Racial disparities in ALS diagnostic delay: a single center's experience and review of potential contributing factors.

OBJECTIVE: Outcomes for amyotrophic lateral sclerosis (ALS) patients are improved with prompt diagnosis, earlier initiation of disease-modifying treatments, and participation in a multidisciplinary clinic. We studied diagnostic delay and disease severity at time of clinic presentation between Black and non-Hispanic Caucasian ALS patients. METHODS: We performed a retrospective analysis of non-Hispanic Caucasian and Black ALS patients seen in the Virginia Commonwealth University Health System multidisciplinary ALS clinic between 2017 and 2023. Diagnostic delay, ALS Functional Rating Scale-Revised (ALSFRS-R) and upright forced vital capacity (FVC) scores at baseline appointment were collected. Patient's distance from clinic and affluency of residential neighborhood were evaluated. RESULTS: We analyzed 172 non-Hispanic Caucasian and 33 Black ALS patients. Black patients had a 64% increase in diagnostic delay compared to non-Hispanic Caucasian patients. Black patients had a lower performance on ALSFRS-R (5.3 points, p < 0.001) and FVC (17.9 percentage points p < 0.001) at time of first clinic visit. Black patients lived closer to clinic, with higher proportion living in the city of Richmond, but in less affluent areas with lower median house income ($55,300 ± 22,600 vs $69,900 ± 23,700). DISCUSSION: Our findings demonstrate a large racial difference in ALS diagnostic delay, and greater disease severity and lower respiratory function at time of diagnosis for Black ALS patients. Delay in diagnosis prolongs access to disease-modifying therapies, multidisciplinary care, durable medical equipment, and respiratory and nutritional support. Potential sources of these racial disparities include providers' implicit bias and structural racism.

Evaluation of a 'drop box' doorstep assessment service to aid remote assessments for COVID-19 in general practice.

The COVID-19 is an established threat whose clinical features and epidemiology continues to evolve. In an effort to contain the disease, the National Health Service has adopted a digital first approach in UK general practice resulting in a significant shift away from face-to-face consultations. Consequently, more consultations are being completed without obtaining objective recording of vital signs and face-to-face examination. Some regions have formed hot hubs to facilitate the review of suspected COVID-19 cases and keep their practice site 'clean' including the use of doorstep observations in avoiding the risk of face-to-face examination. To support the safe, effective and efficient remote assessment of suspected and confirmed patients with COVID-19, we established a doorstep assessment service to compliment telephone and video consultations. This allows physiological parameters such as temperature, pulse, blood pressure and oxygen saturation to be obtained to guide further triage. Quality improvement methods were used to integrate and optimise the doorstep assessment and measure the improvements made. The introduction of a doorstep assessment service increased the proportion of assessments for patients with suspected COVID-19 in routine care over weeks. At the same time we were able to dramatically reduce face-to-face assessment over a 6-week period by optimising through a range of measures including the introduction of a digital stethoscope. The majority of patients were managed by their own general practitioner following assessment supporting continuity of care. There were no adverse events during the period of observation; no staff absences related to COVID-19. Quality improvement methods have facilitated the successful integration of doorstep assessments into clinical care.

An investigation into the diagnostic accuracy, reliability, acceptability and safety of a novel device for Continuous Ambulatory Vestibular Assessment (CAVA).

Dizziness is a common condition that is responsible for a significant degree of material morbidity and burden on health services. It is usually episodic and short-lived, so when a patient presents to their clinician, examination is normal. The CAVA (Continuous Ambulatory Vestibular Assessment) device has been developed to provide continuous monitoring of eye-movements, allowing insight into the physiological parameters present during a dizziness attack. This article describes the first clinical investigation into the medical and technical aspects of this new diagnostic system. Seventeen healthy subjects wore the device near continuously for up to thirty days, artificially inducing nystagmus on eight occasions. 405 days' worth of data was captured, comprising around four billion data points. A computer algorithm developed to detect nystagmus demonstrated a sensitivity of 99.1% (95% CI: 95.13% to 99.98%) and a specificity of 98.6% (95% CI: 96.54% to 99.63%). Eighty-two percent of participants wore the device for a minimum of eighty percent of each day. Adverse events were self-limiting and mostly the consequence of skin stripping from the daily replacement of the electrodes. The device was shown to operate effectively as an ambulatory monitor, allowing the reliable detection of artificially induced nystagmus.

Benchmarking the performance of density functional theory and point charge force fields in their description of sI methane hydrate against diffusion Monte Carlo.

High quality reference data from diffusion Monte Carlo calculations are presented for bulk sI methane hydrate, a complex crystal exhibiting both hydrogen-bond and dispersion dominated interactions. The performance of some commonly used exchange-correlation functionals and all-atom point charge force fields is evaluated. Our results show that none of the exchange-correlation functionals tested are sufficient to describe both the energetics and the structure of methane hydrate accurately, while the point charge force fields perform badly in their description of the cohesive energy but fair well for the dissociation energetics. By comparing to ice Ih, we show that a good prediction of the volume and cohesive energies for the hydrate relies primarily on an accurate description of the hydrogen bonded water framework, but that to correctly predict stability of the hydrate with respect to dissociation to ice Ih and methane gas, accuracy in the water-methane interaction is also required. Our results highlight the difficulty that density functional theory faces in describing both the hydrogen bonded water framework and the dispersion bound methane.

Development of the benefit finding in multiple sclerosis (MS) caregiving scale: a longitudinal study of relations between benefit finding and adjustment.

UNLABELLED: Benefit finding (BF) is a meaning-making construct that has been shown to predict carer and care recipient adjustment. PURPOSE: This longitudinal study investigated the dimensions, stability, and validity of the benefit finding in multiple sclerosis caregiving (BFiMSCare) scale. METHODS: Participants were 232 carers of persons with MS and their care recipients. Questionnaires were completed at Time 1 and 12 months later (Time 2). RESULTS: Factor analysis of the BFiMSCare scale revealed six psychometrically sound factors: enriched relationship; spiritual growth; family relations growth; life-style gains; inspiration; and relationship opportunities. Results of regression analyses indicated that the Time 1 BFiMSCare factors and the total score accounted for significant amounts of variance in each of the Time 1 positive adjustment outcomes (life satisfaction, positive affect, dyadic adjustment) and in Time 2 positive affect and dyadic adjustment. The BFiMSCare total score predicted all Time 2 adjustment domains (positive affect, dyadic adjustment, care recipient adjustment ratings of carer) except life satisfaction and distress, whereas the six factors as a block predicted positive affect and life satisfaction. CONCLUSIONS: Findings delineate the dimensional structure of BF in caregiving and the differential links between BF dimensions and adjustment, and have implications for the measurement of BF.

A retrospective review of significant events reported in one district in 2004-2005.

BACKGROUND: Patient safety is a key issue in primary care. Significant event analysis (SEA) is a long established method of improving safety. In 2004, SEA was introduced as part of the Quality and Outcomes Framework (QOF) of the new general medical services (GMS) contract. AIM: To review SEAs submitted for the QOF by general practices for a primary care trust (PCT) in 2004-2005. DESIGN OF STUDY: A retrospective review of SEAs. SETTING: St Helens PCT, Merseyside, North West England, UK (185 000 patients), now part of Halton and St Helens PCT. METHOD: Three hundred and thirty-seven QOF-reported SEAs were reviewed from 32 (91%) of a total of 35 St Helens PCT practices (mean 10.5, range 4-17). RESULTS: Practices identified learning points in 89% of SEAs. Twenty-two of 32 (69%) practices successfully performed SEA and required no further support. Four practices identified learning points but needed further facilitation in implementing change or actions arising from SEA. Six practices had significant difficulties with SEA processes and were referred for extra SEA training locally. Ninety (26.7%) of all significant events were classified as patient-safety incidents. Of these, 22 (6.5%) were 'serious or life threatening' and 67 (19.9%) were 'potentially serious'. Ninety-six (28.5%) of the significant events related to medicines management issues; and 63 (18.7%) had key learning points for partnership organisations. Main outcome measures were review of SEA process as a team learning event; QOF significant event criteria; National Patient Safety Agency classification of significant events, and category of patient-safety incidents. CONCLUSION: SEA in general practice is a valuable clinical governance and educational tool with potential patient safety benefits. Most practices performed SEA successfully but there were performance concerns and patient-safety issues were highlighted. This review emphasises the need for primary care organisations to be able to analyse and share SEAs effectively.

Assessment of pathogens and toxicants in New Orleans, LA following Hurricane Katrina.

Storm surge associated with Hurricane Katrina and the breach of levees protecting New Orleans, Louisiana allowed floodwaters from Lake Pontchartrain to inundate 80% of the city. Environmental samples were collected during September 16-18, 2005 to determine immediate human and wildlife health hazards from pathogens and toxicants in the floodwaters. Baseline information on potential long-term environmental damage resulting from contaminants in water and sediments pumped into Lake Pontchartrain was also collected. Concentrations of aldrin, arsenic, lead, and seven semivolatile organic compounds in sediments/soils exceeded one or more United States Environmental Protection Agency (USEPA) thresholds for human health soil screening levels and high priority bright line screening levels. High numbers of Aeromonas spp., pathogenic Vibrio spp., and other coliform bacteria were found in floodwater samples. Alligator and snake tissues did not contain excessive toxicant concentrations. Initial findings suggest numerous environmental contaminants are present in New Orleans and support the need for further evaluation of the extent of those threats.

General practitioners believe that hypnotherapy could be a useful treatment for irritable bowel syndrome in primary care.

BACKGROUND: Irritable bowel syndrome is a common condition in general practice. It occurs in 10 to 20% of the population, but less than half seek medical assistance with the complaint. METHODS: A questionnaire was sent to the 406 GPs listed on the West Sussex Health Authority Medical List to investigate their views of this condition and whether they felt hypnotherapy had a place in its management RESULTS: 38% of general practitioners responded. The achieved sample shared the characteristics of target sample. Nearly half thought that irritable bowel syndrome (IBS) was a "nervous complaint" and used a combination of "the placebo effect of personal care," therapeutic, and dietary advice. There is considerable divergence in the perceived effectiveness of current approaches. Over 70% thought that hypnotherapy may have a role in the management of patients with IBS; though the majority (68%) felt that this should not be offered by general practitioners. 84% felt that this should be offered by qualified hypnotherapist, with 40% feeling that this should be offered outside the health service. CONCLUSIONS: General practitioners vary in their perceptions of what constitutes effective therapy in IBS. They are willing to consider referral to a qualified hypnotherapist.