A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare.

BACKGROUND: Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort. METHODS: A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team. RESULTS: Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain. CONCLUSIONS: The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

Acquired haemophilia A diagnosed during pregnancy.

Pregnancy-associated haemophilia A is an uncommon, acquired bleeding disorder which usually presents post-partum; very rarely it may present during pregnancy. No consensus guidelines exist on the management of this condition in pregnancy and very few cases have been reported in the literature. Here we describe the case of a woman presenting with acquired haemophilia A during pregnancy and outline the management of her bleeding disorder. We contrast her case with that of two other women, presenting to the same tertiary referral centre, with acquired haemophilia A presenting post-partum. These cases highlight the heterogeneous management of this condition and how it may be successfully managed in pregnancy.

Impact of MyD88, Microbiota, and Location on Type 1 and Type 3 Innate Lymphoid Cells during Toxoplasma gondii Infection.

Toxoplasma gondii induces strong IFN-γ-based immunity. Innate lymphoid cells (ILC), in particular ILC1, are an important innate source of this protective cytokine during infection. Our objective was to determine how MyD88-dependent signaling influences ILC function during peroral compared with i.p. infection with T. gondii. MyD88 +/+ and MyD88 -/- mice were orally inoculated with ME49 cysts, and small intestinal lamina propria ILC were assessed using flow cytometry. We observed T-bet+ ILC1, retinoic acid-related orphan receptor γt+ ILC3, and a population of T-bet+retinoic acid-related orphan receptor γt+ double-positive ILC. In MyD88 -/- mice, IFN-γ-producing T-bet+ ILC1 frequencies were reduced compared with wild-type. Treatment of MyD88 -/- mice with an antibiotic mixture to deplete microflora reduced IFN-γ+ ILC1 frequencies. To examine ILC responses outside of the mucosal immune system, peritoneal exudate cells were collected from wild-type and knockout mice after i.p. inoculation with ME49 cysts. In this compartment, ILC were highly polarized to the ILC1 subset that increased significantly and became highly positive for IFN-γ over the course of infection. Increased ILC1 was associated with expression of the Ki67 cell proliferation marker, and the response was driven by IL-12p40. In the absence of MyD88, IFN-γ expression by ILC1 was not maintained, but proliferation remained normal. Collectively, these data reveal new aspects of ILC function that are influenced by location of infection and shaped further by MyD88-dependent signaling.

Impact of IFN-y and CD40 signalling on Toxoplasma gondii cyst formation in differentiated Neuro-2a neuroblastoma cells.

Signalling by IFN-y and CD40 is known to trigger anti-microbial activity in macrophages infected with Toxoplasma gondii, but their effects on infected neurons are less well known. Here, we compared how stimulation with IFN-y and an agonistic anti-CD40 mAb impacts infection and cyst formation in the mouse neuroblastoma cell line Neuro-2a relative to bone marrow-derived macrophages. Both IFN-y and CD40 mAb decreased cyst emergence in Neuro-2a cells. In macrophages, these stimuli decreased infection, but had no impact on infection in the neuroblastoma cell line. Resistance to killing in Neuro-2a cells may explain why neurons preferentially harbour parasites during chronic infection in the brain.

Exploring relationships between oxygen consumption and biologger-derived estimates of heart rate in two warmwater piscivores.

Estimating metabolic rate in wild, free-swimming fish is inherently challenging. Here, we explored using surgically implanted heart rate biologgers to estimate metabolic rate in two warmwater piscivores, bowfin Amia calva (Linneaus 1766) and largemouth bass Micropterus salmoides (Lacepède 1802). Fish were surgically implanted with heart rate loggers, allowed to recover for 24 h, exposed to a netting and air exposure challenge, and then placed into respirometry chambers so that oxygen consumption rate (MO2 ) could be measured in parallel to heart rate (fH ) for a minimum of 20 h (ca. 20 estimates of MO2 ). Heart rate across the duration of the experiment (at 19°C) was significantly higher in largemouth bass (mean ± s.d., 45 ± 14 beats min-1 , range 18-86) than in bowfin (27 ± 9 bpm, range 16-98). Standard metabolic rate was also higher in largemouth bass (1.06 ± 0.19 mg O2  kg-1  min-1 , range 0.46-1.36) than in bowfin (0.89 ± 0.17 mg O2  kg-1  min-1 , range 0.61-1.28). There were weak relationships between fH and MO2 , with heart rate predicting 28% of the variation in oxygen consumption in bowfin and 23% in largemouth bass. The shape of the relationship differed somewhat between the two species, which is perhaps unsurprising given their profound differences in physiology and life history, illustrating the need to carry out species-specific validations. Both species showed some potential for a role of fH in efforts to estimate field metabolic rates, although further validation experiments with a wider range of conditions (e.g., digestive states, swimming activity) would likely help improve the strength of the MO2 -fH relationship for use in field applications.

Induction of IL-12p40 and type 1 immunity by Toxoplasma gondii in the absence of the TLR-MyD88 signaling cascade.

Toxoplasma gondii is an orally acquired pathogen that induces strong IFN-γ based immunity conferring protection but that can also be the cause of immunopathology. The response in mice is driven in part by well-characterized MyD88-dependent signaling pathways. Here we focus on induction of less well understood immune responses that do not involve this Toll-like receptor (TLR)/IL-1 family receptor adaptor molecule, in particular as they occur in the intestinal mucosa. Using eYFP-IL-12p40 reporter mice on an MyD88-/- background, we identified dendritic cells, macrophages, and neutrophils as cellular sources of MyD88-independent IL-12 after peroral T. gondii infection. Infection-induced IL-12 was lower in the absence of MyD88, but was still clearly above noninfected levels. Overall, this carried through to the IFN-γ response, which while generally decreased was still remarkably robust in the absence of MyD88. In the latter mice, IL-12 was strictly required to induce type I immunity. Type 1 and type 3 innate lymphoid cells (ILC), CD4+ T cells, and CD8+ T cells each contributed to the IFN-γ pool. We report that ILC3 were expanded in infected MyD88-/- mice relative to their MyD88+/+ counterparts, suggesting a compensatory response triggered by loss of MyD88. Furthermore, bacterial flagellin and Toxoplasma specific CD4+ T cell populations in the lamina propria expanded in response to infection in both WT and KO mice. Finally, we show that My88-independent IL-12 and T cell mediated IFN-γ production require the presence of the intestinal microbiota. Our results identify MyD88-independent intestinal immune pathways induced by T. gondii including myeloid cell derived IL-12 production, downstream type I immunity and IFN-γ production by ILC1, ILC3, and T lymphocytes. Collectively, our data reveal an underlying network of immune responses that do not involve signaling through MyD88.

The Biopsychosocial Impact of COVID-19 on Older Adults.

COVID-19 has spread rapidly around the world and taken over 2.6 million lives. Older adults experience disproportionate morbidity and mortality from the disease because increasing age and the presence of comorbidities are important predictors of negative outcomes. Lasting effects of COVID-19 have been described after recovery from the acute illness despite eradication of the virus from the body. The impact of COVID-19 on a person's biological health post-infection is observed in multiple systems including respiratory, cardiac, renal, haematological, and neurological. Psychological dysfunction following recovery is also prevalent. Social factors such as distancing and stay at home measures leave older adults isolated and food insecure; they also face intertwined financial and health risks due to the resulting economic shutdown. This study examines the effects of COVID-19 on older adults using the biopsychosocial model framework.

Toxoplasma gondii dense granule protein GRA24 drives MyD88-independent p38 MAPK activation, IL-12 production and induction of protective immunity.

The apicomplexan Toxoplasma gondii induces strong protective immunity dependent upon recognition by Toll-like receptors (TLR)11 and 12 operating in conjunction with MyD88 in the murine host. However, TLR11 and 12 proteins are not present in humans, inspiring us to investigate MyD88-independent pathways of resistance. Using bicistronic IL-12-YFP reporter mice on MyD88+/+ and MyD88-/- genetic backgrounds, we show that CD11c+MHCII+F4/80- dendritic cells, F4/80+ macrophages, and Ly6G+ neutrophils were the dominant cellular sources of IL-12 in both wild type and MyD88 deficient mice after parasite challenge. Parasite dense granule protein GRA24 induces p38 MAPK activation and subsequent IL-12 production in host macrophages. We show that Toxoplasma triggers an early and late p38 MAPK phosphorylation response in MyD88+/+ and MyD88-/- bone marrow-derived macrophages. Using the uracil auxotrophic Type I T. gondii strain cps1-1, we demonstrate that the late response does not require active parasite proliferation, but strictly depends upon GRA24. By i. p. inoculation with cps1-1 and cps1-1:Δgra24, we identified unique subsets of chemokines and cytokines that were up and downregulated by GRA24. Finally, we demonstrate that cps1-1 triggers a strong host-protective GRA24-dependent Th1 response in the absence of MyD88. Our data identify GRA24 as a major mediator of p38 MAPK activation, IL-12 induction and protective immunity that operates independently of the TLR/MyD88 cascade.

Post-exercise respirometry underestimates maximum metabolic rate in juvenile salmon.

Experimental biologists now routinely quantify maximum metabolic rate (MMR) in fishes using respirometry, often with the goal of calculating aerobic scope and answering important ecological and evolutionary questions. Methods used for estimating MMR vary considerably, with the two most common methods being (i) the 'chase method', where fish are manually chased to exhaustion and immediately sealed into a respirometer for post-exercise measurement of oxygen consumption rate (M O2), and (ii) the 'swim tunnel method', whereby M O2 is measured while the fish swims at high speed in a swim tunnel respirometer. In this study, we compared estimates for MMR made using a 3-min exhaustive chase (followed by measurement of M O2 in a static respirometer) versus those made via maximal swimming in a swim tunnel respirometer. We made a total of 134 estimates of MMR using the two methods with juveniles of two salmonids (Atlantic salmon Salmo salar and Chinook salmon Oncorhynchus tshawytscha) across a 6°C temperature range. We found that the chase method underestimated 'true' MMR (based on the swim tunnel method) by ca. 20% in these species. The gap in MMR estimates between the two methods was not significantly affected by temperature (range of ca. 15-21°C) nor was it affected by body mass (overall range of 53.5-236 g). Our data support some previous studies that have suggested the use of a swim tunnel respirometer generates markedly higher estimates of MMR than does the chase method, at least for species in which a swim tunnel respirometer is viable (e.g. 'athletic' ram ventilating fishes). We recommend that the chase method could be used as a 'proxy' (i.e. with a correction factor) for MMR in future studies if supported by a species-specific calibration with a relevant range of temperatures, body sizes or other covariates of interest.

The Impact of a School-Based Water, Sanitation and Hygiene Intervention on Knowledge, Practices, and Diarrhoea Rates in the Philippines.

A school-based water, sanitation, and hygiene (WASH) intervention in the Philippines was evaluated. Students and households from four schools that received the WASH intervention (intervention schools) were compared with four schools that had not (comparison schools). Knowledge of critical handwashing times was high across all schools, but higher in intervention schools. Students reported higher rates of handwashing after toilet use (92% vs. 87%; RR = 1.06; p = 0.003) and handwashing with soap (83% vs. 60%; RR = 1.4; p < 0.001) in intervention versus comparison schools. In intervention schools, 89% of students were directly observed to handwash after toilet use versus 31% in comparison schools (RR = 2.84; p < 0.0001). Observed differences in handwashing with soap after toilet use were particularly marked (65% vs. 10%; RR = 6.5; p < 0.0001). Reported use of school toilets to defecate (as opposed to use of toilet elsewhere or open defecation) was higher among intervention versus comparison schools (90% vs. 63%; RR = 1.4; p < 0.001). Multilevel modelling indicated that students from intervention schools reported a 10-fold reduction in odds (p < 0.001) of school absence due to diarrhoea. In addition to school-based findings, self-reported handwashing at critical times was found to be higher among household members of students from intervention schools. This school-based WASH program appeared to increase knowledge and hygiene behaviours of school students, reduce absences due to diarrhoea, and increase handwashing at critical times among household members.

Nations' income inequality predicts ambivalence in stereotype content: how societies mind the gap.

Income inequality undermines societies: The more inequality, the more health problems, social tensions, and the lower social mobility, trust, life expectancy. Given people's tendency to legitimate existing social arrangements, the stereotype content model (SCM) argues that ambivalence-perceiving many groups as either warm or competent, but not both-may help maintain socio-economic disparities. The association between stereotype ambivalence and income inequality in 37 cross-national samples from Europe, the Americas, Oceania, Asia, and Africa investigates how groups' overall warmth-competence, status-competence, and competition-warmth correlations vary across societies, and whether these variations associate with income inequality (Gini index). More unequal societies report more ambivalent stereotypes, whereas more equal ones dislike competitive groups and do not necessarily respect them as competent. Unequal societies may need ambivalence for system stability: Income inequality compensates groups with partially positive social images.

Pain relief for neonates in Australian hospitals: a need to improve evidence-based practice.

OBJECTIVE: To ascertain the extent to which neonatal analgesia was used in Australia for minor invasive procedures as an indicator of evidence-based practice in neonatology. METHODS: A cross-sectional telephone survey of hospitals in all Australian states and territories with more than 200 deliveries per year was carried out. Questions were asked regarding awareness of the benefits and the use of analgesia for minor invasive procedures in term and near term neonates. Analysis was undertaken according to state and territory, annual birth numbers and the level of neonatal nursery care available. RESULTS: Data were available from 212 of 214 eligible hospitals. Of the total respondents, 51% and 70% respectively were aware of the benefits of sucrose and breast-feeding for neonatal analgesia. Eleven per cent of units administered sucrose before venepuncture and 25% of units used breast-feeding. Ten per cent of units used sucrose before heel prick with 49% utilizing breast-feeding. Expressed breast milk was used in 10% of units. Analgesia was given less frequently before intravenous cannulation compared to venepuncture and heel prick. Awareness and implementation of neonatal analgesia varied widely in the states and territories. There was a trend for hospitals providing a higher level of neonatal care to have a greater awareness of sucrose as an analgesic (P < 0.0001) and the use of sucrose for venepuncture (P = 0.029), heel prick (P = 0.025) and intravenous catheter insertion (P = 0.013). Similar trends were found on analysis according to birth number of the maternity units. Smaller units had a greater usage of breast-feeding as an analgesic for heel prick (P = 0.017). CONCLUSION: Despite good evidence for the administration of sucrose and breast milk in providing effective analgesia for newborn infants, it is not widely used in Australia. It is imperative that the gap between research findings and clinical practice with regard to neonatal analgesia be addressed.