A mixed-methods study on the pharmacological management of pain in Australian and Japanese nursing homes.

BACKGROUND: Understanding how analgesics are used in different countries can inform initiatives to improve the pharmacological management of pain in nursing homes. AIMS: To compare patterns of analgesic use among Australian and Japanese nursing home residents; and explore Australian and Japanese healthcare professionals' perspectives on analgesic use. METHODS: Part one involved a cross-sectional comparison among residents from 12 nursing homes in South Australia (N = 550) in 2019 and four nursing homes in Tokyo (N = 333) in 2020. Part two involved three focus groups with Australian and Japanese healthcare professionals (N = 16) in 2023. Qualitative data were deductively content analysed using the World Health Organization six-step Guide to Good Prescribing. RESULTS: Australian and Japanese residents were similar in age (median: 89 vs 87) and sex (female: 73% vs 73%). Overall, 74% of Australian and 11% of Japanese residents used regular oral acetaminophen, non-steroidal anti-inflammatory drugs or opioids. Australian and Japanese healthcare professionals described individualising pain management and the first-line use of acetaminophen. Australian participants described their therapeutic goal was to alleviate pain and reported analgesics were often prescribed on a regular basis. Japanese participants described their therapeutic goal was to minimise impacts of pain on daily activities and reported analgesics were often prescribed for short-term durations, corresponding to episodes of pain. Japanese participants described regulations that limit opioid use for non-cancer pain in nursing homes. CONCLUSION: Analgesic use is more prevalent in Australian than Japanese nursing homes. Differences in therapeutic goals, culture, analgesic regulations and treatment durations may contribute to this apparent difference.

Radioiodine uptake after monotherapy with potassium iodide in patients with Graves' disease.

The effect of potassium iodide (KI) on radioiodine uptake (RAIU) before radioisotope therapy in Graves' disease (GD) patients was investigated. A total of 82 patients who had been treated with KI monotherapy before 24-hour RAIU (24 h RAIU) were evaluated and 354 of those who had been treated with thiamazole (MMI) monotherapy were extracted from the 1,130 GD patients who were identified as having had appropriate iodine restriction based on urinary iodine excretion. Urinary iodine excretion (UIE) <200 µg/day was confirmed in all subjects. Propensity score-matching was performed to identify the difference in 24 h RAIU between the KI group and the MMI group. In addition, multiple regression analysis was performed to evaluate related to 24 h RAIU. Propensity score-matching resulted in 57 matched patients in each group. After matching, 24 h RAIU was still significantly lower in the KI group than in the MMI group (median 53% (interquartile range 47-61%) vs. 63% (56-66%); p = 0.001). In addition, KI monotherapy was weakly negatively correlated with 24 h RAIU, whereas the female sex and FT3 were very weakly positively correlated on multiple regression analysis. The results suggest that KI monotherapy likely suppressed 24 h RAIU more than MMI monotherapy in GD patients with appropriate iodine restriction, given the difference in the mechanism of hormone suppression.

Establishment of reference intervals for fT3, fT4, and TSH levels in Japanese children and adolescents.

The present study aimed to establish new reference intervals (RIs) for serum free triiodothyronine (fT3), free thyroxine (fT4), and thyroid stimulating hormone (TSH) levels in Japanese children and adolescents aged 4 to 19 years. A total of 2,036 (1,611 girls, 425 boys) participants were included over a 17-year period; they all tested negative for antithyroid antibodies (TgAb, TPOAb) and were found to have no abnormalities on ultrasonography. RIs were determined by nonparametric methods. The results showed that serum fT3 was significantly higher in the 4-15-year-olds than in the 19-year-olds. The serum fT4 was significantly higher in the 4-10-year-olds than in the 19-year-olds. The serum TSH was significantly higher in the 4-12-year-olds than in the 19-year-olds. All of them gradually decreased with age to approximate the adult levels. The upper limit of TSH was lower in those aged 13 to 19 years than in adults. The differences were examined by sex. The serum fT3 was significantly higher in boys than in girls between the ages of 11 and 19 years. The serum fT4 was significantly higher in boys than in girls between the ages of 16 and 19 years. There did not seem to be any sex difference in those under 10 years of age. In conclusion, serum fT3, fT4, and TSH levels in children and adolescents differ from those in adults. It is important to evaluate thyroid function using the new RIs that are appropriate for chronological age.

Superconducting Behavior of BaTi2(Sb1-yBiy)2O under Pressure.

The crystal structure and superconducting properties of a new type of titanium-pnictide superconductor, BaTi2(Sb1-yBiy)2O (y = 0.2, 0.5, and 0.8), are comprehensively investigated over a wide pressure range to elucidate the effect of substituting Bi for Sb on the superconducting behavior. The behavior of superconducting properties under pressure changes drastically with y, as expected from the double-dome Tc-y phase diagram obtained at ambient pressure. In this study, three BaTi2(Sb1-yBiy)2O samples (y = 0.2, 0.5, and 0.8) are considered, which correspond to the first superconducting dome, nonsuperconducting part, and second superconducting dome, respectively, in the Tc-y phase diagram. The crystal of BaTi2(Sb1-yBiy)2O with y = 0.2 shows a clear collapse transition, i.e., a drastic shrinkage of the lattice constant c at ca. 5 GPa. Strictly speaking, the collapsed crystal phase coexists with the noncollapsed phase above 5 GPa. On the other hand, BaTi2(Sb1-yBiy)2O with y = 0.8 shows a continuous change in the crystal lattice with pressure, i.e., no collapse transitions. The pressure dependence of Tc for BaTi2(Sb1-yBiy)2O with y = 0.2 shows a drastic increase in Tc at approximately 5 GPa, where the collapse transition occurs, indicating a clear pressure-induced superconducting phase transition related to the collapse transition. The value of Tc for BaTi2(Sb1-yBiy)2O with y = 0.8 increases slightly up to ∼2 GPa and is almost constant at 2-13 GPa. It is found that the superconducting behavior under pressure can be unambiguously classified by y based on the double-dome Tc-y phase diagram, indicative of distinguishable superconducting features at different y values. In this study, we comprehensively discuss the superconducting properties of the exotic material, BaTi2(Sb1-yBiy)2O, with a double-dome Tc-y phase diagram.

Genetic characteristics of archival noroviruses detected from the 1970s to the 1990s.

The genetic characterization of archival specimens is important for evaluating the evolutionary processes of noroviruses. Complete viral genome sequences, GVIII.1[GII.P28] and GIX.1[GII.P15], were determined from two archival specimens collected in Tokyo, Japan, in 1986 and 1995. In addition, complete VP1 and partial RdRp sequences of four samples collected between 1975 and 1983 were determined. Two viruses were classified as GI.5[P5] and GI.9[P9]; however, the viruses from the other two samples could not be assigned to any known genotypes using norovirus typing tools and phylogenetic analysis, suggesting that they might be untypable genotypes. Further evolutionary analysis of these viruses is warranted.

Pressure dependence of superconductivity in alkali-Bi compounds KBi2 and RbBi2.

The structural and superconducting properties of alkali-Bi-based compounds, KBi2 and RbBi2, were investigated over a wide pressure range for the first time. The samples of KBi2 and RbBi2 were prepared using a liquid ammonia (NH3) technique, and demonstrated superconductivity with superconducting transition temperatures, Tc, of 3.50 and 4.21 K at ambient pressure, respectively. The onset superconducting transition temperature, Tconset, of KBi2 decreased slightly; however, it suddenly jumped at 2 GPa and increased gradually with pressure, indicating the presence of two superconducting phases in the low-pressure range. The pressure-dependent X-ray diffraction patterns indicate that the KBi2 sample decomposed into KBi and Bi at pressures higher than 2.5 GPa. Moreover, a discontinuous change in Tconset was observed for KBi2 at 9 GPa, which reflects the decomposition of KBi2 into KBi and Bi. By contrast, the value of Tconset of RbBi2 was almost constant over a pressure range of 0-8 GPa. Thus, the superconducting properties and stability of alkali-Bi-based compounds against pressure were comprehensively explored in this study. In addition, the superconducting Cooper pair symmetry was investigated from the magnetic field dependence of Tc of KBi2 at 0.790 and 2.32 GPa, and of RbBi2 at 1.17 GPa, indicating the exact deviation from the simple s-wave paring model, which may be due to the complex electronic structure of Bi. The results elucidated the exotic superconducting properties of KBi2 and RbBi2 based on the pressure and magnetic field dependence of Tc and verified the chemical stability of KBi2 under pressure.

Prediction model of Graves' disease in general clinical practice based on complete blood count and biochemistry profile.

Although untreated Graves' disease (GD) is associated with a higher risk of cardiac complications and mortality, there is no well-established way to predict the onset of thyrotoxicosis in clinical practice. The aim of this study was to identify important variables that will make it possible to predict GD and thyrotoxicosis (GD + painless thyroiditis (PT)) by using a machine-learning-based model based on complete blood count and standard biochemistry profile data. We identified 19,335 newly diagnosed GD patients, 3,267 PT patients, and 4,159 subjects without any thyroid disease. We built a GD prediction model based on information obtained from subjects regarding sex, age, a complete blood count, and a standard biochemistry profile. We built the model in the training set and evaluated the performance of the model in the test set by using the artificial intelligence software Prediction One. Our machine learning-based model showed high discriminative ability to predict GD in the test set (area under the curve [AUC] 0.99). The main contributing factors to predict GD included age and serum creatinine, total cholesterol, alkaline phosphatase, and total protein levels. We still found high discriminative ability even when we restricted the variables to these five most contributory factors in our prediction model (AUC 0.97) built by using artificial intelligence software showed high GD prediction ability based on information regarding only five factors.

Superconducting properties of BaBi3 at ambient and high pressures.

Herein, we report the preparation and characterization of BaBi3 clarified by DC magnetic susceptibility, powder X-ray diffraction (XRD), and electrical transport. The superconducting properties of BaBi3 were elucidated through the magnetic and electrical transport properties in a wide pressure range. The superconducting transition temperature, Tc, showed a slight decrease (or almost constant Tc) against pressure up to 17.2 GPa. The values of the upper critical field, Hc2, at 0 K, were determined to be 1.27 T at 0 GPa and 3.11 T at 2.30 GPa, using the formula, because p-wave pairing appeared to occur for this material at both pressures, indicating the unconventionality of superconductivity. This result appears to be consistent with the topological non-trivial nature of superconductivity predicted theoretically. The pressure-dependent XRD patterns measured at 0-20.1 GPa indicated no structural phase transitions up to 20.1 GPa, i.e., the structural phase transitions from the α phase to the ß or γ phase which are induced by an application of pressure were not observed, contrary to the previous report, demonstrating that the α phase is maintained over the entire pressure range. Admittedly, the lattice constants and the volume of the unit cell, V, steadily decrease with increasing pressure up to 20.1 GPa. In this study, the plots of Tcversus p and V versus p of BaBi3 are depicted over a wide pressure range for the first time.

Superconducting behavior of BaTi2Bi2O and its pressure dependence.

A new superconducting sample, BaTi2Bi2O, was synthesized and characterized over a wide pressure range. The superconducting transition temperature, Tc, of BaTi2Bi2O was 4.33 K at ambient pressure. The crystal structure was tetragonal (space group of P4/mmm (No. 123)), according to the X-ray diffraction (XRD) pattern at ambient pressure. The XRD pattern was analyzed using the Le Bail method. The magnetic-field dependence of the magnetization at different temperatures was precisely investigated to elucidate the characteristics of the superconductivity. The pressure-dependent XRD patterns showed absence of structural phase transitions up to 19.8 GPa. The superconducting properties of BaTi2Bi2O were investigated under pressure. Tc monotonously increased with the pressure (p) up to 4.0 GPa and saturated above 4.0 GPa. The variations in the Tc-p plot were thoroughly analyzed. The Cooper pair symmetry (or superconducting pairing mechanism) was analyzed based on the magnetic field dependence of the superconductivity at ambient and high pressures, which indicated a sign of p-wave pairing for the superconductivity of BaTi2Bi2O, i.e., topologically nontrivial sign was suggested for BaTi2Bi2O.

Changes in social participation and life-space mobility in newly enrolled home-based rehabilitation users over 6 months.

[Purpose] This study aimed to examine whether we were able to measure changes in social participation and life-space mobility of newly enrolled home-based rehabilitation (HR) users by using the activities and participation components of the International Classification of Functioning, Disability and Health (ICF) and Life-Space Assessment (LSA) over a 6-months period. [Participants and Methods] We enrolled 47 HR users who had suffered from a stroke or other condition within the previous year. A 6-month prospective cohort study was conducted. The performance qualifiers "d6 domestic life" and "d9 community, social and civic life" in the activities and participation components of the ICF and LSA were used. [Results] We observed significant improvements in the performance qualifier "d9 community, social and civic life" of the ICF over 3 months, and the LSA over a 6-months period. We also identified significant improvements in "d910 community life" and "d920 recreation and leisure" of the ICF. The LSA results showed that HR users had more frequent mobility within the neighborhood. [Conclusion] This study showed that newly enrolled HR users improved their social activities in the community, recreational activities, and life-space mobility over a 6-months period. These were measured using performance qualifiers from the ICF and LSA.

Enterovirus D68 respiratory infection in a children's hospital in Japan in 2015.

BACKGROUND: Outbreaks of enterovirus D68 (EV-D68) respiratory infections in children were reported globally in 2014. In Japan, there was an EV-D68 outbreak in the autumn of 2015 (September-October). The aim of this study was to compare EV-D68-specific polymerase chain reaction (PCR)-positive and EV-D68-specific PCR-negative patients. METHODS: Pediatric patients admitted for any respiratory symptoms between September and October 2015 were enrolled. Nasopharyngeal swabs were tested for multiplex respiratory virus PCR and EV-D68-specific reverse transcription-PCR. EV-D68-specific PCR-positive and -negative patients were compared regarding demographic data and clinical information. RESULTS: A nasopharyngeal swab was obtained from 76 of 165 patients admitted with respiratory symptoms during the study period. EV-D68 was detected in 40 samples (52.6%). Median age in the EV-D68-specific PCR-positive and -negative groups was 3.0 years (IQR, 5.5 years) and 3.0 years (IQR, 4.0 years), respectively. The rates of coinfection in the two groups were 32.5% and 47.2%, respectively. There was no significant difference in the history of asthma or recurrent wheezing, length of hospitalization, or pediatric intensive care unit admission rate between the groups. The median days between symptom onset and admission was significantly lower for the EV-D68-positive group (3.0 days vs 5.0 days, P = 0.001). EV-D68 was identified as clade B on phylogenetic analysis. No cases of acute flaccid myelitis were encountered. CONCLUSIONS: More than half of the samples from the children admitted with respiratory symptoms were positive for EV-D68-specific PCR during the outbreak. Asthma history was not associated with the risk of developing severe respiratory infection.

Total Synthesis of (+)-Goniodenin.

Goniodenin is a lipophilic polyketide originating from plant sources and which possesses a potent cytotoxic activity against cancer cell lines. The first total synthesis of (+)-goniodenin has been achieved in 23 steps from (R)-glycidol. The synthetic sequence featured a cross metathesis for the formation of the C8-C9 bond and installation of the terminal γ-butenolactone ring unit by the alkylation of α-phenylthio-γ-butyrolactone with the corresponding C3-O-triflate. The stereogenic center at C18 carbon was created by Hiyama-Fujita reduction of the corresponding ketone with high diastereoselectivity.

Human cell growth regulator Ly-1 antibody reactive homologue accelerates processing of preribosomal RNA.

Ribosome biogenesis is an essential process for cell growth and proliferation and is enhanced in cancer and embryonic stem cells. Mouse Ly-1 antibody reactive clone product (Lyar) is expressed at very high levels in many tumor, leukemia or embryonic stem cells; is a novel nucleolar protein with zinc-finger DNA-binding motifs and is involved in cell growth regulation. However, cellular function of Lyar remains unexplored. Here, we show that human homologue of Lyar (LYAR) accelerates ribosome biogenesis at the level of processing of preribosomal RNA (pre-rRNA). We show that LYAR is excluded from the nucleolus after actinomycin D treatment and is present in preribosomal fraction of the nuclear extract as well as in the fractions with 40S, 60S and 90S sedimentation coefficients. LYAR is required for processing of 47S/45S, 32S, 30S and 21S pre-rRNAs. In addition, we show that over-expression of LYAR increases cell proliferation without affecting the expression of c-Myc or p53. Combined, these results suggest that some rapidly growing cells enhance ribosome biogenesis by increasing the expression of LYAR.

Clinical subtypes of older adults starting long-term care in Japan and their association with prognoses: a data-driven cluster analysis.

We aimed to identify the clinical subtypes in individuals starting long-term care in Japan and examined their association with prognoses. Using linked medical insurance claims data and survey data for care-need certification in a large city, we identified participants who started long-term care. Grouping them based on 22 diseases recorded in the past 6 months using fuzzy c-means clustering, we examined the longitudinal association between clusters and death or care-need level deterioration within 2 years. We analyzed 4,648 participants (median age 83 [interquartile range 78-88] years, female 60.4%) between October 2014 and March 2019 and categorized them into (i) musculoskeletal and sensory, (ii) cardiac, (iii) neurological, (iv) respiratory and cancer, (v) insulin-dependent diabetes, and (vi) unspecified subtypes. The results of clustering were replicated in another city. Compared with the musculoskeletal and sensory subtype, the adjusted hazard ratio (95% confidence interval) for death was 1.22 (1.05-1.42), 1.81 (1.54-2.13), and 1.21 (1.00-1.46) for the cardiac, respiratory and cancer, and insulin-dependent diabetes subtypes, respectively. The care-need levels more likely worsened in the cardiac, respiratory and cancer, and unspecified subtypes than in the musculoskeletal and sensory subtype. In conclusion, distinct clinical subtypes exist among individuals initiating long-term care.

Molecular and Epidemiological Analysis of Respiratory Syncytial Virus Detected in Tokyo, Japan in 2021 Season.

During the COVID-19 pandemic in 2021, Japan experienced an outbreak of respiratory syncytial virus (RSV) infection. A total of 51 RSV cases were detected in infant specimens, including 38 rhinorrhea and 13 nasopharyngeal swabs, collected at the Tokyo Metropolitan Institute of Public Health. Of the 51 cases, 12 were RSV-A and 39 were RSV-B. The G protein gene sequence of RSV-A belonged to the ON1 genotype, whereas RSV-B belonged to the BA9 genotype; thus, different types of RSV were detected during the same period, suggesting that the unusual 2021 RSV season was not due to a single strain or genotype. Of all RSV-positive cases, the proportion of patients aged ≥2 years was 56.8% in 2021, higher than the 31.2% reported in the past 5 years. This indicates that infants aged <1 year who were originally susceptible to RSV infection were less likely to be infected with RSV because of the COVID-19 control measures. The 2021 epidemic peaked in the 28th week, 9 weeks earlier than the average from 2016 to 2020. Therefore, it seems necessary to accumulate and analyze further data, such as factors that led to the outbreak and the characteristics of the detected viruses in 2021.

Rehabilitation Approach for Children With Joubert Syndrome and Related Disorders.

Joubert syndrome and related disorders (JSRD) are rare and intractable diseases characterized by delayed psychomotor development, hypotonia and/or ataxia, and abnormal respiratory and eye movements. Cerebellar vermis agenesis and molar tooth signs are distinct on cerebral magnetic resonance imaging (MRI). Children with JSRD present with delayed psychomotor development, including intellectual disability and emotional or behavioral problems. Rehabilitation treatments are provided to promote psychomotor development. However, limited reports and evidence exist on rehabilitation treatments for children with JSRD. Three children with JSRD received rehabilitation treatment. The children received rehabilitation treatment once a week to once every one to two months at our hospital and/or other facilities. All patients received physical, occupational, and speech-language-hearing therapy, depending on their symptoms and conditions. In children with tracheostomies due to abnormal respiration, respiratory physical therapy and speech-language-hearing therapy, including augmentative and alternative communication, were needed. For hypotonia and ataxia, an orthotic intervention was considered in all three cases, and foot or ankle-foot orthoses were used in two cases. Although there is no specific or established rehabilitation method for children with JSRD, appropriate rehabilitation approaches, including physical, occupational, speech-language-hearing therapies and orthotic intervention, should be considered and provided to improve their function and expand their activity and participation. Orthotic intervention for hypotonia seems reasonable for improving gross motor development and function in children with JSRD.

A conventional PCR-based method to detect the E2 gene of the rubella virus for epidemiological analysis.

To eliminate the rubella virus (RV), genetic characterization is vital for its detection, identification of endemic transmission, and diagnosis of imported cases. The 739-nucleotide region in the E1 gene has primarily been used for genotyping for epidemiological analysis. However, in the 2018-2019 RV outbreak, identical sequences were observed in patients who were not epidemiologically linked. Additionally, the 739 nt sequences from the outbreak in Tokyo in 2018-2019 were identical to RV identified in China in 2019. This suggests that this region may be insufficient to identify the detected RV strains as endemic or imported. In 62.4% of the specimens, the E1 gene sequences of the 1E RV genotype were identical. Additionally, the observed discordance of sequences from the mainly detected identical sequence in the 739-nt sequence of the E1 gene were one (31.0%), two (3.5%), three (2.6%), and four (0.23%). Moreover, a comparison of the complete structural protein-coding region suggests that the E2 gene is more diverse than the E1 and the capsid gene. Thus, conventional polymerase chain reaction (PCR) primers were developed to detect the E2 gene and improve epidemiological analysis. A comparison of the sequences identified during the RV outbreak in Tokyo revealed genetic differences in the sequences (15 of the 18 specimens). These results suggest that additional information could be obtained by simultaneously analyzing the E2 and the E1 region. The identified sequences can potentially aid in evaluating the RV strains detected during epidemiological analysis.

Incidence of and Risk Factors for Neonatal Hypothyroidism Among Women with Graves' Disease Treated with Antithyroid Drugs Until Delivery.

Background: The incidence of neonatal hypothyroidism among newborns born to mothers with Graves' disease (GD) who continued antithyroid drug (ATD) treatment until delivery has never been reported. Objective: Our primary objective was to investigate the incidence of neonatal hypothyroidism among newborns born to mothers with GD who were treated with ATD until delivery. Our secondary objective was to identify the cutoff ATD daily doses for neonatal hypothyroidism risk, based on maternal thyrotropin (TSH) receptor antibody (TRAb) levels. Methods: We conducted a retrospective cohort study. We included 305 pregnant women with GD who were treated with an ATD until delivery (63 treated with methimazole [MMI] and 242 treated with propylthiouracil [PTU]). Umbilical cord TSH, free thyroxine (fT4), and TRAb levels were measured at delivery, and we investigated the respective relationships between neonatal hypothyroidism at delivery and maternal fT4 levels, TRAb levels, and daily ATD doses during pregnancy. Neonatal hypothyroidism was diagnosed when the umbilical cord fT4 level was below the lower limit of the reference range. Results: The incidence of neonatal hypothyroidism at delivery was 19.0% ([confidence interval, CI, 11.2-30.4]; 12/63) in the MMI group and 12.8% ([CI, 9.2-17.6]; 31/242) in the PTU group. Neonatal goiter was observed in one neonate in the PTU group, and two infants in the PTU group required levothyroxine treatment. The daily ATD dose in the third trimester was the strongest predictor of neonatal hypothyroidism at delivery; the cutoff MMI dose was 10 mg/day, and the cutoff PTU dose was 150 mg/day. When the maternal TRAb level in the third trimester was above three times the upper limit of the normal range, the cutoff MMI dose was 20 mg/day, and the cutoff PTU dose was 150 mg/day. Conclusions: Maternal fT4 and TRAb levels were higher in the neonatal hypothyroid group, which suggested prolonged GD activity. Careful follow-up is necessary when maternal GD remains active and the ATD dose to control maternal thyrotoxicosis cannot be reduced.

Factors Affecting Care-Level Deterioration among Older Adults with Mild and Moderate Disabilities in Japan: Evidence from the Nationally Standardized Survey for Care-Needs Certification.

This study aims to investigate the factors of care-level deterioration in older adults with mild and moderate disabilities using nationally standardized survey data for care-needs certification. We enrolled people aged 68 years or older, certified as support levels 1-2 (mild disability) or care levels 1-2 (moderate disability) with no cancer. The outcome was care-level deterioration after two years. The possible factors were physical and mental functions which were categorized as the following five dimensions according to the survey for care-needs certification: body function, daily life function, instrumental activities of daily living (IADL) function, cognitive function, and behavioral problems. A multivariate logistic regression analysis was conducted after stratifying the care level at baseline. A total of 2844 participants were included in our analysis. A low IADL function was significantly associated with a risk of care-level deterioration in all participants. In addition, low cognitive function was linked to care-level deterioration, except for those with support level 1 at baseline. Participants with more behavioral problems were more likely to experience care-level deterioration, except for those with care level 2 at baseline. Our study showed the potential utility of the care-needs certification survey for screening high-risk individuals with care-level deterioration.