Rebooting the ambulatory enterprise in a community medical group in Kentucky following the initial surge of COVID-19.

ABSTRACT: The novel coronavirus disease 2019 (COVID-19) pandemic has intensified globally since its origin in Wuhan, China in December 2019. Many medical groups across the United States have experienced extraordinary clinical and financial pressures due to COVID-19 as a result of a decline in elective inpatient and outpatient surgical procedures and most nonurgent elective physician visits. The current study reports how our medical group in a metropolitan community in Kentucky rebooted our ambulatory and inpatient services following the guidance of our state's phased reopening. Particular attention focused on the transition between the initial COVID-19 surge and post-COVID-19 surge and how our medical group responded to meet community needs. Ten strategies were incorporated in our medical group, including heightened communication; ambulatory telehealth; safe and clean outpatient environment; marketing; physician, other medical provider, and staff compensation; high quality patient experience; schedule optimization; rescheduling tactics; data management; and primary care versus specialty approaches. These methods are applicable to both the current rebooting stage as well as to a potential resurgence of COVID-19 in the future.

Co-adsorption of synthetic Mincle agonists and antigen to silica nanoparticles for enhanced vaccine activity: A formulation approach to co-delivery.

To date there is no clinically approved adjuvant to drive a protective T-helper cell 17 (Th17) immune response against Mycobacterium tuberculosis (Mtb). Trehalose Dimycolate (TDM) is a glycolipid molecule found in the cell wall of Mtb and similar species. Our team has discovered novel synthetic TDM derivatives that target Mincle receptors and when presented on the surface of amine functionalized silica nanoparticles (A-SNPs) adopt the requisite supramolecular structure for Mincle receptor agonism. Here we describe the preparation and characterization methods for these critical silica nanoparticles (SNPs) co-loaded with Mincle agonists (MAs) and a model antigen. In this work, A-SNPs with a particle diameter of 246 ± 11 nm were prepared and examined for co-adsorption of two synthetic MAs along with ovalbumin (OVA). Due to the insolubility of the studied MAs in aqueous environment, aggregation of the MAs made separation of the adjuvant-loaded A-SNPs from the free-form MAs via centrifugation very challenging. To facilitate separation, we synthesized modified SNPs with comparable amine surface functionalization to the original A-SNPs, but with a superparamagnetic iron oxide core (M-A-SNPs), to allow for magnetic separation. We also substituted Alexa Fluor 488-labeled ovalbumin (AF 488 OVA) for the un-tagged OVA to improve the sensitivity of our quantitation method. A RP-HPLC method was developed to simultaneously determine the amount of adsorption of both the Mincle adjuvant and the model antigen to the A-SNPs. AF488 OVA demonstrated higher than 90% adsorption, with or without the co-adsorption of MAs. Likewise, MAs exhibited higher than 80% adsorption in the presence or absence of antigen. The developed formulations were tested in vitro using murine RAW cells and human peripheral blood mononuclear cells, exhibiting good cytokine induction in both cell lines. Results from these studies indicate that A-SNPs could be used as a customizable presentation platform to co-deliver antigens along with different MAs of varying structural features and biophysical properties.

Mitigation of electroencephalographic and cardiovascular responses to castration in Bos indicus bulls following the administration of either lidocaine or meloxicam.

OBJECTIVE: To investigate the mitigating effects of administration of local anaesthetic or systemic meloxicam on the electroencephalographic (EEG) and cardiovascular responses during surgical castration of Bos indicus bull calves. STUDY DESIGN: Prospective, randomized, experimental study. ANIMALS: Thirty-six 6-8 month-old Bos indicus bull calves, with a mean ± standard deviation weight of 237 ± 19 kg. METHODS: Animals were allocated randomly to three groups of 12 (group L, 260 mg of 2% lidocaine subcutaneously and intratesticularly 5 minutes prior to castration; group M, 0.5 mg kg-1 of meloxicam subcutaneously 30 minutes prior to castration; group C, no preoperative analgesia administered). Anaesthesia was induced and maintained with halothane (0.9-1.1%) in oxygen. Electroencephalogram, heart rate (HR) and mean blood pressure (MAP) were recorded for 300 seconds prior to (baseline, B) and from the start of surgery (first testicle removal, T1). HR and MAP were compared at 10 second intervals for 90 seconds from the start of T1. Median frequency (F50), spectral edge frequency (F95) and total power of the EEG (Ptot) were analysed using area under the curve comparing T1 to B. RESULTS: All EEG variables were significantly different between B and T1 (p ≤ 0.0001). No differences in F50 were found between groups during T1 (p = 0.6491). F95 and Ptot were significantly different between group L and groups C and M during T1 (p = 0.0005 and 0.0163, respectively). There were transient significant changes in HR and MAP in groups L and M compared to group C during the 20-50 second periods. CONCLUSIONS: The EEG changes indicate nociceptive responses in all three groups during surgical castration, greater in group L compared to groups C and M. Both analgesics attenuated the peracute cardiovascular response. Lidocaine and meloxicam administered prior to castration attenuated these responses in Bos indicus bull calves. CLINICAL RELEVANCE: These findings provide support for the preoperative administration of lidocaine and potentially meloxicam for castration in Bos indicus bull calves.

Electroencephalographic assessment of oral meloxicam, topical anaesthetic cream and cautery iron for mitigating acute pain in pigs (Sus scrofa) undergoing tail docking.

OBJECTIVE: To evaluate the efficacy of oral meloxicam, topical anaesthetic cream and cautery iron in mitigating acute nociceptive responses of pigs to tail docking. STUDY DESIGN: A prospective, randomized, controlled experimental study. ANIMALS: A total of 40 healthy Large WhitexLandrace pigs aged 21±1 days, weighing 6.1±0.9 kg. METHODS: Pigs were randomly assigned to one of four treatments (n=10 per treatment): CONTROL: docked using clippers without analgesia; MEL: docked using clippers after administration of oral meloxicam; EMLA: docked using clippers after application of topical anaesthetic cream; and CAUT: docked using a cautery iron without analgesia. Anaesthesia was induced and maintained with halothane in oxygen. Following induction, end-tidal halothane was stabilized at 0.95-1.05% and electroencephalograph (EEG) recording commenced. After 5 minutes of baseline data collection, tail docking was performed and recording continued for a further 10 minutes. The EEG summary variables median frequency (F50), 95% spectral edge frequency (F95) and total power (PTOT) were calculated for the baseline period and for consecutive 30-second intervals following docking. RESULTS: Following docking, F50 increased and PTOT decreased significantly in CONTROL and MEL pigs. EMLA pigs exhibited no change in any variable, whilst CAUT pigs exhibited a reduction in PTOT but no change in F50. F50 was higher in control pigs than in EMLA pigs 30-60 seconds after docking (p≤0.01). PTOT was lower in CONTROL than in EMLA pigs 30-90 seconds after docking (p<0.03) and in CAUT pigs 60 seconds after docking (p=0.01). CONCLUSIONS AND CLINICAL RELEVANCE: Prior application of EMLA cream abolished EEG indicators of nociception in pigs docked using clippers. Docking using a cautery iron without analgesia ameliorated EEG indicators of nociception, relative to using clippers without analgesia. Prior administration of EMLA cream or the use of cautery instead of clippers may reduce the acute pain experienced by pigs undergoing tail docking.

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes.

OBJECTIVE: To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes. METHODS: Aboriginal people with diabetes were invited to participate in one of five focus groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team. RESULTS: Participants described colonisation and dislocation from Country and family members' experiences with diabetes as significant historical influences which, in conjunction with the model of care experienced and the type of interaction with health services, shaped how they came to understand and manage their diabetes. CONCLUSIONS: Patient experience of a model of care alone is not what influences understanding and management of diabetes in Aboriginal people. Implications for Public Health: Health service improvements should focus on understanding past experiences of Aboriginal patients, improving interactions with health services and supporting holistic family centred models of care. Focusing on just the model of care in absence of other improvements is unlikely to deliver health benefits to Aboriginal people.

Commonly cited website quality criteria are not effective at identifying inaccurate online information about breast cancer.

BACKGROUND: Consumers increasingly consult the Internet for breast cancer information. Concerned about accuracy, multiple organizations developed quality criteria for online content. However, the effectiveness of these tools is unknown. The authors determined whether existing quality criteria can identify inaccurate breast cancer information online. METHODS: The authors identified 343 unique webpages by using 15 breast cancer-related queries on 5 popular web search-engines. Each page was assessed for 15 quality criteria and 3 website characteristics, link type (sponsored or not), search engine used to find the page, and domain extension. Two clinician-reviewers independently assessed accuracy and topics covered. The authors then determined whether quality criteria, website characteristics, and topics were associated with the presence of inaccurate statements. RESULTS: The authors found 41 inaccurate statements on 18 webpages (5.2%). No quality criteria or website characteristic, singly or in combination, reliably identified inaccurate information. The total number of quality criteria met by a website accounted for a small fraction of the variability in the presence of inaccuracies (point biserial r=-0.128; df=341; P=.018; r2=0.016). However, webpages containing information on complementary and alternative medicine (CAM) were significantly more likely to contain inaccuracies compared with pages without CAM information (odds ratio [OR], 15.6; P<.001). CONCLUSIONS: Most breast cancer information that consumers are likely to encounter online is accurate. However, commonly cited quality criteria do not identify inaccurate information. Webpages that contain information about CAM are relatively likely to contain inaccurate statements. Consumers searching for health information online should still consult a clinician before taking action.

Usability of quality measures for online health information: Can commonly used technical quality criteria be reliably assessed?

PURPOSE: Many criteria have been developed to rate the quality of online health information. To effectively evaluate quality, consumers must use quality criteria that can be reliably assessed. However, few instruments have been validated for inter-rater agreement. Therefore, we assessed the degree to which two raters could reliably assess 22 popularly cited quality criteria on a sample of 42 complementary and alternative medicine Web sites. METHODS: We determined the degree of inter-rater agreement by calculating the percentage agreement, Cohen's kappa, and prevalence- and bias-adjusted kappa (PABAK). RESULTS: Our un-calibrated analysis showed poor inter-rater agreement on eight of the 22 quality criteria. Therefore, we created operational definitions for each of the criteria, decreased the number of assessment choices and defined where to look for the information. As a result 18 of the 22 quality criteria were reliably assessed (inter-rater agreement > or = 0.6). CONCLUSIONS: We conclude that even with precise definitions, some commonly used quality criteria cannot be reliably assessed. However, inter-rater agreement can be improved with precise operational definitions.

Searching for cancer-related information online: unintended retrieval of complementary and alternative medicine information.

PURPOSE: The Web is an important source of health information for consumers. Use of complementary and alternative medicine (CAM) is also increasing. Therefore, we studied the likelihood that consumers will incidentally encounter CAM information while searching the Web and the factors that influence retrieval of CAM information. METHODS: We evaluated results retrieved by 10 cancer-related searches on six common search engines. RESULTS: Of 1121 search results, 16.2% displayed CAM information. Sponsored (i.e., paid) results were more likely to display CAM information than non-sponsored results (38% versus 7.5%, p < 0.001). In Overture and Google, sponsored results accounted for 51% and 39% of results on the first page. These search engines also retrieved more CAM web pages. Search engines distinguished sponsored and non-sponsored results, but disclosure statements describing the differences were confusing. Cancer type used as the search keyword did not influence the number of CAM web pages retrieved. However, synonyms of cancer differed in their retrieval of CAM web pages (p < 0.001). Consistent with prior studies of Web search engine overlap, we found that 28% of CAM results were retrieved by two or more search engines. CONCLUSIONS: Clinicians should help consumers recognize sponsored results and encourage search engines to clearly explain sponsored results.

Inter-observer agreement for quality measures applied to online health information.

Many quality criteria have been developed to rate the quality of online health information. However, few instruments have been validated for inter-observer reliability. Therefore, we assessed the degree to which two raters agree upon the presence or absence of information based on 22 popularly cited quality criteria on a sample of 21 complementary and alternative medicine websites. Our preliminary analysis showed a poor inter-rater agreement on 10 out of the 22 quality criteria. Therefore, we created operational definitions for each of the criteria, decreased the allowed choices and defined a location to look for the information. As a result 15 out of the 22 quality criteria had a kappa >0.6. We conclude that even with precise definitions some commonly used quality criteria to assess the quality of health information online cannot be reliably assessed. However, inter-rater agreement can be improved by providing precise operational definitions.

Cancer-related complementary and alternative medicine online: factors affecting information retrieval.

Cancer patients increasingly turn to the Internet for health information. As the use of complementary and alternative medicine (CAM) is also increasing, we studied the likelihood that consumers will incidentally encounter CAM information while searching the Internet and the factors that influence CAM information retrieval. We evaluated results retrieved from ten cancer-related searches in six common search engines, and found that 16.2% of 1121 results contained CAM information. Sponsored (i.e. paid) results contained more CAM information than non-sponsored results (38% vs. 7.5%, p<0.001). Sponsored results in the Overture and Google search engines accounted for 51% and 39% of results on the first page. These search engines also retrieved the most CAM web pages. The type of cancer used as the search keyword did not influence the number of CAM-related web pages retrieved. However, the synonyms of cancer used as search keywords differed in their retrieval of CAM web pages (p<0.001). We conclude that clinicians should help consumers recognize sponsored listings and encourage search engines to clearly identify sponsored results.

Efficacy of quality criteria to identify potentially harmful information: a cross-sectional survey of complementary and alternative medicine web sites.

BACKGROUND: Many users search the Internet for answers to health questions. Complementary and alternative medicine (CAM) is a particularly common search topic. Because many CAM therapies do not require a clinician's prescription, false or misleading CAM information may be more dangerous than information about traditional therapies. Many quality criteria have been suggested to filter out potentially harmful online health information. However, assessing the accuracy of CAM information is uniquely challenging since CAM is generally not supported by conventional literature. OBJECTIVE: The purpose of this study is to determine whether domain-independent technical quality criteria can identify potentially harmful online CAM content. METHODS: We analyzed 150 Web sites retrieved from a search for the three most popular herbs: ginseng, ginkgo and St. John's wort and their purported uses on the ten most commonly used search engines. The presence of technical quality criteria as well as potentially harmful statements (commissions) and vital information that should have been mentioned (omissions) was recorded. RESULTS: Thirty-eight sites (25%) contained statements that could lead to direct physical harm if acted upon. One hundred forty five sites (97%) had omitted information. We found no relationship between technical quality criteria and potentially harmful information. CONCLUSIONS: Current technical quality criteria do not identify potentially harmful CAM information online. Consumers should be warned to use other means of validation or to trust only known sites. Quality criteria that consider the uniqueness of CAM must be developed and validated.

Cancer research training for high school and college students at a comprehensive cancer center.

BACKGROUND: The number of American students pursuing advanced science degree continues to wane. Summer research experience programs are ideal mechanisms to introduce high school and college students to scientific lifestyles. METHODS: A follow-up of participants from 1995-2003 was conducted to gauge student perception of the program and to measure outcomes. RESULTS: Data are presented from the responses of 287 (81%) participants. The Program was successful in recruiting female (67%) and underrepresented (>35%) students. Very high percentages of trainees reported pursuing advanced scientific study (>85% of high school and >92% college students). CONCLUSIONS: Summer research experiential programs can be successful in initiating or maintaining a student's interest in science careers.