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Health technology assessment (HTA) is a form of policy analysis that informs decisions about funding and scaling up health technologies to improve health outcomes. An equity-focused HTA recommendation explicitly addresses the impact of health technologies on individuals disadvantaged in society because of specific health needs or social conditions. However, more evidence is needed on the relationships between patient engagement processes and the development of equity-focused HTA recommendations.
Objectives
The objective of this study is to assess relationships between patient engagement processes and the development of equity-focused HTA recommendations.
Methods
We analyzed sixty HTA reports published between 2013 and 2021 from two Canadian organizations: Canada’s Drug Agency and Ontario Health.
Results
Quantitative analysis of the HTA reports showed that direct patient engagement (odds ratio (OR): 3.85; 95 percent confidence interval (CI): 2.40–6.20) and consensus in decision-making (OR: 2.27; 95 percent CI: 1.35–3.84) were more likely to be associated with the development of equity-focused HTA recommendations than indirect patient engagement (OR: .26; 95 percent CI: .16–.41) and voting (OR: .44; 95 percent CI: .26–.73).
Conclusion
The results can inform the development of patient engagement strategies in HTA. These findings have implications for practice, research, and policy. They provide valuable insights into HTA.
We provide an assessment of the Infinity Two Fusion Pilot Plant (FPP) baseline plasma physics design. Infinity Two is a four-field period, aspect ratio A = 10, quasi-isodynamic stellarator with improved confinement appealing to a max-J approach, elevated plasma density and high magnetic fields (⟨B⟩ = 9 T). At the envisioned operating point [800 MW deuterium-tritium (DT) fusion], the configuration has robust magnetic surfaces based on magnetohydrodynamic (MHD) equilibrium calculations and is stable to both local and global MHD instabilities. The configuration has excellent confinement properties with small neoclassical transport and low bootstrap current (|Ibootstrap| ∼ 2 kA). Calculations of collisional alpha particle confinement in a DT FPP scenario show small energy losses to the first wall (< 1.5%) and stable energetic particle/Alfvén eigenmodes at high ion density. Low turbulent transport is produced using a combination of density profile control consistent with pellet fueling and reduced stiffness to turbulent transport via three-dimensional shaping. Transport simulations with the T3D-GX-SFINCS code suite with self-consistent turbulent and neoclassical transport predict that the Pfus = 800 MW operating point is attainable with high fusion gain (Q = 40) at volume-averaged electron densities ne ≈ 2×1020 m−3, below the Sudo density limit. Additional transport calculations show that an ignited (Q = ∞) solution is available at slightly higher density (2.2×1020 m−3) with Pfus = 1.5 GW. The magnetic configuration is defined by a magnetic coil set with sufficient room for an island divertor, shielding and blanket solutions with tritium breeding ratios (TBR) above unity. An optimistic estimate for the gas-cooled solid breeder designed Helium Cooled Pebble Bed is TBR ∼ 1.3. Infinity Two satisfies the physics requirements of a stellarator fusion pilot plant.
Medicare claims are frequently used to study Clostridioides difficile infection (CDI) epidemiology. However, they lack specimen collection and diagnosis dates to assign location of onset. Algorithms to classify CDI onset location using claims data have been published, but the degree of misclassification is unknown.
Methods:
We linked patients with laboratory-confirmed CDI reported to four Emerging Infections Program (EIP) sites from 2016–2021 to Medicare beneficiaries with fee-for-service Part A/B coverage. We calculated sensitivity of ICD-10-CM codes in claims within ±28 days of EIP specimen collection. CDI was categorized as hospital, long-term care facility, or community-onset using three different Medicare claims-based algorithms based on claim type, ICD-10-CM code position, duration of hospitalization, and ICD-10-CM diagnosis code presence-on-admission indicators. We assessed concordance of EIP case classifications, based on chart review and specimen collection date, with claims case classifications using Cohen’s kappa statistic.
Results:
Of 12,671 CDI cases eligible for linkage, 9,032 (71%) were linked to a single, unique Medicare beneficiary. Compared to EIP, sensitivity of CDI ICD-10-CM codes was 81%; codes were more likely to be present for hospitalized patients (93.0%) than those who were not (56.2%). Concordance between EIP and Medicare claims algorithms ranged from 68% to 75%, depending on the algorithm used (κ = 0.56–0.66).
Conclusion:
ICD-10-CM codes in Medicare claims data had high sensitivity compared to laboratory-confirmed CDI reported to EIP. Claims-based epidemiologic classification algorithms had moderate concordance with EIP classification of onset location. Misclassification of CDI onset location using Medicare algorithms may bias findings of claims-based CDI studies.
The selection, design, and optimization of a suitable blanket configuration for an advanced high-field stellarator concept is seen as a key feasibility issue and has been incorporated as a vital and necessary part of the Infinity Two Fusion Pilot Plant (FPP) physics basis. The focus of this work was to identify a baseline blanket which can be rapidly deployed for Infinity Two while also maintaining flexibility and opportunities for higher performing concepts later in development. Results from this analysis indicate that gas-cooled solid breeder designs such as the Helium Cooled Pebble Bed (HCPB) are the most promising concepts, primarily motivated by the neutronics performance at applicable blanket build depths, and the relatively mature technology basis. The lithium lead (PbLi) family of concepts, particularly the Dual Cooled Lithium Lead (DCLL), offer a compelling alternative to solid blanket concepts as they have synergistic developmental pathways while simultaneously mitigating much of the technical risk of those designs. Homogenized 3-dimensional neutronics analysis of the Infinity Two configuration indicates that the HCPB achieves an adequate tritium breeding ratio (TBR) (1.30 which enables sufficient margin at low engineering fidelity), and near appropriate shielding of the magnets (average fast fluence of 1.3 x 1018 n/cm2 per fullpower year). The thermal analysis indicates that reasonably high thermal efficiencies (greater than 30%) are readily achievable with the HCPB paired with a simple Rankine cycle using reheat. Finally, the tritium fuel cycle analysis for Infinity Two shows viability, with anticipated operational inventories of less than one kilogram (approximately 675 grams) and a required TBR (TBRreq) of less than 1.05 to maintain fuel self-sufficiency (approximately 1.023 for a driver blanket with no inventory doubling). Although further optimization and engineering design is still required, at the physics basis stage all initial targets have been met for the Infinity Two configuration.
This paper reports an experiment designed to assess the effects of a rotation in the marginal cost curve on convergence in a repeated Cournot triopoly. Increasing the cost curve's slope both reduces the serially-undominated set to the Nash prediction, and increases the peakedness of earnings. We observe higher rates of Nash equilibrium play in the design with the steeper marginal cost schedule, but only when participants are also rematched after each decision. Examination of response patterns suggests that the treatment with a steeper marginal cost curve and with a re-matching of participants across periods induces the selection of Nash Consistent responses.
Experiments in engineering are typically conducted in controlled environments where parameters can be set to any desired value. This assumes that the same applies in a real-world setting, which is often incorrect as many experiments are influenced by uncontrollable environmental conditions such as temperature, humidity, and wind speed. When optimizing such experiments, the focus should be on finding optimal values conditionally on these uncontrollable variables. This article extends Bayesian optimization to the optimization of systems in changing environments that include controllable and uncontrollable parameters. The extension fits a global surrogate model over all controllable and environmental variables but optimizes only the controllable parameters conditional on measurements of the uncontrollable variables. The method is validated on two synthetic test functions, and the effects of the noise level, the number of environmental parameters, the parameter fluctuation, the variability of the uncontrollable parameters, and the effective domain size are investigated. ENVBO, the proposed algorithm from this investigation, is applied to a wind farm simulator with eight controllable and one environmental parameter. ENVBO finds solutions for the entire domain of the environmental variable that outperform results from optimization algorithms that only focus on a fixed environmental value in all but one case while using a fraction of their evaluation budget. This makes the proposed approach very sample-efficient and cost-effective. An off-the-shelf open-source version of ENVBO is available via the NUBO Python package.
Next generation high-power laser facilities are expected to generate hundreds-of-MeV proton beams and operate at multi-Hz repetition rates, presenting opportunities for medical, industrial and scientific applications requiring bright pulses of energetic ions. Characterizing the spectro-spatial profile of these ions at high repetition rates in the harsh radiation environments created by laser–plasma interactions remains challenging but is paramount for further source development. To address this, we present a compact scintillating fiber imaging spectrometer based on the tomographic reconstruction of proton energy deposition in a layered fiber array. Modeling indicates that spatial resolution of approximately 1 mm and energy resolution of less than 10% at proton energies of more than 20 MeV are readily achievable with existing 100 μm diameter fibers. Measurements with a prototype beam-profile monitor using 500 μm fibers demonstrate active readouts with invulnerability to electromagnetic pulses, and less than 100 Gy sensitivity. The performance of the full instrument concept is explored with Monte Carlo simulations, accurately reconstructing a proton beam with a multiple-component spectro-spatial profile.
This editorial considers the value and nature of academic psychiatry by asking what defines the specialty and psychiatrists as academics. We frame academic psychiatry as a way of thinking that benefits clinical services and discuss how to inspire the next generation of academics.
Chicken production has increased over the past decade, resulting in a concomitant rise in the demand for more humane options for poultry products including cage-free, free-range, and organic meat and eggs. These husbandry changes, however, have come hand-in-hand with increased prevalence of Ascaridia galli infection, which can cause clinical disease in chickens as well as the occasional appearance of worms in eggs. Additionally, development of anthelmintic resistance in closely related helminths of turkeys highlights the need for closely monitored anthelmintic treatment programs. Manual faecal egg counts (FECs) can be time-consuming and require specialist training. As such, this study sought to validate an automated FEC system for use in detection and quantification of A. galli eggs in chicken faeces. Automated counts using the Parasight System (PS) were compared to traditional manual McMaster counting for both precision and correlation between methods. Overall, ten repeated counts were performed on twenty individual samples for a total of 200 counts performed for each method. A strong, statistically significant correlation was found between methods (R2 = 0.7879, P < 0.0001), and PS counted more eggs and performed with statistically significant higher precision (P = 0.0391) than manual McMaster counting. This study suggests that PS is a good alternative method for performing A. galli FECs and provides a new tool for use in helminth treatment and control programs in chicken operations.
Phosphate in the form of organic compounds can be bound in soils containing the aluminosilicate allophane. A significant part of this phosphorus is believed to be present as nucleic acids. The interaction of yeast RNA with allophane was studied to further the understanding of the allophane/organic macro molecule interaction as well as the binding of organic phosphorus by allophanic soils. The extent of RNA adsorption on the allophane was dependent upon the pH, the charge and concentration of simple cations, the concentration of RNA, and the time of interaction. From a mixture containing 145 mg/liter RNA and 2.9 g/liter allophane in 10−2 M NaCl, the amount of RNA adsorbed increased from 6% at pH 10 to 98% at pH 3. The adsorption also increased as the concentration of added NaCl was increased from 10−4 M to 10−1 M, but only when the pH was greater than 5, i.e., above the isoelectric point of the clay. Mg2+ and Ca2+ were equally much more effective at promoting adsorption than Na+ at the same concentrations. There was no difference in the effectiveness of SO4−2, Cl−, or NO3− at pH 5 or higher. The adsorption isotherm at pH 7 can be described by the Langmuir equation; the apparent adsorption maximum was 38 mg/g. Van der Waals and simple electrostatic forces appear to dominate the interaction leading to the adsorption of RNA by allophane.
The clay minerals formed in a deeply weathered boulder conglomerate of Middle Old Red Sandstone (Devonian) age in north-east Scotland have been studied by a variety of physical and chemical techniques. The granite and granulite boulders in this deposit are completely weathered. With the exception of microcline, all the feldspars in these rocks—orthoclase feldspar, orthoclase-microperthite, albite, and oligoclase—weather to a Cheto-type montmorillonite, poor in iron. Electron and optical microscopy indicate that the weathering transformation is a direct one, without the intervention of any intermediate crystalline or well-defined amorphous phase. Structural control of the primary mineral over the formation of the montmorillonite seems to have been a minimal factor and the evidence suggests that the clay mineral crystallized from the soluble or colloidal products arising from the decomposed feldspars. Smaller amounts of kaolinite also formed during weathering but largely from the weathering of muscovite. The environment in which these changes occurred seems to have been alkaline in a relatively closed system. Chemical analyses of related cores and weathered shells of granite and granulite bounders show only a slight decrease of silica and an increase in magnesia. Judging from the extent of alteration to secondary clay minerals, the order of resistance towards weathering of the primary minerals in these rocks is plagioclase = orthoclase < muscovite < biotite < microcline < quartz.
Understanding characteristics of healthcare personnel (HCP) with SARS-CoV-2 infection supports the development and prioritization of interventions to protect this important workforce. We report detailed characteristics of HCP who tested positive for SARS-CoV-2 from April 20, 2020 through December 31, 2021.
Methods:
CDC collaborated with Emerging Infections Program sites in 10 states to interview HCP with SARS-CoV-2 infection (case-HCP) about their demographics, underlying medical conditions, healthcare roles, exposures, personal protective equipment (PPE) use, and COVID-19 vaccination status. We grouped case-HCP by healthcare role. To describe residential social vulnerability, we merged geocoded HCP residential addresses with CDC/ATSDR Social Vulnerability Index (SVI) values at the census tract level. We defined highest and lowest SVI quartiles as high and low social vulnerability, respectively.
Results:
Our analysis included 7,531 case-HCP. Most case-HCP with roles as certified nursing assistant (CNA) (444, 61.3%), medical assistant (252, 65.3%), or home healthcare worker (HHW) (225, 59.5%) reported their race and ethnicity as either non-Hispanic Black or Hispanic. More than one third of HHWs (166, 45.2%), CNAs (283, 41.7%), and medical assistants (138, 37.9%) reported a residential address in the high social vulnerability category. The proportion of case-HCP who reported using recommended PPE at all times when caring for patients with COVID-19 was lowest among HHWs compared with other roles.
Conclusions:
To mitigate SARS-CoV-2 infection risk in healthcare settings, infection prevention, and control interventions should be specific to HCP roles and educational backgrounds. Additional interventions are needed to address high social vulnerability among HHWs, CNAs, and medical assistants.
In 2020, an outbreak of Salmonella Hadar illnesses was linked to contact with non-commercial, privately owned (backyard) poultry including live chickens, turkeys, and ducks, resulting in 848 illnesses. From late 2020 to 2021, this Salmonella Hadar strain caused an outbreak that was linked to ground turkey consumption. Core genome multilocus sequence typing (cgMLST) analysis determined that the Salmonella Hadar isolates detected during the outbreak linked to backyard poultry and the outbreak linked to ground turkey were closely related genetically (within 0–16 alleles). Epidemiological and traceback investigations were unable to determine how Salmonella Hadar detected in backyard poultry and ground turkey were linked, despite this genetic relatedness. Enhanced molecular characterization methods, such as analysis of the pangenome of Salmonella isolates, might be necessary to understand the relationship between these two outbreaks. Similarly, enhanced data collection during outbreak investigations and further research could potentially aid in determining whether these transmission vehicles are truly linked by a common source and what reservoirs exist across the poultry industries that allow Salmonella Hadar to persist. Further work combining epidemiological data collection, more detailed traceback information, and genomic analysis tools will be important for monitoring and investigating future enteric disease outbreaks.
Edited by
William J. Brady, University of Virginia,Mark R. Sochor, University of Virginia,Paul E. Pepe, Metropolitan EMS Medical Directors Global Alliance, Florida,John C. Maino II, Michigan International Speedway, Brooklyn,K. Sophia Dyer, Boston University Chobanian and Avedisian School of Medicine, Massachusetts
Healthcare providers at mass gathering events may deliver basic, intermediate, or critical care interventions in accordance with their scope of practice. Early identification of the goals of mass gathering medical care allows stakeholders to address risk assessments and develop medical plans to appropriately employ community healthcare resources. The Event Medical Director plays a pivotal role in pre-event planning, event medical care delivery, and post-event analyses for continuous quality improvement.
Edited by
William J. Brady, University of Virginia,Mark R. Sochor, University of Virginia,Paul E. Pepe, Metropolitan EMS Medical Directors Global Alliance, Florida,John C. Maino II, Michigan International Speedway, Brooklyn,K. Sophia Dyer, Boston University Chobanian and Avedisian School of Medicine, Massachusetts
A mass gathering is often a preplanned event, like a concert or sporting event, held at a specific location for a defined duration that strains planning and response resources. However, a mass gathering can also be spontaneous, such as the gathering of mourners associated with the death of a celebrity or a protest. Over the last few years, we have seen an increase in the number of protests, some events that are pre-planned and organized but others that are not and that can quickly become out-of-control and end in tragedy. The bottom line is that despite the many years of dealing with and researching mass gatherings, there remains a lack of in depth understanding of the mass gathering and, despite often being attended by reasonably healthy or well people, the gatherings seem to be more hazardous than expected
OBJECTIVES/GOALS: To evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics. METHODS/STUDY POPULATION: We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California’s Office of Statewide Health Planning and Development Linked Birth Files from 1991-2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population level risk associated with these characteristics was determined by calculating population attributable fractions. RESULTS/ANTICIPATED RESULTS: The incidence of BPBI between 1991-2012 was 1.28 per 1000 live births, with peak incidence of 1.84 per 1000 in 1998 and low of 0.9 per 1000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1000) and Hispanic (1.34 per 1000) mothers having the highest incidences. Controlling for relevant covariates, infants of Black (AOR=1.88, 95% CI 1.70, 2.08), Hispanic (AOR=1.25, 95% CI 1.18, 1.32) and advanced-age mothers (AOR=1.16, 95% CI 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5%, 10%, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time. DISCUSSION/SIGNIFICANCE: Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared to White, Non-Hispanic, and younger mothers.
OBJECTIVES/GOALS: To evaluate the association of maternal delivery history with a brachial plexus birth injury (BPBI) risk in subsequent deliveries, and to estimate the effect of subsequent delivery method on BPBI risk. METHODS/STUDY POPULATION: We conducted a retrospective cohort study of all livebirth deliveries occurring in California-licensed hospitals from 1996-2012. The primary outcome was recurrent BPBI in a subsequent pregnancy. The exposure was prior delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering an infant with BPBI). Multiple logistic regression was used to model adjusted associations of prior delivery history with BPBI in a subsequent pregnancy. The adjusted risk (AR) and adjusted risk difference (ARD) for BPBI between vaginal and cesarean delivery in subsequent pregnancies were determined, stratified by prior delivery history, and the number of cesarean deliveries needed to prevent one BPBI was determined. RESULTS/ANTICIPATED RESULTS: Of 6,286,324 infants delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a BPBI. Higher parity was associated with a 5.7% decrease in BPBI risk with each subsequent delivery (aOR 0.94, 95%CI 0.92, 0.97). Previous shoulder dystocia or BPBI were associated with 5-fold (aOR=5.39, 95%CI 4.10, 7.08) and 17-fold increases (aOR=17.22, 95%CI 13.31, 22.27) in BPBI risk, respectively. Among individuals with a history of delivering an infant with a BPBI , cesarean delivery was associated with a 73.0% decrease in BPBI risk (aOR=0.27, 95%CI 0.13, 0.55), compared with an 87.9% decrease in BPBI risk (aOR=0.12, 95%CI 0.10, 0.15) in individuals without this history. Among individuals with a previous history of BPBI, 48.1 cesarean deliveries are needed to prevent one BPBI. DISCUSSION/SIGNIFICANCE: Parity, previous shoulder dystocia, and previously delivering a BPBI infant are associated with future BPBI risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding BPBI risk and planned mode of delivery.
Clinical outcomes of repetitive transcranial magnetic stimulation (rTMS) for treatment of treatment-resistant depression (TRD) vary widely and there is no mood rating scale that is standard for assessing rTMS outcome. It remains unclear whether TMS is as efficacious in older adults with late-life depression (LLD) compared to younger adults with major depressive disorder (MDD). This study examined the effect of age on outcomes of rTMS treatment of adults with TRD. Self-report and observer mood ratings were measured weekly in 687 subjects ages 16–100 years undergoing rTMS treatment using the Inventory of Depressive Symptomatology 30-item Self-Report (IDS-SR), Patient Health Questionnaire 9-item (PHQ), Profile of Mood States 30-item, and Hamilton Depression Rating Scale 17-item (HDRS). All rating scales detected significant improvement with treatment; response and remission rates varied by scale but not by age (response/remission ≥ 60: 38%–57%/25%–33%; <60: 32%–49%/18%–25%). Proportional hazards models showed early improvement predicted later improvement across ages, though early improvements in PHQ and HDRS were more predictive of remission in those < 60 years (relative to those ≥ 60) and greater baseline IDS burden was more predictive of non-remission in those ≥ 60 years (relative to those < 60). These results indicate there is no significant effect of age on treatment outcomes in rTMS for TRD, though rating instruments may differ in assessment of symptom burden between younger and older adults during treatment.