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Therapeutic clowns are increasingly common in nursing homes, where residents often encounter factors that can undermine their quality of life and dignity. We aimed to understand the strategies of successful therapeutic clowning with a diverse older adult population, and the unique contributions of elder-clowning to the nursing home experience. Using an interpretivist descriptive methodology, twenty-three (n=23) experienced therapeutic clowns from eight countries were interviewed to understand the needs of nursing home residents met by elder-clowns, and strategies and techniques the clowns use to address them. Participants identified five major needs: to escape routine; for reassurance of worth; for meaningful, personalized social interaction unrestricted by communication barriers; to have culturally meaningful opportunities for reminiscence; and to have a space where residents could be unapologetically themselves. The artistic and emotional strategies used by the therapeutic clowns to address these needs illustrate how creativity, imagination and relational presence can provide nursing home residents with a sense of being known and belonging. Elder-clowns also positively affect the nursing home staff and enrich the interpersonal interactions in the residence. Through their focus on the social and emotional needs of residents, elder-clowns can play an important and distinct role in creating an optimal nursing home experience.

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BACKGROUND: Therapeutic clowns use embodied practices to engage with clients, their families and healthcare staff to empower patients and create therapeutic relationships. This study explored the effectiveness of a virtual therapeutic clown initiative. METHODS: Thirteen therapeutic clowns participated in a semi-structured interview to discuss their experiences with online clowning; additionally, four dyads consisting of a clown duo and a client explored multiple perspectives of a shared online clowning experience. Data were analyzed according to the six core competencies of therapeutic clowning. RESULTS: Although all therapeutic clowns and caregivers reported challenges and limitations with the medium, virtual therapeutic clowning was effective for empowering clients and forming therapeutic relationships. Clowns successfully used many strategies to maintain their core clowning competencies in the virtual environment. CONCLUSIONS: Virtual clowning may be more beneficial for some clients than in-person clowning and has the potential to extend therapeutic clowning beyond its traditional domains of practice.

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For the last decade, there has been growing concern regarding the rising rates of youth engagement in self-injury and suicide. The worldwide outbreak of the coronavirus disease 2019 (COVID-19) has elevated these concerns due to increased risk factors pertaining to social, family, economic, and health stressors, in addition to changes to typical routines and support systems. Unfortunately, there are many barriers to at-risk youth being able to access evidence-based mental health services including cost, lack of trained providers, transportation issues, and physical distancing due to the pandemic. Providing school-based prevention and intervention programs that promote social, emotional, and behavioral well-being helps to address many of these barriers. This article highlights important considerations to providing these services in a school-based telehealth modality. Symptom clusters that put youth at risk of harm to self are described. Best practice therapeutic modalities that can be disseminated in a school-based telehealth modality, such as cognitive behavior therapy, dialectical behavior therapy, and mindfulness-based approaches, are reviewed. Although there is growing empirical literature for these school-based prevention and intervention approaches, additional research is needed to determine how to best support at-risk youth remotely.

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Gastroesophageal reflux disease (GERD) is a common upper esophageal condition and typical symptoms can include heartburn and sensation of regurgitation while atypical symptoms include chronic cough, asthma, hoarseness, dyspepsia and nausea. Typically, diagnosis is presumptive given the presence of typical and atypical symptoms and is an indication for empiric therapy. Treatment management can include lifestyle modifications and/or medication therapy with proton pump inhibitor (PPI) class being the preferred and most effective. Complete symptom resolution is not always achieved and long-term PPI therapy can put patients at risk for serious side effects and needless expense. The brain-gut connection and hypervigilance plays an important role in symptom resolution and treatment success, especially in the case of non-PPI responders. Hypervigilance is a combination of increased esophageal sensory sensitivity in combination with exaggerated threat perception surrounding esophageal symptoms. Hypervigilance requires a different approach to GERD managements, where continued PPI therapy and surgery are usually not recommended. Rather, helping physicians and patients understand the brain-gut connection can guide and improve care. Education and reassurance should be the main pillars or treatment. However, it is important not to suggest the symptoms are due to anxiety alone, this often leads to patient dissatisfaction. Patient dissatisfaction with treatment reveals the need for a more patient-centered approach to GERD management and better communication between patients and providers. Shared decision making (SDM) with the incorporation of patient-reported outcomes (PRO) promotes patient adherence and satisfaction. SDM is a joint discussion between clinician and patient in which a mutually shared solution is explored for GERD symptoms. For SDM to work the physician needs to capture patients' perceptions which may not be obtained in the standard interview. This can be done through the use of PROs which promote a dialogue with patients about their symptoms and treatment priorities in the context of the SDM patient encounter. SDM could potentially help in the management of patient expectations for GERD treatment, ultimately positively impacting their health-related quality of life.

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OBJECTIVES: To compare antiretroviral adherence (measured as the proportion of days covered [PDC]) and change in viral load in insured, HIV-infected, adult outpatients enrolled and not enrolled in a medication synchronization program. METHODS: This was a multicenter, retrospective, pilot cohort study. Fifty-eight insured, HIV-infected, outpatients at least 18 years of age receiving antiretroviral therapy (ART) for at least 3 months as of August 2015 were included. PDC, viral load, PDC dichotomized into adherent or nonadherent, and viral load dichotomized into detectable or undetectable were collected for each patient. Study data were compared in those with (enrolled) and without (not enrolled or control) medication synchronization. The study end points were analyzed between the 2 groups retrospectively after 3 months. RESULTS: PDC in patients undergoing medication synchronization was significantly higher than in control patients: mean ± SD 96 ± 9% versus 71 ± 27%, respectively (P < 0.0001). The medication synchronization group was also more likely to be adherent to ART than the control group (odds ratio 10.67, 95% confidence interval 2.63-43.31). In the medication synchronization group, 75.9% of patients had an undetectable baseline viral load, and 83.3% had an undetectable viral load at study completion. In the control group, 62.1% and 64.7% had an undetectable viral load at baseline and completion, respectively. No statistically significant change in viral load was observed between groups (P = 0.34). CONCLUSION: In insured, HIV-infected, adult outpatients, implementation of a medication synchronization program was associated with improved ART adherence. Future studies are needed to better assess the impact of medication synchronization on clinical outcomes.

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BACKGROUND: This study analyzed visits for and factors associated with gout and gout medication treatment trends for the years 2007-2011 in the United States given the introduction of febuxostat, the first new treatment option for gout in over 40 years, which was introduced to the market in 2009. METHODS: This study was a retrospective, cross-sectional, observational study of patients age 20 and older seen by providers who participated in the National Ambulatory Medical Care Survey (NAMCS), the National Hospital Ambulatory Medical Care Survey Outpatient Department (NHAMCS-OPD) or Emergency Department (NHAMCS-ED) in the United States. The outcome of interest was visits for gout diagnosis and visits where a gout medication was prescribed. RESULTS: Approximately 1.2% of visits had a diagnosis of gout. There was a significant increase in the percentage of visits with a diagnosis of gout in years 2009-2011 compared to 2007-2008, which remained after adjusting for covariates of interest. Groups more likely to have a visit with gout included those ≥65 and 45-64 (both as compared to those 20-44), the African-American and 'Other' race groups (as compared to Caucasians) and those on a diuretic. Groups less likely to have a visit with gout included females, Hispanic/Latinos, those with insurance type of 'Other' and Medicaid (both as compared to private insurance) and visits to a hospital emergency setting (as compared to physician's office visits). CONCLUSION: Although there was a significant increase in visits where gout is diagnosed across study years, the overall percentage of visits with a gout diagnosis is low in the US population. Treatment trends over the study years has remained consistent, with the introduction of febuxostat appearing to have little impact for the study years through 2011.

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INTRODUCTION: Vitamin D has been suggested as a marker for prostate cancer risk, but prior study results are conflicting. This study evaluated the association of prostate cancer diagnosis with vitamin D levels as well as with each of the following variables of interest: age, race group, military service, smoking status, and alcohol use. METHODS: A total of 11,547 adult males aged 18 or older who participated in the National Health and Nutrition Examination Survey for years 2001-2010 were included in this retrospective, cross-sectional, observational study. National Health and Nutrition Examination Survey is an annual, nationally representative sample of noninstitutionalized civilian adult and child residents of the United States. Active duty military are excluded from the survey. Subjects were excluded if they answered "don't know" or "refused" to vitamin D or prostate cancer survey questions. χ2 analyses were performed to analyze associations between diagnosis of prostate cancer and variables of interest. The military service variable was developed on the basis of the response to survey question "Did you ever serve in the Armed Forces of the United States?" A multivariable logistic regression model included all the variables of interest that were available in the database. All analyses were appropriately weighted for extrapolation to average annual population-based estimates for the years included in the study. RESULTS: Two percent had a diagnosis of prostate cancer, whereas 72% had less than 75 nmol/L of vitamin D. Unadjusted χ2 test results suggested those with a vitamin D level of <75 nmol/L, <65 years of age and consuming at least one alcoholic drink per day were significantly less likely to be diagnosed with prostate cancer although smokers and those with military service were significantly more likely to be diagnosed with prostate cancer. However, after adjusting for covariates included in the multivariable logistic regression model, only the following covariates remained significant: men <65 years old were less likely to be diagnosed with prostate cancer (odds ratio [OR] = 0.07, 95% confidence interval [CI] = 0.04-0.12), although those with military service and non-Hispanic blacks were more likely to be diagnosed with prostate cancer (OR = 1.66, 95% CI = 1.09-2.53 and OR 1.73, 95% CI 1.28-2.33, respectively). No other factors in the model, including vitamin D level, retained significance. CONCLUSION: Among the documented risk factors for prostate cancer from the available data, age, military service, and race group were significantly associated with prostate cancer diagnosis. Further study on a larger cohort with prostate cancer is needed to better assess for associations.

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BACKGROUND: This study was designed to investigate whether racial and ethnic disparities in infant mortality still exist in North Carolina and to examine predictors of infant mortality using the North Carolina Vital Statistics Dataverse. METHODS: This was a retrospective, cross-sectional, observational study that included all 257,543 births in North Carolina in 2008-2009. Infant mortality was assessed based on birth records included in the database. Infant births and deaths were summarized by demographic and maternal/infant characteristics. A multivariate logistic regression model was constructed to jointly assess predictors of infant mortality. RESULTS: The overall infant mortality rate in North Carolina was 0.8%. Adjusting for confounders through the construction and assessment of a multivariate logistic regression model, statistically significant associations were found between infant mortality and each of the following: maternal race (both black and 'other' versus white), infant sex, both premature and preterm gestation (versus full term), birth weight (both low and high versus normal), maternal education (both less than high school graduate and more than high school versus college graduate), prenatal care (both intermediate and inadequate versus adequate), and maternal tobacco use. LIMITATIONS: Maternal race was limited to white, black, and other. Data on socioeconomic status, maternal medical risk factors, and quality of prenatal care were not available. At the time of the analysis, data for years beyond 2009 were limited. CONCLUSIONS: Racial disparities in infant mortality persist in North Carolina; specifically, infants of nonwhite mothers have a higher mortality rate than do infants of white mothers. Other factors that continue to play a significant role in infant mortality in North Carolina include preterm and premature births, male infant sex, low birth weight, maternal education less than college graduate, maternal tobacco use, and less than adequate prenatal care.

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OBJECTIVE: The objective of this study was to determine if a difference exists in the proportion of visits for the prescribing of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARBs) in diabetic patients during 2007-2010. METHODS: This retrospective, cross-sectional, observational study included adults diagnosed with diabetes mellitus from the National Ambulatory Medical Care Survey (NAMCS) during 2007-2010. Weighted chi-square tests and a multivariable logistic regression model were used to analyze associations between ACEI/ARB prescriptions and predictors of interest. Odds ratios and 95% confidence intervals were reported. RESULTS: An unweighted total of 13,590 outpatient ambulatory care visits were identified for adult patients with diabetes without contraindications to ACEIs or ARBs in the NAMCS for the years studied. No statistically significant increase in the proportion of visits with an ACEI/ARB prescription was identified for years 2007-2010 (28.1% in 2007 to 32.2% in 2010). Females (OR 0.78, 95% CI 0.69- 0.89), patients 18-39 years old (OR 0.56, 95% CI 0.43- 0.75), and Medicare users (OR 0.81, 95% CI 0.70- 0.94) were significantly less likely to receive an ACEI/ARB prescription. Patients with hypertension (OR 2.80, 95% CI 2.39-3.29), hyperlipidemia (OR 1.42, 95% CI 1.22-1.65), and ischemic heart disease (OR 1.36, 95% CI 1.10-1.70) were significantly more likely to receive an ACEI/ARB prescription. CONCLUSIONS: Despite extensive evidence showing the benefits of ACEI/ARB medications in diabetic patients, disparities of treatment remain evident.

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PURPOSE: Although newer agents (dipeptidyl peptidase [DPP]-4 inhibitors and glucagon-like peptide [GLP]-1 receptor agonists) are available for the treatment of hyperglycemia in patients with type 2 diabetes mellitus (T2DM), the impact of the availability of these agents on the use of second-generation sulfonylureas (SUs) is unknown. This article presents percentages of patients prescribed SUs, using data from the National Ambulatory Medical Care Survey (NAMCS). The associations between SU prescribing and prespecified variables of interest were also explored. METHODS: The NAMCS database was queried for visits of patients aged ≥18 years with an International Classification of Diseases, Ninth Revision diagnostic code relevant to T2DM. χ(2) tests were conducted to assess the associations between SU use and year-group (2003-2004, 2007-2008, or 2009-2010) and other variables of interest. A multivariate logistic regression model was constructed to jointly assess the value of these variables in predicting SU use. All analyses were weighted using procedures recommended by the National Center for Health Statistics. FINDINGS: Data from 7042 eligible visits were included, representing an extrapolated national estimate of 280,733,405 patient visits. The percentages of patients who received a prescription for an SU, by study year, were 25.7%, 23.4%, and 23.7% in 2003 to 2004, 2007 to 2008, and 2009 to 2010, respectively (P = 0.57). In the multivariate model, age ≥70 years, male sex, nonwhite race, primary care physician seen, and concurrent DPP-4 inhibitor use were significantly associated with SU use. IMPLICATIONS: No significant decrease in the use of SUs was observed after the introduction of DPP-4 inhibitors and GLP-1 receptor agonists. However, patient-specific factors (eg, select demographic variables, site of care, and concurrent medication use) were associated with SU use.

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PURPOSE: In 2008, the American Diabetes Association (ADA) recommended that patients aged >40 years with diabetes and cardiovascular disease or with ≥1 cardiovascular disease risk factor be prescribed a statin. This study assessed statin prescribing patterns in patients with diabetes, per the ADA guideline, using data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey-Outpatient Department for the years 2005 to 2010. This study also examined patients' demographic characteristics associated with statin prescribing, including sex, age, ethnicity, race, insurance type, body mass index, region, primary care provider, hypertension and hyperlipidemia. METHODS: This retrospective, cross-sectional, observational study included data dated between 2005 and 2010 from patients aged ≥18 years with diabetes and without contraindications to statin use. Associations between statin prescribing and variables of interest were analyzed using χ(2) tests. A multivariate logistic regression model included 2 groups stratified by 3-year observation period (2005-2007 and 2008-2010) plus all variables with an overall χ(2) test result of P < 0.2. P values, odds ratios (ORs) and 95% CIs are reported. FINDINGS: The majority of patients were aged ≥40 years (93.1%), had a body mass index of ≥30 (58.7%), had hypertension (65.6%), and did not have hyperlipidemia (54.0%). A low percentage of patients were prescribed a statin (35.1%), but it appears that this percentage is on the rise. During 2005-2007, 31.9% of patients received a statin, whereas 37.7% of patients received a statin during 2008-2010. After adjustment for covariates included in the multivariate logistic regression model, those with hypertension (vs none [reference]: OR = 1.31; 95% CI, 1.12-1.53) and/or hyperlipidemia (vs none [reference]: OR = 4.44; 95% CI, 3.70-5.33) were significantly more likely to have been prescribed a statin, whereas those in age group 18-<40 years (vs 40-<65 years [reference]: OR = 0.45; 95% CI, 0.31-0.65) and Hispanic/Latino patients (vs non-Hispanic/Latino patients [reference]: OR = 0.77; 95% CI, 0.61-0.97) were significantly less likely to have been prescribed a statin. IMPLICATIONS: Despite the call in the latest ADA recommendations for prescribing statins in many diabetic patients, an unexpectedly low percentage of patients were receiving them. Health disparities in age and ethnicity were also evident. The findings from this study highlight the need for further research into low statin prescribing rates.

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OBJECTIVE: The purpose of this study was to analyze the data on brachial plexus injury and its relationship with shoulder dystocia from a tertiary center for a 23-year period. STUDY DESIGN: A review of the logbooks on labor and delivery and the nursery and the International Classification of Diseases codes identified all newborn infants with brachial plexus injury who were delivered at our center. RESULTS: During the 23 years (1980-2002), there were 89,978 deliveries, of which there were 85 cases of brachial plexus injury (1/1000 births) with vaginal delivery. The injury was permanent (> or =1 year) in 12% of the cases, and only 2 cases have been litigated. Newborn infants that weighed > or =4 kg were significantly more common among those infants who had shoulder dystocia and brachial plexus injury than those infants without injury (odds ratio, 6.55; 95% CI, 2.30, 18.63). The rate of permanent brachial plexus injury was similar between the 2 groups. CONCLUSION: A case of brachial plexus injury occurs 1 time in every 1000 births, is permanent in 1 of every 10,000 deliveries, and is litigated 1 time for every 45,000 deliveries. The infrequent nature of injury may preclude prevention.

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