Predicting Response to Neuromodulators or Prokinetics in Patients with Suspected Gastroparesis Using Machine Learning: the "BIDnD" Model.

INTRODUCTION: Pharmacologic therapies for symptoms of gastroparesis have limited efficacy and it is difficult to predict which patients will respond. In this study, we implemented a machine-learning model to predict the response to prokinetics and/or neuromodulators in patients with gastroparesis-like symptoms. METHODS: Subjects with suspected gastroparesis underwent simultaneous gastric emptying scintigraphy (GES) and wireless motility capsule (WMC) and were followed for 6 months. Subjects were included if they were started on neuromodulators and/or prokinetics. Subjects were considered responders if their Gastroparesis Cardinal Symptom Index (GCSI) at 6 months decreased by ≥1 from baseline. A machine-learning model was trained using lasso regression, ridge regression or random forest. Five-fold cross-validation was used to train the models and the area under the receiver operator characteristic curve (AUC-ROC) was calculated using the test set. RESULTS: Of the 150 patients enrolled, 123 patients received either a prokinetic and/or a neuromodulator. Of the 123, 45 were considered responders and 78 were non-responders. A ridge regression model with the variables: BMI, Infectious prodrome, delayed GES, no diabetes (BIDnD), had the highest AUC-ROC of 0.72. The model performed well for subjects on prokinetics without neuromodulators (AUC-ROC of 0.83) but poorly for those on neuromodulators without prokinetics. A separate model with GET, duodenal MI, no diabetes, and functional dyspepsia performed better (AUC-ROC of 0.75). DISCUSSION: This machine learning model has an acceptable accuracy in predicting those who will respond to neuromodulators and/or prokinetics. If validated, our model provides valuable data in predicting treatment outcomes in patients with gastroparesis-like symptoms.

Navigating Farm Stress: Traumatic and Resilient Dimensions of the Black Agrarian Frame.

The current period of economic and social instability in the farm economy has generated renewed interest in the framing processes used by farmers to interpret and ascribe blame for the distress they have experienced. Studies show that agrarian frames are differentiated into types based on farmers' historical and contemporary racialized experiences. To investigate the role that agrarian frames play in navigating farm stress, we conducted a thematic analysis using data from interviews with 15 Black farmers from three Southern states. The results identify a Black Agrarian frame with two dimensions: traumatic and resilient. The traumatic dimension provides a system-blame narrative that highlights financial risk driven by institutions and racism as a core factor in farm stress. The resilient dimension describes collective action as a key coping strategy linked to understanding the farm as a multi-faceted asset. In conclusion, research on differentiated agrarian frames is an important component towards understanding how diverse populations navigate farm stress and the development of culturally appropriate resources for addressing it.

Benefits of Prokinetics, Gastroparesis Diet, or Neuromodulators Alone or in Combination for Symptoms of Gastroparesis.

BACKGROUND & AIMS: Prokinetics have limited effectiveness for treating symptoms of gastroparesis. Thus, alternative or adjunct therapies, such as gastroparesis diets or neuromodulators, are often prescribed. Their therapeutic benefits alone or in combination remain unclear. METHODS: One hundred and twenty-nine patients with symptoms of gastroparesis underwent wireless motility capsule gastric emptying time and gastric emptying scintigraphy. Based on test results, changes in therapy were recommended. Changes in Gastroparesis Cardinal Symptom Index (GCSI) and individual symptom scores over 6 months were related to recommendations for prokinetics, gastroparesis diet, or neuromodulators given as solo new therapies or in dual combinations. Multivariate analyses were performed to adjust for gastric emptying and other variables. RESULTS: In the whole group regardless of therapy, GCSI scores decreased by 0.53 points (interquartile range, -1.25 to 0.05; P < .0001) over 6 months. GCSI did not decrease for prokinetics as solo new therapy (P = .95). Conversely, neuromodulators as solo therapy decreased GCSI scores (P = .04) and all individual symptoms except nausea/vomiting (P = .86). Prokinetics combined with gastroparesis diets or neuromodulators improved GCSI scores (P ≤ .04) and most individual symptoms. Adjusting for gastric emptying time on multivariate analyses showed greater GCSI decreases for nondelayed emptying for neuromodulators as solo new therapy (P = .01). Gastric emptying scintigraphy, gender, diabetes, and functional dyspepsia did not influence responses to any treatment. CONCLUSIONS: Initiating prokinetics as solo new therapy had little benefit for patients with symptoms of gastroparesis. Neuromodulators as the only new therapy decreased symptoms other than nausea and vomiting, especially with nondelayed gastric emptying. Adding gastroparesis diets or neuromodulators to prokinetics offered relief, suggesting that combination therapies may be more useful in managing these patients. (ClinicalTrials.gov NCT02022826.).

Baseline Predictors of Longitudinal Changes in Symptom Severity and Quality of Life in Patients With Suspected Gastroparesis.

BACKGROUND & AIMS: Whether gastric emptying tests predict longitudinal outcomes in patients with symptoms of gastroparesis is unclear. We aimed to determine whether baseline gastric emptying tests and gut motility parameters could impact longitudinal symptom(s) and quality of life (QOL) in a prospective, observational cohort study of patients with symptoms of gastroparesis. METHODS: One hundred fifty patients with gastroparesis symptoms underwent simultaneous scintigraphy (GES) and wireless motility capsule (WMC) measurement of gastric emptying and other motility parameters. Patient Assessment of Upper Gastrointestinal Symptoms and Quality of Life were administered at baseline, and 3 and 6 months after testing. Multivariable generalized linear marginal models were fit to determine which baseline parameters predict longitudinal changes in symptoms and QOL. RESULTS: Overall upper GI symptoms and QOL scores were moderate in severity at baseline and significantly improved over 6 months. Clinical variables, including female gender, harder stools by Bristol stool form score, and presence of functional dyspepsia (FD) by Rome III criteria, were predictive of more severe upper GI symptoms. Even after controlling for these clinical factors, delayed gastric emptying by GES or WMC was associated with worse symptom severity and QOL scores. Low gastric and elevated small bowel contractile parameters by WMC were also independently associated with more severe upper GI symptoms and worse QOL scores. CONCLUSIONS: Baseline features, including demographic and clinical variables, delayed gastric emptying and abnormal gastrointestinal contractility, were independent predictors of more severe longitudinal symptoms and worse quality of life outcomes. These factors may help to risk stratify patients and guide treatment decisions. ClinicalTrials.gov no: NCT02022826.

Influence of Gastric Emptying and Gut Transit Testing on Clinical Management Decisions in Suspected Gastroparesis.

INTRODUCTION: Gastric emptying scintigraphy (GES) or wireless motility capsules (WMCs) can evaluate upper gastrointestinal symptoms in suspected gastroparesis; WMC tests can also investigate lower gut symptoms. We aimed to determine whether these tests impact treatment plans and needs for additional diagnostic evaluation. METHODS: In a prospective, multicenter study, 150 patients with gastroparesis symptoms simultaneously underwent GES and WMC testing. Based on these results, investigators devised management plans to recommend changes in medications, diet, and surgical therapies and order additional diagnostic tests. RESULTS: Treatment changes were recommended more often based on the WMC vs GES results (68% vs 48%) (P < 0.0001). Ordering of additional test(s) was eliminated more often with WMC vs GES (71% vs 31%) (P < 0.0001). Prokinetics (P = 0.0007) and laxatives (P < 0.0001) were recommended more often based on the WMC vs GES results. Recommendations for prokinetics and gastroparesis diets were higher and neuromodulators lower in subjects with delayed emptying on both tests (all P ≤ 0.0006). Laxatives and additional motility tests were ordered more frequently for delayed compared with normal WMC colonic transit (P ≤ 0.02). Multiple motility tests were ordered more often on the basis of GES vs WMC findings (P ≤ 0.004). Antidumping diets and transit slowing medications were more commonly recommended for rapid WMC gastric emptying (P ≤ 0.03). DISCUSSION: WMC transit results promote medication changes and eliminate additional diagnostic testing more often than GES because of greater detection of delayed gastric emptying and profiling the entire gastrointestinal tract in patients with gastroparesis symptoms. TRANSLATIONAL IMPACT: Gastric scintigraphy and WMCs have differential impact on management decisions in suspected gastroparesis.

Validation of Diagnostic and Performance Characteristics of the Wireless Motility Capsule in Patients With Suspected Gastroparesis.

BACKGROUND & AIMS: It is a challenge to make a diagnosis of gastroparesis. There is good agreement in results from wireless motility capsule (WMC) analysis and gastric emptying scintigraphy (GES), but the diagnostic yield of WMC is unclear and the accuracy of this method has not been validated. We compared the performance characteristics of WMC vs GES in assessing gastric emptying in patients with suspected gastroparesis. METHODS: We performed a prospective study of 167 subjects with gastroparesis (53 with diabetes and 114 without) at 10 centers, from 2013 through 2016. Subjects were assessed simultaneously by GES and with a WMC to measure gastric emptying and regional transit. Delayed gastric emptying by GES was defined as more than 10% meal retention at 4 hrs whereas delayed gastric emptying by WMC was defined as more than 5 hrs for passage of the capsule into the duodenum; a severe delay in gastric emptying was defined as a gastric emptying time of more than 12 hrs by WMC or more than 35% retention at 4 hrs by GES. Rapid gastric emptying was defined as less than 38% meal retention at 1 hr based on by GES or gastric emptying times less than 1:45 hrs by WMC. We compared diagnostic and performance characteristics of GES vs WMC. RESULTS: Delayed gastric emptying was detected in a higher proportion of subjects by WMC (34.6%) than by GES (24.5%) (P=.009). Overall agreement in results between methods was 75.7% (kappa=0.42). In subjects without diabetes, the WMC detected a higher proportion of subjects with delayed gastric emptying (33.3%) than GES (17.1%) (P < .001). A higher proportion of subjects with diabetes had delayed gastric emptying detected by GES (41.7%) compared with non-diabetic subjects (17.1%) (P=.002). Severe delays in gastric emptying were observed in a higher proportion of subjects by WMC (13.8%) than by GES (6.9%) (P = .02). Rapid gastric emptying was detected in a higher proportion of subjects by GES (13.8%) than by WMC (3.3%) (P < .001). Regional and generalized transit abnormalities were observed in 61.8% subjects and only detected by WMC. CONCLUSION: Although there is agreement in analysis of gastric emptying by GES vs WMC, WMC provides higher diagnostic yield than GES. WMC detects delayed gastric emptying more frequently than GES and identifies extra-gastric transit abnormalities. Diabetic vs non-diabetic subjects have different results from GES vs WMC. These findings could affect management of patients with suspected gastroparesis. ClinicalTrials.gov no: NCT02022826.

School Context Matters: The Impacts of Concentrated Poverty and Racial Segregation on Childhood Obesity.

BACKGROUND: Schools are important sites for interventions to prevent childhood obesity. This study examines how variables measuring the socioeconomic and racial composition of schools and counties affect the likelihood of obesity among third to fifth grade children. METHODS: Body mass index data were collected from third to fifth grade public school students by teachers from 317 urban and rural North Carolina schools in 38 counties. Multilevel models are used to examine county-, school-, and individual-level effects. RESULTS: Low concentrations of poverty at the school level are associated with lower odds of obesity. Schools in rural counties had significantly higher rates of obesity, net the other variables in the model. Students in minority-segregated schools had higher rates of obesity than those in more racially diverse schools, but the effect was not statistically significant once school-level poverty was controlled. CONCLUSIONS: Place-based inequalities are important determinants of health inequalities. The results of this study show that school-level variables related to poverty are important for understanding and confronting childhood obesity.

Young worker safety in construction: do family ties and workgroup size affect hazard exposures and safety practices?

OBJECTIVE: Little is known about how social aspects of the work environment influence exposures or safety practices affecting young construction workers. Our objective was to investigate whether working on a construction site with a small number of workers (≤10 vs. 11-50) or having a family-firm connection (working in a family-owned firm or one in which a family member also works) impacts hazard exposures and safety practices. PARTICIPANTS: Participants included 187 North Carolina construction workers 14 to 17 years old who were surveyed about their jobs. METHODS: We conducted stratified analyses using cross-tabulations and chi-square statistics to measure associations between workgroup size (i.e., the total number of workers on a jobsite) and family-firm connections (yes/no) and hazard exposures (e.g., saws) and safety practices (e.g., supervision). RESULTS: Having a family-firm connection was associated with fewer hazard exposures and greater safety practices. Youth who worked on jobsites with a larger workgroup (11-50 workers) reported more hazards but also more safety practices. CONCLUSIONS: Family-firm connections, in particular, may have a protective effect for youth in construction. Even though the statistical significance of our findings on workgroup size was limited in places, the pattern of differences found suggest that further research in this area is warranted.

Parental involvement with their working teens.

Adolescents work in varied environments and are exposed to hazards. Parents of these working adolescents have an opportunity to help them select jobs and address worker safety issues with employers. The present study conducted telephonic interviews among a national sample of 922 working adolescents along with one parent of each to examine the involvement of parents in their children's employment and safety issues. Over 70% of parents were found who helped their children identify job opportunities, consider questions about work hours or tasks, fill out job applications, prepare for interviews, or handle difficult safety issues. Parents suggested stronger actions in response to hypothetical situations than when confronted with real problems. Mean level of parental involvement did not vary by the number of hazards reported by teen workers. Parents were involved in helping their teens with work. Further research should explore how to enhance parental effectiveness by making work safe for teens.

Construction firm practices and manager beliefs regarding the employment and safety of teenaged employees: a North Carolina based study.

OBJECTIVE: The objective of this study was to examine the reported practices of construction firms and the beliefs of firm managers/supervisors with respect to employing youth under age 18 and ensuring their safety. PARTICIPANTS: The participants in this study were firm representatives from 54, mostly small to medium sized, construction firms in North Carolina. METHODS: Survey responses were analyzed for the entire sample and within strata of firm size (1-10, 11+ employees) using descriptive statistics. Percentages and 95% confidence intervals were calculated. Chi-square tests were used to test for statistical significance in differences between firm sizes. RESULTS: The findings suggest limits in the adequacy of safety training given to youth in construction, particularly in light of the minimal experience firms require of young hires, that managers' beliefs about the causes of young worker injury are largely focused on worker behaviors rather than on the presence of hazards, and that managers' compliance with child labor laws may be hampered by their lack of knowledge of these laws and an ambivalence toward their usefulness and enforcement. CONCLUSIONS: While larger studies are needed to confirm and advance these findings, when considered along with prior studies, they demonstrate the need to improve the safety of the construction environment for youth. The development of new educational interventions by health and safety professionals targeted at construction firms are supported, as are efforts by government regulators to increase enforcement and employer knowledge of the child labor laws.

Awareness and knowledge of the U.S. child labor laws among a national sample of working adolescents and their parents.

This study investigated awareness and knowledge of U.S. child labor laws among a nationally representative sample of 677 working adolescents and their parents. Findings demonstrate broad awareness of the child labor laws among adolescents, but little knowledge of the laws' specific provisions among either youth or their parents.

Hazardous task recognition among U.S. adolescents working in the retail or service industry.

BACKGROUND: Although the hazardous tasks adolescent workers perform in service and retail industries are well documented, little is known about the extent to which young workers recognize these tasks as hazardous or dangerous. METHODS: Using data from a nationally representative cross-sectional telephone survey conducted in 2003, we examined hazardous task recognition among 858 adolescents working in the retail or service industry. RESULTS: Approximately 13% (n = 123) of respondents reported that they consider at least one of their job tasks to be hazardous or dangerous. Among the respondents who performed tasks known to be hazardous, very few actually recognized these tasks as being hazardous or dangerous. CONCLUSION: Working adolescents appear to underestimate the dangers associated with work, thus increasing the potential likelihood of injury. Emphasis should be placed on eliminating or reducing hazards in the workplace while simultaneously improving young workers' recognition of the hazardous nature of many of the tasks they perform.

Political economy of US states and rates of fatal occupational injury.

OBJECTIVES: We investigated the extent to which the political economy of US states, including the relative power of organized labor, predicts rates of fatal occupational injury. METHODS: We described states' political economies with 6 contextual variables measuring social and political conditions: "right-to-work" laws, union membership density, labor grievance rates, state government debt, unemployment rates, and social wage payments. We obtained data on fatal occupational injuries from the National Traumatic Occupational Fatality surveillance system and population data from the US national census. We used Poisson regression methods to analyze relationships for the years 1980 and 1995. RESULTS: States differed notably with respect to political-economic characteristics and occupational fatality rates, although these characteristics were more homogeneous within rather than between regions. Industry and workforce composition contributed significantly to differences in state injury rates, but political-economic characteristics of states were also significantly associated with injury rates, after adjustment accounting for those factors. CONCLUSIONS: Higher rates of fatal occupational injury were associated with a state policy climate favoring business over labor, with distinct regional clustering of such state policies in the South and Northeast.

Attitudes and beliefs about adolescent work and workplace safety among parents of working adolescents.

PURPOSE: This study was designed to examine the attitudes and beliefs of the parents of working adolescents related to the safety of the employment of their children. METHODS: A cross-sectional telephone survey was conducted in 2003 among English-speaking parents of working adolescents aged 14-18 years in the continental United States. Questions addressed parental concerns about adolescents' employment and potential safety issues at work. RESULTS: Most parents expressed favorable attitudes about adolescent employment, although many expressed concerns about fatigue (48%), problems completing schoolwork (33%), or spending time with families (35%). Half of all parents indicated concerns about adolescents being present during a robbery, and 40-50% were concerned about adolescents working alone or not having adequate safety training. Parents were favorable to laws that regulate the teen work environment, although most (69%) also indicated that parents, not laws, should determine the work that teens do. CONCLUSIONS: Parents of working teens are favorable to their teens working, but they do have varied concerns about safety. Although many parents believe they should set the rules about teen work, they are also generally supportive of governmental regulation of hours and tasks. Helping parents understand child labor policies and consider evidence about work hazards may facilitate their ability to provide appropriate advice to their children.

Risk factors for a farm vehicle public road crash.

Driver, vehicle, public road, and farm enterprise characteristics were examined for their combined association with farm vehicle public road crash group membership. North Carolina farms experiencing a public road crash from 1992 to 2003 (n=200) were compared with a non-crash control group (n=185) for a 1:1 case:control ratio. Five characteristics were associated with increased odds of crash group membership in the combined model (likelihood ratio=175.95; d.f.=15; p<.001): use of non-English speaking drivers (OR=3.71); use of non-family hired help drivers (OR=4.25); types of non-farm vehicle public road use (OR=1.39); farm injury history (OR=1.33); and, use of younger farm vehicle drivers (OR=1.02). Farms reporting older farm vehicle drivers (OR=0.97), and low farm income (OR=0.29) were less likely crash group members. Recommendations are discussed for incorporating findings into farm vehicle crash prevention research and interventions.

Teen workers' exposures to occupational hazards and use of personal protective equipment.

BACKGROUND: Prior research indicates that working adolescents seek care for the toxic effects of on-the-job chemical and environmental hazard exposures. METHODS: This cross-sectional survey of a nationally representative sample of 866 adolescent workers in the retail and service sector examines their exposures, personal protective equipment (PPE) use, and training. RESULTS: Two-thirds of respondents were exposed to continuous, very loud noise, 55% to thermal hazards and 54% to chemical hazards. Few teens reported using any PPE, though those who had been trained reported somewhat higher usage. CONCLUSIONS: Teens working in the retail and service sectors experience a variety of chemical, thermal, biologic and noise exposures. Efforts to eradicate such exposures need to be complemented by increased provision of PPE and appropriate training in their use by employers.

US child labor violations in the retail and service industries: findings from a national survey of working adolescents.

OBJECTIVES: We investigated child labor violations among US adolescents working in the retail and service industries. METHODS: We used interview data from a nationally representative sample of working adolescents, and investigated reports of select child labor violations (e.g., hours, equipment, and work permits). We computed weighted percentages of respondents reporting each type of discrete (and aggregated) violation. RESULTS: Nearly 37% of respondents reported a violation of the hazardous occupations orders (i.e., prohibited jobs or use of equipment), and 40% reported a work permit violation. Fewer than 2% reported working more than the maximum weekly hours allowed during the school year, but 11% reported working past the latest hour allowed on a school night, and 15% reported working off the clock. CONCLUSIONS: Significant numbers of US adolescents are employed in violation of the child labor laws and as a result are exposed to safety risks. Although our data did not allow for an analysis of enforcement, our findings demonstrate gaps in employer compliance with the law. We suggest that closer attention to enforcement policy and practice is needed.

Work-related hazards and workplace safety of US adolescents employed in the retail and service sectors.

OBJECTIVE: Our goal was to examine the hazard exposures, work experiences, and workplace safety training of adolescents employed in retail and service jobs in the United States. METHODS: This was a cross-sectional telephone survey among working adolescents, 14 to 18 years old, in the continental United States. Data were collected in 2003. Survey items measured self-reported hazard exposures, training, and supervision experiences of working adolescents. RESULTS: Teens reported working an average of 16.2 hours per week during the school year, including working an average of 2.9 times per week after 7 PM on school nights and 2.6 nights per week after 9 PM. Thirty-seven percent of those under age 16 reported working after 7 PM on a school night, indicating employer violation of federal law. Teens typically perform multiple kinds of tasks in a given job. Higher proportions of females than males are involved in cash handling (84% vs 61%), whereas males are more likely than females to be involved in physically challenging tasks, such as lifting heavy objects (57% vs 22%) or working at heights (35% vs 17%). Despite federal regulations prohibiting teens under 18 from using certain types of dangerous equipment (eg, slicers, dough mixers, box crushers, paper balers) or serving or selling alcohol in places where it is consumed, 52% of males and 43% of females reported having performed > or = 1 prohibited task. Although more males reported receiving safety training, they were also more likely to report working without supervision than their female counterparts. CONCLUSIONS: Teens are exposed to multiple hazards, use dangerous equipment despite federal prohibitions, and work long hours during the school week. They also lack consistent training and adult supervision on the job. It is important for adolescent medicine practitioners to become involved in prevention efforts through both anticipatory guidance and policy advocacy.

Work hazards and workplace safety violations experienced by adolescent construction workers.

OBJECTIVE: To describe the working conditions of adolescents employed in construction in North Carolina, documenting hazards, safety practices, and prohibited activities. DESIGN: A cross-sectional telephone survey. SETTING: North Carolina. PARTICIPANTS: Adolescents (aged <18 years) with work permits for the construction industry in North Carolina during summer 2001. MAIN OUTCOME MEASURES: Types of jobs, work tasks, supervisory conditions, tools, equipment, and processes. RESULTS: A total of 187 survey respondents were in this study. Adolescents were employed in varied construction settings and business types. Nineteen of the 187 permitted workers were younger than 16 years, despite prohibitions against their employment in construction unless working for their parents. The remainder (n = 168) were working legally based on age, but most performed prohibited tasks. In fact, 84% of all the 16- to 17-year-olds had performed at least 1 clearly prohibited task and 47% had performed 3 or more. Although most reported being supervised and working with others, approximately 19% of all respondents reported working where they were not in hearing distance of other workers. Data were collected from teenagers with work permits, suggesting that these adolescents may work for more responsible employers. If violations of child labor laws exist in this group, it is likely that adolescents without permits are exposed to even greater hazards and violations. CONCLUSION: Involvement of teenagers in dangerous and/or prohibited tasks is cause for concern and suggests a pressing need to examine the enforcement of existing laws and the need for additional protection.

Adequacy of health and safety training among young Latino construction workers.

OBJECTIVES: This study aimed to assess the adequacy of safety training provided to young Latino immigrant construction workers. The study posited that, because of their youth and immigrant status, these workers would be less likely to receive adequate training. METHODS: We interviewed 50 youths aged < or =21 who had worked at least 10 days in construction in the previous year. The in-person interview included 140 questions covering a range of construction work and health and safety experiences. RESULTS: Participants reported performing a range of hazardous tasks, some while under the age of 18. Of these, 68% to 72% reported receiving some training, but median training time was only 1 hour. Only 24% reported receiving written training material. Those with less English ability received less training. CONCLUSIONS: Young Latino immigrants in this study received inadequate training given the hazardous work they performed. CLINICAL SIGNIFICANCE: Results of this research, especially the relatively low level of English communication skills among young Latino workers, point to the need for increased bilingual services not just in worker safety training programs, but also in medical clinics and emergency rooms that treat Latino workers.