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Keck JW, Lacy ME, Bressler S, Blake I, Chukwuma U, Bruce MG. COVID-19 infection and incident diabetes in American Indian and Alaska Native people: a retrospective cohort study. Lancet Reg Health Am 2024; 33:100727. [PMID: 38590324 PMCID: PMC11000165 DOI: 10.1016/j.lana.2024.100727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
Background Evidence suggests an increased risk of new-onset diabetes following COVID-19 infection. American Indian/Alaska Native (AI/AN) people were disparately impacted by the COVID-19 pandemic and historically have had higher diabetes incidence than other racial/ethnic groups in the US. We measured the association between COVID-19 infection and incident diabetes in AI/AN people. Methods We conducted a retrospective cohort study using de-identified patient data from the Indian Health Service's (IHS) National Patient Information Reporting System. We estimated age-adjusted diabetes incidence rates, incidence rate ratios, and adjusted hazard ratios among three cohorts spanning pre-pandemic (1/1/2018-2/28/2020) and pandemic (3/1/2020-12/31/2021) timeframes: 1) pre-pandemic cohort (1,503,085 individuals); 2) no-COVID-19 pandemic cohort (1,344,339 individuals); and 3) COVID-19 cohort (176,483 individuals). Findings The COVID-19 cohort had an increased hazard of diabetes compared to the no-COVID-19 group (adjusted hazard ratio (aHR) = 1.56; 95% CI: 1.50-1.62) and the pre-pandemic group (aHR = 1.27; 95% CI: 1.22-1.32). The association between COVID-19 infection and new-onset diabetes was stronger in those with severe COVID-19 illness. A sensitivity analysis comparing the COVID-19 cohort to members of other cohorts that had acute upper respiratory infections showed an attenuated but higher risk of new-onset diabetes in those with COVID-19. Interpretation AI/AN people diagnosed with COVID-19 had an elevated risk of a new diabetes diagnosis when compared to the no-COVID-19 group and the pre-pandemic group. The increased diabetes risk in the COVID-19 group remained in a sensitivity analysis that limited the comparator groups to individuals with an AURI diagnosis. Funding US National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- James W. Keck
- Research Services Department, Alaska Native Tribal Health Consortium, and Centers for Disease Control and Prevention Guest Researcher, Anchorage, AK, USA
| | - Mary E. Lacy
- Department of Epidemiology and Environmental Health, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Sara Bressler
- Arctic Investigations Program, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Anchorage, AK, USA
| | - Ian Blake
- Arctic Investigations Program, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Anchorage, AK, USA
| | - Uzo Chukwuma
- Office of Public Health Support, Division of Epidemiology and Disease Prevention, Indian Health Service, Rockville, MD, USA
| | - Michael G. Bruce
- Arctic Investigations Program, National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Anchorage, AK, USA
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Keck JW, Adatorwovor R, Liversedge M, Mijotavich B, Olsson C, Strike WD, Amirsoleimani A, Noble A, Torabi S, Rockward A, Banadaki MD, Smith T, Lacy P, Berry SM. Wastewater Surveillance for Identifying SARS-CoV-2 Infections in Long-Term Care Facilities, Kentucky, USA, 2021-2022. Emerg Infect Dis 2024; 30:530-538. [PMID: 38407144 PMCID: PMC10902530 DOI: 10.3201/eid3003.230888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Persons living in long-term care facilities (LTCFs) were disproportionately affected by COVID-19. We used wastewater surveillance to detect SARS-CoV-2 infection in this setting by collecting and testing 24-hour composite wastewater samples 2-4 times weekly at 6 LTCFs in Kentucky, USA, during March 2021-February 2022. The LTCFs routinely tested staff and symptomatic and exposed residents for SARS-CoV-2 using rapid antigen tests. Of 780 wastewater samples analyzed, 22% (n = 173) had detectable SARS-CoV-2 RNA. The LTCFs reported 161 positive (of 16,905) SARS-CoV-2 clinical tests. The wastewater SARS-CoV-2 signal showed variable correlation with clinical test data; we observed the strongest correlations in the LTCFs with the most positive clinical tests (n = 45 and n = 58). Wastewater surveillance was 48% sensitive and 80% specific in identifying SARS-CoV-2 infections found on clinical testing, which was limited by frequency, coverage, and rapid antigen test performance.
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Affiliation(s)
| | - Reuben Adatorwovor
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | | | - Blazan Mijotavich
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Cullen Olsson
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - William D. Strike
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Atena Amirsoleimani
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Ann Noble
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Soroosh Torabi
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Alexus Rockward
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Mohammad Dehghan Banadaki
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Ted Smith
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Parker Lacy
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
| | - Scott M. Berry
- University of Kentucky, Lexington, Kentucky, USA (J.W. Keck, R. Adatorwovor, M. Liversedge, C. Olsson, W.D. Strike, A. Amirsoleimani, A. Noble, S. Torabi, A. Rockward, M. Dehghan Banadaki, S.M. Berry)
- University of Louisville, Louisville, Kentucky, USA (T. Smith)
- Trilogy Health Services, LLC, Louisville (P. Lacy)
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Dehghan Banadaki M, Torabi S, Rockward A, Strike WD, Noble A, Keck JW, Berry SM. Simple SARS-CoV-2 concentration methods for wastewater surveillance in low resource settings. Sci Total Environ 2024; 912:168782. [PMID: 38000737 PMCID: PMC10842712 DOI: 10.1016/j.scitotenv.2023.168782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/18/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023]
Abstract
Wastewater-based epidemiology (WBE) measures pathogens in wastewater to monitor infectious disease prevalence in communities. Due to the high dilution of pathogens in sewage, a concentration method is often required to achieve reliable biomarker signals. However, most of the current concentration methods rely on expensive equipment and labor-intensive processes, which limits the application of WBE in low-resource settings. Here, we compared the performance of four inexpensive and simple concentration methods to detect SARS-CoV-2 in wastewater samples: Solid Fraction, Porcine Gastric Mucin-conjugated Magnetic Beads, Calcium Flocculation-Citrate Dissolution (CFCD), and Nanotrap® Magnetic Beads (NMBs). The NMBs and CFCD methods yielded the highest concentration performance for SARS-CoV-2 (∼16-fold concentration and ∼ 41 % recovery) and require <45 min processing time. CFCD has a relatively low consumable cost (<$2 per four sample replicates). All methods can be performed with basic laboratory equipment and minimal electricity usage which enables further application of WBE in remote areas and low resource settings.
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Affiliation(s)
| | - Soroosh Torabi
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States
| | - Alexus Rockward
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States
| | - William D Strike
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States
| | - Ann Noble
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States
| | - James W Keck
- WWAMI School of Medicine, University of Alaska Anchorage, United States
| | - Scott M Berry
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States; Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States.
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Keck JW, Lindner J, Liversedge M, Mijatovic B, Olsson C, Strike W, Noble A, Adatorwovor R, Lacy P, Smith T, Berry SM. Wastewater Surveillance for SARS-CoV-2 at Long-Term Care Facilities: Mixed Methods Evaluation. JMIR Public Health Surveill 2023; 9:e44657. [PMID: 37643001 PMCID: PMC10467632 DOI: 10.2196/44657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/26/2023] [Accepted: 07/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Wastewater surveillance provided early indication of COVID-19 in US municipalities. Residents of long-term care facilities (LTCFs) experienced disproportionate morbidity and mortality early in the COVID-19 pandemic. We implemented LTCF building-level wastewater surveillance for SARS-CoV-2 at 6 facilities in Kentucky to provide early warning of SARS-CoV-2 in populations considered vulnerable. OBJECTIVE This study aims to evaluate the performance of wastewater surveillance for SARS-CoV-2 at LTCFs in Kentucky. METHODS We conducted a mixed methods evaluation of wastewater surveillance following Centers for Disease Control and Prevention (CDC) guidelines for evaluating public health surveillance systems. Evaluation steps in the CDC guidelines were engaging stakeholders, describing the surveillance system, focusing the evaluation design, gathering credible evidence, and generating conclusions and recommendations. We purposively recruited stakeholders for semistructured interviews and undertook thematic content analysis of interview data. We integrated wastewater, clinical testing, and process data to characterize or calculate 7 surveillance system performance attributes (simplicity, flexibility, data quality, sensitivity and positive predictive value [PPV], timeliness, representativeness, and stability). RESULTS We conducted 8 stakeholder interviews. The surveillance system collected wastewater samples (N=811) 2 to 4 times weekly at 6 LTCFs in Kentucky from March 2021 to February 2022. Synthesis of credible evidence indicated variable surveillance performance. Regarding simplicity, surveillance implementation required moderate human resource and technical capacity. Regarding flexibility, the system efficiently adjusted surveillance frequency and demonstrated the ability to detect additional pathogens of interest. Regarding data quality, software identified errors in wastewater sample metadata entry (110/3120, 3.53% of fields), technicians identified polymerase chain reaction data issues (140/7734, 1.81% of reactions), and staff entered all data corrections into a log. Regarding sensitivity and PPV, using routine LTCF SARS-CoV-2 clinical testing results as the gold standard, a wastewater SARS-CoV-2 signal of >0 RNA copies/mL was 30.6% (95% CI 24.4%-36.8%) sensitive and 79.7% (95% CI 76.4%-82.9%) specific for a positive clinical test at the LTCF. The PPV of the wastewater signal was 34.8% (95% CI 27.9%-41.7%) at >0 RNA copies/mL and increased to 75% (95% CI 60%-90%) at >250 copies/mL. Regarding timeliness, stakeholders received surveillance data 24 to 72 hours after sample collection, with delayed reporting because of the lack of weekend laboratory staff. Regarding representativeness, stakeholders identified challenges delineating the population contributing to LTCF wastewater because of visitors, unknown staff toileting habits, and the use of adult briefs by some residents preventing their waste from entering the sewer system. Regarding stability, the reoccurring cost to conduct 1 day of wastewater surveillance at 1 facility was approximately US $144.50, which included transportation, labor, and materials expenses. CONCLUSIONS The LTCF wastewater surveillance system demonstrated mixed performance per CDC criteria. Stakeholders found surveillance feasible and expressed optimism regarding its potential while also recognizing challenges in interpreting and acting on surveillance data.
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Affiliation(s)
- James W Keck
- Department of Family & Community Medicine, University of Kentucky, Lexington, KY, United States
| | - Jess Lindner
- College of Medicine - Northern Kentucky Campus, University of Kentucky, Highland Heights, KY, United States
| | - Matthew Liversedge
- Department of Family and Community Medicine, University of Kentucky, Lexington, KY, United States
| | - Blazan Mijatovic
- Department of Family and Community Medicine, University of Kentucky, Lexington, KY, United States
| | - Cullen Olsson
- Department of Family and Community Medicine, University of Kentucky, Lexington, KY, United States
| | - William Strike
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, United States
| | - Anni Noble
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY, United States
| | - Reuben Adatorwovor
- Department of Biostatistics, University of Kentucky, Lexington, KY, United States
| | - Parker Lacy
- Trilogy Health Services, Louisville, KY, United States
| | - Ted Smith
- Christina Lee Brown Envirome Institute, University of Louisville, Louisville, KY, United States
| | - Scott M Berry
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, United States
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY, United States
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Torabi S, Amirsoleimani A, Dehghan Banadaki M, Strike WD, Rockward A, Noble A, Liversedge M, Keck JW, Berry SM. Stabilization of SARS-CoV-2 RNA in wastewater via rapid RNA extraction. Sci Total Environ 2023; 878:162992. [PMID: 36948314 PMCID: PMC10028336 DOI: 10.1016/j.scitotenv.2023.162992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/21/2022] [Accepted: 03/17/2023] [Indexed: 05/13/2023]
Abstract
Wastewater-based Epidemiology (WBE) has contributed to surveillance of SARS-CoV-2 in communities across the world. Both symptomatic and asymptomatic patients with COVID-19 can shed the virus through the gastrointestinal tract, enabling the quantification of the virus in stool and ultimately in wastewater (WW). Unfortunately, instability of SARS-CoV-2 RNA in wastewater limits the utility of WBE programs, particularly in remote/rural regions where reliable cold storage and/or rapid shipping may be unavailable. This study examined whether rapid SARS-CoV-2 RNA extraction on the day of sample collection could minimize degradation. Importantly, the extraction technology used in these experiments, termed exclusion-based sample preparation (ESP), is lightweight, portable, and electricity-free, making it suitable for implementation in remote settings. We demonstrated that immediate RNA extraction followed by ambient storage significantly increased the RNA half-life compared to raw wastewater samples stored at both 4 °C or ambient temperature. Given that RNA degradation negatively impacts both the sensitivity and precision of WBE measurements, efforts must be made to mitigate degradation in order to maximize the potential impact of WBE on public health.
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Affiliation(s)
- Soroosh Torabi
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States of America
| | - Atena Amirsoleimani
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States of America
| | - Mohammad Dehghan Banadaki
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States of America
| | - William Dalton Strike
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States of America
| | - Alexus Rockward
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States of America
| | - Ann Noble
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States of America
| | - Matthew Liversedge
- Department of Family and Community Medicine, College of Medicine, University of Kentucky, United States of America
| | - James W Keck
- Department of Family and Community Medicine, College of Medicine, University of Kentucky, United States of America
| | - Scott M Berry
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States of America; Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States of America.
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Dehghan Banadaki M, Torabi S, Strike WD, Noble A, Keck JW, Berry SM. Improving wastewater-based epidemiology performance through streamlined automation. J Environ Chem Eng 2023; 11:109595. [PMID: 36875746 PMCID: PMC9970922 DOI: 10.1016/j.jece.2023.109595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/02/2023] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
Wastewater-based epidemiology (WBE) has enabled us to describe Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections in populations. However, implementation of wastewater monitoring of SARS-CoV-2 is limited due to the need for expert staff, expensive equipment, and prolonged processing times. As WBE increases in scope (beyond SARS-CoV-2) and scale (beyond developed regions), there is a need to make WBE processes simpler, cheaper, and faster. We developed an automated workflow based on a simplified method termed exclusion-based sample preparation (ESP). Our automated workflow takes 40 min from raw wastewater to purified RNA, which is several times faster than conventional WBE methods. The total assay cost per sample/replicate is $6.50 which includes consumables and reagents for concentration, extraction, and RT-qPCR quantification. The assay complexity is reduced significantly, as extraction and concentration steps are integrated and automated. The high recovery efficiency of the automated assay (84.5 ± 25.4%) yielded an improved Limit of Detection (LoDAutomated=40 copies/mL) compared to the manual process (LoDManual=206 copies/mL), increasing analytical sensitivity. We validated the performance of the automated workflow by comparing it with the manual method using wastewater samples from several locations. The results from the two methods correlated strongly (r = 0.953), while the automated method was shown to be more precise. In 83% of the samples, the automated method showed lower variation between replicates, which is likely due to higher technical errors in the manual process e.g., pipetting. Our automated wastewater workflow can support the expansion of WBE in the fight against Coronavirus Disease of 2019 (COVID-19) and other epidemics.
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Affiliation(s)
| | - Soroosh Torabi
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States
| | - William D Strike
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States
| | - Ann Noble
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States
| | - James W Keck
- Department of Family and Community Medicine, College of Medicine, University of Kentucky, United States
| | - Scott M Berry
- Department of Mechanical Engineering, College of Engineering, University of Kentucky, United States
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, United States
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Sullivan JF, Keck JW, Stephens MB, O'Connell TA, Smith DK, Sanchack KE, Lennon RP. Increased Scholarly Activity: A Benefit of 4-Year Family Medicine Residencies. Mil Med 2023; 188:e479-e483. [PMID: 34244756 DOI: 10.1093/milmed/usab284] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/28/2021] [Accepted: 07/01/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The optimal length of Family Medicine Residency is unknown. As part of the American Board of Family Medicine 4-year Length of Training (LoT) pilot project, Naval Hospital Jacksonville (NHJ) maintained a dual-track 3- and 4-year Family Medicine Residency, graduating seven 4-year residents over consecutive 4 years of the LoT program. One measure of success regarding the impact of 4-year residents on program outcomes is scholarly output during residency. MATERIALS AND METHODS Cumulative scholarly activity points are tracked for all NHJ residents. Cumulative scholarly activity points, points per year per, and raw percentile USMLE/COMLEX scores from academic years 2016-17 to 2019-20 were compared between PGY3 and PGY4 graduates using one-way ANOVA to 95% confidence with post hoc Tukey honestly significant difference pairwise comparison to evaluate pairwise significance between groups where multi-group differences were found. RESULTS During the 2016-17 through 2019-20 academic years, NHJ had 28 residents complete 3 years of training without interruption (3 Years), 11 residents complete 3 years of training interrupted by general medical officer tours (Resiterns), and 7 residents complete 4 years of training without interruption (4 Years). There were no significant differences in average raw USMLE and COMLEX scores between 3 Year (71%), Resitern (68%), and 4 Year (76%) residents (P = .335). 4-Year residents had significantly more cumulative scholarly points (103) than 3-Year residents (32.6, P < .001) and Resiterns (18.7, P < .001) and also had more cumulative scholarly points per year of residency (27.8) than 3-Year residents (9.8, P < .001) and Resiterns (7.0, P < .001). CONCLUSIONS An observed benefit of a 4-year Family Medicine Residency was a marked increase in scholarly output at this program.
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Affiliation(s)
- John F Sullivan
- Department of Family Medicine, Naval Hospital Jacksonville, Jacksonville, FL 32214, USA
| | - James W Keck
- Department of Family Medicine, Naval Hospital Jacksonville, Jacksonville, FL 32214, USA
| | - Mark B Stephens
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA 16801, USA
| | - Tara A O'Connell
- Family Medicine/Operational Detailer, Navy Personnel Command, Millington, TN 38054, USA
| | - Dustin K Smith
- Department of Family Medicine, Naval Hospital Jacksonville, Jacksonville, FL 32214, USA
| | - Kristian E Sanchack
- Department of Family Medicine, Naval Hospital Jacksonville, Jacksonville, FL 32214, USA
| | - Robert P Lennon
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, PA 17033, USA
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Affiliation(s)
- James W Keck
- James W. Keck is with the Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington. Scott M. Berry is with the Department of Mechanical Engineering, College of Engineering, University of Kentucky
| | - Scott M Berry
- James W. Keck is with the Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington. Scott M. Berry is with the Department of Mechanical Engineering, College of Engineering, University of Kentucky
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Lukacena KM, Keck JW, Freeman PR, Harrington NG, Huffmyer MJ, Moga DC. Patients' attitudes toward deprescribing and their experiences communicating with clinicians and pharmacists. Ther Adv Drug Saf 2022; 13:20420986221116465. [PMID: 36003624 PMCID: PMC9393353 DOI: 10.1177/20420986221116465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Developing effective deprescribing interventions relies on understanding
attitudes, beliefs, and communication challenges of those involved in the
deprescribing decision-making process, including the patient, the primary
care clinician, and the pharmacist. The objective of this study was to
assess patients’ beliefs and attitudes and identify facilitators of and
barriers to deprescribing. Methods: As part of a larger study, we recruited patients ⩾18 years of age taking ⩾3
chronic medications. Participants were recruited from retail pharmacies
associated with the University of Kentucky HealthCare system. They completed
an electronic survey that included demographic information, questions about
communication with their primary care clinician and pharmacists, and the
revised Patients’ Attitudes Toward Deprescribing (rPATD) questionnaire. Results: Our analyses included 103 participants (n = 65 identified as
female and n = 74 as White/Caucasian) with a mean age of
50.4 years [standard deviation (SD) = 15.5]. Participants reported taking an
average of 8.4 daily medications (SD = 6.1). Most participants reported
effective communication with clinicians and pharmacists (66.9%) and
expressed willingness to stop one of their medications if their clinician
said it was possible (83.5%). Predictors of willingness to accept
deprescribing were older age [odds ratio (OR) = 2.99, 95% confidence
interval (CI) = 1.45–6.2], college/graduate degree (OR = 55.25, 95%
CI = 5.74–531.4), perceiving medications as less appropriate (OR = 8.99, 95%
CI = 1.1–73.62), and perceived effectiveness of communication with the
clinician or pharmacist (OR = 4.56, 95% CI = 0.85–24.35). Conclusion: Adults taking ⩾3 chronic medications expressed high willingness to accept
deprescribing of medications when their doctor said it was possible.
Targeted strategies to facilitate communication within the patient–primary
care clinician–pharmacist triad that consider patient characteristics such
as age and education level may be necessary ingredients for developing
successful deprescribing interventions. Plain Language Summary Are patients willing to accept stopping medications? Sometimes, medicines that a patient takes regularly become inappropriate. In
other words, the risks of adverse effects might be greater than a medicine’s
potential benefits. The decision to stop such medicines should involve the
patient and consider their preferences. We surveyed a group of patients
taking multiple medicines to see how they felt about having those medicines
stopped. We also asked patients whether and how much they talk to their
primary care clinician and pharmacists about their medicines. To qualify for
this study, patients had to be at least 18 years old and to take three or
more medicines daily; they also needed to speak English. Participants
provided demographic information and answered questions about their
medicines, their communication with primary care clinicians and pharmacists,
and their feelings about having one or more of their medicines stopped. We
recruited 107 people and were able to use responses from 103 of them. Their
average age was 50 years; 65 of them identified as female, and 75 identified
as White/Caucasian. Most of our participants mentioned having conversations
with primary care clinicians and pharmacists and said they would be willing
to stop a medication if their clinician said it was possible. Older
participants, those with more years of education, those who thought their
medications might lead to side effects, and those who communicated with
their clinician or pharmacists were more willing to have one of their
medicines stopped. Our results indicate that patient characteristics and communication with
clinicians and pharmacists are factors to consider when designing
interventions to reduce the use of inappropriate medicines.
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Affiliation(s)
- Kaylee M Lukacena
- Center for Social and Behavioral Science, Office of the Vice Chancellor for Research and Innovation, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - James W Keck
- Department of Family and Community Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Nancy Grant Harrington
- Department of Communication, College of Communication and Information, University of Kentucky, Lexington, KY, USA
| | - Mark J Huffmyer
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Daniela C Moga
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA. Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
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10
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Hutchcraft ML, Zhang S, Lin N, Gottschalk GL, Keck JW, Belcher EA, Sears C, Wang C, Liu K, Dietz LE, Pickarski JC, Wei S, Cardarelli R, DiPaola RS, Kolesar JM. Real-World Evaluation of a Population Germline Genetic Screening Initiative for Family Medicine Patients. J Pers Med 2022; 12:1297. [PMID: 36013246 PMCID: PMC9410316 DOI: 10.3390/jpm12081297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022] Open
Abstract
Hereditary factors contribute to disease development and drug pharmacokinetics. The risk of hereditary disease development can be attenuated or eliminated by early screening or risk reducing interventions. The purpose of this study was to assess the clinical utility of germline medical exome sequencing in patients recruited from a family medicine clinic and compare the mutation frequency of hereditary predisposition genes to established general population frequencies. At the University of Kentucky, 205 family medicine patients underwent sequencing in a Clinical Laboratory Improvement Amendments of 1988-compliant laboratory to identify clinically actionable genomic findings. The study identified pathogenic or likely pathogenic genetic variants-classified according to the American College of Medical Genetics and Genomics variant classification guidelines-and actionable pharmacogenomic variants, as defined by the Clinical Pharmacogenetics Implementation Consortium. Test results for patients with pharmacogenomic variants and pathogenic or likely pathogenic variants were returned to the participant and enrolling physician. Hereditary disease predisposition gene mutations in APOB, BRCA2, MUTYH, CACNA1S, DSC2, KCNQ1, LDLR, SCN5A, or SDHB were identified in 6.3% (13/205) of the patients. Nine of 13 (69.2%) underwent subsequent clinical interventions. Pharmacogenomic variants were identified in 76.1% (156/205) of patients and included 4.9% (10/205) who were prescribed a medication that had pharmacogenomic implications. Family physicians changed medications for 1.5% (3/205) of patients to prevent toxicity. In this pilot study, we found that with systemic support, germline genetic screening initiatives were feasible and clinically beneficial in a primary care setting.
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Affiliation(s)
- Megan Leigh Hutchcraft
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, Lexington, KY 40536, USA
| | - Shulin Zhang
- Department of Pathology and Laboratory Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - Nan Lin
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, USA
| | - Ginny Lee Gottschalk
- Department of Family and Community Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - James W. Keck
- Department of Family and Community Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - Elizabeth A. Belcher
- Department of Clinical Research, University of Kentucky Markey Cancer Center, Lexington, KY 40536, USA
| | - Catherine Sears
- Department of Pathology and Laboratory Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - Chi Wang
- Shared Resource Facility, University of Kentucky Markey Cancer Center, Lexington, KY 40536, USA
- Division of Cancer Biostatistics, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY 40506, USA
| | - Kun Liu
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY 40536, USA
| | - Lauren E. Dietz
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, USA
| | | | - Sainan Wei
- Department of Pathology and Laboratory Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - Roberto Cardarelli
- Department of Family and Community Medicine, University of Kentucky Chandler Medical Center, Lexington, KY 40536, USA
| | - Robert S. DiPaola
- University of Kentucky Markey Cancer Center, Lexington, KY 40536, USA
| | - Jill M. Kolesar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, Lexington, KY 40536, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40506, USA
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11
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Keck JW, Bush M, Razick R, Mohammadie S, Musalia J, Hamm J. Performance of formal smell testing and symptom screening for identifying SARS-CoV-2 infection. PLoS One 2022; 17:e0266912. [PMID: 35413084 PMCID: PMC9004758 DOI: 10.1371/journal.pone.0266912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/29/2022] [Indexed: 01/08/2023] Open
Abstract
Background Altered sense of smell is a commonly reported COVID-19 symptom. The performance of smell testing to identify SARS-CoV-2 infection status is unknown. We measured the ability of formal smell testing to identify SARS-CoV-2 infection and compared its performance with symptom screening. Methods A convenience sample of emergency department patients with COVID-19 symptom screening participated in smell testing using an eight odor Pocket Smell Test (PST). Participants received a SARS-CoV-2 viral PCR test after smell testing and completed a health conditions survey. Descriptive analysis and receiver operating characteristic (ROC) curve models compared the accuracy of smell testing versus symptom screening in identifying SARS-CoV-2 infection. Results Two hundred and ninety-five patients completed smell testing and 87 (29.5%) had a positive SARS-CoV-2 PCR test. Twenty-eight of the SARS-CoV-2 positive patients (32.2%) and 49 of the SARS-CoV-2 negative patients (23.6%) reported at least one of seven screening symptoms (OR = 1.54, P = 0.13). SARS-CoV-2 positive patients were more likely to have hyposmia (≤5 correctly identified odors) than SARS-CoV-2 negative patients (56.1% vs. 19.3%, OR = 5.36, P<0.001). Hyposmia was 52.9% (95% CI 41.9%-63.7%) sensitive and 82.7% (95% CI 76.9%-87.6%) specific for SARS-CoV-2 infection. Presence of ≥1 screening symptom was 32.2% (95% CI 22.6%-43.1%) sensitive and 76.4% (70.1%-82.0%) specific for SARS-CoV-2 infection. The ROC curve for smell testing had an area under the curve (AUC) of 0.74 (95% CI 0.67–0.80). The ROC curve for symptom screening had lower discriminatory accuracy for SARS-CoV-2 infection (AUC = 0.55, 95% CI 0.49–0.61, P<0.001) than the smell testing ROC curve. Conclusion Smell testing was superior to symptom screening for identifying SARS-CoV-2 infection in our study.
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Affiliation(s)
- James W. Keck
- Department of Family and Community Medicine, University of Kentucky, Lexington, KY, United States of America
- * E-mail:
| | - Matthew Bush
- Department of Otolaryngology–Head and Neck Surgery, University of Kentucky, Lexington, KY, United States of America
| | - Robert Razick
- Department of Emergency Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Setareh Mohammadie
- Department of Emergency Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Joshua Musalia
- College of Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Joel Hamm
- Department of Emergency Medicine, University of Kentucky, Lexington, KY, United States of America
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12
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Sullivan JF, Keck JW, Stephens MB, O'Connell TA, Smith DK, Sanchack K, Lennon RP. Cost Neutrality of Fourth Year in Military Programs. Fam Med 2021; 53:732-733. [PMID: 34587275 DOI: 10.22454/fammed.2021.521931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - James W Keck
- Naval Hospital Jacksonville, Department of Family Medicine, Jacksonville, FL
| | - Mark B Stephens
- Department of Family and Community Medicine, and Department of Humanities, Penn State College of Medicine
| | | | | | - Kristian Sanchack
- Naval Hospital Jacksonville, Department of Family Medicine, Jacksonville, FL
| | - Robert P Lennon
- Penn State College of Medicine, Department of Family and Community Medicine, Hershey, PA
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13
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Huffmyer MJ, Keck JW, Harrington NG, Freeman PR, Westling M, Lukacena KM, Moga DC. Primary care clinician and community pharmacist perceptions of deprescribing. J Am Geriatr Soc 2021; 69:1686-1689. [PMID: 33689170 DOI: 10.1111/jgs.17092] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mark J Huffmyer
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - James W Keck
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nancy Grant Harrington
- Department of Communication, University of Kentucky College of Communication and Information, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Matthew Westling
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Kaylee M Lukacena
- Department of Communication, University of Kentucky College of Communication and Information, Lexington, Kentucky, USA.,Center for Social and Behavioral Science, University of Illinois at Urbana-Champaign, Champaign, IL, USA
| | - Daniela C Moga
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky, USA.,Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA
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Abstract
BACKGROUND AND OBJECTIVES Scholarly activity (SA) is an Accreditation Council of Graduate Medical Education (ACGME) requirement for family medicine residents. Engaging residents in scholarly activity can be challenging. Naval Hospital Jacksonville Family Medicine Residency (NHJ) pioneered a curriculum that led to a dramatic, sustained increase in resident SA. We sought to implement the curriculum in other family medicine residency programs. METHODS The curriculum was implemented at two additional family medicine residencies. Three curricular interventions were identified: a 3-hour case report workshop, a written practical guide to scholarly activity, and a resident peer research leader. One program implemented all three elements. The other implemented the workshop and written guide, but did not identify a resident peer leader. SA was measured using the annual ACGME program director report and compared the intervention year to the previous 3 years of SA using a 2-sample test for equality of proportions with continuity correction. We used pre- and postintervention surveys to evaluate resident attitudes about SA. RESULTS The program implementing all three interventions increased residents' conference presentation 302% (n=34, P<.001). The program that did not identify a resident peer leader had no significant change in SA as reported to the ACGME. CONCLUSIONS The curriculum was implemented in two additional residencies with promising results. We recommend further implementation across multiple sites to determine the extent to which the results are generalizable.
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Affiliation(s)
- Robert P Lennon
- Penn State College of Medicine, Department of Family and Community Medicine, Hershey, PA
| | | | - Christine Broszko
- Eglin Air Force Base Family Medicine Residency Program, Eglin Air Force Base, FL
| | - John J Koch
- Naval Hospital Camp Pendleton, Department of Family Medicine, Camp Pendleton, CA
| | - Kristian Sanchack
- Naval Hospital Jacksonville, Department of Family Medicine, Jacksonville, FL
| | - James W Keck
- Naval Hospital Jacksonville, Department of Family Medicine, Jacksonville, FL
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15
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Plumb ID, Lecy D, Singleton R, Engel MC, Hirschfeld M, Keck JW, Klejka J, Rudolph KM, Hennessy TW, Bruce MG. Invasive Haemophilus influenzae Serotype a Infection in Children: Clinical Description of an Emerging Pathogen-Alaska, 2002-2014. Pediatr Infect Dis J 2018; 37:298-303. [PMID: 29189672 PMCID: PMC6362456 DOI: 10.1097/inf.0000000000001764] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Invasive infections from Haemophilus influenzae serotype a (Hia) have been reported with increasing frequency, especially among indigenous populations. However, there are limited population-based studies of clinical severity. We studied invasive Hia infections in Alaska to determine clinical characteristics, mortality and sequelae. METHODS We defined an invasive Hia infection as the first detection of Hia from a usually sterile site in a child <10 years of age from Alaska. We identified cases using the Alaska Invasive Bacterial Diseases Surveillance System and reviewed medical charts up to 2 years after reported illness. RESULTS We identified invasive Hia infections in 36 children, 28 (78%) <1 year old, 34 (94%) living in an Alaskan village and 25 (69%) without documented underlying illness. Overlapping clinical presentations included meningitis in 15 children (42%); bacteremia and pneumonia in 10 children (28%); and bone, joint or soft tissue infections in 10 children (22%). In 4 other children, no source of invasive infection was identified. Intensive care was provided for 11 children (31%); 12 children (33%) required surgical intervention. One year after infection, 4 children (11%) had died from Hia, and 5 children (14%) had ongoing neurologic sequelae. CONCLUSIONS Invasive Hia infections in Alaska occurred predominantly in Alaska Native infants in rural communities. Although one-third of children had preexisting conditions, most cases occurred without known comorbidity. Clinical syndromes were frequently severe. One year after infection, 1 in 4 children had either died or had neurologic sequelae. An effective vaccine would prevent significant morbidity and mortality in affected populations.
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16
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Seehusen DA, Ledford CJW, Grogan S, Kim E, Johnson JJ, Stackle ME, Runser LA, Fargo MV, Keck JW, Oberhofer AL, Shoemaker R. A Point System as Catalyst to Increase Resident Scholarship: An MPCRN Study. Fam Med 2017; 49:222-224. [PMID: 28346625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Encouraging resident scholarly activity has been a longstanding challenge for medical educators. The Accreditation Council for Graduate Medical Education (ACGME) has been increasing its emphasis on scholarly activity, forcing programs to evaluate their existing processes. This study sought to evaluate the impact of a scholarly activity point system on the resident scholarly productivity at multiple programs. METHODS Five military family medicine residencies evaluated resident outcomes 2 years before and 2 years after the introduction of a scholarly activity point system. Outcome measures included peer-reviewed publications with a resident as first author, peer-reviewed publications with a resident as any author, resident presentation of scholarship at a regional, national, and international conference, IRB-approved protocols with a resident as principal investigator, and IRB-approved protocols with a resident in any role. RESULTS Four of the five programs experienced substantial increases in nearly every outcome. The fifth program, which had a more robust culture of inquiry at baseline, did not experience an increase in resident scholarly productivity. CONCLUSIONS A scholarly activity point system was associated with an increase in resident scholarly production in family medicine programs. It appears to work best in programs that start from a lower level of scholarly productivity at baseline. A point system appears to be a useful addition to scholarly activity curricula.
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Affiliation(s)
- Dean A Seehusen
- Department of Family and Community Medicine, Eisenhower Army Medical Center
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17
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Herce ME, Elmore SN, Kalanga N, Keck JW, Wroe EB, Phiri A, Mayfield A, Chingoli F, Beste JA, Tengatenga L, Bazile J, Krakauer EL, Rigodon J. Assessing and responding to palliative care needs in rural sub-Saharan Africa: results from a model intervention and situation analysis in Malawi. PLoS One 2014; 9:e110457. [PMID: 25313997 PMCID: PMC4197005 DOI: 10.1371/journal.pone.0110457] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/19/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. METHODS Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP's first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. RESULTS The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. CONCLUSIONS We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.
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Affiliation(s)
- Michael E. Herce
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Shekinah N. Elmore
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Noel Kalanga
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - James W. Keck
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Emily B. Wroe
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Atupere Phiri
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Alishya Mayfield
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Felix Chingoli
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Jason A. Beste
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Listern Tengatenga
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Junior Bazile
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Eric L. Krakauer
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jonas Rigodon
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
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18
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Keck JW, Wenger JD, Bruden DL, Rudolph KM, Hurlburt DA, Hennessy TW, Bruce MG. PCV7-induced changes in pneumococcal carriage and invasive disease burden in Alaskan children. Vaccine 2014; 32:6478-84. [PMID: 25269095 DOI: 10.1016/j.vaccine.2014.09.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 09/12/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Changes in pneumococcal serotype-specific carriage and invasive pneumococcal disease (IPD) after the introduction of pneumococcal conjugate vaccine (PCV7) could inform serotype epidemiology patterns following the introduction of newer conjugate vaccines. METHODS We used data from statewide IPD surveillance and annual pneumococcal carriage studies in four regions of Alaska to calculate serotype-specific invasiveness ratios (IR; odds ratio of a carried serotype's likelihood to cause invasive disease compared to other serotypes) in children <5 years of age. We describe changes in carriage, disease burden, and invasiveness between two time periods, the pre-PCV7 period (1996-2000) and the late post-PCV7 period (2006-2009). RESULTS Incidence of IPD decreased from the pre- to post-vaccine period (95.7 vs. 57.2 cases per 100,000 children, P<0.001), with a 99% reduction in PCV7 disease. Carriage prevalence did not change between the two periods (49% vs. 50%), although PCV7 serotype carriage declined by 97%, and non-vaccine serotypes increased in prevalence. Alaska pre-vaccine IRs corresponded to pooled results from eight pre-vaccine comparator studies (Spearman's rho=0.44, P=0.002) and to the Alaska post-vaccine period (Spearman's rho=0.28, P=0.029). Relatively invasive serotypes (IR>1) caused 66% of IPD in both periods, although fewer serotypes with IR>1 remained in the post-vaccine (n=9) than the pre-vaccine period (n=13). CONCLUSIONS After PCV7 introduction, serotype IRs changed little, and four of the most invasive serotypes were nearly eliminated. If PCV13 use leads to a reduction of carriage and IPD for the 13 vaccine serotypes, the overall IPD rate should further decline. NOTE The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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Affiliation(s)
- James W Keck
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, 600 Clifton Rd Atlanta, GA 30333, USA; Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA.
| | - Jay D Wenger
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
| | - Dana L Bruden
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
| | - Karen M Rudolph
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
| | - Debby A Hurlburt
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
| | - Thomas W Hennessy
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
| | - Michael G Bruce
- Arctic Investigations Program, Centers for Disease Control and Prevention, 4055 Tudor Centre Dr., Anchorage, AK 99508, USA
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19
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Keck JW, Bulkow LR, Raczniak GA, Negus SE, Zanis CL, Bruce MG, Spradling PR, Teshale EH, McMahon BJ. Hepatitis B virus antibody levels 7 to 9 years after booster vaccination in Alaska native persons. Clin Vaccine Immunol 2014; 21:1339-42. [PMID: 25056363 PMCID: PMC4178570 DOI: 10.1128/cvi.00263-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/17/2014] [Indexed: 01/05/2023]
Abstract
Hepatitis B antibody persistence was assessed in individuals who had previously received a vaccine booster. We measured hepatitis B surface antigen antibody (anti-HBs) levels 7 to 9 years post-hepatitis B booster in individuals with primary vaccination at birth. While 95 (91.3%) of 104 participants had detectable anti-HBs (minimum, 0.1 mIU/ml; maximum, 1,029 mIU/ml), only 43 (41%) had protective levels of ≥10 mIU/ml. Pre- and week 4 postbooster anti-HBs levels were significant predictors of hepatitis B immunity at follow-up (P < 0.001). Almost all participants had detectable anti-HBs 7 to 9 years after the hepatitis B vaccine booster, but less than half had levels ≥10 mIU/ml.
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Affiliation(s)
- James W Keck
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA
| | - Lisa R Bulkow
- Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA
| | - Gregory A Raczniak
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA
| | - Susan E Negus
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska, USA
| | - Carolyn L Zanis
- Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA
| | - Michael G Bruce
- Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA
| | - Philip R Spradling
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eyasu H Teshale
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Brian J McMahon
- Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska, USA Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, Alaska, USA
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20
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Lennon RP, Oberhofer AL, McNair V, Keck JW. Curriculum changes to increase research in a family medicine residency program. Fam Med 2014; 46:294-298. [PMID: 24788427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Scholarly activity is an important component of residency programs. Amidst many other professional obligations, finding time and support for resident research can be challenging. Thus, it is important to equip residents with the tools needed to perform scholarly activity both during and after residency. METHODS We studied a series of curriculum initiatives on scholarly productivity at Naval Hospital Jacksonville. Educational interventions were rolled out in three parts. First, a faculty research coordinator (FRC) was established. Second, a scholarly activity point system was adapted from one published by Seehusen et al, along with research and conference tracking systems. Third, a resident research coordinator (RRC) position was created. The FRC and RRC acted as liaisons between residents, faculty, and non-faculty staff and created an annual scholarly activity workshop. Scholarly productivity was analyzed using descriptive statistics. RESULTS Prior to the roll out of these curriculum changes, the number of resident scholarly projects per resident, defined as regional or higher posters/presentations and peer-reviewed publications, was 0.07 with four residents involved. In 2012, the research per resident was 0.91, with 26 residents involved. CONCLUSIONS Our analysis reveals an association between these new curricular initiatives and increased research among residents, similar to growth demonstrated by the innovations of Seehusen et al. Limitations of this study include reliance on the accuracy of past records and a small sample size. We believe this is a model that could be implemented in other residency programs to support scholarly activity requirements.
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Keck JW, Redd JT, Cheek JE, Layne LJ, Groom AV, Kitka S, Bruce MG, Suryaprasad A, Amerson NL, Cullen T, Bryan RT, Hennessy TW. Influenza surveillance using electronic health records in the American Indian and Alaska Native population. J Am Med Inform Assoc 2013; 21:132-8. [PMID: 23744788 DOI: 10.1136/amiajnl-2012-001591] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed. MATERIALS AND METHODS The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network. RESULTS The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day. DISCUSSION EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.
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Affiliation(s)
- James W Keck
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Wenger JD, Castrodale LJ, Bruden DL, Keck JW, Zulz T, Bruce MG, Fearey DA, McLaughlin J, Hurlburt D, Hummel KB, Kitka S, Bentley S, Thomas TK, Singleton R, Redd JT, Layne L, Cheek JE, Hennessy TW. 2009 Pandemic influenza A H1N1 in Alaska: temporal and geographic characteristics of spread and increased risk of hospitalization among Alaska Native and Asian/Pacific Islander people. Clin Infect Dis 2011; 52 Suppl 1:S189-97. [PMID: 21342894 DOI: 10.1093/cid/ciq037] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Alaska Native people have suffered disproportionately from previous influenza pandemics. We evaluated 3 separate syndromic data sources to determine temporal and geographic patterns of spread of 2009 pandemic influenza A H1N1 (pH1N1) in Alaska, and reviewed records from persons hospitalized with pH1N1 disease in 3 areas in Alaska to characterize clinical and epidemiologic features of disease in Alaskans. A wave of pH1N1 disease swept through Alaska beginning in most areas in August or early September. In rural regions, where Alaska Native people comprise a substantial proportion of the population, disease occurred earlier than in other regions. Alaska Native people and Asian/Pacific Islanders (A/PI) were 2-4 times more likely to be hospitalized than whites. Alaska Native people and other minorities remain at high risk for early and substantial morbidity from pandemic influenza episodes. These findings should be integrated into plans for distribution and use of vaccine and antiviral agents.
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Affiliation(s)
- Jay D Wenger
- Arctic Investigations Program, Centers for Disease Control and Prevention, Anchorage, Alaska 99508, USA.
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Rodansky B, Keck JW, Kiser WR, Battafarano DF, Wortham WG, Enzenauer RJ. Letters to the Editor. Mil Med 1998. [DOI: 10.1093/milmed/163.10.v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - James W. Keck
- Department of Family Practice, United States Naval Hospital, 2080 Child Street, Jacksonville, FL 32214-5227
| | - W. Robert Kiser
- Department of Family Practice, United States Naval Hospital, 2080 Child Street, Jacksonville, FL 32214-5227
| | - Daniel F. Battafarano
- Department of Medical Science, Academy of Health Sciences, Fort Sam Houston, Texas 78234
| | - William G. Wortham
- Nephrology Service, Brooke Army Medical Service, Fort Sam Houston, Texas 78234
| | - Raymond J. Enzenauer
- Rheumatology Service, Brooke Army Medical Service, Fort Sam Houston, Texas 78234
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Affiliation(s)
- James W. Keck
- Department of Family Practice United States Naval Hospital 2080 Child Street Jacksonville, FL 32214-5227
| | - W. Robert Kiser
- Department of Family Practice United States Naval Hospital 2080 Child Street Jacksonville, FL 32214-5227
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Keck JW, Kiser WR. HAPR questioned. Mil Med 1998; 163:659. [PMID: 9795538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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Abstract
The study was concerned with the adequacy of several methods for reducing or preventing hostility toward a frustrating teacher and examined whether classroom performance was affected. Two cathartic methods, Rating Scale and Mutual Expression, and two non-cathartic methods, Explanation and Control, were induced. Residual hostility toward the teacher was measured by means of a Teacher Evaluation Form. Results showed that the Explanation method was most effective and the two cathartic methods were least effective in preventing or reducing residual hostility. The two cathartic methods actually increased residual hostility as compared to the Control treatment. Task performance efficiency varied directly with the level of residual hostility. Doubt is cast upon the catharsis hypothesis and a relationship between residual hostility and performance was found.
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