Treatable trait guided asthma management: A feasibility study

Introduction/Aim: Treatable traits based personalised medicine has been shown to improve outcomes in severe asthma clinic. We assessed the feasibility of a randomised controlled trial of protocolised 'focused' and 'extended' treatable trait guided asthma management in patients not under a severe asthma clinic. Method(s): Ten week single-group cohort study. Participants had a doctor's diagnosis of asthma, asthma control questionnaire (ACQ) score >1, and a history of exacerbation in the last year. Patients already under the care of a severe asthma clinic or receiving high-dose inhaled corticosteroids, biological therapy or maintenance oral corticosteroids were excluded. Intervention(s): asthma medication according to application of a 'focused' treatable trait algorithm, targeting type-2 inflammation and airflow obstruction. Feasibility outcomes: recruitment rates, acceptability of intervention, willingness to enrol in a full RCT, need for 'extended' trait assessment after 10 weeks, and estimation of trait prevalence. Result(s): Recruitment ceased after 14 months with 30/50 participants due to difficulties associated with COVID-19. 92% found the intervention acceptable and were willing to be randomised in a future study. 65% remained not well-controlled with an ACQ >1 after 10 weeks and would have required the 'extended' algorithm. Participants had a mean (SD) 4.8(2.3) of 13 traits assessed. Participation in the study was associated with clinically important improvements in ACQ, -1.0 (1.5) units;St George Respiratory Questionnaire, -15.1 (14.7) units;Asthma Quality of Life Questionnaire, +1.0 (1.1) units;and FEV1, +0.4 (0.4) L. Post-bronchodilator airflow obstruction reduced from 60% of participants at study commencement to 35%. 53% of participants were allocated continuous oral corticosteroids at some point during the study. Conclusion(s): Protocolised treatable trait management was acceptable, associated with significant clinical benefit and a full trial appears feasible. Targeting two traits was insufficient to control asthma in the majority of patients over the timeframe of this study, despite significant corticosteroid exposure.

The Inequality of COVID-19: Immediate Health Communication, Governance and Response in Four Indigenous Regions

The Inequality of COVID-19: Immediate Health Communication, Governance and Response in Four Indigenous Regions explores the use of information, communication technologies (ICTs) and longer-term guidelines, directives and general policy initiatives. The cases document implications of the failure of various governments to establish robust policies to mitigate the spread of COVID-19 in a sample of advanced and low-income countries. Because the global institutions charged with managing the COVID-19 crisis did not work in harmony, the results have been devastating. The four Indigenous communities selected were the Navajo of the southwest United States, Siddi people in India, Aboriginal and Torres Strait Islander peoples of Australia and the Maasai in East Africa. Although these are all diverse communities, spread across different continents, their base economic oppression and survival from colonial violence is a common denominator in hypothesizing the public health management outcomes. However, the research reveals that national leadership and other incoherent pandemic mitigation policies account for a significant amount of the devastation caused in these communities. © 2022 Elsevier Inc. All rights reserved.

The development of an entrepreneurial mindset at a HBCU during a pandemic

Over the years, African American leaders and entrepreneurs have been preaching the gospel of preparing students at Historical Black Colleges and Universities (HBCUs) to have an entrepreneurial mindset. The entrepreneurial mindset concept at an HBCU is at an early stage of development. As a result, the concept lacks rigorous theoretical foundations to adapt. The goal of this chapter is to introduce a conceptual change intelligence approach to explain the factors leading to the evolution of the way that an entrepreneurial mindset is developed in an HBCU. The conceptual change intelligence approach draws upon the Input-Process-Output (IPO) Model. In this chapter, the authors postulate that to develop an entrepreneurial mindset (output), the environment (process) in which the student (input) resides must be changed. This chapter is intended to highlight how an HBCU student environment can assist the students to develop an entrepreneurial mindset during COVID-19. © 2021, IGI Global.

Humira level 8 looking great: A quality improvement study on optimizing therapeutic drug monitoring for patients with IBD on treatment with adalimumab (Humira)

Background: Adalimumab (Humira) is an injectable monoclonal antibody that has been used to induce and sustain remission in moderate to severe inflammatory bowel disease (IBD). Recent studies show that proactive laboratory assessment of adalimumab level and a target trough level > 8 μg/mL is associated with improved clinical outcomes and reduced treatment failure. In this quality improvement (QI) study, we aimed to increase the percentage of IBD patients on adalimumab with a drug level > 8 μg/mL from 65% to 80%. Methods: This QI study included all patients with IBD who were prescribed adalimumab by a pediatric gastroenterologist at Cincinnati Children's Hospital Medical Center from October 2020 to May 2021. Our primary outcome measure was the percent of patients with a drug level > 8 μg/mL. Our secondary outcome measure was the number of patients in maintenance therapy with no drug level in the last year. Using a plan-do-study-act (PDSA) approach, interventions were implemented including tailored education for all gastroenterology staff regarding the recommended target adalimumab trough of > 8 μg/mL, personalized emails to providers of specific patients with sub-therapeutic drug levels, a best practice alert within the electronic medical record (EMR) notifying providers of low trough levels, and updating nursing EMR documentation sheets to include timing of labs. Outcome measures were reviewed bi-monthly and feedback was elicited from providers and nursing staff throughout the process. Results: An average of 184 patients were including in the primary outcome measure each month. There was an average of 3 patients initiating treatment with adalimumab each month. Our primary outcome was achieved in 68% of patients (Figure 1). The secondary outcome of those in maintenance therapy with no therapeutic drug level in the last year decreased from 31% to 23% over the study period. Of the failures in the last month, 33% of subjects had levels between 7-8 μg/mL and physician assessed quiescent disease. Conclusions: Quality improvement methodology was successful in improving adalimumab trough drug levels in patients with IBD. Effective interventions included an EMR best practice alert and personalized communication with providers regarding low drug levels. Barriers to further improvement included lower rates of labs obtained after telehealth encounters during the COVID pandemic. Future directions of the study include continued monitoring of levels with further interventions as warranted to achieve goal of 80%.Run Chart for the Primary Outcome Measure: Percent of Patients with an Adalimumab (Humira) Drug Level > 8 μg/mL.

Managing Burnout in a Prolonged Crisis: A 2-Wave Cross-Sectional Analysis of Emergency Department Personnel Over 6 Months of the COVID-19 Pandemic

Study Objective: Management research suggests that inclusive leaders, problem-solving teams and clear processes might matter for addressing uncertainty, but how these factors unfold during prolonged crisis and their relationship to burnout is not well understood. The study objective was to examine associations between teamwork and leadership factors and clinician burnout as the care burden increased over 8 months of the COVID-19 pandemic. Methods: Across two California hospitals, cross-sectional surveys were administered to emergency department (ED) personnel in July and December 2020 (N1 = 328 & N2 = 356). Overall burnout (“Overall, based on your definition of burnout, how would you rate your level of burnout?”) and worsening burnout during the crisis (“Compared to your level of burnout prior to COVID, to what extent is your current level of burnout worse, improved or the same?”) were measured on a 5-point Likert scale and analyzed as binary variables. Burnout was defined as having at least some burnout (ie, reporting at least “definitely” burning out). Worsening burnout was defined as either burnout that had “gotten much worse” or “gotten a little worse” since before the COVID-19 crisis. These outcomes were assessed in relation to joint problem-solving (JPS), clear process and leader inclusiveness using logistic regressions. Models controlled for age, sex, race, location, tenure and shift, as well as county COVID-19 case burden using open-access data from John Hopkins University’s Coronavirus Resource Center. Results: The sample across both waves consisted of 75 attendings (14.79%), 50 residents/fellows (9.89%), 38 advance practice providers (5.56%), 254 registered nurses (37.13%) and 90 other ED personnel (therapists, social workers, etc.) (13.16%). Burnout increased over time, where 32.22% reported burnout in wave 1 and 56.51% in wave 2. Worsening burnout also increased over time, 57.32% to 80.52% respectively. Clear process and leader inclusiveness were significantly associated with lower odds of burnout across both time points, 0.28 (p < 0.001) and 0.45 (p < 0.05) in wave 1 and 0.30 (p <0.01) and 0.35 (p < 0.01) in wave 2, respectively (Figure 1). Joint-problem solving was significantly associated with lower odds of burnout in wave 2 only, 0.60 (p-value < 0.01). All factors were significantly associated with lower odds of worsening burnout in wave 2 only, 0.45 (p < 0.01) for JPS, 0.29 (p < 0.01) for clear process and 0.37 (p < 0.05) for leader inclusiveness (Figure 1). Conclusions: During a prolonged crisis, communicating a clear process to ED personnel, and encouraging leaders to include staff in decisions may do more to reduce burnout early on. However, solving problems together and relying on staff interchangeably may continue to prevent burnout as time goes on and the burden of disease increases. When managing burnout among ED personnel, leaders should focus initially on providing structure, and then, reinforce strong teamwork to help their staff continue on. [Formula presented]

AI for Covid-19: Conduits for Public Health Surveillance

The spread of SARS-Covid-19 virus has impacted the world as it continues to raise questions on the long-term impacts. With the absence of historic/big data sets, digital public health surveillance measures are informed via modelling using real-time data, which is collected and validated by public health agencies;and also aggregated/merged with self/open reported data by the public, via mobile apps and social media channels. This chapter informs on such conduits (using two case studies: Australia and Canada) that enabled AI-based solutions for informing public health strategies. Blue tooth technology used in contact tracing apps seems to allay privacy concerns to an extent, in both countries. Real-time streamed data collection to train predictive models and combining AI methods with active learning seems to be the way forward. © 2021, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.