Exploring a broader context of the home environment and its relationship with asthma control in American Indian children.

In this cross-sectional study of 60 American Indian mother-child dyads from Southeastern North Carolina, we examined whether childhood asthma control was related to household-level factors, such as environmental tobacco smoke and family management behaviors. We also examined the relationships among family management behaviors and maternal depressive symptoms. We used logistic regression to assess the relationships among childhood asthma control, the presence of environmental tobacco smoke, and family management behaviors, specifically condition management ability (CMA) and condition management effort (CME). We used linear regression to evaluate the relationships between both CMA and CME and maternal depressive symptoms. Better asthma control in children was associated with the absence of environmental tobacco smoke in the home and the maternal perception of asthma as a manageable condition. Mothers perceived an increase in effort to manage their child's asthma as their depressive symptoms increased. These findings emphasize the importance of environmental triggers, perceptions of condition management, and maternal mental health in controlling asthma in American Indian children. Interventions to reduce environmental triggers, treat maternal depressive symptoms, and support mothers in their ability to manage childhood asthma may yield better asthma control and help to reduce existing racial disparities in this population.

Nursing Assistants' Use of Personal Protective Equipment Regarding Contact With Excreta Contaminated With Antineoplastic Drugs.

PURPOSE: To examine the feasibility of observing and interviewing nursing assistants about handling of antineoplastic drugs contaminated with excreta, acceptability of a measure of personal protective equipment (PPE) use with nursing assistants, and predictors of PPE use. PARTICIPANTS & SETTING: 27 nursing assistants in an inpatient hematology-oncology unit at an academic medical center in the southeastern United States. METHODOLOGIC APPROACH: This was an exploratory, multimethod study using observation, verbally administered questionnaires, and interviews. Research variables included recruitment rates, acceptability of observation, and understandability of a safe-handling instrument. FINDINGS: Observed use of double gloves, chemotherapy gowns, and face shields was low; use of plastic-backed pads when flushing excreta was high. IMPLICATIONS FOR NURSING: Nursing assistants are willing to participate in research. Standardized training and education about PPE use are needed.

Characterization of Dizziness After Lasmiditan Usage: Findings From the SAMURAI and SPARTAN Acute Migraine Treatment Randomized Trials.

TRIAL DESIGN: SAMURAI and SPARTAN were double-blind, placebo-controlled Phase 3 studies conducted in the United States, as well as the United Kingdom and Germany (SPARTAN only). Individuals with migraine were randomized to receive oral lasmiditan 50 mg (SPARTAN only), 100 mg, 200 mg, or placebo within 4 hours of onset of a migraine attack. The aim of this analysis was to characterize dizziness reported with lasmiditan treatment. METHODS: Data from SAMURAI and SPARTAN were pooled for the current post hoc analyses. Onset time and duration of dizziness were analyzed using descriptive statistics. Subgroup analyses based on presence/absence of dizziness were performed for the endpoints of interference with daily activity, patient global impression of change (PGIC), pain at 2 hours, and most bothersome symptom (MBS) at 2 hours based on adverse events occurring within 2 hours of taking study drug. RESULTS: Dizziness incidence was as follows: Placebo (N = 1262), 2.9% (0.1% severe); lasmiditan 50 mg (N = 654), 8.6% (0.3% severe); lasmiditan 100 mg (N = 1265), 14.9% (0.7% severe); and lasmiditan 200 mg (N = 1258), 16.8% (1.4% severe). Among participants who received lasmiditan as their first dose, risk factors for dizziness were higher lasmiditan dosage, being non-Hispanic/Latino, mild or moderate severity of migraine attack, and lower body mass index. The median time to onset of dizziness was generally 30-40 minutes, and the median duration was 1.5-2 hours. The presence of dizziness did not appear to have a negative influence on lasmiditan's effect on daily activity, PGIC, freedom from pain, or MBS. Overall, 21 participants experienced vertigo: Lasmiditan 50 mg, n = 2 (0.3%); 100 mg, n = 11 (0.9%); 200 mg, n = 7 (0.6%); and placebo, n = 1 (<0.1%). CONCLUSION: The incidence of dizziness with lasmiditan increased with dose. Dizziness was generally mild or moderate in severity and of quick onset and short duration. The presence of dizziness did not influence drug efficacy.

Characteristics of Prehospital Electrocardiogram Use in North Carolina Using a Novel Linkage of Emergency Medical Services and Emergency Department Data.

Objective: Prehospital electrocardiography (ECG) is recommended for patients with suspected acute coronary syndrome (ACS), yet only 20-80% of chest pain patients receive a prehospital ECG. Less is known about prehospital ECG use in patients with less common complaints (e.g., fatigue) suspicious for ACS who are transported by emergency medical services (EMS). The aims of this study were to determine: (1) the proportion of patients with chest pain and less typical complaints, and (2) patient characteristics associated with prehospital ECG use in patients transported by EMS to emergency departments across North Carolina. Methods: A novel linked database was created between prehospital and emergency department (ED) patient care data from the North Carolina Prehospital Medical Information System and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. Institutional review board approval and a data use agreement were received prior to the start of the study. Patients ≥21 transported during 2010-14 by EMS with select variables were included. We examined patients' complaints (symptoms), characteristics (e.g., race, ethnicity, final hospital diagnosis), and prehospital ECG use (yes/no). Analysis included descriptive statistics and mixed logistic regression. Results: During 2010-14, there were 1,967,542 patients with linked EMS-ED data (mean age: 56.9 [SD: 22.2], 43.2% male, 63.7% White). Of these, 643,174 (32.6%) received a prehospital ECG. Patients with prehospital ECG presented with the following complaints: 20% chest pain; 10% shortness of breath; 6% abdominal pain/problems; 6% altered level of consciousness; 5% syncope/dizziness; 4% palpitations; 12% other complaints; and 37% missing. Patients' presenting complaints were the strongest predictor of prehospital ECG use, adjusting for age, sex, race, ethnicity, urbanicity, and date and time of EMS dispatch. Conclusions: Patients with chest pain were significantly more likely to receive a prehospital ECG compared to those with less typical but suspicious complaints for ACS. Patients with less common presentations remain disadvantaged for early triage, risk stratification, and intervention prior to the hospital.

Enhancing Survivorship Care Planning for Patients With Localized Prostate Cancer Using a Couple-Focused mHealth Symptom Self-Management Program: Protocol for a Feasibility Study.

BACKGROUND: This project explores a new model of care that enhances survivorship care planning and promotes health for men with localized prostate cancer transitioning to posttreatment self-management. Survivorship care planning is important for patients with prostate cancer because of its high incidence rate in the United States, the frequent occurrence of treatment-related side effects, and reduced quality of life (QOL) for both men and their partners. A key component of comprehensive survivorship care planning is survivorship care plans (SCPs), documents that summarize cancer diagnosis, treatment, and plans for follow-up care. However, research concerning the effectiveness of SCPs on patient outcomes or health service use has thus far been inconclusive. SCPs that are tailored to individual patients' needs for information and care may improve effectiveness. OBJECTIVE: This study aims to examine the feasibility of an enhanced survivorship care plan (ESCP) that integrates a symptom self-management mHealth program called Prostate Cancer Education and Resources for Couples (PERC) into the existing standardized SCP. The specific aims are to (1) examine the feasibility of delivering ESCPs and (2) to estimate the magnitude of benefit of ESCPs. METHODS: We will use a two-group randomized controlled pretest-posttest design and collect data at baseline (T1) and 4 months later (T2) among 50 patients completing initial treatment for localized prostate cancer and their partners. First, we will assess the feasibility of ESCP by recruitment, enrollment, and retention rates; program satisfaction with the ESCP; and perceived ease of use of the ESCP. To achieve the secondary aim, we will compare the ESCP users with the standardized SCP users and assess their primary outcomes of QOL (overall, physical, emotional, and social QOL); secondary outcomes (reduction in negative appraisals and improvement in self-efficacy, social support, and health behaviors to manage symptoms); and number of visits to posttreatment care services between T1 and T2. We will assess the primary and secondary outcomes using measurements with sound psychometrical properties. We will use a qualitative and quantitative mixed methods approach to achieve the research aims. RESULTS: This project is ongoing and will be completed by the end of 2018. CONCLUSIONS: The results from this study will help design a definitive randomized trial to test the efficacy of the ESCPs, a potentially scalable program, to enhance supportive care for prostate cancer patients and their families.

Guideline-Directed Medical Therapy and Survival Following Hospitalization in Patients with Heart Failure.

BACKGROUND: Modification of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure (HF) has not been extensively evaluated. METHODS: The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models. RESULTS: For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% ß-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF. CONCLUSIONS: Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.

Patient reminder and recall interventions to improve immunization rates.

BACKGROUND: Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review. OBJECTIVES: To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017. SELECTION CRITERIA: We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model. MAIN RESULTS: The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants). AUTHORS' CONCLUSIONS: Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Covariate adjusted classification trees.

In studies that compare several diagnostic groups, subjects can be measured on certain features and classification trees can be used to identify which of them best characterize the differences among groups. However, subjects may also be measured on additional covariates whose ability to characterize group differences is not meaningful or of interest, but may still have an impact on the examined features. Therefore, it is important to adjust for the effects of covariates on these features. We present a new semi-parametric approach to adjust for covariate effects when constructing classification trees based on the features of interest that is readily implementable. An application is given for postmortem brain tissue data to compare the neurobiological characteristics of subjects with schizophrenia to those of normal controls. We also evaluate the performance of our approach using a simulation study.

Connect-Home: Transitional Care of Skilled Nursing Facility Patients and their Caregivers.

BACKGROUND: Older adults that transfer from skilled nursing facilities (SNF) to home have significant risk for poor outcomes. Transitional care of SNF patients (i.e., time-limited services to ensure coordination and continuity of care) is poorly understood. OBJECTIVE: To determine the feasibility and relevance of the Connect-Home transitional care intervention, and to compare preparedness for discharge between comparison and intervention dyads. DESIGN: A non-randomized, historically controlled design-enrolling dyads of SNF patients and their family caregivers. SETTING: Three SNFs in the Southeastern United States. PARTICIPANTS: Intervention dyads received Connect-Home; comparison dyads received usual discharge planning. Of 173 recruited dyads, 145 transferred to home, and 133 completed surveys within 3 days of discharge. INTERVENTION: The Connect-Home intervention consisted of tools and training for existing SNF staff to deliver transitional care of patient and caregiver dyads. MEASUREMENTS: Feasibility was assessed with a chart review. Relevance was assessed with a survey of staff experiences using the intervention. Preparedness for discharge, the primary outcome, was assessed with Care-Transitions Measure-15 (CTM-15). RESULTS: The intervention was feasible and relevant to SNF staff (i.e., 96.9% of staff recommended intervention use in the future). Intervention dyads, compared to comparison dyads, were more prepared for discharge (CTM-15 score 74.7 vs 65.3, mean ratio 1.16, 95% CI: 1.08, 1.24). CONCLUSION: Connect-Home is a promising transitional care intervention for older patients discharged from SNF care. The next step will be to test the intervention using a cluster randomized trial, with patient outcomes including re-hospitalization.

Network Structure of Perinatal Depressive Symptoms in Latinas: Relationship to Stress and Reproductive Biomarkers.

Based on emerging evidence, mood disorders can be plausibly conceptualized as networks of causally interacting symptoms, rather than as latent variables of which symptoms are passive indicators. In an innovative approach in nursing research, we used network analysis to estimate the network structure of 20 perinatal depressive (PND) symptoms. Then, two proof-of-principle analyses are presented: Incorporating stress and reproductive biomarkers into the network, and comparing the network structure of PND symptoms between non-depressed and depressed women. We analyzed data from a cross-sectional sample of 515 Latina women at the second trimester of pregnancy and estimated networks using regularized partial correlation network models. The main analysis yielded five strong symptom-to-symptom associations (e.g., cry-sadness), and five symptoms of potential clinical importance (i.e., high centrality) in the network. In exploring the relationship of PND symptoms to stress and reproductive biomarkers (proof-of-principle analysis 1), a few weak relationships were found. In a comparison of non-depressed and depressed women's networks (proof-of-principle analysis 2), depressed participants had a more connected network of symptoms overall, but the networks did not differ in types of relationships (the network structures). We hope this first report of PND symptoms as a network of interacting symptoms will encourage future network studies in the realm of PND research, including investigations of symptom-to-biomarker mechanisms and interactions related to PND. Future directions and challenges are discussed. © 2017 Wiley Periodicals, Inc.

What characteristics of nutrition and physical activity interventions are key to effectively reducing weight gain in obese or overweight pregnant women? A systematic review and meta-analysis.

Lifestyle interventions targeting gestational weight gain (GWG) report varying degrees of success. To better understand factors influencing efficacy, we reviewed randomized trials specifically among obese and overweight pregnant women. METHODS: We conducted a systematic review and a meta-analysis of 32 studies with a pooled population of 5,869 overweight or obese pregnant women. Random effects models were fit to compute the weighted mean difference (WMD) in GWG between groups across studies. Subgroup analyses were conducted to compare intervention efficacy in overweight vs. obese pregnant women, and interventions delivered by prenatal care providers (PCPs) vs. non-PCPs during pregnancy. Moderator analyses ensured. RESULTS: Nine (28%) of 32 studies reported significant reductions in GWG in response to intervention. Of these, six (66%) of nine were delivered by PCPs. Overall, the WMD in GWG was -1.71 (95% confidence interval [CI]: -2.55, -0.86) kg. However, interventions delivered by PCPs yielded a significantly greater reduction in GWG compared to interventions delivered by non-PCPs (WMD = -3.88 kg; 95% CI: -7.01, -0.75 vs. -0.80 kg; 95% CI: -1.32, -0.28; p for difference = 0.005). CONCLUSION: When PCPs counsel nutrition and physical activity, obese and overweight pregnant women have greater success meeting GWG targets and may be more motivated to modify their behaviour than with other modes of intervention deliveries.

Bayesian Variable Selection Methods for Matched Case-Control Studies.

Matched case-control designs are currently used in many biomedical applications. To ensure high efficiency and statistical power in identifying features that best discriminate cases from controls, it is important to account for the use of matched designs. However, in the setting of high dimensional data, few variable selection methods account for matching. Bayesian approaches to variable selection have several advantages, including the fact that such approaches visit a wider range of model subsets. In this paper, we propose a variable selection method to account for case-control matching in a Bayesian context and apply it using simulation studies, a matched brain imaging study conducted at Massachusetts General Hospital, and a matched cardiovascular biomarker study conducted by the High Risk Plaque Initiative.

Episodic memory of odors stratifies Alzheimer biomarkers in normal elderly.

OBJECTIVE: The objective of this study was to relate a novel test of identifying and recalling odor percepts to biomarkers of Alzheimer's disease (AD) in well-characterized elderly individuals, ranging from cognitively normal to demented. METHODS: One hundred eighty-three participants (cognitively normal: n = 70; subjective cognitive concerns: n = 74; mild cognitive impairment [MCI]: n = 29, AD dementia: n = 10) were administered novel olfactory tests: the Odor Percept IDentification (OPID) and the Percepts of Odor Episodic Memory (POEM) tests. Univariate cross-sectional analyses of performance across diagnoses; logistic regression modeling, including covariates of age, sex, education, APOE genotype, and neuropsychological test scores; and linear mixed modeling of longitudinal cognitive scores were performed. Amyloid deposition and MRI volumetrics were analyzed in a subset of participants. RESULTS: Accuracy of identification and episodic memory of odor percepts differed significantly across diagnosis and age, with progressively worse performance across degrees of impairment. Among the participants who were cognitively normal or had subjective cognitive concerns, poorer than expected performance on the POEM test (based on the same individual's performance on the OPID and odor discrimination tests) was associated with higher frequencies of the APOE ε4 allele, thinner entorhinal cortices, and worse longitudinal trajectory of Logical Memory scores. INTERPRETATION: Selective impairment of episodic memory of odor percepts, relative to identification and discrimination of odor percepts revealed by this novel POEM battery, is associated with biomarkers of AD in a well-characterized pre-MCI population. These affordable, noninvasive olfactory tests offer potential to identify clinically normal individuals who have greater likelihood of future cognitive decline. Ann Neurol 2016;80:846-857.

Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study.

BACKGROUND AND OBJECTIVES: Intensive RRT may have adverse effects that account for the absence of benefit observed in randomized trials of more intensive versus less intensive RRT. We wished to determine the association of more intensive RRT with changes in urine output as a marker of worsening residual renal function in critically ill patients with severe AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The Acute Renal Failure Trial Network Study (n=1124) was a multicenter trial that randomized critically ill patients requiring initiation of RRT to more intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 ml/kg per hour) versus less intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 ml/kg per hour) RRT. Mixed linear regression models were fit to estimate the association of RRT intensity with change in daily urine output in survivors through day 7 (n=871); Cox regression models were fit to determine the association of RRT intensity with time to ≥50% decline in urine output in all patients through day 28. RESULTS: Mean age of participants was 60±15 years old, 72% were men, and 30% were diabetic. In unadjusted models, among patients who survived ≥7 days, mean urine output was, on average, 31.7 ml/d higher (95% confidence interval, 8.2 to 55.2 ml/d) for the less intensive group compared with the more intensive group (P=0.01). More intensive RRT was associated with 29% greater unadjusted risk of decline in urine output of ≥50% (hazard ratio, 1.29; 95% confidence interval, 1.10 to 1.51). CONCLUSIONS: More intensive versus less intensive RRT is associated with a greater reduction in urine output during the first 7 days of therapy and a greater risk of developing a decline in urine output of ≥50% in critically ill patients with severe AKI.

Transitional care of older adults in skilled nursing facilities: A systematic review.

Transitional care may be an effective strategy for preparing older adults for transitions from skilled nursing facilities (SNF) to home. In this systematic review, studies of patients discharged from SNFs to home were reviewed. Study findings were assessed (1) to identify whether transitional care interventions, as compared to usual care, improved clinical outcomes such as mortality, readmission rates, quality of life or functional status; and (2) to describe intervention characteristics, resources needed for implementation, and methodologic challenges. Of 1082 unique studies identified in a systematic search, the full texts of six studies meeting criteria for inclusion were reviewed. Although the risk for bias was high across studies, the findings suggest that there is promising but limited evidence that transitional care improves clinical outcomes for SNF patients. Evidence in the review identifies needs for further study, such as the need for randomized studies of transitional care in SNFs, and methodological challenges to studying transitional care for SNF patients.

Challenges of Integrating an Evidence-based Intervention in Health Departments to Prevent Excessive Gestational Weight Gain among Low-income Women.

OBJECTIVE: To examine health departments' (HD) capacity to adapt and implement an intervention to prevent excessive gestational weight gain. DESIGN AND SAMPLE: Seventy-seven stakeholders (nurses, nutritionists, social workers, health educators, health directors, and multilingual service providers) in nine HDs participated. A descriptive mixed methods approach was used to collect data at workshops held onsite to introduce the evidence-based intervention (EBI) and discuss its adaptation. MEASURES: A survey was administered to assess the intervention's fit with the HDs context. Generalized logit mixed models were used to analyze the survey data. The discussions of adaptation were audiotaped and thematically analyzed to identify factors influencing implementation. RESULTS: The majority of stakeholders desired to participate in the training portion of the EBI, but they were reluctant to adopt it, and noted a lack of adequate resources. From the audiotaped narratives, three themes emerged: (1) Patient needs and resources, (2) Perception about adaptability of the EBI, and (3) The complexity of the EBI for pregnant populations. CONCLUSION: Although the EBI was effective for low-income nonpregnant populations in southeastern regions, pregnancy and complex antenatal services make this intervention unrealistic to be adapted as a part of prenatal care at HDs.

Normal prehospital electrocardiography is linked to long-term survival in patients presenting to the emergency department with symptoms of acute coronary syndrome.

AIMS/METHODS: We studied 735 patients who activated "911" for chest pain and/or anginal equivalent symptoms and received 12-lead ECG monitoring with specialized ischemia monitoring software in the ambulance. Prehospital electrocardiograms (PH ECG) were analyzed to determine the proportion of patients who present with completely normal PH ECG findings (absence of ischemia/infarction, arrhythmia, or any other abnormality) and to compare outcomes among patients with and without any PH ECG abnormality. RESULTS: Of 735 patients (mean age 70.5, 52.4% male), 68 (9.3%) patients had completely normal PH ECG findings. They experienced significantly less adverse hospital outcomes (12% vs 37%), length of stay (1.19 vs 3.86 days), and long-term mortality (9% vs 28%) than those with any PH ECG abnormality (p<.05). CONCLUSION: Normal PH ECG findings are associated with better short and long-term outcomes in ambulance patients with ischemic symptoms. These findings may enhance early triage and risk stratification in emergency cardiac care.

A Pairwise Naïve Bayes Approach to Bayesian Classification.

Despite the relatively high accuracy of the naïve Bayes (NB) classifier, there may be several instances where it is not optimal, i.e. does not have the same classification performance as the Bayes classifier utilizing the joint distribution of the examined attributes. However, the Bayes classifier can be computationally intractable due to its required knowledge of the joint distribution. Therefore, we introduce a "pairwise naïve" Bayes (PNB) classifier that incorporates all pairwise relationships among the examined attributes, but does not require specification of the joint distribution. In this paper, we first describe the necessary and sufficient conditions under which the PNB classifier is optimal. We then discuss sufficient conditions for which the PNB classifier, and not NB, is optimal for normal attributes. Through simulation and actual studies, we evaluate the performance of our proposed classifier relative to the Bayes and NB classifiers, along with the HNB, AODE, LBR and TAN classifiers, using normal density and empirical estimation methods. Our applications show that the PNB classifier using normal density estimation yields the highest accuracy for data sets containing continuous attributes. We conclude that it offers a useful compromise between the Bayes and NB classifiers.

Intracortical excitatory and thalamocortical boutons are intact in primary auditory cortex in schizophrenia.

Schizophrenia is associated with auditory processing impairments that could arise as a result of primary auditory cortex excitatory circuit pathology. We have previously reported a deficit in dendritic spine density in deep layer 3 of primary auditory cortex in subjects with schizophrenia. As boutons and spines can be structurally and functionally co-regulated, we asked whether the densities of intracortical excitatory or thalamocortical presynaptic boutons are also reduced. We studied 2 cohorts of subjects with schizophrenia and matched controls, comprising 27 subject pairs, and assessed the density, number, and within-bouton vesicular glutamate transporter (VGluT) protein level of intracortical excitatory (VGluT1-immunoreactive) and thalamocortical (VGluT2-immunoreactive) boutons in deep layer 3 of primary auditory cortex using quantitative confocal microscopy and stereologic sampling methods. We found that VGluT1- and VGluT2-immunoreactive puncta densities and numbers were not altered in deep layer 3 of primary auditory cortex of subjects with schizophrenia. Our results indicate that reduced dendritic spine density in primary auditory cortex of subjects with schizophrenia is not matched by a corresponding reduction in excitatory bouton density. This suggests excitatory boutons in primary auditory cortex in schizophrenia may synapse with structures other than spines, such as dendritic shafts, with greater frequency. The discrepancy between dendritic spine reduction and excitatory bouton preservation may contribute to functional impairments of the primary auditory cortex in subjects with schizophrenia.

Adjusting for matching and covariates in linear discriminant analysis.

In studies that compare several diagnostic or treatment groups, subjects may not only be measured on a certain set of feature variables, but also be matched on a number of demographic characteristics and measured on additional covariates. Linear discriminant analysis (LDA) is sometimes used to identify which feature variables best discriminate among groups, while accounting for the dependencies among the feature variables. We present a new approach to LDA for multivariate normal data that accounts for the subject matching used in a particular study design, as well as covariates not used in the matching. Applications are given for post-mortem tissue data with the aim of comparing neurobiological characteristics of subjects with schizophrenia with those of normal controls, and for a post-mortem tissue primate study comparing brain biomarker measurements across three treatment groups. We also investigate the performance of our approach using a simulation study.