Randomized feasibility trial of a digital intervention for hypertension self-management.

Home blood pressure monitoring (HBPM) can improve hypertension management. Digital tools to facilitate routinized HBPM and patient self-care are underutilized and lack evidence of effectiveness. MyBP provides video-based education and automated text messaging to support continuous BP self-monitoring with recurring feedback. In this pragmatic trial, we sought to generate preliminary evidence of feasibility and efficacy in community-dwelling adults ≥55 y/o with hypertension recruited from primary care offices. Enrollees were provided a standard automatic BP cuff and randomized 2:1 to MyBP vs treatment-as-usual (control). Engagement with MyBP was defined as the proportion of BP reading prompts for which a reading was submitted, tracked over successive 2-week monitoring periods. Preliminary measures of efficacy included BP readings from phone-supervised home measurements and a self-efficacy questionnaire. Sixty-two participants (40 women, 33 Blacks, mean age 66, mean office BP 164/91) were randomized to MyBP (n = 41) or a control group (n = 21). Median follow-up was 22.9 (SD = 6.7) weeks. In the MyBP group, median engagement with HBPM was 82.7% (Q1 = 52.5, Q3 = 89.6) and sustained over time. The decline in systolic [12 mm Hg (SD = 17)] and diastolic BP [5 mm Hg (SD = 7)] did not differ between the two treatment groups. However, participants with higher baseline systolic BP assigned to MyBP had a greater decline compared to controls [interaction effect estimate -0.56 (-0.96, -0.17)]. Overall hypertension self-efficacy improved in the MyBP group. In conclusion, trial results show that older hypertensive adults with substantial minority representation had sustained engagement with this digital self-monitoring program and may benefit clinically.

Challenges of Seeking Reproductive Health Care in People Experiencing Intimate Partner Violence.

Title X is a federally funded family planning initiative that provides low-cost and confidential reproductive health services to its clients. In recent years, Title X has been the subject of debate as its core tenants have been revised by the current administration. Though advocates have fought against these changes, the voices of survivors on intimate partner violence are absent from this conversation. This study was designed to elicit the opinions and experiences on survivors of intimate partner violence on reproductive decision-making, their access to care, and their opinions about political efforts to restrict this access. Twenty-six semi-structured interviews were conducted with women who were seeking services for intimate partner violence. These interviews were audio-recorded, transcribed, and coded. Codes were then organized into themes. Participants endorsed the need for confidential services due to experiences of coercion from their partners and the fear of retaliation against them. Participants largely supported accessible contraception but reported the need for contraception to be reliable. Participants addressed pregnancy and its many complexities and advocated for nondirective options-counseling. Overall, participants spoke about their challenges with reproductive health care and their opinions on how best to service survivors of intimate partner violence. This study asserts the need for advocates for survivors to advocate for the preservation of Title X and establishes the need for future studies on the prevalence of intimate partner violence in Title X clinics.

Pediatric non-urgent emergency department visits and prior care-seeking at primary care.

BACKGROUND: We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS: We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS: Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS: Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.

Neoadjuvant Chemoradiation Therapy Followed by Extrafascial Hysterectomy in Locally Advanced Type II Endometrial Cancer Clinically Extending to Cervix.

PURPOSE: The role of neoadjuvant chemoradiation therapy in locally advanced type II endometrial cancer is controversial. We thus aimed to present our experience with the hypothesis that neoadjuvant chemoradiation therapy is associated with similarly high rates of downstaging and locoregional control for type II endometrial cancer and type I endometrial cancer. METHODS AND MATERIALS: Thirty-four patients with type II endometrial cancer with clinical evidence of cervical ± parametrium involvement treated with neoadjuvant external beam radiation therapy (45-50.4 Gy in 25-28 fractions) and high-dose-rate brachytherapy with a median total dose of 20 Gy (range, 15-27.5) in 4 fractions (range, 3-5) and concurrent platinum chemotherapy ± adjuvant chemotherapy from 2008 to 2018 were retrospectively reviewed. Patients with type I pathologic diagnoses and those treated with definitive (rather than preoperative) intent were excluded. RESULTS: Pathologic characteristics were as follows: 38% were carcinosarcoma, 18% serous, and 24% clear cell. Ninety-four percent of patients were downstaged to an extrafascial hysterectomy, and 94% had negative surgical margins. The 2-year local control, regional control, distant control, disease-free survival, and overall survival were 87.8%, 81.3%, 76.3%, 52.5%, and 63.7%, respectively. There was 1 subacute grade 3 and 1 late grade 3 small bowel obstruction, directly attributable to radiation therapy. CONCLUSIONS: Neoadjuvant chemoradiation therapy effectively downstages the majority of locally advanced type II endometrial cancers, thereby increasing the likelihood of achieving complete resection with negative margins.

Implementation of a research capstone course with expanded flexibility.

BACKGROUND AND PURPOSE: A research-focused capstone course was designed to improve flexibility in the way pharmacy students meet the university's capstone requirement. The requirement aims to integrate knowledge, skills, and attitudes from didactic coursework and to apply them in a scholarly way to improve critical and evidence-based thinking, communication skills, and professionalism. This report describes the capstone course and faculty and student perceptions after the first year of implementation. EDUCATIONAL ACTIVITY AND SETTING: The course allows students to work with a faculty advisor on a four-semester hour research project of mutual interest that can be completed in any one of three semesters. After the first student cohort completed their projects, faculty and student perceptions were captured via electronic survey. FINDINGS: A total of 38 students (36%) and 22 advisors (71%) responded to the survey. Approximately 90% of students and faculty agreed that student groups had achieved course objectives upon completion. Although faculty members felt that participating in the capstone course increased their workload and in some cases reduced their productivity, faculty members felt that the course had a beneficial impact for students. SUMMARY: The new capstone course was well received. The flexibility of the course was both a strength and a limitation as most students wanted more structure in the expectations and grading of the project in the form of a rubric or other standardized assessments.

How Stochasticity Influences Leading Indicators of Critical Transitions.

Many complex systems exhibit critical transitions. Of considerable interest are bifurcations, small smooth changes in underlying drivers that produce abrupt shifts in system state. Before reaching the bifurcation point, the system gradually loses stability ('critical slowing down'). Signals of critical slowing down may be detected through measurement of summary statistics, but how extrinsic and intrinsic noises influence statistical patterns prior to a transition is unclear. Here, we consider a range of stochastic models that exhibit transcritical, saddle-node and pitchfork bifurcations. Noise was assumed to be either intrinsic or extrinsic. We derived expressions for the stationary variance, autocorrelation and power spectrum for all cases. Trends in summary statistics signaling the approach of each bifurcation depend on the form of noise. For example, models with intrinsic stochasticity may predict an increase in or a decline in variance as the bifurcation parameter changes, whereas models with extrinsic noise applied additively predict an increase in variance. The ability to classify trends of summary statistics for a broad class of models enhances our understanding of how critical slowing down manifests in complex systems approaching a transition.

A qualitative approach using the integrative model of behaviour change to identify intervention strategies to increase optimal child restraint practices among culturally and linguistically diverse families in New South Wales.

OBJECTIVES: To qualitatively explore barriers to optimal child restraint use using the integrative behaviour change model in culturally and linguistically diverse (CALD) communities in New South Wales (NSW), Australia. METHODS: A semi-structured discussion was used to conduct 11 language specific focus groups in Arabic, Assyrian, Cantonese, Mandarin, Vietnamese and Turkish. Translated transcriptions were analysed using the major concepts of the integrative behaviour change model. RESULTS: Restraint use intent among CALD community carers is related to perceived safety of their children and complying with the law. While most participants appreciated the safety benefits of correct and appropriate use, a minority did not. Child restraint legislation may positively influence social norms, and enforcement appears to increase parental self-efficacy. However, concerns over child comfort may negatively influence both norms and self-efficacy. There are clear deficits in knowledge that may act as barriers as well as confusion over best practice in safely transporting children. Large family size, vehicle size and cost appear to be real environmental constraints in CALD communities. CONCLUSION: Determinants of intent and deficits in knowledge in this diverse range of CALD communities in NSW Australia are similar to those reported in other qualitative studies regardless of the population studied. This indicates that key messages should be the same regardless of the target population. However, for CALD communities there is a specific need to ensure access to detailed information through appropriate delivery strategies and languages. Furthermore, practical constraints such as cost of restraints and family size may be particularly important in CALD communities.

Firing probability and mean firing rates of human muscle vasoconstrictor neurones are elevated during chronic asphyxia.

Elevated muscle sympathetic nerve activity (MSNA) features in many cardiovascular diseases, but how this sympathoexcitation is brought about differs across pathologies. Unitary recordings from post-ganglionic muscle vasoconstrictor neurones in human subjects have shown that the augmented MSNA in the obstructive sleep apnoea syndrome (OSAS) is associated with an increase in firing probability and mean firing rate, and an increase in multiple within-burst firing. Here we characterize the firing properties of muscle vasoconstrictor neurones in patients with chronic obstructive pulmonary disease (COPD), who are chronically asphyxic. We tested the hypothesis that this elevated chemical drive would shift the firing pattern from that seen in healthy subjects to that seen in OSAS. The mean firing probability (52%) and mean firing rate (0.92 Hz) of 17 muscle vasoconstrictor neurones recorded in COPD were comparable to those previously recorded in OSAS (51% and 0.96 Hz), but significantly higher than those recorded in a group of healthy subjects with high levels of resting MSNA (35% and 0.33 Hz). In COPD single neurones fired once in 63% of cardiac intervals, comparable to OSAS (59%), but significantly lower than in the healthy group (78%). Conversely, single neurones fired twice in 25% of cardiac intervals, similar to OSAS (27%), but significantly higher than in the healthy group (18%). We conclude that the chronic asphyxia associated with COPD results in an increase in the firing probability and mean firing frequency of muscle vasoconstrictor neurones and causes a shift towards multiple firing, reflecting an increase in central muscle vasoconstrictor drive.