Recommendations For Health Maintenance Research Articles

Autoimmune gastritis as an unexpected cause of diarrhea in a young adult with type I diabetes: a case report

BackgroundType 1 diabetes mellitus (T1DM) is a lifelong diagnosis that involves immune-mediated damage of pancreatic beta cells and subsequent hyperglycemia, manifesting as: polyuria, polydipsia, polyphagia, and weight loss. Treatment of type 1 diabetes centers on insulin administration to replace or supplement the body's own insulin with the goal of achieving euglycemia and preventing or minimizing complications. Patients with T1DM are at risk for developing other autoimmune conditions, most commonly thyroid or celiac disease.Case presentationA 20-year-old African American female with T1DM was referred by her endocrinologist to pediatric gastroenterology for 2 months of nocturnal, non-bloody diarrhea, left lower quadrant pain, and nausea; she was also being followed by neurology for complaints of lower extremity paresthesias and pain. The patient’s initial lab-workup was remarkable for a low total Immunoglobulin A (IgA) level of < 6.7 mg/dL. As IgA deficiency is associated with an increased risk of celiac disease, the patient underwent upper and lower endoscopy, which was grossly unremarkable; however, histology revealed a pattern consistent with autoimmune gastritis. Subsequent serum evaluation was remarkable for an elevated fasting gastrin level and an elevated parietal cell antibody level without macrocytic anemia, iron deficiency, or vitamin B12 depletion. The patient was diagnosed with autoimmune gastritis (AIG) and subsequently initiated on parenteral B12 supplementation therapy with improvement in her neurologic and gastrointestinal symptoms.ConclusionThis case illustrates the importance of recognition of red flag findings in a patient with known autoimmune disease. Following well-established health maintenance recommendations for individuals with T1DM ensures that common comorbidities will be detected. Autoimmune gastritis, while a rarer pathology in the pediatric population, deserves consideration in patients with pre-existing autoimmune conditions and new gastrointestinal or neurologic symptoms, as AIG can be associated with poor outcomes and risk of malignancy. Initial lab findings associated with an eventual diagnosis of AIG typically include anemia, iron deficiency, or Vitamin B12 deficiency. However, as demonstrated in this case, symptoms of AIG can rarely present before anemia or Vitamin B12 deficiency develops. To prevent permanent neurological damage, parenteral Vitamin B12 therapy must be considered even in the absence of Vitamin B12 deficiency, especially in those patients already experiencing neurological symptoms.

Nutrition, Sleep, Circadian Rhythms, and Health Implications: “Come Together”

Over the last few years, novel and important aspects of nutrition that are often overlooked in nutritional epidemiology, experimental research, and recommendations for health maintenance and disease prevention concerning the circadian rhythmicity of feeding, as well as the bidirectional interaction of nutrition with central and peripheral endogenous circadian clocks, and with other rhythmic behaviors including the sleep-wake cycle have received increasing attention from the research community [...].

The impact of COVID-19 lockdowns on physical activity amongst older adults: evidence from longitudinal data in the UK

BackgroundA sedentary lifestyle increases the risk of adverse health outcomes and frailty,particularly for older adults. To reduce transmission during the COVID-19 pandemic, people were instructed to stay at home, group sports were suspended, and gyms were closed, thereby limiting opportunities for physical activity. Whilst evidence suggests that physical activity levels reduced during the pandemic, it is unclear whether the proportion of older adults realising the recommended minimum level of physical activity changed throughout the various stages of lockdown.MethodsWe used a large sample of 3,660 older adults (aged ≥ 65) who took part in the UK Household Longitudinal Study’s annual and COVID-19 studies. We examined changes in the proportion of older adults who were realising the UK Chief Medical Officers’ physical activity recommendations for health maintenance at several time points before and after COVID-19 lockdowns were imposed. We stratified these trends by the presence of health conditions, age, neighbourhood deprivation, and pre-pandemic activity levels.ResultsThere was a marked decline in older adults’ physical activity levels during the third national lockdown in January 2021. The proportion realising the Chief Medical Officers’ physical activity recommendations decreased from 43% in September 2020 to 33% in January 2021. This decrease in physical activity occurred regardless of health condition, age, neighbourhood deprivation, or pre-pandemic activity levels. Those doing the least activity pre-lockdown increased their activity during lockdowns and those doing the most decreased their activity levels.ConclusionsReductions in older adults’ physical activity levels during COVID-19 lockdowns have put them at risk of becoming deconditioned and developing adverse health outcomes. Resources should be allocated to promote the uptake of physical activity in older adults to reverse the effects of deconditioning.

Exercise and Interorgan Communication: Short-Term Exercise Training Blunts Differences in Consecutive Daily Urine 1H-NMR Metabolomic Signatures between Physically Active and Inactive Individuals.

Physical inactivity is a worldwide health problem, an important risk for global mortality and is associated with chronic noncommunicable diseases. The aim of this study was to explore the differences in systemic urine 1H-NMR metabolomes between physically active and inactive healthy young males enrolled in the X-Adapt project in response to controlled exercise (before and after the 3-day exercise testing and 10-day training protocol) in normoxic (21% O2), normobaric (~1000 hPa) and normal-temperature (23 °C) conditions at 1 h of 50% maximal pedaling power output (Wpeak) per day. Interrogation of the exercise database established from past X-Adapt results showed that significant multivariate differences existed in physiological traits between trained and untrained groups before and after training sessions and were mirrored in significant differences in urine pH, salinity, total dissolved solids and conductivity. Cholate, tartrate, cadaverine, lysine and N6-acetyllisine were the most important metabolites distinguishing trained and untrained groups. The relatively little effort of 1 h 50% Wpeak per day invested by the untrained effectively modified their resting urine metabolome into one indistinguishable from the trained group, which hence provides a good basis for the planning of future recommendations for health maintenance in adults, irrespective of the starting fitness value. Finally, the 3-day sessions of morning urine samples represent a good candidate biological matrix for future delineations of active and inactive lifestyles detecting differences unobservable by single-day sampling due to day-to-day variability.

IDENTIFYING BARRIERS TO HEALTH MAINTENANCE IN MEDICALLY-UNDERSERVED PATIENTS WITH IBD: A QUALITATIVE STUDY

Abstract BACKGROUND Disparities in adherence to health maintenance recommendations have been well-documented in patients with IBD. Solutions to address these issues remain under-described or evaluated. We sought to engage at-risk patients with IBD for a qualitative assessment of their barriers to health maintenance targets. The goal of this endeavor is to inform the design of interventions to address these disparities in practice. METHODS Boston University School of Medicine (BUSM) and the Crohn’s and Colitis Program at Boston Medical Center (BMC), in partnership with Health Resources in Action (HRiA), conducted focus groups with medically underserved patients with inflammatory bowel disease (IBD), and interviews with IBD providers between April-July of 2021. Four focus groups were conducted virtually in English (n=3) and Spanish (=1) with IBD patients (n=11) receiving care at BMC’s Crohn’s and Colitis Program. Enrollees were selected based on criteria for being ‘at-risk’ for health maintenance non-adherence; defined as insured by MassHealth or a Boston Medical Center Accountable Care Organization (ACO) and who have outstanding health maintenance needs (i.e., lacking a documented flu shot in the past 2 years). In addition, two interviews were conducted with clinical providers serving patients with IBD. Qualitative analyses were conducted with NVivo (NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 12). Transcripts were double coded by two analysts based upon a mutually agreed upon codebook and differences were reconciled through discussion until a consensus was reached (average kappa=0.96). Key themes were identified by discussion frequency and intensity. FINDINGS Key themes that emerged from these comprehensive discussions regarding barriers to patients completing their health maintenance requirements included: lack of culturally appropriate education and information in the patients’ primary languages, specifically patients cited that they had not received information regarding the connection between their IBD and required vaccinations. Also, living with IBD can be stressful, stigmatizing, and isolating, and more mental health supports are needed through ways of integrated care, mental health resources, and support groups. Patients recommended integrating holistic approaches to IBD care and management, including diet/nutrition, exercise, and managing stress Furthermore, other themes that emerged included: insights into patients dealing with chronic pain; medical management is a critical component to preventing flare ups, yet numerous barriers to accessing care exist;. Findings from this process are intended to inform a 12-month quality improvement (QI) initiative within BMC’s Crohn’s and Colitis Program with the ultimate goal of improving patient care.

IDENTIFYING BARRIERS TO HEALTH MAINTENANCE IN MEDICALLY-UNDERSERVED PATIENTS WITH IBD: A QUALITATIVE STUDY

Disparities in adherence to health maintenance recommendations have been well-documented in patients with IBD. Solutions to address these issues remain under-described or evaluated. We sought to engage at-risk patients with IBD for a qualitative assessment of their barriers to health maintenance targets. The goal of this endeavor is to inform the design of interventions to address these disparities in practice.

Health Maintenance Consensus for Adults With Inflammatory Bowel Disease.

With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.

Gaps on rheumatologists' knowledge of physical activity.

To assess the rheumatologists' knowledge and willingness to prescribe physical activity, we conducted a nationwide survey. All adult and paediatric rheumatologist members of the Brazilian Rheumatology Society were invited to fulfil a questionnaire on their knowledge and willingness to promote physical activity. Four hundred twenty-eight rheumatologists participated in the survey, representing approximately 25% of the society's members. Forty-five percent of the rheumatologists reported having had training to prescribe physical activity, and 68% believe that physical activity is a part of patients' treatment. Most reported assessing physical activity levels (86%) and recommending physical activity (98%) always or most of the time. However, 48% do not know the minimum physical activity recommendations for health maintenance, nor do they know how much vigorous activity should be done in replacement of moderate activity. In addition, only 20% are aware of physical activity recommendation for paediatric patients, whereas 31% know that very light-intensity physical activity promotes health-related beneficial effects. Year of graduation, having been trained on physical activity prescription, and regularly recommending physical activity to patients did not associate with the overall score of correct answers (OR: 1.00 [0.99, 1.02], p = 0.391; OR: 0.99 [0.69, 1.44], p = 983; OR: 0.90 [0.61, 1.32], p = 0.576; respectively). Rheumatologists are highly willing to promote physical activity, but major gaps in their knowledge were identified. Given the widespread recognition of physical activity as a key element on the management of rheumatic patients, these data hint to the need of incorporating physical activity in the rheumatologist' training. Key Points • This survey showed that rheumatologists are highly prone to promote physical activity. • However, rheumatologists have major gaps in knowledge of physical activity. • Adding physical activity to rheumatologist's training programs is key to improve physical activity promotion.

Sickle cell disease: A primary care update.

Sickle cell disease (SCD) is the most common hemoglobinopathy in the United States and causes significant disease-related morbidity including multiorgan damage, chronic anemia, and debilitating pain crises. Primary care physicians play a key role in the medical home model of care for adults with SCD. This review focuses on current recommendations for health maintenance and provides a brief summary of disease complications and current updates.

P021 The potential impact of provider gender on IBD management

BACKGROUND: Health maintenance guidelines have been published to ensure optimal clinical outcomes for individuals with inflammatory bowel disease (IBD), with recommendations including the evaluation of bone density, eye, and skin health. However, it has been suggested that there is variability in adherence to health maintenance recommendations. This study evaluated both the gender of providers discussing health maintenance with patients, and the overall rate of physicians' recommendations for Dual-energy X-ray absorptiometry (DXA) scans, vitamin D levels, ophthalmologic exams, and skin protective measures at an urban university medical center. METHODS: A retrospective chart review was performed evaluating all IBD patients seen at a university gastroenterology clinic over a 5-year period was performed. Patients' IBD diagnosis, recommendations for DXA, vitamin D levels, ophthalmologic exams, and skin protective measures (sunscreen and/or dermatology referral) were obtained. Patient and physician gender were recorded. A database was generated using Microsoft Excel. Statistical analysis was performed using Fisher's Exact Test with significance set at P &lt; 0.05. The study was approved by the IRB. RESULTS: 393 IBD patients were identified (175 males, 218 females) with mean age of 44.4 (age range: 20–82). 279 (71.0%) had Ulcerative Colitis (UC), 96 (24.4%) had Crohn's disease (CD), 7 (1.8%) with unspecified colitis, and 11 (2.8%) had microscopic colitis. Of the 393 patients, 279 (71.0%) were seen by male providers and 114 (29.0%) were seen by female providers. 249 (63.4%) patients had vitamin D and 110 (28%) had DXA scans performed. Ophthalmologic referrals were offered to 125 (27.8%). 83 (21.1%) were counseled about skin protective measures and given dermatology referrals. Significantly more female providers recommended vitamin D (P = 0.015), DXA screening (P = 0.027), ophthalmologic evaluations (P &lt; 0.0001) and dermatologic referrals (P &lt; 0.0001) compared to male providers. There was no significant difference of the performance of health maintenance recommendations based upon disease type. CONCLUSION(S): This study revealed that there was inconsistent adherence to IBD health maintenance recommendations. While female physicians more frequently recommended vitamin D screening, DXA scans, ophthalmologic examinations, and skin evaluations, there was a clear need to improve screening by all physicians. While this study was limited based upon retrospective design, small sample size, and single institution cohort, it provides a foundation for future research that addresses IBD management. Increased efforts to optimize IBD care will improve overall clinical outcomes.

P015 WHO YOU ARE MAY DEFINE HOW DOCTORS TREAT YOU: GENDER AND RACIAL DISPARITIES IN IBD MANAGEMENT

Patients with inflammatory bowel disease (IBD) require more frequent and varied screening tests in order to reduce patient morbidity and mortality. Beyond colonoscopies, routine skin, ophthalmologic, vitamin D, and DXA evaluations are recommended to reduce IBD complications. This study investigated the rates of health maintenance evaluations in IBD patients and whether demographics impacted patient management in a university medical center. A retrospective chart review evaluating all IBD patients seen at a university gastroenterology clinic over a five-year period was performed. Patient gender, self-categorized race, IBD diagnosis and whether the patient was recommended to get bone (DXA, vitamin D), dermatologic or ophthalmologic evaluations were noted. A database was created using Microsoft Excel. Statistical analysis was performed using a two-tailed Fisher’s Exact Test with significance set at P<0.05. The study was approved by the IRB. Medical records of 393 patients (218 female, 175 male) were reviewed. 279 (71.0%) had ulcerative colitis, 96 (24.4%) had Crohn’s disease, 7 (1.8%) had indeterminate colitis, and 11 (2.8%) had microscopic colitis. 249 (63.4%) had vitamin D levels, 110 (28%) had DXA, 125 (31.8%) had ophthalmologic exams and 83 (21.1%) had skin evaluations. Women received significantly more DXA scans (p=0.007) and vitamin D testing (p=0.049) compared to men. There were no significant differences in performance of skin exams and recommendations (p=0.71) or ophthalmologic exams (p=0.66) between women and men. 204 patients (51.9%) were Caucasian, 100 (29.0%) were African American, 12 (3.1%) were Asian, and 77 (19.6%) were unspecified race. There were no significant differences in vitamin D surveillance in Caucasians with African Americans (p=0.092) or Asians (p=1). There were no significant differences in DXA scans between Caucasians and African Americans (p=0.121) or Asians (p=0.152). On the other hand, skin exams were performed at significantly higher rates in Caucasians compared to African Americans (p<0.0001) and Asians (p<0.0001), as was ophthalmologic screening among Caucasians relative to African Americans (p<0.0001) and Asians (p<0.0001). This study revealed that there was inconsistent adherence to IBD health maintenance recommendations. Women received significantly more testing for bone health compared to men. There was no difference in skin exams and ophthalmologic exams based upon patient gender. Notably, Caucasian patients received significantly more ophthalmologic and skin exams compared to patients of other races. While this study is limited based upon retrospective and single institution design, this study supports recommendations for increased efforts to improve health maintenance recommendations among all patients to optimize clinical outcomes.

Health maintenance for adults with neuromuscular diseases on immunosuppression.

Immunosuppressants are commonly used in the treatment of neuromuscular diseases. The use of these medications requires health maintenance screening and monitoring for multiple potential sides effects, which may be best conducted when the prescribing physician and primary care physician work in tandem. Clinical practice guidelines, recommendations from professional organizations, prescription drug labeling, and expert opinion were reviewed and combined to provide recommendations for health maintenance for eight different immunosuppressants. Recommendations are provided for vaccinations, infection prophylaxis, laboratory monitoring, bone density screening, cancer screening, and other considerations. While studies in individuals with neuromuscular diseases are sparse, knowledge gained from the use of immunosuppressants in other conditions is applied in this review to provide recommendations to be used during the treatment of neuromuscular diseases in adults. Muscle Nerve 59:397-403, 2019.

Novel Multidisciplinary Comprehensive Clinic Program Improves Patient Compliance, Patient Satisfaction and Health Maintainance Outcomes in the Outpatient Setting for Patients with Severe Sickle Cell Disease

IntroductionSickle Cell Disease (SCD) is the most common genetic disease identified in newborns in the United States. It results from a single amino acid substitution in the beta globin protein. This results in severe chronic complications, long-term end-organ damage and reduced life expectancy.Evidence Based Health Maintenance (HM) recommendations (HMR) provide the best framework for reducing chronic complications of SCD. Many barriers to healthcare utilization exists for patients with SCD and patients are often unable to access HMR. The decrease in comprehensive care often leads to poor compliance and outcomes. To address this we established a novel patient centered comprehensive SCD clinic (CSCDC).MethodsCSCDC occurs the third Wednesday of every month. Sub-specialists commit to CSCDC and subspecialty clinic slots are reserved. Available services: Cardiology, Radiology, Ophthalmology, Pulmonology, Nephrology, Social Work, Immunizations. Other services are available as needed. Lunch and group patient education are provided.There are 188 SCD patients in our program (the cohort). This includes HbSS, HbSC and HbSB thalassemia only. Patients electronic charts are reviewed to determine HM needs. Families are contacted by phone 4-6 weeks prior to the scheduled CSCDC. The HM needs are reviewed with families. The family has an opportunity to adjust work, school and other personal commitments in advance of the clinic date. Family and SCD clinic commits to the CSCDC date. Clinic flexibility is allowed.Electronic medical records and Qlik Sense Software (Qlik ,Randor PA) were used to determine visit numbers and clinic no show rates (NSR). Patient initiated same day cancellations are included in the NSR. NSR date range was January 2016-July 2018. First we determined NSR for all SCD related clinic visits for the cohort (NSR-SCD). Then we determined NSR for the cohort on CSCDC dates only (NSR-CSCDC). We then divided the cohort into three groups based on NSR-SCD. Low, middle and high NSR. We then compared NSR-SCD and NSR-CSCDC for each group. The two proportion Z test was used to calculate p valuesVolunteers unrelated to CSCDC contacted patients by telephone. Prior IRB approval was obtained. Family participation was voluntary and limited to families with CSCDC attendance. Parents or patients (18 years and older) were asked to answer questions. The questions evaluated 1.Patient overall satisfaction with CSCDC, 2.Likely to return to CSCDC, 3.Likely to recommend CSCDC and 4.Did CSCDC improve the patients individual SCD management.CSCDC dates Aug 2015-July 2018 were used to select the sub-cohort of patients that attended two or more CSCDC clinics. We determined if the HM evaluations occurred according to published guidelines.ResultsThere was a statistically significant decrease in NSR for patients attending CSCDC vs the general SCD clinic. The cohort consisted of 188 patients, 1243 clinic visits and 322 no shows(NS). In CSCDC there were 134 patients, 182 clinic visits and 18 NS. NSR-SCD vs NSR-CSCDC was 25.9% vs 9.9% (p 0.000002).(Table 1)When the cohort was divided into NSR subgroups. NSR decrease was most significant for the high NSR sub group.For high and middle NSR, NSR-SCD vs NSR-CSCDC were 50.8% vs 28.8% (p 0.002759) and 19.8% vs 4.2% (p 0.001187) respectively.(Table 2)The low subgroup had 0% NSR. Patients with the historically highest NSR had significant decrease in their NSR during CSCDC.There were 170 phone contacts and 122 responses for a 72% response rate. Families were asked to grade their answers in a range of 1-5 with 5 being the highest (top box). Results: 86%, 91% and 92% top box scores for CSCDC patient reporting “extremely satisfied” with CSCDC, “extremely likely” to recommend CSCDC and “extremely likely” to return to CSCDC respectively. 97% responded “yes” that CSCDC improved their individual family SCD care.CSCDC increased adherence to standard HMR. Total patient visits for the time range was 236. There were 56 patients (24%) who attended at least 2 CSCDC. 62% of these repeat attendees received health maintenance evaluations within 4-8 weeks of the recommended time.ConclusionOur CSCDC demonstrates increase in SCD patient compliance with clinic visits, high patient satisfaction and high level of HM adherence to standard. We believe this is an effective model for SCD comprehensive care and this data may be useful to initiate evaluation of a larger patient cohort. DisclosuresNo relevant conflicts of interest to declare.

THE PHYSICAL ACTIVITY, SELF-CONCEPT AND ACADEMIC PERFORMANCE AMONG PORTUGUESE ADOLESCENTS

The present study aimed to study the relationship between physical exercise, self-concept and school achievement in students of the second and third cycles of schooling aged 12 to 19 years. It also aims to verify if exercise habits reflect the recommendations for health maintenance. The sample consisted of 624 individuals (268 males, 354 females). The self-concept Questionnaire II (SDQ-II) (Marsh, 1990; Portuguese version of Goncalves & Vasconcelos-Raposo, 2001) was used to measure self-concept and to evaluate the school achievement we took into consideration the accumulated number of failures in school. In general, it was concluded that there is a positive correlation between self-concept and physical exercise, as well as a positive correlation between self-concept and school performance.text

Survivorship care planning after participation in communication skills training intervention for a consultation about lymphoma survivorship.

A survivorship care plan refers to a written summary of the treatment received and recommendations regarding surveillance and management of late effects. To provide evaluation of a communication skills training (CST) intervention to enhance the transition of lymphoma survivors to cancer survivorship. Nineteen oncologists specializing in lymphoma treatment were recruited and completed a survivorship CST workshop, and two standardized patient assessments (SPAs), one pretraining and one posttraining. Significant improvements in SPA scores were observed in six of the seven SPA assessment categories: use of survivorship care plan, review of disease and treatment details, long-term effects, potential late effects, specific physician recommendations, and additional health maintenance recommendations. The intervention had significant effects on physicians' uptake of new strategies and skills, as measured through pre- and posttraining SPAs, as well as on the physicians' self-efficacy about having these conversations.

35: Examining the Evidence and Strength of Recommendations Behind the 2014 Rourke Baby Record Preventive Care Guide

Recommendations for preventive care in children, including screening maneuvers, anticipatory guidance and specific interventions, should be based on sound evidence. The health maintenance recommendations should be effective if applied, should not cause unintended consequences (harm), and should optimize the time spent in clinic between the primary care provider and family. The Rourke Baby Record (RBR) is a tool for primary care providers, which includes preventive care recommendations based on available evidence. We sought to rank recommendations for preventive care in the most recent iteration of the RBR by order of priority based on level of evidence and strength of recommendation. We also highlighted advantages and drawbacks to assigning a priority value to preventive services in children based on the current classification system. We assigned a level of evidence (low, moderate, or high) using the GRADE system and a strength of recommendation (weak or strong) for each of the recommendations in the 2014 RBR. We gave the highest values to strong recommendations supported by high quality evidence, and the lowest values to weak recommendations supported by low quality evidence. We re-examined the evidence base for strong recommendations and ranked them according to 1) importance of outcomes, 2) uncertainty and magnitude of estimates of benefits or harms, and 3) feasibility for implementation during well-baby and well-child visits. The number of preventive care recommendations in children supported by high quality studies is limited. A large majority of recommendations are based on expert consensus. Recommendations that ranked high in priority had a large potential for health improvement, including immunizations, growth monitoring, breastfeeding counseling, vehicle safety and counseling to prevent sudden infant death syndrome. We highlight some of the difficulties encountered in developing an evidence base for pediatric preventive care, including the lack of evidence for long-term health benefits and the poor methodological quality of studies. Evidence of benefits and harms from randomized controlled trials is often lacking for ethical or feasibility reasons. Except for maneuvers with a clear potential for health improvement such as immunizations, the evidence is limited for preventive care recommendations, leaving clinicians with little empirical guidance on how to implement them. While evidence of causality between preventive care and better health outcomes should be established, estimates of benefits from randomized trials should not always be sought. Observational study designs or quasi-experimental designs of high quality can make a large contribution to the evidence base in this field and should be considered in future research.

Webinars as a tool for breast cancer survivorship education.

109 Background: Survivorship education may facilitate coordination of care between the patient and health care providers, increase adherence to health maintenance recommendations, and improve outcomes. Approximately 80% of Americans regularly use the internet. Interactive seminars (webinars) may offer an efficient tool to reach a diverse audience of cancer survivors, caregivers, and providers. Methods: From September 2012-April 2013, we offered 3 free 1-hour webinars advertised via social media, print flyers, email, newsletters, and advocacy and support groups. Topics included next steps after breast cancer treatment, integrative medicine, and nutrition. Participants registered online or by phone. Format consisted of a 30-minute lecture followed by live Q&amp;A with electronically submitted questions. Demographic data were collected at registration and participants were asked to complete a brief 9-question survey after the webinar. Results: 728 participants registered for at least 1 webinar (median age 56, range 18-81 years; 14% African American). 681 participants were U.S.-based and 47 joined from 21 other countries. Participants self-identified as a cancer survivor (71%), provider (20%), caregiver (8%), or other (2%). Most (79%) had at least a high school education. Among the 184 (25%) who completed the post-webinar survey, 86% reported that information was relevant to situation, 85% said they had the opportunity to ask questions, 94% felt speakers were knowledgeable, and 90% were satisfied with the information quality. Participants ranked one-on-one care followed by webinars as their preferred way to receive survivorship information, above other tools like videos, websites, and handouts. Conclusions: As part of a multidisciplinary approach to breast cancer survivorship care, webinars are a feasible modality to deliver quality health information. Limitations include overall generalizability with a potential selection bias of those who may be more educated than the general population, have access to the internet, and feel comfortable with this technology. Nonetheless, data suggest that this format may allow us to reach a diverse audience that appears receptive and satisfied with survivorship education provided in an electronic format.

Health Maintenance in Older Adults: Combining Evidence and Individual Preferences

There is increasing interest in maintaining health and delaying disability for older adults as this population segment expands. And instead of focusing on a traditional disease-specific approach to health maintenance, there is an ongoing shift to a patient-centered approach, and defining outcomes based on the older adults' goals. In this approach, their goals and preferences are central, and other factors such as their health status and prognosis help determine which goals may be realistic. These subjective goals and objective characteristics are then balanced with the risks, benefits, and harms of established evidence-driven health-maintenance recommendations. Hence, older adults share their goals and preferences with clinicians; while clinicians share information on risks, benefits, harms, and uncertainties of existing health-maintenance recommendations, and help guide the older adult through how existing evidence can respond to their health goals and preferences. In this article, the concept of patient-centered care in the context of health maintenance for older adults is discussed; and health maintenance recommendations for older adults are reviewed.

Nurse practitioner-led breast cancer survivorship clinic

e20723 Background: The 2.5 million breast cancer survivors in the US demands increasing awareness of and need for healthcare organizations to address survivorship issues. Cancer survivorship care has become a specialty emphasizing health promotion, disease prevention, and patient satisfaction. It is a natural setting for advanced practice nurses to be leaders. This abstract presents a model for a nurse practitioner-led breast cancer survivorship clinic. Methods: Eligible patients are those previously diagnosed with invasive and/or in situ breast cancer and at least 5 years post-diagnosis without recurrence. Eligible survivors are identified annually through the University of New Mexico Tumor Registry. Clinic notes are reviewed to confirm the patient has not had a recurrence, new diagnosis, or death. Letters are sent to eligible survivors introducing the Breast Cancer Survivorship Clinic (Clinic) and inviting them to participate, and oncologists are encouraged to transfer eligible patients into the Clinic. Results: Eighty-six survivors are currently participating in the Clinic. Survivors are seen on an annual basis after mammogram. Each survivor receives a personalized Survivorship Care Plan at the first visit. The care plan was developed by a multi-disciplinary team of a breast oncologist, psychologist, social worker, nutritionist, and patient educator to provide input on the issues that survivors face. Components of Survivorship Care Plan: pathologic and genetic findings, summary of treatment, bloodwork, bone health, lymphedema, secondary malignancies, health maintenance recommendations, psychological assessment, nutrition/weight assessment. Conclusions: The establishment of the Clinic has several advantages: Breast cancer survivors are being followed in this specialty clinic after 5 years instead of being discharged from the Cancer Center. The Clinic has allowed oncologists more time for patients actively on therapy and more time to accommodate newly diagnosed patients. The Clinic addresses the unique issues faced by long term survivors, which could increase patient satisfaction. A multi-disciplinary team is key to developing a care plan for a survivorship clinic. However, the day-to-day operation of the clinic can be effectively led by a nurse practitioner. No significant financial relationships to disclose.

Forecast of the Health Status, Working Capacity, and Professional Successes under Arid Zone Conditions

Forecasting data on the human heat resistance, professional successes, and health level under hot arid conditions of Turkmenistan are described. A relationship has been established between the characteristics of the thermoregulation system performance under thermoneutral environments, which is shown by the skin surface temperature, and the organism's capacity to maintain a high level of working capacity on heat exposure. The skin temperature patterns are shown to be informative when analyzing the organism's heat state and forecasting the extent to which the total working capacity decreases in response to the intensive heat effect. On the basis of the findings, we developed the criteria for psychophysiological professional selection of linemen for the work under hot arid zone conditions of Turkmenistan. A comparative analysis of the health status of women employed in industry and of housewives living in the arid zone has been carried out using the automated system for the quantitative estimation of risk of the major pathological syndromes (ASQEPS). Groups with tense adaptation have been detected. Analysis and comparison of the syndrome rating in the test groups make it possible to estimate the effect of natural climatic and industrial conditions on the risk of development of major noninfectious diseases and to formulate recommendations for health maintenance.