Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis.

BACKGROUND: Alcohol Withdrawal Syndrome (AWS) among patients with chronic and heavy alcohol consumption can range from mild to severe and is associated with high morbidity and mortality. Currently, treating AWS with benzodiazepines is the standard of care, but phenobarbital has also been hypothesized to be an effective first-line treatment due to its pharmacological properties and mechanism of action. We conducted a meta-analysis to review relevant literature and compare the clinical outcomes for patients diagnosed with AWS in ED and ICU settings. METHODS: We performed a literature search in in the PubMed, Scopus, and Web of Science databases from inception to June 30, 2022. Randomized trials and observational (prospective or retrospective) studies were eligible if they included adult patients who presented in the ED and were treated in the ED and/or the intensive care unit (ICU) with a diagnosis of AWS. The primary outcome was the rate of intubation among patients who received phenobarbital, compared with benzodiazepines. Secondary outcomes such as rates of seizures, hospital, and ICU length of stay (LOS), also were included. The PROSPERO registration is CRD42022318862. RESULTS: We included twelve studies (1934 patients) in our analysis. Of the 1934 patients in these studies, 765 (41.7%) were treated with phenobarbital and 1169 (58.3%) were treated with other modalities for alcohol withdrawal. Treating AWS patients with phenobarbital did not affect their risk for intubation, as the risk for intubation was similar between the phenobarbital and the control group (RR 0.70, 95% CI 0.36-1.38, P = 0.31). In addition, patients who were treated with phenobarbital were found to have similar rates of seizures (RR 0.73, 95% CI 0.29-1.89) and length of stay in the hospital (Standardized Mean Difference -0.02, 95% CI -0.26, 0.21) or the ICU (SMD -0.02, 95% CI -0.21, 0.25) when compared with patients receiving benzodiazepines. CONCLUSIONS: Management of patients with AWS with phenobarbital is associated with similar rates of intubation, length of stay in the ICU, or length of stay in the hospital as treatment with benzodiazepines. However, due to the inclusion of mostly observational studies and a significant level of heterogeneity among the studies assessed in this review, additional trials with strong methodology are needed.

Decision-Making about COVID-19 Vaccines among Health Care Workers and Their Adolescent Children.

Health care workers promote COVID-19 vaccination for adolescent patients, and as parents, may influence their own children to get vaccinated. We conducted virtual, semi-structured qualitative interviews with vaccinated health care workers and their adolescent children to explore their decision-making process for COVID-19 vaccination. In total, 21 health care workers (physicians, nurses, and medical staff) and their adolescent children (N = 17) participated in interviews. The following three themes described parent-adolescent decision-making for COVID-19 vaccination: (1) family anticipation and hesitation about COVID-19 vaccine approval; (2) parents' or adolescents' choice: the decision maker for adolescent COVID-19 vaccination; and (3) leveraging one's vaccination status to encourage others to get vaccinated. Nurses encouraged adolescent autonomy in decisions for COVID-19 vaccination while physicians viewed vaccination as the parent's decision. Health care workers and their adolescent children used role-modeling to motivate unvaccinated peers and may model their decision-making process for adolescent COVID-19 vaccination with their own children to support their patients' and parents' vaccine decisions.

Adolescent Self-Consent for COVID-19 Vaccination: Views of Healthcare Workers and Their Adolescent Children on Vaccination Autonomy.

PURPOSE: This study explored the perceptions of healthcare worker parents (physicians, nurses, and staff) and their adolescents (aged 12-17 years) on adolescent self-consent to COVID-19 vaccination by applying the concept of positive deviance of those already vaccinated against COVID-19. METHODS: We used a qualitative descriptive design to conduct individual, semi-structured interviews with COVID-19-vaccinated healthcare workers in Southern California and their vaccinated adolescent children. Separate interviews were conducted with parents and adolescents from November to December 2021 using digital phone conferencing software. All interviews were recorded and transcribed. Thematic and constant comparative analysis techniques were used to identify relevant themes and subthemes. RESULTS: Twenty one healthcare workers (9 nurses, one nurse practitioner, one technologist, and 10 physicians) and their adolescents (N = 17) participated. Three overarching themes were identified to describe participants' perspectives about adolescent self-consent for COVID-19 vaccination: (1) Family values and practices around adolescent vaccination; (2) Differences in parent and adolescent support for vaccine self-consent laws; and (3) Parent and adolescent uncertainty on readiness for vaccine self-consent laws. Adolescents largely supported self-consent while parents supported the policy if they would be able to have a discussion with their adolescent prior to the decision. DISCUSSION: Parents and adolescents supported adolescent self-consent for COVID-19 vaccination, with the reservation that adolescents should discuss the decision alongside their parents to exercise their medical autonomy with supportive guidance. Greater adolescent involvement in making decisions and providing self-consent for healthcare, including vaccines, could prepare adolescents to have a greater sense of autonomy over their health and contribute to population health measures.

COVID-19 vaccine concerns of health care providers and ancillary staff.

A web-based survey was widely distributed between November 1st-December 27th, 2021, to health care providers and ancillary staff to assess reported COVID-19 vaccination of their children as well as their vaccine concerns. Fewer nurses and laboratory / radiology technicians reported COVID-19 vaccination of their adolescent children and intent to vaccinate their younger children compared to physicians and pharmacists, along with more frequently reported concern about anaphylaxis and infertility. Focused efforts to update ancillary staff as well as all health care providers on emerging COVID-19 vaccine safety information for children is crucial to promote strong COVID-19 vaccine recommendations. IMPACT: Nurses, laboratory technicians and radiology technicians frequently reported concern about anaphylaxis and infertility after COVID-19 vaccination despite reassuring safety data. Education of ancillary staff with emerging safety data is important to strengthen health care provider vaccine recommendations.

Trends in HPV vaccine administration and HPV vaccine coverage in children by race/ethnicity and socioeconomic status during the COVID-19 pandemic in an integrated health care system in California.

BACKGROUND: We sought to evaluate the trends of HPV vaccination between 03/2019-09/2021 and whether the impact of the COVID pandemic on HPV vaccination varied by race/ethnicity and neighborhood deprivation index (NDI). METHODS: Electronic medical records at Kaiser Permanente Southern California were used to assess monthly volume of HPV vaccine doses administered among children aged 9-12.9yrs, and up-to-date coverage (% vaccinated) by age 13 between 03/2019-09/2021. Modified Poisson models were used to evaluate the interactions between race/ethnicity, NDI and the pandemic periods on HPV vaccine coverage. RESULTS: HPV vaccine doses administered in 2020/2021 have returned to the 2019 level after the initial drop. The average up-to-date coverage in 05/2021-09/2021 (54.8%) remained lower than the pre-pandemic level (58.5%). The associations between race/ethnicity, NDI and HPV vaccine coverage did not vary due to the pandemic. CONCLUSION: HPV vaccine promotion efforts are needed to address COVID-19 pandemic's lasting impact on HPV vaccination coverage.

Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States.

OBJECTIVE: Home health care agencies (HHAs) are skilled care providers for Medicare home health beneficiaries in the United States. Rural HHAs face different challenges from their urban counterparts in delivering care (eg, longer distances to travel to patient homes leading to higher fuel/travel costs and fewer number of visits in a day, impacting the quality of home health care for rural beneficiaries). We review evidence on differences in care outcomes provided by urban and rural HHAs. DESIGN: Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using the Newcastle-Ottawa Scale (NOS) for quality appraisal. SETTING: Care provided by urban and rural HHAs. METHODS: We conducted a systematic search for English-language peer-reviewed articles after 2010 on differences in urban and rural care provided by U.S. HHAs. We screened 876 studies, conducted full-text abstraction and NOS quality review on 36 articles and excluded 2 for poor study quality. RESULTS: Twelve studies were included; 7 focused on patient-level analyses and 5 were HHA-level. Nine studies were cross-sectional and 3 used cohorts. Urban and rural differences were measured primarily using a binary variable. All studies controlled for agency-level characteristics, and two-thirds also controlled for patient characteristics. Rural beneficiaries, compared with urban, had lower home health care utilization (4 of 5 studies) and fewer visits for physical therapy and/or rehabilitation (3 of 5 studies). Rural agencies had lower quality of HHA services (3 of 4 studies). Rural patients, compared with urban, visited the emergency room more often (2 of 2 studies) and were more likely to be hospitalized (2 of 2 studies), whereas urban patients with heart failure were more likely to have 30-day preventable hospitalizations (1 study). CONCLUSION AND IMPLICATIONS: This review highlights similar urban/rural disparities in home health care quality and utilization as identified in previous decades. Variables used to measure the access to and quality of care by HHAs varied, so consensus was limited. Articles that used more granular measures of rurality (rather than binary measures) revealed additional differences. These findings point to the need for consistent and refined measures of rurality in studies examining urban and rural differences in care from HHAs.

Measuring Palliative Care-Related Knowledge, Attitudes, and Confidence in Home Health Care Clinicians, Patients, and Caregivers: A Systematic Review.

Background: Integrating palliative care services in the home health care (HHC) setting is an important strategy to provide care for seriously ill adults and improve symptom burden, quality of life, and caregiver burden. Routine palliative care in HHC is only possible if clinicians who provide this care are prepared and patients and caregivers are well equipped with the knowledge to receive this care. A key first step in integrating palliative care services within HHC is to measure preparedness of clinicians and readiness of patients and caregivers to receive it. Objective: The objective of this systematic review was to review existing literature related to the measurement of palliative care-related knowledge, attitudes, and confidence among HHC clinicians, patients, and caregivers. Methods: We searched PubMed, CINAHL, Web of Science, and Cochrane for relevant articles between 2000 and 2021. Articles were included in the final analysis if they (1) reported specifically on palliative care knowledge, attitudes, or confidence, (2) presented measurement tools, instruments, scales, or questionnaires, (3) were conducted in the HHC setting, (4) and included HHC clinicians, patients, or caregivers. Results: Seventeen articles were included. While knowledge, attitudes, and confidence have been studied in HHC clinicians, patients, and caregivers, results varied significantly across countries and health care systems. No study captured knowledge, attitudes, and confidence of the full HHC workforce; notably, home health aides were not included in the studies. Conclusion: Existing instruments did not comprehensively contain elements of the eight domains of palliative care outlined by the National Consensus Project (NCP) for Quality Palliative Care. A comprehensive psychometrically tested instrument to measure palliative care-related knowledge, attitudes, and confidence in the HHC setting is needed.

"Still on the Fence": A Mixed Methods Investigation of COVID-19 Vaccine Confidence Among Health Care Providers.

BACKGROUND: There is evidence of disparities in COVID-19 vaccine acceptance among health care providers. The purpose of this study was to examine confidence receiving and recommending COVID-19 vaccines by health care provider type and race/ethnicity. METHODS: This mixed methods study involved a cross-sectional survey and qualitative, semi-structured interviews from March to May 2021 among a sample of physicians, advanced practice providers, nurses, and pharmacists. These workers were recruited through voluntary response sampling from an integrated health system in Southern California. The primary dependent variables were (a) confidence in vaccine safety, (b) confidence in vaccine effectiveness, and (c) intent to recommend the vaccine to others. The primary independent variables were health care provider type and race/ethnicity. FINDINGS: A total of 2,948 providers completed the survey. Nurses relative to physicians were 15% less likely to perceive the COVID-19 vaccine to be safe (risk ratio [RR] = 0.85; 95% confidence interval [CI] = 0.83-0.87); 27% less likely to perceive the vaccine to prevent COVID-19 (RR = 0.73; 95% CI = 0.69-0.76); and 11% less likely to recommend the vaccine to others (RR = 0.89; 95% CI = 0.87-0.91). Hispanic/Latinx providers were 10% less likely to perceive the vaccine to prevent COVID-19 (RR = 0.90; 95% CI = 0.83-0.98) relative to White providers. Qualitative themes included: No need for vaccine; distrusting vaccine research and roll-out; caretaking barriers; uncertainty and potential to change one's mind; framing vaccine decisions around personal beliefs. CONCLUSIONS & APPLICATION TO PRACTICE: Health care workplaces should consider interventions to increase COVID-19 vaccination among their workers, including education and mandatory vaccination policies.

Race/Ethnicity Differences in COVID-19 Vaccine Uptake Among Nurses.

INTRODUCTION: There is evidence for relatively lower COVID-19 vaccine uptake among people of color in the United States. The purpose of this study was to investigate associations between race/ethnicity and COVID-19 vaccine uptake among nurses. METHODS: Nurses in Southern California (N = 1183) completed a one-time, web-based survey to assess COVID-19 vaccine perceptions and uptake. RESULTS: In all, 82.8% of respondents (N = 979) received at least one COVID-19 vaccine dose. Identifying as East Asian was associated with 14% higher odds of COVID-19 vaccine uptake relative to identifying as White (odds ratio [OR] = 1.14/95% confidence interval [CI] = [1.06, 1.24]); identifying as Filipino was associated with 14% higher odds of uptake (OR = 1.14/95% CI = [1.08, 1.20]); and identifying as Hispanic/Latinx was associated with 6% higher odds of uptake (OR = 1.06/95% CI = [1.00, 1.12]). DISCUSSION: Although nurses and people of color have been identified as groups with low levels of COVID-19 vaccine uptake, this study found that nurses of color received the vaccine at higher levels than their White counterparts.

Health Care Providers' Trusted Sources for Information About COVID-19 Vaccines: Mixed Methods Study.

BACKGROUND: Information and opinions shared by health care providers can affect patient vaccination decisions, but little is known about who health care providers themselves trust for information in the context of new COVID-19 vaccines. OBJECTIVE: The purpose of this study is to investigate which sources of information about COVID-19 vaccines are trusted by health care providers and how they communicate this information to patients. METHODS: This mixed methods study involved a one-time, web-based survey of health care providers and qualitative interviews with a subset of survey respondents. Health care providers (physicians, advanced practice providers, pharmacists, nurses) were recruited from an integrated health system in Southern California using voluntary response sampling, with follow-up interviews with providers who either accepted or declined a COVID-19 vaccine. The outcome was the type of information sources that respondents reported trusting for information about COVID-19 vaccines. Bivariate tests were used to compare trusted information sources by provider type; thematic analysis was used to explore perspectives about vaccine information and communicating with patients about vaccines. RESULTS: The survey was completed by 2948 providers, of whom 91% (n=2683) responded that they had received ≥1 dose of a COVID-19 vaccine. The most frequently trusted source of COVID-19 vaccine information was government agencies (n=2513, 84.2%); the least frequently trusted source was social media (n=691, 9.5%). More physicians trusted government agencies (n=1226, 93%) than nurses (n=927, 78%) or pharmacists (n=203, 78%; P<.001), and more physicians trusted their employer (n=1115, 84%) than advanced practice providers (n=95, 67%) and nurses (n=759, 64%; P=.002). Qualitative themes (n=32 participants) about trusted sources of COVID-19 vaccine information were identified: processing new COVID-19 information in a health care work context likened to a "war zone" during the pandemic and communicating information to patients. Some providers were hesitant to recommend vaccines to pregnant people and groups they perceived to be at low risk for COVID-19. CONCLUSIONS: Physicians have stronger trust in government sources and their employers for information about COVID-19 vaccines compared with nurses, pharmacists, and advanced practice providers. Strategies such as role modeling, tailored messaging, or talking points with standard language may help providers to communicate accurate COVID-19 vaccine information to patients, and these strategies may also be used with providers with lower levels of trust in reputable information sources.

Wheezing in children with pertussis associated with delayed pertussis diagnosis.

BACKGROUND: The classic clinical features of paroxysmal pertussis are often absent in older children and adults and after vaccination. The California pertussis epidemic of 2010 occurred in a highly vaccinated population. METHODS: All pediatric patients (0-18 years) with positive pertussis polymerase chain reaction from July to December 2010 were identified retrospectively from the Kaiser SCAL database. Information extracted by chart review included age at diagnosis, vaccine history, race, cough duration, number of clinic visits before diagnosis, presence of paroxysms, post-tussive emesis or wheezing, treatment for asthma during the course of illness and exposure to confirmed or suspected pertussis cases. RESULTS: Overall 501 pediatric patients (mean age = 8.4 years) with positive pertussis nasopharyngeal polymerase chain reaction were identified. Complete DTaP series and Tdap vaccine had been received by 93% and 38% of eligible patients, respectively. Paroxysms, post-tussive emesis and wheezing on physical examination were present in 34%, 30% and 8% of patients, respectively. Each was associated with a longer duration of symptoms at diagnosis. Wheezing was associated with a delay in diagnosis (60% requiring >1 clinic visit for diagnosis vs. 29% in the overall population, P < 0.0001). Documented exposures were associated with a more timely pertussis diagnosis (after 9.4 days vs. 14.5 days; P < 0.0001). CONCLUSIONS: Wheezing is present on examination of some patients with pertussis in a highly vaccinated pediatric population and appears to delay the diagnosis of pertussis. The presence of wheezing should not be used to exclude this diagnosis in children with chronic cough or other reasons to suspect pertussis.

Necessary and sufficient causes of participation post-stroke: practical and philosophical perspectives.

INTRODUCTION: Participation, a construct within the disability/functioning framework, is evaluated on a person's involvement in life situations including family, community, work, social, and civic life. In the context of recovering from a major health event, participation is a treatment goal and it is known to correlate with the quality of life. OBJECTIVE: The purpose of this study is to track the dynamics of participation post-stroke in relationship to the dynamics of walking capacity, social support, and mood. METHODS: An inception cohort was followed over the first post-stroke year. Group-based trajectory analysis, a form of latent class analysis, was used to identify distinctive groups of individuals with similar trajectories. Dual trajectories were used to estimate concordance between participation trajectory and trajectories for each of the three constructs under study. RESULTS: From the sample of 102 persons (mean age 70), four trajectories of participation were identified, two of which were qualified as excellent and very good, and two qualified as fair and poor. All those with excellent walking showed excellent participation. However, people with excellent (and very good) community participation had a range of walking capacities. Most (82%) people with normal mood showed excellent participation. People with good mood but not meeting norms for age showed the complete range of participation trajectories from excellent to poor. The higher proportion of people with excellent or good social support (57%) showed excellent participation. CONCLUSION: Two treatable component causes of participation, walking capacity and mood, were identified; of these, only excellent walking capacity could be considered a sufficient cause.

Recurrent papular urticaria after varicella immunization in a fifteen-month-old girl.

Varicella-like rash after immunization with the live attenuated varicella vaccine is relatively common. Such vaccine-associated rashes generally consist of fewer lesions than occur in chickenpox. We describe a 15-month-old girl who experienced the onset of recurring papular urticaria after varicella immunization. The rash was varicella-like and thought by us to be caused by vaccine virus.

A large outbreak of histoplasmosis among American travelers associated with a hotel in Acapulco, Mexico, spring 2001.

During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illness after returning from spring break vacation in Acapulco, Mexico. Acute pulmonary histoplasmosis was presumptively diagnosed and the cluster of illness was reported to the Centers of Disease Control and Prevention. A large investigation then ensued, which included finding student-travelers for interviews and requesting sera for histoplasmosis testing. We defined a clinical case by fever and at least one of the following: cough, shortness of breath, chest pain, or headache, in an Acapulco traveler during March-May 2001. A laboratory-confirmed case had positive serology. An initial study determined that the likely site of histoplasmosis exposure was Hotel H; we therefore performed a large cohort study among travelers who stayed at Hotel H. Of 757 contacted, 262 (36%) met the clinical case definition. Of 273 serum specimens tested, 148 (54%) were positive. Frequent use of Hotel H's stairwells, where construction was ongoing, was associated with increased risk of illness (relative risk = 10.5, 95% confidence interval = 3.7-30.5; P < 0.001). This is the first histoplasmosis outbreak associated with a hotel undergoing construction. Hotels in endemic areas should consider construction precaution measures to prevent histoplasmosis among their guests.

Beta-endorphin processing and cellular origins in rat spinal cord.

While enkephalin and dynorphin peptides have been well characterized in the spinal cord, the cellular localization of beta-endorphin (beta E) and the processing of pro-opiomelanocortin (POMC) to beta E and other non-opioid peptides in the cord have not been extensively investigated. Other investigators have characterized the various beta E forms present in rat spinal cord regions. Previous studies have also suggested that spinal POMC content is entirely derived from supraspinal sources. However, high proportions of beta E precursors present in spinal cord sieving profiles led us to suspect the presence of POMC cell bodies intrinsic to the cord. In this study, we performed thoracic spinal cord lesions on a group of animals and demonstrated the persistence of about one-third of control levels of beta E immunoreactivity (beta E-IR) below the level of the lesions. We also characterized POMC processing in various regions of the spinal cord both before and after lesioning. These data suggested that there may be intrinsic POMC/endorphinergic neuronal systems in the spinal cord.