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Frailty is an important geriatric syndrome that is common and commonly missed, and affects more than a third of people over age 85. Frailty is characterized by diminished physiologic reserves and function, leading to decreased capacity to withstand stressors. Frail adults are at a higher risk of dependency, institutionalization, and death. Multiple interventions have been attempted, including physical activity, improving nutrition, and hormonal therapy, but there are no curative interventions for frailty and it is not clear if frailty can be reversed. Several issues have limited the advancement of frailty research and translation into practice, including the lack of consensus regarding the definition of frailty, the proliferation of assessment tools, and the gaps in validated best practice guidance for frail patients. The recognition of frailty, especially in its early stages, offers the possibility of preventing or mitigating adverse clinical outcomes. Older adults who are frail may benefit most from a comprehensive geriatric evaluation to help elucidate a plan of care that is consistent with patient's goals, values, and preferences.
Anxiety can interfere with attention and working memory, which are components that affect learning. Statistical models have been designed to study learning, such as the Bayesian Learning Model, which takes into account prior possibilities and behaviors to determine how much of a new behavior is determined by learning instead of chance. However, the neurobiological basis underlying how anxiety interferes with learning is not yet known. Accordingly, we aimed to use neuroimaging techniques and apply a Bayesian Learning Model to study learning in individuals with generalized anxiety disorder (GAD).
Participants were 25 controls and 14 individuals with GAD and comorbid disorders. During fMRI, participants completed a shape-button association learning and reversal task. Using a flexible factorial analysis in SPM, activation in the dorsolateral prefrontal cortex, basal ganglia, and hippocampus were compared between groups during First Reversal. Beta values from the peak of these regions were extracted for all learning conditions and submitted to repeated measures analyses in SPSS.
Individuals with GAD showed less activation in the basal ganglia and the hippocampus only in the First Reversal compared with controls. This difference was not present in the Initial Learning and Second Reversal.
Given that the basal ganglia is associated with initial learning, and the hippocampus with transfer of knowledge from short to long term memory, our results suggest that GAD may engage these regions to a lesser extent during early accommodation or consolidation of learning, but have no longer term effects in brain activation patterns during subsequent learning.
OBJECTIVES/GOALS: Translating Research into Practice (TRIP), a hybrid implementation pragmatic clinical trial and CTSA collaboration, aims to implement a standardized breast cancer patient navigation protocol across five sites in Boston, MA. The goal of this study was to assess individual and institutional barriers and facilitators to implementing this protocol. METHODS/STUDY POPULATION: From November 2019 to August 2020, researchers conducted ethnographic observations of Patient Navigators (PN) at three of the five participating sites. Each PN at each site was observed for two, four-hour blocks by researchers trained in ethnographic research. Observers took notes using TRIPs 11 Step Protocol as a guide, which includes identifying patients at risk for delays in care, screening and referring patients to resources for health-related social needs, and tracking patients across the care continuum. Fieldnotes were uploaded into Dedoose and coded deductively by four researchers using a comparison and consensus approach. Researchers analyzed the data to identify barriers and facilitators to both implementing each protocol step and maximizing navigations ability to promote health equity. RESULTS/ANTICIPATED RESULTS: Across all sites, PNs faced barriers to adhering to the TRIP Protocol due to practical workflow constraints including their level of engagement across the cancer care continuum. Although there are other staff members who engage in navigation activities, navigation is often viewed solely as the responsibility of the PN. Operationalizing navigation as a person rather than a process creates confusion around the role, and PNs are often seen as a catchall position when other staff do not know how to help a patient. The time that PNs spend on tasks unrelated to core navigation activities described in the TRIP Protocol prevents PNs from navigating patients most at risk for delays in care. A lack of continuity across the care continuum can create role confusion for the PNs. DISCUSSION/SIGNIFICANCE: Patient Navigation can promote health equity; however, any task that pulls PNs away from navigating patients most at risk for delays in care diminishes this potential. PNs abilities to enact the TRIP protocol, which they saw as valuable, is circumscribed by the extent to which navigation is operationalized as a process within the institution.
Clinically significant weight gain (CSWG) is associated with increased morbidity and mortality. This study describes CSWG and comorbidities observed in patients with bipolar I disorder (BD-I) and schizophrenia (SZ) after initiating select second-generation antipsychotics (SGAs).
Percent change in weight, CSWG (=7% weight increase), and incident comorbidities within 12 months of treatment were assessed among patients initiating oral SGAs of moderate-to-high weight gain risk using medical records/claims (OM1 Real-World Data Cloud; January 2013-February 2020). Oral SGAs included clozapine (SZ), iloperidone (SZ), paliperidone (SZ), olanzapine, olanzapine/fluoxetine (BD-I), quetiapine, and risperidone. Outcomes were stratified by baseline body mass index and reported descriptively.
Among patients with BD-I (N = 9142) and SZ (N = 8174), approximately three-quarters were overweight/obese at baseline. During treatment (mean duration = 30 weeks), average percent weight increase was 3.7% (BD-I) and 3.3% (SZ). Average percent weight increase was highest for underweight/normal weight patients (BD-I = 5.5%; SZ = 4.8%), followed by overweight (BD-I = 3.8%; SZ = 3.4%) and obese patients (BD-I = 2.7%; SZ = 2.3%). Within 3 months of treatment, 12% of all patients experienced CSWG. A total of 11.3% (BD-I) and 14.7% (SZ) of patients developed coronary artery disease, hypertension, dyslipidemia, or type 2 diabetes within 12 months of treatment; development of comorbidities was highest among overweight/obese patients and those with CSWG.
Patients who were underweight/normal weight at baseline had the greatest percent change in weight during treatment. Increased comorbidities were observed within 12 months of treatment, specifically among overweight/obese patients and those with CSWG. The magnitude of weight gain and development of comorbidities were similar for patients with BD-I and SZ.
Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen in neonatal intensive care units (NICU) that confers significant morbidity and mortality.
Improving our understanding of MRSA transmission dynamics, especially among high-risk patients, is an infection prevention priority.
We investigated a cluster of clinical MRSA cases in the NICU using a combination of epidemiologic review and whole-genome sequencing (WGS) of isolates from clinical and surveillance cultures obtained from patients and healthcare personnel (HCP).
Phylogenetic analysis identified 2 genetically distinct phylogenetic clades and revealed multiple silent-transmission events between HCP and infants. The predominant outbreak strain harbored multiple virulence factors. Epidemiologic investigation and genomic analysis identified a HCP colonized with the dominant MRSA outbreak strain who cared for most NICU patients who were infected or colonized with the same strain, including 1 NICU patient with severe infection 7 months before the described outbreak. These results guided implementation of infection prevention interventions that prevented further transmission events.
Silent transmission of MRSA between HCP and NICU patients likely contributed to a NICU outbreak involving a virulent MRSA strain. WGS enabled data-driven decision making to inform implementation of infection control policies that mitigated the outbreak. Prospective WGS coupled with epidemiologic analysis can be used to detect transmission events and prompt early implementation of control strategies.
Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients’ weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity.
To develop and pilot test an innovative care model – the Weight Navigation Program (WNP) – to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care.
Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients (n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring.
Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.
This study examined whether bilinguals automatically activate lexical options from both of their languages when performing a picture matching task in their dominant language (L1) by using event related potentials. English–French bilinguals and English monolinguals performed a picture-spoken word matching task with three conditions: match (BEACH-“beach”), unrelated mismatch (BEACH-“tack”), and L2 onset competitor mismatch (BEACH-“plaid”; plaid sounds like plage, the French word for beach). Critically, bilinguals, but not monolinguals, showed reduced N400s for L2-cohort vs. unrelated mismatches. The results provide clear evidence that when bilinguals identify pictures, they automatically activate lexical options from both languages, even when expecting oral input from only their dominant language. N400 attenuation suggests bilinguals activate but do not expect L2 lexical options.
To determine the incidence of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare personnel (HCP) and to assess occupational risks for SARS-CoV-2 infection.
Prospective cohort of healthcare personnel (HCP) followed for 6 months from May through December 2020.
Large academic healthcare system including 4 hospitals and affiliated clinics in Atlanta, Georgia.
HCP, including those with and without direct patient-care activities, working during the coronavirus disease 2019 (COVID-19) pandemic.
Incident SARS-CoV-2 infections were determined through serologic testing for SARS-CoV-2 IgG at enrollment, at 3 months, and at 6 months. HCP completed monthly surveys regarding occupational activities. Multivariable logistic regression was used to identify occupational factors that increased the risk of SARS-CoV-2 infection.
Of the 304 evaluable HCP that were seronegative at enrollment, 26 (9%) seroconverted for SARS-CoV-2 IgG by 6 months. Overall, 219 participants (73%) self-identified as White race, 119 (40%) were nurses, and 121 (40%) worked on inpatient medical-surgical floors. In a multivariable analysis, HCP who identified as Black race were more likely to seroconvert than HCP who identified as White (odds ratio, 4.5; 95% confidence interval, 1.3–14.2). Increased risk for SARS-CoV-2 infection was not identified for any occupational activity, including spending >50% of a typical shift at a patient’s bedside, working in a COVID-19 unit, or performing or being present for aerosol-generating procedures (AGPs).
In our study cohort of HCP working in an academic healthcare system, <10% had evidence of SARS-CoV-2 infection over 6 months. No specific occupational activities were identified as increasing risk for SARS-CoV-2 infection.
As people interact in online venues, they need to represent who they are to others. The details of how we do this matter. Sociologist Erving Goffman explains how, in the face-to-face world, we are always performing roles. These elements of identity translate into the online world. One of the key questions for online activity is the role of anonymity. The chapter explains the advantages and disadvantages of anonymous interaction. In fact, we’re all really some degree of “pseudonymous” (between anonymous and identified) most of the time anyway. How identity is represented turns out to be one of the most powerful design decisions that you make in creating an online communications environment.
Introduces some powerful examples of constructive uses of online collaboration—like Wikipedia and citizen science. Why do people spend hundreds of volunteer hours writing encyclopedia articles or counting birds? The chapter explains the incentive structure in peer production, and what kinds of things are possible using peer production methods, explores citizen science in some detail, and introduces Yochai Benkler’s theory of why peer production is important, and what factors are important for a peer production project to succeed.
In 2004, my son Noah was turning one year old and I had a problem: How do I make him a birthday cake? He was seriously allergic to dairy, soy, and egg. A mis-read food label or a bite snuck from another child’s plate at daycare could send us to the emergency room. But he was turning one – I wanted him to have birthday cake. I found a website called kidswithfoodallergies.org, and asked on the forum there: Did anyone have a dairy-, soy- and egg-free cake recipe? In response to my query, I got a flurry of warm welcomes from parents on the site. They shared an excellent safe cake recipe, and provided a host of other support. Parents on the site helped me figure out how to make a clear and effective allergy-awareness sheet for his daycare teachers. They shared tips for how to safely order food in a restaurant. Their experience was invaluable, and they also were emotionally supportive in a way no one else could be. Parenting an allergic toddler is stressful, and they understood completely.
Building on ideas from epistemology, metaphysics, and social construction of knowledge, the chapter explores what it means to “know” something, and how good a job Wikipedia does at building knowledge. The argument is that “truth” exists (even if we only have indirect and unsure access to it). Knowledge is socially constructed. Social consensus is our best metric for what “is true,” but sometimes that consensus can be wrong.
Explores the ways we can regulate online behavior. Larry Lessig divides regulation into laws, social norms, markets, and technology. As we’ll see, ideas about “free speech” vary around the world, and laws about hate speech are quite different in the United States compared to other nations. Where we draw the line between free speech and illegal speech is the most hotly contested issue about the internet. What is at stake is not just what we all read or watch, but who we are. At its worst, the internet can make insane and hateful ideas seem normal, and make it easy for new people to be radicalized. On the other hand, if some speech is not allowed, who decides where to draw the line? How do we make balanced decisions about what content to allow?