Abstract Background Intake of dietary fiber has been recommended for many years as part of the guidelines from the American Heart Association, the Institute of Medicine, and other groups. The ...recommended Adequate Intake for dietary fiber for adults is 25 to 38 g/day (14 g/1,000 kcal/day). Objective To determine the average daily intake of dietary fiber among adults during the past decade and, specifically, to document progress toward national goals. Design Cross-sectional weighted data from the National Health and Nutrition Examination Survey among adults aged 18 years and older. Participants/setting Data were collected from noninstitutionalized adults aged 18 years and older using a nationally representative, complex, multistage, probability-based survey of people living in the United States that was conducted by the National Center for Health Statistics. Main outcome measures Daily dietary fiber intake by members of the US population based on 2-year groupings of the continuous survey from 1999 to 2008. Results Mean daily dietary fiber intake for 1999-2000 was 15.6 g/day, for 2001-2002 intake was 16.1g/day, for 2003-2004 intake was 15.5 g/day, for 2005-2006 intake was 15.8 g/day, and for 2007-2008 intake was 15.9 g/day. Participants with obesity (body mass index ≥30) consistently reported lower fiber intake than did individuals with normal weight or overweight (14.6 to 15.4 g/day and 15.6 to 16.8 g/day, respectively; P <0.0001). Mexican Americans had significantly higher intake in 1999-2000 than non-Hispanic whites (18.0 vs 16.1g/day; P <0.05), but Mexican Americans' intake did not increase over time (17.7 g/day in 2007-2008). Non-Hispanic blacks had fiber intake of 12.5 g/day at baseline that increased modestly to 13.1 g/day by 2007-2008. Conclusions Daily fiber intake generally has not progressed toward national goals during the past decade, but there are some differences according to health and social factors. Additional clinical practice and public health strategies are needed.
To assess the effect of a clinical decision support system (CDSS) integrated into an electronic health record (EHR) on antibiotic prescribing for acute respiratory infections (ARIs) in primary care.
...Quasi-experimental design with nine intervention practices and 61 control practices in the Practice Partner Research Network, a network of practices which all use the same EHR (Practice Partner). The nine intervention practices were located in nine US states. The design included a 3-month baseline data collection period (October through December 2009) before the introduction of the intervention and 15 months of follow-up (January 2010 through March 2011). The main outcome measures were the prescribing of antibiotics in ARI episodes for which antibiotics are inappropriate and prescribing of broad-spectrum antibiotics in all ARI episodes.
In adult patients, prescribing of antibiotics in ARI episodes where antibiotics are inappropriate declined more (-0.6%) among intervention practices than in control practices (+4.2%) (p=0.03). However, among adults, the CDSS intervention improved prescribing of broad-spectrum antibiotics, with a decline of 16.6% among intervention practices versus an increase of 1.1% in control practices (p<0.0001). A similar effect on broad-spectrum antibiotic prescribing was found in pediatric patients with a decline of 19.7% among intervention practices versus an increase of 0.9% in control practices (p<0.0001).
A CDSS embedded in an EHR had a modest effect in changing prescribing for adults where antibiotics were inappropriate but had a substantial impact on changing the overall prescribing of broad-spectrum antibiotics among pediatric and adult patients.
IntroductionMore than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%–0.5% fatal PE, and over 1000 deaths. ...Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications.Methods and analysisPulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7–2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board.Ethics and disseminationThe Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants.Trial registrationNCT02810704.
The influence of anesthetic type on mental health after total hip arthroplasty (THA) is poorly understood. Adverse effects of general anesthesia (GA) on cognition following major non-cardiac surgery ...are well known, but mental health following THA is less well-studied. We hypothesized that neuraxial anesthesia (NA) would provide favorable mental health profiles compared with GA after THA.
Prospectively collected Patient-Reported Outcomes Measurement Information System-10 (PROMIS) Global Mental Health (GMH) scores at preoperative baseline, and 1, 3, and 6 months after THA were accessed on 4,353 patients in the Pulmonary Embolism Prevention After HiP and KneE Replacement (PEPPER) Trial (ClinicalTrials.gov: NCT02810704). Anesthesia was categorized as: general (GA), neuraxial (NA), and neuraxial with peripheral block (NAP). The GMH was assessed longitudinally and compared between groups.
Postoperative GMH improved (P < .05) over preoperative in every anesthetic group. Groups receiving NA had higher baseline GMH scores. Improvement in GMH was diminished after GA alone and plateaued after 1 month. Adding NA or peripheral nerve block to GA conferred additional benefit to GMH improvement.
Patient-perceived mental health improves significantly after THA regardless of anesthetic type. Patients who have higher baseline GMH scores more commonly received NA, likely due to nonsurgical care determinants; these differences in mental wellness persisted at follow-up. Adjunctive NA or peripheral nerve block favored GMH improvement, whereas solitary GA diminished GMH improvement, which plateaued after 1 month. Substantial mental health benefits of THA may overshadow subtle differences in GMH attributable to anesthetic type.
Patient-reported outcomes are essential to demonstrate the value of hip and knee arthroplasty, a common target for payment reforms. We compare patient-reported global and condition-specific outcomes ...after hip and knee arthroplasty based on hospital participation in Medicare’s bundled payment programs.
We performed a prospective observational study using the Comparative Effectiveness of Pulmonary Embolism Prevention after Hip and Knee Replacement trial. Differences in patient-reported outcomes through 6 months were compared between bundle and nonbundle hospitals using mixed-effects regression, controlling for baseline patient characteristics. Outcomes were the brief Knee Injury and Osteoarthritis Outcomes Score or the brief Hip Disability and Osteoarthritis Outcomes Score, the Patient-Reported Outcomes Measurement Information System Physical Health Score, and the Numeric Pain Rating Scale, measures of joint function, overall health, and pain, respectively.
Relative to nonbundled hospitals, arthroplasty patients at bundled hospitals had slightly lower improvement in Knee Injury and Osteoarthritis Outcomes Score (−1.8 point relative difference at 6 months; 95% confidence interval −3.2 to −0.4; P = .011) and Hip Disability and Osteoarthritis Outcomes Score (−2.3 point relative difference at 6 months; 95% confidence interval −4.0 to −0.5; P = .010). However, these effects were small, and the proportions of patients who achieved a minimum clinically important difference were similar. Preoperative to postoperative change in the Patient-Reported Outcomes Measurement Information System Physical Health Score and Numeric Pain Rating Scale demonstrated a similar pattern of slightly worse outcomes at bundled hospitals with similar rates of achieving a minimum clinically important difference.
Patients receiving care at hospitals participating in Medicare’s bundled payment programs do not have meaningfully worse improvements in patient-reported measures of function, health, or pain after hip or knee arthroplasty.
Despite the efforts of international health agencies to reduce global health inequalities, indigenous populations around the world remain largely unaffected by such initiatives. This chapter reviews ...the biomedical literature indexed by the PubMed database published between 1963 and 2003 on South American indigenous populations, a total of 1864 studies that include 63,563 study participants. Some language family groupings are better represented than are others, and lowland groups are better represented than are highland groups. Very few studies focus on major health threats (e.g., tuberculosis, influenza), public health interventions, or mestizo-indigenous epidemiological comparisons. The prevalence rates of three frequently studied infections-parasitism, human T-cell lymphotropic viral infection (HTLV), and hepatitis-are extraordinarily high, but these facts have been overlooked by national and international health agencies. This review underscores the urgent need for interventions based on known disease prevalence rates to reduce the burden of infectious diseases in indigenous communities.
The socioeconomic and ethnic characteristics of parents are some of the most important correlates of adverse health outcomes in childhood. However, the relationships between ethnic, economic, and ...behavioral factors and the health outcomes responsible for this pervasive finding have not been specified in child health epidemiology. The general objective of this paper is to propose a theoretical approach to the study of maternal behaviors and child health in diverse ethnic and socioeconomic environments. The specific aims are: (a) to describe a causal pathway between the utility that women obtain through work outside the home and through child care and disease hazard rates in childhood using an optimization model; (b) to specify the influence of ethnic and socioeconomic factors on model constraints; (c) to use the model as a tool to learn about how different combinations of maternal wage labor and child care time might influence child health outcomes in diverse social contexts; (d) to identify parameters that will require measurement in future research; (e) to discuss research strategies that will enable us to obtain these measurements; and (f) to discuss the implications of the model for biostatistical modeling and public health intervention. Optimization models are powerful heuristic tools for understanding how ethnic, environmental, family, and personal characteristics can place important constraints on both the quality and quantity of care that women can provide to their children. They provide a quantitative appreciation for the difficult trade-offs that most women face between working in order to purchase basic goods that children cannot do without (e.g., food, clothing, shelter, health insurance), and increasing offspring well-being through child care (e.g., training in social skills, affection, protection from environmental hazards, help with homework).
When compared to other primates, human juvenile development is unique in that it includes a prolonged post-pubertal adolescent phase, during which individuals continue to be dependent upon parents ...and other adults for care, guidance, provisioning, and the acquisition of skills and knowledge required for adult roles and responsibilities. The way in which resources are allocated during this period thus has important implications for future reproductive and economic outcomes. However, contrary to prevailing assumptions about the nuclear family ideal, paternal loss, due to divorce or other causes, is neither a new nor rare phenomenon in human history. Instead, the absence of investment from grandparents, aunts, uncles, and other non-parental related adults during development may be the notable difference between the familial contexts of youth living in affluent nuclear family-based environments such as the United States, and their antecedents throughout most of human history. With this knowledge, the aim of this study was to gain a better understanding of the extent to which members of the extended family are able to mediate the relationship between educational outcomes and sexual behavior during adolescence, using a sample of 390 undergraduate students at the University of New Mexico. This study varies from much of the existing literature in this area by employing an evolutionary anthropological perspective, which enables us to interpret observed patterns of behavior as context-specific, within a broader range of temporally and cross-culturally variable environments. The dissertation comprises three major sections. Firstly, I test the main hypothesis that educational achievement and investment is compromised during adolescence by the timing of the onset and pattern of sexual behavior. Secondly, I incorporate childhood exposures to non-parental adult relatives to investigate whether these players have any mediating impacts upon the trade-off identified above, by enabling individuals to better withstand the educational costs of sexual behavior. Finally, and motivated by the burgeoning literature on the deleterious effects of father-absence amongst girls, I test the hypothesis that exposure to grandmothers during pre-pubertal development mediates the education-sexual behavior effects associated with paternal loss.
BackgroundIn order to prepare CP3 medical students for the first year of foundation training, they shadow foundation doctors. During this assistantship course the students are expected to be involved ...in the work of their clinical teams. However there is certain tasks that are not authorised. Yet newly qualified doctors are expected to manage patients, communicate effectively, and manage workload from day one, as well as prescribing independently which may lead to errors. To equip the students with the strategies required to prevent such errors, before qualification, the clinical teaching fellow team in Royal Derby teaching Hospital, the education centre designed and run the simulated rounds.Summary of WorkThe simulated ward round ran in a 90 min cycles, figure 1, where the students independently managed patients and interacted with each other. Data collected retrospectively over the last five years. 2013 – 2017: Student numbers, Assistantship category, number sessions, and feedback scores. SPSS17 used to analyze data.Simulated patients given clinical scenarios with instruction to role play including history and clinical examination findings. Qualified doctors, nurses, and pharmacists invited to join the simulated ward round and play their respective roles,Students briefed about the course of the simulated ward round and reassured no ABCDE scenarios involved. Aim of the rounds to give insight about ability to prioritise, communicate, delegate, team work, manage time and be efficient. Students encouraged not to let fear of mistake hold them back (safe environment).Summary of Results115 Simulated ward rounds conducted over five years period (2013–2017), with a total of 172 hours of simulation. Figure 2471 Students took part, with 690 simulated patient encounter. Figure 2More than two thirds of the Simulated Ward rounds conducted morning to late morning, figure 4. The students were mainly in groups of threes, figure 5.There was no difference in average score of morning Am sessions and afternoon PM sessions (average score=8.5162 Vs 8.7967, P-Value 0.01) figure 6.There was no difference of when the students attended the ward rounds. Both students who attended the Simulated ward rounds before or after elective have the same valuable experience.Abstract PG90 Figure 1Abstract PG90 Figure 2Abstract PG90 Figure 3Abstract PG90 Figure 4Abstract PG90 Figure 5Abstract PG90 Figure 6ConclusionsThe simulated ward rounds are highly valued experience. Students learn from their errors. Students learn about their strengths and how to develop them. Also, they learn about their own limitations and how to overcome them. Simulated ward rounds should be formal part of assistantship course and formally assessed.
PDF
