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Background: Adults with congenital heart disease (CHD) are an emerging adult heart disease subset, now outnumbering the pediatric population with CHD. Objective: We aimed to gain understanding and knowledge of what adults with CHD perceive as important for self-management and describe these needs across demographic factors, developmental characteristics, lesion severity, and quality of life. Methods: We used a descriptive mixed-methods online survey merging 4 instruments: Adult CHD Self-management Experience Questionnaire; Adult CHD Demographic Questionnaire; Adaptive Behavior Assessment System, Third Edition; and Stanford Quality of Life Visual Numeric. Participants with CHD 18 to 30 years of age with initial defect repair before 12 months of age were recruited through support from the Adult Congenital Heart Association, clinic adult CHD support groups, and newspaper advertising. Thematic analysis for short-answer questions, descriptive analysis for demographic data and the visual numeric, and intrument-specific scoring assistant software for the Adaptive Behavior Assessment System were used. Results: We received 22 responses from 13 women and 9 men. These individuals represented 15 different heart defect diagnoses, mostly of moderate or complex lesion severity. Most had postsecondary education and were employed. Four prominent themes emerged related to self-management: desire for connectivity--psychological support; a plan for the future--education about health and life expectations; coping needs--skills formental stress; and access to care--navigation of healthcare systems. Conclusions: Future longitudinal research and replication studies with larger samples are needed. Educational materials and targeted interventions that promote self-management benefit the aging adult with CHD population. [ABSTRACT FROM AUTHOR]

We present an introduction to, and examples of, Cox proportional hazards regression in the context of animal lethality studies of potential radioprotective agents. This established method is seldom used to analyze survival data collected in such studies, but is appropriate in many instances. Presenting a hypothetical radiation study that examines the efficacy of a potential radioprotectant both in the absence and presence of a potential modifier, we detail how to implement and interpret results from a Cox proportional hazards regression analysis used to analyze the survival data, and we provide relevant SAS® code. Cox proportional hazards regression analysis of survival data from lethal radiation experiments (1) considers the whole distribution of survival times rather than simply the commonly used proportions of animals that survived, (2) provides a unified analysis when multiple factors are present, and (3) can increase statistical power by combining information across different levels of a factor. Cox proportional hazards regression should be considered as a potential statistical method in the toolbox of radiation researchers. [ABSTRACT FROM AUTHOR]

Frequent episodes of water stress in managed landscapes have led the nursery industry to look for attractive woody species that perform well under extreme conditions of drought and flooding. We chose to evaluate three taxa with highly localized natural distributions in the United States, Calycanthus occidentalis (north-central California), Fraxinus anomala (northeastern Utah), and Pinckneya pubens (northeastern Florida), each of which may merit further use under cultivated conditions beyond their respective ranges. Although widespread cultivation of each taxon may not be possible as a result of limitations related to cold hardiness, we hypothesized that each species can tolerate extremes in soil moisture availability more so than their native habitats imply. Our objective was to characterize, under greenhouse conditions, how the quantity of soil water affects gas exchange of potted plants of each species. Plants were divided into five groups, each exposed to treatment conditions ranging from complete submersion to severe drought. Complete submersion killed plants of C. occidentalis and F. anomala, although in drought or severe drought conditions, C. occidentalis plants had lower net photosynthesis and less leaf area and plant dry weight than control plants. Net photosynthesis, leaf area, and plant dry weight of partially flooded plants, however, were not found to be significantly less than that of the control plants. Mean net photosynthetic levels and plant dry weights of severe drought, drought, and control F. anomala did not differ. While severe drought plants of P. pubens exhibited much lower levels of net photosynthesis, but not plant dry weights or leaf area, than the control plants, those exposed to drought, partial flood, and complete submersion were not found to differ in net photosynthesis levels from the control plants. Due to the sustained tolerance of F. anomala and P. pubens to a range of extreme soil moisture conditions, as exhibited by net photosynthetic responses, carbon accumulation, and survival, we conclude that use of these species in landscapes is warranted if invasiveness and other potential problems are not identified. Calycanthus occidentalis, however, appears unsuitable for cultivation in areas with organic soils greater than ≈66% and lower than ≈30% soil moisture content as a result of its high mortality in flooded conditions and poor physiological responses under dry conditions. [ABSTRACT FROM AUTHOR]

Purpose: To examine the differences in quality performance among agencies in urban areas and those in high utilization, low population density, and all other rural areas, defined in the Bipartisan Budget Act (BBA)., Methods: We conducted a retrospective study using 2015 data: the Home Health Compare, the Home Health Agency Utilization and Payment Use, the Provider of Services, and the Area Health Resources Files, and a file with rural categories in BBA. The quality measures included (1) hospitalizations, (2) emergency visits, (3) patient experience, (4) composite scores for improvement in activities of daily living (ADL), (5) improvement in pain and treating symptoms, (6) preventing harm, and (7) treating wounds and preventing pressure sores. We applied weighted least squares regression., Findings: Among all quality measures, differences in emergency visits of the 3 rural categories from urban agencies were the largest. The adjusted mean emergency visit for urban agencies was 12.42%, with agencies in rural areas having 1.01-1.96 percentage points higher rates than urban agencies (95% CI: 0.72-1.29 for high utilization areas, 95% CI: 0.51-3.42 for low population areas, and 95% CI: 1.28-1.78 for all other areas)., Conclusions: The differences in the quality of care among agencies in 3 categories of rural areas were small, except for emergency visits. Given policies to reduce rural add-on payments for home health services, continued monitoring of the services provided and the quality of care by home health agencies in rural areas is recommended., (© 2020 National Rural Health Association.)

Objective: This study examined monitoring for metabolic side effects among older outpatients with dementia starting a new antipsychotic., Methods: In a retrospective cohort analysis of U.S. Department of Veterans Affairs data, monitoring, as recommended by the American Diabetes Association and the American Psychiatric Association, was examined between October 1, 2005, and September 30, 2011. The sample included outpatients aged ≥60 years with dementia but without a psychotic disorder (N=3,903) and outpatients with a psychotic disorder but without dementia (N=5,779) who were prescribed a new antipsychotic. Because dementia patients differed from psychosis patients in all observed patient characteristics, especially age, metabolic monitoring of dementia patients was compared with a propensity score-matched sample of outpatients with psychosis (1,576 matched pairs)., Results: At baseline (±30 days from the index prescription), 68% of the matched dementia patients were weighed, compared with 63.7% of the matched psychosis patients (odds ratio [OR]=1.28, 95% confidence interval [CI]=1.03-1.48). Monitoring for glucose or glycosylated hemoglobin (HBA1c) and low-density lipoprotein (LDL) was not significantly different between the groups: glucose or HBA1c, 41% versus 44%; LDL, 24% versus 27%. At three months (±30 days), metabolic monitoring for all three parameters was significantly lower for the dementia group: weight, OR=.86, CI=.75-.99; glucose or HBA1c, OR=.83, CI=.71-.97; and LDL, OR=.69, CI=.57-.85., Conclusions: Monitoring rates for metabolic side effects were low for both dementia and psychosis groups, with lower rates for dementia patients at follow-up compared with matched psychosis patients. Quality improvement efforts are needed to improve monitoring, especially for patients with dementia.

Background: Treatment of psychotic disorders consists primarily of second generation antipsychotics, which are associated with metabolic side effects such as overweight/obesity, diabetes, and dyslipidemia. Evidence-based clinical practice guidelines recommend timely assessment and management of these conditions; however, research studies show deficits and delays in metabolic monitoring and management for these patients. This protocol article describes the project 'Monitoring and Management for Metabolic Side Effects of Antipsychotics,' which is testing an approach to implement recommendations for these practices., Methods/design: This project employs a cluster randomized clinical trial design to test effectiveness of an evidence-based quality improvement plus facilitation intervention. Eligible study sites were VA Medical Centers with ≥300 patients started on a new antipsychotic prescription in a six-month period. A total of 12 sites, matched in pairs based on scores on an organizational practice survey, were then randomized within pairs to intervention or control conditions.Study participants include VA employees involved in metabolic monitoring and management of patients treated with antipsychotics at participating sites. The intervention involves researchers partnering with clinical stakeholders to facilitate tailoring of local implementation strategies to address barriers to metabolic side-effect monitoring and management. The intervention includes a Design Phase (initial site visit and subsequent development of a local implementation plan); Implementation Phase (guided by an experienced external facilitator); and a Sustainability Phase. Evaluation includes developmental, implementation-focused, progress-focused and interpretative formative evaluation components, as well as summative evaluation. Evaluation methods include surveys, qualitative data collection from provider participants, and quantitative data analysis of data for all patients prescribed a new antipsychotic medication at a study site who are due for monitoring or management of metabolic side effects during the study phases. Changes in rates of recommended monitoring and management actions at intervention and control sites will be compared using time series analyses., Discussion: Improving monitoring for metabolic side effects of antipsychotics, as well as promoting timely evidence-based management when these effects emerge, will lead to improved patient safety and long-term outcomes. This article discusses key strengths and challenges of the study., Trial Registration: NCT01875861.

Objectives: To compare the effectiveness of a conceptually-based, multicomponent "enhanced" strategy with a "basic" strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines., Methods: Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose., Results: Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0-30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention., Conclusions: The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.