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Postoperative communication errors contribute to patient harm and excess costs. There are no existing standards for postoperative handoff to the acute care inpatient unit. We aimed to compare the experiences and preferences of pediatric hospitalists and surgeons about the content and timing of this handoff.We conducted a cross-sectional multisite survey of pediatric hospitalists and surgeons at 4 hospitals using a novel survey tool developed through a systematic 7-step process. We collected data on the perceived frequency of communication for 37 handoff elements and how essential each element was for an ideal handoff. We used 5-point Likert scales of communication frequency and essentialness. Respondents identified perceived and preferred handoff timing. Mention frequency and timing data were analyzed with the Mann-Whitney U test and Fisher’s exact test, respectively.Seventy hospitalists (61%) and 27 surgeons (25%) responded to the survey. Over half of both hospitalist and surgeon respondents rated 13 handoff elements a 5 on the essentialness Likert scale. Surgeons perceived that 33 handoff elements were mentioned significantly more frequently than perceived by hospitalists (P < .05). Of hospitalists, 58% preferred that handoff occur immediately before the patient leaves the postanesthesia care unit. Of surgeons, 60% preferred that handoff occur immediately postoperatively.The 13 core elements we identified may facilitate the development of a standardized handoff checklist for postoperative communication between surgeons and hospitalists on acute care units. Areas of future study could include checklist validation, audits of handoff practice, and qualitative research on handoff preferences.

Objective:To investigate the role of an adherent soft silicone antimicrobial occlusive foam silver-impregnated dressing for reduction of surgical site infections (SSI) in primary low-transverse caesarean section (1°LTCS) delivery.Method:Women aged 18–45 years admitted to the labour and delivery or the antepartum unit undergoing a 1°LTCS were recruited. Exclusion criteria included repeat caesarean, vertical skin incision, intrapartum fever and closure with staples. Consented participants delivered by scheduled or unscheduled 1°LTCS received the silver-impregnated dressing. Those who declined to participate and were delivered by scheduled or unscheduled caesarean received a standard gauze with tape dressing (controls). Surgical preparation and preoperative antibiotics were administered as per hospital policy.Results:A total of 362 participants were consented for use of the silver-impregnated dressing, with 190 participants undergoing 1°LTCS, of whom 185 were included in the final analysis. Of those who declined to participate, 190 ultimately underwent 1°LTCS during the same time period. Cases and controls were similar in demographics, body mass index, diabetes status, labour and procedure length, and tobacco use. The overall incidence of SSI was 3.7%. A 50% reduction in incidence of SSI was observed in the silver-impregnated dressing group compared with control group (2.7% versus 4.7%, respectively), but this was not statistically significant (p=0.08; odds ratio 0.55; 95% confidence interval: 0.18–1.67).Conclusion:Among women undergoing 1°LTCS with subcuticular closure of a transverse incision, use of a silver-impregnated dressing reduced the rate of SSI by >50% but was not statistically significant.

AbstractObjectiveThis was a cross-sectional study associating vitamin D, calcium, magnesium, and potassium intakes with markers of glucose metabolism in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). MethodsHCHS/SOL is a multicenter, prospective, population-based cohort study on Hispanics/Latinos aged 18–74 years in the US. For this analysis, we included 10,609 participants who were free of diabetes. Analysis of covariance was used to assess associations of a range of micronutrient intake on the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), Hemoglobin A1c (HbA1c), and 2-hour post-oral glucose tolerance test (2h-plasma glucose) separately for normoglycemic and with pre-diabetes, after controlling for important confounders. All analyses accounted for the complex sample design and sampling weights. ResultsHOMA-IR levels were significantly lower among adults with intakes in the highest quartile for vitamin D, magnesium, and potassium compared to the respective lowest quartiles, for those with normoglycemia and pre-diabetes, even after adjusting for confounders, such as diet quality (p< 0.05). For those with pre-diabetes, HOMA-IR levels were also significantly lower for those in the highest quartile of calcium intake. However, 2h-plasma glucose was significantly higher in those with intakes higher than quartile 1 for vitamin D and calcium among those with normoglycemia and significantly higher in quartile 3 of potassium intake for those with pre-diabetes, p< 0.05. No significant associations were found for HbA1c in either group.ConclusionsHigher consumption of vitamin D, magnesium, and potassium are associated with optimal levels of HOMA-IR among participants with normoglycemia and pre-diabetes.

ObjectiveCardiovascular disease (CVD) is a leading cause of mortality and morbidity in the USA. The role of occupational exposures to chemicals in the development of CVD has rarely been studied even though many agents possess cardiotoxic properties. We therefore evaluated associations of self-reported exposures to organic solvents, metals and pesticides in relation to CVD prevalence among diverse Hispanic/Latino workers.MethodsCross-sectional data from 7404 employed individuals, aged 18–74 years, enrolled in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) were analysed. Participants from four US cities provided questionnaire data and underwent clinical examinations, including ECGs. CVD was defined as the presence of at least one of the following: coronary heart disease, atrial fibrillation, heart failure or cerebrovascular disease. Prevalence ratios reflecting the relationship between each occupational exposure and CVD as well as CVD subtypes were calculated using Poisson regression models.ResultsHispanic/Latino workers reported exposures to organic solvents (6.5%), metals (8.5%) and pesticides (4.7%) at their current jobs. Overall, 6.1% of participants had some form of CVD, with coronary heart disease as the most common (4.3%) followed by cerebrovascular disease (1.0%), heart failure (0.8%) and atrial fibrillation (0.7%). For individuals who reported working with pesticides, the prevalence ratios for any CVD were 2.18 (95% CI 1.34 to 3.55), coronary heart disease 2.20 (95% CI 1.31 to 3.71), cerebrovascular disease 1.38 (95% CI 0.62 3.03), heart failure 0.91 (95% CI 0.23 to 3.54) and atrial fibrillation 5.92 (95% CI 1.89 to 18.61) after adjustment for sociodemographic, acculturation, lifestyle and occupational characteristics. Metal exposures were associated with an almost fourfold (3.78, 95% CI 1.24 to 11.46) greater prevalence of atrial fibrillation. Null associations were observed for organic solvent exposures.ConclusionsOur results suggest that working with metals and pesticides could be risk factors for CVD among Hispanic/Latino workers. Further work is needed to evaluate these relationships prospectively.

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Nutrient-enriched formulas were developed to provide extra nutrients and facilitate optimal growth for low birth weight infants. This study examined the association between use of nutrient-enriched formulas and weight gain among low birth weight infants (birth weight 1500–2500 g). This retrospective cohort study used data from infants enrolled in the Illinois Special Supplemental Nutrition Program for Women, Infants, and Children. Analyses were limited to infants born in 2010 with low birth weight (1500–2500 g, n = 3130). We examined weight gain by use of nutrient-enriched versus standard term formula, which was assigned to the infant by the Women, Infants, and Children program during the first month of life. The analyses used a multilevel mixed-effects linear regression model with random intercepts to determine the association between use of enriched versus standard term formula and weight gain while simultaneously adjusting for confounders including gestational age, birth weight, and history of breast-feeding. Among 670 infants in the 1500 to 1999 g birth weight group, those fed enriched formula gained 46.4 g (95% confidence interval 7.4–85.3, P< 0.05) more per month in the first 6 months, and 34.0 g (95% confidence interval -0.4 to 68.3, P= 0.05) more per month >6 to 12 months of age compared with infants using standard term infant formula after adjustment for covariates. Similar findings were noted among the 2460 infants in the 2000 to 2500 g birth weight group. Use of nutrient-enriched formulas is associated with higher weight gain in low birth weight infants.

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A multivariable logistic regression model resulting from a case-control study of nutritional rickets in Nigerian children suggested that higher levels of serum 25(OH)D may be required to prevent nutritional rickets in populations with low-calcium intakes.

Context:Compensatory increases in fibroblast growth factor 23 (FGF23) with increasing phosphate intake may adversely impact health. However, population and clinical studies examining the link between phosphate intake and FGF23 levels have focused mainly on populations living in highly industrialized societies in which phosphate exposure may be homogenous.Objective:The objective of the study was to contrast dietary phosphate intake, urinary measures of phosphate excretion, and FGF23 levels across populations that differ by the level of industrialization.Design:This was a cross-sectional analysis of three populations.Setting:The study was conducted in Maywood, Illinois; Mahé Island, Seychelles; and Kumasi, Ghana.Participants:Adults with African ancestry aged 25–45 years participated in the study.Main Outcome:FGF23 levels were measured.Results:The mean age was 35.1 (6.3) years and 47.9% were male. Mean phosphate intake and fractional excretion of phosphate were significantly higher in the United States vs Ghana, whereas no significant difference in phosphate intake or fractional excretion of phosphate was noted between the United States and Seychelles for men or women. Overall, median FGF23 values were 57.41 RU/mL (interquartile range [IQR] 43.42, 75.09) in the United States, 42.49 RU/mL (IQR 33.06, 55.39) in Seychelles, and 33.32 RU/mL (IQR 24.83, 47.36) in Ghana. In the pooled sample, FGF23 levels were significantly and positively correlated with dietary phosphate intake (r = 0.11; P< .001) and the fractional excretion of phosphate (r = 0.13; P< .001) but not with plasma phosphate levels (r = −0.001; P= .8). Dietary phosphate intake was significantly and positively associated with the fractional excretion of phosphate (r = 0.23; P< .001).Conclusion:The distribution of FGF23 levels in a given population may be influenced by the level of industrialization, likely due to differences in access to foods preserved with phosphate additives.

Background:Pulmonary valve replacement (PVR) is required to address residual lesions after tetralogy of Fallot repair (rTOF). We wished to determine the progression of ventricular dilation after rTOF, using cardiac magnetic resonance (CMR) data in children, to determine age related RV and LV volume differences in patients who did or did not require PVR.Methods:Single center, retrospective longitudinal study, including 214 patients with rTOF who had primary repair before 24 months and at least one CMR performed from 2000-2020. During follow-up, 142 patients (66.3%) had PVR at median age 12 years (IQR 9-15.5). Linear mixed effect modeling was used to evaluate time-related changes in ventricular volumes by log-transformed age at CMR adjusted for sex and regurgitant lesion status. Patients were grouped as per need for PVR during follow-up.Results:A total of 323 CMR from 201 patients performed before PVR were analyzed. The median age at first CMR was 9.4 years (IQR 5.9-12.3): 126 (62.7%) patients had one CMR, 34 (16.9%) had 2 and 41 (20.4%) had 3 or more. Prior to PVR there was steeper time-related RV dilation compared to non-PVR requiring patients: RVEDVi = 19.4 (CI 15.1 - 23.7) vs 2.8 (CI -2.5 - 8.2) ml/m2/log2year, p&lt0.001; RVESVi = 11.9 (8.9 - 14.8) vs 0.8 (CI -2.9 - 4.4) ml/m2/log2year, p&lt0.001. A time-related increase in LV volume also occurred in the PVR group compared to non-PVR: LVEDVi = 7.2 (CI 4.7 - 9.7) vs 1.5 (CI -1.6 - 4.6) ml/m2/log2year, p=0.005; LVESVi = 3.2 (CI 1.9 - 4.6) vs -0.4 (CI -2.1 - 1.3) ml/m2/log2year, p=0.001) (Figure 1). The factors associated with PVR were presence of regurgitant residual lesion, more prolonged QRS duration and transannular patch as surgical technique for TOF repair.Conclusion:Early and significantly increased progression of RV dilation and LV dilation are identifiable by CMR in patients destined to require PVR following rTOF. Early CMR surveillance may be indicated to permit early identification of progressive remodeling.

To compare serum total, serum free and salivary cortisol in critically ill children.

Blood pressures in persons of African descent exceed those of other racialethnic groups in the United States. Whether this trait is attributable to the genetic factors in African-origin populations, or a result of inadequately measured environmental exposures, such as racial discrimination, is not known. To study this question, we conducted a multisite comparative study of communities in the African diaspora, drawn from metropolitan Chicago, Kingston, Jamaica, rural Ghana, Cape Town, South Africa, and the Seychelles.

The goal of this study was to determine if a robotic dry laboratory curriculum for gynecology and urology residents improved their basic robotic skills.

AbstractAim:To assess prevalence and population estimates of increased risk of 25-hydroxyvitamin D [25(OH)D] deficiency and inadequacy in US children based on the current Institute of Medicine Committee to Review Dietary References Intakes for Vitamin D and Calcium guidelines.Methods:The analysis was limited to a nationally representative sample of non-institutionalized US children and adolescents aged 6–18 years who participated in the National Health and Nutrition Examination Survey completed in 2003–2006 and had complete data on 25(OH)D measurements (n=2877). The 25(OH)D levels were adjusted for assay drift and prevalence, and population estimates of increased risk of 25(OH)D deficiency (<12 ng/mL), risk of inadequacy (<16 ng/mL), and adequacy (>20 ng/mL) were calculated.Results:Overall, 4.61% of children and adolescents are at increased risk of deficiency (population estimate 2.5 million) and 10.3% are at risk of inadequacy (population estimate 5.5 million) based on the Institute of Medicine guidelines.Conclusion:Approximately 10.3% of US children aged 6–18 years (population estimate 5.5 million) have 25(OH)D levels <16 ng/mL.

Modifiable lifestyle-related factors are associated with risk of coronary heart disease and may also influence kidney disease risk.

Research in industrialized countries has demonstrated that a key factor limiting the control of hypertension is poor patient adherence and that the most successful interventions for long-term adherence employ multiple strategies. Very little data exist on this question in low-income countries, wherein medication-taking behavior may be less well developed.

Obesity management requires understanding the mortality risks associated with different adiposity measures.

Humans are distinguished from the other living apes in having larger brains and an unusual life history that combines high reproductive output with slow childhood growth and exceptional longevity. This suite of derived traits suggests major changes in energy expenditure and allocation in the human lineage, but direct measures of human and ape metabolism are needed to compare evolved energy strategies among hominoids. Here we used doubly labelled water measurements of total energy expenditure (TEE; kcal day−1) in humans, chimpanzees, bonobos, gorillas and orangutans to test the hypothesis that the human lineage has experienced an acceleration in metabolic rate, providing energy for larger brains and faster reproduction without sacrificing maintenance and longevity. In multivariate regressions including body size and physical activity, human TEE exceeded that of chimpanzees and bonobos, gorillas and orangutans by approximately 400, 635 and 820 kcal day−1, respectively, readily accommodating the cost of humans’ greater brain size and reproductive output. Much of the increase in TEE is attributable to humans’ greater basal metabolic rate (kcal day−1), indicating increased organ metabolic activity. Humans also had the greatest body fat percentage. An increased metabolic rate, along with changes in energy allocation, was crucial in the evolution of human brain size and life history.

AbstractBackground and Problem StatementThe goals of the patient-centered medical home (PCMH) include the efficient and effective delivery of patient-centered care in the context of a continuity relationship. In residency training programs, competing demands on faculty, residents, and office staff create considerable challenge in demonstrating these vital attributes of the PCMH to residents. Given the emphasis on the PCMH, primary care residency programs need to strengthen the methods for teaching and modeling continuity, office efficiency, and team-based approaches to care.InterventionWe designed and implemented a new system of “patient care management teams” in our family medicine residency and evaluated its impact on team members. Our quality improvement interventions included the creation of team structures linking faculty advisors and residents with patients, intrateam management of office tasks, and the implementation of multidisciplinary team meetings.EvaluationWe surveyed faculty (n 11), residents/fellows (n 39), and staff (n 12) before and at 2 points after the patient care management team interventions, and we collected patient satisfaction data during the intervention time period.ResultsThe intervention resulted in significant improvements in perceptions of continuity of patient care, office efficiency, and team communication before and after the team interventions. During a 2-year period, the greatest improvements were in the areas of office efficiency and continuity of care. Independent patient satisfaction scores correlated with patient care management team improvements.ConclusionsTeam structures, streamlined team-based management of routine office tasks, and consistent and frequent multidisciplinary meetings can improve the sense of continuity, office efficiency, and team collaboration in primary care residency clinics.

•Improving hypertension control will reduce heart disease and mortality.•After age 65 years, women are less likely than men to have controlled hypertension.•Sex differences in hypertension control widen with advancing age.•Sex differences in hypertension control appear independent of obesity and diabetes.

In February 2002, the Department of Veterans Affairs (VA) raised medication copayments from $2 to $7 per 30-day supply of medication for certain veteran groups. We examined the impact of the copayment increase on medication acquisition from VA.

Although individuals’ health insurance coverage changes frequently, previous analyses have not accounted for changes in insurance coverage over time.

OBJECTIVE:. The Behavioral Risk Factor Surveillance System (BRFSS) telephone interview study provides estimates indicating that approximately one-third of US adults meet the Centers for Disease Control and Prevention (CDC) case definition for arthritis. However, this population includes very diverse groups with major differences in health status, risk factors and disability. METHODS: BRFSS data for 2001 were compared for 4 roughly equal size groups of respondents reporting joint symptoms or a physician's diagnosis of arthritis: those with transient joint symptoms (TJS), chronic joint symptoms (CJS), a physician diagnosis of arthritis (PDA), and those with both PDA and CJS. RESULTS: By far the greatest burden of arthritis related disability is concentrated among individuals reporting both CJS and PDA. After controlling for age, sex, race, ethnicity, and education, this group had over 7 times the likelihood of fair to poor health status compared to the general adult population without arthritis. About one-third of those with undiagnosed CJS reported activity limitations, one-quarter were without health insurance at some point during the previous year, and this group had over 3 times the likelihood of reporting fair to poor health compared to the general population. Obesity was an even more prevalent arthritis risk factor than physical inactivity. Conclusion. The results support the validity of the CDC case definition of arthritis, which excludes TJS. However, a previous PDA in the absence of current symptoms was in itself a poor predictor of activity limitations due to arthritis. Findings will be useful in evaluating subsequent revisions of the CDC arthritis case definition and monitoring the burden of arthritis.

Reactive oxygen species (ROS) are increasingly believed to be important intracellular signaling molecules in mitogenic pathways involved in the pathogenesis of glomerulonephritis (GN). We explored the effects of the antioxidants α-lipoic acid and N-acetyl-l-cysteine on ERK activation in cultured mesangial cells and the role of ERK activation in the severity of glomerular injury in a rat model of anti-Thy 1 GN. In cultured mesangial cells, growth factors stimulated ERK phosphorylation by 150–450%. Antioxidants reduced this increase by 50–60%. Induction of anti-Thy 1 nephritis in rats led to a 210% increase in glomerular ERK phosphorylation. This increase in phosphorylated ERK was reduced by 50% in animals treated with α-lipoic acid. Treatment with α-lipoic acid resulted in significant improvement of glomerular injury. Cellular proliferation was reduced by 100%, and the number of proliferating cell nuclear antigen-positive cells was reduced by 64%. The increased expression of glomerular transforming growth factor-β1protein and mRNA in rats with anti-Thy 1 nephritis was significantly attenuated and mesangial cell transformation into myofibroblasts was completely prevented by treatment with α-lipoic acid. The effects of α-lipoic acid were at least partially due to inhibition of oxidative stress. In rats with anti-Thy 1 nephritis, ROS production was increased 400–500%, and this increase was inhibited by 55% by treatment with α-lipoic acid. We suggest that ROS may mediate glomerular injury by inducing ERK phosphorylation. α-Lipoic acid should be considered a potential therapeutic agent in certain types of human GN.

Alcoholism and depression are common disorders that frequently cooccur in the same individual. Selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of depression and also had decreased drinking in some studies of heavy drinkers and alcoholics. The reported effect of serotonergic medications on alcohol intake in depressed alcoholics has not been consistent. Most previous studies have not investigated the use of an SSRI in the context of cognitive behavioral therapy (CBT), a known efficacious treatment of both alcoholism and depression. The study presented here was a randomized placebo-controlled 12-week trial of sertraline combined with individual CBT focused on both alcoholism relapse prevention and depressive symptoms. Subjects were 82 currently depressed, actively drinking alcohol-dependent individuals. Subjects had either primary (independent) major depression (70 subjects) or substance-induced mood disorder and at least 1 first-degree relative (parent, sibling, or child) with an affective disorder (12 subjects). Depression and alcohol consumption outcomes were measured weekly over 12 weeks. Sertraline was well tolerated and all subjects had decreases in both depression and alcohol use during the study compared with baseline. Subjects who received sertraline had fewer drinks per drinking day than subjects who received placebo, but other drinking outcomes were not different between the 2 treatment groups. Treatment with sertraline was associated with less depression at the end of treatment in female subjects compared with female subjects who received placebo. Less drinking during the study was associated with improved depression outcome. The findings in this study suggest that sertraline, compared with placebo, may provide some modest benefit in terms of drinking outcome and also may lead to improved depression in female alcohol-dependent subjects. Additionally, alcohol relapse prevention CBT, delivered according to manual guidelines with modifications that provide specific attention to depression, appeared to be of benefit to subjects, although this interpretation is limited by the design of the study.

Objective. This ecologic study examined the association of mortality with selected socioeconomic indicators of inequality and segregation among blacks and whites younger than age 65 in 267 US metropolitan areas. The primary aim of the analysis was to operationalize the concept of institutional racism in public health.Methods. Socioeconomic indicators were drawn from Census and vital statistics data for 1989–1991 and included median household income; two measures of income inequality; percentage of the population that was black; and a measure of residential segregation.Results. Age-adjusted premature mortality was 81% higher in blacks than in whites, and median household income was 40% lower. Income inequality, as measured by the Gini coefficient, was greater within the black population (0.45) than within the white population (0.40; p< 0.001). To confirm that the proxy socioeconomic variables were relevant markers of population health status, regression analysis was performed initially on data for the total population. These variables were all independently and significantly related to premature mortality (p≤ 0.01; R2= 0.74). Income inequality for the total population was significantly correlated with premature mortality (r= 0.33). Black (r= 0.26) and white (r= 0.20) population-specific correlations between income inequality and premature mortality, while still significant, were smaller. Residential segregation was significantly related to premature mortality and income inequality for blacks (r= 0.38 for both); among whites, however, segregation was modestly correlated with premature mortality (r= 0.19) and uncorrelated with income inequality. Regional analyses demonstrated that the association of segregation with premature mortality was much more pronounced in the South and in areas with larger black populations.Conclusion. Social factors such as income inequality and segregation strongly influence premature mortality in the US. Ecologic studies of the relationships among social factors and population health can measure attributes of the social context that may be relevant for population health, providing the basis for imputing macro-level relationships.

Objectives/HypothesisTo evaluate the differences between female and male patients with obstructive sleep apnea syndrome (OSAS) in the preoperative period.

Objective:To determine the influence of environmental factors on resting energy expenditure (REE) and its relationship to adiposity in two populations of West African origin, Nigerians and U.S. blacks. Research Methods and Procedures:REE and body composition were measured in a cross‐sectional sample of 89 Nigerian adults (39 women and 50 men), and 181 U.S. black adults (117 women and 65 men). Both groups represent randomly selected population samples. REE was measured by indirect calorimetry after an overnight fast in both sites using the same instrument. Body composition was estimated using bioelectrical impedance analysis (BIA) in 72 Nigerians and 156 U.S. participants. Multivariate regression analysis was used to determine the significant predictors of REE. The analyses were repeated in a set of 17 Nigerians and 28 U.S. blacks in whom body composition was measured using deuterium dilution. Results:U.S. black adults were significantly heavier and had both more fat‐free mass (FFM) and body fat than Nigerians. FFM was the only significant determinant of REE in both population groups, whether body composition was measured using BIA or deuterium dilution. The relationship between REE and body composition did not differ by site. There was no relationship between REE and adiposity. Discussion:Differences in current environmental settings did not impact REE. The differences observed in mean levels of body fat between Nigerians and U.S. blacks were not the result of differences in REE adjusted for body composition.