Considering the impact of social risk screening and referral interventions on adults in the safety-net: a mixed methods approach to health system perspectives

The United States’ healthcare system has focused on identifying determinants of negative health outcomes through the standardized assessment of unmet social needs, termed as ‘social risk screenings.’ Prior research has established different health sector stakeholders’ perceptions regarding the acceptability and utility of these screenings, but there is limited evidence regarding the impact of social risk screening on patient health outcomes. Evidence is especially limited on the impact of social risk screening on persons with mental health or cancer diagnoses, despite high levels of reported unmet social needs in these populations. Additionally, an important consideration in the development and use of social risk screens lies in the potential disconnect between the conceptualization of social needs from the provider versus patient perspectives – a disconnect that may be driven by the ‘medicalization’ of the complex contextual factors that shape one’s social determinants of health. The goal of this dissertation is to generate evidence on the experience of clinical providers charged with administering and responding to social risk screenings, how screenings are associated with service use for patients with mental health needs, and patients’ own experiences of and reactions to being asked about social needs and the resultant impacts on the patient-provider interactive relationship. This dissertation contains three chapters that explore the impact of social risk screening on the adult safety net from multiple health sector perspectives. The first study, Patient Navigator and Clinical Team Perceptions on Addressing Unmet Social Needs: Results from a Breast Cancer Patient Navigation Intervention Study, utilizes primary data collection to characterize how patient navigators and clinical teams seek to screen and address unmet social needs for their patients via a social risk screening and referral intervention embedded in breast cancer care sites across Boston, MA. The second study, The Association between Social Needs Screening and Health Care Utilization Among Adults with Mental Health Needs in the Safety-Net, utilizes secondary data analysis of patient electronic health record data to examine the association of social risk screening on healthcare utilization for patients with mental health needs. The third study, Patient Perceptions and Consideration of Unmet Social Needs whilst Accessing Medical Services: A Qualitative Study utilizes primary data collection to understand the ambulatory care patient experience of responding to social risk screens, how patients prioritize different unmet social needs in light of seeking care, and the impact of social risk screening on the patient-provider relationship

Assessing Legislative Interest for a Sugar-Sweetened Beverage Tax in a Midwestern State

BACKGROUND: This study sought to ascertain the opinions of members of the Kansas Legislature regarding pending sugar-sweetened beverage taxation legislation, including perceptions that such a tax would generate revenue or be associated with personal sugar-sweetened beverage consumption habits. METHODS: This study utilized a cross-sectional survey design and was conducted by administering an electronic or telephone survey of the 2010-2011 Kansas Legislature. Publicly-listed contact information for the 165 members in both chambers of the 2010-2011 Kansas Legislature was obtained. State legislators were invited via e-mail, telephone, or both to complete the survey. The main outcome measure was the degree of agreement or disagreement with the idea of sugar-sweetened beverage taxation. RESULTS: Seventy-eight legislators (47.3%) responded. Of these, 90.5% disagreed or strongly disagreed with taxation of sugar-sweetened beverages, and 86.5% disagreed or strongly disagreed with taxation of sugar-sweetened beverages if generated funds were set aside to subsidize healthy choices. Party affiliation, geographic area represented, and personal consumption of sugar-sweetened behaviors were not associated significantly with legislators’ opinions of sugar-sweetened beverage taxation. CONCLUSIONS: The majority of respondents in the Kansas Legislature reported opposing a sugar-sweetened beverage tax. While some respondents identified obesity as a problem, taxation of sugar-sweetened beverages was not a favorable option among Kansas legislators

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use

OBJECTIVES: To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use. DESIGN: Prospective observational cohort. SETTING: Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015. PARTICIPANTS: Individuals aged 65 and older in the ED (N = 57,287). INTERVENTION: The intervention was first TCN contact. Controls never saw a TCN during the study period. MEASUREMENTS: We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits. RESULTS: A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%). CONCLUSION: Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission

Customer orientation and office space performance: assessing the moderating effect of building grade using PLS-MGA

This study presents a framework to measure and empirically validate the relationship between customer orientation and office space performance. The framework uses two types of customer orientation (i.e., responsive customer orientation and proactive customer orientation) and two types of office space performance metrics (i.e., tenant satisfaction and tenant loyalty). Moreover, the building grade (Grade A and Non-grade A) is incorporated into the framework to assess its moderating effect on the relationships. 380 usable responses were collected from building managers in Grade A and Non-grade A buildings using a questionnaire survey. Partial least squares structural equation modeling was utilized to perform latent variable and multi-group analyses. The findings indicate that proactive customer orientation enhances satisfaction to a level not reached by responsive customer orientation as well as suggesting the applicability of both customer orientations in different scenarios. While proactive customer orientation practices lead to higher satisfaction in Non-grade A office ten-ants, responsive customer orientation practices lead to greater satisfaction in grade A office tenants. The latter tend to be more satisfied with Grade A office and thus loyal. Theoretical and managerial implications are discussed

Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients

Objectives: Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone. Design: Retrospective, combined analysis of 2 prospective cohorts. Setting and Participants: Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department. Methods: We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models’ clinical value (ie, net benefit) against that of falls history for different decision thresholds. Results: During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively.Conclusions and Implications: The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.</p

Common variable immunodeficiency in two kindreds with heterogeneous phenotypes caused by novel heterozygous NFKB1 mutations

NFKB1 haploinsufficiengcy was first described in 2015 in three families with common variable immunodeficiency (CVID), presenting heterogeneously with symptoms of increased infectious susceptibility, skin lesions, malignant lymphoproliferation and autoimmunity. The described mutations all led to a rapid degradation of the mutant protein, resulting in a p50 haploinsufficient state. Since then, more than 50 other mutations have been reported, located throughout different domains of NFKB1 with the majority situated in the N-terminal Rel homology domain (RHD). The clinical spectrum has also expanded with possible disease manifestations in almost any organ system. In silico prediction tools are often used to estimate the pathogenicity of NFKB1 variants but to prove causality between disease and genetic findings, further downstream functional validation is required. In this report, we studied 2 families with CVID and two novel variants in NFKB1 (c.1638-2A>G and c.787G>C). Both mutations affected mRNA and/or protein expression of NFKB1 and resulted in excessive NLRP3 inflammasome activation in patient macrophages and upregulated interferon stimulated gene expression. Protein-protein interaction analysis demonstrated a loss of interaction with NFKB1 interaction partners for the p.V263L mutation. In conclusion, we proved pathogenicity of two novel variants in NFKB1 in two families with CVID characterized by variable and incomplete penetrance.Peer reviewe

Common variable immunodeficiency in two kindreds with heterogeneous phenotypes caused by novel heterozygous NFKB1 mutations

NFKB1 haploinsufficiengcy was first described in 2015 in three families with common variable immunodeficiency (CVID), presenting heterogeneously with symptoms of increased infectious susceptibility, skin lesions, malignant lymphoproliferation and autoimmunity. The described mutations all led to a rapid degradation of the mutant protein, resulting in a p50 haploinsufficient state. Since then, more than 50 other mutations have been reported, located throughout different domains of NFKB1 with the majority situated in the N-terminal Rel homology domain (RHD). The clinical spectrum has also expanded with possible disease manifestations in almost any organ system. In silico prediction tools are often used to estimate the pathogenicity of NFKB1 variants but to prove causality between disease and genetic findings, further downstream functional validation is required. In this report, we studied 2 families with CVID and two novel variants in NFKB1 (c.1638-2A>G and c.787G>C). Both mutations affected mRNA and/or protein expression of NFKB1 and resulted in excessive NLRP3 inflammasome activation in patient macrophages and upregulated interferon stimulated gene expression. Protein-protein interaction analysis demonstrated a loss of interaction with NFKB1 interaction partners for the p.V263L mutation. In conclusion, we proved pathogenicity of two novel variants in NFKB1 in two families with CVID characterized by variable and incomplete penetrance.Peer reviewe

A Brain-Computer Interface Based Attention Training Program for Treating Attention Deficit Hyperactivity Disorder

10.1371/journal.pone.0046692PLoS ONE710

Faecal pharmacokinetics of orally administered vancomycin in patients with suspected Clostridium difficile infection

<p>Abstract</p> <p>Background</p> <p>Oral vancomycin (125 mg qid) is recommended as treatment of severe <it>Clostridium difficile </it>infection (CDI). Higher doses (250 or 500 mg qid) are sometimes recommended for patients with very severe CDI, without supporting clinical evidence. We wished to determine to what extent faecal levels of vancomycin vary according to diarrhoea severity and dosage, and whether it is rational to administer high-dose vancomycin to selected patients.</p> <p>Methods</p> <p>We recruited hospitalized adults suspected to have CDI for whom oral vancomycin (125, 250 or 500 mg qid) had been initiated. Faeces were collected up to 3 times/day and levels were measured with the AxSYM fluorescence polarization immunoassay.</p> <p>Results</p> <p>Fifteen patients (9 with confirmed CDI) were treated with oral vancomycin. Patients with ≥4 stools daily presented lower faecal vancomycin levels than those with a lower frequency. Higher doses of oral vancomycin (250 mg or 500 mg qid) led to consistently higher faecal levels (> 2000 mg/L), which were 3 orders of magnitude higher than the MIC₉₀of vancomycin against <it>C. difficile</it>. One patient receiving 125 mg qid had levels below 50 mg/L during the first day of treatment.</p> <p>Conclusions</p> <p>Faecal levels of vancomycin are proportional to the dosage administered and, even in patients with increased stool frequency, much higher than the MIC₉₀. Patients given the standard 125 mg qid dosage might have low faecal levels during the first day of treatment. A loading dose of 250 mg or 500 mg qid during the first 24-48 hours followed by the standard dosage should be evaluated in larger studies, since it might be less disruptive to the colonic flora and save unnecessary costs.</p

Rituximab and improved nodular regenerative hyperplasia-associated non-cirrhotic liver disease in common variable immunodeficiency: a case report and literature study

Common variable immunodeficiency (CVID) associated liver disease is an underrecognized and poorly studied non-infectious complication that lacks an established treatment. We describe a CVID patient with severe multiorgan complications, including non-cirrhotic portal hypertension secondary to nodular regenerative hyperplasia leading to diuretic-refractory ascites. Remarkably, treatment with rituximab, administered for concomitant immune thrombocytopenia, resulted in the complete and sustained resolution of portal hypertension and ascites. Our case, complemented with a literature review, suggests a beneficial effect of rituximab that warrants further research