Parent/Guardian Experiences With the Healthcare System and Community Supports for Pediatric Asthma Management

Determinants of pediatric asthma management include child, family, healthcare, and community factors. The purpose of this study is to investigate how parents/guardians are impacted by and act on these factors to aid in their child’s asthma self-management. Interviews were conducted in Fall 2020 with 12 female parents/guardians of Black/African American children who participated in a community paramedic pilot study with their child in South Carolina. Children in the initial study had an asthma diagnosis of moderate persistent asthma, had Medicaid insurance, and were determined high-risk for emergency room presentation. Inductive and deductive qualitative analysis identified that child management self-efficacy and independence, parent/guardian health literacy, parent and child negative experiences related to asthma diagnosis and management, asthma management tools, and social support from multiple sources impact child self-management. Findings from this study highlight the importance of clear asthma education and management tool recommendations from healthcare and community providers, particularly for parents/guardians with low health literacy. Health literacy impacted parental responses and likely how families comprehend Medicaid and clinical asthma guidance.

Multidimensional risk score to stratify community-dwelling older adults by future fall risk using the Stopping Elderly Accidents, Deaths and Injuries (STEADI) framework

BACKGROUND

The Stopping Elderly Accidents, Deaths and Injuries (STEADI) screening algorithm aligns with current fall prevention guidelines and is easy to administer within clinical practice. However, the stratification into low, moderate and high risk categories limits the meaningful interpretation of the fall-related risk factors.

METHODS

Baseline measures from a modified STEADI were used to predict self-reported falls over 4 years in 3170 respondents who participated in the 2011-2015 National Health and Aging Trends Study. A point method was then applied to find coefficient-based integers and 4-year fall risk estimates from the predictive model. Sensitivity and specificity estimates from the point method and the combined moderate and high fall risk STEADI categories were compared.

RESULTS

There were 886 (27.95%) and 387 (12.21%) respondents who were classified as moderate and high risk, respectively, when applying the stratification method. Falls in the past year (OR: 2.16; 95% CI: 1.61 to 2.89), multiple falls (OR: 2.94; 95% CI: 1.89 to 4.55) and a fear of falling (OR: 1.77; 95% CI: 1.45 to 2.16) were among the significant predictors of 4-year falls in older adults. The point method revealed integers that ranged from 0 (risk: 27.21%) to 44 (risk: 99.71%) and a score of 10 points had comparable discriminatory capacity to the combined moderate and high STEADI categories.

CONCLUSION

Coefficient-based integers and their risk estimates can provide an alternative interpretation of a predictive model that may be useful in determining fall risk within a clinical setting, tracking changes longitudinally and defining the effectiveness of an intervention.

MR Imaging Characteristics of Intraocular Perfluoro-n-Octane

We describe the unique MR imaging characteristics of intraocular perfluoro-n-octane, a liquid used for intraoperative and postoperative tamponade in the context of complex retinal detachment repair, and contrast it with other intraocular pathologies. Because trace amounts of perfluoro-n-octane may be left in the globe postoperatively, it may be confused for other abnormalities, such as foreign bodies or tumors.

Microbiota of bovine milk, teat skin, and teat canal: Similarity and variation due to sampling technique and milk fraction

The aim of this study was to evaluate the effect of sampling technique and milk fraction on bovine milk microbiota data and to compare the microbiota in milk to microbiota on the teat end and in the teat canal. Representative milk samples are highly important for assessment of bacteriological findings and microbiota in milk. Samples were obtained from 5 healthy lactating dairy cows at udder quarter level during 1 milking. Swab samples from the teat end and teat canal, and milk samples collected using different techniques and in different milk fractions were included. Milk was collected by hand stripping and through a teat canal cannula before and after machine milking, through a trans-teat wall needle aspirate after milking, and from udder quarter composite milk. The microbiota of the samples was analyzed with sequencing of the V1-V3 region of the 16S rRNA gene. In addition, somatic cell counts and bacterial cultivability were analyzed in the milk samples. Microbiota data were analyzed using multivariate methods, and differences between samples were tested using analysis of similarity (ANOSIM). Differences between samples were further explored via individual studies of the 10 most abundant genera. The microbiota on the teat end, in the teat canal, and in udder quarter composite milk, collected using a milking machine, differed in composition from the microbiota in milk collected directly from the udder quarter. No differences in milk microbiota composition were detected between hand-stripped milk samples, milk samples taken through a teat canal cannula, or milk samples taken as a trans-teat wall needle aspirate before or after milking. We conclude that for aseptic milk samples collected directly from the lactating udder quarter, sampling technique or milk fraction has minor effect on the microbiota composition.

Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study

Background

Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information.

Objective

The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting.

Methods

A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes.

Results

The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA_1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA_1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA_1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12).

Conclusions

Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group.

Trial Registration

ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.6993

A Patient-Centered Mobile Phone App (iHeartU) With a Virtual Human Assistant for Self-Management of Heart Failure: Protocol for a Usability Assessment Study

Background

Heart failure (HF) causes significant economic and humanistic burden for patients and their families, especially those with a low income, partly due to high hospital readmission rates. Optimal self-care is considered an important nonpharmacological aspect of HF management that can improve health outcomes. Emerging evidence suggests that self-management assisted by smartphone apps may reduce rehospitalization rates and improve the quality of life of patients. We developed a virtual human–assisted, patient-centered mobile health app (iHeartU) for patients with HF to enhance their engagement in self-management and improve their communication with health care providers and family caregivers. iHeartU may help patients with HF in self-management to reduce the technical knowledge and usability barrier while maintaining a low cost and natural, effective social interaction with the user.

Objective

With a standardized systematic usability assessment, this study had two objectives: (1) to determine the obstacles to effective and efficient use of iHeartU in patients with HF and (2) to evaluate of HF patients’ adoption, satisfaction, and engagement with regard to the of iHeartU app.

Methods

The basic methodology to develop iHeartU systems consists of a user-centric design, development, and mixed methods formative evaluation. The iterative design and evaluation are based on the guidelines of the American College of Cardiology Foundation and American Heart Association for the management of heart failure and the validated “Information, Motivation, and Behavioral skills” behavior change model. Our hypothesis is that this method of a user-centric design will generate a more usable, useful, and easy-to-use mobile health system for patients, caregivers, and practitioners.

Results

The prototype of iHeartU has been developed. It is currently undergoing usability testing. As of September 2018, the first round of usability testing data have been collected. The final data collection and analysis are expected to be completed by the end of 2019.

Conclusions

The main contribution of this project is the development of a patient-centered self-management system, which may support HF patients’ self-care at home and aid in the communication between patients and their health care providers in a more effective and efficient way. Widely available mobile phones serve as care coordination and “no-cost” continuum of care. For low-income patients with HF, a mobile self-management tool will expand their accessibility to care and reduce the cost incurred due to emergency visits or readmissions. The user-centered design will improve the level of engagement of patients and ultimately lead to better health outcomes. Developing and testing a novel mobile system for patients with HF that incorporates chronic disease management is critical for advancing research and clinical practice of care for them. This research fills in the gap in user-centric design and lays the groundwork for a large-scale population study in the next phase.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13502

Bioelectric impedance vector analysis (BIVA) in hospitalised children; predictors and associations with clinical outcomes

BACKGROUND

Clinical use of bioelectric impedance is limited by variability in hydration. Analysis of raw bioelectric impedance vectors (BIVA), resistance (R), reactance (Xc) and phase angle (PA) may be an alternative for monitoring disease progression/treatment. Clinical experience of BIVA in children is limited. We investigated predictors of BIVA and their ability to predict clinical outcomes in children with complex diagnoses.

METHODS

R, Xc and PA were measured (BODYSTAT Quadscan 4000) on admission in 108 patients (4.6-16.8 years, mean 10.0). R and Xc were indexed by height (H) and BIVA-SDS for age and sex calculated using data from healthy children. Potential predictors and clinical outcomes (greater-than-expected length-of-stay (LOS), complications) were recorded.

RESULTS

Mean R/H-SDS was significantly higher (0.99 (SD 1.32)) and PA-SDS lower (-1.22 (1.68))) than expected, with a wide range for all parameters. In multivariate models, the Strongkids risk category predicted R/H-SDS (adjusted mean for low, medium and high risk = 0.49, 1.28, 2.17, p = 0.009) and PA-SDS (adjusted mean -0.52, -1.53, -2.36, p = 0.01). BIVA-SDS were not significantly different in patients with or without adverse outcomes.

CONCLUSIONS

These complex patients had abnormal mean BIVA-SDS suggestive of reduced hydration and poor cellular health according to conventional interpretation. R/H-SDS was higher and PA-SDS lower in those classified as higher malnutrition risk by the StrongKids tool. Further investigation in specific patient groups, including those with acute fluid shifts and using disease-specific outcomes, may better define the clinical role of BIV.

Family and Friend Influences on Fruit and Vegetable Intake in Elementary Aged Children

The purpose of this study was to investigate the eating behaviors and social cognitive factors that affect fruit and vegetable consumption. Strategies to change, pros & cons, enjoyment, family support, and peer influence were measured in children ages 8-10 years both pre- and post- Zest Quest® program (pre: n = 82; post: n = 80). Children for a comparison group were selected from comparable elementary schools and pre- and post- measures were evaluated (pre: n = 92; post: n = 87). Chi-squared analyses were conducted on individual measures and Spearman correlations & linear regression were used for composite variables with fruit and vegetable consumption as the dependent variable. Results from the study demonstrated significant moderate correlations for fruit change strategies pre- (r_s = 0.39) and post-intervention (r_s = 0.33) and vegetable change strategies pre-intervention (r_s = 0.42) in the Zest Quest® group. Peer influence (r_s = 0.33) and enjoyment (r_s = 0.38) showed significant moderate correlations with fruit intake in the comparison group. The regression analysis showed pros (β = 0.24, p value 0.05) and cons (β = 0.14, p value 0.05) to be significant predictors for fruit intake post-intervention in the Zest Quest® group. Prior to the intervention, strategies to change (β = 0.10, p value 0.02) was a significant predictor for fruit intake and cons (β = 0.15, p value = 0.03) for vegetable intake in this group. Family support and peer influence were not significant in the regression models, but demonstrated significance in the crude model. Eating behaviors and social cognitive factors may have an effect on fruit and vegetable consumption, but these measures are difficult to capture. Future research should continue exploring the impact of family support and peer influence on fruit and vegetable intake.

Telemedicine and Mobile Health Technology Are Effective in the Management of Digestive Diseases: A Systematic Review

BACKGROUND

Mobile applications and interactive websites are an increasingly used method of telemedicine, but their use lacks evidence in digestive diseases.

AIM

This study aims to explore digestive disease studies that use telemedicine to effectively manage disease activity, help monitor symptoms, improve compliance to the treatment protocol, increase patient satisfaction, and enhance the patient-to-provider communication.

METHODS

EBSCO, PubMed, and Web of Science databases were searched using Medical Subject Headings and other keywords to identify studies that utilized telemedicine in patients with digestive disease. The PRISMA guidelines were used to identify 20 research articles that had data aligning with 4 common overlapping themes including, patient compliance (n = 13), patient satisfaction (n = 11), disease activity (n = 15), and quality of life (n = 13). The studies focused on digestive diseases including inflammatory bowel disease (n = 7), ulcerative colitis (n = 4), Crohn's Disease (n = 1), irritable bowel syndrome (n = 6), and colorectal cancer (n = 2).

RESULTS

From the studies included in this systematic review, patient compliance and patient satisfaction ranged between 25.7-100% and 74-100%, respectively. Disease activity, measured by symptom severity scales and physiological biomarkers, showed improvements following telemedicine interventions in several, but not all, studies. Similar to disease activity, general and disease-specific quality of life showed improvements following telemedicine interventions in as little as 12 weeks in some studies.

CONCLUSION

Telemedicine and mobile health technology may be effective in managing disease activity and improving quality of life in digestive diseases. Future studies should explore both gastrointestinal and gastroesophageal diseases using these types of interventions.

Enhancing mHealth Technology in the Patient-Centered Medical Home Environment to Activate Patients With Type 2 Diabetes: A Multisite Feasibility Study Protocol

BACKGROUND

The potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow.

OBJECTIVE

We aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities.

METHODS

This is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics.

RESULTS

We have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016.

CONCLUSIONS

The study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei).

Qualitative Study of Oncologists' Views on the CancerLinQ Rapid Learning System

INTRODUCTION

ASCO is actively developing CancerLinQ (CLQ), a rapid learning system for oncology care. The purpose of this study was to explore providers' opinions and concerns related to implementation of CLQ, including ethical issues.

METHODS

Twenty key informant oncologists were recruited for individual in-depth interviews through ASCO contacts, purposively selected to represent a wide variety of cancer specialties as well as different levels of familiarity with CLQ (familiar v unfamiliar). Qualitative data analysis was completed by a three-member team using an inductive narrative approach. Themes were examined by participants familiar and unfamiliar with CLQ, and quotations exemplifying each theme are provided.

RESULTS

Participants' opinions centered on three main themes: (1) general attitudes regarding learning health care systems, (2) optimal approach to patient consent, and (3) appropriateness of data use. There was clear support for the use of big data in clinical decision making for patients and in research. Unfamiliar participants expressed concerns regarding system protections against patient identification, and both familiar and unfamiliar participants discussed the dilemma of including genetic information. Respondents were in agreement with notifying patients early; however, there was debate over whether patients should opt in or opt out. Overall, there was great concern regarding sharing data with drug companies and insurers.

CONCLUSION

Understanding oncologists' perspectives regarding the ethical implications of CLQ implementation is critical to its success. More research is needed on the impact of rapid learning systems on providers, patients, health systems, and the ultimate effect on cancer care.

Does Awareness of the Affordable Care Act Reduce Adverse Selection? A Study of the Long-term Uninsured in South Carolina

Adverse selection predicts that individuals with lower health status would be more likely to sign up for health insurance. This hypothesis was tested among the long-term uninsured population in South Carolina (SC). This study used data from an in-person survey conducted from May 2014 to January 2015. Interviews were held with the long-term uninsured individuals at multiple sites throughout the state, using a multistage sampling method. SC residents aged 18 to 64 years who had had no health insurance for at least 24 consecutive months were eligible for the survey. The dependent variable is the participants' attempt to obtain insurance coverage. Key independent variables are self-reported health status, hospitalization in the past year, use of emergency department in the past year, and presence of serious long-standing health problems. The analysis is stratified by the awareness of the Affordable Care Act (ACA)'s individual mandate while controlling for age, gender, race/ethnicity, and household income. Participants' self-reported health status was not significantly associated with the attempt to sign up for health insurance in both groups (those aware and those unaware of the individual mandate). Being hospitalized in the previous year was significantly associated with their attempt to sign up for insurance in both groups. Participants with serious long-term health problems were more likely to have attempted to sign up for insurance among those who were not aware of the ACA. However, this association was statistically insignificant among those who had heard of ACA. Sicker people were more likely to attempt to sign up for insurance. However, being aware of the ACA's individual mandate seemed to play a role in reducing adverse selection.

Activating Patients for Sustained Chronic Disease Self-Management: Thinking Beyond Clinical Outcomes

This article describes the impact of an 8-week community program implemented by trained volunteers on the hypertension self-management of 185 patients who were batch randomized to intervention or wait-list control groups. Compared with control group participants, a higher proportion of treatment group participants moved from the cognitive to behavioral stages of motivational readiness for being physically active (P < .001), practicing healthy eating habits (P = .001), handling stress well (P = .001), and living an overall healthy lifestyle (P = .003). They also demonstrated a greater average increase in perceived competence for self-management, F(1.134) = 4.957, P = .028, η2 = .036, and a greater increase in mean hypertension-related knowledge, F(1.160) = 16.571, P < .0005, η(2) = .094. Enduring lifestyle changes necessary for chronic disease self-management require that psychosocial determinants of health behavior are instilled, which is typically beyond standard medical practice. We recommend peer-led, community-based programs as a complement to clinical care and support the increasing health system interest in promoting population health beyond clinical walls.

Routine screening for pain combined with a pain treatment protocol in head and neck cancer: a randomised controlled trial

BACKGROUND

We compared the effectiveness and cost of a pain screening and treatment program, with usual care in head and neck cancer patients with significant pain.

METHODS

Patients were screened for the presence of pain and then randomly assigned to either an intervention group, consisting of a pain treatment protocol and an education program, or to usual care. Primary outcome was change in the Pain Severity Index (PSI) over three months.

RESULTS

We screened 1074 patients of whom 156 were randomized to either intervention or usual care. Mean PSI was reduced over three months in both groups, with no significant difference between the two groups. The Pain Management Index (PMI) at three months, was significantly improved in the intervention group compared with usual care (P<0.001), as was Patient Satisfaction (mean difference in scores was statistically significant: -0.30 [-0.60 to -0.15]). All subjects reported clinically significant levels of anxiety and depression throughout the study. Treatment costs were significantly higher for intervention (mean=£400) compared with usual care (£200), with a low likelihood of being cost-effective.

CONCLUSIONS

There was no difference in the Pain Severity Index between the two groups. However there were significant improvements in the intervention group in patient satisfaction and PMI. The pain screening process itself was effective. Sufficient benefit was demonstrated as a result of the intervention to allow continued development of pain treatment pathways, rather than allowing pain treatment to be left to nonformalised ad hoc arrangements.

The use of high-intensity focused ultrasound as a novel treatment for painful conditions-a description and narrative review of the literature

High-intensity focused ultrasound (HIFU) is a non-invasive technique that allows a small, well-circumscribed thermal lesion to be generated within a tissue target. Tissue destruction occurs due to direct heating within the lesion and the mechanical effects of acoustic cavitation. HIFU has been used in a broad range of clinical applications, including the treatment of malignancies, uterine fibroids and cardiac arrhythmias. Interest in the use of the technique to treat pain has recently increased. A number of painful conditions have been successfully treated, including musculoskeletal degeneration, bone metastases and neuropathic pain. The exact mechanism by which HIFU results in analgesia remains poorly understood, but it is thought to be due to localised denervation of tissue targets and/or neuromodulatory effects. The majority of studies conducted investigating the use of HIFU in pain are still at an early stage, although initial results are encouraging. Further research is indicated to improve our understanding of the mechanisms underlying this treatment and to fully establish its efficacy; however, it is likely that HIFU will play a role in pain management in the future. This narrative review provides a synthesis of the recent, salient clinical and basic science research related to this topic and gives a general introduction to the mechanisms by which HIFU exerts its effects.

Body composition in young female eating-disorder patients with severe weight loss and controls: evidence from the four-component model and evaluation of DXA

Background/Objectives:

Whether fat-free mass (FFM) and its components are depleted in eating-disorder (ED) patients is uncertain. Dual energy X-ray absorptiometry (DXA) is widely used to assess body composition in pediatric ED patients; however, its accuracy in underweight populations remains unknown. We aimed (1) to assess body composition of young females with ED involving substantial weight loss, relative to healthy controls using the four-component (4C) model, and (2) to explore the validity of DXA body composition assessment in ED patients.

Subjects/Methods:

Body composition of 13 females with ED and 117 controls, aged 10–18 years, was investigated using the 4C model. Accuracy of DXA for estimation of FFM and fat mass (FM) was tested using the approach of Bland and Altman.

Results:

Adjusting for age, height and pubertal stage, ED patients had significantly lower whole-body FM, FFM, protein mass (PM) and mineral mass (MM) compared with controls. Trunk and limb FM and limb lean soft tissue were significantly lower in ED patients. However, no significant difference in the hydration of FFM was detected. Compared with the 4C model, DXA overestimated FM by 5±36% and underestimated FFM by 1±9% in ED patients.

Conclusion:

Our study confirms that ED patients are depleted not only in FM but also in FFM, PM and MM. DXA has limitations for estimating body composition in individual young female ED patients.

Do thawing and warming affect the integrity of human milk?

OBJECTIVE

To evaluate the integrity of the human milk (pH, bacterial counts, host defense factors and nutrients) subjected to thawing, warming, refrigeration and maintenance at room temperature.

STUDY DESIGN

Mothers in the neonatal intensive care unit donated freshly expressed milk. A baseline sample was stored at -80 °C and the remainder of the milk was divided and stored for 7 days at -20 °C. The milk was then subjected to two methods of thawing and warming: tepid water and waterless warmer. Thawed milk also was refrigerated for 24 h prior to warming. Lastly, warmed milk was maintained at room temperature for 4 h to simulate a feeding session. Samples were analyzed for pH, bacterial colony counts, total fat and free fatty acids, and the content of protein, secretory IgA and lactoferrin. Data were analyzed by repeated-measures analysis of variance and paired t test.

RESULT

There were no differences between processing methods and no changes in fat, protein, lactoferrin and secretory immunoglobulin A with processing steps. Milk pH and bacterial colony counts declined while free fatty acids rose with processing. Refrigeration of thawed milk resulted in greater declines in pH and bacteria and increases in free fatty acids. Bacterial colony counts and free fatty acids increased with maintenance at room temperature.

CONCLUSION

The integrity of the milk was affected similarly by the two thawing and warming methods. Thawing and warming change the integrity of previously frozen human milk, but not adversely. Concerns about maintaining warmed milk at room temperature need to be explored.

Establishing sustainable performance-based incentive schemes: views of rural health workers from qualitative research in three sub-Saharan African countries

INTRODUCTION

Performance-based incentives (PBIs) are currently receiving attention as a strategy for improving the quality of care that health providers deliver. Experiences from several African countries have shown that PBIs can trigger improvements, particularly in the area of maternal and neonatal health. The involvement of health workers in deciding how their performance should be measured is recommended. Only limited information is available about how such schemes can be made sustainable. This study explored the types of PBIs that rural health workers suggested, their ideas regarding the management and sustainability of such schemes, and their views on which indicators best lend themselves to the monitoring of performance. In this article the authors reported the findings from a cross-country survey conducted in Burkina Faso, Ghana and Tanzania.

METHODS

The study was exploratory with qualitative methodology. In-depth interviews were conducted with 29 maternal and neonatal healthcare providers, four district health managers and two policy makers (total 35 respondents) from one district in each of the three countries. The respondents were purposively selected from six peripheral health facilities. Care was taken to include providers who had a management role. By also including respondents from district and policy level a comparison of perspectives from different levels of the health system was facilitated. The data that was collected was coded and analysed with support of NVivo v8 software.

RESULTS

The most frequently suggested PBIs amongst the respondents in Burkina Faso were training with per-diems, bonuses and recognition of work done. The respondents in Tanzania favoured training with per-diems, as well as payment of overtime, and timely promotion. The respondents in Ghana also called for training, including paid study leave, payment of overtime and recognition schemes for health workers or facilities. Respondents in the three countries supported the mobilisation of local resources to make incentive schemes more sustainable. There was a general view that it was easier to integrate the cost of non-financial incentives in local budgets. There were concerns about the fairness of such schemes from the provider level in all three countries. District managers were worried about the workload that would be required to manage the schemes. The providers themselves were less clear about which indicators best lent themselves to the purpose of performance monitoring. District managers and policy makers most commonly suggested indicators that were in line with national maternal and neonatal healthcare indicators.

CONCLUSIONS

The study showed that health workers have considerable interest in performance-based incentive schemes and are concerned about their sustainability. There is a need to further explore the use of non-financial incentives in PBI schemes, as such incentives were considered to stand a greater chance of being integrated into local budgets. Ensuring participation of healthcare providers in the design of such schemes is likely to achieve buy-in and endorsement from the health workers involved. However, input from managers and policy makers is essential to keep expectations realistic and to ensure the indicators selected fit the purpose and are part of routine reporting systems.

Improving hypertension self-management with community health coaches

Approximately two thirds of those older than 60 years have a hypertension diagnosis. The aim of our program, Health Coaches for Hypertension Control, is to improve hypertension self-management among rural residents older than 60 years through education and support offered by trained community volunteers called Health Coaches. Participants received baseline and follow-up health risk appraisals with blood work, educational materials, and items such as blood pressure monitors and pedometers. Data were collected at baseline, 8 weeks, and 16 weeks on 146 participants who demonstrated statistically significant increases in hypertension-related knowledge from baseline to 8 weeks that persisted at 16 weeks, as well as significant improvements in stage of readiness to change behaviors and in actual behaviors. Furthermore, clinically significant decreases in all outcome measures were observed, with statistically significant changes in systolic blood pressure (-5.781 mmHg; p = .001), weight (-2.475 lb; p < .001), and glucose (-5.096 mg/dl; p = .004) after adjusting for multiple comparisons. Although 40.4% of participants met the Healthy People 2020 definition of controlled hypertension at baseline, the proportion of participants meeting this definition at 16 weeks postintervention increased to 51.0%. This article describes a university-community-hospital system model that effectively promotes hypertension self-management in a rural Appalachian community.

Stakeholder perspectives on barriers for healthy living for low-income african american families

BACKGROUND

Childhood obesity is a growing problem for children in the United States, especially for children from low-income, African American families.

OBJECTIVE

The purpose of this qualitative study was to understand facilitators and barriers to engaging in healthy lifestyles faced by low-income African American children and their families.

METHODS

This qualitative study used semi-structured focus group interviews with eight African American children clinically identified as overweight or obese (BMI ≥ 85) and their parents. An expert panel provided insights in developing culturally appropriate intervention strategies.

RESULTS

Child and parent focus group analysis revealed 11 barriers and no definitive facilitators for healthy eating and lifestyles. Parents reported confusion regarding what constitutes nutritional eating, varying needs of family members in terms of issues with weight, and difficulty in engaging the family in appropriate and safe physical activities; to name a few themes. Community experts independently suggested that nutritional information is confusing and, often, contradictory. Additionally, they recommended simple messaging and practical interventions such as helping with shopping lists, meal planning, and identifying simple and inexpensive physical activities.

CONCLUSION

Childhood obesity in the context of low-resource families is a complex problem with no simple solutions. Culturally sensitive and family informed interventions are needed to support low-income African American families in dealing with childhood obesity.

Dual energy x-ray absorptiometry and quantitative ultrasound are not interchangeable in diagnosing abnormal bones

OBJECTIVE

To evaluate whether dual energy x-ray absorptiometry (DXA) and quantitative ultrasound (QUS) classify the same children as 'abnormal' (SD (z) score (SDS) ≤-2).

METHODS

Speed of sound (SOS) was measured at the radius and tibia using QUS and lumbar spine bone mineral density (BMD) using DXA in 621 subjects aged 5-20 years; healthy 412, cystic fibrosis 117 and obese 92.

RESULTS

BMD SDS positively (p<0.001) and tibia SOS SDS negatively correlated with size (p<0.05). Disagreement between DXA and QUS for 'abnormal' scans occurred in 6-31%. Those with abnormal BMD and normal SOS SDS had lower mean BMI SDS than those with normal BMD and abnormal SOS SDS. SOS measurements were unobtainable in some children, especially in the obese group.

CONCLUSIONS

DXA and QUS identify different individuals as 'abnormal'. Agreement between BMD and tibia SOS is lower in obese subjects. Without a gold-standard, it is difficult to determine which technique is more 'correct'.

Parent-reported social support for child's fruit and vegetable intake: validity of measures

OBJECTIVE

To develop and validate measures of parental social support to increase their child's fruit and vegetable (FV) consumption.

DESIGN

Cross-sectional study design.

SETTING

School and home.

PARTICIPANTS

Two hundred three parents with at least 1 elementary school-aged child.

MAIN OUTCOME MEASURE

Parents completed a questionnaire that included instrumental social support scale (ISSPS), emotional social support scale (ESSPS), household FV availability and accessibility index, and demographics.

ANALYSIS

Exploratory factor analysis with promax rotation was conducted to obtain the psychometric properties of ISSPS and ESSPS. Internal consistency and test-retest reliabilities were also assessed.

RESULTS

Factor analysis indicated a 4-factor model for ESSPS: positive encouragement, negative role modeling, discouragement, and an item cluster called reinforcement. Psychometric properties indicated that ISSPS performed best as independent single scales with α = .87. Internal consistency reliabilities were acceptable, and test-retest reliabilities ranged from low to acceptable. Correlations between scales, subscales, and item clusters were significant (P < .05). In addition, ISSPS and the positive encouragement subscale were significantly correlated with household FV availability.

CONCLUSIONS AND IMPLICATIONS

The ISSPS and ESSPS subscales demonstrated good internal consistency reliability and are suitable for impact assessment of an intervention designed to target parents to help their children eat more fruit and vegetables.

Development of psychosocial scales for evaluating the impact of a culinary nutrition education program on cooking and healthful eating

OBJECTIVE

Develop scales to assess the impact of the Cooking with a Chef program on several psychosocial constructs.

METHODS

Cross-sectional design in which parents and caregivers were recruited from child care settings (Head Start, faith-based, public elementary schools), and cooks were recruited from church and school kitchens. Analysis involved descriptive statistics, correlations, and exploratory factor analysis.

RESULTS

Test-retest reliability coefficients ranged from r = 0.63 to r = 0.88. Exploratory factor analysis indicated a simple structure for 3 scales: Cooking Techniques Self-Efficacy, Negative Cooking Attitude, and Self-Efficacy Fruit and Vegetables and accounted for 85.0% of the total variance. Mean responses to each scale were not statistically different between parents and cooks.

CONCLUSIONS AND IMPLICATIONS

Evidence of face validity and construct validity were provided through expert review, factor analysis, and scale correlations. Analyses presented constitute the first step in developing psychosocial scales for evaluating the Cooking with a Chef program and provide preliminary evidence that these scales work well with diverse groups.

Commentary: A social-ecological perspective on obesity among Latinos

The Southeast United States has experienced rapid growth in the Latino population - mostly Mexican immigrants - with the number of Latinos in the region nearly quadrupling over the past decade. These states, known as new settlement areas, are not as well prepared to meet the health needs of Spanish-speaking immigrants compared to traditional settlement states like Florida, Texas, and California. Unfortunately for these families, immigration to the United States is often associated with becoming obese, or having children at a higher risk for obesity. Rates of obesity have risen dramatically among all racial and ethnic groups in the past few decades, however, Latinos of all ages have the highest rates of overweight and obesity compared to other racial and ethnic groups. One explanation is that although adjustment to a new environment and culture takes considerable time, the adoption of a more sedentary lifestyle and unhealthy diet occurs more rapidly, leading to significant increases in obesity between first and subsequent generations. Families are important referents in establishing health behaviors in children, and there are broader social and physical environmental factors that have strong associations with the development of obesity as well. Moreover, immigrant families must strive to be healthy while coping with acculturative stressors. Relationships between all of these factors are typically studied in isolation. This article explores obesity among new settlement Latino families and provides an integrated conceptual model anchored in the social ecological perspective.

Mid-IR laser oscillation in Cr2+:ZnSe planar waveguide

We demonstrate 2.6 µm mid-infrared lasing at room temperature in a planar waveguide structure. Planar waveguides were fabricated using pulsed laser deposition (PLD) by depositing chromium doped zinc selenide thin films on sapphire substrate (Cr2+:ZnSe/sapphire). Highly doped Cr2+:ZnSe/Sapphire thin film sample was also used to demonstrate passive Q-switching of Er:YAG laser operating at 1.645 µm.

Using Community-Based Programming to Increase Family Social Support for Healthy Eating among African American Adolescents

Little is known about emotional and instrumental social support for nutrition behaviors among African-American adolescents. In this paper, we specifically examine intervention effects on emotional, instrumental and total (composite) social support for fruit/vegetable and low-fat dairy intake. Data from a larger intervention, based on Social Cognitive Theory, which was implemented with 38 African-American adolescents and their families to increase fruit/vegetable intake, low-fat dairy intake and physical activity behaviors are presented. One-way ANOVA analyses revealed that intervention participants had positive and significant increases in emotional social support for low-fat dairy intake (P=0.01), total social support for fruit/vegetable intake (P=0.05), and total social support for low-fat dairy intake (P=0.02). Specific recommendations addressing family social support for healthy eating through youth development programming are discussed.

Variation in injury risk over the course of a two-day youth club soccer tournament

Athletic injury risk in youth is known to be greater in organised sport, higher levels of competition, games, and tournaments, yet young athletes are often expected to participate in tournaments that involve multiple matches per day on consecutive days. In 2006 and 2008 injury rates were observed during a club youth soccer tournament that involved athletes aged 9-18 years playing three to four matches over two consecutive days, to determine if injury risk varied over the course of the event. The injury rate for day 1 was 7.91/1000 hours with a mean severity of 3.5 days missed versus a day 2 rate of 6.75 and severity of 2.3. The rate and severity for the first game in a day were 7.13 and 3.5 respectively compared to 7.9 and 2.5 for game 2. Further research is needed to determine if a high density match schedule increases injury risk for youth soccer players.

INTERSTITIAL BRONCHOPNEUMONIA : II. PRODUCTION OF INTERSTITIAL MONONUCLEAR PNEUMONIA BY THE BORDET-GENGOU BACILLUS

Pure cultures of Bordet-Gengou bacilli produce in rabbits an interstitial mononuclear pneumonia which cannot be differentiated from that occurring in children dying of pertussis or from lhat caused in animals by the viruses of epidemic influenza and psittacosis. A similar pneumonia can be produced in rabbits by typhoid bacilli.

INTERSTITIAL BRONCHOPNEUMONIA : I. SIMILARITY OF A TOXIN PNEUMONIA TO THAT PRODUCED BY THE VIRUSES

Bacterial toxins can produce a pneumonia similar to that caused by viruses, and the presence of a toxin-producing bacterium in the lungs may account for some of the interstitial bronchopneumonias observed in diseases other than those caused by viruses.

The Assessment of Transactional Analysis Ego States Via the Adjective Checklist

Transactional Analysis (TA) conceptualizes personality in terms of five functional ego states: Critical Parent (CP), Nurturing Parent (NP), Adult (A), Free Child (FC), and Adapted Child (AC). The present investigation was designed to develop a procedure for the assessment of the relative strength of ego states from the responses of persons who are not familiar with TA theory. Fifteen TA experts assigned ego-state ratings to the 300 items of the Adjective Check List (ACL) with high interjudge agreement being found. Using the judges' mean raft rigs, a system was developed for obtaining ego-state scores for any selected set of ACL adjectives. The use of the system was illustrated by its application to the ACL self-descriptions of 100 university students which were analyzed in terms of "egograms" in which the five functional ego states were expressed relative to one another. A test-retest study involving an additional 154 students demonstrated stable individual differences in ego-state scores. Mean egograms of female and male students did not differ from one another but showed appreciable differences from the expert judges' ratings of the "psychologically healthy person." The potential Usefulness of the procedure in clinical practice and in testing TA theory is discussed.

Engaging recreational fishers in management and conservation: global case studies

Globally, the number of recreational fishers is sizeable and increasing in many countries. Associated with this trend is the potential for negative impacts on fish stocks through exploitation or management measures such as stocking and introduction of non-native fishes. Nevertheless, recreational fishers can be instrumental in successful fisheries conservation through active involvement in, or initiation of, conservation projects to reduce both direct and external stressors contributing to fishery declines. Understanding fishers' concerns for sustained access to the resource and developing methods for their meaningful participation can have positive impacts on conservation efforts. We examined a suite of case studies that demonstrate successful involvement of recreational fishers in conservation and management activities that span developed and developing countries, temperate and tropical regions, marine and freshwater systems, and open- and closed-access fisheries. To illustrate potential benefits and challenges of involving recreational fishers in fisheries management and conservation, we examined the socioeconomic and ecological contexts of each case study. We devised a conceptual framework for the engagement of recreational fishers that targets particular types of involvement (enforcement, advocacy, conservation, management design [type and location], research, and monitoring) on the basis of degree of stakeholder stewardship, scale of the fishery, and source of impacts (internal or external). These activities can be enhanced by incorporating local knowledge and traditions, taking advantage of leadership and regional networks, and creating collaborations among various stakeholder groups, scientists, and agencies to maximize the probability of recreational fisher involvement and project success.

Association among results of serum ELISA, faecal culture and nested PCR on milk, blood and faeces for the detection of paratuberculosis in dairy cows

Paratuberculosis is a chronic, infectious disease of ruminants that entails a serious concern for the cattle industry. One of the main issues relates to the efficiency of diagnosis of subclinically infected animals. The objective of this field study was to analyse the association among results of a serum enzyme-linked immunosorbent assays (ELISA), faecal culture and nested PCR tests on milk, blood and faeces for Mycobacterium avium subsp. paratuberculosis detection in dairy cows. Faeces, blood and milk samples were collected from 328 lactating dairy cows in four known infected herds. Results were analysed to determine associations and levels of agreement between pairs of tests. A total of 61 animals (18.6%) tested positive when all the tests were interpreted in parallel. The agreement between results in different pairs of tests was poor, slight and fair in two, five and three of the 10 possible combinations respectively. Faecal culture and faecal polymerase chain reaction (PCR) resulted in the highest kappa coefficient (0.39; fair agreement), with the lowest agreement being for ELISA and blood PCR (-0.036; poor agreement). Fisher's exact test resulted in statistically significant associations (P < or = 0.05) between the following test pairs: ELISA : faecal culture; ELISA : faecal PCR; milk PCR : faecal PCR, blood PCR : faecal PCR and faecal culture : faecal PCR. Enzyme-linked immunosorbent assays showed the highest complementary sensitivity values for all the possible two-test combinations, followed by faecal PCR. The combined use of ELISA and faecal PCR has the potential to increase the overall sensitivity for the diagnosis of paratuberculosis infection.

Reduction in bone mineral density in glycogenosis type III may be due to a mixed muscle and bone deficit

Glycogen storage disease type III (GSD III; OMIM 232400) is an autosomal recessive deficiency of the glycogen debrancher enzyme, amylo-1,6-glucosidase (EC 3.2.1.33). Patients with other hepatic glycogenoses are known to have reduced bone mineral content (BMC) and to be at consequent risk of fractures. They have key metabolic differences from GSD III patients, however. This study examines bone density and metabolism in 15 GSD III patients (6 female) from childhood to adulthood (aged 10-34 years). The results demonstrate that patients with GSD III have low bone mass at all skeletal sites compared with healthy individuals of the same age and sex, with a significant proportion (40-64%) having BMD > 2 standard deviations below the mean for whole body and lumbar spine. The deficiency seems to be attributable to a mixed muscle andbone deficit. Lower bone mass was found at all sites for GSD IIIa patients (combined liver and muscle defect) compared with GSD IIIb patients (liver only defect).

CONCLUSION

Patients with GSD III have significantly abnormal bone mass, placing them at increased risk of potential fracture. The underlying mechanism is probably multifactorial with contributions from abnormal muscle physiology, abnormal metabolic milieu and altered nutrition affecting micronutrient intake. Therapies need to address all these factors to be successful.

An overview of "The Active by Choice Today" (ACT) trial for increasing physical activity

BACKGROUND

Although school-based behavioral interventions for increasing physical activity (PA) in children and adolescents have been conducted, little evidence suggests that these curriculum-based approaches lead to increases in overall activity outside of program days. The overall goal of the "Active by Choice Today" (ACT) trial is to expand the body of knowledge concerning the factors that influence long-term increases in PA in underserved adolescents (low socioeconomic status, minorities) during their middle school years.

DESIGN AND SETTING

An overview of the ACT study design, theoretical framework, process evaluation, and primary hypotheses is presented. The trial involves twenty-four middle schools (1560 6th graders) in South Carolina that are randomly assigned to one of two after-school programs (motivational and life skills intervention, or general health education).

INTERVENTION

The intervention integrates constructs from Self-Determination and Social Cognitive Theories to enhance intrinsic motivation and behavioral skills for PA. The intervention targets skill development for PA outside of program days and the after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) is designed to positively impact cognitive mediators (self-efficacy, perceived competence), and motivational orientation (intrinsic motivation, commitment, positive self-concept). MAIN HYPOTHESES/OUTCOMES: It is hypothesized that the 17-week motivational and life skills intervention will lead to greater increases in moderate-to-vigorous PA (based on 7-day accelerometry estimates) at post-intervention as compared to the general health education program.

CONCLUSIONS

Implications of this innovative school-based trial are discussed.

Use of complementary and alternative medicine for weight control in the United States

OBJECTIVES

The purpose was to assess the prevalence and correlates of complementary and alternative medicine use for weight control.

DESIGN

A list-assisted random-digit-dialed telephone survey of adults was conducted in the fall of 2002 (n = 11,211). The focus of the study was complementary and alternative medicine (CAM) use, other than dietary supplements, in the previous 12 months.

SETTINGS/LOCATION

The sample of respondents was drawn from the total noninstitutionalized U.S. adult population residing in telephone-equipped locations.

SUBJECTS

The sampling procedures were designed to obtain adequate representation of Hispanic and non-Hispanic black respondents. Data from the total sample of 11,211 were weighted to achieve an estimate of the U.S. population. Analyses focused on 372 people who had used CAM within the previous 12 months.

RESULTS

Of the total, 3.3% (n = 372) had used a CAM therapy in the previous 12 months. Higher adjusted odds ratios for CAM use were found among respondents who were exercising for weight control; using a lower carbohydrate, higher protein diet; using a nonprescription weight-loss product(s); overweight; physically active; and not satisfied with one's body (adjusted for age, race, gender, education, and city size). The most often used therapies were yoga (57.4%), meditation (8.2%), acupuncture (7.7%), massage (7.5%), and Eastern martial arts (5.9%). CAM users used CAM therapies on their own (62.6%), in a group setting (26.8%) or with a CAM practitioner (10.6%).

CONCLUSIONS

The use of CAM therapies other than dietary supplements for weight loss was relatively low. The most popular therapy was yoga, and the majority of CAM users used CAM therapies on their own. Persons who had used other weight loss methods had greater odds for using CAM in the previous 12 months, suggesting that CAM use is often added to other weight-loss strategies.

A simplified approach to analysing bio-electrical impedance data in epidemiological surveys

BACKGROUND

Bio-electrical impedance analysis (BIA) is widely used to estimate body composition. It is simple, quick and cheap, but less accurate than other methods. It has potential epidemiological value, but has conventionally required validation before application.

AIMS

To develop a simple method of expressing weight, height and impedance data that avoids the need for population-specific validation equations in order to facilitate epidemiological application.

METHODS

Body composition was measured using the four-component model in young adults (43 males, 90 females). Impedance (R) was measured hand-foot and foot-foot. Lean mass and fat mass were adjusted for height to give lean mass index (LMI) and fat mass index (FMI). Based on theoretical principles, we generated the index 1/R, which provides an index of body water adjusted for height. Sex-specific regression models were used to investigate the relationships between (a) 1/R and LMI, and (b) body mass index (BMI) adjusted for 1/R and FMI. The success of this approach was evaluated in relation to the conventional BIA approach, using correlation analysis.

RESULTS

1/R was a highly significant predictor of LMI. BMI adjusted for 1/R was a significant predictor of FMI. Our approach performed as well as the conventional approach for LMI, but not for FMI.

DISCUSSION

Direct use of BIA data, rather than their combination with population-specific equations for the prediction of total body water, proved successful at ranking individuals of both sexes in terms of LMI and FMI. The index 1/R may prove particularly valuable in epidemiological studies where ranking of LMI is required.

Body composition in normal weight, overweight and obese children: matched case–control analyses of total and regional tissue masses, and body composition trends in relation to relative weight

BACKGROUND

Childhood obesity is defined on the basis of weight and height, using body mass index (BMI). There is little detailed information on the body composition characteristic of overweight and obesity.

OBJECTIVE

To evaluate total and regional body composition in overweight, obese and control children aged 7-14 years.

DESIGN

Body composition was measured by the four-component model and dual X-ray absorptiometry in 38 age- and sex-matched pairs of obese and control children. Body composition trends were also evaluated by quintile of BMI standard deviation score (SDS) in these and 31 other children (n=107; BMI SDS range -1.0 to 4.3).

RESULTS

Obese children were taller than controls (Delta=0.6 SDS; P=0.01) and had greater hydration of fat-free mass (FFM) (Delta=1.8 %, P<0.0001). After adjusting for these variables, obese children had greater FFM, fat mass (FM) and mineral (P<0.0001). Regional analyses showed that these differences were apparent in the arm, leg and trunk, but the three tissues had different proportional distributions of the excess. Fat was primarily in the trunk, but mineral in the leg. FM, FFM, hydration and mineral mass all increased across BMI SDS quintiles (P<0.0001), but the trend for FM was much the steepest.

DISCUSSION

The greater weight of obese children is due to excess FFM including mineral as well as excess fatness. Increasing weight has a strong continuous relationship with increasing FM across the whole spectrum of weight.

The effect of L-alanine therapy in a patient with adult onset glycogen storage disease type II

Adult-onset glycogen storage disease type II (GSD II) (McKusick 232300) is a progressive disabling myopathy. At present there is no treatment of proven clinical efficacy. Enzyme replacement therapy may in the future provide benefit but it will be costly and is not yet freely available. L-Alanine, a simple and relatively cheap therapy, has been shown to reduce protein degradation in GSD II patients but has not previously been assessed for clinical benefit in a controlled study. In this study L-alanine was assessed in a double blind, placebo-controlled, crossover n = 1 study. Assessments consisted of spirometry, cardiopulmonary exercise testing, quality of life measurements, biochemical markers and assessment by the criterion 4-component model of body composition. Alanine therapy was associated with a 15% gain in total body protein. However, the patient showed no functional improvement and reported feeling worse after treatment. Further controlled studies in a small group may be warranted, but not widespread use of this therapy.

The Annual African American Conference on Diabetes: evolving program evaluation with evolving program implementation

BACKGROUND

According to 2003 Behavioral Risk Factor Surveillance System data, South Carolina has the fourth highest rate of overall diabetes among the 50 states (9.3%) but the second highest rate among African Americans (15.5%). Nationwide, African Americans are disproportionately affected by diabetes. In addition, 40% of the African American population in South Carolina lives in a rural area, and approximately 26% live at or below the poverty level. Lack of access to health care and diabetes education are additional barriers for people with diabetes and their families.

CONTEXT

Since 1997, the South Carolina Diabetes Prevention and Control Program and the Diabetes Today Advisory Council have sponsored the African American Conference on Diabetes, which targets African Americans with diabetes, their families, and their caregivers. This article describes the evolution of the conference and its evaluation.

METHODS

In 2002, we conducted focus groups with 20 African American conference attendees with diabetes to 1) assess the program's effects, 2) determine how to reach more individuals, and 3) improve programming. In 2004, we incorporated the preconference and postconference Diabetes Understanding Scale survey to assess the cognitive impact of the conference on participants.

CONSEQUENCES

Focus group results revealed that participants wanted to attend the conference because of the opportunity to increase their knowledge and change their behaviors through 1) education, 2) social support, 3) resources, and 4) logistics. Self-rated understanding increased significantly after the conference for each cognitive understanding item on the Diabetes Understanding Scale.

INTERPRETATION

Focus group results suggested that participants who continue to attend the conference year after year may improve diabetes self-management skills. A quantitative evaluation showed that this 1-day diabetes education conference significantly increased short-term, self-rated cognitive understanding of diabetes behaviors.

Prediction of total body water in infants and children

BACKGROUND

In paediatric clinical practice treatment is often adjusted in relation to body size, for example the calculation of pharmacological and dialysis dosages. In addition to use of body weight, for some purposes total body water (TBW) and surface area are estimated from anthropometry using equations developed several decades previously. Whether such equations remain valid in contemporary populations is not known.

METHODS

Total body water was measured using deuterium dilution in 672 subjects (265 infants aged <1 year; 407 children and adolescents aged 1-19 years) during the period 1990-2003. TBW was predicted (a) using published equations, and (b) directly from data on age, sex, weight, and height.

RESULTS

Previously published equations, based on data obtained before 1970, significantly overestimated TBW, with average biases ranging from 4% to 11%. For all equations, the overestimation of TBW was greatest in infancy. New equations were generated. The best equation, incorporating log weight, log height, age, and sex, had a standard error of the estimate of 7.8%.

CONCLUSIONS

Secular trends in the nutritional status of infants and children are altering the relation between age or weight and TBW. Equations developed in previous decades significantly overestimate TBW in all age groups, especially infancy; however, the relation between TBW and weight may continue to change. This scenario is predicted to apply more generally to many aspects of paediatric clinical practice in which dosages are calculated on the basis of anthropometric data collected in previous decades.

Development and use of a tool for assessing sidewalk maintenance as an environmental support of physical activity

The importance of regular physical activity is well documented, yet according to epidemiological surveillance data, physical inactivity among all age groups persists. Past attempts to promote physical activity focused on individual-level changes; current approaches focus on environmental changes that will provide opportunities for whole communities to be active. The current ecological focus has led to an increase in funding and research regarding environmental supports of physical activity. As this is a new area of research, much work needs to be done to improve the ability to assess environmental features that support physical activity. This article describes a partnership between researchers and community members to develop and test an objective tool to measure sidewalk maintenance. Community members used data collected with the tool to increase awareness about sidewalk maintenance issues among local policy makers. Collaboration between researchers and community partners was critical for the success of this study.