Rationing Rights: Administrative Burden in Medicaid Long-term Care Programs.

CONTEXT: States use Medicaid waivers to provide supports for disabled people in communities, rather than in institutions. Because waivers are not entitlements, those deemed eligible are not guaranteed these supports. How do states, in practice, use bureaucratic procedures to ration this 'conditional' right? METHODS: Drawing on primary and secondary data, we analyze waiver programs, and document state administrative procedures to indirectly and directly ration access. FINDINGS: Burdens indirectly limit disabled peoples' access to Medicaid home and community-based services, via a complex array of waiver programs that exacerbate costs associated with gaining eligibility, and directly limit access, via waitlists and prioritization among the eligible. There is also evidence that states strategically deploy opaqueness to provide political cover for unpopular waitlists. The overall process is opaque, confusing, and time intensive, with burdens falling hardest on marginalized groups. CONCLUSIONS: Administrative burdens impede the right to live in the community afforded to people with disabilities under the American with Disabilities Act. The opaqueness and associated burdens with waiver programs are a way to conceal these costs, thereby demonstrating how burdens "neatly carry out the 'how' in the production of inequality, while concealing . . . the why."

Lassa fever research priorities: towards effective medical countermeasures by the end of the decade.

In 2016, WHO designated Lassa fever a priority disease for epidemic preparedness as part of the WHO Blueprint for Action to Prevent Epidemics. One aspect of preparedness is to promote development of effective medical countermeasures (ie, diagnostics, therapeutics, and vaccines) against Lassa fever. Diagnostic testing for Lassa fever has important limitations and key advancements are needed to ensure rapid and accurate diagnosis. Additionally, the only treatment available for Lassa fever is ribavirin, but controversy exists regarding its effectiveness. Finally, no licensed vaccines are available for the prevention and control of Lassa fever. Ongoing epidemiological and behavioural studies are also crucial in providing actionable information for medical countermeasure development, use, and effectiveness in preventing and treating Lassa fever. This Personal View provides current research priorities for development of Lassa fever medical countermeasures based on literature published primarily in the last 5 years and consensus opinion of 20 subject matter experts with broad experience in public health or the development of diagnostics, therapeutics, and vaccines for Lassa fever. These priorities provide an important framework to ensure that Lassa fever medical countermeasures are developed and readily available for use in endemic and at-risk areas by the end of the decade.

Physiologic and behavioral effects of long-acting subcutaneous and transdermal buprenorphine in rats.

OBJECTIVE: To investigate thermoregulation, thermal antinociception, food/kaolin intake, fecal output, and behavior following long-acting buprenorphine preparations in rats. ANIMALS: 8 adult male rats (Rattus norvegicus) were administered long-acting SC buprenorphine (SB; 0.65 mg/kg), transdermal buprenorphine (TB; 10 mg/kg), and controls in a randomized, cross-over design. METHODS: Body temperature, self-injury, sedation, food/kaolin intake, fecal output, and thermal withdrawal latencies were measured 1, 4, 8, 12, 24, 48, and 72 hours posttreatment. Data analysis was performed with mixed linear models. RESULTS: Self-injury was present between 1 and 12 hours and 4 and 12 hours following TB and SB, respectively; sedation was associated with TB at 12 to 24 hours. Withdrawal latencies were longer in both TB and SB groups than in the control group. Food intake decreased with time in all groups but was significantly lower 24 to 48 hours after TB and 24 to 72 hours after SB versus controls. Kaolin intake decreased from baseline 48 to 72 hours in the control group. Fecal output decreased from baseline 24 to 72 hours in all groups but was significantly lower than controls 24 hours following TB and 24 to 48 hours in SB. Body temperature increased from baseline at 1 hour, 1 to 12 hours, and 1 to 24 hours in the control, TB, and SB groups, respectively, and was significantly higher than the control group 1 to 72 hours following TB and 4 to 24 hours after SB. Transdermal buprenorphine and SB in normal rats produced antinociception, self-injurious behavior, hyperthermia, and decreased food/fecal output. CLINICAL RELEVANCE: Although these buprenorphine preparations may produce antinociception, untoward effects such as hyperthermia, self-injurious behavior, and reduced food intake/fecal output may be seen.

A randomized controlled trial evaluating the effects of nurse-led triage of 911 calls.

To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (ncontrol = 3,023) or further triage (ntreatment = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (ß = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (ß = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (ß = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (ß = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care.

The Effect of Socioeconomic Status and Race/Ethnicity on the Risk of Presenting With Advanced Stage at Diagnosis in Embryonal Tumors.

We evaluated whether socioeconomic status (SES), race/ethnicity, and their interaction were associated with the presentation of advanced stage at diagnosis in embryonal tumors. Children 0 to 19 years of age diagnosed with embryonal tumors between 2006 and 2018 were identified from the US Surveillance, Epidemiology, and End Results program database specialized with Census Tract SES/Rurality. SES quintile was derived from a composite index for census tracts. We performed logistic regression to estimate odds ratios (ORs) and 95% confidence intervals by SES and race/ethnicity, adjusting for sex, age, and diagnosis year. Overall, no significant associations were found between either SES or race/ethnicity and the risk of presenting with advanced stage at diagnosis, although patterns of risk reductions were observed in atypical teratoid/rhabdoid tumors and embryonal rhabdomyosarcoma with increasing SES. In the stratified analysis, decreased odds of presenting with advanced-stage embryonal rhabdomyosarcoma were observed for Hispanics with higher SES (OR: 0.24, 95% Confidence Interval: 0.08-0.75) compared with Hispanics with lower SES. Future studies incorporating individual-level SES, cancer-specific staging information, and potential demographic, clinical, epidemiological, and genetic risk factors are warranted to confirm our findings.

Development of a selective and scalable N1-indazole alkylation.

N1-Alkyl indazoles are a ubiquitous and privileged motif within medicinal chemistry, yet methods to selectively furnish N1-alkyl indazoles with simple alkyl side chains remain sparse. Herein, negative data from high-throughput experimentation (HTE) enabled a confident pivot of resource from continued optimisation to the development of an alternative reaction. This workflow culminated in a methodology for the synthesis of N1-alkyl indazoles. The procedure is highly selective for N1-alkylation, practical, and broad in scope, with no N2-alkyl products detected at completion. Mechanistic understandings were consistent with attributing the high selectivity to thermodynamic control. Additional data-driven process development led to this reaction being safely demonstrated on a 100 g scale, with potential for further scale up. This study highlights pragmatic principles followed to develop a necessitated methodology, suitable for large scale manufacture.

The association between maternal nutrient intake during pregnancy and the risk of sporadic unilateral retinoblastoma among offspring.

Previous studies have associated maternal diet during pregnancy with the development of sporadic unilateral retinoblastoma (RB), but few studies have focused on the role of individual nutrients. The aim of this study is to investigate the association between maternal nutrient intake during pregnancy and the development of sporadic unilateral RB in the offspring. A modified food frequency questionnaire, with additional questions on supplement use, was completed via a phone interview. Cases were recruited from hospitals and controls were comprised of friends and relatives of the patient without a history of cancer. Overall, 168 sporadic unilateral RB cases and 145 controls were included in case-control study. We performed logistic regression to estimate odds ratios (ORs) and 95 % confidence intervals (CI), adjusting for child's age, child's sex, parental race/ethnicity, maternal education, total calorie intake during pregnancy, maternal age at birth, maternal smoking during pregnancy, pre-pregnancy body mass index, maternal weight gain during pregnancy, paternal age at birth, and maternal multivitamin use in the year before pregnancy. In the adjusted model, the interquartile (IQR) increase in vitamin A intake, which was measured in retinol activity equivalent (RAE; OR: 0.64, 95 % CI: 0.46-0.90), and vitamin D intake (OR: 0.62, 95 % CI: 0.42-0.91) significantly reduced the risk of sporadic unilateral RB. These findings suggest that a higher intake of vitamins A and D can be a protective factor for sporadic unilateral RB. Further analyses in consideration of multi-exposures such as parental occupational exposures are warranted to discover the complex etiology of sporadic unilateral RB. In addition, the role of nutritional epigenetics for how maternal nutrient intake influences the risk of sporadic unilateral RB in the offspring still needs to be explored.

A legal dispute resolution intervention for patients with substance use disorders: a study protocol for a randomized controlled trial.

BACKGROUND: Substance use disorders (SUDs) represent major public health concerns and are linked to enhanced risk of legal consequences. Unresolved legal issues may prevent individuals with SUD from completing treatment. Interventions aimed at improving SUD treatment outcomes are limited. Filling that gap, this randomized controlled trial (RCT) tests the ability of a technology-assisted intervention to increase SUD treatment completion rates and improve post-treatment health, economic, justice-system, and housing outcomes. METHODS: A randomized controlled trial with a two-year administrative follow-up period will be conducted. Eight hundred Medicaid eligible and uninsured adults receiving SUD treatment will be recruited at community-based non-profit health care clinics in Southeast, Michigan, USA. Using an algorithm embedded in a community-based case management system, we randomly assign all eligible adults to one of two groups. The treatment/intervention group will receive hands-on assistance with a technology aimed at resolving unaddressed legal issues and the control group receives no treatment. Upon enrollment into the intervention, both treatment (n = 400) and control groups (n = 400) retain traditional options to resolve unaddressed legal issues, such as hiring an attorney, but only the treatment group is targeted the technology and offered personalized assistance in navigating the online legal platform. To develop baseline and historical contexts for participants, we collect life course history reports from all participants and intend to link those in each group to administrative data sources. In addition to the randomized controlled trial (RCT), we used an exploratory sequential mixed methods and participatory-based design to develop, test, and administer our life course history instruments to all participants. The primary objective is to test whether targeting no-cost online legal resources to those experiencing SUD improves their long-term recovery and decreases negative health, economic, justice-system, and housing outcomes. DISCUSSION: Findings from this RCT will improve our understanding of the acute socio-legal needs faced by those experiencing SUD and provide recommendations to help target resources toward the areas that best support long-term recovery. The public health impact includes making publicly available a deidentified, longitudinal dataset of uninsured and Medicaid eligible clients in treatment for SUD. Data include an overrepresentation of understudied groups including African American and American Indian Alaska Native persons documented to experience heightened risk for SUD-related premature mortality and justice-system involvement. Within these data, several intended outcome measures can inform the health policy landscape: (1) health, including substance use, disability, mental health diagnosis, and mortality; (2) financial health, including employment, earnings, public assistance receipt, and financial obligations to the state; (3) justice-system involvement, including civil and criminal legal system encounters; (4) housing, including homelessness, household composition, and homeownership. TRIAL REGISTRATION: Retrospectively registered # NCT05665179 on December 27, 2022.

A cluster randomized controlled trial of a modified vaccination clinical reminder for primary care providers.

OBJECTIVE: Adult vaccination rates in the United States fall short of national goals, and rates are particularly low for Black Americans. We tested a provider-focused vaccination uptake intervention: a modified electronic health record clinical reminder that bundled together three adult vaccination reminders, presented patient vaccination history, and included talking points for providers to address vaccine hesitancy. METHOD: Primary care teams at the Atlanta Veterans Affairs Medical Center, who saw 28,941 patients during this period, were randomly assigned to receive either the modified clinical reminder (N = 44 teams) or the status quo (N = 40 teams). RESULTS: Uptake of influenza and other adult vaccinations was 1.6 percentage points higher in the intervention group, which was not statistically significant (confidence interval, CI [-1.3, 4.4], p = .28). The intervention had similar effects on Black and White patients and did not reduce the disparity in vaccination rates between these groups. CONCLUSION: Provider-focused interventions are a promising way to address vaccine hesitancy, but they may need to be more intensive than a modified clinical reminder to have appreciable effects on vaccination uptake. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exploration of genetic ancestry and socioeconomic status in the incidence of neuroblastoma: An ecological study.

Although global differences in the incidence of neuroblastoma have been examined, the underlying mechanism has yet to be elucidated. Previous studies have suggested genetic ancestry and human development index (HDI) as contributing factors, but few studies have been conducted at the international level. Here, we aimed to examine whether the frequency of common genomic variation associated with neuroblastoma can affect its risk at the ecological level with consideration of the HDI. Minor allele frequencies (MAFs) for 22 single-nucleotide polymorphisms (SNPs) were abstracted from the Geography of Genetic Variants Browser. The number of incident neuroblastomas for each population was obtained from the Cancer Incidence in Five Continents series. Further, population pseudo-polygenic risk scores (pp-PRSs) were calculated as a sum of MAFs at the population level, each of which was weighted by effect sizes from prior studies. Negative binomial regression was used to estimate the incidence rate ratios (IRRs) and the 95% confidence intervals (CIs) to examine whether differences in MAFs across the population influence the risk of neuroblastoma, with and without adjustment for HDI and whether pp-PRSs can be a predictor of the risk of neuroblastoma. Overall, our results indicated that the neuroblastoma risk associated with variation in SNP frequency could not be differentiated from that of HDI at the ecological level. Additionally, pp-PRSs were not significantly associated with the risk of neuroblastoma (IRR: 0.99, 95% CI: 0.62-1.60). Further study using individual-level data is warranted to minimize the bias related to the use of population-level data in this study.

Animal-Assisted Interventions for Dementia: A Systematic Review.

Behavioral and psychological symptoms of dementia (BPSD) can be devastating for people who have dementia and their families. More than 5 million Americans are living with dementia, and approximately 97% of these individuals have BPSD, including agitation, aggression, anxiety, depression, apathy, sleep disturbances, wandering, and disinhibition. Animal-assisted interventions (AAI) have increasingly been used to treat these symptoms in individuals with dementia and constitute an optimal nonpharmacological treatment strategy. The current review aims to explore the literature regarding AAI in treating BPSD. Of 3,573 publications reviewed, 15 articles met inclusion criteria. All studies included a type of AAI exploring BPSD within individuals with dementia. The systematic review unveils AAI may be beneficial for those with dementia; however, further research is necessary to address limitations in the existing literature. [Research in Gerontological Nursing, 14(6), 317-324.].

Exploratory Study of Fecal Cortisol, Weight, and Behavior as Measures of Stress and Welfare in Shelter Cats During Assimilation Into Families of Children With Autism Spectrum Disorder.

Background: Cats are a common companion animal (CA) in US households, and many live in families of children with autism spectrum disorder (ASD). The prevalence of ASD is one in 54, and many children have behavior challenges as well as their diagnostic communication disorders. Objective: Benefits of CAs for children with ASD have been identified, but little is known about the welfare of CAs in these homes. This study explored the welfare of cats (N = 10) screened for ideal social and calm temperament using the Feline Temperament Profile (FTP) and adopted by families of children with ASD. Methods: Cat stress was measured using fecal cortisol, weight, and a behavior stress measure (cat stress score). Measures were taken at baseline in the shelter, 2-3 days after adoption, and at weeks 6, 12, and 18. Result: Outcome measures suggested the adopted cats' stress levels did not increase postadoption; however, the small sample size limited analytical power and generalizability. Conclusion: This study provides preliminary evidence for the success of cat adoption by families of children with ASD, when cats have been temperament screened and cat behavior educational information is provided. Further research is warranted to confirm these findings.

Experiences of Military Veterans in a Therapeutic Horseback Riding Program.

Posttraumatic stress disorder commonly occurs among U.S. military veterans. Therapeutic horseback riding (THR) has emerged as an adjunct therapy. We explored 20 veterans' perceived benefits, drawbacks and views of a 6-week THR program. Participants had confirmed diagnoses of posttraumatic stress disorder, traumatic brain injury, or both. Veterans rode the same horse weekly, the same day, at the same time. Data were collected as part of a randomized clinical trial testing the effects of THR on Post-Traumatic Stress Disorder. Veterans responded to an open-ended questionnaire. Content analysis was used for data analysis. Benefits were "Connection to the Horse," "Relaxing," "180 Degree Change," and "Meeting New People." Drawbacks were "None," "Struggle to Get There," "Pain," "Too Short," and "It is Structured." Overall perceptions were "I Absolutely Loved It," "Feel Again," "The Horse," "The People," and "No Worries." Participants viewed THR as positive. Findings may elucidate why THR may be clinically beneficial.

Public attitudes toward genetic risk scoring in medicine and beyond.

Advances in genomics research have led to the development of polygenic risk scores, which numerically summarize genetic predispositions for a wide array of human outcomes. Initially developed to characterize disease risk, polygenic risk scores can now be calculated for many non-disease traits and social outcomes, with the potential to be used not only in health care but also other institutional domains. In this study, we draw on a nationally-representative survey of U.S. adults to examine three sets of lay attitudes toward the deployment of genetic risk scores in a variety of medical and non-medical domains: 1. abstract belief about whether people should be judged on the basis of genetic predispositions; 2. concrete attitudes about whether various institutions should be permitted to use genetic information; and 3. personal willingness to provide genetic information to various institutions. Results demonstrate two striking differences across these three sets of attitudes. First, despite almost universal agreement that people should not be judged based on genetics, there is support, albeit varied, for institutions being permitted to use genetic information, with support highest for disease outcomes and in reproductive decision-making. We further find significant variation in personal willingness to provide such information, with a majority of respondents expressing willingness to provide information to health care providers and relative finder services, but less than a quarter expressing willingness to do so for an array of other institutions and services. Second, while there are no demographic differences in respondents' abstract beliefs about judging based on genetics, demographic differences emerge in permissibility ratings and personal willingness. Our results should inform debates about the deployment of polygenic scores in domains within and beyond medicine.

Neighborhood Engagement, Dogs, and Life Satisfaction in Older Adulthood.

OBJECTIVES: This study examined the relationships between dog ownership, dog walking, and the emotional bond with a dog to neighborhood engagement and life satisfaction among those over age 50. METHOD: Using data from the Health and Retirement Study (N = 476), two path analysis models were conducted to test the research hypotheses. RESULTS: Findings indicated that dog ownership did not have a direct or indirect relationship on life satisfaction. However, time spent in dog walking was associated with frequency of social interactions, which itself had a positive association with life satisfaction. The bond with a dog was not directly associated with life satisfaction but was associated with dog walking. DISCUSSION: Dog walking is a promising strategy for simultaneously promoting better health and social engagement, and these factors in turn can promote greater life satisfaction of older adults.

Exploratory Study of Cat Adoption in Families of Children with Autism: Impact on Children's Social Skills and Anxiety.

PURPOSE: The diagnosis of Autism Spectrum Disorder (ASD) occurs in one in 54 children and companion animals (CA) are common in families of children with ASD. Despite evidence of CA ownership benefits for children with ASD, little is known about cats. The purpose was to explore the impact of shelter cat adoption by families of children with ASD. DESIGN AND METHODS: This was the first randomized controlled trial of adoption of a temperament screened cat by families of children with ASD. Families assigned to the treatment group adopted a cat and were followed for 18 weeks. Families assigned to the control group were followed for 18 weeks without intervention, then converted to treatment, by adopting a cat and were followed another 18 weeks. Adopted cats were screened using the Feline Temperament Profile to identify a calm temperament. Surveys measured children's social skills and anxiety and parent/child cat bonding. RESULTS: Our study (N = 11) found cat adoption was associated with greater Empathy and less Separation Anxiety for children with ASD, along with fewer problem behaviors including Externalizing, Bullying and Hyperactivity/Inattention. Parents and children reported strong bonds to the cats. CONCLUSION: This exploratory study found introduction of a cat into the home may have a positive impact on children with ASD and their parents. Based on this intial finding, future studies with larger sample sizes are recommended. PRACTICE IMPLICATIONS: If parents of children with ASD are considering cat adoption, health care providers might consider recommending adoption of a cat screened for calm temperament.

Anesthetic risk during subsequent anesthetic events in brachycephalic dogs that have undergone corrective airway surgery: 45 cases (2007-2019).

OBJECTIVE: To determine whether previous corrective upper airway surgery in brachycephalic dogs would decrease perianesthetic complications in subsequent anesthetic events. ANIMALS: 45 client-owned dogs. PROCEDURES: Brachycephalic dogs undergoing any combination of staphylectomy, nasal alaplasty, or laryngeal sacculectomy that were anesthetized at a later date for additional surgical procedures or imaging from August 2, 2007, to February 8, 2019, had their medical records reviewed during both anesthetic events for signalment, American Society of Anesthesiologists status, perianesthetic drug administration, anesthetic duration, presence and total time of positive-pressure ventilation, procedure invasiveness, and perianesthetic complications such as bradycardia, hypothermia, hypotension, cardiac arrhythmias, hypertension, vomiting or regurgitation, dysphoria, respiratory distress, hypoxemia, reintubation, and prolonged periods of recovery. RESULTS: The odds of having complications during the postanesthetic period following subsequent anesthetic events were decreased by 79% in dogs having previous surgical intervention to correct clinical signs of brachycephalic airway syndrome. Intra-anesthetic bradycardia increased the odds of developing a postanesthetic complication by 4.56 times. Every 15-minute increase in anesthetic duration increased the odds of having a postanesthetic complication by 12% and having an intra-anesthetic complication by 11%. CONCLUSIONS AND CLINICAL RELEVANCE: Previous corrective upper airway surgery decreased odds of postanesthetic complications in brachycephalic dogs that underwent subsequent anesthetic events. Findings in this study indicated that corrective upper airway surgery for brachycephalic dogs may reduce postanesthetic complications following subsequent anesthetic events, which may reduce perianesthetic morbidity in patients undergoing multiple surgical or diagnostic imaging procedures.

Exploring Human-Companion Animal Interaction in Families of Children with Autism.

The study goal was to explore companion animal (CA) ownership in families of children with autism spectrum disorder (ASD), including parents' beliefs about benefits and burdens of CAs, as well as parent stress. Participants (N = 764) completed online survey instruments anonymously. Findings revealed that parents with lower incomes perceived more benefits of CAs and their children were more strongly bonded with their CAs. Parents owning both a dog and cat perceived more benefits than those with only a dog or cat. Dog owners perceived more benefits than cat owners. Parents who perceived their CAs as providing more benefits had less stress. Provider implications are to consider recommending CAs to families of children with ASD for family benefits including lower parental stress.