Racial disparities with PRN medication usage in inpatient psychiatric treatment

Racial disparities in psychiatric diagnoses and treatment have significant public health implications, contributing to inequities in healthcare outcomes. We specifically examined racial disparities regarding pro re nata (PRN), or as needed, medications. Data from 14,616 encounters across 2019-2020 within Community Health Network's inpatient psychiatric setting in Indianapolis, Indiana were included in this study. Due to the demographic sample size, analyses were narrowed to Black and White patients. Primary outcomes included comparisons across race for all PRN administrations and PRN administrations of antipsychotics vs. non-antipsychotics. Logistic regression was used to examine associations between race and PRN administrations by medication category, including all antipsychotics vs. non-antipsychotics overall, hydroxyzine, and lorazepam, independently. Significant differences in the percentage of administrations between Black and White patients were observed. Black patients received more PRN medications overall (71.0%) compared to White patients (67.7%) (p < 0.01). Further, while 17.7% of Black patients were administered PRN antipsychotics, this was true for only 8.2% of White patients (p < 0.001). When comparing antipsychotic PRNs with non-antipsychotic, hydroxyzine, and lorazepam PRNs, independently, Black patients were 58% (OR 1.58, p < 0.001), 109% (OR 2.09, p < 0.001), and 32% (OR 1.32, p < 0.001), more likely to receive antipsychotic PRNs, respectively, than White patients, controlling for sex, age, length of stay, and psychotic disorder diagnosis. Our study identifies yet another area of medical care with significant racial disparities. In this analysis of PRN medications during psychiatric admission, we identified significant differences in medication utilization by race. This information provides a basis for further investigation of disparities in patient-centered data.

Deceased donors as nondirected donors in kidney paired donation

As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain-initiating kidneys (DD-CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD-CIK gives to a candidate in the KPDP, and that candidate's incompatible donor donates to theDD waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) nondirected donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD-CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over 2 years. With an initial pool of 400, respective candidate and NDD arrival rates of 2 per day and 3 per month, and delay times for access to DD-CIK of 6 months or less, including DD-CIKs increases the number of transplants by at least 447 over 2 years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.

Socioeconomic and demographic predictors of resident knowledge, attitude, and practice regarding arthropod-borne viruses in Panama

Background

We sought to identify if socioeconomic and demographic factors play a role in resident knowledge, attitude, and practice regarding Dengue, Chikungunya, and Zika in order to inform effective management procedures for disease prevention in Panama, a middle-income tropical country in Central America. All three are arthropod-borne viruses transmitted by Aedes mosquito vectors present in the focal region of Panama City, the largest city in Central America and an urban region of extreme socioeconomic polarization.

Methods

Between November 2017 and February 2018, we administered standardized, anonymous knowledge, attitude, and practice surveys to 263 residents split between two neighborhoods of high socioeconomic status (SES) and two neighborhoods of low SES. We then summed the knowledge, attitude, and practice scores respectively, and used linear and logistic regressions to quantify relationships with socioeconomic and demographic factors.

Results

Low-SES neighborhoods with high proportions of low income residents, residents over 70 years old had lower mean knowledge scores compared to other groups. Furthermore, residents in neighborhoods of low SES reported more mosquito biting relative to residents in neighborhoods of high SES, yet comparably lower level of concerns for disease transmission. Additionally, knowledge was lower for the more novel emergent threats of Chikungunya and Zika, compared to the endemic Dengue.

Conclusion

Findings suggest that low-SES neighborhoods with high proportions of low income, low education, and elderly residents should be targeted for outreach programs designed to prevent DENV, CHIKV, or ZIKV in Panama City. These outcomes support our initial hypotheses as lower relative knowledge and fewer practices related to the prevention of Dengue, Chikungunya, and Zika were found in low-SES neighborhoods. There is also a widespread lack of adequate knowledge regarding these diseases as well as low levels of concern in areas of highly reported mosquito biting. We provide suggestions for taking neighborhood socioeconomic status and specific aspects resident health literacy and attitude into account for creating more effective outreach campaigns as both endemic and novel arthropod-borne disease rates continue to increase throughout Latin America.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6172-4) contains supplementary material, which is available to authorized users.

Space-time clusters and co-occurrence of chikungunya and dengue fever in Colombia from 2015 to 2016

Vector-borne diseases (VBDs) infect over one billion people and are responsible for over one million deaths each year, globally. Chikungunya (CHIK) and Dengue Fever (DENF) are emerging VBDs due to overpopulation, increases in urbanization, climate change, and other factors. Colombia has recently experienced severe outbreaks of CHIK AND DENF. Both viruses are transmitted by the Aedes mosquitoes and are preventable with a variety of surveillance and vector control measures (e.g. insecticides, reduction of open containers, etc.). Spatiotemporal statistics can facilitate the surveillance of VBD outbreaks by informing public health officials where to allocate resources to mitigate future outbreaks. We utilize the univariate Kulldorff space-time scan statistic (STSS) to identify and compare statistically significant space-time clusters of CHIK and DENF in Colombia during the outbreaks of 2015 and 2016. We also utilize the multivariate STSS to examine co-occurrences (simultaneous excess incidences) of DENF and CHIK, which is critical to identify regions that may have experienced the greatest burden of VBDs. The relative risk of CHIK and DENF for each Colombian municipality belonging to a univariate and multivariate cluster is reported to facilitate targeted interventions. Finally, we visualize the results in a three-dimensional environment to examine the size and duration of the clusters. Our approach is the first of its kind to examine multiple VBDs in Colombia simultaneously, while the 3D visualizations are a novel way of illustrating the dynamics of space-time clusters of disease.

Allergy testing in children with persistent asthma: comparison of four diagnostic methods

BACKGROUND

Multiple allergic sensitizations are common in persistent childhood asthma, and thorough assessment of allergy is crucial for optimal care of these children. Microarray testing offers opportunities for improved sIgE characterization, which has been projected to be useful in the management of multisensitized patients.

OBJECTIVE

The aim of this study was to investigate the accuracy and information obtained by two microarray platforms applied on a well-characterized pediatric asthma cohort.

METHODS

Seventy-one children were recruited from a nationwide Swedish study on severe childhood asthma. Severe (n = 40) and controlled (n = 31) asthmatics were assessed for allergic sensitization by two microarray systems (Microtest and ISAC) and by two standard diagnostic methods (ImmunoCAP and skin prick test). Data on clinical history, physical examination, spirometry, asthma control test, and doctor's diagnosis were collected. Results from the four diagnostic methods were analyzed and compared.

RESULTS

A high prevalence of allergic sensitization was observed in this cohort. The pairwise concordance between two methods was 90-92% independently of methods compared. The sensitivity of the four methods against doctor's diagnosis was 0.77-0.88, and the specificity was 0.97-0.99. Microarray methods provided new information in 47% of the sensitized children in comparison with results obtained by standard diagnostic methods.

CONCLUSION

The high prevalence of food and respiratory sensitization supports the clinical guideline recommendation that allergies should be evaluated in all children with suspected asthma. The microarray platforms studied here demonstrated acceptable accuracy and provided refined IgE characterization in 47% of the patients compared to standard extract-based methods.

Identifying key denning habitat to conserve brown bear (Ursus arctos) in Croatia

Context The preservation of denning habitat is paramount to the recovery of threatened bear populations because of the effect that den site disturbance can have on cub mortality. Understanding habitat suitability for denning can allow management efforts to be directed towards the regions where conservation interventions would be most effective. Aim We sought to identify the environmental and anthropogenic habitat variables associated with the presence of Eurasian brown bear (Ursus arctos) den sites in Croatia. Based on these associations, in order to inform future conservation decisions, we also sought to identify regions of high suitability for denning across Croatia. Methods Using the locations of 91 dens inhabited by bears between 1982 and 2011, we opted for the presence-only modelling option in software Maxent to determine the most important predictors of den presence, and thus predict the distribution of high-value denning habitat across Croatia. Key results We found that structural elements were the most important predictors, with ruggedness and elevation both relating positively to den presence. However, distance to nearest settlement was also positively associated with den presence. Conclusion We determine that there is considerable denning habitat value in areas with high and rugged terrain as well as areas with limited human activity. We suspect that high and rugged terrain contains a greater concentration of the karstic formations used for denning than lower-lying regions. Implications Our study presents the first habitat suitability model for brown bears in Croatia, and identifies core areas suitable for denning both within and outside the species’ current range. As such, it provides useful evidence for conservation decision making and the development of scientifically-based management plans. Our results also support the need for finer spatial scale studies that can reveal specific denning preferences of subpopulations.

Prescription drug monitoring program data tracking of opioid addiction treatment outcomes in integrated dual diagnosis care involving injectable naltrexone

BACKGROUND AND OBJECTIVES

Fourfold increases in opioid prescribing and dispensations over 2 decades in the U.S. has paralleled increases in opioid addictions and overdoses, requiring new preventative, diagnostic, and treatment strategies. This study examines Prescription Drug Monitoring Program (PDMP) tracking as a novel measure of opioid addiction treatment outcomes in a university-affiliated integrated mental health-addiction treatment clinic.

METHODS

Repeated measure parametrics examined PDMP and urine drug screening (UDS) data before and after first injection for all patients (N = 68) who received at least one long-acting naltrexone injection (380 mg/IM) according to diagnostic groupings of having either (i) alcohol (control); (ii) opioid; or (iii) combined alcohol and opioid use disorders.

RESULTS

There were no group differences post-injection in treatment days, injections delivered, or treatment service encounters. UDS and PDMP measures of opioid exposures were greater in opioid compared to alcohol-only patients. Post-first injection, UDS's positive for opioids declined (p < .05) along with PDMP measures of opioid prescriptions (p < .001), doses (p < .01), types (p < .001), numbers of dispensing prescribers (p < .001) and pharmacies (p < .001). Opioid patients without alcohol disorders showed the best outcomes with 50% to 80% reductions in PDMP-measures of opioids, down to levels of alcohol-only patients.

CONCLUSIONS

This study shows PDMP utility for measuring opioid addiction treatment outcomes, supporting the routine use of PDMPs in clinical and research settings.

SCIENTIFIC SIGNIFICANCE

These findings demonstrate that opioid addiction in patients with complex addictions and mental illnesses comorbidities can show effective treatment responses as measured by PDMP tracking of decreases in opioid prescriptions to those patients. (Am J Addict 2016;25:557-564).

Does arthroscopic subacromial decompression improve quality of life

INTRODUCTION

There has been a significant rise in the volume of subacromial decompression surgery performed in the UK. This study aimed to determine whether arthroscopic subacromial decompression improves health related quality of life in a cost effective manner.

METHODS

Patients undergoing arthroscopic subacromial decompression surgery for impingement were enrolled between 2012 and 2014. The Oxford shoulder score and the EQ-5D™ instruments were completed prior to and following surgery. A cost-utility analysis was performed.

RESULTS

Eighty-three patients were eligible for the study with a mean follow-up duration of 15 months (range: 4-27 months). The mean Oxford shoulder score improved by 13 points (95% confidence interval [CI]: 11-15 points). The mean health utility gain extrapolated from the EQ-5D™ questionnaire improved by 0.23 (95% CI: 0.16-0.30), translating to a minimum cost per QALY of £5,683.

CONCLUSIONS

Subacromial decompression leads to significant improvement in function and quality of life in a cost effective manner. This provides justification for its ongoing practice by appropriately trained shoulder surgeons in correctly selected patients.

Patient-reported outcome measures: an on-line system empowering patient choice

An innovative web-based system was developed to allow patient-reported outcome measures (PROMs) to be easily administered. Stakeholders guided the design and implementation. The software gives patients access to their current and previous scores. This pilot study focused on patients undergoing arthroscopic subacromial decompression, evaluated using the Oxford shoulder score (OSS). Patients showing good improvement in their OSS were offered the choice to return for routine follow-up clinic appointments, or continue rehabilitation, reassured by their improved score. Thirty-six of 117 patients were eligible. Thirty of these (83%) were opted to avoid further clinics. PROMs 2.0 can be used for any medical intervention with a validated PROM. Evolution and refinement is ongoing. Funding has been granted for 12 primary and secondary healthcare trusts to implement PROMs 2.0. Further work is needed to assess economic impact, patient views and satisfaction with the process.

Mass depopulation of laying hens in whole barns with liquid carbon dioxide: evaluation of welfare impact

Appropriate emergency disaster preparedness is a key priority for agricultural agencies to allow effective response to serious avian disease outbreaks. There is a need to develop rapid, humane, and safe depopulation techniques for poultry that are widely applicable across a range of farm settings. Whole barn depopulation with carbon dioxide (CO(2)) has been investigated as a humane and efficient means of killing large numbers of birds in the event of a reportable disease outbreak. It has also been considered as a method for depopulating barns containing end-of-lay hens, particularly when there is limited local slaughter and rendering capacity. Determining the best method of humanely killing large flocks of birds remains problematic and is being investigated by a coordinated international effort. While whole barn depopulation using CO(2) inhalation has been explored, physiologic responses of chickens have not been characterized in field settings and assessment of animal welfare is hampered without this information. In this study, 12 cull laying hens were surgically instrumented with telemetry transmitters to record electroencephalographs, electrocardiographs, body temperature, and activity during 2 large-scale field CO(2) euthanasia trials of end-of-lay hens. The day following surgery, instrumented hens were placed in barns with other birds, barns were sealed, and animals were killed by CO(2) inhalation delivered via a specially designed liquid CO(2) manifold. Instrumented birds were monitored by infrared thermography, and ambient temperature, CO(2), and O(2) concentrations were recorded. Results from these studies indicate that instrumented hens lost consciousness within 2 min of CO(2) levels reaching 18 to 20%. Mild to moderate head shaking, gasping, and 1 to 2 clonic muscle contractions were noted in hens before unconsciousness; however, brain death followed rapidly (<5 min). Evaluation of welfare costs and benefits suggest clear advantages over catching and transporting cull hens for slaughter. The financial costs with this method are greater, however, than those estimated for traditional slaughter techniques. Results of these studies are being used to develop national protocols for whole barn depopulation of hens by CO(2) inhalation.

Trypanosoma cruzi infection of squirrel monkeys: comparison of blood smear examination, commercial enzyme-linked immunosorbent assay, and polymerase chain reaction analysis as screening tests for evaluation of monkey-related injuries

BACKGROUND AND PURPOSE

Wild-caught New World monkeys (NWM) from Central or South America are often infected with Trypanosoma species, including T. cruzi. In humans, T. cruzi causes Chagas' disease. Even in closed monkey colonies, T. cruzi can be propagated by blood-to-blood exposure, sexual activity, and transplacental transmission. Animal handlers and laboratory staff who deal with blood and tissues from infected NWM are at riskfor acquiring Chagas' disease via accidental exposure.

METHODS

We screened 162 blood samples from wild-caught Saimiri sp. monkeys for Trypanosoma species infections by use of blood smear examination, ELISA, and polymerase chain reaction (PCR) analysis. Blood samples from 19 employees with recent history of monkey-associated injuries also were tested.

RESULTS

Six percent (10/162) of the monkey samples were T. cruzi positive on the basis of blood smear examination results, 10.4% (17/162) were positive by ELISA results, and 26.5% (43/162) were positive by PCR results. Other organisms identified by PCR analysis included T. rangeli in two animals, Plasmodium spp. in two animals (P. malariae confirmed by PCR results) and microfilariae in one animal (morphologically, Mansonella perstans). Evidence of trypanosome infection was not found in the 19 employee samples on the basis of results of any of the three aforementioned tests.

CONCLUSIONS

Close attention must be paid to worker safety where wild-caught NWM are used. The PCR analysis has a clear advantage over conventional techniques (ELISA, blood smear) for screening NWM for trypanosome infections during quarantine and after employee injury.

The effect of various methods of trimming of a stone die on the margins of a cast gold crown

Four common methods of trimming a die and the effects on the contour of the wax pattern have been described. Carving of the wax pattern may be facilitated by trimming of the die as a continuation of the unprepared portion of the tooth. When the finishing line is apical to the cervical line only the contour of the adjacent teeth and a knowledge of dental anatomy can guide the technician in reaching an acceptable contour. When part of the unprepared tooth is not reproduced in the impression the die should be trimmed at an angle or more than 180 degrees to the long axis of the preparation to provide a prominent cavo-surface angle and a guiding contact surface for the wax carving instrument.

Determination of internal insect infestation of wheat: collaborative study

An improved method has been developed for determining internal insect infestation of wheat kernels. The method involves acid hydrolysis of cracked wheat, wet sieving to remove the acid, transferring to a 2 L Wildman trap flask, deaeration by boiling, and treatment with Tween 80-Na4EDTA. Insects are extracted with light mineral oil. Reports from 6 collaborators showed that recovery was 95.92% for adult insect heads and 97.22% for larvae by the proposed method as compared with 87.05% and 6.12%, respectively, by the official method. The method has been adopted official first action.

New Brine Saturation Method for Extraction of Light Filth from Corn Meal: Collaborative Study

An improved method has been developed for extracting light filth from corn meal. The proposed method uses only tap water, salt, olive oil, and alcohol, eliminating the need for costly and toxic solvents for the separation. Reports from 8 collaborators showed that recovery was 95.8% for insect fragments and 84.3% for rodent hairs by the proposed method, as compared with 90.6 and 88.6%, respectively, by the official method. The proposed method has been adopted as official first action to replace official method 44.042 for corn meal only.