Keshab Subedi

Purpose: This study sought to adapt a chronic pain group curriculum for adults with sickle cell disease (SCD). Given the association of experiences of racism and discrimination with health outcomes, this study also explored how such experiences for patients with SCD impact their interactions with clinicians and health-care systems. Patients and Methods: This mixed methods study recruited patients (aged ≥ 18 years) in a sickle cell treatment program; all self-identified as Black or African American. Key informant interviews evaluated a chronic pain program curriculum and rated the curriculum sessions’ importance for SCD pain management. A survey containing six validated instruments then measured experiences of pain and discrimination, level of emotional expressivity, and trust in physicians and health insurers. Results: Of the 19 adult patients approached, 12 (63%) completed the interview and survey. Interview data analysis resulted in five themes comprising pain, treatment, mental/emotional, health-care clinicians, and differences in SCD versus other chronic conditions. Each curriculum session was rated as “very important” or “important” by participants. Most described at least one experience of racism or discrimination in the medical setting and identified clinicians’ lack of knowledge as a barrier to appropriate SCD care. Participants identified the importance of non-pharmacological treatments for SCD pain and appropriately managing pain caused by comorbid chronic conditions. Conversely, survey responses reported moderate levels of pain, infrequent discriminatory experiences in the medical setting, and moderate trust in medical professionals, whereas most reported experiences of discrimination in general settings. Many participants reported they either accepted it or did nothing in response to discriminatory experiences. Conclusion: Study findings emphasize the need to address experiences of racism and stigma in addition to experiences of emotional and physical pain among patients with SCD in the context of pain management. Findings from this study will inform the development of a SCD pain group curriculum for adult patients.

1. Probiotics can enhance health and performance of broiler chickens by improving intestinal microbiota (1). They have been used as potential alternatives to in-feed antibiotics against some bacter...

Individuals experiencing homelessness are known to have increased rates of healthcare utilization when compared to the average patient population, often attributed to their complex health care needs and under or untreated comorbid conditions. With increasing focus on hospital readmissions among acute care settings, a better understanding of these comorbidity patterns and their impacts on acute care utilization could help improve quality of care. This study aims to identify distinct comorbidity profiles of homeless patients, and to explore the correlates of the identified comorbidity profiles and their impact on hospital readmission. This is a retrospective analysis using electronic health records (EHR) of patients experiencing homelessness encountered in the hospitals of ChristianaCare from 2015 to 2019 (N = 3445). Latent class analysis (LCA) was used to identify the comorbidity profiles of homeless patients. The mean age of the study population was 44-year, and the majority were male (63%). The most prevalent comorbid conditions were tobacco use (77%), followed by depression (58%), drug use disorder (56%), anxiety disorder (50%), hypertension (44%), and alcohol use disorder (43%). The LCA model identified 4 comorbidity classes—“relatively healthy” class with 31% of the patients, “medically-comorbid with SUD” class with 15% of the patients, “substance use disorder (SUD)” class with 39%, and “Medically comorbid” class with 15% of the patients. The Kaplan-Meir curves of probability of readmission against time from the index visits were significantly different for the four classes (p<0.001). The multivariable Cox proportional hazard model adjusted for age, sex, race, ethnicity, and insurance type showed that the hazard for readmission among patients in medically comorbid with SUD class is 3.16 (CI: 2.72, 3.67) times higher than the patients in the relatively healthy class.

Background: Past works have linked the COVID-19 pandemic and subsequent public health responses such as isolation, quarantine, and lockdown to increased anxiety, sleep disorders, depressive symptoms, and suicidal ideation. Only a few studies, mostly carried out in high-income countries, have investigated the association between the pandemic and suicide rate. We seek to investigate the changes in the monthly suicide rates during the COVID-19 pandemic in Nepal, compared to the pre-pandemic suicide rates.Methods and findings: This is a retrospective study investigating the changes in suicide rates in Nepal during the COVID-19 pandemic period (April 2020 to June 2021), compared to the pre-pandemic period (July 2017 to March 2020), adjusted for seasonality and long-term trend in the suicide rate. We performed analysis for the entire country as well as sub-sample analyses stratified by gender and provinces. A total of 24350 suicides deaths during four years of the study window were analyzed. We found an overall increase in the monthly suicide rate in Nepal with an average increase of 0.28 (CI: 0.12,0.45) suicide per 100,000 during the pandemic months. The increase in suicide rate was significant both among males (increase in rate = 0.26, CI: 0.02,0.50) and females (increase in rate = 0.30, CI: 0.18,0.43). The most striking increments in suicide rates were observed in June, July, and August 2020. The pattern of increased suicide rates faded away early on among males, but the effect was sustained for a longer duration among females. Sudurpaschim and Karnali provinces had the highest increase in suicide rates associated with the COVID-19 pandemic.Conclusions: The COVID-19 pandemic is associated with an increased suicide rate in Nepal. The findings may inform policymakers in designing appropriate public health responses to the pandemic that are considerate of the potential impact on mental health and suicide.

Introduction and Objective: Emergency department (ED) length of stay (LOS) is an important indicator of the quality of care in ED and is associated with patients’ outcomes and healthcare costs. However, there is limited data on how the patient characteristics affect the ED LOS of opioid-related visits. This study aims to identify and quantify the effect of patient-related characteristics on LOS of opioid-related ED visits. Methods: This is a retrospective analysis of electronic health records (EHR) of patients with diagnoses of opioid abuse. The study included patients with a diagnosis of opioid abuse who visited the ED at Christiana Care Hospital from January 1, 2017, to December 31, 2018 (N=5,661). The opioid-related visits were identified using ICD-10 diagnosis codes. We used accelerated failure time (AFT) models, a time-to-event analysis approach to evaluate the relationships of different patient characteristics with ED LOS. Results: The mean age of the study population was 39 years. The study population had 40% female, 20% Black/African American, and 5% Hispanic or Latino. The prevalence of co-use of cocaine and co-use of alcohol was 11%, and 9%, respectively. Also, 58% had mental health comorbidity, and 1% were homeless. The distribution of ED LOS was right-skewed with a median of 4.3 (IQR: 2.6, 6.8). Co-use of alcohol (time ratio, TR: 1.31, CI: 1.23-1.40), co-use of cocaine (TR: 1.18, CI: 1.11-1.25), the presence of mental health comorbidity (TR: 1.05, CI 1.01-1.09), and homelessness (TR: 1.57, CI: 1.32-1.86) were associated with increased ED LOS. Conclusions: Co-use of alcohol, co-use of cocaine, homelessness, and mental health comorbidity are associated with the longer LOS of opioid-related ED visits.

Objective To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants. Study design A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used. Results Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age p < 0.001) and improved oxygen saturation and stability (p < 0.01). Conclusions Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.

Autism spectrum disorder (ASD) prevalence has increased to a current level of 1 in 59 children in the United States.¹ Although genetics impart 50% to 80% of risk in ASD, nongenetic contribution of risk is also significant but poorly understood.² Perinatal and demographic factors have been associated with ASD risk.^3-5 However, findings are inconsistent regarding the association between socioeconomic status and ASD prevalence^6,7 and differences in prevalence among minority and nonminority populations.^1,8

Objective: To subjectively identify low-risk ST-elevation myocardial infarction (STEMI) patients and triage this low-risk population to an intermediate level of care. Background: Many patients with STEMI are admitted to the intensive care unit (ICU), however, a large portion do not merit ICU admission. We sought to examine whether, among post-STEMI patients admitted to the ICU, if an easily obtainable subjective scoring system could predict low-risk patients and safely triage them to an intermediate level of care. Methods: Retrospective observational study at Christiana Hospital, a 900-bed regional referral center. Data were defined by the ACTION Registry and CathPCI Registry. Acute Physiology and Chronic Health Evaluation (APACHE) predictions were retrieved for all patients with STEMI and were analyzed for complications, length of stay, and inhospital mortality. We then examined subjective criteria to triage patients with STEMI out of the ICU. Results: Among 253 patients with STEMI, 179 (70.75%) were classified as low risk (intermediate level care appropriate) and 74 (29.25%) were classified as high risk (ICU appropriate). The mean age was 64.95 years. The APACHE III score was right skewed with a mean of 36.97 and a median of 31. There was a significant difference between the APACHE III score of low-risk patients and the APACHE III score of high-risk patients (P < .001). Conclusion: In conclusion, patients characterized as low risk, as defined by our criteria, had low APACHE III scores and a low likelihood of complications post-STEMI. This low-risk population could potentially be admitted to an intermediate level of care, avoiding the ICU altogether.