Valuing and sustaining older peoples' day care services.

BACKGROUND: Unprecedented ageing and growth of the global population of older people is predicted. Between independent and residential care, day care is an essential part of a population-based strategy to support ageing well in place. AIMS: To describe experiences of older people attending day care services. METHOD: Using the qualitative method, two focus groups were completed in 2018 in a region of Ireland with 12 participants. Interviews were audio-recorded and transcribed; grounded theory guided the subsequent analysis. FINDINGS: Older people valued their participation in day care, describing the 'home from home' experience positively. Community nurses from the local public health nursing service played a key role in fostering and sustaining participation. CONCLUSIONS: National commitment to population-based age friendly environments is required to facilitate the wellbeing of a growing older demographic.

Targeting patients for early COVID-19 therapy; Pre-infection metabolic dysfunction, polycystic ovary syndrome and risk of severe disease in patients under 65: A Massachusetts community-based observational study.

INTRODUCTION: The demographics of those developing severe coronavirus disease (COVID-19) outcomes are shifting to younger patients. In an observational study utilizing electronic health records from a Massachusetts group medical practice, we identified 5025 patients with confirmed COVID-19 from March 1 to December 18, 2020. Of these, 3870 were under 65 years of age. We investigated the hypothesis that pre-infection metabolic or immunologic dysregulation including polycystic ovary syndrome (PCOS) increased risk of serious COVID-19 outcomes in patients under 65 years of age. MATERIALS AND METHODS: We compared those with COVID-19 related hospitalization or mortality to all other COVID-19 patients, using a case control approach. Using logistic regression and propensity score modeling, we evaluated risk of developing severe COVID-19 outcomes (hospitalization or death) in those with pre-infection comorbidities, metabolic risk factors, or PCOS. RESULTS: Overall, propensity score matched analyses demonstrated pre-infection elevated liver enzymes alanine aminotransferase (ALT) >40, aspartate aminotransferase (AST) >40 and blood glucose ≥215 mg/dL were associated with more severe COVID-19 outcomes, OR = 1.74 (95% CI 1.31, 2.31); OR = 1.98 (95% CI 1.52, 2.57), and OR = 1.55 (95% CI 1.08, 2.23) respectively. Elevated hemoglobin A1C or blood glucose levels were even stronger risk factors for severe COVID-19 outcomes among those aged < 65, OR = 2.31 (95% CI 1.14, 4.66) and OR = 2.42 (95% CI 1.29, 4.56), respectively. In logistic regression models, women aged < 65 with PCOS demonstrated more than a four-fold increased risk of severe COVID-19, OR 4.64 (95% CI 1.98, 10.88). CONCLUSION: Increased risk of severe COVID-19 outcomes in those < age 65 with pre-infection indicators of metabolic dysfunction heightens the importance of monitoring pre-infection indicators in younger patients for prevention and early treatment. The PCOS finding deserves further investigation. Meanwhile women who suffer from PCOS should be carefully evaluated and prioritized for earlier COVID-19 treatment and vaccination.

Irish Public Health Nursing Services and Home Support Services: governance of older persons' home care.

OBJECTIVE: To describe experiences of nurses in the Irish Public Health Nursing service working with Home Support Services (HSS) when providing home care for older people. DESIGN: Qualitative design. Two of twenty-four focus groups undertaken in 2018 are examined to report specific experiences of registered nurses. SAMPLE: The first group comprised three Public Health Nurses (PHNs) and two community Registered General Nurses (cRGNs) and the second comprised three PHNs and one cRGN. In total nine nurses participated. MEASUREMENTS: Focus group interviews were used to collect data, discussions lasted 60-90 minutes and were audio-recorded, professionally transcribed verbatim, and anonymised. RESULTS AND CONCLUSIONS: Gaps in lines of authority and accountability in day-to-day care exist, posing risks to safety. Establishing an enhanced home care model for complex cases and levels of accountability and supervision is critical. Investigating ways of adopting digital solutions to share commissioned home care plans with primary care teams (PCTs) would clarify responsibility and roles and reduce the risks of care left undone. Formally defining the role of commissioned home care agencies in primary care and that which they are expected to play during times of crisis, such as during COVID-19 pandemic will enhance integrated care and governance.

Hypertension, medications, and risk of severe COVID-19: A Massachusetts community-based observational study.

It remains uncertain whether the hypertension (HT) medications angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) mitigate or exacerbate SARS-CoV-2 infection. We evaluated the association of ACEi and ARB with severe coronavirus disease 19 (COVID-19) as defined by hospitalization or mortality among individuals diagnosed with COVID-19. We investigated whether these associations were modified by age, the simultaneous use of the diuretic thiazide, and the health conditions associated with medication use. In an observational study utilizing data from a Massachusetts group medical practice, we identified 1449 patients with a COVID-19 diagnosis. In our study, pre-infection comorbidities including HT, cardiovascular disease, and diabetes were associated with increased risk of severe COVID-19. Risk was further elevated in patients under age 65 with these comorbidities or cancer. Twenty percent of those with severe COVID-19 compared to 9% with less severe COVID-19 used ACEi, 8% and 4%, respectively, used ARB. In propensity score-matched analyses, use of neither ACEi (OR = 1.30, 95% CI 0.93 to 1.81) nor ARB (OR = 0.94, 95% CI 0.57 to 1.55) was associated with increased risk of severe COVID-19. Thiazide use did not modify this relationship. Beta blockers, calcium channel blockers, and anticoagulant medications were not associated with COVID-19 severity. In conclusion, cardiovascular-related comorbidities were associated with severe COVID-19 outcomes, especially among patients under age 65. We found no substantial increased risk of severe COVID-19 among patients taking antihypertensive medications. Our findings support recommendations against discontinuing use of renin-angiotensin system (RAS) inhibitors to prevent severe COVID-19.

Validating the 'intervention wheel' in the context of Irish public health nursing.

Illuminating the full range of nursing actions is a challenge for nurses globally; the invisibility of nursing and of public health nursing in particular is well documented. Visibility can be enhanced by identifying core functions of nursing and matching corresponding levels of interventions and outcomes. This is a priority for the contemporary Irish public health nursing (PHN) service. In the United States, public health nurses have developed an 'Intervention Wheel' naming public health interventions at community, systems and individual/family levels. This aimed to make visible the core functions of PHN practice. The values and beliefs underpinning the Intervention Wheel have been shown to capture the essence of public health nursing within the European context. In total, US nurses described 17 Wheel interventions by recording stories from practice. Owing to concern that the public health aspect of their role was not only invisible but was at risk of erosion, Irish PHNs decided to replicate this storytelling approach to provide evidence for and authenticate the 17 interventions on the Intervention Wheel from their day-to-day public health practice.

Identification of potent antagonist antibodies against mouse IL-13Rα1 using novel bioassays.

Interleukin-13 (IL-13) is a cytokine implicated in airway diseases such as asthma and idiopathic pulmonary fibrosis. IL-13 signals through a heterodimeric receptor complex consisting of IL-13Rα1 and IL-4Rα, known as the type II IL-4R. IL-4 also signals through this receptor and as such many of the biological effects of IL-13 and IL-4 are similar. Here we describe the development of two sensitive bioassays to determine the potency of antagonists of the mouse type II IL-4R. Both IL-13 and IL-4 dose-dependently induce CCL17 production from J774 mouse monocytic cells and CCL11 production from NIH3T3 mouse fibroblasts in the presence of TNFα. The assays were optimized to minimize TNFα concentration, cell number and incubation time whilst retaining a suitable signal-to-background ratio. Anti-cytokine antibodies or recombinant soluble receptors completely neutralized IL-13 or IL-4 activity in these bioassays. The J774 assay was used to screen a panel of anti-mIL-13Rα1 antibodies for neutralizing activity against this receptor. We report the identification of the first monoclonal antibodies that bind mouse IL-13Rα1 and neutralize both IL-13-induced and IL-4-induced cellular function. These antibodies should prove useful for determining the effects of neutralizing IL-13Rα1 in mouse models of disease. In addition, these bioassays may be used for measuring the bioactivity of mouse IL-13 and IL-4 and for the discovery of additional antagonists of the mouse IL-13Rα1/IL-4Rα complex.

Caseload management: an approach to making community needs visible.

AIM: To explore the process employed in the development of a population health framework and documentation for managing community nursing caseloads. BACKGROUND: No formal structure exists to validate and link local health information collected by Irish public health nurses to a wider epidemiological framework. Neglect of this bottom up information forfeits opportunities to resource and manage public health nursing services. DESIGN: Action research methods guided the development of the framework in one geographic area in Dublin and 34 participants engaged in Stringer's (1996) Look, Think and Act cycle. RESULTS: The framework identified four patient registers: family health, chronic sick/disability, older adults and acute care, which identify public health outcomes for discussion within the caseload analysis process and can predict risk factors in local populations. CONCLUSIONS: The use of the developed documentation identified a framework that describes caseloads in primary care and provides nurse managers with an evidence base to allocate resources, match skill mix to need, and estimate future workforce requirements.

Inter-rater reliability in child sexual abuse diagnosis among expert reviewers.

OBJECTIVES: To determine how well experts agree when assessing child sexual abuse cases. METHODS: A total of twelve physician subjects were recruited and voluntarily enrolled from an existing peer review network. Experts from the network had been chosen for their experience in the field and their affiliation with children's advocacy centers. Each expert submitted three cases of prepubertal female genital examinations clearly demonstrable of the case findings. Submitted cases included demographics, history, physical and genital exam findings, photodocumentation, and diagnosis. Experts reviewed each submitted case and labeled the case negative for physical finding(s), positive for physical finding(s), or indeterminate. Cases were analyzed to determine the level of agreement. RESULTS: Thirty-six cases were submitted for use in this study; one case was excluded prior to starting the review process. After all experts completed their reviews the authors reviewed the cases and results. Two additional cases were excluded, one due to poor quality photodocumentation and one for not meeting the study criteria. Thirty-three cases were used for data analysis. All 12 expert reviewers agreed in 15 of the cases. Overall, in 22 of 33 (67%) cases at least 11 of the 12 reviewers agreed with the original diagnosis. Six of 33 (18%) cases had variable agreement (8-10 reviewers agreed with original diagnosis) among reviewers; 5 of 33 (15%) cases had poor or mixed agreement (7 or less reviewers agreed with original diagnosis). CONCLUSIONS: Experts exhibit consensus in cases where the findings clearly are normal and abnormal, but demonstrate much more variability in cases where the diagnostic decisions are less obvious. Most of the diagnostic variability is due to interpretation of the findings as normal, abnormal or indeterminate, not on the perception of the examination findings themselves. More research should be done to develop a national consensus on the accurate interpretation of anogenital examination findings. Photographic image quality plays an important role in this quality review process and universally needs to be improved.

Precision of histological bone marrow staging in follicular lymphoma and diffuse large B-cell lymphoma.

INTRODUCTION: In Non-Hodgkin Lymphoma (NHL), bone marrow histology is the gold standard against which ancillary investigations such as immunophenotyping and gene rearrangement studies are interpreted. There is currently no data on the reproducibility of histological findings. This study was conducted to determine the rates of inter- and intra-observer agreement in histological detection of bone marrow involvement in the two major subtypes of NHL, Diffuse Large B-cell Lymphoma (DLBCL), and Follicular Lymphoma (FL). METHODS: The bone marrow slides of randomly selected DLBCL and FL cases were independently examined by two hematologists using standardized reporting criteria on two occasions at least two weeks apart. Samples included both aspirate and trephine biopsy slides. Weighted kappa statistics were used to examine agreement for the discrete measures. RESULTS: Weighted kappa analyses showed variable inter-observer agreement in 38 DLBCL cases [aspirate=0.52; trephine= 0.77] and 38 FL cases [aspirate=0.48; trephine=0.77]. CONCLUSION: Overall, higher agreement rates were noted with trephine biopsies than with aspirates. Except for the high intra-observer agreement on trephine biopsy assessment in FL, there is poor agreement in histological staging of both FL and DLBCL which demonstrates the limitations of histological diagnosis and the futility of interpreting ancillary tests against histology.

A new approach to ensuring oral health care for people living with HIV/AIDS: the dental case manager.

INTRODUCTION: The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health. METHODS: We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes. RESULTS: The following themes emerged from discussions on the DCM's role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM. CONCLUSION: The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health.

Routine use of ancillary investigations in staging diffuse large B-cell lymphoma improves the International Prognostic Index (IPI).

BACKGROUND: The International Prognostic Index (IPI) is used to determine prognosis in diffuse large B-cell lymphoma (DLBCL). One of the determinants of IPI is the stage of disease with bone marrow involvement being classified as stage IV. For the IPI, involvement on bone marrow is traditionally defined on the basis of histology with ancillary investigations used only in difficult cases to aid histological diagnosis. This study aimed to determine the effect of the routine use of flow cytometry, immunohistochemistry and molecular studies in bone marrow staging upon the IPI. RESULTS: Bone marrow trephines of 156 histologically proven DLBCL cases at initial diagnosis were assessed on routine histology, and immunohistochemistry using two T-cell markers (CD45RO and CD3), two B-cell markers (CD20 and CD79a) and kappa and lambda light chains. Raw flow cytometry data on all samples were reanalysed and reinterpreted blindly. DNA extracted from archived paraffin-embedded trephine biopsy samples was used for immunoglobulin heavy chain and light chain gene rearrangement analysis. Using immunophenotyping (flow cytometry and immunohistochemistry), 30 (19.2%) cases were upstaged to stage IV. A further 8 (5.1%) cases were upstaged using molecular studies. A change in IPI was noted in 18 cases (11.5%) on immunophenotyping alone, and 22 (14.1%) cases on immunophenotyping and molecular testing. Comparison of two revised IPI models, 1) using immunophenotyping alone, and 2) using immunophenotyping with molecular studies, was performed with baseline IPI using a Cox regression model. It showed that the revised IPI model using immunophenotyping provides the best differentiation between the IPI categories. CONCLUSION: Improved bone marrow staging using flow cytometry and immunohistochemistry improves the predictive value of the IPI in patients with DLBCL and should be performed routinely in all cases.

Role of immunohistochemistry in staging diffuse large B-cell lymphoma (DLBCL).

The use of immunohistochemistry (IHC) in staging bone marrow in non-Hodgkin's lymphoma (NHL) is largely limited to ambiguous cases, particularly those with lymphoid aggregates. Its role in routine clinical practice remains unestablished. This study aimed to determine whether the routine use of IHC in diffuse large B-cell lymphoma (DLBCL) would improve the detection of lymphomatous involvement in the bone marrow. It also sought to determine the impact of IHC on predicting survival compared with routine histological diagnosis using hematoxylin and eosin (H&E), Giemsa, and reticulin staining. The bone marrow trephines of 156 histologically proven DLBCL cases were assessed on routine histology, and IHC using two T-cell markers (CD45RO and CD3), two B-cell markers (CD20 and CD79a), and kappa and lambda light chains. IHC detected lymphomatous involvement on an additional 11% cases compared with histology alone. Although both routine histology and IHC were good predictors of survival, IHC was better at predicting survival on stepwise multivariate Cox regression analysis. IHC performed routinely on bone marrow trephines has the ability to improve detection of occult lymphoma in experienced hands. Furthermore, it is a better predictor of survival compared with routine histological examination alone.

Blood transfusion prescribing in the ACT: an insight into clinical decision making.

Medical practitioners with varying levels of experience may make medical decisions in hospitals. Little is known about who is responsible for these decisions. We determined transfusion appropriateness during an audit of blood transfusion, before developing practice improvement strategies, by concurrent medical record review. The prescriber could be determined in 78% of transfusion episodes: most were specialist staff. Registrars and after-hours staff prescribed significantly fewer inappropriate transfusions. The findings have significant implications in understanding clinical decision making in the hospital setting and for the targeting of quality improvement strategies in particular.

Observations and recommendations for assessing patient satisfaction in a primary care setting using a previously validated questionnaire.

Within the rapidly changing climate of primary care, there is an increasing need to evaluate the reactions of patients to real and proposed changes in practice. There are a number of methodologies, both qualitative and quantitative which have been employed to do this. This article presents the methodological problems which may be encountered in evaluating patients' opinions and attitudes in a primary care setting. We begin by discussing the issues which need evaluation, then describe the research process of a recent case study which aimed to evaluate patient satisfaction using a previously validated survey instrument, including the modifications which had to be made to overcome the problems of research in a real life practice setting. We then discuss the strengths and weaknesses of applying different methodological instruments within a primary care setting, and propose a mixed methodological framework as a template for future research which combines the strengths of both large scale survey and small scale qualitative methods to give more insight into the concerns and beliefs of patients as changes occur within their local practice.