OBJECTIVES/GOALS: Physical therapy (PT) is key for treating functional decline that inpatients experience but is a constrained resource in hospital settings. The Activity Measure Post-Acute Care (AM-PAC) score is a mobility measurement tool that has been used to define misallocation of PT. We aim to optimize PT referrals using AM-PAC-based clinical decision support . METHODS/STUDY POPULATION: We conducted a prospective study of patients admitted to University of Chicago Medical Center. AM-PAC scores were assessed by nursing staff every 12 hours. Clinical decision support was designed using validated AM-PAC cutoffs (> 18, a predictor of discharge to home). The tool was embedded in hospital medicine note templates, requiring providers to indicate PT referral status based on current AM-PAC scores. The primary outcome, unskilled consult , was defined as PT referral for patients with AM-PAC > 18. Data were collected for one year prior to implementation and one year after implementation for intervention (hospital medicine) and control (general internal medicine) services. Difference in differences analysis was used to assess the association between the intervention and unskilled consults. RESULTS/ANTICIPATED RESULTS: Between October 2018 and March 2021, 18,241 admissions were eligible for the study. Compared to preintervention, there was a lower rate of referral to PT for patients with high AM-PAC mobility scores in the post-intervention period [18.5% vs 16.6%; X2(1) = 7.02; p < 0.01]. In the postintervention time period, the control group experienced a 2.6% increase in unskilled consults while the intervention group experienced a 2.3% decrease, a difference in differences of 4.9% (95% CI -0.07–-0.03 for difference in differences) controlling for age sex, race, LOS, and change in mobility. Compared to preintervention, there was no statistically significant difference in mean change in mobility score post-intervention for either group. DISCUSSION/SIGNIFICANCE: Our results suggest that clinical decision support can decrease unskilled PT consults. Many functionally independent patients can mobilize with nursing or other mobilization staff. Hospitals should consider mobility score-based decision support to prioritize PT for impaired and at-risk patients.

Non-communicable diseases (NCD) such as CVD and type 2 diabetes mellitus are major contributors to the burden of disease. NCD are largely driven by modifiable lifestyle factors including poor diet and insufficient physical activity, and consequently, prevention is a public health priority. Although diet and physical activity levels can be improved via lifestyle interventions, long-term adherence to such interventions remains low, which limits their effectiveness. Thus, it is critical to identify the underlying mechanisms that challenge uptake and adherence to such interventions. The current commentary discusses an important, but underexplored, psychological driver of poor adherence to lifestyle interventions, namely, future discounting, which describes the tendency to prefer smaller, short-term rewards over larger, long-term rewards. For example, in the nutrition domain, future discounting refers to valuing the immediate reward of excessive intake of energy-dense, nutrient-poor, discretionary foods high in salt, sugar, and saturated fat, and insufficient intake of low-energy, nutrient-dense, whole foods such as vegetables. Prominent theoretical models propose that excessive future discounting is a major contributor to the development of unhealthy lifestyle behaviours. Furthermore, a vast body of evidence suggests that future discounting plays a key role in risk of NCD. Thus, the evidence to date supports the idea that future discounting is an important multi-behaviour target for supporting lifestyle behaviour change; however, this approach has been largely neglected in preventive health efforts. Furthermore, this commentary discusses promising techniques (e.g. Episodic Future Thinking) for disrupting future discounting to promote improved adherence to lifestyle interventions aimed at reducing NCD risk.

Though presidents often criticize organized interests, presidents also expend considerable effort engaging them. Using original elite interviews, a survey of lobbyists, and administrative data, I consider how this engagement manifests, why presidents engage interests, and with which interests presidents engage. Unlike in other institutions, presidents exercise substantial control over engagement with interests, and they engage to mobilize interests’ institutional resources in service of their goals. To optimize mobilization, presidents focus engagement on well-resourced interests and interests who share presidents’ preferences. Pairing over seven million White House visitor log entries from two administrations with lobbying and campaign finance records, I demonstrate that presidential engagement is informed by interests’ electoral and policy resources and partisan alignment, though these characteristics’ substantive effects are modest. My findings highlight coalition building with interests as an underappreciated source of presidential power and elucidate the degree to which presidents amplify the political voice of well-resourced and copartisan interests.

Living within state care can have detrimental effects on children’s development, as substantial research has proposed. Recognising how music-making may support children’s social, emotional and personal development, many cultural organisations have begun developing music projects that work specifically with care-experienced children. Although evaluation has detailed the various benefits these projects may have, there has been little research into the approaches employed by the facilitators who deliver these projects. With this in mind, this article examines a community music project that focused on foster family music-making. It explores the facilitators’ social pedagogical approach to music-making and the benefits participants report they have gained from the project, both to themselves and the children in their care.

Amiodarone may be considered for patients with junctional ectopic tachycardia refractory to treatment with sedation, analgesia, cooling, and electrolyte replacements. There are currently no published pediatric data regarding the hemodynamic effects of the newer amiodarone formulation, PM101, devoid of hypotensive agents used in the original amiodarone formulation. We performed a single-center, retrospective, descriptive study from January 2012 to December 2020 in a pediatric ICU. Thirty-three patients were included (22 male and 11 female) between the ages of 1.1 and 1,460 days who developed post-operative junctional ectopic tachycardia or other tachyarrhythmias requiring PM101. Data analysis was performed on hemodynamic parameters (mean arterial pressures and heart rate) and total PM101 (mg/kg) from hour 0 of amiodarone administration to hour 72. Adverse outcomes were defined as Vasoactive-Inotropic Score >20, patients requiring ECMO or CPR, or patient death. There was no statistically significant decrease in mean arterial pressures within the 6 hours of PM101 administration (p > 0.05), but there was a statistically significant therapeutic decrease in heart rate for resolution of tachyarrhythmia (p < 0.05). Patients received up to 25 mg/kg in an 8-hour time for rate control. Average rate control was achieved within 11.91 hours and average rhythm control within 62 hours. There were four adverse events around the time of PM101 administration, with three determined to not be associated with the medication. PM101 is safe and effective in the pediatric cardiac surgical population. Our study demonstrated that PM101 can be used in a more aggressive dosing regimen than previously reported in pediatric literature with the prior formulation.

Many families, despite need and eligibility, struggle to meet programme deadlines to retain critical benefits. When families fail to complete programme recertification on time, they lose needed support. While scholars have tested behavioural theories like chunking, implementation intention, and loss framing to promote programme uptake, less is known about how well-designed communications can promote continuity through successful recertification, especially where recertification entails a significant administrative burden. Further, scant evidence guides how best to frame recertification deadlines. In a randomised trial with government partners (n = 3,539), we find that sending a reminder letter informed by these behavioural theories increased the number of families maintaining participation by 14 per cent. Further, anchoring people to a deadline month may suffice to thread the motivational needle: overcoming procrastination without lowering self-efficacy by anchoring them to a specific day. Adopting the most effective letter in Washington, DC, would lead 766 more families to participate uninterrupted each year.

This article is a clinical guide which discusses the “state-of-the-art” usage of the classic monoamine oxidase inhibitor (MAOI) antidepressants (phenelzine, tranylcypromine, and isocarboxazid) in modern psychiatric practice. The guide is for all clinicians, including those who may not be experienced MAOI prescribers. It discusses indications, drug-drug interactions, side-effect management, and the safety of various augmentation strategies. There is a clear and broad consensus (more than 70 international expert endorsers), based on 6 decades of experience, for the recommendations herein exposited. They are based on empirical evidence and expert opinion—this guide is presented as a new specialist-consensus standard. The guide provides practical clinical advice, and is the basis for the rational use of these drugs, particularly because it improves and updates knowledge, and corrects the various misconceptions that have hitherto been prominent in the literature, partly due to insufficient knowledge of pharmacology. The guide suggests that MAOIs should always be considered in cases of treatment-resistant depression (including those melancholic in nature), and prior to electroconvulsive therapy—while taking into account of patient preference. In selected cases, they may be considered earlier in the treatment algorithm than has previously been customary, and should not be regarded as drugs of last resort; they may prove decisively effective when many other treatments have failed. The guide clarifies key points on the concomitant use of incorrectly proscribed drugs such as methylphenidate and some tricyclic antidepressants. It also illustrates the straightforward “bridging” methods that may be used to transition simply and safely from other antidepressants to MAOIs.

This study investigated the transactional relations between vocabulary and disruptive behaviors (DB; physical aggression and opposition/rule breaking/theft and vandalism), during the transition to formal schooling, using a community sample of 572 children. Cross-lagged panel model analyses were used to examine bidirectional relationships, comparing physical aggression to non-aggressive DB. Transactional associations between vocabulary and DB were observed, coinciding with school entry. Lower vocabulary in preschool (60mo.) was predictive of higher physical aggression scores in kindergarten. In turn, higher physical aggression in kindergarten was predictive of lower vocabulary in 1st grade. For non-aggressive DB, recurrent associations were found. Lower verbal skills in preschool (42mo.) and kindergarten predicted higher non-aggressive DB scores later in preschool and in 1st grade respectively. In turn, higher non-aggressive DB in kindergarten predicted lower vocabulary scores in 1st grade. In contrast to transactional paths from vocabulary to DB, transactional paths from DB to vocabulary observed after the transition to elementary school remained significant after controlling for comorbid hyperactivity, impulsivity and inattention behaviors, suggesting these links were specific to aggressive and non-aggressive DB. Practical implications for prevention are discussed.

Herbicides with soil-residual activity have the potential for carryover into subsequent crops, resulting in injury to sensitive crops and limiting productivity if severe. The increased use of soil-residual herbicides in the United States for management of troublesome weeds in corn- and soybean-cropping systems has potential to result in more cases of carryover. Soil management practices have different effects on the soil environment, potentially influencing herbicide degradation and likelihood of carryover. Field experiments were conducted at three sites in 2019 and 2020 to determine the effects of corn (clopyralid and mesotrione) and soybean (fomesafen and imazethapyr) herbicides applied in the fall at reduced rates (25% and 50% of labeled rates) and three soil management practices (tillage, no-tillage, and a fall-established cereal rye cover crop) on subsequent growth and productivity of the cereal rye cover crop and the soybean and corn crops, respectively. Most response variables (cereal rye biomass and crop canopy cover at cover crop termination in the spring, early-season crop stand and herbicide injury ratings, and crop yield) were not affected by herbicide carryover. Corn yield was lower when soil was managed with a cereal rye cover crop compared with tillage at all three sites, while yield was lower for no-till compared with tillage at two sites. Soybean yield was lower when managed with a cereal rye cover crop compared with tillage and no-till at one site. Findings from this research indicate a low carryover risk for these herbicides across site-years when label rotational restrictions are followed and environmental conditions favorable for herbicide degradation exist, regardless of soil management practice on silt loam or silty clay loam soil types in the U.S. Midwest region.

Agitation is a common complication of Alzheimer’s dementia (Agit-AD) associated with substantial morbidity, high healthcare service utilization, and adverse emotional and physical impact on care partners. There are currently no FDA-approved pharmacological treatments for Agit-AD. We present the study design and baseline data for an ongoing multisite, three-week, double-blind, placebo-controlled, randomized clinical trial of dronabinol (synthetic tetrahydrocannabinol [THC]), titrated to a dose of 10 mg daily, in 80 participants to examine the safety and efficacy of dronabinol as an adjunctive treatment for Agit-AD. Preliminary findings for 44 participants enrolled thus far show a predominately female, white sample with advanced cognitive impairment (Mini Mental Status Examination mean 7.8) and agitation (Neuropsychiatric Inventory-Clinician Agitation subscale mean 14.1). Adjustments to study design in light of the COVID-19 pandemic are described. Findings from this study will provide guidance for the clinical utility of dronabinol for Agit-AD. ClinicalTrials.gov Identifier: NCT02792257.

Epistemic hubris—the expression of unwarranted factual certitude—is a conspicuous yet understudied democratic hazard. Here, in two nationally representative studies, we examine its features and analyze its variance. We hypothesize, and find, that epistemic hubris is (a) prevalent, (b) bipartisan, and (c) associated with both intellectualism (an identity marked by ruminative habits and learning for its own sake) and anti-intellectualism (negative affect toward intellectuals and the intellectual establishment). Moreover, these correlates of epistemic hubris are distinctly partisan: intellectuals are disproportionately Democratic, whereas anti-intellectuals are disproportionately Republican. By implication, we suggest that both the intellectualism of Blue America and the anti-intellectualism of Red America contribute to the intemperance and intransigence that characterize civil society in the United States.