Languages of the Heart: The Biomedical and the Metaphorical in American Fiction

The role of heart disease in American fiction has received less attention from scholars of literature, history, and medicine than have portrayals of tuberculosis, cancer, or HIV/AIDS, despite the fact that heart disease topped mortality charts for most of the 20th century. This article surveys manifestations of coronary artery disease in popular works of 20th-century American fiction to trace how authors and their protagonists grappled with the disease while knowledge of pathophysiology and therapeutics evolved. Countering Susan Sontag’s mechanistic vision of patient encounters—where disease is absent of metaphor—we pair popular fiction with concurrent historical analysis to show that the proliferation of technological narratives of cardiac therapeutics could not displace the deeply symbolic nature of characters’ encounters with heart disease. Because of the limited ability of the biomedical narrative to convey the meanings of disease and treatments, doctors and patients need to communicate through the rich possibilities of metaphor.History of Scienc

Long-term Patterns of Self-reported Opioid Use, VACS Index, and Mortality Among People with HIV Engaged in Care.

Longitudinal analyses of opioid use and overall disease severity among people with HIV (PWH) are lacking. We used joint-trajectory and Cox proportional hazard modeling to examine the relationship between self-reported opioid use and the Veterans Aging Cohort Study (VACS) Index 2.0, a validated measure of disease severity and mortality, among PWH engaged in care. Using data from 2002 and 2018, trajectory modeling classified 20% of 3658 PWH in low (i.e., lower risk of mortality), 40% in moderate, 28% in high, and 12% in extremely high VACS Index trajectories. Compared to those with moderate VACS Index trajectory, PWH with an extremely high trajectory were more likely to have high, then de-escalating opioid use (adjusted odds ratio [AOR], 95% confidence interval [CI] 5·17 [3·19-8·37]) versus stable, infrequent use. PWH who report high frequency opioid use have increased disease severity and mortality risk over time, even when frequency of opioid use de-escalates

Revealing the Functional Neuroanatomy of Intrinsic Alertness Using fMRI: Methodological Peculiarities

Clinical observations and neuroimaging data revealed a right-hemisphere fronto-parietal-thalamic-brainstem network for intrinsic alertness, and additional left fronto-parietal activity during phasic alertness. The primary objective of this fMRI study was to map the functional neuroanatomy of intrinsic alertness as precisely as possible in healthy participants, using a novel assessment paradigm already employed in clinical settings. Both the paradigm and the experimental design were optimized to specifically assess intrinsic alertness, while at the same time controlling for sensory-motor processing. The present results suggest that the processing of intrinsic alertness is accompanied by increased activity within the brainstem, thalamus, anterior cingulate gyrus, right insula, and right parietal cortex. Additionally, we found increased activation in the left hemisphere around the middle frontal gyrus (BA 9), the insula, the supplementary motor area, and the cerebellum. Our results further suggest that rather minute aspects of the experimental design may induce aspects of phasic alertness, which in turn might lead to additional brain activation in left-frontal areas not normally involved in intrinsic alertness. Accordingly, left BA 9 activation may be related to co-activation of the phasic alertness network due to the switch between rest and task conditions functioning as an external warning cue triggering the phasic alertness network. Furthermore, activation of the intrinsic alertness network during fixation blocks due to enhanced expectancy shortly before the switch to the task block might, when subtracted from the task block, lead to diminished activation in the typical right hemisphere intrinsic alertness network. Thus, we cautiously suggest that – as a methodological artifact – left frontal activations might show up due to phasic alertness involvement and intrinsic alertness activations might be weakened due to contrasting with fixation blocks, when assessing the functional neuroanatomy of intrinsic alertness with a block design in fMRI studies

Obesity prevention in child care: A review of U.S. state regulations

<p>ABSTRACT</p> <p>Objective</p> <p>To describe and contrast individual state nutrition and physical activity regulations related to childhood obesity for child care centers and family child care homes in the United States.</p> <p>Methods</p> <p>We conducted a review of regulations for child care facilities for all 50 states and the District of Columbia. We examined state regulations and recorded key nutrition and physical activity items that may contribute to childhood obesity. Items included in this review were: 1) Water is freely available; 2) Sugar-sweetened beverages are limited; 3) Foods of low nutritional value are limited; 4) Children are not forced to eat; 5) Food is not used as a reward; 6) Support is provided for breastfeeding and provision of breast milk; 7) Screen time is limited; and 8) Physical activity is required daily.</p> <p>Results</p> <p>Considerable variation exists among state nutrition and physical activity regulations related to obesity. Tennessee had six of the eight regulations for child care centers, and Delaware, Georgia, Indiana, and Nevada had five of the eight regulations. Conversely, the District of Columbia, Idaho, Nebraska and Washington had none of the eight regulations. For family child care homes, Georgia and Nevada had five of the eight regulations; Arizona, Mississippi, North Carolina, Oregon, Tennessee, Texas, Vermont, and West Virginia had four of the eight regulations. California, the District of Columbia, Idaho, Iowa, Kansas, and Nebraska did not have any of the regulations related to obesity for family child care homes.</p> <p>Conclusion</p> <p>Many states lack specific nutrition and physical activity regulations related to childhood obesity for child care facilities. If widely implemented, enhancing state regulations could help address the obesity epidemic in young children in the United States.</p

Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study.

BACKGROUND: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care. SETTING: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites. METHODS: Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use. RESULTS: Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. CONCLUSION: Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK.

BACKGROUND: A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials. METHODS: This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674. FINDINGS: Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0-75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4-97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8-80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3-4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation. INTERPRETATION: ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials. FUNDING: UK Research and Innovation, National Institutes for Health Research (NIHR), Coalition for Epidemic Preparedness Innovations, Bill & Melinda Gates Foundation, Lemann Foundation, Rede D'Or, Brava and Telles Foundation, NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and AstraZeneca

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

Background A safe and efficacious vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), if deployed with high coverage, could contribute to the control of the COVID-19 pandemic. We evaluated the safety and efficacy of the ChAdOx1 nCoV-19 vaccine in a pooled interim analysis of four trials. Methods This analysis includes data from four ongoing blinded, randomised, controlled trials done across the UK, Brazil, and South Africa. Participants aged 18 years and older were randomly assigned (1:1) to ChAdOx1 nCoV-19 vaccine or control (meningococcal group A, C, W, and Y conjugate vaccine or saline). Participants in the ChAdOx1 nCoV-19 group received two doses containing 5 × 1010 viral particles (standard dose; SD/SD cohort); a subset in the UK trial received a half dose as their first dose (low dose) and a standard dose as their second dose (LD/SD cohort). The primary efficacy analysis included symptomatic COVID-19 in seronegative participants with a nucleic acid amplification test-positive swab more than 14 days after a second dose of vaccine. Participants were analysed according to treatment received, with data cutoff on Nov 4, 2020. Vaccine efficacy was calculated as 1 - relative risk derived from a robust Poisson regression model adjusted for age. Studies are registered at ISRCTN89951424 and ClinicalTrials.gov, NCT04324606, NCT04400838, and NCT04444674. Findings Between April 23 and Nov 4, 2020, 23 848 participants were enrolled and 11 636 participants (7548 in the UK, 4088 in Brazil) were included in the interim primary efficacy analysis. In participants who received two standard doses, vaccine efficacy was 62·1% (95% CI 41·0–75·7; 27 [0·6%] of 4440 in the ChAdOx1 nCoV-19 group vs71 [1·6%] of 4455 in the control group) and in participants who received a low dose followed by a standard dose, efficacy was 90·0% (67·4–97·0; three [0·2%] of 1367 vs 30 [2·2%] of 1374; pinteraction=0·010). Overall vaccine efficacy across both groups was 70·4% (95·8% CI 54·8–80·6; 30 [0·5%] of 5807 vs 101 [1·7%] of 5829). From 21 days after the first dose, there were ten cases hospitalised for COVID-19, all in the control arm; two were classified as severe COVID-19, including one death. There were 74 341 person-months of safety follow-up (median 3·4 months, IQR 1·3–4·8): 175 severe adverse events occurred in 168 participants, 84 events in the ChAdOx1 nCoV-19 group and 91 in the control group. Three events were classified as possibly related to a vaccine: one in the ChAdOx1 nCoV-19 group, one in the control group, and one in a participant who remains masked to group allocation. Interpretation ChAdOx1 nCoV-19 has an acceptable safety profile and has been found to be efficacious against symptomatic COVID-19 in this interim analysis of ongoing clinical trials

Evidence Based Practice for the Built Environment: Can Systematic Reviews Close the Research - Practice Gap?

© 2017 The Authors. A high performance building is designed and operated to minimise environmental impact whilst providing an indoor environment that maximises occupant health and comfort. The wealth of academic research into technical and non-technical solutions for high performance building continues to grow. However, industry utilisation of academic research is limited and inconsistent due to a number of factors. This situation is compounded by academics using a broad range of methodologies, which prevents a consistent and widely accepted body of knowledge being developed. These factors contribute to a widening research-practice gap. Evidence based (EB) practice is a potential avenue to close this gap. Applied in medicine, EB practice uses a rigorous, more systematic approach on which to base decisions and increase the likelihood of the desired outcome. This paper will outline an approach being used to introduce evidence based practice to the built environment by a research project of the CRC for Low Carbon Living, an Australian based, industry focussed research collaboration. This paper will detail results from the first stage of the research, which assesses the applicability and suitability of using a systematic review process for built environment research. The paper will discuss the difficulties with such an approach to the built environment field, and proposes a 'realist synthesis' adaptation