicators documented in the electronic health record. SDoH data were inconsistently documented, including race, education, history of neglect/abuse, and occupation. Conclusion: The FHP framework captured many nurse‐sensitive indicators during the first COVID‐19 surge, although screening for and documenting SDoH data were limited. Implications for nursing practice: Findings can influence the development of nursing assessment and documentation during crisis care delivery that are inclusive of distinct sociodemographic factors, in addition to clinical factors, to provide comprehensive, culturally sensitive care. Such documentation will enhance the use of nursing knowledge guided by a nursing framework to make visible the essential contributions of nurses to healthcare delivery. [ABSTRACT FROM AUTHOR]

Background: Hospitals quickly adapted perinatal care to mitigate SARS‐CoV‐2 transmission at the onset of the COVID‐19 pandemic. The objective of this study was to estimate the impact of pandemic‐related hospital policy changes on perinatal care and outcomes in one region of the United States. Methods: This interrupted time series analysis used retrospective data from consecutive singleton births at 15 hospitals in the Pacific Northwest from 2017 to 2020. The primary outcomes were those hypothesized to be affected by pandemic‐related hospital policies and included labor induction, epidural use, oxytocin augmentation, mode of delivery, and early discharge (<48 hours after cesarean and <24 hours after vaginal births). Secondary outcomes included preterm birth, severe maternal morbidity, low 5‐minute Apgar score, neonatal intensive care unit (NICU) admission, and 30‐day readmission. Segmented Poisson regression models estimated the outcome level shift changes after the pandemic onset, controlling for underlying trends, seasonality, and stratifying by parity. Results: No statistically significant changes were detected in intrapartum interventions or mode of delivery after onset of the pandemic. Early discharge increased for all births following cesarean and vaginal birth. Newborn readmission rates increased but only among nulliparas (aRR: 1.49, 95%CI: 1.17, 1.91). Among multiparas, decreases were observed in preterm birth (aRR: 0.90, 95%CI: 0.84, 0.96), low 5‐minute Apgar score (aRR: 0.75, 95%CI: 0.68, 0.81), and term NICU admission rates (aRR: 0.85, 95%CI: 0.80, 0.91). Conclusions: Increases in early discharge and newborn readmission rates among nulliparas suggest a need for more postpartum support during the pandemic. Decreases in preterm birth and term NICU admission among multiparas may have implications beyond the pandemic and deserve further study. [ABSTRACT FROM AUTHOR]

We desired to carefully evaluate a novel autologous heterogeneous skin construct in a prospective randomised clinical trial comparing this to a standard‐of‐care treatment in diabetic foot ulcers (DFUs). This study reports the interim analysis after the first half of the subjects have been analysed. Fifty patients (25 per group) with Wagner 1 ulcers were enrolled at 13 wound centres in the United States. Twenty‐three subjects underwent the autologous heterogeneous skin construct harvest and application procedure once; two subjects required two applications due to loss of the first application. The primary endpoint was the proportion of wounds closed at 12 weeks. There were significantly more wounds closed in the treatment group (18/25; 72%) vs controls (8/25; 32%) at 12 weeks. The treatment group achieved significantly greater percent area reduction compared to the control group at every prespecified timepoint of 4, 6, 8, and 12 weeks. Thirty‐eight adverse events occurred in 11 subjects (44%) in the treatment group vs 48 in 14 controls (56%), 6 of which required study removal. In the treatment group, there were no serious adverse events related to the index ulcer. Two adverse events (index ulcer cellulitis and bleeding) were possibly related to the autologous heterogeneous skin construct. Data from this planned interim analysis support that application of autologous heterogeneous skin construct may be potentially effective therapy for DFUs and provide supportive data to complete the planned study. [ABSTRACT FROM AUTHOR]

The purpose of this cross‐sectional study was to examine factors associated with nurses' resilience during the COVID‐19 pandemic. Data were collected in the latter half of 2020 from 904 nurses across Japan, Republic of Korea, Republic of Turkey, and the United States. The questionnaire included the Connor‐Davidson Resilience Scale 10, plus demographics and 20 questions about practice environment, workplace safety concerning infection control, COVID‐related experience, and organizational support. Fear of becoming infected, intention to leave nursing, and having had a positive COVID‐19 test were inversely associated with resilience (p < 0.05). Regression analysis indicated that U.S. nurses had significantly greater resilience than nurses in the other countries examined (p < 0.001). Nurses reporting organization support and those who participated in policy and procedure development had higher resilience scores (p < 0.01). Organizational support, involving nurses in policy development, and country of practice were found to be important resilience factors in our research, which aligns with other findings. Further research is recommended to determine the optimal practice environment to support nurse resilience. [ABSTRACT FROM AUTHOR]

This article describes the benefits of monthly family team meetings for parents involved with child welfare. Findings are shared from semi-structured, qualitative interviews conducted with 17 parents whose children had been placed in substitute care. While much of the scholarship on family meetings focuses on opportunities for family voice, this study found that parents received multiple benefits from meetings including, but not limited to, the opportunity for input into decision-making. Specifically, parents appreciated receiving information and feedback, encouragement, and a range of other supports from members of the team. Meetings also facilitated communication and improved the coordination of services and other efforts by team members. Notably, parents reported that regular meetings helped to hold caseworkers and other providers accountable regarding their activities and duties related to the case, often resulting in better follow through. Parents and their advocates were also able to use meetings to push child welfare to respond in a timely way to parents' progress. These findings should be viewed as preliminary evidence of how a particular model of family meetings might work and thereby expand our understanding of what family team decision meetings can do to improve parents' experiences and child welfare outcomes more generally. [ABSTRACT FROM AUTHOR]

Background: Implementing task specific training is a commonly reported challenge for less experienced therapists. A potential method to improve the ability of recent graduate and student therapists is to upskill regarding task specific training via an online education resource. Purpose: To evaluate the use and acceptability of the TRAIN program as an online learning resource for physiotherapists. Methods: Data from Google Analytics was sourced to determine use of the program and details about the users. Users of the TRAIN program were also invited to complete two surveys; prior to beginning and upon completion of the program. The surveys collected information about the demographics of the users, perceptions of usefulness of the online resource and overall sentiment. Results: Almost 6000 new users interacted with the TRAIN modules during the 15‐months study period. The surveys indicated a high level of usability (mean score 9/10, SD 1.5) and clinical utility (mean score 8.8/10, SD 1.6) of the TRAIN program. Perceived knowledge and user confidence in implementing task‐specific training was higher for those users completing the post compared to those completing the pre‐module survey (knowledge 1.9 and confidence 1.7 out of 10 points higher). Recurring comments in the open‐ended feedback pertained to the usefulness, clarity, and ease of use of the TRAIN program. Discussion and Conclusion: This study provides preliminary evidence supporting the use and acceptability of the TRAIN program as an online learning resource for physiotherapists. This further contributes to the growing body of literature indicating online learning is generally a well‐received teaching tool for physiotherapists. [ABSTRACT FROM AUTHOR]

Policy PointsTelehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. Context: The COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic. Methods: The study analyzed data about small primary care practices' telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State's stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents' telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. Findings: While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas. Conclusions: Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. [ABSTRACT FROM AUTHOR]

The benefits of open data for helping to address societal problems and strengthen communities are well recognized, and unfortunately previous studies found that smaller communities are often excluded from the current data ecosystem because of existing technological, technical, cognitive, and practical barriers. This study aims to investigate the process of communitiesʼ data use for community development and decision‐making—focusing on the opportunities and challenges of data for communities. From the interviews with 25 staff from community‐based organizations (CBOs) in nine small, medium, and large cities in the United States, the findings of this study describe dataʼs role in supporting communitiesʼ development while reporting several major challenges that hinder CBOs data use: difficulty accessing data, limitations of open data (un‐local nature, excluding essential data from being open), limited data capacity (especially in data literacy skills), and difficulties using and accessing existing data infrastructures. Our findings suggest opportunities for addressing these challenges, particularly by creating educational programming, building partnerships within data ecosystems, and bringing community voices forward in current data ecosystems, which are critical to realizing dataʼs potential for all citizens. [ABSTRACT FROM AUTHOR]

Nursing students' beliefs about etiology and manifestation of mental illness will impact on their professional attitudes in future clinical practice. The aims of the present study were to examine and compare US and Chinese undergraduate nursing students' recognition of, and beliefs about, causes of depression and schizophrenia. A total of 310 US (n = 152) and Chinese (n = 158) nursing students completed the Australian National Mental Health Literacy Survey questionnaire between April 2016 and April 2017. Although nursing students in the USA and China were highly accurate in recognizing depression and schizophrenia, the US students were more likely to nominate multiple items alongside the correct diagnosis than the Chinese students. The Chinese students were more likely to view depression and schizophrenia as multi‐causally‐determined mental disorders than the US students. The findings highlight the need for the incorporation of mental health issues, including symptomatology of different mental disorders and their application to patient care, into various aspects of the US nursing curriculum. In China, opportunities can be created for nursing students to discuss the impact of personal beliefs on care delivery and social stigma during clinical placement. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute aortic dissection (AAD) is a rare condition with a high mortality that is often missed. The objective of our study was to assess the diagnostic accuracy of clinical and laboratory findings for AAD, in confirmed cases of AAD and in a low‐risk control group. Methods: This was a historical matched case–control study: participants were adults > 18 years old presenting to two tertiary care emergency departments (EDs) or one regional cardiac referral center. Cases were patients with new ED or in‐hospital diagnosis of nontraumatic AAD confirmed by computed tomography or echocardiography. Controls were patients with a triage diagnosis of truncal pain (<14 days) and an absence of a clear diagnosis on basic investigation. Cases and controls were matched in a 1:4 ratio by sex and age. A sample size of 165 cases and 660 controls was calculated based on 80% power and confidence interval of 95% to detect an odds ratio of greater than 2. Results: Data were collected from 2002 to 2014 yielding 194 cases of AAD and 776 controls (mean ± SD age = 65 ± 14.1 years; 66.7% male). Absence of abrupt‐onset pain (sensitivity = 95.9%, negative likelihood ratio = 0.07 [0.03–0.14]) can help rule out AAD. Presence of tearing/ripping pain (specificity = 99.7%, positive likelihood ratio [LR+] = 42.1 [9.9–177.5]), aortic aneurysm (specificity = 97.8%, LR+ = 6.35 [3.54–11.42]), hypotension (specificity = 98.7%, LR+ = 17.2 [8.8–33.6]), pulse deficit (specificity = 99.3, LR+ = 31.1 [11.2–86.6]), neurologic deficits (specificity = 96.9%, LR+ = 5.26 [2.9–9.3]), and a new murmur (specificity = 97.8%, LR+ = 9.4 [5.5–16.2]) can help rule in the diagnosis of AAD. Conclusions: Patients with one or more high‐risk feature should be considered high risk, whereas patients with no high‐risk and multiple low‐risk features are at low risk for AAD. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Relatively little is known about outcomes after disposition among syncope patients assigned various diagnostic categories during emergency department (ED) evaluation. We sought to measure the outcomes among these groups within 30 days of the initial ED visit. Methods: We prospectively enrolled adult syncope patients at six EDs and excluded patients with presyncope, persistent mental status changes, intoxication, seizure, and major trauma. Patient characteristics, ED management, diagnostic impression (presumed vasovagal, orthostatic, cardiac, or other/unknown) at the end of the ED visit, and physicians’ confidence in assigning the etiology were collected. Serious outcomes at 30 days included death, arrhythmia, myocardial infarction, structural heart disease, pulmonary embolism, and hemorrhage. Results: A total of 5,010 patients (mean ± SD age = 53.4 ± 23.0 years; 54.8% females) were enrolled; 3.5% suffered serious outcomes—deaths (0.3%), arrhythmias (1.8%), nonarrhythmic cardiac (0.5%), and noncardiac (0.9%) including pulmonary embolism (0.2%). The cause of syncope was presumed as vasovagal among 53.3% and cardiac in 5.4% of patients. The proportion of patients with ED investigations (p < 0.001) and short‐term serious outcomes (p < 0.01) increased in each diagnostic category in the following order: presumed vasovagal, orthostatic hypotension, other/unknown cause, and cardiac. No deaths occurred in patients with presumed vasovagal syncope. A higher proportion of all serious outcomes occurred among patients suspected of cardiac syncope in the ED (p < 0.01). Confidence was highest among physicians for a presumed vasovagal syncope diagnosis and lowest when the cause was other/unknown. Conclusion: Short‐term serious outcomes strongly correlated with the etiology assigned in the ED visit. The importance of the physician's clinical judgment should be further studied to determine if it should become incorporated in risk‐stratification tools for prognostication and safe management of ED syncope patients. [ABSTRACT FROM AUTHOR]

Background Patient-centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient-centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient-centred care, conceptualize what they are implementing. Objective To examine how hospital employees conceptualize patient-centred care. Research Design We conducted qualitative interviews about patient-centred care during site four visits, from January to April 2013. Subjects We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration ( VHA) medical centres leading VHA's patient-centred care transformation. Measures Data were analysed using grounded thematic analysis. Findings were then mapped to established patient-centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient-as-person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor-as-person. Results We identified three distinct conceptualizations: (i) those that were well aligned with established patient-centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient-centred care into the organizational culture, encompassing the entire patient-experience; and (iii) still others that were poorly aligned with patient-centred care constructs, reflecting more traditional patient care practices. Conclusions Patient-centred care ideals have permeated into healthcare systems. Additionally, patient-centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient-centred care so broadly, it encompasses on-going hospital initiatives, while others consider patient-centred care as inherent to specific positions. These latter conceptualizations risk undermining patient-centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes. [ABSTRACT FROM AUTHOR]

Background and aims Prescription opioid overdose is a leading cause of injury-related morbidity and mortality in the United States. We aimed to identify characteristics associated with clinical severity in emergency department patients with prescription opioid overdose. Design This was a secondary data analysis of adult prescription opioid overdoses from a large prospective cohort of acute overdoses. We examined elements of a typical emergency department evaluation using a multivariable model to determine which characteristics were associated with clinical severity, specifically severe respiratory depression (SRD). Setting This study was conducted at two urban academic emergency departments in New York City, USA. Participants Adult patients who presented with acute prescription opioid overdose between 2009 and 2013 were included in the current study. We analyzed 307 patients (mean age = 44.7, 42% female, 2.0% mortality). Measurements Patient demographics, reported substances ingested, suspected intent for ingesting the substance, vital signs, laboratory data, treatments including antidotes and intubation and outcome of death were recorded by trained research assistants. Intent was categorized into four mutually exclusive categories: suicide, misuse, therapeutic error and undetermined. The primary outcome was SRD, defined as administration of either (a) naloxone or (b) endotracheal intubation (ETI). Findings A total of 109 patients suffered SRD with 90 patients receiving naloxone alone, nine ETI alone and 10 both naloxone and ETI. The most common opioids were oxycodone ( n = 124) and methadone ( n = 116). Mean age was higher in patients with SRD (51.1 versus 41.1, P < 0.001). Opioid misuse was associated with SRD in the multivariable analysis [odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.21-3.55]. The unadjusted relative risk of SRD was high for fentanyl (83.3% SRD) and lowest for codeine (3.6% SRD). Conclusion In emergency department patients in the United States with prescription opioid overdose, worse clinical severity was associated with opioid misuse, increased with age and was widely variable, depending on the specific opioid medication involved. [ABSTRACT FROM AUTHOR]

ABSTRACT BACKGROUND We examined the relationship between exposure to electronic bullying and absenteeism as a result of being afraid. METHODS This multivariate, multinomial regression analysis of the 2013 Youth Risk Behavior Survey data assessed the association between experiencing electronic bullying in the past year and how often students were absent in the last month due to feeling unsafe at/in transit to school. The model controlled for other predictors of school absence including demographics, physical/behavioral health, and risk factors. Missing data were multiply imputed. RESULTS Electronic bullying was significantly associated with absences. Controlling for model covariates, the relative risk of missing 1 day of school was 1.77 times higher, the relative risk of missing 2 to 3 days of school per month increased by a factor of 2.08, and the relative risk of missing 4 or more days of school per month increased by a factor of 1.77 for those who experienced electronic bullying in the past year compared with those who were not electronically bullied. CONCLUSIONS Electronic bullying's association with absenteeism places it among already recognized negative influences such as depression and binge drinking, necessitating schools to implement policies to mediate the resulting harmful effects. [ABSTRACT FROM AUTHOR]

Aims Screening and brief intervention for harmful substance use in medical settings is being promoted heavily in the United States. To justify service provision fiscally, the field needs accurate estimates of the number and type of staff required to provide services, and thus the time taken to perform activities used to deliver services. This study analyzed the time spent in activities for the component services of the substance misuse Screening, Brief Intervention and Referral to Treatment (SBIRT) program implemented in emergency departments, in-patient units and ambulatory clinics. Design Observers timed activities according to 18 distinct codes among SBIRT practitioners. Setting Twenty-six US sites within four grantees. Participants Five hundred and one practitioner-patient interactions; 63 SBIRT practitioners. Measurements Timing of practitioner activities. Interventions Delivery of component services of SBIRT. Findings The mean (standard error) time to deliver services was 1:19 (0:06) for a pre-screen ( n = 210), 4:28 (0:24) for a screen ( n = 97) and 6:51 (0:38) for a brief intervention ( n = 66). Estimates of service duration varied by setting. Overall, practitioners spent 40% of their time supporting SBIRT delivery to patients and 13% of their time delivering services. Conclusions In the United States, support activities (e.g. reviewing the patient's chart, locating the patient, writing case-notes) for substance abuse Screening, Brief Intervention and Referral to Treatment require more staff time than delivery of services. Support time for screens and brief interventions in the emergency department/trauma setting was high compared with the out-patient setting. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the associations between a broad array of cardiorespiratory and noncardiorespiratory impairments and dyspnea in older persons. Design Cross-sectional. Setting Cardiovascular Health Study. Participants Community-dwelling persons (N = 4,413; mean age 72.6, 57.1% female, 4.5% African American, 27.2% 1)), maximal inspiratory pressure (respiratory muscle strength), echocardiography, ankle-brachial index, blood pressure, whole-body muscle mass (bioelectrical impedance), single chair stand (lower extremity function), grip strength, serum hemoglobin and creatinine, Center for Epidemiologic Studies Depression Scale ( CES-D), Mini-Mental State Examination, medication use, and body mass index ( BMI). Results In a multivariable logistic regression model, impairments that had strong associations with moderate to severe dyspnea were FEV1 less than the lower limit of normal (adjusted odds ratio ( aOR) = 2.88, 95% confidence interval ( CI) = 2.37-3.49), left ventricular ejection fraction less than 45% ( aOR = 2.12, 95% CI = 1.43, 3.16), unable to perform a single chair stand ( aOR = 2.10, 95% CI = 1.61-2.73), depressive symptoms ( CES-D score ≥16; aOR = 2.02, 95% CI = 1.26-3.23), and obesity ( BMI ≥30; aOR = 2.07, 95% CI = 1.67-2.55). Impairments with modest but still statistically significant associations with moderate to severe dyspnea included respiratory muscle weakness, diastolic cardiac dysfunction, grip weakness, anxiety symptoms, and use of cardiovascular and psychoactive medications ( aORs = 1.31-1.71). Conclusion In community-dwelling older persons, several cardiorespiratory and noncardiorespiratory impairments were significantly associated with moderate to severe dyspnea, akin to a multifactorial geriatric health condition. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Project Connect Health Systems Intervention (Project Connect) uses a systematic process of collecting community and healthcare infrastructure information to craft a referral guide highlighting local healthcare providers who provide high quality sexual and reproductive healthcare. Previous self-report data on healthcare usage indicated Project Connect was successful with sexually experienced female youth, where it increased rates of human immunodeficiency virus (HIV) and sexually transmitted disease (STD) testing and receipt of contraception. This adaption of Project Connect examined its effectiveness in a new context and via collection of clinic encounter-level data. METHODS: Project Connect was implemented in 3 high schools. (only 2 schools remained open throughout the entire project period). Participant recruitment and data collection occurred in 5 of 8 participating health clinics. Students completed Youth Surveys (N=608) and a Clinic Survey (paired with medical data abstraction in 2 clinics [N=305]). RESULTS: Students were more likely than nonstudents to report having reached a clinic via Project Connect. Nearly 40% of students attended a Project Connect school, with 32.7% using Project Connect to reach the clinic. Students were most likely to have been referred by a school nurse or coach. CONCLUSIONS: Project Connect is a low-cost, sustainable structural intervention with multiple applications within schools, either as a standalone intervention or in combination with ongoing efforts. [ABSTRACT FROM AUTHOR]

In this article we use a stated choice experiment to study researcher preferences in the information sciences and to investigate the relative importance of different journal characteristics in convincing potential authors to submit to a particular journal. The analysis distinguishes high quality from standard quality articles and focuses on the question whether communicating acceptance rates rather than rejection rates leads to other submission decisions. Our results show that a positive framing effect might be present when authors decide on submitting a high quality article. No evidence of a framing effect is found when authors consider a standard quality article. From a journal marketing perspective, this is important information for editors. Communicating acceptance rates rather than rejection rates might help to convince researchers to submit to their journal. [ABSTRACT FROM AUTHOR]

Background There is a critical need to document the mental health effects of immigration policies and practices on children vulnerable to parental deportation. Few studies capture the differential experiences produced by U.S. citizen-children's encounters with immigration enforcement, much less in ways that analyse mental health outcomes alongside the psychosocial contexts within which those outcomes arise. Methods We explore the psychosocial dimensions of depression in U.S. citizen-children with undocumented Mexican parents to examine differences between citizen-children affected and not affected by parental deportation. An exploratory mixed-method design was used to integrate a quantitative measure of depression symptoms (CDI-2) within qualitative data collected with 48 citizen-children aged 8 to 15 with and without experiences of parental deportation. Results Stressors elicited by citizen-children in the qualitative interview included an inability to communicate with friends, negative perceptions of Mexico, financial struggles, loss of supportive school networks, stressed relation with parent(s) and violence. Fifty percent of citizen-children with probable depression - regardless of experiences with parental deportation - cited 'stressed relation with parents,' compared to 9% without depression. In contrast, themes of 'loss of supportive school network' and 'violence' were mentioned almost exclusively by citizen-children with probable depression and affected by parental deportation. Conclusions While citizen-children who suffer parental deportation experience the most severe consequences associated with immigration enforcement, our findings also suggest that the burden of mental health issues extends to those children concomitantly affected by immigration enforcement policies that target their undocumented parents. [ABSTRACT FROM AUTHOR]

Background Reducing the nicotine content in cigarettes could improve public health by reducing smoking and toxicant exposure, but may also have unintended consequences on alcohol use. The primary objective of this study was to examine the effect of reducing the nicotine content in cigarettes on alcohol outcomes. The secondary aim was to examine whether the effects of these cigarettes on alcohol outcomes were mediated by changes in nicotine exposure, smoking behavior, or withdrawal. Methods Between June 2013 and July 2014, we conducted a 7-arm, double-blind, randomized clinical trial at 10 U. S.-based sites. Daily smokers not currently interested in quitting ( n = 839) were assigned to equally sized groups to smoke for 6 weeks cigarettes containing either normal nicotine content ( NNC; 15.8 mg/g, 9 mg tar), moderate nicotine content (5.2 mg/g nicotine, 9 mg tar), or very low nicotine content ( VLNC; 0.4 to 2.4 mg/g, 9 to 13 mg tar). This investigation focused on a subsample of current drinkers ( n = 403). Each reduced nicotine content cigarette condition was compared to the NNC control condition with respect to trajectories over the 6-week period of average daily alcohol use and occurrence of binge drinking. Moderating variables were considered. Mediation analyses tested potential explanatory processes including changes in nicotine exposure, cigarettes per day, and withdrawal. Results Over time, reduced nicotine exposure and smoking rate mediated effects of VLNC cigarette use on reduced alcohol use. There was no evidence of compensatory drinking in response to nicotine reduction or nicotine withdrawal, even among subgroups expected to be at greater risk (e.g., relatively heavier drinkers, highly nicotine-dependent individuals). Conclusions The findings suggest that compensatory drinking is unlikely to occur in response to switching to VLNC cigarettes. In contrast, reducing the nicotine content of cigarettes may reduce alcohol use (clinicalTrials.gov number, NCT01681875). [ABSTRACT FROM AUTHOR]

Objectives The purpose of this multicentre study was to determine the incidence of oral candidiasis in patients treated with topical steroids for oral lichen planus (OLP) and to determine whether the application of a concurrent antifungal therapy prevented the development of an oral candidiasis in these patients. Materials and Methods Records of 315 patients with OLP seen at four Oral Medicine practices treated for at least 2 weeks with steroids with and without the use of an antifungal regimen were retrospectively reviewed. Results The overall incidence of oral fungal infection in those treated with steroid therapy for OLP was 13.6%. There was no statistically significant difference in the rate of oral candidiasis development in those treated with an antifungal regimen vs those not treated prophylactically (14.3% vs 12.6%) ( P = 0.68). Conclusions Despite the use of various regimens, none of the preventive antifungal strategies used in this study resulted in a significant difference in the rate of development of an oral candidiasis in patients with OLP treated with steroids. [ABSTRACT FROM AUTHOR]

Chronic nonhealing wounds have a prevalence of 2% in the United States, and cost an estimated $50 billion annually. Accurate stratification of wounds for risk of slow healing may help guide treatment and referral decisions. We have applied modern machine learning methods and feature engineering to develop a predictive model for delayed wound healing that uses information collected during routine care in outpatient wound care centers. Patient and wound data was collected at 68 outpatient wound care centers operated by Healogics Inc. in 26 states between 2009 and 2013. The dataset included basic demographic information on 59,953 patients, as well as both quantitative and categorical information on 180,696 wounds. Wounds were split into training and test sets by randomly assigning patients to training and test sets. Wounds were considered delayed with respect to healing time if they took more than 15 weeks to heal after presentation at a wound care center. Eleven percent of wounds in this dataset met this criterion. Prognostic models were developed on training data available in the first week of care to predict delayed healing wounds. A held out subset of the training set was used for model selection, and the final model was evaluated on the test set to evaluate discriminative power and calibration. The model achieved an area under the curve of 0.842 (95% confidence interval 0.834-0.847) for the delayed healing outcome and a Brier reliability score of 0.00018. Early, accurate prediction of delayed healing wounds can improve patient care by allowing clinicians to increase the aggressiveness of intervention in patients most at risk. [ABSTRACT FROM AUTHOR]

Objectives To examine facility-level pressure ulcer (PrU) development rates and variations in these rates after a system-wide adoption of culture change in Veterans Health Administration (VHA) nursing homes. Design Four-year retrospective longitudinal design. Setting VHA facilities (N = 109) representing 132 nursing homes known as community living centers (CLCs). Participants VHA nursing home residents. Measurements PrUs were identified using fiscal year (FY) 2008-11 Minimum Data Set (MDS) data. PrU development was defined as a Stage 2 or larger PrU on an MDS assessment with no PrU on the previous assessment. A risk adjustment model was developed using 105,274 MDS observations to predict the likelihood of PrUs (c-statistic = 0.72). A Bayesian hierarchical model that adjusted for differences in the precision of PrU rates from different-size facilities was used to calculate smoothed risk-adjusted (SRA) rates for each facility. The statistical significance of the trend over the 4 years was determined by examining the 95% interval estimate for the slope. Results Over the 4-year period, the beginning of which coincided with the VHA's system-wide adoption of culture change as a performance measure, median SRA facility PrU development rates were fairly consistent at approximately 4%. The range in SRA rates declined over the years, from a 14.8-percentage point spread to 10.1-percentage point spread. Some facilities had significantly improving SRA rates (e.g., declined steadily from 5.5% to 3.9%) and some had significantly worsening SRA rates (e.g., increased steadily from 5.1% to 7.9%). Seven sites had significantly improving rates ( P < .001) that were below the median across all 4 years. Conclusion A system-wide culture change implementation did not affect CLC PrU development rates, but there was significant variation in facility rates, and some facilities had sustained high performance. [ABSTRACT FROM AUTHOR]

Objectives To quantify the prognostic importance of prefrailty and frailty in a population-based sample of cancer survivors. Design The Third National Health and Nutrition Examination Survey mortality-linked prospective cohort study. Setting Eighty-nine survey locations across the United States. Participants Population-based sample of older adults (average age 72.2) with a self-reported diagnosis of non-skin-related cancer (N = 416). Measurements The primary outcome was all-cause mortality. Frailty components included low weight for height, slow walking, weakness, exhaustion, and low physical activity. Participants with none of the five criteria were classified as nonfrail, those with one or two as prefrail, and those with three or more as frail. Results The prevalence of prefrailty was 37.3% and of frailty was 9.1%. During a median follow-up of 11.2 years, 319 (76.7%) participants died. Median survival was 13.9 years for participants classified as nonfrail, 9.5 years for those classified as prefrail, and 2.5 years for those classified as frail. Cancer survivors classified as prefrail (hazard ratio (HR) = 1.84, 95% confidence interval (CI) = 1.28-2.65, P = .001) or frail (HR = 2.79, 95% CI = 1.34-5.81, P = .006) had a higher risk of premature mortality than those classified as nonfrail. Conclusion Prefrailty and frailty are prevalent clinical syndromes that may confer greater risk of premature mortality in older adult cancer survivors. Identifying frail cancer survivors and targeting interventions for them may be a strategy to improve survival after cancer. [ABSTRACT FROM AUTHOR]

The neonatal intensive care unit (NICU) is a setting with high nurse-to-patient ratios. Little is known about the factors that determine nurse workload and assignment. The goals of this study were to (1) develop a measure of NICU infant acuity; (2) describe the acuity distribution of NICU infants; (3) describe the nurse/infant ratio at each acuity level, and examine the factors other than acuity, including nurse qualifications and the availability of physicians and other providers, that determined staffing ratios; and (4) explore whether nurse qualifications were related to the acuity of assigned infants. In a two-stage cohort study, data were collected in 104 NICUs in 2008 by nurse survey (6,038 nurses and 15,191 infants assigned to them) and administrators reported on unit-level staffing of non-nurse providers; in a subset of 70 NICUs in 2009-2010, census data were collected on four selected shifts (3,871 nurses and 9,276 infants assigned to them). Most NICU infants (62%) were low-acuity (Levels 1 and 2); 12% of infants were high-acuity (Levels 4 and 5). The nurse-to-infant ratio ranged from 0.33 for the lowest-acuity infants to 0.95 for the highest-acuity infants. The staffing ratio was significantly related to the acuity of assigned infants but not to nurse education, experience, certification, or availability of other providers. There was a significant but small difference in the percentage of high-acuity (Levels 4 and 5) infants assigned to nurses with specialty certification (15% vs. 12% for nurses without certification). These staffing patterns may not optimize patient outcomes in this highly intensive pediatric care setting. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Although pica, the craving and purposive consumption of non‐food substances, is common among many populations, especially during pregnancy, the health consequences are not well understood. Further, very little is known about pica among Mexican populations in the United States and Mexico. Therefore, we conducted formative research to understand pica in this understudied population. Our objectives were to identify the frequency and types of pica behaviours, to understand perceived aetiologies and consequences of pica and to ascertain if the behaviour was common enough to warrant a larger study. We held nine focus group discussions (three in the Salinas Valley, California; six in Xoxocotla, Morelos, Mexico) with 76 Mexican‐born women who were currently pregnant or had delivered within the past 2 years. Earth, adobe, bean stones and ice were the most commonly reported pica substances. Twenty‐eight of the 76 participants (37%) reported ever engaging in pica; 22 participants (29%) reported doing so during pregnancy. The proportion of women reporting pica in the United States and Mexico was 43% and 34%, respectively. Women attributed pica to the overwhelming organoleptic appeal of pica substances (especially smell and texture) and to micronutrient deficiencies. Perceived consequences of unfulfilled pica cravings were birthmarks or fetal loss; fulfilled pica cravings were also thought to be generally harmful to the mother or child, with several women specifying toxic lead, pesticides or ‘worms’. In sum, pica among Mexican women is common enough to warrant a larger epidemiologic study of its sociodemographic correlates and physiological consequences. [ABSTRACT FROM AUTHOR]

Background Parenting stress has been consistently reported among parents of children with developmental disabilities. However, to date, no studies have investigated the impact of a molecular subtype of Angelman syndrome ( AS) on parent stress, despite distinct phenotypic differences among subtypes. Method Data for 124 families of children with three subtypes of AS: class I and II deletions ( n = 99), imprinting centre defects ( IC defects; n = 11) and paternal uniparental disomy ( UPD; n = 14) were drawn from the AS Rare Diseases Clinical Research Network ( RDCRN) database and collected from five research sites across the Unites States. The AS study at the RDCRN gathered health information to understand how the syndrome develops and how to treat it. Parents completed questionnaires on their perceived psychological stress, the severity of children's aberrant behaviour and children's sleep patterns. Children's adaptive functioning and developmental levels were clinically evaluated. Results Child-related stress reached clinical levels for 40% of parents of children with deletions, 100% for IC defects and 64.3% for UPD. Sleep difficulties were similar and elevated across subtypes. There were no differences between molecular subtypes for overall child and parent-related stress. However, results showed greater isolation and lack of perceived parenting skills for parents of children with UPD compared with deletions. Better overall cognition for children with deletions was significantly related to more child-related stress while their poorer adaptive functioning was associated with more child-related stress. For all three groups, the severity of children's inappropriate behaviour was positively related to different aspects of stress. Conclusions How parents react to stress depends, in part, on children's AS molecular subtype. Despite falling under the larger umbrella term of AS, it is important to acknowledge the unique aspects associated with children's molecular subtype. Identifying these factors can lead to tailored interventions that fit the particular needs of families of children with different AS subtypes. [ABSTRACT FROM AUTHOR]

Objectives To compare risk-adjusted differences between men and women 30 and 60 days after hip fracture surgery in not walking, ability to return home in a community-dwelling subset, not walking in a nursing home resident subset, and mortality within 60 days. Design Cohort study. Setting Data were from a randomized clinical trial that compared two blood transfusion protocols after hip fracture. Participants Individuals with hip fracture (N = 2,016; 489 (24%) male). Measurements Walking, dwelling, and mortality were determined in telephone follow-up 30 and 60 days after randomization, which occurred within 3 days of surgery. Sex differences for each outcome were compared using univariate and multivariate regression adjusting for potential confounders. Results Men were younger ( P < .001) and more likely to have comorbidity ( P = .003) than women at the time of hip fracture and to die within 60 days, even after risk adjustment (odds ratio ( OR) = 1.76, 95% confidence interval ( CI) = 1.15-2.69). After risk adjustment, male survivors were as likely as female survivors not to walk ( OR = 1.03, 95% CI = 0.78-1.34) and no less likely to return home ( OR = 0.90, 95% CI = 0.69-1.17) 60 days after hip fracture. No differences were noted between male and female nursing home residents in not walking within 60 days ( OR = 0.95, 95% CI = 0.32-2.86). Conclusion Although men experience higher mortality, male survivors can expect recovery of walking ability similar to that of female survivors and are as likely to return to community living. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between performance on a single chair stand and moderate to severe exertional dyspnea. Design Cross-sectional. Setting Cardiovascular Health Study. Participants Community-dwelling individuals aged 65 and older (N = 4,413; mean age 72.6; female, n = 2,518 (57.1%); nonwhite, n = 199 (4.5%); obese, n = 788 (17.9%); history of smoking, n = 2,410 (54.6%)). Measurements Performance on single chair stand (poor (unable to rise without arm use) vs normal (able to rise without arm use)), moderate to severe exertional dyspnea (American Thoracic Society grade ≥2), age, sex, ethnicity, obesity, smoking, frailty status (Fried-defined nonfrail, prefrail, frail), high cardiopulmonary risk (composite of cardiopulmonary diseases and diabetes mellitus), spirometric impairment, arthritis, depression, stroke, and kidney disease. Results Poor performance on the single chair stand was established in 369 (8.4%) and moderate to severe exertional dyspnea in 773 (17.5%). Prefrail status was established in 2,210 (50.1%), frail status in 360 (8.2%), arthritis in 2,241 (51.4%), high cardiopulmonary risk in 2,469 (55.9%), spirometric impairment in 1,076 (24.4%), kidney disease in 111 (2.5%), depression in 107 (2.4%), and stroke in 93 (2.1%). In multivariable regression models, poor performance on the single chair stand was associated with moderate to severe exertional dyspnea (unadjusted odds ratio ( OR) = 3.48, 95% confidence interval ( CI) = 2.78-4.36; adjusted OR = 1.85, 95% CI = 1.41-2.41). Conclusion Poor performance on a single chair stand was associated with an adjusted 85% greater likelihood of moderate to severe exertional dyspnea than normal performance. These results suggest that reduced proximal muscle function of the lower extremities is associated with moderate to severe exertional dyspnea, even after adjusting for multiple confounders. [ABSTRACT FROM AUTHOR]

Objectives To compare the effectiveness of chemotherapy in prolonging survival according to age in breast and colon cancer. Design Retrospective cohort study with a matched cohort analysis based on the conditional probability of receiving chemotherapy. Setting The 16 Surveillance, Epidemiology, and End Results ( SEER) areas from the SEER- Medicare linked database. Participants Women diagnosed with Stage I to IIIa hormone receptor-negative breast cancer (n = 14,440) and 26,893 men and women with Stage III colon cancer (n = 26,893) aged 65 and older in 1992 to 2009. Measurements The main exposure was the receipt of chemotherapy, and the main outcome was mortality. Results In women with breast cancer aged 65 to 69, the risk of all-cause mortality was statistically significantly lower in those who received chemotherapy than in those who did not in the entire cohort (hazard ratio ( HR) = 0.70, 95% confidence interval ( CI) = 0.57-0.88) and in a propensity-matched cohort ( HR = 0.82, 95% CI = 0.70-0.96) after adjusting for measured confounders. These patterns were similar in participants aged 70 to 74 and 75 to 79, but in women aged 80 to 84 and 85 to 89, risk of all-cause mortality was no longer significantly lower in those receiving chemotherapy in the entire and matched cohorts, except that, in a small number of women who received doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan), risk of mortality was significantly lower for those aged 80 to 84. Chemotherapy appeared to be effective in all ages from 65 through 84 in participants with Stage III colon cancer. For example, in those aged 85 to 89, chemotherapy was significantly associated with lower risk of mortality in the entire cohort ( HR = 0.79, 95% CI = 0.67-0.92) and the matched cohort ( HR = 0.79, 95% CI = 0.66-0.95). Conclusion The effectiveness of chemotherapy decreased with age in participants with breast cancer, in whom chemotherapy appears to be effective until age 79 except for the doxorubicin-cyclophosphamide combination, which was effective in participants aged 80 to 84. In individuals with Stage III colon cancer, chemotherapy appears to be effective to age 89. These findings were consistent with those of randomized clinical trials. [ABSTRACT FROM AUTHOR]

MRI Assessment of Ablation-Induced Scarring in Atrial Fibrillation Background There is limited knowledge on the extent and location of scarring that results from catheter ablation and its role in suppressing atrial fibrillation (AF). We examined the effect of atrial fibrosis and ablation-induced scarring on catheter ablation outcomes in AF. Methods We conducted a prospective multicenter study that enrolled 329 AF patients presenting for catheter ablation. Delayed enhancement magnetic resonance imaging (DE-MRI) of the left atrium was obtained preablation. Scarring was evaluated in 177 patients with a DE-MRI scan obtained 90 days postablation. We evaluated residual fibrosis, defined as preablation atrial fibrosis not covered by ablation scar. The primary outcome was freedom from recurrent atrial arrhythmia. Results In the analysis cohort of 177 patients, preablation fibrosis was 18.7 ± 8.7% of the atrial wall. Ablation aimed at pulmonary vein (PV) isolation was performed in 163 patients (92.1%). Ablation-induced scar averaged 10.6 ± 4.4% of the atrial wall. Scarring completely encircled all 4 PVs only in 12 patients (7.3%). Residual fibrosis was calculated at 15.8 ± 8.0%. At 325 days follow-up, 35% of patients experienced recurrent arrhythmia. Multivariable Cox proportional hazards models demonstrated that baseline atrial fibrosis (HR and 95% CIs) (1.09 [1.06-1.12], P < 0.001) and residual fibrosis (1.09 [1.05-1.13], P < 0.001) were associated with atrial arrhythmia recurrence, while PV encirclement and overall scar were not. Conclusions Catheter ablation of AF targeting PVs rarely achieves permanent encircling scar in the intended areas. Overall atrial fibrosis present at baseline and residual fibrosis uncovered by ablation scar are associated with recurrent arrhythmia. [ABSTRACT FROM AUTHOR]

Objectives To determine the proportion of variation in long-term fall rates attributable to variability between rather than within hospital units and to identify unit- and hospital-level characteristics associated with persistently low- and high-fall units. Design Retrospective study of administrative data on inpatient falls. Eighty low-fall and 74 high-fall units were identified based on monthly rankings of fall rates. Unit- and hospital-level characteristics of these units were compared. Setting U.S. general hospitals participating in the National Database of Nursing Quality Indicators. Participants Nonsubspecialty medical units (n = 800) with 24 consecutive months of falls data. Measurements Monthly self-reported unit fall rates (falls per 1,000 patient-days). Results An estimated 87% of variation in 24-month fall rates was due to between-unit differences. With the exception of patient-days, a proxy for unit bed size, low- and high-fall units did not differ on nurse staffing or any other unit or hospital characteristic variable. Conclusion There are medical units with persistently low and persistently high fall rates. High-fall units had higher patient volume, suggesting patient turnover as a variable for further study. Understanding additional factors underlying variability in long-term fall rates could lead to sustainable interventions for reducing inpatient falls. [ABSTRACT FROM AUTHOR]

The purpose of the study was to examine the effects of participation in the Living Legends program upon health science students' image of older adults and interest in working with older people. A multisite quasi-experimental control group design with a connected qualitative component was used. Program sites included three Naturally Occurring Retirement Communities (NORCs) and one senior center. Health science students (n = 43) from two universities and two community colleges and community-dwelling seniors (n = 39) participated in the program. A baseline questionnaire was used to ascertain demographic characteristics and prior type and amount of contact with older adults. The Image of Aging Scale and Likert-style questions to measure interest in working with older adults were the primary outcome measures. Written responses to program experiences were also collected. Analysis of covariance was used to compare changes in Image of Aging subscale scores from pre- to posttest. Mean change in positive image of older adults subscale scores was 4.6 (SD = 4.4) for the intervention group and −0.6 (SD = 4.8) for the control group. The difference between groups was significant (F = 22.0, P < .001), and the effect size was large (Cohen's d = 1.07). Nine of the 22 students in the intervention group had a greater interest in working with seniors after the program. Qualitative themes that emerged included a positive and beneficial experience, life lessons, seeing the person beyond the visible, power of the written word, and shared lives. Living Legends is an effective program to enhance positive images of older adults in future healthcare professionals and may have a positive impact on some students with regard to interest in working with older adults. [ABSTRACT FROM AUTHOR]

Objectives To determine life expectancy for older women with breast cancer. Design Prospective longitudinal study with 10 years of follow-up data. Setting Hospitals or collaborating tumor registries in four geographic regions (Los Angeles, California; Minnesota; North Carolina; Rhode Island). Participants Women aged 65 and older at time of breast cancer diagnosis with Stage I to IIIA disease with measures of self-rated health ( SRH) and walking ability at baseline (N = 615; 17% aged ≥80, 52% Stage I, 58% with ≥2 comorbidities). Measurements Baseline SRH, baseline self-reported walking ability, all-cause and breast cancer-specific estimated probability of 5- and 10-year survival. Results At the time of breast cancer diagnosis, 39% of women reported poor SRH, and 28% reported limited ability to walk several blocks. The all-cause survival curves appear to separate after approximately 3 years, and the difference in survival probability between those with low SRH and limited walking ability and those with high SRH and no walking ability limitation was significant (0.708 vs 0.855 at 5 years, P ≤ .001; 0.300 vs 0.648 at 10 years, P < .001). There were no differences between the groups in breast cancer-specific survival at 5 and 10 years ( P = .66 at 5 years, P = .16 at 10 years). Conclusion The combination of low SRH and limited ability to walk several blocks at diagnosis is an important predictor of worse all-cause survival at 5 and 10 years. These self-report measures easily assessed in clinical practice may be an effective strategy to improve treatment decision-making in older adults with cancer. [ABSTRACT FROM AUTHOR]

Objectives To determine whether sleep-disordered breathing ( SDB), a group of disorders common in older adults characterized by breathing pauses during sleep often accompanied by hypoxemia, is associated with cognitive decline. Design Population-based longitudinal study. Setting Six centers in the United States. Participants Community-dwelling older men (N = 2,636; aged 76.0 ± 5.3) without probable mild cognitive impairment or dementia followed for 3.4 ± 0.5 years. Measurements SDB was measured using in-home polysomnography: nocturnal hypoxemia (≥1% of sleep time with oxygen saturation (SaO2) <90%, oxygen desaturation index ( ODI: number of oxygen desaturations of ≥3% per hour of sleep)) and apnea-hypopnea index ( AHI, number of apneas and hypopneas at ≥3% desaturation per hour of sleep). Cognitive decline was measured using the Modified Mini-Mental State Examination (3 MS) and the Trail-Making Test Part B (Trails B) at baseline and two follow-up points. Associations between predictors and cognitive decline were examined using linear mixed models adjusted for multiple confounders. Models were further adjusted for potential mediators (sleep duration, sleep fragmentation, resting SaO2). Results Nocturnal hypoxemia was related to greater decline on the 3 MS. Men with 1% or more of sleep time with SaO2 less than 90% had an adjusted annualized decline of 0.43 points, compared with 0.25 for men in the reference group ( P = .003). For each 5-point increase in ODI, there was an average annualized decline of 0.36 points ( P = .01). Results were robust to further adjustment for potential mediators. The association between AHI and cognitive decline did not reach significance. No associations were seen with SDB and decline on the Trails B. Conclusion In older community-dwelling men, there was a modest association between nocturnal hypoxemia and global cognitive decline, suggesting the importance of overnight oxygenation for cognitive function. [ABSTRACT FROM AUTHOR]

Background There is little information about pregnancy-related changes in alcohol use and factors contributing to changes among women with unwanted pregnancies. This study describes changes in alcohol use from before pregnancy recognition to during pregnancy and identifies important predictors of alcohol use severity among women with unwanted pregnancies. Methods Data are from the Turnaway Study of 956 women seeking pregnancy termination at 30 U.S. facilities between 2008 and 2010, some of whom were denied care because they were past the gestational limit of the facility where they were recruited and were still pregnant at the baseline interview, 1 week after termination seeking. Predictors of alcohol use severity (a latent variable) were identified. Results About 56% of the total sample reported any alcohol use the month before pregnancy recognition, with 23% reporting 6 or more drinks on an occasion. Among the total sample, 35% of those drinking before pregnancy recognition had quit and 20% had reduced 1 week after termination seeking. Among those denied terminations and still pregnant, 71% had quit and 14% had reduced. In a multivariate model predicting alcohol severity, younger age, still pregnant, 1 or more previous births, later gestation, childhood physical abuse, and marijuana and other drug use were associated with lower severity; having completed college, tobacco use, and recent physical violence were associated with higher severity. Conclusions The proportion of the total sample drinking before pregnancy recognition is similar to national samples of women of childbearing age, while the proportion binge drinking appears higher. Of women denied terminations, who were still pregnant, the proportion having quit is similar to other populations of pregnant women. More research is needed to examine whether pregnant women may be substituting alcohol for marijuana and other drugs. Interventions focusing on alcohol use severity during pregnancy may need to also focus on tobacco. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between cognition and levels of cystatin C in persons with chronic kidney disease ( CKD). Design Prospective observational study. Setting Chronic Renal Insufficiency Cohort Cognitive Study. Participants Individuals with a baseline cognitive assessment completed at the same visit as serum cystatin C measurement (N = 821; mean age 64.9, 50.6% male, 48.6% white). Measurements Levels of serum cystatin C were categorized into tertiles; cognitive function was assessed using six neuropsychological tests. Scores on these tests were compared across tertiles of cystatin C using linear regression and logistic regression to examine the association between cystatin C level and cognitive performance (1 standard deviation difference from the mean). Results After multivariable adjustment for age, race, education, and medical comorbidities in linear models, higher levels of cystatin C were associated with worse cognition on the modified Mini-Mental State Examination, Buschke Delayed Recall, Trail-Making Test Part (Trails) A and Part B, and Boston Naming ( P < .05 for all). This association remained statistically significant for Buschke Delayed Recall ( P = .01) and Trails A ( P = .03) after additional adjustment for estimated glomerular filtration rate (e GFR). The highest tertile of cystatin C was associated with greater likelihood of poor performance on Trails A (odds ratio ( OR) = 2.17, 95% confidence interval ( CI) = 1.16-4.06), Trails B ( OR = 1.89, 95% CI = 1.09-3.27), and Boston Naming ( OR = 1.85, 95% CI = 1.07-3.19) than the lowest tertile after multivariate adjustment in logistic models. Conclusion In individuals with CKD, higher serum cystatin C levels were associated with worse cognition and greater likelihood of poor cognitive performance on attention, executive function, and naming. Cystatin C is a marker of cognitive impairment and may be associated with cognition independent of e GFR. [ABSTRACT FROM AUTHOR]