Background With increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines. Methods One hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher’s Exact test to assess group differences in guideline adherence at 2 months. Results One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25–52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28–46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI − 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface. Conclusions Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices. Trial registration Name: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048; Date of Registration: September 7, 2018; Data Sharing Statement: None

BACKGROUND: Tolerance of uncertainty may influence how physicians and other providers practice and make clinical decisions. We hypothesized that increased tolerance of uncertainty would be associated with an increased uptake of a quality improvement (QI) intervention. METHODS: We examined tolerance of uncertainty using the Physicians’ Reactions to Uncertainty Scale in the context of a national QI project in the Value in Inpatient Pediatrics network. The QI project aimed to increase exclusive isotonic fluid use and decrease laboratory draws. Exposure to the intervention was measured by using the stepped wedge design with sequential implementation across a diverse group of US hospitals. Multivariable analysis was conducted by using exposure to the intervention and tolerance of uncertainty as independent variables and exclusive isotonic fluid use or laboratory testing as the dependent variable. RESULTS: Of 106 participating hospitals, 97 contributed valid responses, with an overall mean reported tolerance of uncertainty of 3.39 (95% confidence interval: 3.27–3.50), with lower numbers on the 6-point scale indicating greater tolerance of uncertainty. Exposure to the QI intervention was significantly associated with exclusive isotonic fluid use (P <.001). Lower tolerance of uncertainty at baseline was associated with lower baseline isotonic fluid use and greater uptake of the use of isotonic fluids but not reduction in laboratory testing. CONCLUSIONS: Contrary to our hypothesis, lower tolerance of uncertainty was associated with greater uptake of the QI intervention for the outcome of isotonic fluids. This initial association warrants further study to evaluate how tolerance of uncertainty plays a role in quality improvement science.

An amendment to this paper has been published and can be accessed via the original article.

When studying perceptions of health-risk behavior such as smoking it is important to consider perceptions of both long-term health risks ("LTR"), and short-term health and social risks ("STR"), benefits, and addiction separately. Our hypothesis is that short-term health and social risks, benefits, and addiction will be more strongly associated with behavior among adolescents compared to older adults as adolescents are less-equipped to consider long-term health risks. Further, measuring specific perceptions of long-term health risks, short-term health and social risks, benefits, and addiction is better than asking only about general perceptions of harm. We undertook data reduction, underlying factor structure identification, scale development, and measurement validation. Methods: Analysis was carried out in three stages, following the same procedure for each product. First, to identify the underlying structure of our perception measures, we used principal component analysis and an analysis of internal consistency. Second, to determine internal consistency, Cronbach's a was computed for each derived factor, and percep-

Background: Chronic urticaria (CU), characterized by ≥6 weeks of intense pruritus, remains a debilitating condition for patients. New and safe treatments are needed to manage CU recalcitrant to standard therapy. Objective: A review of the current literature of standard and novel therapeutics in the management of CU was conducted. Methods: A literature search via a medical literature data base and clinical trial data base was conducted to identify treatment options for CU and current clinical trials. Results: Second-generation antihistamines, omalizumab, and cyclosporine remain the most proven therapeutic options for CU. Dupilumab, mepolizumab, benralizumab, tezepelumab, and CDX-0159 are all undergoing clinical trials for CU. Although ligelizumab demonstrated initial promising results, a phase III study was discontinued due to a nonsuperior clinical impact compared with omalizumab. Conclusion: Novel therapies are needed for the treatment of recalcitrant CU. With a deeper understanding of the pathophysiology of CU, promising therapeutics are in clinical trials for CU.

The purpose of this study was to assess the magnitude of hypoglycemia barrier in terms of physician's treatment choices and algorithm and the impact of hypoglycemia in adherence and persistence to insulin treatment. MethOds: Four hundred thirteen Turkish physicians were interviewed by close ended questions with a mix of dichotomous or bounded continuous response formats. Questions were asked face to face in 2 national diabetes congresses, with a physician mix of 75% internists, 23% endocrinologists, 1,9% family physicians and rest pediatricians and obstetrics. Results: Within 413 replies on how important is the hypoglycemia barrier to reach the target HbA1c on an importance scale, 95% replied either important or very important. 82% of physicians declared that they would change their target HbA1c, if they were not concerned about hypoglycemia. Similarly, 88% of physicians believed more of insulin-treated patients might reach target HbA1c if physicians are not concerned about hypoglycemia. Among the physicians replied 79% stated that less than 40% of their patients reported their hypoglycemic status. If patients experience hypoglycemia, 75% of physicians would reduce the insulin dose for more than 60% of patients, 85% would stop insulin treatment for less than 20% of patients, 91% would switch to other insulins and 62% would to prefer to keep same treatment for less than 20% of the patients. Among the physicians replied, 35% of them declared that patients are willing to stop treatment due to hypoglycemia and more than 50% declared that patient needs a new insulin that causes less hypoglycemia. cOnclusiOns: In this study, physician dimension of hypoglycemia was explored. From the results obtained, it is obvious for the Turkish physicians that hypoglycemia is perceived as a major barrier for the better treatment of the patients. These results show that new treatment options causing less hypoglycemia are needed in the treatment of diabetes mellitus.