Jacobs Institute of Women's Health
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Quantity of Caloric Support After Pediatric Severe Traumatic Brain Injury: Description of Associated Outcomes in a Single Retrospective Center Cohort, 2010-2022
No full textOBJECTIVES: To examine the relationship between adequacy of caloric nutritional support during the first week after severe traumatic brain injury (TBI) and outcome. DESIGN: Single-center retrospective cohort, 2010-2022. SETTING: Tertiary care children\u27s hospital with a level 1 trauma center. PATIENTS: Children younger than 18 years with PICU stay greater than 7 days for management of TBI, who had severe TBI, defined as Glasgow Coma Scale (GCS) score less than or equal to 8 at initial presentation and/or placement of an intracranial pressure monitor or external ventricular drain, and/or decompressive hemicraniectomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 93 patients were identified (median age 46 mo; 53% male; median GCS 5; hospital mortality 4%). Caloric goal was assigned by a dietician and the proportion of prescribed calories delivered to each patient over the first 7 days of PICU admission were analyzed. At the end of the first 7 days post-injury, overall median (interquartile range [IQR]) caloric and protein adequacies were 42% (IQR, 28-62%) and 48% (IQR, 29-61%), respectively. We failed to identify an association between adequacy of caloric support and greater odds of higher Functional Status Scale (FSS) score or higher Glasgow Outcome Scale Extended for Pediatrics score at discharge. However, at outpatient follow-up, prior adequacy of PICU caloric support was associated with greater odds of worse FSS (multiplicative increase per 10% increase in calories [MI], 1.10; 95% CI, 1.03-1.18; p = 0.002) and worse GOS E-Peds (MI, 1.16; 95% CI, 1.08-1.27; p \u3c 0.001) at outpatient follow-up. CONCLUSIONS: In pediatric patients with severe TBI, there is an association between delivery of a greater proportion of their goal calories during the first 7 days after injury and greater odds of worse outcome at outpatient follow-up
The American Clinical Neurophysiology Society Guideline on Indications for Continuous Electroencephalography Monitoring in Neonates
No full textPURPOSE: Continuous EEG (cEEG) monitoring is increasingly used in the management of neonates with seizures. There remains debate on what clinically relevant information can be gained from cEEG in neonates with suspected seizures, at high risk for seizures, or with definite seizures, as well as the use of cEEG for prognosis in a variety of conditions. In this guideline, we address these questions using American Clinical Neurophysiology Society structured methodology for clinical guideline development. METHODS: A working group was formed from American Clinical Neurophysiology Society membership with expertise in neonatal cEEG and a set of priority questions developed. We performed literature searches in PubMed and EMBASE to identify relevant studies. Evidence tables were compiled from extracted data and quality assessments performed. A modification of the GRADE process was used to evaluate the body of evidence and draft recommendations. RESULTS: Our working group identified six priority questions to evaluate the accuracy of cEEG for neonatal seizure diagnosis and the formulation of prognosis. An initial literature search yielded 18,167 results, which were distilled to a set of 217 articles. Overall, the quality of evidence for most priority questions was rated as very low and we provided conditional recommendations based on published literature and expert consensus. For each priority question, we also considered the benefits and harms of cEEG, with relative harms considered to be far less than the potential benefits across recommendations. CONCLUSIONS: We present evidence-based clinical guidelines regarding indications for cEEG monitoring in neonates. Considering resource utilization and feasibility, when cEEG monitoring results have a likelihood of altering clinical decision making, the authors felt the resource investment was justifiable
Longitudinal analysis of the role of mindfulness on HIV stigma, depression, substance use and HIV outcomes among female sex workers living with HIV in the Dominican Republic
No full textFemale sex workers (FSW) living with HIV experience greater depression and worse HIV outcomes than people living with HIV (PLHIV) overall. Mindfulness is related to lower depression and higher ART adherence in PLHIV. Few studies have assessed these relationships among FSW, especially longitudinally. This study assessed the temporal relationship between mindfulness, mental health and HIV outcomes among FSW from the Dominican Republic (DR). We analyzed data collected between 2018 and 2021 among 240 FSW using mixed modeling to assess contemporaneous relationships and time-lagged relationships between mindfulness and mental health (i.e., depression,HIV stigma, drug and alcohol use ), and HIV outcomes (i.e., ART adherence, viral suppression) , accounting for clustering of repeated measures. Greater mindfulness showed contemporaneous and time-lagged associations with lower depression (contemporaneous: b = -0.57, SE = 0.03, p \u3c 0.001; time-lagged: b = -0.16, SE = 0.05, p \u3c 0.001), lower HIV stigma (contemporaneous: b = -0.11, SE = 0.02, p \u3c 0.001; time-lagged: b = -0.08, SE = 0.03, p = 0.003) and higher ART adherence (contemporaneous: b = 0.03, SE = 0.01, p = 0.003; time-lagged: b = 0.04, SE = 0.01, p = 0.004), and contemporaneous associations with reduced at-risk alcohol use and higher viral suppression (aOR = 0.99, 95% CI = 0.99-1.00, p = 0.003; aOR = 1.01, 95% CI: 1.00-1.01, p = 0.036, separately). Mindfulness instruction is a promising intervention for reducing depression and HIV stigma, and promoting better HIV outcomes among FSW living with HIV, meriting future intervention research in this area
Impact of Viral Lower Respiratory Tract Infection (LRTI) in Early Childhood (0-2 Years) on Lung Growth and Development and Lifelong Trajectories of Pulmonary Health: A National Institutes of Health (NIH) Workshop Summary
No full textViral lower respiratory tract infections (LRTI) are ubiquitous in early life. They are disproportionately severe in infants and toddlers (0-2 years), leading to more than 100,000 hospitalizations in the United States per year. The recent relative resilience to severe Coronavirus disease (COVID-19) observed in young children is surprising. These observations, taken together, underscore current knowledge gaps in the pathogenesis of viral lower respiratory tract diseases in young children and respiratory developmental immunology. Further, early-life respiratory viral infections could have a lasting impact on lung development with potential life-long pulmonary sequelae. Modern molecular methods, including high-resolution spatial and single-cell technologies, in concert with longitudinal observational studies beginning in the prenatal period and continuing into early childhood, promise to elucidate developmental pulmonary and immunophenotypes following early-life viral infections and their impact on trajectories of future respiratory health. In November 2019, under the auspices of a multi-disciplinary Workshop convened by the National Heart Lung Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, experts came together to highlight the challenges of respiratory viral infections, particularly in early childhood, and emphasize the knowledge gaps in immune, virological, developmental, and clinical factors that contribute to disease severity and long-term pulmonary morbidity from viral LRTI in children. We hope that the scientific community will view these challenges in clinical care on pulmonary health trajectories and disease burden not as a window of susceptibility but as a window of opportunity
An online assessment of pricing for ready-to-drink alcohol products: Implications for risk and policy solutions
No full textBACKGROUND: Alcohol pricing policies can reduce population-level alcohol consumption. To inform these policies, it is essential to understand the price per standard alcoholic drink of the least expensive brands. This study focused on prices of ready-to-drink products because of their accessibility, popularity among young people, and market expansion in recent years. METHODS: In 2023, we systematically identified 39 retail stores selling alcohol online in Fort Worth, Texas. For each product, we recorded information regarding brand name, alcohol-by-volume (abv), liquid volume, and price (n = 10,818). Ready-to-drink products encompassed beer, malt liquor, cider, premixed cocktails, and flavored alcoholic beverages (FAB) including hard beverages (seltzer, soda, tea, lemonade), excluding wine and distilled spirits. We limited analyses to brands sold by at least three stores and deduplicated products within stores. Our analytic sample size was 3924. RESULTS: The least expensive brands included the following: Four Loko, MXD Drinks Co., Steel Reserve (High Gravity Lager and Alloy Series), Hurricane High Gravity, Natural Ice, Natty Daddy, Clubtails, Sauza Agave Cocktails, Truly Extra, and Icehouse. The average abv among all products was 5.9%. Among the 20 least expensive brands, the average abv was 9.0%, and 70% were available in single-serve containers. CONCLUSIONS: The least expensive brands of ready-to-drink alcohol products were often high abv, single-serve containers of FAB, malt liquor, or beer. Retail price assessments can strengthen the case for policy solutions, such as targeted taxes and re-classification of products, to reduce the risks posed by low-priced alcohol. The current study identifies some brands these retail assessments should include
Target Trial Emulation Using Cohort Studies: Estimating the Effect of Antihypertensive Medication Initiation on Incident Dementia
No full textBACKGROUND: Observational studies link high midlife systolic blood pressure to increased dementia risk. However, the synthesis of evidence from randomized controlled trials has not definitively demonstrated that antihypertensive medication use reduces dementia risk. Here, we emulate target trials of antihypertensive medication initiation on incident dementia using three cohort studies, with attention to potential violations of necessary assumptions. METHODS: We emulated trials of antihypertensive medication initiation on incident dementia using data from the Atherosclerosis Risk in Communities study, Cardiovascular Health Study, and Health and Retirement Study. We used data-driven methods to restrict participants to initiators and noninitiators with overlap in propensity scores and positive control outcomes to look for violations of positivity and exchangeability assumptions. RESULTS: Analyses were limited by the small number of cohort participants who met eligibility criteria. Associations between antihypertensive medication initiation and incident dementia were inconsistent and imprecise (Atherosclerosis Risk in Communities: HR = 0.30 [0.05, 1.93]; Cardiovascular Health Study: HR = 0.66 [0.27, 1.64]; Health and Retirement Study: HR = 1.09 [0.75, 1.59]). More stringent propensity score restrictions had little effect on findings. Sensitivity analyses using a positive control outcome unexpectedly suggested antihypertensive medication initiation increased the risk of coronary heart disease in all three samples. CONCLUSIONS: Positive control outcome analyses suggested substantial residual confounding in effect estimates from our target trials, precluding conclusions about the impact of antihypertensive medication initiation on dementia risk through target trial emulation. Formalized processes for identifying violations of necessary assumptions will strengthen confidence in target trial emulation and avoid inappropriate confidence in emulated trial results
Knowledge, Attitudes, and Behaviors Regarding HPV Vaccination and Self-sampling Among US Young Adults
No full textTraining socially accountable clinician-citizens: integrating clinical public health education in a medical school curriculum
No full textBy adopting a holistic perspective that looks \u27upstream\u27 at the underlying determinants of health, physicians can develop more effective strategies for promoting wellness and reducing health inequities in an increasingly diverse and complex society. Public health focuses on disease prevention and promotion of health through organized efforts by individuals and society. Population health focuses on the health outcomes of a group of individuals. We designed the Clinical Public Health curriculum, a pedagogical framework designed at the George Washington University School of Medicine & Health Sciences that breaks down traditional silos between didactic public and population health teaching, patient care and community engagement for medical students. It aims to train socially accountable clinician-citizens through an integrated, longitudinal curriculum across the four years of medical school. In this article we describe one aspect of the curriculum - four self-contained \u27summits\u27 - which can be used as a template for others seeking to develop a curriculum focusing on social accountability and engagement with community and governmental partners. During these multi-day applied educational experiences, medical students engage with key stakeholders, community members, community-based organizations, and state and national agencies to develop innovative approaches to engage in advocacy and population health. Enhanced medical school curricula focusing on the development of socially accountable clinician-citizens is an urgent need to develop more meaningful clinical-community interventions, support professional development, put context on the impact of health-related social needs on patients and families, and transform healthcare delivery and policy through greater community connection and advocacy
Recovery of cardiovascular testing in Asia during the COVID-19 pandemic: findings from the INCAPS COVID 2 study
No full textBACKGROUND: Understanding pandemic-related reductions and subsequent recovery of cardiovascular testing in Asia is important for guiding regional public health efforts. OBJECTIVES: This study sought to evaluate the recovery of cardiovascular testing in Asia 1 year into the COVID-19 pandemic. METHODS: In this subanalysis of a worldwide survey on the impact of COVID-19 on cardiovascular diagnostic care in April 2020 and April 2021, recovery of testing volume in Asia was compared among subregions, World Bank income groups and imaging modalities. RESULTS: Of 669 sites worldwide, 164 sites were in 33 Asian countries. Cardiovascular testing volumes in Asia decreased by 53% from March 2019 to April 2020, then recovered 96% of this decrease by April 2021, compared with 98% recovery in the rest of the world. Eastern Asia and Western and Central Asia reported recovery rates of 123% and 110%, compared with 50% and 80% recovery in Southern and South-eastern Asia. Testing volumes among high-income and upper-middle-income Asian countries recovered to 117% and 121% but remained depressed at 49% and 14% recovery in lower-middle and low-income countries, respectively. Stress ECG, stress echo and stress positron emission tomography studies experienced median reductions of 48%, 35% and 57% in testing volume between March 2019 and April 2021, while volumes of coronary artery calcium, coronary CT angiography and cardiac MR remained stable during this period. CONCLUSIONS: The recovery of cardiovascular testing in Asia 1 year into the COVID-19 pandemic lagged in the Southern and South-eastern subregions, as well as in lower-income countries. Recovery favoured advanced cardiac imaging modalities over standard stress testing modalities
Differential Treatment Effects on β-Cell Function Using Model-Based Parameters in Type 2 Diabetes: Results From the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)
No full textOBJECTIVE: To evaluate how model-based parameters of β-cell function change with glucose-lowering treatment and associate with glycemic deterioration in adults with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS: In the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), β-cell function parameters derived from mathematical modeling of oral glucose tolerance tests were assessed at baseline (N = 4,712) and 1, 3, and 5 years following randomization to insulin glargine, glimepiride, liraglutide, or sitagliptin, added to baseline metformin. Parameters included insulin secretion rate (ISR), glucose sensitivity (insulin response to glucose), rate sensitivity (early insulin response), and potentiation. Linear mixed-effects models were used to compare changes across treatments. With Cox proportional hazards and Classification And Regression Tree (CART) analyses we evaluated associations between model parameters and glycemic failure (A1C \u3e7.5%; 58.5 mmol/mol). RESULTS: β-Cell function parameters increased variably at year 1 across treatments but subsequently declined for all treatments. Statistically significant changes were noted. Liraglutide led to the greatest increases in ISR, glucose sensitivity and potentiation, remaining above baseline at study end. Sitagliptin improved glucose sensitivity, with modest effects on other parameters. Glimepiride temporarily increased ISR and rate sensitivity but minimally increased glucose sensitivity or potentiation. Rate sensitivity increased most with glargine. Higher β-cell function parameters were protective against glycemic deterioration, but treatment did not alter the relationship between these parameters and glycemic outcomes. CONCLUSIONS: Common glucose-lowering medications impact different physiologic components of β-cell function in T2D. Regardless of treatment modality, lower β-cell function associated with early glycemic failure, and β-cell function progressively declined after initial improvement