Initial Encounter Research Articles

Novices’ reasoning with big data and data-ing through the lens of uncertainty

AbstractAdvancements in computing and statistical analyses have significantly transformed mathematics education, integrating it with data and computer science. As big data becomes increasingly prevalent, understanding its complexities, including its unique uncertainties, is crucial. This study explores the uncertainty that novice students can articulate during their initial engagement with big data, including both data preparation activities or data-ing as well as data analysis activities. Consistent with prior research on students’ engagement with small data, we offer a case study revealing that novices can also exhibit extreme views of uncertainty while engaging with big data. Contrary to the context of small data engagement, our analysis revealed different sources for these extreme views. The classification we used can offer means to identify students’ uncertainty views and support them in developing a more balanced, mature, perception of uncertainty. Moreover, the analysis underscores students’ inclination towards high-uncertainty articulations during their initial encounters with big data-ing activities.

Electroconvulsive therapy (ECT) and Psychiatric rehospitalization rates: a retrospective study

BackgroundElectroconvulsive therapy (ECT) induces a generalized seizure under anesthesia with an electrical current for treatment-resistant patients and may be underutilized. To our knowledge, no large-scale, American, nationwide hospital system retrospective study has examined how ECT affects psychiatric rehospitalization chances.MethodsWe analyzed initial inpatient encounters for adults aged > 18 years at HCA Healthcare Behavioral Health Units from 2016 to 2021 with diagnoses of major depressive disorder with/without psychosis, bipolar disorder with/without psychosis, schizoaffective disorder, and schizophrenia. Excluding pregnancy and incarceration cases, we compared psychiatric rehospitalization rates within 365 days for patients receiving ECT versus those with the same diagnoses not receiving ECT. Subgroup analyses were conducted by diagnosis, length of stay, sex, and race. Detailed statistical analyses included bivariate analyses with Fisher’s Exact Test and Wilcoxon Rank Sum Test.ResultsWe analyzed 38,109 distinct patients, 637 of which received ECT. The rehospitalization rate was 37.52% for ECT recipients versus 20.71% for non-ECT patients (p < 0.0001). ECT was associated with higher rehospitalization rates, particularly for severe diagnoses like psychosis (87.28%), schizoaffective disorder (3.77%), and schizophrenia (6.59%). ECT patients had significantly longer rehospitalization lengths of stay (mean 14.53 days vs. 6.54 days for non-ECT, p < 0.0001). White patients received ECT more frequently. Females received ECT more often, while males had higher rehospitalization rates.ConclusionsECT was associated with higher psychiatric rehospitalization rates and longer lengths of stay. This suggests ECT is more commonly used for complex, severe cases which may contribute to higher rehospitalization. Stronger social support and hospital and geographic ties among ECT patients may also play a role.

Sociodemographic Disparities in 1-Year Outcomes of Children With Community-Acquired Acute Kidney Injury

Racial disparities have been identified in pediatric community-acquired acute kidney injury (CA-AKI), and they are associated with increased risk of child mortality, morbidity, and progression of kidney disease. To assess clinical outcomes at 1 year among children with CA-AKI, stratified by age, race, and ethnicity. This retrospective cohort study is a population-based analysis of deidentified, aggregated electronic health record data collected by 61 large health care organizations from 2003 to 2023 and accessed through the TriNetX platform. Outcomes were assessed at 1 year after a CA-AKI episode. Participants included pediatric patients (aged <18 years) with AKI. Data were accessed in January 2024. A diagnosis of CA-AKI and sociodemographic factors such as race, ethnicity, and age, as reported in electronic health records. The primary end point of this study was to assess differences in clinical outcomes within 1 year of an episode of CA-AKI, including all-cause emergency department (ED) visits, intensive care unit (ICU) admissions, mechanical intubation and ventilation, and mortality. Risk was compared between White children and Asian (including Asian, Native Hawaiian, and Other Pacific Islander), Black, and Hispanic children, stratified by age group. Measures of association, Cox proportional hazard analyses, and Kaplan-Meier survival curves were performed within the TriNetX Advanced Analytics Platform between racial and ethnic groups for each analysis. From the total sample of 18 152 children, those with hospital-acquired AKI, chronic kidney disease, end-stage kidney failure, or dialysis dependence were excluded, leaving a final cohort of 17 125 children (mean [SD] age, 11.2 [5.2] years; 9424 male [55.3%]). Eligible patients were divided into racial and ethnic groups as follows: non-Hispanic Asian, 1169 children (6.5%); non-Hispanic Black, 4636 children (27.3%); Hispanic, 1786 children (10.2%); and non-Hispanic White, 9534 children (55.9%). Patients were further subdivided into groups aged 0 to 9 years (546 Asian children, 1675 Black children, 689 Hispanic children, and 3340 White children) and 10 to 18 years (623 Asian children, 2961 Black children, 1091 Hispanic children, and 6104 White children). Within 1 year of CA-AKI diagnosis, compared with White children, Black children experienced greater rates of ED visits (hazard ratio [HR], 1.53; 95% CI, 1.40-1.67), ICU admissions (HR, 1.31; 95% CI, 1.16-1.47), mechanical ventilation (HR, 1.33; 95% CI, 1.13-1.56), and all-cause mortality (HR, 1.27; 95% CI, 1.09-1.48), as well as the greatest risk for composite outcomes (HR, 1.43; 95% CI, 1.33-1.53). Hispanic children experienced greater rates of ED visits (HR, 1.40; 95% CI, 1.21-1.62) and the greatest risk of all-cause mortality (HR, 1.66; 95% CI, 1.31-2.09), whereas Asian children experienced greater rates of mechanical ventilation (HR, 1.69; 95% CI, 1.26-2.27), compared with White children. Black and Hispanic children aged 0 to 9 years were at greatest risk of experiencing poor clinical outcomes. Black children had a 11.41% lower survival probability and Hispanic children had a 7.14% lower survival probability compared with White children after an initial ED encounter. Among children with an identified episode of CA-AKI diagnosed in an ED, within 1 year, Black and Hispanic children had a poorer survival probability compared with White children. Future studies are needed to understand these disparities and improve awareness and follow-up after emergency care.

Survival in STEMI in resource limited settings - obstacles and potential solutions. Critical lesson learnt thorough a prospective observational study

Abstract Background Early revascularization in ST segment elevation myocardial infarction(STEMI) by Primary Percutaneous coronary Intervention (PPCI) or fibrinolysis, reduces mortality. In the absence of a well-functioning STEMI care system, patients may not get guideline directed revascularisation (GDR). Objective We sought to determine the prevalent mode of revascularisation for STEMI in the community, to discern the factors contributing to lack of GDR during their initial medical encounter, and to investigate the consequences of not getting GDR. Methods Consecutive patients within 24 hours of STEMI from October 2021 to December 2021 in a public hospital from a developing nation, were enrolled. In addition to baseline data, the details of the first medical contact (FMC) and second medical contacts (SMC) before reaching the study site were collected. The hospitals where patients sought care earlier, could be lysis capable hospitals (LCH), PCI/lysis capable hospitals (PLCH) and non-lysis-capable hospitals (NLCH). Medical records related to these visits were scrutinised and in-depth interviews were conducted with patients and their care givers. Details of GDR offered / received during FMC/SMC and the reasons for not receiving GDR were collected. Results 300 patients were enrolled during the study period. 19 reported directly to the study site, while others had visited 1-3 hospitals en route(Figure-1). The 159 who received fibrinolysis in at least one of their medical contacts, had a significantly lower incidence of cardiogenic shock and in-hospital mortality, compared to the rest(Figure-2). 162(54%) patients had had FMC in NLCH and had to be referred to SMC for GDR. Of the 157 visits by a patient with STEMI in a LCH / PLCH within 6 hours’ time window (6HTW), GDR was provided only 44 visits(28%) (Figure-1). The common reason for not receiving GDR was financial. This revascularisation solutions offered were not affordable. These include, PPCI only or pharmaco-invasive package only in PLCH and high cost bolus lytic only in LCH. Of the 132 patients, who had FMC ≤ 12 hours in LCH, only 33 had lysis. Patients who did not receive revascularisation, despite reaching within 6HTW, had adverse in-hospital outcome. (Figure-2) Conclusion The public awareness of the need for early revascularisation in STEMI and the revascularisation solutions available in the neighbourhood hospitals is low. Most patients with STEMI do not receive GDR despite reaching revascularisation capable hospitals within 6HTW. The common reasons for this include, non-availability of low cost fibrinolytics and lack of financial resources. Hospitals should offer fibrinolysis when patients cannot afford PPCI, and low-cost infusion lytics, when patients cannot afford high cost bolus lytics. Provision of GDR in STEMI at the first medical contact, is a social responsibility. Governmental and non-governmental organisations should work in tandem, to ensure 100% GDR at first medical contact.

Hospitalisation cost for paediatric osteomyelitis and septic arthritis in New Zealand.

Hospitalisation rates for paediatric bone and joint infection (BJI) in New Zealand (NZ) are among the highest globally. This study aims to quantify hospitalisation costs of BJI in 2018-2019. National hospitalisation data from the NZ Ministry of Health was used to describe costs associated with all paediatric hospitalisations coded for osteomyelitis or septic arthritis in those aged <16 years. Data included age, ethnic group, area level deprivation, diagnosis-related-group coding, admission length and cost-weight. Readmissions up to 24 months following the initial encounter were analysed for associated costs. More than ten million dollars was spent on hospitalisation for paediatric BJI over the study period (NZ$10 819 474). There were 869 primary hospitalisations and 229 related readmissions. Median length of stay was 7.4 days (95% confidence interval 6.8-7.9). Re-admission costs were NZ$1 196 640 within 24 months following diagnosis. Higher median hospitalisation costs occurred for children residing in the most deprived versus least deprived neighbourhoods (NZ$12 126 vs. NZ$9010, P < 0.01). NZ Māori compared with non-Māori children had longer length of stay (8.4 vs. 6.3 days, P = 0.04), more complex and severe illnesses (53% vs. 17%, P < 0.01), and higher median hospitalisation costs (NZ$11 796 vs. NZ$9581, P = 0.03). Direct BJI hospitalisation costs in 2018-2019 were NZ$10 819 474 with 11% of costs due to re-admission. Direct hospitalisation costs for paediatric BJI in NZ vary by deprivation and ethnic group. Illness complexity of paediatric BJI varies by ethnic group. Interventions are needed to reduce incidence and severity of these debilitating infections.

Paul’s Economic Relationship With the Galatians: Burdensome Imposer or Welcomed Guest?

How did Paul subsist during his travels in Galatia? This article contests Nasrallah’s claim that Paul placed burdens and imposed upon the local communities in Galatia akin to the Roman practice of requisitioning supplies and argues that the Galatians non-coercively welcomed Paul as a host and developed mutual relations with him. We first consider the social practices of Roman requisitions and ancient hospitality as suitable comparanda for interpreting Paul’s travel in Galatia. Then we examine two types of evidence clarifying the socio-economic aspects of Paul’s initial relationship with the Galatians—i.e., Paul’s recollections of his initial encounter with the Galatians (Gal 4:12–20) and subsequent traditions regarding the Galatians’ response to Paul. The evidence suggests that Paul’s relationship with the Galatians was, most probably, welcomed and mutual, not imposing or burdensome. This historical reconstruction contextualizes Paul’s subsequent letter and bears upon interpretations of Galatians.

6784 A Case of Euthyroid Hyperthyroxinemia due to Thyroid Binding Globulin Excess Syndrome

Abstract Disclosure: A.S. Iyer: None. Background: Congenital thyroid binding globulin (TBG) excess is a rare phenomenon associated with elevated serum total T3 and total T4 concentrations but normal serum concentrations of free thyroid hormones, with clinically euthyroid patients. While TBG excess can be caused by pregnancy, estrogen-secreting tumors, and estrogen therapy, congenital TBG excess follows an X-linked pattern, with hemizygous males most affected, and heterozygous females showing a spectrum of disease due to random inactivation of one X chromosome. Clinical Case: A 39-year-old Caucasian female presented as a referral from the Gastroenterology clinic due to concern for thyroid resistance syndrome. Symptoms included chronic constipation (improving with Miralax®), gradual weight gain of 8 pounds in one year, fatigue, and palpitations. She reported that her total thyroid hormone levels have always been elevated, with other thyroid labs remaining within normal limits, along with family history of similar labs noted in her two sons, father, and paternal grandmother. Upon initial encounter, TSH was 1.637 (0.430-3.550 uIU/mL), total T4 15.4 (4.8-11.7 ug/dL), total T3 231 (80-200 ng/dL), free T4 0.97 (0.70-1.25 ng/dL), free T3 3.2 (1.7-3.7 pg/mL), and albumin 4.2 (3.5-5.0 g/dL). The patient was not on oral contraceptive pills and she denied any pregnancies in the last three years. Thyroid ultrasound showed a normal-appearing homogeneous thyroid gland with a small cyst with colloid and no cervical lymphadenopathy. Initial differential diagnosis included TBG excess syndrome versus familial dysalbuminemic hyperthyroxinemia. Permission was obtained from the patient to access one of her son’s medical records from age 8-weeks old when he was also evaluated for abnormal thyroid labs. TSH was 2.144 (0.350-6.500 uIU/mL), total T4 28.2 (5.0-12.0 ug/dL), free T4 1.55 (0.8-1.8 ng/dL), and free T3 4.0 pg/mL (no reference available). Thyroid binding globulin was found to be elevated at 81 (12-26 mcg/mL) in her son and found to be elevated to 78.0 (13.5-30.9 mcg/mL) in this patient, confirming a diagnosis of TBG excess syndrome. Conclusions: TBG excess syndrome should be considered in the differential of patients with high total T3 and total T4 levels with normal levels of free T3, free T4, and TSH, especially in individuals who have a known family history and who have minimal or nonspecific symptoms. Definitive diagnosis will make further testing and treatment unnecessary. However, if these patients develop hypo- or hyperthyroidism, then use of TSH and free levels of T4 and T3 is necessary to direct management and avoid confusion. Reference: Pappa, T., and S. Refetoff. “Thyroid hormone transport proteins: Thyroxine-binding globulin, transthyretin, and albumin.” Reference Module in Neuroscience and Biobehavioral Psychology, 2017, https://doi.org/10.1016/b978-0-12-809324-5.03494-5. Presentation: 6/2/2024

7474 Demographic Patterns In Early Vertebral Fracture Diagnoses Among Women After Initiation Of Bisphosphonate Therapy

Abstract Disclosure: J.C. Lo: None. G.H. Tabada: None. M. Chandra: None. L.D. Carbone: None. T.C. Tan: None. J. Yang: None. E. Garcia: None. Introduction: Vertebral fractures (VFX) are a major osteoporotic fracture that identify women at high risk for subsequent fracture. However, less is known about demographic patterns in VFX diagnoses among women initiating osteoporosis therapy, including prior and subsequent VFX diagnoses. In this study, we examined racial and ethnic variation in VFX diagnoses among older women who initiated oral BP therapy in a large healthcare system. Methods: The study cohort included women aged 65-85y who initiated oral bisphosphonate (BP) therapy in 2008-2017, excluding those with selective bone disorders, metastatic cancer, multiple myeloma, kidney dialysis or transplant. Prior VFX diagnosis was based on ICD-9/10-CM diagnosis codes in the 5 years prior to or at BP initiation, excluding fracture codes related to open fracture or spinal cord injury. In the 2 years after BP initiation, new or initial encounter diagnoses of VFX were examined among those without prior VFX diagnoses. Findings were compared by race and ethnicity, overall and within age strata (65-74y, 75-85y). New VFX diagnoses after BP initiation were examined using Cox proportional hazard analyses, reporting hazard ratios (HR) with 95% confidence intervals (CI). Results: Among 50,870 women aged 65-85y (56.5% age &amp;lt;75y) who initiated BP (66.9% White, 16.7% Asian/PI, 11.9% Hispanic, 3.2% Black), 2819 (5.5%) had prior VFX diagnosis. By race and ethnicity, 4.5% of White, 2.3% of Asian/PI, 3.5% of Hispanic, and 4.1% of Black women aged 65-74y had prior VFX diagnosis, increasing to 7.9% of White, 6.6% of Asian/PI, 7.9% of Hispanic, and 6.3% of Black women aged 75-85y. During 2 years follow-up after BP initiation and stratified by age, the incidence of new VFX diagnosis (per 1000 person-years) was 8.9 (7.9-9.9) for White, 3.2 (2.3-4.5) for Asian/PI, 7.1 (5.3-9.5) for Hispanic, and 6.8 (3.8-12.3) for Black women aged 65-74y, and 17.4 (15.9-19.0) for White, 13.0 (10.2-16.6) for Asian/PI, 14.2 (11.2-18.1) for Hispanic, and 6.1 (3.1-12.2) for Black women aged 75-85y. Adjusting for age, prior clinical fracture, and BP initiation year, the risk of new VFX diagnosis among women aged 65-74y (White as reference) was much lower for Asian/PI women (HR 0.40, CI 0.28-0.57) but not Black (HR 0.70, CI 0.38-1.29) and Hispanic (HR 0.80, CI 0.59-1.10) women. For older women aged 75-85y, the risk was much lower for Black women (0.36 (CI 0.18-0.72) but not Asian/PI (0.78, CI 0.60-1.02) and Hispanic (0.83, CI 0.64-1.07) women. Conclusion: Compared to White women, much lower VFX diagnosis among younger but not older Asian/PI women and among older but not younger Black women were seen in the 2 years after BP initiation. While new VFX diagnoses may represent prevalent or incident VFX and underlying fracture risk and continuation of BP may differ by group, these pilot findings support the need for more studies examining ethnic variation in VFX among older women, including differences by age. Presentation: 6/3/2024

Dynamic changes of media prefrontal cortex astrocytic activity in response to negative stimuli in male mice

Astrocytes play significant roles in regulating the central stress response. Chronic stress impairs the structure and function of astrocytes in many brain regions such as media prefrontal cortex (mPFC) in multiple neuropsychiatric conditions, but the astrocytic dynamics on the timescale of behavior remains unclear. Here, we recorded mPFC astrocytic activity in freely behaving mice and found that astrocytes are activated immediately by different aversive stimuli. Astrocyte specific GCaMP6s calcium indicator were virally expressed in mPFC astrocytes and fiber photometry experiments revealed that astrocytes are activated by tail-restraint (TRT), foot shock (FS), open arm exploration, stressor of height, predator odor and social defeat (SD) stress. ΔF/F analyses demonstrated that an unpredictable stimulus such as elevated platform stress (EPS) at the initial encounter induced the most intense and rapid changes in astrocytic calcium activity, while a predictable 2,5-dihydro-2,4,5-trimethylthiazoline (TMT) stimulus resulted in the weakest response with a longer peak latency. In TRT, FS or SD test, a somatic stimulus led to higher average calcium activity level and faster average peak latency in repeated trails. Similar to TMT stimulus, astrocytic calcium activity in elevated plus maze (EPM) test exhibited a smaller average change in amplitude and the longest peak latency during open arm exploration. Moreover, astrocytic calcium activity exhibited different changes across behavioral states in SD tests. Our findings show that mPFC astrocytes exhibit distinct patterns of calcium activity in response to various negative stimuli, indicating that the dynamic activity of astrocytes may reflect the stress-related behavioral state under different stimulus conditions.

Polar Neptunes Are Stable to Tides

There is an intriguing and growing population of Neptune-sized planets with stellar obliquities near ∼90°. One previously proposed formation pathway is a disk-driven resonance, which can take place at the end stages of planet formation in a system containing an inner Neptune, outer cold Jupiter, and protoplanetary disk. This mechanism occurs within the first ∼10 Myr, but most of the polar Neptunes we see today are ∼Gyr old. Up until now, there has not been an extensive analysis of whether the polar orbits are stable over ∼Gyr timescales. Tidal realignment mechanisms are known to operate in other systems, and if they are active here, this would cause theoretical tension with a primordial misalignment story. In this paper, we explore the effects of tidal evolution on the disk-driven resonance theory. We use both N-body and secular simulations to study tidal effects on both the initial resonant encounter and long-term evolution. We find that the polar orbits are remarkably stable on ∼Gyr timescales. Inclination damping does not occur for the polar cases, although we do identify subpolar cases where it is important. We consider two case study polar Neptunes, WASP-107 b and HAT-P-11 b, and study them in the context of this theory, finding consistency with present-day properties if their tidal quality factors are Q ≳ 104 and Q ≳ 105, respectively.

It takes a village: Feedback from personnel in addiction treatment programs indicates support for changing the intake process

IntroductionThe initial intake encounter represents a critical point for treatment engagement in outpatient addiction treatment programs. Despite the intake assessment being more comprehensive, personalized, and capable of matching clients to level of treatment, addiction treatment programs continue to have among the highest attrition rates. Thus, it may not be what, but how services are delivered that contributes to attrition. The Consolidated Framework for Implementation Research (CFIR) offers a comprehensive framework to attend to sources of needed innovation for the intake process. The current study used a mixed method design, guided by CFIR, to obtain feedback from personnel in addiction treatment programs on the current intake process, as well as the facilitators and barriers to changing the intake process. MethodsPersonnel within New Mexico-based addiction treatment programs completed measures of individual and organizational readiness to make changes within their programs (N = 79; 76 % women, 79 % White, 55 % Latino/a). From this sample, 38 participants completed a CFIR-based semi-structured interview to identify potential barriers and facilitators to changing the intake process. ResultsParticipants reported moderate-to-high scores on readiness and capability to make organizational changes. For qualitative data, we identified nine broad themes, grouped based on (1) perspectives of current intake process (Intake Process, Organization Culture, Change Perspectives, Internal Communication, Client Needs) and (2) perspectives of changing the intake to an MI session (MI knowledge/attitudes, MI at intake, MI in organization, MI fit with Client Needs). ConclusionsFindings highlight that there are specific components of the intake content and process that appear to disengage clients, specific policies and procedures that appear to overburden staff, and key stakeholders and resources needed to improve the intake process. Recommendations are provided for intake-specific and procedural-level changes both in the organization and with outside agencies to improve the intake process.

Experiences of service and diagnosis among immigrant families of young children with suspected or diagnosed developmental disabilities

ABSTRACT Objectives While early diagnosis is fundamental to the development of children with developmental disabilities (DD), limited attention has been paid to immigrant parents’ experience of early encounters with systems when they begin seeking supports for their children with DD. This study aimed to contribute to better understanding of immigrant parents’ experiences of early encounters with services for families and children with suspected or diagnosed DD. Design A longitudinal, qualitative approach was adopted. Over 12 months, multiple interviews were conducted with four immigrant families with children aged between two and four years who were attending a mobile playgroup offering early learning supports for children with suspected or diagnosed DD in communities with low access to formal supports. During the first three months of the study, families were accompanied by the first author on weekly visits to the playgroup. Participant observations and informal discussions with staff delivering early intervention supports via the playgroup provided further insight into families’ initial and on-going encounters with services and supports. During the remaining nine months, multiple interviews were conducted with participating families, to document their on-going experiences and encounters with medical practitioners and therapists. Results Thematic analysis of data generated four key themes: Initial encounters with medical professionals, Confusion and ‘missed’ diagnosis, Gaps in understanding, collaboration and communication, and Families’ desire to learn and implement strategies. Conclusion Families made concerted efforts to locate appropriate supports. They also faced barriers including a lack of openness and genuine consultation, particularly in their encounters with health professionals. These barriers resulted in a level of mistrust and detachment from formalised supports. Results highlight the critical importance for health professionals of ‘tuning into’ family concerns through relationship-based approaches, in order to establish shared understanding and mutual respect between professionals and families, particularly for immigrant families seeking support for their young children.

Use of Telemedicine Services Is Associated with Longer ime to TInitiation of Hormone Therapy in Transgender Teens and Young Adults.

Purpose: This is a retrospective chart review examining factors, which may contribute to timing of receipt of prescription for testosterone or estrogen-based interventions for transgender adolescents and young adults who do not receive such a prescription at their first medical appointment. Methods: A total of 176 patient records were available; of this a minority received a prescription for hormone therapy at first medical appointment. Of the remaining 108 unique individuals, 49 received a prescription at a subsequent medical. Results: Participants seen through virtual health care had a significantly longer time in care prior to receipt of estrogen or testosterone prescription (331 days vs. 220 days, p = 0.046). No other significant relationships were found. Conclusion: Patients who utilize telemedicine services for gender-related health care purposes and who did not receive a prescription for estrogen or testosterone at their initial medical encounter have a longer lead time to receipt of hormone therapy.

Behavioral Transition Path and Pivotal Nodes Regulating Attack in Initial Encounters between Unfamiliar Pigs.

This study leverages the inherent curiosity of pigs and their competitive nature among conspecifics to explore behavioral transition paths and critical nodes that govern aggression during initial encounters between unfamiliar individuals. Two consecutive experiments were designed to investigate these dynamics under controlled conditions. In Experiment 1, unfamiliar pigs engaged in one-on-one fights with quick retreats, displaying a simple behavioral sequence of looking followed by attacking. In Experiment 2, the addition of new pigs to resident groups resulted in a more complex and structured behavioral sequence. Resident pigs exhibited a 'four-step' exploratory behavior pattern: looking, sniffing, touching, and attacking. Further analysis revealed distinct exploratory pathways. In Experiment 1, only short behavioral paths were observed, while Experiment 2 revealed both long and short paths. Specifically, Experiment 2 uncovered seven types of behavioral transition paths, four of which were long and three short, highlighting different combinations of the basic behaviors. The transition paths involving aggression were more varied in Experiment 2 compared to Experiment 1. Overall, the 15 most frequent and obvious behavioral transition paths were identified across both experiments. Eight types of paths were categorized based on the transitions between the basic behaviors. These findings enhance our understanding of the behavioral dynamics in unfamiliar pig encounters, emphasizing the complexity of social interactions and the conditions under which aggression occurs.

Moving beyond "Better Late than Never": High Symptom Burden and Diminished Functional Status at First Palliative Care Visit for Patients with Gynecological Cancers.

Background: Despite physical and emotional distress in patients with gynecologic malignancies, palliative care (PC) is underutilized. Objectives: We characterize referral practices, symptom burden and functional status at the time of initial PC encounter for patients with gynecologic cancer. Design: Data were extracted from the standardized Quality Data Collection Tool for Palliative Care (QDACT-PC). We describe symptom burden and performance status. Results: At initial specialty PC encounter, patients with gynecologic cancers reported a mean of 3.3 moderate/severe symptoms. Outpatients experienced the most moderate/severe symptoms (mean 3.9) versus inpatient (mean 2.1) or home (mean 1.5). A total of 72.7% of patients had significantly impaired functional status (palliative performance scale [PPS] <70) at initial encounter. Inpatients had a more impaired functional status (mean PPS 48.8) than outpatients (mean PPS 67.0). Conclusions: The symptom burden for gynecologic cancer patients at initial PC encounter is high. Despite better functional status, patients referred in the outpatient setting had the highest symptom burden.

Evaluating surgeon communication of pancreatic cancer prognosis using the VitalTalk ADAPT framework.

Few data exist to guide optimal communication practices for surgical oncologists. VitalTalk, an evidence-based communication skills training model for clinicians, offers the five-step ADAPT tool for discussing prognosis. This study aimed to characterize surgeon communication of pancreatic cancer prognosis using VitalTalk's ADAPT framework. Contemporaneous audio recordings from 12 initial surgeon-patient encounters for borderline resectable pancreatic cancer were transcribed. Directed qualitative content analysis based on ADAPT (Ask, Discover, Anticipate, Provide, and Track) was used to deductively code transcripts. All encounters contained at least one ADAPT step while only one (8%) incorporated four or five steps. Surgeons provided prognostic information (Provide) in all but one encounter (92%); most was qualitative and clustered into themes: serious illness, surgical candidacy, prognostic ambiguity, and cancer recurrence. Surgeons elicited understanding (Ask), requested information preferences (Discover), anticipated ambivalence (Anticipate), and responded to emotion (Track) in a minority of encounters (25%-42%); of 15 patient emotional cues, six were not addressed by surgeons. During an initial encounter for pancreatic cancer, surgeons focus heavily on providing information but omit critical prognostic communication steps. Future studies are needed to investigate if surgeon training in palliative care-based communicationis feasible and impacts patient-perceived quality of communication.

Prescription patterns of home rescue benzodiazepines for febrile seizures

ObjectiveTo describe the prescription patterns of home, non-intravenous rescue benzodiazepines (non-IV-rBZDs) for febrile seizures and the factors associated with their prescription. MethodsRetrospective descriptive study using the MarketScan Commercial Database, a large database of employer-sponsored privately insured patients in the United States. We used data from January 1st 2006 to December 31st 2022. We studied patients with febrile seizures as the main code for the healthcare encounter (identified with International Classification of Diseases codes) with age from 6 months to 5 years of age and with at least 1 month of follow-up. ResultsThere were a total of 82,835 patients [median (p25-p75) age 1.0 (1.0–2.0) years, 56.7 % males] with at least one febrile seizure, of whom 9,737 (11.8 %) filled at least one non-IV-rBZD prescription. Among the 9,737 patients who filled at least one prescription, the median (p25-p75) time from first febrile seizure to non-IV-rBZD prescription was 27 (2–186) days. Among the factors known at the time of the first febrile seizure, complex febrile seizure (OR: 3.51, 95 % CI: 3.24–3.79), and an initial inpatient hospitalization for febrile seizure (OR: 3.53, 95 % CI: 3.29–3.79) were the factors most strongly associated with filling a non-IV-rBZD prescription. In contrast, sex, rural patient's residence, and salary employment (versus other employment class) were not independently associated with filling a non-IV-rBZD prescription. Among the factors known at the end of follow-up, complex febrile seizures, type of initial encounter, and an eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. ConclusionOnly approximately 12 % of children with a febrile seizure filled a prescription for a home non-IV-rBZD. The major factors independently associated with prescription were complex febrile seizure, hospital admission, recurrent febrile seizures, and an eventual diagnosis of epilepsy.

Differential impacts of the COVID-19 pandemic on mental health service access among Medicaid-enrolled individuals.

The COVID-19 public health emergency (PHE) caused significant disruptions in the delivery of care, with in-person visits decreasing and telehealth use increasing. We investigated the impact of these changes on mental health services for Medicaid-enrolled adults and youth in Washington State. Among enrollees with existing mental health conditions, the first year of the PHE was associated with a surge in specialty outpatient mental health visits (13% higher for adults and 7% higher for youth), returning to pre-PHE levels in the second year. Conversely, youth with new mental health needs experienced a decline in specialty outpatient visit rates by ∼15% and 37% in the first and second years of the PHE, respectively. These findings indicate that while mental health service use was maintained or improved for established patients, these patterns did not extend to Medicaid-enrolled youth with new mental health needs, potentially due to barriers such as difficulty in finding providers and establishing new patient-provider relationships remotely. To bridge this gap, there is a need for a multi-faceted approach that includes improving service accessibility, enhancing provider availability, and optimizing initial care encounters, whether in-person or virtual, to better support new patients.

A Cost Analysis of Traditional Versus Robotic Total Knee Arthroplasty Performed With an Imageless, Second-generation Robotic System.

This study compared perioperative outcomes as well as encounter and 90-day costs between patients undergoing traditional vs robotic total knee arthroplasty (rTKA). A total of 430 TKAs (215 rTKAs, 215 traditional) were retrospectively reviewed. All rTKAs were performed with an imageless, second-generation robotic system. Cohorts were propensity score matched by age, sex, body mass index, and American Society of Anesthesiologists score. Perioperative data and 90-day complications were subsequently compared. Cox regression analyses evaluated survival to all-cause revisions. Univariable analyses compared total cost of care for the initial encounter and 90-day postoperative period. Multivariable regression analyses were then performed to evaluate associations with increased encounter and 90-day costs. Patients undergoing rTKA had a higher incidence of discharge home (86.5% vs 60.0%; P<.001). The rTKA cohort trended toward a lower incidence of 90-day emergency department visits, and there was a significantly lower percentage of 90-day readmissions (4.2% vs 13.5%; P=.001). Cox hazard ratio demonstrated no difference in survival to all-cause revisions (hazard ratio, 1.3; 95% CI, 0.5-3.7; P=.64). The cost of surgery was significantly higher in the rTKA cohort ($9292 vs $8392; P<.001); however, there was no difference in cost of encounter ($10,356.86 vs $10,396.44; P=.110) or at 90 days postoperatively ($11,103.89 vs $11,040.13; P=.739). rTKA did not have a significant association with increased cost at 90 days postoperatively (odds ratio, 0.96; 95% CI, 0.90-1.02; P=.180). rTKA had a higher intraoperative cost compared with traditional TKA. However, with increased home discharges and fewer 90-day readmissions, rTKA was not associated with increased cost at 90 days. [Orthopedics. 202x;4x(x):xx-xx.].

Disc novae: thermodynamics of gas-assisted binary black hole formation in AGN discs

ABSTRACT We investigate the thermodynamics of close encounters between stellar mass black holes (BHs) in the gaseous discs of active galactic nuclei (AGNs), during which binary black holes (BBHs) may form. We consider a suite of 2D viscous hydrodynamical simulations within a shearing box prescription using the Eulerian grid code athena++. We study formation scenarios where the fluid is either an isothermal gas or an adiabatic mixture of gas and radiation in local thermal equilibrium. We include the effects of viscous and shock heating, as well as optically thick cooling. We co-evolve the embedded BHs with the gas, keeping track of the energetic dissipation and torquing of the BBH by gas and inertial forces. We find that compared to the isothermal case, the minidiscs formed around each BH are significantly hotter and more diffuse, though BBH formation is still efficient. We observe massive blast waves arising from collisions between the radiative minidiscs during both the initial close encounter and subsequent periapsis periods for successfully bound BBHs. These ‘disc novae’ have a profound effect, depleting the BBH Hill sphere of gas and injecting energy into the surrounding medium. In analysing the thermal emission from these events, we observe periodic peaks in local luminosity associated with close encounters/periapses, with emission peaking in the optical/near-infrared (IR). In the AGN outskirts, these outbursts can reach 4 per cent of the AGN luminosity in the IR band, with flares rising over 0.5–1 yr. Collisions in different disc regions, or when treated in 3D with magnetism, may produce more prominent flares.