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Background Perinatal TORCH infections (Toxoplasma gondii, rubella, cytomegalovirus [CMV], herpes simplex virus [HSV]) cause significant fetal and neonatal morbidity and mortality. While perinatal infections are associated with a variety of clinical manifestations in the fetus, they rarely cause isolated intrauterine growth restriction (IUGR). TORCH screens are often ordered to investigate isolated IUGR, but there is limited evidence to support screening for these infections in the absence of other ultrasound abnormalities. Methods A retrospective review of antenatal TORCH testing between January 2014 and December 2018 was carried out at two hospitals in Melbourne, Australia. Records were reviewed to identify indications for testing, serology results, and subsequent antenatal investigations. Neonatal outcomes were also evaluated. Serology performed for stillbirth or pregnancy losses were excluded. Results Medical records of 718 pregnancies were reviewed, representing 760 fetuses. 82.5% of screens were ordered in the third trimester, with 43.5% ordered after 32 weeks gestation. TORCH serology was performed for the following indications: isolated IUGR (71.2%), neurological abnormality (6.8%), echogenic bowel (3.4%), and maternal illness (1.7%). Screens ordered for isolated IUGR were positive in 7.4% (95% CI 5.5-10.0%). TORCH screening identified 49 positive maternal IgM results (CMV = 34, toxoplasma = 15) Two acute maternal infections during pregnancy were diagnosed (CMV = 1, toxoplasma = 1). Both were identified due to symptomatic maternal illness. There was one confirmed neonatal CMV infection. Eight women did not have follow-up to determine the significance of a positive IgM result. No TORCH screen changed maternal management or neonatal outcomes. Rubella IgM was ordered in 83.5% of women who had clearly documented evidence of prior rubella immunity. No acute HSV infections were identified. Conclusion Antenatal TORCH screening for IUGR is of minimal utility and is often performed as a reflex rather than in response to specific clinical syndromes. A more guided approach with selective testing is needed. Disclosures All Authors: No reported disclosures.

The long-term effects of prenatal coronavirus disease 2019 (COVID-19) infection on the fetal brain are mostly unknown at this time; however, there is increasing evidence being published.Two cases of severe ventriculomegaly, neurological dysfunction, and seizures were found in neonates with prenatal exposure to COVID-19 infection during the first and third trimesters of pregnancy.Inflammation during the prenatal and neonatal periods may be associated with neurological disorders or injury. Despite the presumed lack of vertical transmission, post-COVID-19 syndrome and its associated inflammation may have an impact on the unborn fetus. Hyper-vigilance and dissemination of adverse findings are of significant importance as we navigate through this evolving pandemic and its effects.· Prenatal exposure to COVID-19 may affect the fetal brain.. · There is a possibility of neonatal neurological sequelae from maternal COVID-19.. · Does maternal COVID-19 infection cause infantile seizures?.

Introduction Despite a high prevalence of sleep problems, there is a gross shortage of sleep clinicians within the military health system. To increase access to care, a novel telehealth platform was designed to empower patients and clinicians to make evidence-based sleep treatment decisions. Here, we present initial results from the implementation of this novel sleep telehealth platform in two military treatment facilities (MTFs). Methods Participants (N=305) with sleep complaints were recruited remotely and/or in-person from two MTFs. Participants were predominately men (53.4%), who self-identified as White (55.4%) or Black (24.1%) race and were retired or active-duty military servicemembers (69%). Average age was 45.9 (SD=13.3) years. Participants completed a baseline assessment including standardized research questionnaires via a mobile application (WellTap®). During a 10-day remote monitoring assessment, participants completed daily sleep diaries and twice-daily mood/daytime function surveys, while wearing a commercial-off-the-shelf device (Fitbit®). A personalized sleep report including evidence-based treatment recommendations was provided. Participants completed a satisfaction survey regarding the remote monitoring assessment. Results The most commonly reported sleep problems were difficulty staying asleep (65%), insufficient sleep (61%), and snoring (40%). Most participants described their sleep quality as “a little good” (51%) or “not at all good” (27%). Thirty-nine percent of participants reported moderate to severe insomnia complaints, 38% reported moderate to severe excessive daytime sleepiness, and 22% reported moderate to severe depressive symptoms. In terms of satisfaction, participants reported the sleep assessments were “easy” to complete (92%) and would consider sleep telehealth approaches in the future (95%). The vast majority of participants preferred to continue with sleep telehealth and preferred to combine a mobile app and remote monitoring with either virtual or face-to-face provider support. Conclusion Patients at two military treatment hospitals reported high levels of satisfaction with a novel 10-day intensive remote monitoring assessment including a mobile health assessment and wrist-wearable device. Future studies should evaluate the clinical and economic impact of sleep telehealth and remote monitoring in the U.S. military. Support (if any) Department of Defense (W81XWH1990006) via the Medical Technology Enterprise Consortium) to the University of Maryland, Baltimore (PI: EMW).

Objective The study aimed to evaluate the validity of transcutaneous bilirubin (TcB) measurements at three sites in premature infants born at 230/7 to 346/7 weeks' gestational age (GA) compared with total serum bilirubin (TSB) measurements. Study design A prospective study was conducted at Banner - University Medical Center Phoenix, where informed consent was obtained from the infant's parent or legally authorized representative. Cohort A was comprised of infants 230/7 to 286/7 weeks' GA and Cohort B contained subjects 290/7 to 346/7 weeks' GA. Baseline TSB measurements were collected at approximately 24 hours of life, as the standard of care and the TcB measurements were obtained from the sternum, interscapular, and buttock areas at approximately ± 30 minutes from collection of the TSB. Statistical analysis of measurements including sensitivity, specificity, positive, and negative predictive values, and the area under the receiver operator characteristic curve (AUROC) were performed. Results A total of 166 infants were included in the study population. Cohort A consisted of 41 subjects and Cohort B contained 125 subjects. The results showed that baseline TcB measurements from the interscapular area were the most sensitive and specific with TSB levels >5.0 mg/dL in Cohort A. Baseline TcB measurements from the sternum demonstrated greatest sensitivity and specificity when the TSB level was >8.0 mg/dL in Cohort B. In general, each of the three sites in both cohorts demonstrated excellent AUROCs and negative predictive values. Conclusion The use of a TcB meter in preterm infants can be a reliable noninvasive screening tool for hyperbilirubinemia, and it may be beneficial in decreasing painful stimuli and iatrogenic blood loss when used as an adjunct to TSB monitoring. Key points · Interscapular TcB is sensitive/specific in 23 to 29 weeks' GA.. · Sternal TcB is sensitive/specific in 29 to 35 weeks' GA.. · TcB readings are reliable in preterm infants.. · TcB is reliable when serum bilirubin is >5.0 mg/dL..

Objective Since the global outbreak of the novel coronavirus disease 2019 (COVID-19), there have been increasing reports of children developing a croup-like cough associated with concurrent COVID-19 infection. Currently, there is not much information available regarding newborn infants and COVID-19 infection and the incidence of vertical transmission is thought to be rare. This novel case report depicts a term newborn infected at the time of birth with COVID-19 and includes details about the course of their complicated hospitalization. Study Design A term infant, found to be infected at birth with COVID-19, developed respiratory distress resulting in transfer to our neonatal intensive care unit. Due to the increasing respiratory support requirements, endotracheal intubation was required on day of life (DOL) 7. Later, when the infant was extubated, on DOL 21, a croup-like cough developed. Results Despite respiratory treatment with albuterol, budesonide, racemic epinephrine, lidocaine, dornase alfa, and a 10-day course of dexamethasone, the cough persisted. A prolonged hospitalization was required and eventually the infant was discharged home on 0.4 L/minute of oxygen via nasal cannula on DOL 95. Conclusion As the COVID-19 virus mutates over time, there are some seemingly different presentations in both the pediatric and adult populations. The hypervigilance and sharing of new findings among providers are paramount in the treatment of infants with COVID-19 disease. Key Points

Objective This study was aimed to evaluate the effect of human milk protein fortifier (HMPF) versus bovine milk protein fortifier (BMPF) on feeding tolerance defined as the time to reach full feeds and necrotizing enterocolitis (NEC) in premature very low birth weight (VLBW) infants. Study design A retrospective review using the BabySteps Database included 493 infants born ≤33 weeks of gestational age and ≤1,250 g (g) birth weight. A total of 218 infants fed a human milk diet (HMD) with BMPF were compared with 275 infants fed an HMD with HMPF. Results Full feeds were reached significantly sooner in the HMPF group (median: 14 vs. 16 days, p = 0.04). Weight at full feeds was significantly lower in the HMPF group (1,060 vs. 1110 g, p = 0.03). Conclusion Using HMPF to provide an exclusively HMD allowed VLBW infants to achieve full feeds sooner, but did not affect rate of NEC compared with using a BMPF with an HMD. Key points · Human milk fortifiers with human milk are better than bovine human milk protein fortifiers.. · Full feeds are reached sooner with a human milk protein fortifier.. · The incidence of NEC did not change with the use of Prolacta..

Introduction Cognitive complaints are common among older adults with insomnia. However, previous research is inconsistent regarding the association between insomnia and objective cognitive function. The purpose of this study was to compare subjective and objective cognitive function between older adults with insomnia and healthy sleepers. We hypothesized that relative to healthy sleepers, older adults with insomnia would display diminished subjective and objective cognitive function as measured via multiple remote assessment methods. Methods Participants were recruited from an academic medical center through multiple pathways. Cognitive assessments were administered via several approaches. First, subjective cognitive function was assessed via the 5-item Alert Cognition subscale of the psychometrically derived Daytime Insomnia Symptoms Scale (DISS), completed via smartphone 4x/day throughout a two-week study period (i.e., 56 administrations over 14 days). Second, objective cognitive function was assessed via telephone using the Brief Test of Adult Cognition by Telephone (BTACT), which assesses memory, reasoning, verbal fluency, and executive function. Finally, the psychomotor vigilance task [PVT], Stroop test, and a task-switching exercise were administered remotely via participant’s home desktop computer. Results Participants included 31 older adults who met DSM-V diagnostic criteria for insomnia disorder (67.5 [sd 6.6] years) and 33 older adults without sleep disorders (70.5 [sd 5.7] years). Large between-group differences were observed in the Alert Cognition subscale of the DISS (p-values < 0.0001); compared to healthy sleeper controls, participants with insomnia reported worsened forgetfulness, concentration, alertness, clear-headedness, and cognitive effort. No between-groups differences were observed in any domain of the BTACT or PVT. A numeric but not statistically significant between-groups difference was observed in overall response speed (e.g., Incongruent Response Time) on the Stroop test (p-values > 0.125). Conclusion Remote assessment of cognition is feasible among older adults with insomnia. Significant differences in subjective but not objective cognitive function, likely due to low statistical power, as cognitive deficits in insomnia tend to have small effect sizes. Overall, findings highlight the importance of multimethod assessments of cognition in older adults with insomnia and need for large sample sizes when evaluating objective cognitive function. Support (if any) Research was supported by an investigator-initiated research award from Merck Investigator Studies Program (PI: EMW).

OBJECTIVE To evaluate the effect of a single dose of prophylactic vancomycin prior to the removal of a peripherally inserted central catheter (PICC) in decreasing sepsis evaluations, positive cultures, and antibiotic usage in neonates. METHODS A retrospective review was conducted from December 1, 2015, through November 30, 2019, to evaluate outcomes of sepsis evaluations, positive cultures, and antibiotic usage in neonates not receiving prophylactic vancomycin prior to the discontinuation of a PICC as compared with those receiving prophylaxis vancomycin in a neonatal intensive care unit (NICU). RESULTS Of the 138 neonates enrolled in the study, 82 did not receive vancomycin prophylaxis (Cohort 1), and 56 did (Cohort 2). Both cohorts were similar in sex distribution, gestational age, and PICC days. The frequency of sepsis evaluations, positive cultures, and the need for antibiotics was not found to be significant (p = 0.404, 0.703, 0.808) (Table 2). CONCLUSIONS The results did not show a statistically significant improvement in the incidence of sepsis in neonates who received prophylactic vancomycin prior to PICC discontinuation. However, there were lower percentages of sepsis evaluations, positive cultures, and antibiotics administered in the Cohort 2 patients. Although the advantage of implementing this antibiotic policy is uncertain based on this study, further research across multiple centers including a larger number of subjects may provide more conclusive results.

Study objective The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. Methods We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in the parent trial included critically injured adult patients admitted to 1 of 12 North American Level I trauma centers who received at least 1 unit of packed RBCs and were predicted to require massive blood transfusion. The primary exposure was volume of packed RBC units transfused during the first 24 hours of hospitalization, stratified by packed RBC age category: 0 to 7 days, 8 to 14 days, 15 to 21 days, and greater than or equal to 22 days. The primary outcome was 24-hour mortality. We evaluated the association between transfused volume of each packed RBC age category and 24-hour survival, using random-effects logistic regression, adjusting for total packed RBC volume, patient age, sex, race, mechanism of injury, Injury Severity Score, Revised Trauma Score, clinical site, and trial treatment group. Results The 678 patients included in the analysis received a total of 8,830 packed RBC units. One hundred patients (14.8%) died within the first 24 hours. On multivariable analysis, the number of packed RBCs greater than or equal to 22 days old was independently associated with increased 24-hour mortality (adjusted odds ratio [OR] 1.05 per packed RBC unit; 95% confidence interval [CI] 1.01 to 1.08): OR 0.97 for 0 to 7 days old (95% CI 0.88 to 1.08), OR 1.04 for 8 to 14 days old (95% CI 0.99 to 1.09), and OR 1.02 for 15 to 21 days old (95% CI 0.98 to 1.06). Results of sensitivity analyses were similar only among patients who received greater than or equal to 10 packed RBC units. Conclusion Increasing quantities of older packed RBCs are associated with increased likelihood of 24-hour mortality in trauma patients receiving massive packed RBC transfusion (≥10 units), but not in those who receive fewer than 10 units.

Context.—Automated analyzers have advanced the field of clinical hematology, mandating updated complete blood count (CBC) reference intervals (RIs) to be clinically useful. Contemporary newborn CBC RI publications are mostly retrospective, which some authors have cited as one of their cardinal limitations and recommended future prospective studies.Objective.—To prospectively establish accurate hematologic RIs for normal healthy term newborns at 24 hours of life given the limitations of the current medical literature.Design.—This prospective study was conducted at an academic tertiary care center, and hematology samples were collected from 120 participants deemed to be normal healthy term newborns. Distributions were assessed for normality and tested for outliers. Reference intervals were values between the 2.5th percentile and 97.5th percentile.Results.—The novel RIs obtained for this study population are as follows: absolute immature granulocyte count, 80/μL to 1700/μL; immature granulocyte percentage, 0.6% to 6.1%; reticulocyte hemoglobin equivalent, 31.7 to 38.4 pg; immature reticulocyte fraction, 35.9% to 52.8%; immature platelet count, 4.73 × 103/μL to 19.72 × 103/μL; and immature platelet fraction, 1.7% to 9.8%.Conclusions.—This prospective study has defined hematologic RIs for this newborn population, including new advanced clinical parameters from the Sysmex XN-1000 Automated Hematology Analyzer. These RIs are proposed as the new standard and can serve as a strong foundation for continued research to further explore their value in diagnosing and managing morbidities such as sepsis, anemia, and thrombocytopenia.

Endotheliopathy of trauma is characterized by breakdown of the endothelial glycocalyx. Elevated biomarkers of endotheliopathy, such as serum syndecan-1 (Synd-1) ≥ 40 ng/mL, have been associated with increased need for transfusions, complications, and mortality. We hypothesized that severely injured trauma patients who exhibit elevated Synd-1 levels shortly after admission have an increased likelihood of developing sepsis.We analyzed a subset of patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial who survived at least 72 hours after hospital admission, and we determined elevated Synd-1 levels (≥ 40 ng/mL) 4 hours after hospital arrival. Sepsis was defined a priori as meeting systemic inflammatory response criteria and having a known or suspected infection. Univariate analysis was performed to identify variables associated with elevated Synd-1 levels and sepsis. Significant variables at a value of p0.2 in the univariate analysis were chosen by purposeful selection and analyzed in a mixed effects multivariate logistic regression model to account for the 12 different study sites.We included 512 patients. Of these, 402 (79%) had elevated Synd-1 levels, and 180 (35%) developed sepsis. Median Synd-1 levels at 4 hours after admission were 70 ng/dL (interquartile range [IQR] 36 to 157 ng/dL) in patients who did not develop sepsis, and 165 ng/dL [IQR 67 to 336 ng/dL] in those who did (p0.001). Adjusting for treatment arm and site, multivariable analyses revealed that elevated Synd-1 status, Injury Severity Score (ISS), and total blood transfused were significantly associated with an increased likelihood of developing sepsis.Elevated Synd-1 levels 4 hours after admission in severely injured adult trauma patients who survived the initial 72 hours after hospital admission are associated with subsequent sepsis.

BACKGROUND:A noninvasive decision support tool for emergency transfusion would benefit triage and resuscitation. We tested whether 15 minutes of continuous pulse oximetry–derived hemoglobin measurements (SpHb) predict emergency blood transfusion better than conventional oximetry, vital signs, and in

University of Texas Medical Branch (UTMB) implemented the Clinical Competency and Advancement Program (CCAP) in January 2011. The program, built upon American Nurse Association (ANA) standards,1 is a professional development tool for competency assessment, performance evaluation, and career advancement for nurse clinicians from levels Nurse Clinician (NC) I to NC V. UTMB requires each nurse clinician to complete and submit CCAP program documents annually to the manager. In CCAP, nurse clinicians have required and elective (self-selected) criteria that must be demonstrated through performance, activity, or documentation. Nurses earn points, weighted by complexity, for accomplishments. Eligibility criteria and point requirements are progressively higher for each NC level, I to V. Elective criteria include a wide range of professional activities from which the nurse clinician may select, whereas required criteria reflect the expected nursing practice and performance for every nurse. Implementing CCAP meets the definition of "innovation" as a core group of nurse clinicians and leaders constructed, created, and implemented a totally new visionary process. CCAP reflects a stronger UTMB culture of professional practice and personal accountability, with an overarching outcome of higher levels of professional performance in patient care delivery. CCAP changes the way nurses view their practice. In June of 2012, UTMB submitted an initial CCAP article that was published in AONE's Nurse Leader.2

5567 Background: Hormonal therapy has limited activity in gynecologic (Gyn) cancer treatment. mTOR inhibitors plus aromatase inhibitors (AI's) improve the response rate and response duration in breast cancer patients. We studied this combination in heavily pre-treated women having estrogen receptor positive (ER+) Gyn cancers. Methods: This phase II study combines everolimus and letrozole for ER+ Gyn cancers with disease progression following primary and salvage chemotherapy. 19 patients participated (Ovary-10, Endometrium-7, and Primary Peritoneal Cancer-2). The mean age was 64, prior lines of therapy ranged from 2-7, and median time from diagnosis to study entry was 67 months (m) (range 10-348m). Results: There were no complete responders, but 7 of 19 (37%) patients treated had clinical benefit, with 1 PR and 6 with stable disease. In responding patients, the earliest time to best response was 2m and the median time to progression was 5m (range 5-40+m). The mean number of treatment cycles was 11. Toxicities: The most common adverse events were: hyperglycemia, rash, stomatitis, fatigue, and anemia. 7 patients required dose reductions, and 2 discontinued study drugs due to pneumonitis. The therapy was generally well tolerated in both women < 65 and > 65 years old. Toxicities were less common with reduced everolimus doses. Conclusions: Recurrent Gyn cancers become refractory to chemotherapy. We tested the combination of everolimus plus letrozole in heavily pretreated patients with ER + recurrent disease. 1 patient had a PR and 6 had stable disease with a range of 5-40+m. This oral regimen was generally well tolerated and allowed time without IV chemotherapy, while providing clinical benefit to patients with refractory ER+ Gyn cancers.

Objective The aim of this study was to determine whether very low-birth-weight (VLBW) infants who had feedings withheld during all blood transfusions had a lower incidence of necrotizing enterocolitis (NEC) compared with infants who were fed during transfusions. Study Design A retrospective chart review over a 3-year period in a level-3 neonatal intensive care unit was conducted. A total of 108 inborn VLBW infants (weight range: 500–1,500 g) who had received a transfusion before 36 weeks were reviewed. Diagnosis of NEC (≥ Bell stage II), demographics, feeds, transfusions, outcomes, and variables associated with NEC were collected. Results The percentage of NEC cases was lower in infants who had feeds withheld during transfusions: 5/64 (7.8%) compared with 16/116 (13.8%) infants who were fed during transfusions. While potentially clinically important (6% absolute difference), this difference was not statistically significant ( p = 0.33 by two-tailed Fisher exact test). Conclusions No significant decrease in the incidence of NEC was found when feeds were withheld during blood transfusions. Holding feeds during transfusions is not without consequences such as the need for intravenous access, additional fluids, and the disruption of optimum nutrition. Further studies are needed to establish the relationship between blood transfusions, feeds, and NEC.

Background: The brain acoustic monitor (BAM), an indicator of cerebral autoregulation, has previously shown high sensitivity but low specificity for computed tomographic (CT) abnormality in patients following the clinical diagnosis of traumatic brain injury. We assessed the utility of the BAM in diagnosing mild TBI (mTBI) in patients with and without normal findings of CT scan, a population for which there are a few objective markers of disease. Methods: We prospectively studied 369 patients with mechanism of injury consistent with TBI. The diagnosis was evaluated by five methods: (a) study enrollment (i.e., mechanism of injury), (b) signs of head trauma, (c) expert physician assessment, (d) presence of initial symptoms (loss of consciousness [LOC]; amnesia), and (e) BAM. All patients had a head CT scan. We compared the BAM screen results with the diagnosis of mTBI and BAM data from 50 normal volunteers and 49 trauma control patients not thought to have TBI. Results: None of the diagnostic methods correlated well with the others. Correlation between the methods ranged from 21% to 71%. BAM discriminated between patients with mTBI versus without TBI (p < 0.01) and patients with mTBI versus normal subjects (p < 0.001). There were 14 patients with new abnormal findings of CT scans. A history of LOC and physical signs of head injury were associated with a new abnormality on head CT (p < 0.05 and p < 0.01, respectively), whereas an abnormal BAM signal was suggestive (p = 0.08). The sensitivity of BAM abnormality for head CT abnormality was 100%, with a specificity of 30.14%. Conclusion: There is no gold standard for the diagnosis of mTBI. BAM screening is a useful diagnostic adjunct in patients with mTBI and may facilitate decision making. An abnormal BAM reading adds significance to LOC as a predictor of a new abnormality on head CT. In our study, opting not to CT scan patients with a normal BAM signal would have missed no new CT findings and no patients who required medical intervention for TBI, at a cost savings of $202,950.

Background Complementary and alternative medicine (CAM) is often used alongside conventional medical care, yet fewer than half of patients disclose CAM use to medical doctors. CAM disclosure is particularly low among racial/ ethnic minorities, but reasons for differences, such as type of CAM used or quality of conventional healthcare, have not been explored. Objective We tested the hypotheses that disclosure of CAM use to medical doctors is higher for provider-based CAM and among non-Hispanic whites, and that access to and quality of conventional medical care account for racial/ ethnic differences in CAM disclosure. Methods Bivariate and multiple variable analyses of the 2002 National Health Interview Survey and 2001 Health Care Quality Survey were performed. Results Disclosure of CAM use to medical providers was higher for provider-based than self-care CAM. Disclosure of any CAM was associated with access to and quality of conventional care and higher among non-Latino whites relative to minorities. Having a regular doctor and quality patient-provider relationship mitigated racial/ethnic differences in CAM disclosure. Conclusion Insufficient disclosure of CAM use to conventional providers, particularly for self-care practices and among minority populations, represents a serious challenge in medical encounter communications. Efforts to improve disclosure of CAM use should be aimed at improving consistency of care and patient-physician communication across racial/ethnic groups.

Medical pluralism can be defined as the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness. American women use a variety of health services and practices for women's health conditions, yet no national study has specifically characterized women's medical pluralism. Our objective was to describe medical pluralism among American women.A nationally representative telephone survey of 808 womenor=18 years of age was conducted in 2001. Cross-sectional observations of the use of 11 CAM domains and the use of an additional domain--spirituality, religion, or prayer for health--during the past year are reported. Women's health conditions, treatments used, reasons for use, and disclosure to conventional physicians are described, along with predictors of CAM use.Over half (53%) of respondents used CAM for health conditions, especially for those involving chronic pain. The majority of women disclosed such practices at clinical encounters with conventional providers. Biologically based CAM therapies, such as nutritional supplements and herbs, were commonly used with prescription and over-the-counter (OTC) pharmaceuticals for health conditions.Medical pluralism is common among women and should be accepted as a cultural norm. Although disclosure rates of CAM use to conventional providers were higher than in previous population-based studies, disclosure should be increased, especially for women who are pregnant and those with heart disease and cancer. The health risks and benefits of polypharmacy should be addressed at multiple levels of the public health system.

This study provides national prevalence estimates for complementary and alternative (CAM) use, visits to doctors for health problems, and the effects of acculturation on health practices in Chinese women living in the United States. A national telephone survey of 3,172 women on their use of complementary and alternative medicine was conducted in 2001. This study focuses on a subsample of 804 Chinese-American women who were asked about health practices and service utilization. Interviews were conducted in Mandarin, Cantonese and English. Forty-one percent of Chinese-American women used some form of CAM in 2001. Socio-economic status, a common predictor of CAM use in other studies of the general population in the United States, did not predict use in this sample. Traditional Chinese medicine (TCM) is used across acculturation levels. As Chinese women adapt to American culture they tend to use a greater variety of healthcare practices and to adopt mainstream CAM practices, but they also continue to use TCM.

Accurate prognostication of outcomes following traumatic brain injury (TBI) affects not only the aggressiveness of intervention and therapeutic decision-making but also clinicians' ability to provide reliable expectations. To investigate the relative ability of clinicians to accurately predict a patient's outcomes, compared with point-of-care prognostic models, we surveyed clinical providers of 86 patients with moderate-severe TBI at admission, Day 3, and Day 7 post-injury for a patient's predicted mortality and functional outcome at 6 months. The predicted mortality and functional outcomes were compared with actual occurrence of 14-day mortality and functional outcomes at six months. A prognostic score was then calculated utilizing the Corticoid Randomization After Significant Head Injury (CRASH) and International Mission on Prognosis and Analysis of Clinical Trials (IMPACT) models and categorized as high, intermediate, and low likelihood of mortality or poor functional outcome, and compared with clinical predictions. Overall, clinicians of varying backgrounds showed an accurate prediction of survival (87.2-97.4%) but struggled in prognosticating poor functional outcomes (24.3-36.6%). These values did not statistically improve over 7 days. Stratified CRASH (87.2%) and IMPACT (84.9%) accuracy rates were statistically better than clinical judgment alone in predicting functional outcomes (

This study documents the use of complementary and alternative medicine (CAM), among White, African American, and Hispanic/Latina women living in New York City. A pilot to a national survey of CAM use among American women, this study explores women's use of categories of CAM and various CAM practitioners, racial and ethnic differences in CAM use, and women's perceptions regarding the effectiveness of CAM. DESIGN AND LOCATION: Data were collected from women residing in New York City using random digit dialing/computer-assisted telephone interviewing (CATI). The sample of 300 had equal numbers of women (n = 100) who self-identified as White, Hispanic/Latina, and African American, equally stratified by age (below and above age 40).Eligibility requirements included self-identification as Anglo/white, African American, or Hispanic/Latina and between ages 18 and 80.Three distinct categories of CAM were explored: (1) medicinal teas, homeopathic remedies, herbs, vitamins; (2) yoga, meditation, spiritual practices; and (3) manual therapies including chiropractic, massage, acupressure. Health concerns of interest were those frequently described in prior focus groups, and included reproductive health issues (e.g., pregnancy, menstruation, menopause) as well as other common women's health problems (e.g., heart disease, high blood pressure, headaches).More than half the sample has used a CAM treatment or remedy, and 40% have visited a CAM practitioner. Among users, half have used only one of the CAM categories, approximately one third have used two, and 16% used all three. The category of CAM used most often was medicinal tea/herbs/vitamins; the practitioners visited most frequently were chiropractors (18%) and nutritionists (17%). Racial and ethnic differences in CAM use were minimal, and approximately one third of all treatments used were rated "very effective" by users.Substantial utilization of CAM remedies and treatments for a variety of women's health concerns is observed. Further inquiry with larger samples of women is recommended.

Purpose The purposes of this study were to: 1) determine if previously published descriptors of the supine to stand rising task in healthy individuals could be applied to the movements of persons with Prader-Willi Syndrome (PWS); and 2) assess upper extremity (UE), axial region (AX), and lower extremity (LE) movements among subjects with PWS compared with controls. Methods Nine subjects with PWS (seven-36 years of age) and matched controls were videotaped performing 10 rising trials. The UE, AX, and LE movements were classified using published descriptors. Occurrence frequencies of movement patterns, duration of movement, and the relationships among body region movement score, BMI, and age were determined. Results Subjects with PWS utilized developmentally less advanced asymmetrical rising patterns, took longer to rise, and demonstrated less within subject variability than controls. Conclusions Categorical descriptors, with minor modifications, can be used to describe rising movements in persons with PWS. Knowledge of successful rising patterns may assist PTs when examining or planning intervention strategies for teaching the rising task.

This small, pilot study examined presenting complaint, brief health history, use of complementary and alternative medicine (CAM), and sociodemographic characteristics, among patients attending the emergency department (ED) of a large urban hospital. The sample (n = 50) was primarily Dominican and of low socioeconomic status. Almost half had used CAM for their presenting complaint or another health problem during the past year, most commonly in the form of medicinal plants made into herbal teas. CAM users were more likely to be female, longer-term residents of the United States, and to have also used religious practices for health problems. Subjects who had used CAM for any problem other than the presenting complaint during the past year rated its effectiveness higher than subjects who had used CAM for their presenting complaint. In conclusion, it is likely that a significant proportion of Dominican ED patients use CAM, suggesting that they should be asked about their CAM use during triage.

Complementary and alternative medicine is becoming an established intervention modality within the contemporary health care system. Various forms of complementary and alternative medicine are used by patients and practitioners alike, including chiropractic, massage, botanical medicine, homeopathy, and energy therapies. The National Center for Complementary and Alternative Medicine was established within the National Institutes of Health to facilitate evaluation of these alternative therapies, establish an information clearinghouse, and promote research in the field. This article discusses several aspects of complementary and alternative medicine, relates them to women's health, and describes the need for a research agenda to evaluate the impact of the complementary and alternative medicine modalities used for important conditions affecting women.

Mitochondrial dysfunction may be central to the pathophysiology of traumatic brain injury (TBI) and often can be recognized cytologically by changes in mitochondrial ultrastructure. This study is the first to broadly characterize and quantify mitochondrial morphologic alterations in surgically resected human TBI tissues from three contiguous cortical injury zones. These zones were designated as injury center (Near), periphery (Far), and Penumbra. Tissues from 22 patients with TBI with varying degrees of damage and time intervals from TBI to surgical tissue collection within the first week post-injury were rapidly fixed in the surgical suite and processed for electron microscopy. A large number of mitochondrial structural patterns were identified and divided into four survival categories: normal, normal reactive, reactive degenerating, and end-stage degenerating profiles. A tissue sample acquired at 38 hours post-injury was selected for detailed mitochondrial quantification, because it best exhibited the wide variation in cellular and mitochondrial changes consistently noted in all the other cases. The distribution of mitochondrial morphologic phenotypes varied significantly between the three injury zones and when compared with control cortical tissue obtained from an epilepsy lobectomy. This study is unique in its comparative quantification of the mitochondrial ultrastructural alterations at progressive distances from the center of injury in surviving TBI patients and in relation to control human cortex. These quantitative observations may be useful in guiding the translation of mitochondrial-based neuroprotective interventions to clinical implementation.

Nature-derived antimalarials might have anticancer potential, yet no systematic reviews exist on the topic. We screened MEDLINE using an automated algorithm in a high-volume search for antimalarial agents recognized by the WHO and natural antimalarials from knowledge-resource texts and databases for reported evidence of anticancer activity. Results are reported by source (plants, fungi, marine organisms and bacteria) and anticancer mechanism. In total, 14 out of 15 nature-derived antimalarials (93%) referenced by WHO as well as 146 of 235 antimalarial natural species (62%) from our defined MEDLINE search were reported as having anticancer activity. Therefore, antimalarial natural products might provide a fertile and much needed lead in anticancer drug discovery.

Twist1 has been demonstrated to play critical roles in the early development of neural crest and mesodermally derived tissues including the limb. Twist2 has been less well characterised but its relatively late onset of expression suggests specific roles in the development of a number of organs. Expression of Twist2 within the developing limbs begins after formation of the limb bud and persists within the peripheral mesenchyme until digital rays condense. We have used RCAS-mediated overexpression in chick to investigate the function of Twist2 in limb development. Viral misexpression following injection into the lateral plate mesoderm results in a spectrum of hypoplastic limb phenotypes. These include generalized shortening of the entire limb, fusion of the autopod skeletal elements, loss of individual digits or distal truncation resulting in complete loss of the autopod. These phenotypes appear to result from a premature termination of limb outgrowth and manifest as defective growth in both the proximal–distal and anterior–posterior axes. In situ hybridisation analysis demonstrates that many components of the Shh/Grem1/Fgf regulatory loop that controls early limb growth and patterning are downregulated by Twist2 overexpression. Grem1 has a complementary expression pattern to Twist2 within the limb primordia and co-expression of both Grem1 and Twist2 results in a rescue of the Twist2 overexpression phenotype. We demonstrate that Twist proteins directly repress Grem1 expression via a regulatory element downstream of the open reading frame. These data indicate that Twist2 regulates early limb morphogenesis through a role in terminating the Shh/Grem1/Fgf autoregulatory loop.

Chemokines are small secreted signalling molecules best known for their roles as chemoattractants for cells of the immune system. CXCL12 and its receptor CXCR4 comprise one chemokine signalling pathway with essential functions in non-immune cell types during embryonic development. CXCL14, a chemokine-encoding gene related to CXCL12, is developmentally regulated in zebrafish and Xenopus embryos, but its role during embryogenesis remains unknown. Here we describe the embryonic expression pattern of CXCL14 in an amniote, the chick. Although expression in some regions is conserved with that of fish and frog, chick CXCL14 displays a complex pattern of expression in several novel sites. We analyse the expression pattern in the branchial arches, trigeminal placode and ganglion, inner ear, dorsal midline of the brain, somites, trunk neural tube and limb bud. Expression in several domains raises the possibility that CXCL14 may be involved in some of the same developmental events during which CXCL12-CXCR4 signalling is known to play a role.

Intravaginal topical microbicides are being investigated for prevention of HIV transmission. Use of vaginal microbicides will constitute a new type of practice, occurring in the context of other vaginal practices related to contraception, hygiene, and self-care, which are affected by cultural norms and personal beliefs. Given the high rate of HIV infection among black women, research on practices and decision making relevant to microbicide acceptability is needed in this population.Twenty-three black women in New York City, aged 25-64, completed in-person semistructured interviews and self-administered questionnaires. Quantitative analyses examined vaginal practices and willingness to use microbicides. Qualitative analyses explored underlying decision-making processes involved in choices regarding vaginal practices and general healthcare.Willingness to use vaginal products for HIV prevention was high, especially among more educated women. Safety was a major concern, and women were cautious about using vaginal products. Whereas some viewed synthetic products as having potentially harmful side effects, others perceived natural products as risky because of insufficient testing. Choices about vaginal practices were affected by assessments of risk and efficacy, prior experience, cultural background, and general approach to healthcare.The majority of women in the sample expressed willingness to use a vaginal product for HIV prevention. Decision-making processes regarding vaginal practices were complex and were affected by social, cultural, and personal factors. Although specific preferences may vary, attitudes toward using a vaginal product are likely to be positive when side effects are minimal and the product is considered safe.

Objective To determine if injection of vitamin K3 in an acupuncture point is optimal for the treatment of primary dysmenorrhoea, when compared with 2 other injection treatments. Setting A Menstrual Disorder Centre at a public hospital in Shanghai, China. Participants Chinese women aged 14–25 years with severe primary dysmenorrhoea for at least 6 months not relieved by any other treatment were recruited. Exclusion criteria were the use of oral contraceptives, intrauterine devices or anticoagulant drugs, pregnancy, history of abdominal surgery, participation in other therapies for pain and diagnosis of secondary dysmenorrhoea. Eighty patients with primary dysmenorrhoea, as defined on a 4-grade scale, completed the study. Two patients withdrew after randomisation. Interventions A double-blind, double-dummy, randomised controlled trial compared vitamin K3 acupuncture point injection to saline acupuncture point injection and vitamin K3 deep muscle injection. Patients in each group received 3 injections at a single treatment visit. Primary and secondary outcome measures The primary outcome was the difference in subjective perception of pain as measured by an 11 unit Numeric Rating Scale (NRS). Secondary measurements were Cox Pain Intensity and Duration scales and the consumption of analgesic tablets before and after treatment and during 6 following cycles. Results Patients in all 3 groups experienced pain relief from the injection treatments. Differences in NRS measured mean pain scores between the 2 active control groups were less than 1 unit (−0.71, CI −1.37 to −0.05) and not significant, but the differences in average scores between the treatment hypothesised to be optimal and both active control groups (1.11, CI 0.45 to 1.78) and (1.82, CI 1.45 to 2.49) were statistically significant in adjusted mixed-effects models. Menstrual distress and use of analgesics were diminished for 6 months post-treatment. Conclusions Acupuncture point injection of vitamin K3 relieves menstrual pain rapidly and is a useful treatment in an urban outpatient clinic. Trial registration number NCT00104546; Results.

Objective: This study examined patterns of and reasons for use of complementary and alternative therapies among women with depression, focusing in particular on three popular types of complementary and alternative therapies—manual therapies (for example, chiropractic treatments, massage, and acupressure), herbs, and vitamins. Methods: The multiethnic sample consisted of 220 women with depression who were assessed as part of a nationally representative telephone survey of 3,068 women. Results: Fifty-four percent of these women with depression reported past-year use of complementary and alternative medicine. African-American women were less likely to use complementary and alternative therapies in general, compared with non-Hispanic white women. Other factors significantly associated with use of complementary and alternative medicine in general included being employed, being single, and having self-perceived poor health. The relationships between the sociodemographic factors and use of each of the three individually examined types of therapies differed from their relationships with use of complementary and alternative medicine in general. Participants’ most commonly cited reasons for use of these therapies were wanting treatments to be based on a “natural approach,” wanting treatments to be congruent with their own values and beliefs, and past experiences in which conventional medical therapies had caused unpleasant side effects or had seemed ineffective. Conclusions: It is important for mental health and other health professionals to increase their own awareness of the types of complementary and alternative therapies that their patients may be using and to improve communication with their patients about the benefits and potential risks of these therapies. (Psychiatric Services 58:349–356, 2007)

Although racial/ethnic differences in the prevalence of complementary and alternative medicine (CAM) utilization have been documented, differences in the reasons for using CAM have not been empirically assessed. In an increasingly diverse society, understanding differences in rates of and reasons for CAM use could elucidate cultural and social factors of health behaviors and inform health care improvements. The current study examines reasons for CAM use among women in four racial/ethnic groups.A national telephone survey of 3172 women aged 18 years and older was conducted in four languages. Respondents were asked about their use of remedies or treatments not typically prescribed by a medical doctor. This study focuses on those women who used CAM in the previous year and their reasons for using CAM.Non-Hispanic white women were most likely to cite personal beliefs for CAM use. Cost of conventional medicine was most prevalent among Mexican-American women CAM users. Physician referral, family and friends, and media sources were all equally likely to lead to CAM use in non-Hispanic white women. In contrast, informal networks of family and friends were the most important social influences of CAM use among African-, Mexican-, and Chinese-American women.Racial/ethnic differences in reasons for CAM use highlight cultural and social factors that are important to consider in public evaluation of the risks and benefits of CAM remedies and treatments.

This paper explores the challenges and opportunities associated with the evaluation of treatments arising from traditional medical systems (TMS). Globalization and popular consumer-and industry-driven market forces contribute to the spread of traditional treatments, techniques and technologies, but do not necessarily ensure their usefulness or safety. The international scientific community is obliged to evaluate the safety and efficacy of these treatments because of their potential impact on global public health. Clinical evaluations of traditional treatments, however, have complex methodological and practical challenges, depending on the goals of the research and the audience for the results (country of origin; or new host countries and new patient populations). To address these challenges, the authors offer the following recommendations to identify and prioritize treatments to study and how to design study protocols. Evaluations of traditional treatments are best addressed first by collaborative, international, pragmatic studies. Protocols for observational, prospective, pragmatic pilot study (randomized and controlled, when feasible) should be designed collaboratively and executed simultaneously in the culture of origin and in new contexts. This, in turn, could determine the acceptability, usefulness and feasibility of larger randomized controlled trials (RCTs). International multicentre RCTs would have the potential benefits of evaluating safety and effectiveness and also assessing the transferability of a traditional treatment across social and cultural contexts.

Vitamin K acupuncture point injection, a menstrual pain treatment derived from traditional Chinese medicine, has been a standard treatment in some hospitals in China since the 1980s.To investigate the effects of vitamin K acupuncture point injection on menstrual pain in young women aged 14 to 25 from different countries and cultural backgrounds who have had unmitigated severe primary dysmenorrhea for 6 months or more.Prospective, observational, clinical pilot studyOne site in China (a hospital outpatient clinic in Shanghai) and 2 sites in Italy (a hospital clinic in Milan and a private gynecology practice in Verona).All subjects were treated with bilateral acupuncture point injection of vitamin K on the first or second day of menstrual pain. Vitamin K3 was used in China and vitamin K4 in Italy.Pain intensity, total duration, and average intensity of menstrual distress, hours in bed, normal daily activity restrictions, and numbers of analgesic tablets taken to relieve pain were recorded before the treatment and for 4 subsequent menstrual cycles.Noticeable pain relief was observed 2 minutes after treatment, and subsequent pain reduction occurred at 30 minutes (P.001). Subjects reported significantly fewer daily life restrictions, fewer hours in bed, less consumption of analgesic tablets, and lower scores of menstrual pain duration and intensity (P.001). There were no adverse events. Some women experienced mild, self-limited pain at the injection site.Acupuncture point injection with vitamin K alleviated acute menstrual pain, and relief extended through the nontreatment follow-up cycles in this uncontrolled pilot study conducted in 2 countries. Further investigation employing controlled experimental designs is warranted.

This study describes the prevalence and patterns of use of religion and spirituality for health reasons among African-American women.Respondents were asked about their use of religion/spirituality for health reasons as part of a larger study of the prevalence and correlates of complementary and alternative medicine (CAM) use among women. In 2001, a national survey of 3,172 women, aged 18 and older, was conducted in 4 languages, with over-sampling among African-, Mexican-, and Chinese-American participants. This paper focuses on the sub-sample of 812 African-American women.Overall, 43% of the African-American women reported using religion/spirituality for health reasons in the past year. Factors significantly associated with the use of religion/spirituality for health reasons included having an income of dollar 40,000-dollar 60,000, an education level of college graduate or more, or being 37-56 years of age; worse health status approached significance. African-American women utilized religion and spirituality most often for serious conditions such as cancer, heart disease, and depression. African-American women who had used religion/spirituality in the past year for health reasons were more than twice as likely to have used some form of CAM, and also more likely to have seen a medical doctor during the year prior to the interview, compared to their counterparts.Religion and spirituality are associated with health-seeking behaviors of African-American women. The use of religion and spirituality for health reasons warrants additional research, particularly its use for chronic and serious conditions, and its role in the health-seeking behavior of African-American women in conjunction with the utilization of conventional medicine and CAM.

The purpose of this study was to determine the utility of descending evoked potentials in evaluating functional recovery in rats after spinal cord contusion injury. Rats received thoracic contusions at T9 using a controlled-displacement impactor. They were evaluated for 5 weeks postinjury using auditory startle responses (ASR) while alert, or by cerebellar motor evoked potentials (CMEP) while anesthetized. ASR and CMEP were recorded electromyographically from forelimb and hindlimb muscles. Open field locomotor performance was also assessed and recovered to almost normal levels by 3 weeks postinjury. Histologic analysis of the injury site indicated that the contusions destroyed approximately 70% of the cross-sectional area of the cord. Although the remaining 30% was sufficient to preserve nearly normal locomotor behavior, ASR and CMEP amplitudes in hindlimb flexors and extensors were reduced by 90% or more after injury and showed virtually no recovery. Significant ASR and CMEP responses were present in the cutaneous trunk muscles of the lower torso after injury. These muscles are innervated via peripheral nerves originating at cord levels above the injury. Multi-wave field potentials normally recorded from the dorsal cord surface in response to cerebellar stimulation were absent in injured rats, suggesting minimal if any activation of segmental neurons via the pathways normally mediating CMEP. The tracts mediating ASR and CMEP thus appear to be highly sensitive to mild spinal cord trauma but are evidently not essential for support or walking.