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Mindfulness training (MT) has emerged as a promising tool to promote cognitive functioning and psychological health. As a result, demand for scalable dissemination of MT is increasing across many time-pressured settings. One such setting is the military family. Military spouses face numerous challenges and yet there is a paucity of evidence-based training programs available that are tailored to promote their cognitive functioning and psychological health. In the present study, we examined the impact of a 4-week MT program contextualized for military spouses and delivered via a peer train-the-trainer approach by fellow military spouse instructors (SIs). SIs first participated in an MT teaching practicum to learn how to deliver the program. They then delivered the MT program to military spouse participants (MT group, n = 48). The MT group was tested before (T1) and after (T2) the training interval and compared to a no-training control group (NTC group, n = 58) that did not receive MT but completed both testing sessions. Compared to the NTC group, the MT group showed benefits on measures of cognitive abilities, psychological health, and well-being. Particularly, benefits were reflected in the decrease over time (T1 to T2) in daily cognitive failures and depressive symptoms. Furthermore, correlation analyses revealed that greater MT practice corresponded with greater improvements in objective attentional performance. These findings provide initial evidence for the beneficial effects of a tailored MT program when delivered by peer trainers. Clinicaltrials.gov (NTC03308344).

BACKGROUND To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center. METHODS There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant. RESULTS Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m2 ) (all p values

We reviewed haematological investigations for 43 patients treated at a single centre with alectinib, an inhibitor of anaplastic lymphoma kinase (ALK) which is considered standard first-line treatment for patients with ALK-rearranged advanced non-small cell lung cancer. Ninety-five percent of patients developed marked acanthocytosis, echinocytosis and/or spheroacanthocytosis, not observable with prior treatment with other ALK-inhibitors. Anaemia developed in 73% of patients (38%

Background Spreading depolarizations (SDs) occur in some 60% of patients receiving intensive care following severe traumatic brain injury and often occur at a higher incidence following serious subarachnoid hemorrhage and malignant hemisphere stroke (MHS); they are independently associated with worse clinical outcome. Detection of SDs to guide clinical management, as is now being advocated, currently requires continuous and skilled monitoring of the electrocorticogram (ECoG), frequently extending over many days. Methods We developed and evaluated in two clinical intensive care units (ICU) a software routine capable of detecting SDs both in real time at the bedside and retrospectively and also capable of displaying patterns of their occurrence with time. We tested this prototype software in 91 data files, each of approximately 24 h, from 18 patients, and the results were compared with those of manual assessment (“ground truth”) by an experienced assessor blind to the software outputs. Results The software successfully detected SDs in real time at the bedside, including in patients with clusters of SDs. Counts of SDs by software (dependent variable) were compared with ground truth by the investigator (independent) using linear regression. The slope of the regression was 0.7855 (95% confidence interval 0.7149–0.8561); a slope value of 1.0 lies outside the 95% confidence interval of the slope, representing significant undersensitivity of 79%. R2 was 0.8415. Conclusions Despite significant undersensitivity, there was no additional loss of sensitivity at high SD counts, thus ensuring that dense clusters of depolarizations of particular pathogenic potential can be detected by software and depicted to clinicians in real time and also be archived.

Systemic lupus erythematous is a systemic autoimmune disease that can cause severe pain and impair quality of life. Pain in lupus can arise from a variety of mechanisms and is usually assessed in terms of activity and damage. In contrast, categorization of symptoms as type 1 and type 2 manifestations encompasses a broader array of symptoms, including widespread pain, fatigue, and depression that may track together. The categorization of symptoms as type 1 and type 2 manifestations can facilitate communication between patient and provider as well as provide a framework to address more fully the complex symptoms experienced by patients.

Background The success of clinical trials in Epidermolysis Bullosa (EB) is dependent upon the availability of a valid and reliable scoring tool that can accurately assess and monitor disease severity. The Epidermolysis Bullosa Disease Activity and Scarring Index (EBDASI) and Instrument for Scoring Clinical Outcomes of Research for Epidermolysis Bullosa (iscorEB) were independently developed and validated against the Birmingham Epidermolysis Bullosa Severity Score but have never been directly compared. Objective To compare the reliability, convergent validity, and discriminant validity of the EBDASI and iscorEB scoring tools. Methods An observational cohort study was conducted in 15 patients with EB. Each patient was evaluated using the EBDASI and iscorEB-clinician scoring tools by 6 dermatologists with expertise in EB. Quality of life was assessed using the iscorEB-patient and Quality of Life in EB measures. Results The intraclass correlation coefficients for interrater reliability were 0.942 for the EBDASI and 0.852 for the iscorEB-clinician. The intraclass correlation coefficients for intrarater reliability was 0.99 for both scores. The two tools demonstrated strong convergent validity with each other. Conclusion Both scoring tools demonstrate excellent reliability. The EBDASI appears to better discriminate between EB types and disease severities.

Objective The type 1 and type 2 systemic lupus erythematosus (SLE) categorization system was recently proposed to validate the patients' perspective of disease and to capture a more comprehensive spectrum of symptoms. The objective of this study was to characterize the clinical manifestations of SLE subtypes and to determine the correlation between the patient- and physician-reported measures used in the model. Methods This was a cross-sectional study of patients with SLE in a university clinic. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and 2011 American College of Rheumatology fibromyalgia (FM) criteria. Active SLE was defined as Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score ≥6, clinical SLEDAI score ≥4, or active lupus nephritis. We identified 4 groups: type 1 SLE (active SLE without FM), type 2 SLE (inactive SLE with FM), mixed SLE (active SLE with FM), and minimal SLE (inactive SLE without FM). Results In this cohort of 212 patients (92% female, mean age 45 years), 30% had type 1 SLE, 8% had type 2 SLE, 13% had mixed SLE, and 49% had minimal SLE. Regardless of SLE disease activity, patients with FM (21%), reported higher SLAQ scores, patient global assessment scores, and self-reported lupus flare that resulted in discordance between patient- and physician-reported measures. Conclusion Fatigue, widespread pain, sleep dysfunction, and mood disorders are common symptoms in SLE. Identifying these symptoms as type 2 SLE may be a method to improve patient communication and understanding. The level of type 2 SLE impacts patients' perception of disease and self-reported symptoms. The SLAQ may need to be reinterpreted based on the FM severity scale.

Background Helicopter transport (HT) is an efficient, but costly, means for injured patients to receive life-saving, definitive trauma care. Identifying the characteristics of inappropriate HT presents an opportunity to improve the utilization of this finite medical resource. Methods Trauma registry records of all HT for a 3-year period (2016-2018) to an urban Level I trauma center were reviewed. HT was defined as inappropriate for patients who were discharged home from the emergency department or had a hospital length of stay Results There were 713 patients who received HT during the study period. One-hundred and forty-eight (20.8%) patients met the criteria as an inappropriate HT. In univariate analysis, Glasgow Coma Scale >8, Shock Index 55 was found to be associated with an appropriate HT. The average Injury Severity Score of the inappropriate HT group was 3.86 (±3.85) compared with 16.80 (±11.23) ( P = .0001, Student’s t-test). Discussion Our findings suggest that there are evidence-based predictors of patients receiving inappropriate HT. Triage of HT using these predictors has the potential to decrease unnecessary deployments and reduce health care costs.

Background While the potential buffering effects of spirituality are well established in the general population, how spirituality affects those in extremely high-stress occupations like the military and law enforcement is less clear. Aims This paper explores the possibility that spiritual influences may operate differently among military veterans than other people. It specifically proposes that attendance at religious services is an especially important buffer for combat veterans. Methods This study engaged in a secondary analysis of 74 480 respondents from the National Survey on Drug Use and Health for the years 2013–17. The respondents were split into four groups; veterans with combat experience before September 2001, veterans with combat experience since September 2001, veterans with no combat experience and non-veterans. Results The likelihood of mental illness decreased in the general population along three different measures of religion; the importance of religion, friendships that shared religious beliefs and attendance at religious services. The relationship was weak and disappeared when controls for non-religion variables were included. A major exception was combat veterans, for whom the religious effects were limited to attendance at services, and the effect survived with the addition of non-religion control variables. Conclusions Mental health professionals, chaplains, pastoral counsellors and clergy need to recognize that among the therapeutic benefits of religious attendance and recognize the value of the religious rituals as ends in themselves.

The aim of this study is to show that the addition of a fundic gastropexy to a laparoscopic hiatal hernia repair (HHR) and magnetic sphincter augmentation (MSA) with LINX (Johnson and Johnson, New Brunswick, NJ) in patients with high risk for hiatal hernia recurrence improves outcomes without altering perioperative course. An IRB approved, single institution retrospective review of patient outcomes after hiatal hernia repair with magnetic sphincter augmentation was performed. Data were obtained from the electronic health record and stored in a REDCap database. Using statistical software, the patient data were analyzed and stratified to assess the specific variables of the perioperative and postoperative course focusing on the high risk of hiatal hernia recurrence group (HRHR) and low risk hiatal hernia of recurrence group (LRHR). The HRHR group received a gastropexy and were defined using the following variables: comorbid state increasing abdominal pressure, gastric herniation > 30%, maximum transverse crural diameter > 4 cm, age 70 years or older, previous hiatal or abdominal wall hernia repair, BMI > 34, heavy weight bearing job/hobby, and/or emergent repair. Hiatal hernia repair with magnetic sphincter augmentation was performed on 137 patients. The HRHR group (N = 86) and the LRHR group (N = 51) were compared and there was a difference observed with acute hernia recurrence, dysphagia (p value = 0.008), and number of post-op EGDs (p value = 0.005) in favor of the HRHR group. Other postoperative variables observed (i.e., length of stay and PPI use) showed no significant difference between the two groups. Fundic gastropexy for individuals who are considered high risk for recurrence does not appear to alter the perioperative course in our sample of patients. The HRHR group has the same length of stay experience and improved postoperative outcomes with reference to postoperative EGD, dysphagia and a decreasing trend in hiatal hernia recurrence.

Varicella-zoster virus vaccination is recommended for virtually all young children in the United States, Canada, and several other countries. Varicella vaccine is a live attenuated virus that retains some of its neurotropic properties. Herpes zoster caused by vaccine virus still occurs in immunized children, although the rate is much lower than in children who had wild-type varicella. It was commonly thought that 2 varicella vaccinations would protect children against the most serious complication of meningitis following herpes zoster; however, 2 meningitis cases have already been published. We now report a third case of varicella vaccine meningitis and define risk factors shared by all 3 immunized adolescents. The diagnosis in cerebrospinal fluid in this third case was verified by amplifying and sequencing portions of the viral genome, to document fixed alleles found only in the vaccine strain. Viral antibody was also detected in the cerebrospinal fluid by confocal microscopy. When compared with the other 2 cases, remarkably all 3 were 14 years old when meningitis occurred. All 3 were treated with intravenous acyclovir, with complete recovery. The adolescent in our case report also had recurrent asthma, which was treated with both prednisone tablets and beclomethasone inhaler before onset of meningitis. When the 3 cases were considered together, they suggested that immunity to varicella-zoster virus may be waning sufficiently in some twice-immunized adolescents to make them vulnerable to varicella vaccine virus reactivation and subsequent meningitis. This complication rarely happens in children after wild-type varicella.

This study’s purpose is to determine the application and effectiveness of a POEM program in the rural healthcare setting. Achalasia has a substantial impact on the lives of afflicted patients. Traditionally, a Heller myotomy with fundoplication has been the standard of care for treatment. In 2008, the first per oral endoscopic myotomy (POEM) was performed in Japan. Since 2017, our rural healthcare institution has performed approximately 60 POEMs. An IRB approved, single-institution retrospective review of patient outcomes after POEM was performed along with prospective analysis of post-operative surveys. An institutional cost analysis was also performed. Demographic and qualitative variables were measured and included PPI use, a Likert scale of 0–5 for progressively worsening symptoms of heartburn, dysphagia, and regurgitation. In addition, we included a Dysphagia Outcome and Severity Scale. The number of myotomy operations increased from 4.5 per year to 28.8 per year after initiation of the POEM program. Mean Likert scale scores were 0.91, 0.73, and 1 for heartburn, dysphagia, and regurgitation, respectively. 72.5% percent of patients were satisfied with their present condition. 87.5% of patients reported minimal or no dysphagia on the Dysphagia Severity Scale. Intraoperative costs were $2477 for laparoscopic myotomy and $1650 for POEM. The capital expense of the equipment required to perform POEM was $110,232. Average contribution margin per case was $6024. The procedure pays off capital outlay upon completion of the 19th case. This study shows that patients have excellent symptom control after POEM. When compared to the institution’s laparoscopic myotomy volume, POEM far surpasses in terms of operative volume and monetary benefit. Examination of these data shows that a rural hospital can successfully employ a state-of-the-art intervention when there is a population in need and an infrastructure in place.

ObjectivesMindfulness training (MT) guidelines recommend that trainers have familiarity and knowledge of the training group as well as extensive MT expertise. Herein, a “train-the-trainer” (TTT) dissemination model was investigated for military service members whose access to MT is threatened by a scarcity of qualified trainers.MethodsUS Army Master Resilience Trainer-Performance Experts (PEs), who had extensive familiarity with soldiers but no prior MT experience, participated in an MT practicum, and then delivered a 4-week MT program (Mindfulness-Based Attention Training, MBAT) contextualized for military personnel. Soldiers (n = 180) undergoing intensive military field training over the study interval were recruited as participants. MBAT was delivered to soldiers by PEs (n = 89) or by a trainer with extensive MT experience (Mindfulness Expert; ME,n = 45) but no military familiarity. The remaining participants served as no-training controls (NTC,n = 46). Soldiers’ performance on sustained attention and working memory (WM) tasks was assessed before (week 0, T1) and after MBAT delivery (week 5, T2), and again 4 weeks later (week 10, T3).ResultsFor all participants, sustained attention and WM performance declined over the high-demand field training interval (p p = 0.040) and WM (p ConclusionsThese results suggest that TTT delivery of short-form MT by context-familiar trainers may be an expeditious route by which to increase access to MT in the service of promoting cognitive resilience in high-demand groups.

Background There remains debate regarding the need for venous imaging in pediatric intracranial hypertension. Methods Records of patients aged 18 years or younger who were evaluated in the intracranial hypertension clinic at Nationwide Children's Hospital in Columbus, Ohio, were reviewed. Past medical history, diagnostic evaluation, and presenting symptoms were examined to evaluate differences in symptomatology presentation and risk factors in patients with pediatric intracranial hypertension with and without thrombosis. Results A total of 226 patients met inclusion criteria, 145 were diagnosed with primary intracranial hypertension, 81 with secondary intracranial hypertension, with 17 noted to have venous sinus thrombosis as the cause of their secondary intracranial hypertension. Of those with thrombosis, 41.2% did not have any thrombosis risk factors. Headache was the most prominent symptom, present in 73.8% (n = 107) of patients with primary intracranial hypertension, 87.5% (n = 56) of patients with secondary intracranial hypertension without thrombosis, and 82.4% (n = 14) with thrombosis. Conclusions The only clinically significant difference in presenting symptomatology between the thrombosis and the other groups was nausea or vomiting. Predisposing factors to develop thrombosis were absent in 41.2% of patients. Hence, the need for venous imaging in pediatric intracranial hypertension cannot be clearly determined by clinical presentation or risk factors alone. Patients with indwelling catheters should receive imaging in the region of their catheter to rule out catheter-associated thrombosis.

Objectives To analyze the distribution of patient-centered medical homes (PCMHs) among US adolescents, and to examine whether disparities exist among subgroups. Study design Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007. Results Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007. Conclusions PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Background Overweight and obesity have become a serious public health problem in both developed and developing countries, particularly in urban areas. However, there are limited studies conducted to identify the risk factors of overweight and obesity in Ethiopia, especially among men. Therefore, this study aimed to assess individual and community level determinants of overweight and obesity among urban men in Ethiopia. Methods This study used the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A weighted sample of 2259 urban men aged 15–59 years were included in this analysis. A multilevel logistic regression model was used to assess the determinants of overweight and obesity among the study participants. Results Men aged 30–44 years old (AOR = 3.1, 95% CI: 2.3–4.11), 45–59 years old (AOR = 4.8, 95% CI: 3.4–6.9), married (AOR = 1.7, 95% CI: 1.3–2.2), with secondary education (AOR = 2.7, 95% CI: 1.6–4.7), with higher education (AOR = 3.6, 95% CI: 2.1–6.2), watching television at least once a week (AOR = 1.7, 95% CI: 1.1–2.7), being from high rich communities (AOR = 2.4, 95% CI: 1.5–3.7), and living in three metropolises (Addis Ababa, Harari, Diredawa) were more likely to be overweight or obese (AOR = 1.8, 95% CI: 1.1–2.9). However, currently unemployed men were less likely to be overweight or obese (AOR = 0.5, 95% CI: 0.3–0.7). Conclusion Being older age, being married, having higher educational status, having higher frequency of watching television, being residents of three metropolises (Addis Ababa, Harari, and Diredawa), and being from high rich communities were found to be predictors of overweight and obesity in Ethiopian men. Therefore, it is essential to design strategies and programs to reduce or prevent overweight and obesity with special focus on the identified risk factors.

1205 Figure 1Respondents indicated which factors would have a positive influence on their likelihood of getting vaccinated against COVID-19;more than two-thirds of respondents indicated they would be more likely to pursue vaccination if they were presented with evidence of COVID-19 vaccine safety in lupus.[Figure omitted. See PDF]ConclusionsThese results indicate an opportunity for healthcare professionals and patient advocacy organizations to assuage unfounded patient concerns, such as vaccine interactions with medications or food allergies being a contraindication to COVID-19 vaccination, while reassuring patients that vaccine-triggered flares are rare.AcknowledgementWe would like to thank the Lupus Foundation of American for their partnership in this research.

Purpose: We sought to expand telehealth at an academic multidisciplinary pediatric gender center to increase access to gender-affirming care without compromising communication, privacy, or patient satisfaction. Materials and Methods: Patient needs assessments were performed from January 2019 to March 2020. The severe acute respiratory syndrome coronavirus 2 pandemic accelerated implementation of the quality improvement project, and clinically appropriate patients were scheduled for video visits starting March 16, 2020. From September 8, 2020 to October 2, 2020, caregivers of transgender and gender diverse (TGD) minors or TGD young adults pursuing gender-affirming medications completed 9-item surveys evaluating communication quality and privacy, access to care, and quality of services for video and clinic visits. Answers were rated via Likert scales (1 = strongly agree, 5 = strongly disagree; 1 = less travel time, 4 = more travel time). Results: Needs assessment (n = 69) showed that 63.8% felt that video visits would improve follow-up. Survey participants (n = 91) reported statistically significant differences (p < 0.05) in several areas. Compared with clinic visits, video visits were more convenient, 1.21 ± 0.435 versus 2.36 ± 1.207, took less time from other activities, 4.55 ± 0.522 versus 2.93 ± 1.281, required less travel time, 1.03 ± 0.180 versus 2.63 ± 0.901, and were more acceptable, 1.35 ± 0.545 versus 1.65 ± 0.736. Participants were more likely to choose video visits in the future, 1.32 ± 0.555 versus 1.57 ± 0.732. There were no statistically significant differences in communication quality, privacy, or overall satisfaction. Conclusion: An integrated clinic-video visit model increases access to gender-affirming care for TGD youth while maintaining excellent communication, privacy, and patient satisfaction.

BACKGROUND: Following mild traumatic brain injury individuals often exhibit quantifiable gait deficits over flat surfaces, but little is known about how they control gait over complex surfaces. Such complex surfaces require precise neuromotor control to anticipate and react to small disturbances in walking surfaces, and mild traumatic brain injury-related balance deficits may adversely affect these gait adjustments. METHODS: This study investigates anticipatory and reactive gait adjustments for expected and unexpected underfoot perturbations in healthy adults (n = 5) and individuals with mild traumatic brain injury (n = 5). Participants completed walking trials with random unexpected or expected underfoot perturbations from a mechanized shoe and inertial measurement units collected kinematic data from the feet and sternum. Linear mixed-effects models assessed the effects of segment, group, and their interaction on standardized difference of accelerations between perturbation and non-perturbation trials. FINDINGS: Both groups demonstrated similar gait strategies when perturbations were unexpected. During late swing phase before expected perturbations, persons with mild traumatic brain injury exhibited greater lateral acceleration of their perturbed foot and less lateral movement of their trunk compared with unperturbed gait. Control participants exhibited less lateral foot acceleration and no difference in mediolateral trunk acceleration compared with unperturbed gait during the same period. A significant group*segment interaction (p < 0.001) during this part of the gait cycle suggests the groups adopted different anticipatory strategies for the perturbation. INTERPRETATION: Individuals with mild traumatic brain injury may be adopting cautious strategies for expected perturbations due to persistent neuromechanical deficits stemming from their injury.

OBJECTIVE This research aims to take an in-depth look into the child, housing, and neighborhood characteristics associated with Providence children's likelihood of having elevated blood lead levels (BLLs). DESIGN AND SETTING The 2019 Providence, Rhode Island, Property Tax Assessor's database, containing each property owner's address, was geocoded and spatially joined with the 2017-2019 blood lead tests for children aged 0 to 6 years from the Rhode Island Department of Health. MAIN OUTCOME MEASURES The prevalence of elevated BLLs (≥5 μg/dL) overall, as well as by property type, number of properties owned, owner occupancy, assessed value, and neighborhood rates of old housing and poverty, was computed. We assessed the relationship between having elevated BLLs and these housing and neighborhood characteristics, adjusting for gender, age at test, and test method. RESULTS We found that, compared with children living in properties with landlords who owned only one property, children living in properties with landlords who owned 4 or more properties had lower odds of having elevated BLLs (odds ratio = 0.98; 95% confidence interval, 0.97-0.99). The proportion of houses built pre-1950 in the neighborhood was associated with increased odds of elevated BLLs. There was no significant association between owner-occupancy status and property type with children having elevated BLLs. CONCLUSIONS Children living in properties with landlords who owned 4 or more properties were less likely to have elevated BLLs. This association may suggest that the current lead legislation is having some impact, but public health efforts should address lead exposure in properties that are currently exempt from the law.

Objective Despite high rates of medication non-adherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence (clinicaltrials.gov identifier NCT03738826). Methods The intervention used pharmacy refill data to monitor non-adherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% three months before and after the intervention visit using the McNemar's test. Results Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial-ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (p=0.03) after the intervention visit. Conclusion Our intervention showed feasibility, acceptability, and appropriateness, and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings. This article is protected by copyright. All rights reserved.

Background Cryopyrin-associated periodic syndrome is characterized by periodic fever, rash, and joint pain. Papilledema rarely occurs. We present our series of patients with cryopyrin-associated periodic syndrome who clinically met the diagnostic criteria for Muckle-Wells syndrome and our experience with secondary intracranial hypertension. Methods Retrospective review of all patients with cryopyrin-associated periodic syndrome at Nationwide Children's Hospital from October 2015 to September 2017. Results Eighteen children met inclusion criteria: 15 females and three males, aged 1.5 to 16.2 years. Fifteen had periodic fever genetic testing; three had a known genetic defect identified, eight had a defect identified not currently known to be associated with cryopyrin-associated periodic syndrome, and four had no defect identified. Six patients (30%) developed headaches and were diagnosed with secondary intracranial hypertension. Lumbar puncture opening pressures ranged from 28 to 45 cm H2O. Only one patient had papilledema. Initial treatment was medical in all cases, by increasing interleukin-1 inhibitor dose and/or acetazolamide. One patient required a ventriculoperitoneal shunt for headache management. No visual acuity loss was detected. All six patients with secondary intracranial hypertension had a known genetic mutation or genetic variant of unknown significance; five involved the NLRP3 gene. Conclusions In our series of 18 patients with cryopyrin-associated periodic syndrome, secondary intracranial hypertension occurred at a higher than expected rate. We suspect that genetic defects involving the NLRP3 gene may be a risk factor. Papilledema was present in only one patient. Physicians treating cryopyrin-associated periodic syndrome should be aware of this vision-threatening association and potential therapeutic approach.

Background Evidence indicates that emotions such as anger are associated with increased incidence of sudden cardiac death, but the biological mechanisms remain unclear. We tested the hypothesis that, in patients with sudden death vulnerability, anger would be associated with arrhythmic vulnerability, indexed by cardiac repolarization instability.Methods Patients with coronary artery disease (CAD) and an implantable cardioverter defibrillator (ICD; n = 41) and healthy controls (n = 26) gave an anger-inducing speech (anger recall), rated their current (state) anger, and completed measures of trait (chronic) levels of Anger and Hostility. Repolarization instability was measured using QT Variability Index (QTVI) at resting baseline and during anger recall using continuous ECG.Results ICD patients had significantly higher QTVI at baseline and during anger recall compared with controls, indicating greater arrhythmic vulnerability overall. QTVI increased from baseline to anger recall to a similar extent in both groups. In ICD patients but not controls, during anger recall, self-rated anger was related to QTVI (r = .44, p = .007). Trait (chronic) Anger Expression (r = .26, p = .04), Anger Control (r = -.26, p = .04), and Hostility (r = .25, p = .05) were each associated with the change in QTVI from baseline to anger recall (Delta QTVI). Moderation analyses evaluated whether psychological trait associations with Delta QTVI were specific to the ICD group. Results indicated that Hostility scores predicted Delta QTVI from baseline to anger recall in ICD patients (beta = 0.07, p = .01), but not in controls.Conclusions Anger increases repolarization lability, but in patients with CAD and arrhythmic vulnerability, chronic and acute anger interact to trigger cardiac repolarization lability associated with susceptibility to malignant arrhythmias.

Novel oral anticoagulant (NOAC) medications have revolutionized hematology and cardiology. Recently, NOACs have demonstrated additional promise in dermatology. Specifically, rivaroxaban, a direct factor Xa inhibitor NOAC, has been shown to be successful in the treatment of livedoid vasculopathy. Herein, we describe a patient with systemic lupus erythematosus who presented with painful cutaneous vasculopathy, demonstrated on biopsy with occlusive microvascular fibrin thrombi without evidence of concurrent vasculitis. Interestingly, imaging and laboratory studies did not show evidence of hypercoagulability, arterial disease, or embolic disease. The patient’s vasculopathy and pain progressed despite antiplatelet therapy, often considered first-line in cases of microvascular occlusive disease. However, with rivaroxaban therapy, the patient experienced complete regression of her painful lesions, thereby supporting a further role for NOACs in cutaneous vasculopathy treatment. J Drugs Dermatol. 2020;19(5) doi:10.36849/JDD.2020.4684.

Objectives: Pegfilgrastim is a granulocyte colony-stimulating factor (G-CSF) used as primary prophylaxis in patients receiving myelosuppressive chemotherapy regimens that have greater than 20% risk of developing febrile neutropenia (FN). Historically, pegfilgrastim has been administered 24 to 72 hours after chemotherapy, necessitating a return to clinic to receive the provider-administered injection. An alternative option is the pegfilgrastim on-body injector (OBI). With the OBI device, patients have their pegfilgrastim administered 27 hours after receiving chemotherapy while remaining at home, avoiding an additional clinic appointment. Concerns with pegfilgrastim OBI include lack of experience with the device in both the patient and provider, device-related failures, and the success of delivery. This study evaluates pegfilgrastim OBI failure rates through associated patient outcomes among cancer patients receiving chemotherapy requiring G-CSF. Methods: A retrospective electronic chart review was conducted of adult patients with cancer who received chemotherapy and pegfilgrastim OBI from July 1, 2016, to July 31, 2018. The primary objective of this study was the incidence of FN in patients receiving pegfilgrastim OBI. Results: There were no reported cases of hospitalization due to FN in patients who received pegfilgrastim OBI. Dose delays and dosage modifications were not observed in our review. The OBI device failure rate was found to be low (1.92%). Conclusion: The low device failure rate from this study suggests that the OBI is a viable option for administration of pegfilgrastim in patients receiving chemotherapy requiring G-CSF.

Background: Patient gender and race, and physician–patient communication are associated with clinical outcomes. Aim: To understand the role of these factors in the diagnosis of colorectal cancer (CRC) during primary care visits as measured by appropriate outcome. Materials and Methods: Caucasian and African American unannounced standardized patients (USPs) of both genders presented to 207 primary care physicians (PCPs) from community and academic practices in Ohio and Virginia as new patients with CRC symptoms. PCPs were blinded to the diagnosis. Physician subjects consented to audiotaping the encounter. Medical records were obtained. Communication elements were coded by trained observers and appropriate visit outcomes were coded from the medical record and audiofiles, defined as (1) recommendation for colonoscopy/sigmoidoscopy/fecal occult blood test (FOBT) or (2) referral to gastroenterologist. Results: A total of 141 of 367 USP visits (38%) resulted in appropriate clinical outcomes. Patient race was not associated with outcome, but being a male USP was (χ(2) = 4.12, p = 0.04). Relational communication was represented as a latent variable with seven indicators (alpha = 0.84) and was independently associated with outcome (beta = 0.15; p = 0.025). After controlling for clustered sampling, relational communication, and race, structural equational modeling indicated that female USPs were less likely to have an appropriate clinical visit outcome (beta = −0.13; p = 0.033). Conclusions: Using a novel and innovative methodology capturing PCP behaviors during real-time clinician–patient interaction, appropriate clinical outcome was independently associated with being male and PCP relational communication factors such as encouraging patient communication, being engaged and expressive in the physician–patient conversation, and appearing friendly and sincere. There are persistent biases in the delivery of health care to female patients and further research into targeted communication skills programs may be warranted.

Heterotopic ossification (HO) is the abnormal growth of bone in soft tissue outside of the usual skeletal anatomical locations. This condition should not be confused with metastatic or dystrophic calcification, both of which result from calcium deposition in soft tissues rather than from the transformation of primitive mesenchymal cells into osteogenic cells, resulting in the growth of true mature lamellar bone, as is seen in HO (1-3). HO can cause swelling, limitations in range of motion secondary to ankylosis, and pain secondary to peripheral nerve entrapment, all of which contribute to significant long term disability. Although the pathophysiology of HO is complicated and poorly understood, identifiable precipitants include traumatic musculoskeletal injuries (e.g., fractures, dislocations, orthopedic surgeries, etc.), central nervous system (CNS) injuries, and, rarely, genetic diseases (4). Orthopedic surgeries, including joint arthroplasty and surgical fixation of upper and lower extremity fractures, are some of the most widely reported operations linked to HO; however, to our knowledge, HO following fixation of traumatic rib fractures has not previously been reported in the literature.

PURPOSE/OBJECTIVE(S) Recurrent GBM (rGBM) is a diffuse disease, and local treatment alone does not provide durable local control (LC) or prolong overall survival (OS). Hypothesizing resection (R) plus immediate-onset radiation therapy (RT) may achieve durable LC and secondarily improve OS by permitting time for subsequent potentially effective but biologically slower treatments to have an impact, we analyzed R plus surgically targeted radiation therapy (STaRT) using a collagen tile brachytherapy (CTBT) device without or with additional systemic (Sys) therapies. MATERIALS/METHODS From 2/13-2/18 patients (pts) with locally recurrent GBM were treated on a prospective single arm, single institution trial (NCT03088579) of maximum safe resection and a permanently implanted CTBT device (GammaTile, GT Medical Technologies, Tempe AZ USA). At resection completion at-risk areas of the surgical bed were lined with bioresorbable collagen squares containing four 3.5U Cs 131 seed sources designed to deliver 60-80 Gy at 5 mm deep to the operative bed. Follow up treatments were not specified; no pt. underwent additional local therapy without progression, and no pt. was lost to follow up. We present here the study-specified endpoints of local control (LC), overall survival (OS), and adverse events (AE), and a post hoc, hypothesis-generating analysis of LC and OS by receipt of Sys therapy. RESULTS 28 locally recurrent GBM were treated, 20 at first progression (range 1-3). Median age was 58 years (yrs.) (range 21-80), KPS 80 (60-100), female: male ratio 10:18 (36/64%). MGMT was methylated in 11%, unmethylated in 18%, and unknown in 71%. For all pts., median OS was 10.7 months (mo.) (range .1-42.3), and radiographic LC was 8.8 mo. (range 0.01-34.5). LC (defined as ≤ 15 mm from surgical bed) was maintained in 50% of pts., and no first failure was local. 12 mo. OS was 75% for pts. < 50 yrs. vs. 43% for ≥ 50 yrs. (HR .46, P = 0.009). MGMT, KPS, and sex were non-predictive. After R+GT, 17 pts. received ≥ 1 cycle of Sys therapy, alone or in combination. Sys was bevacizumab (BEV) in 15 pts., temozolomide (TMZ) in 12, and lomustine (CCNU) in 8. Post hoc analysis disclosed a 15.1 mo. OS for pts. receiving ≥ 1 cycle of Sys (Sys+, N = 17) vs. 6.5 mo. for no Sys (Sys-, N = 11) (hazard ratio (HR) .38, P = 0.017). LC was 11.4 mo. for Sys+ and 2.1 mo. for Sys- (HR .44; P = .16). Median OS (mo.) for BEV+ vs. BEV- was 16.7/4.5 (HR .38, P = 0.017), for TMZ+ vs. TMZ- 17.5/6.7 (HR .40, P = 0.025) and for CCNU+ vs. CCNU- 17.5/7.9 (HR .61, P = .25), respectively. Three AE occurred, 1 dehiscence requiring surgery and 2 radiation brain effects treated medically. CONCLUSION In this study local treatment alone was insufficient to achieve prolonged OS. Post hoc analysis suggests R+ CTBT + Sys may have potential to impact OS in rGBM. A phase 4 study enrolling rGBM pts opened in 2020 (NCT04427384). The device is FDA cleared for newly diagnosed malignant and all recurrent intracranial neoplasms. AUTHOR DISCLOSURE P. Nakaji: Stock; GT Medical Technology. D. Brachman: Stock; GT Medical Technology. Uncompensated member; GT Medical Technology. K. Smith: Stock; GT Medical Technology. T. Thomas: Stock; GT Medical Technology. C. Dardis: None. D. Pinnaduwage: None. G. Wallstrom: None. C. Rogers: Research Grant; NCI - ActNOW. Stock; GT Medical Technology. E.F. Youssef: Stock; GT Medical Technology.

Objectives To investigate the association of residential mobility with flourishing among school-age children. Methods Data from the 2011/2012 National Survey of Children's Health were used to examine parent/caregiver-reported information on flourishing and residential mobility for children age 6-17 (N = 63,333). Residential mobility was the number of times the child moved categorized as: none, 1-2, and 3+. Children who were reported to show interest/curiosity, finish tasks, stay calm/in control, care about doing well in school, and do all homework were coded as flourishing. Sex-specific multivariable models were used to model the relative risk of mobility on flourishing. Interactions of mobility with age and poverty were tested. Results Among US school-age children, 22% had no moves, 39% had 1-2 moves and 39% had 3+ moves in their lifetime. Nearly half (45%) were flourishing. Both boys and girls who moved 3+ times were less likely to flourish compared to children with no moves. Among poor boys moving 3+ times was associated with less flourishing (aRR 0.83, 95% CI 0.71, 0.98) with no association for non-poor boy. Among girls the pattern was reversed (aRR 0.88, 95% CI 0.81, 0.95 for non-poor girls and no association for poor girls). Conclusions for Practice Residential mobility may lead to lower rates of flourishing. The patterns, when stratified by age or poverty, are different for boys and girls.

Recent standardized nomenclature has suggested distinctions among aborted, interrupted, and actual suicide attempts. This study examined differences in self-reported symptoms among individuals with a history of aborted, interrupted, and actual suicide attempts. 167 young adults with a history of suicidality completed self-report measures of suicide attempt history and current symptoms, a clinical interview assessing past suicidal behavior, and a pain tolerance task. Only 78.8% of participants who initially reported a suicide attempt history were classified as suicide attempters following the clinical interview. Individuals who reported only aborted attempts during the clinical interview reported less severe clinical symptoms than those reporting a history of at least one actual attempt. Individuals with a history of actual suicide attempts may represent a more clinically severe group than those with a history of aborted attempts only.

Phentermine is the most prescribed antiobesity drug in America, with 2.43 million prescriptions written in 2011. Case reports suggest there are anesthetic risks, such as refractory hypotension, involved with its perioperative use. Despite these risks and the frequency of phentermine use among plastic surgery patients, there are no published guidelines for the perioperative management of phentermine use in the plastic surgery literature. To address this patient safety issue, we performed a systematic review and provide management recommendations.A systematic review of the pharmacology of phentermine and the anesthetic risks involved with its perioperative use was undertaken using the search engines PubMed/MEDLINE, EMBASE, and Scopus.A total of 251 citations were reviewed, yielding 4 articles that discussed perioperative phentermine use and complications with anesthesia. One was a review article, 2 were case reports, and 1 was a letter. Complications included hypotension, hypertension, hypoglycemia, hyperthermia, bradycardia, cardiac depression, and acute pulmonary edema.The relationship between phentermine and anesthesia, if any, is unclear. Hypotension on induction of general anesthesia is the most reported complication of perioperative phentermine use. Specifically, phentermine-induced hypotension may be unresponsive to vasopressors that rely on catecholamine release, such as ephedrine. Therefore, the decision to perform surgery, especially elective surgery, in a patient taking phentermine should be made with caution. Because of the half-life of phentermine, we recommend discontinuing phentermine for at least 4 days prior to surgery. This differs from the classic 2-week discontinuation period recommended for "fen-phen." The patient should be made aware of the increased risk of surgery, and a skilled anesthesiologist should monitor intraoperative blood pressure and body temperature for signs of autonomic derailment.

OBJECTIVE Underrepresented racial and ethnic minorities are disproportionately affected by systemic lupus erythematosus (SLE). Racial and ethnic minorities also have more severe SLE manifestations that require use of immunosuppressive medications, and often have lower rates of medication adherence. We aimed to explore barriers of adherence to SLE immunosuppressive medications among minority SLE patients. METHODS We conducted a qualitative descriptive study using in-depth interviews with a purposeful sample of 1) racial minority SLE patients taking oral immunosuppressants (methotrexate, azathioprine, or mycophenolate), and 2) lupus clinic providers and staff. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. We grouped themes using the Capability, Opportunity, Motivation, Behavior conceptual model. RESULTS We interviewed 12 SLE patients (4 adherent, 8 non-adherent) and 12 providers and staff. We identified Capability barriers to include external factors related to acquiring medications, specifically cost, pharmacy, and clinic related issues; Opportunity barriers to include external barriers to taking medications, specifically logistic and medication related issues; and Motivation factors to include intrinsic barriers, encompassing patients' knowledge, beliefs, attitudes, and physical and mental health. The most frequently described barriers were cost, side effects, busyness/forgetting, and lack of understanding, although barriers differed by patient and adherence level, with logistic and intrinsic barriers described predominantly by non-adherent patients and side effects described predominantly by adherent patients. CONCLUSION Our findings suggest that interventions may be most impactful if they are designed to facilitate logistics of taking medications and increase patients' motivation while allowing for personalization to address the individual differences in adherence barriers.

Summary:. Infantile myofibromatosis is an unusual and rare lesion of the bone and soft tissue, which can be seen in the craniofacial skeleton. These complex tumors present a challenge to craniofacial surgeons regarding diagnosis, management, and safe and effective surgical treatment, frequently requiring complex reconstruction. We present the case of a 7-month-old girl with multicentric infantile myofibromatosis of the right parietal and fronto-orbital region, the associated clinical presentation, histopathologic findings, and surgical management, along with a review of the relevant literature.

Purpose of Review Told from the viewpoint of rheumatologists, this review tells the story of hydroxychloroquine and its swift ascent to become a household name as a therapeutic strategy against the novel SARS-CoV-2 virus. This review describes the history, mechanisms, pharmacokinetics, therapeutic applications, and safety profile of hydroxychloroquine as an immunomodulatory and antiviral agent. It also summarizes the major studies that launched and assessed the use of hydroxychloroquine against COVID-19 infection. Recent Findings More recent literature calls into question the long-held dogma that endolysosomal alkalinization is the primary mode of action of hydroxychloroquine. Ongoing uncertainty about the multiple potential mechanisms contributing to the therapeutic effect of hydroxychloroquine in rheumatic and viral disease led to a natural avenue for exploration in the treatment of COVID-19. Taken as a whole, the literature does not support utilizing hydroxychloroquine to treat or prevent infection from the SARS-CoV-2 virus. This is, at least in part, due to the wide variability in hydroxychloroquine pharmacokinetics between patients and difficulty achieving adequate target tissue concentrations of hydroxychloroquine without encountering unacceptable toxicities. Summary Hydroxychloroquine continues to be a routinely prescribed, well-tolerated, effective, and low-cost treatment for rheumatic disease. Its therapeutic versatility has led to frequent repurposing for other conditions, most recently as an investigative treatment against the SARS-CoV-2 virus. Despite overall negative findings, the intense study of hydroxychloroquine against COVID-19 infection has enhanced our overall understanding of how hydroxychloroquine operates in autoimmune disease and beyond.

PURPOSE OF REVIEW: Inadequate health literacy is common among American adults, but little is known about the impact of health literacy in rheumatic diseases. The purpose of this article is to review studies investigating health literacy and its association with clinical outcomes in systemic lupus erythematosus (SLE). RECENT FINDINGS: Several validated health literacy measures have been examined in SLE patients. Low health literacy is associated with worse patient-reported outcomes and lower numeracy with higher disease activity. Two studies found no association of low health literacy with medication adherence. One randomized controlled trial tested a medication decision aid among patients with low health literacy. SUMMARY: We found a paucity of studies exploring health literacy in SLE. Low health literacy is associated with worse patient-reported outcomes and limited numeracy with higher disease activity in SLE. Further studies are needed exploring the impact of low health literacy on clinical outcomes and the effectiveness of literacy-sensitive interventions.

Background A novel coronavirus first reported in Wuhan City in China in 2019 (COVID-19) developed into a global pandemic throughout 2020. Many countries around the world implemented strict social distancing policies to curb the spread of the virus. In this study we aimed to examine potential change in mental/physical health and social relationships during a highly restrictive COVID-19 lockdown period in Australia during April 2020. Methods Our survey (n = 1, 599) included questions about concerns, social behaviour, perceived change in relationship quality, social media use, frequency of exercise, physical health, and mental health during COVID-19 lockdown (April, 2020). Results When estimating their mental health for the previous year 13% of participants reported more negative than positive emotion, whereas this increased to 41% when participants reflected on their time during COVID-19 lockdown. A substantial proportion (39–54%) of participants reported deterioration in mental health, physical health, financial situation, and work productivity. However, most of these participants reported ’somewhat’ rather than ’a lot’ of deterioration, and many others reported ’no change’ (40–50%) or even ’improvement’ (6–17%). Even less impact was apparent for social relationships (68% reported ’no change’) as participants compensated for decreased face-to-face interaction via increased technology-mediated interaction. Conclusions The psychological toll of COVID-19 on Australians may not have been as large as other parts of the world with greater infection rates. Our findings highlight how technology-mediated communication can allow people to adequately maintain social relationships during an extreme lockdown event.

Burn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury.A retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care.We analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (75th percentile NRI; 95% CI: 1.08-2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child's likelihood of admission increased by 6% (95% CI: 4-9%).Children with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.

Objective The percentage of operative vaginal deliveries (OVDs) in the United States has sharply declined. In May 2016, our institution's obstetrics and gynecology (OB/GYN) residency program implemented a twice-yearly OVD curriculum consisting of didactics and simulation. We sought to evaluate the impact of this curriculum. Study Design We performed a retrospective cohort study of all deliveries at our institution from July 2011 to May 2018. Deliveries were evaluated quarterly for the pre- (July 2011–April 2016) and postcurriculum (July 2016–May 2018) periods. Forceps-assisted vaginal delivery (FAVD), vacuum-assisted vaginal delivery (VAVD), and total OVD percentages, and the ratio of forceps to vacuums were calculated. Pre- and postcurriculum percentages were compared using Wilcoxon's rank-sum test. Cubic regression curves were fit to quarterly percentages to illustrate trends over time. Results The quarterly OVD percentage was unchanged following curriculum implementation (mean 3.2% [Q1–Q3: 2.6–3.5%] pre- vs. 3.1% [2.5–3.8%] post-, p > 0.99). The FAVD percentage was increased (1.2% [0.8–1.5%] vs. 2.0% [1.4–2.6%], p = 0.027) and the VAVD percentage was decreased (2.0% [1.6–2.2%] vs. 1.2% [0.9–1.3%], p Conclusion The implementation of an OVD curriculum in our OB/GYN residency program resulted in an increase in the percentage of FAVD and the ratio of FAVD to VAVD. Key Points

Parental knowledge about adolescents’ whereabouts and activities remains one of the strongest predictors of reduced adolescent substance use. A recent study found that across middle childhood and adolescence, parental knowledge is characterized by fluctuations on a year-to-year basis, termed lability, even more-so than by linear trends, and that lability too is a predictor of adolescent substance use (Lippold et al., Dev. Psychol. 17, 274–283, 2016). The present study replicates Lippold et al. (Dev. Psychol. 17, 274–283, 2016) by quantifying developmental change and lability in parental knowledge across adolescence and examining associations with drinking, smoking, and other drug use later in adolescence, and extends the study by examining the sources of knowledge: child disclosure, parental solicitation, and parental control, separately. Using a community-based sample of 1023 youth in the Northeastern region of the USA, all three sources of knowledge were characterized by developmental change and lability. In general, higher levels and steeper developmental declines in knowledge were associated with substance use outcomes. Findings for child disclosure replicated the prior findings: increased lability of child disclosure predicted substance use. Unexpectedly, decreased lability of parental solicitation and control was associated with worse substance use outcomes. Findings suggest different mechanisms by which lability in child- and parent-driven cultivation of knowledge is associated with substance use. If replicated in studies that address causality, these mechanisms could be leveraged for prevention/intervention efforts. For example, increasing the consistency of child disclosure may help prevent substance use, but teaching parents to be more responsive to time-specific challenges with adolescents may be more effective than increasing the consistency of parents’ knowledge-building parenting behaviors.

STUDY OBJECTIVES: There is a well-established association between headache disorders and sleep disturbances in children, but it is unknown whether sleep disturbance plays a role in pediatric intracranial hypertension. The objective of this study was to examine sleep issues related to pediatric intracranial hypertension. METHODS: Patients with intracranial hypertension in the Pediatric Intracranial Hypertension Clinic were recruited between July 2017 and September 2018. Demographic data were collected from the electronic medical record in addition to patient and parent completed questionnaires. Information on sleep behaviors was gathered using the Children’s Sleep Habits Questionnaire, and control data were obtained from patient siblings. Statistical analyses were performed using paired t tests or two-sample t tests, as appropriate. RESULTS: Sixty-two pairs of patients and matched sibling controls were compared. We found a statistically significant difference in total sleep disturbance score (control mean, 44.3; patient mean, 48.1; n = 33 pairs, t = −2.2, P = .035), as well as subscale scores of sleep onset delay (control mean, 1.4; patient mean, 1.7; n = 52 pairs, t = −2.53, P = .014), parasomnias (control mean, 8.5; patient mean, 9.5; n = 42 pairs, t = −2.59, P = .013), and sleep-disordered breathing (control mean, 3.1; patient mean, 3.4; n = 44 pairs, t = −2.61, P = .013). No difference was found in bedtime resistance, sleep duration, sleep anxiety, night awakenings, and daytime sleepiness subscales. Furthermore, no difference was found in total sleep disturbance score between patient subsets, including primary vs secondary intracranial hypertension, body mass index, pubertal status, presence of headaches, or intracranial hypertension treatment. CONCLUSIONS: This observational study suggests that pediatric intracranial hypertension is associated with a modest increase in sleep disturbances. CITATION: Kornbluh AB, Thompson K, Mcmahen G, et al. Sleep disturbance in pediatric intracranial hypertension. J Clin Sleep Med. 2020;16(7):1099–1105.

Objective Medication nonadherence is more common in African Americans compared with Caucasians. We examined the racial adherence gaps among patients with systemic lupus erythematosus (SLE) and explored factors associated with nonadherence. Methods Cross-sectional data were obtained from consecutive patients prescribed SLE medications seen at an academic lupus clinic between August 2018 and February 2019. Adherence was measured using both self-report and pharmacy refill data. High composite adherence was defined as having both high self-reported adherence and high refill rates. Covariates were patient-provider interaction, patient-reported health status, and clinical factors. We compared adherence rates by race and used race-stratified analyses to identify factors associated with low composite adherence. Results Among 121 patients (37% Caucasian, 63% African American), the median age was 44 years (range 22-72), 95% were female, 51% had a college education or more, 46% had private insurance, and 38% had high composite adherence. Those with low composite adherence had higher damage scores, patient-reported disease activity scores, and more acute care visits. High composite adherence rate was lower among African Americans compared with Caucasians (30% vs 51%, P = 0.02), and the gap was largest for those taking mycophenolate (26% vs 75%, P = 0.01). Among African Americans, low composite adherence was associated with perceiving fewer "Compassionate respectful" interactions with providers and worse anxiety and negative affect. In contrast, among Caucasians, low composite adherence was only associated with higher SLE medication regimen burden and fibromyalgia pain score. Conclusion Significant racial disparities exist in SLE medication adherence, which likely contributes to racial disparities in SLE outcomes. Interventions may be more effective if tailored by race, such as improving patient-provider interaction and mental health among African Americans.