Abstract
Background
Increases in fatal drug poisonings and hepatitis C infections associated with the opioid epidemic are relatively well defined, because passive surveillance systems for these ...conditions exist. Less described is the association between the opioid epidemic and skin, soft-tissue, and venous infections (SSTVIs), endocarditis, sepsis, and osteomyelitis.
Methods
Michigan hospitalizations between 2016 and 2018 that included an International Classification of Diseases, Tenth Revision, Clinical Modification, code indicating substance use were examined for codes indicative of infectious conditions associated with injecting drugs. Trends in these hospitalizations were examined, as were demographic characteristics, discharge disposition, payer, and cost data.
Results
Among hospitalized patients with a substance use diagnosis code, endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations increased by 33%, 35%, 24%, and 12%, respectively between 2016 and 2018. During this time frame, 1257 patients died or were discharged to hospice. All SSTVI hospitalizations resulted in >$1.3 billion in healthcare costs. Public insurance accounted for more than two-thirds of all hospitalization costs.
Conclusions
This study describes a method for performing surveillance for infection-related sequelae of injection drug use. Endocarditis, osteomyelitis, sepsis, and SSTVI hospitalizations have increased year over year between 2016 and 2018. These hospitalizations result in significant morbidity, mortality, and healthcare costs and should be a focus of future surveillance and prevention efforts.
Previous studies have demonstrated effects of racial and socioeconomic factors on survival of adults with cancer. While less studied in the pediatric population, data exist demonstrating disparities ...of care and survival in pediatric oncology patients based on socioeconomic and racial/ethnic factors. Brain cancers recently overtook leukemia as the number one cause of childhood cancer fatalities, but demographic and socioeconomic disparities in these tumors have not been adequately studied. We obtained data from the SEER Program of the National Cancer Institute (NCI). We selected patients under 19 years of age with central nervous system (CNS) cancers diagnosed between 2000 and 2015. We included patient demographics, tumor characteristics, treatment, and socioeconomic characteristics as covariates in the analysis. We measured overall survival and extent of disease at diagnosis. We saw that Black and Hispanic patients overall had a higher risk of death than non-Hispanic White patients on multivariable analysis. On stratified analysis, Black and Hispanic patients with both metastatic and localized disease at diagnosis had a higher risk of death compared to White, non-Hispanic patients, although the difference in Black patients was not significant after adjusting for mediating factors. However, our findings on extent of disease at diagnosis demonstrated that neither Black race nor Hispanic ethnicity increased the chance of metastatic disease at presentation when controlling for mediating variables. In summary, racial and ethnic disparities in childhood CNS tumor survival appear to have their roots at least partially in post-diagnosis factors, potentially due to the lack of access to high quality care, leading to poorer overall outcomes.
Background
Congenital (< 3 months) and infant (3 to 11 months) brain tumors are biologically different from tumors in older children, but their epidemiology has not been studied comprehensively. ...Insight into epidemiological differences could help tailor treatment recommendations by age and increase overall survival (OS).
Methods
Population-based data from SEER were obtained for 14,493 0–19-year-olds diagnosed with CNS tumors 1990–2015. Congenital and infant age groups were compared to patients aged 1–19 years based on incidence, treatment, and survival using Chi-square and Kaplan–Meier analyses. Hazard ratios were estimated from univariate and multivariable Cox proportional hazards survival analyses.
Results
Between the < 3-month, 3–5-month, 6–11 month, and 1–19-year age groups, tumor type distribution differed significantly (p < 0.001). 5-year OS for all tumors was 36.7% (< 3 months), 56.0% (< 3–5 months), 63.8% (6–11 months), and 74.7% (1–19 years) (p < 0.001). Comparing between age groups by tumor type, OS was worst for < 3-month-olds with low-grade glioma, medulloblastoma, and other embryonal tumors; OS was worst for 3–5-month-olds with ependymoma, < 1-year-olds collectively with atypical teratoid-rhabdoid tumor, and 1–19-year-olds with high-grade glioma (HGG) (log rank p < 0.02 for all tumor types). Under 3-month-olds were least likely to receive any treatment for each tumor type and least likely to undergo surgery for all except HGG. Under 1-year-olds were far less likely than 1–19-year-olds to undergo both radiation and chemotherapy for embryonal tumors.
Conclusions
Subtype distribution, treatment patterns, and prognosis of congenital/infant CNS tumors differ from those in older children. Better, more standardized treatment guidelines may improve poorer outcomes seen in these youngest patients.
Both cardiac magnetic resonance (CMR) and cardiac catheterization (cath) may assess patients with single ventricle physiology prior to stage II or Fontan palliation. However, development of ...significant aortopulmonary collaterals may invalidate assumptions of the Fick method. We compared CMR and cath flow measurements and evaluated the relation to collateral flow. This single-center study included all pre-stage II and pre-Fontan patients between 2010 and 2017 with CMR and cath within 1 month. Pulmonary (Qp) and systemic flow (Qs) by cath were calculated by Fick method. CMR Qp was calculated by total pulmonary venous flow, and Qs by total vena caval flow. Collateral flow by CMR was the difference of pulmonary vein and pulmonary artery flow. In 26 studies (16 pre-stage II and 10 pre-Fontan) in 21 patients, collateral flow was higher in pre-Fontan patients (1.8 ± 0.6 vs 0.9 ± 0.8 L/min/m
2
,
p
= 0.01). Overall, CMR and cath had good agreement for Qs and Qp:Qs, with moderate correlation (
r
= 0.44,
p
= 0.02 for Qs,
r
= 0.48,
p
= 0.02 for Qp:Qs). In pre-Fontan but not in pre-stage II patients, CMR had higher Qp (mean difference − 1.71 L/min/m
2
) and Qp:Qs (mean difference − 0.36). The underestimation of cath Qp correlated with amount of collateral flow (
r
= − 0.47,
p
= 0.02). Neither cath nor CMR flow measurements correlated with outcomes in this small cohort. In conclusion, collaterals lead to systematically higher Qp and Qp:Qs measurements by CMR vs cath in single ventricle patients. Measurements may not be used interchangeably, with potential clinical significance in estimating pulmonary vascular resistance. Further study is necessary to evaluate possible relation to clinical outcomes.
Abstract
Background
medical education must adapt to meet the challenges and demands of an ageing population, ensuring that graduates are equipped to look after older patients with complex health and ...social care needs. Recommended curricula in geriatric medicine in the United Kingdom and Europe offer guidance for optimal undergraduate education in ageing. The UK version, written by the British Geriatrics Society (BGS), requires updating to take account of innovations in the specialty, changing guidance from the General Medical Council (GMC), and the need to support medical schools preparing for the introduction of the national Medical Licensing Assessment (MLA).
Methods
the BGS recommended curriculum was mapped to the most recent European curriculum (2014) and the MLA content map, to compare and contrast between current recommendations and nationally mandated guidance. These maps were used to guide discussion through a virtual Nominal Group Technique (NGT), including 21 expert stakeholders, to agree consensus on the updated BGS curriculum.
Results
the curriculum has been re-structured into seven sections, each with 1–2 overarching learning outcomes (LOs) that are expanded in multiple sub-LOs. Crucially, the curriculum now reflects the updated GMC/MLA requirements, having incorporated items flagged as missing in the mapping stages.
Conclusion
the combined mapping exercise and NGT have enabled appropriate alignment and benchmarking of the UK national curriculum. These recommendations will help to standardise and enhance teaching and learning around the care of older persons with complexity.
Abstract Purpose The purpose was to determine ( a ) safety and feasibility of functional electrical stimulation (FES)-cycling and ( b ) compare FES-cycling to case-matched controls in terms of ...functional recovery and delirium outcomes. Materials and methods Sixteen adult intensive care unit patients with sepsis ventilated for more than 48 hours and in the intensive care unit for at least 4 days were included. Eight subjects underwent FES-cycling in addition to usual care and were compared to 8 case-matched control individuals. Primary outcomes were safety and feasibility of FES-cycling. Secondary outcomes were Physical Function in Intensive Care Test scored on awakening, time to reach functional milestones, and incidence and duration of delirium. Results One minor adverse event was recorded. Sixty-nine out of total possible 95 FES sessions (73%) were completed. A visible or palpable contraction was present 80% of the time. There was an improvement in Physical Function in Intensive Care Test score of 3.9/10 points in the intervention cohort with faster recovery of functional milestones. There was also a shorter duration of delirium in the intervention cohort. Conclusions The delivery of FES-cycling is both safe and feasible. The preliminary findings suggest that FES-cycling may improve function and reduce delirium. Further research is required to confirm the findings of this study and evaluate the efficacy of FES-cycling.
BackgroundNHS England’s ‘Enhanced Health in Care Homes’ specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, ...but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered.AimTo determine whether a proactive healthcare model could improve healthcare outcomes for care home residents.Design and settingQuality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival.MethodAll care home residents had healthcare coordinated by the PCN’s Older Peoples’ Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP.ResultsBy 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables.ConclusionA PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.
Of the 461 licensed long-term care facilities (LTCFs) in Michigan, 129 responded to the first survey of LTCF healthcare personnel (HCP) immunization policies, coverage estimates, and perceived ...barriers to vaccination. Survey results suggest opportunities to improve HCP vaccination through polices, education, barrier removal, and HCP immunity status tracking in licensed LTCFs in Michigan.
Global warming and climate change have increased the pollen burden and the frequency and intensity of wildfires, sand and dust storms, thunderstorms, and heatwaves—with concomitant increases in air ...pollution, heat stress, and flooding. These environmental stressors alter the human exposome and trigger complex immune responses. In parallel, pollutants, allergens, and other environmental factors increase the risks of skin and mucosal barrier disruption and microbial dysbiosis, while a loss of biodiversity and reduced exposure to microbial diversity impairs tolerogenic immune development. The resulting immune dysregulation is contributing to an increase in immune-mediated diseases such as asthma and other allergic diseases, autoimmune diseases, and cancer. It is now abundantly clear that multisectoral, multidisciplinary, and transborder efforts based on Planetary Health and One Health approaches (which consider the dependence of human health on the environment and natural ecosystems) are urgently needed to adapt to and mitigate the effects of climate change. Key actions include reducing emissions and improving air quality (through reduced fossil fuel use), providing safe housing (e.g., improving weatherization), improving diets (i.e., quality and diversity) and agricultural practices, and increasing environmental biodiversity and green spaces. There is also a pressing need for collaborative, multidisciplinary research to better understand the pathophysiology of immune diseases in the context of climate change. New data science techniques, biomarkers, and economic models should be used to measure the impact of climate change on immune health and disease, to inform mitigation and adaptation efforts, and to evaluate their effectiveness. Justice, equity, diversity, and inclusion (JEDI) considerations should be integral to these efforts to address disparities in the impact of climate change.
Young exoplanets are snapshots of the planetary evolution process. Planets that orbit stars in young associations are particularly important because the age of the planetary system is well ...constrained. We present the discovery of a transiting planet larger than Neptune but smaller than Saturn in the 45 Myr Tucana-Horologium young moving group. The host star is a visual binary, and our follow-up observations demonstrate that the planet orbits the G6V primary component, DS Tuc A (HD 222259A, TIC 410214986). We first identified transits using photometry from the Transiting Exoplanet Survey Satellite (TESS; alerted as TOI 200.01). We validated the planet and improved the stellar parameters using a suite of new and archival data, including spectra from Southern Astrophysical Research/Goodman, South African Extremely Large Telescope/High Resolution Spectrograph and Las Cumbres Observatories/Network of Robotic Echelle Spectrographs; transit photometry from Spitzer; and deep adaptive optics imaging from Gemini/Gemini Planet Imager. No additional stellar or planetary signals are seen in the data. We measured the planetary parameters by simultaneously modeling the photometry with a transit model and a Gaussian process to account for stellar variability. We determined that the planetary radius is 5.70 0.17 R⊕ and that the orbital period is 8.1 days. The inclination angles of the host star's spin axis, the planet's orbital axis, and the visual binary's orbital axis are aligned within 15° to within the uncertainties of the relevant data. DS Tuc Ab is bright enough (V = 8.5) for detailed characterization using radial velocities and transmission spectroscopy.
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