Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors.

OBJECTIVE: Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis. METHODS: We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023). RESULTS: Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20). CONCLUSION: In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Indigenous Practices of Soil and Water Conservation for Sustainable Hill Agriculture and Improving Livelihood Security.

In the foothills of the North-West Himalayan region of India, agriculture is the main occupation of the residents. The soil and water resources are becoming the major constraints in agricultural production in the erosion-prone fragile ecosystem of the region. However, due to intensive rains and sloping lands of the region, erosion of the topsoil becoming the major problem for practicing sustainable agriculture in the region, which further dissects the lands, reduces the fertility potentials and land productivities of the region. The root cause of this huge erosion in the region is the intensive rains within a short interval of time on the bare sloping hillsides and handling this problem in both ways could reduce their erosion damage. Socio-economically the farmers are illiterate, poor, and hesitate to adopt innovative techniques of both land and water conservation. All this makes the challenge of reducing erosion losses quite difficult. Farmers in the region do have the skills to manage the problem of soil erosion which they learned from their forefathers and have faith in them. These technologies put together are termed as "Indigenous Technical Knowledge" (ITKs) and these ITKs have helped them a lot for sustainable agriculture in the region. Among different ITKs bunding of field, plowing before monsoon, filter strips, earthing-up in maize, mulching, compression of soil in sugarcane are the important ones for restoring the fertility of soils, reducing erosion losses, improving land productivity, and ultimately livelihoods in the region.

A Review of Brain-Targeted Nonviral Gene-Based Therapies for the Treatment of Alzheimer's Disease.

Diseases of the central nervous system (CNS) are difficult to treat owing to the complexity of the brain and the presence of a natural blood-brain-barrier (BBB). Alzheimer's disease (AD) is one of the major progressive and currently incurable neurodegenerative disorders of the CNS, which accounts for 60-80% of cases of dementia. The pathophysiology of AD involves the accumulation of amyloid beta (Aß) plaques and neurofibrillary tangles (NFTs) in the brain. Additionally, synaptic loss and imbalance of neuronal signaling molecules are characterized as important markers of AD. Existing treatments of AD help in the management of its symptoms and aim toward the maintenance of cognitive functions, behavior, and attenuation of gradual memory loss. Over the past decade, nonviral gene therapy has attracted increasing interest due to its various advantages over its viral counterparts. Moreover, advancements in nonviral gene technology have led to their increasing contributions in clinical trials. However, brain-targeted nonviral gene delivery vectors come across various extracellular and intracellular barriers, limiting their ability to transfer the therapeutic gene into the target cells. Chief barriers to nonviral gene therapy have been discussed briefly in this review. We have also highlighted the rapid advancement of several nonviral gene therapies for AD, which are broadly categorized into physical and chemical methods. These methods aim to modulate Aß, beta-site amyloid precursor protein (APP) cleaving enzyme 1 (BACE1), apolipoprotein E, or neurotrophic factors' expression in the CNS. Overall, this review discusses challenges and recent advancements of nonviral gene therapy for AD.

Design and Validation of Liposomal ApoE2 Gene Delivery System to Evade Blood-Brain Barrier for Effective Treatment of Alzheimer's Disease.

Targeting gene-based therapeutics to the brain is a strategy actively sought to treat Alzheimer's disease (AD). Recent findings discovered the role of apolipoprotein E (ApoE) isoforms in the clearance of toxic amyloid beta proteins from the brain. ApoE2 isoform is beneficial for preventing AD development, whereas ApoE4 is a major contributing factor to the disease. In this paper, we demonstrated efficient brain-targeted delivery of ApoE2 encoding plasmid DNA (pApoE2) using glucose transporter-1 (glut-1) targeted liposomes. Liposomes were surface-functionalized with a glut-1 targeting ligand mannose (MAN) and a cell-penetrating peptide (CPP) to enhance brain-targeting and cellular internalization, respectively. Among various CPPs, rabies virus glycoprotein peptide (RVG) or penetratin (Pen) was selected as a cell-penetration enhancer. Dual (RVGMAN and PenMAN)-functionalized liposomes were cytocompatible at 100 nM phospholipid concentration and demonstrated significantly higher expression of ApoE2 in bEnd.3 cells, primary neurons, and astrocytes compared to monofunctionalized and unmodified (plain) liposomes. Dual-modified liposomes also showed ∼2 times higher protein expression than other formulation controls in neurons cultured below the in vitro BBB model. These results translated well to in vivo efficacy study with significantly higher transfection of pApoE2 in the C57BL/6 mice brain following single tail vein administration of RVGMAN and PenMAN functionalized liposomes without any noticeable signs of toxicity. These results illustrate the potential of surface-modified liposomes for safe and brain-targeted delivery of the pApoE2 gene for effective AD therapy.

Improved insulin sensitivity in obese-diabetic mice via chitosan Nanomicelles mediated silencing of pro-inflammatory Adipocytokines.

Obesity induced chronic low-level inflammation is strongly associated with the development of insulin resistance and progression of type-2 diabetes. Systemic treatment with anti-inflammatory therapeutics requires high doses and is associated with serious adverse effects owing to generalized suppression of the immune system. Here we study localized knockdown of pro-inflammatory adipocytokines in adipose tissue macrophages (ATMs) and adipocytes using RNA interference for the treatment of insulin resistance. Chitosan nanomicelles conjugated to ATM and adipocyte targeting ligands were used to transfect short hairpin RNA (shRNA) against tumor necrosis factor-α (TNFα) and monocyte chemoattractant protein-1 (MCP-1). Subcutaneous administration of nanomicellar/pDNA polyplexes in obese-diabetic mice resulted in decreased concentration of pro-inflammatory cytokines TNFα, MCP-1, IL-6, and IL-1ß along with increased concentration of insulin-sensitizing adipokine adiponectin. Downregulation of inflammatory cytokines resulted in improved insulin sensitivity and glucose tolerance for up to six-weeks following single dose, compared to untreated obese-diabetic mice.

Neighborhood-level stroke hot spots within major United States cities.

OBJECTIVE: Identifying communities at high risk of stroke is an important step in improving systems of stroke care. Stroke is known to show spatial clustering at the state and county levels, but it is not known if clusters are present within city boundaries. METHODS: We performed a geospatial analysis of the prevalence of stroke within 500 major cities in the United States using the Centers for Disease Control and Prevention 500 Cities Project. For each city, we calculated the Moran's I statistic, which looks for evidence of spatial clustering, and used Monte Carlo simulation to assess for clustering significance. RESULTS: The mean overall crude prevalence of self-reported history of stroke at the city level was 2.8% (IQR 2.4-3.2%). Monte Carlo simulations of spatial patterns of stroke were successfully performed for 497 cities, of which 136 (27.3%) showed significant spatial clustering at the neighborhood level. All nine cities with more than one million inhabitants in 2010 showed significant spatial clustering. CONCLUSIONS: This is the first study to demonstrate that stroke shows clustering at the neighborhood level within many major cities in the United States and within all of the largest cities. Understanding where stroke clusters exist within cities can form the basis of optimizing emergency medical services deployment and improving systems of stroke care.

Adolescents' Willingness to Commit to Safe Use and Disposal of Prescription Opioids.

Introduction and aims: Leftover pills from prescriptions written in emergency departments are a key source of misused opioids among adolescents. Recently, the AMA has proposed emphasizing safe use and disposal of opioids, but patient perceptions on this proposed solution are largely unknown. In this study, we evaluate the willingness of adolescents to commit to pill security and safe opioid use in a clinical setting. Design and methods: In this prospective survey study conducted in an urban emergency department, a consecutive sample of adolescent patients between 15 and 22 years were asked about their exposure to opioids and attitudes toward the potential harm of opioid use/misuse and whether they were willing to consider to committing to pill security and safe opioid use in a clinical setting. We then assessed if willingness to commit varied based on attitude toward opioid misuse or previous experience with prescription opioids. Results: Eighty-one percent (91/113) of eligible patients agreed to participate. Overall 29.7% of adolescents had received a prescription for opioids and 40.7% had leftover pills. 87.9% were willing to commit to take opioids only as prescribed and 83.5% were willing to commit to disposing leftover opioids. Willingness did not vary by previous exposure to prescription opioids or attitudes toward recreational opioid use. Discussion and conclusions: Adolescents are highly willing to commit to safe opioid use and disposal regardless of previous exposure to opioids or attitude toward opioid misuse.

Susceptibility Pattern of Doxycycline in Comparison to Azithromycin, Cefuroxime and Amoxicillin against Common Isolates: A Retrospective Study Based on Diagnostic Laboratory Data.

INTRODUCTION: Doxycycline acts against a broad range of gram-positive, gramnegative and 'atypical' bacteria as well as some protozoan pathogens such as malaria. In this era of increasing multidrug-resistance, recycling of old antimicrobials should be considered and need more focus in this domain of research. We, therefore, aimed to assess the antimicrobial susceptibility patterns of commonly isolated pathogens against doxycycline, azithromycin, cefuroxime, and amoxicillin from common clinical specimens by using laboratory-based diagnostic data from western India. MATERIALS AND METHODS: The non-interventional retrospective study was conducted on secondary data extracted from multi-center diagnostic laboratory based in Mumbai, India. Susceptibility data of bacteria isolated from blood, urine, pus, and sputum were used in the study and culture positive samples were segregated. Antimicrobial susceptibility status of doxycycline was checked and compared with azithromycin, cefuroxime, and amoxicillin. Chi-square tests of significance were carried out to assess significant differences in susceptibility patterns. Association between variables was considered statistically significant if the p-value was <0.05. RESULTS: Percentage susceptibility of collective bacterial isolates was found to be highest for doxycycline in all four specimens (93.1%). Individual percentage susceptibility was observed to be highest for sputum isolates (97.5%) followed by blood (93.8%), pus (92.7%) and urine (70.0%). The activity of doxycycline was found to be 93.5% for the samples resistant to azithromycin. Doxycycline also showed good susceptibility for the isolates resistant to amoxicillin and cefuroxime which was 75.9% and 64.8%, respectively. CONCLUSION: Several bacterial isolates from all four sources were found to be susceptible to Doxycycline. It has an important role in the form of a better alternative of major antimicrobial agents like azithromycin, cefuroxime, and amoxicillin against gram-positive cocci. Doxycycline appeared to show better activity against isolates which were resistant to other three antimicrobials.

Rice pest management with reduced risk pesticides in India.

Sitapur district in the Uttar Pradesh (U.P.) state of northern India has been observed to consume large amounts of WHO classified "extremely" and "highly hazardous" pesticides, in rice crop, posing significant health and environmental threats. Keeping in view this problem, integrated pest management (IPM) modules were synthesized for rice crop and then compared with non-IPM/farmer's practice (NIPM). This study assisted in identifying pesticides with reduced risk to the environment. To measure and compare risks, environmental impact quotient (EIQ) has been used as a pesticide risk indicator model, between IPM and NIPM programs. Using this model, the field EIQ values (EIQ field use rating or EIQ-FUR), for 32 commonly used pesticides in the region, were evaluated based on dosage, frequency, and percent active ingredients present in the pesticide formulations. The results conclude that copper oxychloride (CuOCl2) (50 WP at 1.25 kg/ha) and mancozeb (75 WP at 1.25 kg/ha) were the most detrimental to arthropod parasitoids and were the highest contributors to environmental risk (13-16%), in rice crop. This is based on the comparison of total dosage and active ingredients of pesticides applied under IPM and NIPM, with the total field EIQ values. The IPM modules were observed to have least impact on natural enemies with 30-40% increase in population, while keeping the weed population below 10%. NIPM, on the other hand, had resulted in 20% reduction in crop yields, 50% reduction in biodiversity, and about 150% increase in weed population, relative to the control (untreated) rice fields. Moreover, NIPM practices had been observed to pose 56% greater risk as per the total field EIQ values (62 for IPM and 141 for NIPM). The observations concluded that the EIQ model is a useful tool and can be easily used by the pesticide managers for assessing the risk against NIPM.

Enforcement of the Emergency Medical Treatment and Labor Act, 2005 to 2014.

STUDY OBJECTIVE: We determine the incidence of and trends in enforcement of the Emergency Medical Treatment and Labor Act (EMTALA) during the past decade. METHODS: We obtained a comprehensive list of all EMTALA investigations conducted between 2005 and 2014 directly from the Centers for Medicare & Medicaid Services (CMS) through a Freedom of Information Act request. Characteristics of EMTALA investigations and resulting citation for violations during the study period are described. RESULTS: Between 2005 and 2014, there were 4,772 investigations, of which 2,118 (44%) resulted in citations for EMTALA deficiencies at 1,498 (62%) of 2,417 hospitals investigated. Investigations were conducted at 43% of hospitals with CMS provider agreements, and citations issued at 27%. On average, 9% of hospitals were investigated and 4.3% were cited for EMTALA violation annually. The proportion of hospitals subject to EMTALA investigation decreased from 10.8% to 7.2%, and citations from 5.3% to 3.2%, between 2005 and 2014. There were 3.9 EMTALA investigations and 1.7 citations per million emergency department (ED) visits during the study period. CONCLUSION: We report the first national estimates of EMTALA enforcement activities in more than a decade. Although EMTALA investigations and citations were common at the hospital level, they were rare at the ED-visit level. CMS actively pursued EMTALA investigations and issued citations throughout the study period, with half of hospitals subject to EMTALA investigations and a quarter receiving a citation for EMTALA violation, although there was a declining trend in enforcement. Further investigation is needed to determine the effect of EMTALA on access to or quality of emergency care.

HIV Prevention and Treatment: The Evolving Role of the Emergency Department.

Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

Exposure to and Use of Electronic Cigarettes: Does Language Matter?

OBJECTIVES: To determine whether patients who are English proficient become aware of e-cigarettes through different marketing tactics and have dissimilar patterns of use than patients who are non-English speaking. DESIGN: This was a cross-sectional study surveying adult English- and Spanish-speaking patients. ANOVA and chi-squared tests were used to examine differences between groups. SETTING: A large public, safety-net hospital in Los Angeles County, California. RESULTS: Respondents (N=1899) were predominately Hispanic (78%), foreign-born (68%), and reported Spanish as a primary language (64%). Native English speakers reported the highest use of e-cigarettes (26%), followed by non-native (13%) and non-English speakers (2%) (P<.001). In terms of marketing, native and non-native English speakers were more likely to have friends and family as sources of e-cigarette information (P<.001). Native speakers were more likely to see advertisements for e-cigarettes on storefronts (P=.004) and on billboards (P<.001). Non-English speakers were most likely to learn about e-cigarettes on the news (P<.001) and in advertisements on the television and radio (P=.002). Differences in reasons for use were not significant between the three groups. CONCLUSIONS: Native and non-native English speakers become aware of e-cigarettes through different mechanisms and use e-cigarettes at a significantly higher rate than non-English speakers. These results highlight an opportunity for public health programs to concentrate on specific channels of communication that introduce patient populations to e-cigarettes to slow the spread of e-cigarette usage.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.

STUDY OBJECTIVE: Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population. METHODS: We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction. RESULTS: Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends. CONCLUSION: The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.

Perceptions of successful cues to action and opportunities to augment behavioral triggers in diabetes self-management: qualitative analysis of a mobile intervention for low-income Latinos with diabetes.

BACKGROUND: The increasing prevalence of diabetes and the associated cost of managing this complicated disease have a significant impact on public health outcomes and health expenditures, especially among resource-poor Latino patients. Mobile health (mHealth) may be the solution to reaching this group and improving their health. OBJECTIVE: In this qualitative study, we examined nuances of motivation, intention, and triggers to action effected by TExT-MED (Trial to Examine Text Messaging for Emergency Department patient with Diabetes), an mHealth intervention tailored to low-income, urban Latinos with diabetes. TExT-MED is a fully-automated, text message-based program designed to increase knowledge, self-efficacy, and subsequent disease management and glycemic control. METHODS: We conducted 5 focus group interviews with 24 people who participated in TExT-MED. We employed a modified grounded theory analytic approach-an iterative process of coding and immersion in the data used to recognize the patterns and links between concepts voiced by the participants. We coded data to identify themes of participant experiences, motivations, and responses to the program. We organized themes into a theory of TExT-MED's action. RESULTS: Participants enjoyed their experience with TExT-MED and believed it improved their diabetes management. Through analysis of the transcripts, we identified that the strengths of the program were messages that cued specific behaviors such as medication reminders and challenge messages. Our analysis also revealed that increasing personalization of message delivery and content could augment these cues. CONCLUSIONS: This in-depth qualitative analysis of TExT-MED shows that low-income Latino patients will accept text messages as a behavioral intervention. This mHealth intervention acts as a behavioral trigger rather than an education platform. Personalization is an opportunity to enhance these cues to action and further research should be conducted on the ideal forms of personalization.

Fragile health status of Latino patients with diabetes seen in the emergency department of an urban, safety-net hospital.

OBJECTIVE: Patients with diabetes presenting to safety-net emergency departments (ED) represent an at-risk population with limited resources and significant medical and social needs. We conducted a needs assessment of this group evaluating its demographic composition, health status, attitudes and beliefs about diabetes self-care and utilization of health maintenance services. We hypothesized that decreased self-efficacy and primary care use would correlate with higher glycosylated hemoglobin (HbA1C). RESEARCH DESIGN AND METHODS: Consecutive patients with a known history of diabetes seen in an urban, safety-net ED completed a 102-item questionnaire and had HbA1C measured. The questionnaire was developed using elements of the transtheoretical model of behavior change and self-efficacy theory. RESULTS: In 230 patients enrolled, mean age was 53 years and HbA1C was 8.8%. The overwhelming majority were Hispanic, low-income, and Spanish-speaking. Major depression was common (34% prevalence). By the transtheoretical model, 81.8% demonstrated advanced readiness to change (preparation/ action stages). HbA1C varied with self-efficacy as the least empowered quartile had the highest HbA1C (9.3%) while progressively higher quartiles had lower HbA1C (9.2%, 8.3%, 8.5%, P = .03 for trend). Only 69% reported having a primary care provider (PCP) and only 3% received all ADA recommended health maintenance services. Patients with a PCP had lower HbA1C than those without a PCP (7.6% vs. 9.5%, P < .01). CONCLUSIONS: In this study of largely Latino patients seen in an urban county ED, we observed extremely poor glycemic control, low diabetes-specific knowledge, high rates of major and severe major depression, low self-efficacy and unacceptably low rates of primary care and preventive health service utilization.

Implementation and Evaluation of an Automated Text Message-Based Diabetes Prevention Program for Adults With Pre-diabetes.

BACKGROUND: Despite the efficacy of diabetes prevention programs, only an estimated 5% of people with pre-diabetes actually participate. Mobile health (mHealth) holds promise to engage patients with pre-diabetes into lifestyle modification programs by decreasing the referral burden, centralizing remote enrollment, removing the physical requirement of a brick-and-mortar location, lowering operating costs through automation, and reducing time and transportation barriers. METHODS: Non-randomized implementation study enrolling patients with pre-diabetes from a large health care organization. Patients were exposed to a text message-based program combining live human coaching guidance and support with automated scheduled, interactive, data-driven, and on-demand messages. The primary analysis examined predicted weight outcomes at 6 and 12 months. Secondary outcomes included predicted changes in HbA1c and minutes of exercise at 6 and 12 months. RESULTS: Of the 163 participants included in the primary analysis, participants had a mean predicted weight loss of 5.5% at six months (P < .001) and of 4.3% at 12 months (P < .001). We observed a decrease in predicted HbA1c from 6.1 at baseline to 5.8 at 6 and 12 months (P < .001). Activity minutes were statistically similar from a baseline of 155.5 minutes to 146.0 minutes (P = .567) and 142.1 minutes (P = .522) at 6 and 12 months, respectively, for the overall cohort. CONCLUSIONS: In this real-world implementation of the myAgileLife Diabetes Prevention Program among patients with pre-diabetes, we observed significant decreases in weight and HbA1c at 6 and 12 months. mHealth may represent an effective and easily scalable potential solution to deliver impactful diabetes prevention curricula to large numbers of patients.

Rationalizing mineral gypsum use through microbially enriched municipal solid waste compost for amelioration and regaining productivity potential of degraded alkali soils.

Reclamation of alkali soils to harness their productivity potential is more complex due to the presence of excess sodium ions, poor hydraulic conductivity and infiltration rate, resulting in poor plant growth and crop productivity. Sodic soil reclamation using inorganic ameliorants like mineral gypsum or phosphogypsum is beyond the reach of small and marginal farmers having alkali soils because of their higher market prices and shortage of availability. Conjoint use of inorganic and organic amendments can be a pragmatic solution for improving soil physico-chemical and biological properties and sustaining crop productivity. Municipal solid waste compost (MSWC) available in abundant quantity if enriched with the efficient halophilic microbial consortium and used in conjunction with a reduced dose of gypsum can be a cost-effective approach for sustainable reclamation of alkali soils and harnessing their productivity potential. Hence, a field experiment was conducted on a high alkali soil (pH2 9.2 ± 0.10), electrical conductivity (EC) 1.14 ± 0.12 dS m-1, exchangeable sodium percentage 48 ± 2.50 and organic carbon (0.30%) was conducted during 2018-19 to 2020-21 to study the combined effect inorganic and organic (enriched municipal solid waste compost (EMSWC)) amendments on amelioration of alkali soils and sustaining productivity of rice-wheat cropping system. Application of gypsum @ 25% GR + enriched MSW compost @ 10 t ha-1 (T6) showed significant improvement in soil physico-chemical and biological properties over the sole application of organic (T3 and T4), inorganic (T2) and control (T1). A significant improvement in soil fertility status in terms of available nitrogen and micronutrients as well as CO3, HCO3, Cl, Ca and Mg content were recorded with the combined application of organic and inorganic soil amendments (T5 and T6) over the sole application of mineral gypsum. Soil microbial biomass carbon (MBC), nitrogen (MBN) and phosphorus (MBP) improved significantly due to the application of EMSWC with gypsum over the application of gypsum only. Grain yield of rice and wheat increased significantly (P < 0.05) owing to the application of a reduced dose of gypsum (25% GR) and EMSWC @ 10 t ha-1 (T6) with values of 5.55 and 3.83 t ha-1, respectively over rest of the treatments. Three years economic analysis of the study revealed that treatments T6 and T5 gave the highest positive net return whereas it was lowest in treatment T1 and negative in treatment T2. The highest benefit-to-cost ratio (B:C) was obtained in treatments T6 and T5 which were significantly higher compared to the rest of the treatments.

Prevalence of hypokalemia in ED patients with diabetic ketoacidosis.

OBJECTIVE: Although patients with diabetic ketoacidosis (DKA) are expected to have total body potassium depletion, measured levels may be normal or elevated due to extracellular shifts of potassium secondary to acidosis. Because insulin therapy decreases serum potassium levels, which creates potential to precipitate a fatal cardiac arrhythmia in a patient with hypokalemia, the American Diabetes Association (ADA) recommends obtaining a serum potassium level before giving insulin. Although the ADA guidelines are clear, the evidence on which they are based is largely anecdotal. The purpose of this study was to estimate the prevalence of hypokalemia in patients with DKA before initiation of fluid resuscitation and insulin therapy. METHODS: This is a prospective cross-sectional descriptive study of patients with a capillary blood glucose level of 250 mg/dL or higher (at risk for DKA) seen in an urban county emergency department over a 1-year period. Those who consented provided basic demographic information and had a venous blood gas and chemistry panel drawn. Diabetic ketoacidosis and hypokalemia were defined using ADA recommendations. RESULTS: The mean age in our sample was 40.2 years, and 81% of patients were Hispanic. Of 503 analyzable patients with hyperglycemia, 54 (10.7%) met all criteria for DKA. Of patients with DKA, 3 (5.6%) of 54 (95% confidence interval, 1.2%-15.4%) had hypokalemia. Two of these patients had values of 3.0 mmol/L, and 1 had a value of 2.8 mmol/L. CONCLUSION: Hypokalemia was observed in 5.6% of patients with DKA. These findings support the ADA recommendation to obtain a serum potassium before initiating intravenous insulin therapy in a patient with DKA.

Trends in diabetes-related visits to US EDs from 1997 to 2007.

OBJECTIVE: The aims of the study were to describe temporal trends in the number, proportion, and per capita use of diabetes-related emergency department (ED) visits and to examine any racial/ethnic disparity in ED use for diabetes-related reasons. METHODS: We analyzed the ED portion of the National Hospital Ambulatory Medical Care Survey from 1997 through 2007. Diabetes-related ED visits were identified by International Classification of Diseases, Ninth Revision codes. Descriptive statistics were developed. Weighted linear and logistic regression models were used to determine significance of temporal trends, and multivariate logistic regression was used to examine racial/ethnic disparities. RESULTS: A total of 20.2 million (1.69%; 95% confidence interval [CI], 1.59%-1.78%) ED visits were diabetes-related during the study period. We observed significant increases in the number and proportion of diabetes-related ED visits. Overall, there was a 5.6% relative annual increase in the proportion of ED visits that were diabetes-related during the study period. However, the per capita ED use among the population with diabetes did not change over time (P>.05 for trend). On multivariate analysis, black race (odds ratio, 1.8; 95% CI, 1.7-2.0), Hispanic ethnicity (odds ratio, 1.6; 95% CI, 1.4-1.8), and advancing age were associated with significantly higher odds of having a diabetes-related visit. CONCLUSIONS: Despite a marked increase in number and proportion of diabetes-related ED visits during the study period, the per capita use of ED services for diabetes-related visits among the diabetic population remained stable.