Limitations in health care access and utilization among long‐term survivors of adolescent and young adult cancer

BACKGROUND:

Health care outcomes for long‐term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

METHODS:

Eligible participants were 20 to 39 years of age. There were N = 979 who self‐reported a cancer diagnosis between the ages of 15 to 34 years and were at least 5 years from diagnosis (excluding nonmelanoma skin cancer). The remaining 67,216 participants with no cancer history were used as controls. Using multivariable regressions, relative risks and 95% confidence intervals were generated to examine the relationship of survivor status on indicators of poor health care (uninsured, no personal health care provider, no routine care, and avoiding seeing a doctor due to cost). Adjusted proportions were calculated by demographic groups. Results are weighted by Behavioral Risk Factor Surveillance System survey design.

RESULTS:

Although the proportion uninsured did not differ (21% of survivors vs 23% of controls), AYA survivors reported forgoing care due to cost at higher levels than controls (relative risk = 1.67, 95% CI = 1.44‐1.94). Cost barriers were particularly high for survivors aged 20 to 29 years (44% vs 16% of controls; P < .001) and female survivors (35% vs 18% of controls; P < .001). Survivors reporting poorer health had more cost barriers. Moreover, uninsured survivors tended to report lower use of health care than did controls.

CONCLUSIONS:

AYA cancer survivors may forgo health care due to cost barriers, potentially inhibiting the early detection of late effects. Expanding health insurance coverage for young cancer survivors may be insufficient without adequate strategies to reduce their medical cost burdens. Cancer 2012. © 2012 American Cancer Society.     

Hybrid measurement of respiratory aerosol reveals a dominant coarse fraction resulting from speech that remains airborne for minutes

Accurate measurements of the size and quantity of aerosols generated by various human activities in different environments are required for efficacious mitigation strategies and accurate modeling of respiratory disease transmission. Previous studies of speech droplets, using standard aerosol instrumentation, reported very few particles larger than 5 μm. This starkly contrasts with the abundance of such particles seen in both historical slide deposition measurements and more recent light scattering observations. We have reconciled this discrepancy by developing an alternative experimental approach that addresses complications arising from nucleated condensation. Measurements reveal that a large volume fraction of speech-generated aerosol has diameters in the 5- to 20-μm range, making them sufficiently small to remain airborne for minutes, not hours. This coarse aerosol is too large to penetrate the lower respiratory tract directly, and its relevance to disease transmission is consistent with the vast majority of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections initiating in the upper respiratory tract. Our measurements suggest that in the absence of symptoms such as coughing or sneezing, the importance of speech-generated aerosol in the transmission of respiratory diseases is far greater than generally recognized.

Respiratory tract infections are caused by a wide range of pathogenic organisms (1), including a large array of respiratory viruses, such as influenza virus, rhinovirus, measles virus, respiratory syncytial virus, adenovirus, and most recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In all these diseases, person-to-person spread involves respiratory droplets, which originate from the mucus layer that covers the epithelium of the respiratory tract or from oral fluid present in the mouth, mostly as saliva. Thus, characterizing respiratory droplets is essential to understanding respiratory pathogen transmission and will inform effective public health policies to curb infections. Four mechanisms for droplet generation are generally considered: breathing, speaking (singing, laughing, etc.), coughing, and sneezing (2). Considering the well-recognized importance of asymptomatic transmission of SARS-CoV-2 (3), our study focuses on the first two of these mechanisms.As highlighted by Wells (4) and Duguid (2) nearly a century ago, the vast majority of respiratory droplets are smaller than ca. 100-μm diameter and fully dehydrate once entering the atmosphere. These desiccated droplets can remain airborne for minutes to hours before landing on solid surfaces. If generated by a person infected by a respiratory virus, they will contain virions that can remain viable and infectious for many hours (5, 6). Upon inhalation, airborne particles can reach different parts of the respiratory tract depending on their size: coarse aerosols with diameter D ≳ 5 μm (7) deposit in the upper respiratory tract (URT), and fine aerosols with D < 5 μm can penetrate deep into the lower respiratory tract (LRT). Many viral pathogens, including SARS-CoV-2, influenza, rhinovirus, and measles virus, can infect both URT and LRT epithelia (1, 8, 9), with URT infections typically associated with mild initial symptoms and LRT infections possibly resulting in life-threatening pneumonia (1, 10–13). Direct infection of the LRT, before the adaptive immune system has been triggered by vaccination or a preceding URT infection, presents a greater risk.An URT infection also can expand into the LRT through microaspiration of oropharyngeal fluids (14, 15). The extent to which inhalation of self-generated URT cough, speech, or sneeze aerosols may contribute to this migration remains unknown. However, it has been argued that this pathway could be significant because an infected carrier is invariably at the center of their own speech aerosol cloud, which results in strongly elevated exposure (16). The risk of migration from the URT to the LRT rises with the viral load and the viability of the virus, which peak around and just prior to the onset of symptoms, respectively (17, 18). For the original Wuhan strain of the SARS-CoV-2 virus, the onset of symptoms occurs about 5 days after the initial infection (17, 19), but it occurs somewhat earlier for the more infectious delta and omicron variants (20).To evaluate the risk of LRT infection, it is important to know the size distribution of particles generated by various respiratory activities. For talking, coughing, and sneezing, studies historically relied on slide sampling techniques of increasing sophistication, followed by microscope observation (2, 21, 22). Droplets generated by breathing or vowel sounds are numerous but very small (≲2 μm) and thus more difficult to evaluate with those classical methods. Instead, such small droplets are now commonly quantified by aerosol detection equipment, such as optical particle sizers (OPSs), based on light scattering (22, 23); aerodynamic particle sizers (APSs), based on the time-of-flight measurement in an accelerating flow field (24); and scanning mobility particle sizers that derive a particle’s size from its mobility in an electric field and are best suited for very small sizes (≲1 μm) (25, 26). APS instruments are less efficient at detecting medium-sized liquid particles, and undercounts as high as 75% for 10-μm droplets have been reported (27).There is some confusion in the literature about the hydration state of reported sizes of respiratory aerosol particles, which shrink by a factor of γ upon evaporation of their aqueous content, thus by a factor of γ³ in volume. After full dehydration, a particle’s radius is determined by its amount of nonvolatile matter. Estimates for γ vary substantially: Nicas et al. (28) proposed γ = 2 for breath particles, based on data extracted from breath condensate by Effros et al. (29) that indicated a high fraction (ca. 8% wt/vol) of glycoproteins, presumably mucins. Holmgren et al. (30) reported γ = 2.4 for breath particles when the relative humidity (RH) is reduced from 99.5% in the small airways to 75%. Bagheri et al. (26) observed γ = 4.5 for singing particles in a diffusion dryer or γ = 4 for large saliva droplets observed directly by microscope imaging. Some of those measurements were conducted directly at the mouth opening, observing the hydrated state using light scattering or holographic imaging techniques (26, 31). Clearly, the concentration of pathogens in dehydrated particles scales with γ³ relative to the originating airway lining fluid (ALF) or saliva. However, the high uncertainty in the applicable γ value, which is frequently not even reported, prevents accurate estimates of airborne virus concentrations.Recently, we and others demonstrated that speech particles can be readily observed by simple video recordings of light scattering by these particles (32–35). Such recordings not only present a visually compelling warning to the public but also provide opportunities to monitor particles before, during, and after dehydration. Those light scattering measurements focused on particles larger than a few microns due to technical sensitivity issues. The intensity of scattered light scales with the square of a particle’s diameter, causing a dynamic range problem and rendering it more challenging to observe the smallest particles, especially in the presence of larger particles. Inexpensive, fast consumer cameras typically use 10- to 12-bit analog-to-digital converters (ADCs), thereby limiting dynamic range; while detectors with an increased ADC range are available, their speed is often insufficient for high-speed recording.Here, we aim to evaluate the entire range of speech droplet sizes produced during different breathing and speaking protocols. To do so, we combined video-recorded light scattering and an OPS to evaluate droplets from 0.3 to 100 μm. Our data show a continuous spectrum that lacks previously reported gaps in the size distribution (36). Our measurements confirm that the gravitational settling rate for dehydrated particles larger than 5 μm steeply increases with size, but considering the high numbers, volumes, and airborne lifetimes of those particles, they are likely to be a dominant factor in transmission of disease.     

Stakeholder-Generated Implementation Strategies to Promote Evidence-Based ADHD Treatment in Community Mental Health

Community implementation of evidence-based practices (EBPs) for Attention Deficit/Hyperactivity Disorder (ADHD) is greatly lacking. A recent randomized community-based trial of an EBP for ADHD (Supporting Teens’ Autonomy Daily; STAND) demonstrated suboptimal implementation and effectiveness outcomes. In the present study, we conducted an Innovation Tournament (IT) with agency staff stakeholders (N?=?26) to identify barriers to successful implementation of STAND and implementation strategies for a revised service delivery model. We conducted member-checking of agency staff-generated ideas with parents (N?=?226) and subsequent querying of additional parent (N?=?226) and youth-generated (N?=?205) strategies to improve care. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance. Practical barriers (i.e., transportation, scheduling difficulties) and parent/youth engagement were the most commonly cited obstacles to successful implementation of STAND in community contexts. Eighteen “winning” implementation strategies were identified that survived member checking. These were classified as train and educate stakeholders (n?=?5; e.g., train agency supervisors to deliver supervision, digitize treatment materials and trainings), engage consumers (n?=?9; e.g., begin treatment with rapport building sessions, increase psychoeducation), provide interactive assistance (n?=?2; e.g., add group supervision, increase roleplay in supervision), and use of evaluative/iterative strategies (n?=?2; e.g., perform fidelity checks, supervisor review of session recordings). Parents and youth desired longer duration of treatment and increased focus on maintenance. Strategies will be developed and tested as part of a pilot effectiveness trial designed to refine STAND’s service delivery model.

Trial Registration NCT02694939 www.clinicaltrials.gov

     

Inconsistencies Between Actual and Estimated Blood Alcohol Concentrations in a Field Study of College Students: Do Students Really Know How Much They Drink?

BACKGROUND: Alcohol use by college students is commonly measured through the use of surveys. The validity of such data hinge on the assumption that students are aware of how much alcohol they actually consume. Recent studies call this assumption into question. Students tend to overestimate the appropriate sizes of standard drinks, suggesting that they might underestimate how much alcohol they consume. If this is true, then students' actual blood alcohol concentrations (BACs) should be higher than BACs estimated based on self-report data. The present study examined this issue METHODS: Breathalyzer readings and self-reported drinking data were collected from 152 college students during the fall of 2004. Estimated BACs were calculated by means of a standard formula, and the relation between actual and estimated BACs was examined. Factors contributing to discrepancies between the two values were identified RESULTS: Estimated BAC levels were significantly higher, not lower, than breath BAC measures. The accuracy of estimated BACs decreased as the number of drinks and amount of time spent drinking increased. Being male and drinking only beer predicted greater accuracy of estimated BACs CONCLUSIONS: Although laboratory data suggest that students underestimate how much they drink, the hypothesis was not supported by data collected in the field. It appears that students might actually overestimate rather than underestimate their levels of consumption when surveyed in the midst of a night of drinking. The findings corroborate observations made by other researchers and suggest that the findings of laboratory studies on college drinking do not necessarily extend to real-world settings.     

Designing a Primary Care–Based Deprescribing Intervention for Patients with Dementia and Multiple Chronic Conditions: a Qualitative Study

BackgroundPatients with dementia and multiple chronic conditions (MCC) frequently experience polypharmacy, increasing their risk of adverse drug events.ObjectivesTo elucidate patient, family, and physician perspectives on medication discontinuation and recommended language for deprescribing discussions in order to inform an intervention to increase awareness of deprescribing among individuals with dementia and MCC, family caregivers and primary care physicians. We also explored participant views on culturally competent approaches to deprescribing.DesignQualitative approach based on semi-structured interviews with patients, caregivers, and physicians.ParticipantsPatients aged ≥ 65 years with claims-based diagnosis of dementia, ≥ 1 additional chronic condition, and ≥ 5 chronic medications were recruited from an integrated delivery system in Colorado and an academic medical center in Maryland. We included caregivers when present or if patients were unable to participate due to severe cognitive impairment. Physicians were recruited within the same systems and through snowball sampling, targeting areas with large African American and Hispanic populations.ApproachWe used constant comparison to identify and compare themes between patients, caregivers, and physicians.Key ResultsWe conducted interviews with 17 patients, 16 caregivers, and 16 physicians. All groups said it was important to earn trust before deprescribing, frame deprescribing as routine and positive, align deprescribing with goals of dementia care, and respect caregivers’ expertise. As in other areas of medicine, racial, ethnic, and language concordance was important to patients and caregivers from minority cultural backgrounds. Participants favored direct-to-patient educational materials, support from pharmacists and other team members, and close follow-up during deprescribing. Patients and caregivers favored language that explained deprescribing in terms of altered physiology with aging. Physicians desired communication tips addressing specific clinical situations.ConclusionsCulturally sensitive communication within a trusted patient-physician relationship supplemented by pharmacists, and language tailored to specific clinical situations may support deprescribing in primary care for patients with dementia and MCC.Electronic supplementary materialThe online version of this article (10.1007/s11606-020-06063-y) contains supplementary material, which is available to authorized users.KEY WORDS: deprescribing, patient-physician communication, dementia