Building the Infrastructure to Integrate Social Care in a Safety Net Health System.

A recent National Academies report recommended that health systems invest in new infrastructure to integrate social and medical care. Although many health systems routinely screen patients for social concerns, few health systems achieve the recommended model of integration. In this critical case study in an urban safety net health system, we describe the human capital, operational redesign, and financial investment needed to implement the National Academy recommendations. Using data from this case study, we estimate that other health systems seeking to build and maintain this infrastructure would need to invest $1 million to $3 million per year. While health systems with robust existing resources may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by insurers and other payers will be necessary for most health systems to achieve the recommended integration of medical and social care. Researchers seeking to test whether integrating social and medical care leads to better patient and population outcomes require access to health systems and communities who have already invested in this model infrastructure. (Am J Public Health. 2024;114(6):619-625. https://doi.org/10.2105/AJPH.2024.307602).

Do FIQR Severity Categories and Symptoms, Differentiate Between Continuous, Intermittent and Non-Opioid Users in the Treatment of Fibromyalgia?

BACKGROUND: Many fibromyalgia patients utilize opioids to treat symptoms. It is important to better understand nuances regarding this treatment option and any stigma associated with this treatment modality. AIM: This study: (1) assessed the prevalence of opioid use among continuous, intermittent, and non-opioid users in fibromyalgia patients; (2) determined whether the Revised Fibromyalgia Impact Questionnaire (FIQR) was useful in distinguishing opioid use and symptom burden; and (3) assessed whether fibromyalgia patients encountered stigma and/or invalidation. DESIGN: A cross-sectional, observational study of 1,105 participants' responses to validated fibromyalgia and invalidation scales and demographic questions. METHODS: The study employed online survey methodology. RESULTS: A total of 45% of patients reported utilizing opioids (27% continuous, 18% intermittent, 55% non-users). FIQR disease categories (mild to most severe) strongly distinguished between opioid and non-opioid users with 59% of users falling in the most severe category and 68% of non-users falling in mild disease category (p < .0001). Interestingly, intermittent users were similar to non-users on FIQR severity (65.9 versus 65.7; p <0.60, 0-100) while continuous users reported greater severity than the former (73.9, p < .0001). Continuous users particularly reported more problems with daily activities (p < .0001), being overwhelmed (p < .0001), and being unable to accomplish goals (p < .0001). Stigma related to being 'drug seeking' and being 'judged'. Invalidation was infrequent. CONCLUSIONS: Opioid use is common in fibromyalgia and increases monotonically with FIQR severity. Multidisciplinary approaches which help patients perform daily activities, decrease feelings of overwhelm, accomplish goals, and reduce stigma may be beneficial.

Cooperative regulation of C1-domain membrane recruitment polarizes atypical protein kinase C.

Recruitment of the Par complex protein atypical protein kinase C (aPKC) to a specific membrane domain is a key step in the polarization of animal cells. While numerous proteins and phospholipids interact with aPKC, how these interactions cooperate to control its membrane recruitment has been unknown. Here, we identify aPKC's C1 domain as a phospholipid interaction module that targets aPKC to the membrane of Drosophila neural stem cells (NSCs). The isolated C1 binds the NSC membrane in an unpolarized manner during interphase and mitosis and is uniquely sufficient among aPKC domains for targeting. Other domains, including the catalytic module and those that bind the upstream regulators Par-6 and Bazooka, restrict C1's membrane targeting activity-spatially and temporally-to the apical NSC membrane during mitosis. Our results suggest that aPKC polarity results from cooperative activation of autoinhibited C1-mediated membrane binding activity.

Mainstream partial denitrification-anammox in sand and expanded clay deep-bed polishing filters under practical loading rates and backwashing conditions.

This study focused on evaluating the feasibility of expanded clay and sand as media types for mainstream partial denitrification-anammox (PdNA) in deep-bed single-media polishing filters under nitrogen and solids loading rates as well as backwash conditions similar to conventional denitrification filters. The surface roughness and iron content of the expanded clay were hypothesized to allow for enhanced anammox retention, nitrogen removal rates, and runtimes. However, under the tested loading rates and backwash conditions, no clear benefit of expanded clay was observed compared with conventional sand. This study showed the feasibility of PdNA in filters with both sand and expanded clay with PdN efficiencies of 76% and 77%, PdNA rates of 840 and 843 g N/m3 /d and TIN removal rates of 960 and 964 g N/m3 /d, respectively. Glycerol demands were 1.5-1.6 g COD added per g TIN removed , thus indicating potential carbon savings up to 75% compared with conventional denitrification. Overall, this study showed for the first time PdNA filters performing at nitrogen removal rates double that of previous PdNA studies under realistic conditions while providing insights into the media choice and backwashing conditions. Future research on expanded clay backwash conditions is needed to provide its full potential in PdNA filters. PRACTITIONER POINTS: Hydraulic and TSS loading rates similar to conventional denitrification can be applied in PdNA filters. Conventional sand can be used when retrofitting conventional denitrification filters into PdNA filters. Carbon savings up to 75% can be achieved with glycerol when retrofitting conventional filters into PdNA filters.

Media selection for anammox-based polishing filters: Balancing anammox enrichment and retention with filtration function.

Retrofitting conventional denitrification filters into partial denitrification-anammox (PdNA)- or anammox (AnAOB)-based filters will reduce the needs for external carbon addition. The success of AnAOB-based filters depends on anammox growth and retention within such filters. Studies have overlooked the importance of media selection and its impact on AnAOB capacity, head loss progression dynamics, and shear conditions applied onto the AnAOB biofilm. The objective of this study was to evaluate viable media types (10 types) that can enhance AnAOB rates for efficient nitrogen removal in filters. Given the higher backwash requirement and lower AnAOB capacity of the conventionally used sand, expanded clay (3-5 mm) was recommended for AnAOB-based filters in this study. Owing to its surface characteristics, expanded clay had higher AnAOB activity (304- vs. 104-g NH4 + -N/m2 /day) and higher AnAOB retention (43% more) than sand. Increasing the iron content of expanded clay to 37% resulted in an increase in zeta potential, which led to 56% more anammox capacity compared to expanded clay with 7% iron content. This work provides insight into the importance of media types in the growth and retention of AnAOB in filters, and this knowledge could be used as basis in the development of PdNA filters. PRACTITIONER POINTS: Expanded clay showed the lowest head loss buildup and most likely will result in longer runtime for full-scale PdNA applications The highest AnAOB rates were achieved in expanded clay types and sand compared with smaller media typically used in biofiltration Expanded clay resulted in better AnAOB retention under shear, whereas sand could not withstand shear and required more frequent backwashing Expanded clay iron coating enhanced AnAOB enrichment and retention, most likely due to increased surface roughness and/or positive charge.

Full-scale transition from denitrification to partial denitrification-anammox (PdNA) in deep-bed filters: Operational strategies for and benefits of PdNA implementation.

This study shows for the first time more than 2 years of operation of a mainstream anammox application at full-scale under temperate climate. This implementation of partial denitrification-anammox (PdNA) in deep bed filters at the HRSD York River treatment plant was demonstrated to achieve the benefits of shortcut nitrogen removal without nitrite oxidizing bacteria (NOB) out-selection. The transition from denitrification to PdNA filters required bleeding ammonium to the filters using an optimized ammonium versus NOx (AvN) control in the upstream aeration tanks and maintaining a nitrate residual in the filter effluent through feedforward/feedback control. The latter actions led to savings of 85% in methanol, 100% in alkalinity, and 35% in capacity enhancement. Up to 6 mg NH4 + -N/L with an average of 2.2 ± 0.98 mg NH4 + -N/L was removed through the anammox pathway, which accounted for about 15% of the overall plant nitrogen removal. Anammox enrichment was confirmed by activity testing and molecular analysis. The large excess of AnAOB capacity present in the filters (5-10 times more than normal operation) resulted in stable and reliable operation through winter conditions and showed potential for further intensification. PRACTITIONER POINTS: For the first time, long-term mainstream anammox was established full-scale through PdNA implementation in deep-bed filters. PdNA implementation required upstream aeration control optimization to provide a blend of ammonium and nitrate to the filters. Efficient anammox enrichment and retention resulted in reliable PdNA performance under different seasonal and influent conditions. PdNA implementation resulted in significant methanol and alkalinity savings and upstream capacity enhancement as ammonia removal depended less on aerobic nitrification. In the event of NOB out-selection and presence of nitrite, carbon savings in PdNA polishing filters can be enhanced via partial nitritation-anammox.

Upper and lower blepharoplasty technique associated with canthopexy with double pre septal orbicularis muscle elevation with a single suture / Blefaroplastia superior e inferior associada à cantopexia com elevação dupla de músculo orbicular pré-septal em sutura única

ABSTRACT Objective: To describe the upper and lower blepharoplasty technique associated with canthopexy with double pre septal orbicularis muscle elevation with a single suture in order to evaluate the efficacy of the technique. Methods: This is a retrospective study in which the medical records of 5,882 patients who underwent this technique between January 1999 and July 2015 were evaluated. The frequency and main causes of clinical complications and surgical reoperation were analyzed. Results: The incidence of complications found was 12.7% (n=750), being 0.8% (n=47) due to persistent chemosis, 3% (n=176) due to poor lower eyelid positioning, 4.17% (n=245) due to mild eyelid retraction and 4.8% (n=282) because of mild to moderate chemosis. Conclusion: The technique appears to be effective as it is simple and practical, and capable of resulting in positive functional and aesthetic outcomes with low rates of complications.

RESUMO Objetivo: Descrever a técnica de blefaroplastia superior e inferior associada à cantopexia associada à dupla elevação do músculo orbicular pré-septal em uma única sutura e avaliar sua eficácia. Métodos: Trata-se de estudo retrospectivo, no qual foram avaliados 5.882 prontuários de pacientes submetidos à blefaroplastia superior e inferior com a utilização da cantopexia, entre janeiro de 1999 e julho de 2015. Taxas e principais causas de complicações clínicas e reintervenção cirúrgica foram analisadas. Resultados: A incidência de complicações encontradas foi de 12,7% (n=750), sendo 0,8% (n=47) de caso de quemose persistente, 3% (n=176) de mau posicionamento palpebral inferior (ectrópio), 4,17% (n=245) de leve retração pálpebra e 4,8% (n=282) de quemose leve a moderada. Conclusão: A técnica mostra-se eficaz por ser simples e prática, podendo ter resultados funcionais e estéticos positivos e com baixo índice de complicações.

Validating the revised Symptom Impact Questionnaire with a proposed fibromyalgia phenotype using experimentally-induced pain and patient self-reports.

OBJECTIVES: The Symptom Impact Questionnaire (SIQR), now used for over a decade, has strong psychometric properties based on patients' subjective questionnaire data and correlations with other general measures of severity. However, the construct validity of the SIQR in assessing the central features of fibromyalgia (FM) has not been tested specifically with more objective measures. This study examined the construct validity of the SIQR using clinical examination of prominent features of FM, as well as patient questionnaire data. METHODS: We determined if SIQR severity groups (low, moderate, high severity) in 158 chronic pain patients (50 FM, 108 Pain/No FM) predicted four central features of FM tenderness and pain: digital palpation tenderness, blood pressure cuff evoked pain, widespread pain locations, and a persistent deep ache question. RESULTS: Low, moderate, and high SIQR severity groups showed concomitant increases in tenderness in response to digital evoked palpation (F=23.5; p<0.0000; ηp2=0.23; MR=.54), blood pressure cuff evoked pain (F=17.0; p<0.0000; ηp2=0.18; MR=0.48) and number of pain location (F=38.8; p<0.0000; ηp2=0.33; MR.59). Strongest differences in SIQR severity were found in response to the question, "I have a persistent deep aching over most of my body" (F=87.5; p<0.0000; ηp2=0.53; MR=0.74). CONCLUSIONS: The SIQR strongly predicts the central features of FM tenderness and pain including its widespreadness and its multifaceted character. We propose that tenderness, both locally and over most of the body, attendant to the SIQR is the hallmark of the FM phenotype: tenderness is focal, diffuse, deep, and superficial.

Downbeat Nystagmus in a 7-Year-Old Girl With Epstein-Barr Virus-Associated Meningitis and Cerebellitis.

Downbeat nystagmus is a type of jerk nystagmus that may be seen in patients with lesions affecting the vestibulocerebellum. This is a case of a 7-year-old girl presenting with a history of fever, headache, and episodic vertigo with downbeat nystagmus. The diagnosis of Epstein-Barr virus meningitis with acute cerebellitis was made by contrast magnetic resonance imaging, cerebrospinal fluid analysis, and serum Epstein-Barr virus titers. Contrast magnetic resonance imaging demonstrated enhancement of the meninges and inferior cerebellar folia, correlating with the neuroophthalmological symptom of downbeat nystagmus.

Proteomic discovery in sickle cell disease: Elevated neurogranin levels in children with sickle cell disease.

PURPOSE: Sickle cell disease (SCD) is an inherited hemoglobinopathy that causes stroke and silent cerebral infarct (SCI). Our aim was to identify markers of brain injury in SCD. EXPERIMENTAL DESIGN: Plasma proteomes were analyzed using a sequential separation approach of hemoglobin (Hb) and top abundant plasma protein depletion, followed by reverse phase separation of intact proteins, trypsin digestion, and tandem mass spectrometry. We compared plasma proteomes of children with SCD with and without SCI in the Silent Cerebral Infarct Multi-Center Clinical Trial (SIT Trial) to age-matched, healthy non-SCD controls. RESULTS: From the SCD group, 1172 proteins were identified. Twenty-five percent (289/1172) were solely in the SCI group. Twenty-five proteins with enriched expression in the human brain were identified in the SCD group. Neurogranin (NRGN) was the most abundant brain-enriched protein in plasma of children with SCD. Using a NRGN sandwich immunoassay and SIT Trial samples, median NRGN levels were higher at study entry in children with SCD (0.28 ng/mL, N = 100) compared to control participants (0.12 ng/mL, N = 25, p < 0.0004). CONCLUSIONS AND CLINICAL RELEVANCE: NRGN levels are elevated in children with SCD. NRGN and other brain-enriched plasma proteins identified in plasma of children with SCD may provide biochemical evidence of neurological injury.

The Strong Black Woman versus Mental Health Utilization: A Qualitative Study.

Recent investigations have elucidated the influence of the strong Black woman (SBW) ideal on the mental health and treatment-seeking behaviors of Black women in the United States. However, factors related to how the SBW ideal affects Black women's positive and negative attitudes toward seeking professional psychological help have yet to be identified. The current study fills this void in the literature through a qualitative examination of how the SBW ideal affects Black women's mental health utilization. Analyses were based on 62 participants, including college students and community members, ranging in age from 18 to 72 years. The present study advances the idea that endorsement of the SBW ideal affects Black women's mental utilization. These results offer evidence and clarification of the impact of the SBW ideal on Black women's mental health and identity-specific points of intervention for mental health practitioners conducting therapeutic work with Black women. Authors provide practice recommendations for practitioners and suggestions for future research.

Residual ß cell function in long-term type 1 diabetes associates with reduced incidence of hypoglycemia.

BACKGROUNDWe investigated residual ß cell function in Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study participants with an average 35-year duration of type 1 diabetes mellitus (T1DM).METHODSSerum C-peptide was measured during a 4-hour mixed-meal tolerance test. Associations with metabolic outcomes and complications were explored among nonresponders (all C-peptide values after meal <0.003 nmol/L) and 3 categories of responders, classified by peak C-peptide concentration (nmol/L) as high (>0.2), intermediate (>0.03 to ≤0.2), and low (≥ 0.003 to ≤0.03).RESULTSOf the 944 participants, 117 (12.4%) were classified as responders. Residual C-peptide concentrations were associated with higher DCCT baseline concentrations of stimulated C-peptide (P value for trend = 0.0001). Residual C-peptide secretion was not associated with current or mean HbA1c, HLA high-risk haplotypes for T1DM, or the current presence of T1DM autoantibodies. The proportion of subjects with a history of severe hypoglycemia was lower with high (27%) and intermediate (48%) residual C-peptide concentrations than with low (74%) and no (70%) residual C-peptide concentrations (P value for trend = 0.0001). Responders and nonresponders demonstrated similar rates of advanced microvascular complications.CONCLUSIONß Cell function can persist in long-duration T1DM. With a peak C-peptide concentration of >0.03 nmol/L, we observed clinically meaningful reductions in the prevalence of severe hypoglycemia.TRIAL REGISTRATIONClinicalTrials.gov NCT00360815 and NCT00360893.FUNDINGDivision of Diabetes Endocrinology and Metabolic Diseases of the National Institute of Diabetes and Digestive and Kidney Diseases (DP3-DK104438, U01 DK094176, and U01 DK094157).

Pathways Related to the Anti-Cancer Effects of Metabolites Derived from Cerrado Biome Native Plants: An Update and Bioinformatics Analysis on Oral Squamous Cell Carcinoma.

BACKGROUND: Oral cancer is a significant health problem worldwide. Oral squamous cell carcinoma (OSCC) is a malignant neoplasm of epithelial cells that mostly affects different anatomical sites in the head and neck and derives from the squamous epithelium or displays similar morphological characteristics. Generally, OSCC is often the end stage of several changes in the stratified squamous epithelium, which begin as epithelial dysplasia and progress by breaking the basement membrane and invading adjacent tissues. Several plant-based drugs with potent anti-cancer effects are considered inexpensive treatments with limited side effects for cancer and other diseases. OBJECTIVE: The aim of this review is to explore whether some Brazilian plant extracts or constituents exhibit anti-tumorigenic activity or have a cytotoxic effect on human oral carcinoma cells. METHODS: Briefly, OSCC and several metabolites derived from Brazilian plants (i.e., flavonoids, vinblastine, irinotecan, etoposide and paclitaxel) were used as keywords to search the literature on PubMed, GenBank and GeneCards. RESULTS: The results showed that these five chemical compounds found in Cerrado Biome plants exhibit anti-neoplastic effects. Evaluating the compounds revealed that they play a main role in the regulation of cell proliferation. CONCLUSION: Preserving and utilising the biodiversity of our planet, especially in unique ecosystems, such as the Cerrado Biome, may prove essential to preserving and promoting human health in modern contexts.

Training hospital inpatient nursing to know (THINK) delirium: A nursing educational program.

BACKGROUND/OBJECTIVES: Recognition and documentation of delirium is a challenge in the hospital. Education programs lack standardized screening tools. The presence of dementia or depression contribute to poor recognition of delirium. Many front-line healthcare workers attribute delirium to dementia, often misidentifying or delaying a correct diagnosis and in turn, treatment. Unrecognized and untreated delirium is costly. Non-pharmacologic interventions improve patient outcomes and decrease costs. Without delirium education, nurses are vulnerable to injury and low job satisfaction when caring for delirious patients. We describe an education program improving recognition and attitudes towards patients experiencing delirium. DESIGN: An education program about screening, documenting, and treating delirium. SETTING: A large Veterans Health System Hospital. PARTICIPANTS: Healthcare professionals(n = 389) participated in the education program. 355 Nurses and patient-care assistants took the pre and post-test, and 43 returned the post program follow-up survey. A delirium education program with three steps; 1) self-directed online module; 2) dementia simulation experience; and 3) a multi-station delirium skills fair. Pre and post-tests were conducted after step 2, as well as a four-month follow-up survey. MEASUREMENTS: Changes in attitude toward patients with cognitive impairment and their abilities. Self-assessment of attitudes toward patients with delirium. RESULTS: Statistically significant differences in pre and post-testing suggested increased understanding of the experience and abilities of people experiencing cognitive impairment . The four-month follow-up survey showed a continued understanding of the importance of recognizing, documenting, and treating delirium. CONCLUSION: Nursing Education about delirium that includes instruction on a standardized screening tool, documentation, and non-pharmacologic interventions improved knowledge and recognition of delirium and may have changed attitudes surrounding delirium in the hospital.

Lead Toxicity in Children: An Unremitting Public Health Problem.

BACKGROUND: Lead is a pervasive environmental contaminant. Lead accumulates in the body, impairing a molecular level various cellular processes. Lead exposure during childhood causes adverse and permanent neurodevelopmental consequences, sometimes even with "low" blood lead levels. Symptoms are frequently silent, making lead exposure an often unrecognized and underestimated threat for pervasive neurocognitive disorders. METHODS: We identified articles focusing on childhood exposure to lead and neurodevelopment via a search of the electronic database PubMed (National Library of Medicine), including journal articles published from 2007 to 2019. These articles were used to evaluate the effect of environmental lead exposure and analyze whether control efforts over the past decades have altered the prevalence of exposed children. CONCLUSIONS: Children are still being exposed to lead despite evidence of the adverse impact of exposure, even for children with blood lead levels below the currently recognized threshold for intervention. Legislative and educational efforts have reduced lead exposure but are not being followed universally. Primary prevention and identification of high-risk populations are the best cost-benefit interventions to fight this public health problem.

Behavioral modifications by a large-northern herbivore to mitigate warming conditions.

BACKGROUND: Temperatures in arctic-boreal regions are increasing rapidly and pose significant challenges to moose (Alces alces), a heat-sensitive large-bodied mammal. Moose act as ecosystem engineers, by regulating forest carbon and structure, below ground nitrogen cycling processes, and predator-prey dynamics. Previous studies showed that during hotter periods, moose displayed stronger selection for wetland habitats, taller and denser forest canopies, and minimized exposure to solar radiation. However, previous studies regarding moose behavioral thermoregulation occurred in Europe or southern moose range in North America. Understanding whether ambient temperature elicits a behavioral response in high-northern latitude moose populations in North America may be increasingly important as these arctic-boreal systems have been warming at a rate two to three times the global mean. METHODS: We assessed how Alaska moose habitat selection changed as a function of ambient temperature using a step-selection function approach to identify habitat features important for behavioral thermoregulation in summer (June-August). We used Global Positioning System telemetry locations from four populations of Alaska moose (n = 169) from 2008 to 2016. We assessed model fit using the quasi-likelihood under independence criterion and conduction a leave-one-out cross validation. RESULTS: Both male and female moose in all populations increasingly, and nonlinearly, selected for denser canopy cover as ambient temperature increased during summer, where initial increases in the conditional probability of selection were initially sharper then leveled out as canopy density increased above ~ 50%. However, the magnitude of selection response varied by population and sex. In two of the three populations containing both sexes, females demonstrated a stronger selection response for denser canopy at higher temperatures than males. We also observed a stronger selection response in the most southerly and northerly populations compared to populations in the west and central Alaska. CONCLUSIONS: The impacts of climate change in arctic-boreal regions increase landscape heterogeneity through processes such as increased wildfire intensity and annual area burned, which may significantly alter the thermal environment available to an animal. Understanding habitat selection related to behavioral thermoregulation is a first step toward identifying areas capable of providing thermal relief for moose and other species impacted by climate change in arctic-boreal regions.

Use of Complementary and Alternative Medicine in Fibromyalgia: Results of an Online Survey.

BACKGROUND: Fibromyalgia is a chronic condition which may negatively impact various aspects of patients' lives. Many people with fibromyalgia look to complementary and alternative medicine treatments for symptom relief. AIMS: The three main objectives of this study were to examine self-reported complementary and alternative medicine use in patients with fibromyalgia, to determine associations between the use of complementary and alternative medicine treatments and patients' self-reported quality of live and self-reported pain levels. DESIGN: Cross-sectional survey. SETTING: Web-based. PARTICIPANTS/SUBJECTS: Adults over the age of 18 years who had been diagnosed with fibromyalgia. METHODS: Patients with fibromyalgia responded to an online questionnaire regarding the following: treatments (complementary and alternative medicine, prescription and over-the-counter medications), quality of life (Quality of Life Scale-16), assessment of current pain (visual analog scale), and demographic information. RESULTS: Approximately 66% of the respondents used complementary and alternative treatments. Vitamins, massage therapy, and meditation were the most commonly used complementary and alternative therapies. Results indicated respondents using a combination of complementary and alternative medicine and pharmacologic treatments (prescription or over-the-counter) had significantly higher quality of life versus those using pharmacologic treatments alone, p = .011. Similarly, respondents using only complementary and alternative medicine treatment reported significantly lower pain levels versus those using pharmacologic treatment alone, p = .046. CONCLUSIONS: The study suggests that a large proportion of fibromyalgia patients use complementary and alternative medicine, and these treatments may offer beneficial effects to these patients. Integration of complementary and alternative medicine into conventional treatment regimens may provide opportunities for a holistic treatment approach and greater symptom relief for fibromyalgia patients. This approach is timely, as controlled substances are increasingly difficult for patients with fibromyalgia to access.