Racial, Ethnic, and Socioeconomic Differences in Primary Care No-Show Risk with Telemedicine During the COVID-19 Pandemic.

BACKGROUND: The coronavirus 2019 (COVID-19) pandemic resulted in rapid implementation of telemedicine. Little is known about the impact of telemedicine on both no-show rates and healthcare disparities on the general primary care population during the pandemic. OBJECTIVE: To compare no-show rates between telemedicine and office visits in the primary care setting, while controlling for the burden of COVID-19 cases, with focus on underserved populations. DESIGN: Retrospective cohort study. SETTING: Multi-center urban network of primary care clinics between April 2021 and December 2021. PARTICIPANTS: A total of 311,517 completed primary care physician visits across 164,647 patients. MAIN MEASURES: The primary outcome was risk ratio of no-show incidences (i.e., no-show rates) between telemedicine and office visits across demographic sub-groups including age, ethnicity, race, and payor type. RESULTS: Compared to in-office visits, the overall risk of no-showing favored telemedicine, adjusted risk ratio of 0.68 (95% CI 0.65 to 0.71), absolute risk reduction (ARR) 4.0%. This favorability was most profound in several cohorts with racial/ethnic and socioeconomic differences with risk ratios in Black/African American 0.47 (95% CI 0.41 to 0.53), ARR 9.0%; Hispanic/Latino 0.63 (95% CI 0.58 to 0.68), ARR 4.6%; Medicaid 0.58 (95% CI 0.54 to 0.62) ARR 7.3%; Self-Pay 0.64 (95% CI 0.58 to 0.70) ARR 11.3%. LIMITATION: The analysis was limited to physician-only visits in a single setting and did not examine the reasons for visits. CONCLUSION: As compared to office visits, patients using telemedicine have a lower risk of no-showing to primary care appointments. This is one step towards improved access to care.

Normative Scores for Malayalam Cognitive Screening Test Battery among Older Adults in Kerala, India.

Background: Many neuropsychological tests are primarily developed in high-income countries, and normative data are not readily available for low- and middle-income countries (LMICs). We need culturally appropriate cognitive screening tests for India. Objective: Hence, we decided to translate the Hindi cognitive screening test battery (HCSTB) tool to Malayalam and establish the age and education-stratified norms for a Malayalam cognitive screening test battery (MCSTB). Material and Methods: HCSTB was translated to Malayalam, back-translated by bilinguals conversant in Malayalam and English, and pretested on 30 older normal adults. Using a multistage sampling technique, we conducted a descriptive cross-sectional survey in the Thiruvananthapuram district of Kerala, India. We approached older adults aged ≥60 years for informed and written consent. We excluded subjects with depression, functional impairment, cognitive impairment, history of stroke, psychosis, and visual/hearing loss that impaired cognitive assessment. Results: The normative data were derived from 441 older adults: 226 (51%) from rural areas and 215 (49%) from urban areas. Age and education affected the cognitive scores. The time to administer MCSTB among normal adults was approximately 17 minutes. Discussion and Conclusion: The derived normative data showed lower values than the published literature. A limitation of our study was the small number of older people with ≥12 years of education and the lack of neuroimaging of the subjects.

Exploring the role of telehealth in providing equitable healthcare to the vulnerable patient population during COVID-19.

The COVID 19 pandemic resulted in widespread telehealth implementation. Existent health disparities were widened, with under-represented minorities (URM) disproportionately affected by COVID. In this study, we assess the role of telehealth in improving access to care in the URMs and vulnerable populations. We noted a statistically significant increase in the number of visits in Hispanic or Latino patients (15.2% increase, p < 0.01) and Black patients (19% increase, p < 0.01). Based on payer type, there was a statistically significant increase in the number of visits in the Medicare (10.2%, p = 0.0001) and Medicaid (16.2%, p < 0.01) groups. We also noted increased access to care with telehealth in patients who were 65 and older (10.6%, p = 0.004). This highlights the importance of telehealth in increasing access to care and promoting health equity in the URM and vulnerable patient populations.

The Impact of Cultural Dimensions of Clinicians on the Adoption of Artificial Intelligence in Healthcare.

INTRODUCTION: Healthcare is probably the last frontier that Artificial Intelligence (AI) has not conquered. Cultural factors significantly impact the way healthcare is accessed and delivered. Affordability, educational and social status, physician training, lack of physician talent in difficult to serve areas all contribute to this. Cultural perspectives of clinicians and clinical habits during the human-computer interaction and inherent suspicion of lack of human to human interaction contribute to perceptions of inhibition in the adoption of AI in routine medical practice. In this paper we examine whether measurable cultural dimensions would impact the adoption of AI in routine clinical practice. MATERIALS AND METHODS: Qualified Medical Professionals (n=206) were chosen randomly and an online secure survey was conducted consisting of 26 questions. 83% of respondents were from different parts of India, remaining 17 % from other countries like USA, Canada, UK, UAE, Oman, Zambia, Nigeria, Bangladesh, Vietnam and Japan. We defined four different cultural dimensions inspired by Hofstede's cultural dimension theory and one dimension based on attitudes of clinicians towards technology in general. We measured the following: Compliance distance (the degree of adherence to evidence based standards) Collectivism vs Individualism (the sense of belonging to a group) Long term vs Short term orientation (the idea of planning and thinking long term) Uncertainty Avoidance (the degree of tolerance to uncertainty) Technology Friendliness (the degree to which technology is perceived as being helpful) Results: We found that there were no differences in adoption of AI in clinical practices based on compliance, collectivism, and long term orientation. However, we found a correlation between the requirement for a face to face consultation (high uncertainty avoidance) and Non-adoption of AI. The results demonstrate that uncertainty avoidance hinder the acceptance of technology like telemedicine and AI alike. There were also no major differences in the adoption of AI based on any geographical variation, specialty or practice sector on the adoption of AI. Notably, tech savviness or technology friendliness did not affect the adoption of AI. We conclude that any useful AI technology which gives validated results could be adopted by clinicians in general and has potential to become a good screening measure in areas with poor healthcare access. CONCLUSION: Of the many cultural dimensions we studied, the only dimension that seemed to have an impact on the adoption of any technology including AI was the high uncertainty avoidance. Other dimensions did not impact the adoption of AI.

Cutaneous and Pulmonary Manifestations: COVID-19 Virus or Coccidioidomycosis?

COVID-19 viral pandemic continues to manifest itself in the form of various clinical symptoms. Due to concerns of COVID-19 in the setting of high rates of false-negative, there is increased likelihood of anchoring bias. We present a case of a 48-year-old white female who presented with two weeks of dry cough and diffuse pruritic nodular cutaneous rash. Patient was exposed to a colleague who tested positive for COVID 19. Initial visits were conducted virtually and workup was negative for COVID-19. Patient was offered supportive care; however, her symptoms continued to worsen. Subsequent workup was positive for left lower lobe nodular opacity on the chest X-ray, follow up CT chest showed demonstrated a focal 3.4 cm infiltrate in the left lower lobe pleural base posteriorly, blood workup was positive for eosinophil count, elevated liver enzymes and positive coccidioides antibody IgG and IgM. This case highlights the importance of avoiding anchoring bias when creating differential diagnoses and triaging patients.

Identifying State-Wide Health Disparities in Diabetes Mellitus Management in Arizona: Review of Healthy People 2020 Performance.

Healthy People (HP) 2020 is a national initiative focused on health promotion and disease prevention. Three state-wide metrics in Arizona were evaluated including diabetes-related death rate, biannual measurement of glycosylated hemoglobin (HA1c), and annual foot exam. The overall results of this review point to an alarming level of disparity that exists among Black patients for the three analyzed metrics. The American Indian population also experienced disproportionately high rates of diabetes-related death in Arizona. Additional variances were noted among uninsured patients and those who had received less than a high school degree. Identifying groups who are the most vulnerable to health inequity, investigating root cause, and addressing social determinants of health are critical to improving the health of our nation.

Fluticasone Particles Bind to Motile Respiratory Cilia: A Mechanism for Enhanced Lung and Systemic Exposure?

Background: Inhaled corticosteroids (ICSs) are the main prophylactic treatment for asthma and are used in other diseases, including chronic pulmonary obstructive disease, yet the interaction of ICS particles with the ciliated epithelium remains unclear. The aim of this study was to investigate the earliest interaction of aerosolized fluticasone propionate (FP) particles with human ciliated respiratory epithelium. Methods: A bespoke system was developed to allow aerosolized FP particles to be delivered to ciliated epithelial cultures by nebulization and from a pressurized metered-dose inhaler (pMDI) through a spacer with interactions observed in real time using high-speed video microscopy. Interaction with nonrespiratory cilia was investigated using steroids on brain ependymal ciliary cultures. The dissolution rate of steroid particles was determined. Results: FP particles delivered by aerosol attached to the tips of rapidly beating cilia. Within 2 hours, 8.7% ± 1.8% (nebulization) and 12.1% ± 2.1% (pMDI through spacer) of ciliated cells had one or more particles attached to motile cilia. These levels decreased to 5.8% ± 1.6% (p = 0.59; nebulization) and 5.3% ± 2.2% (p = 0.14; pMDI through spacer) at 24 hours. Particle attachment did not affect ciliary beat frequency (p > 0.05) but significantly (p < 0.001) reduced ciliary beat amplitude. Steroid particles also attached to the tips of motile ependymal brain cilia and also reduced beat amplitude (24 hours: >2 particles bound p < 0.001). Dissolution of FP particles was slow with only 22.8% ± 1.3% of nebulized and 12.8% ± 0.5% of pMDI-delivered drug dissolving by 24 hours. Conclusions: FP particles adhere to the tips of rapidly moving cilia with significant numbers remaining bound at 24 hours, resisting the shear stress generated by ciliary beating. In vivo, this mechanism may predispose to high local drug concentrations and enhance respiratory and systemic corticosteroid exposure.

Deferred Personal Life Decisions of Women Physicians.

OBJECTIVE: Inadequate work-life balance can have significant implications regarding individual performance, retention, and on the future of the workforce in medicine. The purpose of this study was to determine whether women physicians defer personal life decisions in pursuit of their medical career. MATERIALS AND METHODS: We conducted a survey study of women physicians ages 20-80 from various medical specialties using a combination of social media platforms and women physicians' professional listservs with 801 survey responses collected from May through November 2015. The primary endpoint was whether women physicians deferred personal life decisions in pursuit of their medical career. Secondary outcomes include types of decisions deferred and correlations with age, hours worked per week, specialty, number of children, and career satisfaction. RESULTS: Respondents were categorized into deferred and nondeferred groups. Personal decision deferments were reported by 64% of respondents. Of these, 86% reported waiting to have children and 22% reported waiting to get married. Finally, while 85% of women in the nondeferment group would choose medicine again as a career, only 71% of women in the deferment group would do so (p < 0.0001). Physicians who would choose medicine again cited reasons such as career satisfaction, positive patient interactions, and intellectual stimulation, whereas those who would not choose medicine again reported poor work-life balance, decreasing job satisfaction, and insurance/administrative burden. CONCLUSIONS: The results of this survey have significant implications on the future of the workforce in medicine. Overall, our analysis shows that 64% of women physicians defer important life decisions in pursuit of their medical career. With an increase in the number of women physicians entering the workforce, lack of support and deferred personal decisions have a potential negative impact on individual performance and retention. Employers must consider the economic impact and potential workforce shortages that may develop if these issues are not addressed.

Bacteriophage Delivery by Nebulization and Efficacy Against Phenotypically Diverse Pseudomonas aeruginosa from Cystic Fibrosis Patients.

BACKGROUND: The rise in antibiotic-resistant Pseudomonas aeruginosa and the considerable difficulty in eradicating it from patients has re-motivated the study of bacteriophages as a therapeutic option. For this to be effective, host range and viability following nebulization need to be assessed. Host-range has not previously been assessed for the Liverpool Epidemic Strain (LES) isolates that are the most common cystic fibrosis-related clone of P. aeruginosa in the UK. Nebulization studies have not previously been linked to clinically relevant phages. METHODS: 84 phenotypically variable isolates of the LES were tested for susceptibility to seven bacteriophages known to have activity against P. aeruginosa. Five of the phages were from the Eliava Institute (IBMV) and 2 were isolated in this study. The viability of the two bacteriophages with the largest host ranges was characterized further to determine their ability to be nebulized and delivered to the lower airways. Phages were nebulized into a cascade impactor and the phage concentration was measured. RESULTS: The bacteriophages tested killed between 66%-98% of the 84 Liverpool Epidemic Strain isolates. Two isolates were multi phage resistant, but were sensitive to most first line anti-Pseudomonal antibiotics. The amount of viable bacteriophages contained in particles that are likely to reach the lower airways (<4.7 µm) was 1% for the Omron and 12% AeroEclipse nebulizer. CONCLUSIONS: Individual P. aeruginosa bacteriophages can lyse up to 98% of 84 phenotypically diverse LES strains. High titers of phages can be effectively nebulized.

Respiratory syncytial virus increases the virulence of Streptococcus pneumoniae by binding to penicillin binding protein 1a. A new paradigm in respiratory infection.

RATIONALE: Respiratory syncytial virus (RSV) and Streptococcus pneumoniae are major respiratory pathogens. Coinfection with RSV and S. pneumoniae is associated with severe and often fatal pneumonia but the molecular basis for this remains unclear. OBJECTIVES: To determine if interaction between RSV and pneumococci enhances pneumococcal virulence. METHODS: We used confocal microscopy and Western blot to identify the receptors involved in direct binding of RSV and pneumococci, the effects of which were studied in both in vivo and in vitro models of infection. Human ciliated respiratory epithelial cell cultures were infected with RSV for 72 hours and then challenged with pneumococci. Pneumococci were collected after 2 hours exposure and changes in gene expression determined using quantitative real-time polymerase chain reaction. MEASUREMENTS AND MAIN RESULTS: Following incubation with RSV or purified G protein, pneumococci demonstrated a significant increase in the inflammatory response and bacterial adherence to human ciliated epithelial cultures and markedly increased virulence in a pneumonia model in mice. This was associated with extensive changes in the pneumococcal transcriptome and significant up-regulation in the expression of key pneumococcal virulence genes, including the gene for the pneumococcal toxin, pneumolysin. We show that mechanistically this is caused by RSV G glycoprotein binding penicillin binding protein 1a. CONCLUSIONS: The direct interaction between a respiratory virus protein and the pneumococcus resulting in increased bacterial virulence and worsening disease outcome is a new paradigm in respiratory infection.

RHPS4 G-quadruplex ligand induces anti-proliferative effects in brain tumor cells.

BACKGROUND: Telomeric 3' overhangs can fold into a four-stranded DNA structure termed G-quadruplex (G4), a formation which inhibits telomerase. As telomerase activation is crucial for telomere maintenance in most cancer cells, several classes of G4 ligands have been designed to directly disrupt telomeric structure. METHODS: We exposed brain tumor cells to the G4 ligand 3,11-difluoro-6,8,13-trimethyl-8H-quino[4,3,2-kl]acridinium methosulfate (RHPS4) and investigated proliferation, cell cycle dynamics, telomere length, telomerase activity and activated c-Myc levels. RESULTS: Although all cell lines tested were sensitive to RHPS4, PFSK-1 central nervous system primitive neuroectodermal cells, DAOY medulloblastoma cells and U87 glioblastoma cells exhibited up to 30-fold increased sensitivity compared to KNS42 glioblastoma, C6 glioma and Res196 ependymoma cells. An increased proportion of S-phase cells were observed in medulloblastoma and high grade glioma cells whilst CNS PNET cells showed an increased proportion of G1-phase cells. RHPS4-induced phenotypes were concomitant with telomerase inhibition, manifested in a telomere length-independent manner and not associated with activated c-Myc levels. However, anti-proliferative effects were also observed in normal neural/endothelial cells in vitro and ex vivo. CONCLUSION: This study warrants in vivo validation of RHPS4 and alternative G4 ligands as potential anti-cancer agents for brain tumors but highlights the consideration of dose-limiting tissue toxicities.

Ciliary dyskinesia is an early feature of respiratory syncytial virus infection.

Respiratory syncytial virus is a major cause of respiratory disease. There are conflicting accounts of the response of human epithelial cells to respiratory syncytial virus and a lack of data on its effect on ciliary function. Our aim was to study the early stages of respiratory syncytial virus infection of primary human basal and ciliated cultures. Using high speed videomicroscopy, we found that ciliary beat frequency was unaffected by respiratory syncytial virus infection over 72 h; however, ciliary dyskinesia significantly increased within 24 h of infection (p<0.05). Transmission electron microscopy revealed that ultrastructural abnormalities were confined to ciliated cells, including increased cilia loss and mitochondrial damage. Confocal immunofluorescence microscopy showed that respiratory syncytial virus antigen gradually spread from the cell surface to the ciliary tip of infected cells over 3 days. Interestingly, ciliated cultures secreted fewer viruses than basal (progenitor) cell cultures and produced a chemokine response focused on recruitment of neutrophils. This study highlights differences in infection models and underscores the need to explore further the role of ciliated cells in the establishment of respiratory syncytial virus infection. Increased ciliary dyskinesia combined with ciliary loss and epithelial damage is likely to result in reduced mucociliary clearance early in the infective process.

The effect of ethanol and acetaldehyde on brain ependymal and respiratory ciliary beat frequency.

BACKGROUND: Ethanol has been shown to stimulate the beat frequency of respiratory cilia at concentrations encountered during social drinking, while one of its metabolites, acetaldehyde, has been shown to cause a marked decrease in ciliary beat frequency. The aim of this study was to determine whether short-term exposure to ethanol stimulated ependymal cilia and whether exposure to acetaldehyde had a toxic effect on ependymal and respiratory cilia. METHODS: Using ex vivo rat ependymal brain slice and human nasal brush biopsy models, we investigated the effect of exposure of cilia to various concentrations of ethanol and acetaldehyde at either 37°C or 24°C. Ciliary beat frequency was measured using digital high-speed video analysis. RESULTS: Exposure of ependymal and respiratory cilia to control, 0.1%, 0.5% and 1% ethanol solutions resulted in a maximal increase of 15% in the ciliary beat frequency from baseline values, compared with the control of 6%. A one-way analysis of variance comparing the mean slopes for the three concentrations of ethanol and control showed no significant differences between the groups (P >0.05). Exposure of ependymal and respiratory cilia to 100 and 250 µM acetaldehyde solutions resulted in a maximal increase of 15% in the ciliary beat frequency from baseline, compared with the control of 12%. A one-way analysis of variance performed to compare the mean slopes in these groups showed no significant differences (P >0.05). CONCLUSIONS: Short-term exposure of brain ependymal and respiratory cilia to the concentrations of ethanol likely to be encountered during episodes of heavy drinking and to acetaldehyde at concentrations well above those encountered by man did not have a significant effect on ciliary beat frequency.

Splenectomy in plasma cell dyscrasias: a review of the clinical practice.

Plasma cell dyscrasias are a group of clinically and biochemically diverse disorders of unknown etiology, characterized by the disproportionate proliferation of one or more clones of B cells, and the presence of a structurally and electrophoretically homogeneous (monoclonal) immunoglobulin or polypeptide subunit in serum or urine. The role of splenectomy in the management of plasma cell dyscrasias has not been well defined. Using MEDLINE, the authors searched the English-language published literature from the year 1970 through September 2005 to determine the indications for splenectomy in plasma cell dyscrasias. A review of the literature in humans and animals supported the idea that the spleen provides a special microenvironment favorable for homing or differentiation of IgM producing B cells, and splenectomy can, at times, lead to remission in Waldenström's macroglobulinemia. The other reported reasons for splenectomy in plasma cell dyscrasias are hypersplenism-related pancytopenia, control of splenic plasmacytomas, and management of a splenic abscess. Splenic infiltration in primary amyloidosis can be an indication for splenectomy, where removal of a large spleen can also reverse an acquired factor X deficiency. Thus, the spleen can be considered a potential target organ for management of plasma cell dyscrasias, and therapeutic success has been achieved with removal of this organ. However, splenectomy can be a potentially morbid procedure in patients with plasma cell dyscrasias, and major postoperative complications include infection, hemorrhage, and thrombosis.

Zone-specific micromechanical properties of the extracellular matrices of growth plate cartilage.

Growth plate cartilage demonstrates a unique capacity for cell proliferation and matrix synthesis while sustaining mechanical stresses. To test the hypothesis that the extracellular matrices along various depth of growth plate cartilage have different elastic properties, microindentation by atomic force microscopy was applied to en bloc dissected rabbit cranial base growth plate samples from the reserve zone to mineralizing zone in 50-microm increments. The average elastic modulus upon transverse indentation orthogonal to the long axis of the growth plate showed a gradient distribution, increasing significantly from the reserve zone (0.57 +/- 0.05 MPa) to mineralizing zone (1.41 +/- 0.19 MPa). Longitudinal indentation of the reserve zone along the long axis of the growth plate revealed an average elastic modulus of 0.77 +/- 0.12 MPa, significantly different from the same zone upon transverse indentation. Thus, the extracellular matrix of growth plate cartilage seems to be inhomogenous in its capacity to withstand mechanical stresses.