How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic

OBJECTIVES

In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors' executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic.

METHODS

We conducted an in-depth document review of state governors' executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers.

RESULTS

We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals.

CONCLUSION

Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

When Adolescents Disagree with Their Vaccine-Hesitant Parents about COVID-19 Vaccination

AbstractAs we journey into the fourth year of the COVID-19 pandemic, a majority of Americans express relief at a "return to normal," experience pandemic fatigue, or embrace the idea of living with COVID-19 in much the same way we live with the seasonal flu. But transition to a new phase of life with SARS-CoV-2 does not diminish the importance of vaccination. The US Centers for Disease Control and the Food and Drug Administration recently recommended another round of booster dose for persons age 5 and up, or an initial series for those not previously vaccinated, with an updated bivalent formula that protects against both the original virus strain and Omicron subvariants that are now the dominant source of infection. By most accounts most of the population has been or will become infected with SARS-CoV-2. Suboptimal uptake of the COVID-19 vaccines among the approximately 25 million adolescents in the United States is a significant obstacle to population coverage, public health, and the health and well-being of adolescents. A major cause of low adolescent uptake is parental vaccine hesitancy. This article discusses parental vaccine hesitancy and argues that permitting independent adolescent consent to COVID-19 vaccination should be an ethical and policy priority as we continue to confront the threat of Omicron and other variants of the coronavirus. We discuss the central role of the pediatric healthcare team in caring for adolescent patients who disagree with their parents about vaccination.

[Association between depression tendency and cognitive trajectory in the elderly in rural area in China]

Objective: To explore cognitive trajectory and its association with depression tendency in the elderly in rural area in China. Methods: Based on the data of the rural elderly aged ≥65 years in the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2011 to 2018, unconditional and conditional latent variable growth curve models were constructed to analyze the mini-mental state examination (MMSE) score trajectory and its association with depression tendency in the elderly. Results: A total of 1 788 elderly persons were included, and 19.1% of them had a depression tendency. The average MMSE score of those with and without a depression tendency at baseline survey were 26.62±3.54 and 27.59±3.17 respectively. The rate of MMSE score decline was 0.52 points (P<0.05). Before and after controlling covariates, the initial score was 0.84 points lower (P<0.05) and 0.81 points lower (P<0.05) in those with depressive tendency than in those without depressive tendency respectively, furthermore, the decline rate of MMSE score was 0.33 points lower (P<0.05) and 0.40 points lower (P<0.05) in those with depressive tendency than in those without respectively. Conclusions: The depression tendency in the elderly in rural area in China was associated with the cognitive function change trajectory, with those with depression tendency had lower-level trajectory. Attention should be paid to the mental health of the elderly in rural area to prevent dementia and slow its development.

How Preemption Can Lead to Inequity

American cities and localities have historically been places of innovation and incubation when it comes to advancing equity and inclusion. Now, local governments in many states are leading the fight for stronger public health protections against COVID-19-through mask mandates, stay-at-home orders, and paid leave provisions, among other actions. However, state lawmakers have long used preemption-state laws that block, override, or limit local ordinances-to stifle local government action, often under pressure from corporate interests and political ideology. Through preemption, state lawmakers have obstructed local communities-often majority-minority communities-from responding to the expressed needs and values of their residents through policies. In this article, we first look at the context behind preemption and its disparate effects. After establishing a conceptual framework for measuring disparities, we discuss how the current COVID-19 pandemic is disproportionately harming the same communities that have been preempted from taking local action, limiting their ability to effectively combat the public health crisis. We argue that all stakeholders interested in health equity have a role to play in addressing the misuse of state preemption.

Imposing a health insurance surcharge on the unvaccinated

COVID-19 hospitalizations among unvaccinated individuals cost billions of dollars. More employers are considering imposing a premium surcharge on employees participating in the company's health plan who are not vaccinated against COVID-19. These employers see this approach as similar to health premium surcharges for tobacco use, justifying the higher premiums on the basis that unvaccinated individuals could cause the plan to experience higher hospitalization and related costs. However, imposing a surcharge on unvaccinated employees will require employers to think through legal and policy implications and the interests of their employees and their businesses. Employers should weigh their vaccination goals against these interests and consider whether a legally compliant surcharge would further their goals. Employers should carefully consider the prevailing culture among their employees and assess whether the policy would be effective and noncoercive. Premium surcharges may be effective for some but not all employers.

Perceptions and patient care needs among hepatitis B patients during COVID-19

Background

The novel coronavirus of 2019 (COVID-19) has been and continues to be a rapidly developing public health crisis, that has also disrupted routine and maintenance health care for people living with chronic conditions. Some of these chronic conditions also put individuals at increased risk of COVID-19 complications, particularly if the condition is not under control. For these reasons, the exploratory study reported here examined the needs and preparedness of patients at a community health organization that specifically provides hepatitis B virus (HBV) care for high-risk groups that had previously tested positive for HBV.

Methods

Current study utilized exploratory analysis of qualitative COVID-19-related statements collected during calls to a total of 44 patients reached during April and May, 2020 in the Washington D.C. area. Researchers worked with a community based non-profit organization to reach current HBV + and HCV + patients to provide retention in care and assess patient needs in maintaining management of their condition adapted to include offering medication refills, telehealth, and other resources. We gathered emergent themes, using socio-ecological framework, regarding capacity and needs for managing their chronic condition in a vulnerable population during the initial, most interrupted, time period of a global public health crisis.

Results

From the notes of the calls, five thematic categories emerged: COVID-19 prevention awareness, assistance program access, medical resource access, access to knowledge and awareness about assistance programs, and needs and barriers. From these five themes, providers can develop strategies to better prepare their patients and provide care to patients with chronic conditions during major disruptions.

Conclusions

Future recommendations include increasing hepatitis and COVID-19 vaccine efforts, collaborating with community partners, and screening and understanding social determinants of health that affect racial and ethnic minorities.

Liability Waivers for COVID-19: Law, Policy, and Practice

As businesses reopen, the practice of asking customers to sign COVID-19 liability waivers is increasing throughout the United States. Although the courts have not yet decided the enforceability of COVID-19-related liability waivers, existing case law, as well as new executive and legislative actions, suggests that such waivers may offer some protection to businesses from liability. Nevertheless, we believe that the legal and ethical rationales underlying liability waivers are not applicable to a pandemic. We further argue that the challenging nature of and the substantial unknowns about the novel coronavirus make waivers contrary to public policy. Fears over floods of litigation appear thus far unfounded, and businesses should not be relieved from their obligation of taking reasonable safety precautions. Waivers are not a panacea to reopen businesses in an ongoing pandemic, and the ultimate protection against liability is to operate in a manner that minimizes the spread of the virus consistent with evidence-based guidelines.

Linkage-to-Care Following Community-Based HBV and HCV Screening Among Immigrants from the Washington–Baltimore Metropolitan Area, 2016–2019

Understanding characteristics that impact linkage-to-care (LTC) among individuals living with HBV and/or HCV can enhance public health efforts to provide tailored care services to prevent and treat viral hepatitis among immigrants. Using HBV/HCV screening and LTC data from immigrants (2016–2019), descriptive and logistic regression analyses were conducted to assess (1) the relationship between LTC and sociodemographic factors and (2) factors associated with HBV/HCV LTC. About 87% of those positive HBsAg had LTC and 52% had LTC among those with HCVAB and confirmed PCR. Access to care was an important LTC predictor for HBV–LTC: those who had neither health insurance nor primary care provider (PCP) were more likely to have HBV–LTC than those who had either health insurance or PCP (aOR = 2.95, 95% CI = 1.32–6.59). It is essential to equally provide HBV/HCV LTC support to all immigrants from countries with high prevalence regardless of access to care.

[Differences of water barrier function between keloid and its surrounding normal skin in patients with keloids and its related mechanism]

Objective: To compare the differences of water barrier function between keloids and its surrounding normal skin in patients with keloids, and to explore the primary mechanism. Methods: A cross-sectional observational study was conducted. From October 2020 to March 2021, 30 patients with keloids who met the inclusion criteria visited Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, including 18 females and 12 males, aged 20-48 years. The transepidermal water loss (TEWL) of their keloids and the surrounding normal skin of the 30 patients were measured by multi probe adapter on the reception day. The keloid tissues and normal skin of 5 patients after keloid repair surgery were processed for hematoxylin-eosin staining to measure the thickness of epidermis. Immunohistochemistry was performed on samples from 3 of those 5 patients to detect the expressions of cytokeratin-10, involucrin, and filaggrin in keloids and normal skin. Data were statistically analyzed with paired sample t test and independent sample t test. Results: On the reception day, the TEWL of keloids of 30 patients was 9.0 (6.9, 13.4) g·m-2·h-1 and the TEWL of the normal skin was 8.1 (6.4, 18.1) g·m-2·h-1, between which the difference was not statistically significant (t=0.44, P>0.05). After keloid repair surgery, the thickness of epidermis in the keloids of 5 patients was (194±44) μm, which was significantly thicker than that of the normal skin (44±11) μm, (t=6.88, P<0.01). Furthermore, increased keratinocytes, lack of normal epidermal ridge structures, and thickened stratum corneum were observed in the keloid area. After keloid repair surgery, the expression level of cytokeratin-10 in keloids was significantly lower than that in normal skin of 3 patients (t=8.50, P<0.01), but there were no statistically significant differences in the expression levels of involucrin or filaggrin between keloids and normal skin (with t values of 0.07 and 0.96, respectively, P>0.05). Conclusions: Keloid tissue from patients with keloids displays increased number of keratinocytes and thickened epidermis. But the water barrier function in keloid area is similar to the surrounding normal skin, suggesting that TEWL may not be the main mechanism lead to the persistent development of keloids.

Marijuana Use and Increases in Use over Time among Young Adult College Students in the State of Georgia: Analyses of Sociocontexual Predictors

BACKGROUND

While research has assessed correlates of marijuana use, there has been less focus on predictors of differing levels of changes in use during young adulthood, a critical period for use/escalation.

OBJECTIVES

We examined changes in marijuana use and related sociocontextual predictors (e.g., earlier-onset substance use, parental use, college type).

METHODS

Using data from Georgia college students (ages 18-25 years) in a 2-year, 6-wave longitudinal study (64.6% female, 63.4% White), 2-part random-effects modeling examined use at any assessment and number of days used.

RESULTS

Predictors of use status at any assessment included being male (OR = 1.87, 95%CI = [1.28-2.73]), Black (OR = 1.91, 95%CI = [1.15-3.19]), earlier-onset marijuana (OR = 2.63, 95%CI = [1.70-4.06]), cigarette (OR = 2.04, 95%CI = [1.19-3.48]), and alcohol users (OR = 1.49, 95%CI = 1.00-2.22]), parental tobacco (OR = 2.14, 95%CI = [1.18-3.86]) and/or alcohol use (OR = 1.55, 95%CI = [1.09-2.20]), and attending private (vs. public) institutions (OR = 1.68, 95%CI = [1.10-2.59]). Predictors of lower likelihood of use over time included being male (OR = 0.87, 95%CI = [0.77-0.98]), earlier-onset cigarette use (OR = 0.82, 95%CI = [0.68-0.98]), parental alcohol use (OR = 0.86, 95%CI = [0.77-0.97]), and private institution students (OR = 1.17, 95%CI = [1.02-1.34]). Predictors of more days used at baseline included being male (OR = 1.77, 95%CI = [1.40-2.23]), Black (OR = 1.42, 95%CI = [1.04-1.93]), earlier-onset marijuana (OR = 2.32, 95%CI = [1.78-3.01]) and alcohol users (OR = 1.29, 95%CI = [1.01-1.66]), and parental tobacco use (OR = 1.90, 95%CI = [1.32-2.73]). Predictors of fewer days used over time included being older (OR = 0.98, 95%CI = [0.97-1.00]), parental tobacco use (OR = 0.86, 95%CI = [0.78-0.95]), and attending private institutions (OR = 0.89, 95%CI = [0.83-0.93]).

CONCLUSIONS

Intervention efforts can be informed by current findings that correlates of baseline use (e.g., being male, attending private institutions) also predicted less use over time, and one's earlier use and parents' use of various substances impacted young adult use.

[Comprehensive measurement and quantification of bio-mechanical properties of the temporomandibular joint disc]

Objective: To comprehensively investigate the biomechanical properties of the temporomandibular joint (TMJ) disc and to perfect the mechanical testing system of the TMJ disc by conducting tests of compression, tension, cyclic compression, cyclic tension, creep and friction. Methods: Fifteen fresh goat heads (weighing 2.5-3.0 kg) were purchased from the market. They were all ordinary goats (9-12 months old, body weighing 18-21 kg) regardless of gender. Bilateral articular discs (a total of 30) were dissected within 30 minutes after execution. According to the national standard for mechanical testing of viscoelastic materials, fresh TMJ disc specimens of goat were prepared and tests were carried out in physiological conditions. The universal mechanical testing machine was utilized to test biomechanical properties of TMJ discs. Results: The compressive modulus of TMJ discs was (8.41±2.12) MPa and the tensile modulus was (9.54±3.26) MPa. The mechanical characteristics would be irreversibly altered once the load exceeded the physiological range. In addition, it underwent apparent creep relaxation under continuous strain (0.5 MPa or 3.0 MPa) and the surface friction coefficient of the TMJ discs (0.015+0.011) was much lower than that of general viscoelastic materials. Conclusions: The TMJ disc was a bio-viscoelastic structure with excellent tensile and compressive properties and its surface was extremely smooth in wet conditions.

Campus tobacco control policies and cessation interventions in college students: a commentary calling for research and action to address tobacco-related health disparities

Tobacco-related health disparities (TRHDs) have a significant impact on population health in the USA. Effectively preventing and controlling TRHDs among young adult populations require multiple prevention and cessation points, including within college/university contexts. This commentary addresses current campus tobacco control policies and cessation interventions for U.S. college students, with an emphasis on TRHDs and opportunities for research and research translation to reduce these disparities. This commentary is informed by literature published between 2010 and 2020 regarding (a) prevalence and impact of campus tobacco control policies; and/or (b) behavioral outcomes from cessation interventions for young adults attending colleges. Despite a doubling of college campuses adopting tobacco-free policies from 2012 to 2017, roughly two-thirds continue to operate without such policies. Few policies address alternative tobacco products (e.g., e-cigarettes, cigars/cigarillos, and hookah), and communication about and enforcement of existing policies is extremely limited. A broad range of cessation intervention strategies have targeted individuals in this age group, but with little focus on TRHDs and limited intervention dissemination. Importantly, college students representing populations at risk for TRHDs (e.g., racial/ethnic/sexual/gender minorities, low socioeconomic status) are less likely to be exposed to strong tobacco control policies or supports for cessation. There are untapped opportunities for behavioral medicine approaches to reduce TRHDs in college settings. Research findings regarding multilevel (policy, community-level, and individual-level) interventions must be translated to policy/practice in order to address tobacco use, particularly among vulnerable college student populations.

[Role of histone demethylase KDM6B in HBx-mediated podocyte-macrophage transdifferentiation]

Objective: To explore the expression of lysine (k)-specific demethylase 6B (KDM6B) in the renal tissues of hepatitis B virus-associated glomerulonephritis (HBV-GN) patients and human podocytes transfected with hepatitis B virus X (HBx) gene, and its role in HBx-mediated podocyte-macrophage transdifferentiation (PMT). Methods: Forty-eight patients diagnosed as HBV-GN by renal biopsy from 2013 to 2018 at the Shanghai Jiaotong University Affiliated First People's Hospital were included in this study. Thirty patients with primary glomerulonephritis (PGN) and fifteen patients with renal tumor were chosen as control group. The expression of KDM6B and macrophage marker F4/80 in renal tissues of HBV-GN patients was observed by immunofluorescence and immunohistochemistry. The association between kidney KDM6B levels and clinical features of HBV-GN patients was analyzed. The expression of KDM6B, F4/80, major histocompatibility complex (MHC)-Ⅱ and CD40 in the podocytes was detected by Western blotting. The contents of interferon-γ (IFN-γ) and interleukin-6 (IL-6) in the supernatant were determined by enzyme-linked immunosorbent assay (ELISA). The small interfering RNA of KDM6B (KDM6B siRNA) was used to silence the expression of KDM6B and the protein levels of KDM6B, F4/80 and tri-methylation of lysine 27 of histone H3 (H3K27me3) induced by HBx gene transfection were detected by Western blotting. Results: Renal KDM6B expression was significantly increased in HBV-GN patients compared to normal control (0.022±0.004 vs 0.006±0.002, P=0.006). There was no significant difference in the positive rate of KDM6B among different pathological types of HBV-GN (P=0.139). Moreover, co-expression of KDM6B and F4/80 could be observed in the podocytes of HBV-GN patients. Patients with estimated glomerular filtration (eGFR)<60 ml·min^-1·(1.73 m²)^-1or proteinuria ≥ 3.5 g/day had a significantly higher renal KDM6B expression compared to control groups (all P<0.05). In addition, the expression of KDM6B, F4/80, MHC-II and CD40 was significantly up-regulated in the podocytes transfected with HBx gene (all P<0.05). The content of IFN-γ and IL-6 in the supernatant was significantly increased (all P<0.05). After gene silencing of KDM6B, the expression of F4/80 induced by HBx in the podocytes was significantly down-regulated, while the level of H3K27me3 was significantly increased (both P<0.05). Conclusions: HBx could induce KDM6B expression in podocytes and initiate PMT, thereby involving in the dysfunction of immune microenviroment in the renal tissues of HBV-GN.

Effect of alfalfa hay and starter feed supplementation on caecal microbiota and fermentation, growth, and health of yak calves

The caecum is the primary site where microbial fermentation and acidosis occurred. The supplementation of starter feed and alfalfa hay has the potential to influence caecal microbiota and then affect caecal fermentation. This study aims to investigate the effect of starter feed and alfalfa hay supplementation on caecal microbiota, immune homeostasis, and growth of preweaning yaks. Twenty 30-day-old male yak calves were randomly assigned to four groups, which separately fed with milk replacer (CON group), milk replacer with alfalfa hay (A group), milk replacer with starter feed (S group), and milk replacer with starter feed plus alfalfa hay (SA group) throughout the trial. Growth performance and plasma physiological and biochemical indicators were measured every 30 days. Calves were sacrificed at 120 days of age. The caecal contents were collected for measuring pH and contents of volatile fatty acids (VFAs) and lipopolysaccharide (LPS) and for characterizing caecal microbiota. The results indicated that individual or simultaneous supplementation with alfalfa hay and starter feed all significantly increased the BW, body height, body length, and chest girth of yak calves. However, supplementation with starter feed significantly increased plasma cortisol, nitric oxide, tumor necrosis factor-α, and interferon-γ concentrations and the ratio of aspartate aminotransferase to alanine aminotransferase of yak calves when compared with the control and alfalfa hay feeding groups, while the co-supplementation of starter feed and alfalfa hay could significantly decrease these inflammation-related indices when compared with the starter feeding group. Sequencing of the 16S rRNA gene showed that starter feed and alfalfa hay separately stimulated the proliferation of starch-decomposing and cellulose- or hemicellulose-decomposing bacteria. This also significantly increased the levels of acetate, propionate, butyrate, valerate, isobutyrate, and isovalerate in the caecal contents. Furthermore, compared with the S and CON groups, the significantly increased genera of Desulfobulbus, Olsenella, Pseudoflavonifractor, and Stomatobaculum in the SA and A groups were beneficial to the immune homeostasis, and the significantly decreased Blautia, Clostridium IV, Bacteroides, Eubacterium, Clostridium XVIII, and Mogibacterium in the SA and A groups were related to the reduced caecal lactate and LPS contents, the decreased inflammatory reaction, and the improved healthy hepatic condition of yak calves. In conclusion, milk replacer supplemented with alfalfa hay and starter feed is recommended during preweaning to improve yak calf health and growth because this regimen promotes the growth and maintains the immune homeostasis of yak calves.

The First 2 Years of Biosimilar Epoetin for Cancer and Chemotherapy-Induced Anemia in the U.S.: A Review from the Southern Network on Adverse Reactions

Biosimilars are biologic drug products that are highly similar to reference products in analytic features, pharmacokinetics and pharmacodynamics, immunogenicity, safety, and efficacy. Biosimilar epoetin received Food and Drug Administration (FDA) approval in 2018. The manufacturer received an FDA nonapproval letter in 2017, despite receiving a favorable review by FDA's Oncologic Drugs Advisory Committee (ODAC) and an FDA nonapproval letter in 2015 for an earlier formulation. We discuss the 2018 FDA approval, the 2017 FDA ODAC Committee review, and the FDA complete response letters in 2015 and 2017; review concepts of litigation, naming, labeling, substitution, interchangeability, and pharmacovigilance; review European and U.S. oncology experiences with biosimilar epoetin; and review the safety of erythropoiesis-stimulating agents. In 2020, policy statements from AETNA, United Health Care, and Humana indicated that new epoetin oncology starts must be for biosimilar epoetin unless medical need for other epoetins is documented. Empirical studies report that as of 2012, reference epoetin use decreased from 40%-60% of all patients with cancer with chemotherapy-induced anemia to <5% of such patients because of safety concerns. Between 2018 and 2020, biosimilar epoetin use varied, increasing to 81% among one private insurer's patients covered by Medicare whose cancer care is administered with Oncology Analytics and to 41% with the same private insurer's patients with cancer covered by commercial health insurance and administered by the private insurer, to 0% in several Veterans Administration Hospitals, increasing to 100% in one large county hospital in California, and with yet-to-be-reported data from most oncology settings. We conclude that biosimilar epoetin appears to have overcome some barriers since 2015, although current uptake in the U.S. is variable. Pricing and safety considerations for all erythropoiesis-stimulating agents are primary determinants of biosimilar epoetin oncology uptake. IMPLICATIONS FOR PRACTICE: Few oncologists understand substitution and interchangeability of biosimilars with reference drugs. Epoetin biosimilar is new to the market, and physician and patient understanding is limited. The development of epoetin biosimilar is not familiar to oncologists.

The lost decade: clinical trials data access after Seife v HHS

A 2020 federal court ruling requires clinical trial sponsors to report a decade's worth of previously exempted data to the National Institutes of Health (NIH) for publication on ClinicalTrials.gov. In Seife v HHS, the US District Court for the Southern District of New York invalidated NIH regulations that exempted certain clinical trials conducted between 2007 and 2017 from results reporting requirements mandated by the Food and Drug Administration Amendments Act. Sharing data from publicly funded research can maximize the benefits of that research by allowing taxpayers, who effectively fund the research, to see the results of their investment. Regardless of the source of their funding, clinical trial data also facilitate replicability, critical analysis, and trust in the scientific community. These benefits make the recent decision in Seife particularly significant. However, its impact will be dampened if the government does not take steps to enforce it.