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Indigenous North Americans, particularly those within the historical and current borders of the United States, were (and are) subjected to displacement and marginalisation by pre- and post-colonial government policies and practices. Initially focused on colonial land settlements and Indian removal to land reserves, many of these policies and practices live on through violations of treaties, challenges to sovereignty rights and ongoing existential threats. Today, the starkest visualisation of negative outcomes associated with these policies and practices exists across US systems of public education, especially higher education. Although American Indian college students are finding improved access points to higher education, they remain the least likely of all racial/ethnic groups to experience successful outcomes in secondary and post-secondary settings. Progress in these areas has been too slow and often fraught with tangible and intangible barriers negatively affecting success. This chapter will discuss direct consequences of marginalisation and displacement of Native peoples in the United States; current efforts to improve education outcomes; suggested steps for improving collegiate success for Native students; emerging national higher education initiatives, including those among tribal government education departments; and ethical considerations for collecting, analysing and reporting Native data.
Hoarding is associated with problems engaging in social activities, lower social support, increased isolation and poses substantial challenges to family functioning. The aim of this investigation was to explore the relationship between hoarding severity and family and social functioning variables in 60 treatment-seeking adults with hoarding disorder (HD). Participants completed a battery of self-report measures during a baseline assessment completed prior to treatment. Forty-seven percent of participants reported they live alone. Forty-eight percent of participants reported that family and friends never visit them in their home, and 33% indicated they never had visitors to their home, not even service workers or repair people. Twelve percent of participants indicated they never visit with family or friends outside of their home; however, 55% of participants endorsed phoning family or friends more than 9 times each month. Increased clutter and hoarding severity was associated with a lower frequency of family and friends visiting in the home. Family competence and conflict were both positively associated with hoarding severity. Our results shed light on family and social impairment in HD and their relationship with symptom severity; however, additional research should examine social dysfunction among non-treatment-seeking individuals who may be more impaired or isolated.
Unemployment is common in persons with severe mental illness (SMI) and more in Latino population. Department of Mental Health and Addiction Services (DMHAS) of Connecticut offers a supported employment (SE) Program to help clients get competitive work in integrated settings with nondisabled workers in the community.
Capture perspectives of key informant groups to describe barriers for linking Latinos with SMI to employment and adapt SE Services for subpopulations.
Four focus groups were conducted (employment specialists, case managers and peer support counselors/employers/two with clients-one in Spanish and other in English). They were conducted during January-February 2015, 70–90 minutes each one. A question guide was developed for each group. Participants per focus group ranged from 3–10, voluntarily. Two new questionnaires to the baseline pack were developed: challenges to Employment Assessment–provider and client version.
Thirty individuals participated. Several barriers to employment were reported. Clients and staff reported criminal record, lack of employment history and lack of motivation. Staff described client hygiene, mental status, physical health, substance abuse and discrimination. Clients, staff and employers reported language barrier for Latinos who don’t speak English. Non-adherence to medication was reported by clients and employers. About Spanish-Speaking Latinos with mental illness, medication, discrimination, previous abuse by employers, inappropriate employment, difficulties of the job interview and computer skills appeared as challenges. English-Speaking Latinos with mental illness identified transport, stability, support, keeping apartment and financial needs.
Focus groups can help in knowledge about the diversity of Latino communities to improve SE Services and outcomes for Latinos.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The objective of this paper was to examine the implementation and effectiveness of a community-based intervention for hoarding disorder (HD) using Cognitive Rehabilitation and Exposure/Sorting Therapy (CREST).
This was a mixed-method, pre-post quasi-experimental study informed by the Practical, Robust Implementation and Sustainability Model for implementation science.
Program activities took place in San Diego County, mainly within clients’ homes or community, with some activities in-office.
Participants were aged 60 years or older, met eligibility for Medi-Cal or were uninsured, and met criteria for HD.
A manualized, mobile protocol that incorporated CREST was utilized.
The Clutter Image Rating and Hoarding Rating Scale were used as effectiveness outcomes. An investigator-created staff questionnaire was used to evaluate implementation.
Thirty-seven clients were reached and enrolled in treatment and 15 completed treatment during the initial 2 years of the program. There were significant changes in hoarding severity and clutter volume. Based on the initial 2 years of the program, funding was provided for expansion to cover additional San Diego County regions and hire more staff clinicians in year three.
Preliminary data suggest that the CREST intervention can be successfully implemented in a community setting with positive results for older adults with HD.
OBJECTIVES/SPECIFIC AIMS: This study aims to first describe the unique cytokine profile and TGFbeta levels of young children with CF, then understand the pathologic effects of TGFbeta on lung function in a CF animal model. These powerful translational studies linking observations in clinical disease with a transgenic mouse model allow us a unique opportunity to investigate the role of TGFbeta in early CF lung disease. METHODS/STUDY POPULATION: Cytokine levels (TGFbeta, TNFalpha, IL-8, IL-6, HNE, and IL-1beta) in bronchoalveolar lavage fluid (BALF) from CF patients (n = 15) and non-CF control patients (n = 21) under 6 years old were determined by ELISA and Luminex assay. Tracheotomized patients without significant underlying lung disease were chosen as non-CF inflamed control patients, as they had similar levels of neutrophilic inflammation and infection as CF patients. The percentage of BAL neutrophils (% PMNs) in each sample was assessed. The relationships between cytokines were analyzed using linear regression and principal components analysis. In animal studies, CF and non-CF mice (n = 4-5 per group) were treated with intratracheal adenoviral TGFbeta1 vector, an empty vector control, or PBS. After one week, animals were collected; lung function, response to the bronchoconstrictor methacholine, and rescue with albuterol were measured utilizing a FlexiVent machine. Lungs were collected for histology. Immunohistochemistry for alpha-SMA was performed and pictures of all cross-sectional airways were obtained. Burden of ASM was assessed by dividing the square root of alpha-SMA stained airway smooth muscle by the basement membrane perimeter length of each airway. RESULTS/ANTICIPATED RESULTS: Patient characteristics of CF and non-CF inflamed control patients were similar in terms of age (3.6 yrs vs 3.3 yrs respectively, p = 0.49), positive BAL culture (13% vs 14%, p = 0.94), and % PMNs (65% vs 56%, p = 0.64). Despite these similarities, TGFbeta levels were 2-fold higher in CF versus non-CF BAL (p = 0.034). Analysis of BAL cytokines from both patient groups showed that three principal components describe 86% of total variance across the cytokine variables. These components represent different contributions from the cytokines, with TGFbeta, IL6, and % PMNs comprising one component of similarly regulated inflammatory markers. These components can distinguish CF versus non-CF patients with 77% accuracy (area under the curve: 0.77). TGFbeta concentrations were uniquely associated with increased IL-6 in CF samples (r = 0.74; p = 0.0015) but did not demonstrate association with other cytokines. After TGFbeta exposure, CF mice demonstrated greater abnormalities in airway resistance than non-CF mice, with heightened response to methacholine. Importantly, this increase in airway obstruction in CF mice was reversible with albuterol treatment, indicating airway smooth muscle dysfunction as a principal driver of lung function abnormalities. Furthermore, TGFbeta induced an increased ASM burden on lung histology in both CF and non-CF mice (p<0.05). IL-6 levels in the BAL of CF mice showed greater increases after TGFbeta treatment compared to non-CF mice (p<0.05). Empty vector control treatment did not cause lung pathology. DISCUSSION/SIGNIFICANCE OF IMPACT: Young children with CF have a unique pattern of pulmonary inflammation compared to inflamed non-CF control patients. In CF, TGFbeta pulmonary levels are uniquely associated with IL-6, a driver of ASM dysfunction in other pulmonary diseases. We followed up this clinical observation study by investigating the effect of TGFbeta on pulmonary disease in a mouse model. CF mice demonstrate increased pulmonary IL-6, airway obstruction, and ASM dysfunction after TGFbeta exposure. This study provides evidence that TGFbeta is associated with a distinct cytokine pattern that may promote ASM dysfunction in early CF lung disease. Understanding the mechanism of early CF pathophysiology will be critical in developing targeted therapeutics that can prevent early lung damage.
OBJECTIVES/SPECIFIC AIMS: Transforming growth factor-beta (TGFβ) is a genetic modifier of cystic fibrosis (CF) lung disease. TGFβ’s pulmonary levels in young CF patients and its mechanism of action in CF are unknown. We examined TGFβ levels in children with CF and investigated responses of human airway epithelial cells (AECs) and mice to TGFβ. METHODS/STUDY POPULATION: TGFβ levels in bronchoalveolar lavage fluid from CF patients (n=15) and non-CF control patients (n=21)<6 years old were determined by ELISA. CF mice and non-CF mice were intratracheally treated with an adenoviral TGFβ1 vector or PBS; lungs were collected for analysis at day 7. Human CF and non-CF AECs were treated with TGFβ or PBS for 24 hours then collected for analysis. RESULTS/ANTICIPATED RESULTS: Young CF patients had higher bronchoalveolar lavage fluid TGFβ than non-CF controls (p=0.03). Mouse lungs exposed to TGFβ demonstrated inflammation, goblet cell hyperplasia, and decreased CFTR expression. CF mice had greater TGFβ-induced lung mechanics abnormalities than controls; both CF human AECs and CF mice showed higher TGFβ induced MAPK and PI3K signaling compared with controls. DISCUSSION/SIGNIFICANCE OF IMPACT: For the first time, we show increased TGFβ levels very early in CF. TGFβ drives CF lung abnormalities in mouse and human models; CF models are more sensitive to TGFβ’s effects. Understanding the role of TGFβ in promoting CF lung disease is critical to developing patient specific treatments.
Diuraphis noxia (Kurdjumov), Russian wheat aphid, is one of the world's most invasive and economically important agricultural pests of wheat and barley. In May 2016, it was found for the first time in Australia, with further sampling confirming it was widespread throughout south-eastern regions. Russian wheat aphid is not yet present in New Zealand. The impacts of this pest if it establishes in New Zealand, could result in serious control problems in wheat- and barley-growing regions. To evaluate whether D. noxia could establish populations in New Zealand we used the climate modelling software CLIMEX to locate where potential viable populations might occur. We re-parameterised the existing CLIMEX model by Hughes and Maywald (1990) by improving the model fit using currently known distribution records of D. noxia, and we also considered the role of irrigation into the potential spread of this invasive insect. The updated model now fits the current known distribution better than the previous Hughes and Maywald CLIMEX model, particularly in temperate and Mediterranean areas in Australia and Europe; and in more semi-arid areas in north-western China and Middle Eastern countries. Our model also highlights new climatically suitable areas for the establishment of D. noxia, not previously reported, including parts of France, the UK and New Zealand. Our results suggest that, when suitable host plants are present, Russian wheat aphid could establish in these regions. The new CLIMEX projections in the present study are useful tools to inform risk assessments and target surveillance and monitoring efforts for identifying susceptible areas to invasion by Russian wheat aphid.
To reduce inappropriate antimicrobial prescribing across ambulatory care, understanding the patient-, provider-, and practice-level characteristics associated with antibiotic prescribing is essential. In this study, we aimed to elucidate factors associated with inappropriate antimicrobial prescribing across urgent care, family medicine, and pediatric and internal medicine ambulatory practices.
DESIGN, SETTING, AND PARTICIPANTS
Data for this retrospective cohort study were collected from outpatient visits for common upper respiratory conditions that should not require antibiotics. The cohort included 448,990 visits between January 2014 and May 2016. Carolinas HealthCare System urgent care, family medicine, internal medicine and pediatric practices were included across 898 providers and 246 practices.
Prescribing rates were reported per 1,000 visits. Indications were defined using the International Classification of Disease, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) criteria. In multivariable models, the risk of receiving an antibiotic prescription was reported with adjustment for practice, provider, and patient characteristics.
The overall prescribing rate in the study cohort was 407 per 1,000 visits (95% confidence interval [CI], 405–408). After adjustment, adult patients seen by an advanced practice practitioner were 15% more likely to receive an antimicrobial than those seen by a physician provider (incident risk ratio [IRR], 1.15; 95% CI, 1.03–1.29). In the pediatric sample, older providers were 4 times more likely to prescribe an antimicrobial than providers aged ≤30 years (IRR, 4.21; 95% CI, 2.96–5.97).
Our results suggest that patient, practice, and provider characteristics are associated with inappropriate antimicrobial prescribing. Future research should target antibiotic stewardship programs to specific patient and provider populations to reduce inappropriate prescribing compared to a “one size fits all” approach.
We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.
There is limited knowledge on vitamin D status of children residing in the Andes and its association with undernutrition. We evaluated the vitamin D status of children residing in a low socio-economic status (SES) setting in the Ecuadorian Andes and assessed the association between vitamin D status, stunting and underweight. We hypothesized that children who were underweight would have lower serum 25-hydroxyvitamin D (25(OH)D) levels and lower 25(OH)D levels would be associated with a higher risk of stunting.
We conducted a cross-sectional secondary analysis of a randomized controlled trial, the Vitamin A, Zinc and Pneumonia study. Children had serum 25(OH)D concentrations measured. A sensitivity analysis was undertaken to determine a vitamin D cut-off specific for our endpoints. Associations between serum 25(OH)D and underweight (defined as weight-for-age Z-score≤−1) and stunting (defined as height-for-age Z-score≤−2) were assessed using multivariate logistic regression.
Children residing in five low-SES peri-urban neighbourhoods near Quito, Ecuador.
Children (n 516) aged 6–36 months.
Mean serum 25(OH)D concentration was 58·0 (sd 17·7) nmol/l. Sensitivity analysis revealed an undernutrition-specific 25(OH)D cut-off of <42·5 nmol/l; 18·6 % of children had serum 25(OH)D<42·5 nmol/l. Children who were underweight were more likely to have serum 25(OH)D<42·5 nmol/l (adjusted OR (aOR)=2·0; 95 % CI 1·2, 3·3). Children with low serum 25(OH)D levels were more likely to be stunted (aOR=2·8; 95 % CI 1·6, 4·7).
Low serum 25(OH)D levels were more common in underweight and stunted Ecuadorian children.
Background: Psychological therapy services are often required to demonstrate their effectiveness and are implementing systematic monitoring of patient progress. A system for measuring patient progress might usefully ‘inform supervision’ and help patients who are not progressing in therapy. Aims: To examine if continuous monitoring of patient progress through the supervision process was more effective in improving patient outcomes compared with giving feedback to therapists alone in routine NHS psychological therapy. Method: Using a stepped wedge randomized controlled design, continuous feedback on patient progress during therapy was given either to the therapist and supervisor to be discussed in clinical supervison (MeMOS condition) or only given to the therapist (S-Sup condition). If a patient failed to progress in the MeMOS condition, an alert was triggered and sent to both the therapist and supervisor. Outcome measures were completed at beginning of therapy, end of therapy and at 6-month follow-up and session-by-session ratings. Results: No differences in clinical outcomes of patients were found between MeMOS and S-Sup conditions. Patients in the MeMOS condition were rated as improving less, and more ill. They received fewer therapy sessions. Conclusions: Most patients failed to improve in therapy at some point. Patients’ recovery was not affected by feeding back outcomes into the supervision process. Therapists rated patients in the S-Sup condition as improving more and being less ill than patients in MeMOS. Those patients in MeMOS had more complex problems.
We consider rotating convection in a shallow, cylindrical domain. We examine the conditions under which the resulting vortex develops an eye at its core; that is, a region where the poloidal flow reverses and the angular momentum is low. For simplicity, we restrict ourselves to steady, axisymmetric flows in a Boussinesq fluid. Our numerical experiments show that, in such systems, an eye forms as a passive response to the development of a so-called eyewall, a conical annulus of intense, negative azimuthal vorticity that can form near the axis and separates the eye from the primary vortex. We also observe that the vorticity in the eyewall comes from the lower boundary layer, and relies on the fact the poloidal flow strips negative vorticity out of the boundary layer and carries it up into the fluid above as it turns upward near the axis. This process is effective only if the Reynolds number is sufficiently high for the advection of vorticity to dominate over diffusion. Finally we observe that, in the vicinity of the eye and the eyewall, the buoyancy and Coriolis forces are negligible, and so although these forces are crucial to driving and shaping the primary vortex, they play no direct role in eye formation in a Boussinesq fluid.
Kummerite, ideally Mn2+Fe3+A1(PO4)2(OH)2.8H2O, is a new secondary phosphate mineral belonging to the laueite group, from the Hagendorf-Süd pegmatite, Hagendorf, Oberpfalz, Bavaria, Germany. Kummerite occurs as sprays or rounded aggregates of very thin, typically deformed, amber yellow laths. Cleavage is good parallel to ﹛010﹜. The mineral is associated closely with green Zn- and Al-bearing beraunite needles. Other associated minerals are jahnsite-(CaMnMn) and Al-bearing frondelite. The calculated density of kummerite is 2.34 g cm 3. It is optically biaxial (-), α= 1.565(5), β = 1.600(5) and y = 1.630(5), with weak dispersion. Pleochroism is weak, with amber yellow tones. Electron microprobe analyses (average of 13 grains) with H2O and FeO/Fe2O3 calculated on structural grounds and normalized to 100%, gave Fe2O3 17.2, FeO 4.8, MnO 5.4, MgO 2.2, ZnO 0.5, Al2O3 9.8, P2O5 27.6, H2O 32.5, total 100 wt.%. The empirical formula, based on 3 metal apfu is (Mn2+0.37Mg0.27Zn0.03Fe2+0.33)Σ1.00(Fe3+1.06Al0. 94)Σ2.00PO4)1.91(OH)2.27(H2O)7.73. Kummerite is triclinic, P1̄, with the unit-cell parameters of a = 5.316(1) Å, b =10.620(3) Å , c = 7.118(1) Å, α = 107.33(3)°, β= 111.22(3)°, γ = 72.22(2)° and V= 348.4(2) Å3. The strongest lines in the powder X-ray diffraction pattern are [dobs in Å(I) (hkl)] 9.885 (100) (010); 6.476 (20) (001); 4.942 (30) (020); 3.988 (9) (̄110); 3.116 (18) (1̄20); 2.873 (11) (1̄21). Kummerite is isostructural with laueite, but differs in having Al and Fe3+ ordered into alternate octahedral sites in the 7.1 Å trans-connected octahedral chains.
Introduction: Some non-urgent/low-acuity Emergency Department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study surveyed patients who presented to the ED and explored their self-reported reasons and barriers for not being connected to a primary care provider (PCP). Methods: Patients aged 17 years and older were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada. Following initial triage, stabilization, and verbal informed consent, patients completed a 47-item questionnaire. Data from the survey were cross-referenced to a minimal patient dataset consisting of ED and demographic information. The questionnaire collected information on patient characteristics, their connection to a PCP, and patients' reasons for not having a PCP. Results: Of the 2144 eligible patients, 1408 (65.7%) surveys were returned and 1402 (65.4%) were completed. The majority of patients (74.4%) presenting to the ED reported having a family physician; however, the ‘closeness’ of the connection to their family physician varied greatly among ED patients with the most recent family physician visit ranging from 1 hour before ED presentation to 45 years prior. Approximately 25% of low acuity ED patients reported no connection with a family physician. Reasons for a lack of PCP connection included: prior physician retired, left, or died (19.8%), they had never tried to find one (19.2%), they had recently moved to Alberta (18.0%), and they were unable to find one (16.5%). Conclusion: A surprisingly high proportion of ED patients (25.6%) have no identified PCP. Patients had a variety of reasons for not having a family physician. These need to be understood and addressed in order for primary care access to successfully contribute to diverting non-urgent, low acuity presentations from the ED.
Introduction: Some low acuity Emergency Department (ED) presentations are considered non-urgent or convenience visits and potentially avoidable with improved access to primary care. This study explored self-reported reasons why non-urgent patients presented to the ED. Methods: Patients, 17 years and older, were randomly selected from electronic registration records at three urban EDs in Edmonton, Alberta (AB), Canada during weekdays (0700 to 1900). A 47-item questionnaire was completed by each consenting patient, which included items on whether the patient believed the ED was their best care option and the rationale supporting their response. A thematic content analysis was performed on the responses, using previous experience and review of the literature to identify themes. Results: Of the 2144 eligible patients, 1408 (65.7%) questionnaires were returned, and 1402 (65.4%) were analyzed. For patients who felt the ED was their best option (n = 1234, 89.3%), rationales included: safety concerns (n = 309), effectiveness of ED care (n = 284), patient-centeredness of ED (n = 277), and access to health care professionals in the ED (n = 204). For patients who felt the ED was not their best care option (n = 148, 10.7%), rationales included a perception that: access to health professionals outside the ED was preferable (n = 39), patient-centeredness (particularly timeliness) was lacking in the ED (n = 26), and their health concern was not important enough to require ED care (n = 18). Conclusion: Even during times when alternative care options are available, the majority of non-urgent patients perceived the ED to be the most appropriate location for care. These results highlight that simple triage scores do not accurately reflect the appropriateness of care and that understanding the diverse and multi-faceted reasons for ED presentation are necessary to implement strategies to support non-urgent, low acuity care needs.
To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period.
The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications.
A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%).
This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.