The Impact of Telehealth on Obstetrical Outcomes during the COVID-19 Pandemic.

OBJECTIVE: Nationwide, obstetric clinics modified prenatal care to include telehealth visits in response to the coronavirus disease 2019 (COVID-19) pandemic, enabling the opportunity to investigate its impact on patient outcomes. We hypothesized that use of prenatal telehealth visits would increase the number of prenatal visits, decrease the frequency of urgent triage/emergency department (ED) visits, and improve perinatal outcomes. This study aimed to determine the impact of telehealth on number of obstetric prenatal visits and urgent triage/ED visits amidst the COVID-19 pandemic. STUDY DESIGN: This is a retrospective cohort of patients from a federally qualified health center in central Texas. Patients with a singleton gestation who delivered after 32 weeks were included. Comparison groups were made between those patients who delivered between May 2020 and December 2020 (presumed modified prenatal visit schedule with in-person and telehealth) and those patients delivering between June 2019 and February 2020 (the traditional care model with in-person visits only). Multivariable linear and logistic regression models were used to estimate differences in the number of prenatal visits and unscheduled triage/ED visits. RESULTS: A total of 1,654 patients were identified with 801 (48.4%) patients undergoing modified prenatal care and 853 (51.6%) patients receiving traditional care during the study period. No significant differences were seen in overall prenatal attendance or triage/ED presentations. However, when stratified by parity, multiparous patients undergoing modified prenatal care were less likely to experience an urgent triage/ED presentation (8.7 vs. 12.7%; odds ratio, 1.69; 95% confidence interval, 1.10-2.61). CONCLUSION: When compared with a traditional prenatal visitation cohort prepandemic, patients who received modified telehealth prenatal care during the COVID-19 pandemic had similar prenatal attendance and unscheduled emergency presentations. However, multiparous patients experienced a decreased rate of unscheduled emergency presentations. Supplementing prenatal care with telehealth may provide overall comparable prenatal care delivery. KEY POINTS: · Use of telehealth has the potential to improve prenatal care.. · The COVID-19 pandemic allowed for comparison to traditional prenatal care.. · Multiparous patients had a decreased frequency of ED visits.. · Similar prenatal attendance was seen between both prenatal models..

Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries.

BACKGROUND: Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. METHODS: We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. RESULTS: We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. CONCLUSIONS: Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

[Formula: see text] Neural and behavioral indicators of cognitive control in preschoolers with and without prenatal opioid exposure.

Prenatal opioid exposure is one consequence of the opioid epidemic, but effects on child development remain poorly understood. There is emerging evidence that children exposed to opioids in utero exhibit elevated emotional and behavioral problems, which may be partially due to alterations in cognitive control. Using multiple methods (i.e., neuropsychological, behavioral, and event-related potential [ERP] assessments), the present study examined differences in emotional, behavioral, and cognitive control difficulties in preschool-aged children with (n = 21) and without (n = 23) prenatal opioid exposure (Mage = 4.30, SD = 0.77 years). Child emotional and behavioral problems were measured with a caregiver questionnaire, indicators of cognitive control were measured using developmentally appropriate behavioral (i.e., delay discounting, Go/No-Go) and neuropsychological (i.e., Statue) tasks, and electroencephalogram was recorded to error and correct responses in a Go/No-Go task. ERP analyses focused on the error-related negativity (ERN), an ERP that reflects error monitoring, and correct-response negativity (CRN), a component reflecting performance monitoring more generally. Opioid exposure was associated with elevated difficulties across domains and a blunted ERN, reflecting altered cognitive control at the neural level, but groups did not significantly differ on behavioral measures of cognitive control. These result replicate prior studies indicating an association between prenatal opioid exposure and behavioral problems in preschool-aged children. Further, our findings suggest these differences may be partially due to children with prenatal opioid exposure exhibiting difficulties with cognitive control at the neural level. The ERN is a potential target for future research and intervention efforts to address the sequelae of prenatal opioid exposure.

Concurrent and prospective associations between infant frontoparietal and default mode network connectivity and negative affectivity.

Emotion dysregulation is linked to differences in frontoparietal (FPN) and default mode (DMN) brain network functioning. These differences may be identifiable early in development. Temperamental negative affectivity has been identified as a precursor to later emotion dysregulation, though the underlying neurodevelopmental mechanism is unknown. The present study explores concurrent and prospective associations between FPN and DMN connectivity in infants and measures of negative affectivity. 72 infants underwent 5.03-13.28 min of resting state fMRI during natural sleep (M±SD age=4.90 ± 0.84 weeks; 54% male; usable data=9.92 ± 2.15 min). FPN and DMN intra- and internetwork connectivity were computed using adult network assignments. Crying was obtained from both parent-report and day-long audio recordings. Temperamental negative affectivity was obtained from a parent-report questionnaire. In this preregistered study, based on analyses conducted with a subset of this data (N = 32), we hypothesized that greater functional connectivity within and between FPN and DMN would be associated with greater negative affectivity. In the full sample we did not find support for these hypotheses. Instead, greater DMN intranetwork connectivity at age one month was associated with lower concurrent parent-reported crying and temperamental negative affectivity at age six months (ßs>-0.35, ps<.025), but not crying at age six months. DMN intranetwork connectivity was also negatively associated with internalizing symptoms at age eighteen-months (ß=-0.58, p = .012). FPN intra- and internetwork connectivity was not associated with negative affectivity measures after accounting for covariates. This work furthers a neurodevelopmental model of emotion dysregulation by suggesting that infant functional connectivity at rest is associated with later emotional functioning.

Impaired robotic surgical visualization: archaic issues in a modern operating room.

While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow.

Post-epidemic health system recovery: A comparative case study analysis of routine immunization programs in the Republics of Haiti and Liberia.

Large-scale epidemics in resource-constrained settings disrupt delivery of core health services, such as routine immunization. Rebuilding and strengthening routine immunization programs following epidemics is an essential step toward improving vaccine equity and averting future outbreaks. We performed a comparative case study analysis of routine immunization program recovery in Liberia and Haiti following the 2014-16 West Africa Ebola epidemic and 2010s cholera epidemic, respectively. First, we triangulated data between the peer-reviewed and grey literature; in-depth key informant interviews with subject matter experts; and quantitative metrics of population health and health system functioning. We used these data to construct thick descriptive narratives for each case. Finally, we performed a cross-case comparison by applying a thematic matrix based on the Essential Public Health Services framework to each case narrative. In Liberia, post-Ebola routine immunization coverage surpassed pre-epidemic levels, a feat attributable to investments in surveillance, comprehensive risk communication, robust political support for and leadership around immunization, and strong public-sector recovery planning. Recovery efforts in Haiti were fragmented across a broad range of non-governmental agencies. Limitations in funding, workforce development, and community engagement further impeded vaccine uptake. Consequently, Haiti reported significant disparities in subnational immunization coverage following the epidemic. This study suggests that embedding in-country expertise within outbreak response structures, respecting governmental autonomy, aligning post-epidemic recovery plans and policies, and integrating outbreak response assets into robust systems of primary care contribute to higher, more equitable levels of routine immunization coverage in resource-constrained settings recovering from epidemics.

Facilitating Medical Care for Latinx Individuals at Risk for CKD: A Pilot Intervention.

Rationale and Objective: Latinx individuals are at a higher risk for kidney failure than non-Latinx White individuals; however, they are less likely to receive pre-kidney failure medical care. The objective of this study was to determine the feasibility and acceptability of a community health worker (CHW) intervention that facilitated access to medical care for Latinx individuals. Study Design: Single-arm prospective study. Setting and Participants: Latinx adults were found to have albuminuria or risk factors for kidney disease at community screening events in Austin, Texas. Intervention: A 6-month CHW intervention that facilitated the following: (1) obtaining medical insurance; (2) medical care coordination with primary and nephrology care; (3) kidney disease education; and (4) connection with local resources to address health-related social needs. Outcomes: Recruitment, retention, medical care linkage, and participant and CHW-reported satisfaction with the intervention. Results: Of the 173 individuals who attended the 2 community screening events, 49 agreed to participate in the study, of whom, 51% were men with a mean ± standard deviation (SD) age of 45 ± 14 years, and all self-identified as Mexican or Chicano. The mean ± SD estimated glomerular filtration rate (eGFR) was 110 ± 21 mL/min/1.73 m2 and 41% of the participants reported a urine albumin-creatinine ratio of ≥30 mg/g. Among those enrolled, 28 of the 49 (57%) completed at least 1 CHW visit, and 20 of 49 (41%) completed the intervention. 7 individuals who needed assistance with insurance obtained insurance, and 15 of 20 (75%) scheduled an appointment with a primary care physician within 180 days. Participants reported that the US health care previously seemed inaccessible but gained insurance, the ability to navigate the system, and the ability to help others in their community to access medical care because of the program. Limitations: Small sample size and a single community may limit generalizability. Conclusions: We reported the acceptability of a CHW intervention. We encountered challenges with feasibility and identified strategies to overcome them. Studies are needed to test the effect of CHW interventions on outcomes and kidney health disparities. Funding: National Kidney Foundation young investigator research grant to Dr Novick. Plain Language Summary: Latinx individuals are at a higher risk for kidney failure than non-Latinx White individuals; however, they are less likely to receive pre-kidney failure medical care. We piloted a community health worker intervention that connected people with risk factors or showed evidence of kidney dysfunction at community screening events with medical care. Our findings indicate the acceptability of the intervention. We encountered challenges with feasibility and identified strategies to overcome them.

Parenting and childhood irritability: Negative emotion socialization and parental control moderate the development of irritability.

Irritability, characterized by anger in response to frustration, is normative in childhood. While children typically show a decline in irritability from toddlerhood to school age, elevated irritability throughout childhood may predict later psychopathology. The current study (n = 78) examined associations between trajectories of irritability in early childhood (ages 2-7) and irritability in adolescence (age 12) and tested whether these associations are moderated by parenting behaviors. Results indicate that negative emotion socialization moderated trajectories of irritability - relative to children with low stable irritability, children who exhibited high stable irritability in early childhood and who had parents that exhibited greater negative emotion socialization behaviors had higher irritability in adolescence. Further, negative parental control behavior moderated trajectories of irritability - relative to children with low stable irritability, children who had high decreasing irritability in early childhood and who had parents who exhibited greater negative control behaviors had higher irritability in adolescence. In contrast, positive emotion socialization and control behaviors did not moderate the relations between early childhood irritability and later irritability in adolescence. These results suggest that both irritability in early childhood and negative parenting behaviors may jointly influence irritability in adolescence. The current study underscores the significance of negative parenting behaviors and could inform treatment.

Developmental Changes in the Association Between Cognitive Control and Anxiety.

Anxiety has been associated with reliance on reactive (stimulus-driven/reflexive) control strategies in response to conflict. However, this conclusion rests primarily on indirect evidence. Few studies utilize tasks that dissociate the use of reactive ('just in time') vs. proactive (anticipatory/preparatory) cognitive control strategies in response to conflict, and none examine children diagnosed with anxiety. The current study utilizes the AX-CPT, which dissociates these two types of cognitive control, to examine cognitive control in youth (ages 8-18) with and without an anxiety diagnosis (n = 56). Results illustrate that planful behavior, consistent with using a proactive strategy, varies by both age and anxiety symptoms. Young children (ages 8-12 years) with high anxiety exhibit significantly less planful behavior than similarly-aged children with low anxiety. These findings highlight the importance of considering how maturation influences relations between anxiety and performance on cognitive-control tasks and have implications for understanding the pathophysiology of anxiety in children.

Modeling epidemic recovery: An expert elicitation on issues and approaches.

Since the emergence of the SARS-CoV-2 virus in late 2019, the world has been in a state of high alert and reactivity. Once the acute stage of the infectious disease crisis does abate, however, few if any communities will have a detailed roadmap to guide recovery - that is, the process of becoming whole again and working to reduce similar, future risk. In both research and policy contexts where data are absent or difficult to obtain, expert judgment can help fill the void. Between November 2019 and February 2020, we conducted an expert elicitation process, asking fourteen key informants - with specializations in infectious diseases, disaster recovery, community resilience, public health, emergency management, and policymaking - to identify the design principles, priority issues, and field experiences that should inform development of an epidemic recovery model. Participants argued that recovery from epidemics is distinct from natural disasters due to epidemics' potential to produce effects over large areas for extended periods of time and ability to generate high levels of fear, anticipatory anxiety, and antisocial behavior. Furthermore, epidemic recovery is a complex, nonlinear process involving many domains - political, economic, sociocultural, infrastructural, and human health. As such, an adequate model of post-epidemic recovery should extend beyond strictly medical matters, specify units of interest (e.g., individual, family, institution, sector, community), capture differing trajectories of recovery given social determinants of health, and be fit for use depending upon user group (e.g., policymakers, responders, researchers). This formative study commences a longer-term effort to generate indicators for a holistic, transformative epidemic recovery at the community level.

Using prediction polling to harness collective intelligence for disease forecasting.

BACKGROUND: The global spread of COVID-19 has shown that reliable forecasting of public health related outcomes is important but lacking. METHODS: We report the results of the first large-scale, long-term experiment in crowd-forecasting of infectious-disease outbreaks, where a total of 562 volunteer participants competed over 15 months to make forecasts on 61 questions with a total of 217 possible answers regarding 19 diseases. RESULTS: Consistent with the "wisdom of crowds" phenomenon, we found that crowd forecasts aggregated using best-practice adaptive algorithms are well-calibrated, accurate, timely, and outperform all individual forecasters. CONCLUSIONS: Crowd forecasting efforts in public health may be a useful addition to traditional disease surveillance, modeling, and other approaches to evidence-based decision making for infectious disease outbreaks.

Amygdala Functional Connectivity and Negative Reactive Temperament at Age 4 Months.

OBJECTIVE: Infant amygdala connectivity correlates with maternal reports of infant temperament characterized by novelty-evoked distress and avoidance. However, no studies have examined how human infant amygdala connectivity relates to direct observations of novelty-evoked distress. This study examined the link between amygdala connectivity and infant novelty-evoked distress using direct observation of temperament. METHOD: Novelty-evoked distress was assessed at 4 months of age (N = 90) using a standardized reactivity assessment and parent report. Within 3 weeks of assessment, resting-state functional magnetic resonance imaging was collected in a subset of infants (n = 34). Using a whole-brain voxelwise approach, amygdala connectivity associated with positive and negative affect during the reactivity assessment was examined. Regions where the association of amygdala connectivity with negative affect was higher than with positive affect were then examined. Associations between amygdala connectivity and parent report of temperament were also examined. RESULTS: Greater amygdala-cingulate and amygdala-superior frontal gyrus connectivity was associated with lower positive affect during the reactivity assessment. Further, the association between amygdala-cingulate connectivity was greater for negative affect compared with positive affect. There were no significant associations between latency to approach novelty (as measured by parent report) and amygdala connectivity. Validation analyses conducted using a large independent longitudinal sample (N = 323) demonstrated that negative reactivity was associated with increased child-reported anxiety symptoms in adolescence. CONCLUSION: These results provide novel insight into the developmental pathophysiology of novelty-evoked distress. This is consistent with research linking an altered cognitive control mechanism to temperamental risk for anxiety.

The public's role in COVID-19 vaccination: Human-centered recommendations to enhance pandemic vaccine awareness, access, and acceptance in the United States.

Given the social and economic upheavals caused by the COVID-19 pandemic, political leaders, health officials, and members of the public are eager for solutions. One of the most promising, if they can be successfully developed, is vaccines. While the technological development of such countermeasures is currently underway, a key social gap remains. Past experience in routine and crisis contexts demonstrates that uptake of vaccines is more complicated than simply making the technology available. Vaccine uptake, and especially the widespread acceptance of vaccines, is a social endeavor that requires consideration of human factors. To provide a starting place for this critical component of a future COVID-19 vaccination campaign in the United States, the 23-person Working Group on Readying Populations for COVID-19 Vaccines was formed. One outcome of this group is a synthesis of the major challenges and opportunities associated with a future COVID-19 vaccination campaign and empirically-informed recommendations to advance public understanding of, access to, and acceptance of vaccines that protect against SARS-CoV-2. While not inclusive of all possible steps than could or should be done to facilitate COVID-19 vaccination, the working group believes that the recommendations provided are essential for a successful vaccination program.

The value proposition of the Global Health Security Index.

Infectious disease outbreaks pose major threats to human health and security. Countries with robust capacities for preventing, detecting and responding to outbreaks can avert many of the social, political, economic and health system costs of such crises. The Global Health Security Index (GHS Index)-the first comprehensive assessment and benchmarking of health security and related capabilities across 195 countries-recently found that no country is sufficiently prepared for epidemics or pandemics. The GHS Index can help health security stakeholders identify areas of weakness, as well as opportunities to collaborate across sectors, collectively strengthen health systems and achieve shared public health goals. Some scholars have recently offered constructive critiques of the GHS Index's approach to scoring and ranking countries; its weighting of select indicators; its emphasis on transparency; its focus on biosecurity and biosafety capacities; and divergence between select country scores and corresponding COVID-19-associated caseloads, morbidity, and mortality. Here, we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the importance of scoring and ranking; (4) describe the robust methodology underpinning country scores and ranks; (5) highlight the GHS Index's emphasis on transparency and (6) articulate caveats for users wishing to use GHS Index data in health security research, policymaking and practice.

Applying an Innovative Model of Disaster Resilience at the Neighborhood Level : The COPEWELL New York City Experience.

Community resilience is a community's ability to maintain functioning (ie, delivery of services) during and after a disaster event. The Composite of Post-Event Well-Being (COPEWELL) is a system dynamics model of community resilience that predicts a community's disaster-specific functioning over time. We explored COPEWELL's usefulness as a practice-based tool for understanding community resilience and to engage partners in identifying resilience-strengthening strategies. In 2014, along with academic partners, the New York City Department of Health and Mental Hygiene organized an interdisciplinary work group that used COPEWELL to advance cross-sector engagement, design approaches to understand and strengthen community resilience, and identify local data to explore COPEWELL implementation at neighborhood levels. The authors conducted participant interviews and collected shared experiences to capture information on lessons learned. The COPEWELL model led to an improved understanding of community resilience among agency members and community partners. Integration and enhanced alignment of efforts among preparedness, disaster resilience, and community development emerged. The work group identified strategies to strengthen resilience. Searches of neighborhood-level data sets and mapping helped prioritize communities that are vulnerable to disasters (eg, medically vulnerable, socially isolated, low income). These actions increased understanding of available data, identified data gaps, and generated ideas for future data collection. The COPEWELL model can be used to drive an understanding of resilience, identify key geographic areas at risk during and after a disaster, spur efforts to build on local metrics, and result in innovative interventions that integrate and align efforts among emergency preparedness, community development, and broader public health initiatives.

A checklist to improve health system resilience to infectious disease outbreaks and natural hazards.

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding global health security. Importantly, the human, economic and political tolls of these crises are being amplified by health systems' inabilities to respond quickly and effectively. Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. Using data gathered from a scoping literature review, interviews with key informants and from stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist ('the checklist'). The aim of the checklist is to measure the specific capacities, capabilities and processes that health systems need in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. The checklist is an important first step in improving health system resilience to these threats, but additional research and resources will be necessary to further refine and prioritise the checklist items and to pilot the checklist with the frontline health facilities that would be using it. This will help ensure its feasibility and durability for the long-term within the health systems strengthening and health security fields.

State by state implementation of Zika virus testing guidance in the United States in 2017 and 2018.

In 2015 and 2016, outbreaks of the Zika virus began occurring in the Americas and the Caribbean. Following the introduction of this new threat, the United States' Centers for Disease Control and Prevention (CDC) issued testing guidance for the nation's state public health laboratories. We collected and analyzed testing guidance for all fifty states and the District of Columbia for both 2017 and 2018. In both years, state testing guidance was consistent for men and non-pregnant women, but there was notable variation in guidance for pregnant women. In addition, there were changes between the two years as testing algorithms shifted toward guidance that recommended testing in more limited circumstances. States adopted large, or complete, portions of CDC testing guidance, but were not required to conform completely, 33% of states had identical guidance in 2017 and 49% in 2018. Some of these trends, such as specifying that testing be contingent on travel, or sexual contact with an individual who has recently traveled, to an area where the Zika virus was circulating, presents a potential deficiency in the United States surveillance capacity. Understanding variations in state testing guidance enables public health professionals to better understand ongoing surveillance. This analysis provides insight into the testing practices for the various states across the country. Better understanding of how states approach Zika testing, and how that testing changes over time, will increase the public health community's ability to interpret future Zika case counts.

Biphenyl Wrinkled Mesoporous Silica Nanoparticles for pH-Responsive Doxorubicin Drug Delivery.

Biphenyl wrinkled mesoporous silica nanoparticles with controlled particle size and high surface area were evaluated for the storage and delivery of doxorubicin. The average particle size and surface area were ~70 nm and ~1100 m2/g. The doxorubicin loading efficiency was 38.2 ± 1.5 (w/w)% and the release was pH dependent. The breast cancer cell line, MCF-7 (Michigan Cancer Foundation-7) was used for the in vitro drug release study. The cytotoxicity of doxorubicin-loaded nanoparticles was significantly higher than free doxorubicin. Fluorescence images showed biphenyl wrinkled mesoporous silica (BPWS) uptake by the MCF-7 cells. The biphenyl bridged wrinkled silica nanoparticles appear promising for hydrophobic drug loading and delivery.