Pediatric integrative medicine: pediatrics\u27 newest subspecialty

BACKGROUND: Integrative medicine is defined as relationship-centered care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing, including evidence-based complementary and alternative medicine. Pediatric integrative medicine (PIM) develops and promotes this approach within the field of pediatrics. We conducted a survey to identify and describe PIM programs within academic children\u27s hospitals across North America. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada. METHODS: Academic PIM programs were identified by email and eligible for inclusion if they had each of educational, clinical, and research activities. Program directors were interviewed by telephone regarding their clinical, research, educational, and operational aspects. RESULTS: Sixteen programs were included. Most (75%) programs provided both inpatient and outpatient services. Seven programs operated with less than 1 FTE clinical personnel. Credentialing of complementary and alternative medicine (CAM) providers varied substantially across the programs and between inpatient and outpatient services. Almost all (94%) programs offered educational opportunities for residents in pediatrics and/or family medicine. One fifth (20%) of the educational programs were mandatory for medical students. Research was conducted in a range of topics, but half of the programs reported lack of research funding and/or time. Thirty-one percent of the programs relied on fee-for-service income. CONCLUSIONS: Pediatric integrative medicine is emerging as a new subspecialty to better help address 21st century patient concerns

Economic Outcomes of Patients Receiving Antiretroviral Therapy for HIV/AIDS in South Africa Are Sustained through Three Years on Treatment

BACKGROUND. Although the medical outcomes of antiretroviral therapy (ART) for HIV/AIDS are well described, less is known about how ART affects patients' economic activities and quality of life, especially after the first year on ART. We assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy patients in South Africa over three full years following ART initiation. METHODOLOGY/PRINCIPAL FINDINGS. A cohort of 855 adult pre-ART patients and patients on ART for <6 months was enrolled and interviewed an average of 4.4 times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before ART initiation to 32% after three years on ART, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting ART, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over 3 years and for some outcomes increased in the second and third year. CONCLUSIONS/SIGNIFICANCE. Improvements in adult ART patients' symptom prevalence, general health, ability to perform normal activities, and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale treatment provision, such as increases in workforce participation and productivity and the ability of patients to carry on normal lives, may indeed be accruing.South Africa Mission of the U.S. Agency for International Development (GHSA-00-00020-00, 674-A-00-09-00018-00, 674-A-00-02-00018); National Institute of Allergies and Infectious Diseases (PEPFAR 13, K01AI083097); APDA Advanced Center for Parkinson Research at UAB (NIH F30NS065661, NIH R01CA122930); National Institutes of Health Blueprint Core for Neuroscience Research (NS057098

920-52 Are Provider Profiles Affected by Risk-adjustment Methodology? Results from the Cooperative Cardiovascular Project

Health care payors and consumers have a growing interest in risk-adjusted provider profiles. Using chart-abstracted clinical data from the Cooperative Cardiovascular Project, we ranked 28 hospitals performing bypass surgery in Alabama and Iowa by their risk-adjusted surgical mortality rates using three published risk-adjustment methodologies: Parsonnet (PI, O’Connor (a) and Hannan (H). In total. 3653 bypass surgery cases performed from 6/92 to 3/93 were reviewed (mean 130 cases/hospital). The discriminatory abilities of each method for predicting surgical mortality were quite similar (area under ROC curves 0.72–0.75). Below, we display the risk-adjusted hospital rankings (comparing observed with expected mortality) by these three riskadjustment techniques:In terms of hospital rankings, there was generally close correlation between any two of the methods (Spearman's R=0.87,0.88, and 0.93, comparing P-O, P-H, and H-O). Rankings for an individual hospital varied, however, an average of ±3.3 ranks (range 0–12 ranks) depending on which riskadjustment methodology was used.ConclusionIn general. published methods of risk-adjustment for bypass surgery accurately identify institutions with low, moderate and high adjusted mortality outcomes. The precise ranking of an individual hospital. however, may vary depending on the risk adjustment method applied

Implementation of Patient Engagement Tools in Electronic Health Records to Enhance Patient-Centered Communication: Protocol for Feasibility Evaluation and Preliminary Results

BACKGROUND: Patient-physician communication during clinical encounters is essential to ensure quality of care. Many studies have attempted to improve patient-physician communication. Incorporating patient priorities into agenda setting and medical decision-making are fundamental to patient-centered communication. Efficient and scalable approaches are needed to empower patients to speak up and prepare physicians to respond. Leveraging electronic health records (EHRs) in engaging patients and health care teams has the potential to enhance the integration of patient priorities in clinical encounters. A systematic approach to eliciting and documenting patient priorities before encounters could facilitate effective communication in such encounters. OBJECTIVE: In this paper, we report the design and implementation of a set of EHR tools built into clinical workflows for facilitating patient-physician joint agenda setting and the documentation of patient concerns in the EHRs for ambulatory encounters. METHODS: We engaged health information technology leaders and users in three health care systems for developing and implementing a set of EHR tools. The goal of these tools is to standardize the elicitation of patient priorities by using a previsit patient important issue questionnaire distributed through the patient portal to the EHR. We built additional EHR documentation tools to facilitate patient-staff communication when the staff records the vital signs and the reason for the visit in the EHR while in the examination room, with a simple transmission method for physicians to incorporate patient concerns in EHR notes. RESULTS: The study is ongoing. The anticipated completion date for survey data collection is November 2021. A total of 34,037 primary care patients from three health systems (n=26,441; n=5136; and n=2460 separately recruited from each system) used the previsit patient important issue questionnaire in 2020. The adoption of the digital previsit questionnaire during the COVID-19 pandemic was much higher in one health care system because it expanded the use of the questionnaire from physicians participating in trials to all primary care providers midway through the year. It also required the use of this previsit questionnaire for eCheck-ins, which are required for telehealth encounters. Physicians and staff suggested anecdotally that this questionnaire helped patient-clinician communication, particularly during the COVID-19 pandemic. CONCLUSIONS: EHR tools have the potential to facilitate the integration of patient priorities into agenda setting and documentation in real-world primary care practices. Early results suggest the feasibility and acceptability of such digital tools in three health systems. EHR tools can support patient engagement and clinicians\u27 work during in-person and telehealth visits. They could potentially exert a sustained influence on patient and clinician communication behaviors in contrast to prior ad hoc educational efforts targeting patients or clinicians. TRIAL REGISTRATION: ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/ct2/show/NCT03385512. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30431

A New 626 s Periodic X-ray Source in the Direction of the Galactic Center

Here we report the detection of a 626 s periodic modulation from the X-ray source 2XMM J174016.0-290337 located in the direction of the Galactic center. We present temporal and spectral analyses of archival XMM-Newton data and photometry of archived near-infrared data in order to investigate the nature of this source. We find that the X-ray light curve shows a strong modulation at 626 +/- 2 s with a confidence level > 99.9% and a pulsed fraction of 54%. Spectral fitting demonstrates that the spectrum is consistent with an absorbed power law. No significant spectral variability was observed over the 626 s period. We have investigated the possibility that the 626 s period is orbital in nature (either that of an ultra-compact X-ray binary or an AM CVn) or related to the spin of a compact object (either an accretion powered pulsar or an intermediate polar). The X-ray properties of the source and the photometry of the candidate near-infrared counterparts are consistent with an accreting neutron star X-ray binary on the near-side of the Galactic bulge, where the 626 s period is most likely indicative of the pulsar spin period. However, we cannot rule out an ultra-compact X-ray binary or an intermediate polar with the data at hand. In the former case, if the 626 s modulation is the orbital period of an X-ray binary, it would be the shortest period system known. In the latter case, the modulation would be the spin period of a magnetic white dwarf. However, we find no evidence for absorption dips over the 626 s period, a low temperature black body spectral component, or Fe Kalpha emission lines. These features are commonly observed in intermediate polars, making 2XMM J174016.0-290337 a rather unusual member of this class if confirmed. We instead suggest that 2XMM J174016.0-290337 could be a new addition to the emerging class of symbiotic X-ray binaries.Comment: 11 pages, 10 figures, submitted to A&A on 18th January 2010, accepted for publication 20th August 201

How to Estimate the Cost of Point-of-Care CD4 Testing in Program Settings: An Example Using the Alere Pima™ Analyzer in South Africa

Integrating POC CD4 testing technologies into HIV counseling and testing (HCT) programs may improve post-HIV testing linkage to care and treatment. As evaluations of these technologies in program settings continue, estimates of the costs of POC CD4 tests to the service provider will be needed and estimates have begun to be reported. Without a consistent and transparent methodology, estimates of the cost per CD4 test using POC technologies are likely to be difficult to compare and may lead to erroneous conclusions about costs and cost-effectiveness. This paper provides a step-by-step approach for estimating the cost per CD4 test from a provider's perspective. As an example, the approach is applied to one specific POC technology, the Pima™ Analyzer. The costing approach is illustrated with data from a mobile HCT program in Gauteng Province of South Africa. For this program, the cost per test in 2010 was estimated at $23.76 (material costs =$8.70; labor cost per test = $7.33; and equipment, insurance, and daily quality control =$7.72). Labor and equipment costs can vary widely depending on how the program operates and the number of CD4 tests completed over time. Additional costs not included in the above analysis, for on-going training, supervision, and quality control, are likely to increase further the cost per test. The main contribution of this paper is to outline a methodology for estimating the costs of incorporating POC CD4 testing technologies into an HCT program. The details of the program setting matter significantly for the cost estimate, so that such details should be clearly documented to improve the consistency, transparency, and comparability of cost estimates

UCP1 deficiency causes brown fat respiratory chain depletion and sensitizes mitochondria to calcium overload-induced dysfunction.

Brown adipose tissue (BAT) mitochondria exhibit high oxidative capacity and abundant expression of both electron transport chain components and uncoupling protein 1 (UCP1). UCP1 dissipates the mitochondrial proton motive force (Δp) generated by the respiratory chain and increases thermogenesis. Here we find that in mice genetically lacking UCP1, cold-induced activation of metabolism triggers innate immune signaling and markers of cell death in BAT. Moreover, global proteomic analysis reveals that this cascade induced by UCP1 deletion is associated with a dramatic reduction in electron transport chain abundance. UCP1-deficient BAT mitochondria exhibit reduced mitochondrial calcium buffering capacity and are highly sensitive to mitochondrial permeability transition induced by reactive oxygen species (ROS) and calcium overload. This dysfunction depends on ROS production by reverse electron transport through mitochondrial complex I, and can be rescued by inhibition of electron transfer through complex I or pharmacologic depletion of ROS levels. Our findings indicate that the interscapular BAT of Ucp1 knockout mice exhibits mitochondrial disruptions that extend well beyond the deletion of UCP1 itself. This finding should be carefully considered when using this mouse model to examine the role of UCP1 in physiology

Urban public health, a multidisciplinary approach

Urban environment is a highly complex interactive socio-physical system, with competing expectations and priorities. Public health interventions have always had a fundamental role in the control of diseases in cities. WHO considers urbanization as one of the key challenges for public health in the twenty-first century, since cities offer significant opportunities to improve public health if health-enhancing policies and actions are promoted. A multidisciplinary approach is required, but the basic differences existing between technical and health disciplines make the interaction difficult. The multidisciplinary collaboration is still at a very early stage of development, and needs to be further understood and planned. The author concludes stressing the need for a transversal training, but also for sharing knowledge, instruments and methods, involving all the actors in the planning process, to develop a real multidisciplinary approach

The XMM large scale structure survey: optical vs. X-ray classifications of active galactic nuclei and the unified scheme

Our goal is to characterize AGN populations by comparing their X-ray and optical classifications. We present a sample of 99 spectroscopically identified X-ray point sources in the XMM-LSS survey which are significantly detected in the [2-10] keV band, and with more than 80 counts. We performed an X-ray spectral analysis for all of these 99 X-ray sources. Introducing the fourfold point correlation coefficient, we find only a mild correlation between the X-ray and the optical classifications, as up to 30% of the sources have differing X-ray and optical classifications: on one hand, 10% of the type 1 sources present broad emission lines in their optical spectra and strong absorption in the X-rays. These objects are highly luminous AGN lying at high redshift and thus dilution effects are totally ruled out, their discrepant nature being an intrinsic property. Their X-ray luminosities and redshifts distributions are consistent with those of the unabsorbed X-ray sources with broad emission lines. On the other hand, 25/32 are moderate luminosity AGN, which are both unabsorbed in the X-rays and only present narrow emission lines in their optical spectra. The majority of them have an optical spectrum which is representative of the host galaxy. We finally infer that dilution of the AGN by the host galaxy seems to account for their nature. 5/25 have been defined as Seyfert 2. In conclusion, most of these 32 discrepant cases can be accounted for by the standard AGN unified scheme, as its predictions are not met for only 12% of the 99 X-ray sources. ABRIDGEDComment: 25 pages, 19 figures, Accepted for publication in A&

Treating Solar Model Uncertainties: A Consistent Statistical Analysis of Solar Neutrino Models and Data

We describe how to consistently incorporate solar model uncertainties, along with experimental errors and correlations, when analyzing solar neutrino data to derive confidence limits on parameter space for proposed solutions of the solar neutrino problem. Our work resolves ambiguities and inconsistencies in the previous literature. As an application of our methods we calculate the masses and mixing angles allowed by the current data for the proposed MSW solution using both Bayesian and frequentist methods, allowing purely for solar model flux variations, to compare with previous work. We consider the effects of including metal diffusion in the solar models and also discuss implications for future experiments.Comment: 29 pages (incl figs), latex, 6 figures (appended as separate uuencoded file. To embed figures in text, uncomment 6 \epsfysize lines which appear before bibliography), CWRU-P5-94, CfPA-94-TTH-29, Fermilab-Pub-94/176-