Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and ...post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date.
Rationale
The purpose of this study was to begin researching the effects of very low nicotine content cigarettes in smokers especially vulnerable to dependence to assess their potential as a less ...dependence-producing alternative to current commercial cigarettes.
Methods
Participants were 26 adult, daily cigarette smokers from one of three populations: economically disadvantaged women of reproductive age (
n
= 9), opioid-dependent individuals (
n
= 11), and individuals with affective disorders (
n
= 6). Participants completed fourteen 2–4-h experimental sessions in a within-subjects research design. Sessions were conducted following brief smoking abstinence. Four research cigarettes varying in nicotine content (0.4, 2.4, 5.2, and 15.8 mg/g) were studied under double-blind conditions, assessing smoking topography, subjective effects, and relative reinforcing effects of varying doses in concurrent choice tests. Results were collapsed across vulnerable populations and analyzed using repeated measures ANOVA.
Results
No significant differences between doses were discernible in smoking topography. All doses were equi-effective at reducing nicotine withdrawal. Ratings of satisfaction from smoking were lower at the 0.4 compared to 15.8 mg/g dose. Participants preferred the 15.8 mg/g dose over the 0.4 and 2.4 but not the 5.2 mg/g doses in concurrent choice testing; no differences between the two lowest doses were noted.
Conclusions
All cigarettes effectively reduced nicotine withdrawal with no differences in smoking topography, suggesting minimal compensatory smoking. Dependence potential was lowest at the 0.4 mg/g dose. These initial results are promising regarding the feasibility of lowering nicotine content in cigarettes to very low levels in vulnerable populations without untoward effects.
Background
A better understanding of the extent to which prior occurrences of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) predict psychopathological reactions to ...subsequent traumas might be useful in targeting posttraumatic preventive interventions.
Methods
Data come from 1306 patients presenting to 29 U.S. emergency departments (EDs) after a motor vehicle collision (MVC) in the advancing understanding of recovery after trauma study. Patients completed self‐reports in the ED and 2‐weeks, 8‐weeks, and 3‐months post‐MVC. Associations of pre‐MVC probable PTSD and probable MDE histories with subsequent 3‐months post‐MVC probable PTSD and probable MDE were examined along with mediation through intervening peritraumatic, 2‐, and 8‐week disorders.
Results
27.6% of patients had 3‐month post‐MVC probable PTSD and/or MDE. Pre‐MVC lifetime histories of these disorders were not only significant (relative risk = 2.6–7.4) but were dominant (63.1% population attributable risk proportion PARP) predictors of this 3‐month outcome, with 46.6% prevalence of the outcome among patients with pre‐MVC disorder histories versus 9.9% among those without such histories. The associations of pre‐MVC lifetime disorders with the 3‐month outcome were mediated largely by 2‐ and 8‐week probable PTSD and MDE (PARP decreasing to 22.8% with controls for these intervening disorders). Decomposition showed that pre‐MVC lifetime histories predicted both onset and persistence of these intervening disorders as well as the higher conditional prevalence of the 3‐month outcome in the presence of these intervening disorders.
Conclusions
Assessments of pre‐MVC PTSD and MDE histories and follow‐ups at 2 and 8 weeks could help target early interventions for psychopathological reactions to MVCs.
Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies ...with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.
The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.
In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.
Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
Abstract Objective Community-based video interventions offer an effective and potentially scalable early interaction coaching tool for caregivers living in low resource settings. We tested the ...Universal Baby (UB) video innovation; an early interaction coaching tool using video sourced and produced locally with early child development (ECD) expert supervision. Methods This proof-of-concept study enrolled 40 caregivers of children ages 10–18 months assigned to intervention and control groups by health establishments in Carabayllo, Lima, Peru. Mother/child dyads received 12 weekly group health education sessions with social support. Of those, 16 caregivers also received 6 UB videos featuring brain science education and local clips of responsive, reciprocal interaction, also known as “serve and return” interaction. Survey data assessed feasibility and acceptability of the intervention. We assessed improved quality of mother/child interaction using the Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO). Results We found the program feasible. We successfully trained the local team to produce UB videos using locally-sourced footage and delivered the videos as part of a community-based intervention. We also found it to be acceptable in that participants enthusiastically received the UB videos, reporting they enjoyed being videotaped, and learned how to recognize and appropriately respond to their child’s nuanced sounds and gestures. The median change in total PICCOLO scores favored the intervention group compared to the control group. Conclusions UB offers great potential as a sustainable, potentially scalable, and culturally appropriate tool to promote equity for child development among young children living in low resource homes globally.
Most children with ADHD have impaired working memory abilities. These working memory deficits predict impairments in activities of daily living (ADLs) for adults with ADHD. However, our understanding ...of the relation between pediatric ADHD and ADLs is limited. Thus, this study aimed to examine (1) the extent to which pediatric ADHD is associated with ADL difficulties; and if so (2) the extent to which these difficulties are related to their well-documented working memory difficulties and/or core ADHD inattentive and hyperactive/impulsive symptom domains. A well-characterized, clinically evaluated sample of 141 children ages 8-13 years (M = 10.36, SD = 1.46; 51 girls; 70% White/non-Hispanic) were administered a battery of well-validated working memory tests and assessed for ADHD symptoms (teacher-ratings) and ADL difficulties (parent-ratings); cross-informant reports were used to control for mono-informant bias. Children with ADHD exhibited medium magnitude difficulties with ADLs (d = 0.61, p < .005, 38% impaired). Results of the bias-corrected, bootstrapped conditional effects model indicated that lower working memory predicted reduced performance of age-expected ADLs (β =0.28) and greater ADHD inattentive (β = −0.40) and hyperactive/impulsive symptoms (β = −0.16). Greater inattentive, but not hyperactive/impulsive, symptoms predicted greater ADL difficulties (β = −0.36) even after controlling for working memory. Interestingly, working memory exerted a significant indirect effect on ADLs via inattentive (indirect effect: β = 0.15, effect ratio = .54) but not hyperactive/impulsive symptoms. These findings implicate ADHD inattentive symptoms as a potential mechanism underlying ADL difficulties for children with ADHD, both independently and via working memory's role in regulating attention.
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Previous studies have reported no clear critical region for medical comorbidities in children with deletions or duplications of 22q11.2. The purpose of this study was to evaluate whether individuals ...with small nested deletions or duplications of the LCR-A to B region of 22q11.2 show an elevated rate of autism spectrum disorder (ASD) compared to individuals with deletions or duplications that do not include this region.
We recruited 46 patients with nested deletions (
= 33) or duplications (
= 13) of 22q11.2, including LCR-A to B (
= 11), LCR-A to C (
= 4), LCR-B to D (
= 14;
= 8), LCR-C to D (
= 4;
= 2), and smaller nested regions (
= 3). Parent questionnaire, record review, and, for a subset, in-person evaluation were used for ASD diagnostic classification. Rates of ASD in individuals with involvement of LCR-B to LCR-D were compared with Fisher's exact test to LCR-A to LCR-B for deletions, and to a previously published sample of LCR-A to LCR-D for duplications. The rates of medical comorbidities and psychiatric diagnoses were determined from questionnaires and chart review. We also report group mean differences on psychiatric questionnaires.
Individuals with deletions involving LCR-A to B showed a 39-44% rate of ASD compared to 0% in individuals whose deletions did not involve LCR-A to B. We observed similar rates of medical comorbidities in individuals with involvement of LCR-A to B and LCR-B to D for both duplications and deletions, consistent with prior studies.
Children with nested deletions of 22q11.2 may be at greater risk for autism spectrum disorder if the region includes LCR-A to LCR-B. Replication is needed.
PDF
