COVID-19 Cases and Deaths in Skilled Nursing Facilities in Cook County, Illinois.

OBJECTIVE: The COVID-19 pandemic has had a devastating impact on older adults residing in skilled nursing facilities. This study examined the pathways through which community and facility factors may have affected COVID-19 cases and deaths in skilled nursing facilities. METHODS: We used structural equation modeling to examine the number of COVID-19 cases and deaths in skilled nursing facilities in Cook County, Illinois, from January 1 through September 30, 2020. We used data from the Centers for Medicare & Medicaid Services, the Illinois Department of Public Health, and the Cook County Medical Examiner's Office to determine the number of resident COVID-19 cases and deaths, number of staff cases, facility-level characteristics, and community-level factors. RESULTS: Poorer facility quality ratings and higher numbers of staff COVID-19 cases were associated with increased numbers of resident COVID-19 cases and deaths. For-profit ownership was associated with larger facilities and higher resident-to-staff ratios, which increased the number of staff COVID-19 cases. Furthermore, skilled nursing facilities with a greater percentage of White residents were in areas with lower levels of social vulnerability and were less likely to be for-profit and, thus, were associated with higher quality. CONCLUSIONS: For-profit ownership was associated with lower facility quality ratings and increases in the number of staff COVID-19 cases, leading to increased resident COVID-19 cases and deaths. Establishing enforceable regulations to ensure quality standards in for-profit skilled nursing facilities is critical to prevent future outbreaks and reduce health disparities in facilities serving racial and ethnic minority populations.

Integrating Social Services and Home-Based Primary Care for High-Risk Patients.

There is a consensus that our current hospital-intensive approach to care is deeply flawed. This review article describes the research evidence for developing a better system of care for high-cost, high-risk patients. It reviews the evidence that home-centered care and integration of health care with social services are the cornerstones of a more humane and efficient system. The article describes the strengths and weaknesses of research evaluating the effects of social services in addressing social determinants of health, and how social support is critical to successful acute care transition programs. It reviews the history of incorporating social services into care management, and the prospects that recent payment reforms and regulatory initiatives can succeed in stimulating the financial integration of social services into new care coordination initiatives. The article reviews the literature on home-based primary care for the chronically ill and disabled, and suggests that it is the emergence of this care modality that holds the greatest promise for delivery system reform. In the hope of stimulating further discussion and debate, the authors summarize existing viewpoints on how a home-centered system, which integrates social and medical services, might emerge in the next few years.

Social Phobia: The Role of In-Situation Safety Behaviors in Maintaining Anxiety and Negative Beliefs - Republished Article.

One of the puzzles surrounding social phobia is that patients with this problem are often exposed to phobic situations without showing a marked reduction in their fears. It is possible that individuals with social phobia engage in behaviors in the feared situation that are intended to avert feared catastrophes but that also prevent disconfirmation of their fears. This hypothesis was tested in a single case series of eight socially phobic patients. All patients received one session of exposure alone and one session of exposure plus decrease in "safety" behaviors in a counterbalanced within-subject design. Exposure plus decreased safety behaviors was significantly better than exposure alone in reducing within-situation anxiety and belief in the feared catastrophe. Other factors that may moderate exposure effects are also discussed.

Allogeneic stem cell transplantation for myelodysplastic syndromes with bone marrow fibrosis.

BACKGROUND: Bone marrow fibrosis in patients with myelodysplastic syndrome is associated with a poor outcome, but whether the outcome after allogeneic stem cell transplantation is related to the degree of bone marrow fibrosis is unknown. DESIGN AND METHODS: Patients with myelodysplastic syndrome and known bone marrow histology (n=721) who underwent hematopoietic stem cell transplantation were classified according to the degree of bone marrow fibrosis into those without fibrosis (n=483), those with mild or moderate fibrosis (n=199) and those with severe fibrosis (n=39) and analyzed regarding engraftment, treatment-related mortality, relapse and survival. RESULTS: The degree of fibrosis was not associated with disease status or abnormal cytogenetics. The cumulative incidence of engraftment achieved at day +30 in non-fibrotic patients was 93% and was significantly lower in those with mild or moderate fibrosis (89%) and severe fibrosis (75%) (P=0.009). Neutrophil engraftment occurred later in patients with mild or moderate fibrosis and severe fibrosis than in patients without fibrosis (median 17 versus 20 versus 16 days, respectively; P=0.002). The cumulative incidence of relapse at 3 years was significantly higher in patients with severe fibrosis than in those with a lesser degree of fibrosis or no fibrosis (47% versus 28% versus 27%, respectively; P=0.04), resulting in comparable 3-year disease-free survival rates in patients without fibrosis and in those with mild or moderate fibrosis (42% versus 38%, respectively) but a lower disease-free survival rate in those with severe fibrosis (18%; P=0.002). Severe fibrosis remained an independent factor for reduced survival (hazard ratio, 1.9; P=0.006). CONCLUSIONS: Among patients with myelodysplastic syndromes, only severe fibrosis affects survival after hematopoietic stem cell transplantation while patients with mild or moderate fibrosis have an outcome comparable to that of patients without bone marrow fibrosis.

Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: a pilot study.

Exposure therapy and cognitive behaviour therapy (CBT) are both effective in the treatment of panic disorder with agoraphobia. Cognitive theories suggest that the way in which exposure to avoided situations is implemented in either treatment may be crucial. In particular, it is suggested that clinical improvement will be greatest if opportunities for disconfirmation of feared catastrophes are maximized. In a small pilot study, 16 patients with panic disorder and (moderate or severe) agoraphobia were randomly allocated to either habituation based exposure therapy (HBET) or exposure planned as a belief disconfirmation strategy and accompanied by dropping of safety-seeking behaviours. Both treatments were brief (total of 3.25 h of exposure) and were similar in terms of expectancy of change. Patients in the CBT condition showed significantly greater improvements in self-report measures of anxiety, panic and situational avoidance. They also completed significantly more steps in a standardized behavioural walk, during which they experienced significantly less anxiety. The controlled effect sizes for CBT were substantial (range 1.7-2.7), which suggests it may be a particularly efficient way of managing therapeutic exposure to feared situations in panic disorder with agoraphobia. Further research is needed to clarify the mechanism of change involved.

Stigmatization of people with mental illnesses: a follow-up study within the Changing Minds campaign of the Royal College of Psychiatrists.

A population survey before the start of the Changing Minds campaign showed that negative opinions about people with mental illnesses were widely held, and that opinions about different disorders differed in important ways. We repeated the survey 5 years later, when the campaign had ended. Interviews were again conducted with a representative population sample (1725 interviews; response rate 65%), enquiring about demographic variables, about eight opinions concerning seven common mental disorders, and whether the respondents knew anyone with one of these mental disorders. The pattern of response in this second survey resembled that in the first. However, there were significant changes. Though often small, apart from reported opinions concerning treatment and outcome, they were all reductions in the percentages of stigmatizing opinions. Seventy seven percent of respondents reported knowing someone with one of the seven disorders. Those who did so in respect of severe depression or panic and phobias were less likely to have stigmatizing opinions about people with the corresponding disorder, but the same did not apply to the other disorders. The greatest proportion of negative opinions was in the 16-19 year age group, and respondents with higher education were less likely than the rest to express such views. We conclude that stigmatizing opinions are frequent in the community but the various disorders are not stigmatized in the same way. Campaigns to reduce stigma should take account of these differences, and of the need to address young people.