Publications by authors named "Mary Roberts"

271 Publications

Maintenance of non-pharmacological strategies 6 months after patients with chronic obstructive pulmonary disease (COPD) attend a breathlessness service: a qualitative study.

BMJ Open 2021 05 13;11(5):e050149. Epub 2021 May 13.

Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, New South Wales, Australia.

Objectives: This study aimed to explore the degree to which non-pharmacological strategies for chronic breathlessness are sustained 6 months after completing a breathlessness service in patients with chronic obstructive pulmonary disease (COPD), and patient perceptions regarding the need for ongoing support.

Design: A qualitative approach was taken using semistructured telephone interviews. Thematic analysis used an integrative approach.

Setting: The Westmead Breathlessness Service (WBS) trains patients with COPD to self-manage chronic breathlessness over an 8-week programme with multidisciplinary input and home visits.

Participants: Patients with moderate to very severe COPD who had completed the WBS programme 6 months earlier.

Results: Thirty-two participants were interviewed. One or more breathlessness self-management strategies were sustained by most participants, including breathing techniques (n=22; 69%), the hand-held fan (n=17; 53%), planning/pacing and exercise (n=14 for each; 44%) and strategic use of a four-wheeled walker (n=8; 25%). However, almost a third of participants appeared to be struggling psychologically, including some who had refused psychological intervention. A 'chaos narrative' appeared to be prevalent, and many participants had poor recall of the programme.

Conclusions: Self-management strategies taught by breathlessness services to patients with moderate to very severe COPD have potential to be sustained 6 months later. However, psychological coping may be more challenging to maintain. Research is needed on ways to improve resilience to set-backs and uptake of psychological interventions, as well as to understand and address the implications of poor recall for self-management.

Trial Registration Number: ACTRN12617000499381.
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http://dx.doi.org/10.1136/bmjopen-2021-050149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126310PMC
May 2021

Citrus Consumption and the Risk of Non-Melanoma Skin Cancer in the Women's Health Initiative.

Cancers (Basel) 2021 Apr 30;13(9). Epub 2021 Apr 30.

Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.

Evidence from animal studies suggests that furocoumarins, compounds present in citrus products, can increase the risk of non-melanoma skin cancer (NMSC) when combined with ultraviolet radiation. The objective of this study was to determine the relationship between citrus intake and NMSC risk among postmenopausal women from the Women's Health Initiative (WHI) Observational Study, who were aged 50-79 years at enrollment (1993-1998). The consumption of citrus fruit, citrus juice, and non-citrus fruit and juice were measured at the baseline of the study using a food frequency questionnaire (FFQ). NMSC cases (basal or squamous cell carcinomas) were self-reported during annual follow-up surveys. The outcome data used for this analysis were collected through March 2020. The relative risk (RR) for incident NMSC by citrus consumption was calculated. Among 49,007 non-Hispanic white participants, there were 8642 cases of incident NMSC. Using less than one serving of citrus juice per week as reference, the RRs and 95% confidence intervals (CI) for incident NMSC by citrus juice intake were 1.03 (0.95, 1.10) for one serving/week, 1.06 (1.00, 1.12) for two to four servings/week, 0.98 (0.90, 1.07) for five to six servings/week, and 1.08 (1.02, 1.13) for one or more serving/day (-trend = 0.007). Subgroup analyses did not reveal meaningful associations by sun exposure variables. In conclusion, there were indications of a slightly higher risk of incident NMSC among citrus juice consumers; however, further longitudinal and mechanistic studies are needed to confirm the key risk factors.
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http://dx.doi.org/10.3390/cancers13092173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8125104PMC
April 2021

Living with Dementia in Aotearoa (LiDiA): a cross-sectional feasibility study protocol for a multiethnic dementia prevalence study in Aotearoa/New Zealand.

BMJ Open 2021 05 3;11(5):e046143. Epub 2021 May 3.

Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand

Introduction: Aotearoa/New Zealand (NZ) is officially recognised as a bicultural country composed of Māori and non-Māori. Recent estimations have projected a threefold increase in dementia prevalence in NZ by 2050, with the greatest increase in non-NZ-Europeans. The NZ government will need to develop policies and plan services to meet the demands of the rapid rise in dementia cases. However, to date, there are no national data on dementia prevalence and overseas data are used to estimate the NZ dementia statistics. The overall aim of the Living with Dementia in Aotearoa study was to prepare the groundwork for a large full-scale NZ dementia prevalence study.

Methods And Analysis: The study has two phases. In phase I, we will adapt and translate the 10/66 dementia assessment protocol to be administered in Māori, Samoan, Tongan and Fijian-Indian elders. The diagnostic accuracy of the adapted 10/66 protocol will be tested in older people from these ethnic backgrounds who were assessed for dementia at a local memory service. In phase II, we will address the feasibility issues of conducting a population-based prevalence study by applying the adapted 10/66 protocol in South Auckland and will include NZ-European, Māori, Samoan, Tongan, Chinese and Fijian-Indian participants. The feasibility issues to be explored are as follows: (1) how do we sample to ensure we get accurate community representation? (2) how do we prepare a workforce to conduct the fieldwork and develop quality control? (3) how do we raise awareness of the study in the community to maximise recruitment? (4) how do we conduct door knocking to maximise recruitment? (5) how do we retain those we have recruited to remain in the study? (6) what is the acceptability of study recruitment and the 10/66 assessment process in different ethnic groups?

Ethics And Dissemination: The validity and feasibility studies were approved by the New Zealand Northern A Health and Disability Ethics Committee (numbers 17NTA234 and 18NTA176, respectively). The findings will be disseminated through peer-reviewed academic journals, national and international conferences, and public events. Data will be available on reasonable request from the corresponding author.
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http://dx.doi.org/10.1136/bmjopen-2020-046143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8098966PMC
May 2021

The Lived Experience of Covid-19.

J Nurse Pract 2021 Apr 27. Epub 2021 Apr 27.

Duquesne University/Saint Francis University, Pittsburgh/Loretto, Pennsylvania.

The purpose of this qualitative study was to examine the essence of living with COVID-19. The researchers used a phenomenological research design and interviewed 14 individuals ages 18 and older during the pandemic's first wave. Data analysis using Colaizzi's method for analysis revealed two overarching themes: Physical Experiences and Psychological/Emotional experiences and eight subthemes which identify concerns that impact quality of life. The findings provide insights for nurses and health care providers on the experiences of living with COVID-19.
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http://dx.doi.org/10.1016/j.nurpra.2021.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075807PMC
April 2021

Strategies and techniques to enhance nurse practitioner learning.

J Am Assoc Nurse Pract 2021 May 21;33(5):339-341. Epub 2021 May 21.

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http://dx.doi.org/10.1097/JXX.0000000000000572DOI Listing
May 2021

Safe Use of Erythromycin For Refractory Gastroparesis After Small Bowel Transplantation.

Exp Clin Transplant 2021 Apr 16. Epub 2021 Apr 16.

From the the Intestinal Rehabilitation and Transplant Center, Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Current therapeutic options with prokinetic agents for posttransplant gastroparesis are limited. Erythromycin is associated with adverse reactions, including corrected QT interval prolongation and cytochrome P450 3A4 isoenzyme inhibition. The use of erythromycin has been avoided in patients undergoing treatment with cyclosporine or tacrolimus because of significant fluctuations in therapeutic immunosuppression levels. We report herein the successful use of erythromycin after visceral transplant to treat delayed gastric emptying. Two patients were managed with oral erythromycin (initial dose of 750 mg/d divided into 3 doses) for gastroparesis after visceral transplant. Patient 1 was a woman aged 42 years with a history of chronic intestinal pseudo-obstruction syndrome who underwent isolated small bowel transplant with dual (gastric and duodenal) proximal allograft anastomosis. Posttransplant gastroparesis was initially managed with oral metoclopramide. The patient also required high doses of tacrolimus (36 mg/d) to maintain adequate immunosuppression levels. The decision was made to change metoclopramide to erythromycin, which significantly decreased the daily tacrolimus dose requirement (from 36 to 9 mg/d), with resolution of nausea and intermittent bloating symptoms. Patient 2 was a woman aged 35 years with ultra-short gut syndrome after extensive enterectomy due to intestinal volvulus who underwent uneventful combined intestinal and colon transplant. Conventional pharmacologic therapy for gastroparesis was initiated after surgery without success. Erythromycin was started 15 days posttransplant, with significant improvement in her symptoms, and discontinued 47 days post-transplant. To maintain therapeutic levels (8-10 mg/dL), daily tacrolimus dose was decreased 75.8% and 36.5% for patients 1 and 2, respectively. No significant side effects associated with erythromycin use were observed in either patient. Our findings here suggest that erythromycin may be safely used for gastroparesis after small bowel transplant. Close monitoring of immunosuppressive drug levels and dose adjustments of other medications affected by inhibition of cytochrome P450 3A4 are advised.
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http://dx.doi.org/10.6002/ect.2020.0463DOI Listing
April 2021

Erosive Hand Osteoarthritis: Incidence and Predictive Characteristics among Participants in the Osteoarthritis Initiative.

Arthritis Rheumatol 2021 Apr 12. Epub 2021 Apr 12.

Care New England Medical Group/Primary Care and Specialty Services, Pawtucket, RI, USA.

Objective: To evaluate age, sex, race, osteoarthritis severity, metabolic factors, and bone health as risk factors for incident erosive hand osteoarthritis (EHOA) at baseline and over 48-month period.

Methods: This study was a longitudinal cohort design including participants from the Osteoarthritis Initiative with complete hand radiographs from baseline and 48-month visits who were eligible at baseline for incident EHOA. Individuals were classified as having EHOA if they had Kellgren-Lawrence (KL) grade≥2 in at least one interphalangeal joint on two different fingers and central erosion in at least one joint.

Results: Of the 3365 individuals identified without prevalent EHOA at baseline, 86 (2.6%) developed EHOA during the 48-month period. Risk factors included being older [relative risk (RR) per standard deviation=0.76 (95% confidence interval 0.59, 0.98)], female [RR=1.73 (1.05, 2.85)], greater osteoarthritis severity (sum of KL grade 13.9 vs. 5.3, p<0.001) and less cortical width (1.38 vs 1.52 mm, p<0.001). After 48 months, people who developed EHOA were characterized by greater progressions of radiographic osteoarthritis (i.e., joint space narrowing, KL grade progression [RRs = 1.35 to 1.9] and loss of cortical thickness [RR = 1.23], adjusted for age, sex, race, body mass index, and baseline osteoarthritis severity (sum KL scores).

Conclusion: These findings present EHOA as a disorder of advanced age and female sex, strongly associated with severity of articular structural damage and its progression. Individuals who develop EHOA have thinner bones prior to EHOA development and as it progresses, suggesting EHOA as a disorder of skeletal frailty.
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http://dx.doi.org/10.1002/art.41757DOI Listing
April 2021

Remnant cholesterol is prospectively associated with CVD events and all-cause mortality in kidney transplant recipients: the FAVORIT study.

Nephrol Dial Transplant 2021 Mar 24. Epub 2021 Mar 24.

Center for Primary Care, Prevention, Brown University, Providence, RI, USA.

Background: The cholesterol content of circulating triglyceride-rich lipoproteins is characterized as remnant cholesterol, although little is known about its role in the development of CVD outcomes, all-cause mortality, or transplant failure in kidney transplant recipients. Our primary aim was to investigate the prospective association of remnant cholesterol and the risk of CVD events in renal transplant recipients with secondary aims evaluating remnant cholesterol and renal graft failure and all-cause mortality among participants in the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial.

Methods: Among 4,110 enrolled participants, 98 were excluded for missing baseline remnant cholesterol levels and covariates. Non fasting remnant cholesterol levels were calculated based upon lipid profiles in 3,812 FAVORIT trial participants at randomization. Wilcoxon-type test for trend were used to compare baseline characteristics across remnant cholesterol quartiles. Cox proportional hazards regression was used to evaluate the association of baseline remnant cholesterol levels with time to primary and secondary study outcomes.

Results: During a median follow-up of 4.0 years, we documented 548 CVD incident events, 343 transplant failures, 452 All-Cause deaths. When comparing highest quartile 4 to quartile 1, proportional hazards modeling revealed a significant increase in CVD risk (HR, 1.32; 95% CI, 1.04-1.67) and all-cause mortality risk (HR, 1.34; 95% CI, 1.01-1.69). A non-significant increase in transplant failure was seen as well (HR, 1.20; 95% CI, 0.87-1.64).

Conclusion: Remnant cholesterol is associated with CVD and all-cause mortality in long-term kidney transplant recipients KTRs. A randomized controlled clinical trial in KTRs that assesses the potential impact of remnant cholesterol-lowering therapy on these outcomes may be warranted.
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http://dx.doi.org/10.1093/ndt/gfab068DOI Listing
March 2021

Confidence of nurses with inhaler device education and competency of device use in a specialised respiratory inpatient unit.

Chron Respir Dis 2021 Jan-Dec;18:14799731211002241

Department of Respiratory and Sleep Medicine, 8539Westmead Hospital, Westmead, NSW, Australia.

We performed a cross-sectional study within a specialised respiratory inpatient unit assessing 25 nurses' [85% female, 8.0 ± 7.9 (mean ± SD) years' experience in nursing] confidence in providing inhaler device education using a self-reported questionnaire, and their competency (% correct steps) in using eight different inhaler devices. Sixteen percent of participants were 'not confident' providing inhaler education, while 84% were 'moderately' or 'extremely' confident. The mean (±SD)% correct steps for all devices was 47 ± 17%. There was no correlation between % correct steps and nursing years (r = 0.21, p = 0.31), or 'confidence' with providing inhaler education (r = 0.02, p = 0.91) but % correct steps strongly correlated with number of individual device prescriptions within the hospital in the preceding year (r = 0.78, p = 0.039). Most respiratory nurses felt confident in teaching inhaler technique but their overall demonstrated ability to correctly use inhalers was poor, especially for less frequently prescribed devices within our hospital. Regular assessment and ongoing education on correct inhaler technique for respiratory nurses is necessary to optimise all device usage by nurses, irrespective of experience or confidence.
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http://dx.doi.org/10.1177/14799731211002241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983467PMC
March 2021

Use of social determinants of health codes in home-based primary care.

J Am Assoc Nurse Pract 2021 Apr 1. Epub 2021 Apr 1.

College of Nursing, University of Rhode Island, Providence, Rhode Island.

Background: The Affordable Care Act created funding for nurse practitioner education programs to transform the primary health care workforce through student awareness of how social, political, economic, and environmental factors influence individual and population health. Funding established Academic Clinical Partnerships (ACPs) that created value-based health care models, which improved patient outcomes and decreased hospital and emergency department admissions and health care costs. The ACP established a home-based primary health care (HBPC) program to deliver primary care and collect patient data.

Purpose: The purposes were to describe the incidence of chronic conditions for HBPC patients and determine associations between chronic conditions and presence of social determinants of health (SDoH).

Methodology: Nurse practitioner students were assigned to HBPC clinical placements. A convenience sample of 102 high-risk, homebound patients was identified. Nurse practitioners and students recorded deidentified patient data, including ICD-10-CM codes into a Health Insurance Portability and Accountability Act compliant platform. Secondary analysis of patient records assessed for SDoH through Z codes.

Results: Patients had high incidences of hypertension, diabetes, pulmonary disease, heart disease, chronic pain, mood, and substance abuse disorders. Secondary analysis revealed that 92% of patients had indications for the use of Z codes, but these were not recorded.

Conclusions: Common Z codes were personal risk factors, housing/economic circumstances, care provider dependency, lifestyle, and family support.

Implications For Practice: By coding for SDoH, providers and agencies can realize higher reimbursement rates in HBPC settings. Nurse practitioners can use this information to provide better treatment recommendations, more accurate diagnoses, and referrals to enhance primary care services to a patient population negatively affected by SDoH.
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http://dx.doi.org/10.1097/JXX.0000000000000586DOI Listing
April 2021

Maternal Worry About Infant Weight and its Influence on Artificial Milk Supplementation and Breastfeeding Cessation.

J Hum Lact 2021 Mar 11:8903344211000284. Epub 2021 Mar 11.

4260 College of Nursing, University of Rhode Island, USA.

Background: Maternal worry about infant weight has inconsistently been reported as a breastfeeding barrier. Weight monitoring is a critical tool to assess adequacy of infant feeding. Yet, little is known about the intensity of maternal worry about infant weight or associated breastfeeding outcomes.

Research Aims: To examine (1) the frequency and intensity of maternal worry about infant weight; (2) the relationship between worry about weight and use of artificial milk; and 3) the relationship between worry about weight and breastfeeding cessation.

Methods: A prospective cross-sectional design was used. A questionnaire was completed by women in the United States ( = 287) from 12 web-based maternal support groups.

Results: Sixty-three percent of women ( = 182) had some worry about infant weight. Participants breastfeeding for the first time had more worry ( = .035). Participants still breastfeeding had less worry about weight compared to those who had stopped (67%, = 147 vs. 41%, = 28). Exclusive breastfeeding participants had less worry ( < .001) compared to those who supplemented with artificial milk. Increased worry was associated with the use of artificial milk within 1 week of birth ( < .001) and early breastfeeding cessation ( < .001).

Conclusions: Worry about weight is a significant breastfeeding barrier. It is associated with first time breastfeeding, less exclusive breastfeeding, use of artificial milk, and earlier breastfeeding cessation. Lactating mothers need anticipatory guidance about expected neonatal weight changes and interventions to help relieve worry about infant weight.
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http://dx.doi.org/10.1177/08903344211000284DOI Listing
March 2021

THE RELIABILITY OF CLINICAL BALANCE TESTS UNDER SINGLE-TASK AND DUAL-TASK TESTING PARADIGMS IN UNINJURED ACTIVE YOUTH AND YOUNG ADULTS.

Int J Sports Phys Ther 2020 Aug;15(4):487-500

Background: Previous researchers have suggested that balance control deficits are detected more accurately with dual-task testing than single-task testing. However, it is necessary to examine the clinimetric properties of dual-task testing before employing it in clinical and research settings.

Objective: To examine and compare the relative and absolute reliability of the Balance Error Scoring System (BESS), Tandem Gait Test (TGT), and Clinical Reaction Time (CRT) under single and dual-task conditions in uninjured active youth and young adults.Study Design: Single-group, repeated-measures study.

Methods: Twenty-three individuals [9 female; median age 17 years] completed three trials of the BESS, TGT, and CRT under single and dual-task testing conditions during testing session one. Two raters assessed participants to assess inter-rater reliability. Either later on the same day or the following day, the protocol was repeated by one rater to assess intra-rater reliability. The average of three trials was used to calculate intra-rater (between-session) and inter-rater (within-session) intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC), and Cohen's Kappa coefficient for tests as appropriate under both conditions. Bland-Altman plots (mean difference and 95% limits of agreement) were used to assess for a systematic error associated with a learning effect.

Results: Only one participant attended the second session on the following day, while 22 participants (95%) attended the second session within four hours after testing session one. Under single-task testing, estimated ICCs, SEMs, MDCs, and Kappa coefficients ranged from 0.24 to 0.99, 0.3 to 23, 0.8 to 64, and 0.03 to 0.64, respectively. Under dual-task testing, estimated ICCs, SEMs, MDCs, and Kappa coefficients ranged from 0.70 to 0.99, 0.4 to 17, 1.1 to 47, and 0.39 to 0.83, respectively. A learning effect was identified for all tests under all conditions.

Conclusion: The BESS is the only clinical test that demonstrated acceptable reliability for clinical use under single-task testing conditions. The BESS, TGT, and CRT all demonstrated acceptable reliability for clinical use under dual-task testing conditions. A practice session should be used to reduce the possible learning effect seen. Further studies examining sources of the systematic error observed are needed.

Level Of Evidence: 2b.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735688PMC
August 2020

Burosumab for the Treatment of Tumor-Induced Osteomalacia.

J Bone Miner Res 2021 Apr 12;36(4):627-635. Epub 2021 Jan 12.

Yale University School of Medicine, New Haven, CT, USA.

Tumor-induced osteomalacia (TIO) is caused by phosphaturic mesenchymal tumors producing fibroblast growth factor 23 (FGF23) and is characterized by impaired phosphate metabolism, skeletal health, and quality of life. UX023T-CL201 is an ongoing, open-label, phase 2 study investigating the safety and efficacy of burosumab, a fully human monoclonal antibody that inhibits FGF23, in adults with TIO or cutaneous skeletal hypophosphatemia syndrome (CSHS). Key endpoints were changes in serum phosphorus and osteomalacia assessed by transiliac bone biopsies at week 48. This report focuses on 14 patients with TIO, excluding two diagnosed with X-linked hypophosphatemia post-enrollment and one with CSHS. Serum phosphorus increased from baseline (0.52 mmol/L) and was maintained after dose titration from week 22 (0.91 mmol/L) to week 144 (0.82 mmol/L, p < 0.0001). Most measures of osteomalacia were improved at week 48: osteoid volume/bone, osteoid thickness, and mineralization lag time decreased; osteoid surface/bone surface showed no change. Of 249 fractures/pseudofractures detected across 14 patients at baseline, 33% were fully healed and 13% were partially healed at week 144. Patients reported a reduction in pain and fatigue and an increase in physical health. Two patients discontinued: one to treat an adverse event (AE) of neoplasm progression and one failed to meet dosing criteria (receiving minimal burosumab). Sixteen serious AEs occurred in seven patients, and there was one death; all serious AEs were considered unrelated to treatment. Nine patients had 16 treatment-related AEs; all were mild to moderate in severity. In adults with TIO, burosumab exhibited an acceptable safety profile and was associated with improvements in phosphate metabolism and osteomalacia. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research..
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http://dx.doi.org/10.1002/jbmr.4233DOI Listing
April 2021

X-Linked Hypophosphatemia: A New Era in Management.

J Endocr Soc 2020 Dec 14;4(12):bvaa151. Epub 2020 Oct 14.

Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.

X-linked hypophosphatemia (XLH) is a rare, hereditary, progressive musculoskeletal disease that often causes pain and short stature, as well as decreased physical function, mobility, and quality of life. Hypophosphatemia in XLH is caused by loss of function mutations in the phosphate-regulating endopeptidase homolog X-linked () gene, resulting in excess levels of the phosphate-regulating hormone fibroblast growth factor 23 (FGF23), which leads to renal phosphate wasting and decreased serum 1,25-dihydroxyvitamin D production. Historically, treatment options were limited to oral phosphate and active vitamin D analogues (conventional management) dosed several times daily in an attempt to improve skeletal mineralization by increasing serum phosphorus. The recent approval of burosumab, a fully human monoclonal antibody to FGF23, has provided a new, targeted treatment option for patients with XLH. This review summarizes our current understanding of XLH, the safety and efficacy of conventional management and burosumab, existing recommendations for managing patients, and unanswered questions in the field.
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http://dx.doi.org/10.1210/jendso/bvaa151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649833PMC
December 2020

Behavior Problems During Early Childhood in Children With Prenatal Methamphetamine Exposure.

Pediatrics 2020 12 10;146(6). Epub 2020 Nov 10.

Brown Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University and Women and Infants Hospital of Rhode Island, Providence, Rhode Island.

Background And Objectives: The effects of in utero methamphetamine exposure on behavioral problems in school-aged children are unclear. Our objective for this study was to evaluate behavior problems in children at aged 3, 5, and 7.5 years who were prenatally exposed to methamphetamine.

Methods: Subjects were enrolled in the Infant Development, Environment, and Lifestyle study, a longitudinal prospective study of prenatal methamphetamine exposure and child outcomes. Exposed and comparison groups were matched on birth weight, race, education, and health insurance.  At ages 3, 5, and 7.5 years, 339 children (171 exposed) were assessed for behavior problems by using the Child Behavior Checklist. Generalized estimating equations were used to determine the effects of prenatal methamphetamine exposure, age, and the interaction of exposure and age on behavior problems. Caregiver psychological symptoms were assessed by using the Brief Symptom Inventory.

Results: Analyses adjusted for covariates revealed that relative to age 3, children at 5 years had less externalizing and aggressive behavior and more internalizing behavior, somatic complaints, and withdrawn behavior.  By age 7.5, aggressive behavior continued to decrease, attention problems increased and withdrawn behavior decreased. There were no main effects for methamphetamine exposure and no interactions of exposure and age.  Caregiver psychological symptoms predicted all behavior problems and the quality of the home predicted externalizing problems and externalizing syndrome scores.

Conclusions: Behavioral effects longitudinally from ages 3 to 7.5 years were not associated with prenatal methamphetamine exposure, whereas caregiver psychological symptoms and the quality of the home were predictors of behavior problems.
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http://dx.doi.org/10.1542/peds.2019-0270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706113PMC
December 2020

Integrative Dance for Adults with Down Syndrome: Effects on Postural Stability.

Int J Exerc Sci 2020 1;13(3):1317-1325. Epub 2020 Sep 1.

Concordia University, Department of Health, Kinesiology & Applied Physiology, Montreal, CANADA.

Postural stability, one's ability to maintain an upright stable position, is a crucial aspect of functional mobility and independent living. The purpose of this study was to examine if integrative dance classes have the potential to improve the postural stability in individuals with Down syndrome (DS). Utilizing a one group design, seven participants with DS were evaluated before and after a 12-week integrative dance class (ClinicalTrials.gov#NCT03660423). Postural stability was evaluated in uni- and bilateral quiet standing using a Wii Balance Board. Stability levels were measured based on changes in center of pressure (CoP) variables. Pre to post changes were found in in CoPx displacement (Z = -2.028, p = 0.043) and average speed (Z = -2.197, p = 0.028) in the eyes closed condition and in CoPy displacement with eyes open (Z = -2.366, p = 0.018). These data indicate improved postural stability following an intervention of integrative dance and a potential for improved functional mobility and decreased fall risk for the participants involved. This preliminary study suggests the need for further research into the effects of integrative dance on postural stability in those with DS and its use as a rehabilitative tool.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523910PMC
September 2020

Key stakeholder experiences of an integrated healthcare pilot in Australia: a thematic analysis.

BMC Health Serv Res 2020 Oct 7;20(1):925. Epub 2020 Oct 7.

Department General Practice, School of Medicine, Western Sydney University, Building 30.3.18 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.

Background: In Australia and other developed countries, chronic illness prevalence is increasing, as are costs of healthcare, particularly hospital-based care. Integrating healthcare and supporting illness management in the community can be a means of preventing illness, improving outcomes and reducing unnecessary hospitalisation. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health funded a range of key strategies through the Western Sydney Integrated Care Program (WSICP) to integrate care across hospital and community settings for patients with these illnesses. Complementing our previously reported analysis related to specific WSICP strategies, this research provided information concerning overall experiences and perspectives of WSICP implementation and integrated care generally.

Methods: We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners and primary care nurses, and program managers. Half of the participants (n = 42) were interviewed twice. We conducted an inductive, thematic analysis on the interview transcripts.

Results: Key themes related to the set-up and operationalising of WSICP; challenges encountered; and the added value of the program. Implementing WSICP was a large and time consuming undertaking but challenges including those with staffing and information technology were being addressed. The WSICP was considered valuable in reducing hospital admissions due to improved patient self-management and a focus on prevention, greater communication and collaboration between healthcare providers across health sectors and an increased capacity to manage chronic illness in the primary care setting.

Conclusions: Patients, carers and health providers experienced the WSICP as an innovative integrated care model and valued its patient-centred approach which was perceived to improve access to care, increase patient self-management and illness prevention, and reduce hospital admissions. Long-term sustainability of the WSICP will depend on retaining key staff, more effectively sharing information including across health sectors to support enhanced collaboration, and expanding the suite of activities into other illness areas and locations. Enhanced support for general practices to manage chronic illness in the community, in collaboration with hospital specialists is critical. Timely evaluation informs ongoing program implementation.
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http://dx.doi.org/10.1186/s12913-020-05794-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7542969PMC
October 2020

Prospective phenotyping of long-term survivors of generalized arterial calcification of infancy (GACI).

Genet Med 2021 02 2;23(2):396-407. Epub 2020 Oct 2.

Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.

Purpose: Generalized arterial calcification of infancy (GACI), characterized by vascular calcifications that are often fatal shortly after birth, is usually caused by deficiency of ENPP1. A small fraction of GACI cases result from deficiency of ABCC6, a membrane transporter. The natural history of GACI survivors has not been established in a prospective fashion.

Methods: We performed deep phenotyping of 20 GACI survivors.

Results: Sixteen of 20 subjects presented with arterial calcifications, but only 5 had residual involvement at the time of evaluation. Individuals with ENPP1 deficiency either had hypophosphatemic rickets or were predicted to develop it by 14 years of age; 14/16 had elevated intact FGF23 levels (iFGF23). Blood phosphate levels correlated inversely with iFGF23. For ENPP1-deficient individuals, the lifetime risk of cervical spine fusion was 25%, that of hearing loss was 75%, and the main morbidity in adults was related to enthesis calcification. Four ENPP1-deficient individuals manifested classic skin or retinal findings of PXE. We estimated the minimal incidence of ENPP1 deficiency at ~1 in 200,000 pregnancies.

Conclusion: GACI appears to be more common than previously thought, with an expanding spectrum of overlapping phenotypes. The relationships among decreased ENPP1, increased iFGF23, and rickets could inform future therapies.
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http://dx.doi.org/10.1038/s41436-020-00983-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867608PMC
February 2021

The value of faculty during student on-site evaluations.

J Am Assoc Nurse Pract 2020 Sep;32(9):618-620

AANPCB, American Academy of Nurse Practitioners Certification Board, Austin, Texas.

The American Academy of Nurse Practitioners Certification Board recognizes the value of nurse practitioner faculty in evaluating students at the clinical site. The Board of Commissioners recently approved the awarding of clinical hours to nurse practitioner faculty for clinical site visits. This article outlines the rationale and procedure for conducting and documenting student visits that can be applied to recertification.
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http://dx.doi.org/10.1097/JXX.0000000000000497DOI Listing
September 2020

Business documents of the advanced practice registered nurse: Curriculum vitae, resume, and biosketches.

J Am Assoc Nurse Pract 2020 Sep;32(9):610-615

Acute Care Nurse Practitioner Programs, Seton Hall University, College of Nursing South Orange, New Jersey.

Advanced practice nurses (APNs) now have great opportunities to serve in leadership positions for organizations, institutions of higher education, community and public agencies, and more. The need exists for APNs to have a full set of professional business documents readily available. Such common documents would extend beyond the professional business card and professional photograph to include the curriculum vitae, the resume, and the National Institutes of Health Biographical Sketch (biosketch) and a professional biosketch. Advanced practice nurses should understand the differences between the documents as each document helps to share the professional identity.
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http://dx.doi.org/10.1097/JXX.0000000000000453DOI Listing
September 2020

Themed Issue: Topics in nurse practitioner professional role development.

J Am Assoc Nurse Pract 2020 Sep;32(9):595-597

College of Graduate Nursing, Western University of Health Sciences, Pomona, California.

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http://dx.doi.org/10.1097/JXX.0000000000000496DOI Listing
September 2020

Impact of Teaching Sexual Health Education on Medical Students.

Fam Med 2020 06;52(7):518-522

The Warren Alpert Medical School of Brown University, Providence, RI.

Background And Objectives: Physician discomfort, embarrassment, and perceived lack of time and/or training all play a role in preventing physicians from discussing sexual health with patients. Past research shows this discomfort begins in medical school. We aimed to determine whether teaching sexual health education increases medical students' self-efficacy in discussing sexual health topics with adolescents.

Methods: We emailed a retrospective pre/postsurvey to all medical students who taught sexual health education in a local middle school through Sex Ed by Brown Med (N=61).

Results: Participation in Sex Ed by Brown Med improves self-efficacy in discussing nine sexual health topics and in performing nine advanced interviewing skills relevant to sexual health in a retrospective analysis using self-reported data.

Conclusions: Programs similar to Sex Ed by Brown Med may be useful in improving medical students' ability to adequately care for their patients' sexual health by making future clinicians more comfortable when discussing the important topic of sexuality, and concurrently providing evidence-based comprehensive sexual health education to middle school students. Further research is needed to determine the impact of our program (and similar programs) before disseminating this model of sexual education.
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http://dx.doi.org/10.22454/FamMed.2020.939791DOI Listing
June 2020

Krukenberg's Spindles Strongly Suggest Long Anterior Zonule Associated Pigment Dispersion Mechanism in Older Patients.

Invest Ophthalmol Vis Sci 2020 07;61(8)

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Purpose: The purpose of this study was to further investigate factors associated with Krukenberg's spindle (KS) presence in a primary eye care setting.

Methods: As part of a larger investigation, several practitioners in an academic eye care facility in Chicago, IL, USA evaluated patients for the long anterior zonule (LAZ) trait during 2011 to 2018, and data were collected on ocular/systemic health, lifestyle, and demographic variables, including the presence of a KS. Multivariate regression was used to assess relationships to KS presence.

Results: Analysis included 3501 subjects with mean age of 51 ± 15 years (18-98 years; 65% women; and 84% African American). Among the right eyes, 57 (1.6%) had a KS, with this group having a mean age of 62 ± 13 years (25-86 years; 75% women; and 82% African American). There were 120 subjects (3.4%) with right eye LAZ, with mean age of 64 ± 11 years (36-91 years; 77% women; and 92% African American). There were 19 of 57 (33.3%) KS eyes that also had LAZ. Controlling for other factors, variables with the strongest relationship to KS presence were the LAZ trait (odds ratio [OR] = 12.2, 95% confidence interval [CI] = 6.5 to 22.8, P < 0.0001) and advancing age (OR = 1.3 per decade, 95% CI = 1.3 to 1.9, P < 0.0001).

Conclusions: In the population studied, KS presence had its strongest relationship to the LAZ trait and advancing age. The KS-LAZ relationship may not be well-known, but these data strongly suggest that pigment dispersion signs, such as a KS, should prompt the clinician to consider the LAZ trait as a potential etiology, especially because LAZ is associated with higher IOP and possibly glaucoma.
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http://dx.doi.org/10.1167/iovs.61.8.8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425699PMC
July 2020

Nephropathic Cystinosis: A Distinct Form of CKD-Mineral and Bone Disorder that Provides Novel Insights into the Regulation of FGF23.

J Am Soc Nephrol 2020 09 6;31(9):2184-2192. Epub 2020 Jul 6.

Skeletal Disorders and Mineral Homeostasis Section, National Institutes of Dental and Craniofacial Research, Bethesda, Maryland.

Background: The rare lysosomal storage disease nephropathic cystinosis presents with renal Fanconi syndrome that evolves in time to CKD. Although biochemical abnormalities in common causes of CKD-mineral and bone disorder have been defined, it is unknown if persistent phosphate wasting in nephropathic cystinosis is associated with a biochemical mineral pattern distinct from that typically observed in CKD-mineral and bone disorder.

Methods: We assessed and compared determinants of mineral homeostasis in patients with nephropathic cystinosis across the predialysis CKD spectrum to these determinants in age- and CKD stage-matched patients, with causes of CKD other than nephropathic cystinosis.

Results: The study included 50 patients with nephropathic cystinosis-related CDK and 97 with CKD from other causes. All major aspects of mineral homeostasis were differentially effected in patients with CKD stemming from nephropathic cystinosis versus other causes. Patients with nephropathic cystinosis had significantly lower percent tubular reabsorption of phosphate and fibroblast growth factor-23 (FGF23) at all CKD stages, and lower blood phosphate in CKD stages 3-5. Linear regression analyses demonstrated lower FGF23 levels in nephropathic cystinosis participants at all CKD stages when corrected for eGFR and age, but not when adjusted for serum phosphate.

Conclusions: Nephropathic cystinosis CKD patients have mineral abnormalities that are distinct from those in CKD stemming from other causes. Persistently increased urinary phosphate excretion maintains serum phosphate levels within the normal range, thus protecting patients with nephropathic cystinosis from elevations of FGF23 during early CKD stages. These findings support the notion that phosphate is a significant driver of increased FGF23 levels in CKD and that mineral abnormalities associated with CKD are likely to vary depending on the underlying renal disease.
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http://dx.doi.org/10.1681/ASN.2019111172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7461669PMC
September 2020

Enzyme-Substrate-Cofactor Dynamical Networks Revealed by High-Resolution Field Cycling Relaxometry.

Biochemistry 2020 06 15;59(25):2359-2370. Epub 2020 Jun 15.

Department of Biology, Brandeis University, MS009, 415 South St., Waltham, Massachusetts 02453-9110, United States.

The remarkable power and specificity of enzyme catalysis rely on the dynamic alignment of the enzyme, substrates, and cofactors, yet the role of dynamics has usually been approached from the perspective of the protein. We have been using an underappreciated NMR technique, subtesla high-resolution field cycling P NMR relaxometry, to investigate the dynamics of the enzyme-bound substrates and cofactor on guanosine-5'-monophosphate reductase (GMPR). GMPR forms two dead end, yet catalytically competent, complexes that mimic distinct steps in the catalytic cycle: E·IMP·NADP undergoes a partial hydride transfer reaction, while E·GMP·NADP undergoes a partial deamination reaction. A different cofactor conformation is required for each partial reaction. Here we report the effects of mutations designed to perturb cofactor conformation and ammonia binding with the goal of identifying the structural features that contribute to the distinct dynamic signatures of the hydride transfer and deamination complexes. These experiments suggest that Asp129 is a central cog in a dynamic network required for both hydride transfer and deamination. In contrast, Lys77 modulates the conformation and mobility of substrates and cofactors in a reaction-specific manner. Thr105 and Tyr318 are part of a deamination-specific dynamic network that includes the 2'-OH of GMP. These residues have comparatively little effect on the dynamic properties of the hydride transfer complex. These results further illustrate the potential of high-resolution field cycling NMR relaxometry for the investigation of ligand dynamics. In addition, exchange experiments indicate that NH/NH has a high affinity for the deamination complex but a low affinity for the hydride transfer complex, suggesting that the movement of ammonia may gate the cofactor conformational change. Collectively, these experiments reinforce the view that the enzyme, substrates, and cofactor are linked in intricate, reaction-specific, dynamic networks and demonstrate that distal portions of the substrates and cofactors are critical features in these networks.
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http://dx.doi.org/10.1021/acs.biochem.0c00212DOI Listing
June 2020

Healthy lifestyle and risk of incident heart failure with preserved and reduced ejection fraction among post-menopausal women: The Women's Health Initiative study.

Prev Med 2020 09 28;138:106155. Epub 2020 May 28.

Brown University, Department of Epidemiology, Providence, RI, United States of America; Care New England, Center for Primary Care and Prevention, Pawtucket, RI, United States of America; Brown University, Department of Family Medicine, Providence, RI, United States of America. Electronic address:

We examined associations of diet, physical activity, cigarette smoking, and body mass index (BMI), separately and as a cumulative lifestyle score, with incident hospitalized HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). This analysis included 40,095 postmenopausal women in the Women's Health Initiative clinical trial and observational studies, aged 50-79 years and without self-reported HF at baseline. A healthy lifestyle score (HLS) was developed, in which women received 1 point for each healthy lifestyle. A weighted HLS was also created to examine the independent magnitude of each of the lifestyle factors in HF subtypes. Trained adjudicators determined cases of incident hospitalized HF, HFpEF, HFrEF through March 2018. Multiple variable Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI). During a mean follow-up period of 14.5 years, 659 incident HFrEF and 1276 HFpEF cases were documented. Across unweighted HLS of 0 (referent), 1, 2, 3, and 4, multivariable adjusted HRs (95% CI) for HFrEF were 1.00, 0.52 (0.38, 0.71), 0.40 (0.29, 0.56), 0.33 (0.23, 0.48), and 0.33 (0.19, 0.56) (P-trend = 0.03) and for HFpEF were 1.00, 0.47 (0.37, 0.59), 0.39 (0.30, 0.49), 0.26 (0.20, 0.34), and 0.23 (0.15, 0.35) (P-trend < 0.001). Results were similar for the weighted HLS. Our findings suggest that following a healthy lifestyle pattern is associated with lower risks of HFpEF and HFrEF among postmenopausal women.
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http://dx.doi.org/10.1016/j.ypmed.2020.106155DOI Listing
September 2020

Traditional serrated adenomas (TSA) and the company they keep: TSA presence predicts advanced neoplasm states.

Int J Colorectal Dis 2020 Jul 1;35(7):1351-1354. Epub 2020 May 1.

Department of Gastroenterology, University of California Irvine Medical Center, Orange, CA, USA.

Background: The association of TSAs with metachronous neoplasms is well established and suggests that TSAs would also have an association with synchronous neoplasms.

Methods: We compared odds ratios and rates of synchronous neoplasms found in colonoscopies with and without TSAs.

Results: There was a mean of 2.44 neoplasms among TSA cases in comparison with 1.72 in non-TSA cases. The odds ratio for advanced neoplasia was highest among cases with one or more TSAs relative to cases with one or more HPs (7.54 [CI, 4.23-13.44]) when compared with adenomas (1.95 [CI, 1.75-2.17]) and SSPs (2.98 [CI, 2.54-3.5]).

Conclusions: In this study population, there is a 7-fold higher risk of synchronous advanced neoplasms among cases with one or more TSAs.
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http://dx.doi.org/10.1007/s00384-020-03587-xDOI Listing
July 2020

Patient perspectives on how to optimise benefits from a breathlessness service for people with COPD.

NPJ Prim Care Respir Med 2020 04 8;30(1):16. Epub 2020 Apr 8.

Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, NSW, Australia.

This study aimed to inform understanding of how to optimise patient-perceived benefits from a breathlessness service designed for patients with moderate to very severe chronic obstructive pulmonary disease (COPD). The Westmead Breathlessness Service (WBS) trains patients to self-manage over an 8-week programme, with multidisciplinary input and home visits. A qualitative approach was taken, using semi-structured telephone interviews. Each transcript was globally rated as suggesting 'significant', 'some' or 'no' impact from WBS, and thematic analysis used an integrative approach. Forty-one consecutive participants were interviewed to reach 'information power'. Eighteen (44%) participants reported 'significant' impact, 17 (41%) 'some' impact, and two (5%) 'no' impact. Improvements to breathlessness were usually in the affective and impact dimensions but, more uncommonly, also sensory-perceptual. Participants who benefited in self-esteem, confidence and motivation attributed this to one-to-one multidisciplinary coaching and home visits. Further research should test whether including/excluding more intensive programme elements based on individual need might improve cost-effectiveness.
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http://dx.doi.org/10.1038/s41533-020-0172-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142111PMC
April 2020

Prospective association of obstructive sleep apnea risk factors with heart failure and its subtypes in postmenopausal women: The Women's Health Initiative.

J Clin Sleep Med 2020 07;16(7):1107-1117

Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island.

Study Objectives: The relationship between obstructive sleep apnea (OSA) and heart failure (HF) incidence in postmenopausal women has been understudied, given the limited representation of women in heart failure studies. We investigated the relationship between OSA risk factors and HF and its subtypes in postmenopausal women.

Methods: We performed a prospective analysis on the adjudicated HF outcomes in the Women's Health Initiative from enrollment (1993-1998) to September 30, 2016. HF with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) were defined as adjudicated acute HF hospitalization with EF ≥ 45% or < 45%, respectively. We employed Cox regression to examine the association between OSA risk factors and symptoms (individually and using a summary risk score) and time to first hospitalized HF.

Results: Of 42,362 women, 2,205 (5.21%) developed all HF, 1,162 (2.74%) women developed HFpEF, and 679 (1.60%) developed HFrEF. Individual OSA risk factors and symptoms, including obesity (hazard ratio = 1.33, 95% confidence interval [CI] 1.20-1.48), snoring (hazard ratio = 1.30, 95% CI 1.16-1.46), and hypertension (HR = 1.45, 95% CI 1.35-1.56), were positively associated with risk of HF and HFpEF, but only hypertension was associated with HFrEF. When examined as a summary risk score compared with those with none of the OSA risk factors, presence of each additional factor was significantly associated with increased risk of hospitalized HF in a dose-response fashion for HFpEF (P trend < .001), but not HFrEF (P trend = .26).

Conclusions: OSA risk factors and symptoms were associated with HFpEF, but not HFrEF, among postmenopausal women and are largely dependent on body mass index, snoring, and hypertension.
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http://dx.doi.org/10.5664/jcsm.8438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954064PMC
July 2020