Investigating lupus retention in care to inform interventions for disparities reduction: an observational cohort study.

BACKGROUND:Systemic lupus erythematous (SLE) disproportionately impacts patients of color and socioeconomically disadvantaged patients. Similar disparities in HIV were reduced through a World Health Organization-endorsed Care Continuum strategy targeting "retention in care," defined as having at least two annual visits or viral load lab tests. Using similar definitions, this study aimed to examine predictors of lupus retention in care, to develop an SLE Care Continuum and inform interventions to reduce disparities. We hypothesized that Black patients and those residing in disadvantaged neighborhoods would have lower retention in care. METHODS:Abstractors manually validated 545 potential adult cases with SLE codes in 2013-2014 using 1997 American College of Rheumatology (ACR) or 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria. We identified 397 SLE patients who met ACR or SLICC criteria for definite lupus, had at least one baseline rheumatology visit, and were alive through 2015. Retention in care was defined as having two ambulatory rheumatology visits or SLE labs (e.g., complement tests) during the outcome year 2015, analogous to HIV retention definitions. Explanatory variables included age, sex, race, ethnicity, smoking status, neighborhood area deprivation index (ADI), number of SLE criteria, and nephritis. We used multivariable logistic regression to test our hypothesis and model predictors of SLE retention in care. RESULTS:Among 397 SLE patients, 91% were female, 56% White, 39% Black, and 5% Hispanic. Notably, 51% of Black versus 5% of White SLE patients resided in the most disadvantaged ADI neighborhood quartile. Overall, 60% met visit-defined retention and 27% met complement lab-defined retention in 2015. Retention was 59% lower for patients in the most disadvantaged neighborhood quartile (adjusted OR 0.41, CI 0.18, 0.93). No statistical difference was seen based on age, sex, race, or ethnicity. More SLE criteria and non-smoking predicted greater retention. CONCLUSIONS:Disadvantaged neighborhood residence was the strongest factor predicting poor SLE retention in care. Future interventions could geo-target disadvantaged neighborhoods and design retention programs with vulnerable populations to improve retention in care and reduce SLE outcome disparities

Establishing chronic condition concordance and discordance with diabetes: a Delphi study

Background The vast majority of patients with diabetes have multiple chronic conditions, increasing complexity of care; however, clinical practice guidelines, interventions, and public reporting metrics do not adequately address the interaction of these multiple conditions. To advance the understanding of diabetes clinical care in the context of multiple chronic conditions, we must understand how care overlaps, or doesn’t, between diabetes and its co-occurring conditions. This study aimed to determine which chronic conditions are concordant (share care goals with diabetes) and discordant (do not share care goals) with diabetes care, according to primary care provider expert opinion. Methods Using the Delphi technique, we administered an iterative, two-round survey to 16 practicing primary care providers in an academic practice in the Midwestern USA. The expert panel determined which specific diabetes care goals were also care goals for other chronic conditions (concordant) and which were not (discordant). Our diabetes care goals were those commonly used in quality reporting, and the conditions were 62 ambulatory-relevant condition categories. Results Sixteen experts participated and all completed both rounds. Consensus was reached on the first round for 94% of the items. After the second round, 12 conditions were concordant with diabetes care and 50 were discordant. Of the concordant conditions, 6 overlapped in care for 4 of 5 diabetes care goals and 6 overlapped for 3 of 5 diabetes care goals. Thirty-one discordant conditions did not overlap with any of the diabetes care goals, and 19 overlapped with only 1 or 2 goals. Conclusions This study significantly adds to the number of conditions for which we have information on concordance and discordance for diabetes care. The results can be used for future studies to assess the impact of concordant and discordant conditions on diabetes care, and may prove useful in developing multimorbidity guidelines and interventions

Ultrastructural changes of the intracellular surfactant pool in a rat model of lung transplantation-related events

<p>Abstract</p> <p>Background</p> <p>Ischemia/reperfusion (I/R) injury, involved in primary graft dysfunction following lung transplantation, leads to inactivation of intra-alveolar surfactant which facilitates injury of the blood-air barrier. The alveolar epithelial type II cells (AE2 cells) synthesize, store and secrete surfactant; thus, an intracellular surfactant pool stored in lamellar bodies (Lb) can be distinguished from the intra-alveolar surfactant pool. The aim of this study was to investigate ultrastructural alterations of the intracellular surfactant pool in a model, mimicking transplantation-related procedures including flush perfusion, cold ischemia and reperfusion combined with mechanical ventilation.</p> <p>Methods</p> <p>Using design-based stereology at the light and electron microscopic level, number, surface area and mean volume of AE2 cells as well as number, size and total volume of Lb were determined in a group subjected to transplantation-related procedures including both I/R injury and mechanical ventilation (I/R group) and a control group.</p> <p>Results</p> <p>After I/R injury, the mean number of Lb per AE2 cell was significantly reduced compared to the control group, accompanied by a significant increase in the luminal surface area per AE2 cell in the I/R group. This increase in the luminal surface area correlated with the decrease in surface area of Lb per AE2. The number-weighted mean volume of Lb in the I/R group showed a tendency to increase.</p> <p>Conclusion</p> <p>We suggest that in this animal model the reduction of the number of Lb per AE2 cell is most likely due to stimulated exocytosis of Lb into the alveolar space. The loss of Lb is partly compensated by an increased size of Lb thus maintaining total volume of Lb per AE2 cell and lung. This mechanism counteracts at least in part the inactivation of the intra-alveolar surfactant.</p

The Interplay of Empathy and Individualism in Support for Social Welfare Policies

Public support for government welfare programs is grounded in two potentially conflicting factors: a belief in individualism which undermines support for welfare assistance, and the capacity for empathy which potentially enhances support. However, empathy is an expensive psychological commodity subject to pervasive up- and down-regulation. This study examines the degree to which a belief in individualism affects the expression of compassionate support for a person in need among those with the capacity for empathy. In two online survey experiments, empathic ability powerfully increases support for a welfare recipient and social welfare policies when it does not conflict with individualism. But, empathic ability decreases compassion and support for government welfare among strong individualists. Evidence that individualists downregulate empathy for someone in need of government assistance is consistent with the conservative view that welfare promotes dependency and undermines individual agency. In contrast, charitable assistance is not associated with long-term dependency and we find that empathy is up-regulated by strong individualists to generate charitable support for the same individual to whom they denied government assistance. The up- and down-regulation of empathy in response to someone in need of government welfare helps illuminate the sharp divisions over social welfare policy among the American publi

RAFT aqueous dispersion polymerization yields poly(ethylene glycol)-based diblock copolymer nano-objects with predictable single phase morphologies

A poly(ethylene glycol) (PEG) macromolecular chain transfer agent (macro-CTA) is prepared in high yield (>95%) with 97% dithiobenzoate chain-end functionality in a three-step synthesis starting from a monohydroxy PEG113 precursor. This PEG113-dithiobenzoate is then used for the reversible addition-fragmentation chain transfer (RAFT) aqueous dispersion polymerization of 2-hydroxypropyl methacrylate (HPMA). Polymerizations conducted under optimized conditions at 50 °C led to high conversions as judged by 1H NMR spectroscopy and relatively low diblock copolymer polydispersities (Mw/Mn < 1.25) as judged by GPC. The latter technique also indicated good blocking efficiencies, since there was minimal PEG113 macro-CTA contamination. Systematic variation of the mean degree of polymerization of the core-forming PHPMA block allowed PEG113-PHPMAx diblock copolymer spheres, worms, or vesicles to be prepared at up to 17.5% w/w solids, as judged by dynamic light scattering and transmission electron microscopy studies. Small-angle X-ray scattering (SAXS) analysis revealed that more exotic oligolamellar vesicles were observed at 20% w/w solids when targeting highly asymmetric diblock compositions. Detailed analysis of SAXS curves indicated that the mean number of membranes per oligolamellar vesicle is approximately three. A PEG 113-PHPMAx phase diagram was constructed to enable the reproducible targeting of pure phases, as opposed to mixed morphologies (e.g., spheres plus worms or worms plus vesicles). This new RAFT PISA formulation is expected to be important for the rational and efficient synthesis of a wide range of biocompatible, thermo-responsive PEGylated diblock copolymer nano-objects for various biomedical applications

Population ecology of the sea lamprey (Petromyzon marinus) as an invasive species in the Laurentian Great Lakes and an imperiled species in Europe

The sea lamprey Petromyzon marinus (Linnaeus) is both an invasive non-native species in the Laurentian Great Lakes of North America and an imperiled species in much of its native range in North America and Europe. To compare and contrast how understanding of population ecology is useful for control programs in the Great Lakes and restoration programs in Europe, we review current understanding of the population ecology of the sea lamprey in its native and introduced range. Some attributes of sea lamprey population ecology are particularly useful for both control programs in the Great Lakes and restoration programs in the native range. First, traps within fish ladders are beneficial for removing sea lampreys in Great Lakes streams and passing sea lampreys in the native range. Second, attractants and repellants are suitable for luring sea lampreys into traps for control in the Great Lakes and guiding sea lamprey passage for conservation in the native range. Third, assessment methods used for targeting sea lamprey control in the Great Lakes are useful for targeting habitat protection in the native range. Last, assessment methods used to quantify numbers of all life stages of sea lampreys would be appropriate for measuring success of control in the Great Lakes and success of conservation in the native range

The impact of a patient’s concordant and discordant chronic conditions on diabetes care quality measures

AimsMost patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality.MethodsLogistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics.ResultsA higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions.ConclusionsHaving more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient's comorbidities, including the absence of comorbidities, especially concordant comorbidities