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As the aging population continues to grow, the issue of caregiving has increasingly moved into the public spotlight. Caregiving is defined as “assistance provided to individuals who are in need of support because of a disability, mental illness, chronic condition, terminal illness or who are frail.” More recently, the COVID-19 pandemic has added an additional spotlight on the issue of how we are caring for older patients in the midst of societal shutdowns, increasing social isolation, and economic impacts that affect patient and caregiver alike. This chapter focuses on the informal caregivers who care for chronically ill older adults. It also broadens the toolset of the primary care provider to include a more systematic approach when assessing the degree of caregiver burden. Recognizing caregiver needs and burden can then inform the primary care provider to counsel caregivers about common stresses, suggest practical interventions, and provide additional resources.
Most medical diagnostic tests are expensive, involve slow turnaround times from centralized laboratories and require highly specialized equipment with seasoned technicians to carry out the assay. To facilitate realization of precision medicine at the point of care, we have developed a mixed-scale nanosensor chip featuring high surface area pillar arrays where solid-phase reactions can be performed to detect and identify nucleic acid targets found in diseased patients. Products formed can be identified and detected using a polymer nanofluidic channel. To guide delivery of this platform, we discuss the operation of various components of the device and simulations (COMSOL) used to guide the design by investigating parameters such as pillar array loading, and hydrodynamic and electrokinetic flows. The fabrication of the nanosensor is discussed, which was performed using a silicon (Si) master patterned with a combination of focused ion beam milling and photolithography with deep reactive ion etching. The mixed-scale patterns were transferred into a thermoplastic via thermal nanoimprint lithography, which facilitated fabrication of the nanosensor chip making it appropriate for in vitro diagnostics. The results from COMSOL were experimentally verified for hydrodynamic flow using Rhodamine B as a fluorescent tracer and electrokinetic flow using single fluorescently labelled oligonucleotides (single-stranded DNAs, ssDNAs).
In a prospective cohort of healthcare personnel (HCP), we measured severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) nucleocapsid IgG antibodies after SARS-CoV-2 infection. Among 79 HCP, 68 (86%) were seropositive 14–28 days after their positive PCR test, and 54 (77%) of 70 were seropositive at the 70–180-day follow-up. Many seropositive HCP (95%) experienced an antibody decline by the second visit.
Subthreshold/attenuated syndromes are established precursors of full-threshold mood and psychotic disorders. Less is known about the individual symptoms that may precede the development of subthreshold syndromes and associated social/functional outcomes among emerging adults.
We modeled two dynamic Bayesian networks (DBN) to investigate associations among self-rated phenomenology and personal/lifestyle factors (role impairment, low social support, and alcohol and substance use) across the 19Up and 25Up waves of the Brisbane Longitudinal Twin Study. We examined whether symptoms and personal/lifestyle factors at 19Up were associated with (a) themselves or different items at 25Up, and (b) onset of a depression-like, hypo-manic-like, or psychotic-like subthreshold syndrome (STS) at 25Up.
The first DBN identified 11 items that when endorsed at 19Up were more likely to be reendorsed at 25Up (e.g., hypersomnia, impaired concentration, impaired sleep quality) and seven items that when endorsed at 19Up were associated with different items being endorsed at 25Up (e.g., earlier fatigue and later role impairment; earlier anergia and later somatic pain). In the second DBN, no arcs met our a priori threshold for inclusion. In an exploratory model with no threshold, >20 items at 19Up were associated with progression to an STS at 25Up (with lower statistical confidence); the top five arcs were: feeling threatened by others and a later psychotic-like STS; increased activity and a later hypo-manic-like STS; and anergia, impaired sleep quality, and/or hypersomnia and a later depression-like STS.
These probabilistic models identify symptoms and personal/lifestyle factors that might prove useful targets for indicated preventative strategies.
Background: Pharyngitis is 1 of the most common conditions leading to inappropriate antibiotic prescriptions. When personal protective equipment (PPE) was at first constrained during the COVID-19 pandemic, Intermountain Healthcare recommended limiting rapid group A streptococcal pharyngitis (GAS) testing in urgent-care clinics to preserve PPE. Notably, the percentage of pharyngitis encounters prescribed an antibiotic and that underwent GAS testing is a key Healthcare Effectiveness Data and Information Set (HEDIS) measure. We have described our experience with urgent-care pharyngitis encounters and the impact of temporarily reducing GAS testing on antibiotic prescribing before and during the COVID19 pandemic. Method: We identified all urgent care encounters between July 2018 and August 2021 associated with a primary diagnosis of pharyngitis using ICD-10 CM codes and a validated methodology. Pharyngitis encounters were assessed for antibiotic prescriptions ordered through the electronic health record (EHR) and the use of point-of-care rapid GAS tests. Pharyngitis encounters were analyzed monthly. We assessed the percentage of encounters associated with an antibiotic prescription regardless of testing and the percentage of encounters associated with an antibiotic prescription when a GAS test was or was not performed. We examined 3 periods relating to COVID-19 and GAS testing recommendations: the prepandemic period (July 2018–March 2020), the pandemic onset period (April 2020–June 2020), and the pandemic period (July 2020–August 2021). Results: Prior to the pandemic, the monthly percentage of pharyngitis encounters for which rapid GAS testing was performed was nearly 90% (Fig. 1). The average monthly percentage of urgent-care pharyngitis encounters prescribed an antibiotic was 38.9%, and the average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing was 90.4%. This HEDIS measure declined from 90.4% during the prepandemic period to 29.8% in the pandemic onset period when GAS testing was limited. Following resumption of routine testing practices the monthly percentage of urgent-care pharyngitis encounters for which rapid GAS testing was performed returned to levels ≥80% by July 2020 (Fig. 1). The average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing rose to 87.3% during this period. Conclusions: Limited PPE in our urgent care centers during the initial months of the COVID-19 pandemic was associated with a mandated substantial decline in rapid GAS testing. As testing volume decreased, we noted a simultaneous relative increase of >30% in antibiotic prescribing for pharyngitis. These findings suggest that rapid streptococcal testing promotes appropriate antibiotic prescribing.
Scholars contend that the reason for stasis in human rights measures is a biased measurement process, rather than stagnating human rights practices. We argue that bias may be introduced as part of the compilation of the human rights reports that serve as the foundation of human rights measures. An additional source of potential bias may be human coders, who translate human rights reports into human rights scores. We first test for biases via a machine-learning approach using natural language processing and find substantial evidence of bias in human rights scores. We then present findings of an experiment on the coders of human rights reports to assess whether potential changes in the coding procedures or interpretation of coding rules affect scores over time. We find no evidence of coder bias and conclude that human rights measures have changed over time and that bias is introduced as part of monitoring and reporting.
Excited delirium, which has been defined as combativeness, agitation, and altered sensorium, requires immediate treatment in prehospital or emergency department (ED) settings for the safety of both patients and caregivers. Prehospital ketamine use is prevalent, although the evidence on safety and efficacy is limited. Many patients with excited delirium are intoxicated with illicit substances. This investigation explores whether patients treated with prehospital ketamine for excited delirium with concomitant substance intoxication have higher rates of subsequent intubation in the ED compared to those without confirmed substance usage.
Over 28 months at two large community hospitals, all medical records were retrospectively searched for all patients age 18 years or greater with prehospital ketamine intramuscular (IM) administration for excited delirium and identified illicit and prescription substance co-ingestions. Trained abstractors collected demographic characteristics, history of present illness (HPI), urine drug screens (UDS), alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by UDS and alcohol positivity or negativity, as well as physician HPI. Patients without toxicological testing or documentation of substance intoxication, or who may have tested positive due to ED sedation, were excluded from relevant analyses. Subsequent ED intubation was the primary pre-specified outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare variables.
Among 86 patients given prehospital ketamine IM for excited delirium, baseline characteristics including age, ketamine dose, and body mass index were similar between those who did or did not undergo intubation. Men had higher intubation rates. Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones, both bath salts and flakka, had similar rates of intubation compared to those negative for these substances. Of 27 patients with excited delirium and concomitant cocaine intoxication, nine (33%) were intubated compared with four of 50 (8%) without cocaine intoxication, yielding a 5.75 OR (95%, CI 1.57 to 21.05; P = .009).
Patients treated with ketamine IM for excited delirium with concomitant cocaine intoxication had a statistically significant 5.75-fold increased rate of subsequent intubation in the ED. Amongst other substances, no other trends with intubation were noted, but further study is warranted.
This study examines the link between behavior in kindergarten and adult-life welfare receipt. Teacher-rated behavioral assessments were obtained for inattention, hyperactivity, aggression–opposition, anxiety, and prosociality when children (n=2960) were aged 5–6 years and linked to their tax return records from age 18–35 years. We used group-based based trajectory modeling to identify distinct trajectories of welfare receipt and multinomial logistic regression models to examine the association between behaviors and trajectory group membership. The child's sex, IQ, and family background were adjusted for. Four trajectories of welfare receipt were identified: low (n = 2,390, 80.7%), declining (n = 260, 8.8%), rising (n = 150, 5.2%), and chronic (n = 160, 5.4%). Relative to the low trajectory, inattention and aggression–opposition at age 6 years were associated with increased risk of following a declining, rising, and chronic trajectory of welfare receipt, independent of hyperactivity and anxiety. Prosocial behaviors were independently associated with a lower risk of following a chronic trajectory. This study shows that kindergarten children exhibiting high inattention and aggression–opposition and low prosocial behaviors may be at increased risk of long-term welfare receipt in adulthood. The implications for early screening, monitoring, and prevention are discussed.
In this retrospective cohort study of patients presenting to a national direct-to-consumer medical practice, we found that provider geographic location is a stronger driver of antibiotic prescribing than patient location. Physicians in the Northeast and South are significantly more likely than physicians in the West to prescribe antibiotics for upper respiratory infection and bronchitis.
Human trafficking affects millions of people globally, disproportionately harming women, girls and marginalized groups. Yet one of the main sources of data on global trafficking, the annual Trafficking in Persons (TIP) Reports, is susceptible to biases because report rankings are tied to political outcomes. The literature on human rights measurements has established two potential sources of bias. The first is the changing standards of accountability, where more information and increased budgets change the standard to which countries are held over time. The second is political biases in reports, which are amended to comply with the interests of the reporting agency. This letter examines whether either of these biases influence the TIP Reports. In contrast to other country-level human rights indicators, the State Department issues both narratives and rankings, which incentivizes attempts to influence the rankings based on political interests. The study uses a supervised machine-learning algorithm to examine how narratives are translated into rankings, to determine whether rankings are biased, and to disentangle whether bias stems from changing standards or political interests. The authors find that the TIP Report rankings are more influenced by political biases than changing standards.
The COVID-19 pandemic highlights the importance of the Federal Reserve as a leading actor in global economic governance. As a creature of U.S. domestic law with an international presence and operational independence, the Fed wields authority without a well-defined international legal status, international legal standards to guide its conduct, or accountability to those around the world affected by its decisions. This Essay explores three conceptual approaches that could be used to develop norms, standards, and principles to address this gap.
Background: Antimicrobial resistance (AMR) is an increasingly critical global public health challenge. An initial step in prevention is the understanding of resistance patterns with accurate surveillance. To improve accurate surveillance and good clinical care, we developed training materials to improve the appropriate collection of clinical culture samples in Ethiopia. Methods: Specimen-collection training materials were initially developed by a team of infectious diseases physicians, a clinical microbiologist, and a monitoring and evaluation specialist using a training of trainers (ToT) platform. Revisions after each training session were provided by Ethiopian attendees including the addition of regional and culturally relevant material. The training format involved didactic presentations, interactive practice sessions with participants providing feedback and training to each other and the entire group as well as assessments of all training activities. Results: Overall, 4 rounds of training were conducted from August 2017 to September 2019. The first 2 rounds of training were conducted by The Ohio State University (OSU) staff, and Ethiopian trainers conducted the last 2 rounds. Initial training was primarily in lecture format outlining use of microbiology laboratory findings in clinical practice and steps for collecting specimens correctly. Appropriate specimen collection was demonstrated and practiced. Essential feedback from this early audience provided input for the final development of the training manual and visual aids. The ToT for master trainers took place in July 2018 and was conducted by OSU staff. In sessions held in February and August 2019, these master trainers provided training to facility trainers, who provide training to personnel directly responsible for specimen collection. In total, 144 healthcare personnel (including physicians, nurses, and laboratory staff), from 12 representative Ethiopian public and academic hospitals participated in the trainings. Participants were satisfied with the quality of the training (typically ranked >4.5 of 5.0) and strongly agreed that the objectives were clearly defined and that the information was relevant to their work. Posttraining scores increased by 23%. Conclusions: Training materials for clinical specimen collection have been developed for use in low- and middle-resource settings and with initial pilot testing and adoption in Ethiopia. The trainings were well accepted, and Ethiopian personnel were able to successfully lead the trainings and improve their knowledge and skills regarding specimen collection. The materials are being finalized in an online format for easier open access dissemination. Further studies are planned to determine the effectiveness of the trainings in improving the quality of clinical specimen submissions to the microbiology laboratory.
Prehospital intramuscular (IM) ketamine is increasingly used for chemical restraint of agitated patients. However, few studies have assessed emergency department (ED) follow-up of patients receiving prehospital ketamine for this indication, with previous reports suggesting a high rate of post-administration intubation. This study examines the rate of and reasons for intubation and other airway interventions in agitated patients who received ketamine by Emergency Medical Services (EMS).
This retrospective cohort study included patients who received prehospital ketamine for agitation and were transported to two community hospital EDs. Charts were reviewed for demographics, ketamine dose, and airway intervention by EMS or in the ED. Characteristics of patients who were intubated versus those who did not receive airway intervention were analyzed.
Over 28 months, 86 patients received ketamine for agitation. Fourteen (16.3%) underwent endotracheal intubation. Patients with a higher temperature and a lower Glasgow Coma Score (GCS) were more likely to require intubation. There was no age or dose-dependent association on intubation rate. Intubated patients averaged 39 years old versus 44 for patients not intubated (negative five-year difference; 95% CI, -16 to 6). The mean ketamine dose was 339.3mg in patients intubated versus 350.7mg in patients not (-11.4mg difference; 95% CI, -72.4 to 49.6). The mean weight-based ketamine dose was 4.44mg/kg in patients intubated versus 4.96mg/kg in patients not (-0.53mg/kg difference; 95% CI, -1.49 to 0.43).
The observed rate of intubation in patients receiving prehospital ketamine for agitation was 16.3%. Study data did not reveal an age or dose-dependent rate of intubation. Further research should be conducted to compare the airway intervention rate of agitated patients receiving ketamine versus other sedatives in a controlled fashion.
We consider the question of when a rational homology $3$-sphere is rational homology cobordant to a connected sum of lens spaces. We prove that every rational homology cobordism class in the subgroup generated by lens spaces is represented by a unique connected sum of lens spaces whose first homology group injects in the first homology group of any other element in the same class. As a first consequence, we show that several natural maps to the rational homology cobordism group have infinite-rank cokernels. Further consequences include a divisibility condition between the determinants of a connected sum of $2$-bridge knots and any other knot in the same concordance class. Lastly, we use knot Floer homology combined with our main result to obstruct Dehn surgeries on knots from being rationally cobordant to lens spaces.
To characterize the spectrum of BRCA1 and BRCA2 pathogenic germline variants in women from south-west Poland and west Ukraine affected with breast or ovarian cancer. Testing in women at high risk of breast and ovarian cancer in these regions is currently mainly limited to founder mutations.
Unrelated women affected with breast and/or ovarian cancer from Poland (n = 337) and Ukraine (n = 123) were screened by targeted sequencing. Excluded from targeted sequencing were 34 Polish women who had previously been identified as carrying a founder mutation in BRCA1. No prior testing had been conducted among the Ukrainian women. Thus, this study screened BRCA1 and BRCA2 in the germline DNA of 426 women in total.
We identified 31 and 18 women as carriers of pathogenic/likely pathogenic (P/LP) genetic variants in BRCA1 and BRCA2, respectively. We observed five BRCA1 and eight BRCA2 P/LP variants (13/337, 3.9%) in the Polish women. Combined with the 34/337 (10.1%) founder variants identified prior to this study, the overall P/LP variant frequency in the Polish women was thus 14% (47/337). Among the Ukrainian women, 16/123 (13%) women were identified as carrying a founder mutation and 20/123 (16.3%) were found to carry non-founder P/LP variants (10 in BRCA1 and 10 in BRCA2).
These results indicate that genetic testing in women at high risk of breast and ovarian cancer in Poland and Ukraine should not be limited to founder mutations. Extended testing will enhance risk stratification and management for these women and their families.
Poor physical health in severe mental illness (SMI) remains a major issue for clinical practice.
To use electronic health records of routinely collected clinical data to determine levels of screening for cardiometabolic disease and adverse health outcomes in a large sample (n = 7718) of patients with SMI, predominantly schizophrenia and bipolar disorder.
We linked data from the Glasgow Psychosis Clinical Information System (PsyCIS) to morbidity records, routine blood results and prescribing data.
There was no record of routine blood monitoring during the preceding 2 years for 16.9% of the cohort. However, monitoring was poorer for male patients, younger patients aged 16–44, those with schizophrenia, and for tests of cholesterol, triglyceride and glycosylated haemoglobin. We estimated that 8.0% of participants had diabetes and that lipids levels, and use of lipid-lowering medication, was generally high.
Electronic record linkage identified poor health screening and adverse health outcomes in this vulnerable patient group. This approach can inform the design of future interventions and health policy.