Comparison of home-based palliative care delivered by community health workers versus usual care: research protocol for a pilot randomized controlled trial.

BACKGROUND: Research studies demonstrate that palliative care can improve patient outcomes such as quality of life, symptom burden and patient satisfaction with care (Gomes B, et al. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. 2013(6):CD00776) (World Health Organization. Palliative Care. Published 2020.). While 76% of patients who need palliative care live in limited-resource countries, access to high quality palliative services in these countries is minimal (Worldwide Hospice and Palliative Care Association and World Health Organization. Global Atlas of Palliative Care (2nd ed). 2020.). In 2014 the Worldwide Hospice Palliative Care Alliance, with strong endorsement by the WHO, released the Palliative Care Toolkit to provide a training and implementation toolkit for empowering community members to deliver palliative care in resource poor settings (Worldwide Hospice and Palliative Care Association and World Health Organization. Global Atlas of Palliative Care at the End of Life. Geneva, Switzerland 2014.). They encouraged researchers and public health practitioners to conduct rigorous evaluation of the toolkit in diverse settings and contexts. To address this need, we will conduct a pilot randomized controlled trial (RCT) to examine implementation and explore potential effect of an intervention based upon the Palliative Care Toolkit, as adapted and used by community health workers (CHWs) working with a cancer center in Kolkata, India to deliver home-based palliative care for rural patients. METHODS: Utilizing a randomized controlled trial design, intervention patients (n = 45) receive home-based palliative services (Pal-Care) delivered by community health workers (CHWs), with comparison against a control group of patients (n = 45) who receive usual cancer-center-based palliative services. Primary outcome measures include evaluation of CHW training outcomes, roles and responsibilities of the CHWS and how they assist patients, trial recruitment, stakeholder perceptions of the intervention, and fidelity to study protocol. Secondary outcomes measure patient self-report of health-related quality of life, symptom burden, palliative needs and patient care experience, outcomes The RE-AIM framework guides our evaluation plan to measure the reach, effectiveness, adoption, implementation and maintenance of the Pal-Care intervention (Gaglio B, et al. The RE-AIM framework: a systematic review of use over time. Am J Public Health. 2013;103(6):e38?46.). Data will be analyzed in SAS. All measures will be evaluated overall and by patient age, gender and cancer type and by CHW caseload. DISCUSSION: Pal-Care is a RCT funded by the NCI to explore utilization of CHWs to deliver a home-based palliative care intervention built upon the WHO Palliative Care toolkit (PCT), as compared to a usual care control group. The long-term goal of this research is to develop an effective and sustainable model for delivering home-based palliative care for cancer patients in underserved areas. TRIAL REGISTRATION (TRN): ClinicalTrials.gov ID# NCT04972630.

Capturing COVID-19 spread and interplay with multi-hop contact tracing intervention.

A preemptive multi-hop contact tracing scheme that tracks not only the direct contacts of those who tested positive for COVID-19, but also secondary or tertiary contacts has been proposed and deployed in practice with some success. We propose a mathematical methodology for evaluating this preemptive contact tracing strategy that combines the contact tracing dynamics and the virus transmission mechanism in a single framework using microscopic Markov Chain approach (MMCA). We perform Monte Carlo (MC) simulations to validate our model and show that the output of our model provides a reasonable match with the result of MC simulations. Utilizing the formulation under a human contact network generated from real-world data, we show that the cost-benefit tradeoff can be significantly enhanced through an implementation of the multi-hop contact tracing as compared to traditional contact tracing. We further shed light on the mechanisms behind the effectiveness of the multi-hop testing strategy using the framework. We show that our mathematical framework allows significantly faster computation of key attributes for multi-hop contact tracing as compared to MC simulations. This in turn enables the investigation of these attributes for large contact networks, and constitutes a significant strength of our approach as the contact networks that arise in practice are typically large.

Impact of opinion dynamics on the public health damage inflicted by COVID-19 in the presence of societal heterogeneities.

Introduction: Certain behavioral practices, such as wearing masks, practicing social distancing, and accepting vaccines, play a crucial role in impeding the spread of COVID-19 and reducing the severity of symptoms. Opinions regarding whether to observe such behavioral practices evolve over time through interactions via networks that overlap with but are not identical to the physical interaction networks over which the disease progresses. This necessitates the joint study of the dynamics of COVID-19 and opinion evolution. Methods: We develop a mathematical model that can be easily adapted to a wide range of behavioral practices and captures in a computationally tractable manner the joint evolution of the disease and relevant opinions in populations of large sizes. Populations of large sizes are typically heterogeneous in that they comprise individuals of different age groups, genders, races, and underlying health conditions. Such groups have different propensities to imbibe severe forms of the disease, different physical contact, and social interaction patterns and rates. These lead to different disease and opinion dynamics in them. Our model is designed to effectively capture such diversities. Results: Computations using our model reveal that opinion dynamics have a strong impact on fatality and hospitalization counts and the number of man-days lost due to symptoms both in the regular form of the disease and the extended forms, more commonly known as long COVID. We show that opinion dynamics in certain groups have a disproportionate impact on the overall public health attributes because they have high physical interaction rates, even when they have the lowest propensity to imbibe severe forms of the disease. This identifies a social vulnerability that malactors can utilize to inflict heavy public health damages through opinion campaigns targeting specific segments. Once such vulnerabilities are identified, which we accomplish, adequate precautions may be designed to enhance resilience to such targeted attacks and better protect public health. Discussion: By recognizing and understanding the vulnerabilities, appropriate precautions can be developed to enhance resilience against targeted attacks and safeguard public health. Our study underscores the importance of considering opinion evolution alongside disease dynamics, providing insights into the interplay between behavioral practices, opinions, and disease outcomes. We believe that our model is a valuable tool for understanding the joint dynamics of COVID-19 and opinions. We hope that our findings will help to inform public health policy and facilitate evidence-based decision-making for public health interventions.

Tracing and testing multiple generations of contacts to COVID-19 cases: cost-benefit trade-offs.

Traditional contact tracing tests the direct contacts of those who test positive. But, by the time an infected individual is tested, the infection starting from the person may have infected a chain of individuals. Hence, why should the testing stop at direct contacts, and not test secondary, tertiary contacts or even contacts further down? One deterrent in testing long chains of individuals right away may be that it substantially increases the testing load, or does it? We investigate the costs and benefits of such multi-hop contact tracing for different number of hops. Considering diverse contact networks, we show that the cost-benefit trade-off can be characterized in terms of a single measurable attribute, the initial epidemic growth rate. Once this growth rate crosses a threshold, multi-hop contact tracing substantially reduces the outbreak size compared with traditional tracing. Multi-hop even incurs a lower cost compared with the traditional tracing for a large range of values of the growth rate. The cost-benefit trade-offs can be classified into three phases depending on the value of the growth rate. The need for choosing a larger number of hops becomes greater as the growth rate increases or the environment becomes less conducive toward containing the disease.

Feasibility and Acceptability of Engaging Significant Adults in Youth Sexual and Relationship Violence Prevention Work.

Relationship and sexual violence (RSV) disproportionately affect youth in immigrant and other marginalized communities yet few prevention initiatives are truly grounded in their experiences. The current study represents a pilot implementation evaluation of youth-led workshops to engage significant adults (parents, grandparents, aunts, adult siblings, community leaders) as RSV prevention partners in diverse communities in a large urban area. The current mixed methods evaluation examined the perceptions of 66 adults and six youth leaders of four, day-long adult training workshops. Results showed high feasibility and acceptability and an important role for significant adults in enhancing RSV prevention.

Countering the potential re-emergence of a deadly infectious disease-Information warfare, identifying strategic threats, launching countermeasures.

OBJECTIVES: Eradicated infectious diseases like smallpox can re-emerge through accident or the designs of bioterrorists, and cause heavy casualties. Presently, the populace is largely susceptible as only a small percentage is vaccinated, and their immunity is likely to have waned. And when the disease re-emerges, the susceptible individuals may be manipulated by disinformation on Social Media to refuse vaccines. Thus, a combination of countermeasures consisting of antiviral drugs and vaccines and a range of policies for their application need to be investigated. Opinions regarding whether to receive vaccines evolve over time through social exchanges via networks that overlap with but are not identical to the disease propagation networks. These couple the spread of the biological and information contagion and necessitate a joint investigation of the two. METHODS: We develop a computationally tractable metapopulation epidemiological model that captures the joint spatio-temporal evolution of an infectious disease (e.g., smallpox, COVID-19) and opinion dynamics. RESULTS: Considering smallpox, the computations based on the model show that opinion dynamics have a substantial impact on the fatality count. Towards understanding how perpetrators are likely to seed the infection, we identify a) the initial distribution of infected individuals that maximize the overall fatality count; and b) which habitation structures are more vulnerable to outbreaks. We assess the relative efficacy of different countermeasures and conclude that a combination of vaccines and drugs minimize the fatalities, and by itself, drugs reduce fatalities more than the vaccine. Accordingly, we assess the impact of increase in the supply of drugs and identify the most effective among a collection of policies for administering of drugs for various parameter combinations. Many of the observed patterns are stable to variations of a diverse set of parameters. CONCLUSIONS: Our findings provide a quantitative foundation for various important elements of public health discourse that have largely been conducted qualitatively.

Monsoon forced evolution of savanna and the spread of agro-pastoralism in peninsular India.

An unresolved issue in the vegetation ecology of the Indian subcontinent is whether its savannas, characterized by relatively open formations of deciduous trees in C4-grass dominated understories, are natural or anthropogenic. Historically, these ecosystems have widely been regarded as anthropogenic-derived, degraded descendants of deciduous forests. Despite recent work showing that modern savannas in the subcontinent fall within established bioclimatic envelopes of extant savannas elsewhere, the debate persists, at least in part because the regions where savannas occur also have a long history of human presence and habitat modification. Here we show for the first time, using multiple proxies for vegetation, climate and disturbances from high-resolution, well-dated lake sediments from Lonar Crater in peninsular India, that neither anthropogenic impact nor fire regime shifts, but monsoon weakening during the past ~ 6.0 kyr cal. BP, drove the expansion of savanna at the expense of forests in peninsular India. Our results provide unambiguous evidence for a climate-induced origin and spread of the modern savannas of peninsular India at around the mid-Holocene. We further propose that this savannization preceded and drove the introduction of agriculture and development of sedentism in this region, rather than vice-versa as has often been assumed.

Patients'/Caregivers' Perspectives on Telemedicine Service for Advanced Cancer Patients during the COVID-19 Pandemic: An Exploratory Survey.

INTRODUCTION: Novel coronavirus disease 2019 (COVID 19) has usurped human peace and mobility. The confinement of the population and the rising epidemic has disrupted the routine care for non-COVID-19 patients. Telehealth is a growing field, and its application in palliative care is seen as a solution to serve the population in this difficult crisis. METHODOLOGY: A exploratory survey was designed to assess the changes in the hospital-based practice of palliative care in the COVID-19 pandemic and patient/caregiver's perception about the provision of telehealth services to palliative care patients of a tertiary care cancer hospital of eastern India. RESULTS: There was a dramatic reduction in the outpatient clinic footfalls by 51% with teleconsultation. Although there was no change in the number of emergency visits, the inpatient admissions reduced by 44%. Nearly 82% of patient/caregivers gave a positive feedback about telemedicine care provided by the department and mentioned that the service provided them with support and connectedness. Almost 64% of the patients and caregivers reported that the service helped allay the fear and reassured them that there was a someone to support them. As high as 76% of the participants felt that they would prefer teleconsultation in future and were ready to pay for teleconsultations if charges were to be applied in the future. CONCLUSION: Telemedicine is an important tool and an essential service to care for palliative care patients in the community especially when the patient and health-care professionals are separated by a pandemic or natural disaster.

Hierarchically Structured Macro with Nested Mesoporous Zinc Indium Oxide Conducting Film.

Fabrication of homogeneously distributed (HD) macropores by breath figure process is an active research area. Adopting the process, for the first time, we report the fabrication of HD macro with nested meso (hierarchical) porous nanocrystalline zinc indium oxide conducting sol-gel thin film on glass by dip-coating at 45-50% room relative humidity (RH) from a solution in ethanol-2-butanol (1:1, w/w) medium with a 1:1, Zn:In ratio. In this process, solution composition and RH are found to play key roles on HD macropore generation. The film is highly promising toward visible-light-driven photoelectrochemical water splitting.

Efficacy and tolerability of topical sertaconazole versus topical terbinafine in localized dermatophytosis: A randomized, observer-blind, parallel group study.

OBJECTIVE: Epidermal dermatophyte infections most commonly manifest as tinea corporis or tinea cruris. Topical azole antifungals are commonly used in their treatment but literature suggests that most require twice-daily application and provide lower cure rates than the allylamine antifungal terbinafine. We conducted a head-to-head comparison of the effectiveness of the once-daily topical azole, sertaconazole, with terbinafine in these infections. MATERIALS AND METHODS: We conducted a randomized, observer-blind, parallel group study (Clinical Trial Registry India [CTRI]/2014/09/005029) with adult patients of either sex presenting with localized lesions. The clinical diagnosis was confirmed by potassium hydroxide smear microscopy of skin scrapings. After baseline assessment of erythema, scaling, and pruritus, patients applied either of the two study drugs once daily for 2 weeks. If clinical cure was not seen at 2 weeks, but improvement was noted, application was continued for further 2 weeks. Patients deemed to be clinical failure at 2 weeks were switched to oral antifungals. RESULTS: Overall 88 patients on sertaconazole and 91 on terbinafine were analyzed. At 2 weeks, the clinical cure rates were comparable at 77.27% (95% confidence interval [CI]: 68.52%-86.03%) for sertaconazole and 73.63% (95% CI 64.57%-82.68%) for terbinafine (P = 0.606). Fourteen patients in either group improved and on further treatment showed complete healing by another 2 weeks. The final cure rate at 4 weeks was also comparable at 93.18% (95% CI 88.75%-97.62%) and 89.01% (95% CI 82.59%-95.44%), respectively (P = 0.914). At 2 weeks, 6 (6.82%) sertaconazole and 10 (10.99%) terbinafine recipients were considered as "clinical failure." Tolerability of both preparations was excellent. CONCLUSION: Despite the limitations of an observer-blind study without microbiological support, the results suggest that once-daily topical sertaconazole is as effective as terbinafine in localized tinea infections.

Back pressure based multicast scheduling for fair bandwidth allocation.

We study the fair allocation of bandwidth in multicast networks with multirate capabilities. In multirate transmission, each source encodes its signal in layers. The lowest layer contains the most important information and all receivers of a session should receive it. If a receiver's data path has additional bandwidth, it receives higher layers which leads to a better quality of reception. The bandwidth allocation objective is to distribute the layers fairly. We present a computationally simple, decentralized scheduling policy that attains the maxmin fair rates without using any knowledge of traffic statistics and layer bandwidths. This policy learns the congestion level from the queue lengths at the nodes, and adapts the packet transmissions accordingly. When the network is congested, packets are dropped from the higher layers; therefore, the more important lower layers suffer negligible packet loss. We present analytical and simulation results that guarantee the maxmin fairness of the resulting rate allocation, and upper bound the packet loss rates for different layers.