Getting to the bottom of why children with spina bifida use the emergency department: A qualitative analysis of parent and stakeholder perspectives.

BACKGROUND: Children with Spina Bifida (SB) have considerable healthcare utilization, including Emergency Department use (EDU). We aimed to elicit reasons for EDU using qualitative analysis of interviews with both patient-caregiver dyads and stakeholders. METHODS: A cohort of children with SB followed at our institution between 2016 and 2020 was identified and patient and clinical characteristics abstracted. Purposeful sampling by age and degree of past EDU was performed. Semi-structured interviews of dyads were performed using iteratively revised interview guides. Spanish-language interviews were conducted by a native Spanish speaker and transcripts professionally translated. Supplemental interviews with stakeholders, namely knowledgeable healthcare professionals, were also conducted. A qualitative framework approach was used for analysis, including open followed by closed independent coding with calculation of inter-rater reliability. A final interpretation of coding reports assessing convergence, divergence, and variation in themes across participant characteristics. RESULTS: 116 families (4 Spanish-speaking) and 7 stakeholders were interviewed. Sampling yielded a heterogenous cohort for EDU (56% with 0-10, 44% with >10 visits) and age (25% 0-4, 44% 5-11, 31% > 11 years). IRR was optimal (κ = 0.9). Themes in perceived reasons for EDU were 1) desire for "one-stop-shop" care, 2) an emergent medical problem, 3) providers' instructions, 4) negative past healthcare experience, 5) intrinsic caregiver moderators, and 6) temporospatial influences. Themes 1, 2, and 5 predominated in dyads, whereas themes 6, 3, and 5 were most common in stakeholders. Stakeholders focused largely on negative institutional and patient characteristics. Among dyads only, theme #1 was disproportionately emphasized by Spanish-speaking patients. DISCUSSION: Families desired access to coordinated expert care, testing and imaging. The ED offers this for children with SB, regardless of clinical acuity. This may be especially valued by families with inherent challenges to navigating the healthcare system. Negative experiences in community clinical settings, healthcare provider recommendations and intrinsic parental factors were themes that seemed to contribute to seeking this "one-stop-shop" type of care. Care coordination may reduce ED reliance, but themes for the interviews suggest a systems-based efforts should weave in the community care setting. CONCLUSIONS: For both stakeholders and caregivers, the ED represented a valued form of immediate access to multispecialty, expert care and testing in the context of perceived lack of timely, coordinated outpatient care. This may be moderated by intrinsic caregiver factors and negative past experiences. Although stakeholders discussed ideas that fit into patient-caregiver themes, the also uniquely focused on systems-based and patient-caregiver limitations.

Health-promoting benefits of lentils: Anti-inflammatory and anti-microbial effects.

This paper describes how lentils (Lens culinaris species) can positively affect health by reducing inflammation, providing antioxidants, and displaying antimicrobial properties. Lentils are rich in proteins, essential amino acids, minerals, and fibers, making them a valuable source of nutrition, particularly in low and middle-income countries. Lentils have many health benefits, including positive effects on diabetes management, support for cardiovascular health, and antioxidative properties. The antioxidative properties of lentils, attributed to their phenolic content, and their ability to inhibit inflammation-related enzymes are also discussed. We discuss the potential of lentils as a dietary tool in promoting immunity, reducing disease burdens, and preventing nutritional deficiencies. Overall, lentils are a highly nutritious food with various health benefits, including anti-inflammatory and antimicrobial effects. The fiber and protein content in lentils make them beneficial for weight management, blood sugar regulation, and supporting overall gut health. Furthermore, the slow rate at which lentils affect blood sugar levels, due to their low glycemic index, can be advantageous for individuals with diabetes.

Trauma as a Public Health Moment: Addressing Vaccine Uptake in Trauma Patients.

Objective: Our objective was to identify factors associated with COVID-19 vaccination in trauma patients and to provide an opportunity for patients to engage in conversations about vaccination. Background: The trauma surgery service offers a unique opportunity to promote preventative health interventions in hard-to-reach populations. Methods: Trauma inpatients in Chicago, IL were recruited for this mixed-methods study from February 2022 to April 2022. Participants completed a survey on demographics, COVID-19 vaccination status, and Experiences of Discrimination Scale adapted for medical settings. Differences between vaccinated and unvaccinated patients were analyzed using the Wilcoxon-rank sum test. A semistructured, qualitative interview was completed. Qualitative data was transcribed and analyzed using Grounded Theory Methodology. Results: Fifty-eight trauma patients were surveyed, representing 88% of patients approached. Only 23 (40%) patients reported full vaccination to COVID-19. Previous vaccination (at least 1 dose) was associated with greater concern for COVID-19 (OR 3.47, 95% CI 1.987-6.964, P < 0.001) and higher income (OR 1.21, 95% CI 1.02-1.44, P = 0.03). Higher Experiences of Discrimination Scale scores were associated with decreased likelihood of prior vaccination (OR 0.97, 95% CI 0.95-0.99, P = 0.04). On qualitative analysis, recurrent themes included vaccination motivated by either community-based or personal health-related values, and disinterest in vaccination based on perceived low need or skepticism of experimentation. Fifteen patients (26%) eligible for a vaccine dose consented to onsite vaccination after the survey. Conclusions: Trauma patients who have experienced more discrimination in medical settings have lower rates of COVID-19 vaccination. Vaccination rates in our population were over 2 times lower than citywide rates, but admission to the trauma service can increase comprehensive care.

Identifying the palliative care needs of patients and families in gynecologic surgical oncology: A scoping review.

Introduction: Patients undergoing oncology-related gynecologic surgical procedures experience substantial symptom burden and distress. Support from specialist palliative care teams may benefit these patients and their families; however, an evidence-informed approach to the integration of palliative care and gynecologic surgical oncology is needed. To inform such an approach, a scoping review synthesizing current evidence on the palliative care needs of patients and families in gynecologic surgical oncology was conducted.Methods: Reviewers performed a structured search of online databases CINAHL, Scopus, PsycINFO, MEDLINE, and PubMed in addition to the grey literature to identify relevant studies published between 2011 and June 11th, 2021. The original search identified 993 articles, which were dually screened for study inclusion, resulting in a final sample of articles from which data were systematically extracted and synthesized.Results: This review of 59 publications predominantly consisted of European studies (n = 26, 44.1%), described quantitative study methods (n = 47, 79.6%), followed an observational study design (n = 49, 83.1%), and focused on psychological impact of treatment as a major topic of study (n = 21, 35.6%). The dataset also described sexual function of women post treatment (n = 15, 25.4%), quality of life (n = 10, 16.9%), therapeutic decision making (n = 9, 15.2%), pain assessment (n = 2, n = 3.6%), and medication for symptom management (n = 2, 3.6%). Explicit discussion of specialist palliative care involvement was rare.Conclusion: The needs of patients and families in gynecologic surgical oncology are well-suited to palliative care collaboration; however, the body of literature on palliative care services provided to this unique population is underdeveloped.

Multiple endocrine neoplasia type 2 (MEN2) and RET specific modifications of the ACMG/AMP variant classification guidelines and impact on the MEN2 RET database.

The Multiple Endocrine Neoplasia type 2 (MEN2) RET proto-oncogene database, originally published in 2008, is a comprehensive repository of all publicly available RET gene variations associated with MEN2 syndromes. The variant-specific genotype/phenotype information, age of earliest reported medullary thyroid carcinoma (MTC) onset, and relevant references with a brief summary of findings are cataloged. The ACMG/AMP 2015 consensus statement on variant classification was modified specifically for MEN2 syndromes and RET variants using ClinGen sequence variant interpretation working group recommendations and ClinGen expert panel manuscripts, as well as manuscripts from the American Thyroid Association Guidelines Task Force on Medullary Thyroid Carcinoma and other MEN2 RET literature. The classifications for the 166 single unique variants in the MEN2 RET database were reanalyzed using the MEN2 RET specifically modified ACMG/AMP classification guidelines (version 1). Applying these guidelines added two new variant classifications to the database (likely benign and likely pathogenic) and resulted in clinically significant classification changes (e.g., from pathogenic to uncertain) in 15.7% (26/166) of the original variants. Of those clinically significant changes, the highest percentage of changes, 46.2% (12/26), were changes from uncertain to benign or likely benign. The modified ACMG/AMP criteria with MEN2 RET specifications will optimize and standardize RET variant classifications.

Inorganic phosphate-induced cytotoxicity.

Phosphate, an essential nutrient, is available in organic and inorganic forms. The balance of phosphate is central for cellular homeostasis through the genomic roles of DNA and RNA synthesis and cell signaling processes. Therefore, an imbalance of this nutrient, manifested, either as a deficiency or excess in phosphate levels, can result in pathology, ranging from cytotoxicity to musculoskeletal defects. Inorganic phosphate (Pi) overdosing can result in a wide spectrum of cytotoxicity processes, as noted in both animal models and human studies. These include rewired cell signaling pathways, impaired bone mineralization, infertility, premature aging, vascular calcification, and renal dysfunction. This article briefly reviews the regulation of phosphate homeostasis and elaborates on cytotoxic effects of excessive Pi, as documented in cell-based models.

Ternary Trends in Nursing Home Information Technology and Quality Measures in the United States.

Nursing home information technology (NH IT) adoption trends are not measured regularly. Evidence indicates digital footprints are growing, but gaps about NH IT adoption and quality impacts remain. We hypothesize as NH IT adoption grows, quality improves. This research assessed ternary (2014-2017) trends in IT and quality measures using a primary survey of U.S. NHs. Survey measures included nine dimensions/domains and total IT sophistication. Administrators completed 815 Year 1 surveys. Each year mean total IT sophistication scores in nine dimensions/domains consistently increased. Eighteen significant correlations (r > .13, absolute value) between IT sophistication and quality measures existed. Regression shows that for every 10 units increase in administrative activity extent of IT use, a decrease of 1.3% occurs in the percentage of low-risk long-stay residents with bowel or bladder incontinence. Increases in NH IT sophistication positively impact quality. Estimating ongoing trends in NH IT sophistication provides new information that should be consistently available.

NOTCH1 Gene MicroRNA Target Variation and Ventricular Septal Defect Risk.

Birth defects, the ventricular septal defect (VSD) in particular, have major public health significance. There is evidence that genetic factors play a role in VSD risk. We report here our findings on the relationship between VSD and microRNA (miRNA)-3691-3p target sequence single-nucleotide polymorphisms (SNPs) in the 3' untranslated region of the NOTCH1 gene. Functional SNPs in NOTCH1 target sequence were screened from the SNP database. A case-control study in a large Chinese Han population sample of 350 children with VSD and 430 healthy controls examined the association between rs6563 SNPs and VSD. NOTCH1 wild and mutant recombinant expression vectors were constructed by the luciferase reporter gene system. The effects of miRNA on gene regulatory effects were also analyzed. The allelic distributions at the locus rs6563 showed statistically significant susceptibility to VSD (odds ratio [OR] = 1.502, 95% confidence interval [CI] = 1.209-1.866, p < 0.001). Compared with the subjects with G/G genotype, individuals with G/A genotype or A/A genotype showed ORs 1.414 (95% CI = 1.047-1.908, p = 0.020) and 2.366 (95% CI = 1.430-3.914, p < 0.001), respectively. The miRNA-3691-3p reduced luciferase activity of the A allele. The rs6563G > A genetic variation appears to be associated with congenital VSD through gene regulatory effects of miR-3691-3p on the NOTCH1 gene. Further studies in other population samples are called for diagnostics and public health innovation in relation to birth defects.

A modular architecture for articulatory synthesis from gestural specification.

This paper proposes a modular architecture for articulatory synthesis from a gestural specification comprising relatively simple models for the vocal tract, the glottis, aero-acoustics, and articulatory control. The vocal tract module combines a midsagittal statistical analysis articulatory model, derived by factor analysis of air-tissue boundaries in real-time magnetic resonance imaging data, with an αß model for converting midsagittal section to area function specifications. The aero-acoustics and glottis models were based on a software implementation of classic work by Maeda. The articulatory control module uses dynamical systems, which implement articulatory gestures, to animate the statistical articulatory model, inspired by the task dynamics model. Results on synthesizing vowel-consonant-vowel sequences with plosive consonants, using models that were built on data from, and simulate the behavior of, two different speakers are presented.

The State of Nursing Home Information Technology Sophistication in Rural and Nonrural US Markets.

OBJECTIVE: To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location. METHODS: We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons. PRINCIPAL FINDINGS: Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas. CONCLUSIONS: This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined.

A national report of nursing home information technology: year 1 results.

OBJECTIVE: To provide a report on year 1 results of a national study investigating nursing home information technology (IT) adoption, called IT sophistication. METHODS: A reliable and valid survey was used to measure IT sophistication. The target goal was 10% from each state in the United States, 1570 nursing homes. A random sample of homes from each state was recruited from Nursing Home Compare. RESULTS: The team reached 2627 nursing home administrators, among whom 1799 administrators agreed to participate and were sent a survey. A total of 815 surveys were completed (45.3% response rate), which was below the goal. Facilities in the participating sample have similar demographic characteristics (ownership, total population in a location, and bed size) to the remaining homes not participating. There are greater IT capabilities in resident care and administrative activities, less in clinical support. The extent of use of these capabilities appears to be highest in administrative activities and lowest in clinical support. IT in resident care appears to be the most integrated with internal and external stakeholders. IT capabilities appear to be greater than IT extent of use in all health domains, with the greatest difference in resident care. DISCUSSION: National evaluations of nursing home IT are rare. Measuring trends in IT adoption in a nationally representative sample provides meaningful analytics that could be more useful for policy makers and nursing home leaders in the future. CONCLUSION: Discovering national baseline assessments is a first step toward recognizing nursing home trends in IT adoption.

Reliability of sagittal plane hip, knee, and ankle joint angles from a single frame of video data using the GAITRite camera system.

The purpose of this study was to establish intra-rater, intra-session, and inter-rater, reliability of sagittal plane hip, knee, and ankle angles with and without reflective markers using the GAITRite walkway and single video camera between student physical therapists and an experienced physical therapist. This study included thirty-two healthy participants age 20-59, stratified by age and gender. Participants performed three successful walks with and without markers applied to anatomical landmarks. GAITRite software was used to digitize sagittal hip, knee, and ankle angles at two phases of gait: (1) initial contact; and (2) mid-stance. Intra-rater reliability was more consistent for the experienced physical therapist, regardless of joint or phase of gait. Intra-session reliability was variable, the experienced physical therapist showed moderate to high reliability (intra-class correlation coefficient (ICC) = 0.50-0.89) and the student physical therapist showed very poor to high reliability (ICC = 0.07-0.85). Inter-rater reliability was highest during mid-stance at the knee with markers (ICC = 0.86) and lowest during mid-stance at the hip without markers (ICC = 0.25). Reliability of a single camera system, especially at the knee joint shows promise. Depending on the specific type of reliability, error can be attributed to the testers (e.g. lack of digitization practice and marker placement), participants (e.g. loose fitting clothing) and camera systems (e.g. frame rate and resolution). However, until the camera technology can be upgraded to a higher frame rate and resolution, and the software can be linked to the GAITRite walkway, the clinical utility for pre/post measures is limited.

Main types of skin cancer and treatment options.

This first in a two-part series on skin cancer gives an overview of the most common types and outlines the main treatment options. Part 2, to be published next week, discusses the causes of and risk factors for skin cancer, highlighting those people who are most at risk and the importance of early diagnosis.

Skin cancer: causes and groups at risk.

This second in a two-part series focuses on the causes and risk factors of skin cancer, highlighting risk factors among the general population as well as in high-risk groups. Part 1, published last week, outlined the main types of skin cancer and the treatment options available for each type; this article stresses the importance of early identification and patient education to prevent skin cancer.

Intervention programme: a supported learning programme for educationally disadvantaged students.

The apartheid system of social engineering in South Africa enforced the segregation of racial groups. It lasted for 50 years, and had an impact on every aspect of society. It particularly affected the education system, resulting in inferior primary and secondary teaching of black learners. Ten years after the dissolution of apartheid, the consequences are still being felt in tertiary institutions. This legacy presents a challenge to South African medical schools, especially at a time of curriculum transformation. This paper describes how the issues of social and educational discrepancies are being addressed at the University of Cape Town.

Red cell mass responses to daily erythropoietin and iron injections in the ovine fetus.

OBJECTIVE: Anemic ovine fetuses supplemented with intra-amniotic iron undergo rapid expansion of red cell mass. The present study tested the hypothesis that nonanemic fetuses that were supplemented with daily intra-amniotic iron plus intravascular injections of erythropoietin would experience accelerated erythrocyte production. STUDY DESIGN: Nine late gestation ovine fetuses received 100 to 120 units of erythropoietin intravascularly plus 10 mg of iron intra-amniotically daily for 7 days (low erythropoietin dose group). Four additional fetuses received 1000 units of erythropoietin plus 10 mg iron daily for the same period (high erythropoietin dose group). Responses were compared with 9 nonsupplemented time-control fetuses. Statistical testing was by 3-factor repeated measures analysis of variance. RESULTS: Immediately after erythropoietin injection, plasma erythropoietin concentration was elevated approximately 25- and 250-fold in the low and high erythropoietin dose groups, respectively. Erythropoietin returned to basal levels by 24 hours after the injection. Plasma iron concentration increased in the low erythropoietin dose group but not in the control or high erythropoietin dose groups. Reticulocyte index increased in both erythropoietin supplemented groups but not in control fetuses. Hematocrit level increased above control by day 5 in the low erythropoietin dose group and by day 2 in the high erythropoietin dose group. Red cell mass increased significantly on supplement day 7 in the low erythropoietin dose group and on day 5 in the high erythropoietin dose group. Fetal blood gases and pH were unchanged with time in all 3 groups. CONCLUSION: Although daily combined erythropoietin and iron supplements in nonanemic ovine fetuses significantly increased circulating red cell mass in a dose-dependent manner, this increase was small relative to the rapid expansion of red cell mass previously observed after iron supplementation in fetuses with hemorrhage-induced anemia. We speculate that this difference in response may be due to a combination of rapid fetal clearance of erythropoietin plus a relative insensitivity to erythropoietin caused by the absence of other cytokines, which are elevated during fetal anemia.