In-home Visits and Subsequent Health Outcomes in Medicare Advantage Beneficiaries With Coronary Artery Disease, Diabetes, Hypertension, and Depression.

BACKGROUND: Coronary artery disease, diabetes, hypertension, and depression are common burdensome conditions. OBJECTIVES: To examine whether multidimensional preventive in-home visits were associated with fewer emergency and inpatient care episodes and higher quality of care. RESEARCH DESIGN: An observational, retrospective data analysis. SUBJECTS: A nationwide Medicare Advantage population from the Optum Labs Data Warehouse. MEASURES: We compared beneficiaries with 1 or more of the conditions with an in-home visit in 2018 ("Exposure") with those without a visit in 2018 but with a future visit in 2019 ("Wait List Control") using a difference-in-differences analysis. Primary outcomes were 1-year all-cause inpatient care and emergency visit counts. Secondary outcomes included primary care visits, major adverse cardiovascular events, and select quality-of-care metrics. An exploratory outcome was the time-to-first primary care visit after the index date. RESULTS: Among those eligible to receive an in-home visit, a total of 48,566 patients had an in-home visit in 2018 (the "Exposure" group), and 36,549 beneficiaries constituted the "Wait List" control group. Receiving an in-home visit early was associated with a greater decrease in inpatient stays for all 4 conditions (change score range for any stay: -5.22% to -2.47%) (P<0.001, depression <0.05); decrease in emergency visits (change score range for any stay: -4.39% to -3.67%) (P<0.0.001, depression <0.05); and fewer major adverse cardiovascular events for coronary artery disease and depression (P<0.001 and <0.025, respectively) 1 year later. Minimal differences were noted for change in ambulatory and primary care visits, with no consistent increase in quality-of-care metrics. Time-to-first primary care visit was shorter for the "Exposure" versus the Wait List control group in all conditions (difference between 2.45 and 4.95 d). CONCLUSIONS: The feasibility and impact of a nationwide multidimensional preventive in-home visit were demonstrated, targeting common and high morbidity conditions. Benefits were observed against a Wait List control group, resulting in less resource-intense care.

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011-2019.

OBJECTIVES: To examine changes in the positive infectious syphilis test rate among women and heterosexual men in major Australian cities, and rate differences by social, biomedical, and behavioural determinants of health. DESIGN, SETTING: Analysis of data extracted from de-identified patient records from 34 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses (ACCESS). PARTICIPANTS: First tests during calendar year for women and heterosexual men aged 15 years or more in major cities who attended ACCESS sexual health clinics during 2011-2019. MAIN OUTCOME MEASURES: Positive infectious syphilis test rate; change in annual positive test rate. RESULTS: 180 of 52 221 tested women (0.34%) and 239 of 36 341 heterosexual men (0.66%) were diagnosed with infectious syphilis. The positive test rate for women was 1.8 (95% confidence interval [CI], 0.9-3.2) per 1000 tests in 2011, 3.0 (95% CI, 2.0-4.2) per 1000 tests in 2019 (change per year: rate ratio [RR], 1.12; 95% CI, 1.01-1.25); for heterosexual men it was 6.1 (95% CI, 3.8-9.2) per 1000 tests in 2011 and 7.6 (95% CI, 5.6-10) per 1000 tests in 2019 (RR, 1.10; 95% CI, 1.03-1.17). In multivariable analyses, the positive test rate was higher for women (adjusted RR [aRR], 1.85; 95% CI, 1.34-2.55) and heterosexual men (aRR, 2.39; 95% CI, 1.53-3.74) in areas of greatest socio-economic disadvantage than for those in areas of least socio-economic disadvantage. It was also higher for Indigenous women (aRR, 2.39; 95% CI, 1.22-4.70) and for women who reported recent injection drug use (aRR, 4.87; 95% CI, 2.18-10.9) than for other women; it was lower for bisexual than heterosexual women (aRR, 0.48; 95% CI, 0.29-0.81) and for women who reported recent sex work (aRR, 0.35; 95% CI, 0.29-0.44). The positive test rate was higher for heterosexual men aged 40-49 years (aRR, 2.11; 95% CI, 1.42-3.12) or more than 50 years (aRR, 2.36; 95% CI, 1.53-3.65) than for those aged 15-29 years. CONCLUSION: The positive test rate among both urban women and heterosexual men tested was higher in 2019 than in 2011. People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis.

The Nevada peripheral artery disease screening effort in a Medicare Advantage population and subsequent mortality and major adverse cardiovascular event risk.

BACKGROUND: Contemporary estimates of undetected asymptomatic lower extremity peripheral artery disease (PAD) in the community and its association with adverse outcomes in the population are lacking. We investigated the long-term association between previously undetected PAD and subsequent all-cause mortality and major adverse cardiovascular events (MACE) for Medicare Advantage beneficiaries aged ≥65 years in a large metropolitan area characterized by concentrations of atherosclerotic risk factors and a more vulnerable socioeconomic risk profile. METHODS: Data were derived from the patients' electronic medical records and linked with claims outcomes data for 13,971 Medicare Advantage beneficiaries aged ≥65 years who had undergone PAD screening in 2016 as a part of their routine annual health assessment in the greater Las Vegas, Nevada, metropolitan area. PAD screening was performed with their primary care provider using volume plethysmography system methods. The association between PAD screening status and 1- and 3-year all-cause mortality and MACE rates was documented. RESULTS: The cohort had a mean age of 75.3 ± 6.6 years, and 57.7% were women. Of the 13,768 patients, 4351 (31.6%) had had a positive PAD screening result. Almost 60% had had a lower socioeconomic income level, with 15.1% living under the poverty level. The risk estimates associated with a positive vs negative PAD screening result for both all-cause mortality and MACE were as follows: unadjusted hazard ratio (HR) for mortality, 2.17 (95% confidence interval [CI], 1.79-2.63) and unadjusted HR for MACE, 2.00 (95% CI, 1.15-3.49) at 1 year and unadjusted HR for mortality, 2.04 (95% CI, 1.84-2.26) and unadjusted HR for MACE, 1.67 (95% CI, 1.37-2.02) at 3 years. After multivariable adjustment, all associations persisted (P < .001), with HRs ranging from 1.41 to 1.69, except for that for 1-year MACE (similar risk estimate but P = .09). CONCLUSIONS: A positive screening result for previously undetected lower extremity PAD was independently associated with short- and long-term increased risks of mortality and MACE for individuals aged ≥65 years living in a large, metropolitan area.

Modeling scale up of anthropogenic impacts from individual pollinator behavior to pollination systems.

Understanding how anthropogenic disturbances affect plant-pollinator systems has important implications for the conservation of biodiversity and ecosystem functioning. Previous laboratory studies show that pesticides and pathogens, which have been implicated in the rapid global decline of pollinators over recent years, can impair behavioral processes needed for pollinators to adaptively exploit floral resources and effectively transfer pollen among plants. However, the potential for these sublethal stressor effects on pollinator-plant interactions at the individual level to scale up into changes to the dynamics of wild plant and pollinator populations at the system level remains unclear. We developed an empirically parameterized agent-based model of a bumblebee pollination system called SimBee to test for effects of stressor-induced decreases in the memory capacity and information processing speed of individual foragers on bee abundance (scenario 1), plant diversity (scenario 2), and bee-plant system stability (scenario 3) over 20 virtual seasons. Modeling of a simple pollination network of a bumblebee and four co-flowering bee-pollinated plant species indicated that bee decline and plant species extinction events could occur when only 25% of the forager population showed cognitive impairment. Higher percentages of impairment caused 50% bee loss in just five virtual seasons and system-wide extinction events in less than 20 virtual seasons under some conditions. Plant species extinctions occurred regardless of bee population size, indicating that stressor-induced changes to pollinator behavior alone could drive species loss from plant communities. These findings indicate that sublethal stressor effects on pollinator behavioral mechanisms, although seemingly insignificant at the level of individuals, have the cumulative potential in principle to degrade plant-pollinator species interactions at the system level. Our work highlights the importance of an agent-based modeling approach for the identification and mitigation of anthropogenic impacts on plant-pollinator systems.

Aumento en el Modelado de los Impactos Antropogénicos de Polinizador Individual a Sistemas de Polinización Resumen El entendimiento de cómo las perturbaciones antropogénicas afectan a los sistemas planta-polinizador tiene consecuencias importantes para la conservación de la biodiversidad y el funcionamiento del ecosistema. Los estudios previos realizados en laboratorios muestran que los pesticidas y los patógenos, los cuales han estado implicados en la rápida declinación global de los polinizadores en los años recientes, pueden perjudicar los procesos de comportamiento necesarios para que los polinizadores exploten adaptativamente los recursos florales y transfieran de manera efectiva el polen entre las plantas. Sin embargo, todavía no está claro el potencial de que estos efectos estresantes subletales sobre las interacciones planta-polinizador a nivel individual escalen a cambios en las dinámicas de las plantas y las poblaciones silvestres de polinizadores a nivel de sistema. Desarrollamos un modelo basado en el agente y con parámetros empíricos para un sistema de polinización de abejorros llamado SimBee. Con él analizamos los efectos de las disminuciones inducidas por estresantes sobre la capacidad de memoria y la velocidad de procesamiento de información de los forrajeros individuales en la abundancia de abejas (escenario 1), diversidad de plantas (escenario 2) y la estabilidad en el sistema abeja-planta (escenario 3) durante 20 temporadas virtuales. El modelado de una red simple de polinización de un abejorro y cuatro especies de plantas con floración a la par y polinizadas por abejas indicó que la declinación de abejas y los eventos de extinción de plantas podrían ocurrir cuando sólo el 25% de la población forrajera muestra daños cognitivos. Los porcentajes más altos de daños cognitivos mostraron 50% de pérdida de abejas en sólo cinco temporadas virtuales y eventos de extinción en todo el sistema en <20 temporadas virtuales bajo algunas condiciones. La extinción de las especies de plantas ocurrió sin importar el tamaño poblacional de las abejas, lo que indica que los cambios inducidos por los estresantes tan sólo al comportamiento polinizador podrían resultar en la pérdida de especies dentro de las comunidades botánicas. Estos resultados indican que los efectos estresantes subletales en los mecanismos de comportamiento de los polinizadores, aunque parezcan insignificantes a nivel de individuo, tienen el potencial acumulativo, en principio, de degradar las interacciones entre especies de plantas y polinizadores a nivel de sistema. Nuestro trabajo resalta la importancia de una estrategia de modelado basado en el agente para la identificación y mitigación de los impactos antropogénicos sobre los sistemas planta-polinizador.

xenoGI: reconstructing the history of genomic island insertions in clades of closely related bacteria.

BACKGROUND: Genomic islands play an important role in microbial genome evolution, providing a mechanism for strains to adapt to new ecological conditions. A variety of computational methods, both genome-composition based and comparative, have been developed to identify them. Some of these methods are explicitly designed to work in single strains, while others make use of multiple strains. In general, existing methods do not identify islands in the context of the phylogeny in which they evolved. Even multiple strain approaches are best suited to identifying genomic islands that are present in one strain but absent in others. They do not automatically recognize islands which are shared between some strains in the clade or determine the branch on which these islands inserted within the phylogenetic tree. RESULTS: We have developed a software package, xenoGI, that identifies genomic islands and maps their origin within a clade of closely related bacteria, determining which branch they inserted on. It takes as input a set of sequenced genomes and a tree specifying their phylogenetic relationships. Making heavy use of synteny information, the package builds gene families in a species-tree-aware way, and then attempts to combine into islands those families whose members are adjacent and whose most recent common ancestor is shared. The package provides a variety of text-based analysis functions, as well as the ability to export genomic islands into formats suitable for viewing in a genome browser. We demonstrate the capabilities of the package with several examples from enteric bacteria, including an examination of the evolution of the acid fitness island in the genus Escherichia. In addition we use output from simulations and a set of known genomic islands from the literature to show that xenoGI can accurately identify genomic islands and place them on a phylogenetic tree. CONCLUSIONS: xenoGI is an effective tool for studying the history of genomic island insertions in a clade of microbes. It identifies genomic islands, and determines which branch they inserted on within the phylogenetic tree for the clade. Such information is valuable because it helps us understand the adaptive path that has produced living species.

Peripheral Artery Disease Screening in the Community and 1-Year Mortality, Cardiovascular Events, and Adverse Limb Events.

Introduction: This study aimed to examine all-cause mortality, 1- and 2-year major cardiovascular events, and major adverse limb events in individuals aged ≥65 years who received an in-home health visit with peripheral artery disease screening. In addition, we compared 1-year healthcare utilization before and after peripheral artery disease screening for those who screened positive. Setting/Participants: Medicare Advantage beneficiaries aged ≥65 years participating in the Optum HouseCalls program in the U.S. between April 1, 2017 and February 1, 2019 were included. Intervention: The intervention consisted of a peripheral artery disease screening program using a plethysmography system. Main outcome measures: One-year all-cause mortality as a landmark analysis, 1- and 2-year major cardiovascular events, and major adverse limb events after screening were compared by peripheral artery disease screen status using claims data. We compared cardiovascular medications and revascularization procedures between the year before and after the peripheral artery disease screening event for those with peripheral artery disease. Results: Of 192,500 beneficiaries, 27.7% screened positive. One-year all-cause mortality rates for those who screened positive for peripheral artery disease versus those who screened negative were higher (1.51% vs 0.89%; p<0.001; adjusted hazard ratio=1.21; 95% CI=1.08, 1.36) as well as 1-year major cardiovascular events (5.54% vs 3.60%; adjusted hazard ratio= 1.22; 95% CI=1.15, 1.30) and major adverse limb events (0.23% vs 0.04%; adjusted hazard ratio=3.15; 95% CI=2.10, 4.73). Similar risks were observed for 2-year results. Before and after peripheral artery disease screening, medications remained stable for those who screened positive (e.g., statin therapy=54.2% vs 56.6%); rates of peripheral vascular interventions remained stable (0.0% vs 0.1%). Conclusions: A national peripheral artery disease screening effort is feasible. Detecting previously undiagnosed peripheral artery disease is a way to risk stratify a population that would benefit from further cardiovascular risk management.

Risk of persistent and new clinical sequelae among adults aged 65 years and older during the post-acute phase of SARS-CoV-2 infection: retrospective cohort study.

OBJECTIVE: To characterize the risk of persistent and new clinical sequelae in adults aged ≥65 years after the acute phase of SARS-CoV-2 infection. DESIGN: Retrospective cohort study. SETTING: UnitedHealth Group Clinical Research Database: deidentified administrative claims and outpatient laboratory test results. PARTICIPANTS: Individuals aged ≥65 years who were continuously enrolled in a Medicare Advantage plan with coverage of prescription drugs from January 2019 to the date of diagnosis of SARS-CoV-2 infection, matched by propensity score to three comparison groups that did not have covid-19: 2020 comparison group (n=87 337), historical 2019 comparison group (n=88 070), and historical comparison group with viral lower respiratory tract illness (n=73 490). MAIN OUTCOME MEASURES: The presence of persistent and new sequelae at 21 or more days after a diagnosis of covid-19 was determined with ICD-10 (international classification of diseases, 10th revision) codes. Excess risk for sequelae caused by infection with SARS-CoV-2 was estimated for the 120 days after the acute phase of the illness with risk difference and hazard ratios, calculated with 95% Bonferroni corrected confidence intervals. The incidence of sequelae after the acute infection was analyzed by age, race, sex, and whether patients were admitted to hospital for covid-19. RESULTS: Among individuals who were diagnosed with SARS-CoV-2, 32% (27 698 of 87 337) sought medical attention in the post-acute period for one or more new or persistent clinical sequelae, which was 11% higher than the 2020 comparison group. Respiratory failure (risk difference 7.55, 95% confidence interval 7.18 to 8.01), fatigue (5.66, 5.03 to 6.27), hypertension (4.43, 2.27 to 6.37), memory difficulties (2.63, 2.23 to 3.13), kidney injury (2.59, 2.03 to 3.12), mental health diagnoses (2.50, 2.04 to 3.04), hypercoagulability 1.47 (1.2 to 1.73), and cardiac rhythm disorders (2.19, 1.76 to 2.57) had the greatest risk differences compared with the 2020 comparison group, with similar findings to the 2019 comparison group. Compared with the group with viral lower respiratory tract illness, however, only respiratory failure, dementia, and post-viral fatigue had increased risk differences of 2.39 (95% confidence interval 1.79 to 2.94), 0.71 (0.3 to 1.08), and 0.18 (0.11 to 0.26) per 100 patients, respectively. Individuals with severe covid-19 disease requiring admission to hospital had a markedly increased risk for most but not all clinical sequelae. CONCLUSIONS: The results confirm an excess risk for persistent and new sequelae in adults aged ≥65 years after acute infection with SARS-CoV-2. Other than respiratory failure, dementia, and post-viral fatigue, the sequelae resembled those of viral lower respiratory tract illness in older adults. These findings further highlight the wide range of important sequelae after acute infection with the SARS-CoV-2 virus.

Risk of clinical sequelae after the acute phase of SARS-CoV-2 infection: retrospective cohort study.

OBJECTIVE: To evaluate the excess risk and relative hazards for developing incident clinical sequelae after the acute phase of SARS-CoV-2 infection in adults aged 18-65. DESIGN: Retrospective cohort study. SETTING: Three merged data sources from a large United States health plan: a large national administrative claims database, an outpatient laboratory testing database, and an inpatient hospital admissions database. PARTICIPANTS: Individuals aged 18-65 with continuous enrollment in the health plan from January 2019 to the date of a diagnosis of SARS-CoV-2 infection. Three comparator groups, matched by propensity score, to individuals infected with SARS-CoV-2: a 2020 comparator group, an historical 2019 comparator group, and an historical comparator group with viral lower respiratory tract illness. MAIN OUTCOME MEASURES: More than 50 clinical sequelae after the acute phase of SARS-CoV-2 infection (defined as the date of first SARS-CoV-2 diagnosis (index date) plus 21 days) were identified using ICD-10 (international classification of diseases, 10th revision) codes. Excess risk in the four months after acute infection and hazard ratios with Bonferroni corrected 95% confidence intervals were calculated. RESULTS: 14% of adults aged ≤65 who were infected with SARS-CoV-2 (27 074 of 193 113) had at least one new type of clinical sequelae that required medical care after the acute phase of the illness, which was 4.95% higher than in the 2020 comparator group. The risk for specific new sequelae attributable to SARS-Cov-2 infection after the acute phase, including chronic respiratory failure, cardiac arrythmia, hypercoagulability, encephalopathy, peripheral neuropathy, amnesia (memory difficulty), diabetes, liver test abnormalities, myocarditis, anxiety, and fatigue, was significantly greater than in the three comparator groups (2020, 2019, and viral lower respiratory tract illness groups) (all P<0.001). Significant risk differences because of SARS-CoV-2 infection ranged from 0.02 to 2.26 per 100 people (all P<0.001), and hazard ratios ranged from 1.24 to 25.65 compared with the 2020 comparator group. CONCLUSIONS: The results indicate the excess risk of developing new clinical sequelae after the acute phase of SARS-CoV-2 infection, including specific types of sequelae less commonly seen in other viral illnesses. Although individuals who were older, had pre-existing conditions, and were admitted to hospital because of covid-19 were at greatest excess risk, younger adults (aged ≤50), those with no pre-existing conditions, or those not admitted to hospital for covid-19 also had an increased risk of developing new clinical sequelae. The greater risk for incident sequelae after the acute phase of SARS-CoV-2 infection is relevant for healthcare planning.

Using COVID-19 as a teaching tool in a time of remote learning: A workflow for bioinformatic approaches to identifying candidates for therapeutic and vaccine development.

The COVID-19 pandemic has led to an urgent need for engaging computational alternatives to traditional laboratory exercises. Here we introduce a customizable and flexible workflow, designed with the SARS CoV-2 virus that causes COVID-19 in mind, as a means of reinforcing fundamental biology concepts using bioinformatics approaches. This workflow is accessible to a wide range of students in life science majors regardless of their prior bioinformatics knowledge, and all software is freely available, thus eliminating potential cost barriers. Using the workflow can thus provide a diverse group of students the opportunity to conduct inquiry-driven research. Here we demonstrate the utility of this workflow and outline the logical steps involved in the identification of therapeutic or vaccine targets against SARS CoV-2. We also provide an example of how the workflow may be adapted to other infectious microbes. Overall, our workflow anchors student understanding of viral biology and genomics and allows students to develop valuable bioinformatics expertise as well as to hone critical thinking and problem-solving skills, while also creating an opportunity to better understand emerging information surrounding the COVID-19 pandemic.