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Importance: Parent recall is the primary method for measuring positioning practices such as tummy time in infants. Concerns regarding the accuracy of parent recall have been raised in the literature. To date, no study has examined the agreement of tummy time recall measures with gold-standard methods., Objective: To assess the agreement between parental recall versus direct observation of tummy time in infants, and to explore the impact of prematurity on this relationship., Design: Cross-sectional observational study, spanning 1 yr., Setting: Participants' homes Participants: Thirty-two infant-parent dyads (19 full-term, 13 preterm), with infants ages 3 to 6 mo and caregivers ages older than 18 yr., Outcome and Measures: Home-recorded videos of infant play across 3 days were used as a proxy for direct observation of tummy time and compared with a 12-item parent recall survey., Results: Parent recall had a significant moderate correlation (ρ = .54, p = .002) with direct observation in full-term infants but was not correlated (p = .23) with direct observation in preterm infants. On average, parents of preterm infants overestimated tummy time by 2.5 times per day compared with direct observation., Conclusions and Relevance: For full-term infants, parent recall measures of tummy time exhibit an acceptable level of agreement with direct observation and can be reliably used over shorter periods. Parents of preterm infants may display a bias in recalling tummy time, leading to overestimations. To accurately assess tummy time in this population, a combination of subjective and objective measures should be explored. Plain-Language Summary: Tummy time is an essential movement experience for infants, especially for preterm infants, who are at a higher risk for motor delays. The most common way to track tummy time is through parent reports, or recall, versus a practitioner directly observing tummy time in the home. Despite the widespread use of parent recall to track tummy time, no study has examined the accuracy of parent recall versus direct observation in the home. Accurately assessing tummy time is crucial for improving and supporting health outcomes for infants. This study found that prematurity may affect the accuracy of parent recall for assessing tummy time in young infants. The authors discuss the implications of this finding and provide suggestions to guide the selection of appropriate methods to measure tummy time in clinical practice and research studies., (Copyright © 2024 by the American Occupational Therapy Association, Inc.)

Introduction: Diet can affect ammoniagenesis in cirrhosis and hepatic encephalopathy (HE), but the impact of dietary preferences on metabolomics in cirrhosis is unclear. As most Western populations follow meat-based diets, we aimed to determine the impact of substituting a single meat-based meal with an equal protein-containing vegan/vegetarian alternative on ammonia and metabolomics in outpatients with cirrhosis on a meat-based diet., Methods: Outpatients with cirrhosis with and without prior HE on a stable Western meat-based diet were randomized 1:1:1 into 3 groups. Patients were given a burger with 20 g protein of meat, vegan, or vegetarian. Blood for metabolomics via liquid chromatography-mass spectrometry and ammonia was drawn at baseline and hourly for 3 hours after meal while patients under observation. Stool microbiome characteristics, changes in ammonia, and metabolomics were compared between/within groups., Results: Stool microbiome composition was similar at baseline. Serum ammonia increased from baseline in the meat group but not the vegetarian or vegan group. Metabolites of branched chain and acylcarnitines decreased in the meat group compared with the non-meat groups. Alterations in lipid profile (higher sphingomyelins and lower lysophospholipids) were noted in the meat group when compared with the vegan and vegetarian groups., Discussion: Substitution of a single meat-based meal with a non-meat alternatives results in lower ammoniagenesis and altered serum metabolomics centered on branched-chain amino acids, acylcarnitines, lysophospholipids, and sphingomyelins in patients with cirrhosis regardless of HE or stool microbiome. Intermittent meat substitution with vegan or vegetarian alternatives could be helpful in reducing ammonia generation in cirrhosis., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Objective: To develop and implement a resident-led firearm safety curriculum, delivered to pediatrics residents, and to evaluate outcomes., Study Design: A firearm safety curriculum was developed in 2019-2020 at a single academic center, using Kern's framework and cognitive load theory. The curriculum was organized using the "Be SMART" firearm safety model. Sessions were led by resident peers. The content included workshops on firearm safety counseling, advocacy training, and a gun lock program in collaboration with the local police department. Content was integrated into existing residency didactic curriculum. Impact was measured by a pre/posttest knowledge assessment and a systematic chart review., Results: The curriculum was provided to 41/66 (62%) pediatrics residents. Knowledge improved (67% to 77% correct) when comparing pre-intervention with post-intervention. A total of 1477 charts were reviewed. Compared with a historical cohort, participants more often asked about presence of a firearm (27% vs 69%, P < .0001) and counseled on firearm safety (9% vs 25%, P < .0001). In the post-intervention timeframe, 25% of eligible families were provided a gun lock., Conclusions: A firearm safety curriculum designed by pediatrics residents and administered to their peers resulted in a statistically significant improvement in inquiries about firearm ownership and safety counseling in an urban tertiary care continuity clinic. These results demonstrate the promising outcomes of a firearm safety program developed by residents and delivered to peers., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium., Objectives: To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later., Methods: A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests., Results: Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04)., Conclusions: The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury., (©2023 American Association of Critical-Care Nurses.)

Purpose: Although uncommon, vascular injury can be seen in patients with lateral skull base fractures (LSBF). However, little is known about this potentially life-threatening comorbidity. The objective of this study is to better characterize the vascular injuries associated with temporal and lateral sphenoid bone fractures., Basic Procedures: Retrospective review of all patients with computed tomography angiography (CTA) performed specifically to evaluate for vascular injury following LSBF. In addition to patient demographics (age, gender, race), the mechanism of injury, the location of fracture(s), and the nature of vascular injury diagnosed by CTA was recorded. Two-way ANOVA was performed to determine if any variables were predictive of vascular injury., Main Findings: From 2011 to 2021, 143 patients with 333 subsite fractures met inclusion criteria. Of all patients, 46 (32.2 %) had CTA evidence of at least one vascular injury, the most common type being venous thrombosis/filling defect (41.7 %). Evidence of vascular injury was unclear in 14 patients (9.8 %). Fractures most associated with vascular injury ranged from 0.7 % (otic capsule fractures) to 26.7 % (mastoid, lateral sphenoid fractures). Risk of vascular injury was no different between patients with single vs multiple fractures. There were no fracture locations that could reliably predict specific vascular injury., Conclusions: Over 40 % of all CTAs ordered following LSBF identified were suspicious for associated vascular injury. Yet fracture location and number cannot reliably predict vascular injury. Until such determinants can be better identified, clinicians should have a low threshold to obtain CTA to rule out associated vascular injury., Competing Interests: Conflict of interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background & Aims: Even after recovery from overt hepatic encephalopathy (HE), minimal HE (MHE), which impairs quality of life (QoL), can persist. A double-blind, placebo-controlled randomized clinical trial was performed to determine the impact of albumin vs. saline on MHE and QoL in individuals with prior HE already on standard of care., Methods: Outpatients with cirrhosis and prior HE, MHE and hypoalbuminemia already on treatment for HE were included. Patients on regular IV albumin infusions were excluded. Participants were randomized 1:1 to receive either weekly infusions of 25% IV albumin 1.5 g/kg or saline over 5 weeks. MHE was defined using either psychometric hepatic encephalopathy score (PHES), Stroop or critical clicker frequency. MHE, QoL (based on sickness impact profile [SIP] total, physical, psychosocial domain) and serum markers (inflammation, endothelial dysfunction, and ischemia-modified albumin) were compared between baseline, the final infusion visit (end-of-drug [EOD]) and 1-week post final infusion (end-of-study [EOS])., Results: Forty-eight (24/group) participants were randomized and balanced (including by HE medication use) at baseline. Adverse events were similar, with MELD and ammonia remaining stable between/within groups. Albumin levels increased and ischemia-modified albumin decreased only in the albumin group at EOD and EOS vs. baseline. PHES and Stroop MHE reversal and improvement were greater in the albumin group at EOD and persisted at EOS. SIP total and psychosocial, but not physical, domain improved only in the albumin group at EOD and EOS vs. baseline. A significant reduction in IL-1β and endothelial dysfunction markers was also observed in the albumin group., Conclusion: In a double-blind, placebo-controlled trial of outpatients with cirrhosis, prior HE and current MHE, albumin infusions were associated with improved cognitive function and psychosocial QoL, likely due to amelioration of endothelial dysfunction., Clinical Trials Registration: www., Clinicaltrials: gov NCT03585257., Impact and Implications: Even after recovery from overt hepatic encephalopathy (HE), minimal HE (MHE), which impairs quality of life, can persist. We found that intravenous albumin infusions were associated with improved cognitive function and psychosocial quality of life, likely owing to amelioration of endothelial dysfunction, compared to placebo in outpatients with prior HE and current MHE. In patients who continue to demonstrate cognitive dysfunction and impaired quality of life despite standard of care therapy for HE, albumin infusions could be considered if these results are validated., (Copyright © 2022 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Driving is independently affected by cirrhosis and hepatic encephalopathy (HE) and alcohol/substance use, but their concomitant impact is unclear. We aimed to determine the impact of alcohol and other substances on driving-simulator performance in cirrhosis with and without HE. Outpatients with cirrhosis and controls underwent cognitive testing and driving simulation for the following three conditions: baseline, wearing goggles simulating alcohol intoxication, and wearing goggles simulating opioid/benzodiazepine abuse. Outcomes were number of centerline crossings (CCs) and road-edge excursions (REEs). We compared controls versus patients with cirrhosis then subjects with cirrhosis with and without HE for all conditions, using generalized linear modeling (GLM). Sixty subjects (17 controls, 43 with cirrhosis [Model for End-Stage Liver Disease score, 10; 21 subjects with prior HE]) were included. Simulations showed higher CCs and REEs at baseline in patients with cirrhosis with and without HE versus controls. With alcohol- and substance abuse-impairment goggles, CCs increased but REEs decreased in cirrhosis. In the GLM, a time and group interaction was seen (p < 0.001) for CCs and REEs. Patients with cirrhosis showed higher CCs and REEs at baseline than controls (CCs, p = 0.003; REEs, p = 0.0001) and higher CCs (p = 0.03) and lower REEs (p = 0.001) with alcohol-simulating goggles. All groups were equally impaired with opioid/benzodiazepine-simulating goggles (CCs, p = 0.49; REEs, p = 0.46). Controls with alcohol-simulating goggles had similar CCs as the baseline of patients with cirrhosis (p = 0.98). conclusions: Simulating alcohol intake induces greater driving impairment in patients with cirrhosis versus controls, but similar patterns were seen with opioid/benzodiazepine-simulating goggles. At baseline, patients with cirrhosis have simulator outcomes equivalent to intoxicated controls. Driving simulation with goggles modeling substance abuse could improve insight into driving errors and enhance driving rehabilitation in patients with cirrhosis., (© 2022 The Authors. Hepatology Communications published by Wiley Periodicals LLC on behalf of American Association for the Study of Liver Diseases.)

Introduction: Premenstrual syndrome (PMS) affects the majority of women and is characterized by physical, behavioral, and mood symptoms, which can have a profound impact on quality of life. PMS symptoms have also been linked to licit substance use. This study examined the relationships between daily/problem use (DPU) of caffeine (Caf + ), alcohol (Alc + ), and tobacco (Cig + ) and PMS symptomology in a sample of college women., Methods: Participants ( N  = 196) completed an anonymous one-time health survey. Demographic, PMS symptomatology, and DPU of licit substance variables were examined. Independent t -tests compared PMS symptom scores in women with and without Caf + , Cig + , and Alc + use. One-way analysis of variances examined the associations between PMS symptom severity and number of DPU-positive substances., Results: PMS subscale severity (pain [ F (2,190) = 4.47, p  = 0.013], affective [ F (2,192) = 8.21, p  < 0.001], and water retention [ F (2,191) = 13.37, p  < 0.001]) and total PMS symptom severity [ F (2,189) = 10.22, p  < 0.001] showed a dose response effect, with the number of licit substances with DPU significantly associated with PMS symptom severity., Conclusions: This study findings provide important new information about the relationship between PMS symptoms and at-risk substance use. These are cross-sectional data, however, and affirm a need for longitudinal research to better understand the associations, with a focus on potential benefits of education and intervention., Competing Interests: No competing financial interests exist., (© Kathryn Polak et al., 2022; Published by Mary Ann Liebert, Inc.)

Background: Managing Cancer and Living Meaningfully (CALM) is an evidence-based, brief, semi-structured psychotherapy designed to help patients with advanced cancer cope with the practical and profound challenges of their illness. However, no study to date has investigated its feasibility, acceptability, and preliminary effectiveness in adults with malignant glioma, despite the well-documented incidence of psychological distress in this vulnerable and underserved population., Methods: Fourteen patients with glioma and elevated symptoms of depression and/or death anxiety enrolled in the trial: 83% glioblastoma, 75% female, M age  = 56 years (SD = 15.1; range = 27-81). Feasibility was assessed based on established metrics. Acceptability was measured by post-session surveys and post-intervention interviews. Preliminary intervention effects were explored using paired t-tests, comparing psychological distress at baseline and post-intervention., Results: Of the 14 enrolled patients, 12 were evaluable. Nine completed the study (75% retention rate). Three patients withdrew due to substantial disease progression which affected their ability to participate. Participants reported high perceived benefit, and all recommended the program to others. Baseline to post-intervention assessments indicated reductions in death anxiety, generalized anxiety, and depression, and increases in spirituality. Quality of life and fear of cancer recurrence remained stable throughout the study period., Conclusions: CALM appears feasible for use with adults with malignant glioma. Enrollment and retention rates were high and comparable to psychotherapy trials for patients with advanced cancer. High perceived benefit and reductions in symptoms of death anxiety, generalized anxiety, and depression were reported by participants. These findings are extremely encouraging and support further study of CALM in neuro-oncology., Trial Registration Number: NCT04646213 registered on 11/27/2020., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The prognosis of acute kidney disease (AKD), defined as a glomerular filtration rate of <60 ml/min/1.73 m 2 or a rise in serum creatinine (sCr) of <50% for <3 months, is not clearly known., Aim: To study the prevalence, predictive factors and clinical outcomes in hospitalized cirrhotic patients with AKD., Methods: The North American Consortium for the Study of End-Stage Liver Disease prospectively enrolled hospitalized decompensated cirrhotic patients. Patients were separated into those with normal renal function (controls or C), AKD or stage 1 AKI as their worst renal dysfunction per International Club of Ascites definition and compared. Parameters assessed included demographics, laboratory data, haemodynamics, renal and patient outcomes., Results: 1244 patients with cirrhosis and ascites (C: 704 or 57%; AKD: 176 or 14%; stage 1 AKI: 364 or 29%) with similar demographics were enrolled. AKD patients had similar baseline sCr but higher hospital admission in the previous 6 months, and higher peak sCr, compared to controls, with their peak sCr being lower than that in stage 1 AKI patients (all P < .0001). The in-hospital and 30-day survival for AKD patients were intermediary between that for controls and stage 1 AKI patients (96% vs 91% vs 86%, P < .0001). The strongest predictors for AKD development while in hospital were the presence of a second infection (OR: 2.44) and diabetes (OR: 1.53)., Conclusions: Patients with AKD had intermediate outcomes between stage 1 AKI and controls. AKD patients, especially those with diabetes and a second infection, need careful monitoring and prompt treatment for AKD to prevent negative outcomes., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The Centers for Medicare and Medicaid uses the standardized readmission ratio (SRR) to evaluate 30-day readmissions among dialysis providers in the U.S. Readmissions among dialysis recipients remains 37%. This study investigates associations among dialysis facilities and patient characteristics with facility's performance on the SRR., Methods: Descriptive, longitudinal, approach using multivariate regression analysis on data retrieved from the Dialysis Facility Report to evaluate the associations between facility-level (staffing, profit status, chain membership, clinic size, care, length of care, vascular access type, glomerular filtration rate (GFR), creatinine, hemoglobin, use of erythropoietin-stimulating agent, albumin, and primary dialysis modality) with the SRR., Results: Factors associated with a high SRR included nurse ratios, facility average GFR, and Northeast geographic location. Factors associated with a low SRR included patient care technician ratio, length of predialysis nephrology care, initiation of dialysis with an arteriovenous fistula, average hemoglobin, and Western geographic location., Conclusions: This study defines the influence predialysis nephrology care has on dialysis facilities SRRs. Access to care, adequate preparation for dialysis, and transitional support affect facilities' performance; however, without an appropriate staffing model, dialysis facilities may continue to struggle to reduce readmissions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 National Association for Healthcare Quality.)

To identify predictors of neonatal ECMO circuit health, a retrospective analysis of circuit functional pressure and flow parameters as well as infant clotting values were collected 48 h prior to and 24 h post circuit change. Circuit impairment was defined as need for partial or total circuit change. Statistical analysis used multivariate statistics and non-parametric Mann-Whitney U-test with possible non-normality of measurements. A total of 9764 ECMO circuit and clotting values in 21 circuits were analyzed. Circuit delta-P mean, and maximum values increased from 8.62 to 48.59 mmHg (p < 0.011) and 16.00 to 53.00 mmHg (p < 0.0128) respectively prior to need for circuit change. Maximum and mean Pump Flow Revolutions per minute (RPM) increased by 75% (p < 0.0043) and 81% (p < 0.0057), respectively. Mean plasma free hemoglobin (pfHb) increased from 26.45 to 76.00 mg/dl, (p < 0.0209). Sweep, venous pressure, and clotting parameters were unaffected. ECMO circuit delta-P, RPM, and pfHb were early predictors of circuit impairment., (© 2022. The Author(s).)

Objective: This study investigated death anxiety in patients with primary brain tumor (PBT). We examined the psychometric properties of two validated death anxiety measures and determined the prevalence and possible determinants of death anxiety in this often-overlooked population., Methods: Two cross-sectional studies in neuro-oncology were conducted. In Study 1, 81 patients with PBT completed psychological questionnaires, including the Templer Death Anxiety Scale (DAS). In Study 2, 109 patients with PBT completed similar questionnaires, including the Death and Dying Distress Scale (DADDS). Medical and disease-specific variables were collected across participants in both studies. Psychometric properties, including construct validity, internal consistency, and concurrent validity, were investigated. Levels of distress were analyzed using frequencies, and determinants of death anxiety were identified using logistic regression., Results: The DADDS was more psychometrically sound than the DAS in patients with PBT. Overall, 66% of PBT patients endorsed at least one symptom of distress about death and dying, with 48% experiencing moderate-severe death anxiety. Generalized anxiety symptoms and the fear of recurrence significantly predicted death anxiety., Significance of Results: The DADDS is a more appropriate instrument than the DAS to assess death anxiety in neuro-oncology. The proportion of patients with PBT who experience death anxiety appears to be higher than in other advanced cancer populations. Death anxiety is a highly distressing symptom, especially when coupled with generalized anxiety and fears of disease progression, which appears to be the case in patients with PBT. Our findings call for routine monitoring and the treatment of death anxiety in neuro-oncology.

Objective: We report outcomes of endoscopic interventions in the management of pediatric subglottic stenosis (SGS), and factors that lead to open airway reconstruction., Methods: A retrospective cohort review of all pediatric patients with SGS, treated by a single surgeon, at a tertiary academic medical center from 2012 to 2020 was conducted. Variables recorded included patient demographics, initial grade of stenosis, gestational age, length of intubation, comorbidities as well as total number of interventions., Results: A total of 47 patients were included in the study, of which 51% (n = 24) were female. Laryngotracheal reconstruction (LTR) was performed in 49% (n = 23) of patients. Decannulation was achieved in 25 of 32 tracheostomized patients. Fifteen patients did not have tracheostomy. There was a significant difference in gestational age (28.7 ± 5.36 vs 33.2 ± 6.13), initial grade of stenosis (2.3 ± 0.82 vs 1.6 ± 0.88), and total number of interventions (5.7 ± 2.8 vs 2.3 ± 1.5) when stratifying patients proceeding to LTR versus not (p < 0.05). There was no significant difference, however, in the length of intubation between the two groups. Of the comorbidities recorded, none were found to have a significant impact on the outcome., Conclusion: Subglottic stenosis is a challenging condition to treat, often requiring multiple interventions including LTR. We propose a set of risk factors that may assist in the treatment of SGS patients with certain comorbidities to minimize interventions and maximize outcomes., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background & Aims: Progression of stages 2 and 3 acute kidney injury (AKI) in cirrhosis has not been characterized adequately. Patients with higher stages of AKI are believed to have worse outcomes. We assessed outcomes and factors associated with stages 2 and 3 AKI in patients with cirrhosis in the North American Consortium for the Study of End-stage Liver Disease cohort., Methods: We collected data from 2297 hospitalized patients with cirrhosis and ascites from December 2011 through February 2017. Our final analysis included 760 patients who developed AKI per the International Ascites Club 2015 definition (419 with maximum stage 1 and 341 with maximum stage 2 or 3; 63% male; mean age, 58 y). We compared demographic features, laboratory values, AKI treatment response, and survival between patients with maximum stage 1 vs patients with stage 2 or 3 AKI., Results: Patients with stage 2 or 3 AKI had higher Model for End-Stage Liver Disease scores (25.9 ± 7.3) than patients with stage 1 AKI (21.9 ± 7.5) (P < .0001). More patients fulfilled systemic inflammatory response syndrome criteria on admission, and more developed a second nosocomial infection (P < .05 for both comparisons). More patients with stage 2 or 3 AKI also had progression of AKI and required dialysis and admission into intensive care units when compared to stage 1 AKI patients (P < .0001 for both). A lower proportion of patients with stage 2 or 3 AKI survived their hospital stay (80% vs 99% with stage 1 AKI; P < .0001), or survived for 30 days without a liver transplant (56% vs 81%; P < .0001). The development of stage 2 or 3 AKI was associated with a higher Model for End-Stage Liver Disease score at the time of admission (P < .0001), presence of systemic inflammatory response on admission (P = .039), and second infection (P < .0001)., Conclusions: Based on an analysis of data from the North American Consortium for the Study of End-stage Liver Disease cohort, we found that patients with cirrhosis and more advanced liver disease, as well as a second infection, are more likely to develop stages 2 or 3 AKI, with a progressive course associated with decreased 30-day transplant-free survival. Prevention of AKI progression in patients with cirrhosis and stage 2 or 3 AKI might improve their outcomes., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Valganciclovir is the preferred drug for cytomegalovirus (CMV) prophylaxis in solid organ transplantation. A limitation to its use is profound myelosuppression. Letermovir is a new agent approved for CMV prophylaxis in hematopoietic stem cell transplantation and is associated with less toxicity. This study aims to assess the effectiveness and safety of letermovir in solid organ transplantation., Methods: A single-center, matched cohort study was performed on 31 transplant recipients who were converted from valganciclovir to letermovir from November 2017 to June 2020. The primary outcome was the rate of CMV breakthrough infections while on prophylaxis. Secondary outcomes included rate of leukopenia, doses of immunosuppression, rejection, non-CMV infection, and renal function. Statistical analyses of continuous variables included the student's t-test, ANOVA test, and Wilcoxon Signed Rank test. Categorical data were analyzed with chi-square test and Fisher's Exact test., Results: There was no difference in the rate of CMV breakthrough between patients on letermovir (8.7%) and valganciclovir (13.5%), (P = .7097). After conversion to letermovir, patients required lower tacrolimus doses at -3.34 mg (SD-1.3, P = .0273), between conversion and day 7. Transplant Infectious Disease The median difference in tacrolimus trough concentrations from conversion to day seven was 9.1 ng/ml [4.9, 16.95] (P = .0002). Leukopenia improved by 1.8 109/L [1.08, 4.85] (P < .0001)., Conclusions: Patients converted from valganciclovir to letermovir did not show an increased rate of CMV breakthrough compared to a historical, matched cohort of patients remaining on valganciclovir. A significant drug interaction was noted with tacrolimus, leading to a recommendation to reduce the dose by 40-50% upon initiation of letermovir., (© 2021 Wiley Periodicals LLC.)

Objective: Fear of cancer recurrence (FCR) is related to psychological distress and poor quality of life in cancer patients and their caregivers. However, no studies have investigated FCR in neuro-oncology. Given the varied prognosis, treatment, and disease trajectory of brain cancer, FCR may affect patients and their caregivers differently., Methods: Eighty adult primary brain tumor (PBT) patients and 52 caregivers completed questionnaires assessing FCR and psychological distress (depressive symptoms, generalized anxiety, and death anxiety). Differences in patient and caregiver FCR by demographic and medical characteristics were examined. Using multilevel modeling, the Actor-Partner Interdependence Model (APIM) was used to investigate the interrelationship between patient and caregiver FCR with demographics and psychological distress measures., Results: Caregivers reported significantly higher FCR than patients. There were no effects of demographic or medical characteristics on patient FCR. Time since diagnosis was negatively related to caregiver FCR. All measures of psychological distress exerted a significant actor effect on FCR among both patients and caregivers. Two partner effects were found: caregiver depressive symptoms and death anxiety negatively predicted patients' FCR., Conclusions: This is the first investigation of FCR in PBT patients and their caregivers. Most demographic and medical characteristics were not related to patient or caregiver FCR. Caregiver FCR may be higher at the time of diagnosis and decrease over time. APIMs revealed actor effects on patient and caregiver FCR for all measures of psychological distress. Results demonstrated the dyadic effects of a brain tumor diagnosis, emphasizing the need to include caregivers in psychotherapy for neuro-oncology patients., (© 2021 John Wiley & Sons Ltd.)

Background : Chronic pain affects one in five persons and is a leading contributor to years lived with disability and high health care costs. In 2016, the government of Ontario increased public funding for pediatric and adult hospital-based interprofessional chronic pain clinics (HICPCs) in Ontario, Canada, expanding the role of physiotherapy in chronic pain management in the province. This role has yet to be described in the literature. Aim : The aim of this study was to explore physiotherapy practice within HICPCs in Ontario. Methods : We conducted an interpretive description qualitative study based on semistructured interviews with physiotherapists employed in pediatric and adult HICPCs in Ontario. Interviews were audio recorded, transcribed verbatim, and reviewed for accuracy. We analyzed interview data using thematic analysis. Results : Ten physiotherapists who practiced in pediatric and adult HICPCs ( n = 4 pediatric; n = 6 adult) in Ontario were interviewed between February and April 2020. We constructed five themes related to physiotherapy practice in this setting. Themes included (1) contributing a functional lens to care; (2) empowering through pain education; (3) facilitating participation in physical activity and exercise; (4) supporting engagement in self-management strategies; and (5) implementing a collaborative approach to whole-person care. Conclusions : Our results illuminate how physiotherapy practice within HICPCs in Ontario focuses on providing a collaborative and whole-person approach to care, with an emphasis on supporting patients to increase their functional capacity by promoting engagement in active chronic pain management strategies., Competing Interests: Linnea Thacker does not have any conflicts of interest. Robert M. Walsh does not have any conflicts of interest. Gabriella Shinyoung Song does not have any conflicts of interest. Hammad A. Khan does not have any conflicts of interest. Prem Parmar does not have any conflicts of interest. Kaitlin T. Vance does not have any conflicts of interest. Gillian Grant does not have any conflicts of interest. Giulia Mesaroli does not have any conflicts of interest. Judith Hunter does not have any conflicts of interest. Kyle Vader does not have any conflicts of interest., (© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Nearly 20% of women in the United States experience clinically significant depressive symptoms during pregnancy or the postpartum period. These women may benefit from easily accessible, nonpharmacologic, and inexpensive self-management approaches, such as via internet and mobile-based interventions, to prevent development of symptoms and/or intervene with current symptoms. This paper summarizes the research protocol of a nationally-funded large-scale randomized controlled study to evaluate "Mamma Mia," a self-guided program with 44 modules that women use throughout pregnancy to 6 months postpartum. The program contains a novel combination of components designed to enable women to enhance self-efficacy, emotional self-regulation, and perceived social support. The overall goal of this three-arm longitudinal randomized controlled trial is to evaluate the effects and mechanisms of this self-management approach in diverse women in the U.S. (n = 1950). Enrolled pregnant women will be randomly assigned to one of three groups: (1) "Mamma Mia" alone, which is self-guided; (2) "Mamma Mia Plus" in which participants engage in the "Mamma Mia" modules plus receive brief guided support from a registered nurse; or (3) usual prenatal/postpartum care. The first specific aim is to evaluate effects by group on the primary outcome of interest, depressive symptoms, over time. The second aim is to evaluate effects by group on subjective well-being, anxiety, and stress. Using a conceptual framework based upon Individual and Family Self-Management Theory, the third aim is to evaluate possible mediators (self-efficacy, emotion self-regulation, perceived support) and possible moderators (e.g., race/ethnicity, type of healthcare clinician) of this self-management approach., (© 2020 Wiley Periodicals LLC.)

Background: The incidence of hemodialysis (HD)-dependent renal failure after total artificial heart (TAH) implantation is high. We sought to determine the preoperative predictors of HD after TAH implantation., Methods and Results: We studied 87 patients after TAH implantation at our institution between April 2006 and March 2017. Baseline clinical data were obtained from the medical records, and patients were followed until death or heart transplantation. We performed logistic regression analysis to identify predictors of HD after TAH implantation. Of the patients, 24 (28%) required postimplantation HD. Those requiring HD were more likely to have histories of coronary artery disease (58% vs 29%; P = 0.01), required preoperative membrane oxygenation (33% vs 4.8%; P = 0.001) and had lower baseline estimated glomerular filtration rates (54 ± 29 vs 67 ± 24 mL/min/1.73m 2 ; P = 0.04). Patients requiring HD were at a higher risk of death on device at 1 year (33% vs 5%, P = 0.001; log rank test: P =0.001, hazard ratio 6.6 [95% CI:1.8-23], P = 0.003)., Conclusions: The incidence of postimplantation HD is high and is associated with increased likelihood of mortality. Lower baseline estimated glomerular filtration rates, histories of coronary artery disease and preoperative membrane oxygenation support are predictors of postimplantation requirement of HD. These data may help to identify patients at risk for adverse outcomes after TAH implantation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Pregnant women with depressive symptoms face significant treatment challenges and are in great need of safe, effective, accessible, inexpensive, and nonpharmacological self-management therapies to enhance well-being, reduce the burden of symptoms both during their pregnancy and postpartum, and prevent chronic sequelae., Objectives: In this article, we describe the protocol for our pilot study testing a self-management intervention entitled, "Mindful Moms," designed to foster women's ability to address current depressive symptoms and enhance resilience to prevent recurrence., Methods: We will conduct a longitudinal pilot trial of the 12-week intervention with pregnant women with depressive symptoms (n = 40); the primary aim is to determine the feasibility and acceptability of the intervention. The secondary aim is to examine preliminary effects of the intervention on maternal psychobehavioral outcomes in pregnancy and 6 weeks postpartum. The third aim will quantify genome-wide and gene-specific DNA methylation patterns associated with depressive symptoms during pregnancy and investigate whether intervention participation influences these patterns., Results: This study is currently ongoing., Discussion: Findings from this study will inform future research addressing the need for nonpharmacological self-management interventions for pregnant women with depressive symptoms.

We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD-associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in-hospital clinical course, and postdischarge 3-month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease-4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD-) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD- group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD- group (all P < 0.001). Propensity matching (n = 922 in each group) by Child-Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD- patients. CKD+ patients also had more cases of acute-on-chronic liver failure as defined by the NACSELD group, which was associated with reduced 30- and 90-day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30-day mortality. In conclusion, patients with CKD should be treated as a high-risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI., (Copyright © 2019 by the American Association for the Study of Liver Diseases.)

Introduction: Health guidelines suggest that pregnant women should participate in daily physical activity, yet rarely do they meet these guidelines. Means to enhance accessibility of physical activity for pregnant women are required, and yoga has been suggested as a possible method to enhance women's sense of confidence and competence with physical activity. In this pilot study, our primary aim is to evaluate pregnant women's perceptions about their lived experience of an intervention which integrates a low-intensity form of physical activity, yoga, into prenatal care; our secondary aim is to evaluate changes in participants' self-efficacy for physical activity and time spent in physical activity over time., Methods: Held in an outpatient obstetrics department of an urban hospital system in the United States, this pilot study enrolled 16 pregnant women to participate in the intervention throughout their pregnancy. We explored participants' lived experience of the intervention using qualitative methods (phenomenology). Means, variances, and covariances were calculated for the 2 measures (self-efficacy and time spent in physical activity) over the intervention period., Results: Qualitative findings from focus groups suggest that it is acceptable for prenatal yoga to be integrated into group prenatal care classes and women reported increased confidence with physical activity during pregnancy. Participants did not consider the intervention to fit within the traditional definition of exercise. Women reported increased amounts of time spent in physical activity from baseline to the end of pregnancy, but there were no statistically significant changes in self-efficacy over time., Discussion: The integration of gentle physical activity into the group prenatal care model warrants further attention for potential benefits with regard to maternal physical and mental wellness., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The majority of college students report caffeine use with many using caffeine daily. Energy drink (ED) use, in particular, is common among college students, and numerous studies link these heavily caffeinated drinks to a variety of adverse consequences including substance use and risky behaviors. However, little is known about correlations between any-source caffeine use and other substance use and problems. The purpose of this study was to evaluate patterns of caffeine use and examine the relationships between caffeine, in general, and EDs specifically, and adverse health behaviors in college students. Methods: We used data from a longitudinal study of alcohol use and health-related outcomes to assess caffeine, alcohol, nonprescription drug, and tobacco use and symptoms of alcohol dependence in 1958 freshmen from a mid-Atlantic university during Fall 2012. We compared adverse health behaviors between caffeine users and nonusers and ED users and nonusers. Data were evaluated separately in men and women. Results: While women reported significantly more caffeine use than men, men reported more ED use. EDs, regardless of frequency of use, were associated with all adverse health behaviors, but only in female students. Similarly, daily any-source caffeine use was significantly associated with alcohol, nonprescription drug, and tobacco use in female students, but in men, the association was less robust. Conclusions: This research shows that caffeine use is prevalent among college students, and, in female students, is associated with alcohol, nonprescription drug, and tobacco use and alcohol dependence symptoms. Interventions aimed at promoting healthy behaviors may be especially useful in this population., Competing Interests: No competing financial interests exist.

Objectives: To determine the awareness and use of an external medication history (EMH) function within an electronic health record and its impact on patient perception of medication adherence., Methods: Two self-administered surveys were given: one to providers and one to patients. Participants included providers from an academic medical center and patients from 2 general internal medicine clinics., Results: Of 154 completed provider surveys, 61% were aware the EMH existed. More of the respondents aware of the EMH were primary care and medicine subspecialty providers (79.1%) when compared with surgical providers (20.9%, P < 0.0001). The most common reasons chosen for looking at the EMH included checking for medication adherence (44%), questions about a specific medication (40%), and checking controlled substance prescription history (37%). Of those aware of the EMH, 65% found medications on the EMH that they were not aware their patient was getting filled. Of the 94 patient surveys, 34% felt the EMH feature might change their medication taking behavior, and 48% responded that it already had. Patients with a history of depression and/or anxiety were less likely to report the intent to change their medication taking behavior, OR, 0.34 [95% CI, 0.13-0.87]., Conclusion: An external medication history function can provide further insight about a patient's medication profile and prescription filling. Knowledge attained from the EMH may improve patient safety by helping to uncover nonadherence, dosing discrepancies, and medications prescribed by other providers. Additionally, patient knowledge of this feature might improve medication adherence. Although further studies are needed to obtain objective data, the external medication history function may have significant impact on both providers and patients, and its benefit should be widely publicized.

Objective: The objective of this study was to assess the association of analgesics and sedatives on oral feeding function and need for feeding tube at discharge in the very low birth weight (VLBW) (<1,500 g) preterm infant., Study Design: A retrospective review of surviving inborn infants < 1,500 g and < 32 weeks' gestation ( n  = 209), discharged between January 1, 2012, and December 31, 2014, from the neonatal intensive care unit identified exposure to analgesic and sedative medications, demographics, medical course, and nasogastric or gastrostomy tube (GT) feeding at discharge. Predictive modeling with logistic regression to identify independent factors associated with discharge on tube feedings., Results: Out of 209, 45 (21.5%) infants received an analgesic/sedative with 23 out of 45 (51.1%) discharged with tube feedings. Infants discharged with tube feedings were born smaller, of younger gestation, with greater SNAPPE-II scores, periventricular leukomalacia, chronic lung disease, postnatal glucocorticoids, lansoprazole, and longer time intubated. After adjusting for covariates, exposure to analgesic/sedatives (fentanyl, midazolam, or morphine) was independently predictive of discharge on tube feedings., Conclusion: Analgesic and sedative exposure in VLBW infants is highly associated with poor oral feeding and need for tube feedings at discharge., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The purpose of this pilot randomized controlled trial (RCT) was to intervene with parents of overweight/obese 4- to 8-year-old children to improve child internalizing and externalizing behaviors. Parent-child dyads ( N = 60) were randomly assigned to treatment or comparison conditions. Parents attended four intervention sessions at their child's primary health care office over 3 months. Child behaviors were assessed at 0, 3, 6, and 12 months post intervention. Parental beliefs in their skills/abilities increased in the experimental group parents, but there was no statistical difference between groups at any time. Child externalizing behaviors significantly decreased from baseline to postintervention for both groups ( F = 3.26, p = .020). Post hoc model testing suggests that this change was more pronounced in the intervention group ( F = 0.56, p = .692). Child somatic symptoms significantly decreased over time ( F = 4.55, p = .004), and there were group differences in child depressive behaviors ( F = 6.19, p = .020). These findings suggest that a parent-focused intervention program demonstrated positive preliminary effects on children's behaviors.

Objectives: The International Ascites Club (IAC) recently defined Stage 1 acute kidney injury (AKI) for cirrhosis as an acute increase in serum creatinine (SCr) by ≥0.3 mg/dl or by ≥50% in <48 h from a stable value within 3 months. The baseline SCr may influence AKI risk and patient outcomes. The objective of this study is to determine in cirrhosis whether the baseline SCr has any effect on the in-hospital AKI course and patient survival., Methods: North American Consortium for the Study of End-Stage Liver Disease is a consortium of tertiary-care hepatology centers prospectively enroling non-elective cirrhotic inpatients. Patients with different baseline SCr levels (≤0.5, 0.51-1.0, 1.01-1.5, >1.5 mg/dl) were evaluated for the development of AKI, and compared for AKI outcomes and 30-day survival., Results: 653 hospitalized cirrhotics (56.7±10years, 64% men, 30% with infection) were included. The incidence of AKI was 47% of enrolled patients. Patients with higher baseline SCr were more likely to develop AKI, with significantly higher delta and peak SCr (P<0.001) than the other groups, more likely to have a progressive AKI course (P<0.0001), associated with a significantly reduced 30-day survival (P<0.0001). Multivariate logistic regression showed that the delta SCr during an AKI episode to be the strongest factor impacting AKI outcomes and survival (P<0.001), with a delta SCr of 0.70 mg/dl having a 68% sensitivity and 80% specificity for predicting 30-day mortality., Conclusions: Admitted cirrhotic patients with higher baseline SCr are at higher risk for in-hospital development of AKI, and more likely to have AKI progression with reduced survival. Therefore, such patients should be closely monitored and treated promptly for their AKI.

Background: Women have lower serum creatinine values than men for similar renal function., Aims: We aimed to determine the differential effect of baseline, peak, and delta creatinine between genders on outcomes in infected hospitalized cirrhotic patients., Methods: North American Consortium for the Study of End-Stage Liver Disease is a 15-center consortium of tertiary care hepatology centers prospectively enrolling infected cirrhotic inpatients. Baseline, peak, and delta creatinine during hospitalization were compared between genders, and their impact on overall survival, transplant-free survival, probability of transplantation, and need for renal replacement therapy (RRT) was analyzed., Results: In total, 532 patients with cirrhosis (males = 59% median admission MELD = 20) had significantly lower median baseline (1.07 vs. 1.30 mg/dL, p < 0.0001) and peak creatinine (1.47 vs. 1.59 mg/dL, p = 0.024) in women than men during hospitalization for an infection, but both genders had similar delta creatinine levels (0.30 vs. 0.30 mg/dL, p = 0.957). Thirty-day mortality was similar between genders. RRT was not used more often in women (19 vs. 12%, p = 0.050), and women were 1.8 times more likely than men to receive RRT at the same creatinine (p = 0.028). Both peak and delta creatinine significantly predicted 6-month overall and transplant-free survival (p < 0.0001), but the probability of liver transplantation was affected by the interaction between gender and both peak and delta creatinine., Conclusions: Infected hospitalized cirrhotic women are significantly more likely than men to receive RRT at similar creatinine levels. Gender-specific differences in baseline, peak, and delta creatinine need further investigation to determine whether women need acute kidney injury treatment at lower creatinine thresholds than men.

Purpose: The aim of the present study was to explore clusters of psychoneurological symptoms and inflammation (levels of C-reactive protein) over time in a cohort of women with early-stage breast cancer. Specifically, we examined the relationships among affective symptoms (depression, anxiety, fatigue, sleep disturbances, pain, and perceived stress), domains of cognitive performance, and levels of peripheral C-reactive over a period of 2 years., Methods: This was a prospective, longitudinal study of 77 women diagnosed with early-stage breast cancer. Data collection, including symptom questionnaires, performance-based cognitive testing, and blood draws, took place at 5 time points: prior to initiating adjuvant chemotherapy, prior to the fourth chemotherapy treatment, and at 6, 12, and 24 months after the initiation of chemotherapy., Results: Exploratory factor analysis with varimax orthogonal rotation was used to examine the covariance among symptoms at each visit. Using the factor scores and weighted sums, three clusters were identified: global cognition, affective symptoms, and cognitive efficiency. Peripheral levels of C-reactive protein were inversely correlated with the cognitive efficiency factor across time., Conclusions: The findings suggest that objectively measured domains of cognitive function occur independently of other affective symptoms that are commonly reported by women with breast cancer in long-term survivorship. The cognitive efficiency symptom cluster may be amenable to interventions targeted to biological influences that reduce levels of C-reactive protein., Competing Interests: Compliance with ethical standards Conflicts of interest For the remaining authors, none were declared.

The increasing prevalence of energy drink (ED) use and its link with negative behaviors and adverse health outcomes has garnered much attention. Use of EDs combined with alcohol among college students has been of particular interest. It is unclear if these relationships develop in the context of college, or if similar associations exist in younger individuals. The present study examined associations between ED consumption patterns and other substance use in an adolescent, school-based sample. Participants were N = 3743 students attending 8th, 10th or 12th grade in a suburban central Virginia public school system who completed a prevention needs assessment survey in 2012. Chi-square analyses and logistic regressions were used to compare rates of alcohol, tobacco and other drug use across three ED use groups: moderate/heavy (12.6%), light (30.5%), and non-users (57%). Over 40% of the sample reported recent (past month) ED use, with males more likely to report moderate/heavy ED use than females (14.0% and 11.1%, respectively; p = 0.02). After adjusting for gender and grade, ED use group predicted lifetime alcohol, tobacco and other drug use (all p < 0.001). Moderate/heavy ED users were most likely and ED non-users were least likely to report using each of the 13 substances in the survey, with light ED users intermediate to the other two groups. Moderate/heavy ED users were consistently most likely to report licit and illicit substance use. Additional research is needed to better understand which adolescents are at greatest risk for adverse health behaviors associated with ED use.

Purpose: Women with breast cancer may experience symptoms of depression, anxiety, pain, fatigue and sleep disturbances during chemotherapy. However, there are few modalities that address multiple, commonly occurring symptoms that may occur in individuals receiving cancer treatment. Cranial electrical stimulation (CES) is a treatment that is FDA cleared for depression, anxiety and insomnia. CES is applied via electrodes placed on the ear that deliver pulsed, low amplitude electrical current to the head., Methods: This phase III randomized, sham-controlled study aimed to examine the effects of cranial microcurrent stimulation on symptoms of depression, anxiety, pain, fatigue, and sleep disturbances in women receiving chemotherapy for early-stage breast cancer. Patients were randomly assigned to either an actual or sham device and used the device daily for 1 h. The study was registered at clinicaltrials.gov, NCT00902330., Results: The sample included N = 167 women with early-stage breast cancer. Symptom severity of depression, anxiety, and fatigue and sleep disturbances were generally mild to moderate. Levels of pain were low. Anxiety was highest prior to the initial chemotherapy and decreased over time. The primary outcome assessment (symptoms of depression, anxiety, fatigue, pain, sleep disturbances) revealed no statistically significant differences between the two groups, actual CES vs. sham., Conclusion: In this study, women receiving chemotherapy for breast cancer experienced multiple symptoms in the mild to moderate range. Although there is no evidence for the routine use of CES during the chemotherapy period for symptom management in women with breast cancer, further symptom management modalities should be evaluated to mitigate symptoms of depression, anxiety, fatigue, pain and sleep disturbances over the course of chemotherapy.

Individuals with substance use disorders are often plagued by psychiatric comorbidities and histories of physical and/or sexual trauma. Males and females, although different in their rates of expressed trauma and psychiatric symptomatology, experience comparable adverse consequences, including poorer substance abuse treatment outcomes, diminished psychosocial functioning, and severe employment problems. The goal of the current study was to examine the relationships between trauma history, lifetime endorsement of psychiatric symptoms, and gender in a sample of individuals participating in outpatient substance abuse treatment. Study participants (N = 625) from six psychosocial counseling and five methadone maintenance programs were recruited as part of a larger study conducted through the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN). Study measures included lifetime trauma experience (yes/no), type of trauma experienced (sexual, physical, both), lifetime depression/anxiety, and lifetime suicidal thoughts/attempts (as measured by the Addiction Severity Index-Lite [ASI-Lite]). Lifetime endorsement of psychiatric symptoms was compared between individuals with and without trauma history. The role of gender was also examined. Results indicated that the experience of trauma was associated with an increase in lifetime report of psychiatric symptoms. Experience of physical and combined physical and sexual trauma consistently predicted positive report of psychiatric symptoms in both males and females, even when controlling for demographic and treatment-related variables. Employment outcomes, however, were not predicted by self-reported history of lifetime trauma., (© The Author(s) 2014.)

Unlabelled: Adolescents diagnosed with Type 1 Diabetes Mellitus often exhibit reduced adherence to their medical regimen and poor glycemic control. A retrospective study examined longitudinal hemoglobin A1c (HgbA1c) outcomes for adolescent patients referred to the psychology service embedded within an endocrinology clinic. Three patient groups were examined: (1) TREATMENT: 59 adolescents referred who engaged in psychotherapy; (2) No, Treatment: 40 adolescents referred yet failed to initiate psychotherapy; (3) CONTROL: 58 adolescents not referred for treatment and matched on demographics to the two treatment groups. Over 1 year, the TREATMENT group had a sustained decrease in HgbA1c while the No TREATMENT and CONTROL groups had an overall increase in HgbA1c. At study end, the TREATMENT group had HgbA1c values that were not significantly different from patients who were not considered in need of psychological treatment (CONTROL). Adolescents that utilized the pediatric psychology service saw decreased HgbA1c values over time.

Background & Aims: Hyponatremia (HN) and hepatic encephalopathy (HE) together can impair health-related quality of life (HRQOL) and cognition in cirrhosis. We aimed at studying the effect of hyponatremia on cognition, HRQOL, and brain MR spectroscopy (MRS) independent of HE., Methods: Four cirrhotic groups (no HE/HN, HE alone, HN alone (sodium <130 mEq/L), HE+HN) underwent cognitive testing, HRQOL using Sickness Impact Profile (SIP: higher score is worse; has psychosocial and physical sub-scores) and brain MRS (myoinositol (mI) and glutamate+glutamine (Glx)), which were compared across groups. A subset underwent HRQOL testing before/after diuretic withdrawal., Results: 82 cirrhotics (30 no HE/HN, 25 HE, 17 HE+HN, and 10 HN, MELD 12, 63% hepatitis C) were included. Cirrhotics with HN alone and without HE/HN had better cognition compared to HE groups (median abnormal tests no-HE/HN: 3, HN: 3.5, HE: 6.5, HE+HN: 7, p=0.008). Despite better cognition, HN only patients had worse HRQOL in total and psychosocial SIP while both HN groups (with/without HE) had a significantly worse physical SIP (p<0.0001, all comparisons). Brain MRS showed the lowest Glx in HN and the highest in HE groups (p<0.02). mI levels were comparably decreased in the three affected (HE, HE+HN, and HN) groups compared to no HE/HN and were associated with poor HRQOL. Six HE+HN cirrhotics underwent diuretic withdrawal which improved serum sodium and total/psychosocial SIP scores., Conclusions: Hyponatremic cirrhotics without HE have poor HRQOL despite better cognition than those with concomitant HE. Glx levels were lowest in HN without HE but mI was similar across affected groups. HRQOL improved after diuretic withdrawal. Hyponatremia has a complex, non-linear relationship with brain Glx and mI, cognition and HRQOL., (Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objective: To describe motivations correlating with subspecialty choices, particularly rheumatology., Methods: A total of 179 respondents answered queries about various aspects affecting specialty and subspecialty choice with ordinal ratings of importance. Likert scale response data were analyzed to determine independent predictors of being a rheumatology fellow. Multivariate logistic regression analyses were used to develop models predicting rheumatology fellowship. Factor analysis methods to condense the individual responses into fewer underlying variables or factors were employed., Results: While every group ranked intellectual interest as more important than all other responses, its score in the rheumatology fellow group was significantly higher than that in the medical student group. A model using 4 composite variables based on prior literature did not fit well. Exploratory factor analysis identified 5 underlying motivations, which were designated as time, money, external constraints, practice content, and academics. All motivations except money were statistically significant, with the rheumatology fellow group attributing greater importance than medical students to time, practice content, and academics, and lesser importance than medical students to external constraints., Conclusion: Values and motivations leading toward rheumatology subspecialty choice can be traced to identifiable factors. Intellectual interest appears to be split between 2 distinct significant variables: practice content and academics. Time or controllable lifestyle, external constraints, practice content, and academic issues appear to be important influences on the choice of rheumatology fellowship. Such variables appear to reflect underlying values and motivations., (Copyright © 2010 by the American College of Rheumatology.)

Although pneumonia is a leading cause of death from infectious disease worldwide, comprehensive information about its causes and incidence in low- and middle-income countries is lacking. Active surveillance of hospitalized patients with pneumonia is ongoing in Thailand. Consenting patients are tested for seven bacterial and 14 viral respiratory pathogens by PCR and viral culture on nasopharyngeal swab specimens, serology on acute/convalescent sera, sputum smears and antigen detection tests on urine. Between September 2003 and December 2005, there were 1730 episodes of radiographically confirmed pneumonia (34·6% in children aged <5 years); 66 patients (3·8%) died. A recognized pathogen was identified in 42·5% of episodes. Respiratory syncytial virus (RSV) infection was associated with 16·7% of all pneumonias, 41·2% in children. The viral pathogen with the highest incidence in children aged <5 years was RSV (417·1/100,000 per year) and in persons aged ≥50 years, influenza virus A (38·8/100,000 per year). These data can help guide health policy towards effective prevention strategies.

Deficits in sensory modulation have been linked clinically with impaired attention, arousal, and impulsivity for years, but a clear understanding of the relationship between sensory modulation disorders and attention deficit hyperactivity disorder (ADHD) has proven elusive. Our preliminary work suggested that patterns of salivary cortisol and electrodermal responsivity to sensation may be linked to different groups of children with ADHD; those with and without sensory over-responsivity (SOR). Additionally, SOR has been linked to anxiety, and anxiety has been linked to ADHD. A clearer understanding of the relationship between anxiety, SOR, and ADHD may support a better understanding of ADHD diagnostic subtypes. We examined neuroendocrine, electrodermal and behavioral characteristics and sought to predict group membership among 6- to 12-year-old children with ADHD and SOR (ADHDs), ADHD and no SOR (ADHDt), and typicals (TYP). Behavioral questionnaires were completed to document SOR and anxiety. Lab testing used a Sensory Challenge Protocol (SCP) with concurrent electrodermal measurement and the collection of cortisol prior to and following the SCP. Results substantiated links between SOR and anxiety, in both TYP and ADHD children. Results suggests that ADHD should be considered in conjunction with anxiety and sensory responsivity; both may be related to bottom-up processing differences, and deficits in prefrontal cortex/hippocampal synaptic gating.

Background: To enhance quality improvement, we created a unique statewide collaboration among 3 organizations: the Virginia Health Quality Center (Virginia's Medicare Quality Improvement Organization), the American College of Cardiology, and the American Heart Association. The goal was to improve discharge measures for acute myocardial infarction and heart failure., Methods and Results: In 2004, 29 hospitals participated in the collaborative initiative. Using Medicare data submitted from 2004 through the second quarter of 2006, we analyzed adherence to individual discharge measures and all-or-none appropriate care measures for acute myocardial infarction, heart failure, and both. To control for differences in hospital characteristics, we were able to match 21 of the participating hospitals with 21 similar nonparticipating hospitals. In this paired analysis, the total appropriate care measure increased from 61% to 77% in participating hospitals compared with an increase from 51% to 60% in nonparticipating hospitals (P<0.0001). A generalized linear mixed model examining the full data set at the patient level failed to show a clear advantage among participating hospitals. Participating hospitals had higher baseline rates for most quality measures, suggesting a possible effect of a prior collaborative. Further analysis of only hospitals that participated in a prior collaborative showed that participants in the current collaborative initiative had higher rates of improvement for 7 of 10 quality measures and appropriate care measures for heart failure, acute myocardial infarction, or both (all P<0.05)., Conclusions: We report a unique collaboration of a Medicare Quality Improvement Organization and 2 national organizations to address quality of care for acute myocardial infarction and heart failure. A composite measure of quality (the total appropriate care measure) improved more in the participating hospitals during the timeframe of the intervention, although the greater improvement in this and other measures in the participating hospitals appeared to be dependent on participation in a prior collaborative initiative.

Background: The difficulty of transplanting sensitized patients increases proportionally to the panel reactive antibody (PRA) titer. Because of the high likelihood of a positive final crossmatch, these patients are often excluded from a prospective transplant unless there is a 0 HLA-A, -B, -DR mismatch. To address this problem, we developed a computerized algorithm, termed the Kentucky Antibody Testing System (KATS), that predicts class I HLA antigens that would be both "unacceptable" and "acceptable" to the recipient. This report describes the results of a prospective trial among voluntarily participating centers that agreed to share kidneys based on the KATS predictions for patients whose PRA exceeded 40%., Methods: The results of three antibody screens on each patient were compared with the HLA phenotypes of the cells in the panel in 2x2 tables with calculation of chi-square and correlation coefficient statistics. Private, broad, and public antigens were identified and a list of acceptable and unacceptable antigens were entered into the UNOS computer for each patient listed in the KATS sharing algorithm., Results: Of the total 418 patients meeting the inclusion/exclusion criteria, the largest single group submitted was Black-not-of-Hispanic-origin females. The mean PRA of the patients was 72%. The first transplant via KATS allocation was performed on March 8, 1997. Between that time and the last transplant on July 31, 2000, 145 kidneys were offered to the participating centers and 48 transplants were performed. Of the many reasons listed for not accepting an offer or not transplanting the shared kidney into its intended recipient, only two occurred because of a positive T cell crossmatch and six because of a positive B cell crossmatch. As compared to all other high PRA patients within Southeastern Organ Procurement Foundation who were transplanted during the study period, they were more likely to be non-Caucasian, to be less well matched for private HLA-A, B, and DR antigens, and to have waited for a longer time than the other groups. Although there was a higher incidence of delayed graft function, there was no significant difference in cold ischemia, rejection episodes, or patient or graft survival., Conclusions: We conclude that KATS, or some other system to prospectively identify a list of acceptable and unacceptable HLA antigens, could improve the access of highly sensitized patients to a successful kidney transplant.

To determine whether recipient HLA phenotypes are correlated with an increased or decreased risk of alloantibody sensitization in end-stage renal disease (ESRD) candidates for first or repeat kidney transplantation; we analyzed 19440 kidney allograft recipients consisting of 13,216 Caucasians and 6224 non-Caucasians transplanted between 10/87 and 11/98 at South-Eastern Organ Procurement Foundation (SEOPF) member institutions. Relative risk values and 95% confidence limits were obtained using Wolfe's method. Logistic regression was used to adjust for covariates that influence sensitization, i.e. ethnicity, gender, age, pregnancies, transfusions, primary/repeat transplant and living versus cadaver donor. Univariate analysis of the entire cohort indicated that nine HLA allelotypes (DR1,4,7; B8,12,40; A1,2,11) were associated with a significantly reduced risk of sensitization, and five allelotypes (B42,B53; A 10,19,36) were associated with an increased risk of PRA responses. Corrected for the number of statistical comparisons, recipients with DR1, DR4, A1 or A2 were 15% less likely to be sensitized per allelotype. Recipients with B42, B53 or A36 were at increased risk of preformed antibodies, after correction of the P value, for an average of 38% increased risk per allelotype. In the multivariate analysis, HLA phenotypes identified as independent risk factors associated with protection against sensitization were DR1,4,7; B12(44,45); and A1,2, with an average reduced risk of 9% per allelotype. The only independent susceptibility allelotype was A36 with an increased risk of 29%. The A10 (25,26,34,66) group reached borderline significance. We also looked for HLA-DR,-B,-A combinations that could potentially represent protective or at risk haplotypes/genotypes. Stepwise logistic regression identified five combinations associated with protection: DR1-B35-A3; DR1-B35-A2; DR1-B44-A2; DR4-B44-A2; DR7-B57-A1 (RR range 0.83-0.63) with 27% average reduced risk per combination. Phenotype combinations associated with an increased risk of sensitization were: DR2-B44-A2; DR2B53-A2; DR3-B8-A1: DR3-B42-A30; DR6-B42-A30; DR11-B53-A30 (RR range 2.76-1.48) with an average increased risk of 70% per combination. This study provides strong evidence that HLA-linked genes influence the anti-HLA PRA response. The magnitude of the altered PRA response risk in DR-B-A combinations was approximately twice that of the allelotypes at individual loci. HLA-DR genes seemed to contribute most of the altered risk. The correlations between DR types and PRA responsiveness are consistent with the DR types previously regarded as predictors of kidney graft survival. The magnitude of increased PRA risk attributable to an allelotype or combination was approximately twice that associated with a decreased risk. We conclude that some HLA class II-linked genes modulate the PRA response in a clinically significant manner. This immune response gene (Ir) regulation probably operates through polymorphic HLA molecules in their physiologic roles of antigen processing and presentation to helper T cells.

Providing the best possible care for the child and family is paramount to health professionals working in paediatric palliative care. However, there is little research which enables practitioners to question their current practice. There are concerns about conducting research on children receiving palliative care at such a sensitive time for the child and his/her family. These concerns must be considered against the growing demand for clear standards and guidelines for practice within health care. According to the Department of Health (DoH) there is no place within the modern healthcare system for the adoption of unproven theories or outdated care (DoH, 1998). While no-one would question the dedication and care being delivered to children and their families by well-trained staff, the lack of research is a cause for concern. A group of students undertaking a degree module in paediatric palliative care identified the lack of literature and research in this area and have undertaken a review of the available literature.

Background: The offspring of parents who suffer from premature coronary heart disease have a significantly higher risk of early cardiac death than controls. A genetic predisposition is compounded by a commonality of environmental risk factors within families. Increasing awareness, early detection and modification of risk factors are essential components of an effective public health strategy to protect this highly vulnerable population., Methods: The sons (n = 571) of parents with premature coronary heart disease attended the Toronto Rehabilitation Centre for a risk factor evaluation that included an interview with questionnaire, measurement of body dimensions and blood lipids, and cardiopulmonary exercise testing. A follow-up questionnaire was sent out 2 years after the evaluation., Results: Despite concern about family history, 23% of subjects were smokers and 75% were inactive. Objective data confirmed a substantial prevalence of cardiac risk factors: less than optimal cardiovascular fitness (48%), overweight (34%), total cholesterol > or = 200 mg/dL (46%), high-density lipoprotein cholesterol < or = 35 mg/dL (26%), low-density lipoprotein cholesterol > or = 160 mg/dL (16%), triglycerides > or = 200 mg/dL (27%), and lipoprotein (a) > 30 mg/dL (24%). Although almost all had a family physician whom they had seen an average of 1.8 times in the past year, and 4.7 times in the previous 3 years, screening and risk factor intervention strategies were disappointing. Two-year follow-up data showed a heightened health awareness, with a greater proportion of subjects exercising and attempting to maintain an appropriate body mass., Conclusions: The male offspring of parents who have suffered a premature coronary event exhibit a substantial prevalence of modifiable risk factors. The family physician can play an essential role in promoting a healthy lifestyle through risk reduction counselling and screening.

Background: Bus drivers with ischemic heart disease have been denied normal employment, although they satisfy Canadian Cardiovascular Society (CCS) Guidelines. To show the safety of their reemployment, we compared their responses when driving buses with those seen during graded exercise testing., Methods: Twenty-two male city bus drivers, aged 48.1 +/- 5.6 years (19 had a myocardial infarction, 2 had coronary artery bypass graft, 1 had documented ischemic heart disease) were referred for work evaluation. After a CCS cardiopulmonary exercise test, they were accompanied by a physician and a therapist/technician on a normal shift. Note was kept of symptoms, signs, electrocardiogram (telemetry), blood pressure (ambulatory recording unit), and Borg rating of effort throughout., Results: Average values for peak heart rate (101 +/- 12.5 versus 148.2 +/- 17.2 beats/min), peak systolic pressure (150.0 +/- 20.8 versus 198.9 +/- 25.7 mm Hg), peak rate-pressure product (15,259 +/- 3,369 versus 29,500 +/- 5,283 units), peak Borg RPE (9.9 +/- 1.4 versus 17.4 +/- 3.0 units), and peak ST-segmental depression (-0.03 +/- 0.07 versus -0.07 +/- 0.09 mV) during the shift were only about a half of average values reached during the graded stress test. Moreover, peak values were reached at the end of the shift, when carrying the loaded fare box, rather than when driving., Conclusions: Cardiovascular strain during bus driving is much less than during the CCS stress test for drivers. Using CCS methodology, the risk that a sudden cardiovascular incident will cause injury or death of others in the first year after recovery from myocardial infarction is estimated at 1 in 50,000 driver-years. Thus, those satisfying CCS requirements can return to full driving duties promptly, with minimal risk to themselves, passengers, or other road users.

ROP trays containing patient serum samples and distributed by the South-Eastern Organ Procurement Foundation (SEOPF) were instituted to increase the likelihood of transplanting potential renal recipients who are highly sensitized to HLA antigens. This study examines kidney distribution and transplant outcome to assess equitable placement and clinical function post transplant with and without the use of ROP trays. Data were collected over a 26-month period on the distribution of kidneys from 328 consecutive SEOPF donors from whom at least 1 kidney was procured. Shared kidneys were placed via the UNOS and SEOPF-variance computer match programs. Of 656 kidneys, 596 were placed into 582 recipients; 60 were not used. ROP trays were used in placement of 492 kidneys and were not used for placement of 104 kidneys. Outcome was determined for 435 kidneys transplanted into SEOPF recipients. Only 33 (6.9%) recipients with ROP tray use and 10 (9.8%) without were sensitized to HLA. A 10% increase in placement to the originally intended recipient was seen with ROP tray usage over kidneys placed without ROP tray use (p < or = 0.025). Recipients matched using ROP tray data averaged 29 positions higher on the match printout. There was no difference in tray use regarding placement of kidneys within or outside the donor's local UNOS region, nor was there a difference in mean HLA match of transplant pairs with and without ROP tray use, 3.2 and 3.1 antigens, respectively. Cold ischemia time was similar, 22.9 and 23.6 h, respectively, for kidneys placed with and without ROP trays. At post-transplant discharge, there were no differences in patient status, graft failure, rejection treatment, dialysis need, or urine output whether or not ROP trays were used. Significantly, however, plasma creatinine at discharge and at 12 months was lower for those placed with ROP trays (2.5 mg/dl and 1.7 mg/dl) vs (3.1 mg/dl and 1.9 mg/dl), respectively. During this time period, all kidneys transplanted with use of ROP trays functioned as well or better than those transplanted without ROP tray placement. Thus, the use of ROP trays appeared to have a beneficial effect in getting more recipients of higher priority transplanted with equivalent, if not better, graft function.