Time Of Visit Research Articles

Anxiety, depression, and headache-related disability in a large pediatric clinic-based sample.

To explore the relationships among anxiety, depression, and headache-related disability in a pediatric clinic-based retrospective cross-sectional study. Anxiety and depression are commonly considered comorbidities of headache disorders and are frequently seen in children and adolescents. These conditions can contribute to disability and may have a cumulative impact. In this study, we tested whether self-reported anxiety and/or depression in youth were associated with headache-related disability. This was a retrospective cross-sectional study of children ages 6-17 years old who completed a headache intake questionnaire at the time of a new outpatient neurology visit. Those who reported on behavioral health symptoms, involvement of a behavioral health provider (i.e., yes/no), and the PedMIDAS (a validated metric of headache-related disability) were included. The relationship between anxiety and/or depression and headache-related disability was examined. Of the 12,660 questionnaires queried, 9118 met criteria for inclusion. Respondents were 64.0% female and had a median age of 13.5 years (interquartile range [IQR] 10.3, 15.7). Compared to patients without self-reported anxiety/depression, patients with anxiety and depression reported higher headache-related disability (M = 17.0, [IQR 6.0, 41.0]) even after accounting for covariates (estimated difference = 6.0, 95% confidence interval [CI: 4.4-7.5]). For participants with anxiety and/or depression, having a behavioral health provider was associated with greater headache-related disability (estimated difference = 7.0; 95% CI 4.6-9.3). Patients with self-reported anxiety and/or depression reported higher headache-related disability. Having a behavioral health provider was associated with greater headache-related disability, indicating the complexity and high level of need for this population. Further research is needed to understand the directionality of these results; however, patients with headache as well as depression and or anxiety are a vulnerable group who may benefit from an integrated care model.

Cost analysis of adding hypertension and diabetes management into routine HIV care in Mbarara and Ibanda districts, Uganda.

In 2016, Uganda introduced services for hypertension and diabetes in selected HIV clinics. We evaluated the costs associated with scaling up these services in HIV clinics in Mbarara and Ibanda districts, Uganda. We estimated the annual costs of providing hypertension and diabetes services using an activity-based costing approach from the health system perspective in ten randomly selected HIV clinics in Mbarara and Ibanda districts. Cost inputs included 2023 data on costs of medications, health provider time, salaries, training costs, and monitoring costs. We determined the average annual cost and medication costs for hypertension and diabetes treatment per enrolled adult patient, stratified by type of health facility. The total annual cost of hypertension and diabetes management services in ten selected HIV clinics was estimated to be $413,850 (range: $8,386 - 186,973). The annual average clinic-level cost per enrolled patient was estimated at $14 (range: $7 - 31). Of the total annual cost, the cost of provider time for initial and follow-up visits represented the largest cost component in 5/10 clinics (mean: 37%, range [13-58%]). In 4/10 clinics, the major cost components were the costs of medication, diagnostic tests, and related supplies (mean: 37%, range [10-75%]). The average cost per enrolled adult patient was $11 at public facilities and $21 in private not-for-profit facilities. The average medication cost per patient for hypertension was $24 (range: $7 - 97) annually; $13 at public facilities and $50 at private not-for-profit facilities. For diabetes treatment, the average annual medication cost per patient was estimated at $14 (range: $6 - 35); $11 at public facilities and $22 at private not-for-profit facilities. Adding hypertension and diabetes management to routine HIV care might be feasible based on the estimated annual cost per patient. Hypertension and diabetes treatment was more costly in private not-for-profit facility-based clinics than at public facilities. This variation was primarily driven by higher medication procurement prices at private facilities, revealing a potential area for optimizing costs through improved procurement practices.

Association Between Follow-Up Visit Timing After A Concussion and Subsequent Care Seeking in Children and Youth: A Population-Based Study in British Columbia.

To assess the relationship between follow-up visit timing and occurrence of the first subsequent health care seeking visit. The province of British Columbia, Canada. A total of 21029 children and youth who were diagnosed with an initial concussion from January 1, 2016, to December 31, 2017. These data were obtained from Population Data BC. A retrospective, descriptive correlational study. Follow-up timing was measured categorically as timely (4weeks), delayed (1-3months), or no follow-up; the occurrence of a subsequent health care visit beyond 3months postinjury was measured up to 12months at 3-month intervals (ie, 4-6, 7-9, and 10-12months). These variables were measured using diagnostic codes for concussion, post-concussion syndrome, and the 17 concussion symptoms. After controlling for sociodemographic characteristics, having a delayed follow-up, relative to timely follow-up, was associated with higher odds of a subsequent health care seeking visit at 4 to 6months (odds ratio [OR]=2.68; confidence interval [CI], 2.08-3.47), 7 to 9months (OR=1.71; CI, 1.21-2.40), and 10 to 12months (OR=1.67; CI, 1.13-2.48). In contrast to having a delayed follow-up, having no follow-up, relative to timely follow-up, was associated with not having a subsequent health care seeking visit at 4 to 6months (OR=0.57; CI, 0.48-0.67) and 7 to 9months (OR=0.79; CI, 0.66-0.96), respectively. Follow-up visit timing after a concussion in children and youth is associated with subsequent health care seeking. Greater efforts are needed to investigate the importance of initial follow-up visit timing, as they may play an integral role in injury prevention and symptom management following injury.

A qualitative study about the public's perception of primary care providers.

With the growth of physician associates/assistants (PAs) and NPs providing primary care services, we sought to understand the public's perception of the different types of healthcare providers (HCPs) they might encounter in a clinical setting, such as primary care. This study aimed to evaluate public perceptions about various types of primary care providers (PCPs), identify public preferences for PCPs in relation to experience and training, and examine public preferences for PCP credentials. We conducted semistructured interviews with adults, and used inductive and deductive coding and reflexive thematic analysis to analyze the data. We reached thematic saturation after 12 completed interviews. Participants reported confusion about the types of HCPs they might encounter in a primary care setting (for example, physician, PA, NP). Participants who reported a preference for a physician valued more years in training and their role in the hierarchy of medicine; those who reported a preference for a PA or NP indicated that compassion, patience, and longer clinic visit times were most important to them. Previous reports suggested that the public might be confused by the different types of HCPs they might encounter during a primary care visit. Participants identified specific characteristics that are important when they are choosing their PCP. A direct, coordinated marketing campaign may be needed to educate the public and reduce confusion about different types of PCPs, how they contribute to safe and high-quality care, and ensure preference-concordant care.

Comparative Analysis of Factors Influencing Optimal and Timely Antenatal Care Uptake in Kenya, South Africa, and Nigeria: A Cross-Section Study

Background Adequate antenatal care (ANC) visits and early timing are crucial for maternal and foetal health. However, many pregnant women in Kenya, South Africa, and Nigeria delay ANC initiation and fail to meet recommended visit numbers. This study aimed to identify factors associated with timely ANC initiation and achieving optimal number of ANC visits in these countries. Methods A cross-sectional analysis with data from the most recent Demographic Health Survey (DHS) datasets for Kenya (2022), Nigeria (2018) and South Africa (2016) were used. The study included 35,219 women aged 15–49 who had given birth within the previous two years. The women's sociodemographic and maternal health care-seeking characteristics were summarised using descriptive statistics. Multiple logistic regression was used to identify associations between explanatory variables, the timing of the first ANC visit, and the frequency of ANC visits. Results Optimal ANC visits (≥4 visits) were 67.2% in Kenya, South Africa (75.5%), and Nigeria (56.9%). Early timing of first ANC visits (≤3 months) was 30.2% in Kenya, 47.3% in South Africa and 18.3% in Nigeria. Factors associated with adequate ANC visits were maternal age, wealth status, and caesarean section, while parity and household size reduced the odds of optimal ANC visits. Maternal age, caesarean section, wealth status, and others were associated with increased odds of early timing of ANC visits. Parity, male-headed households, employed women and women who had a challenge with treatment costs had reduced the odds of timely ANC uptake. Conclusion More than half of the participants had optimal ANC visits, while less than half initiated ANC early. Tailored interventions addressing specific social, cultural, and economic contexts are crucial to improving early ANC visits and the frequency of ANC visits. Mixed methods research could provide in-depth insights into barriers and facilitators of ANC uptake, informing the design of targeted interventions.

Prediction of the outcome of intracerebral hemorrhage by blood neutrophil to lymphocyte ratio: a prospective observational study.

Intracerebral haemorrhage (ICH) is defined as bleeding within the brain parenchyma. Neutrophil lymphocyte ratio (NLR) is a dynamic parameter that can be affected by an underlying condition like microangiopathy (e.g. hemorrhagic stroke). The NLR value at the time of stress (e.g. ICH) could be a predictor among various other factors on the outcome of the disease. The aim of this study is to see if NLR could be a predictor of the outcome of the ICH. This is a prospective observational study conducted in the Department of Neurosurgery and Department of Neurology, from March 2020 to February 2021. The ICH cases presented to the emergency department within 24h of symptoms were included. The baseline haematological and biochemical investigations were sent and the noncontrast computed tomography (NCCT) head was done for the diagnosis of ICH. The NLR was measured. The ICH volume was calculated by ABC/2. Follow-up of the patient to measure outcome was done with a modified Rankin scale (mRS) on 30 days. Student's t-test was used to correlate NLR-mRS. Fischer's exact test was used for a categorical association of NLR to mRS. A total of 89 patients with ICH were enrolled in this study. In this study, 62.92% of patients had good outcomes (NLR of 4.88±3.06), whereas 37.08% of patients had bad outcomes (NLR of 9.09± 4.92). Statistically, higher NLR was significantly predictive of poorer outcomes. ICH causes stress in the body, which alters the value of NLR. Components of NLR are altered after haemorrhage due to a change in homeostasis of brain parenchyma. The NLR value obtained at the time of emergency department visits may help to predict the 30 days outcome of ICH.

Jaguar at the Edge: movement patterns in human-altered landscapes

Human-caused habitat loss and fragmentation have significantly impacted the natural environments of large carnivores, altering their movement patterns and increasing risks such as hunting and road collisions. This study aims to understand the movement of jaguars (Panthera onca) through forests, agriculture of varying patch sizes, their distances to these structures, and roads and drainages. By analyzing movement speed, revisits, time spent inside these structures, and the timing of the last visit, data from 54 GPS-tagged jaguars in South America reveal a pronounced tendency to revisit the edges of these landscape variables. Additionally, jaguars showed a stronger affinity for natural areas, spending more time in large forest patches and reducing their speed in natural drainages. Areas with extensive agriculture had fewer revisits, and jaguars moved faster near roads. These results demonstrate the level of tolerance and the dangers this species faces in a landscape with anthropogenic aspects. This comprehensive assessment of movement patterns and landscape use provides valuable insights into how landscape structure influences habitat preference and mobility rates, which is crucial for future jaguar conservation and management strategies.

Gardasil at the time of abortion visit: A quality improvement initiative

Gardasil at the time of abortion visit: A quality improvement initiative

Deformational Plagiocephaly Multi-Group Outpatient Clinics Reduce Referral to Visit Times and Visit Length

ObjectiveDeformational plagiocephaly (DP) is a well-recognized condition, affecting up to 20% of all babies. Its prevalence lead centers worldwide to create multi-group clinics and incorporate technology to decrease repetitive counselling, save clinic hours and shorten waiting times.This paper describes the modalities incorporated in our craniofacial clinic since 2016 and their effect on our patient population. MethodsData were collected retrospectively between November 2016 and September 2022 and prospectively between April and May of 2024. This period was divided into eight bimesters constituting several different clinic modalities. Data included the number of patients, no-shows, referral to visit times (RVT), visit length (VL), satisfaction rates, and demographics of all patients visiting our clinic and those referred specifically for DP. ResultsA total of 1794 patients, reviewed retrospectively, were included, 202 were referred for DP. Mean RVT was 38.5 days for all patients. For DP patients, mean RVTs were (according to bimesters): 107 days (older triage system), 59 days (newer system, new monthly craniofacial clinic, additional clinic slots), 58 days (cranial orthosis program, first multi-group clinic), 52 days (online lecture), 35 days (end of Covid lockdown), 43 days (pre-recorded presentations), and 47 days (multi-group encounters). RVT decreased to 17 days in the prospective bimester, during which another 117 DP patients were seen. Mean VL averaged 22 minutes for the first six bimesters and then decreased to 11 and 7 minutes during the seventh and eighth bimesters respectively. ConclusionMulti-group encounters for DP are highly effective in reducing RVTs and VL.

The impact of reduced pediatric emergency care hours on the patterns of emergency department utilization

Purpose: The declining recruitment rate of pediatric residents in Korea has led to a decrease in the number of emergency departments (EDs) offering a 24/7 pediatric emergency care (PEC). This study evaluated the impact of reduced PEC hours on the utilization patterns of a single ED.Methods: We reviewed medical records of pediatric patients who were defined as individuals aged 14 years or younger undergoing pediatricians’ practices in a tertiary hospital ED in Korea. Given the reduction of PEC hours from full-time to 08:00-24:00 on September 27, 2022, the patients were grouped as those who visited during March 27, 2022-September 26, 2022 (“control”), and those who visited during September 27, 2022-March 26, 2023 (“reduction”). The following variables were analyzed between the 2 periods: the number of patients, age, sex, visits via ambulances, severity by the Korean Triage and Acuity Scale with high acuity (a level 1-2 of the scale), disease-related visits, time of visit, ED length of stay (EDLOS), disposition, chief complaints, and diagnoses.Results: Among 3,577 pediatric patients, 1,315 visited the ED during the reduction period, down by 41.9% in numbers from the control period. From the control to reduction periods, we observed an increase in the median age (from 3.0 years [interquartile range, 1.0-7.0] to 4.0 years [1.0-8.0]; P = 0.005) and decreases in the median EDLOS (from 140.0 minutes [80.0-217.0] to 104.0 minutes [54.0-169.8]; P < 0.001) and proportion of hospitalization (from 22.1% to 12.6%; P < 0.001). No change was observed in the proportions of highacuity cases or chief complaints. We noted decreases in infection-related diagnoses during the reduction.Conclusion: Reducing PEC hours was associated with shorter EDLOS, fewer hospitalizations, and older age, with no difference in the severity. Even with reduced PEC hours, relevant resources should be redistributed to ensure the accessibility to PEC.

Multichannel Healthcare: Impact of Asynchronous Telemedicine Adoption on Patient Flow

Problem definition: This paper studies a multichannel healthcare system where physicians diagnose patients and prescribe treatment in-person or through asynchronous telemedicine (AT), a widely adopted yet relatively under-explored form of telemedicine. In collaboration with physicians at the Veterans Healthcare Administration (VHA), we examine the impact of introducing an AT channel on the existing in-person channel and on overall system performance. Methodology/results: VHA implemented AT at select clinics in the state of Georgia in 2012. Using a difference-in-differences design, we find that the introduction of the AT channel led to a sorting process whereby more complex patients were seen in the in-person channel. AT implementation led to a 20% increase in recommended visit time and an 8.5% increase in required clinical resources for in-person consultations. In addition, the adoption of AT resulted in higher throughput—more patients seen by the specialists per month across both channels. Using a fixed-effects model we find a reduction in average wait time for in-person referrals (37.5%), and for the most common medically necessary procedure (43%) despite an increase in the total number of consultations at the specialist clinic. We attribute the improved efficiency to early patient triage, better match between patient needs and treatment modality, and reduction of setup and switching costs in physicians’ workflow. Managerial implications: This paper contributes to our understanding of a rapidly expanding form of healthcare delivery: multichannel healthcare with in-person and AT channels. Our results suggest that healthcare managers and physicians can adopt AT to improve overall system efficiency. At the same time, they should take into account the additional impact of AT on the in-person channel when making capacity decisions and developing guidance on patient referrals. Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2022.0235 .

Regional inequalities in waiting times: analysis of orthopedic appointments in Slovenia

Abstract Background Long waiting times for healthcare services are a priority issue in the Slovenian healthcare system. Over the past decade the system for monitoring waiting times has evolved and is currently linked to the eReferral system, which allows detailed monitoring of data in particular related to secondary care services, such as outpatient specialist visits. Our aim was to explore the differences in waiting times between Slovenian regions in the case of first orthopedic outpatient visits in order to identify potential causes or contributing factors. Methods The analysis was based on the data from the waiting list database on 1 January 2024. The database includes information on region of residence of the patient and the region where the provider is located. Data were available on the number of persons on the waiting list and on the average expected waiting time for them. Waiting times relate to each of three urgency levels, which are indicated on the referral (very fast, fast and ordinary). Results Average expected waiting times for first orthopedic outpatient visits differed considerably among residents of different regions, ranging from 159 day to 265 days (60% more). The regional differences were even larger if only “very fast” and “ordinary” referrals were considered. The share of appointments in each urgency referral level also varied considerably, for example the share of patients with a “very fast” referral ranged between 15,7% and 37,6%, depending on the patient region of residence. The Pearson correlation coefficient between the region of residence of patients and the region where the provider is located was 0,78. Conclusions Waiting times and referral patterns for first orthopedic outpatient visits for patients from different regions vary considerably. Despite a free choice of provider and public data on expected waiting times, the differences correlate closely with the geographic distribution of providers. Key messages • Waiting times for outpatient visits in orthopedics differ by Slovenian region, despite free choice of provider. • The assessment of inequalities is made more difficult by varying share of different urgency levels of referrals.

Type 2 diabetes individuals have a shorter QRS duration, prolonged QTc interval, flatter T wave, and reduced left ventricular cycle volumes compared to matched controls in the UK Biobank

Abstract Background Type 2 diabetes is associated with an increased risk of heart failure even in the absence of overt coronary artery disease, though underlying mechanisms are unclear. ECG and cardiac magnetic resonance (CMR) imaging provide windows into subclinical changes in myocardial structure and function and could be exploited to understand this. Purpose We investigate differences in ECG and CMR biomarkers in a large cohort of participants with type 2 diabetes, compared to a matched control cohort. We hypothesise that individuals with diabetes may exhibit concurrent differences in biomarkers, reflecting underlying cardiac remodelling. Methods We carried out a pair-matched cross-sectional study to examine the association between type 2 diabetes and multi-modal cardiac biomarkers. The exposure cohort consists of 1,781 UK Biobank participants with an imaging and ECG visit, prevalent type 2 diabetes and no known cardiovascular events at the time of visit. The control cohort is matched on age, sex and body mass index (BMI), and consists of 1,781 participants without diabetes. ECG and CMR biomarkers derived from UK Biobank data were used as outcome variables. We built four multiple multivariate linear regression models, incrementally adjusted for socio-demographic, lifestyle, and clinical covariates. Results Both cohorts were mostly male (63.6%), had a median age of 67 years [IQR: 72-85] and a median BMI of 27.8 kg/m2 [24.6-31.0]. Individuals with type 2 diabetes were more likely to be non-white (7.9% vs 2.7%, p<0.001), current or previous smokers (43.6% vs 40.6%, p=0.04), have lower diastolic blood pressure (79 [72-85] vs 81 [74-88] mmHg, p<0.001), and take cholesterol medication (72.3% vs 27.2%, p<0.001); anti-hypertensives (56.3% vs 27.3%, p<0.001); insulin (13.7% vs 0.1%, p<0.001); and metformin (53.1% vs 0.1%, p<0.001). They had a higher ventricular rate, shorter QRS duration, longer QTc interval, and flatter T wave amplitude, as well as lower left ventricular end-diastolic and end-systolic volumes, among other differences (Table 1). Covariates including cholesterol medication, metformin, and HbA1c were excluded as they were strongly correlated with diabetes, age and/or sex (Pearson correlation coefficient >0.3 or <-0.3). After full adjustment, we found that the exposure variable, diabetes, had a statistically significant association with ventricular rate, QRS duration, T wave offset, T wave amplitude in lead V3, left ventricular stroke volume and global average thickness (p<0.05) (Table 2). Conclusion Our results reveal that individuals with type 2 diabetes exhibit a shorter QRS, longer QTc, and lower end-diastolic and end-systolic volumes, compared to matched controls. This may be indicative of subclinical cardiac abnormalities, both electrophysiological and mechanical. Our association analysis suggests that other factors correlated with diabetes may be also responsible for certain biomarker differences and their underlying causes.

Hypertensive myocardial disease screening in low-income settings using smartphone-based technologies: a prospective multicenter trial

Abstract Background Mobile health technologies are revolutionizing cardiovascular (CV) medicine. However, more than 80% of heart disease related deaths occur in low-income settings, that are unable to take advantage of such technologies for healthcare awareness and prevention. Purpose To assess the feasibility of a pilot telemedicine-based CV screening campaign with D-Heart, a validated low-cost 8-lead smartphone portable ECG, coupled with blood-pressure (BP) monitoring in three regions of Africa. Methods A total of 950 patients (60%) men, age 29±21) were enrolled at 5 African rural dispensaries, 2 in Kenya, 2 in Senegal and at a hospital (Uganda). ECGs recording were obtained by community health workers with D- Heart smartphone ECG; BP was measured with a validated smartphone BP recorder. Global burden of ECG abnormalities was defined by a semi-quantitative score based on the sum of 9 criteria, identifying four classes of increasing severity. ECGs that were moderately and severely abnormal and from patients with severe hypertension, were sent for consultation via smartphone to D-Heart tele-cardiology centre: an advice on how to manage the patient was sent back to the community health worker’s smartphone within 15 minutes. If referral was needed, patients were sent to the local hospital. Results Mean BMI was 26.2 ± 8.5 (men 22.3±1.5 vs women 27.2±1.1, p<0.01). Active/recent history of smoking and alcohol intake were 327 (45%, 298 men) and 232/590 (40%, 198 men) respectively. A total of 142 (15%) patients had been previously diagnosed with diabetes, 199(25%) had known hypertension of whom 95/199 on treatment), whereas 43(4%) had a previous myocardial infarction. A total of 487 (51%) patients never had their blood pressure measured, whereas 798(91%) never received an ECG. Mean SBP/DBP were 138±31/71±12 mmHg respectively. Patients with normal BP were 304(32%), whereas 380(40%) were mildly-moderately hypertensive (SBP/DBP 148±7/91±5 mmHg) and 130 (29%) with severe hypertension (SBP/DBP 162±8/99±6 mmHg). D-Heart ECGs tracings were respectively classified as: normal: 361(38%); mildly abnormal: 332(35%); moderately abnormal: 199 (21%) and severely abnormal 58(6%). Most common ECG abnormality was a positive Romhilt-Estes index in 361, 38%. For 174(18%) patients smartphone tele-report advised referral to the local hospital, but only 121 69%) presented to the visit: 9 (8%) were found to have normal hearts, 57(47%) with hypertensive heart disease, 35 (29%) with rheumatic heart disease, 20 (16%) with HFrEF. Visit time was 8±2 minutes; cost of screening per patient was 1.10€: 0,30€ for consumable electrodes, 0.80€ for the community health worker visit time. Conclusions D-Heart ECG screening combined with smartphone BP measurement proved feasible and cost-effective. This should encourage to develop and extend low-cost/high-technology community-based CV screening programs in low-income settings.

A large-scale retrospective study in China explores risk factors for disease severity in plaque psoriasis

Severe psoriasis has a long course and poor outcome, and it has long been a problem for patients. Understanding the independent risk factors that contribute to patients with severe psoriasis is critical for the development of effective treatment strategies. This large, multicenter study recruited 2,109 plaque psoriasis patients from 12 hospitals across China (October 31, 2019 – May 31, 2022). The logistic regression model underwent internal validation and external validation using two independent cohorts over future time periods (June 1, 2022 – January 31, 2023). The discriminative power of our model was substantiated by a C-index of 0.863 (95% CI: 0.848–0.879) in internal validation, further affirmed through 1,000 bootstrap validation (C-index: 0.860, 95% CI: 0.836–0.885) and external validation cohorts, where the C-index reached up to 0.910 (95% CI: 0.868–0.953) and 0.951 (95% CI: 0.924–0.977) in 2 external validation cohorts. To enhance accessibility for clinicians, the model has been made available as a dynamic nomogram and QR code. Our study identified 10 risk factors (the “DELPHI” consensus dichotomy, the DLQI index, the extent of skin involvement as measured by body surface area, the age of the patient at the time of clinical visit, sex, body weight in kilograms, career, the presence of scalp involvement, facial involvement, and arthropathy) for the overall severity of psoriasis (PASI ≥ 10). “Nomogram-10” provides clinicians with a practical tool to develop personalized intervention strategies based on an individual’s risk profile.Trial registration: Chinese Clinical Trial Registry: ChiCTR1900024852.

HIV DNA Levels in Persons Who Acquired HIV in the Setting of Long-Acting Cabotegravir for HIV Prevention: Analysis of Cases from HPTN 083 and 084.

We evaluated HIV DNA levels in individuals who received long-acting cabotegravir (CAB-LA) or tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) pre-exposure prophylaxis in the HPTN 083 and 084 trials and had HIV DNA testing performed to help determine HIV status. HIV DNA testing was performed using peripheral blood mononuclear cell (PBMC) samples collected after a reactive HIV test was obtained at a study site. DNA was quantified using droplet digital PCR (lower limit of detection [LLOD]: 4.09 copies/million PBMCs). Final HIV status and the timing of the first HIV-positive visit were determined by an independent adjudication committee based on HIV test results from real-time site testing and retrospective testing at a centralized laboratory. HIV DNA testing was performed for 133 participants [21 HIV-positive (7 CAB-LA arm, 14 TDF/FTC arm) and 112 HIV-negative; 1-6 tests/person]. For persons with HIV, the time between the first HIV-positive visit and collection of the first sample for DNA testing was a median of 81 days for those receiving CAB-LA (range 41-246) and 11 days for those receiving TDF/FTC (range 3-127). Four (57.1%) of the seven CAB-LA cases with infection had a low initial DNA result [three detected <LLOD; one near the LLOD (4.2 copies/106 PBMCs); in 2/4 cases, the DNA level was still <10 copies/106 PBMCs ≥40 weeks after the first HIV-positive visit. In contrast, only 3/14 (21.4%) of the TDF/FTC cases had a low or negative initial DNA test result (one not detected; two <10 copies/106 PBMCs). In this study, the time between the first HIV-positive visit and the first DNA test was longer in the CAB-LA cases than the TDF/FTC cases. Despite this difference, low or undetectable DNA levels were more frequently observed in the CAB-LA cases. This suggests that CAB-LA exposure may limit seeding of the HIV reservoir in early infection.

Shared parameter modeling of longitudinal data allowing for possibly informative visiting process and terminal event.

Joint modeling of longitudinal and time-to-event data, particularly through shared parameter models (SPMs), is a common approach for handling longitudinal marker data with an informative terminal event. A critical but often neglected assumption in this context is that the visiting/observation process is noninformative, depending solely on past marker values and visit times. When this assumption fails, the visiting process becomes informative, resulting potentially to biased SPM estimates. Existing methods generally rely on a conditional independence assumption, positing that the marker model, visiting process, and time-to-event model are independent given shared or correlated random effects. Moreover, they are typically built on an intensity-based visiting process using calendar time. This study introduces a unified approach for jointly modeling a normally distributed marker, the visiting process, and time-to-event data in the form of competing risks. Our model conditions on the history of observed marker values, prior visit times, the marker's random effects, and possibly a frailty term independent of the random effects. While our approach aligns with the shared-parameter framework, it does not presume conditional independence between the processes. Additionally, the visiting process can be defined on either a gap time scale, via proportional hazard models, or a calendar time scale, via proportional intensity models. Through extensive simulation studies, we assess the performance of our proposed methodology. We demonstrate that disregarding an informative visiting process can yield significantly biased marker estimates. However, misspecification of the visiting process can also lead to biased estimates. The gap time formulation exhibits greater robustness compared to the intensity-based model when the visiting process is misspecified. In general, enriching the visiting process with prior visit history enhances performance. We further apply our methodology to real longitudinal data from HIV, where visit frequency varies substantially among individuals.

Challenging Case: Family Navigation for Autism Spectrum Disorder.

Leo is a 28-month-old boy from a monolingual Spanish-speaking family who was referred to a developmental-behavioral pediatrics (DBP) clinic for concerns regarding autism. His parents migrated to the United States 8 years ago and currently live and work on a farm. He was born in a US hospital after an uncomplicated pregnancy and has been generally healthy. His parents first became concerned about his development when he was 16 months old. He stopped saying mama/dada in Spanish and started lining up random objects. He had frequent temper tantrums and was difficult to console during unexpected changes in his routine. He screened positive on the Modified Checklist for Autism in Toddlers,Revised with Follow-Up (M-CHAT-R/F) at his 18-month well-child visit, and his pediatrician referred him to the local early intervention program. Calls from the early intervention program to his parents were unanswered. At his 24-month well-child visit, he again screened positive on the M-CHAT-R/F, and his pediatrician placed a referral for a DBP consultation. During the DBP visit at 28 months of age, developmental testing indicated his receptive and expressive language skills to be in the extremely low range, with significant scatter in his cognitive and adaptive skills. Behavioral observations were consistent with parental history and showed differences in social communication and interaction, the presence of repetitive behaviors, and extreme distress with transitions. He was diagnosed with autism spectrum disorder. Recommendations, including referral to early intervention, applied behavior analysis therapy, speech and language therapy, audiology evaluation, and genetic testing, were discussed with his parents through an interpreter. An autism packet, written in Spanish, with detailed information about autism and community resources was given to the family. By the time of a follow-up DBP visit 6 months later, Leo had not started on any early intervention or therapeutic services. Where do you go from here?

Statistical Analysis of Telehealth Use and Pre- and Postpandemic Insurance Coverage in Selected Health Care Specialties in a Large Health Care System in Arkansas: Comparative Cross-Sectional Study.

The COVID-19 pandemic triggered policy changes in 2020 that allowed insurance companies to reimburse telehealth services, leading to increased telehealth use, especially in rural and underserved areas. However, with many emergency rules ending in 2022, patients and health care providers face potential challenges in accessing these services. This study analyzed telehealth use across specialties in Arkansas before and after the pandemic (2017-2022) using data from electronic medical records from the University of Arkansas for Medical Sciences Medical Center. We explored trends in insurance coverage for telehealth visits and developed metrics to compare the performance of telehealth versus in-person visits across various specialties. The results inform insurance coverage decisions for telehealth services. We used pre- and postpandemic data to determine the impacts of the COVID-19 pandemic and changes in reimbursement policies on telehealth visits. We proposed a framework to calculate 3 appointment metrics: indirect waiting time, direct waiting time, and appointment length. Statistical analysis tools were used to compare the performance of telehealth and in-person visits across the following specialties: obstetrics and gynecology, psychiatry, family medicine, gerontology, internal medicine, neurology, and neurosurgery. We used data from approximately 4 million in-person visits and 300,000 telehealth visits collected from 2017 to 2022. Our analysis revealed a statistically significant increase in telehealth visits across all specialties (P<.001), showing an 89% increase from 51,589 visits in 2019 to 97,461 visits in 2020, followed by a 21% increase to 117,730 visits in 2021. Around 92.57% (134,221/145,001) of telehealth patients from 2020 to 2022 were covered by Medicare, Blue Cross and Blue Shield, commercial and managed care, Medicaid, and Medicare Managed Care. In-person visits covered by Medicare and Medicaid decreased by 15%, from 313,196 in 2019 to 264,696 in 2022. During 2020 to 2022, about 22.84% (33,123/145,001) of total telehealth visits during this period were covered by Medicare and 53.58% (86,317/161,092) were in psychiatry, obstetrics and gynecology, and family medicine. We noticed a statistically significant decrease (P<.001) in the average indirect waiting time for telehealth visits, from 48.4 to 27.7 days, and a statistically significant reduction in appointment length, from 93.2 minutes in 2020 to 39.59 minutes in 2022. The indirect waiting time for psychiatry telehealth visits was almost 50% shorter than that for in-person visits. These findings highlight the potential benefits of telehealth in providing access to health care, particularly for patients needing psychiatric care. Reverting to prepandemic regulations could negatively affect Arkansas, where many live in underserved areas. Our analysis shows that telehealth use remained stable beyond 2020, with psychiatry visits continuing to grow. These findings may guide insurance and policy decisions in Arkansas and other regions facing similar access challenges.

Insights into artificial waterhole utilization patterns by elephants and rhinos: Lessons from a South African Nature Reserve.

Artificial water provisioning is a common practice in southern African nature reserves, where different game species exhibit preferences for specific waterhole types. The movement patterns and behaviour of elephants and rhinos are closely linked to water availability, with these mega-herbivores noticeably influencing the environment and other species they interact with at waterholes. Since there is limited research on this topic, understanding preferences for different types of artificial waterholes is crucial, particularly during periods of water scarcity. This knowledge enables reserve managers to effectively manage the numbers and types of waterholes. In this study, we investigate artificial waterhole selection and preferences by elephants and rhinos in the Olifants West Nature Reserve, South Africa. The study area featured various waterhole types, including earth dams, concrete pans, reservoirs, and troughs. By employing camera traps, we analysed visitation frequency, timing of visits, and factors influencing visit frequency. Our findings revealed distinct preferences for specific waterhole types among different social groupings of the study species. Breeding herds of elephants predominantly utilized reservoirs and occasionally visited troughs, while bachelor herds favoured earth dams. Black rhinos showed a preference for earth dams, whereas white rhinos selected troughs and earth dams, with bachelor groups favouring troughs and female rhinos favouring earth dams. The outcomes of this study have significant implications for the development of comprehensive conservation plans in areas where these species reside, and for potential release sites.