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To achieve WHO targets for the elimination of hepatitis C virus (HCV) as a public threat, an increased uptake of HCV treatment among people who inject drugs (PWID) is urgently needed. Optimal HCV co-located treatment models for PWID have not yet been identified. We aimed to compare two patient-centred models of HCV care in PWID with active drug use.

Introduction: Behavioral and mental health conditions present significant challenges in the United States where access to care is limited. Family medicine physicians play a crucial role in addressing these challenges, often serving as frontline clinicians for behavioral and mental health conditions.Methods: This study examined the current behavioral and mental health system in a predominantly rural 10-county region in the Southeastern United States through gap analysis in addition to a survey of preparedness and barriers among family medicine physicians in the region.Results: Gap analysis results indicated that (1) stigma and lack of accessible education about behavioral and mental health, (2) fragmented resources, (3) inaccessible care, and (4) workforce shortage and burnout were primary drivers of poor outcomes in the region. Survey results indicated that physicians feel prepared to treat anxiety and depression but feel less prepared to manage bipolar disorder, schizophrenia, and substance use disorders. Respondents disagreed that there are adequate local resources and referral options for patients with behavioral and mental health conditions. Lack of timely access, distance, cost/insurance status, were all cited by respondents as barriers to appropriate care.Conclusion and Recommendations: Findings underscore the importance of supporting family medicine physicians to enhance behavioral and mental healthcare outcomes. Behavioral health integration in primary care settings is a promising strategy to improve care accessibility and clinician preparedness. Bridging gaps in health care outcomes requires collaborative efforts, enhanced training, and policy advocacy within the family medicine community to ensure comprehensive and equitable behavioral and mental healthcare delivery.

(Abstracted from Am J Obstet Gynecol2022;227:893.e1–893.e15Preterm birth (PTB) is far too common in the United States and disproportionately affects Black individuals. To address these differences, a group care model was proposed that would provide health care with family and peer support and provider-led patient-centered health education.

AbstractBackground:Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.Methods:We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case–control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.Results:In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37–3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32–12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0–48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6–9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9–315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.Conclusions:Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

The SARS-CoV-2 outbreak from October 2020 through February 2021 was the largest outbreak as of February 2021, and timely information on current representative prevalence, vaccination, and loss of prior antibody protection was unknown. In February 2021, the South Carolina Department of Health and Environmental Control conducted a random sampling point prevalence investigation consisting of viral and antibody testing and an associated health survey, after selecting participants aged ≥5 years using a population proportionate to size of South Carolina residents. A total of 1917 residents completed a viral test, 1803 completed an antibody test, and 1463 completed ≥1 test and a matched health survey. We found an incidence of 2.16 per 100 residents and seroprevalence of 16.4% among South Carolina residents aged ≥5 years. Undetectable immunoglobulin G and immunoglobulin M antibodies were noted in 28% of people with a previous positive test result, highlighting the need for targeted education among people who may be susceptible to reinfection. We also found a low rate of vaccine hesitancy in the state (13%). The results of this randomly selected surveillance and associated health survey have important implications for prospective COVID-19 public health response efforts. Most notably, this article provides a feasible framework for prompt rollout of a statewide evidence-based surveillance initiative.

Body mass is the primary metabolic compartment related to a vast number of clinical indices and predictions. The extent to which skeletal muscle (SM), a major body mass component, varies between people of the same sex, weight, height, and age is largely unknown. The current study aimed to explore the magnitude of muscularity variation present in adults and to examine if variation in muscularity associates with other body composition and metabolic measures. Muscularity was defined as the difference (residual) between a person's actual and model‐predicted SM mass after controlling for their weight, height, and age. SM prediction models were developed using data from a convenience sample of 492 healthy non‐Hispanic (NH) White adults (ages 18–80 years) who had total body SM and SM surrogate, appendicular lean soft tissue (ALST), measured with magnetic resonance imaging and dual‐energy X‐ray absorptiometry, respectively; residual SM (SMR) and ALST were expressed in kilograms and kilograms per square meter. ALST mass was also evaluated in a population sample of 8623 NH‐White adults in the 1999–2006 National Health and Nutrition Examination Survey. Associations between muscularity and variation in the residual mass of other major organs and tissues and resting energy expenditure were evaluated in the convenience sample. The SM, on average, constituted the largest fraction of body weight in men and women up to respective BMIs of 35 and 25 kg/m2. SM in the convenience sample varied widely with a median of 31.2 kg and an SMRinter‐quartile range/min/max of 3.35 kg/−10.1 kg/9.0 kg in men and 21.1 kg and 2.59 kg/−7.2 kg/7.5 kg in women; per cent of body weight as SM at 25th and 75th percentiles for men were 33.1% and 39.6%; corresponding values in women were 24.2% and 30.8%; results were similar for SMRindices and for ALST measures in the convenience and population samples. Greater muscularity in the convenience sample was accompanied by a smaller waist circumference (men/women: P< 0.001/=0.085) and visceral adipose tissue (P= 0.014/0.599), larger liver (P= 0.065/<0.001), kidneys (P= 0.051/<0.009), and bone mineral (P< 0.001/<0.001), and larger magnitude resting energy expenditure (P< 0.001/<0.001) than predicted for the same sex, age, weight, and height. Muscle mass is the largest body compartment in most adults without obesity and is widely variable in mass across people of similar body size and age; and high muscularity is accompanied by distinct body composition and metabolic characteristics. This previously unrecognized heterogeneity in muscularity in the general population has important clinical and research implications.

Background/Objectives: Fat-free mass (FFM) often serves as a body composition outcome variable in weight loss studies. An important assumption is that the proportions of components that make up FFM remain stable following weight loss; some body composition models rely on these “constants”. This exploratory study examined key FFM component proportions before and following weight loss in two studies of participants with overweight and obesity. Subjects/Methods: 201 men and women consumed calorie-restricted moderate- or very-low carbohydrate diets leading to 10–18% weight loss in 9–15 weeks. Measured total body fat, lean mass, bone mineral, total body water (TBW), and body weight at baseline and follow-up were used to derive FFM and its chemical proportions using a four-component model. Results: A consistent finding in both studies was a non-significant reduction in bone mineral and a corresponding increase (p&lt; 0.001) in bone mineral/FFM; FFM density increased significantly in one group of women and in all four participant groups combined (both, p&lt; 0.05). FFM hydration (TBW/FFM) increased in all groups of men and women, one significantly (p&lt; 0.01), and in the combined sample (borderline, p&lt; 0.10). The proportion of FFM as protein decreased across all groups, two significantly (p&lt; 0.05–0.01) and in the combined sample (p&lt; 0.05). Conclusion: FFM relative proportions of chemical components may not be identical before and after short-term weight loss, an observation impacting some widely used body composition models and methods. Caution is thus needed when applying FFM as a safety signal or to index metabolic evaluations in clinical trials when these body composition approaches are used.

Objectives: Routine screening for HIV and hepatitis C virus (HCV) among specified age cohorts is recommended. New York State requires consent before screening for HIV but not HCV. We sought to estimate the effect of the consent requirement on screening rates for HIV.Methods: We performed a retrospective study of patients hospitalized in 2015-2016 at a tertiary care hospital in the Bronx, New York, during a period when prompts in the electronic health record facilitated screening for HIV and HCV among specified age cohorts. We compared proportions of patients eligible for screening for HIV and/or HCV who underwent screening and used generalized estimating equations and a meta-analytic weighted average to estimate an adjusted risk difference between undergoing HIV screening and undergoing HCV screening.Results: Among 11 938 hospitalized patients eligible for HIV and/or HCV screening, 38.5% underwent screening for HIV and 59.1% underwent screening for HCV. The difference in screening rates persisted after adjusting for patient and admission characteristics (adjusted risk difference = 22.0%; 95% CI, 20.6%-23.4%).Conclusions: Whereas the requirement for consent was the only difference in the processes of screening for HIV compared with screening for HCV, differences in how the 2 viruses are perceived may also have contributed to the difference in screening rates. Nevertheless, our findings suggest that requiring consent continues to impede progress toward the public health goal of routine HIV screening.

AbstractObjective:Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.Design:Retrospective case-control study.Setting:Four academic medical centers.Patients:Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.Methods:Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.Results:Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).Conclusions:Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

AbstractObjective:Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI.Design:Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors.Setting:Five urban, academic medical centers, part of the New York City Clinical Data Research Network.Patients:Potential patients were age <22 years who were seen between October 2010 and September 2015.Results:In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1–6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics.Conclusions:Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.

Background/Objectives: Three-dimensional optical (3DO) imaging systems that rapidly and accurately provide body shape and composition information are increasingly available in research and clinical settings. Recently, relatively low-cost and space efficient 3DO systems with the ability to report and track individual assessments were introduced to the consumer market for home use. This study critically evaluated the first 3DO imaging device intended for personal operation, the Naked Body Scanner (NBS), against reference methods. Participants/Methods: Circumferences at six standardized anatomic sites were measured with a flexible tape in 90 participants ranging in age (5–74 years), ethnicity, and adiposity. Regression analysis and Bland-Altman plots compared these direct measurements and dual-energy X-ray absorptiometry (DXA) %fat estimates to corresponding NBS values. Method precision was analyzed from duplicate anthropometric and NBS measurements in a subgroup of 51 participants. Results: The NBS exhibited greater variation in test–retest reliability (CV, 0.4–2.7%) between the six measured anatomic locations when compared with manually measured counterparts (0.2–0.4%). All six device-derived circumferences correlated with flexible tape references (R2s, 0.84–0.97; p&lt; 0.0001). Measurement bias was apparent for three anatomic sites while mean differences were present for five. The NBS’s %fat estimates also correlated with DXA results (R2= 0.73, p&lt; 0.0001) with no significant bias. Conclusions: This system opens a new era of digital home-based assessments that can be incorporated into weight loss or exercise interventions accessible to clinical investigators as well as individual users.

Alternation flicker or graphics interchange format technology is an underutilized, more effective way to highlight subtle changes after cosmetic surgery and may be ideal for use in websites or social media accounts.Supplemental Digital Content is available in the text.

This randomized, prospective clinical trial of posterior lamellar spacer grafts for lower eyelid retraction repair showed no statistically significant difference in outcome between porcine acellular dermal matrix, bovine acellular dermal matrix, and autologous auricular cartilage.

Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics.

Survival of patients on ECMO has remained stable in every population. Laboratory values predictors of survival are required to improve patient care.

IMPORTANCE: Body mass index (BMI) is used to diagnose obesity in adolescents worldwide, despite evidence that weight does not scale with height squared in adolescents. To account for this, health care providers diagnose obesity using BMI percentiles for each age (BMI z scores), but this does not ensure that BMI is accurate in adolescents. OBJECTIVE: To compare the accuracy of BMI vs other body fat indices of the form body mass divided by heightn in estimating body fat levels in adolescents. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional data from the 1999 to 2006 US National Health and Nutrition Examination Survey were analyzed between September 2015 and December 2016. MAIN OUTCOMES AND MEASURES: Dual-energy x-ray absorptiometry and anthropometric data were used to determine changes in body fat levels, body proportions, and the scaling relationships among body mass, height, and percent body fat. To assess the merits of each adiposity index, 3 criteria were used: stability with age, accuracy in estimating percent body fat, and accuracy in classifying adolescents as overweight vs normal weight. RESULTS: Participants included 2285 non-Hispanic white participants aged 8 to 29 years. Percent body fat varied with both age and height during adolescence, invalidating the standard weight-to-height regression as the way of finding the optimal body fat index. Because the correct regression model (percent body fat is proportional to mass divided by heightn) suggested that percent body fat scales to height with an exponent closer to 3, we therefore focused on the tri-ponderal mass index (TMI; mass divided by height cubed) as an alternative to BMI z scores. For ages 8 to 17 years, TMI yielded greater stability with age and estimated percent body fat better than BMI (R2 = 0.64 vs 0.38 in boys and R2 = 0.72 vs 0.66 in girls). Moreover, TMI misclassified adolescents as overweight vs normal weight less often than BMI z scores (TMI, 8.4%; 95% CI, 7.3%-9.5% vs BMI, 19.4%; 95% CI, 17.8%-20.0%; P &lt; .001) and performed equally as well as updated BMI percentiles derived from the same data set (TMI, 8.4%; 95% CI, 7.3%-9.5% vs BMI, 8.0%; 95% CI, 6.9%-9.1%; P = .62). CONCLUSIONS AND RELEVANCE: The tri-ponderal mass index estimates body fat levels more accurately than BMI in non-Hispanic white adolescents aged 8 to 17 years. Moreover, TMI diagnoses adolescents as overweight more accurately than BMI z scores and equally as well as updated BMI percentiles but is much simpler to use than either because it does not involve complicated percentiles. Taken together, it is worth considering replacing BMI z scores with TMI to estimate body fat levels in adolescents.

Supplemental Digital Content is Available in the Text.

AbstractBackground:Nationally, approximately 24% of preschool children are overweight or obese, with low-income communities disproportionately affected. Few interventions to prevent obesity in children at greatest risk have demonstrated positive results. Therefore, we evaluated the effectiveness of a novel group well-child care intervention for primary obesity prevention at age 2 years.Methods:Well Baby Group (WBG) is an alternative to traditional well-child care offered at a federally qualified health center in the South Bronx. Facilitated by a pediatrician and nutritionist, WBG fosters positive dietary behaviors, responsive parenting and feeding practices, and peer support during the first 18 months of life. Multivariable logistic regression was conducted to test the effect of WBG on rates of overweight/obesity at 2 years (BMI-for-age ≥85th percentile) using a nonrandomized comparison group of children receiving traditional care at our center over the same period.Results:Characteristics of mothers and infants were comparable between intervention (n= 47) and comparison (n= 140) groups. Children enrolled in WBG were significantly less likely to be overweight/obese at 2 years than children receiving traditional well-child care (2.1% vs. 15.0%; OR 0.12; 95% CI 0.02–0.94; p= 0.02). In multivariable regression analysis, WBG remained a significant independent protective factor (OR 0.12; 95% CI 0.02–0.93; p= 0.04), adjusting for birthweight and parity.Conclusions:WBG, a replicable model integrated into primary care visits, affords a unique opportunity to intervene consistently and early, providing families in at-risk communities with increased provider time, intensive education, and ongoing support. Further study of group well-child care for primary obesity prevention is warranted to confirm the effectiveness of the model.

Background: Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians’ interest in reducing their incidence.

AbstractBackground:Children in the United States (US) are frequently exposed to advertisements for high-fat, high-sugar (HFHS) foods, which is linked to greater demand for and consumption of those foods. Restricting advertisements for HFHS foods may be a viable obesity prevention strategy—however, public support for policy change is unclear.Methods:A secondary analysis of the 2012 Annenberg National Health Communication Survey was conducted. Respondents (N= 1838) were 53.2% female, mean age 50.0 ± 16.5 years. Race/ethnic composition was 76.8% white, 7.4% black, 9.2% Hispanic, and 6.6% other. The percentage of respondents supporting and opposing the regulation was calculated and logistic regression models identified predictors of support. Potential predictors included sociodemographic variables, attitudes towards other health regulations (e.g.,smoking bans in public places), and various health behaviors (e.g.,fruit and vegetable intake).Results:A total of 56.3% of respondents supported or strongly supported advertisement restrictions, while only 8.2% strongly opposed. Approximately 20% had no opinion. Greatest support was found among respondents who supported smoking bans in public settings (OR = 4.3), who supported banning trans fats in restaurants (OR = 1.7), and who were older (OR = 1.7).Conclusion:The US adult population appears to have an appetite for restricting HFHS advertising to children, with more than half the populace supporting such a policy in 2012. This may be an opportune time to implement and rigorously evaluate such childhood obesity prevention strategies.

AbstractBackground:Poorer “division of responsibility” (DoR) feeding, characterized by high parental control and reduced child food choice, may promote pediatric obesity, although population-based prospective data are lacking. We tested whether poorer DoR feeding predicts childhood overweight/obesity onset and BMI z-score gain, over 10 years in the National Longitudinal Study of Youth.Methods:We studied 302 girls and 316 boys, with mean ages 52.24 and 52.35 months, respectively, in 1986, who were followed for 10 years. We excluded children who were initially overweight/obese. Mothers completed three DoR feeding questions in 1986: (1) child eating compliance of prompted foods; (2) child eating compliance of initially refused foods; and (3) mother-allotted child food choice. Child BMI (kg/m2) was calculated from measured weights and heights in 1986, 1988, 1992, 1994, and 1996.Results:Daughters who complied with maternal food prompts [odds ratio (OR), 2.01] and those who obeyed maternal prompts to consume initially rejected foods (OR, 2.29) “most of the time” were significantly more likely than daughters who complied less frequently to become overweight/obese after 8 years. Also, more frequent eating compliance (p<0.001) and more frequent compliance of initially rejected foods (p=0.003) predicted greater BMI z-score gain in girls. These associations were not found for boys. Maternal obesity consistently predicted overweight/obesity risk in girls (ORs, 2.48–8.63) and boys (ORs, 2.27– 4.03).Conclusions:Teaching parents to avoid coercive feeding practices, while encouraging child self-selection of healthier foods, may help their daughters to achieve better energy balance.

Opioid use disorder (OUD) has led to a staggering death toll in terms of drug-related overdoses. Despite the demonstrated benefits and effectiveness of buprenorphine, retention is suboptimal, and patients typically present with high rates of ongoing polysubstance use during treatment. A pilot trial provided preliminary support for the efficacy of computer-based cognitive-behavioral therapy (CBT4CBT) as an add-on to buprenorphine in reducing substance use. Recovery coaching services provided by individuals with substance use experience and successful recovery have also shown to positively influence recovery outcomes for people with OUD by increasing buprenorphine initiation and reducing opioid use.

Abstract:Background:Few interventions targeting severely obese minority youth have been implemented in community-based settings. We evaluate a 9-month multicomponent, community-based program for obese, inner-city adolescents.Methods:Of 5250 estimated eligible adolescents, 349 were recruited; they had a mean age of 15±2 years, mean BMI %ile 98.9±1.5, and comprised 52% African American and 44% Hispanic. Longitudinal trends of anthropometric measures were compared 1 year before enrollment (T−12), at baseline (T0) and after program completion (T9). Dietary and physical activity behaviors were compared at T0 and T9. Anthropometric changes were compared at T9 and 18 months (T18) in completers and noncompleters.Results:A majority of participants were severely obese (67%) and expressed low readiness to change behaviors (82%). For intervals T−12 to T0 versus T0 to T9, there were significant decreases in rates of gain in BMI (0.13 vs. 0.04, p<0.01), BMI percentile (0.0002 vs. −0.0001, p<0.01), percent overweight (0.001 vs. −0.001, p<0.01), and BMI z-score (0.003 vs. −0.003, p<0.01). Significant increases in vegetable and fruit consumption and in vigorous physical activity participation were observed. From T9 to T18, except for a significant increase in BMI (38.3±7.4 vs. 39.0±7.5, p<0.01) in completers, all other anthropometric measures remained unchanged in completers and noncompleters.Conclusions:We demonstrate modest clinical improvements and increased healthy lifestyle behaviors in predominantly severely obese, difficult-to-reach, ethnic minority adolescents attending a community-based weight management program. The loss of clinical improvements 9 months after program completion implies that extending the duration of such a program may prevent long-term weight regain in severely obese adolescents.

Patient experience is a critical measure for ambulatory primary care, although it is unclear how to best improve patient experience scores. This study aimed to determine whether use of a real-time feedback (RTF) device improved patient experience scores in a cluster-randomized trial. The primary outcomes were change from baseline in 9 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) question and domain scores most closely related to the RTF questions asked in a linear mixed effects model. There were no observed statistically significant intervention-related differences in CG-CAHPS scores in any of the 9 CG-CAHPS questions or domains (P= .12-.99). In intervention clinics, there were no statistically significant correlation between CG-CAHPS top box scores and RTF device scores (P= .23-.98). Clinics in an urban primary care network randomized to receive RTF devices did not significantly improve related CG-CAHPS question or domain scores nor were those scores correlated with RTF device scores. More research is needed to identify effective interventions to improve ambulatory primary care patient experience.

Weight gain has often been associated with olanzapine treatment, yet little is known about the influence of patient age or cumulative dose on olanzapine-associated weight gain. The first 118 participants in the National Institutes of Mental Health Study of the Pharmacotherapy of Psychotic Depression randomized clinical trial (Clinical Trials.gov Registration NCT00056472) completing at least 4 weeks of treatment with olanzapine were analyzed to determine the relationship between weight gain, age, and cumulative olanzapine dose. Younger (age 18–59 years) and older (age 60 years) participants received open-label olanzapine and either sertraline or placebo for up to 12 weeks. Linear mixed effect regression modeling was used to determine the effects of age and cumulative olanzapine dose on weight gain, controlling for potential confounders. Age was observed to have a significant negative association with weight gain (P0.01), even after controlling for differences in cumulative dose and baseline body mass index. Each 10-year increase in age was associated with a decrease in mean weight gain over 12 weeks of approximately 0.6 kg (95 confidence interval 0.14–1.05 kg). Cumulative olanzapine dose was also significantly associated with weight gain (P<0.0001). Approximately 60 of completers of the 12-week trial experienced clinically significant weight gain (≥7 of baseline weight).

Attrition from clinical trials is unavoidable in geriatric psychiatry and beyond. It results in incomplete data and consequently imposes three fundamental challenges: greater bias, reduced power, and less generalizability. In an effort to assess the extent of attrition and the relevance of statistical methods applied to analyze incomplete data in geriatric psychiatry, we reviewed 69 published antidepressant randomized clinical trials conducted since 1975. The median attrition rate estimated from these trials was 26.6; nevertheless, we found that many trials lack data analytic strategies to address the problem of attrition. Most of the applied statistical analyses involved chi-square tests, t-tests, and analysis of variance (ANOVA), each of which assume that data are missing completely at random. Even when imputation for missing data due to attrition was attempted, only the last observation carried forward (LOCF) method was implemented. The LOCF imputation can actually increase bias of the results in the analysis of repeatedly measured outcomes. In addition, despite the longitudinal nature of repeatedly measured outcomes, the statistical methods used are for analysis of cross-sectional data. Thus, the data analytic strategies did not adequately meet the challenges arising from attrition. We encourage the use of mixed-effects models to reduce the impact of attrition on bias, power and generalizability in antidepressant RCTs for geriatric depression. For imputation, we recommend use of multiple imputation methods instead of LOCF.

To describe the proportion and characteristics of adults with self‐reported, doctor‐diagnosed arthritis who report ever having been advised by a health professional to become more physically active and to assess whether the advice was associated with recent physical activity.Using population‐based data from the 2003 Behavioral Risk Factor Surveillance Survey, respondents were classified according to their arthritis status, whether or not they were ever advised by a health professional to increase their physical activity to help them better manage their arthritis, and whether they engaged in exercise or physical activity within the past month.Overall, 42% of respondents with arthritis reported ever being advised to increase their physical activity to help their arthritis. Respondents who were more likely to have ever received the advice were female, middle‐aged or older, African American, Hispanic, overweight or obese, sedentary or insufficiently physically active, and had higher levels of education. Persons who reported ever receiving the advice were less likely to report that they had exercised within the past month. A higher level of education was the only variable associated with recent exercise or physical activity among those advised to be more active.Less than 50% of adults with arthritis report ever being advised by a health professional to become more physically active. Advice alone appears insufficient to promote increased physical activity in adults with arthritis.

Increased physical activity is recommended for adults with arthritis.

Objective: To estimate the association between body mass index (BMI) and health‐related quality of life (HRQL) and examine whether joint pain and obesity‐related comorbidities mediate the BMI‐HRQL association. Research Methods and Procedures: Population‐based survey data from the 1999 Behavioral Risk Factor Surveillance Survey. Adults (N= 155, 989) were classified according to BMI as underweight (<18.5 kg/m2), desirable weight (18.5 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), obese class I (30 to 34.9 kg/m2), obese class II (35 to 39.9 kg/m2), and obese class III (≥40 kg/m2). Data including general health status, unhealthy days in the past 30 caused by physical problems and mental problems, and total unhealthy days in the past 30 were collected. Results: After adjusting for age, sex, race, smoking, education, and income, we observed J‐shaped associations between BMI and HRQL. Compared with desirable weight adults, underweight, overweight, and obesity classes I, II, and III adults [odds ratio (OR) = 1.57, 1.19, 1.95, 2.72, and 4.36, respectively] were significantly (p< 0.001) more likely to report fair/poor general health status. For unhealthy days caused by physical problems, the corresponding ORs were 1.51, 1.15, 1.66, 2.27, and 3.61 (p< 0.001). For unhealthy days caused by mental problems, the ORs were 1.35, 1.14 1.43, 1.57, and 2.25 (p< 0.001). For total unhealthy days, the corresponding ORs were 1.27, 1.09, 1.37, 1.73, and 2.46 (p< 0.01). Adding joint pain and obesity‐related comorbidities into models attenuated BMI‐HRQL associations. Discussion: Associations between BMI and HRQL indices were J‐shaped. Joint pain and comorbidities may mediate BMI‐HRQL associations.

Abstract?Project Grow-2-Gether? is a child nutrition study of same-sex, 3- to 7-year-old monozygotic and dizygotic twin pairs. The study attempts to bridge two bodies of literature that have rarely interfaced with respect to obesity and ingestive behavior: the first being behavioral genetic approaches to obesity-related traits, and the second being developmental approaches focusing on parent?child relationships. The overarching aim of Project Grow-2-Gether is to disentangle genetic from potential home-environmental influences on child eating behavior and body fat. This paper reviews the rationale for Project Grow-2-Gether, its procedures, and core phenotypic measurement battery. A focus of the study is acquisition of controlled food intake measurements obtained in the laboratory, measurement of specific home environmental variables, and multi-method evaluation of parent?child feeding relations. Future directions may involve longitudinal assessment of child growth and molecular analyses for specific genes that influence child eating behavior.

Skeletal muscle mass in prepubertal Asian children has not been examined previously. The aims of this study were to test the hypotheses that 1) prepubertal Asians have less appendicular skeletal muscle (ASM) mass compared with African-Americans and Caucasians, and 2) ASM is less in prepubertal Asian girls compared with Asian boys. ASM was estimated by using dual-energy X-ray absorptiometry in healthy prepubertal girls (n= 170) and boys (n= 166). The results showed that, after adjusting for age, height, and body weight, 1) Asian girls and boys had less amounts of ASM than African-Americans (P < 0.001); 2) Asian girls had less amounts of ASM than Caucasian girls (P= 0.004); 3) there was a trend towards less ASM in Asian compared with Caucasian boys (P= 0.07); 4) and Asian girls had significantly less ASM than Asian boys (P< 0.001). This study indicates that skeletal muscle mass as a fraction of body weight is smaller in Asian compared with African-American and Caucasian children.

Muscularity, or the proportion of adipose tissue‐free body mass (ATFM) as skeletal muscle (SM), provides valuable body composition information, especially for age‐related SM loss (i.e., sarcopenia). Limited data from elderly cadavers suggest a relatively constant SM/ATFM ratio, 0.540 ± 0.046 for men (mean ± SD, n= 6) and 0.489 ± 0.049 for women (n= 7). The aim of the present study was to examine the magnitude and constancy of the SM/ATFM ratio in healthy adults. Whole‐body SM and ATFM were measured using multi‐scan magnetic resonance imaging. The SM/ATFM ratio was 0.528 ± 0.036 for men (n= 139) and 0.473 ± 0.037 for women (n= 165). Multiple regression analysis indicated that the SM/ATFM ratio was significantly influenced by sex, age, body weight, and race. The four factors explained 50% of the observed between individual variation in the SM/ATFM ratio. After adjusting for age, body weight, and race, men had a larger SM/ATFM ratio than women. Both older men and women had a lower SM/ATFM ratio than younger subjects, although the relative reduction was greater in men. After adjustment for sex, age, and body weight, there were no significant differences in the SM/ATFM ratios between Asian, Caucasian, and Hispanic subjects. In contrast, African‐American subjects had a significantly greater SM/ATFM ratio than subjects in the other three groups. In addition, the SM/ATFM ratio was significantly lower in AIDS patients than corresponding values in healthy subjects. Am. J. Hum. Biol. 13:612–619, 2001. © 2001 Wiley‐Liss, Inc.

Although magnetic resonance imaging (MRI) can accurately measure lower limb skeletal muscle (SM) mass, this method is complex and costly. A potential practical alternative is to estimate lower limb SM with dual-energy X-ray absorptiometry (DXA). The aim of the present study was to develop and validate DXA-SM prediction equations. Identical landmarks (i.e., inferior border of the ischial tuberosity) were selected for separating lower limb from trunk. Lower limb SM was measured by MRI, and lower limb fat-free soft tissue was measured by DXA. A total of 207 adults (104 men and 103 women) were evaluated [age 43 ± 16 (SD) yr, body mass index (BMI) 24.6 ± 3.7 kg/m2]. Strong correlations were observed between lower limb SM and lower limb fat-free soft tissue (R2= 0.89,P< 0.001); age and BMI were small but significant SM predictor variables. In the cross-validation sample, the differences between MRI-measured and DXA-predicted SM mass were small (−0.006 ± 1.07 and −0.016 ± 1.05 kg) for two different proposed prediction equations, one with fat-free soft tissue and the other with added age and BMI as predictor variables. DXA-measured lower limb fat-free soft tissue, along with other easily acquired measures, can be used to reliably predict lower limb skeletal muscle mass.

IMPORTANCE: Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. OBJECTIVE: To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. INTERVENTIONS: A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. MAIN OUTCOMES AND MEASURES: The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. RESULTS: Overall, 21?331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. CONCLUSIONS AND RELEVANCE: In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03003832

ALLISON, DAVID B., MYLES S. FAITH, MOONSEONG HEO, DIANA TOWNSEND‐BUTTERWORTH, AND DAVID F. WILLIAMSON. Meta‐analysis of the effect of excluding early deaths on the estimated relationship between body mass index and mortality. Obes Res. Objectives: Prospective cohort studies typically observe U‐or J‐shaped relationships between body mass index (BMI) (kg/m2) and mortality. However, some studies suggest that the elevated mortality at lower BMIs is due to confounding by pre‐existing occult disease and recommend eliminating subjects who die during the first several (k)years of follow‐up. This meta‐analysis tests the effects of such early death exclusion on the BMI‐mortality association. Research Methods and Procedures: Studies identified from MEDLINE, review articles, ancestry analyses, and the “invisible college.” Included studies: 1) measured relative body weight at baseline; 2) inchded at least 1000 subjects; 3) reported results with and without early‐death exclusion, or relevant data; and 4) did not study exclusively diseased populations. Blank tables were mailed to 131 investigators covering 59 databases. Completed tables (n = 16 databases), electronic raw data (n = 7 databases), and original articles (n = 6 databases) provided final data. Meta‐analytic regressions compared the BMI‐mortality association with and without early death exclusion. The sample included 29 studies and 1,954,345 subjects. Results: The effect of eliminating early deaths was statistically significant but minuscule in magnitude. Implementation of early death exclusion was estimated to shift the BMI associated with minimum mortality only 0. 4 units for men and 0. 6 units for women at age 50. Even at a BMI 16, the estimated relative risk (compared to BMI 25) decreased only 0. 008 units for men and 0. 076 units for women at age 50. Discussion: Results indicate that either pre‐existing disease does not confound the BMI—mortality association or eliminating early deaths is inefficient for reducing that confounding.

AbstractIt is well known that obtaining adequate statistical power to detect linkage to or association with genes for complex quantitative traits can be very difficult. In response, investigators have developed a number of power-enhancing strategies that consider restraints such as genotyping (and/or phenotyping) costs. In the context of both association and sib pair linkage studies of quantitative traits, one of the most widely discussed techniques is the selective sampling of phenotypically extreme individuals. Several papers have demonstrated that such extreme sampling can markedly increase power (under certain circumstances). However, the parenthetical phrase in the previous sentence has generally not been made explicit and it appears to be implied that the more phenotypically extreme the individuals, the more power one has. In this paper, we show by simulation that this is not true under all circumstances. In particular, we show that under oligogenic models, where some biallelic quantitative trait loci (QTLs) have markedly asymmetric allele frequencies and large mean displacement among genotypes, and others have less asymmetric allele frequencies and smaller mean displacement among genotypes, power to detect linkage to or association with the latter QTL can actually decrease by sampling more extreme sib pairs. This suggests that more extreme sampling is not always better. The ‘optimal’ sampling scheme may depend on both what one suspects the underlying genetic architecture to be and which of the oligogenic QTL one has greatest interest in detecting.

The RV coefficient is known to be suitable for measuring association between homologous configurations. The randomness of such association can be tested by permutational significance. In order to approximate the p-value, we derive the first two moments of the population permutation distribution of the RV coefficient. The permutational distributions of the RV coefficients are explored through several examples. Their permutation distributions appear to be markedly skewed to the right, regardless of the magnitudes of the observed RV coefficients herein. Log-transformation of the first two moments is suggested for a better approximation to the permutational p-value.

Minniti: Bluebird Bio: Other: Adjudicating Committee; Global Blood Therapeutics: Research Funding; Bayer: Research Funding; Teutona: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees.