A multicentre observational study of paediatric head and neck abscesses.

INTRODUCTION: In winter of 2022/3 paediatric ENT surgeons across the UK observed that the incidence of severe abscesses in the head and neck and associated complications was higher than seen in previous years. We aimed to collate and evaluate data from across the UK to establish if this was a true rise in cases, and to describe the factors associated. METHODS: A multicentre retrospective data collection was undertaken from 13 units across the UK. Patients admitted between September 2022-February 2023 with a head and neck abscess including sinogenic, otogenic, deep and superficial neck abscesses were included. Demographic, disease specific, management and outcome data were collected. Hospital episode statistic data were also requested and analysed to allow for comparison with previous 10 years of head and neck abscesses. RESULTS: 262 patients with abscesses of the head and neck were admitted during the study period, 100 between September and November and 163 between December and February. Mastoid abscesses were the most common abscess across both groups. The rate of group A streptococcus + culture results rose significantly from 12 % in autumn group to 30 % in winter (p = 0.02). The rate of intracranial complications rose from 10 % to 18 % (p = 0.11) and the rate of venous thrombosis rose over the same timeframe from 3 % to 14 % (p = 0.01). DISCUSSION: This study demonstrated a statistically significant rise in the rate of group A streptococcus associated abscesses when comparing Autumn and Winter 2022/2023. Over the same timeframe a statistically significant rise in the proportion of patients with venous thromboses associated with H&N abscesses was noted. Interestingly, despite perceived national consensus regarding a spike in abscess incidence, the number of abscesses seen in winter 2022/2023 was in keeping with expected rates of paediatric H&N abscesses, based on pre covid year-on-year rise in incidence.

Decision Support Tool to Improve Decision-Making for HIV Pre-Exposure Prophylaxis (PrEP): Development Process and Alpha Testing.

BACKGROUND: African, Caribbean, and Black (Black) communities in Canada are disproportionately affected by the HIV epidemic. Pre-exposure prophylaxis (PrEP) is a highly effective option for the prevention of HIV. However, the use of PrEP for HIV prevention among eligible Black clients in Canada remains far below the thresholds necessary to achieve the goal of zero new HIV infections. In a recent study in Toronto, PrEP-eligible Black clients were found to have decisional conflict and unmet decisional needs, which affected the quality of their decision-making process regarding the initiation and adherence to PrEP. There is evidence that decision support tools (DSTs) can improve the quality of a decision, the quality of the decision-making process, the implementation or continuation of the chosen option, and the appropriate use of health services. Despite these benefits, there is currently no DST for PrEP-eligible Black clients being asked to consider PrEP for HIV prevention. OBJECTIVE: Our study aimed to develop a DST to improve PrEP decision-making for Black clients and to evaluate the tool's acceptability and usability. METHODS: We developed and evaluated the PrEP DST for Black patients using the 7-step process outlined in the Ottawa Decision Support Group Guideline for the development and evaluation of DST. To facilitate the implementation of the Ottawa Decision Support Group guideline, we assembled a multidisciplinary team of primary health care providers, researchers, community members with lived experiences, and digital content designers to serve as the steering committee. First, we assessed patients' and primary health care providers' views on decisional support needs, after which we determined the content, design, and distribution plan for the DST. Subsequently, we conducted evidence synthesis, reviews, and appraisal before developing the PrEP DST prototype. The final tool was reviewed by steering committee members for completeness before acceptability and usability testing with potential Black clients and PrEP providers. RESULTS: The web-based DST yielded 27 pages divided into 6 distinct sections. The six sections include (1) an introduction of the DST, (2) clarify your decision, (3) knowledge, (4) a value clarification exercise, (5) support system, and (6) next steps. Both Black clients and PrEP providers reported ease of task performance, general satisfaction, and usefulness of the tool to support decision-making for Black clients. Feedback on usability centered on the need to add a user guide to increase usability. All feedback was incorporated into the final tool. CONCLUSIONS: A PrEP DST for Black clients developed using a systematic process and a multidisciplinary steering committee was acceptable and usable by both Black clients and PrEP providers. Further study (eg, randomized controlled trials) may be needed to evaluate the efficacy of the PrEP DST.

How do Cancer Patients in Economically Marginalized Neighborhoods Decide Where to Seek Care: Perspectives From Cancer Patients and Healthcare Professionals.

BACKGROUND: The quality of cancer care affects patient outcomes. It is therefore important to understand what factors and/or barriers shape a cancer patient's decision about where to seek care. We sought to understand factors influencing decision-making for historically marginalized communities in a large metropolitan area with multiple options for cancer care, including a National Cancer Institute (NCI)-designated comprehensive cancer center. METHODS: We conducted semi-structured interviews with cancer patients from economically marginalized neighborhoods in Washington D.C., and with healthcare professionals who work with patients from these areas. Participants were recruited through flyers, social media posts, and word of mouth. Two researchers analyzed the data using a combination of inductive and deductive approaches supported by the ATLAS. ti software. RESULTS: A total of 15 interviews were conducted. Analysis revealed 3 major factors influencing where patients decide to seek care: health insurance, transportation, and prioritization of needs. Participants repeatedly identified navigating the bureaucracy of insurance enrollment and high medical costs as prohibitive to seeking care. Transportation was often mentioned in terms of convenience of use and proximity to the care center. Prioritization of needs refers to circumstances such as unstable housing, poverty, and mental illness, that some patients prioritize over seeking quality cancer care. Across these themes 2 findings arose: a discrepancy between stated and actual factors in choosing an oncologist, and the extent to which a cancer patient is able to choose their oncologist. CONCLUSION: This study helps explain some of the factors that influence how cancer patients in urban settings choose an oncology center, and the barriers which prohibit access. AIMS OF THE STUDY: This study aimed to understand how cancer patients decide where to seek treatment.

Building Social Support and Moral Healing on Nursing Units: Design and Implementation of a Culture Change Intervention.

The healthcare industry continues to experience high rates of burnout, turnover, and staffing shortages that erode quality care. Interventions that are feasible, engaging, and impactful are needed to improve cultures of support and mitigate harm from exposure to morally injurious events. This quality improvement project encompassed the methodical building, implementation, and testing of RECONN (Reflection and Connection), an organizational intervention designed by an interdisciplinary team to mitigate the impact of moral injury and to increase social support among nurses. This quality improvement project was conducted in a medical intensive care unit (MICU) in a rural, academic medical center. We employed an Evidence-Based Quality Improvement (EBQI) approach to design and implement the RECONN intervention while assessing the feasibility, acceptability, and preliminary effectiveness via surveys (n = 17). RECONN was found acceptable and appropriate by 70% of nurses who responded to surveys. Preliminary effectiveness data showed small to moderate effect sizes for improving social support, moral injury, loneliness, and emotional recovery. Further evaluation is warranted to establish the effectiveness and generalizability of RECONN to other healthcare settings.

COVID-19 Coagulopathy.

Coronavirus disease of 2019 (COVID-19) is the respiratory viral infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite being a primary respiratory illness, it is commonly complicated by systemic involvement of the vasculature leading to arterial and venous thrombosis. In this review, we will focus on the association between COVID-19 and thrombosis. We will highlight the pathophysiology of COVID-19 coagulopathy. The clinical manifestations of COVID-19 vasculopathy will be discussed with a focus on venous and arterial thromboembolic events. COVID-19 vasculopathy and disseminated intravascular coagulation (DIC) are distinguished within, as well as areas of controversy, such as "long COVID". Finally, the current professional guidelines on prevention and treatment of thrombosis associated with SARS-CoV-2 infection will be discussed.

Size-dependent effects of dams on river ecosystems and implications for dam removal outcomes.

Understanding the relationship between a dam's size and its ecological effects is important for prioritization of river restoration efforts based on dam removal. Although much is known about the effects of large storage dams, this information may not be applicable to small dams, which represent the vast majority of dams being considered for removal. To better understand how dam effects vary with size, we conducted a multidisciplinary study of the downstream effect of dams on a range of ecological characteristics including geomorphology, water chemistry, periphyton, riparian vegetation, benthic macroinvertebrates, and fish. We related dam size variables to the downstream-upstream fractional difference in measured ecological characteristics for 16 dams in the mid-Atlantic region ranging from 0.9 to 57 m high, with hydraulic residence times (HRTs) ranging from 30 min to 1.5 years. For a range of physical attributes, larger dams had larger effects. For example, the water surface width below dams was greater below large dams. By contrast, there was no effect of dam size on sediment grain size, though the fraction of fine-grained bed material was lower below dams independently of dam size. Larger dams tended to reduce water quality more, with decreased downstream dissolved oxygen and increased temperature. Larger dams decreased inorganic nutrients (N, P, Si), but increased particulate nutrients (N, P) in downstream reaches. Aquatic organisms tended to have greater dissimilarity in species composition below larger dams (for fish and periphyton), lower taxonomic diversity (for macroinvertebrates), and greater pollution tolerance (for periphyton and macroinvertebrates). Plants responded differently below large and small dams, with fewer invasive species below large dams, but more below small dams. Overall, these results demonstrate that larger dams have much greater impact on the ecosystem components we measured, and hence their removal has the greatest potential for restoring river ecosystems.

Symptom Descriptors in Individuals Living With Undiagnosed Lower Extremity Peripheral Artery Disease.

OBJECTIVE: Most individuals with lower extremity peripheral artery disease (PAD) experience symptoms other than claudication and live with undiagnosed PAD yet no tools exist to detect atypical PAD symptoms. The purpose of this study was to identify discriminating PAD symptom descriptors from a community-based sample of patients with no current diagnosis of PAD. METHODS: Symptoms descriptors were obtained in a sample of 22 participants with persistent lower extremity symptoms pre/post exercise. An ankle brachial index with exercise was used to classify participants as "PAD" or "No PAD." RESULTS: Thirteen (59%) participants had a positive ankle brachial index (<0.9, ≥20% drop postexercise, or 30 mmHg drop postexercise). Symptoms do not disappear while walking, trouble keeping up with friends/family, positive response to pain or discomfort while sitting, and pain outside of the calves and thighs were associated with a positive ankle brachial index. CONCLUSION: Atypical symptoms were common among study participants. Symptoms while sitting and symptoms outside of the calf and thigh were negatively associated with a positive ankle brachial index. More precise descriptions of symptom characteristics are needed to improve PAD symptom recognition.

The ethics of natural immunity exemptions to vaccine mandates: the Supreme Court petition.

The Supreme Court of the United States has recently been petitioned to revisit legal issues pertaining to the lawfulness of imposing a vaccine mandate on individuals with proof of natural immunity during the COVID-19 pandemic. While the petition accepts that the protection of public health during COVID-19 was an important governmental interest, the petitioners maintain that the imposition of a vaccine mandate on individuals with natural immunity was not 'substantially related' to accomplishing that purpose. In this short report, we outline how some of the petition's general arguments interact with points we raised in a 2022 article in this journal defending natural immunity exemptions, in light of new evidence. In particular, we reflect on new evidence pertaining to differences between vaccine-induced immunity, natural immunity, and so-called 'hybrid' immunity. We suggest that the nuanced nature of this evidence highlights the importance of making fine-grained judgements about proportionality and necessity when considering vaccine mandates. We conclude by claiming that if future pandemics necessitate the imposition of vaccine mandates, then those seeking to justify them should clearly articulate the relevance (and the evidence) for the comparative protection of vaccine-induced, natural, and hybrid immunity.

Resource and animal use implications of the proposed REACH information requirements for endocrine disruptor assessment.

Revised information requirements for endocrine disruptor (ED) assessment of chemicals under the European Union's Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) Regulation have been proposed. Implementation will substantially increase demands for new data to inform ED assessment. This article evaluates the potential animal use and financial resource associated with two proposed ED policy options, and highlights areas where further clarification is warranted. This evaluation demonstrates that studies potentially conducted to meet the proposed requirements could use tens of millions of animals, and that the approach is unlikely to be feasible in practice. Given the challenges with implementing either policy option and the need to minimise the reliance on animal testing, further consideration and clarification is needed on several aspects prior to implementation of the requirements. This includes how testing will be prioritised in a proportionate approach; how to harness new approach methodologies to waive higher-tier animal testing; and need for provision of clear guidance particularly in applying weight-of-evidence approaches. There is now a clear opportunity for the European Commission to lead the way in developing a robust and transparent ED assessment process for industrial chemicals which fully implements replacement, refinement, and reduction of the use of animals (the 3Rs).

Mixed rare earth metals production from surface soil in Idaho, USA: Techno-economic analysis and greenhouse gas emission assessment.

Rare earth elements are crucial for the development of cutting-edge technologies in various sectors, such as energy, transportation, and health care. Traditional extraction of rare earth elements from soil and ore deposits primarily involves chemical leaching and solvent extraction. Environmental-based biological rare earth element extraction, such as bioleaching, can be a promising alternative to mitigate pollution and hazardous wastes. We investigated the sustainability aspects (techno-economic and environmental impact) of mixed rare earth metals production from soil in Idaho, USA. We focused on the bioleaching of surface soil using techno-economic analysis and "cradle-to-gate" life cycle assessment. The system boundary included collection, transportation, bioleaching, and molten salt electrolysis. Our results revealed that the mixed rare earth metals (including Nd, Ce, and La) production costs approximately $10,851 per metric ton and generates 1.9 × 106 kg CO2 eq./ton. Our results showed that most emissions are due to energy consumption during bioleaching. Over a 100-year time horizon ultrasound-assisted bioleaching can reduce greenhouse gas emissions by approximately 91 % compared to the traditional bioleaching process by decreasing the organic acid leaching process time and energy consumption. Our work demonstrates that higher solids loading in leaching with biological reactions can promote economic feasibility and reduce chemical wastes.

Double-Edged Sword: A Positive Brain Scan Result Heightens Confidence in an Alzheimer's Diagnosis But Also Leads to Higher Stigma Among Older Adults in a Vignette-Based Experiment.

OBJECTIVES: Early diagnosis of Alzheimer's disease (AD) using brain scans and other biomarker tests will be essential to increasing the benefits of emerging disease-modifying therapies, but AD biomarkers may have unintended negative consequences on stigma. We examined how a brain scan result affects AD diagnosis confidence and AD stigma. METHODS: The study used a vignette-based experiment with a 2 × 2 × 3 factorial design of main effects: a brain scan result as positive or negative, treatment availability and symptom stage. We sampled 1,283 adults ages 65 and older between June 11and July 3, 2019. Participants (1) rated their confidence in an AD diagnosis in each of four medical evaluations that varied in number and type of diagnostic tools and (2) read a vignette about a fictional patient with varied characteristics before completing the Modified Family Stigma in Alzheimer's Disease Scale (FS-ADS). We examined mean diagnosis confidence by medical evaluation type. We conducted between-group comparisons of diagnosis confidence and FS-ADS scores in the positive versus negative brain scan result conditions and, in the positive condition, by symptom stage and treatment availability. RESULTS: A positive versus negative test result corresponds with higher confidence in an AD diagnosis independent of medical evaluation type (all p < .001). A positive result correlates with stronger reactions on 6 of 7 FS-ADS domains (all p < .001). DISCUSSION: A positive biomarker result heightens AD diagnosis confidence but also correlates with more AD stigma. Our findings inform strategies to promote early diagnosis and clinical discussions with individuals undergoing AD biomarker testing.

Interpreting International Humanitarian Law to Guarantee Abortion and Other Sexual and Reproductive Health Services in Armed Conflict.

The provision of basic sexual and reproductive health services in humanitarian settings, including armed conflict, is extremely limited, causing preventable mortalities and morbidities and violating human rights. Over 50% of all maternal deaths occur in humanitarian and fragile settings. International humanitarian law falls short in guaranteeing access to the full range of sexual and reproductive health information and services for all persons. Guaranteeing access to sexual and reproductive health services under international humanitarian law can increase access to services, improving the health and well-being of civilians in conflict zones. This paper sets forth ways in which international human rights law on sexual and reproductive health and rights should be incorporated into the forthcoming International Committee of the Red Cross Commentary on Geneva Convention IV, regarding the protection of civilians, to ensure services in the context of armed conflict.

Geriatric conditions and healthcare utilization among older adults living in subsidized housing.

BACKGROUND: Nearly 2.9 million older Americans with lower incomes live in subsidized housing. While regional and single-site studies show that this group has higher rates of healthcare utilization compared to older adults in the general community, little is known about healthcare utilization nationally nor associated risk factors. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries aged ≥65 enrolled in the National Health and Aging Trends Study in 2011, linked to Medicare claims data, including individuals living in subsidized housing and the general community. Participants were followed annually through 2020. Outcomes were hospitalization, short-term skilled nursing facility (SNF) utilization, long-term care utilization, and death. Fine-Gray competing risks regression analysis was used to assess the association of subsidized housing residence with hospitalization and nursing facility utilization, and Cox proportional hazards regression analysis was used to assess the association with death. RESULTS: Among 6294 participants (3600 women, 2694 men; mean age, 75.5 years [SD, 7.0]), 295 lived in subsidized housing at baseline and 5999 in the general community. Compared to older adults in the general community, those in subsidized housing had a higher adjusted subdistribution hazard ratio [sHR] of hospitalization (sHR 1.21; 95% CI, 1.03-1.43), short-term SNF utilization (sHR 1.49; 95% CI, 1.15-1.92), and long-term care utilization (sHR 2.72; 95% CI, 1.67-4.43), but similar hazard of death (HR, 0.86; 95% CI, 0.69-1.08). Individuals with functional impairment had a higher adjusted subdistribution hazard of hospitalization and short-term SNF utilization and individuals with dementia and functional impairment had a higher hazard of long-term care utilization. CONCLUSIONS: Older adults living in subsidized housing have higher hazards of hospitalization and nursing facility utilization compared to those in the general community. Housing-based interventions to optimize aging in place and mitigate risk of nursing facility utilization should consider risk factors including functional impairment and dementia.

Reimagining How We Synthesize Information to Impact Clinical Care, Policy, and Research Priorities in Real Time: Examples and Lessons Learned from COVID-19.

Real-time clinical care, policy, and research decisions need real-time evidence synthesis. However, as we found during the COVID-19 pandemic, it is challenging to rapidly address key clinical and policy questions through rigorous, relevant, and usable evidence. Our objective is to present three exemplar cases of rapid evidence synthesis products from the Veterans Healthcare Administration Evidence Synthesis Program (ESP) and, in the context of these examples, outline ESP products, challenges, and lessons learned. We faced challenges in (1) balancing scientific rigor with the speed in which evidence synthesis was needed, (2) sorting through rapidly evolving large bodies of evidence, and (3) assessing the impact of evidence synthesis products on clinical care, policy, and research. We found solutions in (1) engaging stakeholders early, (2) utilizing artificial intelligence capabilities, (3) building infrastructure to establish living reviews, and (4) planning for dissemination to maximize impact.

Effects of Metreleptin in Patients with Generalized Lipodystrophy Before vs After the Onset of Severe Metabolic Disease.

CONTEXT: Leptin replacement therapy with metreleptin improves metabolic abnormalities in patients with generalized lipodystrophy (GLD). OBJECTIVE: Determine how timing of metreleptin initiation in the clinical course of GLD affects long-term metabolic health. METHODS: Retrospective analysis of patients ≥ 6 months old with congenital (n=47) or acquired (n=16) GLD treated with metreleptin at the National Institutes of Health since 2001. Least squares means (LSM) for HbA1c, insulin area under the curve (AUC) from oral glucose tolerance tests, triglycerides, urine protein excretion, platelets, transaminases, and aspartate aminotransferase (AST) to Platelet Ratio Index (APRI) for early and late treatment groups, defined by baseline metabolic health, were analyzed during median 72 (24, 108) months follow-up. RESULTS: Compared to late groups, early groups based on metabolic status had higher mean±SEM insulin AUC (20831±1 vs 11948±1), lower HbA1c (5.3±0.3 vs 6.8±0.3%), triglycerides (101±1 vs 193±1 mg/dL), urine protein excretion (85±1.5 vs 404±1.4 mg/24 hr), ALT (30±1 vs 53±1 U/L), AST (23±1 vs 40±1 U/L), and APRI (0.22±1.3 vs 0.78±1.3), and higher platelets (257±24 vs 152±28 K/µL) during follow-up (P<0.05). Compared to patients ≥6 years old at baseline, patients <6 years had lower HbA1c (4.5±0.5 vs 6.4±0.2%) and higher AST (40±1vs 23±1 U/L) during follow (P<0.05). CONCLUSION: Patients with GLD who initiated metreleptin before the onset of severe metabolic complications had better long-term control of diabetes, proteinuria, and hypertriglyceridemia. Early treatment may also result is less severe progression of liver fibrosis, but further histological studies are needed to determine the effects of metreleptin therapy on liver disease.

Improving measurement of functional status among older adults in primary care: A pilot study.

Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.

"You Need to Keep It Going, Mind, Body, and Spirit": Older Adults' Perspectives on Aging in Place in Subsidized Housing.

In the U.S., more than one million older adults with low incomes live in apartment buildings subsidized by the Low-Income Housing Tax Credit. Although this population experiences disproportionate rates of nursing home admission, little is known about residents' perspectives on factors that influence their ability to live independently in these settings. Fifty-eight residents aged 62 and older and eight study partners participated in qualitative interviews about their perspectives on living independently in subsidized housing, including barriers and facilitators. We analyzed transcripts using a hybrid inductive and deductive approach to qualitative thematic analysis. Barriers and facilitators for living independently in subsidized housing related to the influence of the social and physical environment on individuals' experiences of living independently, including factors unique to subsidized housing. Findings suggest how interventions to optimize functional status and promote independence among older adults living in subsidized housing can build on existing strengths of the subsidized housing environment to improve outcomes.

Neurofibromatosis Type 1: Optimizing Management with a Multidisciplinary Approach.

Neurofibromatosis Type I (NF1) is a complex genetic condition that affects multiple organ systems and presents a unique set of challenges for clinicians in its management. NF1 is a tumor predisposition syndrome that primarily affect the peripheral and central nervous systems via the impact of haploinsufficiency upon neural crest lineage cells including Schwann cells, melanocytes, fibroblasts, etc. NF1 can further lead to pathology of the skin, bones, visual system, and cardiovascular system, all of which can drastically reduce a patient's quality of life (QOL). This review provides a comprehensive examination of the many specialties required for the care of patients with Neurofibromatosis Type 1 (NF1). We delve into the pathogenesis and clinical presentation of NF1, highlighting its diverse manifestations and the challenges they pose in management. The review underscores the importance of a multidisciplinary approach to NF1, emphasizing how such an approach can significantly improve patient outcomes and overall QOL. Central to this approach is the role of the NF expert, who guides a multidisciplinary team (MDT) comprising healthcare professionals from many areas of expertise. The MDT collaboratively addresses the multifaceted needs of NF1 patients, ensuring comprehensive and personalized care. This review highlights the need for further investigation to optimize the workflow for NF1 patients in an MDT setting, and to improve implementation and efficacy.