After-school programmes response to the COVID-19 pandemic: Lessons learned from Barcelona, Spain.

This article explores the role of after-school programmes (ASPs) in serving underserved families in Barcelona, Spain, during the lockdown phase of the COVID-19 pandemic. Using a mixed-method approach, this exploratory study surveyed 31 directors of ASPs administered by the Pere Tarrés Foundation. These ASPs serve almost 2000 children living under the federal poverty level in Catalonia, Spain. Results showed that the primary needs of children and their families revolved around: a digital divide that prevented them from accessing education remotely, financial difficulties, mental and behavioural problems and difficulty navigating pandemic-related information. The study also explores the ASPs' contributions to address such needs, like engaging families, schools and social and health services to meet the urgent needs of the families, reinforcing school learning, providing support for managing emotions and providing guidance to families to help them better understand health information and gain access to available social and financial resources.

Utility of arginine stimulation testing in preoperative assessment of children undergoing total pancreatectomy with islet autotransplantation.

Metabolic outcomes after total pancreatectomy with islet autotransplantation (TPIAT) are influenced by the islet mass transplanted. Preclinical and clinical studies indicate that insulin and C-peptide levels measured after intravenous administration of the beta cell secretagogue arginine can be used to estimate the available islet mass. We sought to determine if preoperative arginine stimulation test (AST) results predicted transplanted islet mass and metabolic outcomes in pediatric patients undergoing TPIAT. We evaluated the association of preoperative C-peptide and insulin responses to AST with islet isolation metrics using linear regression, and with postoperative insulin independence using logistic regression. Twenty-six TPIAT patients underwent preoperative AST from 2015 to 2018. The acute C-peptide response to arginine (ACRarg) was correlated with isolated islet equivalents (IEQ; r = 0.59, P = 0.002) and islet number (IPN; r = 0.48, P = 0.013). The acute insulin response to arginine (AIRarg) was not significantly correlated with IEQ (r = 0.38, P = 0.095) or IPN (r = 0.41, P = 0.071). Neither ACRarg nor AIRarg was associated with insulin use at 6 months postoperatively. Preoperative C-peptide response to arginine correlates with islet mass available for transplant in pediatric TPIAT patients. AST represents an additional tool before autotransplant to provide counseling on likely islet mass and to inform quality improvements of islet isolation techniques.

Cost-effectiveness of spinal manipulation, exercise, and self-management for spinal pain using an individual participant data meta-analysis approach: a study protocol.

Background: Spinal pain is a common and disabling condition with considerable socioeconomic burden. Spine pain management in the United States has gathered increased scrutiny amidst concerns of overutilization of costly and potentially harmful interventions and diagnostic tests. Conservative interventions such as spinal manipulation, exercise and self-management may provide value for the care of spinal pain, but little is known regarding the cost-effectiveness of these interventions in the U.S. Our primary objective for this project is to estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management for spinal pain using an individual patient data meta-analysis approach. Methods/design: We will estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management using cost and clinical outcome data collected in eight randomized clinical trials performed in the U.S. Cost-effectiveness will be assessed from both societal and healthcare perspectives using QALYs, pain intensity, and disability as effectiveness measures. The eight randomized clinical trials used similar methods and included different combinations of spinal manipulation, exercise therapy, or self-management for spinal pain. They also collected similar clinical outcome, healthcare utilization, and work productivity data. A two-stage approach to individual patient data meta-analysis will be conducted. Discussion: This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.

A multicenter study of total pancreatectomy with islet autotransplantation (TPIAT): POST (Prospective Observational Study of TPIAT).

BACKGROUND/OBJECTIVES: Total pancreatectomy with islet autotransplantation (TPIAT) is considered for managing chronic pancreatitis in selected patients when medical and endoscopic interventions have not provided adequate relief from debilitating pain. Although more centers are performing TPIAT, we lack large, multi-center studies to guide decisions about selecting candidates for and timing of TPIAT. METHODS: Multiple centers across the United States (9 to date) performing TPIAT are prospectively enrolling patients undergoing TPIAT for chronic pancreatitis into the Prospective Observational Study of TPIAT (POST), a NIDDK funded study with a goal of accruing 450 TPIAT recipients. Baseline data include participant phenotype, pancreatitis history, and medical/psychological comorbidities from medical records, participant interview, and participant self-report (Medical Outcomes Survey Short Form-12, EQ-5D, andPROMIS inventories for pain interference, depression, and anxiety). Outcome measures are collected to at least 1 year after TPIAT, including the same participant questionnaires, visual analog pain scale, pain interference scores, opioid requirements, insulin requirements, islet graft function, and hemoglobin A1c. Health resource utilization data are collected for a cost-effectiveness analysis. Biorepository specimens including urine, serum/plasma, genetic material (saliva and blood), and pancreas tissue are collected for future study. CONCLUSIONS: This ongoing multicenter research study will enroll and follow TPIAT recipients, aiming to evaluate patient selection and timing for TPIAT to optimize pain relief, quality of life, and diabetes outcomes, and to measure the procedure's cost-effectiveness. A biorepository is also established for future ancillary studies.

Multifactorial assessment of measurement errors affecting intraoral quantitative sensory testing reliability.

BACKGROUND AND PURPOSE (AIMS): Measurement error of intraoral quantitative sensory testing (QST) has been assessed using traditional methods for reliability, such as intraclass correlation coefficients (ICCs). Most studies reporting QST reliability focused on assessing one source of measurement error at a time, e.g., inter- or intra-examiner (test-retest) reliabilities and employed two examiners to test inter-examiner reliability. The present study used a complex design with multiple examiners with the aim of assessing the reliability of intraoral QST taking account of multiple sources of error simultaneously. METHODS: Four examiners of varied experience assessed 12 healthy participants in two visits separated by 48h. Seven QST procedures to determine sensory thresholds were used: cold detection (CDT), warmth detection (WDT), cold pain (CPT), heat pain (HPT), mechanical detection (MDT), mechanical pain (MPT) and pressure pain (PPT). Mixed linear models were used to estimate variance components for reliability assessment; dependability coefficients were used to simulate alternative test scenarios. RESULTS: Most intraoral QST variability arose from differences between participants (8.8-30.5%), differences between visits within participant (4.6-52.8%), and error (13.3-28.3%). For QST procedures other than CDT and MDT, increasing the number of visits with a single examiner performing the procedures would lead to improved dependability (dependability coefficient ranges: single visit, four examiners=0.12-0.54; four visits, single examiner=0.27-0.68). A wide range of reliabilities for QST procedures, as measured by ICCs, was noted for inter- (0.39-0.80) and intra-examiner (0.10-0.62) variation. CONCLUSION: Reliability of sensory testing can be better assessed by measuring multiple sources of error simultaneously instead of focusing on one source at a time. In experimental settings, large numbers of participants are needed to obtain accurate estimates of treatment effects based on QST measurements. This is different from clinical use, where variation between persons (the person main effect) is not a concern because clinical measurements are done on a single person. IMPLICATIONS: Future studies assessing sensory testing reliability in both clinical and experimental settings would benefit from routinely measuring multiple sources of error. The methods and results of this study can be used by clinical researchers to improve assessment of measurement error related to intraoral sensory testing. This should lead to improved resource allocation when designing studies that use intraoral quantitative sensory testing in clinical and experimental settings.

Evaluation of the Food and Agriculture Sector Criticality Assessment Tool (FASCAT) and the Collected Data.

To protect and secure food resources for the United States, it is crucial to have a method to compare food systems' criticality. In 2007, the U.S. government funded development of the Food and Agriculture Sector Criticality Assessment Tool (FASCAT) to determine which food and agriculture systems were most critical to the nation. FASCAT was developed in a collaborative process involving government officials and food industry subject matter experts (SMEs). After development, data were collected using FASCAT to quantify threats, vulnerabilities, consequences, and the impacts on the United States from failure of evaluated food and agriculture systems. To examine FASCAT's utility, linear regression models were used to determine: (1) which groups of questions posed in FASCAT were better predictors of cumulative criticality scores; (2) whether the items included in FASCAT's criticality method or the smaller subset of FASCAT items included in DHS's risk analysis method predicted similar criticality scores. Akaike's information criterion was used to determine which regression models best described criticality, and a mixed linear model was used to shrink estimates of criticality for individual food and agriculture systems. The results indicated that: (1) some of the questions used in FASCAT strongly predicted food or agriculture system criticality; (2) the FASCAT criticality formula was a stronger predictor of criticality compared to the DHS risk formula; (3) the cumulative criticality formula predicted criticality more strongly than weighted criticality formula; and (4) the mixed linear regression model did not change the rank-order of food and agriculture system criticality to a large degree.

Exploratory analysis of high CT scan utilization in claims data.

PURPOSE: This study explores characteristics that distinguish higher and lower CT use by patients and referring physicians in a population of members of a large health insurance plan. METHODS: We analyzed 310,467 CT scan claims from 2009-10 in a health plan serving approximately 1.5 million members. Patients who used CT scans and their referring physicians were classified into utilization categories. Characteristics distinguishing higher from lower utilization categories were identified. RESULTS: Among patients receiving CT scans, patient characteristics that distinguished higher from lower utilization of scans were: male, older, seeing more total providers, using more prescription and total resources, classified as frail, having higher treatment group severity, and having government insurance. Among physicians ordering scans, physician characteristics that distinguished higher from lower referrals for CT scans were: male, board-certified, in group practice, and in particular specialties. Ownership interest was associated with higher claim volumes in a curvilinear manner but was not associated with claims per physician. Higher total referral counts were related to single-specialty practice type and larger group size. External reviewers (4 physicians) observed that the empirical relationships had plausible explanations based on reasonable medical decision-making. CONCLUSIONS: Aggregate-level review of claims for CT scans in a health plan revealed no striking anomalies in associations of patient and referring physician characteristics with higher utilization. Claims research that examines particular conditions and patients with high utilization rates and physicians with high referral rates would advance the evidence base for quality improvement.

Long-term survival in patients with refractory angina.

AIMS: An increasing number of patients with severe coronary artery disease (CAD) are not candidates for traditional revascularization and experience angina in spite of excellent medical therapy. Despite limited data regarding the natural history and predictors of adverse outcome, these patients have been considered at high risk for early mortality. METHODS AND RESULTS: The OPtions In Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis Heart Institute offers traditional and investigational therapies for patients with refractory angina. A prospective clinical database includes detailed baseline and yearly follow-up information. Death status and cause were determined using the Social Security Death Index, clinical data, and death certificates. Time to death was analysed using survival analysis methods. For 1200 patients, the mean age was 63.5 years (77.5% male) with 72.4% having prior coronary artery bypass grafting, 74.4% prior percutaneous coronary intervention, 72.6% prior myocardial infarction, 78.3% 3-vessel CAD, 23.0% moderate-to-severe left-ventricular (LV) dysfunction, and 32.6% congestive heart failure (CHF). Overall, 241 patients died (20.1%: 71.8% cardiovascular) during a median follow-up 5.1 years (range 0-16, 14.7% over 9). By Kaplan-Meier analysis, mortality was 3.9% (95% CI 2.8-5.0) at 1 year and 28.4% (95% CI 24.9-32.0) at 9 years. Multivariate predictors of all-cause mortality were baseline age, diabetes, angina class, chronic kidney disease, LV dysfunction, and CHF. CONCLUSION: Long-term mortality in patients with refractory angina is lower than previously reported. Therapeutic options for this distinct and growing group of patients should focus on angina relief and improved quality of life.

Extending the Peters-Belson approach for assessing disparities to right censored time-to-event outcomes.

The Peters-Belson (PB) method was developed for quantifying and testing disparities between groups in an outcome by using linear regression to compute group-specific observed and expected outcomes. It has since been extended to generalized linear models for binary and other outcomes and to analyses with probability-based sample weighting. In this work, we extend the PB approach to right-censored survival analysis, including stratification if needed. The extension uses the theory and methods of expected survival on the basis of Cox regression in a reference population. Within the PB framework, among the groups to be compared, one group is chosen as the reference group, and outcomes in that group are modeled as a function of available predictors. By using this fitted model's estimated parameters, and the predictor values for a comparator group, the comparator group's expected outcomes are then calculated and compared, formally with testing and informally with graphics, with their observed outcomes. We derive the extension, show how we applied it in a study of incontinence in nursing home elderly, and discuss issues in implementing it. We used the 'survival' package in the R system to do computations.

Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey.

BACKGROUND: The publication of the 2009 American Academy of Orthopedic Surgeons' (AAOS') guidelines for antibiotic prophylaxis after joint replacement (arthroplasty) has renewed debate concerning appropriate prophylaxis for dental patients. The authors examined an administrative data set to assess whether dental procedures were associated with prosthetic joint infections (PJIs). METHODS: Using data for the years 1997 through 2006 from the Medicare Current Beneficiary Survey (MCBS), the authors identified participants who had undergone total joint arthroplasty and those who had experienced a PJI. They explored associations between dental procedures and subsequent PJIs by using time-to-event analyses (N = 1,000). A nested case-control study included case participants who had had PJIs (n = 42) and matched control participants who had had total arthroplasty but had no PJIs (n = 126). The authors calculated hazard ratios (HRs) and odds ratios (ORs). RESULTS: Control participants (people without PJIs) were more likely than were case participants (those with PJIs) to have undergone an invasive dental procedure, though this trend was not statistically significant in either the time-to-event analysis (HR = 0.78; 95 percent confidence interval [CI], 0.18-3.39) or the case-control analysis (OR = 0.56; 95 percent CI, 0.18-1.74). Only four of 42 case participants had undergone an invasive dental procedure in the 90 days before the infection occurred. Consideration of all dental procedures yielded similar results. CONCLUSIONS: Dental procedures were not associated significantly with subsequent risk for PJIs, although this study's power was somewhat low. The clinical importance of prophylactic antibiotics in dentistry for patients who have undergone joint arthroplasty, therefore, may be questioned. CLINICAL IMPLICATIONS: These results support the view that the 2009 AAOS Information Statement on antibiotic prophylaxis for people with prosthetic joints should be reconsidered for patients in that population who are receiving oral health care.

The application of facial expressions to the assessment of orofacial pain in cognitively impaired older adults.

BACKGROUND: The anticipated rapid growth in the number of cognitively impaired older adults, declining edentulism and increasing oral health expectations suggest a greater need for comprehensive dental care and effective ways to evaluate orofacial pain in people with compromised mental function and impaired communication skills. The authors conducted a study to evaluate facial expressions as a means of identifying orofacial pain in cognitively impaired and cognitively intact older adults, compared with other available pain assessment tools. METHODS: The authors conducted a prospective comparative study using three alternative pain measurement tools in a sample of 22 older adults. They divided subjects into cognitively impaired and cognitively intact groups on the basis of their mental status examination scores. The pain measurement methods evaluated were facial expressions quantified by the Facial Actions Coding System (FACS); self-reported pain via the Verbal Descriptor Scale; and physiological response to pain via changes in heart rate. The pain stimuli were local anesthetic injections in subjects who required them for routine dental procedures. RESULTS: The average FACS scores during anesthetic injections were significantly higher than those during the preinjection period (prebuccal versus buccal, P = .016; prepalatal versus palatal, P = .0002). The differences between preinjection and injection segments were even higher in cognitively impaired patients than in cognitively intact patients. There were no correlations between the three pain measurements (P > .05). CONCLUSIONS: Changes in facial expression proved to be the most useful measure overall in identifying pain in both cognitively intact and cognitively impaired older patients. This measure appeared to be more sensitive in cognitively impaired patients because they demonstrated fewer facial movements in anticipation of pain stimuli.

Generalized spatial structural equation models.

It is common in public health research to have high-dimensional, multivariate, spatially referenced data representing summaries of geographic regions. Often, it is desirable to examine relationships among these variables both within and across regions. An existing modeling technique called spatial factor analysis has been used and assumes that a common spatial factor underlies all the variables and causes them to be related to one another. An extension of this technique considers that there may be more than one underlying factor, and that relationships among the underlying latent variables are of primary interest. However, due to the complicated nature of the covariance structure of this type of data, existing methods are not satisfactory. We thus propose a generalized spatial structural equation model. In the first level of the model, we assume that the observed variables are related to particular underlying factors. In the second level of the model, we use the structural equation method to model the relationship among the underlying factors and use parametric spatial distributions on the covariance structure of the underlying factors. We apply the model to county-level cancer mortality and census summary data for Minnesota, including socioeconomic status and access to public utilities.

Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income.

OBJECTIVE: The goal was to assess the impact of Veterans Affairs (VA) disability benefits for post-traumatic stress disorder (PTSD) on veterans' odds of poverty. Women and African American veterans were of special interest, because they are less likely than other groups to receive PTSD disability benefits. METHODS: A cross-sectional survey of 4,918 veterans who applied for VA disability benefits for PTSD between 1994 and 1998 was performed. Responses were linked to administrative data. RESULTS: Overall, 42% reported low income (defined as household income less than or equal to 20,000 dollars per year). Men's and women's odds of reporting poverty were similar, but receipt of PTSD disability benefits mediated African American veterans' odds of poverty. Veterans' odds of impoverishment were reduced considerably if they received VA PTSD disability benefits and identified themselves as disabled. CONCLUSIONS: VA disability benefits for PTSD reduced odds of impoverishment for psychiatrically ill veterans. This effect appeared to be especially important for African American veterans and for veterans self-identifying as disabled.

Regional variation and other correlates of Department of Veterans Affairs Disability Awards for patients with posttraumatic stress disorder.

BACKGROUND: Minnesota, Minneapolis, Minnesota. Posttraumatic stress disorder (PTSD) is a chronic disabling condition affecting more than 600,000 United States veterans and is the most common psychiatric condition for which veterans seek Veterans Affairs disability benefits. Receipt of such benefits enhances veterans' access to Veteran Affairs health care and reduces their chance of poverty. OBJECTIVES: We sought to determine whether previously identified regional variations in PTSD disability awards are explained by appropriate subject characteristics (eg, differences in PTSD symptomatology or dysfunction) and to estimate the impact of veterans' PTSD symptom severity or level of dysfunction on their odds of obtaining PTSD disability benefits. RESEARCH DESIGN: We used a mailed survey linked to administrative data. SUBJECTS: Subjects included 4918 representative, eligible men and women who filed PTSD disability claims between 1994 and 1998. RESULTS: A total of 3337 veterans returned useable surveys (68%). Before adjustment, PTSD disability claims approval rates ranged from 43% to 75% across regions. After adjustment, rates ranged from 33% to 72% (P <0.0001). Severer PTSD symptoms were associated with greater odds of having PTSD disability benefits (P <0.0001). Unexpectedly, poorer functional status was associated with lower odds of having benefits (P <0.0001). On average, clinical differences between veterans who did and did not have PTSD disability benefits were small but suggested slightly greater dysfunction among those without benefits. CONCLUSIONS: An almost twofold regional difference in claims approval rates was not explained by veterans' PTSD symptom severity, level of dysfunction, or other subject-level characteristics. Veterans who did not obtain PTSD disability benefits were at least as disabled as those who did receive benefits.

Prevalence of in-service and post-service sexual assault among combat and noncombat veterans applying for Department of Veterans Affairs posttraumatic stress disorder disability benefits.

OBJECTIVE: To describe the prevalence of in-service and post-service sexual assault among combat and noncombat veterans seeking Veteran's Affairs disability benefits for posttraumatic stress disorder (PTSD). METHODS: Cross-sectional survey of 4,918 veterans. RESULTS: Surveys were returned by 3,337 veterans (effective response rate, 68%). Among men, 6.5% of combat veterans and 16.5% of noncombat veterans reported in-service or post-service sexual assault. Among women, 69% of combat veterans and 86.6% of noncombat veterans reported in-service or post-service sexual assault. CONCLUSIONS: Reported rates of sexual assault were considerably higher among veterans seeking Veteran's Affairs disability benefits for PTSD than historically reported rates for men and women in the general population. In this population, male gender and veterans' combat status should not dissuade clinicians from screening for sexual traumas.

Patient perceptions of professionalism in dentistry.

The purpose of this study was to examine how patients perceived the professionalism of University of Minnesota School of Dentistry students, faculty, and staff. Professionalism is defined by the authors as an image that will promote a successful relationship with the patient. Patients within comprehensive care clinics were asked to assess physical attributes and behaviors of the dental care providers using a questionnaire. The patients read statements dealing with characteristics of the dental care providers and responded as to whether they agreed, were neutral, or disagreed with the statement. The surveyed population consisted of 103 males and 97 females, 64 percent of whom lacked insurance coverage. Fifty-one percent of the patients were between the ages of forty-four and sixty-nine, but the overall age distribution was dispersed over a range of eighteen to one hundred. Our research found that all dental care providers displayed a professional appearance as well as behavior. The attire of the dental care provider affected the comfort and anxiety levels of patients, as did first impressions of both students and faculty. Most patients reported that students and faculty displayed effective time management and used appropriate language during the appointment. Finally, hairstyle, makeup, and jewelry appeared to have little effect on patients' opinions of the various dental care providers.

On the precision of the conditionally autoregressive prior in spatial models.

Bayesian analyses of spatial data often use a conditionally autoregressive (CAR) prior, which can be written as the kernel of an improper density that depends on a precision parameter tau that is typically unknown. To include tau in the Bayesian analysis, the kernel must be multiplied by tau(k) for some k. This article rigorously derives k = (n - I)/2 for the L2 norm CAR prior (also called a Gaussian Markov random field model) and k = n - I for the L1 norm CAR prior, where n is the number of regions and I the number of "islands" (disconnected groups of regions) in the spatial map. Since I = 1 for a spatial structure defining a connected graph, this supports Knorr-Held's (2002, in Highly Structured Stochastic Systems, 260-264) suggestion that k = (n - 1)/2 in the L2 norm case, instead of the more common k = n/2. We illustrate the practical significance of our results using a periodontal example.

Gender Differences in service connection for PTSD.

BACKGROUND: Mentally ill female veterans obtain a smaller proportion of their care from Department of Veterans Affairs (VA) facilities than mentally ill male veterans do, possibly because women are less likely than men to be service connected for psychiatric disabilities. "Service connected" veterans have documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the VA healthcare system. OBJECTIVES: To see if there are gender discrepancies in rates of service connection for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could be attributed to appropriate subject characteristics (eg, differences in symptom severity or impairment). RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SUBJECTS: Randomly selected veterans seeking VA disability benefits for PTSD. Women were oversampled to achieve a gender ratio of 1:1. RESULTS: A total of 3337 veterans returned usable surveys (effective response rate, 68%). Men's unadjusted rate of service connection for PTSD was 71%; women's, 52% (P < 0.0001). Adjustment for veterans' PTSD symptom severity or functional impairment did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of combat exposure did. Estimated rates of service connection were 53% for men and 56% for women after adjusting for combat exposure. This combat preference could not be explained by more severe PTSD symptoms or greater functional impairment. CONCLUSIONS: Instead of a gender bias in awards for PTSD service connection, we found evidence of a combat advantage that disproportionately favored men. The appropriateness of this apparent advantage is unclear and needs further investigation.