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Area-level social determinants of health (SDoH) and individual-level social risks are different, yet area-level measures are frequently used as proxies for individual-level social risks. This study assessed whether demographic factors were associated with patients being screened for individual-level social risks, the percentage who screened positive for social risks, and the association between SDoH and patient-reported social risks in a nationwide network of community-based health centers.
Methods:
Electronic health record data from 1,330,201 patients with health center visits in 2021 were analyzed using multilevel logistic regression. Associations between patient characteristics, screening receipt, and screening positive for social risks (e.g., food insecurity, housing instability, transportation insecurity) were assessed. The predictive ability of three commonly used SDoH measures (Area Deprivation Index, Social Deprivation Index, Material Community Deprivation Index) in identifying individual-level social risks was also evaluated.
Results:
Of 244,155 (18%) patients screened for social risks, 61,414 (25.2%) screened positive. Sex, race/ethnicity, language preference, and payer were associated with both social risk screening and positivity. Significant health system-level variation in both screening and positivity was observed, with an intraclass correlation coefficient of 0.55 for social risk screening and 0.38 for positivity. The three area-level SDoH measures had low accuracy, sensitivity, and area under the curve when used to predict individual social needs.
Conclusion:
Area-level SDoH measures may provide valuable information about the communities where patients live. However, policymakers, healthcare administrators, and researchers should exercise caution when using area-level adverse SDoH measures to identify individual-level social risks.
Methadone, a medication used to treat opioid use disorder (OUD), has resulted in decreased opioid overdose deaths, while increasing treatment retention and lowering the rates of infectious diseases associated with intravenous substance use. Access to methadone is limited in the United States due to federal laws and regulatory policies that are rooted in racist “criminal justice approaches” to substance use. Unlike other controlled prescription medications, methadone is subject to restrictions on the number of doses a person can receive at any given time, known as “take-home doses” (THDs). Federal regulations mandate that patients receiving methadone must travel to government-certified clinics known as opioid treatment programs (OTPs) almost daily to receive medication for at least the first 90 days of treatment. Due to the need to practice social distancing during COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) – the regulatory agency which sets the accreditation standards for OTPs – released a federal waiver in March 2020 granting significant exemptions to THD regulations. Thousands of patients have now received increased THDs, a historic and impactful shift in care for people with OUD. This chapter begins with an overview of the regulation of methadone for OUD before COVID-19. Next, it reviews the evidence for regulatory reform alongside our analysis of qualitative data we collected during COVID-19 that reflects patients’ experiences with increased access to THDs. Based on the findings of our qualitative study and the empirical literature, we conclude the chapter with recommendations for modifications of THD regulations.
Among nursing home outbreaks of coronavirus disease 2019 (COVID-19) with ≥3 breakthrough infections when the predominant severe acute respiratory coronavirus virus 2 (SARS-CoV-2) variant circulating was the SARS-CoV-2 δ (delta) variant, fully vaccinated residents were 28% less likely to be infected than were unvaccinated residents. Once infected, they had approximately half the risk for all-cause hospitalization and all-cause death compared with unvaccinated infected residents.
One in six nursing home residents and staff with positive SARS-CoV-2 tests ≥90 days after initial infection had specimen cycle thresholds (Ct) <30. Individuals with specimen Ct<30 were more likely to report symptoms but were not different from individuals with high Ct value specimens by other clinical and testing data.
In this era of spatially resolved observations of planet-forming disks with Atacama Large Millimeter Array (ALMA) and large ground-based telescopes such as the Very Large Telescope (VLT), Keck, and Subaru, we still lack statistically relevant information on the quantity and composition of the material that is building the planets, such as the total disk gas mass, the ice content of dust, and the state of water in planetesimals. SPace Infrared telescope for Cosmology and Astrophysics (SPICA) is an infrared space mission concept developed jointly by Japan Aerospace Exploration Agency (JAXA) and European Space Agency (ESA) to address these questions. The key unique capabilities of SPICA that enable this research are (1) the wide spectral coverage
$10{-}220\,\mu\mathrm{m}$
, (2) the high line detection sensitivity of
$(1{-}2) \times 10^{-19}\,\mathrm{W\,m}^{-2}$
with
$R \sim 2\,000{-}5\,000$
in the far-IR (SAFARI), and
$10^{-20}\,\mathrm{W\,m}^{-2}$
with
$R \sim 29\,000$
in the mid-IR (SPICA Mid-infrared Instrument (SMI), spectrally resolving line profiles), (3) the high far-IR continuum sensitivity of 0.45 mJy (SAFARI), and (4) the observing efficiency for point source surveys. This paper details how mid- to far-IR infrared spectra will be unique in measuring the gas masses and water/ice content of disks and how these quantities evolve during the planet-forming period. These observations will clarify the crucial transition when disks exhaust their primordial gas and further planet formation requires secondary gas produced from planetesimals. The high spectral resolution mid-IR is also unique for determining the location of the snowline dividing the rocky and icy mass reservoirs within the disk and how the divide evolves during the build-up of planetary systems. Infrared spectroscopy (mid- to far-IR) of key solid-state bands is crucial for assessing whether extensive radial mixing, which is part of our Solar System history, is a general process occurring in most planetary systems and whether extrasolar planetesimals are similar to our Solar System comets/asteroids. We demonstrate that the SPICA mission concept would allow us to achieve the above ambitious science goals through large surveys of several hundred disks within
$\sim\!2.5$
months of observing time.
The purpose of this study is to identify whether there is an opportunity for improvement to provide palliative care services after a serious fall. We hypothesized that (1) palliative care services would be utilized in less than 10% of patients over the age of 65 who fall and (2) more than 20% of patients would receive aggressive life-sustaining treatments (LSTs) prior to death.
Methods
Using the 2017 Nationwide Inpatient Sample, we identified patients who were admitted to the hospital with a fall (ICD-10 W00-W19) and were hospitalized at least two days with valid discharge data. Palliative care services (Z51.5) or LSTs (cardiopulmonary resuscitation, ventilation, reintubation, tracheostomy, feeding tube placement, vasopressors, transfusion, total parenteral nutrition, and hemodialysis) were identified with ICD-10 codes. We examined the use of palliative care or LSTs by discharge destination (home, facility, and death). Logistic regression was used to identify factors associated with palliative care.
Results
In total, 155,241 patients were identified (median 82 years old, interquartile range 74–88); 2.5% died in hospital, and 69.4% were transferred to a facility. Palliative care occurred in 4.5% of patients, and LST occurred in 15.1%. Patients who died were significantly more likely to have had palliative care (50.1% vs. 3.4% of home or facility discharges) and were more likely to have an LST [53.0% vs. 9.8% (home) vs. 15.9% (facility)]. Palliative care was associated with both death [adjusted odds ratio (AOR) 19.84, 95% confidence interval (CI) 18.39–21.41, p < 0.001] and LST (AOR 1.36, 95% CI 1.27–1.46, p < 0.001).
Significance of results
Palliative care is associated with both death and LST, suggesting that physicians use palliative care as a last resort after aggressive measures have been exhausted. Patients who fall would likely benefit from the early use of palliative care to align future goals of care.
In recent years, several cognitive behavioral therapies have been developed to meet the specific challenges involved in treating personality disorders. Cognitive and behavioral treatment (CBT) is best represented as a family of therapies, including manualized treatment packages (or “branded” CBTs) and principle-driven interventions. This chapter reviews cognitive and behavioral intervention options for patients suffering from personality dysfunction. First, the authors provide an overview of the “branded” CBTs tested with personality disorder populations, including dialectical behavior therapy, schema focused therapy, and cognitive therapy for personality disorders. For clinicians who wish to use a cognitive behavioral approach, they then discuss how CBT case conceptualization can be used to inform a flexible and responsive treatment based on the empirically-supported treatments for personality disorders. In this approach, clinicians would formulate a treatment plan that applies cognitive and behavioral strategies, interventions, and principles of change from these empirically-supported “branded” CBTs. For example, the authors discuss ways in which the CBT principle of exposure may be considered for application across different personality disorders. Finally, they discuss the potential value in application of mindfulness and acceptance strategies with personality disorders.
The commentaries from Gold, Yen, Hughes and Rizvi highlight the challenges associated with using cognitive behavioral therapies to treat individuals with personality disorders (PDs). In this rejoinder, the authors extend upon these observations by arguing the importance of a modular, principle-driven approach to assessment and treatment of PDs. First, they discuss how there is a greater demand for treatments beyond the current “branded” CBTs and their empirical basis. In light of this limitation, clinicians need to flexibly use empirically-supported principles of change to treat processes underlying personality dysfunction. This approach requires careful case formulation and identification of behaviorally-specific targets of treatment using validated screening tools. This approach to treatment may be a useful way of meeting the demands for both patient care and current trends in national health care payor reform.
A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.
Methods
This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.
Results
Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.
Conclusion
The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.
This paper describes the design and fabrication of a range of ‘gas cell’ microtargets produced by the Target Fabrication Group in the Central Laser Facility (CLF) for academic access experiments on the Orion laser facility at the Atomic Weapons Establishment (AWE). The experiments were carried out by an academic consortium led by Imperial College London. The underlying target methodology was an evolution of a range of targets used for experiments on radiative shocks and involved the fabrication of a precision machined cell containing a number of apertures for interaction foils or diagnostic windows. The interior of the cell was gas-filled before laser irradiation. This paper details the assembly processes, thin film requirements and micro-machining processes needed to produce the targets. Also described is the implementation of a gas-fill system to produce targets that are filled to a pressure of 0.1–1 bar. The paper discusses the challenges that are posed by such a target.
To describe our experience and provide guidelines for maximum safe balloon sizes according to age in children undergoing balloon dilatation.
Method:
A retrospective review was conducted of children undergoing balloon dilatation for subglottic stenosis in a paediatric tertiary unit between May 2006 and February 2016.
Results:
A total of 166 patients underwent balloon dilatation. Mean ( ± standard deviation) patient age was 4.5 ± 3.99 years. The median balloon size was 8 mm, the median balloon inflation pressure was 10 atm, and the mean balloon inflation time was 65.1 ± 18.6 seconds. No significant unexpected events occurred. The Pearson correlation co-efficient for the relationship between patient age and balloon size was 0.85 (p = 0.001), suggesting a strongly positive correlation.
Conclusion:
This study demonstrated that balloon dilatation is a safe procedure for airway stenosis. The results suggest using a balloon diameter that is equal to the outer diameter of the age-appropriate endotracheal tube +1 mm for the larynx and subglottis and +2 mm for the trachea.
This work considers debris disks whose spectra can be modelled by dust emission at two different temperatures. These disks are typically assumed to be a sign of multiple belts, but only a few cases have been confirmed via high resolution observations. We derive the properties of a sample of two-temperature disks, and explore whether this emission can arise from dust in a single narrow belt. While some two-temperature disks arise from single belts, it is probable that most have multiple spatial components. These disks are plausibly similar to the outer Solar System's configuration of Asteroid and Edgeworth-Kuiper belts separated by giant planets. Alternatively, the inner component could arise from inward scattering of material from the outer belt, again due to intervening planets. For either scenario, the ratio of warm/cool component temperatures is indicative of the scale of outer planetary systems, which typically span a factor of about ten in radius.
This article describes the fabrication of a suite of laser targets by the Target Fabrication group in the Central Laser Facility (CLF), STFC Rutherford Appleton Laboratory for the first academic-access experiment on the Orion laser facility (Hopps et al., Appl. Opt. 52, 3597–3601 (2013)) at Atomic Weapons Establishment (AWE). This experiment, part of the POLAR project (Falize et al., Astrophys. Space Sci. 336, 81–85 (2011); Busschaert et al., New J. Phys. 15, 035020 (2013)), studied conditions relevant to the radiation-hydrodynamic processes occurring in a remarkable class of astrophysical star systems known as magnetic cataclysmic variables. A large number of complex fabrication technologies and research and development activities were required to field a total of 80 high-specification targets. Target design and fabrication procedures are described and initial alignment and characterization data are discussed.
Comparisons are made concerning labor required and profitability associated with continuous grazing at three stocking rates and rotational grazing at a high stocking rate in the U.S. Gulf Coast region. A unique data set was collected using a time and motion study method to determine labor requirements. Profits are lowest for low stocking rate–continuous grazing and high stocking rate–rotational grazing. Total labor and labor in three specific categories are greater on per acre and/or per cow bases with rotational-grazing than with continuous-grazing strategies. These results help to explain relatively low adoption rates of rotational grazing in the region.
A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17–18,1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap?
Whilst debris discs orbiting main-sequence stars are well studied, very little is known regarding their fate when the star evolves onto the giant branch. For intermediate mass (A-type) stars, giants provide a unique opportunity to detect planets using the radial velocity technique, otherwise prohibited by high jitter levels and rotationally broadened lines in main-sequence intermediate mass (A-type) stars. Such stars can provide key insights into the structure of planetary systems around intermediate mass stars. In our Herschel OT1 program (PI Bonsor) we searched for the presence of debris discs orbiting a sample of 36 subgiants, half of which have RV detected companions. Our best detection is the resolved debris disc orbiting κ CrB.
This contribution summarises the first characterisation of the 12 μm warm dust (“exo-Zodi”) luminosity function around Sun-like stars, focussing on the dustiest systems that can be identified by the WISE mission (Kennedy & Wyatt 2013). We use the sample of main-sequence stars observed by Hipparcos within 150pc as an unbiased sample, and report the detection of six new warm dust candidates. The ages of five of these new sources are unknown, meaning that they may be sites of terrestrial planet formation or rare analogues of other old warm dust systems. We show that the dustiest old (> Gyr) systems such as BD+20 307 are 1 in 10,000 occurrences. Bright warm dust is much more common around young (<120 Myr) systems, with a ~1% occurrence rate. We show that a two component in situ model where all stars have initially massive warm disks and in which warm debris is also generated at some random time along the stars' main-sequence lifetime, perhaps due to a collision, can explain the observations. However, if all stars only have initially massive warm disks these would not be visible at Gyr ages, and random collisions on the main-sequence are too infrequent to explain the high disk occurrence rate for young stars. That is, neither component can explain the observations on their own. Despite these conclusions, we cannot rule out an alternative dynamical model in which comets are scattered in from outer regions because the distribution of systems with the appropriate dynamics is unknown. Our in situ model predicts that the fraction of stars with exo-Zodi bright enough to cause problems for future exo-Earth imaging attempts is at least roughly 10%, and is higher for populations of stars younger than a few Gyr. This prediction of roughly 10% also applies to old stars because bright systems like BD+20 307 imply a population of fainter systems that were once bright, but are now decaying through fainter levels. Our prediction should be strongly tested by the Large Binocular Telescope Interferometer, which will provide valuable constraints and input for more detailed evolution models. A detection fraction lower than our prediction could indicate that the hot dust in systems like BD+20 307 has a cometary origin due to the quirks of the planetary dynamics. Population models of comet delivery need to be developed to help distinguish between different possible origins of warm dust.