Changing Patterns of Medical Visits and Factors Associated with No-show in Patients with Rheumatoid Arthritis during COVID-19 Pandemic

BackgroundThe main barrier to the effective rheumatoid arthritis (RA) therapy is poor adherence. Coronavirus disease 2019 (COVID-19) pandemic have led to a significant change in the pattern and the number of medical visits. We assessed changing patterns of medical visits and no-show, and identified factors associated with no-show in patients with RA during COVID-19 pandemic.MethodsRA patients treated with disease-modifying antirheumatic drugs at least 6 months who had been in remission or those with mild disease activity were observed for 6 months from February to July 2020. No-show was defined as a missed appointment that was not previously cancelled by the patient and several variables that might affect no-show were examined.ResultsA total of 376 patients and 1,189 appointments were evaluated. Among 376 patients, 164 patients (43.6%) missed appointment more than one time and no-show rate was 17.2% during COVID-19 pandemic. During the observation, face-to-face visits gradually increased and no-show gradually decreased. The logistic regression analysis identified previous history of no-show (adjusted odds ratio [OR], 2.225; 95% confidence interval [CI], 1.422–3.479; P < 0.001) and fewer numbers of comorbidities (adjusted OR, 0.749; 95% CI, 0.584–0.961; P = 0.023) as the independent factors associated with no-show.ConclusionMonthly analysis showed that the no-show rate and the pattern of medical visits gradually changed in patients with RA during COVID-19 pandemic. Moreover, we found that previous history of no-show and fewer numbers of comorbidities as the independent factors associated with no-show.     

Subjective Health Complaints and Self-Rated Health: Are Expectancies More Important Than Socioeconomic Status and Workload?

Background

The associations between socioeconomic status (SES), physical and psychosocial workload and health are well documented. According to The Cognitive Activation Theory of Stress (CATS), learned response outcome expectancies (coping, helplessness, and hopelessness) are also important contributors to health. This is in part as independent factors for health, but coping may also function as a buffer against the impact different demands have on health.

Purpose

The purpose of this study was to investigate the relative effect of SES (as measured by level of education), physical workload, and response outcome expectancies on subjective health complaints (SHC) and self-rated health, and if response outcome expectancies mediate the effects of education and physical workload on SHC and self-rated health.

Methods

A survey was carried out among 1,746 Norwegian municipal employees (mean age 44.2, 81 % females). Structural Equation Models with SHC and self-rated health as outcomes were conducted. Education, physical workload, and response outcome expectancies, were the independent 28 variables in the model.

Results

Helplessness/hopelessness had a stronger direct effect on self-rated health and SHC than education and physical workload, for both men and women. Helplessness/hopelessness fully mediated the effect of physical workload on SHC for men (0.121), and mediated 30 % of a total effect of 0.247 for women. For women, education had a small but significant indirect effect through helplessness/hopelessness on self-rated health (0.040) and SHC (?0.040), but no direct effects were found. For men, there was no effect of education on SHC, and only a direct effect on self-rated health (0.134).

Conclusions

The results indicated that helplessness/hopelessness is more important for SHC and health than well-established measures on SES such as years of education and perceived physical workload in this sample. Helplessness/hopelessness seems to function as a mechanism between physical workload and health.     

Assessment of the stylohoid chain by 3D-CT

BACKGROUND: To assess the variations of stylohyoid chain (SHC) using 3D-CT. METHODS: We evaluated a total of 200 SHC on the head/neck CT scans of 100 patients (44 females, 56 males, age range 18-73 years). All of the patients had been scanned for neck lesions other than those concerning the region of the SHC. The morphology of both SHCs was examined in the 3D-CT images and the following aspects were evaluated; 1. length, 2. thickness, 3. mediolateral angling (MLA), 4. anteroposterior angling (APA), and 5. bending of the SHC. RESULTS: Absence of the styloid process (n: 5), double proximal origin (n: 2), segmentation (n: 49), and complete ossification (n: 2) were found. The length of the SHC was 27.9 +/- 11.3 mm, and 26.2 +/- 11.1 mm on the right and left, respectively. The mean thickness of the SHC was 5 mm, and it showed positive correlation with length (P < 0.05). MLA was 73.2 +/- 6.7 and 70.7 degrees +/- 8.0 degrees for the right and left, respectively. APA was 64.6 degrees +/- 10.1 degrees and 62.7 degrees +/- 10.2 degrees for the right and left, respectively. There was a negative correlation between the right and left MLA (P = 0.001), and a positive correlation between the right and left APA (P = 0.001). Nine SHCs had bending of the lower end. CONCLUSION: Three-dimensional CT gives detailed and reliable information about the SHC. We propose that the bending and thickness, which are new parameters, should be taken into consideration in the CT evaluation and classification of SHC variations.     

On the influence of time-series length in EMD to extract frequency content: Simulations and models in biomedical signals

In this paper, fractional Gaussian noise (fGn) was used to simulate a homogeneously spreading broadband signal without any dominant frequency band, and to perform a simulation study about the influence of time-series length in the number of intrinsic mode functions (IMFs) obtained after empirical mode decomposition (EMD). In this context three models are presented. The first two models depend on the Hurst exponent H, and the last one is designed for small data lengths, in which the number of IMFs after EMD is obtained based on the regularity of the signal, and depends on an index measure of regularity. These models contribute to a better understanding of the EMD decomposition through the evaluation of its performance in fGn signals. Since an analytical formulation to evaluate the EMD performance is not available, using well-known signals allows for a better insight into the process.The last model presented is meant for application to real data. Its purpose is to predict, in function of the regularity signal, the time-series length that should be used when one wants to divide the spectrum into a pre-determined number of modes, corresponding to different frequency bands, using EMD. This is the case, e.g., in heart rate and blood pressure signals, used to assess sympathovagal balance in the central nervous system.     

Association analysis of the SHC1 gene locus with longevity in the Japanese population

The SHC1 gene encodes a signaling and transforming protein that has been implicated in the aging process in worms and mammals. In this study we examined 230 Japanese centenarians and 180 healthy younger controls and looked at the SHC1 locus as a candidate region that may be associated with longevity. We identified 12 single nucleotide polymorphisms (SNPs) within a 10-kb region encompassing the entire SHC1 gene from the DNA of 30 centenarians and 24 healthy younger controls. Five SNPs, including three nonsynonymous sites, lay within coding elements, six were located within introns, and one was in the 3 untranslated region. All of these SNPs were relatively rare, with a minor allele frequency of less than 5% in our subjects. A pairwise linkage disequilibrium analysis using the r ² statistic showed that two of the SNP pairs are in tight linkage disequilibrium at this locus. We investigated the possible association of SHC1 with longevity using association analyses with allelotypes and haplotypes but found that the SNPs identified in SHC1 had no impact on longevity for Japanese centenarians.Abbreviations LD Linkage disequilibrium - SNP Single nucleotide polymorphism     

Underdiagnosis of hypochondriasis in family practice

A hypochondriasis questionnaire (the Whitely Index) was administered to 109 family practice outpatients and their medical records were audited to determine the rate of detection of hypochondriasis and its impact on physician behavior. Patients who scored high on the Whitely Index were more likely to have received screening laboratory testing, and to have high no-show rates, along with significantly more numbers of symptoms shown in the record, which, however, did not contain any references to somatization.     

The effect of prospective payment on Medicare expenditures

Medicare's prospective payment system was introduced in 1983 to slow the growth of expenditures for hospital care, which from the bulk of Medicare costs. Instead of reimbursing hospitals for the actual costs of patient care, the system pays them at fixed rates for each admission. In this study, we estimated the savings to Medicare from the use of prospective payment. We analyzed the expenditure projections published in 10 successive annual reports (1979 to 1988) by the trustees of the federal Hospital Insurance Trust Fund, which pays hospital bills for Medicare beneficiaries. To show the effect of prospective payment, these projections were adjusted to correct for the different assumptions about inflation and admissions made in each report. We also examined trends in expenditures from the Supplementary Medical Insurance Trust Fund, which pays for outpatient services, to see whether the savings in hospital expenses were offset by higher spending for out-of-hospital services. We found that prospective payment has reduced Medicare's hospital costs substantially. Expenditures from the Hospital Insurance Trust Fund for 1990 are expected to be +12 billion less in 1980 dollars, and +18 billion in 1990 dollars, than was expected shortly before prospective payment went into effect--the equivalent of a savings of approximately 20 percent. By contrast, the effect of prospective payment on the supplementary fund has not been great. We conclude that the prospective payment system is having a major impact on Medicare's hospital expenditures and that the savings is not offset by an increase in outpatient expenditures.     

散发性丙型肝炎患者病毒学和临床特点

调查了１６例散发性丙型肝炎（ＳＨＣ）患者丙型肝炎病毒（ＨＣＶ）感染原因：３例为外科医生；３例的配偶为慢性输血后丙型肝炎（ＰＴＨＣ）患者；５例有拔牙、注射或接种史；５例感染途径不明。ＳＨＣ患者的病毒血症水平明显低于ＰＴＨＣ患者（血清稀释倍数前者为１０～１００倍；后者为１００～１００００倍，Ｐ＜０．０１）。仅１例ＳＨＣ患者抗－ＨＣＶ阳性。与ＰＴＨＣ患者相比，ＳＨＣ患者肝脏损害程度较轻，转氨酶水平较低，且多无自觉症状。     

Universal school‐based eating disorder prevention: Benefits to both high‐ and low‐risk participants on the core cognitive feature of eating disorders

The objective of this study was to explore two aspects not investigated in a 2.5‐year controlled evaluation of an 8‐lesson media literacy program. First, the impact of the program on over‐evaluation of shape and weight. Second, an examination of the program effects by participant baseline risk of developing an eating disorder. Grade 8 students (N = 540, mean age = 13.62 years) were assessed at baseline, post‐program, 6‐month, and 2.5‐year follow‐up. Controlling for baseline observations, linear mixed model analyses revealed a main effect for group, favouring media literacy, and a group × risk interaction, where high‐risk media literacy participants had significantly lower over‐evaluation scores than high‐risk control participants. Both high‐risk media literacy girls and boys, and low‐risk media literacy girls scored significantly lower at 2.5‐year follow‐up than controls. Media literacy can have a lasting, beneficial impact in reducing the core cognitive component of eating disorders in both high‐ and low‐risk young adolescents.     

Empty nest or revolving door? A prospective study of women's quality of life in midlife during the phase of children leaving and re-entering the home

BACKGROUND: This study documents changes in household composition and effects on women's quality of life of children leaving and returning home. METHODS: A 9-year annual prospective study of a population-based sample of mid-aged Australian-born women who were premenopausal at baseline (N = 438) was conducted. Documentation was made of household composition and change, well-being, bothersome symptoms, daily hassles, feelings for partner and frequency of sexual activities. RESULTS: There was an increase in the number of women living alone, and a reduction in number of households in which there were children or parents. Each year > 25% of women reported a change in household composition. In the first year after the last child departed (N = 155), there was an improvement in women's positive mood and total well-being and a reduction in negative mood and the number of daily hassles. This improvement in mood was confined to those women who at baseline were not worried about children leaving home. In the first year after children return home there was a trend towards reduced frequency of sexual activities but no mood changes. CONCLUSIONS: For the majority of women, the departure of the last child from the household leads to positive changes in women's mood state and a reduced number of daily hassles. Return of offspring may have an adverse effect on sexual relating of the parents.     

Improving clinical productivity in the academic setting: a novel incentive plan based on utility theory.

PURPOSE: Academic internal medicine practices face growing challenges to financial viability due to high overhead, competing institutional missions, and suboptimal physician productivity. The authors describe the development of a clinical incentive plan for a group of academic subspecialty physicians at the Dana Clinic, an outpatient setting at Yale School of Medicine, and report on results of the first year's experience under the plan. METHOD: Utility theory was used to assess the risk profile of clinic faculty and identify incentive payments that would optimize faculty benefit or "utility" while minimizing departmental costs. Under the plan, physicians who reached a productivity target based on work Relative Value Units (wRVUs) between October 2003 and November 2004 had overhead costs covered and received a fixed payment to support salary; additional incentive payments were available for those exceeding the target. Physicians failing to reach the target were responsible for their own overhead costs and received no fixed payment. Physician productivity as measured by wRVU per full-time equivalent (FTE) was compared for the year prior to, and the year following, incentive plan introduction. RESULTS: Forty-seven members of eight academic sections were included in the analysis. Median productivity improved by 34%, with 42 of 47 physicians showing improvement. Significant improvements were also noted in collections (62%) and visit volume (23%), and shifts were observed in coding patterns. CONCLUSIONS: The unique threshold-based structure of the incentive plan, as determined through utility theory modeling, as well as permitting physicians to choose how to achieve the wRVU target were key features of its success, resulting in improved productivity without increasing practice resources or faculty salaries.     

The impact of alternating dissection on student performance in a medical anatomy course: Are dissection videos an effective substitute for actual dissection?

The way in which anatomy is taught to first year medical students at the University of North Carolina at Chapel Hill was recently changed, so that first year students are now divided into two groups that dissect alternately. The effect of this change on both written and practical test performance was analyzed by comparing grades from 2004 with those from the previous year (2003), when students performed all the dissections. A statistically significant decrease (P < or = 0.05) from 2003 was noted on three of the four written test scores in 2004, while practical examination scores in 2004 fluctuated from lower to higher than those in 2003, depending on the unit of material being covered. However, the number of students failing each of the examinations (written and practical combined) was statistically greater on only one of the four examinations in 2004. Scores of the two groups dissecting alternately in 2004 were essentially the same on the practical examinations. There was no difference in the number of questions answered incorrectly between these two groups in the two practical examinations where comparisons were made. Furthermore, students who dissected a particular structure did not score significantly better on practical questions concerning that structure than students who had not dissected it. The effect of the availability of step-by-step dissection videos on student practical examination scores is also discussed. We conclude that the change in the curriculum had a significant impact on the students' written examination performance, given the same material in the course. The reasons for this include student course load, increased need for self-study, and a loss of a learning opportunity in the dissection laboratory, all of which affect student comprehension and retention of the material and their ability to use it in problem solving.     

State pathology societies and the future of pathology

In this time of significant change in pathology and medicine, pathology's future is uncertain. Many issues, including the emergence of molecular medicine, the demand for personalized medicine, confusing payment schemes, increasing governmental regulation, medical education challenges, administrative relationships, and new malpractice concerns, are critical topics pathologists are addressing and must continue to address in the future to best assure quality health care for patients.     

Prediction of psychological functioning one year after the predictive test for Huntington''s disease and impact of the test result on reproductive decision making.

For people at risk for Huntington's disease, the anxiety and uncertainty about the future may be very burdensome and may be an obstacle to personal decision making about important life issues, for example, procreation. For some at risk persons, this situation is the reason for requesting predictive DNA testing. The aim of this paper is two-fold. First, we want to evaluate whether knowing one's carrier status reduces anxiety and uncertainty and whether it facilitates decision making about procreation. Second, we endeavour to identify pretest predictors of psychological adaptation one year after the predictive test (psychometric evaluation of general anxiety, depression level, and ego strength). The impact of the predictive test result was assessed in 53 subjects tested, using pre- and post-test psychometric measurement and self-report data of follow up interviews. Mean anxiety and depression levels were significantly decreased one year after a good test result; there was no significant change in the case of a bad test result. The mean personality profile, including ego strength, remained unchanged one year after the test. The study further shows that the test result had a definite impact on reproductive decision making. Stepwise multiple regression analyses were used to select the best predictors of the subject's post-test reactions. The results indicate that a careful evaluation of pretest ego strength, depression level, and coping strategies may be helpful in predicting post-test reactions, independently of the carrier status. Test result (carrier/ non-carrier), gender, and age did not significantly contribute to the prediction. About one third of the variance of post-test anxiety and depression level and more than half of the variance of ego strength was explained, implying that other psychological or social aspects should also be taken into account when predicting individual post-test reactions.     

Effect of chronic psychosocial stress on nonalcoholic steatohepatitis in mice

Nonalcoholic fatty liver disease (NAFLD) is characterized by hepatic lipid accumulation which may progress towards inflammation (nonalcoholic steatohepatitis (NASH)). NAFLD is regarded as a consequence of a sedentary, food-abundant lifestyle which, in the modern world, often coincides with chronically high levels of perceived psychosocial stress. Here, we aimed to characterize the effect of chronic psychosocial stress on the development of NAFLD/NASH in male mice either fed with standard chow or NASH-inducing high fat diet. Chronic psychosocial stress was induced by chronic subordinate colony housing (CSC), a pre-clinically validated paradigm relevant for human affective and somatic disorders. Single housed (SHC) mice served as controls. Under standard chow conditions CSC mice revealed lower hepatic triglyceride levels but higher hepatic TNFα, MCP-1 and HMOX mRNA expression, while serum transaminase levels did not significantly differ from SHC mice. Under the NASH-inducing high-fat diet CSC and SHC mice showed similar body weight-gain and serum levels of glucose and adiponectin. Moreover, liver histology as well as TNFα, MCP-1 and HMOX expression were similar in CSC and SHC mice fed with HFD. Surprisingly, CSC showed even significantly lower transaminase levels than SHC mice fed with the same NASH-inducing diet. Together, these data indicate that under normal dietary conditions the CSC model induces noticeable hepatic oxidative stress and inflammation without causing manifest hepatocellular injury. In contrast, CSC exhibited a protective effect on hepatocellular injury in a dietary NASH-model. Identification of the underlying mechanisms of this phenomenon may lead to novel therapeutic strategies to prevent progression of NAFLD.     

Differential changes in the end-plate architecture of functionally diverse muscles during aging

Architectural changes at the neuromuscular junctions of three functionally diverse muscles, the diaphragm, extensor digitorum longus (EDL), and soleus, were studied in rats from adulthood (10 mo) through senescence (31 mo). End-plate structure was examined using a silver-gold impregnation of the axon and its terminal arborization. The mean number of terminal branches per end plate, including those that appeared to exhibit signs of sprouting or degeneration, were examined as a function of age. Nerve terminal branch length, the number of major myelinated axon branches per end plate, and end-plate area were also examined. To ascertain trends in the data, smoothing of mean values for time-series analysis was performed. Both fast-twitch diaphragm and EDL muscles revealed more pronounced fluctuations in nerve terminal branch number during aging than did the slow-twitch soleus. Smoothed trends of the mean number of nerve terminal branches per end plate show that nerve terminal proliferation increased with age at the diaphragm neuromuscular junction but decreased at the hindlimb junctions. Age-related changes in average terminal branch number progressed gradually in all muscles until 25 mo of age, after which we observed a precipitous increase at 28 mo and subsequent decline at 31 mo. Trends of change indicate that although sprouting within the diaphragm was maintained during aging, both EDL and soleus experienced a general decline in sprouting. Degeneration generally decreased at all nerve-muscle junctions with aging, although the decline began at a later age in the diaphragm. Analysis of mean data values indicates that in both the EDL and soleus, sprouting and degeneration attained minimum values at 25 mo of age. This was followed by a significant increase at 28 mo and then a decline by 31 mo of age. In general, sprouting fluctuated more severely than degeneration. We conclude that despite the variability from one age to the next, age-related trends of change are evident in nerve terminal branch number. The direction of these changes appears to be influenced by the degree to which muscle activity is maintained during aging. However, regardless of functional status, all three muscles experienced dramatic changes in end-plate morphology after 25 mo of age.     

Moving from preconditions for action to developing a cycle of continued social change: tapping the potential of mini‐grant programs

One way in which community‐based initiatives have sought to overcome challenges to resident participation in neighborhood change processes is through the implementation of neighborhood mini‐grant programs. However, the mechanisms by which these grants function and any related limitations have not yet been empirically evaluated. This paper seeks to close this gap in the literature. Findings from an evaluation of one mini‐grant project are reported. Overall, it was found that mini‐grants were successful at generating preconditions for action in targeted neighborhoods. However, sustained resident involvement in neighborhood change activities was only engendered by a small number of mini‐grant projects. Recipients of these particularly impactful grants shared similar key characteristics. Implications for practice are discussed. © 2009 Wiley Periodicals, Inc.     

Proliferative activity of the parathyroid cells in rats with secondary hyperparathyroidism

Proliferative kinetics of parathyroid cells in secondary hyperparathyroidism (HPT) are still unknown. We examined the histopathological changes and proliferative activity of parathyroid cells in spontaneously hypercholesterolemic (SHC) rats that exhibit secondary HPT and in normal Sprague Dawley (SD) rats from 3 weeks to 32 weeks of age. Proliferative activity [proliferating cell nuclear antigen(PCNA) labeling index], evaluated by means of immunohistochemical examination of PCNA, declined in SD rats with age from 10.8% at 3 weeks of age to 0.15% at 32 weeks of age. In SHC rats, a PCNA labeling index of 11.6% declined to 3.12% at 14 weeks of age and rebounded to 6.15% at 26 weeks of age. Parathyroid glands increased in size as determined by the maximum cross-sectional area, but in SHC rats, the increase was significantly greater, paralleling the progression of renal dysfunction, and at 32 weeks they were almost three times larger than in SD rats. Parathyroid hormone (PTH) levels in SHC rats also rose sharply after 20 weeks and reached 611 pg/ml at 32 weeks, while PTH in SD rats remained unchanged at approximately 110 pg/ml. This study showed that in the course of developing HPT in SHC rats, there is a large increase in the size of the parathyroid gland, a concomitant increase in PTH levels, and a PCNA labeling index that is higher than in normal SD rats.