Impact of do-it-yourself air cleaner design on the reduction of simulated wildfire smoke in a controlled chamber environment

During wildfire smoke events public health agencies release advisories to stay indoors, close doors and windows, and operate a portable air cleaner (PAC). The do-it-yourself (DIY) air cleaner consisting of a box fan and a furnace filter is a widely used low-cost alternative to commercial PACs because of its increased accessibility. In this study, we evaluate the clean air delivery rate (CADR) of different DIY air cleaner designs for reducing simulated wildfire smoke and identify operating parameters that may impact their performance and use. The simplest formulation of a DIY air cleaner (box fan with taped on minimum effectiveness reporting value - [MERV] 13 furnace filter) had a CADR of 111.2 ± 1.3 ft3 /min (CFM). Increasing the fan flow by changing the fan type, increasing the fan setting, or reducing the pressure drop across the filtering surface increased the CADR. Large increases in CADR could be obtained by using a shroud (40%), using a 4″ thick filter (123%) using two filters in a wedge shape (137%), or using four filters in a Corsi-Rosenthal (CR) box design (261%). The CADR was greatly reduced with filters heavily loaded with smoke, pointing to the need for frequent filter changes during smoke events.

Monocytic-Myeloid Derived Suppressor Cells Suppress T-Cell Responses in Recovered SARS CoV2-Infected Individuals

Coronavirus disease 2019 (COVID-19) caused by SARS Coronavirus 2 (CoV2) is associated with massive immune activation and hyperinflammatory response. Acute and severe CoV2 infection is characterized by the expansion of myeloid derived suppressor cells (MDSC) because of cytokine storm, these MDSC suppress T cell functions. However, the presence of MDSC and its effect on CoV2 antigen specific T cell responses in individuals long after first detection of CoV2 and recovery from infection has not been studied. We and others have previously shown that CD11b+CD33+CD14+HLA-DR-/lo monocytic MDSC (M-MDSC) are present in individuals with clinical recovery from viral infection. In this study, we compared the frequency, functional and transcriptional signatures of M-MDSC isolated from CoV2 infected individuals after 5-months of the first detection of the virus (CoV2+) and who were not infected with CoV2 (CoV2-). Compared to CoV2- individuals, M-MDSC were present in CoV2+ individuals at a higher frequency, the level of M-MDSC correlated with the quantity of IL-6 in the plasma. Compared to CoV2-, increased frequency of PD1+, CD57+ and CX3CR1+ T effector memory (TEM) cell subsets was also present in CoV2+ individuals, but these did not correlate with M-MDSC levels. Furthermore, depleting M-MDSC from peripheral blood mononuclear cells (PBMC) increased T cell cytokine production when cultured with the peptide pools of immune dominant spike glycoprotein (S), membrane (M), and nucleocapsid (N) antigens of CoV2. M-MDSC suppressed CoV2 S- antigen-specific T cell in ROS, Arginase, and TGFβ dependent manner. Our gene expression, RNA-seq and pathway analysis studies further confirm that M-MDSC isolated from CoV2+ individuals are enriched in pathways that regulate both innate and adaptive immune responses, but the genes regulating these functions (HLA-DQA1, HLA-DQB1, HLA-B, NLRP3, IL1β, CXCL2, CXCL1) remained downregulated in M-MDSC isolated from CoV2+ individuals. These results demonstrate that M-MDSC suppresses recall responses to CoV2 antigens long after recovery from infection. Our findings suggest M-MDSC as novel regulators of CoV2 specific T cell responses, and should be considered as target to augment responses to vaccine.

Applying cognitive task analysis to health services research

OBJECTIVE

Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study.

DATA SOURCES AND STUDY SETTING

Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration.

STUDY DESIGN

Qualitative study of discharge planning using CTA.

DATA COLLECTION/EXTRACTION METHODS

Data were collected from structured observations and semi-structured interviews using the Critical Decision Method and analyzed using thematic analysis.

PRINCIPAL FINDINGS

We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision-making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task.

CONCLUSIONS

A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision-support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task-related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research.

Effectiveness of a virtual quality improvement training program to improve reach of weight management programs within a large health system

OBJECTIVE

To test effectiveness of the LEAP (Learn Engage Act Process) Program on engaging frontline Veteran Health Administration (VHA) medical center teams in continuous quality improvement (QI), a core capability for learning health systems.

DATA SOURCES AND STUDY SETTING

Data sources included VHA electronic health record (EHR) data, surveys, and LEAP coaching field notes.

STUDY DESIGN

A staggered difference-in-differences study was conducted. Fifty-five facilities participated in LEAP across eight randomly assigned clusters of 6-8 facilities per cluster over 2 years. Non-participating facilities were used as controls. A MOVE! weight management program team completed a Plan-Do-Study-Act cycle of change supported by learning curriculum, coaching, and virtual collaboratives in LEAP facilities. Primary outcome was program reach to Veterans. A mixed-effects model compared pre- versus post-LEAP periods for LEAP versus control facilities. LEAP adherence, satisfaction, and cost to deliver LEAP were evaluated.

DATA COLLECTION/EXTRACTION METHODS

Thirty months of facility-level EHR MOVE! enrollment data were included in analyses. LEAP Satisfaction and QI skills were elicited via surveys at baseline and 6-month post-LEAP.

PRINCIPAL FINDINGS

Fifty-five facilities were randomly assigned to eight time-period-based clusters to receive LEAP (71% completed LEAP) and 82 non-participating facilities were randomly assigned as controls. Reach in LEAP and control facilities was comparable in the 12-month pre-LEAP period (p = 0.07). Though LEAP facilities experienced slower decline in reach in the 12-month post-LEAP period compared with controls (p < 0.001), this is likely due to unexplained fluctuations in controls. For LEAP facilities, satisfaction was high (all mean ratings >4 on a 5-point scale), self-reported use of QI methods increased significantly (p-values <0.05) 6 months post-LEAP, and delivery cost was $4024 per facility-based team.

CONCLUSION

Control facilities experienced declining reach in the 12-month post-LEAP period, but LEAP facilities did not, plus they reported higher engagement in QI, an essential capability for learning health systems.

Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act

OBJECTIVE

To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size.

DATA SOURCES

VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System.

STUDY DESIGN

In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline.

DATA EXTRACTION

Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021.

PRINCIPAL FINDINGS

From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]).

CONCLUSIONS

VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.

Prevalence and Risk of Immunostimulatory Herbal Supplement Treatment Among Autoimmune Dermatology Patients

OBJECTIVE

We assess the prevalence and patterns of herbal supplement treatment among patients with autoimmune skin diseases, particularly dermatomyositis (DM) and cutaneous lupus erythematosus (CLE), and identify commonly taken supplements and their associated risks.

METHODS

This study screened 673 adult patients with clinicopathologic evidence of DM or CLE at the University of Pennsylvania's rheumatologic-dermatology clinic between January 2007 and February 2024. Demographic data, disease characteristics, and detailed information on herbal supplement treatment were collected. Predictors of supplement treatment were analyzed using chi-square tests and reported as odds ratios.

RESULTS

The prevalence of herbal supplement treatment was 32% among the cohort. The relative frequency of herbal supplement treatment was significantly higher in younger patients (44% of patients ages 18-29 years, reference; 29% ages 50-64 years, P = 0.02; 23% ages ≥65 years, P = 0.003) and in Hispanic/Latino patients (58% vs 31% White, P = 0.009). No significant difference in herbal supplement treatment was seen by sex (33% of female participants, 29% of male participants, P = 0.49), race (31% White, P = reference; 31% Black, P = 1.0; 38% Asian, P = 0.55), or disease (30% of patients with DM, 36% of patients with CLE; P = 0.12). Among patients with DM, 31% experienced a disease onset or exacerbation after supplement treatment compared with 10% of patients with CLE. Elderberry treatment was associated with the highest risk of exacerbation in both disease cohorts (62% DM, 50% CLE).

CONCLUSION

Herbal supplement treatment is prevalent among patients with autoimmune skin diseases, with immunostimulatory supplements posing a significant risk for immune dysregulation, particularly in DM. Providers should proactively screen and counsel patients regarding treatment with these supplements.

Extended genome-wide association study employing the African genome resources panel identifies novel susceptibility loci for Alzheimer's disease in individuals of African ancestry

INTRODUCTION

Despite a two-fold risk, individuals of African ancestry have been underrepresented in Alzheimer's disease (AD) genomics efforts.

METHODS

Genome-wide association studies (GWAS) of 2,903 AD cases and 6,265 controls of African ancestry. Within-dataset results were meta-analyzed, followed by functional genomics analyses.

RESULTS

A novel AD-risk locus was identified in MPDZ on chromosome (chr) 9p23 (rs141610415, MAF = 0.002, p = 3.68×10-9). Two additional novel common and nine rare loci were identified with suggestive associations (P < 9×10-7). Comparison of association and linkage disequilibrium (LD) patterns between datasets with higher and lower degrees of African ancestry showed differential association patterns at chr12q23.2 (ASCL1), suggesting that this association is modulated by regional origin of local African ancestry.

DISCUSSION

These analyses identified novel AD-associated loci in individuals of African ancestry and suggest that degree of African ancestry modulates some associations. Increased sample sets covering as much African genetic diversity as possible will be critical to identify additional loci and deconvolute local genetic ancestry effects.

HIGHLIGHTS

Genetic ancestry significantly impacts risk of Alzheimer's Disease (AD). Although individuals of African ancestry are twice as likely to develop AD, they are vastly underrepresented in AD genomics studies. The Alzheimer's Disease Genetics Consortium has previously identified 16 common and rare genetic loci associated with AD in African American individuals. The current analyses significantly expand this effort by increasing the sample size and extending ancestral diversity by including populations from continental Africa. Single variant meta-analysis identified a novel genome-wide significant AD-risk locus in individuals of African ancestry at the MPDZ gene, and 11 additional novel loci with suggestive genome-wide significance at p < 9×10-7. Comparison of African American datasets with samples of higher degree of African ancestry demonstrated differing patterns of association and linkage disequilibrium at one of these loci, suggesting that degree and/or geographic origin of African ancestry modulates the effect at this locus. These findings illustrate the importance of increasing number and ancestral diversity of African ancestry samples in AD genomics studies to fully disentangle the genetic architecture underlying AD, and yield more effective ancestry-informed genetic screening tools and therapeutic interventions.

Senolytic treatment attenuates immune cell infiltration without improving IAV outcomes in aged mice

Aging is a major risk factor for poor outcomes following respiratory infections. In animal models, the most severe outcomes of respiratory infections in older hosts have been associated with an increased burden of senescent cells that accumulate over time with age and create a hyperinflammatory response. Although studies using coronavirus animal models have demonstrated that removal of senescent cells with senolytics, a class of drugs that selectively kills senescent cells, resulted in reduced lung damage and increased survival, little is known about the role that senescent cells play in the outcome of influenza A viral (IAV) infections in aged mice. Here, we tested if the aged mice survival or weight loss IAV infections could be improved using three different senolytic regimens. We found that neither dasatinib plus quercetin, fisetin, nor ABT-263 improved outcomes. Furthermore, both dasatanib plus quercetin and fisetin treatments further suppressed immune infiltration than aging alone. Additionally, our data show that the short-term senolytic agents do not reduce senescent markers in our aged mouse model. These findings suggest that acute senolytic treatments do not universally reverse aging related immune phenotype against all respiratory viral infections.

Differences across race and ethnicity in the quality of antidepressant medication management

OBJECTIVE

To illustrate the importance of a multidimensional view of disparities in quality of antidepressant medication management (AMM), as well as discriminating "within-facility" disparities from disparities that exist between facilities.

DATA SOURCES AND STUDY SETTING

We used data from the Veterans Health Administration's (VA) Corporate Data Warehouse (CDW) which contains clinical and administrative data from VA facilities nationally.

STUDY DESIGN

CDW data were used to measure five indicators of AMM quality, including the HEDIS Effective Acute-Phase and Effective Continuation-Phase measures. Mixed effects regression models were used to examine differences in quality indicators between racial/ethnic groups, controlling for other demographic and clinical factors. An adaptation of the Kitagawa-Blinder-Oaxaca (KBO) method was used to decompose mean differences in treatment quality between racial and ethnic groups into within- and between-facility effects.

DATA EXTRACTION METHODS

Demographic, clinical, and health service utilization data were extracted for patients in fiscal year 2017 with a diagnosis of depression and a new start of an antidepressant medication.

PRINCIPAL FINDINGS

The decomposition of the overall differences between White and Black patients on receiving an initial 90-day prescription (46.7% vs. 32.7%), Effective Acute-Phase (79.7% vs. 66.8%), and Effective Continuation-Phase (64.0% vs. 49.6%) HEDIS measures revealed that most of the overall effects were "within-facility," meaning that Black patients are less likely to meet these measures regardless of where they are treated. Although the overall magnitude of disparities between White and Hispanic patients on these three measures was very similar (46.7% vs. 32.7%; 79.7% vs. 69.2%; 64.0% vs. 53.6%), the differences were more attributable to Hispanic patients being treated in facilities with overall lower performance on these measures.

CONCLUSIONS

Discriminating within- and between-facility disparities and taking a multidimensional view of quality are essential to informing efforts to address disparities in AMM quality.