Vaccinate her? I hardly know her!: Understanding Vaccine Hesitancy

Vaccines are a first defense against highly communicable diseases such as measles. For vaccines to protect the population, a vast majority must be vaccinated to maintain herd immunity. Vaccine hesitancy is delaying vaccination from the suggested schedule or refusing vaccination outright. The hesitance is commonly portrayed as a lack of knowledge or scientific literacy. But highly educated people are still just as likely to be hesitant. The basis of hesitance is likely ethically similar to that of vaccination. Understanding the methods of the vaccine hesitant will better inform attempts to persuade them. Individuals have an obligation to the community to aid herd immunity. The government has an obligation to its citizens to aid herd immunity. Mandatory vaccination is unlikely in the near future so other coercive methods must be used to convince the populace to comply with vaccination recommendations. Education is a just form of coercion that is already implemented by the medical establishment but must consider ways to improve positive interaction with hesitance

Discovering Your Political Ideology [brochure and streaming video]

The increasing political turmoil in the United States has had a powerful and divisive impact on college campuses. Disputes regarding the recent presidential election have bred hatred and distrust between those of competing political persuasions. As a result, colleges and universities attempt to educate their students on the political process and global issues. Following this political awakening, many young adults return home for holidays and find themselves at odds with the beliefs of their parents. This video was designed to inform students of the best way to communicate political differences to their family members. The authors utilize a short case study, a theoretical framework, and student-friendly resources to present the necessary information in an accessible fashion

Finite Index Right-Angled Mock Artin Groups in Right-Angled Mock Reflection Groups

Associated to any graph Γ are several groups where their presentations are encoded by Γ. Two such groups are right-angled Coxeter groups and right-angled Artin groups. By introducing more structure to Γ, what we call local involutions, the graph Γ becomes a right-angled mock reflection system and encodes the presentation of two more groups: right-angled mock reflection groups and right-angled mock Artin groups. Here we show that every right-angled mock Artin group associated with an n-gon graph with local involutions is a finite index subgroup in some right-angled mock reflection group. We employ a strategy similar to the one Davis and Januszkiewicz employ to show all right-angled Artin groups are finite index in some right-angled Coxeter group. In ours, an n-gon graph with local involutions Γ is mapped onto a finite group with graph Γ0, and that map is used to create a graph with local involutions Γ` by pairing the vertices of Γ with those of Γ0 they are not mapped to. The right-angled mock reflection group associated with Γ` is the one in which the right-angled mock Artin group associated with Γ is finite index. This is proven by finding an isomorphism β from the right-angled mock Artin group to a subgroup of W` that is known to be of finite index

Extreme Elevations of Alkaline Phosphatase in Pregnancy: A Case Report

Background: The normal serum concentration of alkaline phosphatase (ALP) in adults over the age of 18 ranges from 37 to 116 U/L, while in pregnant women levels of up to twice that upper limit can still be normal. There have been very few reports of extreme elevations in ALP, and here we present the case of a 29-year-old pregnant woman with an incidentally found 30-fold increase. Case: The patient, G6P2-1-2-4, received routine prenatal care, though presented to obstetric triage at 36 weeks and 1 day of gestation for diagnosis and management of viral rhinosinusitis and was found to have an ALP level of 2817 U/L. She was expectantly managed and levels were monitored during the peripartum period. Conclusion: The literature proposes that elevation of the placental isotype of ALP could be a marker for placental insufficiency, preterm delivery, or infants born large for gestational age. We report a case with delivery of a normal infant and no placental pathology at term

The Impact of an Immunization Training Certificate Program on the Perceived Knowledge, Skills and Attitudes of Pharmacy Students Toward Pharmacy-Based Immunizations

Objective: To assess the impact of a national immunization training certificate program on the perceived knowledge, skills and attitudes of pharmacy students toward pharmacy-based immunizations. Methods: The study design utilized a pre- and post- survey administered to pharmacy students before and after the American Pharmacists Association’s (APhA) Pharmacy-Based Immunization Delivery program. The primary outcome explored was a change in the perceived knowledge, skills, and attitudes of the pharmacy students. A five-point Likert scale (i.e. strongly agree = 5, strongly disagree = 1) was used for measuring the main outcomes, which was summated by adding the individual item scores in each section to form a composite score for each outcome. Results: The certificate training program resulted in a significant improvement in knowledge (38.5% increase in score, p\u3c0.001) and skills (34.5% increase in score, p\u3c0.001), but not attitudes (1% increase in score, p=0.210). Conclusions: The national immunization training certificate program had a positive impact on the perceived knowledge and skills of pharmacy students. However, no change was observed regarding students’ perceived attitudes toward pharmacy-based immunizations

Uncharted WATERS: Sustaining a Meaningful Student Teaching Experience Amidst a Global Pandemic via an Online STEM Curriculum

Field experience is the culminating experience for pre-service teacher training. As COVID-19 closed schools across the country, pre-service teachers’ field experiences were disrupted. This case study examines how a student teacher, a team of mentor teachers, and a university supervisor at a regional public university adapted to remote learning. The findings suggest that there were gains and losses in terms of the pre-service teachers’ ability to develop essential skills; classroom management skills suffered while formative assessment practices, innovative lesson delivery, and reflection on instruction were enhanced. The transition to remote learning also caused the way student teachers’ skills were valued, as well as the effectiveness of their teaching, to change. How future teachers are prepared will need to be altered. Going forward, all teachers will need the skills to reach students in a variety of environments including face-to-face, remotely, and hybrid models

Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia.

ObjectivesEarly recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).DesignRetrospective cohort study.SettingKaiser Permanente Washington (KPWA), an integrated healthcare delivery system.ParticipantsA total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.MeasurementsEHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).ResultsOverall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.ConclusionThe eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019

MEDICATION USE AND FALLS IN OLDER ADULTS: A PHARMACOEPIDEMIOLOGIC APPROACH

More than one-third of community-dwelling older adults fall each year. Falling is classified as a geriatric syndrome which has multiple contributing factors and an interaction between chronic predisposing diseases and impairments and acute precipitating insults. One potentially modifiable risk factor is medication use. While previous research has been conducted on medication-related falls, there are several gaps remaining in the literature, including the lack evidence on dose-response relationships across wide ranges of medication classes and falls as well as the frequent inability to address confounding by indication. Therefore, the overall purpose of this project was to determine—in a large, representative sample of community-dwelling older adults—associations between antihypertensive, anticholinergic, and antidepressant use and recurrent falls. First, we found no increased risk of recurrent falls in antihypertensive users compared to non-users, or those taking higher doses or for longer durations. Only those using a loop diuretic were found to have a modest increased risk of recurrent falls. In conclusion, antihypertensive use overall was not associated with recurrent falls after adjusting for important confounders. Loop diuretic use may be associated with recurrent falls and needs further study. Second, we found no statistically significant increased risk of recurrent falls in anticholinergic users, or those taking higher doses or for longer durations. In conclusion, increased point estimates suggest an association of anticholinergic use with recurrent falls, but the associations did not reach statistical significance. Future studies are needed to examine other measures of anticholinergic burden, and their associations with other outcomes such as cognitive function. Third, we found a statistically significant increased risk of recurrent falls in antidepressant users. An increased risk was also seen among those taking SSRIs, those with short duration of use, and those taking moderate doses. Among those with a history of falls/fracture at baseline, we found an increase in risk for any antidepressant use, but no increased risk was found in those without a history of falls/fracture. Taken together, the findings from this proposal will provide clinicians and researchers with clinically-relevant information on potential harmful outcomes associated with chronic medication therapy among older adults

Supportive Care in Older Adults with Cancer: Across the Continuum

Supportive care is an essential component of anti-cancer treatment regardless of age or treatment intent. As the number of older adults with cancer increases, and supportive care strategies enable more patients to undergo treatment, greater numbers of older patients will become cancer survivors. These patients may have lingering adverse effects from treatment and will need continued supportive care interventions. Older adults with cancer benefit from geriatric assessment (GA)-guided supportive care interventions. This can occur at any stage across the cancer treatment continuum. As a GA commonly uncovers issues potentially unrelated to anti-cancer treatment, it could be argued that the assessment is essentially a supportive care strategy. Key aspects of a GA include identification of comorbidities, assessing for polypharmacy, screening for cognitive impairment and delirium, assessing functional status, and screening for psychosocial issues. Treatment-related issues of particular importance in older adults include recognition of increased bone marrow toxicity, management of nausea and vomiting, identification of anemia, and prevention of neurotoxicity. The role of physical therapy and cancer rehabilitation as a supportive care strategy in older adults is important regardless of treatment stage or intent

Persistent Polypharmacy and Fall Injury Risk: The Health, Aging and Body Composition Study

Background Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults. Methods The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk. Results Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use. Conclusions Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk