Publications by authors named "Adrienne Stolfi"

50 Publications

AERMOD modeling of ambient manganese for residents living near a ferromanganese refinery in Marietta, OH, USA.

Environ Monit Assess 2021 Jun 13;193(7):419. Epub 2021 Jun 13.

Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA.

Elevated exposure to ambient manganese (Mn) is associated with adverse health outcomes. In Marietta, Ohio, the primary source of ambient Mn exposure is from the longest operating ferromanganese refinery in North America. In this study, the US EPA air dispersion model, AERMOD, was used to estimate ambient air Mn levels near the refinery for the years 2008-2013. Modeled air Mn concentrations for 2009-2010 were compared to concentrations obtained from a stationary air sampler. Census block population data were used to estimate population sizes exposed to an annual average air Mn > 50 ng/m, the US EPA guideline for chronic exposure, for each year. Associations between modeled air Mn, measured soil Mn, and measured indoor dust Mn in the modeled area were also examined. Median modeled air Mn concentrations ranged from 6.3 to 43 ng/m across the years. From 12,000-56,000 individuals, including over 2000 children aged 0-14 years, were exposed to respirable annual average ambient air Mn levels exceeding 50 ng/m in five of the six years. For 2009-2010, the median modeled air Mn concentration at the stationary site was 20 ng/m, compared to 18 ng/m measured with the stationary air sampler. All model performance measures for monthly modeled concentrations compared to measured concentrations were within acceptable limits. The study shows that AERMOD modeling of ambient air Mn is a viable method for estimating exposure from refinery emissions and that the Marietta area population was at times exposed to Mn levels that exceeded US EPA guidelines.
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http://dx.doi.org/10.1007/s10661-021-09206-8DOI Listing
June 2021

Child Sleep and Parent Depressive Symptoms.

South Med J 2021 Jun;114(6):368-372

From the Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio.

Objectives: Parent distress and child sleep problems have been associated in earlier research. The present study expands on past research on parent depressive symptoms and their child's sleep. This study examines the relation between parents who screen positive for depressive symptoms and their perception of their child's sleep.

Methods: Three hundred sixty-nine English-speaking parents of children ages 3 to 5 years (n = 134) or 6 to 11 years (n = 235) met this study's inclusion criteria within the Southwestern Ohio Ambulatory Research Network (response rate 90%). The validated scales used were the RAND Depression Screener (DS), the Wisconsin Abbreviated Children's Sleep Habits Questionnaire (WCSHQ), and the Jenkins Sleep Questionnaire. Multiple logistic regression was used to determine adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for associations with the WCSHQ.

Results: In total, 74.3% of the study children were White, 82.4% of respondents were the child's mother, 75.1% had at least some college education, and 54.4% reported an annual income of <$50,000. In total, 54.4% of children were male and 53.8% had public health insurance. Approximately one-fourth of parents had a positive DS and nearly one-third reported sleep problems. Adjusting for child's age and other factors, we found that parents with a positive (vs negative) DS had AOR 2.42 (95% CI 1.38-4.24) for higher WCSHQ scores. Children ages 3 to 5 years (vs 6-11 years) had AOR 2.48 (95% CI 1.56-3.95) for higher WCSHQ scores.

Conclusions: Parents with a positive DS were more likely to report sleep problems in their children after adjusting for the child's age. These findings from a diverse sample of US Midwestern families at primary care venues corroborate previous research.
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http://dx.doi.org/10.14423/SMJ.0000000000001262DOI Listing
June 2021

Screening for Children's Chronic Health Conditions and Their Strengths and Difficulties in Primary Care.

J Dev Behav Pediatr 2021 May 12. Epub 2021 May 12.

Boonshoft School of Medicine, Wright State University, Dayton, OH; Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH; Community Research, Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH.

Objective: This study explores parents' perceptions of their child's health status and their strengths and difficulties using 2 validated instruments in primary care settings.

Methods: This cross-sectional study was conducted between February 2018 and October 2019. Parents of children aged 2 to 18 years completed the Children with Special Health Care Needs (CSHCN) screener and the Strengths and Difficulties Questionnaire (SDQ) as well as demographics. The CSHCN uses 5 questions to identify children with chronic health conditions. Three subgroups were created: children with no chronic health condition (NCHC), chronic health condition with no functional limitations (NFLs), and chronic health condition with functional limitations (FLs). Higher SDQ scores indicate higher degrees of a factor. Associations between CSHCN subgroups and SDQ scores, controlling for demographics, were analyzed with multiple linear regressions.

Results: In total, 970 parents' surveys (87.9% completed surveys) were included in this analysis: 76.4% of respondents were married, 56.4% had an annual household income ≥$50,000%, and 61.7% were employed full time; 53.0% of the index children were males, 72.1% were White, and 61.4% had private insurance. Mean (SD) total SDQ scores across the 3 CSHCN subgroups were significantly different (NCHC, 7.7 [4.8]; NFL, 12.6 [6.6]; FL, 16.0 [6.7], p < 0.001). The mean SDQ prosocial scores were higher in the NCHC subgroup (p < 0.001), as hypothesized. The SDQ means for the 3 subgroups remained significantly different after controlling for demographics.

Conclusion: Children with FLs had significantly higher total SDQ scores than children in the other 2 subgroups, which may aid clinicians in the early identification of children who would benefit from behavioral health resources.
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http://dx.doi.org/10.1097/DBP.0000000000000969DOI Listing
May 2021

Parents' Report of Their Children's Underinsurance Status After the Affordable Care Act.

J Am Board Fam Med 2021 Jan-Feb;34(1):208-215

From the Department of Pediatrics, Wright State University-Boonshoft School of Medicine, Dayton, OH.

Objective: To determine the prevalence and correlates of children's underinsurance pre- and post-implementation of the Affordable Care Act (ACA).

Study Design: A cross-sectional survey of a convenience sample of 5043 parents of children greater than 6 months old who had health insurance in the previous 12 months. Respondents completed the Medical Expenses for Children Survey. Pre-ACA data were collected in summer/fall of 2009 to 2011 (n = 3966); post-ACA data were collected in summer/fall 2016 (n = 1077). All data were collected within the Southwestern Ohio Ambulatory Research Network (SOAR-Net).

Results: Some study parents (16.3%) were unable to follow at least 1 recommendation of their child's pediatrician due to their inability to pay for it, and 17.3% reported it had become more difficult to obtain "needed health care" in the past 3 years. Factors associated with underinsurance after adjusting for demographic factors did NOT include pre/post-ACA, but did include annual household income < $50,000 (adjusted odds ratio [AOR] = 2.71; 95% CI, 2.15-3.40). Poor child health was also a significant risk factor for underinsurance(AOR = 3.71; 95% CI, 2.61-5.29).

Conclusions: About 1 in 6 study children were underinsured. The ACA did not affect the underinsurance rate. Parents continued to report that it had become more difficult to obtain needed health care over the past 3 years post-ACA. About one third of study parents consistently reported that the health of their underinsured child had suffered because they could not afford to pay for their child's health care.
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http://dx.doi.org/10.3122/jabfm.2021.01.200036DOI Listing
January 2021

Patient Portal, Patient-Generated Images, and Medical Decision-Making in a Pediatric Ambulatory Setting.

Appl Clin Inform 2020 10 18;11(5):764-768. Epub 2020 Nov 18.

Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States.

Background: Electronic health record (EHR) patient portals are a secure electronic method of communicating with health care providers. In addition to sending secure messages, images, and videos generated by families can be sent to providers securely. With the widespread use of smart phones, there has been an increase in patient-generated images (PGI) sent to providers via patient portals. There are few studies that have evaluated the role of PGI in medical decision-making.

Objectives: The study aimed to characterize PGI sent to providers via a patient portal, determine how often PGI-affected medical decision-making, and determine the rate of social PGI sent via patient portal.

Methods: A retrospective chart review of PGI uploaded to a children's hospital's ambulatory patient portal from January 2011 to December 2017 was conducted. Data collected included patient demographics, number and type of images sent, person sending images (patient or parent/guardian), and whether an image-affected medical decision-making. Images were classified as medical related (e.g., blood glucose readings and skin rashes), nonmedical or administrative related (e.g., medical clearance or insurance forms), and social (e.g., self-portraits and camp pictures).

Results: One hundred forty-three individuals used the portal a total of 358 times, sending 507 images over the study period. Mean (standard deviation) patient age was 9.5 (5.9) years, 50% were females, 89% were White, and 64% had private insurance. About 9% of images were sent directly by patients and the rest by parents/guardians. A total of 387 (76%) images were sent for medical related reasons, 20% for nonmedical, and 4% were deemed social images. Of the 387 medical related images, 314 (81%) affected medical decision-making.

Conclusion: PGI-affected medical decision-making in most cases. Additional studies are needed to characterize use of PGI in the pediatric population.
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http://dx.doi.org/10.1055/s-0040-1718754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673956PMC
October 2020

Drug treatments for managing cystic fibrosis-related diabetes.

Cochrane Database Syst Rev 2020 10 19;10:CD004730. Epub 2020 Oct 19.

Department of Pediatrics, Children's Medical Center, Dayton, Ohio, USA.

Background: The Cystic Fibrosis Foundation recommends both short-term and long-acting insulin therapy when cystic fibrosis-related diabetes (CFRD) has been diagnosed. Diagnosis is based on: an elevated fasting blood glucose level greater than 6.94 mmol/L (125 mg/dL); or oral glucose tolerance tests greater than 11.11 mmol/L (200 mg/dL) at two hours; or symptomatic diabetes for random glucose levels greater than 11.11 mmol/L (200 mg/dL); or glycated hemoglobin levels of at least 6.5%. This is an update of a previously published review.

Objectives: To establish the effectiveness of insulin and oral agents for managing diabetes in people with cystic fibrosis in relation to blood sugar levels, lung function and weight management.

Search Methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also handsearched abstracts from pulmonary symposia and the North American Cystic Fibrosis Conferences. Date of most recent register search: 10 September 2020. We searched online trials registries; date of most recent searches: 21 March 2020.

Selection Criteria: Randomized controlled trials comparing all methods of pharmacological diabetes therapy in people with diagnosed CFRD.

Data Collection And Analysis: Two authors independently extracted data and assessed the risk of bias in the included studies. Authors also used GRADE to assess the quality of the evidence.

Main Results: The searches identified 29 trials (45 references). Four included trials provide results: one short-term single-center cross-over trial (seven adults) comparing insulin with oral repaglinide and no medication in adults with CFRD and normal fasting glucose; one long-term multicenter trial (61 adults with CFRD) comparing insulin with oral repaglinide and placebo; one long-term multicenter trial (67 adults) comparing insulin with oral repaglinide; and one 12-week single-center cross-over trial (20 adults) comparing the long-acting insulin glargine to short-term neutral protamine Hagedorn insulin. Two ongoing trials of newly approved incretin mimics have been noted for possible future inclusion. Downgrading of the quality of the evidence was mainly due to risks of bias across all domains, but particularly due to concerns surrounding allocation concealment and selective reporting. There were also some concerns due to imprecision from small sample sizes and low event rates. Finally, there may be some bias due to the amounts of insulin and repaglinide given not being comparable. Data from one trial comparing insulin to placebo (39 participants) did not show any difference between groups for the primary outcomes of blood glucose levels (very low-quality evidence), lung function (low-quality evidence) or nutritional status (low-quality evidence). Similarly, no differences between groups were seen for the secondary outcomes of number of hypoglycemic episodes (low-quality evidence), secondary infection complications or quality of life (QoL). These results were mirrored in the narrative reports for the second trial in this comparison (seven participants). Data from the one-year trial comparing repaglinide to placebo (38 participants), showed no differences between groups for the primary outcomes of blood glucose levels (very low-quality evidence), lung function (low-quality evidence) and nutritional status (low-quality evidence). Also, no differences were seen between groups for the secondary outcomes of number of hypoglycemic episodes (low-quality evidence), secondary infection complications or QoL. These findings were mirrored in the narrative reports for the second trial (n = 7) in this comparison. Three trials compared insulin to repaglinide (119 participants). Data from one trial (n = 67) showed no difference in blood glucose levels at either 12 months (high-quality evidence) or 24 months; narrative reports from one trial (45 participants) reported no difference between groups, but the second trial (7 participants) reported a beneficial effect of insulin over repaglinide. Two trials (112 participants) found no difference between insulin and repaglinide in lung function or nutritional status (moderate-quality evidence). Two trials (56 participants) reported no difference in the number of hypoglycemic episodes (low-quality evidence). One trial (45 participants) reported no difference between groups in secondary infections and cystic fibrosis QoL. The single trial comparing glargine to neutral protamine Hagedorn insulin did not report directly on the review's primary outcomes, but did report no differences between groups in post-prandial glucose values and weight; neither group reported infectious complications. There was no difference in episodes of hypoglycemia (very low-quality evidence) and while there was no difference reported in QoL, all participants opted to continue treatment with glargine after the trial was completed. Mortality was not reported by any trial in any comparison, but death was not given as a reason for withdrawal in any trial.

Authors' Conclusions: This review has not found any conclusive evidence that any agent has a distinct advantage over another in controlling hyperglycemia or the clinical outcomes associated with CFRD. Given the treatment burden already experienced by people with cystic fibrosis, oral therapy may be a viable treatment option. While some cystic fibrosis centers use oral medications to help control diabetes, the Cystic Fibrosis Foundation (USA) clinical practice guidelines support the use of insulin therapy and this remains the most widely-used treatment method. Randomized controlled trials specifically related to controlling diabetes and its impact on the course of pulmonary disease process in cystic fibrosis continue to be a high priority. Specifically, investigators should evaluate adherence to different therapies and also whether there is benefit in using additional hypoglycemic agents as well as the newly approved incretin mimics. Agents that potentiate insulin action, especially agents with additional anti-inflammatory potential should also be further investigated as adjuvant therapy to insulin.
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http://dx.doi.org/10.1002/14651858.CD004730.pub5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094754PMC
October 2020

Predicting second-generation antidepressant effectiveness in treating sadness using demographic and clinical information: A machine learning approach.

J Affect Disord 2020 07 3;272:295-304. Epub 2020 May 3.

School of Education and Health Sciences, University of Dayton, Dayton, OH.

Introduction: Current guidelines for choosing antidepressant medications involve a trial-and-error process. Most patients try multiple antidepressants before finding an effective antidepressant. This study uses demographic and clinical information to create models predicting effectiveness of different antidepressants in treating sadness in a nationally representative sample of US adults.

Methods: A secondary analysis of the Collaborative Psychiatric Epidemiology Survey (CPES) was performed. Participants with or without a mental health diagnosis who reported sadness as a symptom, and were taking fluoxetine (n=156), sertraline (n=224), citalopram (n=91), paroxetine (n=156), venlafaxine (n=69), bupropion (n=92), or trazadone (n=26) within the past year were included. Two sets of principal component analyses (PCAs) and logistic regressions were performed: one determined associations between symptom clusters and antidepressant effectiveness for sadness, and the other created models to predict effectiveness. Both PCAs controlled for psychiatric and medical diagnoses, substance use, psychiatric medications, alternative treatments, and demographics.

Results: Anxiety was associated with ineffectiveness of fluoxetine in treating sadness. Low mood scores were associated with ineffectiveness of paroxetine and venlafaxine, and fatigue was associated with ineffectiveness of sertraline. The models for predicting drug effectiveness had a mean accuracy of 83% and internal validity of 72%.

Limitations: CPES data were collected from 2001-2003, so newer drugs were not included. Effectiveness was for sadness, so results are not directly comparable to studies using overall depressive symptom reductions as outcomes.

Conclusion: Since fewer than 50% of patients currently respond to their first antidepressant, this model could provide modest improvement to choosing starting antidepressants in treating sadness.
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http://dx.doi.org/10.1016/j.jad.2020.04.010DOI Listing
July 2020

Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students.

Teach Learn Med 2020 Aug-Sep;32(4):399-409. Epub 2020 Mar 6.

Department of Pediatrics, University of Colorado, Aurora, Colorado, USA.

Theory: Self-regulated learning theory suggests that individualized learning plans can benefit medical trainees by providing a structured means of goal setting, self-monitoring, and self-evaluation. External feedback also plays an important role in affecting learner motivations, perceptions, and self-evaluations. Accordingly, having learners share individualized learning plans with preceptors might promote self-regulated learning by helping align the feedback they receive with their learning goals. : We hypothesized having medical students share individualized learning plans with attendings and residents would improve the quality of the feedback they received, increase the likelihood that feedback correlated to their learning goals, and improve their perceptions of feedback received. : In this multisite study, third-year medical students on their pediatric clerkship created individualized learning plans and shared them with residents and attendings by writing a learning goal on at least one of their required faculty feedback forms. The quality of feedback on forms with versus without a learning goal written on top was scored using a validated scoring tool and compared using a Wilcoxon signed-ranks test, and the frequency with which feedback directly correlated to a student learning goal on forms with versus without a learning goal written on top was compared using a chi-square test. Students completed a post-clerkship survey rating the quality of feedback and teaching they received, perceptions of the individualized learning plans, progress toward achieving learning goals, and whether or not they received teaching and/or feedback related to learning goals. : Thirty-six students completed a total of 108 learning goals and 181 feedback forms, of which 42 forms (23.2%) had a learning goal written on top. The mean () feedback score between forms with [3.9 (0.9)] versus without [3.6 (0.6)] a learning goal written on top was not different ( = .113). Feedback on forms with a learning goal written on top was more likely to correlate to a student learning goal than feedback on forms without a learning goal (92.9% vs 23.0% respectively, < .001). Student perceptions of the usefulness of learning goals did not differ between students who reported receiving teaching or feedback related to a learning goal and those who did not. : Sharing individualized learning plans with preceptors helped align feedback with learning goals but did not affect the quality of feedback. Further research should examine the bidirectional relationship between individualized learning plans and feedback in light of other contextual and interpersonal factors.
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http://dx.doi.org/10.1080/10401334.2020.1713790DOI Listing
August 2021

Relationship of Children's Emotional and Behavioral Disorders With Health Care Utilization and Missed School.

Acad Pediatr 2020 07 19;20(5):687-695. Epub 2020 Feb 19.

Department of Pediatrics, Wright State University (NL Vish and A Stolfi), Dayton, Ohio.

Objective: To assess the association between emotional and behavioral disorders (EBD), missed school days and health care visits while controlling for sociodemographic factors, and comorbid medical conditions in a nationally representative sample.

Methods: Data from the 2016 National Health Interview Survey were used to assess the associations between EBD, in children aged 4 to 11 and 12 to 17 years, on missed days of school, health care office visits, and emergency department visits. EBD was assessed utilizing a validated screener. Multiple logistic regression was used to control for comorbid medical conditions and sociodemographic factors.

Results: Adolescents who screened positive for anxiety, depression, peer problems, and severe impairment had 4 to 8 times the odds of missing more school than their peers that screened negative. Young children with anxiety had 4 times increased odds of missing more school whereas positive emotional and behavioral health was protective against missing school. Young children and adolescents who screened positive for anxiety, depression, and severe impairment had 3 to 6 and 2 to 4 times the odds of more office visits respectively. Emergency department utilization was significantly increased in adolescents with anxiety and younger children with severe impairment.

Conclusions: This study shows that children with EBD are more likely to have increased office visits and missed days of school, even after adjusting for sociodemographic factors and comorbid medical conditions. Recognition of early associations of EBD can create an opportunity for early identification of children with EBD in the pediatric practice.
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http://dx.doi.org/10.1016/j.acap.2020.02.017DOI Listing
July 2020

Risk Behaviors in Teens with Chronic Kidney Disease: A Study from the Midwest Pediatric Nephrology Consortium.

Int J Nephrol 2019 4;2019:7828406. Epub 2019 Dec 4.

Department of Pediatrics, Wright State University, Dayton, OH, USA.

Introduction: There is a paucity of information about risk behaviors in adolescents with chronic kidney disease (CKD). We designed this study to assess the prevalence of risk behaviors among teens with CKD in the United States and to investigate any associations between risk behavior and patient or disease characteristics.

Methods: After informed consent, adolescents with CKD completed an anonymous, confidential, electronic web-based questionnaire to measure risk behaviors within five domains: sex, teen driving, alcohol and tobacco consumption, illicit drug use, and depression-related risk behavior. The reference group was composed of age-, gender-, and race-matched US high school students.

Results: When compared with controls, teens with CKD showed significantly lower prevalence of risk behaviors, except for similar use of alcohol or illicit substances during sex (22.5% vs. 20.8%, =0.71), feeling depressed for ≥2 weeks (24.3% vs. 29.1%, =0.07), and suicide attempt resulting in injury needing medical attention (36.4% vs. 32.5%, =0.78). Furthermore, the CKD group had low risk perception of cigarettes (28%), alcohol (34%), marijuana (50%), and illicit prescription drug (28%). Use of two or more substances was significantly associated with depression and suicidal attempts ( < 0.05) among teens with CKD.

Conclusions: Teens with CKD showed significantly lower prevalence of risk behaviors than controls. Certain patient characteristics were associated with increased risk behaviors among the CKD group. These data are somewhat reassuring, but children with CKD still need routine assessment of and counselling about risk behaviors.
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http://dx.doi.org/10.1155/2019/7828406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914908PMC
December 2019

Findings of metabolic bone disease in infants with unexplained fractures in contested child abuse investigations: a case series of 75 infants.

J Pediatr Endocrinol Metab 2019 Oct;32(10):1103-1120

Clinical Radiologists, SC, Springfield, IL, USA.

Background Infants who present with multiple unexplained fractures (MUF) are often diagnosed as victims of child abuse when parents deny wrongdoing and cannot provide a plausible alternative explanation. Herein we describe evidence of specific and commonly overlooked radiographic abnormalities and risk factors that suggest a medical explanation in such cases. Methods We evaluated such infants in which we reviewed the radiographs for signs of poor bone mineralization. We reviewed medical, pregnancy and family histories. Results Seventy-five of 78 cases showed poor bone mineralization with findings of healing rickets indicating susceptibility to fragility fractures that could result from a wide variety of causes other than child abuse. We found risk factors that could explain the poor bone mineralization: maternal and infant vitamin D deficiency (VDD), decreased fetal bone loading, prematurity and others. Most infants had more than one risk factor indicating that this bone disorder is a multifactorial disorder that we term metabolic bone disease of infancy (MBDI). Maternal and infant VDD were common. When tested, 1,25-dihydroxyvitamin D levels were often elevated, indicating metabolic bone disease. Conclusions Child abuse is sometimes incorrectly diagnosed in infants with MUF. Appreciation of the radiographic signs of MBDI (healing rickets), risk factors for MBDI and appropriate laboratory testing will improve diagnostic accuracy in these cases.
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http://dx.doi.org/10.1515/jpem-2019-0093DOI Listing
October 2019

Physician Advance Care Planning Experiences and Beliefs by General Specialty Status and Sex.

South Med J 2018 12;111(12):721-726

From the Departments of Family Medicine, Population and Public Health Sciences, and Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Objectives: Advance care planning (ACP) involvement could be substantially different by physician specialty or sex group, with implications for training and methods to increase ACP activities. The objective of this article is to compare primary care physicians (PCPs) and other specialty physicians and female compared with male physicians' views and interactions surrounding ACP.

Methods: This was a secondary analysis of an online anonymous survey distributed through a survey link to healthcare providers in hospital, ambulatory, and hospice settings in the greater Dayton, Ohio area in preparation for a community-wide advance care planning multitiered intervention. The measures included demographic data and questions regarding personal ACP decisions/experiences, opinions surrounding ACP in healthcare settings, and willingness to facilitate ACP with patients.

Results: There were 129 physician respondents, of which 39 (30.2%) were PCPs, and 33 (25.6%) were women. Most expressed interest in ACP, responding positively to a desire for more training, and approximately 25% were willing to be trained to teach others. The respondents by specialty group were similar in age and race, the presence or absence of religious affiliation, and stated frequency of ACP conversations. More than half (52.5%) reported having ACP conversations at least twice per month. The female physicians were younger and more likely to be in primary care. Female physicians also were more likely to discuss ACP with patients ( = 0.017), report formal training for ACP ( = 0.025), and be more willing to permit other healthcare provider types to be involved with ACP. PCPs reported time as a barrier more frequently than specialty physicians ( = 0.012). Other barriers to ACP were reported, including space, personal discomfort, and concerns about patient or family distress or disagreement.

Conclusions: Many physicians, regardless of specialty type or sex, are interested in undertaking more ACP conversations and being trained to do so. Overall, more female physicians than male physicians were involved and interested in various aspects of ACP, and they were more accepting of the involvement of nonphysician healthcare professionals in ACP. Multiple barriers for clinicians, patients, and families were identified that will need to be addressed by work settings or through education to increase ACP.
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http://dx.doi.org/10.14423/SMJ.0000000000000903DOI Listing
December 2018

Risk Factors for Cervical Pain in F-15C Pilots.

Aerosp Med Hum Perform 2017 Nov;88(11):1000-1007

Introduction: Many fighter pilots report cervical pain during their careers. Etiology likely relates to +Gz exposure, physical positioning with maneuvers, and varying load associated with headgear. We evaluated whether selected risk factors predicted cervical pain in this population.

Methods: An Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant, controlled crossover study of the use of home cervical traction was undertaken with 20 male F-15C pilots. We recorded pilot age (mean 38 yr, range 34-49), total high-G hours (2338 h, range 1038-4645), and previous neck problems and measured cervical range of motion. For 12 wk, pilots logged pre- and postflight pain, whether the Joint Helmet Mounted Cueing System (JHMCS) was employed, maximum +Gz experienced, and sortie duration. Pain with and without JHMCS was compared using paired t-tests and correlations assessed with Pearson or Spearman coefficients.

Results: Mean flight-related pain increased by 0.73 on the numerical rating scale with JHMCS and 0.52 without. Neck extension coupled with JHMCS use correlated negatively with increased pain (r = -0.551). Higher numbers of previously reported neck problems correlated with pain when using JHMCS (r = 0.629). Age, maximum +Gz per sortie, total high-Gz hours flown, and hours per sortie did not correlate.

Discussion: To our knowledge, this is the first prospective evaluation of risk factors for fighter pilots' cervical pain. Neck pain was significantly worse with JHMCS use and with flexed posture or history of prior neck problems combined with JHMCS use. This information will help guide countermeasure development for high-G pilots.Chumbley EM, Stolfi A, McEachen JC. Risk factors for cervical pain in F-15C pilots. Aerosp Med Hum Perform. 2017; 88(11):1000-1007.
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http://dx.doi.org/10.3357/AMHP.4848.2017DOI Listing
November 2017

Pilot Certification, Age of Pilot, and Drug Use in Fatal Civil Aviation Accidents.

Aerosp Med Hum Perform 2017 Oct;88(10):931-936

Introduction: This study examined the association between mean age of pilot, pilot license, pilot medical certificate and drug use trends in pilots fatally injured in aircraft accidents. The prevalence of prescription drugs, OTC drugs, controlled drugs and drugs that may be potentially impairing was also examined.

Methods: This study was a descriptive observational study in which the NTSB Aviation Accident Database was searched from the period beginning January 1, 2012 to December 31, 2014.

Results: During the study period a total of 706 accidents involving 711 fatalities were investigated by the NTSB. This study included 633 of these accidents, involving 646 fatalities. Of these pilots, 42.1% had drugs in their biological samples. The prevalence of prescription drugs, controlled drugs, OTC drugs, opioids, and potentially impairing drugs in the fatally injured pilot population over the study period was 28.9%, 15.0%, 20.1%, 5.1%, and 25.5%, respectively. Pilots with any drugs in their samples were significantly older than those without drugs. Medical certificate held was associated with drug use; pilots who held third class certificates had the highest prevalence at 54.1%. Pilot license was not associated with drug use. In 3.8% of the accidents, drugs were a contributing factor in the cause.

Discussion: Despite current FAA medical regulations, potentially impairing drugs are frequently found in biological samples of fatally injured pilots in the U.S. More education of airmen by aviation medical examiners is needed on the safety of drug use.Akparibo IY, Stolfi A. Pilot certification, age of pilot, and drug use in fatal civil aviation accidents. Aerosp Med Hum Perform. 2017; 88(10):931-936.
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http://dx.doi.org/10.3357/AMHP.4813.2017DOI Listing
October 2017

Cirrus Airframe Parachute System and Odds of a Fatal Accident in Cirrus Aircraft Crashes.

Aerosp Med Hum Perform 2017 Jun;88(6):556-564

Introduction: General aviation (GA) accidents have continued to demonstrate high fatality rates. Recently, ballistic parachute recovery systems (BPRS) have been introduced as a safety feature in some GA aircraft. This study evaluates the effectiveness and associated factors of the Cirrus Airframe Parachute System (CAPS) at reducing the odds of a fatal accident in Cirrus aircraft crashes.

Methods: Publicly available Cirrus aircraft crash reports were obtained from the National Transportation Safety Board (NTSB) database for the period of January 1, 2001-December 31, 2016. Accident metrics were evaluated through univariate and multivariate analyses regarding odds of a fatal accident and use of the parachute system.

Results: Included in the study were 268 accidents. For CAPS nondeployed accidents, 82 of 211 (38.9%) were fatal as compared to 8 of 57 (14.0%) for CAPS deployed accidents. After controlling for all other factors, the adjusted odds ratio for a fatal accident when CAPS was not deployed was 13.1.

Discussion: The substantial increased odds of a fatal accident when CAPS was not deployed demonstrated the effectiveness of CAPS at providing protection of occupants during an accident. Injuries were shifted from fatal to serious or minor with the use of CAPS and postcrash fires were significantly reduced. These results suggest that BPRS could play a significant role in the next major advance in improving GA accident survival.Alaziz M, Stolfi A, Olson DM. Cirrus Airframe Parachute System and odds of a fatal accident in Cirrus aircraft crashes. Aerosp Med Hum Perform. 2017; 88(6):556-564.
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http://dx.doi.org/10.3357/AMHP.4679.2017DOI Listing
June 2017

Adolescent Male Human Papillomavirus Vaccination.

Glob Pediatr Health 2016 26;3:2333794X16642373. Epub 2016 Apr 26.

Wright State University Boonshoft School of Medicine, Dayton, OH, USA; Dayton Children's Hospital, Dayton, OH, USA.

Objective. To determine male vaccination rates with quadrivalent human papillomavirus vaccine (HPV4) before and after the October 2011 national recommendation to routinely immunize adolescent males. Methods. We reviewed HPV4 dose 1 (HPV4-1) uptake in 292 adolescent males in our urban clinic prior to national recommendations and followed-up for HPV4 series completion rates. After national recommendation, 248 urban clinic and 247 suburban clinic males were reviewed for HPV4-1 uptake. Factors associated with HPV4-1 refusal were determined with multiple logistic regression. Results. Of the initial 292 males, 78% received HPV4-1 and 38% received the 3-dose series. After recommendation, HPV4-1 uptake was 59% and 7% in urban and suburban clinics, respectively. Variables associated with HPV4-1 uptake/refusal included time period, race, type of insurance, and receipt of concurrent vaccines. Conclusions. HPV4-1 vaccination rates in our urban clinic were high before and after routine HPV vaccine recommendations for adolescent males. Our vaccination rates were much higher than in a suburban practice.
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http://dx.doi.org/10.1177/2333794X16642373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4905155PMC
June 2016

Insulin and oral agents for managing cystic fibrosis-related diabetes.

Cochrane Database Syst Rev 2016 Apr 18;4:CD004730. Epub 2016 Apr 18.

Boonshoft School of Medicine, Wright State University, Room 105, Medical Sciences Building, 3640 Colonel Glenn Highway, Dayton, Ohio, USA, OH 45435.

Background: The Cystic Fibrosis Foundation recommends both short-term and long-acting insulin therapy when cystic fibrosis-related diabetes has been diagnosed. Diagnosis is based on: an elevated fasting blood glucose level greater than 6.94 mmol/liter (125 mg/deciliter); or oral glucose tolerance tests greater than 11.11 mmol/liter (200 mg/deciliter) at two hours; or symptomatic diabetes for random glucose levels greater than 11.11 mmol/liter (200 mg/deciliter); or glycated hemoglobin levels of at least 6.5%.

Objectives: To establish the effectiveness of insulin and oral agents for managing diabetes in people with cystic fibrosis in relation to blood sugar levels, lung function and weight management.

Search Methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also handsearched abstracts from pulmonary symposia and the North American Cystic Fibrosis Conferences.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 18 February 2016.

Selection Criteria: Randomized controlled trials comparing all methods of diabetes therapy in people with diagnosed cystic fibrosis-related diabetes.

Data Collection And Analysis: Two authors independently extracted data and assessed the risk of bias in the included studies.

Main Results: The searches identified 22 trials (34 references). Four trials (200 participants) are included: one short-term single-center trial (n = 7) comparing insulin with oral repaglinide and no medication in people with cystic fibrosis-related diabetes and normal fasting glucose; one long-term multicenter trial (n = 100, 74 of whom had cystic fibrosis-related diabetes) comparing insulin with oral repaglinide and placebo; one long-term multicenter trial (n = 73) comparing insulin with oral repaglinide; and one 12-week single-center trial (n = 20) comparing the long-acting insulin glargine to short-term neutral protamine Hagedorn insulin.Two trials with data for the comparison of insulin to placebo did not report any significant differences between groups for the primary outcomes of blood glucose levels, lung function and nutritional status. This was also true for the single trial with data for the comparison of repaglinide to placebo. Two trials (one lasting one year and one lasting two years) contributed data for the comparison of insulin versus repaglinide. There were no significant differences for the primary outcomes at any time point, except at one year (in the two-year trial) when the insulin group had significant improvement in z score for body mass index compared to the repaglinide group. The single trial comparing glargine to neutral protamine Hagedorn insulin also did not report any significant differences in the review's primary outcomes. A few cases of hypoglycemia were seen in three out of the four trials (none in the longest trial), but these events resolved without further treatment.There was an unclear risk of bias from randomization and allocation concealment in two of the four included trials as the authors did not report any details; in the remaining two studies details for randomization led to a low risk of bias, but only one had sufficient details on allocation concealment to allow a low risk judgement, the second was unclear. There was a high risk from blinding for all trials (except for the comparison of oral repaglinide versus placebo) due to the nature of the interventions. Complete data for all outcomes were not available from any trial leading to a high risk of reporting bias. The amounts of insulin and repaglinide administered were not comparable and this may lead to bias in the results. None of the included trials were powered to show a significant improvement in lung function.

Authors' Conclusions: This review has not found any significant conclusive evidence that long-acting insulins, short-acting insulins or oral hypoglycemic agents have a distinct advantage over one another in controlling hyperglycemia or clinical outcomes associated with cystic fibrosis-related diabetes. While some cystic fibrosis centers use oral medications to help control diabetes, the Cystic Fibrosis Foundation (USA) clinical practice guidelines support the use of insulin therapy and this remains the most widely-used treatment method. Randomized controlled trials specifically related to controlling diabetes with this impact on the course of pulmonary disease process in cystic fibrosis continue to be a high priority.There is no demonstrated advantage yet established for using oral hypoglycemic agents over insulin, and further trials need to be evaluated to establish whether there is clear benefit for using hypoglycemic agents. Agents that potentiate insulin action, especially agents with additional anti-inflammatory potential should be further investigated to see if there may be a clinical advantage to adding these medications to insulin as adjuvant therapy.
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http://dx.doi.org/10.1002/14651858.CD004730.pub4DOI Listing
April 2016

Stinging insect identification: Are the allergy specialists any better than their patients?

Ann Allergy Asthma Immunol 2016 05 16;116(5):431-4. Epub 2016 Mar 16.

The Children's Hospital of San Antonio, San Antonio, Texas.

Background: It has been reported that the general population is not skillful at identifying stinging insects with the exception of the honeybee. No information is available to evaluate allergy physicians' accuracy with stinging insect identification.

Objective: To measure the accuracy of allergists' ability to identify stinging insects and assess their common practices for evaluating individuals with suspected insect hypersensitivity.

Methods: A picture-based survey and a dried specimen insect box were constructed to determine allergists' and nonallergists' accuracy in identifying insects. Allergists attending the 2013 American College of Allergy, Asthma, and Immunology meeting were invited to participate in the study. Common practice approaches for evaluating individuals with stinging insect hypersensitivity were also investigated using a brief questionnaire.

Results: Allergy physicians are collectively better at insect identification than nonallergists. Overall, the mean (SD) number of correct responses for nonallergists was 5.4 (2.0) of a total of 10. This score was significantly lower than the score for allergists (6.1 [2.0]; P = .01) who participated in the study. Most allergists (78.5%) test for all stinging insects and use skin testing (69.5%) as the initial test of choice for evaluating individuals with insect hypersensitivity.

Conclusion: Overall, allergists are more skilled at Hymenoptera identification. Most allergy specialists reported testing for all stinging insects when evaluating insect hypersensitivity, and skin testing was the preferred testing method in nearly 70% of allergists. These data support the practice parameter's recommendation to consider testing for all flying Hymenoptera insects during venom evaluation, which most of the participating allergists surveyed incorporate into their clinical practice.
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http://dx.doi.org/10.1016/j.anai.2016.01.025DOI Listing
May 2016

Home Cervical Traction to Reduce Neck Pain in Fighter Pilots.

Aerosp Med Hum Perform 2016 Dec;87(12):1010-1015

U.S. Air Force School of Aerospace Medicine, Wright-Patterson AFB, OH, USA.

Introduction: Most fighter pilots report cervical pain during their careers. Recommendations for remediation lack evidence. We sought to determine whether regular use of a home cervical traction device could decrease reported cervical pain in F-15C pilots.

Methods: An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant, controlled crossover study was undertaken with 21 male F-15C fighter pilots between February and June 2015. Of the 21 subjects, 12 completed 6 wk each of traction and control, while logging morning, postflying, and post-traction pain. Pain was compared with paired t-tests between the periods, from initial pain scores to postflying, and postflying to post-traction.

Results: In the traction phase, initial pain levels increased postflight, from 1.2 (0.7) to 1.6 (1.0) Subsequent post-traction pain levels decreased to 1.3 (0.9), with a corresponding linear decrease in pain relative to pain reported postflight. The difference in pain levels after traction compared to initial levels was not significant, indicating that cervical traction was effective in alleviating flying-related pain. Control pain increased postflight from 1.4 (0.9) to 1.9 (1.3). Daily traction phase pain was lower than the control, but insignificant.

Discussion: To our knowledge, this is the first study of home cervical traction to address fighter pilots' cervical pain. We found a small but meaningful improvement in daily pain rating when using cervical traction after flying. These results help inform countermeasure development for pilots flying high-performance aircraft. Further study should clarify the optimal traction dose and timing in relation to flying.Chumbley EM, O'Hair N, Stolfi A, Lienesch C, McEachen JC, Wright BA. Home cervical traction to reduce neck pain in fighter pilots. Aerosp Med Hum Perform. 2016; 87(12):1010-1015.
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http://dx.doi.org/10.3357/AMHP.4625.2016DOI Listing
December 2016

Associations Between Parental Health Literacy, Use of Asthma Management Plans, and Child's Asthma Control.

Clin Pediatr (Phila) 2016 Feb 20;55(2):111-7. Epub 2015 May 20.

Wright State University Boonshoft School of Medicine, Dayton, OH, USA

Background: There are some studies demonstrating the effectiveness of the provision of written asthma action plans in improving asthma outcomes. There exist little data on the ability of parents to use these plans to make asthma care decisions.

Objective: To assess the associations between parental health literacy (HL), parental ability to use a written asthma management plan (WAMP), and child's asthma control.

Methods: Parents completed a survey with questions related to WAMPs and child's asthma, a HL screening tool, and 5 asthma vignettes. For vignettes, parents identified asthma control zone and then made decisions about asthma management. WAMP scores were totaled (0-32) and converted to a percent correct score. Associations between parental HL, WAMP scores, child's asthma control, and demographics were determined with independent t tests or 1-way analysis of variance, and chi-square tests. Variables significantly associated with WAMP scores or asthma control were included in multiple logistic regression or multiple linear regression analyses.

Results: A total of 176 surveys were included; the mean ± SD WAMP score was 58.9% ± 22.2%, and 25% of respondents had limited HL. Of respondents' children, 38% had not well/poorly controlled asthma. In multiple regression analysis controlling for education level, limited HL was significantly associated with WAMP score (b = 11.3, standard error 3.8, P = .004). WAMP score was not associated with asthma control. Limited HL was associated with poor asthma control in univariate analysis, but not in a logistic regression model controlling for other significant variables. Only unmarried marital status (adjusted odds ratio 4.4, 95% CI 1.8-10.8, P = .001) was associated with asthma control.

Conclusion: HL is associated with parental ability to use WAMPs to respond to asthma scenarios. Parental HL may play a role in parents' ability to appropriately use WAMPs.
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http://dx.doi.org/10.1177/0009922815587089DOI Listing
February 2016

Urine toxicology screen in multiple sleep latency test: the correlation of positive tetrahydrocannabinol, drug negative patients, and narcolepsy.

J Clin Sleep Med 2015 Jan 15;11(2):93-9. Epub 2015 Jan 15.

Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.

Objective: Drugs can influence results of multiple sleep latency tests (MSLT). We sought to identify the effect of marijuana on MSLT results in pediatric patients evaluated for excessive daytime sleepiness (EDS).

Methods: This is a retrospective study of urine drug screens performed the morning before MSLT in 383 patients <21 years old referred for EDS. MSLT results were divided into those with (1) (-) urine drug screens, (2) urine drug screens (+) for tetrahydrocannabinol (THC) alone or THC plus other drugs, and (3) urine drug screens (+) for drugs other than THC. Groups were compared with Fisher exact tests or one-way ANOVA.

Results: 38 (10%) urine drug tests were (+): 14 for THC and 24 for other drugs. Forty-three percent of patients with drug screen (+) for THC had MSLT findings consistent with narcolepsy, 0% consistent with idiopathic hypersomnia, 29% other, and 29% normal. This was statistically different from those with (-) screens (24% narcolepsy, 20% idiopathic hypersomnia, 6% other, 50% normal), and those (+) for drugs other than THC (17% narcolepsy, 33% idiopathic hypersomnia, 4% other, 46% normal (p = 0.01). Six percent (6/93) of patients with MSLT findings consistent with narcolepsy were drug screen (+) for THC; 71% of patients with drug screen (+) for THC had multiple sleep onset REM periods (SOREMS). There were no (+) urine drug screens in patients <13 years old.

Conclusion: Many pediatric patients with (+) urine drug screens for THC met MSLT criteria for narcolepsy or had multiple SOREMs. Drug screening is important in interpreting MSLT findings for children ≥13 years.
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http://dx.doi.org/10.5664/jcsm.4448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4298782PMC
January 2015

The HIT study: Hymenoptera Identification Test--how accurate are people at identifying stinging insects?

Ann Allergy Asthma Immunol 2014 Sep 23;113(3):267-70. Epub 2014 Jun 23.

Wright-Patterson Medical Center, Wright-Patterson Air Force Base, Ohio.

Background: Stinging insects in the order Hymenoptera include bees, wasps, yellow jackets, hornets, and ants. Hymenoptera sting injuries range from localized swelling to rarely death. Insect identification is helpful in the management of sting injuries.

Objective: To determine the accuracy of adults in identifying stinging insects and 2 insect nests.

Methods: This was a cross-sectional, multicenter study using a picture-based survey to evaluate an individual's success at identifying honeybees, wasps, bald-face hornets, and yellow jackets. Bald-face hornet and paper wasp nest identification also was assessed in this study.

Results: Six hundred forty participants completed the questionnaire. Overall, the mean number of correct responses was 3.2 (SD 1.3) of 6. Twenty participants (3.1%) correctly identified all 6 stinging insects and nests and only 10 (1.6%) were unable to identify any of the pictures correctly. The honeybee was the most accurately identified insect (91.3%) and the paper wasp was the least correctly identified insect (50.9%). For the 6 questions regarding whether the participant had been stung in the past by any of the insects (including an unidentified insect), 91% reported being stung by at least 1. Men were more successful at identify stinging insects correctly (P = .002), as were participants stung by at least 4 insects (P = .018).

Conclusion: This study supports the general perception that adults are poor discriminators in distinguishing stinging insects and nests with the exception of the honeybee. Men and those participants who reported multiple stings to at least 4 insects were more accurate overall in insect identification.
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September 2014

Tobacco exposure in children and adolescents with chronic kidney disease: parental behavior and knowledge. A study from the Midwest Pediatric Nephrology Consortium.

Clin Nephrol 2014 May;81(5):307-12

Wright State University, Dayton, OH, Rush Children's Hospital, Chicago, IL, The Children's Hospital of Philadelphia, Division of Nephrology, Philadelphia, PA, University of Michigan, School of Medicine, Ann Arbor, MI, Nationwide Children's Hospital, Division of Nephrology, Columbus, OH, and University of Kentucky Children's Hospital, Division of Nephrology, Hypertension & Renal Transplantation, Lexington, KY, USA.

Aim: The incidence of cardiovascular disease (CVD) in children with chronic kidney disease (CKD) is high. Exposure to second hand smoke (SHS) is a known risk factor for CVD. Due to a recent report of high incidence of SHS in children with CKD, we sought to investigate via questionnaire the smoking behaviors of caregivers of children with CKD.

Material And Methods: A cross sectional study was conducted in which caregivers of children and adolescents with CKD were asked to complete a single anonymous self-administered survey.

Results: Almost 40% of children and adolescents lived with one or more smokers. Over half of smokers smoked in the presence of their children and in the car. Smokers were significantly less aware of the detrimental effect of SHS exposure on the renal health of their children. Among smokers, almost 70% reported they had not been advised by their child's nephrologist to quit tobacco use.

Conclusion: There is a high prevalence of SHS exposure among children and adolescents with CKD, which may contribute to CVD. Caregivers are not fully aware of the detrimental effects of SHS exposure on the renal health of their children.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504134PMC
http://dx.doi.org/10.5414/cn108024DOI Listing
May 2014

Insulin and oral agents for managing cystic fibrosis-related diabetes.

Cochrane Database Syst Rev 2013 Jul 26(7):CD004730. Epub 2013 Jul 26.

Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA.

Background: The Cystic Fibrosis Foundation recommends both short-term and long-acting insulin therapy when cystic fibrosis-related diabetes has been diagnosed. Diagnosis is based on: an elevated fasting blood glucose level greater than 6.94 mmol/liter (125 mg/deciliter); or symptomatic diabetes for random glucose levels greater than 11.11 mmol/liter (200 mg/deciliter); or glycated hemoglobin levels of at least 6.5%.

Objectives: To establish the effectiveness of agents for managing diabetes in people with cystic fibrosis in relation to blood sugar levels, lung function and weight management.

Search Methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also handsearched abstracts from pulmonary symposia and the North American Cystic Fibrosis Conferences.Date of the most recent search of the Group's Cystic Fibrosis Trials Register: 22 July 2013.

Selection Criteria: Randomized controlled trials comparing all methods of diabetes therapy in people with diagnosed cystic fibrosis-related diabetes.

Data Collection And Analysis: Two authors independently extracted data and assessed the risk of bias in the included studies.

Main Results: The searches identified 19 studies (28 references). Three studies (107 participants) are included: one comparing insulin with oral repaglinide and no medication (short-term single-center study of seven patients with cystic fibrosis-related diabetes and normal fasting glucose); one comparing insulin with oral repaglinide and placebo (long-term multi-center study with 81 patients, 61 of whom had cystic fibrosis-related diabetes); and one 12-week single-center study comparing the long-acting insulin, glargine to short-term neutral protamine Hagedorn insulin. The long-term trial of insulin and repaglinide demonstrated no significant difference between treatments. In the smaller study comparing insulin and oral repaglinide, there were two incidents of significant hypoglycemia in the insulin group compared to one in the repaglinide group; in the larger study there were five incidents of significant hypoglycemia in the insulin group and six in the repaglinide group. The study comparing glargine to neutral protamine Hagedorn insulin demonstrated a statistically non-significant weight increase in with longer-acting insulin given at bedtime and reported a mean of six hypoglycemia events in the glargine group compared to five events in the neutral protamine Hagedorn insulin group. None of the three included studies were powered to show a significant improvement in lung function.

Authors' Conclusions: This review has not found any significant conclusive evidence that long-acting insulins, short-acting insulins or oral hypoglycemic agents have a distinct advantage over one another in controlling hyperglycemia or clinical outcomes associated with cystic fibrosis-related diabetes. While some cystic fibrosis centers use oral medications to help control diabetes, the Cystic Fibrosis Foundation (USA) clinical practice guidelines support the use of insulin therapy and this remains the most widely-used treatment method. Randomized controlled trials specifically related to controlling diabetes with this impact on the course of pulmonary disease process in cystic fibrosis continue to be a high priority.There is no demonstrated advantage yet established for using oral hypoglycemic agents over insulin, and further studies need to be evaluated to establish whether there is clear benefit for using hypoglycemic agents. Agents that potentiate insulin action, especially agents with additional anti-inflammatory potential should be further investigated to see if there may be a clinical advantage to adding these medications to insulin as adjuvant therapy.
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http://dx.doi.org/10.1002/14651858.CD004730.pub3DOI Listing
July 2013

Effects of hyperbaric oxygen on motor function in children with cerebral palsy.

Ann Neurol 2012 Nov 15;72(5):695-703. Epub 2012 Oct 15.

Department of Neurology, Children's Medical Center of Dayton, Dayton, OH, USA.

Objective: We conducted a randomized, double-blind, controlled clinical trial to determine whether hyperbaric oxygen (HBO) improves gross motor function in children with cerebral palsy.

Methods: Forty-nine children aged 3 to 8 years with spastic cerebral palsy were randomized to 40 treatments of HBO (100% oxygen at 1.5atm) or hyperbaric air (HBA, 14% oxygen at 1.5atm) over an 8-week period. The primary outcome was the Gross Motor Function Measure (GMFM) global score. Other outcomes included the Pediatric Evaluation of Disability Inventory (PEDI). Assessments were made before and immediately, 3 months, and 6 months after the treatment period. Within-group changes were analyzed with paired t tests or repeated measures analysis of variance. Analysis of covariance was used for between-group comparisons.

Results: Forty-six children (24 HBO, 22 HBA) were analyzed at the second interim analysis, which was scheduled to take place when at least half of the required number of patients in each group had completed pre- and post-treatment testing. No changes occurred in the GMFM from pre- to post-treatment in either group or between groups. Statistically significant increases occurred in both groups on the PEDI, with no difference between groups. The study was stopped because the calculated conditional probability of obtaining a difference between groups if the study continued to the end was only between 0.5% and 1.6%.

Interpretation: HBO was not effective in improving GMFM scores, and was no more effective than HBA in improving PEDI scores. These results do not support use of HBO as a therapy for cerebral palsy in young children who did not have neonatal hypoxic-ischemic encephalopathy.
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http://dx.doi.org/10.1002/ana.23681DOI Listing
November 2012

Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*.

Pediatr Crit Care Med 2012 Nov;13(6):e343-9

Pediatric Critical Care, Dayton Children's Medical Center, Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.

Objectives: Viral bronchiolitis is an acute infection and inflammatory disease of the respiratory tract, with infants typically presenting with the most severe symptoms. Medical management of bronchiolitis is mostly supportive. Several preliminary studies suggest potential benefit from the use of high-flow nasal cannula systems. Although high-flow nasal cannula is a well-established modality in the newborn intensive care unit, its use in the pediatric intensive care unit for acute respiratory failure is far less established. The objective of this study was to identify any laboratory and clinical variables that may predict high-flow nasal cannula failure in management of bronchiolitis in the pediatric intensive care unit.

Design: The study design was a retrospective chart review of all patients admitted to the pediatric intensive care unit from 2006 to 2010 with a diagnosis of viral bronchiolitis. Inclusion criteria included the initiation of high flow nasal cannula therapy at the time of admission and age ≤ 12 months. Exclusion criteria were intubation prior to admission, age >12 months, and the presence of a tracheostomy.

Patients: A total of 113 patients with viral bronchiolitis met the inclusion criteria.

Setting: Academic free standing Children's Hospital in the Midwest.

Interventions: Retrospective chart review.

Measurements And Main Results: The data were analyzed by comparing those patients who responded to high-flow nasal cannula (n = 92) with those who were nonresponders to high-flow nasal cannula and required intubation (n = 21). No differences were noted between the groups for age, sex, or ethnicity. Mean weight and weight-for-corrected-age percentiles were significantly lower for patients who failed high-flow nasal cannula (p = .016 and .031, respectively), but weight-for-corrected-age percentile was not significant in logistic regression controlling for other variables. Respiratory rate prior to the initiation of high-flow nasal cannula also correlated strongly with respiratory deterioration (p < .001). The PCO2 was significantly higher for both before (p < .001) and after (p < .001) initiation of therapy in the nonresponder group. Pediatric Risk of Mortality III scores for the patients who failed high-flow nasal cannula were significantly higher (p < .001) than those of patients who tolerated this therapy.

Conclusions: History of prematurity and the patient's age did not increase a patient's risk of failure. Nonresponders to high-flow nasal cannula therapy were on the onset, more hypercarbic, were less tachypnic prior to the start of high-flow nasal cannula, and had no change in their respiratory rate after the initiation of high-flow nasal cannula therapy. Nonresponders had higher pediatric risk of mortality scores in the first 24 hrs.
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http://dx.doi.org/10.1097/PCC.0b013e31825b546fDOI Listing
November 2012

Alterations in the gut microbiome of children with severe ulcerative colitis.

Inflamm Bowel Dis 2012 Oct 14;18(10):1799-808. Epub 2011 Dec 14.

Department of Pediatric Gastroenterology and Nutrition, University of Southern California, Los Angeles, California 90027, USA.

Background: Although the role of microbes in disease pathogenesis is well established, data describing the variability of the vast microbiome in children diagnosed with ulcerative colitis (UC) are lacking. This study characterizes the gut microbiome in hospitalized children with severe UC and determines the relationship between microbiota and response to steroid therapy.

Methods: Fecal samples were collected from 26 healthy controls and 27 children hospitalized with severe UC as part of a prospective multicenter study. DNA extraction, polymerase chain reaction (PCR) amplification of bacterial 16S rRNA, and microarray hybridization were performed. Results were analyzed in GeneSpring GX 11.0 comparing healthy controls with children with UC, and steroid responsive (n = 17) with nonresponsive patients (n = 10).

Results: Bacterial signal strength and distribution showed differences between UC and healthy controls (adjusted P < 0.05) for Phylum, Class, Order, Family, Genus, and Phylospecies levels with reduction in Clostridia and an increase in Gamma-proteobacteria. The number of microbial phylospecies was reduced in UC (266 ± 69) vs. controls (758 ± 3, P < 0.001), as was the Shannon Diversity Index (6.1 ± 0.23 vs. 6.49 ± 0.04, respectively; P < 0.0001). Steroid nonresponders harbored fewer phylospecies than responders (142 ± 49 vs. 338 ± 62, P = 0.013).

Conclusions: Richness, evenness, and biodiversity of the gut microbiome were remarkably reduced in children with UC compared with healthy controls. Children who did not respond to steroids harbored a microbiome that was even less rich than steroid responders. This study is the first to characterize the gut microbiome in a large cohort of pediatric patients with severe UC and describes changes in the gut microbiome as a potential prognostic feature.
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http://dx.doi.org/10.1002/ibd.22860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3319508PMC
October 2012

The TEN study: time epinephrine needs to reach muscle.

Ann Allergy Asthma Immunol 2011 Sep 23;107(3):235-8. Epub 2011 Jul 23.

Department of Medicine, Division of Allergy and Immunology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas 78236, USA.

Background: An epinephrine autoinjector (EAI) is designed to deliver epinephrine into the vastus lateralis muscle. Several studies have demonstrated both patient and physician difficulties in correctly using EAIs, specifically premature removal of the device from the thigh.

Objective: To evaluate the correlation between duration of injection with an EAI and amount of epinephrine absorbed into muscle tissue.

Methods: Twenty-one EAI devices (0.3 mL) were used to determine the amount of epinephrine injected into marbleized beef during 7 time periods. A digital scale was used to record preinjection and postinjection weights of EAIs and beef. The weight difference between the preinjection and postinjection periods of the EAIs was used to calculate the total amount of epinephrine released and available for absorption into the marbleized beef. The difference between the preinjection and postinjection beef weight was used to determine the amount of epinephrine absorbed into the meat.

Results: The correlation with duration of injection for both the amount of epinephrine absorbed and released was 0.321 (P = .48). At all intervals, 95.9% or more of epinephrine was absorbed into the marbleized beef. The correlation with duration of injection and percent of epinephrine absorbed was 0.464 (P = .29). There were no time periods that were significantly different from the percentage of epinephrine absorbed by the marbleized beef at 10 seconds (analysis of variance P = .16).

Conclusion: No linear relationship between time and amount of epinephrine injected or absorbed into muscle tissue was demonstrated. These data suggest that holding the device in place for 1 second is as effective as 10 seconds.
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http://dx.doi.org/10.1016/j.anai.2011.06.001DOI Listing
September 2011

Parents' perceptions of their children's weight, eating habits, and physical activities at home and at school.

J Pediatr Health Care 2011 Sep-Oct;25(5):294-301. Epub 2010 Jun 9.

Boonshoft School ofMedicine, Wright StateUniversity, Dayton, OH 45404-1815, USA.

Introduction: Parental perceptions of their young children's weight and habits may play an important role in determining whether children develop and maintain healthy lifestyles. This study was conducted to determine perceptions of parents of third-grade children in an urban school setting regarding their children's weight, eating habits, and physical activities.

Methods: Parents anonymously completed surveys about their child's weight, eating habits, and daily activities. The survey also asked about how schools could encourage healthy eating and increased physical activity.

Results: Overall, 26% of the parents perceived their child to be overweight and expressed concern, but 40% of these parents believed that overweight is a condition that will be outgrown. Parents who reported eating more than eight meals per week with their child were less likely to report their child as overweight and more likely to believe that their child's physical activity level was appropriate.

Discussion: Most parents of third-grade students demonstrated concern regarding their child's weight and perceive obesity as a problem. Parents support school interventions such as nutrition education and fitness classes.
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http://dx.doi.org/10.1016/j.pedhc.2010.05.003DOI Listing
December 2011

Weight loss in humans in space.

Aviat Space Environ Med 2011 Jun;82(6):615-21

Japan Aerospace Exploration Agency, Tsukuba, Japan.

Introduction: Bodyweight loss during spaceflight has been observed among astronauts since the early space missions. Considerable mission data has been accumulated, including data from female astronauts, on the many Shuttle and International Space Station missions. The purpose of this study was to investigate the association between observed weight loss during spaceflight and potential covariate factors.

Methods: We performed a statistical analysis of the association between bodyweight change and plausible clinical and mission covariates, using data obtained from the NASA Longitudinal Study of Astronaut Health (LSAH).

Results: We confirmed that spaceflight is associated with weight change (-2.1 +/- 0.1%, N = 514). Prospective predictors of weight loss included: being a first-time astronaut, preflight bodyweight and BMI, routinely performing preflight exercise sessions lasting greater than 1 h, and baseline levels of cholesterol, potassium, and chloride. Severe space motion sickness was significantly associated with greater weight loss. Unexpectedly, a higher number of extravehicular activities per mission protected against weight loss. Mission duration had the strongest association with bodyweight change (-2.4 +/- 0.4% per 100 d in space).

Discussion: On average, space missions are associated with cumulative loss of bodyweight over time. Unless effective countermeasures are implemented, significant weight loss will be a likely outcome in a subset of astronauts as mission durations increase. New predictors of intra-mission bodyweight changes and other associated factors are identified.
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http://dx.doi.org/10.3357/asem.2792.2011DOI Listing
June 2011
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