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Objective: Accurate assessment of gestational age (GA) is critical to paediatric care, but is limited in developing countries without access to ultrasound. Our objectives were to assess the accuracy of prediction of GA at birth and preterm birth classification using routinely collected anthropometry measures.Design: Prospective cohort study.Setting: United States.Population or Sample: A total of 2334 non-obese and 468 obese pregnant women.Methods: Enrolment GA was determined based on last menstrual period, confirmed by first-trimester ultrasound. Maternal anthropometry and fundal height (FH) were measured by a standardised protocol at study visits; FH alone was additionally abstracted from medical charts. Neonatal anthropometry measurements were obtained at birth. To estimate GA at delivery, we developed three predictor models using longitudinal FH alone and with maternal and neonatal anthropometry. For all predictors, we repeatedly sampled observations to construct training (60%) and test (40%) sets. Linear mixed models incorporated longitudinal maternal anthropometry and a shared parameter model incorporated neonatal anthropometry. We assessed models' accuracy under varied scenarios.Main Outcome Measures: Estimated GA at delivery.Results: Prediction error for various combinations of anthropometric measures ranged between 13.9 and 14.9 days. Longitudinal FH alone predicted GA within 14.9 days with relatively stable prediction errors across individual race/ethnicities [whites (13.9 days), blacks (15.1 days), Hispanics (15.5 days) and Asians (13.1 days)], and correctly identified 75% of preterm births. The model was robust to additional scenarios.Conclusions: In low-risk, non-obese women, longitudinal FH measures alone can provide a reasonably accurate assessment of GA when ultrasound measures are not available.Tweetable Abstract: Longitudinal fundal height alone predicts gestational age at birth when ultrasound measures are unavailable. [ABSTRACT FROM AUTHOR]

Context: Respiratory syncytial virus (RSV) causes more lower respiratory tract infections, often manifested as bronchiolitis, among young children than any other pathogen. Few national estimates exist of the hospitalizations attributable to RSV, and recent advances in prophylaxis warrant an update of these estimates.Objectives: To describe rates of bronchiolitis-associated hospitalizations and to estimate current hospitalizations associated with RSV infection.Design and Setting: Descriptive analysis of US National Hospital Discharge Survey data from 1980 through 1996.Participants: Children younger than 5 years who were hospitalized in short-stay, non-federal hospitals for bronchiolitis.Main Outcome Measure: Bronchiolitis-associated hospitalization rates by age and year.Results: During the 17-year study period, an estimated 1.65 million hospitalizations for bronchiolitis occurred among children younger than 5 years, accounting for 7.0 million inpatient days. Fifty-seven percent of these hospitalizations occurred among children younger than 6 months and 81 % among those younger than 1 year. Among children younger than 1 year, annual bronchiolitis hospitalization rates increased 2.4-fold, from 12.9 per 1000 in 1980 to 31.2 per 1000 in 1996. During 1988-1996, infant hospitalization rates for bronchiolitis increased significantly (P for trend <.001), while hospitalization rates for lower respiratory tract diseases excluding bronchiolitis did not vary significantly (P for trend = .20). The proportion of hospitalizations for lower respiratory tract illnesses among children younger than 1 year associated with bronchiolitis increased from 22.2% in 1980 to 47.4% in 1996; among total hospitalizations, this proportion increased from 5.4% to 16.4%. Averaging bronchiolitis hospitalizations during 1994-1996 and assuming that RSV was the etiologic agent in 50% to 80% of November through April hospitalizations, an estimated 51, 240 to 81, 985 annual bronchiolitis hospitalizations among children younger than 1 year were related to RSV infection.Conclusions: During 1980-1996, rates of hospitalization of infants with bronchiolitis increased substantially, as did the proportion of total and lower respiratory tract hospitalizations associated with bronchiolitis. Annual bronchiolitis hospitalizations associated with RSV infection among infants may be greater than previous estimates for RSV bronchiolitis and pneumonia hospitalizations combined. [ABSTRACT FROM AUTHOR]

Background: Gestational weight gain (GWG) and anthropometric trajectories may affect foetal programming and are potentially modifiable., Objectives: To assess concomitant patterns of change in weight, circumferences and adiposity across gestation as an integrated prenatal exposure, and determine how they relate to neonatal body composition., Methods: Data are from a prospective cohort of singleton pregnancies (n = 2182) enrolled in United States perinatal centres, 2009-2013. Overall and by prepregnancy BMI group (overweight/obesity and healthy weight), joint latent trajectory models were fit with prenatal weight, mid-upper arm circumference (MUAC), triceps (TSF) and subscapular (SSF) skinfolds. Differences in neonatal body composition by trajectory class were assessed via weighted least squares., Results: Six trajectory patterns reflecting co-occurring changes in weight and MUAC, SSF and TSF across pregnancy were identified overall and by body mass index (BMI) group. Among people with a healthy weight BMI, some differences were observed for neonatal subcutaneous adipose tissue, and among individuals with overweight/obesity some differences in neonatal lean mass were found. Neonatal adiposity measures were higher among infants born to individuals with prepregnancy overweight/obesity., Conclusions: Six integrated trajectory patterns of prenatal weight, subcutaneous adipose tissue and circumferences were observed that were minimally associated with neonatal body composition, suggesting a stronger influence of prepregnancy BMI., (© 2023 World Obesity Federation.)

Introduction: Exercise in pregnancy is associated with many perinatal benefits, but patterns of home, work, and commuting activity are not well described. We investigated longitudinal activity in singleton and twin pregnancy by activity domain and maternal characteristics., Methods: In the National Institute of Child Health and Human Development Fetal Growth Studies cohorts, 2778 women with singleton and 169 women with twin gestations reported activity using the Pregnancy Physical Activity Questionnaire at up to six or seven study visits, respectively. Metabolic equivalent of task-hours per week (MET-h·wk -1 ) was calculated from reported activity. Baseline measurements (obtained between 10 and 13 wk) reflected past year activity. Linear mixed models estimated MET-h·wk -1 by domain (household/childcare, occupational, inactive, transportation, sports/exercise), self-reported race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander), prepregnancy body mass index (<25, 25 to < 30, ≥30 kg·m -2 ), parity (0, ≥1), baseline activity (quartiles), and plurality (singleton, twin)., Results: Household/caregiving activity made up the largest fraction of reported MET-h·wk -1 at baseline (42%), followed by occupational activity (28%). Median summed activity declined 47%, from 297 to 157 MET-h·wk -1 , between 10 and 40 wk, largely driven by changes in household/caregiving (44% decline), and occupational activity (63% decline). Sports/exercise activity declined 55% but constituted only 5% of reported MET-h·wk -1 at baseline. At baseline, non-Hispanic Black women reported significantly higher activity than non-Hispanic White or Hispanic women, but differences did not persist across pregnancy. Across gestation nulliparous women reported significantly lower activity than parous women. Women with singleton gestations reported significantly more activity than women with twins from weeks 26 to 38. Baseline activity level was strongly associated with later activity levels., Conclusions: Measuring domains of activity beyond exercise, and collecting longitudinal measurements, is necessary to fully describe activity in diverse populations of pregnant women., (Copyright © 2022 by the American College of Sports Medicine.)

Asthma in children poses a significant clinical and public health burden. We examined the association between reported neighborhood traffic (a proxy for traffic-related air pollution) and asthma among 855 multi-racial children aged 4-8 years old who participated in the Environmental Influences on Child Health Outcomes (ECHO) cohort. We hypothesized that high neighborhood traffic density would be associated with the prevalence of asthma. Asthma/asthma-like symptoms (defined as current and/or past physician diagnosed asthma, past wheezing, or nighttime cough or wheezing in the past 12 months) was assessed by parental report. The relationship between neighborhood traffic and asthma/asthma-like symptoms was assessed using logistic regression. The prevalence of asthma/asthma-like symptoms among study participants was 23%, and 15% had high neighborhood traffic. Children with significant neighborhood traffic had a higher odds of having asthma/asthma-like symptoms than children without neighborhood traffic [adjusted OR = 2.01 (95% CI: 1.12, 3.62)] after controlling for child's race-ethnicity, age, sex, maternal education, family history of asthma, play equipment in the home environment, public parks, obesity and prescribed asthma medication. Further characterization of neighborhood traffic is needed since many children live near high traffic zones and significant racial/ethnic disparities exist.

Objective: Accurate assessment of gestational age (GA) is critical to paediatric care, but is limited in developing countries without access to ultrasound. Our objectives were to assess the accuracy of prediction of GA at birth and preterm birth classification using routinely collected anthropometry measures., Design: Prospective cohort study., Setting: United States., Population or Sample: A total of 2334 non-obese and 468 obese pregnant women., Methods: Enrolment GA was determined based on last menstrual period, confirmed by first-trimester ultrasound. Maternal anthropometry and fundal height (FH) were measured by a standardised protocol at study visits; FH alone was additionally abstracted from medical charts. Neonatal anthropometry measurements were obtained at birth. To estimate GA at delivery, we developed three predictor models using longitudinal FH alone and with maternal and neonatal anthropometry. For all predictors, we repeatedly sampled observations to construct training (60%) and test (40%) sets. Linear mixed models incorporated longitudinal maternal anthropometry and a shared parameter model incorporated neonatal anthropometry. We assessed models' accuracy under varied scenarios., Main Outcome Measures: Estimated GA at delivery., Results: Prediction error for various combinations of anthropometric measures ranged between 13.9 and 14.9 days. Longitudinal FH alone predicted GA within 14.9 days with relatively stable prediction errors across individual race/ethnicities [whites (13.9 days), blacks (15.1 days), Hispanics (15.5 days) and Asians (13.1 days)], and correctly identified 75% of preterm births. The model was robust to additional scenarios., Conclusions: In low-risk, non-obese women, longitudinal FH measures alone can provide a reasonably accurate assessment of GA when ultrasound measures are not available., Tweetable Abstract: Longitudinal fundal height alone predicts gestational age at birth when ultrasound measures are unavailable., (© 2018 Royal College of Obstetricians and Gynaecologists.)

Rationale: A molecular test to distinguish between sepsis and systemic inflammation of noninfectious etiology could potentially have clinical utility., Objectives: This study evaluated the diagnostic performance of a molecular host response assay (SeptiCyte LAB) designed to distinguish between sepsis and noninfectious systemic inflammation in critically ill adults., Methods: The study employed a prospective, observational, noninterventional design and recruited a heterogeneous cohort of adult critical care patients from seven sites in the United States (n = 249). An additional group of 198 patients, recruited in the large MARS (Molecular Diagnosis and Risk Stratification of Sepsis) consortium trial in the Netherlands ( www.clinicaltrials.gov identifier NCT01905033), was also tested and analyzed, making a grand total of 447 patients in our study. The performance of SeptiCyte LAB was compared with retrospective physician diagnosis by a panel of three experts., Measurements and Main Results: In receiver operating characteristic curve analysis, SeptiCyte LAB had an estimated area under the curve of 0.82-0.89 for discriminating sepsis from noninfectious systemic inflammation. The relative likelihood of sepsis versus noninfectious systemic inflammation was found to increase with increasing test score (range, 0-10). In a forward logistic regression analysis, the diagnostic performance of the assay was improved only marginally when used in combination with other clinical and laboratory variables, including procalcitonin. The performance of the assay was not significantly affected by demographic variables, including age, sex, or race/ethnicity., Conclusions: SeptiCyte LAB appears to be a promising diagnostic tool to complement physician assessment of infection likelihood in critically ill adult patients with systemic inflammation. Clinical trial registered with www.clinicaltrials.gov (NCT01905033 and NCT02127502).

Background: Accurately identifying pregnancies with accelerated or diminished fetal growth is challenging and generally based on cross-sectional percentile estimates of fetal weight. Longitudinal growth velocity might improve identification of abnormally grown fetuses., Objective: We sought to complement fetal size standards with fetal growth velocity, develop a model to compute fetal growth velocity percentiles for any given set of gestational week intervals, and determine association between fetal growth velocity and birthweight., Study Design: This was a prospective cohort study with data collected at 12 US sites (2009 through 2013) from 1733 nonobese, low-risk pregnancies included in the singleton standard. Following a standardized sonogram at 10w0d-13w6d, each woman was randomized to 1 of 4 follow-up visit schedules with 5 additional study sonograms (targeted ranges: 16-22, 24-29, 30-33, 34-37, and 38-41 weeks). Study visits could occur ± 1 week from the targeted GA. Ultrasound biometric measurements included biparietal diameter, head circumference, abdominal circumference, and femur length, and estimated fetal weight was calculated. We used linear mixed models with cubic splines for the fixed effects and random effects to flexibly model ultrasound trajectories. We computed velocity percentiles in 2 ways: (1) difference between 2 consecutive weekly measurements (ie, weekly velocity), and (2) difference between any 2 ultrasounds at a clinically reasonable difference between 2 gestational ages (ie, velocity calculator). We compared correlation between fetal growth velocity percentiles and estimated fetal weight percentiles at 4-week intervals, with 32 (±1) weeks' gestation for illustration. Growth velocity was computed as estimated fetal growth rate (g/wk) between ultrasound at that gestational age and from prior visit [ie, for 28-32 weeks' gestational age: velocity = (estimated fetal weight 32-28)/(gestational age 32-28)]. We examined differences in birthweight by whether or not estimated fetal weight and estimated fetal weight velocity were <5th or ≥5th percentiles using χ 2 ., Results: Fetal growth velocity was nonmonotonic, with acceleration early in pregnancy, peaking at 13, 14, 15, and 16 weeks for biparietal diameter, head circumference, femur length, and abdominal circumference, respectively. Biparietal diameter, head circumference, and abdominal circumference had a second acceleration at 19-22, 19-21, and 27-31 weeks, respectively. Estimated fetal weight velocity peaked around 35 weeks. Fetal growth velocity varied slightly by race/ethnicity although comparisons reflected differences for parameters at various gestational ages. Estimated fetal weight velocity percentiles were not highly correlated with fetal size percentiles (Pearson r = 0.40-0.41, P < .001), suggesting that these measurements reflect different aspects of fetal growth and velocity may add additional information to a single measure of estimated fetal weight. At 32 (SD ± 1) weeks, if both estimated fetal weight velocity and size were <5th percentile, mean birthweight was 2550 g; however, even when size remained <5th percentile but velocity was ≥5th percentile, birthweight increased to 2867 g, reflecting the important contribution of higher growth velocities. For estimated fetal weight ≥5th percentile, but growth velocity <5th, birthweight was smaller (3208 vs 3357 g, respectively, P < .001)., Conclusion: We provide fetal growth velocity data to complement our previous work on fetal growth size standards, and have developed a calculator to compute fetal growth velocity. Preliminary findings suggest that growth velocity adds additional information over knowing fetal size alone., (Published by Elsevier Inc.)

The current research examines the association between bullying victimization, binge drinking, and marijuana use among adolescents. We seek to determine if this association varies based on the type of bullying experienced, traditional or cyberbullying. We used data from the 2013 Youth Risk Behavior Survey, a nationally representative sample of high school students in the United States. The dependent variables were binge drinking and marijuana use. Our key independent variable, bullying victimization, included both traditional and cyberbullying. We estimated logistic regression models, by gender, to examine the association between bullying victimization and substance use. About 25% of the sample reported bullying victimization, including 10.39% for only traditional, 5.47% for only cyber, and 9.26% for both. Traditional bullying was not significantly associated with binge drinking, but was negatively related to marijuana use. Being the victim of cyberbullying and both types of bullying was significantly associated with binge drinking and marijuana use. We also found important gender differences. The current research adds to a growing list of studies that suggests that cyberbullying is associated with more adverse outcomes than traditional bullying. Bullying prevention and intervention efforts should focus on reducing cyberbullying and providing adolescents with the skills needed to effectively deal with cyberbullying.

Background and Objectives: Diabetic retinopathy is the leading cause of blindness in adults in the United States, and early screening/treatment may preserve vision. This study examined the feasibility of using non-mydriatic digital retinal imaging (DRI) for retinopathy screening in a busy family medicine residency program at the point of care using a nurse-driven protocol., Methods: We compared the number of diabetics screened during a 1-year period before and after DRI protocol implementation. We also determined the prevalence of retinopathy, assessed patient satisfaction with the alternative screening process, and tracked ophthalmologic appointment compliance for patients referred because of abnormal screening results., Results: Screening approximately doubled from 161 patients/year before the protocol to 330 patients/year after protocol implementation. However, DRI screening had no impact on ophthalmologic appointment compliance; only 58% of 153 patients referred for ophthalmologic evaluation because of positive screening findings completed their referral appointment. Seven cases needing urgent ophthalmologic treatment were identified. Satisfaction with primary care retinopathy screening was high., Conclusions: Use of a nurse-driven protocol for digital retinal imaging at the point of care dramatically improves rates of annual retinopathy screening in academic family medicine practice and can identify patients who require subspecialty referral. However, DRI screening does not improve visit compliance rates with ophthalmologists for evaluation and management.

The progress of psychology toward the acquisition of prescriptive authority is critically reviewed. Advances made by other nonphysician health care professions toward expanding their scopes of practice to include prescriptive authority are compared with gains made by professional psychology. Societal trends affecting attitudes toward the use of psychotropic medications are reviewed, and the potential influence of such trends on the prescriptive authority movement is examined. A history of the prescriptive authority movement is documented, and recent legislative and policy initiatives are discussed., (PsycINFO Database Record (c) 2009 APA, all rights reserved.)

beta-mimetics have been prescribed by physicians to arrest or prevent premature labor for more than 20 years. Although not approved by the Food and Drug Administration (FDA) for tocolytic use, terbutaline sulfate has been the most widely prescribed beta-mimetic in the United States. Recently, the role of terbutaline in the treatment and prevention of preterm labor has been questioned by the FDA. Because the off-label use of drugs is a formally accepted practice in medicine when scientific studies support such use, we reviewed the currently available clinical literature on terbutaline use in various routes of delivery: intravenous, oral, and subcutaneous via infusion pump. This review describes the clinical evidence that supports the safe and effective use of terbutaline as a tocolytic agent in certain patient populations. Practicing physicians should continue to have unrestricted use of terbutaline for tocolysis as one of the few remaining therapeutic options remaining in the fight against preterm birth.

One third of all cases of the acquired immunodeficiency syndrome (AIDS) in the United States are associated with the injection of illicit drugs. There is mounting evidence for the effectiveness of syringe exchange programs in reducing human immunodeficiency virus (HIV) risk behavior and HIV transmission among injection drug users. Expansion of syringe exchange would require increased public funding and undoubtedly would include government regulation of syringe exchanges. An analogy is drawn with the present system of regulation of methadone maintenance treatment programs and possible regulation of syringe exchange programs. Specific recommendations are offered to reduce the likelihood of repeating the regulatory problems of methadone maintenance treatment in future regulation of syringe exchange programs.

Manual medicine is an important part of the practice of physical medicine and rehabilitation (PM&R). Using a two-part questionnaire, we surveyed PM&R residents to determine their level of interest in manual medicine, their attitudes about this type of treatment, and the amount of formal training in manual medicine offered in PM&R residencies. Questionnaires were sent to all 75 PM&R residency training programs. Responses were received from 470 residents (41.6%) of 1126 potential respondents; this represented 55 (73%) of the programs surveyed. Of the 470 respondents, 363 (77.2%) believed that manual medicine should be a part of PM&R, 386 (82.1%) wanted more training in manual medicine, 389 (82.8%) believed that manual medicine is useful in the treatment of back/neck pain, and 392 (83.4%) would refer patients for manual medicine treatment. However, only 124 (27.3%) were receiving formal instruction in manual medicine during their PM&R residency training. Most of the 305 respondents who had received some exposure to manual medicine had done so through conferences (88.7%) and independent reading (66.9%). The results of this survey of PM&R residents demonstrate both a widespread interest in the use of manual medicine and an unmet desire for more instruction. Educational experiences in manual medicine should be provided so that, as residents become practicing physiatrists, they can either utilize this form of treatment or appropriately refer patients to other practitioners.

A sea change seems likely in the way health care is delivered. In medicine, public health and nutrition, here's what else the year will bring.

Patients rave about a new treatment. Some doctors are less sure.

Does the use of a restricted drug formulary achieve cost savings within state Medicaid programmes? Restricted formularies are often justified by putting forth the attributes of a perfectly operating and implicitly costless policy. Analysis suggests, however, that the operation of 'actual' restricted formularies produce realised effects that are substantially at odds with the desired effects. Although the implementation of a restricted formulary can reduce a state's drug expenditures, service substitution causes expenditures to increase elsewhere in the system. Furthermore, direct savings in the drug budget are completely offset by these spillover effects.

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?

The relationship between public policy and scientific investigation is explored by a review of the experience with methadone maintenance treatment for narcotic addiction. The implementation of a widespread treatment effort in Hong Kong in the 1970s is contrasted with recent policies in regard to methadone treatment expansion in the United States. In neither case did research findings form the basis for public policy. In Hong Kong, rapid expansion of methadone treatment was initiated before scientific evidence was available to support this course, and in the United States treatment expansion has been rejected despite extensive evidence of its utility and safety. Decisions by government officials and health care providers, as in the case of addiction treatment, may be influenced more by philosophy and intuition than by scientific evidence. Scientists must recognize and address this reality if they are to play a meaningful role in shaping public health policy.

In any contractural relationship, legally and ethically, all parties much benefit. Minor concessions to one party can be significant gains for the other. To establish the win/win environment, it is sometimes necessary to make reasonable concessions that preserve the overall objective of the JIT concept. It is good business sense to make those concessions that are inexpensive and guarantee greater control. The concessions discussed strengthen the buyer-seller relationship and aid in reaching the objectives of JIT.

In most areas of the medical curriculum it is far more important to teach students the approach to problems, rather than to encourage rote learning of the specific diagnostic and therapeutic regimen indicated in every conceivable circumstance. This is especially true in the field of substance abuse, in part because there simply are no clear-cut answers which can be universally applied. Nevertheless, dogmatism has been all too common in the teaching as well as the treatment of addiction, and there is a general tendency to view the problem simplistically and to advocate a specific modality as the solution. Teaching new professionals to apply the holistic perspective of the epidemiologist will enhance the likelihood of establishing realistic program goals, and adopting a comprehensive, balanced approach.