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Abstract Background Peripheral artery disease (PAD) is a common circulatory disorder associated with increased hospitalizations and significant health care-related expenditures. Among patients with PAD, insurance status is an important determinant of health care utilization, treatment of disease, and treatment outcomes. However, little is known about PAD-costs differences across different insurance providers. In this study we examined possible disparities in length of stay and total charge of inpatient hospitalizations among patients with PAD by insurance type. Methods We conducted a cross-sectional analysis of length of stay and total charge by insurance provider for all hospitalizations for individuals with PAD in South Carolina (2010–2018). Cross-classified multilevel modeling was applied to account for the non-nested hierarchical structure of the data, with county and hospital included as random effects. Analyses were adjusted for patient age, race/ethnicity, county, year of admission, admission type, all-patient refined diagnostic groups, and Charlson comorbidity index. Results Among 385,018 hospitalizations for individuals with PAD in South Carolina, the median length of stay was 4 days (IQR: 5) and the median total charge of hospitalization was $43,232 (IQR: $52,405). Length of stay and total charge varied significantly by insurance provider. Medicare patients had increased length of stay (IRR = 1.08, 95 CI%: 1.07, 1.09) and higher total charges (β: 0.012, 95% CI: 0.007, 0.178) than patients with private insurance. Medicaid patients also had increased length of stay (IRR = 1.26, 95% CI: 1.24,1.28) but had lower total charges (β: -0.022, 95% CI: -0.003. -0.015) than patients with private insurance. Conclusions Insurance status was associated with inpatient length of stay and total charges in patients with PAD. It is essential that Medicare and Medicaid individuals with PAD receive proper management and care of their PAD, particularly in the primary care settings, to prevent hospitalizations and reduce the excess burden on these patients.

Abstract Background Managing Abstinence in Newborns (MAiN) is an evidence-based, cost-saving approach to caring for infants at risk of developing neonatal opioid withdrawal syndrome (NOWS). MAiN provides medication management in combination with education and is being implemented in hospitals across South Carolina (SC). This expansion of MAiN throughout the state includes educational training for providers on managing NOWS symptomology and evaluation support for data collection and analysis. This evaluation assessed the readiness of hospitals to implement MAiN by identifying potential barriers and facilitators to early program adoption. Methods We used the Consolidated Framework for Implementation Framework (CFIR) to guide the evaluation. As part of the ongoing evaluation of MAiN implementation, brief, structured interviews were conducted with healthcare providers (n = 82) at seven hospitals between 2019 and 2022 to learn more about perceived barriers and facilitators to implementation readiness. Two coders independently reviewed all transcripts and used deductive thematic analysis to code qualitative data using Atlas.ti Web using the established CFIR codebook. Results We identified barriers and facilitators to implementing MAiN in all five CFIR domains. Providers identified MAiN as an evidence-based, patient-centered model with the flexibility to adapt to patients’ complex needs. Specific champions, external support, alignment with providers’ personal motivation, and an adaptable implementation climate were identified as facilitators for implementation readiness. Barriers included a lack of consistent communication among hospital providers, minimal community resources to support patients and families after discharge, and a lack of provider buy-in early in implementation. Conclusions Key barriers and facilitators of MAiN implementation readiness were identified at seven participating hospitals throughout SC. Communication, staff and hospital culture and climate, and internal and external resource were all reported as essential to implementation. These findings could inform the MAiN program expansion in hospitals across SC.

Abstract Background X-linked sideroblastic anaemia (XLSA) is commonly due to mutations in the ALAS2 gene and predominantly affects hemizygous males. Heterozygous female carriers of the ALAS2 gene mutation are often asymptomatic or only mildly anaemic. XLSA is usually characterized by microcytic erythrocytes (reduced mean corpuscular volume (MCV)) and hypochromia, along with increased red cell distribution width. However, in females with XLSA the characteristic laboratory findings can be dimorphic and present with macrocytic (elevated MCV) in addition to microcytic red cells. Case presentation We report a case of fetal anaemia, presenting in the early third trimester of pregnancy, in a female fetus. Ultrasound findings at 29 weeks were of cardiomegaly, prominent umbilical veins, a small rim of ascites, and mean cerebral artery peak systolic velocity (PSV) value above 1.5 Multiples of the Median (MoM). She underwent non-invasive prenatal testing that determined the rhesus genotype of the fetus to be rhesus B negative. No red blood cell antibodies were reported. Other investigations to determine the underlying cause of fetal anaemia included microarray comparative genomic hybridization, serology to exclude congenital infection and a peripheral blood film and fetal bilirubin to detect haemolysis. The maternal grandmother had a history of sideroblastic anaemia diagnosed at the age of 17 years. The mother had mild macrocytic anaemia with haemoglobin of 10.4 g/dl and MCV of 104 fl. The fetal anaemia was successfully treated with two in utero transfusions (IUTs), and delivery occurred via caesarean section at 37 weeks of gestation. The red cell gene sequencing in both the mother and fetus were heterozygous for an ALAS2 mutation causing in utero manifestations of XLSA. The haemoglobin on discharge to the local hospital at five days of age was 19.1 g/dl. Subsequently, the infant became anaemic, requiring regular 3–4 monthly blood transfusions and demonstrating overall normal development. Her anaemia was unresponsive to pyridoxine. Conclusions This is one of four cases reporting multiple female members presenting with discordant clinical features of XLSA from being entirely asymptomatic to hydropic in utero. Our report is novel in that there are no previous cases in the literature of anaemia in a female fetus heterozygous for ALAS2 mutation.

Increases in lung vascular permeability is a cardinal feature of inflammatory disease and represents an imbalance in vascular contractile forces and barrier‐restorative forces, with both forces highly dependent upon the actin cytoskeleton. The current study investigates the role of Ena‐VASP‐like (EVL), a member of the Ena‐VASP family known to regulate the actin cytoskeleton, in regulating vascular permeability responses and lung endothelial cell barrier integrity. Utilizing changes in transendothelial electricial resistance (TEER) to measure endothelial cell barrier responses, we demonstrate that EVL expression regulates endothelial cell responses to both sphingosine‐1‐phospate (S1P), a vascular barrier‐enhancing agonist, and to thrombin, a barrier‐disrupting stimulus. Total internal reflection fluorescence demonstrates that EVL is present in endothelial cell focal adhesions and impacts focal adhesion size, distribution, and the number of focal adhesions generated in response to S1P and thrombin challenge, with the focal adhesion kinase (FAK) a key contributor in S1P‐stimulated EVL‐transduced endothelial cell but a limited role in thrombin‐induced focal adhesion rearrangements. In summary, these data indicate that EVL is a focal adhesion protein intimately involved in regulation of cytoskeletal responses to endothelial cell barrier‐altering stimuli. Keywords: cytoskeleton, vascular barrier, sphingosine‐1‐phosphate, thrombin, focal adhesion kinase (FAK), Ena‐VASP like protein (EVL), cytoskeletal regulatory protein

BackgroundSocioeconomic factors have been shown to be associated with amputation in peripheral artery disease (PAD); however, analyses have normally focused on insurance status, race, or median income. We sought to determine whether community-level socioeconomic distress was associated with major amputation and if that association differed by race.Materials and methodsCommunity-level socioeconomic distress was measured using the distressed communities index (DCI). The DCI is a zip code level compositive socioeconomic score (0–100) that accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. A distressed community was defined as a zip code with DCI of 40 or greater. We calculated one-year risk of major amputation by DCI score for individuals with peripheral artery disease in South Carolina, 2012–2017. Treating death as competing event, we reported Fine and Gray subdistribution hazards ratios (sdHR), adjusted for patient demographic and clinical comorbidities associated with amputation. Further analyses were completed to identify potential differences in outcomes within strata of race and DCI.ResultsAmong 82,848 individuals with peripheral artery disease, the one-year incidence of amputation was 3.5% (95% CI: 3.3%, 3.6%) and was significantly greater in distressed communities than non-distressed communities (3.9%; 95% CI: 3.8%, 4.1% vs. 2.4%; 95% CI: 2.2%, 2.6%). After controlling for death and adjusting for covariates, we found an increased hazard of amputation among individuals in a distressed community (sdHR: 1.25; 95% CI: 1.14, 1.37), which persisted across racial strata. However, regardless of DCI score, Black individuals had the highest incidence of amputation.ConclusionSocioeconomic status is independently predictive of limb amputation after controlling for demographic characteristics and clinical comorbidities. Race continues to be an important risk factor, with Black individuals having higher incidence of amputation, even in non-distressed communities, than White individuals had in distressed communities.

The pervasive use of antibiotics in human medicine, veterinary medicine, and agriculture can result in a significant increase in the spread and environmental persistence of antibiotic resistance in marine ecosystems. This study describes the presence and distribution of antibiotic-resistant bacteria in Salish Sea harbor seals (Phoca vitulina) and harbor porpoises (Phocoena phocoena) and evaluates species, age class, and geographic differences in resistance patterns. Isolates from 95 dead-stranded animals (74 seals/21 porpoises) were tested for resistance to a suite of 15 antibiotics. Of the 95 sampled, 85 (89%) (67 seals/18 porpoises) successfully yielded 144 isolates, with 37% resistant to at least one antibiotic and 26% multi-drug resistant (24% and 39% of seal and porpoise isolates, respectively). Overall, and by study region, porpoises were significantly more likely to harbor resistant organisms compared to seals. Significant differences between age classes were noted for the antibiotics amoxicillin, cephalexin, and cefovecin. Overall isolate resistance was significantly greater in porpoises than seals for several individual antibiotics. Multiple antibiotic resistance (MAR) indices greater than 0.2 were observed in 55% of multi-drug resistant isolates, suggesting seal and porpoise exposure to anthropogenic pollution. The relatively high and disparate prevalence of antibiotic resistance in these common, but ecologically dissimilar, marine mammals reflects a potentially large environmental pool of antibiotic resistant organisms in the Salish Sea or inherently different resistance gene patterns between the two species.

Objective: This report describes the experiences of a community-based palliative care (CBPC) program's efforts to understand the patterns of hospital utilization, specifically utilization reduction experienced by admitted patients. Efforts to quantify and describe an avoided hospitalization and opportunities to use these data to strengthen partnerships with local insurance payers to assure sustainability of the CBPC will be discussed. Background: Patients with serious chronic illness experience emergency room care and hospitalizations with increasing frequency as their health deteriorates. CBPC programs are well positioned to decrease hospital utilization by early involvement and improved care management. Methods: Arizona Palliative Home Care (AZPHC) program is a free standing CBPC in Maricopa County, Arizona, serving 3300 patients annually. An interdisciplinary team was formed within the CBPC to facilitate the identification of avoided hospital events and communicate these data to community partners in an effective and consistent manner. The processes developed by this team are described. Results: AZPHC has enhanced its hospitalization avoidance strategies by communicating the rate of hospitalization avoidance events in a consistent and strategic manner. Providing instances of avoided hospitalizations with accompanying patient narratives to payers has enabled AZPHC to demonstrate the impact the CBPC has on improving quality of care and reducing overall costs. Discussion: CBPC programs require payment for sustainability; therefore, partnerships with local insurance payers are essential. Presenting data that validate the impact of a program from a clinical and financial perspective will advance the growth of payer?CBPC provider relationships and secure a future for funded CBPC programs.

Determinants of pediatric asthma management include child, family, healthcare, and community factors. The purpose of this study is to investigate how parents/guardians are impacted by and act on these factors to aid in their child’s asthma self-management. Interviews were conducted in Fall 2020 with 12 female parents/guardians of Black/African American children who participated in a community paramedic pilot study with their child in South Carolina. Children in the initial study had an asthma diagnosis of moderate persistent asthma, had Medicaid insurance, and were determined high-risk for emergency room presentation. Inductive and deductive qualitative analysis identified that child management self-efficacy and independence, parent/guardian health literacy, parent and child negative experiences related to asthma diagnosis and management, asthma management tools, and social support from multiple sources impact child self-management. Findings from this study highlight the importance of clear asthma education and management tool recommendations from healthcare and community providers, particularly for parents/guardians with low health literacy. Health literacy impacted parental responses and likely how families comprehend Medicaid and clinical asthma guidance.

Abstract Background Mothers who live with mental illness face diverse challenges. Research suggests that partner support or otherwise is likely to have a crucial influence on mothers’ abilities to manage these challenges, yet little is known about how this plays out. In this study, we aimed to explore the roles played by male partners in the mothering experiences of women living with mental illness. Methods We conducted a qualitative secondary analysis using interview data collected from 18 participants in two previous qualitative studies. Both studies focused on the mothering experiences of women who lived with mental illness. In both studies, the importance of male partners was striking. The data were analyzed using constant comparative analysis. Results The roles of partners in women’s experiences of mothering were multiple and dynamic, with each male partner playing a unique combination of roles. These included: facilitator; teammate; unfulfilled potential; distraction; dismantler, and threat to child. Roles were influenced by: mothers’ interpretations; partners' behaviors, characteristics and circumstances; the family’s living and custody arrangements; mothers’ active management strategies; and a range of external controls and supports. Conclusions Health professionals need to consider the complex roles partners play. This crucial aspect of mothers’ social environments can be optimized by directly supporting and enabling partners themselves, and by supporting mothers to actively shape their partners’ roles.

Delayed surgery is associated with worse lung cancer outcomes. Social determinants can influence health disparities. This study aimed to examine the potential racial disparity and the effects from social determinants on receipt of timely surgery among lung cancer patients in Louisiana, a southern state in the U.S. White and black stage I–IIIA non-small cell lung cancer patients diagnosed in Louisiana between 2004 and 2016, receiving surgical lobectomy or a more extensive surgery, were selected. Diagnosis-to-surgery interval >6 weeks were considered as delayed surgery. Social determinants included marital status, insurance, census tract level poverty, and census tract level urbanicity. Multivariable logistic regression and generalized multiple mediation analysis were conducted. A total of 3,616 white (78.9%) and black (21.1%) patients were identified. The median time interval from diagnosis to surgery was 27 days in whites and 42 days in blacks (P < 0.0001). About 28.7% of white and 48.4% of black patients received delayed surgery (P < 0.0001). Black patients had almost two-fold odds of receiving delayed surgery than white patients (adjusted odds ratio: 1.91; 95% confidence interval: 1.59–2.30). Social determinants explained about 26% of the racial disparity in receiving delayed surgery. Having social support, private insurance, and living in census tracts with lower poverty level were associated with improved access to timely surgery. The census tract level poverty level a stronger effect on delayed surgery in black patients than in white patients. Tailored interventions to improve the timely treatment in NSCLC patients, especially black patients, are needed in the future.