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PURPOSE: Complementary and integrative medicine (CIM) services are more prevalent in cancer centers but continue to be underutilized by patients. This study examines perspectives from patients and caregivers about these services being offered at a comprehensive cancer center. METHODS: Patients and caregivers were surveyed about their familiarity, interest, and experience with five CIM therapies: acupuncture, massage, meditation, music therapy, and yoga. Respondents were asked about their interest in and/or paying for these services at baseline, when recommended by their medical team, and when offered in a clinical trial. Respondents were also asked about perceived barriers to accessing these services. Chi-squared tests were performed to explore associations between past experience, interest levels, and willingness to pay. RESULTS: A total of 576 surveys were obtained (464 patients and 112 caregivers). Most respondents identified as White or Caucasian (65.6%), female (57.2%), had been a patient for < 3 years (74.2%), had some college education (73.8%), and made > $40,000 in US dollars as their annual household income (69.1%). Respondents were most familiar with therapeutic massage (34.2%) and least familiar with acupuncture (20.0%). The average interest in these services increased from 53.3% to 64.1% when recommended by a medical professional. Respondents were most willing to pay $1-60 for therapeutic massage (62.3%) and least willing to pay for meditation (43.7%). The main barriers to accessing CIM services were cost (56.0%) and lack of knowledge (52.1%). CONCLUSION: Overall, a significant proportion of patients and caregivers were unfamiliar with these five integrative therapies. Increasing education, decreasing cost, and a recommendation by medical professionals would improve CIM usage.

Supportive and integrative oncology services aim to improve the quality of life of cancer patients. This study characterizes the views of these services among cancer patients, caregivers, and providers at a comprehensive cancer center. A cross-sectional survey was administered in 2017–2018. The survey asked about participants’ familiarity, perceived importance, use, accessibility, and barriers to 19 supportive and integrative oncology services using a Likert scale. Data were analyzed using the Kruskal-Wallis test and a proportional odds regression model. A total of 976 surveys were obtained (604 patient surveys, 199 caregiver surveys, 173 provider surveys). Patients were mostly female (56.3%), ≥60 years old (59.4%), and Caucasian (66%). Providers were an even distribution of nurses, physicians, and advanced practice providers. Patients felt social work and nutrition services were the most familiar (36.4% and 34.8%) and the most important (46.3% and 54.5%). Caregivers were also most familiar with those two services, but felt that nutrition and learning resources were most important. Social work and nutrition were easiest to access and used the most by both patients and providers. There was a positive correlation between accessibility and perceived importance. Being unaware was the most common barrier identified by patients (38.4%), providers (67.1%), and caregivers (33.7%). Social work and nutrition services were most familiar to respondents, and also generally the most important, accessible, and utilized. Lack of awareness was the most common barrier cited and suggests that increased efforts to educate patients and providers about other services available are needed.

Objectives The objectives of this study are to determine the overall and racial differences in the extent of caries experience and to examine the association between child and parent/caregiver characteristics and caries among 3-6-year-old Medicaid-enrolled children. Methods This study reports baseline cross-sectional data from a larger pragmatic clinical trial in pediatric primary care practices. Child-level clinical dental exams included decayed and filled teeth (dft) using ICDAS criteria and parent/caregiver questionnaire collected information on socio-demographics, child oral health behaviors, oral health related quality of life (OHQoL), and food environment. Results A total of 1,024 parent/caregiver-child dyads participated in the study. The overall caries experience (dft) was 49 percent and untreated decay was 42 percent. Children who were Black had 1.3 and 1.2 times significantly higher frequency of untreated primary decay and caries experience compared to non-Black children. An overall logistic regression model predicted that race, increased age, receiving dental care in the past 12 months for a cavity/toothache, and lower caregiver OHQoL was significantly associated with increased odds of the child having caries. Non-Black caregivers with less education, whose child was older, and lower child OHQoL had increased odds of having a child with caries, but these same variables were not predictive for the Black children. Conclusions Racial disparities exist with respect to caries experience and untreated decay within a Medicaid-enrolled population of young children attending well-child visits. Pediatric primary care offices are well-positioned to provide dental surveillance and preventive care and could play an important role in decreasing oral health inequities.

Aim There are limited data on psychological outcomes in older people with epilepsy (PWE). This analysis, from a large pooled dataset of clinical studies from the Managing Epilepsy Well (MEW) Network, examined clinical variables including depressive symptom severity, quality of life and epilepsy self-management competency among older (age 55+) vs younger (

Background Loss of response in pediatric inflammatory bowel disease patients treated with biologic medications can be due to development of anti-drug antibodies. Natural history of anti-drug antibodies development has not been well described in pediatric inflammatory bowel disease. The primary aim of this study was to describe a single-center experience for the temporal onset of anti-drug antibodies detection. Methods We performed a retrospective, single-center chart review of pediatric inflammatory bowel disease patients at the Division of Pediatric Gastroenterology, Hepatology, and Nutrition at Rainbow Babies and Children's Hospital from 2010 to 2015. Patients were treated with infliximab or adalimumab and had at least two evaluations for anti-drug antibodies with the homogenous mobility shift assay. Demographics, laboratory and medication data, and clinical disease activity were collected. Results A total of 75 subjects are included in the analysis. Eighty-one percent of subjects were treated with infliximab. Eleven subjects developed anti-drug antibodies; average time to anti-drug antibodies detection was 13.2 ± 7.3 months. Longer duration of inflammatory bowel disease, L1 location in Crohn's disease, and not having immunomodulatory therapy before biologic was associated with higher risk of antibody detection. Antibody detection occurred more frequently with infliximab vs. adalimumab. Time-to-antibody detection for infliximab and adalimumab was 14.83 and 23.48 months, respectively. Conclusion Chances of anti-drug antibodies detection in the infliximab group were higher than the adalimumab group. Time-to-antibody detection was 8.65 months longer in patients who received adalimumab when compared to infliximab. These results may have implications for long-term therapy and help guide use of concomitant immunomodulators.

Background Dural substitutes used during hemicraniectomy provide a barrier and dissection plane during subsequent cranioplasty. A recent review by our group showed that use of dural substitutes in hemicraniectomy is associated with reduction in estimated blood loss (EBL) and operative time (OT). In our experience, the use of a dual-layer technique facilitates a dissection plane with minimal adhesions. We hypothesized that use of this dual-layer technique would show decreased OT and EBL in patients undergoing cranioplasty. Methods We conducted a retrospective case-control study comparing use of single-layer versus dual-layer duraplasty on cranioplasty operative outcomes. Data on dual-layer cases were collected from patients who underwent cranioplasty from 2013 to 2017. These data were matched to controls from 2008 to 2012. Patients were identified by query of a neurosurgical database of all procedures performed at our institution. Patients were included if they had complete surgical records for cranioplasty. Cases and controls were compared with a Student t test, χ2 test, or Fisher exact test. Results A total of 78 controls and 45 cases met inclusion criteria. All baseline characteristics between cohorts were similar except for surgical indication. Mean OT (102.97 minutes vs. 102.18 minutes) and mean EBL were not significantly different (204.66 mL vs. 190 mL) between cohorts. Conclusions In this study, we did not detect any significant difference between EBL and OT with use of single-layer versus dual-layer duraplasty. Mean EBL was slightly higher in the controls compared with cases but this difference was not statistically or clinically significant. This concept would benefit from a prospective randomized study.

OBJECTIVE: To examine associations between amounts of fatty acid ethyl esters (FAEEs) in meconium and behavior in school aged children exposed to alcohol and drugs in utero. METHODS: A secondary analysis of a prospective cohort of cocaine, polydrug exposed children, primarily African-American, low socioeconomic status, recruited at birth into a longitudinal study. FAEEs were quantified with gas chromatography via a flame ionization detector. Meconium was analyzed for FAEEs for 216 newborns of whom 194 were assessed with the Child Behavior Checklist (CBCL) at ages 4, 6, 9, 10, 11, and 12. Generalized estimating equation analyses were used to assess the relationship of quantity of FAEEs to outcomes, controlling for maternal psychological distress. RESULTS: Higher concentrations of FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, ethyl linoleate, and ethyl linolenate) were associated with caregiver reported aggressive and/or delinquent behavior at ages 10 and 12. After control for caregiver psychological distress, and age, significant (p < 0.05) FAEE by age interactions were found for ethyl myristate for aggression and for ethyl oleate, ethyl linoleate and ethyl linolenate for delinquency . Thus, higher concentrations of FAEE were related to more caregiver reported aggressive and delinquent behaviors of clinical significance at ages 10 and 12. CONCLUSION: Higher concentrations of FAEEs in meconium are potential markers for children at risk for aggressive and delinquent behaviors related to the effects of prenatal alcohol exposure.

This report is a secondary analysis of data from a larger study of a nurse-led early therapeutic mobility intervention among patients receiving mechanical ventilation. This analysis evaluated whether intervention frequency or intensity was associated with pain or fatigue. Frequency was defined as once-daily versus twice-daily interventions. Intensity was defined as low (in-bed activities) or moderate (out-of-bed activities). Thirty-nine patients self-reported pain and fatigue immediately before and after the intervention. Neither pain nor fatigue increased significantly (mean increase

Aim There are limited data on psychological outcomes in older people with epilepsy (PWE). This analysis, from a large pooled dataset of clinical studies from the Managing Epilepsy Well (MEW) Network, examined clinical variables including depressive symptom severity, quality of life and epilepsy self-management competency among older (age 55+) vs younger (

Background Chronic subdural hematomas (cSDHs) are common neurosurgical pathological entities and typically occur after trauma in elderly patients. The 2 most commonly used strategies for treatment have included burr hole drainage and craniotomy with decompression. However, the choice of these procedures has remained controversial and has been primarily determined by surgeon preference. We designed a matched-cohort analysis to compare these 2 procedures and identify the risk factors associated with the postoperative outcomes. Thus, we compared the rates of reoperation and mortality for patients who had undergone craniotomy versus burr hole evacuation for cSDH. Methods A retrospective review examining the data from 299 consecutive patients with cSHDs from 2002 to 2015 was performed. We compared the following endpoints between the 2 procedures: 30-day mortality, discharge to a skilled nursing facility, and the need for reoperation. We also compared the potential risk factors in the patients with different primary outcomes. Results Patients undergoing craniotomy had a decreased need for reoperation compared with patients treated with burr hole evacuation (7.5% vs. 15.7%; P = 0.044). Older age was associated with both increased disposition to a nursing facility and increased 30-day mortality in both groups. Increased 30-day mortality was associated with aspirin usage in patients who had undergone craniotomy and with warfarin (Coumadin) in patients who had undergone burr hole evacuation. Conclusions Our study identified an increased need for reoperation for patients treated with burr hole evacuation compared with those undergoing craniotomy. Older age and low Glasgow coma scale scores were associated with worse outcomes in both groups. Certain methods of anticoagulation were also associated with worse outcomes, which varied between the 2 groups. We recommend that surgeons individualize the choice of procedure according to the specific patient characteristics with consideration of these findings.

Background Little is known about how prenatal exposure to substances (alcohol, tobacco, marijuana, and cocaine) may contribute to heterogeneous childhood trajectories of internalizing symptoms (i.e., depression, withdrawal, anxiety). The present study aimed to identify developmental trajectories of internalizing symptoms in children using gender-separate analyses and to examine whether trajectories differ by prenatal substance exposure (PSE) and other environmental and biological correlates. Methods Data from two large community-based birth cohorts with PSE were integrated (N = 1,651, 848 boys, 803 girls): the Cleveland cohort and the Maternal Lifestyle Study (MLS). Internalizing symptoms were assessed with the Child Behavior Checklist at ages 2, 4, 6, 9, 10, 11, and 12 in the Cleveland study and at ages 3, 5, 7, 9, 11, and 13 in the MLS. Results Gender-separate group-based trajectory modeling yielded five distinctive developmental trajectories of internalizing symptoms from ages 2 to 13 in both boys and girls: low-risk group (14.4% girls, 28.8% boys); normative-decreasing group (35.3% girls, 33.1% boys); increasing risk group (14.4% girls, 13.0% boys); early-high group (22.3% girls, 17.9% boys); and chronic group (13.8% girls, 7.2% boys). Prenatal tobacco exposure, maternal psychological distress, and postnatal maternal alcohol use differentiated the longitudinal courses of internalizing symptoms. Boys were more likely to follow the low-risk trajectory, whereas girls were more likely to follow the chronic trajectory. Conclusions Prenatal tobacco exposure was associated with suboptimal developmental trajectories of internalizing symptoms in the context of prenatal poly-drug exposure, highlighting a need for continued and increased effort toward prevention of prenatal tobacco use.

Prenatal alcohol exposure (PAE) continues to be a serious public health problem, yet no reliable clinical tools are available for assessing levels of drinking during pregnancy. Fatty acid ethyl esters (FAEEs), the nonoxidative metabolites of ethanol measured in meconium, are potential biomarkers to quantify the level of PAE. The association between the concentrations of FAEEs from meconium and adolescent substance use and related problems was examined in a prospective birth-cohort of adolescents exposed to alcohol and drugs in utero. FAEEs were quantified with gas chromatography via a flame ionization detector. Meconium was analyzed for FAEEs in 216 newborns; 183 of them (81 boys, 102 girls) were assessed at age 15 for alcohol, tobacco, and marijuana use using biologic assays and self-report. Substance use problems were assessed using the Problem Oriented Screening Instrument for Teenagers. Findings from multivariable logistic regression analyses indicated that, after controlling for other prenatal drug exposure and covariates, higher concentrations of FAEEs (ethyl myristate, ethyl palmitate, ethyl oleate, ethyl linoleate, ethyl linolenate, and ethyl arachidonate) were related to a greater likelihood of marijuana use and experiencing substance use problems, but not tobacco or alcohol use, at age 15. Elevated levels of FAEEs in meconium may be promising markers for PAE, identifying newborns at risk for early substance use and developing substance use problems.

Objective: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. Design: Randomized interventional study with repeated measures and blinded assessment of outcomes. Setting: Four adult intensive care units (ICUs) in two academic medical centers. Subjects: Fifty-four patients with > 48 hr of mechanical ventilation (MV). Intervention: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. Measurements: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. Main Results: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. Conclusion: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

Introduction Epilepsy has been reported by the CDC to have a prevalence of 1.2% in the United States, which accounts for roughly 3.4 million adults in 2015. Nearly 1 million of those adults are aged 55 or older.1 Epilepsy is more likely to develop in older adults because risk factors for epilepsy are more common as people age including stroke/cardiovascular disease, neurodegenerative disorders, brain tumor and long-term sequelae of alcohol abuse.2 As our population ages, there will be even more older people with epilepsy. A common comorbidity in epilepsy is depression. While the prevalence of depression in patients with epilepsy varies in literature, it is estimated to be between 15% and 37%.3 The significance of depressive symptoms on quality of life has been shown to be greater than that of short-term seizure control.4 For older people, balancing epilepsy treatment in conjunction with other health problems can present with great difficulty. Many antiepileptic's also have side effects such as bone loss, dizziness and greater risk for falls, which can make someone more likely to fall and become injured.5 This analysis, from a large pooled dataset of multiple epilepsy treatment studies, examined presence and symptom severity of depression in older adults (age > 55) with epilepsy in comparison to younger adults (age Methods Analysis was completed using baseline data and clinical variables from 9 studies of the Managing Epilepsy Well (MEW) Network integrated research database (MEW DB). Patients were divided into two groups; age 18-55 and age greater than or equal to 55. A total of 935 adults participated, out of which 161 (17.2 %) were of age 55 or greater and 774 adults younger than 55 (82.8 %). Other demographics included were gender, race, marital status, highest education level and annual income. Standardized rating scales included Quality of Life in Epilepsy (QOLIE-10) and Patient Health Questionnaire (PHQ-9) for depressive symptoms. The QOLIE-10 scoring was harmonized to accommodate slightly different versions of this scale within the integrated dataset. Results The mean age for older patients was 61.5 vs. 34.4 for younger patients. Approximately 60% of patients in both groups were females. Among older patients 109 (76.2%) were white, 24 (16.8%) African Americans, and 4 (3.1%) Hispanic. Majority of these patients (78.6%) had a college education and 53.4% were either married or co-habiting. Demographics of the under 55 group were largely similar. Mean PHQ-9 score was 8.5 in older patients vs. 9.5 in younger patients (p= 0.07). Amongst older patients, those with moderate-severe depression defined as PHQ-9 > 10 had an average of 7 seizures in 30 days, compared to those with scores 10) in both younger and older groups was associated with worse QOL (p= Conclusions Depression is common in people with epilepsy across the lifespan. Depression is more common in those with poorly controlled epilepsy, and more severe depressive symptoms are associated with poorer quality of life. However, we did not find that these findings were different in older vs. younger patients. Methodological limitations such as the clinical trials’ data source and relatively young age of the sample overall could have biased findings. Future analyses need to sample more elderly people with epilepsy including the “old-old” and those with more extensive medical comorbidity. This research was funded by: This study was supported in part by CDC grants U48DP001930 (CWRU), U48DP005030 (CWRU) U48DP005008 (NYU), 148DP005013 (WA), and 1U48DP005018 (Geisel School of Medicine at Dartmouth) under the Health Promotion and Disease Prevention Research Centers Program.

Objective Primary CNS Vasculitis (PCNSV) is a rare disease that is often challenging to diagnose. Cerebral angiography and biopsy have been utilized in the diagnostic workup for several decades but limited literature reports on the concordance of findings of angiography and biopsy. The primary objective of this work was to examine how cerebral angiography corresponded with biopsy findings in patients with suspected PCNSV. Patients and methods A total of 128 patients who underwent workup for PCNSV between years 2005–2016 were identified by query of existing neurological surgery and angiography databases at University Hospitals Cleveland Medical Center (UHCMC) and the Cleveland Clinic Foundation (CCF). The primary outcome was to examine the concordance of results between angiography and cerebral biopsy. Secondary outcomes included examining concordance between results of biopsy and other commonly performed tests for diagnosis of PCNSV including Magnetic Resonance Imaging (MRI), cerebrospinal fluid white blood cell count (CSF WBC), Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP). Results 128 patients underwent cerebral biopsy for diagnosis of suspected PCNSV. 93 (73%) of these patients also underwent angiography. Of the 34 patients with positive biopsy findings, only 5 also had positive angiography. Positive angiography was not found to be correlated with positive biopsy in our analysis. The only test that was significantly associated with biopsy proven vasculitis was increased CSF WBC count (P = 0.0114). Conclusions PCNSV is a rare disease and often requires multiple tests or procedures to obtain definitive diagnosis. These results suggest that cerebral angiography findings are not associated with biopsy findings and should be used cautiously in the diagnostic work-up of PCNSV.

In response to the overwhelming need for mental health and psychosocial support as a result of the humanitarian crisis in Cox’s Bazar, the Directorate General of Health Services, Ministry of Health and Family Welfare Bangladesh, in collaboration with the World Health Organization, the National Institute of Mental Health and the National Institute of Neurosciences, implemented the World Health Organization’s Mental Health Gap Action Programme in November 2017. Over the course of two trainings and supervision visits, general physicians, counsellors and other health professionals from both government facilities and nongovernmental organisations, working with both the host and Rohingya populations, have improved their capacity to assess and manage priority mental, neurological and substance use conditions using the Mental Health Gap Action Programme intervention guidelines. After the first training, over 75% of participants reported feeling confident to apply their learning to their work. Participants receiving the supervision visit valued this follow-up modality and demonstrated a high level of competency during an observed consultation. This was the first instance of the Mental Health Gap Action Programme implementation by the government of Bangladesh following a humanitarian crisis. Our findings suggest that trainees are providing better quality services to assess and manage mental health conditions and that mental health is being integrated into primary health care service delivery.

100 Background: Supportive and integrative oncology services help to improve quality of life for cancer patients. This study characterizes and compares the perceptions of these services among cancer patients and healthcare providers. Methods: A cross-sectional survey was administered to Seidman Cancer Center (SCC) providers online in Spring 2018 and to SCC patients in waiting rooms March - July 2018. The survey asked about familiarity, perceived importance, frequency of use, accessibility and barriers of 19 supportive and integrative oncology services using a 5 point Likert scale. Data analysis included the Chi-square test and Spearman’s rank correlation. Results: A total of 585 surveys were obtained (421 patients and 164 healthcare providers). Patients were generally > 60 (58.2%), female (57.4%), Caucasian (64.2%) with most at > 1 year from starting treatment (59.9%). Healthcare providers were physicians (38.7%), RN partners (38.1%), and advanced practice providers (APPs) (23.2%). Most were female (74.3%), Caucasian (80%) and worked at SCC for > 5 years (56.4%). When compared with providers, many patients were not familiar with and did not perceive the supportive and integrative oncology services as important (see table). RN partners regarded physical therapy as less important than physicians and APPs (65.5% vs. 83.9% and 82.9%), while > 85% of providers from each category regarded palliative care, social work and diet & nutrition services as important. The most common barrier for both patients and providers was being unaware of the services (41.6% and 67.1%). Conclusions: Overall, healthcare providers were more familiar than patients with many supportive and integrative oncology services and considered most to be more important. Being unaware of the services was a common barrier identified by both providers and patients. [Table: see text]