Maternal well-being and its association to risk of developmental problems in children at school entry

<p>Abstract</p> <p>Background</p> <p>Children at highest risk of developmental problems benefit from early identification and intervention. Investigating factors affecting child development at the time of transition to school may reveal opportunities to tailor early intervention programs for the greatest effectiveness, social benefit and economic gain. The primary objective of this study was to identify child and maternal factors associated with children who screened at risk of developmental problems at school entry.</p> <p>Methods</p> <p>An existing cohort of 791 mothers who had been followed since early pregnancy was mailed a questionnaire when the children were aged four to six years. The questionnaire included a screening tool for developmental problems, an assessment of the child's social competence, health care utilization and referrals, and maternal factors, including physical health, mental health, social support, parenting morale and sense of competence, and parenting support/resources.</p> <p>Results</p> <p>Of the 491 mothers (62%) who responded, 15% had children who were screened at high risk of developmental problems. Based on a logistic regression model, independent predictors of screening at high risk for developmental problems at age 5 were male gender (OR: 2.3; 95% CI: 1.3, 4.1), maternal history of abuse at pregnancy (OR: 2.4; 95% CI: 1.3, 4.4), and poor parenting morale when the child was 3 years old (OR: 3.9; 95% CI: 2.1, 7.3). A child with all of these risk factors had a 35% predicted probability of screening at high risk of developmental problems, which was reduced to 13% if maternal factors were favourable.</p> <p>Conclusions</p> <p>Risk factors for developmental problems at school entry are related to maternal well being and history of abuse, which can be identified in the prenatal period or when children are preschool age.</p

Comparison of performance of psychiatrists vs other outpatient physicians in the 2020 US Medicare Merit-Based Incentive Payment System

Importance: Medicare\u27s Merit-Based Incentive Payment System (MIPS) is a new, mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures for many US clinicians. However, it is currently unknown how the program measures the performance of psychiatrists, who often treat a different patient case mix with different clinical considerations than do other outpatient clinicians. Objective: To compare performance scores and value-based reimbursement for psychiatrists vs other outpatient physicians in the 2020 MIPS. Design Setting and Participants: In this cross-sectional study, the Centers for Medicare & Medicaid Services Provider Data Catalog was used to identify outpatient Medicare physicians listed in the National Downloadable File between January 1, 2018, and December 31, 2020, who participated in the 2020 MIPS and received a publicly reported final performance score. Data from the 593 863 clinicians participating in the 2020 MIPS were used to compare differences in the 2020 MIPS performance scores and value-based reimbursement (based on performance in 2018) for psychiatrists vs other physicians, adjusting for physician, patient, and practice area characteristics. Exposures: Participation in MIPS. Main Outcomes and Measures: Primary outcomes were final MIPS performance score and negative (penalty), positive, and exceptional performance bonus payment adjustments. Secondary outcomes were scores in the MIPS performance domains: quality, promoting interoperability, improvement activities, and cost. Results: This study included 9356 psychiatrists (3407 [36.4%] female and 5 949 [63.6%] male) and 196 306 other outpatient physicians (69 221 [35.3%] female and 127 085 [64.7%] male) (data on age and race are not available). Compared with other physicians, psychiatrists were less likely to be affiliated with a safety-net hospital (2119 [22.6%] vs 64 997 [33.1%]) or a major teaching hospital (2148 [23.0%] vs 53 321 [27.2%]) and had lower annual Medicare patient volume (181 vs 437 patients) and mean patient risk scores (1.65 vs 1.78) ( Conclusions and Relevance: In this cross-sectional study that compared US psychiatrists with other outpatient physicians, psychiatrists had significantly lower 2020 MIPS performance scores, were penalized more frequently, and received fewer bonuses. Policy makers should evaluate whether current MIPS performance measures appropriately assess the performance of psychiatrists

The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial: an adaptive trial design case study

Background: The \u27Adaptive Designs Accelerating Promising Trials into Treatments (ADAPT-IT)\u27 project is a collaborative effort supported by the National Institutes of Health (NIH) and United States Food & Drug Administration (FDA) to explore how adaptive clinical trial design might improve the evaluation of drugs and medical devices. ADAPT-IT uses the National Institute of Neurologic Disorders & Stroke-supported Neurological Emergencies Treatment Trials (NETT) network as a \u27laboratory\u27 in which to study the development of adaptive clinical trial designs in the confirmatory setting. The Stroke Hyperglycemia Insulin Network Effort (SHINE) trial was selected for funding by the NIH-NINDS at the start of ADAPT-IT and is currently an ongoing phase III trial of tight glucose control in hyperglycemic acute ischemic stroke patients. Within ADAPT-IT, a Bayesian adaptive Goldilocks trial design alternative was developed. Methods: The SHINE design includes response adaptive randomization, a sample size re-estimation, and monitoring for early efficacy and futility according to a group sequential design. The Goldilocks design includes more frequent monitoring for predicted success or futility and a longitudinal model of the primary endpoint. Both trial designs were simulated and compared in terms of their mean sample size and power across a range of treatment effects and success rates for the control group. Results: As simulated, the SHINE design tends to have slightly higher power and the Goldilocks design has a lower mean sample size. Both designs were tuned to have approximately 80% power to detect a difference of 25% versus 32% between control and treatment, respectively. In this scenario, mean sample sizes are 1,114 and 979 for the SHINE and Goldilocks designs, respectively. Conclusions: Two designs were brought forward, and both were evaluated, revised, and improved based on the input of all parties involved in the ADAPT-IT process. However, the SHINE investigators were tasked with choosing only a single design to implement and ultimately elected not to implement the Goldilocks design. The Goldilocks design will be retrospectively executed upon completion of SHINE to later compare the designs based on their use of patient resources, time, and conclusions in a real world setting

Representative bureaucracy: does female police leadership affect gender-based violence arrests?

Representative bureaucracy theory postulates that passive representation leads to active representation of minority groups. This article investigates the passive representation of female police officers at leadership levels and the active representation of women vis-a-vis gender-based violence arrest rates in the UK. Much of the extant research on representative bureaucracy is located at street level, with evidence showing that discretionary power of minority bureaucrats can lead to active representation. This article is focused on leadership levels of a public bureaucracy. The empirical research is based upon a panel dataset of female police officers as an independent variable and gender-based violence arrest rates as a dependent variable. The analysis reveals that there is little evidence of active representation of women by female police leadership

Who doesn't receive carotid endarterectomy when appropriate?

AbstractObjectiveThe purpose of this study was to identify clinical and nonclinical factors associated with failure to perform carotid endarterectomy (CEA) in patients with clinically appropriate indications. We analyzed data from a prospective cohort study performed at five Veterans Affairs medical centers. Patients were referred for carotid artery evaluation if they had at least 50% stenosis in one carotid artery, had no history of CEA, and were independently classified preoperatively as appropriate candidates for CEA, according to clinical criteria. The primary outcome was receipt of CEA within 6 months of evaluation. Data were collected by medical record review and interview regarding clinical status, and patient and physician perception of the risks and benefits of CEA.ResultsAmong clinically appropriate candidates for CEA, 66.8% (n = 233) did not undergo the operation. Compared with patients who did undergo CEA, a greater proportion of these patients had no symptoms (68.7% vs 45.7%; P < .001). A twofold greater proportion of patients who did not undergo CEA were in the highest quartile of reported aversion to surgery. Moreover, a fourfold greater proportion were perceived by their physicians to be at less than 5% risk for future stroke without the operation, and more than a twofold greater proportion were believed to experience less than 5% efficacy from the operation by their providers (P < .01). In multivariable analyses, four characteristics were significantly associated with whether an appropriate candidate did not receive CEA: asymptomatic disease, less than 70% stenosis, high expressed aversion to surgery score, and low (<5%) provider-perceived efficacy of the operation.ConclusionAmong patients in the Veterans Affairs health care system who are clinically appropriate candidates for CEA, those who did not receive the operation were less likely to have symptomatic disease or high-grade carotid artery stenosis, but were more likely to report high aversion to surgery and to have a provider who believed CEA would not be efficacious

Comprehensive Solid-State Characterization of Rare Earth Flouride Nanoparticles

The combination of multinuclear solid-state NMR spectroscopy and powder X-ray diffraction has been applied to characterize the octahedron-shaped crystalline nanoparticle products resulting from an inverse micelle synthesis. Rietveld refinements of the powder X-ray diffraction data from the nanoparticles revealed their general formula to be (H3O)Y3F10·xH2O. 1H magic-angle spinning (MAS) NMR experiments provided information on sample purity and served as an excellent probe of the zeolithic incorporation of atmospheric water. 19F MAS NMR experiments on a series of monodisperse nanoparticle samples of various sizes yielded spectra featuring three unique 19F resonances arising from three different fluorine sites within the (H3O)Y3F10·xH2O crystal structure. Partial removal of zeolithic water from the internal cavities and tunnels of the nanoparticles led to changes in the integrated peak intensities in the 19F MAS NMR spectra; the origin of this behavior is discussed in terms of 19F longitudinal relaxation. 19F–89Y variable-amplitude cross-polarization (VACP) NMR experiments on both stationary samples and samples under MAS conditions indicated that two distinct yttrium environments are present, and on the basis of the relative peak intensities, the population of one of the two sites is closely linked to the nanoparticle size. Both 19F MAS and 19F–89Y VACP/MAS experiments indicated small amounts of an impurity present in certain nanoparticles; these are postulated to be spherical amorphous YF3 nanoparticles. We discuss the importance of probing molecular-level structure in addition to microscopic structure and how the combination of these characterization methods is crucial for understanding nanoparticle design, synthesis, and application

Cilostazol for Secondary Stroke Prevention: History, Evidence, Limitations, and Possibilities

Cilostazol is a phosphodiesterase III inhibitor with a long track record of safety that is FDA and EMA approved for the treatment of claudication in patients with peripheral arterial disease. In addition, cilostazol has been approved for secondary stroke prevention in several Asian countries based on trials that have demonstrated a reduction in stroke recurrence among patients with non-cardioembolic stroke. The onset of benefit appears after 60–90 days of treatment, which is consistent with cilostazol’s pleiotropic effects on platelet aggregation, vascular remodeling, blood flow, and plasma lipids. Cilostazol appears safe and does not increase the risk of major bleeding when given alone or in combination with aspirin or clopidogrel. Adverse effects such as headache, gastrointestinal symptoms and palpitations, however, contributed to a 6% increase in drug discontinuation among patients randomized to cilostazol in a large secondary stroke prevention trial (CSPS.com). Due to limitations of prior trials, such as open label design, premature trial termination, large loss to follow-up, lack of functional or cognitive outcome data, and exclusive enrollment in Asia, the existing trials have not led to a change in clinical practice or guidelines in Western countries. These limitations could be addressed by a double-blind placebo-controlled randomized trial conducted in a broader population. If positive, it would increase the evidence in support of long-term treatment with cilostazol for secondary prevention in the millions of patients worldwide who have suffered a non-cardioembolic ischemic stroke

The S troke H yperglycemia I nsulin N etwork E ffort ( SHINE ) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102726/1/ijs12045.pd