Leveraging Social Determinants of Health to Reduce Hospital Length of Stay: A Pilot QI Project for Solid Tumor Oncology Patients During the COVID-19 Pandemic.

PURPOSE: The impact of the social determinants of health (SDOH) on hospitalized cancer patients and hospital length of stay is unknown. At our institution, a hospital-wide SDOH survey that examined patient-specific barriers to various domains of SDOH and facilitated hospital discharge was integrated into the electronic medical record. This study reports the effect of the SDOH survey on length of stay for oncology patients and the outpatient referrals generated to facilitate the discharge. METHODS: We examined length of stay index data on inpatient oncology patients and 2 comparator services (bone marrow transplant, internal medicine). We evaluated the length of stay using a 2-sample t test, and the rate of referrals per discharge using a 2-sample Poisson test. RESULTS: Compared to the baseline length of stay, after the launch of the SDOH survey, there was a significant (8.9%) decrease in the average length of stay for oncology patients (8.14 to 7.41 days, P = 0.004), the LOS decrease for the bone marrow transplant and subset was a nonsignificant trend only (P > 0.1). Average referrals per discharge increased from baseline 1.063 per discharge to 1.159 after implementation (P = 0.004), and the mean values increased by 9%. CONCLUSIONS: The SDOH survey tool assisted in a timely examination of patient-specific barriers to discharge, leveraged care coordination, and facilitated a safe hospital discharge. Such efforts increase the efficiency of health care service delivery in response to public health threats, such as the COVID-19 pandemic.

Parent perceptions of minimally invasive dental treatment of Australian Aboriginal pre-school children in rural and remote communities.

INTRODUCTION: Aboriginal* children in rural and remote communities in Australia have a higher burden of dental decay and poorer access to dental services than their non-Aboriginal counterparts. In the Kimberley region of Western Australia (WA), Aboriginal children experience six times the rate of untreated dental decay of non-Aboriginal children. Access to dental care is challenged by the availability and appropriate delivery of services in remote locations. This study elicited the experiences and perceptions of parents and carers who participated in a project that tested the minimally invasive atraumatic restorative treatment and the Hall technique approaches (ART-HT) to manage early childhood dental caries among Australian Aboriginal preschool children. METHODS: The core study design was a stepped-wedge, cluster-community-randomised controlled trial. Consenting communities in the Kimberley region of WA were randomised into early and delayed intervention groups. Children were clinically examined at study commencement; the early intervention group was offered dental treatment using the ART-HT approach, and the delayed group was advised to seek dental care from their usual service provider. At the 12-month follow-up, children in both groups were re-examined and offered care using the minimally invasive model of care, and parents and carers were invited to take part in focus group or one-to-one interviews. Semistructured interviews, guided by the yarning approach, were conducted with consenting parents and carers in community locations of convenience to participants. The same open-ended questions were asked of all participants, and the interviews were audio-recorded with permission and transcribed by an independent agency. Thematic analysis was undertaken, the transcripts were coded by NVivo software, and emergent themes were identified and developed. RESULTS: One-to-one interviews were conducted with 29 parents and carers (10 from five test communities; 19 from eight control communities). Interview participants consisted of 3 males and 26 females. Following thematic analysis, three main themes (and subthemes) were identified: (1) access to care (barriers, service availability, impact on family due to lack of access); (2) experience of care (cultural safety, child-centred care, comprehensiveness of care); (3) community engagement (service information, engagement, oral health education). Structural and system factors as well as geography were identified as barriers by parents and carers in accessing timely and affordable dental care in culturally safe environments; parents and carers also identified the impacts from lack of access to care. They valued comprehensive care delivered within community, underpinned by child- and family-centred care. Of equal importance was the holistic approach adopted through the building of community engagement and trusting relationships. CONCLUSION: A high level of satisfaction was reported by parents and carers with their experience of dental care for their children with the minimally invasive approach. Satisfaction was expressed around ease of accessing services delivered in a child- and family-centred manner, and that were well supported by appropriate engagement between service providers, communities and families. The findings from this study suggest a minimally invasive dental care model can be considered effective and culturally acceptable and should be considered in delivering oral health services for young children in rural and remote locations. * The term Aboriginal is inclusive of Aboriginal and Torres Strait Islander peoples.

Fine sediment and flow velocity impact bacterial community and functional profile more than nutrient enrichment.

Freshwater ecosystems face many simultaneous pressures due to human activities. Consequently, there has been a rapid loss of freshwater biodiversity and an increase in biomonitoring programs. Our study assessed the potential of benthic stream bacterial communities as indicators of multiple-stressor impacts associated with urbanization and agricultural intensification. We conducted a fully crossed four-factor experiment in 64 flow-through mesocosms fed by a pristine montane stream (21 d of colonization, 21 d of manipulations) and investigated the effects of nutrient enrichment, flow-velocity reduction and added fine sediment after 2 and 3 weeks of stressor exposure. We used high-throughput sequencing and metabarcoding techniques (16S rRNA genes), as well as curated biological databases (METAGENassit, MetaCyc), to identify changes in bacterial relative abundances and predicted metabolic functional profile. Sediment addition and flow-velocity reduction were the most pervasive stressors. They both increased α-diversity and had strong taxon-specific effects on community composition and predicted functions. Sediment and flow velocity also interacted frequently, with 88% of all bacterial response variables showing two-way interactions and 33% showing three-way interactions including nutrient enrichment. Changes in relative abundances of common taxa were associated with shifts in dominant predicted functions, which can be extrapolated to underlaying stream-wide mechanisms such as carbon use and bacterial energy production pathways. Observed changes were largely stable over time and occurred after just 2 weeks of exposure, demonstrating that bacterial communities can be well-suited for early detection of multiple stressors. Overall, added sediment and reduced flow velocity impacted both bacterial community structure and predicted function more than nutrient enrichment. In future research and stream management, a holistic approach to studying multiple-stressor impacts should include multiple trophic levels with their functional responses, to enhance our mechanistic understanding of complex stressor effects and promote establishment of more efficient biomonitoring programs.

Minimally Invasive Dentistry Based on Atraumatic Restorative Treatment to Manage Early Childhood Caries in Rural and Remote Aboriginal Communities: Protocol for a Randomized Controlled Trial.

BACKGROUND: The caries experience of Aboriginal children in Western Australia (WA) and elsewhere in Australia is more than twice that of non-Aboriginal children. Early childhood caries (caries among children <6 years) has a significant impact on the quality of life of children and their caregivers, and its management is demanding and commonly undertaken under general anesthesia. A randomized controlled trial using a minimally invasive dentistry approach based on Atraumatic Restorative Treatment (ART) in metropolitan Perth, WA, has demonstrated a significant reduction in the rate of referral to a dental specialist for dental care among children with early childhood caries, potentially reducing the need for treatment under general anesthesia. The tested approach was clinically successful and was without adverse effects on child dental anxiety. The model of ART-based primary care requires further testing and development if similar outcomes for Aboriginal children in remote and rural settings are to be achieved. OBJECTIVE: The study aims to develop, implement, and evaluate a remote primary care model to deliver effective primary dental services, encompassing treatment and preventive services, to Aboriginal preschool children (based on minimally invasive approaches including ART). METHODS: This is a two-arm parallel cluster randomized controlled study in which a test group will be provided with the intervention treatment at the start of the study and a control group will be provided with the intervention treatment 12 months after study commencement (delayed intervention). Participating communities, stratified by size of community (ie, number of children in the sample frame) and baseline caries experience, will be randomly assigned using a computer-generated block randomized list into immediate (test group) or delayed intervention (control group; provided with standard care). Informed consent will be obtained from all participants. Aboriginal research assistants will explain the study to the parents and assist the parents in completing the questionnaires. Participants in the randomized study will be examined at baseline and at 12 months follow-up by a calibrated examiner. Test group participants will subsequently be contacted and appropriate appointments coordinated for treatment. Control group participants will be provided with standard preventive care by the Aboriginal Health Workers and managed for treatment as per standard procedures. RESULTS: Community consultations have been undertaken and 26 communities have agreed to participate. Fieldwork is in progress to recruit study participants. CONCLUSIONS: The significance of the study lies in its holistic approach to testing the model of care. Clinical evaluations as well as oral health‒related quality of life evaluations will be undertaken. Cost-effectiveness and cost-utility evaluations will assist in the development of policy options for oral health services for rural and remote communities. The elicitation of caregiver perspectives through focus group interviews will supplement the clinical, psychosocial, and cost-utility evaluations and provide a richer evaluation of the intervention. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616001537448; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371735 (Archived by WebCite at http://www.webcitation.org/70UMxndFZ). REGISTERED REPORT IDENTIFIER: RR1-10.2196/10322.

Mortality in a cohort of remote-living Aboriginal Australians and associated factors.

OBJECTIVES: We aimed to describe mortality in a cohort of remote-living Aboriginal Australians using electronic record linkage. METHODS: Between 2004 and 2006, 363 Aboriginal people living in remote Western Australia (WA) completed a questionnaire assessing medical history and behavioural risk factors. We obtained mortality records for the cohort from the WA Data Linkage System and compared them to data for the general population. We used Cox proportional hazards regression to identify predictors of mortality over a 9-year follow-up period. RESULTS: The leading causes of mortality were diabetes, renal failure, and ischaemic heart disease. Diabetes and renal failure accounted for 28% of all deaths. This differed from both the Australian population as a whole, and the general Indigenous Australian population. The presence of chronic disease did not predict mortality, nor did behaviours such as smoking. Only age, male sex, poor mobility, and cognitive impairment were risk factors. CONCLUSIONS: To reduce premature mortality, public health practitioners should prioritise the prevention and treatment of diabetes and renal disease in Aboriginal people in remote WA. This will require a sustained and holistic approach.

Arginine 123 of apolipoprotein A-I is essential for lecithin:cholesterol acyltransferase activity.

ApoA-I activates LCAT that converts lipoprotein cholesterol to cholesteryl ester (CE). Molecular dynamic simulations suggested earlier that helices 5 of two antiparallel apoA-I molecules on discoidal HDL form an amphipathic tunnel for migration of acyl chains and unesterified cholesterol to the active sites of LCAT. Our recent crystal structure of Δ(185-243)apoA-I showed the tunnel formed by helices 5/5, with two positively charged residues arginine 123 positioned at the edge of the hydrophobic tunnel. We hypothesized that these uniquely positioned residues Arg123 are poised for interaction with fatty acids produced by LCAT hydrolysis of the sn-2 chains of phosphatidylcholine, thus positioning the fatty acids for esterification to cholesterol. To test the importance of Arg123 for LCAT phospholipid hydrolysis and CE formation, we generated apoA-I[R123A] and apoA-I[R123E] mutants and made discoidal HDL with the mutants and WT apoA-I. Neither mutation of Arg123 changed the particle composition or size, or the protein conformation or stability. However, both mutations of Arg123 significantly reduced LCAT catalytic efficiency and the apparent Vmax for CE formation without affecting LCAT phospholipid hydrolysis. A control mutation, apoA-I[R131A], did not affect LCAT phospholipid hydrolysis or CE formation. These data suggest that Arg123 of apoA-I on discoidal HDL participates in LCAT-mediated cholesterol esterification.

Examining Burnout, Depression, and Self-Compassion in Veterans Affairs Mental Health Staff.

OBJECTIVES: Burnout, a state of emotional exhaustion associated with negative personal and occupational outcomes, is prevalent among healthcare providers. A better understanding of the psychological factors that may be associated with resilience to burnout is essential to develop effective interventions. Self-compassion, which includes kindness toward oneself, recognition of suffering as part of shared human experience, mindfulness, and nonjudgment toward inadequacies and failures, may be one such factor. The purpose of this study was to examine the relationships between burnout, depression, and self-compassion in Veterans Affairs (VA) mental health staff. DESIGN: Cross-sectional study. SETTING: VA medical center and affiliated community-based clinics. PARTICIPANTS: VA mental health staff. OUTCOME MEASURES: The 19-item Copenhagen Burnout Inventory, the 26-item Self-Compassion Scale, and the Patient Health Questionnaire 2-item depression screen. Demographic information included age, sex, years worked in current position, and number of staff supervised. RESULTS: One hundred and twenty-eight of a potential 379 individuals (33.8%) responded. Clerical support, nursing, social work, psychology, and psychiatry were the major professions represented. Self-compassion was inversely correlated with burnout (r = -0.41, p < 0.001), and inversely correlated with depression (rpb = -0.39, p < 0.001). The inverse relationship between self-compassion and burnout remained significant even after accounting for depressive symptoms and demographic variables in a multiple linear regression model. Of all the variables examined, self-compassion was the strongest predictor of burnout. CONCLUSIONS: The results of this study support the hypothesis that self-compassion may be associated with resilience to burnout. Alternatively, decreased self-compassion may be a downstream effect of increased burnout. Prospective, longitudinal studies are needed to determine the directional relationship between these factors, and whether interventions that cultivate self-compassion may decrease burnout and/or protect against its negative personal and professional outcomes.

Cross-sectional comparison of point-of-care with laboratory HbA1c in detecting diabetes in real-world remote Aboriginal settings.

OBJECTIVES: To determine if point-of-care (POC) glycated haemoglobin (HbA1c) is sufficiently accurate in real-world remote settings to predict or exclude the diagnosis of diabetes based on laboratory HbA1c measurements. DESIGN: Cross-sectional study comparing POC capillary HbA1c results with corresponding venous HbA1c levels measured in a reference laboratory. PARTICIPANTS: Aboriginal patients ≥15 years old who were due for diabetes screening at the participating clinics were invited to participate. Two hundred and fifty-five Aboriginal participants were enrolled and 241 were included in the analysis. SETTING: 6 primary healthcare sites in the remote Kimberley region of Western Australia from September 2011 to November 2013. MAIN OUTCOME MEASURES: Concordance and mean differences between POC capillary blood HbA1c measurement and laboratory measurement of venous blood HbA1c level; POC capillary blood HbA1c equivalence value for screening for diabetes or a high risk of developing diabetes; sensitivity, specificity and positive-predictive value for diagnosing and screening for diabetes; barriers to conducting POC testing. RESULTS: Concordance between POC and laboratory results was good (ρ=0.88, p<0.001). The mean difference was -0.15% (95% limits of agreement, -0.67% to 0.36%). POC HbA1c measurements ≥6.5%, 48 mmol/mol had a specificity of 98.2% and sensitivity of 73.7% for laboratory measurements ≥6.5%. The POC equivalence value for screening for diabetes or a high risk of developing diabetes was ≥5.7%, 39 mmol/mol (sensitivity, 91%; specificity, 76.7% for laboratory measurements ≥6.0%, 42 mmol/mol). Staff trained by other clinic staff 'on the job' performed as well as people with formal accredited training. Staff reported difficulty in maintaining formal accreditation. CONCLUSIONS: POC HbA1c testing is sufficiently accurate to be a useful component in screening for, and diagnosing, diabetes in remote communities. Limited local training is adequate to produce results comparable to laboratory results and accreditation processes need to reflect this.

A brief protocol for the Creative Psychosocial Genomic Healing Experience: the 4-Stage Creative Process in therapeutic hypnosis and brief psychotherapy.

The authors present empirical data on therapeutic hypnosis and brief psychotherapy as a 4-Stage Creative Process of focused attention and positive expectancy in professional training workshops of the American Society of Clinical Hypnosis, the National Institute for the Clinical Applications of Behavioral Medicine, and the Milton H. Erickson Foundation. The authors developed a brief protocol for assessing the 4-Stage Creative Process, which is the core dynamic of the Creative Psychosocial Genomic Healing Experience. They report that the 4-Stage Creative Process for resolving many psychological problems and symptomatic behavior in a satisfactory manner can be learned within 3 trials during 2-day professional workshops. The theory, research, and practice of private problem solving, stress reduction, and mind-body symptom resolution in professional and public settings is discussed. Immediate knowledge of results, positive peer support, and the development of new psychosocial skills in learning how to appropriately communicate live here-and-now novel and numinous experiences is an exhilarating exercise in creating new consciousness that facilitates the confidence and maturation of psychotherapists.

Crystal structure of C-terminal truncated apolipoprotein A-I reveals the assembly of high density lipoprotein (HDL) by dimerization.

Apolipoprotein A-I (apoA-I) plays important structural and functional roles in plasma high density lipoprotein (HDL) that is responsible for reverse cholesterol transport. However, a molecular understanding of HDL assembly and function remains enigmatic. The 2.2-Å crystal structure of Δ(185-243)apoA-I reported here shows that it forms a half-circle dimer. The backbone of the dimer consists of two elongated antiparallel proline-kinked helices (five AB tandem repeats). The N-terminal domain of each molecule forms a four-helix bundle with the helical C-terminal region of the symmetry-related partner. The central region forms a flexible domain with two antiparallel helices connecting the bundles at each end. The two-domain dimer structure based on helical repeats suggests the role of apoA-I in the formation of discoidal HDL particles. Furthermore, the structure suggests the possible interaction with lecithin-cholesterol acyltransferase and may shed light on the molecular details of the effect of the Milano, Paris, and Fin mutations.

A new bioinformatics paradigm for the theory, research, and practice of therapeutic hypnosis.

In a 2008 pilot study we used DNA microarrays to explore the historical ideo-plastic faculty of therapeutic hypnosis. We documented how to measure changes in activity or experience-dependent gene expression over relatively brief time periods (1 hour and 24 hours) following a single intervention of therapeutic hypnosis (about 1 hour). In the present paper we utilize bioinformatic software to explore the possible meaning and significance of this ideo-plastic faculty of therapeutic hypnosis. Indications suggest that the ideo-plastic process of therapeutic hypnosis may be associated with (1) the heightening of a molecular-genomic signature for the up-regulation (heightened activity) of genes characteristic of stem cell growth, (2) a reduction in cellular oxidative stress, and (3) a reduction in chronic inflammation. We identify these three empirical associations as an initial beta version of the molecular-genomic signature of the ideo-plastic process of therapeutic hypnosis, which can serve as a theoretical and practical guide for clinical excellence by beginners as well as senior professionals. We propose this molecular-genomic level of discourse as a supplement to the traditional cognitive-behavioral description of therapeutic suggestion, hypnosis, and psychotherapy that is consistent with "translational research" currently funded by the National Institute of Mental Health (NIMH).

Point-of-care testing of capillary glucose in the exclusion and diagnosis of diabetes in remote Australia.

OBJECTIVES: To determine the utility of point-of-care (POC) capillary blood glucose measurements in the diagnosis and exclusion of diabetes in usual practice in primary health care in remote areas. DESIGN: Cross-sectional study comparing POC capillary glucose results with corresponding venous glucose levels measured in a reference laboratory. PARTICIPANTS: 200 participants aged 16-65 years enrolled: 198 had POC capillary glucose measurements; 164 also had acceptable venous glucose laboratory results. SETTING: Seven health care sites in the Kimberley region of Western Australia from May to November 2006. MAIN OUTCOME MEASURES: Concordance and mean differences between POC capillary blood glucose measurement and laboratory measurement of venous blood glucose level; POC capillary blood glucose equivalence values for excluding and diagnosing diabetes, and their sensitivity, specificity and positive-predictive value. RESULTS: The concordance between POC and laboratory results was high (rho=0.93, P<0.001). The mean difference in results was 0.48 mmol/L (95% CI, 0.23-0.73; limits of agreement, - 2.6 to 3.6 mmol/L). The POC capillary glucose equivalence values for excluding and diagnosing diabetes were < 5.5 mmol/L (sensitivity, 53.3%; specificity, 94.4%; positive-predictive value, 88.9%; for a venous value of < 5.5 mmol/L) and >or= 12.2 mmol/L (sensitivity, 83.3%; specificity, 99.3%; positive-predictive value, 95.2%; for a venous value of >or= 11.1 mmol/L), respectively. While the choice of glucometer and whether or not patients were fasting altered these results, they did not have a significant influence on the diagnostic utility of POC glucose measurement in this setting. CONCLUSION: POC capillary blood glucose analysers can be used as part of the process of diagnosing and excluding diabetes in remote rural communities using these locally established capillary equivalence values.