Community paramedicine in dementia care.

BACKGROUND: Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia. METHODS: This retrospective cohort study examines 251 homebound patients receiving home-based primary care, who utilized a physician-led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over-transport (i.e., transported, but not hospitalized), and under-transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over- and under-transport, adjusting for age, sex, and chief complaint. RESULTS: Fifty-three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over-transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under-transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models. CONCLUSIONS: CP has effectively managed a diverse population of homebound patients with dementia cared for via home-based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings.

Towards a Better Performance in Facial Expression Recognition: A Data-Centric Approach.

Facial expression is the best evidence of our emotions. Its automatic detection and recognition are key for robotics, medicine, healthcare, education, psychology, sociology, marketing, security, entertainment, and many other areas. Experiments in the lab environments achieve high performance. However, in real-world scenarios, it is challenging. Deep learning techniques based on convolutional neural networks (CNNs) have shown great potential. Most of the research is exclusively model-centric, searching for better algorithms to improve recognition. However, progress is insufficient. Despite being the main resource for automatic learning, few works focus on improving the quality of datasets. We propose a novel data-centric method to tackle misclassification, a problem commonly encountered in facial image datasets. The strategy is to progressively refine the dataset by successive training of a CNN model that is fixed. Each training uses the facial images corresponding to the correct predictions of the previous training, allowing the model to capture more distinctive features of each class of facial expression. After the last training, the model performs automatic reclassification of the whole dataset. Unlike other similar work, our method avoids modifying, deleting, or augmenting facial images. Experimental results on three representative datasets proved the effectiveness of the proposed method, improving the validation accuracy by 20.45%, 14.47%, and 39.66%, for FER2013, NHFI, and AffectNet, respectively. The recognition rates on the reclassified versions of these datasets are 86.71%, 70.44%, and 89.17% and become state-of-the-art performance.

Human megakaryocytic microparticles induce de novo platelet biogenesis in a wild-type murine model.

Platelet transfusions are used to treat idiopathic or drug-induced thrombocytopenia. Platelets are an expensive product in limited supply, with limited storage and distribution capabilities because they cannot be frozen. We have demonstrated that, in vitro, human megakaryocytic microparticles (huMkMPs) target human CD34+ hematopoietic stem and progenitor cells (huHSPCs) and induce their Mk differentiation and platelet biogenesis in the absence of thrombopoietin. In this study, we showed that, in vitro, huMkMPs can also target murine HSPCs (muHSPCs) to induce them to differentiate into megakaryocytes in the absence of thrombopoietin. Based on that, using wild-type BALB/c mice, we demonstrated that intravenously administering 2 × 106 huMkMPs triggered de novo murine platelet biogenesis to increase platelet levels up to 49% 16 hours after administration. huMkMPs also largely rescued low platelet levels in mice with induced thrombocytopenia 16 hours after administration by increasing platelet counts by 51%, compared with platelet counts in thrombocytopenic mice. Normalized on a tissue-mass basis, biodistribution experiments show that MkMPs localized largely to the bone marrow, lungs, and liver 24 hours after huMkMP administration. Beyond the bone marrow, CD41+ (megakaryocytes and Mk-progenitor) cells were frequent in lungs, spleen, and especially, liver. In the liver, infused huMKMPs colocalized with Mk progenitors and muHSPCs, thus suggesting that huMkMPs interact with muHSPCs in vivo to induce platelet biogenesis. Our data demonstrate the potential of huMkMPs, which can be stored frozen, to treat thrombocytopenias and serve as effective carriers for in vivo, target-specific cargo delivery to HSPCs.

Role of House Calls in the Care of Patients With Pulmonary Disease.

As the population ages, and more patients with chronic pulmonary diseases become frail and functionally impaired, the prevalence of homebound patients grows. Homebound patients have higher disease burden, inpatient utilization rates, and mortality than nonhomebound patients. Vulnerable homebound patients with pulmonary disease benefit from pulmonary expertise to evaluate and optimize their complex medication regimens; evaluate equipment such as nebulizers, home oxygen, ventilators, and suction machines; and coordinate services. We review the need and benefits of house calls for these patients, and illustrate these needs with cases. We also explore the logistics of making house calls part of pulmonary practice, including supplies needed, safety in the home, and reimbursement. Reimbursement has grown for house calls, and we review how to bill for visits, advance care planning, and care management that is often required when caring for patients with advanced illness. In addition, house calls can often be beneficial for patients who may be identified as high risk and are part of value-based agreements with payers.

Hospital at Home-Plus: A Platform of Facility-Based Care.

OBJECTIVES: To describe the evolution of a hospital at home (HaH) program to a HaH with a 30-day posthospitalization transition period (HaH-Plus) and results of a retrospective review of cases. DESIGN: After launching HaH-Plus, we used the same interdisciplinary clinical team to provide acute home-based care for a broader range of home-based acute-level services than originally conceived in the Hospital at Home model. These included a palliative care unit at home (PCUaH), an observation unit at home (OUaH), a post-acute care rehabilitation at home (RaH), and a program for the hospital averse - those patients needing to be in the hospital but who refuse. SETTING: Urban health system. PARTICIPANTS: Individuals 18 years or older residing in specified catchment area with Medicare fee-for-service or accepted Medicare/Medicaid Advantage plans requiring facility-based care. INTERVENTION: Provision of facility-based acute-level care at home to 685 participants. MEASUREMENTS: Length of stay, readmission, and mortality. RESULTS: HaH-Plus cared for 685 individuals. The PCUaH had the oldest participants (mean age 87), and all groups were predominantly female and dually eligible for Medicare and Medicaid. Diagnoses and length of stay were similar in all groups except that those in RaH had a larger group of diagnoses, than those accepted in to HaH-Plus and those in OUaH had a shorter stay. Rate of readmission was highest for RaH (19%). Mortality during the active treatment episode was highest for PCUaH and hospital averse as compared to HaH-Plus, OUaH and RaH. CONCLUSION: Providing a broader range of facility-based care in the home has significant advantages for patients and increases the scalability of HaH. Developing a spectrum of services was possible by leveraging a robust, 24-hour HaH team. Community- and home-based care could become a greater part of the U.S. healthcare system if a platform of HaH services along with advances in technology and payment models were developed. J Am Geriatr Soc 67:596-602, 2019.

Supporting the on-call primary care physician with community paramedicine.

Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on-call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on-call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on-call primary care providers managing a high-risk patient population with the goal of reducing avoidable ED referrals.

The Influence of Solar Power Plants on Microclimatic Conditions and the Biotic Community in Chilean Desert Environments.

The renewable energy sector is growing at a rapid pace in northern Chile and the solar energy potential is one of the best worldwide. Therefore, many types of solar power plant facilities are being built to take advantage of this renewable energy resource. Solar energy is considered a clean source of energy, but there are potential environmental effects of solar technology, such as landscape fragmentation, extinction of local biota, microclimate changes, among others. To be able to minimize environmental impacts of solar power plants, it is important to know what kind of environmental conditions solar power plants create. This study provides information about abiotic and biotic conditions in the vicinity of photovoltaic solar power plants. Herein, the influence of these power plants as drivers of new microclimate conditions and arthropods diversity composition in the Atacama Desert was evaluated. Microclimatic conditions between panel mounts was found to be more extreme than in the surrounding desert yet beneath the panels temperature is lower and relative humidity higher than outside the panel area. Arthropod species composition was altered in fixed-mount panel installations. In contrast, solar tracking technology showed less influence on microclimate and species composition between Sun and Shade in the power plant. Shady conditions provided a refuge for arthropod species in both installation types. For example, Dipterans were more abundant in the shade whereas Solifugaes were seldom present in the shade. The presented findings have relevance for the sustainable planning and construction of solar power plants.

Linking Vegetation Structure and Spider Diversity in Riparian and Adjacent Habitats in Two Rivers of Central Argentina: An Analysis at Two Conceptual Levels.

The link between vegetation structure and spider diversity has been well explored in the literature. However, few studies have compared spider diversity and its response to vegetation at two conceptual levels: assemblage (species diversity) and ensemble (guild diversity). Because of this, we studied spider diversity in riparian and adjacent habitats of a river system from the Chacoan subregion in central Argentina and evaluated their linkage with vegetation structure at these two levels. To assess vegetation structure, we measured plant species richness and vegetation cover in the herb and shrub - tree layers. We collected spiders for over 6 months by using vacuum netting, sweep netting and pitfall traps. We collected 3,808 spiders belonging to 119 morphospecies, 24 families and 9 guilds. At spider assemblage level, SIMPROF analysis showed significant differences among studied habitats. At spider ensemble level, nevertheless, we found no significant differences among habitats. Concerning the linkage with vegetation structure, BIOENV test showed that spider diversity at either assemblage or ensemble level was not significantly correlated with the vegetation variables assessed. Our results indicated that spider diversity was not affected by vegetation structure. Hence, even though we found a pattern in spider assemblages among habitats, this could not be attributed to vegetation structure. In this study, we show that analyzing a community at two conceptual levels will be useful for recognizing different responses of spider communities to vegetation structure in diverse habitat types.