Differences in Telemedicine Use Between People With and Without an Intellectual or Other Developmental Disability During the COVID-19 Pandemic.

Telemedicine utilization of people with an Intellectual or Other Developmental Disability (IDD) during the COVID-19 Pandemic is not well known. This study compares telemedicine utilization of those with and without IDD prior to the pandemic to after it began. Using the Utah All Payers Claims Database from 2019 to 2021, the study identified telemedicine utilization of adults aged 18 to 62 years old in 2019. Propensity score matching was used to minimize observed confounders of subjects with and without IDD in 2019. Negative binomial regression was used to identify factors that were associated with telemedicine utilization. The final number of subjects in the analysis was 18 204 (IDD: n = 6068, non-IDD: n = 12 136 based on 1:2 propensity score matching). The average (SD) age of the subjects was 31 (11.3) years old in 2019. Forty percent of the subjects were female, about 70% of subjects were covered by Medicaid in 2019. Average (SD) number of telemedicine use in 2020 (IDD: 1.96 (5.97), non-IDD: 1.18 (4.90); P < .01) and 2021 (IDD: 2.24 (6.78) vs 1.37 (5.13); P < .01) were higher for the IDD group than the non-IDD group. The regression results showed that the subjects with IDD had 56% more telemedicine encounters than those in the non-IDD group (Incidence Rate Ratio (IRR) = 1.56, P < .01). The growth of telemedicine during the COVID-19 pandemic has the potential to reduce persistent healthcare disparities in individuals with IDD. However, quality of telemedicine should be considered when it is provided to improve health of subjects with IDD.

Glioblastoma in Beckwith-Wiedemann syndrome: first case report and review of potential pathomechanisms.

Beckwith-Wiedemann syndrome (BWS) is a rare congenital overgrowth syndrome associated with certain childhood tumours. We present the case of a 36-year-old lady with BWS who developed a left frontoinsular secondary glioblastoma. This is the first case report in the literature of glioblastoma associated with BWS. We explore similarities in the molecular pathomechanisms of BWS and glioblastoma.

Impact of New Clinical Policies during the COVID-19 Pandemic on Clinical Incidents and Complaints at a UK Teaching Hospital.

BACKGROUND: To investigate any associations between new clinical policies implemented because of the COVID-19 pandemic and harm to patients. METHODS: Retrospective data collection of incidents and complaints reported through Datix®, and the Patient Advice and Liaison Service (PALS), respectively. The setting was the Family Health division in a University teaching hospital in the UK. Primary and secondary outcome measures included: the proportion of incidents reported on Datix® from 23 March 2020 to 29 May 2020, compared to the period from 23 March 2019 to 29 May 2019. COVID-19 related incidents and complaints and association with newly published guidelines or pathways from 23 March 2020 to 29 May 2020 were investigated. RESULTS: There was no significant difference in the proportion of overall patient activity resulting in incidents reported on Datix in 2020 (2.08%) compared to 2019 (2.09%), with 98% resulting in no/low harm in 2020. Three incident categories had increases in relative proportions of incidents including the terms "COVID" or "Corona" compared to incidents that did not: "Child death", "delay/failure to treatment and procedure" and "information governance". One of the child deaths was a miscarriage and we were unable to link the second child death to a change in clinical policy at this stage. We were only able to link two COVID-19 associated incidents with a pathway or procedural change (one to the Children's Emergency Department admission pathway and the second to the introduction of virtual antenatal clinics). Eighteen complaints related to COVID-19 were logged. However, at this stage, we are unable to link any of these to a published change in clinical policy. CONCLUSIONS: New policies introduced in the division, during the COVID-19 pandemic were associated with similar rates of clinical incidents, when compared with the previous year. There were only two COVID-19-related incidents clearly related to a change in pathways and procedures. Continued surveillance and improved metrics for monitoring the impact of changes to pathways and procedures should be sought with the sustained presence of COVID-19 in clinical areas.

A systematic review of intensive outpatient care programs for high-need, high-cost patients.

Five percent of the patient population accounts for 50% of U.S. healthcare expenditures. High-need, high-cost patients are medically complex for numerous reasons, often including behavioral health needs. Intensive outpatient care programs (IOCPs) are emerging, innovative clinics which provide patient-centered care leveraging multidisciplinary teams. The overarching goals of IOCPs are to reduce emergency department visits and hospitalizations (and related costs), and improve care continuity and patient outcomes. The purpose of this review was to examine the effectiveness of IOCPs on multiple outcomes to inform clinical care. A systematic search of the literature was conducted to identify articles. Six studies were included that varied in rigor of research design, analysis, and measurement of outcomes. Most studies reported results on healthcare utilization (n = 4) and costs (n = 3), with fewer reporting results on patient-reported and health-related outcomes (n = 2). Overall, there were decreasing trends in emergency department visits and hospitalizations. However, results on healthcare utilization varied based on time of follow-up, with shorter follow-up times yielding more significant results. Two of the three studies that evaluated costs found significant reductions associated with IOCPs, and the third was cost-neutral. Two studies reported improvements in patient-reported outcomes (e.g., satisfaction, depression, and anxiety). Overall, these programs reported positive impacts on healthcare utilization and costs; however, few studies evaluated patient characteristics and behaviors (e.g., engagement in care) which may serve as key mechanisms of program effectiveness. Future research should examine patient characteristics, behaviors, and clinic engagement metrics to inform clinical practice.

Evaluation of the intensive outpatient clinic: study protocol for a prospective study of high-cost, high-need patients in the University of Utah Health system.

INTRODUCTION: The University of Utah (UofU) Health intensive outpatient clinic (IOC) is a primary care clinic for medically complex (high-cost, high-need) patients with Medicaid. The clinic consists of a multidisciplinary care team aimed at providing coordinated, comprehensive and patient-centred care. The protocol outlines the quantitative design of an evaluation study to determine the IOC's effects on reducing healthcare utilisation and costs, as well as improving patient-reported health outcomes and quality of care. METHODS AND ANALYSIS: High-risk patients, with high utilisation and multiple chronic illnesses, were identified in the Medicaid ACO population managed by the UofU Health plans for IOC eligibility. A prospective, case-control study design is being used to match 100 IOC patients to 200 control patients (receiving usual care within the UofU) based on demographics, health utilisation and medical complexity for evaluating the primary outcome of change in healthcare utilisation and costs. For the secondary outcomes of patient health and care quality, a prepost design will be used to examine within-person change across the 18 months of follow-up (ie, before and after IOC intervention). Logistic regression and hierarchical, longitudinal growth modelling are the two primary modelling approaches. ETHICS AND DISSEMINATION: This work has received ethics approval by the UofU Institutional Review Board. Results from the evaluation of primary and secondary outcomes will be disseminated in scientific research journals and presented at national conferences.

Sun Navigation Requires Compass Neurons in Drosophila.

Despite their small brains, insects can navigate over long distances by orienting using visual landmarks [1], skylight polarization [2-9], and sun position [3, 4, 6, 10]. Although Drosophila are not generally renowned for their navigational abilities, mark-and-recapture experiments in Death Valley revealed that they can fly nearly 15 km in a single evening [11]. To accomplish such feats on available energy reserves [12], flies would have to maintain relatively straight headings, relying on celestial cues [13]. Cues such as sun position and polarized light are likely integrated throughout the sensory-motor pathway [14], including the highly conserved central complex [4, 15, 16]. Recently, a group of Drosophila central complex cells (E-PG neurons) have been shown to function as an internal compass [17-19], similar to mammalian head-direction cells [20]. Using an array of genetic tools, we set out to test whether flies can navigate using the sun and to identify the role of E-PG cells in this behavior. Using a flight simulator, we found that Drosophila adopt arbitrary headings with respect to a simulated sun, thus performing menotaxis, and individuals remember their heading preference between successive flights-even over several hours. Imaging experiments performed on flying animals revealed that the E-PG cells track sun stimulus motion. When these neurons are silenced, flies no longer adopt and maintain arbitrary headings relative to the sun stimulus but instead exhibit frontal phototaxis. Thus, without the compass system, flies lose the ability to execute menotaxis and revert to a simpler, reflexive behavior.

Flying Drosophilamelanogaster maintain arbitrary but stable headings relative to the angle of polarized light.

Animals must use external cues to maintain a straight course over long distances. In this study, we investigated how the fruit fly Drosophila melanogaster selects and maintains a flight heading relative to the axis of linearly polarized light, a visual cue produced by the atmospheric scattering of sunlight. To track flies' headings over extended periods, we used a flight simulator that coupled the angular velocity of dorsally presented polarized light to the stroke amplitude difference of the animals' wings. In the simulator, most flies actively maintained a stable heading relative to the axis of polarized light for the duration of 15 min flights. We found that individuals selected arbitrary, unpredictable headings relative to the polarization axis, which demonstrates that D. melanogaster can perform proportional navigation using a polarized light pattern. When flies flew in two consecutive bouts separated by a 5 min gap, the two flight headings were correlated, suggesting individuals retain a memory of their chosen heading. We found that adding a polarized light pattern to a light intensity gradient enhanced flies' orientation ability, suggesting D. melanogaster use a combination of cues to navigate. For both polarized light and intensity cues, flies' capacity to maintain a stable heading gradually increased over several minutes from the onset of flight. Our findings are consistent with a model in which each individual initially orients haphazardly but then settles on a heading which is maintained via a self-reinforcing process. This may be a general dispersal strategy for animals with no target destination.

Anatomical Reconstruction and Functional Imaging Reveal an Ordered Array of Skylight Polarization Detectors in Drosophila.

UNLABELLED: Many insects exploit skylight polarization as a compass cue for orientation and navigation. In the fruit fly, Drosophila melanogaster, photoreceptors R7 and R8 in the dorsal rim area (DRA) of the compound eye are specialized to detect the electric vector (e-vector) of linearly polarized light. These photoreceptors are arranged in stacked pairs with identical fields of view and spectral sensitivities, but mutually orthogonal microvillar orientations. As in larger flies, we found that the microvillar orientation of the distal photoreceptor R7 changes in a fan-like fashion along the DRA. This anatomical arrangement suggests that the DRA constitutes a detector for skylight polarization, in which different e-vectors maximally excite different positions in the array. To test our hypothesis, we measured responses to polarized light of varying e-vector angles in the terminals of R7/8 cells using genetically encoded calcium indicators. Our data confirm a progression of preferred e-vector angles from anterior to posterior in the DRA, and a strict orthogonality between the e-vector preferences of paired R7/8 cells. We observed decreased activity in photoreceptors in response to flashes of light polarized orthogonally to their preferred e-vector angle, suggesting reciprocal inhibition between photoreceptors in the same medullar column, which may serve to increase polarization contrast. Together, our results indicate that the polarization-vision system relies on a spatial map of preferred e-vector angles at the earliest stage of sensory processing. SIGNIFICANCE STATEMENT: The fly's visual system is an influential model system for studying neural computation, and much is known about its anatomy, physiology, and development. The circuits underlying motion processing have received the most attention, but researchers are increasingly investigating other functions, such as color perception and object recognition. In this work, we investigate the early neural processing of a somewhat exotic sense, called polarization vision. Because skylight is polarized in an orientation that is rigidly determined by the position of the sun, this cue provides compass information. Behavioral experiments have shown that many species use the polarization pattern in the sky to direct locomotion. Here we describe the input stage of the fly's polarization-vision system.

Functional divisions for visual processing in the central brain of flying Drosophila.

Although anatomy is often the first step in assigning functions to neural structures, it is not always clear whether architecturally distinct regions of the brain correspond to operational units. Whereas neuroarchitecture remains relatively static, functional connectivity may change almost instantaneously according to behavioral context. We imaged panneuronal responses to visual stimuli in a highly conserved central brain region in the fruit fly, Drosophila, during flight. In one substructure, the fan-shaped body, automated analysis revealed three layers that were unresponsive in quiescent flies but became responsive to visual stimuli when the animal was flying. The responses of these regions to a broad suite of visual stimuli suggest that they are involved in the regulation of flight heading. To identify the cell types that underlie these responses, we imaged activity in sets of genetically defined neurons with arborizations in the targeted layers. The responses of this collection during flight also segregated into three sets, confirming the existence of three layers, and they collectively accounted for the panneuronal activity. Our results provide an atlas of flight-gated visual responses in a central brain circuit.

Cellular mechanisms for integral feedback in visually guided behavior.

Sensory feedback is a ubiquitous feature of guidance systems in both animals and engineered vehicles. For example, a common strategy for moving along a straight path is to turn such that the measured rate of rotation is zero. This task can be accomplished by using a feedback signal that is proportional to the instantaneous value of the measured sensory signal. In such a system, the addition of an integral term depending on past values of the sensory input is needed to eliminate steady-state error [proportional-integral (PI) control]. However, the means by which nervous systems implement such a computation are poorly understood. Here, we show that the optomotor responses of flying Drosophila follow a time course consistent with temporal integration of horizontal motion input. To investigate the cellular basis of this effect, we performed whole-cell patch-clamp recordings from the set of identified visual interneurons [horizontal system (HS) cells] thought to control this reflex during tethered flight. At high stimulus speeds, HS cells exhibit steady-state responses during flight that are absent during quiescence, a state-dependent difference in physiology that is explained by changes in their presynaptic inputs. However, even during flight, the membrane potential of the large-field interneurons exhibits no evidence for integration that could explain the behavioral responses. However, using a genetically encoded indicator, we found that calcium accumulates in the terminals of the interneurons along a time course consistent with the behavior and propose that this accumulation provides a mechanism for temporal integration of sensory feedback consistent with PI control.

Central complex neurons exhibit behaviorally gated responses to visual motion in Drosophila.

Sensory systems provide abundant information about the environment surrounding an animal, but only a small fraction of that information is relevant for any given task. One example of this requirement for context-dependent filtering of a sensory stream is the role that optic flow plays in guiding locomotion. Flying animals, which do not have access to a direct measure of ground speed, rely on optic flow to regulate their forward velocity. This observation suggests that progressive optic flow, the pattern of front-to-back motion on the retina created by forward motion, should be especially salient to an animal while it is in flight, but less important while it is standing still. We recorded the activity of cells in the central complex of Drosophila melanogaster during quiescence and tethered flight using both calcium imaging and whole cell patch-clamp techniques. We observed a genetically identified set of neurons in the fan-shaped body that are unresponsive to visual motion while the animal is quiescent. During flight their baseline activity increases, and they respond to front-to-back motion with changes relative to this baseline. The results provide an example of how nervous systems selectively respond to complex sensory stimuli depending on the current behavioral state of the animal.

Flying Drosophila orient to sky polarization.

Insects maintain a constant bearing across a wide range of spatial scales. Monarch butterflies and locusts traverse continents [1, 2], and foraging bees and ants travel hundreds of meters to return to their nests [1, 3, 4], whereas many other insects fly straight for only a few centimeters before changing direction. Despite this variation in spatial scale, the brain region thought to underlie long-distance navigation is remarkably conserved [5, 6], suggesting that the use of a celestial compass is a general and perhaps ancient capability of insects. Laboratory studies of Drosophila have identified a local search mode in which short, straight segments are interspersed with rapid turns [7, 8]. However, this flight mode is inconsistent with measured gene flow between geographically separated populations [9-11], and individual Drosophila can travel 10 km across desert terrain in a single night [9, 12, 13]-a feat that would be impossible without prolonged periods of straight flight. To directly examine orientation behavior under outdoor conditions, we built a portable flight arena in which a fly viewed the natural sky through a liquid crystal device that could experimentally rotate the polarization angle. Our findings indicate that Drosophila actively orient using the sky's natural polarization pattern.

Identifying respiratory viruses in nasal mucus from children.

Large amounts of respiratory viruses are shed in nasal secretions by children. Nasal mucus was compared with nasopharyngeal swabs as a source for respiratory virus testing. Multiplex reverse transcription-polymerase chain reaction detected virus in nasal mucus specimens in 73% (11/15) of positive cases, demonstrating the potential utility of less invasive specimens when a highly sensitive method is used for respiratory virus detection.

The incidence of fibromyalgia and its associated comorbidities: a population-based retrospective cohort study based on International Classification of Diseases, 9th Revision codes.

BACKGROUND: The epidemiology of fibromyalgia is poorly defined. The incidence of fibromyalgia has not been determined using a large population base. Previous studies based on prevalence data demonstrated that females are 7 times more likely to have fibromyalgia than males and that the peak age for females is during the childbearing years. OBJECTIVE: We have calculated the incidence rate of fibromyalgia in a large, stable population and determined the strength of association between fibromyalgia and 7 comorbid conditions. METHODS: We conducted a retrospective cohort study of a large, stable health insurance claims database (62,000 nationwide enrollees per year). Claims from 1997 to 2002 were examined using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify fibromyalgia cases (ICD code 729.1) and 7 predetermined comorbid conditions. RESULTS: A total of 2595 incident cases of fibromyalgia were identified between 1997 and 2002. Age-adjusted incidence rates were 6.88 cases per 1000 person-years for males and 11.28 cases per 1000 person-years for females. Females were 1.64 times (95% confidence interval = 1.59-1.69) more likely than males to have fibromyalgia. Patients with fibromyalgia were 2.14 to 7.05 times more likely to have one or more of the following comorbid conditions: depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, and rheumatoid arthritis. CONCLUSION: Females are more likely to be diagnosed with fibromyalgia than males, although to a substantially smaller degree than previously reported, and there are strong associations for comorbid conditions that are commonly thought to be associated with fibromyalgia.