Demographics, Symptoms, Psychotropic Use, and Caregiver Distress in Patients With Early vs Late Onset Dementia.

BACKGROUND: Understanding experiences and challenges faced by persons living with Early-Onset Dementia (EOD) compared to individuals diagnosed with Late-Onset Dementia (LOD) is important for the development of targeted interventions. OBJECTIVE: Describe differences in sociodemographic, neuropsychiatric behavioral symptoms, caregiver characteristics, and psychotropic use. DESIGN, SETTING, PARTICIPANTS: Cross-sectional, retrospective study including 908 UCLA Alzheimer's Dementia Care Program participants (177 with EOD and 731 with LOD). MEASUREMENTS: Onset of dementia was determined using age at program enrollment, with EOD defined as age <65 years and LOD defined as age >80 years. Sociodemographic and clinical characteristics were measured once at enrollment. Behavioral symptoms were measured using the Neuropsychiatric Inventory Questionnaire (NPI-Q) severity score and caregiver distress was measured using the NPI-Q distress score. Medications included antipsychotic, antidepressant, benzodiazepines and other hypnotics, antiepileptics, and dementia medications. RESULTS: EOD compared to LOD participants were more likely men, college graduates, married, live alone, and have fewer comorbidities. EOD caregivers were more often spouses (56% vs 26%, p <0.01), whereas LOD caregivers were more often children (57% vs 10%, p <0.01). EOD was associated with lower odds of being above the median (worse) NPI-Q severity (adjusted odds ratio [aOR], 0.58; 95% CI 0.35-0.96) and NPI-Q distress scores (aOR, 0.53; 95% CI 0.31-0.88). Psychotropic use did not differ between groups though symptoms were greater for LOD compared to EOD. CONCLUSION: Persons with EOD compared to LOD had sociodemographic differences, less health conditions, and fewer neuropsychiatric symptoms. Future policies could prioritize counseling for EOD patients and families, along with programs to support spousal caregivers of persons with EOD.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.

Sex- and ethnic-specific patterns in the incidence of hip fracture among older US Asian and non-Hispanic White adults.

BACKGROUND: Asian and Pacific Islander (Asian/PI) adults have lower hip fracture incidence than non-Hispanic White (NHW) adults, but data regarding Asian/PI subgroups are limited. We compared hip fracture incidence among older US Asian/PI and NHW populations, including ethnic subgroup differences. METHODS: Using observational data from a California healthcare system, we identified Asian/PI and NHW adults aged ≥50 years (2000-2019) and followed subjects to 2021 for hip fracture determined by principal/primary hospital diagnosis or by secondary hospital diagnosis with hip/femur procedure codes. Age-adjusted hip fracture incidence was calculated with 95% confidence intervals (CIs). Log-Poisson regression was used to determine fracture incidence rate ratios (IRRs, [CI]; NHW or Chinese as reference) adjusting for age and year. RESULTS: Among 215,359 Asian/PI and 776,839 NHW women, hip fracture incidence was 1.34 (1.28-1.40) and 2.97 (2.94-3.01) per 1000 person-years, respectively, with IRR 0.45 (0.43-0.47). Among 188,328 Asian/PI and 697,046 NHW men, hip fracture incidence was 0.62 (0.58-0.67) and 1.81 (1.78-1.84) per 1000 person-years, respectively, with IRR 0.34 (0.32-0.37). For the four largest Asian/PI subgroups, Filipina women (IRR 0.85 [0.75-0.96]) had lower, and Japanese (IRR 1.36 [1.20-1.54]) and South Asian (IRR 1.36 [1.07-1.72]) women had higher hip fracture incidence compared to Chinese women. Hip fracture incidence was only higher among South Asian (IRR 1.61 [1.21-2.14]) compared to Chinese men. CONCLUSION: Hip fracture incidence among US Asian/PI adults was 55% (women) and 66% (men) lower than NHW adults, but incidence varied by Asian/PI subgroup. The heterogeneity among Asian/PI adults highlights the importance of examining fracture risk by ethnic subgroup.

Middle Ear Condition at the Time of Pediatric Myringotomy Tube Placement: Pain Associations Following Intraoperative Fentanyl/Ketorolac and Seasonal Variation.

BACKGROUND: Ketorolac-refractory pain behavior following bilateral myringotomy and pressure equalization tube placement (BMT) is associated with the absence of middle ear fluid. Intraoperative fentanyl/ketorolac affords more reliable pain control than ketorolac alone. We hypothesized that middle ear condition would correlate with postoperative pain despite such combination therapy. We further sought to demonstrate seasonal variation in ear condition and its influence on pain. METHODS: We conducted a single-institution retrospective cohort study of healthy children (9 months-7 years), who underwent BMT by a single surgeon from 2015 to 2020. Anesthetic care included sevoflurane/nitrous oxide/oxygen/air by mask and intramuscular fentanyl/ketorolac. Left/right middle ear fluid status was recorded at the time of BMT, and ear condition (primary exposure) was dichotomized as bilateral infected (mucoid or purulent) or normal/unilateral infected. The primary outcome was maximum postanesthesia care unit Face, Legs, Activity, Cry, and Consolability (FLACC) score: 4-10 (moderate-to-severe pain) versus 0-3 (no-to-low pain). Rescue oxycodone, acetaminophen administration, and emergence agitation were secondary outcomes. Statistical analysis incorporated generalized linear mixed-effect models (GLMMs) with random intercepts to account for clustering by anesthesia provider. A year-over-year monthly time-series analysis was conducted using an autoregressive integrated moving average (ARIMA) regression model. RESULTS: Excluding recurrent cases, 1149 unique evaluable subjects remained. Bilateral infection prevalence was 39.8% (457/1149; 95% confidence interval [CI], 37.0-42.6). Probability of moderate-to-severe pain behavior was 23.5% (270/1149; 95% CI, 21.1-26.0) overall. Compared to patients with bilateral infected middle ears, those with normal/unilateral infected ears were more likely to have a FLACC score ≥4 (26.7% [185/692] versus 18.6% [85/457]; odds ratio [95% CI], 1.7 [1.2-2.3]; P = .002). Variability in pain outcome explained by the multivariable GLMM was 4.7%. Fentanyl dose response was evidenced by oxycodone administration differences ( P ≤ 0.002). Moderate-to-severe pain and emergence agitation were more likely with reduced fentanyl dosing. Bilateral infection prevalence exhibited seasonality, peaking in March and nadiring in July. However, pain outcomes did not vary by season. CONCLUSIONS: Normal/unilateral infected ears at time of pediatric BMT are associated with higher incidence of moderate-to-severe postoperative pain following intraoperative fentanyl/ketorolac administration, but the predictive value of ear condition on pain is limited. Infections were less common in the summer.

A population-based, electronic health record-guided approach to improve the quality of dementia care.

BACKGROUND: The quality of care of the 6.5 million Americans living with dementia has been suboptimal, leading to worse outcomes and higher costs. Few health systems have formal systems in place to guide the care of these patients. To help improve the care of persons living with dementia, we developed and preliminarily evaluated the effectiveness of electronic health record (EHR)-generated recommendations for patients with dementia. METHODS: This quality improvement study was conducted from October 2020 through June 2022 at a single academic healthcare system and included patients identified as having dementia on their problem list and their physicians. Ten (seven outpatient and three inpatient) algorithms based on clinical logic and evidence were embedded in an EHR system to generate specific recommendations based on combinations of utilization, diagnosis, and medications. The number of each type of recommendation generated, and orders for each type of recommendation were recorded, as well as physician's perceptions of this approach. RESULTS: Three thousand six hundred and nine recommendations on 763 patients were triggered by the algorithms in the outpatient setting, and 185 referrals were placed. The most common recommendations were for ongoing care through the UCLA Alzheimer's and Dementia Care program, Palliative Care, the Extensivist Clinic, Urogynecology, and Clinical Pharmacy. The most commonly acted upon by providers were recommendations for referral to Pharmacists and the UCLA Alzheimer's and Dementia Care program. The most common reason for not responding to specific recommendations was that these were not perceived as relevant to the patient. Compared to general medicine physicians, geriatricians felt more comfortable managing dementia care without a referral to a service (23% (95% CI 15%-34%) versus 3% (95% CI 0%-17%), p = 0.012) and less commonly felt the recommendation was appropriate (1% (95% CI 0%-7%) versus 13% (95% CI 4%-30%), p = 0.02). CONCLUSIONS: EHR-generated algorithms can help guide patients with dementia to appropriate clinical services.

Pediatric otolaryngology in the coronavirus disease 2019 pandemic: what have we learned?

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19) has changed the face of healthcare. The current review is to discuss the major aspects that have changed in pediatric otolaryngology, from surgical operations management, to clinic workflow, to procedural precautions. RECENT FINDINGS: There have been many studies over the past year describing different ways to improve the safety of healthcare delivery in pediatric otolaryngology amidst a global pandemic, as well as ways to improve clinic and surgical logistics along with guidelines for telehealth of a surgical specialty. SUMMARY: COVID-19 has forever altered how healthcare is viewed and practiced, and pediatric otolaryngology was not exempt. With an increased focus on provider safety, as well as novel ways of utilizing changes in methods of communication, the practice of pediatric otolaryngology has evolved with the rest of healthcare to take on the new challenges brought on by this global pandemic.

Endoscopic Findings in Male Prepubertal Choir Singers.

OBJECTIVES/HYPOTHESIS: The male singing voice through puberty undergoes many changes that present challenges for the singer and choral director. The purpose of this study was to discuss the endoscopic findings seen in prepubescent choir singers. STUDY DESIGN: Single-institution prospective study. METHODS: Subjects were recruited from the Cincinnati Boychoir and were described as Cooksey stage unchanged or mid-voice I, as described by the Boychoir artistic director. Vocal history was obtained via questionnaire at the initial visit. Subjects with known laryngeal pathologies were excluded. Endoscopic laryngeal examinations were performed using videoendoscopy. During examination, each subject sang four discrete frequencies. Findings of the endoscopic exam were judged by a board-certified pediatric otolaryngologist specializing in pediatric voice. RESULTS: We evaluated 28 subjects prior to vocal maturation. Their age range was 8 to 13 years old (mean = 10.2 ± 1.2 years). The singing voice category of all 28 subjects was described as soprano vocal range by the Boychoir artistic director. The subjects had a mean of 1.7 ± 1.1 years in the Boychoir (0-5 years). None reported history of vocal issues or voice problems in the past; seven (25%) subjects had vocal fold lesions seen at one or more frequencies; 24 (85%) subjects had a posterior gap seen at one or more frequencies. Two subjects (7%) had a posterior gap at one frequency, C3 and G3, respectively. Five subjects (18%) had a posterior gap at two frequencies, seven subjects (25%) at three frequencies, and 10 subjects (36%) in all four frequencies. CONCLUSIONS: Our study aimed to describe the laryngeal examination of dedicated Boychoir singers prior to undergoing pubertal development and vocal maturation. In elite pediatric singers we found that vocal nodules are common (25%) and are not correlated with vocal symptoms. These findings may suggest that asymptomatic lesions may be more prevalent than previously thought. In these individuals, posterior glottic gap is common and can be considered a normal glottal configuration. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:592-597, 2021.

More Than Words: Reflections to Build Resilience during the COVID-19 Pandemic.

Physicians often forget to reflect or take time to process challenging patient encounters, which can ultimately contribute to burnout. This is even more relevant given the increased stressors on patients, families, and health care providers during the coronavirus disease 2019 (COVID-19) pandemic. Two resident physicians wrote this commentary to process a difficult experience in the hospital. It touches on the ramifications of health care institutions' COVID-19 policies in relation to key geriatric syndromes including loneliness, mental health in older adults, and processing of our own emotions and feelings through narrative medicine. As part of the future health care workforce, we are motivated and optimistic about our future contributions, all the while practicing compassion and empathy.

Safety and cost of drug-induced sleep endoscopy outside the operating room.

INTRODUCTION: Drug-induced sleep endoscopy (DISE) is used to assess site of obstruction for patients in a pharmacologically induced sleep-like state. It is traditionally performed in the operating room (OR), however, no data exists regarding the feasibility of this intervention outside the OR in children. The objective is to compare the safety of DISE performed in the MRI induction room to those performed in the OR. METHODS: Prospective case-series of patients undergoing DISE in the MRI induction room (study group) to those assessed in the OR (controls) in a single-institution pediatric tertiary care center. Consecutive patients undergoing DISE examination for persistent obstructive sleep apnea (OSA) after adenotonsillectomy from September 2016 to September 2017 were included. RESULTS: Overall, 118 patients (38 study patients, 80 controls) with a mean age of 10.6 years (95% confidence interval [CI], 9.3-11.9) underwent DISE; 39.8% (47/118) were female. The most frequent comorbidity was cardiac disease (22.0%, 26/118). The mean obstructive apnea-hypopnea index was 12.2 events/hour (95% CI, 8.8-15.6) for controls and 13.5 events/hour (95% CI, 8.7-18.3) for study patients (P = .76). No major complication or unplanned admissions occurred in either group. Induction time was similar (12 vs. 13 minutes, P = .7) as was total procedure time (12 vs. 14 minutes, P = .3) for procedures performed in both settings. CONCLUSION: There were no significant complications for DISE performed in the OR or the MRI induction room and procedure times were similar. Further assessment of patient outcomes and resource utilization is needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 2076-2080, 2020.

Don't Fall for That: A Residency Curricular Innovation about Fall Prevention.

INTRODUCTION: Amid a growing geriatric population and rise in frailty-related morbidity, fall prevention represents an opportunity to improve patient outcomes and reduce health care costs. Traditional lectures on geriatric content have had limited impact on physician behaviors; however, use of multimodal teaching can be more effective in building knowledge and skills. OBJECTIVE: To develop a novel, engaging fall prevention program to empower internal medicine residents to identify and manage patients at risk of falls and fall-related injuries. METHODS: Two 20-minute multimodal workshops were created: 1) a classroom session with a video depicting a fall scenario, a team exercise ("Where's the Fall Risk?") and review of the American Geriatrics Society Beers Criteria; and 2) a small-group session reviewing a screening algorithm, case study, physical examination maneuvers, and patient resources. INNOVATION: The first workshop included a 5-minute Kaiser Permanente video depicting an older couple whose travel plans are upended by a fall and how they modify their home and lifestyle, a competitive game in which trainees identify fall hazards, an overview of Beers Criteria, and Medical Knowledge Self-Assessment Program questions to apply knowledge to practice. The second workshop, held in small groups before clinic, included a discussion of the Centers for Disease Control and Prevention's fall prevention screening algorithm, review of a case, and education on how to properly perform the Timed Up and Go test. CONCLUSION: Fall prevention remains an important yet undertaught topic for trainees and practicing physicians. These brief multicomponent workshops can be easily implemented and adapted for all clinical learners.

Effects of 90Sr on Tree Swallow Nestlings Near Groundwater Contaminant Plumes.

Discharge of groundwater contaminant plumes has created elevated concentrations of Sr in some aquatic sediments at Chalk River Laboratories. Tree swallows (Tachycenita bicolor) feed and supply their nestlings almost exclusively with airborne insects that developed as larvae in aquatic sediments. To monitor the uptake and test for potential detriment due to Sr in a terrestrial animal, we measured the gross beta concentrations in the bone of 12-d-old tree swallow nestlings in areas having sediments with elevated levels of gross beta (Sr and Y) and in several control areas where sediment gross beta was primarily due to naturally occurring K. Nesting behavior and reproductive success of the tree swallows were similar regardless of the gross beta concentrations in sediments near their nest boxes. Radiation can damage DNA and cause micronuclei to form in cells, so we examined the frequency of micronuclei in erythrocytes of nestlings. The formation of micronuclei in the erythrocytes of the nestlings was also similar wherever nestlings were analyzed. The results revealed no significant increases even near sediments with the highest gross beta levels. At Perch Lake, where Chalk River Laboratories has a large area of Sr-contaminated sediments, the bones of 12-d-old nestlings contained gross beta concentrations as high as 29 Bq g. This would produce a skeletal dose rate of 9 µGy h, which is one-fourth of the threshold dose rate of 40 µGy h, above which detriment could occur. Failing to find any indication of detriment in the field study, we irradiated wild eggs in the lab and returned them to their nest for natural incubation, hatching, and feeding by the parents. There was an increase in formation of micronuclei following a dose of 3.2 Gy, and the other results were consistent with existing literature.

Understanding functional and social risk characteristics of frail older adults: a cross-sectional survey study.

BACKGROUND: Frailty is a condition of increasing importance, given the aging adult population. With an anticipated shortage of geriatricians, primary care physicians will increasingly need to manage care for frail adults with complex functional risks and social-economic circumstances. METHODS: We used cross-sectional data from 4551 adults ages 65-90 who responded to the 2014/2015 cycle of the Kaiser Permanente Northern California Member Health Survey (MHS), a self-administered survey that covers multiple health and social characteristics, to create a deficits accumulation model frailty index, classify respondents as frail or non-frail, and then compare prevalence of functional health issues including Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) and social determinants of health (SDOHs) by frailty status. RESULTS: The overall prevalence of frailty was 14.3%, higher for women than men, increased with age, and more common among those with low levels of education and income. Frail older adults were more likely than non-frail to have ≥ 3 chronic diseases (55.9% vs. 10.1%), obesity (32.7% vs. 22.8%), insomnia (36.4% vs. 8.8%), oral health problems (25.1% vs. 4.7%), balance or walking problems (54.2% vs. 4.9%), ≥ 1 fall (56.1% vs. 19.7%), to use ≥ 1 medication known to increase fall risk (56.7% vs. 26.0%), and to need help with ≥2 ADLs (15.8% vs. 0.8%) and ≥ 2 IADLs (38.4% vs. 0.8%). They were more likely to feel financial strain (26.9% vs. 12.6%) and to use less medication than prescribed (7.4% vs. 3.6%), less medical care than needed (8.3% vs 3.7%), and eat less produce (9.5% vs. 3.2%) due to cost. Nearly 20% of frail adults were unpaid caregivers for an adult with frailty, serious illness or disability. CONCLUSIONS: This study examined the prevalence of frailty and identified modifiable and non-modifiable risk factors of health. The frail older adult population is heterogeneous and requires a patient-centered assessment of their circumstances by healthcare providers and caregivers to improve their quality of life, avoid adverse health events, and slow physical and mental decline. The characteristics identified in this study can be proactively used for the assessment of patient health, quality of life, and frailty prevention.

Optimal bioenergy power generation for climate change mitigation with or without carbon sequestration.

Restricting global warming below 2 °C to avoid catastrophic climate change will require atmospheric carbon dioxide removal (CDR). Current integrated assessment models (IAMs) and Intergovernmental Panel on Climate Change scenarios assume that CDR within the energy sector would be delivered using bioenergy with carbon capture and storage (BECCS). Although bioenergy-biochar systems (BEBCS) can also deliver CDR, they are not included in any IPCC scenario. Here we show that despite BECCS offering twice the carbon sequestration and bioenergy per unit biomass, BEBCS may allow earlier deployment of CDR at lower carbon prices when long-term improvements in soil fertility offset biochar production costs. At carbon prices above $1,000 Mg-1 C, BECCS is most frequently (P>0.45, calculated as the fraction of Monte Carlo simulations in which BECCS is the most cost effective) the most economic biomass technology for climate-change mitigation. At carbon prices below $1,000 Mg-1 C, BEBCS is the most cost-effective technology only where biochar significantly improves agricultural yields, with pure bioenergy systems being otherwise preferred.

Prevalence of Frailty and Factors Associated with Frailty in Individuals Aged 90 and Older: The 90+ Study.

OBJECTIVES: To evaluate the prevalence of frailty and examine factors associated with frailty in the 90+ Study. DESIGN: Cross-sectional. SETTING: Population-based longitudinal study of people aged 90 and older. PARTICIPANTS: 90+ Study participants (N = 824). MEASUREMENTS: Participants were assessed at baseline for five components of frailty (low weight, weakness, exhaustion, slowness, low physical activity). Frailty status was defined as meeting the criteria for at least three of the five components of frailty. The prevalence of frailty in people aged 90 and older was estimated according to sex and age (90-94, ≥95). Logistic regression models were constructed to assess the relationship between the prevalence of frailty and sex, age, education level, living situation, and marital status. RESULTS: This study estimated the overall prevalence of frailty in people aged 90 and older to be 28.0%. The overall prevalence of frailty was 24% in those aged 90 to 94 and 39.5% in those aged 95 and older. The prevalence of frailty was significantly associated with age in women but not men and with living with relatives or caregiver or in a group setting. Sex, education, and marital status were not significantly associated with frailty. CONCLUSION: The prevalence of frailty was high in people aged 90 and older and continued to increase with age, particularly for women. As the number of people aged 90 and older continues to increase, it will be increasingly important to identify factors associated with frailty that may provide potential targets for the prevention of adverse health outcomes in this population.