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Tele-mental health (TMH) services, including both mental and behavioral healthcare (MBH) services, emerged as a cornerstone in delivering pediatric mental healthcare during the coronavirus disease 2019 (COVID-19) pandemic, yet their utilization and effects on healthcare resource utilization (HCRU) and medical expenditures remain unclear. To bridge the gap, this study aims to investigate the association between TMH utilization and sociodemographic factors and assess its associated HCRU and medical expenditures within a pediatric population in Mississippi. Studying 1,972 insured pediatric patients who accessed outpatient MBH services at the study institution between January 2020 and June 2023, age, race, insurance type, rural residency, and household income were identified as key determinants of TMH utilization. Adjusting for sociodemographics, TMH utilization was associated with 122% more MBH-associated outpatient visits and 36% higher related medical expenditures, but 27% less overall medical expenditures. This study reveals sociodemographic disparities in pediatric TMH utilization, highlights its role in augmenting outpatient mental healthcare access, and shows its potential for cost savings. Future efforts should aim at fostering more digitally inclusive, equitable, and affordable pediatric mental healthcare services.
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Background: Valid, reliable and cross-cultural equivalent scales and measurement instruments that enable comparisons across diverse populations in different countries are important for global health research and practice. We developed a 10-step framework through a scoping review of the common strategies and techniques used for scale development and validation in a cross-cultural, multi-lingual, or multi-country setting, especially in health care research. Methods: We searched MEDLINE, Embase, and PsycINFO for peer-reviewed studies that collected data from two or more countries or in two or more languages at any stages of scale development or validation and published between 2010-22. We categorised the techniques into three commonly used scale development and validation stages (item generation, scale development, and scale evaluation) as well as during the translation stage. We described the most commonly used techniques at each stage. Results: We identified 141 studies that were included in the analysis. We summarised 14 common techniques and strategies, including focus groups or interviews with diverse target populations, and involvement of measurement experts and linguists for item content validity expert panel at the item generation stage; back-and-forth translation, collaborative team approach for the translation stage; cognitive interviews and different recruitment strategies and incentives in different settings for scale development stage; and three approaches for measurement invariance (multigroup confirmatory factor analysis, differential item functioning and multiple indicator multiple causes) for scale evaluation stage. Conclusions: We provided a 10-step framework for cross-cultural, multi-lingual or multi-country scale development and validation based on these techniques and strategies. More research and synthesis are needed to make scale development more culturally competent and enable scale application to better meet local health and development needs.
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Investigación sobre Servicios de Salud , Humanos , Comparación Transcultural , Reproducibilidad de los Resultados , PsicometríaRESUMEN
During the COVID-19 pandemic, tele-mental health (TMH) was a viable approach for providing accessible mental and behavioral health (MBH) services. This study examines the sociodemographic disparities in TMH utilization and its effects on healthcare resource utilization (HCRU) and medical expenditures in Mississippi. Utilizing a cohort of 6787 insured adult patients at the University of Mississippi Medical Center and its affiliated sites between January 2020 and June 2023, including 3065 who accessed TMH services, we observed sociodemographic disparities between TMH and non-TMH cohorts. The TMH cohort was more likely to be younger, female, White/Caucasian, using payment methods other than Medicare, Medicaid, or commercial insurers, residing in rural areas, and with higher household income compared to the non-TMH cohort. Adjusting for sociodemographic factors, TMH utilization was associated with a 190% increase in MBH-related outpatient visits, a 17% increase in MBH-related medical expenditures, and a 12% decrease in all-cause medical expenditures (all p < 0.001). Among rural residents, TMH utilization was associated with a 205% increase in MBH-related outpatient visits and a 19% decrease in all-cause medical expenditures (both p < 0.001). This study underscores the importance of addressing sociodemographic disparities in TMH services to promote equitable healthcare access while reducing overall medical expenditures.
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COVID-19 , Gastos en Salud , Accesibilidad a los Servicios de Salud , Telemedicina , Humanos , COVID-19/epidemiología , COVID-19/economía , Mississippi/epidemiología , Femenino , Masculino , Gastos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Persona de Mediana Edad , Adulto , Telemedicina/estadística & datos numéricos , Telemedicina/economía , Servicios de Salud Mental/estadística & datos numéricos , Servicios de Salud Mental/economía , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/estadística & datos numéricos , Anciano , Pandemias/economía , SARS-CoV-2 , Adulto JovenRESUMEN
Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.
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Trastorno Depresivo Mayor , Medicaid , Telemedicina , Humanos , Medicaid/estadística & datos numéricos , Mississippi , Femenino , Masculino , Estados Unidos , Telemedicina/estadística & datos numéricos , Estudios Retrospectivos , Adulto , Persona de Mediana Edad , Trastorno Depresivo Mayor/terapia , Adulto Joven , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Factores Sociodemográficos , Gastos en Salud/estadística & datos numéricos , Factores Socioeconómicos , Factores de Edad , Anciano , Teleterapia de Salud MentalRESUMEN
The psychological safety of health care workers is an important but often overlooked aspect of the rising rates of burnout and workforce shortages. In addition, mental health conditions are prevalent among health care workers, but the associated stigma is a significant barrier to accessing adequate care. More efforts are therefore needed to foster health care work environments that are safe and supportive of self-care. The purpose of this brief document is to promote a culture of psychological safety in health care organizations. We review ways in which organizations can create a psychologically safe workplace, the benefits of a psychologically safe workplace, and strategies to promote mental health and reduce suicide risk.
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American Heart Association , Personal de Salud , Salud Mental , Humanos , Personal de Salud/psicología , Estados Unidos , Agotamiento Profesional/psicología , Agotamiento Profesional/prevención & control , Agotamiento Profesional/epidemiología , Lugar de Trabajo/psicología , Salud Laboral , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/psicología , Seguridad PsicológicaRESUMEN
Background: Telemental health (TMH) offers a promising approach to managing major depressive disorder (MDD). The objective of our work was to evaluate TMH usage among a vulnerable population of MDD Medicare beneficiaries and its association with health care utilization and expenditures. Methods: This cohort study analyzed 2019 Mississippi Medicare fee-for-service data for adult beneficiaries with MDD. Subjects were matched by the use of TMH following 1:1 propensity score matching. Comparisons between TMH and non-TMH cohorts were made on health care utilization and expenditure outcomes, adjusting for provider types postmatching. Results: Among 7,673 identified beneficiaries, 551 used TMH and 7,122 did not. Prematching, TMH cohort showed greater proportions of dual beneficiaries, rural residents, subjects with income below $40,000, those with disability entitlement, and higher Charlson comorbidity index scores, compared to the non-TMH cohort (all p < 0.001). Moreover, the TMH cohort had fewer outpatient visits, but more inpatient admissions, emergency department (ED) visits, and higher medical, pharmacy, and total expenditures (all p < 0.001). Postmatching, TMH was associated with a 25% reduction in outpatient visits (p < 0.001) and a 20% reduction in pharmacy expenditures (p = 0.01), with no significant effect on inpatient admissions, ED visits, medical expenditures, or total expenditures. Conclusions: These results underscore the potential of TMH in enhancing accessible health care services for vulnerable populations and affordable services for Medicare. Our results provide a robust baseline for future policy discussions concerning TMH. Future studies should consider identifying barriers to TMH use among vulnerable populations and ensuring equitable and high-quality patient care.
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Trastorno Depresivo Mayor , Gastos en Salud , Medicare , Aceptación de la Atención de Salud , Puntaje de Propensión , Telemedicina , Humanos , Estados Unidos , Medicare/estadística & datos numéricos , Medicare/economía , Femenino , Masculino , Anciano , Gastos en Salud/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Telemedicina/economía , Telemedicina/estadística & datos numéricos , Trastorno Depresivo Mayor/terapia , Trastorno Depresivo Mayor/economía , Mississippi , Anciano de 80 o más Años , Persona de Mediana Edad , Poblaciones Vulnerables/estadística & datos numéricos , Estudios de Cohortes , Teleterapia de Salud MentalRESUMEN
Routine surveys are used to understand the training quality and experiences of junior doctors but there are lack of tools designed to evaluate the training experiences of interns in low-income and middle-income countries (LMICs) where working conditions and resource constraints are challenging. We describe our process developing and validating a 'medical internship experience scale' to address this gap, work involving nine LMICs that varied in geographical locations, income-level and internship training models. We used a scoping review of existing tools, content validity discussions with target populations and an expert panel, back-and-forth translations into four language versions and cognitive interviews to develop and test the tool. Using data collected from 1646 interns and junior medical doctors, we assessed factor structure and assessed its reliability and validity. Fifty items about experiences of medical internship were retained from an initial pool of 102 items. These 50 items represent 6 major factors (constructs): (1) clinical learning and supervision, (2) patient safety, (3) job satisfaction, (4) stress and burnout, (5) mental well-being, and (6) fairness and discrimination. We reflect on the process of multicountry scale development and highlight some considerations for others who may use our scale, using preliminary analyses of the 1646 responses to illustrate that the tool may produce useful data to identify priorities for action. We suggest this tool could enable LMICs to assess key metrics regarding intern straining and initial work experiences and possibly allow comparison across countries and over time, to inform better internship planning and management.
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Internado y Residencia , Médicos , Humanos , Países en Desarrollo , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
Central to an understanding of the physical nature of biosystems is an apprehension of their ability to control entropy dynamics in their environment. To achieve ongoing stability and survival, living systems must adaptively respond to incoming information signals concerning matter and energy perturbations in their biological continuum (biocontinuum). Entropy dynamics for the living system are then determined by the natural drive for reconciliation of these information divergences in the context of the constraints formed by the geometry of the biocontinuum information space. The configuration of this information geometry is determined by the inherent biological structure, processes and adaptive controls that are necessary for the stable functioning of the organism. The trajectory of this adaptive reconciliation process can be described by an information-theoretic formulation of the living system's procedure for actionable knowledge acquisition that incorporates the axiomatic inference of the Kullback principle of minimum information discrimination (a derivative of Jaynes' principle of maximal entropy). Utilizing relative information for entropic inference provides for the incorporation of a background of the adaptive constraints in biosystems within the operations of Fisher biologic replicator dynamics. This mathematical expression for entropic dynamics within the biocontinuum may then serve as a theoretical framework for the general analysis of biological phenomena.
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Importance: Given the rapid increase in telehealth utilization since the onset of the COVID-19 pandemic, it has become essential to examining the vast amount of available data on telehealth encounters to conduct more cogent, robust, and large-scope research studies to examine the utility, cost-impact, and effect on clinical outcomes that telehealth can potentially provide. However, the diversity of data collected by numerous telehealth organizations has made that type of analysis difficult. Objective: The University of Mississippi Medical Center (UMMC), a Telehealth Center of Excellence designated by the Health Resources and Services Administration, is creating a National Telehealth Data Warehouse. Design: UMMC will develop the data warehouse in Microsoft Azure and will use a data dictionary that was created by the Center for Telehealth and eHealth Law (CTeL) to support their national cost-benefit study on the use of telehealth during COVID-19. Impact: The data warehouse will provide unparalleled opportunities to conduct cost-benefit and cost-effectiveness analyses on telehealth, to develop and test quality measures specific to telehealth, and to understand how telehealth and reduce disparities in health care and expand access to care for everyone. The warehouse is expected to go live in the Summer of 2023.
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COVID-19 , Telemedicina , Humanos , COVID-19/epidemiología , Pandemias , Data Warehousing , HospitalesRESUMEN
During the COVID-19 pandemic and public health emergency, telehealth programs vastly expanded with strong support from various federal and state agencies. However, the uncertainty regarding future reimbursement policies for telehealth services has resulted in concerns about long-term sustainability of innovative health service delivery models beyond the financial support. Given the limited literature on creating telehealth programs with long-term sustainability in consideration, we have developed a framework for gathering appropriate data during various stages of program implementation to evaluate clinical effectiveness and economic sustainability that is applicable across various settings, with additional attention to health equity. Recognizing the difficulty of sustaining telehealth programs solely through a fee-for-service payment model, we encourage all telehealth stakeholders, especially payers and policymakers, to consider cost-effectiveness of telehealth programs and support alternate payment models for ensuring long-term sustainability.
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COVID-19 , Telemedicina , Humanos , COVID-19/epidemiología , Pandemias , Telemedicina/métodosRESUMEN
CONTEXT: Metformin is the first-line drug for treating diabetes but has a high failure rate. OBJECTIVE: To identify demographic and clinical factors available in the electronic health record (EHR) that predict metformin failure. METHODS: A cohort of patients with at least 1 abnormal diabetes screening test that initiated metformin was identified at 3 sites (Arizona, Mississippi, and Minnesota). We identified 22 047 metformin initiators (48% female, mean age of 57 ± 14 years) including 2141 African Americans, 440 Asians, 962 Other/Multiracial, 1539 Hispanics, and 16 764 non-Hispanic White people. We defined metformin failure as either the lack of a target glycated hemoglobin (HbA1c) (<7%) within 18 months of index or the start of dual therapy. We used tree-based extreme gradient boosting (XGBoost) models to assess overall risk prediction performance and relative contribution of individual factors when using EHR data for risk of metformin failure. RESULTS: In this large diverse population, we observed a high rate of metformin failure (43%). The XGBoost model that included baseline HbA1c, age, sex, and race/ethnicity corresponded to high discrimination performance (C-index of 0.731; 95% CI 0.722, 0.740) for risk of metformin failure. Baseline HbA1c corresponded to the largest feature performance with higher levels associated with metformin failure. The addition of other clinical factors improved model performance (0.745; 95% CI 0.737, 0.754, P < .0001). CONCLUSION: Baseline HbA1c was the strongest predictor of metformin failure and additional factors substantially improved performance suggesting that routinely available clinical data could be used to identify patients at high risk of metformin failure who might benefit from closer monitoring and earlier treatment intensification.
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Diabetes Mellitus Tipo 2 , Metformina , Humanos , Adulto , Persona de Mediana Edad , Anciano , Metformina/uso terapéutico , Hipoglucemiantes/uso terapéutico , Registros Electrónicos de Salud , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Hemoglobina Glucada , Reposicionamiento de Medicamentos , Estudios RetrospectivosRESUMEN
BACKGROUND: Mental illness among physicians is an increasingly recognized concern. Global data on mental health conditions (MHCs) among cardiologists are limited. OBJECTIVES: The purpose of this study was to investigate the global prevalence of MHCs among cardiologists and its relationships to professional life. METHODS: The American College of Cardiology conducted an online survey with 5,931 cardiologists globally in 2019. Data on demographics, practice, MHC, and association with professional activities were analyzed. The P values were calculated using the chi-square, Fischer exact, and Mann-Whitney U tests. Univariate and multivariate logistic regression analysis determined the association of characteristics with MHC. RESULTS: Globally, 1 in 4 cardiologists experience any self-reported MHC, including psychological distress, or major or other psychiatric disorder. There is significant geographic variation in MHCs, with highest and lowest prevalences in South America (39.3%) and Asia (20.1%) (P < 0.001). Predictors of MHCs included experiencing emotional harassment (OR: 2.81; 95% CI: 2.46-3.20), discrimination (OR: 1.85; 95% CI: 1.61-2.12), being divorced (OR: 1.85; 95% CI: 1.27-2.36), and age <55 years (OR: 1.43; 95% CI: 1.24-1.66). Women were more likely to consider suicide within the past 12 months (3.8% vs 2.3%), but were also more likely to seek help (42.3% vs 31.1%) as compared with men (all P < 0.001). Nearly one-half of cardiologists reporting MHCs (44%) felt dissatisfied on at least one professional metric including feeling valued, treated fairly, and adequate compensation. CONCLUSIONS: More than 1 in 4 cardiologists experience self-reported MHCs globally, and the association with adverse experiences in professional life is substantial. Dedicated efforts toward prevention and treatment are needed to maximize the contributions of affected cardiologists.
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Cardiólogos , Cardiología , Trastornos Mentales , Masculino , Humanos , Femenino , Estados Unidos/epidemiología , Persona de Mediana Edad , Salud Mental , Cardiólogos/psicología , Prevalencia , Trastornos Mentales/epidemiologíaRESUMEN
Wheat yields have plateaued in the UK over the last 25 years, during which time most arable land has been annually cropped continuously with short rotations dominated by cereals. Arable intensification has depleted soil organic matter and biology, including mycorrhizas, which are affected by tillage, herbicides, and crop genotype. Here, we test whether winter wheat yields, mycorrhization, and shoot health can be improved simply by adopting less intensive tillage and adding commercial mycorrhizal inoculum to long-term arable fields, or if 3-year grass-clover leys followed direct drilling is more effective for biological regeneration of soil with reduced N fertiliser. We report a trial of mycorrhization, ear pathology, and yield performance of the parents and four double haploid lines from the Avalon x Cadenza winter wheat population in a long-term arable field that is divided into replicated treatment plots. These plots comprised wheat lines grown using ploughing or disc cultivation for 3 years, half of which received annual additions of commercial arbuscular mycorrhizal (AM) inoculum, compared to 3-year mown grass-clover ley plots treated with glyphosate and direct-drilled. All plots annually received 35 kg of N ha-1 fertiliser without fungicides. The wheat lines did not differ in mycorrhization, which averaged only 34% and 40% of root length colonised (RLC) in the ploughed and disc-cultivated plots, respectively, and decreased with inoculation. In the ley, RLC increased to 52%. Two wheat lines were very susceptible to a sooty ear mould, which was lowest in the ley, and highest with disc cultivation. AM inoculation reduced ear infections by >50% in the susceptible lines. In the ley, yields ranged from 7.2 to 8.3 t ha-1, achieving 92 to 106% of UK average wheat yield in 2018 (7.8 t ha-1) but using only 25% of average N fertiliser. Yields with ploughing and disc cultivation averaged only 3.9 and 3.4 t ha-1, respectively, with AM inoculum reducing yields from 4.3 to 3.5 t ha-1 in ploughed plots, with no effect of disc cultivation. The findings reveal multiple benefits of reintegrating legume-rich leys into arable rotations as part of a strategy to regenerate soil quality and wheat crop health, reduce dependence on nitrogen fertilisers, enhance mycorrhization, and achieve good yields.
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Residency program directors' careers follow several trajectories. For many, the role is relatively short term, lasting 3 to 5 years, during which time the program director may gain educational and administrative experience. However, a sizeable cohort of program directors have remained as program directors for a decade or more, and some have filled the role for the majority of their careers. Over the years, the role of the academic residency program director has become increasingly affected by administrative responsibilities, including scheduling, documentation, and reporting requirements, along with increasing clinical demands that may conflict with ensuring resident wellness and lead to insufficient time to do the job. Burnout in this role is understandable. Given these obstacles, why should any young faculty member choose to become a training director? The authors of this commentary have each served as a residency program director for decades, aggregating approximately 150 years of program director experiences. Based on their collective reflections, the authors describe social and interpersonal aspects of the program director role that have enhanced their professional satisfaction and well-being. These include overseeing residency cycle events from initial interviews through graduation and certification; assuming leadership and social roles in academic departments; counseling, mentoring, and assisting residents with work-personal life difficulties; and helping trainees and programs weather a variety of traumatic circumstances. These life-enriching experiences can compensate for the challenging aspects of these roles and sustain program directors through exceptionally rewarding careers.
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Agotamiento Profesional , Internado y Residencia , Humanos , Mentores , Certificación , Docentes , Encuestas y CuestionariosRESUMEN
Importance: American Indian and Alaska Native populations have some of the highest COVID-19 hospitalization and mortality rates in the US, with those in Mississippi being disparately affected. Higher COVID-19 mortality rates among Indigenous populations are often attributed to a higher comorbidity burden, although examinations of these associations are scarce, and none were believed to have included individuals hospitalized in Mississippi. Objective: To evaluate whether racial mortality differences among adults hospitalized with COVID-19 are associated with differential comorbidity experiences. Design, Setting, and Participants: The described cross-sectional study used retrospective hospital discharge data from the Mississippi Inpatient Outpatient Data System. All adult (aged ≥18 years) Mississippians of a known racial identity and who had been hospitalized with COVID-19 from March 1 to December 31, 2020, in any of the state's 103 nonfederal hospitals were included. Data were abstracted on June 17, 2021. Exposure: Racial identity. Main Outcomes and Measures: In-hospital mortality as indicated by discharge status. Results: A total of 18 731 adults hospitalized with a COVID-19 diagnosis and known racial identity were included (median age, 66 [IQR, 53-76] years; 10 109 [54.0%] female; 225 [1.2%] American Indian and Alaska Native; 9191 [49.1%] Black; and 9121 [48.7%] White). Pooling across comorbidity risk groups, odds of in-hospital mortality among Black patients were 75% lower than among American Indian and Alaska Native patients (odds ratio [OR], 0.25 [95% CI, 0.18-0.34]); odds of in-hospital death among White patients were 77% lower (OR, 0.23 [95% CI, 0.16-0.31]). Within comorbidity risk group analyses, Indigenous patients with the lowest risk (Elixhauser Comorbidity Index score ≤0) had an adjusted probability of in-hospital death of 0.10 compared with 0.03 for Black patients (OR, 0.29 [95% CI, 0.10-0.82]) and 0.04 for White patients (OR, 0.37 [95% CI, 0.13-1.07]). Probability of in-hospital death at the highest comorbidity risk levels (Elixhauser Comorbidity Index score ≥16) was 0.69 for American Indian and Alaska Native patients compared with 0.28 for Black patients (OR, 0.16 [95% CI, 0.08-0.32]) and 0.25 for White patients (OR, 0.14 [95% CI, 0.07-0.27]). Conclusions and Relevance: This cross-sectional study of US adults hospitalized with COVID-19 found that American Indian and Alaska Native patients had lower comorbidity risk scores than those observed among Black or White patients. Despite empirical associations between reduced comorbidity risk scores and reduced odds of inpatient mortality, American Indian and Alaska Native patients were significantly more likely to die in the hospital of COVID-19 than Black or White patients at every level of comorbidity risk. Alternative factors that may contribute to high mortality rates among Indigenous populations must be investigated.
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COVID-19 , Indígenas Norteamericanos , Adolescente , Adulto , Anciano , Prueba de COVID-19 , Estudios Transversales , Femenino , Mortalidad Hospitalaria , Humanos , Estudios RetrospectivosRESUMEN
BACKGROUND: Long-standing health disparities experienced by American Indians (AIs) are associated with increased all-cause mortality rates and shortened life expectancies when compared to other races and ethnicities. Nationally, these disparities have persisted with the COVID-19 pandemic as AIs are more likely than all other races to be infected, hospitalized, or die from SARS-CoV-2. The Mississippi Band of Choctaw Indians, the only federally recognized American Indian tribe in the state, has been one of the hardest hit in the nation. METHODS: Using de-identified data from the University of Mississippi Medical Center's COVID-19 Research Registry, a retrospective cohort study was conducted to assess COVID-19 inpatient mortality outcomes among adults (≥ age 18) admitted at the state's safety net hospital in 2020. RESULTS: Exactly 41% (n = 25) of American Indian adults admitted with a deemed diagnosis of COVID-19 died while in hospital, in comparison to 19% (n = 153) of blacks and 23% (n = 65) of whites. Racial disparities persisted even when controlling for those risk factors the CDC reported put adults at greatest risk of severe outcomes from the disease. The adjusted probability of inpatient mortality among American Indians was 46% (p < 0.00) in comparison to 19% among blacks and 20% among whites. CONCLUSION: Although comorbidities were commonly observed among COVID-19 + American Indian inpatients, only one was associated with inpatient mortality. This challenges commonly cited theories attributing disparate COVID-19 mortality experiences among indigenous populations to disparate comorbidity experiences. Expanded studies are needed to further investigate these associations.
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COVID-19 , Adulto , Humanos , Estados Unidos , Adolescente , SARS-CoV-2 , Pandemias , Pacientes Internos , Proveedores de Redes de Seguridad , Estudios Retrospectivos , Indio Americano o Nativo de AlaskaRESUMEN
Leaf function is influenced by leaf structure, which is itself related not only to the spatial arrangement of constituent mesophyll cells, but also their size and shape. In this study, we used confocal microscopy to image leaves of Triticum genotypes varying in ploidy level to extract 3D information on individual mesophyll cell size and geometry. Combined with X-ray Computed Tomography and gas exchange analysis, the effect of changes in wheat mesophyll cell geometry upon leaf structure and function were investigated. Mesophyll cell size and shape were found to have changed during the course of wheat evolution. An unexpected linear relationship between mesophyll cell surface area and volume was discovered, suggesting anisotropic scaling of mesophyll cell geometry with increasing ploidy. Altered mesophyll cell size and shape were demonstrated to be associated with changes in mesophyll tissue architecture. Under experimental growth conditions, CO2 assimilation did not vary with ploidy, but stomatal conductance was lower in hexaploid plants, conferring a greater instantaneous water-use efficiency. We propose that as wheat mesophyll cells have become larger with increased ploidy, this has been accompanied by changes in cell geometry and packing which limit water loss while maintaining carbon assimilation.