Tibetan Medicated Bathing Therapy for Patients With Post-stroke Limb Spasticity: A Randomized Controlled Clinical Trial

ObjectiveTo determine the short- (4 weeks) and long-term (6 month) effectiveness of Tibetan medicated bathing therapy in patients with post-stroke limb spasticity.DesignProspective, blinded, randomized controlled trial.SubjectsPost-stroke patients with limb spasticity were recruited between December 2013 and February 2017 and randomly assigned 1:1 to a control group that received conventional rehabilitation (n = 222) or an experimental group that received Tibetan medicated bathing therapy in combination with conventional rehabilitation (n = 222).MethodsAll patients received conventional rehabilitation. In addition, the experimental group received Tibetan medicated bathing therapy. The interventions were conducted 5 times per week for 4 weeks. The primary endpoint was changes from baseline after 4 weeks of therapy in muscle tone in the spastic muscles (elbow flexors, wrist flexors, finger flexors, knee extensors, ankle plantar flexors), as measured by the Modified Ashworth Scale (MAS).ResultsThe mean change from baseline after 4 weeks of therapy in the MAS score for the elbow flexors (P = .017), wrist flexors (P < .001), and ankle plantar flexors (P < .001) was significantly greater in patients in the experimental group compared to the control group. The benefit was maintained for 3 muscle groups (elbow flexors P < .001, wrist flexors P = .001, and ankle plantar flexors P < .001) and 6 months (elbow flexors P < .001, wrist flexors P = .002, and ankle plantar flexors P < .001) after therapy. All adverse events were mild, and no serious adverse reactions to Tibetan medicated bathing therapy were recorded.Conclusions and ImplicationsTibetan medicated bathing therapy, in combination with conventional rehabilitation, has potential as a safe, effective treatment for the alleviation of post-stroke upper limb spasticity. Tibetan medicated bathing therapy was most advantageous for patients who had a baseline muscle tone score of 1+ to 2 on the MAS in the affected limb and recent onset of stroke (duration of the disease of 1-3 months).     

Can Botulinum Toxin Decrease Carer Burden in Long Term Care Residents With Upper Limb Spasticity? A Randomized Controlled Study

ObjectiveTo evaluate whether botulinum toxin can decrease the burden for caregivers of long term care patients with severe upper limb spasticity.MethodThis was a double-blind placebo-controlled trial with a 24-week follow-up period.SettingA 250-bed long term care hospital, the infirmary units of 3 regional hospitals, and 5 care and attention homes.ParticipantsParticipants included 55 long term care patients with significant upper limb spasticity and difficulty in basic upper limb care.InterventionsPatients were randomized into 2 groups that received either intramuscular botulinum toxin A or saline.Main outcome measuresThe primary outcome measure was provided by the carer burden scale. Secondary outcomes included goal attainment scale, measure of spasticity by modified Ashworth score, passive range of movement for shoulder abduction, and elbow extension and finger extension. Pain was assessed using the Pain Assessment in Advanced Dementia Scale.ResultsA total of 55 patients (21 men; mean age = 69, SD =18) were recruited. At week 6 post-injection, 18 (60%) of 30 patients in the treatment group versus 2 (8%) of 25 patients in the control group had a significant 4-point reduction of carer burden scale (P < .001). There was also significant improvement in the goal attainment scale, as well as the modified Ashworth score, resting angle, and passive range of movement of the 3 regions (shoulder, elbow, and fingers) in the treatment group which persisted until week 24. There were also fewer spontaneous bone fractures after botulinum toxin injection, although this did not reach statistical significance. No significant difference in Pain Assessment in Advanced Dementia scale was found between the 2 groups. No serious botulinum toxin type A–related adverse effects were reported.ConclusionLong term care patients who were treated for upper limb spasticity with intramuscular injections of botulinum toxin A had a significant decrease in the caregiver burden. The treatment was also associated with improved scores on patient-centered outcome measures.     

The evaluation of an interdisciplinary pain protocol in long term care

ObjectivesTo evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents.DesignA controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data.SettingFour LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group.ParticipantsData were collected from 200 LTC residents; 99 for the intervention and 101 for the control group.InterventionImplementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities.MeasurementsResident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews.ResultsPain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol.ConclusionsThese study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.     

Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Oldest Adults: Predictors of In-Hospital Mortality and Need for Post-acute Care

ObjectivesOlder age is associated with higher risk of death during acute exacerbations of chronic obstructive pulmonary disease (AE-COPD). Older patients hospitalized for AE-COPD often require post-acute care after acute phase. The aim of this study was to evaluate components of a comprehensive geriatric assessment and clinical/laboratory parameters, in order to find predictors of in-hospital mortality and need for post-acute care in patients aged 80 and older hospitalized for AE-COPD.DesignProspective observational study.SettingHospital assessment.Participants121 patients consecutively admitted to an internal medicine and geriatrics department for AE-COPD.MeasuresActivities of Daily Living (ADL) Hierarchy scale, Geriatric Index of Comorbidity, cognitive impairment, and clinical and laboratory parameters were collected.ResultsMean age: 87.0 ± 4.9 years; male: 54.5%. In-hospital mortality (18.2% of patients) was significantly associated with functional disability, high comorbidity, cognitive impairment, anemia, older age, lower albumin, higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) and white blood cell levels, oral corticosteroids taken before admission, and no angiotensin-converting enzyme inhibitors or angiotensin receptor blockers taken before admission. In a stepwise logistic regression, functional dependence (P = .006), cognitive impairment (P = .038), and oral corticosteroids therapy before hospitalization (P = .035) were independently associated with a higher risk of in-hospital mortality. Among laboratory parameters, only NT-proBNP remained significantly associated with in-hospital mortality (P = .026). The need for post-acute care (18.2% of survivors) was associated with older age, higher admission Pco₂, greater comorbidity, and cognitive impairment. In a stepwise logistic regression, only cognitive impairment (P = .016) and ln_Pco₂ (P = .056) confirmed their association with the need for post-acute care.Conclusions/implicationsPreadmission functional dependence, cognitive impairment, and corticosteroid use, plus elevated NT-proBNP at admission are risk factors for mortality during an AE-COPD in the oldest old. Therefore, medical providers should consider these, as well as the patient's advance directives, in planning hospital care. Furthermore, providers should arrange especially careful posthospitalization monitoring and frequent follow-up of individuals with cognitive impairment and baseline hypercapnia.     

Bilateral Anterior Thigh Thickness: A New Diagnostic Tool for the Identification of Low Muscle Mass?

ObjectivesTo develop an ultrasonographic scanning protocol that included an assessment of muscle size [the proposed Bilateral Anterior Thigh Thickness (BATT)] and quality (echogenicity) to support the diagnosis of sarcopenia in a clinical setting. To determine the relationship of BATT and ultrasound echogenicity with physical function parameters of sarcopenia and test the reliability of ultrasound echogenicity measurements.DesignObservational study.Setting and participantsThe BATT criteria were determined from a reference population of 113 healthy younger adults and tested in 39 healthy older adults and 31 frail older adults.MethodsUltrasonography was used to measure the thickness of rectus femoris and vastus intermedius bilaterally; the thickness measurements were summed to calculate the BATT. Diagnostic criteria for low muscle size were calculated from the reference population. Echogenicity was assessed using freeze-frame images. All individuals underwent anthropological, frailty, and physical performance assessments.ResultsThe mean (standard deviation) BATTs for the subsamples were as follows: healthy young women (n = 54), 60.6 mm (±11.1); healthy young men (n = 59), 75.8 mm (±10.71); healthy older women (n = 27), 38.4 mm (±7.18); healthy older men (n = 13), 47.5 mm (±10.8); frail older women (n = 17), 29.2 mm (±11.4); and frail older men (n = 14), 27.3 mm (±13.9). The calculated cutoffs for low muscle size in older adults using the BATT criteria were 38.5 mm in women and 54.4 mm in men in this population. The BATT was correlated with grip strength (ρ = 0.750, P < .001 for women; ρ = 0.619, P < .001 for men) and walk speed (ρ = ?0.599, P < .001 for women; ρ = ?0.324, P = .003 for men). Ultrasound echogenicity increased with age and frailty. Lay sonographers were able to reliably reproduce the same muscle thickness measurements but not the same muscle echogenicity measurements.Conclusions/ImplicationsThe data support the use of ultrasonography to identify low muscle size in sarcopenia. Ultrasonography provides a pragmatic diagnostic tool that is noninvasive, without radiation exposure, and usable in both community and hospital settings. The proposed BATT criteria could be used to identify low muscle size in clinical practice and research, and in this study have excellent correlation with physical parameters of muscle health. However, this now needs testing in a validation cohort. Ultrasound echogenicity has been demonstrated to be an important surrogate marker of muscle health, but difficulties with reproducibility preclude its widespread clinical use.     

Thyroid Function as a Predictor of Handgrip Strength Among Middle-Aged and Older Euthyroid Adults: The TCLSIH Cohort Study

ObjectivesThyroid hormones (THs) play a critical role in skeletal muscle function, such as protein synthesis and energy metabolism, suggesting that thyroid function may be involved in the decline of muscle strength. Studies regarding the long-term effects of THs on muscle strength are limited. Therefore, this large-scale longitudinal study aimed to explore how TH levels were associated with handgrip strength (HGS) among middle-aged and older euthyroid adults.DesignLongitudinal population-based cohort study (approximately 4-year follow-up period, median: 3.0 years).SettingThe Tianjin Chronic Low-grade Systemic Inflammation and Health Cohort Study, Tianjin, China.ParticipantsA total of 2152 participants were enrolled, and annual measures were conducted in this longitudinal study.MeasuresChemiluminescence immunoassay was used to measure free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH). HGS was measured using a handheld digital dynamometer. Multiple linear regression analysis was used to evaluate the association between THs, FT3/FT4 ratio, TSH levels, and annual change in HGS and weight-adjusted HGS.ResultsAfter adjusting for multiple confounding factors, significant associations between FT3 levels, FT3/FT4 ratio, and annual change in HGS [standard regression coefficient (SRC) = 0.073, P < .01, and and SRC = 0.059, P = .01, respectively] were observed. However, no significant difference was observed between FT4, TSH, and annual change in HGS (SRC = 0.021, P = .34; and SRC = ?0.017, P = .44, respectively). Similar associations between FT3, FT4, FT3/FT4 ratio, TSH, and weight-adjusted HGS were observed.Conclusions and implicationsThis longitudinal study is the first to demonstrate that high-normal FT3 levels and higher FT3/FT4 ratios significantly predict annual change in HGS and weight-adjusted HGS and that FT4 and TSH levels are not associated with HGS among middle-aged and older euthyroid subjects. The findings suggest that new therapeutic approaches aimed at FT3 levels and FT3/FT4 ratios may be proposed to maintain muscle strength.     

Dietary Protein Requirement Threshold and Micronutrients Profile in Healthy Older Women Based on Relative Skeletal Muscle Mass

Although multiple nutrients have shown protective effects with regard to preserving muscle function, the recommended amount of dietary protein and other nutrients profile on older adults for maintenance of high muscle mass is still debatable. The aims of this paper were to: (1) identify dietary differences between older women with low and high relative skeletal muscle mass, and (2) identify the minimal dietary protein intake associated with high relative skeletal muscle mass and test the threshold ability to determine an association with skeletal muscle phenotypes. Older women (n = 281; 70 ± 7 years, 65 ± 14 kg), with both low and high relative skeletal muscle mass groups, completed a food questionnaire. Skeletal muscle mass, fat-free mass (FFM), biceps brachii thickness, vastus lateralis anatomical cross-sectional area (VL_ACSA), handgrip strength (HGS), maximum elbow flexion torque (MVC_EF), maximum knee extension torque (MVC_KE), muscle quality (HGS/Body mass), and fat mass were measured. Older women with low relative skeletal muscle mass had a lower daily intake of protein, iodine, polyunsaturated fatty acid (PUFA), Vit E, manganese, milk, fish, nuts and seeds (p < 0.05) compared to women with high relative skeletal muscle mass. The minimum required dietary protein intake for high relative skeletal muscle mass was 1.17 g/kg body mass/day (g/kg/d) (sensitivity: 0.68; specificity: 0.62). Women consuming ≥1.17 g/kg/d had a lower BMI (B = −3.9, p < 0.001) and fat mass (B = −7.8, p < 0.001), and a higher muscle quality (B = 0.06, p < 0.001). The data indicate that to maintain muscle mass and function, older women should consume ≥1.17 g/kg/d dietary protein, through a varied diet including milk, fish and nuts that also contain polyunsaturated fatty acid (PUFA) and micronutrients such as iodine, Vit E and manganese.     

Building Blocks for Healthy Children: Evaluation of a Child Care Center–Based Obesity Prevention Pilot Among Low-Income Children

ObjectiveTo assess the impact of a multilevel nutrition intervention for low-income child care environments, staff, and center-enrolled children.DesignA cluster-randomized, controlled trial conducted among eligible centers. Staff and parent self-report surveys and objective field observations at baseline and follow-up were conducted.SettingA total of 22 low-income child care centers (enrolling ≥ 25 2- to 5-year-old children).ParticipantsChildren aged 18–71 months; 408 children and 97 staff were randomized into intervention (208 children and 50 staff) and waitlist-control groups (200 children and 45 staff). Retention rates were high (87% for children and 93% for staff).Intervention(s)A 6-session, 6-month director's child nutrition course with on-site technical support for center teachers.Main Outcome Measure(s)Center nutrition/physical activity environment; staff feeding styles, dietary patterns, and attitudes about food; child food preferences and dietary patterns.AnalysisCovariance regression analyses to assess the intervention effect, adjusting for clustering within centers.ResultsSignificant intervention effects were found for the center nutrition training/education environment (b = 3.01; P = .03), nutrition total scores (b = 1.29; P = .04), and staff-level prompting/encouraging feeding styles (b = 0.38; P = .04). No significant intervention effects were found for child-level measures.Conclusions and ImplicationsCurriculum-driven training and implementation support improved nutritional policies and practices and staff–child interactions during meals. Future research could extend the intervention to families and the evaluation to children's dietary behaviors and weight changes.     

Effects of the FIT-HIP Intervention for Fear of Falling After Hip Fracture: A Cluster-Randomized Controlled Trial in Geriatric Rehabilitation

ObjectivesFear of falling (FoF) is common after hip fracture and can impede functional recovery because of activity restriction. The Fear of falling InTervention in HIP fracture geriatric rehabilitation (FIT-HIP intervention) was designed to target FoF and consequently to improve mobility. The aim of this study was to evaluate the effect of the FIT-HIP intervention in patients with FoF in geriatric rehabilitation (GR) after hip fracture.Design, setting, and participantsThis cluster-randomized controlled trial was performed in 11 post-acute GR units in the Netherlands (2016-2017). Six clusters were assigned to the intervention group, 5 to the usual care group. We included 78 patients with hip fracture and FoF (aged ≥65 years; 39 per group).Intervention(s)The FIT-HIP intervention is a multicomponent cognitive behavioral intervention conducted by physiotherapists, embedded in usual care in GR. The FIT-HIP intervention was compared to usual care in GR.MeasurementsFoF was assessed with the Falls Efficacy Scale–International (FES-I) and mobility, with the Performance Oriented Mobility Assessment (POMA). Data were collected at baseline, discharge, and 3 and 6 months postdischarge from GR. Primary endpoints were change scores at discharge. Linear mixed models were used to evaluate the treatment effect.ResultsNo significant between-group differences were observed for primary outcome measures. With the usual care group as reference, the FES-I estimated difference between mean change scores was 3.3 [95% confidence interval (CI) ?1.0, 7.5, P = .13] at discharge from GR; ?4.1 (95% CI –11.8, 3.6, P = .29) after 3 months; and ?2.8 (95% CI –10.0, 4.4, P = .44) after 6 months. POMA estimated difference was ?0.3 (95% CI –6.5, 5.8, P = .90).Conclusion/ImplicationsThe FIT-HIP intervention was not effective in reducing FoF. Possibly FoF (shortly) after hip fracture can to some extent be appropriate. This may imply the study was not able to accurately identify and accordingly treat FoF that is maladaptive (reflective of disproportionate anxiety).     

Acute Muscle Mass Loss Predicts Long-Term Fatigue,Myalgia, and Health Care Costs in COVID-19 Survivors

ObjectiveWe examined the impact of loss of skeletal muscle mass in post-acute sequelae of SARS-CoV-2 infection, hospital readmission rate, self-perception of health, and health care costs in a cohort of COVID-19 survivors.DesignProspective observational study.Setting and ParticipantsTertiary Clinical Hospital. Eighty COVID-19 survivors age 59 ± 14 years were prospectively assessed.MethodsHandgrip strength and vastus lateralis muscle cross-sectional area were evaluated at hospital admission, discharge, and 6 months after discharge. Post-acute sequelae of SARS-CoV-2 were evaluated 6 months after discharge (main outcome). Also, health care costs, hospital readmission rate, and self-perception of health were evaluated 2 and 6 months after hospital discharge. To examine whether the magnitude of muscle mass loss impacts the outcomes, we ranked patients according to relative vastus lateralis muscle cross-sectional area reduction during hospital stay into either “high muscle loss” (?18 ± 11%) or “low muscle loss” (?4 ± 2%) group, based on median values.ResultsHigh muscle loss group showed greater prevalence of fatigue (76% vs 46%, P = .0337) and myalgia (66% vs 36%, P = .0388), and lower muscle mass (?8% vs 3%, P < .0001) than low muscle loss group 6 months after discharge. No between-group difference was observed for hospital readmission and self-perceived health (P > .05). High muscle loss group demonstrated greater total COVID-19-related health care costs 2 ($77,283.87 vs. $3057.14, P = .0223, respectively) and 6 months ($90,001.35 vs $12, 913.27, P = .0210, respectively) after discharge vs low muscle loss group. Muscle mass loss was shown to be a predictor of total COVID-19-related health care costs at 2 (adjusted β = $10, 070.81, P < .0001) and 6 months after discharge (adjusted β = $9885.63, P < .0001).Conclusions and ImplicationsCOVID-19 survivors experiencing high muscle mass loss during hospital stay fail to fully recover muscle health. In addition, greater muscle loss was associated with a higher frequency of post-acute sequelae of SARS-CoV-2 and greater total COVID-19-related health care costs 2 and 6 months after discharge. Altogether, these data suggest that the loss of muscle mass resulting from COVID-19 hospitalization may incur in an economical burden to health care systems.     

Individuals’ Preferences for Esophageal Cancer Screening: A Discrete Choice Experiment

ObjectivesThe increasing incidence of esophageal adenocarcinoma (EAC) and the dismal prognosis has stimulated interest in the early detection of EAC. Our objective was to determine individuals’ preferences for EAC screening and to assess to what extent procedural characteristics of EAC screening tests predict willingness for screening participation.MethodsA discrete choice experiment questionnaire was sent by postal mail to 1000 subjects aged 50 to 75 years who were randomly selected from the municipal registry in the Netherlands. Each subject answered 12 discrete choice questions of 2 hypothetical screening tests comprising 5 attributes: EAC-related mortality risk reduction, procedure-related pain and discomfort, screening location, test specificity, and costs. A multinomial logit model was used to estimate individuals’ preferences for each attribute level and to calculate expected rates of uptake.ResultsIn total, 375 individuals (37.5%) completed the questionnaire. Test specificity, pain and discomfort, mortality reduction, and out-of-pocket costs all had a significant impact on respondents’ preferences. The average expected uptake of EAC screening was 62.8% (95% confidence interval [CI] 61.1-64.5). Severe pain and discomfort had the largest impact on screening uptake (–22.8%; 95% CI –26.8 to –18.7). Male gender (β 2.81; P < .001), cancer worries (β 1.96; P = .01), endoscopy experience (β 1.46; P = .05), and upper gastrointestinal symptoms (β 1.50; P = .05) were significantly associated with screening participation.ConclusionsEAC screening implementation should consider patient preferences to maximize screening attendance uptake. Based on our results, an optimal screening test should have high specificity, cause no or mild to moderate pain or discomfort, and result in a decrease in EAC-related mortality.     

Visit-to-Visit Blood Pressure Variability and Progression of White Matter Hyperintensities Among Older People With Hypertension

ObjectivesVisit-to-visit blood pressure (BP) variability is a risk factor for cardiovascular disease and cognitive decline. Our aim was to assess the association between visit-to-visit BP variability and progression of white matter hyperintensities (WMH).DesignPost-hoc analysis in the magnetic resonance imaging substudy of the randomized controlled trial prevention of dementia by intensive vascular care.Setting and participantsCommunity-dwelling people age 70–78 years with hypertension.MethodsParticipants had 3 to 5 twice yearly BP measurements and 2 magnetic resonance imaging scans at 3 and 6 years follow-up. We used linear regression adjusted for age, sex, WMH at scan 1, (change in) total brain volume, and cardiovascular risk factors.ResultsAmong the 122 participants, there was a modest association between visit-to-visit systolic BP variability and WMH progression [beta = 0.03 mL/y per point increase in variability, 95% confidence interval (CI) 0.00–0.05, P = .058]. Additional adjustment for slope in systolic BP reduced the associated P value to .043. Visit-to-visit diastolic BP variability was not associated with WMH progression (beta = 0.01 mL/y, 95% CI ?0.02 to 0.03, P = .68). Visit-to-visit pulse pressure variability was associated with WMH progression (beta 0.03 mL/y, 95% CI 0.01–0.05, P < .01).ConclusionsHigher visit-to-visit systolic BP and pulse pressure variability is associated with more progression of WMH among people age 70–78 years with hypertension.ImplicationsInterventions to reduce visit-to-visit BP variability may be most effective in people with low WMH burden.     

Weight Measurements in School: Setting and Student Comfort

ObjectiveTo examine how body mass index assessments are conducted in schools and whether student comfort with assessments varies by students’ perceived weight status, weight satisfaction, or privacy during measurements.MethodsIn-person cross-sectional surveys with diverse fourth- to eighth-grade students (n = 11,510) in 54 California schools in 2014–2015 about their experience being weighed in the prior school year.ResultsHalf of the students (49%) reported being weighed by a physical education teacher and 28% by a school nurse. Students were more comfortable being weighed by nurses than physical education teachers (P = 0.01). Only 30% of students reported privacy during measurements. Students who were unhappy with their weight (P <0.001) and those who perceived themselves as overweight (P <0.001) were less comfortable being weighed than their peers.Conclusions and ImplicationsStudent weight dissatisfaction, higher perceived weight status, and being female were associated with discomfort with school-based weight measurements. Prioritizing school nurses to conduct weight measurements could mitigate student discomfort, and particular attention should be paid to students who are unhappy with their weight to avoid weight stigmatization.     

Family Eating Behavior and Child Eating Patterns Differences Between Children With and Without Siblings

ObjectiveTo examine the differences in family eating behaviors and child eating patterns in children with siblings (nonsingletons) and without siblings (singletons).MethodsCross-sectional analysis of mother–child dyads of 5–7-year-old children, (nonsingletons with a 2-to-4-year-old sibling) was conducted. Anthropometrics were measured. Mothers completed questionnaires and a child dietary log. Healthy Eating Index 2010 (HEI) score was calculated. Linear regression models adjusting for child age, child sex, maternal body mass index, and hours-away-from-home were conducted, with a revised P < .021.ResultsSixty-eight mother–child dyads (27 singletons, 41 nonsingletons) participated. Singletons exhibited less healthy family eating behaviors (β = ?4.98, SE = 1.88, P = .003), and lower total HEI scores than did nonsingletons (average: β = ?8.91, SE =2.40, P = .001). On average, singletons had lower scores in 3 HEI components compared with nonsingletons (P < .021 for all).ConclusionIn this sample, singleton children exhibited less healthy eating behaviors. Additional investigation into parent-level differences is warranted.     

Comparative Incidence and Health Care Costs of Medically Attended Adverse Effects among U.S. Medicaid HIV Patients on Atazanavir- or Darunavir-Based Antiretroviral Therapy

ObjectivesThis is the first study to compare the incidence and health care costs of medically attended adverse effects in atazanavir- and darunavir-based antiretroviral therapy (ART) among U.S. Medicaid patients receiving routine HIV care.MethodsThis was a retrospective study using Medicaid administrative health care claims from 15 states. Subjects were HIV patients aged 18 to 64 years initiating atazanavir- or darunavir-based ART from January 1, 2003, to July 1, 2010, with continuous enrollment for 6 months before (baseline) and 6 months after (evaluation period) ART initiation and 1 or more evaluation period medical claim. Outcomes were incidence and health care costs of the following medically attended (International Classification of Diseases, Ninth Revision, Clinical Modification–coded or treated) adverse effects during the evaluation period: gastrointestinal, lipid abnormalities, diabetes/hyperglycemia, rash, and jaundice. All-cause health care costs were also determined. Patients treated with atazanavir and darunavir were propensity score matched (ratio = 3:1) by using demographic and clinical covariates. Multivariable models adjusted for covariates lacking postmatch statistical balance.ResultsPropensity-matched study sample included 1848 atazanavir- and 616 darunavir-treated patients (mean age 41 years, 50% women, 69% black). Multivariable-adjusted hazard ratios (HRs) (for darunavir, reference = atazanavir) and per-patient-per-month health care cost differences (darunavir minus atazanavir) were as follows: gastrointestinal, HR = 1.25 (P = 0.04), $43 (P = 0.13); lipid abnormalities, HR = 1.38 (P = 0.07), $3 (P = 0.88); diabetes/hyperglycemia, HR = 0.84 (P = 0.55), $13 (P = 0.69); and rash, HR = 1.11 (P = 0.23), $0 (P = 0.76); all-cause health care costs were $1086 (P<0.001). Too few instances of jaundice (11 in atazanavir and 1 in darunavir) occurred to support multivariable modeling.ConclusionsMedication tolerability can be critical to the success or failure of ART. Compared with darunavir-treated patients, atazanavir-treated patients had significantly fewer instances of medically attended gastrointestinal issues and more instances of jaundice and incurred significantly lower health care costs.     

Self-Paced Online Training on Healthy Beverage Policy for Child Care Providers

ObjectiveDetermine if online training for child care providers increases knowledge and awareness of and adherence to California's Healthy Beverages in Child Care Act (AB2084) policy.DesignCluster, randomized controlled trial with 2 intervention groups and 1 control group.SettingLicensed child care centers and family child care homes.ParticipantsChild care providers in 3 California regions.InterventionThirty-minute, self-paced online training in English or Spanish, with or without 6-months of ongoing technical assistance.Main outcomes measuredProviders’ self-reported knowledge and awareness of and adherence to AB2084 at baseline, after 1 and 6 months.AnalysisGeneralized estimating equations and generalized linear models, adjusted for the percentage of children on child care subsidies and region.ResultsOutcomes were similar between groups receiving and not receiving technical assistance. Providers receiving training (both intervention groups combined) experienced larger increases in knowledge (P = 0.002 and P = 0.003) and awareness (P = 0.004 and P = 0.001) of AB2084 compared with the control group after 1 and 6 months. All groups reported pre-post increases in adherence to AB2084.Conclusions and ImplicationsA brief online training supports increased knowledge and awareness of healthy beverage policy among child care providers. The training is available online and is free for California child care providers.