The Impact of Health Coverage, Race and Ethnicity on Utilization of Preventive Medical Care during the First Year of the Covid-19 Pandemic: Findings from the National Health Interview Survey 2019-2020.

OBJECTIVES: This study examined COVID-19's impact in the 2020 compared to 2019 survey years on preventive medical care utilization. RESEARCH DESIGN: Using a cross-sectional sample of adults aged 18 years and over (2019; n = 31,997; 2020; n = 31,568), from the National Health Interview Survey, multivariable models compared 2020 to 2019 survey years for receiving diabetes screening blood tests, well-care visits, and physical therapy. An additional multivariable model predicted not having medical care due to the COVID-19 pandemic in the 2020 2020 survey year. RESULTS: In the 2020 versus 2019 survey years, the likelihood lowered for receiving a blood test for diabetes screening (aOR .83 CI = .76, .90). There was a lowered likelihood for a well care visits (aOR = .98 CI = .84, 1.1) and physical therapy (aOR = .97 CI = .89, 1.0). Black (aOR = .62 CI = .51, .75), Hispanic (aOR = .62 CI = .51, .75) and Asian (aOR .67 CI = .53, .86) adults had a lowered likelihood of having physical therapy compared to White adults. Having no insurance coverage lowered the likelihood of getting all three indicators of preventive medical care. There was a higher likelihood of not getting medical care due to COVID-19 in the 2020 survey year (aOR = 1.7 CI = 1.3, 2.1) with Medicaid compared to private coverage. CONCLUSIONS: Use of preventive medical care lowered in the pandemic. Race and ethnicity and not having any coverage contributed to not receiving preventive care. Medicaid appeared to increase utilization of preventive medical care but not acute medical care.

Secondary (additional) findings from the 100,000 Genomes Project: Disease manifestation, health care outcomes, and costs of disclosure.

PURPOSE: The UK 100,000 Genomes Project offered participants screening for additional findings (AFs) in genes associated with familial hypercholesterolemia (FH) or hereditary cancer syndromes including breast/ovarian cancer (HBOC), Lynch, familial adenomatous polyposis, MYH-associated polyposis, multiple endocrine neoplasia (MEN), and von Hippel-Lindau. Here, we report disclosure processes, manifestation of AF-related disease, outcomes, and costs. METHODS: An observational study in an area representing one-fifth of England. RESULTS: Data were collected from 89 adult AF recipients. At disclosure, among 57 recipients of a cancer-predisposition-associated AF and 32 recipients of an FH-associated AF, 35% and 88%, respectively, had personal and/or family history evidence of AF-related disease. During post-disclosure investigations, 4 cancer-AF recipients had evidence of disease, including 1 medullary thyroid cancer. Six women with an HBOC AF, 3 women with a Lynch syndrome AF, and 2 individuals with a MEN AF elected for risk-reducing surgery. New hyperlipidemia diagnoses were made in 6 FH-AF recipients and treatment (re-)initiated for 7 with prior hyperlipidemia. Generating and disclosing AFs in this region cost £1.4m; £8680 per clinically significant AF. CONCLUSION: Generation and disclosure of AFs identifies individuals with and without personal or familial evidence of disease and prompts appropriate clinical interventions. Results can inform policy toward secondary findings.

The Relationship Between Financial Stressors, Chronic Pain, and High-Impact Chronic Pain: Findings From the 2019 National Health Interview Survey.

OBJECTIVES: Public health interventions to prevent financial stressors and reduce chronic pain and high-impact chronic pain (HICP) are important to potentially improve the health of the US population. The objectives of our study were to provide an update on the prevalence of chronic pain and HICP and to examine relationships between financial stressors and pain. METHODS: We used data from a cross-sectional sample of adults aged ≥18 years (n = 31 997) collected by the 2019 National Health Interview Survey. We constructed bivariate and multivariate models to examine chronic pain and HICP in relation to financial worries, employment with wages, income, sociodemographic characteristics, number of chronic health conditions, and body mass index. RESULTS: In fully adjusted multivariate regression models, having no employment with wages was strongly associated with increased risk for chronic pain (adjusted odds ratio [aOR] = 1.3; 95% CI, 1.2-1.5) and HICP (aOR = 1.6; 95% CI, 1.4-1.9). Worries about paying medical bills was associated with chronic pain (aOR = 1.1; 95% CI, 1.0-1.2) and HICP (aOR = 1.1; 95% CI, 1.0-1.3). Being unable to pay medical bills was associated with chronic pain (aOR = 2.1; 95% CI, 1.9-2.3) and HICP (aOR = 2.3; 95% CI, 2.0-2.6). Compared with having more income, having less income relative to the federal poverty level was associated with increased risk for chronic pain and HICP. CONCLUSIONS: We found a strong relationship between financial worries, employment for wages, income, and self-reported chronic pain and HICP independent of poor physical health and body mass index. Interventions to reduce chronic pain and HICP should address economic instability and financial stressors.

The effect of the rescue plans and the need for policies to increase economic growth.

This paper evaluates the economic impact of discretionary fiscal and monetary actions taken in the United States during 2020 and 2021. The fiscal actions are The Coronavirus Aid, Relief, and Economic Security Act, or the "CARES" Act, passed in March 2020; The Consolidated Appropriations Act, passed in December 2020; and The American Rescue Plan Act, passed in March 2021. The paper focuses on the impact of the "economic impact payments" that underlie these fiscal actions. The paper also examines discretionary monetary policy actions taken during the same period. The overall implication is that there is a need to return to policies that increase economic growth and stability, including rules-based fiscal and monetary policy, rather than to continue with these one-time discretionary actions.

Assessment of autonomic symptoms may assist with early identification of mild cognitive impairment with Lewy bodies.

OBJECTIVES: Autonomic symptoms are a common feature of the synucleinopathies, and may be a distinguishing feature of prodromal Lewy body disease. We aimed to assess whether the cognitive prodrome of dementia with Lewy bodies, mild cognitive impairment (MCI) with Lewy bodies (MCI-LB), would have more severe reported autonomic symptoms than cognitively healthy older adults, with MCI due to Alzheimer's disease (MCI-AD) also included for comparison. We also aimed to assess the utility of an autonomic symptom scale in differentiating MCI-LB from MCI-AD. METHODS: Ninety-three individuals with MCI and 33 healthy controls were assessed with the Composite Autonomic Symptom Score 31-item scale (COMPASS). Mild cognitive impairment patients also underwent detailed clinical assessment and differential classification of MCI-AD or MCI-LB according to current consensus criteria. Differences in overall COMPASS score and individual symptom sub-scales were assessed, controlling for age. RESULTS: Age-adjusted severity of overall autonomic symptomatology was greater in MCI-LB (Ratio = 2.01, 95% CI: 1.37-2.96), with higher orthostatic intolerance and urinary symptom severity than controls, and greater risk of gastrointestinal and secretomotor symptoms. MCI-AD did not have significantly higher autonomic symptom severity than controls overall. A cut-off of 4/5 on the COMPASS was sensitive to MCI-LB (92%) but not specific to this (42% specificity vs. MCI-AD and 52% vs. healthy controls). CONCLUSIONS: Mild cognitive impairment with Lewy bodies had greater autonomic symptom severity than normal ageing and MCI-AD, but such autonomic symptoms are not a specific finding. The COMPASS-31 may therefore have value as a sensitive screening test for early-stage Lewy body disease.

Descriptive sensory analysis of instant porridge from stored wholegrain and decorticated pearl millet flour cooked, stabilized and improved by using a low-cost extruder.

Pearl millet flour, particularly wholegrain flour, is highly susceptible to development of rancid aromas and flavors during storage. Grain decortication and extrusion cooking using a friction-heated single-screw extruder were investigated as potential flour stabilization processes. Raw and extruded wholegrain and decorticated grain pearl millet flours were stored at ambient (25°C) and elevated (40°C) temperatures for 6 months. A trained descriptive sensory panel developed a lexicon of 44 attributes to profile the aroma, flavor, and texture of porridges prepared from the flours. Grain decortication alone did not show an effect on the aroma and flavor profile of porridge. Extrusion cooking of both wholegrain and decorticated flours increased cereal-like aromas (branny, canned sweetcorn, sweet, and wheaty) and flavor (starchy), as well as stiffness and cohesiveness of the porridges. The porridges from the extruded pearl millet flours stored for up to 6 months at ambient and elevated temperatures did not show any indications of rancidity. In contrast, rancidity-associated aromas (chemical, painty, and soapy) and flavor (chemical) increased in porridges from the raw flours stored for 4 weeks and longer. These results indicate that grain decortication did not sufficiently reduce fat content to prevent oxidation, while extrusion cooking stabilized the pearl millet flours. In addition, intensified "cereal-like" aromas and flavors were probably due to Maillard reactions occurring during extrusion cooking. Resulting aroma compounds could have been immobilized in the extruded matrix and not released during flour storage. The application of extrusion cooking with a simple friction-heated single-screw extruder is a viable process for both precooking and extending the shelf life of pearl millet flours. PRACTICAL APPLICATION: This study demonstrates the potential of extrusion cooking to precook wholegrain pearl millet while preventing fat rancidity in wholegrain pearl millet flour, thereby improving the sensory quality and stability of pearl millet food products. The extensive sensory characterization of pearl millet porridge-type foods can serve as a guidance tool for development, improvement, and quality control of pearl millet foods. Furthermore, it establishes the efficacy of simple friction-heated, single-screw extruders for commercial manufacture of ready-to-eat wholegrain pearl millet food products by small and medium scale entrepreneurs.

Effects of vacuum packaging storage of minimally processed cassava roots at various temperatures on microflora, tissue structure, starch extraction by wet milling and granule quality.

BACKGROUND: Vacuum package storage is commonly applied to reduce postharvest deterioration in minimally processed cassava roots. However, the influence of vacuum packaging conditions on root end-use quality is poorly understood. Hence, the effects of vacuum packaged storage at ambient, refrigerated and freezing temperatures on microflora, cassava tissue structure and starch extraction by wet milling were studied. RESULTS: Vacuum packaged storage temperature strongly affected cassava root quality. Minimal adverse effects were obtained with frozen storage. With refrigerated storage, there was negligible microbial growth but some disruption of the parenchyma cell wall structure suggestive of chilling injury. With ambient temperature storage, there was considerable Lactobacilli dominated fermentation. This caused substantial cell degradation, probably due to the production of extracellular cellulolytic and other cell wall degrading enzymes. A benefit of this cell wall breakdown was that it substantially improved starch extraction with wet milling from the stored cassava pieces; by 18% with pieces that had been ambient vacuum packaged and wet milled using a 2000 µm opening screen. However, ambient temperature storage resulted in some starch granule pitting due to the action of extracellular amylases from the fermenting microorganisms. CONCLUSION: The best vacuum packaging storage conditions for minimally processed cassava depends on application and cost. For short-term storage, refrigeration would be best for vegetable-type products. For several months storage, freezing is best. For wet milling applications, this could be combined with subsequent short-term ambient temperature storage as it improves starch extraction efficiency and could reduce distribution energy costs. © 2021 Society of Chemical Industry.

A Review of Multimodal Hallucinations: Categorization, Assessment, Theoretical Perspectives, and Clinical Recommendations.

Hallucinations can occur in different sensory modalities, both simultaneously and serially in time. They have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Hallucinatory experiences occurring in multiple sensory systems-multimodal hallucinations (MMHs)-are more prevalent than previously thought and may have greater adverse impact than unimodal ones, but they remain relatively underresearched. Here, we review and discuss: (1) the definition and categorization of both serial and simultaneous MMHs, (2) available assessment tools and how they can be improved, and (3) the explanatory power that current hallucination theories have for MMHs. Overall, we suggest that current models need to be updated or developed to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and for clinical practice, including the need for service user involvement and for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena.

The NASSS-CAT Tools for Understanding, Guiding, Monitoring, and Researching Technology Implementation Projects in Health and Social Care: Protocol for an Evaluation Study in Real-World Settings.

BACKGROUND: Projects to implement health care and social care innovations involving technologies are typically ambitious and complex. Many projects fail. Greenhalgh et al's nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to analyze the varied outcomes of such projects. OBJECTIVE: We sought to extend the NASSS framework to produce practical tools for understanding, guiding, monitoring, and researching technology projects in health care or social care settings. METHODS: Building on NASSS and a complexity assessment tool (CAT), the NASSS-CAT tools were developed (in various formats) in seven co-design workshops involving 50 stakeholders (industry executives, technical designers, policymakers, managers, clinicians, and patients). Using action research, they were and are being tested prospectively on a sample of case studies selected for variety in conditions, technologies, settings, scope and scale, policy context, and project goals. RESULTS: The co-design process resulted in four tools, available as free downloads. NASSS-CAT SHORT is a taster to introduce the instrument and gauge interest. NASSS-CAT LONG is intended to support reflection, due diligence, and preliminary planning. It maps complexity through stakeholder discussion across six domains, using free-text open questions (designed to generate a rich narrative and surface uncertainties and interdependencies) and a closed-question checklist; this version includes an action planning section. NASSS-CAT PROJECT is a 35-item instrument for monitoring how subjective complexity in a technology implementation project changes over time. NASSS-CAT INTERVIEW is a set of prompts for conducting semistructured research or evaluation interviews. Preliminary data from empirical case studies suggest that the NASSS-CAT tools can potentially identify, but cannot always help reconcile, contradictions and conflicts that block projects' progress. CONCLUSIONS: The NASSS-CAT tools are a useful addition to existing implementation tools and frameworks. Further support of the implementation projects is ongoing. We are currently producing digital versions of the tools, and plan (subject to further funding) to establish an online community of practice for people interested in using and improving the tools, and hold workshops for building cross-project collaborations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16861.

Parental Status and Biological Functioning: Findings from the Nashville Stress and Health Study.

Does childrearing affect the biological functioning of parents? To address this question, we analyze cross-sectional survey and biomarker data from Vanderbilt University's Nashville Stress and Health Study, a probability sample of non-Hispanic white and black working-age adults from Davidson County, Tennessee (2011-2014; n = 1,252). Multivariable regression analyses reveal a linear dose-response relationship between the number of children living in a respondent's home and (a) increased allostatic load, and (b) decreased leukocyte telomere length. We found no differences in biological functioning between childless respondents and empty-nest parents. These findings also withstood controls for a battery of socioeconomic factors. The implications of these findings and suggestions for future research are discussed.

The complete costs of genome sequencing: a microcosting study in cancer and rare diseases from a single center in the United Kingdom.

PURPOSE: The translation of genome sequencing into routine health care has been slow, partly because of concerns about affordability. The aspirational cost of sequencing a genome is $1000, but there is little evidence to support this estimate. We estimate the cost of using genome sequencing in routine clinical care in patients with cancer or rare diseases. METHODS: We performed a microcosting study of Illumina-based genome sequencing in a UK National Health Service laboratory processing 399 samples/year. Cost data were collected for all steps in the sequencing pathway, including bioinformatics analysis and reporting of results. Sensitivity analysis identified key cost drivers. RESULTS: Genome sequencing costs £6841 per cancer case (comprising matched tumor and germline samples) and £7050 per rare disease case (three samples). The consumables used during sequencing are the most expensive component of testing (68-72% of the total cost). Equipment costs are higher for rare disease cases, whereas consumable and staff costs are slightly higher for cancer cases. CONCLUSION: The cost of genome sequencing is underestimated if only sequencing costs are considered, and likely surpasses $1000/genome in a single laboratory. This aspirational sequencing cost will likely only be achieved if consumable costs are considerably reduced and sequencing is performed at scale.

Staple Food Item Availability among Small Retailers in Providence, RI.

Inventory requirements for authorized Supplemental Nutrition Assistance Program (SNAP) retailers have undergone several revisions to increase the availability of healthful foods. A proposed rule of 84 staple food items was not implemented due to concerns that stores would not withstand this expansion, resulting in a final rule requiring 36 items. This study used the Food Access Research Atlas data to characterize food provisions in 30 small retailers in areas with high and low proportions of SNAP and racial minority residents in Providence, Rhode Island (RI). Stores were assessed with an audit instrument to tally variety, perishability, and depth of stock of four staple food categories. Descriptive, analysis of variance, and chi-square analyses were performed. Across stores, 80% were compliant with the final rule, but 66.7% would need to expand their offerings to meet the proposed rule. Mean dairy variety was lowest among all categories (p < 0.05). Most stores met the perishability (92.3%) and depth-of-stock requirements (96.1%) under both rules. No difference was detected between areas with high and low proportions of SNAP and racial minority residents. Future expansion of requirements may increase healthful food availability without imposing undue burdens on retailers in Providence, RI, excluding increased requirements for dairy variety.

The effect of micronutrient supplementation on growth and hepatic metabolism in diploid and triploid Atlantic salmon (Salmo salar) parr fed a low marine ingredient diet.

The effects of low marine ingredient diets supplemented with graded levels (L1, L2, L3) of a micronutrient package (NP) on growth and metabolic responses were studied in diploid and triploid salmon parr. Diploids fed L2 showed significantly improved growth and reduced liver, hepatic steatosis, and viscerosomatic indices, while fish fed L3 showed suppressed growth rate 14 weeks post feeding. In contrast, dietary NP level had no effect on triploid performance. Whole body mineral composition, with exception of copper, did not differ between diet or ploidy. Whole fish total AAs and N-metabolites showed no variation by diet or ploidy. Free circulating AAs and white muscle N-metabolites were higher in triploids than diploids, while branch-chained amino acids were higher in diploids than triploids. Diploids had higher whole body α-tocopherol and hepatic vitamins K1 and K2 than triploids. Increased tissue B-vitamins for niacin and whole-body folate with dietary NP supplementation were observed in diploids but not triploids, while whole body riboflavin was higher in diploids than triploids. Hepatic transcriptome profiles showed that diploids fed diet L2 was more similar to that observed in triploids fed diet L3. In particular, sterol biosynthesis pathways were down-regulated, whereas cytochrome P450 metabolism was up-regulated. One­carbon metabolism was also affected by increasing levels of supplementation in both ploidies. Collectively, results suggested that, for optimised growth and liver function, micronutrient levels be supplemented above current National Research Council (2011) recommendations for Atlantic salmon when fed low marine ingredient diets. The study also suggested differences in nutritional requirements between ploidy.

Perceived Unfair Treatment by Police, Race, and Telomere Length: A Nashville Community-based Sample of Black and White Men.

Police maltreatment, whether experienced personally or indirectly through one's family or friends, represents a structurally rooted public health problem that disproportionately affects minorities. Researchers, however, know little about the physiological mechanisms connecting unfair treatment by police (UTBP) to poor health. Shortened telomeres due to exposure to this stressor represent one plausible mechanism. Using data from a community sample of black (n = 262) and white (n = 252) men residing in Nashville-Davidson County, we test four hypotheses: (1) Black men will be more likely to report UTBP than white men, (2) those reporting UTBP will have shorter telomeres than those not reporting UTBP, (3) this association will be more pronounced among black men, and (4) these hypotheses will extend to those who report vicarious UTBP. Results reveal support for all hypotheses. The implications for our findings are discussed as they pertain to debates on policing practices and health disparities research.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population.

OBJECTIVE: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Weighed down by discriminatory policing: Perceived unfair treatment and black-white disparities in waist circumference.

Police maltreatment, whether experienced personally or indirectly through one's family or friends, represents a potentially harmful stressor, particularly for minority populations. We address this issue by investigating: (1) how waist circumference (WC) varies by personal and vicarious exposure to unfair treatment by police (UTBP); and (2) to what extent exposure to UTBP explains the black-white disparity in WC. We employed data collected from a community-based sample of black (n = 601) and white (n = 608) adults living in Nashville-Davidson county Tennessee to address these questions. Results from our final linear regression model showed that those who reported vicarious UTBP had WCs that were approximately 2 in. greater than those who did not (b = 2.03; p = 0.003). While personal UTBP was not linked to higher WC, a post-hoc analysis suggested that our ability to detect an association was complicated by selection. Binary mediation analysis revealed that differential exposure to vicarious UTBP accounted for approximately 12% of the black-white WC disparity among women. We found no black-white differences in WC among men. The association between vicarious UTBP and WC did not vary by age, race, or gender. Overall, our findings point toward the role of discriminatory policing as a potential upstream contributor to racial disparities in health.

Racial/Ethnic Contrasts in the Relationships between Physical Disability, Perceived Discrimination, and Depressive Symptoms.

INTRODUCTION: The systematic deprivation of equal access to valued opportunities has greatly harmed the disadvantaged. Discrimination, whether it is based on gender, race, sexual orientation, or physical health exacts a high toll. This is especially true with respect to the role of race and equality in the USA today. This paper attempts to evaluate the significance of perceived discrimination among a multiethnic sample of physically disabled and non-disabled study participants. METHODS: We employ survey data from a community-based multiethnic sample of study participants to assess whether physical disability increases perceptions of discrimination across racial/ethnic groups. Additionally, we assess whether physical disability impacts the relationship between discrimination and depressive symptoms and whether this relationship is consistent across race/ethnicity. RESULTS: Descriptive and multivariate analyses indicate that disabled whites and Hispanics report higher levels of discrimination than their non-disabled counterparts. However, this pattern was not observed among black respondents who report high levels of discrimination regardless of their disability status. OLS models indicate that among Hispanics, physical disability moderates the relationship between discrimination and depressive symptoms. Among black and white study participants, physical disability does not moderate this relationship. CONCLUSION: Taken together, the results demonstrate the continuing significance of race as a source of discrimination and a health risk.

Portable electronic vision enhancement systems in comparison with optical magnifiers for near vision activities: an economic evaluation alongside a randomized crossover trial.

PURPOSE: To determine the incremental cost-effectiveness of portable electronic vision enhancement system (p-EVES) devices compared with optical low vision aids (LVAs), for improving near vision visual function, quality of life and well-being of people with a visual impairment. METHODS: An AB/BA randomized crossover trial design was used. Eighty-two participants completed the study. Participants were current users of optical LVAs who had not tried a p-EVES device before and had a stable visual impairment. The trial intervention was the addition of a p-EVES device to the participant's existing optical LVA(s) for 2 months, and the control intervention was optical LVA use only, for 2 months. Cost-effectiveness and cost-utility analyses were conducted from a societal perspective. RESULTS: The mean cost of the p-EVES intervention was £448. Carer costs were £30 (4.46 hr) less for the p-EVES intervention compared with the LVA only control. The mean difference in total costs was £417. Bootstrapping gave an incremental cost-effectiveness ratio (ICER) of £736 (95% CI £481 to £1525) for a 7% improvement in near vision visual function. Cost per quality-adjusted life year (QALY) ranged from £56 991 (lower 95% CI = £19 801) to £66 490 (lower 95% CI = £23 055). Sensitivity analysis varying the commercial price of the p-EVES device reduced ICERs by up to 75%, with cost per QALYs falling below £30 000. CONCLUSION: Portable electronic vision enhancement system (p-EVES) devices are likely to be a cost-effective use of healthcare resources for improving near vision visual function, but this does not translate into cost-effective improvements in quality of life, capability or well-being.