Significant Change In Slope Research Articles

Impact of the COVID-19 pandemic on telogen effluvium: a nationwide multicentre interrupted time series study

Abstract Background There is ongoing debate regarding the association between telogen effluvium (TE) and COVID-19, as well as COVID-19 vaccines. Objectives To investigate the impact of the COVID-19 pandemic and vaccination on the development of TE among patients visiting dermatology clinics in South Korea. Methods Between 2017 and 2022, data regarding patients with TE and other types of hair loss were collected from 22 hospitals in South Korea. An interrupted time series analysis was conducted, dividing the time into periods before and after the COVID-19 pandemic, as well as before and after the COVID-19 vaccination. Results There was a significant slope change in the percentage of cases of TE during the postpandemic period (slope change 0.011, 95% confidence interval 0.005–0.017, P < 0.001), but no significant changes were observed after vaccination. The percentage of patients with other types of hair loss was not associated with COVID-19 or vaccination. The retrospective nature of the study may have limited the ability to establish causation. Conclusions This multicentre study provides insights into the epidemiology of TE, showing a significant increase in cases of TE following the COVID-19 pandemic. However, there was no association between the occurrence of TE and COVID-19 vaccines.

Strength of Association between Coronavirus Disease 2019 and Neurological Disorders in Children: A Case-Control Study

Introduction: Evidence suggests potential neurological complications of coronavirus disease 2019 (COVID-19), particularly in adults. While case series have hinted at associations between COVID-19 and neurological disorders (NDs) in children, the extent of this link remains unclear. This study investigates temporal trends in NDs during the pandemic and assesses their potential association with COVID-19 infection in children. Methods: We analyzed national Thai hospitalization data (2017–2022) for children under 18 with specific NDs (acute transverse myelitis, central nervous system demyelination, neuromyelitis optica, optic neuritis, polyneuropathy, stroke). An interrupted time series analysis was employed to identify changes in the incidence trends of NDs following the declaration of the COVID-19 pandemic. A matched case-control analysis was conducted using data specific to the Thai COVID-19 outbreak period. This analysis aimed to estimate the association between recent/concurrent COVID-19 infection and NDs in children. A propensity score matching on age group, sex, and month of admission was performed before conducting logistic regression. Results: From 2017–2022, 1,721 children were admitted with NDs (2,474 admissions), with a male predominance (55%) and average age of 10.6 years. Significant slope change was observed in optical neuritis trends coinciding with the third COVID-19 wave. The case-control analysis included 468 cases and 2,340 controls. Children with NDs had a significantly higher prevalence of recent/concurrent COVID-19 (matched odds ratio: 1.95, 95% confidence interval: 1.21–3.16). Subgroup analysis revealed an association between stroke and recent/concurrent COVID-19 (matched odds ratio: 3.05, 95% confidence interval: 1.3–7.16). Thus, this study suggests an association between recent/concurrent COVID-19 and NDs, especially pediatric stroke.

Cannabis-related treatment demand at the eve of German cannabis legalization - a 20-years trend analysis.

Post-2000, the prevalence of cannabis consumption has been rising internationally. This paper investigates whether cannabis-related treatment demand in German outpatient addiction care facilities (OACFs) has been following this trend. Treatment demand related to cannabis use disorder (CUD) for the period 2001 to2021 was investigated using data from the nation-wide standardized German Addiction Care Statistical Service. Analyses covered all and first-time treatment admissions, demographics, and treatment outcomes. We identified years with significant changes in slope or direction of trends through joinpoint regression. Trends within the CUD client population were contrasted with trends among the entire OACF client population. CUD is the second-most common cause for OACF admissions in Germany. Between 2001 and 2021, the share of CUD-related cases among total OACF caseload increased from 7.1 to 19.9%, whereby the share of first-time treatment admissions declined from 79.6 to 55.6%. The share of CUD client population >35years almost tripled from 6.0 to 17.4%, that of female client population rose from 15.6 to 18.1%. From 2001 to 2007, the share of CUD-related treatments completed with improved symptomatology increased from 54.7 to 65.6%, followed by a marginal decline. CUD-related treatment demand is growing in Germany's OACFs, involving a client population that is increasingly older and more experienced with the addiction care system. As current intervention programmes mainly target adolescents and young adults who have been consuming cannabis only for a short time, adapting service offers to the changing client profiles appears paramount to improve treatment effectiveness.

Changes in the incidence of cannabis-related disorders after the Cannabis Act and the COVID-19 pandemic in Québec, Canada

BackgroundThe Canadian Cannabis Act (CCA, implemented in October 2018) and the COVID-19 pandemic (April 2020) might have contributed to cannabis-related harms in Québec, known for its stringent cannabis legal framework. We explored changes in incidence rates of cannabis-related disorders (CRD) diagnoses associated with these events in Québec. MethodsWe utilized linked administrative health data to identify individuals aged 15 year+ newly diagnosed with CRD during hospitalizations, emergency, and outpatients clinics across Québec, from January 2010 and March 2022 (147 months). Interrupted time-series analyses (ITSA) assessed differences (as percentage changes) in sex- and age-standardized, and sex-stratified, monthly incidence rates (per 100,000 population) attributed to the CCA and the COVID-19 pandemic, compared to counterfactual scenarios where pre-events trends would continue unchanged. ResultsThe overall monthly mean rates of incident diagnoses nearly doubled from the pre-CCA period (1.56 per 100,000 population) to the COVID-19 pandemic period (3.02 per 100,000 population). ITSA revealed no statistically significant level or slope changes between adjacent study periods, except for a decrease in the slope of incidence rates among males by 1.84 % (95 % CI −3.41 to −0.24) during the COVID-19 pandemic compared to the post-CCA period. During the post-CCA period, the trends of incidence rates in the general and male populations grew significantly by 1.22 % (95 % CI 0.08 to 2.35) and 1.44 % (0.04 to 2.84) per month, respectively. Similarly significant increases were observed for the general and female populations during the COVID-19 pandemic, with monthly rates rising by 1.43 % (95 % CI 0.75 to 2.12) and 1.75 % (95 % CI 0.13 to 3.37), respectively. These increases more than doubled pre-CCA rates. ConclusionsThe incidence rates of CRD diagnoses across Québec appears to have increased following the implementation of the CCA and during the COVID-19 pandemic. Our findings echo public health concerns regarding potential cannabis-related harms and are consistent with previous Canadian studies.

Survival After Out-of-Hospital Cardiac Arrest Before and After Legislation for Bystander CPR

The lack of evidence-based implementation strategies is a major contributor to increasing mortality due to out-of-hospital cardiac arrest (OHCA) in developing countries with limited resources. To evaluate whether the implementation of legislation is associated with increased bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use and improved clinical outcomes for patients experiencing OHCA and to provide policy implications for low-income and middle-income settings. This observational cohort study analyzed a prospective city registry of patients with bystander-witnessed OHCA between January 1, 2010, and December 31, 2022. The Emergency Medical Aid Act was implemented in Shenzhen, China, on October 1, 2018. An interrupted time-series analysis was used to assess changes in outcomes before and after the law. Data analysis was performed from May to October 2023. The Emergency Medical Aid Act stipulated the use of AEDs and CPR training for the public and provided clear legal guidance for OHCA rescuing. The primary outcomes were rates of bystander-initiated CPR and use of AEDs. Secondary outcomes were rates of prehospital return of spontaneous circulation (ROSC), survival to arrival at the hospital, and survival at discharge. A total of 13 751 patients with OHCA (median [IQR] age, 59 [43-76] years; 10 011 men [72.83%]) were included, with 7858 OHCAs occurring during the prelegislation period (January 1, 2010, to September 30, 2018) and 5893 OHCAs occurring during the postlegislation period (October 1, 2018, to December 31, 2022). The rates of bystander-initiated CPR (320 patients [4.10%] vs 1103 patients [18.73%]) and AED use (214 patients [4.12%] vs 182 patients [5.29%]) increased significantly after legislation implementation vs rates before the legislation. Rates of prehospital ROSC (72 patients [0.92%] vs 425 patients [7.21%]), survival to arrival at the hospital (68 patients [0.87%] vs 321 patients [5.45%]), and survival at discharge (44 patients [0.56%] vs 165 patients [2.80%]) were significantly increased during the postlegislation period. Interrupted time-series models demonstrated a significant slope change in the rates of all outcomes. These findings suggest that implementation of the Emergency Medical Aid Act in China was associated with increased rates of CPR and public AED use and improved survival of patients with OHCA. The use of a systemwide approach to enact resuscitation initiatives and provide legal support may reduce the burden of OHCA in low-income and middle-income settings.

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea.

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD. Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD. We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%). Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

411 Perioperative Complications and Radiographic Outcomes Following Cervical Laminoplasty: A Review of 105 Cases From a Single Academic Center

INTRODUCTION: With advancements in technology, the safety and efficacy of cervical laminoplasty have increased, leading to a reduction in complications frequently associated with posterior cervical surgical approaches, including C5 nerve palsy, axial neck pain, loss of lordosis, and loss of motion. However, the impact of these advancements on cervical radiographic parameters remains poorly documented, and the prevalence of complications in North American populations has not been adequately studied. METHODS: We evaluated patients undergoing cervical laminoplasty between 2011 to 2022 at an academic medical center. Patient demographics, intraoperative and postoperative complications, preoperative and post-operative radiographic parameters were recorded. RESULTS: 150 patients undergoing cervical laminoplasty during this study period were identified. 105 patients met the inclusion criteria. We identified a total of 22 (21.0%) adverse events in 20 patients. There were 4 intra-operative (3.8%), 10 peri-operative (9.5%), and 8 delayed post-operative (7.6%) adverse events. Amongst them, 13 (12.4%) were judged to be minor and 9 (8.6%) were judged to be major complications. Six (5.7%) patients required revision surgery. Forty-seven (44.8%) of the 105 patients had both pre-and post-operative cervical spine radiographic imaging. The average pre-and post-op C2-7 cobb angles were 14.7 degrees and 12.3 degrees (p-value of 0.04). The pre-and post-op SVA was 29.2 mm and 33.3 mm (p-value of 0.07). The pre-op and post-op T1 slopes were 32.3 and 30.2 deg (p-value of 0.07). CONCLUSIONS: Cervical laminoplasty carries a significant risk of adverse events, the majority of which are minor and has a low rate of re-operation (5.7%). The procedure does not result in significant changes in SVA or T1 slope. Cervical laminoplasty remains a valuable surgical option for selected patients with cervical myelopathy.

The Effect of an Electronic Medical Record-Based Clinical Decision Support System on Adherence to Clinical Protocols in Inflammatory Bowel Disease Care: Interrupted Time Series Study.

Clinical decision support systems (CDSSs) embedded in electronic medical records (EMRs), also called electronic health records, have the potential to improve the adoption of clinical guidelines. The University of Alberta Inflammatory Bowel Disease (IBD) Group developed a CDSS for patients with IBD who might be experiencing disease flare and deployed it within a clinical information system in 2 continuous time periods. This study aims to evaluate the impact of the IBD CDSS on the adherence of health care providers (ie, physicians and nurses) to institutionally agreed clinical management protocols. A 2-period interrupted time series (ITS) design, comparing adherence to a clinical flare management protocol during outpatient visits before and after the CDSS implementation, was used. Each interruption was initiated with user training and a memo with instructions for use. A group of 7 physicians, 1 nurse practitioner, and 4 nurses were invited to use the CDSS. In total, 31,726 flare encounters were extracted from the clinical information system database, and 9217 of them were manually screened for inclusion. Each data point in the ITS analysis corresponded to 1 month of individual patient encounters, with a total of 18 months of data (9 before and 9 after interruption) for each period. The study was designed in accordance with the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) guidelines for health informatics evaluations. Following manual screening, 623 flare encounters were confirmed and designated for ITS analysis. The CDSS was activated in 198 of 623 encounters, most commonly in cases where the primary visit reason was a suspected IBD flare. In Implementation Period 1, before-and-after analysis demonstrates an increase in documentation of clinical scores from 3.5% to 24.1% (P<.001), with a statistically significant level change in ITS analysis (P=.03). In Implementation Period 2, the before-and-after analysis showed further increases in the ordering of acute disease flare lab tests (47.6% to 65.8%; P<.001), including the biomarker fecal calprotectin (27.9% to 37.3%; P=.03) and stool culture testing (54.6% to 66.9%; P=.005); the latter is a test used to distinguish a flare from an infectious disease. There were no significant slope or level changes in ITS analyses in Implementation Period 2. The overall provider adoption rate was moderate at approximately 25%, with greater adoption by nurse providers (used in 30.5% of flare encounters) compared to physicians (used in 6.7% of flare encounters). This is one of the first studies to investigate the implementation of a CDSS for IBD, designed with a leading EMR software (Epic Systems), providing initial evidence of an improvement over routine care. Several areas for future research were identified, notably the effect of CDSSs on outcomes and how to design a CDSS with greater utility for physicians. CDSSs for IBD should also be evaluated on a larger scale; this can be facilitated by regional and national centralized EMR systems.

Age- and Race-Specific Changes in ESKD Incidence over Four Decades.

ESKD incidence has changed substantially in the past four decades, but differences by age and race have been unexplored. Using data from the United States Renal Data System, we found that ESKD incidence rose for Black and White teenagers, adults, and older adults for two decades beginning in 1980. Growth in incidence slowed for most groups by 1993, and by 2006, the annual percent change (APC) in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise. By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence rate among Black American patients exceeds that of White patients in every age group. Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors. There may be population-specific opportunities to change the growth of the US ESKD population and address current racial disparities. Substantial changes in ESKD incidence over four decades among Black and White Americans of different ages have been incompletely explored. We analyzed United States Renal Data System data from 1980 to 2019 to determine ESKD incidence trends among Black and White adolescent (13-17 years), adult (18-64 years), and older adult (≥65) populations. We used the National Cancer Institute Joinpoint Regression Program to estimate annual percent change (APC) in ESKD incidence and to define points in time where a statistically significant change in APC slope occurred for each group. ESKD incidence rose after 1980 for all groups, although the trends differed ( P < 0.001). Growth in incidence slowed for most by 1993, and by 2006, the APC in ESKD incidence had declined for all groups, except White adults, for whom rates continued to rise ( P < 0.05). By 2019, ESKD incidence among Black and White adolescents nearly returned to 1980 levels, but no other group achieved that degree of improvement. Nonetheless, the ESKD incidence among Black American patients exceeds that of White patients in every age group. Distinct patterns in ESKD incidence among patients of different age, sex, and racial groups are shown. These findings could reflect changes in dialysis acceptance rates, access to preventive health care, incidence of diabetes mellitus, implementation of evidence-based guidelines for treatment of CKD, or other unrecognized factors. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2024_03_13_ASN0000000000000310.mp3.

The trend of poisonings before and after the COVID-19 pandemic

The COVID-19 pandemic has substantially affected people and healthcare systems. One of the main challenges was the reduction and change in the pattern of non-COVID-19 diseases and conditions. Moreover, due to the mental burden of the pandemic, the trend of poisonings and abuses changed. In this study, we aimed to assess the trends of poisonings from different agents before and during the COVID-19 pandemic using the interrupted time series method. This study was conducted at one of the main Tehran referral centers for poisoning, Baharloo Hospital. Pre-COVID-19 period was defined as April 2018 to January 2020 while the COVID-19 time was from February 2020 to March 2022. The total number of monthly poisoning cases in addition to eight categories of drugs/substances/agents were identified, including drugs (such as psychiatric drugs, cardiovascular drugs, and analgesics), opioids, stimulants, methanol, ethanol, cannabis, pesticides, and carbon monoxide. Interrupted time series analysis was performed to compare the pre-pandemic trend of total monthly cases from each category in addition to the proportion (%) of each one. In total, 13,020 cases were poisoned during the study period, among which 6088 belonged to the pre-pandemic period and 6932 were admitted during the COVID-19 era. There was no significant difference in terms of demographic characteristics of patients before and during the pandemic (p-value > 0.05). At the beginning of the pandemic, there was a sudden fall in the number of poisoning patients (− 77.2 cases/month, p-value = 0.003), however, there was a significant increasing trend during the COVID time (3.9 cases/month, p-value = 0.006). Most of the categories had a sharp decrease at the beginning of the pandemic except for methanol and ethanol which had increases, although not significant. Cannabis also had a significant change in slope (− 0.6 cases/month, p-value = 0.016), in addition to the sudden decrease at the beginning of the pandemic (− 10 cases/month, p-value = 0.007). Regarding the proportion of each category from total monthly poisoning cases, methanol, and ethanol had immediate rises of 4.2% per month and 10.1% per month, respectively (both significant). The pandemic had significant effects on the pattern of poisonings from different agents in Iran, the most important of which were alcohol (ethanol and methanol). These differences had policy implications that can be helpful for policymakers and healthcare systems in combating similar situations in the future.

Evaluation of a Targeted COVID-19 Community Outreach Intervention: Case Report for Precision Public Health.

Cameron County, a low-income south Texas-Mexico border county marked by severe health disparities, was consistently among the top counties with the highest COVID-19 mortality in Texas at the onset of the pandemic. The disparity in COVID-19 burden within Texas counties revealed the need for effective interventions to address the specific needs of local health departments and their communities. Publicly available COVID-19 surveillance data were not sufficiently timely or granular to deliver such targeted interventions. An agency-academic collaboration in Cameron used novel geographic information science methods to produce granular COVID-19 surveillance data. These data were used to strategically target an educational outreach intervention named "Boots on the Ground" (BOG) in the City of Brownsville (COB). This study aimed to evaluate the impact of a spatially targeted community intervention on daily COVID-19 test counts. The agency-academic collaboration between the COB and UTHealth Houston led to the creation of weekly COVID-19 epidemiological reports at the census tract level. These reports guided the selection of census tracts to deliver targeted BOG between April 21 and June 8, 2020. Recordkeeping of the targeted BOG tracts and the intervention dates, along with COVID-19 daily testing counts per census tract, provided data for intervention evaluation. An interrupted time series design was used to evaluate the impact on COVID-19 test counts 2 weeks before and after targeted BOG. A piecewise Poisson regression analysis was used to quantify the slope (sustained) and intercept (immediate) change between pre- and post-BOG COVID-19 daily test count trends. Additional analysis of COB tracts that did not receive targeted BOG was conducted for comparison purposes. During the intervention period, 18 of the 48 COB census tracts received targeted BOG. Among these, a significant change in the slope between pre- and post-BOG daily test counts was observed in 5 tracts, 80% (n=4) of which had a positive slope change. A positive slope change implied a significant increase in daily COVID-19 test counts 2 weeks after targeted BOG compared to the testing trend observed 2 weeks before intervention. In an additional analysis of the 30 census tracts that did not receive targeted BOG, significant slope changes were observed in 10 tracts, of which positive slope changes were only observed in 20% (n=2). In summary, we found that BOG-targeted tracts had mostly positive daily COVID-19 test count slope changes, whereas untargeted tracts had mostly negative daily COVID-19 test count slope changes. Evaluation of spatially targeted community interventions is necessary to strengthen the evidence base of this important approach for local emergency preparedness. This report highlights how an academic-agency collaboration established and evaluated the impact of a real-time, targeted intervention delivering precision public health to a small community.

Exosomal preconditioning of human iPSC-derived cardiomyocytes beneficially alter cardiac electrophysiology during hypoxia

Abstract Introduction and purpose Cardiac-Exosomes (EXO) are nano-sized extracellular vesicles, continuously secreted by the myocardium. Despite previous misconceptions, cardiac-EXO are not just a way for the cell to dispatch waste, but functions as carriers of signaling molecules. Furthermore, the effects of cardiac-EXO signaling during hypoxic stress is not well understood. The present study aimed to determine the biological effects of EXO released from hypoxic cardiomyocytes, focusing on whether the EXO-cargo can benefit recipient cells during hypoxic stress. We hypothesize that cardiomyocytes exposed to hypoxic stress would display advantageous electrophysiological properties after preconditional treatment with isolated cardiac-EXO secreted from cardiomyocytes exposed to hypoxic stress. Methods For preconditional treatment we isolated EXO from human iPSC-derived cardiomyocytes (CM) exposed to hypoxia (1% O2) for 16 h (H-EXO). H-EXO was thereafter administrated as preconditional treatment to a secondary population of CM 24 h before subjection to 16 h of hypoxia. Electrophysiological effects of H-EXO precondition treatment were assessed with a multiwell microelectrode array (MEA) system. Using the MEA-system; field potential, beat period, spike slope, spike amplitude, excitation-contraction (EC) coupling, and cardiac action potentials were recorded and analyzed. Results We found that CM exposed to hypoxic stress conditions (16 hours) displayed significant increase in beat period when preconditioned with H-EXO compared to non-treated CM (+15.7%, p&amp;lt;0.05). Furthermore, precondition with H-EXO resulted in faster EC coupling compared with non-treated CM after 16 h of hypoxia (-25.3%, p&amp;lt;0.05). More efficient EC coupling indicates that the H-EXO recipient cells are less affected by the hypoxic stress. There were no significant changes in field potential, spike slope, spike amplitude and cardiac action potential between the two groups after 16 h of hypoxia. Conclusion The present study report that EXO secreted by CM under hypoxia alter electrophysiological properties in recipient cells exposed to 16 h hypoxic stress. The alterations indicate more efficient cardiomyocyte EC coupling and longer beat period.

Perioperative Complications and Radiographic Outcomes Following Cervical Laminoplasty: A Review of 105 Cases from a Single Academic Center

To assess complications and to compare preoperative and postoperative radiographic measures in patients who underwent cervical laminoplasty. We evaluated patients undergoing cervical laminoplasty between 2011 and 2022 at an academic medical center. Patient demographics, intraoperative and postoperative complications, and preoperative and postoperative radiographic parameters were recorded. Of 150 patients undergoing cervical laminoplasty during 2011-2022, 105 met the inclusion criteria. We identified 22 (21.0%) adverse events in 20 patients: 4 intraoperative (3.8%), 10 perioperative (9.5%), and 8 delayed postoperative (7.6%). Among adverse events, 13 (12.4%) were judged to be minor and 9 (8.6%) were judged to be major complications. Revision surgery was required in 6 (5.7%) patients. Both preoperative and postoperative cervical spine radiographic imaging was available in 47 (44.8%) of the 105 patients. Mean preoperative and postoperative C2-7 Cobb angles were 14.7° and 12.3°, respectively (P= 0.04). Mean preoperative and postoperative sagittal vertical axis measurements were 29.2 mm and 33.3 mm, respectively (P= 0.07). Mean preoperative and postoperative T1 slopes were 32.3° and 30.2°, respectively (P= 0.07). Cervical laminoplasty carries a significant risk of adverse events, the majority of which are minor, and has a low rate of reoperation (5.7%). The procedure does not result in significant changes in sagittal vertical axis or T1 slope. Cervical laminoplasty remains a valuable surgical option for selected patients with cervical myelopathy.

An innovative model of access and triage to reduce waiting in an outpatient epilepsy clinic: an intervention study

BackgroundDelayed access to outpatient care may negatively impact on health outcomes. We aimed to evaluate implementation of the Specific Timely Appointments for Triage (STAT) model of access in an epilepsy clinic to reduce a long waitlist and waiting time.MethodsThis study is an intervention study using pre-post comparison and an interrupted time series analysis to measure the effect of implementation of the STAT model to an epilepsy clinic. Data were collected over 28 months to observe the number of patients on the waitlist and the waiting time over three time periods: 12 months prior to implementation of STAT, ten months during implementation and six months post-intervention. STAT combines one-off backlog reduction with responsive scheduling that protects time for new appointments based on historical data. The primary outcomes were the number of patients on the waitlist and the waiting time across the three time periods. Secondary outcomes evaluated pre- and post-intervention changes in number of appointments offered weekly, non-arrival and discharge rates.ResultsA total of 938 patients were offered a first appointment over the study period. The long waitlist was almost eliminated, reducing from 616 during the pre-intervention period to 11 post-intervention (p = 0.002), but the hypothesis that waiting time would decrease was not supported. The interrupted time series analysis indicated a temporary increase in waiting time during the implementation period but no significant change in slope or level in the post- compared to the pre-intervention period. Direct comparison of the cohort of patients seen in the pre- and post-intervention periods suggested an increase in median waiting time following the intervention (34 [IQR 25–86] to 46 [IQR 36–61] days (p = 0.001)), but the interquartile range reduced indicating less variability in days waited and more timely access for the longest waiters.ConclusionsThe STAT model was implemented in a specialist epilepsy outpatient clinic and reduced a large waitlist. Reductions in the waitlist were achieved with little or no increase in waiting time. The STAT model provides a framework for an alternative way to operate outpatient clinics that can help to ensure that all people referred are offered an appointment in a timely manner.

Regional cerebral atrophy correlates with amyloid accumulation in preclinical Alzheimer’s disease

AbstractBackgroundThis study was aimed to evaluate the regional hierarchical brain atrophy among the preclinical to mild cognitive impairment (MCI) stages of Alzheimer’s disease associated with amyloid deposition using [18F]flutemetamol positron emission tomography and volumetric magnetic resonance imaging.MethodThis was a prospective, single‐cohort study of volunteers who were living independently in Itabashi‐ku (Tokyo, Japan). One hundred thirty‐six participants (female/male = 96/40, mean age/standard deviation = 79.2/4.0 years) were recruited. Two subjects, one with meningeal thickening and another with sequelae in the brain, and 17 visually amyloid‐negative MCI subjects who possibly had neurodegenerative disease other than Alzheimer’s disease were excluded from the further analysis. We applied voxel‐based regression slope analysis between composite voxel of interest values calculated with Cortex ID Suite (GE Healthcare) on [18F]flutemetamol positron emission tomography and volumetric magnetic resonance images in three groups: 70 amyloid‐negative cognitively normal (CN) participants, 29 amyloid‐positive cognitively normal (PreC) participants, and 18 amyloid‐positive MCI (MCI+) participants. Statistical Parametric Mapping 12 software was used for analysis.ResultEven in the cognitively normal stage, the PreC group showed a larger slope of atrophy in the basal forebrain and middle frontal gyri than the CN group. In the MCI+ group, the slopes were larger in the lateral and medial parietal lobes, uncus, and right lateral temporal areas.ConclusionThe speed of amyloid‐related atrophy in the basal forebrain and middle frontal gyri was quick even in the preclinical stage of Alzheimer’s disease. As no significant slope changes were observed among the three groups in the medial temporal area, except for the uncus, the well‐known medial temporal atrophy in early Alzheimer’s disease might not be related to the accumulation of amyloid.

Early prenatal sex steroids and sex-typed play behavior at 4 years of age

During pregnancy, estrogens and testosterone influence brain development, resulting in sex-typical behavioral phenotypes. Prenatal testosterone exposure is associated with more male-typical behaviors in rodents, monkeys, and humans; however, few studies have examined the relationship between maternal sex hormones within the normal range and sex-dimorphic behaviors. In this study, we examined associations between prenatal estrogens and testosterone and sex-typical play in The Infant Development and the Environment Study (TIDES), a multicenter pregnancy cohort. We collected prenatal serum during the first trimester (mean=11.1 ± 2.6 weeks) and assessed child play behavior using the maternally completed Pre-School Activities Inventory (PSAI) at a mean age of 4.5 ± 0.3 years. This analysis includes mother-child pairs with complete data on hormones, play behavior, and covariates (n = 192 boys and 207 girls). No associations were seen between testosterone and PSAI scores in boys or girls or between estrogens and PSAI scores in boys. In girls, we observed an inverse relationship between feminine PSAI scores and both estradiol (E2) and estriol (E3) in multivariable linear regression analyses (E2: −0.11 [95% CI −0.20, −0.02]; E3: −0.44 [95% CI −0.83,−0.04]). Because the relationship between sex hormones and PSAI scores appeared nonlinear, we fit piecewise regression models to better fit the data and identify inflection points (point at which there is a significant change in slope). Piecewise regression analyses yielded inverse associations between masculine PSAI scores and estrone (E1) at values of E1 > 1340 pg/mL and E2 at values of E2 > 2870 pg/mL in girls. Further studies are needed to better understand the role of prenatal sex steroids on sexually dimorphic behavior.

Association of Routine Preoperative Frailty Assessment With 1-Year Postoperative Mortality

Patient frailty is a known risk factor for adverse outcomes following surgery, but data are limited regarding whether systemwide interventions related to frailty are associated with improved patient outcomes. To evaluate whether a frailty screening initiative (FSI) is associated with reduced late-term mortality after elective surgery. This quality improvement study with an interrupted time series analysis used data from a longitudinal cohort of patients in a multihospital, integrated health care system in the US. Beginning in July 2016, surgeons were incentivized to measure frailty with the Risk Analysis Index (RAI) for all patients considering elective surgery. Implementation of the BPA occurred in February 2018. The cutoff for data collection was May 31, 2019. Analyses were conducted between January and September 2022. The exposure of interest was an Epic Best Practice Alert (BPA) used to identify patients with frailty (RAI ≥42) and prompt surgeons to document a frailty-informed shared decision-making process and consider additional evaluation by a multidisciplinary presurgical care clinic or the primary care physician. The primary outcome was 365-day mortality after the elective surgical procedure. Secondary outcomes included 30-day and 180-day mortality as well as the proportion of patients referred for additional evaluation based on documented frailty. A total of 50 463 patients with at least 1 year of postsurgical follow-up (22 722 before intervention implementation and 27 741 after) were included (mean [SD] age, 56.7 [16.0] y; 57.6% women). Demographic characteristics, RAI score, and operative case mix, as defined by Operative Stress Score, were similar between time periods. After BPA implementation, the proportion of frail patients referred to a primary care physician and presurgical care clinic increased significantly (9.8% vs 24.6% and 1.3% vs 11.4%, respectively; both P < .001). Multivariable regression analysis demonstrated an 18% reduction in the odds of 1-year mortality (0.82; 95% CI, 0.72-0.92; P < .001). Interrupted time series models demonstrated a significant slope change in the rate of 365-day mortality from 0.12% in the preintervention period to -0.04% in the postintervention period. Among patients triggering the BPA, estimated 1-year mortality changed by -4.2% (95% CI, -6.0% to -2.4%). This quality improvement study found that implementation of an RAI-based FSI was associated with increased referrals of frail patients for enhanced presurgical evaluation. These referrals translated to a survival advantage among frail patients of similar magnitude to those observed in a Veterans Affairs health care setting, providing further evidence for both the effectiveness and generalizability of FSIs incorporating the RAI.

Functional Evaluation of Microcirculation in Response to Fluid Resuscitation in Hypovolemic Adult Post-cardiac Surgical Patients

Objectives: Microcirculation is bound to be altered during cardiac surgery due to multiple factors, mainly the intense systemic inflammatory response syndrome which peaks in the first 24-h postoperatively. Decreased microvascular flow associated with increased postoperative morbidity has been reported. The literature suggests a potential independence of macrocirculation and microcirculation during fluid loading. The present study was conducted to assess thenar muscle tissue oxygen saturation (StO2) changes during vascular occlusion test (VOT) in response to hypovolemia and to assess the dynamic responses of the StO2 variables post-volume expansion (VE). Material and Methods: Thirty-five adult post-cardiac surgical patients, with stroke volume (SV) variation &gt;12% were included in the study. Fifty-two fluid challenges were studied. Functional evaluation of microcirculation using VOT and near infrared spectroscopy (NIRS) variables along with monitoring of macrocirculatory indices was performed before and after VE. Statistical analysis was done using Student t-test. Results: Post-VE, 34 were responders with increase in SV ≥15% and 18 were non-responders (SV &lt;15%). Rate of resaturation was significantly faster in responders compared to non-responders after VE (P = 0.0293 vs. P = 0.1480). However, macrocirculatory indices including cardiac output, SV, and delivery of oxygen showed significant improvement in both responders and non-responders. Conclusion: Preload dependence is associated with significant change in the StO2 recovery slope measured at the thenar eminence in volume responders. Functional evaluation of microcirculation using VOT and StO2 can be a useful complimentary tool along with the macrocirculatory indices for optimal fluid rescuscitaion in adult post-cardiac surgical patients.

REOPENING UNDER COVID-19: THE IMPACT OF REOPENING SOCIETY ON OLDER ASIAN AMERICAN’S DEPRESSIVE SYMPTOMS

Abstract Background The lockdown due to COVID-19 has influenced individuals’ lives in many aspects. Yet, the impact of reopening under an ongoing pandemic is understudied. This study aims to investigate the impact of reopening policy on older Asian Americans’ depressive symptoms and whether the impact varies by their sociodemographic characteristics.Method: We used interview data collected from 519 Chinese and Korean aged 60 and older in New York City between 5/23/2021 to 7/30/2021. Interrupted time series model was used to test whether there are significant level and slope changes in depressive symptoms (PHQ-9 scale) before and after the reopening on 7/1/2021 in NYC. We then ran the models in stratified sample by gender, education, income, self-reported health, and social connectedness through living arrangements, use of technology, and social interactions. Results Older Asians’ depression increased immediately following the reopening (ß=1.52, p&amp;lt; 0.05), and then slowly decreased then after (ß=-0.12, p&amp;lt; 0.001). A decrease in depression following reopening was significantly associated with the male gender, good health, higher income, living alone, having received or provided social support, daily texting, and no engagement in the discussions related to COVID-19 in social media. Discussions: While reopening may have long-term benefits on mental health, older Asians were anxious about their safety at the beginning of reopening under an ongoing pandemic. Older adults with worse health, lower SES, and limited social connectedness struggled to adjust to “back-to-normal” life. We discussed research, policy, and practice implications to support these disadvantaged older adults after reopening.

Quench detection and early warning based on thermoelastic strain rate for HTS tapes thermally triggered by heat spots

The rapid detection and comprehensive monitoring of quench onset and evolution in high-temperature superconducting (HTS) materials remains immensely challenging because the normal zone propagation velocity in HTS materials is two or three orders of magnitude less than that in low-temperature superconductors. In this study, we experimentally and numerically explore quench events triggered by heat spots in yttrium barium copper oxide HTS tapes to characterize the quench onset and propagation. A multiplexed fiber Bragg grating sensor with multiple gratings was used to perform highly accurate strain measurements. Conventional voltage and temperature measurements were performed synchronously on the HTS tapes. A systematic comparison of these multifield signals during quench onset and development illustrated that the evolution of thermoelastic strain and strain-rate in HTS tapes captures the quench onset and propagation. A distinct feature was exhibited during the quenching of a pre-tensioned HTS tape: the thermoelastic strain initially relaxed but subsequently increased until the strain rate exhibited a significant slope change, which corresponded to the quench onset time. The thermoelastic strain in a nearly unconstrained HTS tape gradually increased until quenching occurred. A prominent characteristic for detecting quench onset in HTS materials have been revealed based on the change in the slope of the thermoelastic strain-rate or the second derivative of the strain remaining nearly constant. For a pre-tensioned HTS tape, the minimization of the thermoelastic strain or the strain-rate becoming zero may be a predictor that preceded the quench by ∼1–2 s, which can be, to a certain extent, regarded as an early warning. Another important and novel result was the experimental demonstration of global strain responses distant from the quench location in the pre-tensioned HTS tape, while the temperature and voltage detection are commonly localized methods. The mechanism behind these thermoelastic strain characteristics was further discussed and simulated from the induced Joule heating throughout the quench event. The measurements and numerical predictions suggested a new paradigm of quench detection based on the thermoelastic strain-rate in HTS materials.