A Quality Improvement Project: Improving Sleep Quality and Duration Among Pediatric Mental Health Patients.

This article is a report of a project to improve the quality and duration of sleep among patients ages 3-17 years in an outpatient mental health clinic. The Pediatric Insomnia Severity Index (PISI) (now the Behavioral Sleep Medicine Clinic Sleep Questionnaire) was administered at baseline. Patients and parents were provided with education about the American Academy of Pediatrics sleep tips. Compliance with the sleep tips was tracked using an electronic health record (EHR) checklist. The PISI was administered again after the interventions and showed overall improvement in sleep quality and duration. Some patients experienced no change or a decline in sleep quality or duration and some had an increase in daytime somnolence.

Association Between Prepregnancy Obesity and Health Behaviors, Adverse Conditions, and Birth Outcomes in South Dakota.

INTRODUCTION: Prepregnancy obesity has been shown to be associated with increased risk of adverse birth outcomes but little is known about the associations with health-related behaviors and conditions before, during and after pregnancy. METHODS: This retrospective cohort study used data from the South Dakota Pregnancy Risk Assessment Monitoring System (SD PRAMS) survey, which is an ongoing state-based surveillance system of maternal behaviors, attitudes, and experiences before, during, and shortly after pregnancy. The 2017 and 2018 SD PRAMS sampled a total of 3,805 mothers who were randomly selected from birth certificate records to be representative of all South Dakota women who delivered a live-born infant. Logistic regression was used to determine whether prepregnancy obesity was associated with adverse health conditions after controlling for demographic factors. RESULTS: Women with prepregnancy obesity, compared to those who were non-obese, were more likely to report an unintended pregnancy (45 percent vs. 39 percent), smoking three months before pregnancy (32 percent vs. 22 percent), delayed prenatal care (12 percent vs. 16 percent), hypertension during pregnancy (22 percent vs. 9 percent), gestational diabetes (19 percent vs. 8 percent), depression during pregnancy (21 percent vs. 14 percent), C-section delivery (35 percent vs. 22 percent), high birth weight (15 percent vs. 8 percent), and the infant hospitalized for three or more days (41 percent vs. 30 percent). Of women with prepregnancy obesity, 37 percent had been talked to by health care providers about maintaining a healthy weight the 12 months before pregnancy compared to 13 percent of non-obese women. CONCLUSIONS: Health care workers should be more intentional about stressing the potential risks of prepregnancy obesity to properly educate mothers and women of childbearing age.

Implementation and Outcomes of Virtual Care Across a Tertiary Cancer Center During COVID-19.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few quantitative data support its rapid implementation and positive associations with service capacity and quality. Objective: To examine the outcomes of a cancer center-wide virtual care program in response to the COVID-19 pandemic. Design, Setting, and Participants: This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020. Main Outcomes and Measures: Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients. Results: The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946. Conclusions and Relevance: These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.

Safe Sleep Behaviors Among South Dakota Mothers and the Role of the Healthcare Provider.

INTRODUCTION: The purpose of this report was to determine the prevalence of safe sleep practices among South Dakota mothers, and the impact that education from their healthcare provider had on infant safe sleep practices as defined by the American Academy of Pediatrics (AAP). METHOD: A population-based survey was administered to a random sample of mothers delivering in 2017. Data were weighted to obtain statewide and race-specific (white, non-Hispanic; American Indian; other races) prevalence rates. RESULTS: Weighted response rate was 67 percent, with 9.9 percent of mothers giving birth in 2017 completing a survey. Greater than 85 percent of mothers met recommendations regarding placing their infant on their back, breastfeeding, not consuming alcohol or illicit drugs during pregnancy, and attending 80 percent or more of prenatal visits. Less than 85 percent met recommendations regarding infant always sleeping alone on an approved sleep surface (30.8 percent), room-sharing without bed-sharing (44.3 percent), keeping soft objects and loose bed- ding out of crib (47.7 percent), and avoiding smoke exposure during and after pregnancy (82.1 percent). Only 7.7 percent of mothers met all eight recommendations. Healthcare providers talking to the mother about placing the infant to sleep in a crib and placing the crib in the mother's room were associated with a higher percent of mothers meeting these recommendations. Although the health care provider asking the mother if she was going to breastfeed was not associated with ever breastfeeding (p=0.95), if the mother received information from the doctor about breastfeeding she was slightly more likely to breastfeed than if she did not receive information (90.3 vs. 85 percent, p=0.06). CONCLUSIONS: A low percentage of South Dakota mothers met all eight AAP safe sleep recommendations that could be assessed using these data. Health care providers can influence a mother's compliance with some of the safe sleeping recommendations.

Upper Gastrointestinal Bleeding in Adults: Evaluation and Management.

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 7 g per dL. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data.

Clinically Relevant Drug-Drug Interactions in Primary Care.

Drug interactions are common in the primary care setting and are usually predictable. Identifying the most important and clinically relevant drug interactions in primary care is essential to patient safety. Strategies for reducing the risk of drug-drug interactions include minimizing the number of drugs prescribed, re-evaluating therapy on a regular basis, considering nonpharmacologic options, monitoring for signs and symptoms of toxicity or effectiveness, adjusting dosages of medications when indicated, and adjusting administration times. Inhibition or induction of cytochrome P450 drug metabolizing isoenzymes is the most common mechanism by which clinically important drug interactions occur. The antimicrobials most likely to affect the international normalized ratio significantly in patients receiving warfarin are trimethoprim/sulfamethoxazole, metronidazole, and fluconazole. An empiric warfarin dosage reduction of 30% to 50% upon initiation of amiodarone therapy is recommended. In patients receiving amiodarone, limit dosages of simvastatin to 20 mg per day and lovastatin to 40 mg per day. Beta blockers should be tapered and discontinued several days before clonidine withdrawal to reduce the risk of rebound hypertension. Spironolactone dosages should be limited to 25 mg daily when coadministered with potassium supplements. Avoid prescribing opioid cough medicines for patients receiving benzodiazepines or other central nervous system depressants, including alcohol. Physicians should consider consultation with a clinical pharmacist when clinical circumstances require the use of drugs with interaction potential.

Hepatitis B: Screening, Prevention, Diagnosis, and Treatment.

Hepatitis B virus (HBV) is a partly double-stranded DNA virus that causes acute and chronic liver infection. Screening for hepatitis B is recommended in pregnant women at their first prenatal visit and in adolescents and adults at high risk of chronic infection. Hepatitis B vaccination is recommended for medically stable infants weighing 2,000 g or more within 24 hours of birth, unvaccinated infants and children, and unvaccinated adults requesting protection from hepatitis B or who are at increased risk of infection. Acute hepatitis B is defined as the discrete onset of symptoms, the presence of jaundice or elevated serum alanine transaminase levels, and test results showing hepatitis B surface antigen and hepatitis B core antigen. There is no evidence that antiviral treatment is effective for acute hepatitis B. Chronic hepatitis B is defined as the persistence of hepatitis B surface antigen for more than six months. Individuals with chronic hepatitis B are at risk of hepatocellular carcinoma and cirrhosis, but morbidity and mortality are reduced with adequate treatment. Determining the stage of liver disease (e.g., evidence of inflammation, fibrosis) is important to guide therapeutic decisions and the need for surveillance for hepatocellular carcinoma. Treatment should be individualized based on clinical and laboratory characteristics and the risks of developing cirrhosis and hepatocellular carcinoma. Immunologic cure, defined as the loss of hepatitis B surface antigen with sustained HBV DNA suppression, is attainable with current drug therapies that suppress HBV DNA replication and improve liver inflammation and fibrosis. Pegylated interferon alfa-2a, entecavir, and tenofovir are recommended as first-line treatment options for chronic hepatitis B.

Strengthening maternal and newborn health in rural Ethiopia: early results from frontline health worker community maternal and newborn health training.

OBJECTIVE: to describe early results from the Community Maternal and Newborn Health (CMNH) training programme of the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project. DESIGN: a non-experimental, descriptive design was employed to assess training implementation. SETTING: six rural districts of Amhara and Oromiya regions, Ethiopia. PARTICIPANTS: 91 Health Extension Workers (HEWs) and 626 Guide Team members including Traditional Birth Attendants (TBAs) and volunteer Community Health Promoters (vCHPs). INTERVENTION: CMNH is one aspect of a broader strategy to improve maternal and newborn health at the community level in rural areas of Ethiopia where pregnant women have limited access to health facilities. MEASUREMENTS: performance testing of HEWs, TBAs, and vCHPs was conducted to assess transfer of knowledge and skills from CMNH Master Trainer level to CMNH Trainer level, and from CMNH Trainer level to CMNH Guide Team (GT) level on the topic areas of Prevent Problems before Baby is Born and Prevent Problems after Baby is Born. FINDINGS: post-training performance scores were significantly higher than immediate pre-training scores for Amhara and Oromiya regions on both topic areas (p<0.001). For HEWs and GT members, respectively, average scores increased over 250% and 300% for Prevent Problems before Baby is Born, and over 300% and 400% for Prevent Problems after Baby is Born. KEY CONCLUSIONS: CMNH was successful in transferring knoweldge to HEWs at the CMNH Trainer level and to Guide Team members at the community level. In order for gains to be realised and sustained, the CMNH programme will be nested within an enabling environment created through behaviour change communication to increase demand for CMNH services, emphasising evidence-based maternal and newborn care practices, teamwork among frontline health workers, and an enhanced role of HEWs in provision of safe care during pregnancy, birth, and the early postnatal period.

Lister's relationship with patients: 'A successful case'

An important aspect of Joseph Lister's work that has received relatively little attention is his relationship with patients. However, a manuscript written by one of his patients, Margaret Mathewson's 'A Sketch of Eight Months a patient, in the Royal Infirmary of Edinburgh, A.D. 1877', provides detail about the surgeon as seen 'from below'-that is, by a charity patient. Although excerpts from Mathewson's 'Sketch' have previously been published, an earlier version of the 'Sketch' has only recently been identified as such. That earlier version represents Lister not only as actively concerned with patient education, but also as strongly supportive of patients' rights, encouraging ward patients to report maltreatment at the hands of the staff.

Activated protein C resistance associated with maternal floor infarction treated with low-molecular-weight heparin.

Factor V Leiden with activated protein C resistance is found in up to 5% of the population. It is associated with current adverse pregnancy outcomes. Maternal floor infarction is a lesion in which fibrin is deposited throughout the placenta, leading to necrosis of villi, and (50% of the time) fetal demise. It is also often recurrent. There is no known etiology of maternal floor infarction, nor is there a known treatment. We report a case of a 34-year-old G5, P2 with multiple pregnancy losses, including two fetal deaths. Placental pathology was obtained from one of the losses and was notable for maternal floor infarction. In the index pregnancy, she was evaluated for thrombophilia and found to have a significant protein C resistance of 1.59, consistent with a factor V Leiden. She was treated with low-molecular-weight heparin, enoxaparin, 40 mg twice a day, titrated to achieve an activated factor Xa activity level of 0.2 prior to her next dose. Her pregnancy was unremarkable until 39 weeks, when she developed a decreased amniotic fluid index. A 2995-kg healthy infant was delivered. The placenta showed no evidence of maternal floor infarction. This case demonstrates an association between maternal floor infarction and activated protein C resistance. It is also notable for a successful treatment of recurrent maternal floor infarction with prophylactic heparin. A single case report can only raise a question regarding associations. As we become more familiar with the thrombophilias, we may better understand the association of thrombophilias and placental disease as well as develop successful treatments.

Acoustic cues to the voicing feature in tracheoesophageal speech.

Tracheoesophageal (TE) speakers often have difficulty producing the voiced/voiceless distinction. This limitation has been attributed to use of the pharyngoesophageal segment as the phonatory source. The nature of this tissue may preclude precise control of voicing onset, a contributing cue to a phoneme's voicing feature, at least in laryngeal speech. The purpose of this study was to determine whether voiced and voiceless consonants produced by TE speakers could be differentiated from those produced by laryngeal speakers using four acoustic measures associated with the voicing characteristic of consonants in laryngeal speech. Sixteen TE and ten laryngeal speakers produced five stop and fricative cognate pairs embedded in a carrier phrase. Three of the four acoustic measures contributed significantly to the discriminant models that differentiated accurately perceived TE and laryngeal samples. The three variables were consonant sound pressure level, consonant duration, and preceding vowel duration. In general, values for each measure were higher/longer for the TE group. The discriminant functions were interpreted as a reflection of TE speaker attempts at overarticulation.