Cambridge Health Alliance

Placenta previa occurs when the placenta has implanted with extension approaching or directly over the internal cervical os. Most cases of placenta previa are actually minor, identified by routine prenatal uterine ultrasounds and do not require any intervention. However, symptomatic cases will often present to the emergency setting with painless vaginal bleeding during the third trimester of pregnancy. When placenta previa is considered, it is one of notable times when the emergency physician should avoid routine digital evaluations of the cervical os to avoid inciting more bleeding. Volumes of bleeding can be significant enough to cause hemorrhagic shock. If the amount of bleeding is small, bed rest and conservative management may be recommended in coordination with an obstetric specialist. However, depending on the amount of bleeding, urgent or emergent cesarean section may be indicated to optimize outcomes for both the mother and fetus. Previa can be confirmed by ultrasound.

Author Summary Prion disease is caused by misfolding of the prion protein (PrP), and can be either sporadic genetic, or acquired. Acquired cases arising from infection through dietary or medical routes are exceedingly rare today (<1% of cases). Sporadic cases occur apparently at random, without any major genetic risk factors, and are not passed down to subsequent generations. All cases of genetic prion disease to date have been traced to DNA changes that alter the amino acid sequence of PrP, and children of people with genetic prion disease are at 50/50 risk of inheriting these autosomal dominant DNA changes. Variably protease sensitive prionopathy, or VPSPr, is a rare and unusual subtype of prion disease, in which there are no changes in PrP’s amino acid sequence, and yet, a high proportion of patients appear to have a family history of dementia, although none to date have had family members diagnosed with prion disease specifically. VPSPr is currently categorized as a sporadic prion disease, but it has been speculated that it may have a genetic cause in a different gene or in a region of the PrP gene that does not change the amino acid sequence. Here we performed DNA sequencing on 67 VPSPr cases to search for a genetic cause. We found no DNA changes that could potentially cause VPSPr. While it is difficult to prove the negative — a causal genetic change could still exist in some part of the genome where we did not search — our data support the notion that VPSPr is truly sporadic in nature, and that risk of VPSPr is not transmitted in families.

Objectives Few opportunities exist for postgraduate physicians to learn to address racism in their professional practice. We created a virtual, 5-session antiracism course that included the development of a formal action project to address racism at participants’ home institution. Methods We delivered this curriculum virtually to 2 cohorts (2021 and 2022) of postgraduate physicians, nationally. The curriculum had 3 educational aims: (1) to increase knowledge on antiracism, (2) to increase comfort and engagement in discussing antiracism at home institutions, and (3) to increase self-efficacy to execute an institution-based project. Theory-informed practice, community building, and project-based learning were used to achieve our educational aims. We analyzed changes in these domains in addressing racism using matched 7-item Likert-scale questions from pre- and post-course surveys and the Wilcoxon signed rank test. We assessed perceptions and impacts of the course with post-course survey items using descriptive statistics. Results Forty-three of 50 participants (86%) who completed pre- and post-course surveys were included in the analysis. We found pre–post course increases in mean scores (converted from Likert scales), for all 15 paired questions. For example, we found improvements in understanding the historical context of racism in medical institutions (mean score change: 5.12 [SD 1.00] to 6.42 [SD 0.76], P < .001), comfort in talking to colleagues about racism (5.21 [SD 1.08] to 6.19 [SD 0.70], P < .001), and capacity to address racism in patient care at their home institution (4.51 [SD 1.35] to 5.56 [SD 0.91], P < 0.001). 93% reported the course increased the likelihood of working to address racism at their institution. Conclusion This project-based antiracism course for postgraduate learners increased self-reported knowledge of, comfort with, and self-efficacy in addressing racism and was well received by participants.

Purpose: Ethical erosion literature describes medical students' patient centredness and empathy declines through their clinical years of training. Longitudinal Integrated Clerkships (LICs), an alternate clinical educational design, have been hypothesised to reduce ethical erosion. The authors aimed to measure change in medical students' patient centredness and empathy at an institution with the largest LIC worldwide. Method: Two whole LIC cohorts (LIC1 and LIC2) were invited to complete a questionnaire, which included patient centredness and empathy scales. Students completed the questionnaire at the start and end of each academic year. Block-rotation students (Non-LIC) were a comparator cohort. Complete cases data were analysed. Results: 22 Non-LIC, 66 LIC1 and 33 LIC2 students responded. Non-LIC students experienced a significant decline in empathy ([start] 113.14 vs. [end] 102.68, p<.001). Empathy did not significantly decline in the LIC cohorts. Patient centredness in LIC1 and LIC2 grew and reduced in the Non-LIC cohort, however, these changes were not statistically significant. Conclusions: This study supports the hypothesis LICs may reduce ethical erosion when compared to block-rotation placements. The results provide evidence that ethical erosion occurs in students who have completed block-rotation placements. This is the first study of UK-based medical students measuring empathy and patient centredness following completion of an LIC.

Lønborg J, Jabbari R, Sabbah M, et al; NOTION-3 Study Group. PCI in patients undergoing transcatheter aortic-valve implantation. N Engl J Med. 2024 Aug 31. [Epub ahead of print.] 39216095.

Background The well-being of healthcare teams is an important consideration when seeking to improve patient experience and quality of care. Prior studies have found that changes to working conditions are most effective in improving clinician well-being. Integrative Group Medical Visits (IGMVs) modify working conditions in ways that have potential to improve clinician experience. Objective The objective of this study was to understand healthcare teams’ experiences with IGMVs. Methods In this qualitative study, interviews were conducted via Zoom and telephone with 21 clinicians, administrators, and staff from safety-net healthcare settings throughout the United States (U.S.) who have implemented IGMVs for patients with chronic pain. Interviews included questions about clinician experience, well-being, and satisfaction with the IGMV model. Interviews were recorded, transcribed, and coded using thematic content analysis by a team of trained qualitative researchers. Results The authors identified five themes describing how IGMV positively affected clinician well-being: organizational supports, human-centered engagement, collaboration with an interprofessional team, provision of guideline-concordant care, and enhanced meaning and purpose for the clinicians. Conclusion The current study was the first to use interviews from healthcare teams who have implemented IGMV to assess their experience. The themes identified warrant further investigation into IGMVs as a strategy to promote clinician well-being and mitigate aspects of burnout.

Introduction Psychiatric measurement‐based care (MBC) can be more effective than usual care, but health systems face implementation challenges. Achieving attitudinal alignment before implementing MBC is critical, yet few studies incorporate perspectives from multiple stakeholders this early in planning. This analysis identifies alignment and themes in pre‐implementation feedback from patients, providers, and administrators regarding a planned MBC implementation in a safety net psychiatry clinic. Methods We used interview guides informed by Conceptual Model of Implementation Research to gather qualitative pre‐implementation attitudes about perceived Appropriateness, Acceptability, and Feasibility of an MBC measure (Computerized Adaptive Test—Mental Health; CAT‐MH) from five patients, two providers, and six administrators. We applied rapid qualitative analysis methods to general actionable feedback for department leadership still planning implementation. We used a multistep process to generate thematic findings with potential relevance for other similar mental health settings. Results There was more attitudinal alignment across stakeholder groups regarding MBC's Acceptability and Feasibility than its Appropriateness. All three groups agreed that it was important to contextualize MBC for patients and providers, anticipate MBC's impact on patient–provider relationships, and consider the system's capacity to respond to patient needs unearthed by CAT‐MH before implementation began. Our thematic analysis suggests: (1) Introducing MBC may complicated patient–provider relationships by adding a new and potentially conflicting input for decision making, that is, MBC data, to the more typical inputs of patient report and provider expertise; (2) MBC poses theoretical risks to health equity for safety net patients because of limitations in access to MBC tools themselves and the resources needed to respond to MBC data; and (3) Tension exists between individual‐ and system‐level applications of MBC. Conclusions Our analysis highlights shifting treatment dynamics, equity considerations, and tension between individual‐ and population‐level needs that our participants anticipated when planning for MBC implementation in a safety net psychiatry clinic.

Following the devastating 1994 Genocide, the Government of Rwanda and its citizens have worked relentlessly to rebuild the country and reassemble a strong health system. Immediately after the genocide, global development partners sought to swiftly provide aid and support to the country to address urgent health system needs. However, inadequate coordination of the influx of aid resulted in duplicated efforts and inefficient health sector management. In 1998, the Central Public Investments and External Finance Bureau undertook the monitoring and evaluation of donor-funded projects and management of the Public Investment Program. However, the Bureau had limited time, resources, and health system expertise, impeding its efforts to effectively coordinate development partners. To address these inefficiencies, the Rwandan government next adopted a Sector-Wide Approach to coordinate the support of development partners at the sector level. Again, this coordination approach did not adequately consider the health sector’s needs. In 2011, the Single Project Implementation Unit (SPIU) structure was created to coordinate national- and district-level government sectoral initiatives, including ensuring that intended populations were included in planning and decision-making processes. In the health sector, this included a focus on the overall goal of achieving universal health coverage. The health sector SPIU has aided Rwanda in addressing systemic financing issues at all health system levels. Challenges remain; in particular, the SPIU has struggled to align some development partners with the Government’s planning calendar to maximize efficiency. It also needs to optimize the use of technology in the health sector to ensure timely decision making.

Objective: The objective of this study was to explore the acceptability and feasibility of a therapeutic assessment protocol for the Screening and Support of Youth (SASY). SASY provides brief but comprehensive community-based screening and support for diverse youth in the community. Methods: SASY screening evaluates symptoms, functioning and clinical risk. The Kiddie Computerized Adaptive Test was used to evaluate seven different diagnoses and symptom severity. The Weiss Functional Impairment Rating Scale-Self was used to measure functional impairment. Measures were scored according to nationally developed norms. An algorithm was developed to aggregate symptom and function ratings into an overall score for clinical risk. The results are discussed with participants in a motivational interview designed to promote insight, followed by the opportunity for the participant to engage in an online intervention. Protocol changes necessitated by social distancing during the pandemic led to innovative methods including the use of a QR code for recruitment, integration of both online and offline participation, and expansion from in-person recruitment within the schools to virtual engagement with youth throughout the community. The final sample included disproportionately more Black or African American and Hispanic youth as compared to school and community statistics, suggesting that optimization of online and offline methods in research may facilitate the recruitment of diverse populations. Qualitative interviews indicated that the screening and feedback raised youth awareness of their wellbeing and/or distress, its impact on their functioning, and engagement with options for improved wellbeing. Conclusions: The emergence of innovative methods optimizing the advantages of both online and offline methods, developed as a necessity during the pandemic, proved advantageous to the feasibility and acceptability of community-based recruitment of at-risk, minoritized youth.

Fumarate hydratase (FH) mutated papillary renal cell carcinoma is an aggressive variant of kidney cancer that poorly responds to conventional targeted therapies and immunotherapy. Here, we present the 10-year follow-up of a heavily pre-treated patient with several lines of therapy, achieving a remarkable complete response to anti-PD-1 rechallenge. In addition, we highlight a common immune-related adverse event of anti-PD-1, eosinophilia, as a possible biomarker of response and using TCGA data analysis, provide proof-of-concept for tumor expression of the eosinophil-related gene SIGLEC8, as a promising powerful predictor of prognosis for papillary renal cell carcinoma patients.

Background Heart-Smile Training (HST) is an interoceptive compassion-based behavioral intervention that in case reports has been beneficial for depression. Interoception refers to the awareness and regulation of physiological signals from inside the body. Depressed patients often have diminished interoceptive awareness and often experience disconnection from bodily needs and sensations. In addition to interoceptive dysfunction, depression often involves negative self-evaluation and self-critical rumination. HST is a compassion-based meditation training program that explicitly cultivates interoceptive awareness of the heart area. This study aims to investigate the possible neurocardiac mechanisms engaged through HST for depression patients. Methods We plan to enroll 50 subjects to be randomized into a 4-week HST intervention group and a waitlist group. A battery of psychological questionnaires will be administered at baseline and post-intervention timepoints, and electroencephalography (EEG) will be collected during compassion meditation guided by pre-recorded audio. The primary clinical outcome measures are on the feasibility of the intervention and research procedures, the primary mechanistic outcome measure is the post-intervention change in Heartbeat Evoked Potential (HEP) amplitude. Secondary outcome measures include changes in depression severity and EEG gamma spectral activity. Exploratory outcome measures include effects of HST on skin conductance response, heart rate variability, EEG spectral properties in other frequency bands, as well as a list of psychological questionnaires that measure depression and anxiety symptoms, emotion regulation, mindfulness, interoceptive awareness, self-compassion, gratitude, sleep quality, quality of life and social connectedness. Results Results not yet available. Conclusion This is the first study on the feasibility and interoceptive neurocardiac mechanism of HST. Our findings will provide frontier knowledge on the physiological working mechanism of behavioral interventions with an interoception-based meditative approach. https://clinicaltrials.gov/study/NCT05564533 .

Rationale: Early-life exposures may precipitate asthma, but their contribution to disparities in asthma is less clear. Objective: To elucidate racial, ethnic, and socioeconomic status (SES) disparities in the age trajectory of asthma burden among US children. Methods: We analyzed three datasets: (1) 2016-2021 National Children's Health Survey (NCHS) (n=223,551); (2) 2015-2017 Child Asthma Call-Back Survey (ACBS) (n=4,289); and (3) 2018-2019 National Inpatient Sample (NIS) (n=23,713 children with asthma). We examined cumulative asthma prevalence by individual-year of age and children's race and ethnicity or SES (NCHS); mean age at asthma diagnosis by race and ethnicity and SES, unadjusted and adjusted for confounders (ACBS); and asthma hospitalization rates overall and per child with asthma by individual year of age and race and ethnicity (NIS). Results: Among White children, cumulative asthma prevalence rises gradually through childhood, to 6.6% at age 5 and 16.1% by age 17. Prevalence rises more sharply in early childhood among Black children, reaching 17.6% at age 5 (RR 2.6;95%CI 1.9,3.8), but plateaus after age 9, with a consequent decline in Black-White relative disparities into adolescence. Disparities according to SES follow a similar trajectory, emerging early and subsequently narrowing. Similarly, Black, Hispanic and low-income children with asthma are diagnosed at an earlier age than White (or high-income) children. The asthma hospitalization rate rises in the first years of life among all children, but most rapidly among Black children, with a peak absolute Black-White gap at age 4; the relative gap remains wide throughout childhood and peaks at age 10. However, per child with asthma, relative disparities in White-Black hospitalizations rise through age 15. Conclusions: Disparities in asthma prevalence emerge in early childhood and then narrow, suggesting that reducing early-life adverse environmental exposures may be key to asthma prevention. Policies to improve the social determinants of health during gestation and childhood, e.g. environmental equity and family income support, are needed.

Research about the distribution of gambling activity and what percentage certain subgroups of gamblers are responsible for is mixed, but all indicates that a small minority (i.e., the vital few) is responsible for a greater amount of gambling activity than the large majority (i.e., the trivial many). The present pre-registered study extends this line of research to a large dataset of digital gambling records for a cohort of sports bettors from Europe (n = 36,331) over a 6-year period (2015–2020) to examine (1) whether distributions based on amount wagered and net loss in this cohort change over time on a yearly basis, (2) the extent to which individuals are stable or change their distribution group membership from the vital few to the trivial many (and vice versa) over time, and (3) how distribution group membership predicts the use of a cool-off feature (i.e., a temporary break from being able to gamble on the website) and self-exclusion (i.e., permanent exclusion from the gambling website). We observed that gambling expenditure distributions were mainly stable over time. Individual distribution group membership varied, such that the size of the vital few comprised 3 to 6.5% of active users each year. The largest subgroup was an early churn subgroup (i.e., stopped playing after the first year; about 66% of the sample), followed by people who remained in the trivial many for their study period (i.e., the stable trivial; 21 to 22%). Moving between distribution groups over time was strongly associated with using cool-off or self-exclusion features. Our findings have important implications for understanding the distributions of gambling spending among sports gamblers, the extent to which membership in high-spending groups remains stable over time, and potential risks for responsible gambling tool use and gambling-related problems.

Introduction: Nanoparticles (NPs) are widely used in the pharmaceutical field to treat various human disorders. Among these, lipid-based NPs (LNPs), including solid lipid nanoparticles (SLN) and nanostructured lipid carriers (NLC), are favored for drug/bioactive delivery due to their high stability, biocompatibility, encapsulation efficiency, and sustained/controlled release. These properties make them particularly suitable as carriers of compounds derived from plant sources. Areas covered: This study comprehensively explores updated literature knowledge on SLN and NLC, focusing on their composition and production methods for the specific delivery of drug/bioactive compounds derived from plant sources of interest in pharmaceutical and biomedical fields. Expert opinion: SLN and NLC facilitate the development of more effective natural product-based therapies, aiming to reduce dosage and minimize side effects. These delivery systems align with the consumer demands for safer and more sustainable products, as there are also based on biocompatible and biodegradable raw materials, thereby posing minimal toxicological risks while also meeting regulatory guidelines.