Quality Assurance in Telehealth: Adherence to Evidence-Based Indicators.

Background: Value enhancing telehealth (TH) lacks a robust body of formal clinically focused quality assessment studies. Innovations such as telehealth must always demonstrate that it preserves or hopefully advances quality. Introduction: We sought to determine whether adherence to the evidence-based Choosing Wisely (CW) recommendations (antibiotic stewardship) for acute sinusitis differs for encounters through direct-to-consumer (DTC) telemedicine verses in-person care in an emergency department (ED) or an urgent care (UC) center. Materials and Methods: Study design was a retrospective review. Patients with a symptom complex consistent with acute sinusitis treated through DTC were matched with ED and UC patients, based upon time of visit. Charts were reviewed to determine patient characteristics, chief complaint, final diagnosis, presence or absence of criteria within the CW guidelines, and whether or not antibiotics were prescribed. The main outcome was adherence to the CW campaign recommendations. Results: A total of 570 visits were studied: 190 DTC, 190 ED, and 190 UC visits. The predominant chief complaints were upper respiratory infection (36%), sore throat (25%), and sinusitis (18%). Overall, there was a 67% (95% CI 62.3-71.7) adherence rate with the CW guidelines for sinusitis: DTC visits (71%), ED visits (68%), and UC visits (61%). There was a nonsignificant difference (p = 0.29) in adherence to CW guidelines based upon type of visit (DTC, UC, and ED). Discussion: The challenge is to demonstrate whether or not DTC TH compromises quality. Conclusion: In this study, DTC visits were associated with at least as good an adherence to the CW campaign recommendations as emergency medicine (EM) and UC in-person visits. © Daniel Halpren-Ruder et al

Shrinking Suburbs in a Time of Crisis

The Routledge Companion to the Suburbs provides one of the most comprehensive examinations available to date of the suburbs around the world. International in scope and interdisciplinary in nature, this volume will serve as the definitive reference for scholars and students of the suburbs. This volume brings together the leading scholars of the suburbs researching in different parts of the world to better understand how and why suburbs and their communities grow, decline, and regenerate. The volume sets out four goals: 1) to provide a synthesis and critical appraisal of the historical and current state of understanding about the development of suburbs in the world; 2) to provide a forum for a comprehensive examination into the conceptual, theoretical, spatial, and empirical discontents of suburbanization; 3) to engage in a scholarly conversation about the transformation of suburbs that is interdisciplinary in nature and bridges the divide between the Global North and the Global South; and 4) to reflect on the implications of the socioeconomic, cultural, and political transformations of the suburbs for policymakers and planners. The Routledge Companion to the Suburbs is composed of original, scholarly contributions from the leading scholars of the study of how and why suburbs grow, decline, and transform. Special attention is paid to the global nature of suburbanization and its regional variations, with a focus on comparative analysis of suburbs through regions across the world in the Global North and the Global South. Articulated in a common voice, the volume is integrated by the very nature of the concept of a suburb as the unit of analysis, offering multidisciplinary perspectives from the fields of economics, geography, planning, political science, sociology, and urban studies.https://scholarworks.wm.edu/asbookchapters/1069/thumbnail.jp

Reliability of Running Stability during Treadmill and Overground Running

Running stability is the ability to withstand naturally occurring minor perturbations during running. It is susceptible to external and internal running conditions such as footwear or fatigue. However, both its reliable measurability and the extent to which laboratory measurements reflect outdoor running remain unclear. This study aimed to evaluate the intra- and inter-day reliability of the running stability as well as the comparability of different laboratory and outdoor conditions. Competitive runners completed runs on a motorized treadmill in a research laboratory and overground both indoors and outdoors. Running stability was determined as the maximum short-term divergence exponent from the raw gyroscope signals of wearable sensors mounted to four different body locations (sternum, sacrum, tibia, and foot). Sacrum sensor measurements demonstrated the highest reliabilities (good to excellent; ICC = 0.85 to 0.91), while those of the tibia measurements showed the lowest (moderate to good; ICC = 0.55 to 0.89). Treadmill measurements depicted systematically lower values than both overground conditions for all sensor locations (relative bias = -9.8% to -2.9%). The two overground conditions, however, showed high agreement (relative bias = -0.3% to 0.5%; relative limits of agreement = 9.2% to 15.4%). Our results imply moderate to excellent reliability for both overground and treadmill running, which is the foundation of further research on running stability

The Emergence of Universal Immune Receptor T Cell Therapy for Cancer

Chimeric antigen receptor (CAR) T cells have shown great success in the treatment of CD19+ hematological malignancies, leading to their recent approval by the FDA as a new cancer treatment modality. However, their broad use is limited since a CAR targets a single tumor associated antigen (TAA), which is not effective against tumors with heterogeneous TAA expression or emerging antigen loss variants. Further, stably engineered CAR T cells can continually and uncontrollably proliferate and activate in response to antigen, potentially causing fatal on-target off-tumor toxicity, cytokine release syndrome, or neurotoxicity without a method of control or elimination. To address these issues, our lab and others have developed various universal immune receptors (UIRs) that allow for targeting of multiple TAAs by T cells expressing a single receptor. UIRs function through the binding of an extracellular adapter domain which acts as a bridge between intracellular T cell signaling domains and a soluble tumor antigen targeting ligand (TL). The dissociation of TAA targeting and T cell signaling confers many advantages over standard CAR therapy, such as dose control of T cell effector function, the ability to simultaneously or sequentially target multiple TAAs, and control of immunologic synapse geometry. There are currently four unique UIR platform types: ADCC-mediating Fc-binding immune receptors, bispecific protein engaging immune receptors, natural binding partner immune receptors, and anti-tag CARs. These UIRs all allow for potential benefits over standard CARs, but also bring unique engineering challenges that will have to be addressed to achieve maximal efficacy and safety in the clinic. Still, UIRs present an exciting new avenue for adoptive T cell transfer therapies and could lead to their expanded use in areas which current CAR therapies have failed. Here we review the development of each UIR platform and their unique functional benefits, and detail the potential hurdles that may need to be overcome for continued clinical translation

Early intervention for obsessive compulsive disorder : An expert consensus statement

© 2019 Elsevier B.V.and ECNP. All rights reserved.Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the ‘toxic’ effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.Peer reviewe

Agricultural mitigation and adaptation to climate change in Yolo County, CA

This place‐based case study in an agricultural county in California’s Central Valley focused on the period of 2010–2050, and dealt with biophysical and socioeconomic issues related to both mitigation of greenhouse gas (GHG) emissions and to adaptation to an uncertain climate. In the past 100 years, changes in crop acreage has been more related to crop price and availability of irrigation water than to growing degree days during summer, and in fact, summer temperatures have increased less than winter temperatures. Econometric analysis indicated that warmer winters, as projected by Geophysical Fluid Dynamics Laboratory‐Bias Corrected Constructed Analog during 2035–2050, could result in less wheat acreage, more alfalfa and tomato acreage, and slight effects on tree and vine crops. The Water Evaluation and Planning (WEAP) model showed that these econometric projections did not reduce irrigation demand under either the B1 or A2 scenarios, but a diverse, water‐efficient cropping pattern combined with improved irrigation technology reduced demand to 12 percent below the historic mean. Collaboration during development of Yolo County’s Climate Action Plan showed that nitrous oxide (mainly from nitrogen fertilizers) was the main source (≅40 percent) of agricultural emissions. Emissions from cropland and rangeland were several orders of magnitude lower than urbanized land per unit area. A survey distributed to 570 farmers and ranchers achieved a 34 percent response rate. Farmers concerned about climate change were more likely to implement water conservation practices, and adopt voluntary GHG mitigation practices. Use of the urban growth model (UPlan) showed that channeling much or all future urban development into existing urban areas will increase ecosystem services by preserving agricultural land and open space, immensely reducing the Yolo County’s GHG emissions, and greatly enhancing agricultural sustainability

A Central Role for Foxp3+ Regulatory T Cells in K-Ras-Driven Lung Tumorigenesis

BACKGROUND: K-Ras mutations are characteristic of human lung adenocarcinomas and occur almost exclusively in smokers. In preclinical models, K-Ras mutations are necessary for tobacco carcinogen-driven lung tumorigenesis and are sufficient to cause lung adenocarcinomas in transgenic mice. Because these mutations confer resistance to commonly used cytotoxic chemotherapies and targeted agents, effective therapies that target K-Ras are needed. Inhibitors of mTOR such as rapamycin can prevent K-Ras-driven lung tumorigenesis and alter the proportion of cytotoxic and Foxp3+ regulatory T cells, suggesting that lung-associated T cells might be important for tumorigenesis. METHODS: Lung tumorigenesis was studied in three murine models that depend on mutant K-Ras; a tobacco carcinogen-driven model, a syngeneic inoculation model, and a transgenic model. Splenic and lung-associated T cells were studied using flow cytometry and immunohistochemistry. Foxp3+ cells were depleted using rapamycin, an antibody, or genetic ablation. RESULTS: Exposure of A/J mice to a tobacco carcinogen tripled lung-associated Foxp3+ cells prior to tumor development. At clinically relevant concentrations, rapamycin prevented this induction and reduced lung tumors by 90%. In A/J mice inoculated with lung adenocarcinoma cells resistant to rapamycin, antibody-mediated depletion of Foxp3+ cells reduced lung tumorigenesis by 80%. Likewise, mutant K-Ras transgenic mice lacking Foxp3+ cells developed 75% fewer lung tumors than littermates with Foxp3+ cells. CONCLUSIONS: Foxp3+ regulatory T cells are required for K-Ras-mediated lung tumorigenesis in mice. These studies support clinical testing of rapamycin or other agents that target Treg in K-Ras driven human lung cancer