Virtual Group Appointments Improve Outcomes in Veterans with Heart Failure During a Global Pandemic: A Quality Improvement Project.

This report on a quality improvement initiative describes a multi-professional approach to improving self-care behaviors and reducing hospitalizations in Veterans with heart failure (HF) by implementing virtual group appointments. Patients with HF are more susceptible to complications related to COVID-19 infection, creating the need for alternative communication methods for patient education during the social isolation and reduced health-care resources brought on by the global pandemic. From March 2020 to June 2021, 57 Veterans participated in 1 of 12 group appointments at the VA Portland Health Care System in Portland, Oregon. Each group was led by a multi-professional team who provided education on self-care behaviors, nutrition, medications, and mental health impacts of HF. Chart reviews and pre-/post-self-care behavior questionnaires showed that the virtual group HF appointments were associated with a decrease in hospitalizations, compared to previous data with the same population, and self-reported self-care behaviors improved from pre- to post-questionnaire. Group appointments offer a unique educational and motivational experience for those with HF and provide the ability to engage with each other during challenging times.

TINF2 is a major susceptibility gene in Danish patients with multiple primary melanoma.

TINF2 encodes the TINF2 protein, which is a subunit in the shelterin complex critical for telomere regulation. Three recent studies have associated six truncating germline variants in TINF2 that have previously been associated with a cancer predisposition syndrome (CPS) caused by elongation of the telomeres. This has added TINF2 to the long telomere syndrome genes, together with other telomere maintenance genes such as ACD, POT1, TERF2IP, and TERT. We report a clinical study of 102 Danish patients with multiple primary melanoma (MPM) in which a germline truncating variant in TINF2 (p.(Arg265Ter)) was identified in four unrelated participants. The telomere lengths of three variant carriers were >90% percentile. In a routine diagnostic setting, the variant was identified in two more families, including an additional MPM patient and monozygotic twins with thyroid cancer and other cancer types. A total of 10 individuals from six independent families were confirmed carriers, all with cancer history, predominantly melanoma. Our findings suggest a major role of TINF2 in Danish patients with MPM. In addition to melanoma, other cancers in the six families include thyroid, renal, breast, and sarcoma, supporting a CPS in which melanoma, thyroid cancer, and sarcoma predominate. Further studies are needed to establish the full spectrum of associated cancer types and characterize lifetime cancer risk in carriers.

Metagenomic sequencing for detection and identification of the boxwood blight pathogen Calonectria pseudonaviculata.

Pathogen detection and identification are key elements in outbreak control of human, animal, and plant diseases. Since many fungal plant pathogens cause similar symptoms, are difficult to distinguish morphologically, and grow slowly in culture, culture-independent, sequence-based diagnostic methods are desirable. Whole genome metagenomic sequencing has emerged as a promising technique because it can potentially detect any pathogen without culturing and without the need for pathogen-specific probes. However, efficient DNA extraction protocols, computational tools, and sequence databases are required. Here we applied metagenomic sequencing with the Oxford Nanopore Technologies MinION to the detection of the fungus Calonectria pseudonaviculata, the causal agent of boxwood (Buxus spp.) blight disease. Two DNA extraction protocols, several DNA purification kits, and various computational tools were tested. All DNA extraction methods and purification kits provided sufficient quantity and quality of DNA. Several bioinformatics tools for taxonomic identification were found suitable to assign sequencing reads to the pathogen with an extremely low false positive rate. Over 9% of total reads were identified as C. pseudonaviculata in a severely diseased sample and identification at strain-level resolution was approached as the number of sequencing reads was increased. We discuss how metagenomic sequencing could be implemented in routine plant disease diagnostics.

Metagenomic Sequencing for Identification of Xylella fastidiosa from Leaf Samples.

Xylella fastidiosa (Xf) is a globally distributed plant-pathogenic bacterium. The primary control strategy for Xf diseases is eradicating infected plants; therefore, timely and accurate detection is necessary to prevent crop losses and further pathogen dispersal. Conventional Xf diagnostics primarily relies on quantitative PCR (qPCR) assays. However, these methods do not consider new or emerging variants due to pathogen genetic recombination and sensitivity limitations. We developed and tested a metagenomics pipeline using in-house short-read sequencing as a complementary approach for affordable, fast, and highly accurate Xf detection. We used metagenomics to identify Xf to the strain level in single- and mixed-infected plant samples at concentrations as low as 1 pg of bacterial DNA per gram of tissue. We also tested naturally infected samples from various plant species originating from Europe and the United States. We identified Xf subspecies in samples previously considered inconclusive with real-time PCR (quantification cycle [Cq], >35). Overall, we showed the versatility of the pipeline by using different plant hosts and DNA extraction methods. Our pipeline provides taxonomic and functional information for Xf diagnostics without extensive knowledge of the disease. This pipeline demonstrates that metagenomics can be used for early detection of Xf and incorporated as a tool to inform disease management strategies. IMPORTANCE Destructive Xylella fastidiosa (Xf) outbreaks in Europe highlight this pathogen's capacity to expand its host range and geographical distribution. The current disease diagnostic approaches are limited by a multiple-step process, biases to known sequences, and detection limits. We developed a low-cost, user-friendly metagenomic sequencing tool for Xf detection. In less than 3 days, we were able to identify Xf subspecies and strains in field-collected samples. Overall, our pipeline is a diagnostics tool that could be easily extended to other plant-pathogen interactions and implemented for emerging plant threat surveillance.

Factors contributing to incomplete excision of nonmelanoma skin cancer by Australian general practitioners.

OBJECTIVE: To study rates of incomplete excision of basal (BCC) and squamous (SCC) cell cancer by Australian general practitioners with a special interest. DESIGN: Records review. SETTING: A network of 15 primary care skin cancer clinics across Australia. PARTICIPANTS: Fifty-seven physicians performing excisions of 9417 BCCs and SCCs in a single network of 15 primary care skin cancer clinics across Australia between 2005 and 2007. MAIN OUTCOME MEASURES: Rates of incomplete excision according to physician, clinic, anatomic location of the lesion, and whether a previous biopsy had been performed. RESULTS: Four hundred forty-three of 6881 BCCs (6.4%) and 159 of 2536 SCCs (6.3%) were excised incompletely. Incomplete BCC and SCC excisions were more frequent on the head and neck (282 of 2872 excisions [9.8%] and 97 of 861 [11.3%], respectively) than elsewhere. Ears (74 of 388 excisions [19.1%]) and nose (78 of 546 [14.3%]) had the highest rates of incompletely excised BCCs, and ears (26 of 144 excisions [18.1%]) and forehead (20 of 157 [12.7%]) had the highest rates of incompletely excised SCCs. Of all BCC excisions, 67.3% were once-off excisions with no previous biopsy, and these excisions were more likely to be incomplete (odds ratio, 1.73; 95% confidence interval, 1.36-2.20) than those with a previous biopsy. There was, however, substantial variation in frequency of incomplete excision between clinics for BCC (ranging from 3.3% to 24.7%) and SCC (ranging from 0% to 17.2%) and between physicians within clinics (BCC ranging from 0% to 31.1%, and SCC ranging from 0% to 23.5%). CONCLUSIONS: Overall frequency of incomplete excision is low and similar to that in other reports. However, high frequency in high-risk sites, low rates of previous biopsy, and substantial variation in performance between physicians and clinics suggests there is significant opportunity to further improve health outcomes.

How good are skin cancer clinics at melanoma detection? Number needed to treat variability across a national clinic group in Australia.

BACKGROUND: The number needed to treat (NNT) is a key measure of the quality of melanoma diagnosis. There are few data on this measure from primary care skin cancer clinics in Australia. OBJECTIVE: We sought to report the NNT from a large pathology database and examine several patient characteristics. METHODS: We calculated NNT by doctor and clinic among 10,612 lesions, 6796 patients, 57 doctors, and 15 clinics from a pathology database. NNT was calculated with and without seborrheic keratoses. RESULTS: Overall NNT was 30 (with seborrheic keratoses) and 23 (without seborrheic keratoses). Excluding the 4 doctors with NNT greater than 60, total NNT decreased from 30 to 21 and from 23 to 15, respectively (with and without seborrheic keratoses). NNT was higher for female patients and younger patients (<30 years). NNT varied by doctor from 0 to 192 and 117, respectively (with and without seborrheic keratoses). LIMITATIONS: Given the retrospective design, we were unable to examine doctor characteristics such as age, sex, medical training, and patient pressure to excise. CONCLUSIONS: Substantial variability in individual doctor NNT produced an overall NNT similar to that reported from mainstream general practice, and higher than specialist practice.

A palliative care intervention in forgiveness therapy for elderly terminally ill cancer patients.

Palliative care is now considered an essential part of end-of-life care, yet little research examines the efficacy of interventions addressing the psychological treatment of dying patients. Forgiveness therapy has been shown to be effective in improving psychological well-being and may provide a valuable addition to a terminal cancer patient's overall treatment plan. This study experimentally tested the effectiveness of a four-week forgiveness therapy in improving the quality of life of elderly terminally ill cancer patients. Participants (n = 20) were randomly assigned to a forgiveness therapy group or to a wait-list control group, which received forgiveness therapy in the second four-week period. All participants completed instruments measuring forgiveness, hope, quality of life, and anger at pre-test, post-test 1, and post-test 2. The forgiveness therapy group showed greater improvement than the control group, with one-tailed t-tests, on all measures. After receiving forgiveness therapy, participants in both forgiveness treatment conditions demonstrated significant improvements on all measures. The aggregated effect size was large. The four-week forgiveness therapy demonstrated psychological benefits for elderly terminally ill cancer patients and thus may be an appropriate addition to the treatment plan for terminal cancer patients.

The use of evidence-based practice by occupational therapists.

The purpose of this study was to explore occupational therapists' attitudes, knowledge, and use of evidence-based practice. Results indicated that therapists have positive attitudes toward evidence-based practice; however, use of research evidence in practice remains limited primarily due to lack of time. Suggestions for clinical and academic partnerships are offered.

Journeys from addiction to recovery.

Addiction affects us all. It has wide-reaching consequences for the individual, the family, and society as a whole. This article attempts to assist providers and addicts in understanding the road to recovery. Transformation from addiction to recovery is best explained by recovering addicts themselves. In this qualitative study, nine participants describe their experiences with long-term recovery. The transtheoretical model of change (Prochaska & DiClemente, 1983) was combined with Mezirow's (1997) transformative learning theory to structure a framework that highlights the transition of these individuals as they moved from addiction to recovery. This new combination model can be used to anticipate behavior, support, and encourage patients in the change from active addiction to a healthier lifestyle without drugs and alcohol.

The Structure of Families who Adopt Children from Foster Care.

The 1997 Adoption and Safe Families Act (ASFA) gave incentives to states to expedite the adoption of children from foster care. Administrative data describe the changes in adoptive families from 1996 to 2003 in terms of the marital status and sex of the household head and in terms of the relationship of the parents to the child prior to adoption. Patterns in the way children with special needs were matched with different kinds of families are described. The data show that agencies have tapped the resources of families headed by single parents to provide permanency for older children and that older children adopted by fathers have spent more time as legal orphans than children adopted by single mothers.

Distribution of a Federal Entitlement: The Case of Adoption Assistance.

Adoption assistance entitlements support children whose birth parents cannot care for them. The entitlements are meant to offset the extra cost to adoptive families of raising children whose early adverse experiences leave them with special needs. Unlike other Social Security Act programs, adoption assistance is not federally administered but is administered by states or localities. State-to-state variation in administration of this federal entitlement leads to unequal treatment of similar children. Moreover, although adoption assistance is an entitlement for children, payments made by many states are systematically correlated with the characteristics of adoptive families.

Using Subsidies to Promote the Adoption of Children from Foster Care.

Since 1978 the federal government has implemented a variety of programs to promote the adoption of children from foster care. A key part of these programs has been the use of subsidies to lower the cost of adopting and parenting children who have been in foster care. Although subsidies are a key part of federal policy, there has been little empirical research on the effect of subsidies on adoption rates. This paper uses data from the Adoption and Foster Care Analysis and Reporting System to estimate the impact of subsidy rates on adoption rates. Subsidies to families have a positive and statistically significant effect on adoption rates.

State-Designated Special Needs, Post-Adoption Support, and State Fiscal Stress.

The Adoption and Safe Families Act of 2007 and its 2003 reauthorization offered bonuses to states that provide more children waiting in foster care with permanent families through adoption. Under ASFA, a majority of states increased the generosity of post-adoption financial support. Moreover, states increased the number and proportion of adopted children that received adoption assistance because the child had a special need. Administrative data indicate that states more diligently recorded the special needs of children, which was necessary to support increases in state requests for federal reimbursements and performance bonuses.