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Objectives: Emergency physicians without specialized Emergency Medical Services (EMS) training are often required to provide online medical oversight. One common ethical question faced by these physicians is the assessment for decision-making capacity in a patient who does not accept EMS transport to the hospital. We sought expert consensus for a standardized set of guiding questions and recommendations to ensure a rigorous and feasible capacity assessment., Methods: A modified Delphi method approach was used to achieve group consensus among expert individuals. Nineteen physician experts were recruited from across the country, representing populations totaling over 22 million and a variety of urban, suburban, and rural practice environments. Experts completed a Round 1 survey that included 19 questions surrounding best practices for capacity evaluation among patients refusing transport. The threshold for consensus was predefined as 80% agreement. Participants gathered virtually meeting where the results from the first round were shared with the group. Discussion generated new items and refined the language of existing items. Following the virtual meeting, a Round 2 survey was conducted, and voted on by the panel for the items that did not meet consensus in Round 1., Results: After the first round, 15 of 19 items reached consensus. Three of the items that met consensus were universally noted to require language modification for clarification. A large portion of the discussion involved the proper method of integrating patient concerns around ambulance transport (e.g., cost of transport, financial concerns, social barriers) into the capacity assessment and whether alternate care options should be discussed. After the second round of voting, one additional item was reversed to meet consensus, resulting in a total of 16 items., Conclusions: A consensus expert panel was able to agree upon 16 standardized steps to guide best practices and assist emergency physicians in real-time evaluation of patients that refuse EMS transport.

Objectives: Current clinical guidelines from the American Academy of Otolaryngology Head & Neck Surgery (AAO-HNS) recommend a preoperative polysomnogram (PSG) for obese patients prior to adenotonsillectomy (T&A). An overnight admission is recommended for children with severe (AHI >10) obstructive sleep apnea (OSA), citing a higher incidence of post-operative respiratory complications (PRCs) and need for respiratory support. Routine admission of obese children based on AHI >10 alone after T&A may place undue strain on hospital resources and increase healthcare costs, especially considering that many of these children have uncomplicated postoperative courses. In this study, we sought to identify variables from the pre-operative PSG and post-anesthesia care unit (PACU) that could more accurately predict overnight PRCs and indicate the need for a post-surgical admission after T&A., Methods: A single-center retrospective chart review was performed on a cohort of 155 obese children who underwent adenotonsillectomy for OSA. Inclusion criteria included patients 17 years of age and younger who had BMI 95th percentile or greater, underwent preoperative polysomnography, and were admitted overnight after T&A. Overnight respiratory complications were defined as an O 2 desaturation under 92%, the need for overnight airway support, a respiratory support regression, respiratory depression, and bronchospasm/laryngospasm. Multivariable binary logistic regression analysis, point-biserial correlation, and Chi-square tests were performed to assess relationship of BMI z-score, polysomnography parameters, and PACU events with overnight respiratory complications., Results: Lower O 2 saturation nadirs on polysomnography were an independent predictor of respiratory complications overnight (OR = 0.953, 95% CI = 0.91-0.99, P = 0.021), as was sleep time with O 2 saturation less than 90% (OR = 1.04, 95% CI = 1.00-1.07, P = 0.048). A prediction model with preoperative and postoperative variables significant on simple logistic regression yielded a ROC curve with AUC 0.89 (95% CI 0.82, 0.96). At a cutoff point of O 2 saturation nadir less than 80%, overnight PRCs were predicted with 70.8% sensitivity and 75.2% specificity. At a cutoff point of greater than 0.5% of sleep time spent with O 2 < 90% on PSG, overnight PRCs were predicted with 82.6% sensitivity and 62% specificity. Obstructive apneas (OAI) was not predictive of PRCs. BMI percentile was not significantly correlated with overnight respiratory complications, but BMI z-score was significantly correlated with overnight respiratory depression and an overnight airway event., Conclusions: O 2 saturation nadir on PSG and time spent with oxygen saturation <90% (TST90) on PSG were found to be independent predictors of overnight postoperative respiratory complications after adenotonsillectomy in obese children. In addition to reaffirming existing guidelines for postoperative admission of patients with O 2 saturation nadir on PSG <80%, these findings also suggest considering postoperative admission for obese patients who experience >0.5% sleep time with O 2 sat <90% during PSG due to increased risk of overnight postoperative respiratory complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: To evaluate the effectiveness of bamlanivimab at reducing return emergency department (ED) visits in primarily Latinx/Hispanic patients with mild or moderate coronavirus disease 2019 (COVID-19). Secondary aims were to evaluate the prevention of subsequent hospitalizations and deaths in a resource-limited United States (U.S.)-Mexico border hospital., Methods: We conducted a retrospective, open-label interventional study on 270 eligible adult patients diagnosed with mild-moderate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who met criteria for receiving bamlanivimab from November 1, 2020 to January 31, 2021. The main outcomes of 14-day return visits to the ED and hospitalizations due to COVID-19 were compared between two groups - those who received bamlanivimab (exposed group) and those who did not receive bamlanivimab (unexposed group). Outcomes were analyzed through chi-square tests followed by multivariate regression modeling to adjust for patient demographics, characteristics, and comorbidities., Results: There were 136 COVID-19 patients who received bamlanivimab in the ED prior to discharge and an unexposed group of 134 COVID-19 patients who were evaluated and discharged from the ED without receiving bamlanivimab. Overall, mean age was 61.7 (S.D. +/-13.9) years, mean body mass index (BMI) 31.0 (S.D. +/-6.6) kg/m 2 , 91.5% identified as Latinx/Hispanic, 51.9% male, and 80.7% reported at least one comorbidity. Most commonly reported comorbidities were obesity (22.6%), hypertension (59.6%), and diabetes (41.1%). The bamlanivimab group had a 22.8% (mean estimate = 0.7717, 95% CI [0.6482, 0.8611]) risk reduction or 84.4% (0.3030, 95% CI = 0.166, 0.554, p=.0001) absolute reduction of ED return visits within 14 days compared to controls after adjusting for chronic kidney disease. The bamlanivimab group had 19.0% (mean estimate=0.8097, 95% CI [0.6451, 0.9087]) risk reduction or 96.2% (0.235, 95% CI 0.100, 0.550, p=0.0008) absolute reduction of subsequent hospitalizations compared to unexposed patients after adjusting for diabetes status., Conclusion: Bamlanivimab infusions for high-risk COVID-19 patients in the ED substantially reduced the risk of return visits to the ED and hospitalizations in our primarily Latinx/Hispanic population. Monoclonal antibody infusions may help reduce hospital utilization during COVID-19 surges at U.S.-Mexico border hospitals.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Objectives: Current clinical guidelines by the American Academy of Pediatrics recommends adenotonsillectomy (T&A) as the first-line treatment for pediatric OSA. However, obese children experience a decreased incidence of cure from T&A compared to non-obese children, with obesity increasing risk of residual post-operative OSA by up to 3.7-fold. In addition to obesity, increased age has also been linked to more severe baseline OSA, among other factors. In this study, we examined how age effects the post-operative outcome in obese children with OSA., Methods: A retrospective chart review was performed to assess post-operative T&A polysomnography outcomes of obese children. Inclusion criteria included patients who were 17 years old and younger, underwent T&A, were obese and had both pre- and post-operative sleep studies. The patients were split into 3 different groups based on their age: Group 1 (0-6 years old), Group 2 (7-11 years old), and Group 3 (12-17 years old)., Results: 55 patients were included in the study: 13 in Group 1, 20 in Group 2, and 22 in Group 3. For Groups 1, 2, and 3 respectively, data averages were BMI percentile 99.20, 98.49, and 98.92 (P = 2.77); z-score 2.79, 2.36, and 2.45 (P = 0.026), tonsil size 3.17, 3.15, and 3.23 (P = 0.898), adenoid size 2.42, 2.05, and 1.77 (P = 0.015), time between the preoperative and postoperative PSG 179, 240, and 202 days (P = 0.481), and time from surgery to postoperative PSG 126, 170, and 127 days (P = 0.544). The average preoperative oAHI was 52.56, 41.23, and 43.49 (P = 0.732), post-operative oAHI was 1.94, 4.79, and 4.44 (P=.417); and change in oAHI was 50.62, 36.44, and 39.25 (P = 0.617). When comparing the age group of 0-6-year-olds to the older remaining patients, the post-operative oAHI was the only variable to show a significant difference between the two-groups with a P value of 0.038. The percentage of patients with post-operative resolution of OSA (oAHI<2), mild, moderate, and severe OSA, respectively, were 53%, 29%, 9%, and 9% for all patients, 70%, 23.1%, 7%, and 0% for group 1; 50%, 35%, 5%, and 10% for group 2; and 45%, 27%, 13%, and 13% for group 3. The percent of the patients requiring post-surgical nighttime airway support were 18%, 7%, 15%, and 26% for Groups All, 1, 2, and 3, respectively., Conclusion: We found that despite having the highest rates of obesity and the most severe OSA, obese patients under 7 years old performed better following T&A, with greater cure rate, overall reduction of oAHI, and decreased need for post-surgical nighttime airway support., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Today, approximately one in five United States adolescents age 12 to 19 years is obese and just over a third are either overweight or obese. This study examines how parents and peers influence diet and physical activity behaviors of older adolescents (14-18 years) with overweight or obesity to inform weight management interventions., Methods: Adolescent participants included 14 to 18-year-olds with a Body Mass Index (BMI) greater than the 85th percentile for their age and sex who were receiving care in a large healthcare system in Northern California. Adolescents and their parents participated in separate focus groups and interviews (if not able to attend focus groups) that were held at the same time in the same location. We used qualitative thematic analysis to identify common themes discussed in the adolescent and parent focus groups as well as paired analysis of adolescent-parent dyads., Results: Participants included 26 adolescents and 27 parents. Adolescent participants were 14 to 18 years old. Half were female and the participants were almost evenly distributed across year in school. The majority self-identified as White (56%) and Asian (36%).Three themes were identified which included 1) parents overestimated how supportive they were compared to adolescents' perception 2) parents and adolescents had different views regarding parental influence on adolescent diet and physical activity behaviors 3) parents and adolescents held similar views on peers' influential role on lifestyle behaviors., Conclusion: Parents' and adolescents' differing views suggest that alignment of parent and adolescent expectations and behaviors for supporting effective weight management could be incorporated into interventions.

Background: Diverse wellness-promoting mobile health technologies, including mobile apps and wearable trackers, became increasingly popular due to their ability to support patients' self-management of health conditions. However, the patient's acceptance and use depend on the perceived experience and the app appropriateness to the patient's context and needs. We have some understating of the experience and factors influencing the use of these technologies in the general public, but we have a limited understanding of these issues in patients., Objective: By presenting results from an explorative study, this paper aims to identify implications for the design of mobile apps and wearables to effectively support patients' efforts in self-management of health with a special emphasis on support for self-efficacy of activities contributing to health., Methods: An explorative mixed-method study involving 200 chronically ill patients of Stanford Medical Center (Stanford, CA, United States) was conducted between mid-2016 and end of 2018. Amongst these, 20 patients were involved in a 4-weeks study, in which we collected the underlying wearable device use logs (e.g., Fitbit) and subjective use experience [via an Ecological Momentary Assessment (EMA)], as well as patients' momentary perception of general self-efficacy in their natural environments and different daily contexts., Results: The results indicate that mobile apps for health and wearables have the potential to enable better self-management and improve patients' wellbeing but must be further refined to address different human aspects of their use. Specifically, the apps/wearables should be easier to use, more personalized and context-aware for the patient's overall routine and lifestyle choices, as well as with respect to the momentary patient state (e.g., location, type of people around) and health(care) needs. Additionally, apps and devices should be more battery efficient and accurate; providing timely, non-judgmental feedback and personalized advice to the patients anywhere-anytime-anyhow. These results are mapped on major sources of the individuals' self-efficacy., Conclusion: Our results show how the apps/wearables that are aimed at supporting the patients' self-management should be designed to leverage and further improve the patients' general self-efficacy and self-efficacy of activities contributing to chronic disease management., (Copyright © 2019 Wulfovich, Fiordelli, Rivas, Concepcion and Wac.)

Objectives: Migration is an increasingly prevalent worldwide phenomenon. In recent years, Maasai men and women have migrated from their traditional rural villages to cities in Tanzania in growing numbers. This study explores the experience of rural-to-urban migration among female Maasai migrants and how this experience affects ethnic identity, resilience, and well-being., Methods: Thirty-one female Maasai migrants were interviewed in Swahili, Maa, or English. Researchers used a rigorous multi-pass, qualitative coding process to analyze interview transcripts., Results: Migration-driving factors, specifically a desire for education (leading to permanent migrants) and a need to support one's family (resulting in circular migrants), influence how Maasai women adapt and respond to challenges in the city. Circular migrants hold closely to their traditional ethnic identity and remain isolated from city life, while permanent migrants modulate their ethnic identity and integrate into urban society., Conclusions: Increasing connections among female Maasai migrants might create a more resilient community leading to improved health. Pilot workshops with this aim are being implemented.

Moderate and severe obesity (BMI ≥35 kg/m 2 ) affect 15% of US adults, with a projected increase over the next two decades. This study reviews evidence of behavioral lifestyle interventions for weight loss in this population. We searched PubMed, PsychInfo, CINAHL®, and Scopus through February 2016 for experimental and quasi-experimental studies that tested a dietary and/or physical activity intervention with a behavioral modification component versus a comparator; and had ≥six-month follow-up and a weight-related primary outcome. Twelve studies representing 1862 participants (mean BMI 37.5-48.3, mean age 30-54 years) were included. Nine studies compared different behavioral interventions and three tested behavioral intervention(s) versus pharmacological or surgical treatments. Among the 25 behavioral interventions in the 12 studies, 18 reported percent of participants achieving clinically significant weight loss up to 12months (32-97% achieving 5% or 3-70% achieving 10%). Three studies measured other cardiometabolic risk factors, but showed no significant risk reduction. Seven interventions with greater effectiveness (i.e., at least 31% achieving ≥10% or 62% achieving ≥5% weight loss up to one year) included multiple components (diet, physical activity, and behavioral strategies), long duration (e.g., one year), and/or intensive contacts (e.g., inpatient stays for clinic-based interventions, weekly contacts for community-based ones). Evidence for the effectiveness of behavioral interventions versus pharmacological or surgical treatment was limited. Comprehensive and intensive behavioral interventions can result in clinically significant, albeit modest, weight loss in this obese subpopulation but may not result significant improvements in other cardiometabolic risk factors. More research on scalable and sustainable interventions is needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)