A comprehensive evaluation of emergency department utilization by patients with cirrhosis.

BACKGROUND: Emergency Department (ED) based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization (HCU) is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) versus non-HEDU in individuals with cirrhosis. METHODS: We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. RESULTS: There were 2124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), MASH (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits 20% (n=424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were MELD-Na (aOR=1.044, 95% CI 1.005-1.085), prior ED encounter (aOR=1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR=1.938, 95% CI 1.014-3.703). CONCLUSIONS: Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.

Expanded phylogeny of extremely halophilic archaea shows multiple independent adaptations to hypersaline environments.

Extremely halophilic archaea (Haloarchaea, Nanohaloarchaeota, Methanonatronarchaeia and Halarchaeoplasmatales) thrive in saturating salt concentrations where they must maintain osmotic equilibrium with their environment. The evolutionary history of adaptations enabling salt tolerance remains poorly understood, in particular because the phylogeny of several lineages is conflicting. Here we present a resolved phylogeny of extremely halophilic archaea obtained using improved taxon sampling and state-of-the-art phylogenetic approaches designed to cope with the strong compositional biases of their proteomes. We describe two uncultured lineages, Afararchaeaceae and Asbonarchaeaceae, which break the long branches at the base of Haloarchaea and Nanohaloarchaeota, respectively. We obtained 13 metagenome-assembled genomes (MAGs) of these archaea from metagenomes of hypersaline aquatic systems of the Danakil Depression (Ethiopia). Our phylogenomic analyses including these taxa show that at least four independent adaptations to extreme halophily occurred during archaeal evolution. Gene-tree/species-tree reconciliation suggests that gene duplication and horizontal gene transfer played an important role in this process, for example, by spreading key genes (such as those encoding potassium transporters) across extremely halophilic lineages.

COVID-19 vaccine hesitancy in underserved communities of North Carolina.

BACKGROUND: In the United States, underserved communities including Blacks and Latinx are disproportionately affected by COVID-19. This study sought to estimate the prevalence of COVID-19 vaccine hesitancy, describe attitudes related to vaccination, and identify correlates among historically marginalized populations across 9 counties in North Carolina. METHODS: We conducted a cross-sectional survey distributed at free COVID-19 testing events in underserved rural and urban communities from August 27 -December 15, 2020. Vaccine hesitancy was defined as the response of "no" or "don't know/not sure" to whether the participant would get the COVID-19 vaccine as soon as it became available. RESULTS: The sample comprised 948 participants including 27.7% Whites, 59.6% Blacks, 12.7% Latinx, and 63% female. 32% earned <$20K annually, 60% owned a computer and ~80% had internet access at home. The prevalence of vaccine hesitancy was 68.9% including 62.7%, 74%, and 59.5% among Whites, Blacks, and Latinx, respectively. Between September and December, the largest decline in vaccine hesitancy occurred among Whites (27.5 percentage points), followed by Latinx (17.6) and only 12.0 points among Blacks. 51.2% of respondents reported vaccine safety concerns, 23.7% wanted others to get vaccinated first, and 63.1% would trust health care providers about the COVID-19 vaccine. Factors associated with hesitancy in multivariable logistic regression included being female (OR = 1.90 95%CI [1.36, 2.64]), being Black (OR = 1.68 1.16, 2.45]), calendar month (OR = 0.76 [0.63, 0.92]), safety concerns (OR = 4.28 [3.06, 5.97]), and government distrust (OR = 3.57 [2.26, 5.63]). CONCLUSIONS: This study engaged the community to directly reach underserved minority populations at highest risk of COVID-19 that permitted assessment of vaccine hesitancy (which was much higher than national estimates), driven in part by distrust, and safety concerns.

System of Psychological Support Based on Positive Suggestions to the Critically Ill Using ICU Doulas.

Surviving critical illness often creates a lasting psychological impact, including depression, anxiety, and post-traumatic stress. Memories of frightening and delusional experiences are the largest potentially modifiable risk factor, but currently, there is no proven intervention to improve these inciting factors. Psychological support based on positive suggestion is a psychotherapeutic approach that can be provided even to patients in altered cognitive states and is therefore a viable psychotherapy intervention throughout the ICU stay. Traditional ICU care team members have limited time and training to provide such psychological support to patients. Doulas are trained supportive companions who have been effectively used to provide patient advocacy and emotional support in other clinical settings and may address this need. Our aim was to train and implement a psychological support based on positive suggestion program for the critically ill using doulas, and measure acceptance of this intervention through stakeholder feedback. METHODS: Doula training included three objectives: an introduction to ICU practice structure and policies; education about fundamental aspects of critical care conditions and procedures; and didactic and hands-on learning experiences in effective use of psychological support based on positive suggestion in the critically ill. Doulas were evaluated at the end of their training and during subsequent clinical activities using competency-based assessments as well as through survey-based questions and interviews with key stakeholders. RESULTS: The ICU doulas performed psychological support based on positive suggestion on 43 critically ill patients in the ICU setting. Stakeholder feedback from nurses, patients, and patient families was positive. The majority (28/32) of surveyed bedside ICU nurses reported that the doulas' involvement was helpful for both patients and nurses alike. All interviewed family members offered positive comments about the ICU doula presence and of the 40 patients who recalled the intervention 37 found it comforting. CONCLUSIONS: Our program successfully trained two doulas to work effectively in the ICU setting performing patient-centered psychological support based on positive suggestion interventions. Their training improved their skill sets and was reported as beneficial by patients, families, and critical care nursing. This training program offers a proof of concept that could be applied in other medical centers, bringing doulas more commonly into the ICU practice to help humanize the experience for patients, families, and medical teams.

COVID-19 Vaccine Hesitancy in Underserved Communities of North Carolina.

BACKGROUND: In the United States, underserved communities including Blacks and Latinx are disproportionately affected by COVID-19, and widespread vaccination is critical for curbing this pandemic. This study sought to estimate the prevalence of COVID-19 vaccine hesitancy, describe attitudes related to vaccination, and identify correlates among racial minority and marginalized populations across 9 counties in North Carolina. METHODS: We conducted a cross-sectional survey with a self-administered questionnaire distributed at free COVID-19 testing events in underserved rural and urban communities from August 27 - December 15, 2020. Vaccine hesitancy was defined as the response of "no" or "don't know/not sure" to whether the participant would get the COVID-19 vaccine as soon as it became available. RESULTS: The sample comprised 948 participants including 27.7% Whites, 59.6% Blacks, 12.7% Latinx, and 63% female. Thirty-two percent earned <$20K annually, 60% owned a computer and ∼80% had internet access at home. The prevalence of vaccine hesitancy was 68.9% including 62.7%, 74%, and 59.5% among Whites, Blacks, and Latinx, respectively. Between September and December, the largest decline in vaccine hesitancy occurred among Whites (27.5 percentage points), followed by Latinx (17.6) and the smallest decline was among Black respondents (12.0). 51.2% of the respondents reported vaccine safety concerns, 23.7% wanted others to get of the respondents reported they would trust health care providers with information about the COVID-19 vaccine. Factors associated with hesitancy in multivariable logistic regression included being female (OR=1.90 95%CI[1.36, 2.64]), being Black (OR=1.68 [1.106 2.45]), calendar month (OR=0.76 [0.63, 0.92]), safety concerns (OR=4.28 [3.06, 5.97]), and government distrust (OR=3.57 [2.26, 5.63]). CONCLUSIONS: This study reached underserved minority populations in a number of different locations to investigate COVID-19 vaccine hesitancy. We built on existing relationships and further engaged the community, stake holders and health department to provide free COVID-19 testing. This direct approach permitted assessment of vaccine hesitancy (which was much higher than national estimates), distrust, and safety concerns. HIGHLIGHTS: This study surveyed 948 adults at COVID-19 testing sites in 9 counties of North Carolina between August 27 and December 15, 2020 where vaccine hesitancy was widespread including 74% in Blacks, 62.7% in Whites and 59.5% in Latinx.Vaccine hesitancy declined over time but remained high for Blacks.On-site surveys conducted in underserved areas that were paper-based and self-administered permitted reaching adults with no internet (17%), no cell phone (20%), no computer (40%) and yearly incomes less than 20K (31%).Widespread vaccine hesitancy in predominately minority communities of NC must be addressed to successfully implement mass COVID-19 vaccination programs.

The impact of HIV on sexual functioning: Considerations for clinicians.

Cultivating a healthy sex life after HIV diagnosis can be difficult for people with HIV (PWH), as stigma and concerns for transmission may act as barriers to sexual activity. Addressing these obstacles is a necessary part of psychotherapy when helping PWH reincorporate sexual activities. However, mental health providers may be unprepared to discuss factors that impact sexual functioning with their HIV-positive clients. Currently, there are no gold-standard evidence-based treatments developed specifically for HIV-positive individuals. Therefore, this article focuses on using cognitive-behavioral techniques to address sexual concerns in PWH. Cognitive-behavioral therapy has been effective at improving sexual health in other medical populations and can be adapted to optimize sexual functioning in PWH. In this article, we discuss cases of common concerns PWH experience and how cognitive-behavioral therapy techniques (e.g., challenging automatic and maladaptive thoughts) can be incorporated into psychotherapy to cultivate a healthy and fulfilling sex life. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

CpG-creating mutations are costly in many human viruses.

Mutations can occur throughout the virus genome and may be beneficial, neutral or deleterious. We are interested in mutations that yield a C next to a G, producing CpG sites. CpG sites are rare in eukaryotic and viral genomes. For the eukaryotes, it is thought that CpG sites are rare because they are prone to mutation when methylated. In viruses, we know less about why CpG sites are rare. A previous study in HIV suggested that CpG-creating transition mutations are more costly than similar non-CpG-creating mutations. To determine if this is the case in other viruses, we analyzed the allele frequencies of CpG-creating and non-CpG-creating mutations across various strains, subtypes, and genes of viruses using existing data obtained from Genbank, HIV Databases, and Virus Pathogen Resource. Our results suggest that CpG sites are indeed costly for most viruses. By understanding the cost of CpG sites, we can obtain further insights into the evolution and adaptation of viruses.

Bias in Rating of Rodent Distress during Anesthesia Induction for Anesthesia Compared with Euthanasia.

Selection of an appropriate method of euthanasia involves balancing the wellbeing of the animal during the procedure with the intended use of the animal after death and the physical and psychologic safety of the observer or operator. The recommended practices for anesthesia as compared with euthanasia are very disparate, despite the fact that all chemical methods of euthanasia are anesthetic overdoses. To explain this disparity, this study sought to determine whether perception bias is inherent in the discussion of euthanasia compared with anesthesia. In this study, participants viewed videorecordings of the anesthesia of either 4 rats or 4 mice, from induction to loss of consciousness. Half of the participants were told that they were observing anesthesia; the other half understood that they were observing euthanasia. Participants were asked to rate the distress of the animals by scoring escape behaviors, fear behaviors, respiratory distress, and other distress markers. For mice, the participants generally rated the distress as high when they were told that the mouse was being euthanized, as compared with the participants who were told that the mouse was being anesthetized. For rats, the effect was not as strong, and the distress was generally rated higher when participants were told they were watching anesthesia. Because the interpretation of distress showed bias in both species-even though the bias differed regarding the procedure that interpreted as distressing-this study demonstrates that laboratory animal professionals must consider the influence of potential perception bias when developing policies for euthanasia and anesthesia.