Effect of Social Determinants of Health Interventions on Adults Living With Disabilities: A Scoping Review.

OBJECTIVE: To investigate social determinants of health (SDoH) interventions on individual health outcomes, population health, and cost for persons in the United States over age 18 living with disabilities and receiving long-term services and supports (LTSS) in noninstitutional settings. DATA SOURCES: A review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted of literature from PubMed, PsycINFO, REHABDATA, and Web of Science Core Collection published between January 1997 and July 2020. STUDY SELECTION: Search terms were based on the primary SDoH domains identified by the Centers for Medicare and Medicaid's Accountable Health Communities Model. A total of 5082 abstracts were screened based on identification criteria of persons age 18 and above living in non-institutional, community-based settings receiving LTSS. DATA EXTRACTION: During Level 2 review, articles were reviewed based on population focus, type of LTSS (personal assistance services, home care, adult day care, home modification, durable medical equipment, community transition services, caregiver supports and/or prevention services related to home- and community-based care), SDoH intervention and association with health outcomes, population health and/or cost. A total of 1037 abstracts underwent Level 2 review, yielding 131 publications or 1.3% for full review. DATA SYNTHESIS: Studies (n=33) designed a priori to test outcomes of interventions were rated according to Grading Recommendations Assessment Development and Evaluation (GRADE) criteria. Qualifying articles that did not include interventions (n=98) were included in our summary of the literature but were not assessed by GRADE. CONCLUSIONS: The preponderance of research surrounding SDoH and health outcomes has focused on older adults living with disabilities, and most interventions scored low or very low using GRADE criteria. Evidence is limited to the extent SDoH interventions are measured against outcomes for persons of all ages living with disabilities. Robust evaluation of models that feature SDoH interventions in partnership with community-based organizations is recommended as home and community-based care infrastructure expands in response to the American Rescue Plan Act of 2021.

The relationship between duration and quality of sleep and upper respiratory tract infections: a systematic review.

BACKGROUND: Upper respiratory tract infections (URTIs) are common, mostly self-limiting, but result in inappropriate antibiotic prescriptions. Poor sleep is cited as a factor predisposing to URTIs, but the evidence is unclear. OBJECTIVE: To systematically review whether sleep duration and quality influence the frequency and duration of URTIs. METHODS: Three databases and bibliographies of included papers were searched for studies assessing associations between sleep duration or quality and URTIs. We performed dual title and abstract selection, discussed full-text exclusion decisions and completed 50% of data extraction in duplicate. The Newcastle-Ottawa Quality Assessment Scale assessed study quality and we estimated odds ratios (ORs) using random effects meta-analysis. RESULTS: Searches identified 5146 papers. Eleven met inclusion criteria, with nine included in meta-analyses: four good, two fair and five poor for risk of bias. Compared to study defined 'normal' sleep duration, shorter sleep was associated with increased URTIs (OR: 1.30, 95% confidence interval [CI]: 1.19-1.42, I2: 11%, P < 0.001) and longer sleep was not significantly associated (OR: 1.11 95% CI: 0.99-1.23, I2: 0%, P = 0.070). Sensitivity analyses using a 7- to 9-hour baseline found that sleeping shorter than 7-9 hours was associated with increased URTIs (OR: 1.31, 95% CI: 1.22-1.41, I2: 0%, P < 0.001). Sleeping longer than 7-9 hours was non-significantly associated with increased URTIs (OR: 1.15, 95% CI: 1.00-1.33, I2: 0%, P = 0.050, respectively). We were unable to pool sleep quality studies. No studies reported on sleep duration and URTI severity or duration. CONCLUSIONS: Reduced sleep, particularly shorter than 7-9 hours, is associated with increased URTIs. Strategies improving sleep should be explored to prevent URTIs.

It is widely believed that poor sleep increases people's chances of catching coughs, colds and other upper airway infections. UK government advice states that poor sleep and catching a cold or the flu could be related and suggests most individuals need 8 hours sleep a night. Studies have helped to explain the link between sleep and infections by showing that shortened sleep reduces the body's ability to fight infections. Studies in humans that look at the link between sleep and catching a cold or other airway infection have mostly been small and have conclusions that differ. We set out to investigate whether the quality of sleep (how 'well' you sleep) and the quantity of sleep (how 'long' you sleep) influence a person's likelihood of getting an upper airway infection. We found that shorter sleep than normal resulted in increased chances of having an upper airway infection, whereas longer sleep did not. We also found that sleeping for shorter or longer than 7­9 hours per night increased the likelihood of having an upper airway infection. Our results are important for informing conversations between patients and doctors around sleep and for encouraging the investigation of the impact of sleep on more serious infections.

Self-monitoring and self-management: new interventions to improve blood pressure control.

PURPOSE OF REVIEW: This article reviews recent developments in self-monitoring and self-management of hypertension aimed at the improvement of blood pressure (BP) control. RECENT FINDINGS: There is an increasing body of evidence examining the effects of self-monitoring on BP control. Several landmark studies in recent years have demonstrated clinically relevant benefit from self-monitoring based interventions. Self-management of BP with self-titration has shown particular promise, as has self-monitoring combined with intensive health-care led support. There is a lack of evidence on the benefits of self-monitoring for those with important comorbidity such as coronary heart disease, chronic kidney disease, diabetes and previous stroke, and future research should be directed towards this. SUMMARY: There is a growing body of evidence supporting the use of self-monitoring along with additional intervention including telemonitoring and self-titration in improving BP control. Further research is needed to understand which patients are likely to benefit most and how this is best integrated with routine care.

Effect of antihypertensive deprescribing on hospitalisation and mortality: long-term follow-up of the OPTiMISE randomised controlled trial.

BACKGROUND: Deprescribing of antihypertensive medications is recommended for some older patients with low blood pressure and frailty. The OPTiMISE trial showed that this deprescribing can be achieved with no differences in blood pressure control at 3 months compared with usual care. We aimed to examine effects of deprescribing on longer-term hospitalisation and mortality. METHODS: This randomised controlled trial enrolled participants from 69 general practices across central and southern England. Participants aged 80 years or older, with systolic blood pressure less than 150 mm Hg and who were receiving two or more antihypertensive medications, were randomly assigned (1:1) to antihypertensive medication reduction (removal of one antihypertensive) or usual care. General practitioners and participants were aware of the treatment allocation following randomisation but individuals responsible for analysing the data were masked to the treatment allocation throughout the study. Participants were followed up via their primary and secondary care electronic health records at least 3 years after randomisation. The primary outcome was time to all-cause hospitalisation or mortality. Intention-to-treat analyses were done using Cox regression modelling. A per-protocol analysis of the primary outcome was also done, excluding participants from the intervention group who did not reduce treatment or who had medication reinstated during the initial trial 12-week follow-up period. This study is registered with the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT2016-004236-38) and the ISRCTN Registry (ISRCTN97503221). FINDINGS: Between March 20, 2017, and Sept 30, 2018, a total of 569 participants were randomly assigned. Of these, 564 (99%; intervention=280; control=284) were followed up for a median of 4·0 years (IQR 3·7-4·3). Participants had a mean age of 84·8 years (SD 3·4) at baseline and 273 (48%) were women. Medication reduction was sustained in 109 participants at follow-up (51% of the 213 participants alive in the intervention group). Participants in the intervention group had a larger reduction in antihypertensives than the control group (adjusted mean difference -0·35 drugs [95% CI -0·52 to -0·18]). Overall, 202 (72%) participants in the intervention group and 218 (77%) participants in the control group experienced hospitalisation or mortality during follow-up (adjusted hazard ratio [aHR] 0·93 [95% CI 0·76 to 1·12]). There was some evidence that the proportion of participants experiencing the primary outcome in the per-protocol population was lower in the intervention group (aHR 0·80 [0·64 to 1·00]). INTERPRETATION: Half of participants sustained medication reduction with no evidence of an increase in all-cause hospitalisation or mortality. These findings suggest that an antihypertensive deprescribing intervention might be safe for people aged 80 years or older with controlled blood pressure taking two or more antihypertensives. FUNDING: British Heart Foundation and National Institute for Health and Care Research.

Substance use, risk behaviours and well-being after admission to a quasi-residential abstinence-based rehabilitation programme: 4-year follow-up.

BACKGROUND: Tackling Scotland's drug-related deaths and improving outcomes from substance misuse treatments, including residential rehabilitation, is a national priority. AIMS: To analyse and report outcomes up to 4 years after attendance at a substance misuse residential rehabilitation programme (Lothians and Edinburgh Abstinence Programme). METHOD: In total, 145 participants were recruited to this longitudinal quantitative cohort study of an abstinence-based residential rehabilitation programme based on the therapeutic community model; 87 of these participants were followed up at 4 years. Outcomes are reported for seven subsections of the Addiction Severity Index-X (ASI-X), together with frequency of alcohol use, heroin use, injecting drug use and rates of abstinence from substances of misuse. RESULTS: Significant improvement in most outcomes at 4 years compared with admission scores were found. Completing the programme was associated with greater rates of abstinence, reduced alcohol use and improvements in alcohol status score (Mann-Whitney U = 626, P = 0.013), work satisfaction score (U = 596, P = 0.016) and psychiatric status score (U = 562, P = 0.007) on the ASI-X, in comparison with non-completion. Abstinence rates improved from 12% at baseline to 48% at 4 years, with the rate for those completing the programme increasing from 14.5% to 60.7% (χ2(2, 87) = 9.738, P = 0.002). Remaining abstinent from substances at follow-up was associated with better outcomes in the medical (U = 540, P < 0.001), psychiatric (U = 273.5, P < 0.001) and alcohol (U = 322.5, P < 0.001) subsections of the ASI-X. CONCLUSIONS: Attending this abstinence-based rehabilitation programme was associated with positive changes in psychological and social well-being and harm reduction from substance use at 4-year follow-up, with stability of change from years 1 to 4.

Online supplementation for teaching evidence-based medicine: feasibility of a randomised-controlled trial.

BACKGROUND AND OBJECTIVES: As teaching technology advances, medical education is increasingly using digital mediums and exploring instructional models such as the flipped classroom and blended learning courses, where the in-class taught sessions are more groups on content delivered before class. Early evidence suggests lectures and foundational material can be equally provided online, but we have low-quality research to be convinced. We aim to test and develop an online evidence-based teaching resource that seeks to improve the availability and scalability of evidence-based medicine (EBM) learning tools. We evaluate the feasibility of a study design that could test for changes in academic performance in EBM skills using an online supplement. METHODS: Mixed-methods feasibility study of a randomised controlled trial (RCT) in an undergraduate medical student cohort. RESULTS: Of a small cohort (n=34), eight participants agreed to randomisation and completed the study. No study participant completed the EBM supplementary course in full. Students report time-management as a significant barrier in participation, and all aspects of the study and communications should be delivered with efficiency a key consideration. CONCLUSION: Randomising students to an online EBM supplement within a medical school programme presents challenges of recruitment and student motivation, but the study design is potentially feasible.

Rapid effects of hypoxia on H+ homeostasis in articular chondrocytes.

Articular chondrocytes experience low oxygen (O(2)) levels compared with many other tissues, and values fall further in disease states. Chondrocyte intracellular pH (pH(i)) is a powerful modulator of matrix synthesis and is principally regulated by Na(+)-H(+) exchange (NHE). In equine chondrocytes, NHE is inhibited when cells are incubated for 3 h at low O(2), leading to intracellular acidosis. O(2)-dependent changes in reactive oxygen species (ROS) levels appear to underlie this effect. The present study examines whether hypoxia can influence chondrocyte NHE activity and pH(i) over shorter timescales using the pH-sensitive fluoroprobe BCECF in cells isolated not only from equine cartilage but also from bovine tissue. O(2) levels in initially oxygenated solutions gassed with N(2) fell to approximately 1% within 2 h. A progressive fall in pH(i) and acid extrusion capacity was observed, with statistically significant effects (P < 0.05) apparent within 3 h. For equine and bovine cell populations subjected to step change in O(2) by resuspension in hypoxic (1%) solutions, a decline in acid extrusion and pH(i) was observed within 10 min and continued throughout the recording period. This effect represented inhibition of the NHE-mediated fraction of acid extrusion. Cells subjected to hypoxic solutions supplemented with CoCl(2) (100 microM) or antimycin A (100 microM) to raise levels of ROS did not acidify. The conserved nature and rapidity of the response to hypoxia has considerable implications for chondrocyte homeostasis and potentially for the maintenance of cartilage integrity.

C-reactive protein and neutrophil count laboratory test requests from primary care: what is the demand and would substitution by point-of-care technology be viable?

AIMS : C-reactive protein (CRP) and neutrophil count (NC) are important diagnostic indicators of inflammation. Point-of-care (POC) technologies for these markers are available but rarely used in community settings in the UK. To inform the potential for POC tests, it is necessary to understand the demand for testing. We aimed to describe the frequency of CRP and NC test requests from primary care to central laboratory services, describe variability between practices and assess the relationship between the tests. METHODS: We described the number of patients with either or both laboratory tests, and the volume of testing per individual and per practice, in a retrospective cohort of all adults in general practices in Oxfordshire, 2014-2016. RESULTS: 372 017 CRP and 776 581 NC tests in 160 883 and 275 093 patients, respectively, were requested from 69 practices. CRP was tested mainly in combination with NC, while the latter was more often tested alone. The median (IQR) of CRP and NC tests/person tested was 1 (1-2) and 2 (1-3), respectively. The median (IQR) tests/practice/week was 36 (22-52) and 72 (50-108), and per 1000 persons registered/practice/week was 4 (3-5) and 8 (7-9), respectively. The median (IQR) CRP and NC concentrations were 2.7 (0.9-7.9) mg/dL and 4.1 (3.1-5.5)×109/L, respectively. CONCLUSIONS: The high demand for CRP and NC testing in the community, and the range of results falling within the reportable range for current POC technologies highlight the opportunity for laboratory testing to be supplemented by POC testing in general practice.

Mixed-methods feasibility study of blood pressure self-screening for hypertension detection.

OBJECTIVE: To assess the feasibility of using a blood pressure (BP) self-measurement kiosk-a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records- to improve hypertension detection. DESIGN: A concurrent mixed-methods feasibility study incorporating observational and qualitative interview components. SETTING: Two English general practitioner (GP) surgeries. PARTICIPANTS: Adult patients registered at participating surgeries. Staff working at these sites. INTERVENTIONS: BP self-measurement kiosks were placed in the waiting rooms for a 12-month period between 2015 and 2016 and compared with a 12-month control period prior to installation. OUTCOME MEASURES: (1) The number of patients using the kiosk and agreeing to transfer of their data into their electronic medical records; (2) the cost of using a kiosk compared with GP/practice nurse BP screening; (3) qualitative themes regarding use of the equipment. RESULTS: Out of 15 624 eligible patients, only 186 (1.2%, 95% CI 1.0% to 1.4%) successfully used the kiosk to directly transfer a BP reading into their medical record. For a considerable portion of the intervention period, no readings were transferred, possibly indicating technical problems with the transfer link. A comparison of costs suggests that at least 52.6% of eligible patients would need to self-screen in order to bring costs below that of screening by GPs and practice nurses. Qualitative interviews confirmed that both patients and staff experienced technical difficulties, and used alternative methods to enter BP results into the medical record. CONCLUSIONS: While interviewees were generally positive about checking BP in the waiting room, the electronic transfer system as tested was neither robust, effective nor likely to be a cost-effective approach, thus may not be appropriate for a primary care environment. Since most of the cost of a kiosk system lies in the transfer mechanism, a solid-cuff sphygmomanometer and manual entry of results may be a suitable alternative.

Schedules for Self-monitoring Blood Pressure: A Systematic Review.

BACKGROUND: Self-monitoring of blood pressure better predicts prognosis than clinic measurement, is popular with patients, and endorsed in hypertension guidelines. However, there is uncertainty over the optimal self-monitoring schedule. We therefore aimed to determine the optimum schedule to predict future cardiovascular events and determine "true" underlying blood pressure. METHODS: Six electronic databases were searched from November 2009 (updating a National Institute for Health and Care Excellence [NICE] systematic review) to April 2017. Studies that compared aspects of self-monitoring schedules to either prognosis or reliability/reproducibility in hypertensive adults were included. Data on study and population characteristics, self-monitoring regime, and outcomes were extracted by 2 reviewers independently. RESULTS: From 5,164 unique articles identified, 25 met the inclusion criteria. Twelve studies were included from the original NICE review, making a total of 37 studies. Increasing the number of days of measurement improved prognostic power: 72%-91% of the theoretical maximum predictive value (asymptotic maximum hazard ratio) was reached by 3 days and 86%-96% by 7 days. Increasing beyond 3 days of measurement did not result in better correlation with ambulatory monitoring. There was no convincing evidence that the timing or number of readings per day had an effect, or that ignoring the first day's measurement was necessary. CONCLUSIONS: Home blood pressure should be measured for 3 days, increased to 7 only when mean blood pressure is close to a diagnostic or treatment threshold. Other aspects of a monitoring schedule can be flexible to facilitate patient uptake of and adherence with self-monitoring.

Serum growth factor analysis in dry eye syndrome.

BACKGROUND: To perform a comprehensive serum growth factor analysis in dry eye syndrome patients and to compare this with matched controls. METHODS: Six female dry eye syndrome patients and six age- and gender-matched controls were recruited. Whole blood was collected, allowed to clot and then centrifuged. Serum was extracted by using sterile technique. Enzyme-linked immunosorbent assays were performed to quantify serum growth factor levels. RESULTS: Levels of transforming growth factor-beta 1 and 2 (TGF-beta1 and beta2), nerve growth factor (NGF), insulin-like growth factor-1 (IGF-1), epidermal growth factor (EGF), acidic and basic fibroblast growth factor (FGF), keratinocyte growth factor (KGF), hepatocyte growth factor (HGF), vascular endothelial growth factor (VEGF), platelet-derived growth factor-AA, AB and BB (PDGF-AA, AB and BB), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3) and glial cell line-derived neurotrophic factor (GDNF) were quantified, and statistical analysis was performed by using the Mann-Whitney U-test with the Bonferroni correction. CONCLUSIONS: No significant difference was found between serum growth factor levels in dry eye syndrome patients versus controls. Our study provides comprehensive analysis of serum growth factor levels in autologous serum eye drops produced from ocular surface disease patients. A knowledge of growth factor levels in serum may be important because of the increasing use of autologous serum eye drops in refractory ocular surface diseases and for an understanding of how topical serum may provide benefit.

The evaluation of anaemia in an older primary care population: retrospective population-based study.

BACKGROUND: Anaemia is common in older people and the identification of potentially reversible haematinic deficiencies relies on appropriate investigation, often undertaken in primary care. AIM: To determine the laboratory prevalence of anaemia, the types of anaemia observed, and the biochemical and haematological investigations undertaken to characterise any associated haematinic abnormality in older primary care patients. DESIGN & SETTING: A retrospective primary care based study of patients aged >65 years undergoing a full blood count in Oxfordshire, UK between 1 January 2012 and 31 December 2013. METHOD: Consecutive patients aged >65 years with a full blood count were identified retrospectively from a laboratory database. Patient demographics, number of blood tests and additional laboratory investigations requested were recorded. World Health Organisation (WHO) criteria were used to define anaemia. RESULTS: In total 151 473 full blood counts from 53 890 participants were included: 29.6% of patients were anaemic. The majority had a normocytic anaemia (82.4%) and 46.0% of participants with anaemia had no additional investigations performed. The mean haemoglobin was lower in the anaemic group that underwent further investigation than those who did not (Hb 10.68 g/dl versus 11.24 g/dl, P<0.05): 33.2 % of patients with a microcytic anaemia (mean cell volume <80) did not have any markers of iron status measured. CONCLUSION: A large proportion of older adults in primary care with a recent blood test are anaemic, the majority with a normocytic anaemia, with evidence of inadequate investigation. Those with lower haemoglobin are more likely to be further investigated. Further work is needed to understand the approach to anaemia in older adults in primary care.

The Effect of Topical Substance-P Plus Insulin-like Growth Factor-1 (IGF-1) on Epithelial Healing After Photorefractive Keratectomy in Rabbits.

PURPOSE: To determine whether topical Substance-P (SP) plus insulin-like growth factor-1 (IGF-1) can improve corneal healing after photorefractive surface ablation in a rabbit. METHODS: After a 9.0-mm corneal de-epithelialization using a combination of chemical (18% alcohol) and mechanical debridement, excimer photorefractive surface ablation was performed bilaterally in eight rabbits (16 eyes) with an 8.0-mm ablation zone and 70-µm depth. The right eye was treated with SP (250 µg/mL) and IGF-1 (25 ng/mL) in hyaluronic acid, one drop twice a day, and the other eye treated with only hyaluronic acid. The epithelial healing process was documented photographically twice a day until healing was complete. Six rabbits were sacrificed 6 weeks after photorefractive keratectomy (PRK) and corneas examined histologically. RESULTS: Seven of eight rabbit eyes treated with SP/IGF-1 healed in a shorter time than the untreated eye. For rabbit #6, both eyes healed at the same time. The average healing time (total time until wound closure) for the treated eyes was 99 hours, while the average healing time for the untreated eyes was 170 hours (P = 0.0490). A persistent epithelial defect was found in two of the nontreated eyes but none in the treated eyes. Corneal pathology showed some degree of epithelial separation in the central corneal wound in three out of six nontreated eyes and in just the treated eye of rabbit #6. CONCLUSION: Topical SP plus IGF-1 increases the epithelial healing rate after PRK. There may have been beneficial effects upon cell adhesion as well. TRANSLATIONAL RELEVANCE: Better and faster healing.

Successful treatment of resistant ocular fusariosis with posaconazole (SCH-56592).

PURPOSE: To describe the successful treatment with systemic posaconazole of a series of Fusarium ocular infections refractory to other antifungal agents. DESIGN: Retrospective, interventional case series. METHODS: We identified three patients from three different centers who received diagnoses of Fusarium keratitis and who received systemic posaconazole after their infections failed to respond to maximal tolerated medical and surgical therapy. All patients received multiple systemic, intracameral, and topical antifungal agents, which were ineffective in controlling their infection. RESULTS: Two patients were contact lens wearers. Two patients developed endophthalmitis. The infections of all three patients failed to respond to systemic and/or topical voriconazole treatment. One patient could not tolerate systemic voriconazole, and another experienced no marked improvement. The third discontinued treatment for both reasons. All patients were treated with oral posaconazole and experienced rapid reduction of intraocular inflammation and pain, as well as resolution of the infection without additional intervention. CONCLUSIONS: Deep Fusarium keratitis is difficult to treat and carries a high risk of progression to endophthalmitis. Posaconazole, which exhibits excellent tissue penetration and demonstrates efficacy in the treatment of systemic Fusarium infection, was successful in treating three cases of pan-resistant keratitis and/or endophthalmitis.

Descemet's stripping automated endothelial keratoplasty in intraoperative floppy-iris syndrome: suture-drag technique.

Descemet's stripping automated endothelial keratoplasty avoids a full-thickness corneal procedure and provides rapid visual rehabilitation. Success depends on positioning the graft successfully while minimizing intraoperative donor endothelial trauma. Previously described techniques for graft insertion may be problematic in patients with intraoperative floppy-iris syndrome, anatomically shallow or unstable anterior chambers, or increased intraoperative posterior vitreous pressure. We describe an alternative called the suture-drag technique that may facilitate lamellar endothelial graft insertion in these special circumstances.