These results suggest that the biological toll of breast cancer may be greater in black women than white women.

Summary Long sleep duration has been associated with increased risk of cardiovascular disease (CVD) and all‐cause mortality. Inflammation and coagulation have been hypothesized as possible physiological pathways to explain this association, although specific biomarkers have not been studied. Using longitudinal data from 3942 postmenopausal women in the Women's Health Initiative observational study and clinical trials, we investigated whether fibrinogen, an acute‐phase inflammatory protein involved in blood clotting, mediates the associations between sleep duration and coronary heart disease (CHD) and mortality among women. Fibrinogen levels were associated positively with self‐reported long sleep duration (9+ h per night), CHD and all‐cause mortality, even after adjustment for a range of sociodemographic characteristics, cardiovascular risk factors and comorbidities.Compared with self‐reported 7–8 h per night sleep duration, self‐reported long sleep duration was associated with increased odds of CHD [odds ratio (OR) = 2.05, 95% confidence interval (CI): 1.02–4.11]. Adjustment for fibrinogen levels reduced the increased odds of CHD associated with long sleep by approximately 8 percentage points (OR = 1.97, 95% CI: 0.98–3.97). A similar reduction in the OR was observed with mortality. For both outcomes there is support for partial mediation of 6–7%, suggesting that fibrinogen may be a mechanism through which long sleep duration is associated with CHD and mortality.

A B S T R A C TBACKGROUND: Asthma exacerbations are a leading cause of hospitalization among children.Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record. METHODS:We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure. RESULTS:The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period.CONCLUSIONS: Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.

Care plans can reduce care fragmentation for children with medical complexity (CMC); however, implementation is challenging. Mobile health innovations could improve implementation. This mixed methods study’s objectives were to (1) evaluate feasibility of mobile complex care plans (MCCPs) for CMC enrolled in a complex care program and (2) study MCCPs’ impact on parent engagement, parent experience, and care coordination. MCCPs were individualized, updated quarterly, integrated within the electronic health record, and visible on parents’ mobile devices via an online portal. In 1 year (September 1, 2016, to August 31, 2017), 94% of eligible patients (n = 47) received 162 MCCPs. Seventy-four percent of parents (n = 35) reviewed MCCPs online. Forty-six percent of these parents (n = 16) sent a follow-up message, and the care team responded within 8 hours (median time = 7.2 hours). In interviews, parents identified MCCPs as an important reference and communication tool. MCCPs for CMC in a complex care program were feasible, facilitated parental engagement, and delivered timely communication.