Providing doula support to publicly insured women in central Texas: A financial cost-benefit analysis.

BACKGROUND: Disparities in birth outcomes continue to exist in the United States, particularly for low-income, publicly insured women. Doula support has been shown to be a cost-effective intervention in predominantly middle-to-upper income White populations, and across all publicly insured women at the state level. This analysis extends previous studies by providing an estimate of benefits that incorporates variations in averted outcomes by race and ethnicity in the context of one region in Texas. The objectives of this study were to determine (1) whether the financial value of benefits provided by doula support exceeds the costs of delivering it; (2) whether the cost-benefit ratio differs by race and ethnicity; and (3) how different doula reimbursement levels affect the cost-benefit results with respect to pregnant people covered by Medicaid in central Texas. METHODS: We conducted a forward-looking cost-benefit analysis using secondary data carried out over a short-term time horizon taking a public payer perspective. We focused on a narrow set of health outcomes (preterm delivery and cesarean delivery) that was relatively straightforward to monetize. The current, usual care state was used as the comparison condition. RESULTS: Providing pregnant people covered by Texas Medicaid with access to doulas during their pregnancies was cost-beneficial (benefit-to-cost ratio: 1.15) in the base model, and 65.7% of the time in probabilistic sensitivity analyses covering a feasible range of parameters. The intervention is most cost-beneficial for Black women. Reimbursing doulas at $869 per client or more yielded costs that were greater than benefits, holding other parameters constant. CONCLUSIONS: Expanding Medicaid pregnancy-related coverage to include doula services would be cost-beneficial and improve health equity in Texas.

Nutrient-regulated dynamics of chondroprogenitors in the postnatal murine growth plate.

Longitudinal bone growth relies on endochondral ossification in the cartilaginous growth plate, where chondrocytes accumulate and synthesize the matrix scaffold that is replaced by bone. The chondroprogenitors in the resting zone maintain the continuous turnover of chondrocytes in the growth plate. Malnutrition is a leading cause of growth retardation in children; however, after recovery from nutrient deprivation, bone growth is accelerated beyond the normal rate, a phenomenon termed catch-up growth. Although nutritional status is a known regulator of long bone growth, it is largely unknown whether and how chondroprogenitor cells respond to deviations in nutrient availability. Here, using fate-mapping analysis in Axin2CreERT2 mice, we showed that dietary restriction increased the number of Axin2+ chondroprogenitors in the resting zone and simultaneously inhibited their differentiation. Once nutrient deficiency was resolved, the accumulated chondroprogenitor cells immediately restarted differentiation and formed chondrocyte columns, contributing to accelerated growth. Furthermore, we showed that nutrient deprivation reduced the level of phosphorylated Akt in the resting zone and that exogenous IGF-1 restored the phosphorylated Akt level and stimulated differentiation of the pooled chondroprogenitors, decreasing their numbers. Our study of Axin2CreERT2 revealed that nutrient availability regulates the balance between accumulation and differentiation of chondroprogenitors in the growth plate and further demonstrated that IGF-1 partially mediates this regulation by promoting the committed differentiation of chondroprogenitor cells.

Nutrient-regulated dynamics of chondroprogenitors in the postnatal murine growth plate.

Longitudinal bone growth relies on endochondral ossification in the cartilaginous growth plate where chondrocytes accumulate and synthesize the matrix scaffold that is replaced by bone. The chondroprogenitors in the resting zone maintain the continuous turnover of chondrocytes in the growth plate. Malnutrition is a leading cause of growth retardation in children; however, after recovery from nutrient deprivation, bone growth is accelerated beyond the normal rate, a phenomenon termed catch-up growth. Though nutritional status is a known regulator of long bone growth, it is largely unknown if and how chondroprogenitor cells respond to deviations in nutrient availability. Here, using fate-mapping analysis in Axin2Cre ERT2 mice, we showed that dietary restriction increased the number of Axin2+ chondroprogenitors in the resting zone and simultaneously inhibited their differentiation. Once nutrient deficiency was resolved, the accumulated chondroprogenitor cells immediately restarted differentiation and formed chondrocyte columns, contributing to accelerated growth. Furthermore, we showed that nutrient deprivation reduced the level of phosphorylated Akt in the resting zone, and that exogenous IGF-1 canceled this reduction and stimulated differentiation of the pooled chondroprogenitors, decreasing their numbers. Our study of Axin2Cre ERT2 revealed that nutrient availability regulates the balance between accumulation and differentiation of chondroprogenitors in the growth plate, and further demonstrated that IGF-1 partially mediates this regulation by promoting the committed differentiation of the chondroprogenitor cells.

The power of feedback: Implementing a comprehensive hand hygiene observer program.

BACKGROUND: Hand hygiene (HH) is a fundamental component of infection prevention within all healthcare settings. We implemented a hospital-wide program built on overt HH observation, real-time feedback, and thematic analysis of HH misses. METHODS: A robust observer training program was established to include foundational training in the WHO's My Five Moments of HH. Observational data from 2011 to 2019 were analyzed by unit, provider type, and thematic analyses of misses. RESULTS: During the study period, we conducted 160,917 hospital-wide observations on 29 units (monthly average of 1,490 observations). Institutional compliance remained above 95% from 2013 to 2019. Thematic analysis revealed "touching self" and "touching phone" as common, institution-wide reasons for HH misses. DISCUSSION: Overt observations facilitated communication between HH program and healthcare staff to better understand workflow and educate staff on HH opportunities. This program is an integral part of the Infection Prevention team and has been deployed to collect supplemental data during clusters and outbreaks investigations. CONCLUSIONS: In addition to having rich HH data, successes of this program, include increased awareness of IPC practices, enhanced communication about patient safety, enriched dialog and feedback around HH misses, and relationship building among program observers, unit staff and leaders.

Innovative use of a flipped-classroom approach to teach fundamental nursing skills.

Prelicensure nursing students are required to master fundamental nursing skills. The COVID-19 pandemic created challenges in maintaining excellence while teaching skill acquisition. The purpose of this study was to evaluate skill validation scores and student satisfaction and self-confidence using a flipped classroom approach and a low-fidelity simulation model to innovatively teach skill acquisition. Researchers used a quasi-experimental method to compare skill validation scores of a control group and intervention group using independent samples t-test. Researchers also evaluated whether prelicensure nursing students had satisfaction and self-confidence with this teaching strategy. Findings suggested that skills validations scores were no different using a flipped-classroom approach than in-person instruction. Prelicensure nursing students were satisfied and self-confident following the implementation of this teaching strategy. This teaching strategy has the potential to decrease in-person clinical practice time, provide alternative opportunities for clinical make-up and remediation, and decrease cost.

Dodging the bundle-Persistent healthcare-associated rhinovirus infection throughout the pandemic.

INTRODUCTION: Healthcare-associated viral infections (HAVI) are a common cause of patient harm in the pediatric population. We implemented a HAVI prevention bundle in 2015, which included 6 core elements: caregiver screening, symptom-based isolation, personal protective equipment (PPE), hand hygiene, staff illness procedures, and monitoring of environmental cleanliness. Enhanced bundle elements were introduced at the start of the COVID-19 pandemic, which provided an opportunity to observe the effectiveness of the bundle with optimal adherence to prevention practices, and to measure the impact on respiratory HAVI epidemiology. METHODS: Respiratory HAVIs were confirmed through review of medical records and application of the National Health Safety Network (NHSN) surveillance criteria for upper respiratory infections (URIs) with predetermined incubation periods for unit attribution. Descriptive statistics of the study population were examined, and comparative analyses were performed on demographic and process metrics. Data analysis was conducted using R statistical software. RESULTS: We observed an overall decrease in respiratory HAVI of 68%, with prepandemic rates of 0.19 infections per 1,000 patient significantly decreased to a rate of 0.06 per 1,000 patient days in the pandemic period (P < .01). Rhinovirus made up proportionally more of our respiratory HAVI in the pandemic period (64% vs 53%), with respiratory HAVI secondary only to rhinovirus identified during 8 of 16 months in the pandemic period. Compliance with our HAVI prevention bundle significantly improved during pandemic period. CONCLUSIONS: Enhancement of our HAVI bundle during the COVID-19 pandemic contributed toward significant reduction in nosocomial transmission of respiratory HAVI. Even with prevention practices optimized, respiratory HAVIs secondary to rhinovirus continued to be reported, likely due to the capacity of rhinovirus to evade bundle elements in hospital, and infection prevention efforts at large in the community, leaving vulnerable patients at continued risk.

Inhibition of glucose use improves structural recovery of injured Achilles tendon in mice.

Injured tendons do not regain their native structure except at fetal or very young ages. Healing tendons often show mucoid degeneration involving accumulation of sulfated glycosaminoglycans (GAGs), but its etiology and molecular base have not been studied substantially. We hypothesized that quality and quantity of gene expression involving the synthesis of proteoglycans having sulfated GAGs are altered in injured tendons and that a reduction in synthesis of sulfated GAGs improves structural and functional recovery of injured tendons. C57BL6/j mice were subjected to Achilles tendon tenotomy surgery. The injured tendons accumulated sulfate proteoglycans as early as 1-week postsurgery and continued so by 4-week postsurgery. Transcriptome analysis revealed upregulation of a wide range of proteoglycan genes that have sulfated GAGs in the injured tendons 1 and 3 weeks postsurgery. Genes critical for enzymatic reaction of initiation and elongation of chondroitin sulfate GAG chains were also upregulated. After the surgery, mice were treated with the 2-deoxy-d-glucose (2DG) that inhibits conversion of glucose to glucose-6-phosphate, an initial step of glucose metabolism as an energy source and precursors of monosaccharides of GAGs. The 2DG treatment reduced accumulation of sulfated proteoglycans, improved collagen fiber alignment, and reduced the cross-sectional area of the injured tendons. The modulus of the 2DG-treated groups was higher than that in the vehicle group, but not of statistical significance. Our findings suggest that mucoid degeneration in injured tendons may result from the upregulated expression of genes involved the synthesis of sulfate proteoglycans and can be inhibited by reduction of glucose utilization.

Influences of the Home Language and Literacy Environment on Spanish and English Vocabulary Growth among Dual Language Learners.

Little is known regarding the extent to which aspects of the home language and literacy environment (HLE) promote growth in language skills among dual language learners (DLLs). Therefore, the purpose of this study was to evaluate which aspects of the HLE significantly predict growth in English and Spanish vocabulary among Spanish-speaking DLLs. 944 Spanish-speaking DLLs (51.6% female; mean age = 53.77 months) completed assessments of English and Spanish vocabulary at four time points across two academic years. Parents completed a survey of the HLE that included information on language exposure, reading exposure, and family reading habits. Results indicated that specific literacy-related practices, including availability of books in the home, language read to the child, and parental reading skills were significant predictors of growth in children's Spanish and English vocabulary knowledge, even after controlling children's initial level of language skills and family socioeconomic status.

KarMMa-RW: comparison of idecabtagene vicleucel with real-world outcomes in relapsed and refractory multiple myeloma.

Patients with relapsed and refractory multiple myeloma (RRMM) who are triple-class exposed (to an immunomodulatory agent, proteasome inhibitor, and anti-CD38 antibody) have limited treatment options and there is no standard of care. Idecabtagene vicleucel (ide-cel, bb2121), a BCMA-directed CAR T-cell therapy, demonstrated efficacy in triple-class exposed RRMM patients in the KarMMa trial (NCT03361748). In this retrospective study (KarMMa-RW), patient-level data from triple-class exposed RRMM patients were merged into a single data model and compared with KarMMa using trimmed stabilized inverse probability of treatment weighting. Endpoints included overall response rate (ORR; primary), rate of very good partial response or better (≥VGPR), progression-free survival (PFS), and overall survival (OS). Of 1949 real-world triple-class exposed RRMM patients, 190 received subsequent (index) line of therapy and met KarMMa eligibility criteria (Eligible RRMM cohort). With a median follow-up of 13.3 months in KarMMa and 10.2 months in Eligible RRMM, ORR, and ≥VGPR were significantly improved in KarMMa versus Eligible RRMM (ORR, 76.4% vs 32.2%; ≥VGPR, 57.9% vs 13.7%; both P < 0.0001) as were PFS (11.6 vs 3.5 months; P = 0.0004) and OS (20.2 vs 14.7 months; P = 0.0006). This study demonstrated that ide-cel significantly improved responses and survival compared with currently available therapies in triple-class exposed RRMM.

Analysis of Association between Morphometric Parameters of Growth Plate and Bone Growth of Tibia in Mice and Humans.

OBJECTIVE: The purposes of this study are to evaluate which growth plate parameters are associated with bone growth in mice and to compare the mouse results with those in humans. DESIGN: The sagittal sections of the proximal growth plate of the mouse tibia from neonate to young adult stages were subjected to histomorphometric and functional analyses. The radiographic images of tibias of human patients until puberty were analyzed to obtain the tibia length and the proximal growth plate height. It was found that a linear correlation best modeled the relationship between the growth plate variables with the tibia growth rate and length. RESULTS: In mice, total height, resting zone height, combined height of the proliferation and prehypertrophic zones, proliferation activity, and the total width of tibia growth plate showed high linear correlation with tibia bone length and bone growth rate, but the hypertrophic zone height and the growth plate area did not. In both mice and humans, the total growth plate width of tibia was found to have the strongest correlation with tibia length and growth rate. CONCLUSIONS: The results validated that growth plate total height, the height of the resting zone and cell proliferation activity are appropriate parameters to evaluate the balance between growth plate activity and bone growth in mice, consistent with previous reports. The study also provided a new growth plate parameter candidate, growth plate width for growth plate activity evaluation in both mouse and human tibia bone.

Cost-effectiveness of a comprehensive immunization program serving high-risk, uninsured adults.

Despite the numerous social and economic benefits of vaccination, adult immunization rates fall far short of recommended levels costing the United States $9 billion annually in health care expenditures and reduced productivity. While it is well recognized that childhood immunization is highly cost-effective, the economic impact of adult immunization programs varies by disease and is influenced by population demographics. This study aimed to assess the cost-effectiveness of a comprehensive adult immunization program serving high-need populations delivered by a local health department (LHD) in partnership with community organizations. We modeled incremental cost-effectiveness taking the payer perspective of each vaccine separately in simulated cohorts of 100,000 over a 20-year horizon using data provided by the LHD and data from the published literature. We adjusted the results to align with actual program delivery and used them to estimate an incremental cost-effectiveness ratio (ICER) for the entire program. We assessed the effects of varying our base model parameters in univariate sensitivity analyses. We discounted benefits and life years saved (LYS) at 3% and adjusted results to 2016 US$. Four of seven disease models were cost-effective (using a $100,000 CE threshold) with ICERS ranging from $14,260 to $79,022/LYS. Sensitivity analyses did not substantially impact the results. The ICER for program as a whole was $67,940/LYS. A community-delivered comprehensive immunization program serving uninsured, low income, high-risk adults is a cost-effective investment even when most do not receive the full regimen of some vaccines.

The iCook 4-H Study: An Intervention and Dissemination Test of a Youth/Adult Out-of-School Program.

OBJECTIVE: To describe outcomes from intervention and dissemination of iCook 4-H. DESIGN: Five-state, community-based participatory research and a randomized, controlled trial followed by a 5-state, nonrandomized dissemination test of the iCook 4-H curriculum with control and treatment groups. SETTING: Community and university sites. PARTICIPANTS: Youths aged 9-10 years and their adult food preparer; 228 dyads in the intervention and 74 dyads in dissemination. INTERVENTION(S): Theoretical frameworks were Social Cognitive Theory and the experiential 4-H learning model. Six 2-hour, biweekly sessions on cooking, eating, and playing together followed by monthly newsletters and boosters until 24 months, expanded to 8 sessions for dissemination. MAIN OUTCOME MEASURE(S): Youth body mass index (BMI) z-scores, measured height and weight, and youth/adult program outcome evaluations surveys. ANALYSIS: Linear mixed models, group, time, and group × time interaction for BMI z-score and program outcomes changes. Significance levels = P ≤ .05; interaction term significance = P ≤ .10. RESULTS: In intervention, treatment BMI z-scores increased compared with controls based on significant interaction (P = .04). For odds of being overweight or obese at 24 months, there was no significant interaction (P = .18). In dissemination, based on significant interaction, treatment youths increased cooking skills (P = .03) and treatment adults increased cooking together (P = .08) and eating together (P = .08) compared with controls. CONCLUSIONS AND IMPLICATIONS: iCook 4-H program outcomes were positive for mealtime activities of cooking and eating together. The program can be successfully implemented by community educators. The increase in BMI z-scores needs further evaluation for youths in cooking programs.

Development of the iCook 4-H Curriculum for Youth and Adults: Cooking, Eating, and Playing Together for Childhood Obesity Prevention.

The objective was to describe the development process of a curriculum (iCook 4-H) targeted to low-income, rural, and/or diverse youths and their adult primary meal preparer to promote cooking, eating, and playing together. Lessons learned highlighted the importance of grounding the curriculum in Social Cognitive Theory and applying the experiential 4-H learning model using a multiphased, community-based participatory approach with cyclical development and evaluation, and key modifications made for dissemination and distribution. Findings across 4 testing phases over 6 years and 5 states demonstrated the time-intensive, cyclical process that required flexibility with fidelity to form a hands-on, interactive curriculum.

Predictors of Moral Distress in a US Sample of Critical Care Nurses.

BACKGROUND: Moral distress in registered nurses causes decreased job satisfaction, turnover in staffing, burnout, and heightened states of psychological distress. To date, investigation of modifiable factors, such as perceptions of the practice environment and patient safety, among a diverse sample of critical care nurses has been limited. OBJECTIVE: To explore the relationships among the severity of moral distress, the practice environment, and patient safety in a national sample of critical care nurses. METHODS: Critical care nurses experienced in working with adults (> 1 year of intensive care unit experience) and who were subscribers to the American Association of Critical-Care Nurses' e-mail listserv and social media sites anonymously participated in this descriptive study. Participants completed a demographic questionnaire, the Moral Distress Scale-Revised, and the Practice Environment Scale of the Nursing Work Index. Descriptive statistics, bivariate correlation coefficients, and a hierarchical regression analysis were used to describe the sample characteristics and to assess relationships among the study variables. RESULTS: Of a national sample of 328 critical care nurses, 56% had less than 20 years of experience as a registered nurse. Moral distress was modestly associated with negative perceptions of the practice environment and patient safety. Job satisfaction, practice environment, and the participant's age were statistically significant predictors of moral distress in this sample. CONCLUSIONS: Modifications of organizational factors such as the development of healthy work environments that promote collegial relationships could reduce moral distress among critical care nurses.

Household costs of breast cancer morbidity: An empirical assessment from Pakistan.

PURPOSE: Health care costs attributable to breast cancer are substantial. In countries with high poverty, lack of public health infrastructure and low availability of health insurance, the economic burden of disease does not accrue solely to health care, but also on patients and their families. This study was conducted to explore the cost burden (i.e. direct medical costs, direct non-medical costs and indirect non-medical costs) incurred by breast cancer patients and their families over diagnosis and treatment. METHODS: Data was collected from 200 breast cancer patients at two hospitals in Lahore, provincial capital of Punjab, Pakistan, by employing purposive sampling technique. Costs were aggregated into three categories and compared with each other as per their weightage. RESULTS: The study found that direct medical care (US$ 1262.18/ Local currency (PKR) 129,717) is the largest expense, followed by direct non-medical (US$ 310.88 / PKR 31,950) and indirect non-medical costs (US$ 273.38 / PKR 28,096). CONCLUSIONS: The results of this study provide rich insight into the financial burden borne by households of breast cancer patients and suggest policy implications.

A multinational study distinguishing Alzheimer's and healthy patients using cerebrospinal fluid tau/Aß42 cutoff with concordance to amyloid positron emission tomography imaging.

INTRODUCTION: Changes in cerebrospinal fluid (CSF) tau and amyloid ß (Aß)42 accompany development of Alzheimer's brain pathology. Robust tau and Aß42 immunoassays were developed to establish a tau/Aß42 cutoff distinguishing mild-to-moderate Alzheimer's disease (AD) subjects from healthy elderly control (HC) subjects. METHODS: A CSF tau/Aß42 cutoff criteria was chosen, which distinguished the groups and maximized concordance with amyloid PET. Performance was assessed using an independent validation cohort. RESULTS: A tau/Aß42 = 0.215 cutoff provided 94.8% sensitivity and 77.7% specificity. Concordance with PET visual reads was estimated at 86.9% in a ∼50% PET positive population. In the validation cohort, the cutoff demonstrated 78.4% sensitivity and 84.9% specificity to distinguish the AD and HC populations. DISCUSSION: A tau/Aß42 cutoff with acceptable sensitivity and specificity distinguished HC from mild-to-moderate AD subjects and maximized concordance to brain amyloidosis. The defined cutoff demonstrated that CSF analysis may be useful as a surrogate to imaging assessment of AD pathology.

Multimodal Speech Capture System for Speech Rehabilitation and Learning.

Speech-language pathologists (SLPs) are trained to correct articulation of people diagnosed with motor speech disorders by analyzing articulators' motion and assessing speech outcome while patients speak. To assist SLPs in this task, we are presenting the multimodal speech capture system (MSCS) that records and displays kinematics of key speech articulators, the tongue and lips, along with voice, using unobtrusive methods. Collected speech modalities, tongue motion, lips gestures, and voice are visualized not only in real-time to provide patients with instant feedback but also offline to allow SLPs to perform post-analysis of articulators' motion, particularly the tongue, with its prominent but hardly visible role in articulation. We describe the MSCS hardware and software components, and demonstrate its basic visualization capabilities by a healthy individual repeating the words "Hello World." A proof-of-concept prototype has been successfully developed for this purpose, and will be used in future clinical studies to evaluate its potential impact on accelerating speech rehabilitation by enabling patients to speak naturally. Pattern matching algorithms to be applied to the collected data can provide patients with quantitative and objective feedback on their speech performance, unlike current methods that are mostly subjective, and may vary from one SLP to another.

Microbial rRNA sequencing analysis of evaporative cooler indoor environments located in the Great Basin Desert region of the United States.

Recent studies conducted in the Great Basin Desert region of the United States have shown that skin test reactivity to fungal and dust mite allergens are increased in children with asthma or allergy living in homes with evaporative coolers (EC). The objective of this study was to determine if the increased humidity previously reported in EC homes leads to varying microbial populations compared to homes with air conditioners (AC). Children with physician-diagnosed allergic rhinitis living in EC or AC environments were recruited into the study. Air samples were collected from the child's bedroom for genomic DNA extraction and metagenomic analysis of bacteria and fungi using the Illumina MiSeq sequencing platform. The analysis of bacterial populations revealed no major differences between EC and AC sampling environments. The fungal populations observed in EC homes differed from AC homes. The most prevalent species discovered in AC environments belonged to the genera Cryptococcus (20%) and Aspergillus (20%). In contrast, the most common fungi identified in EC homes belonged to the order Pleosporales and included Alternaria alternata (32%) and Phoma spp. (22%). The variations in fungal populations provide preliminary evidence of the microbial burden children may be exposed to within EC environments in this region.

Asthma, allergy, and obesity: Examining the relationship among Nevada children.

OBJECTIVE: The majority of pediatric asthma is atopic, but whether pediatric obese asthma is atopic is indeterminate in the literature. In Nevada, children become sensitized to aeroallergens, a risk factor for asthma, at young ages. Additionally, Nevada children have high rates of obesity. Our objective is to determine whether elevated body mass index (BMI) is associated with asthma severity, allergen sensitization, and polysensitization. METHODS: Medical records from a pediatric allergy clinic provided BMI percentile, physician-diagnosed asthma severity, skin prick test data, and sociodemographics such as age, race, sex, and insurance status from asthmatic patients. Descriptive statistics and binary and multinomial logistic regression were conducted. RESULTS: In this population (N = 125) aged 1-16, 61% were male, 65% were white, and 74% had private health insurance. Sixty-five percent of children were under/healthy weight and 29% were overweight/obese. Asthma symptoms were moderate in 66% of the population, and severe in 18%. Nearly 85% of this population was atopic, and 82% were polysensitized. Sensitization and polysensitization occurred in all weight categories. Asthma severity and elevated BMI were not associated significantly. Overweight/obese children (≥85th percentile) had lower odds of allergen sensitization (adjusted odds ratio 0.26, 95% CI = 0.85-0.78, p = 0.016) and polysensitization (adjusted odds ratio 0.30, 95% CI = 0.11-0.85, p = 0.023) than healthy weight children (<85th percentile). CONCLUSION: Although overweight children did show allergen sensitization, those who were overweight had lower odds of allergen sensitization and lower odds of polysensitization, as compared to normal weight asthmatic children. Elevated BMI was not a significant predictor of asthma severity.