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In DCIS, ER status is an important marker. The utility of concomitant PR testing remains unclear.A single-institution retrospective cohort study was performed with a comparative analysis of the NCDB to assess annual cost-savings with omission of routine PR testing. National Medicare payment standards determined PR staining costs to be $124.92.150 institutional DCIS cases with receptor data were identified. 104 (69%) were ER+/PR+, 16 (11%) were ER+/PR-, and none were ER-/PR+. Omission of routine PR testing would have resulted in $18,738 saved annually. Within the NCDB, 34,100 DCIS cases had receptor data: 29,277 (85.9%) patients were ER+, and 26,008 (76%) were both ER/PR+. 211 (0.6%) patients were ER-/PR+. Annual national cost-savings with omission of routine PR-testing would have been $4.3 million.PR testing for DCIS should be reserved only for patients with ER- DCIS undergoing breast conservation to determine the utility of adjuvant endocrine therapy.

Background To reduce antibiotic prescribing, antimicrobial stewards must understand patient knowledge, attitudes, and perceptions (KAP) around antibiotics for URIs. Validated patient KAP surveys are scarce and for Veteran patients, nonexistent. We aimed to explore if published results of an exploratory factor analysis (EFA) of a KAP survey in emergency department (ED) patients and an online sample would approximate results in outpatient Veterans. Methods After cognitive testing in Veterans and healthcare providers, we omitted 13 of the 46 questions from the published KAP survey deemed confusing or with low factor loadings. We mailed the 33-item survey to Veterans seen for URI at 18 Veterans Affairs clinics from January 2018 to December 2019. We excluded Veterans not evaluated in-person, with documented dementia, or who died prior to study start. We excluded surveys with > 3 unanswered questions. We used principal component factor analysis (PCFA) with orthogonal varimax rotation (Fig. 1) to assess Veteran responses and Cronbach’s alpha to assess each factor’s internal consistency. We removed questions to reach alpha of >0.7 (Fig. 2). We repeated PCFA and compared results to published EFA factors and loadings for the ED patients and online sample. Results Of 1329 eligible Veterans invited, 474 (36%) returned the survey; 407 met inclusion criteria (Table 1). PCFA of Veterans’ responses yielded 7 Factors (Fig 2). Like ED patients and the online sample, Veteran responses about side effects clustered together. Veteran responses about “antibiotics help” and “antibiotics don’t hurt” clustered together like ED patients. They grouped separately in the online sample. Veteran responses about safety and efficacy (Factors 3 & 5) and knowledge about viruses and bacteria, (Factors 4 & 5) clustered separately (Fig. 2). For ED patients and the online sample, safety and efficacy and virus and bacteria responses clustered together, respectively (Fig. 1). Conclusion While Veterans did share some KAPs around antibiotics for URIs with ED patients and the online sample, this study shows they also have distinct views. Further testing in Veteran and non-Veteran populations should validate and assess reliability of this survey as an antimicrobial stewardship tool. Disclosures Carlos G. Grijalva, MD, MPH, AHRQ: Grant/Research Support|Campbell Alliance/Syneos Health: Grant/Research Support|CDC: Grant/Research Support|FDA: Grant/Research Support|Merck: Advisor/Consultant|NIH: Grant/Research Support|Pfizer: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi-Pasteur: Advisor/Consultant Milner B. Staub, MD, MPH, Gilead: Stocks/Bonds|Johnson & Johnson: Stocks/Bonds.

PURPOSE OF REVIEW Given recent national attention to the role of racism in perpetuating racial inequities in society and health, this review provides a timely and relevant summary of key measures of systemic racism in kidney transplantation. More specifically, the review identifies current and promising interventions, whereas highlighting the need for more sustainable and impactful interventions. RECENT FINDINGS Racial disparities persist in kidney transplantation. Black and Hispanic individuals are less likely to receive a kidney transplant than non-Hispanic Whites despite disproportionately higher rates of kidney failure. Studies demonstrate that socioeconomic factors do not fully explain existing racial disparities in transplantation. Systemic racism at all levels, individual, interpersonal, institutional, and structural, is at the core of racial disparities, and current interventions are insufficient in mitigating their effects. Thus, targeted and sustainable interventions must be implemented to mitigate systemic racism in kidney transplantation. SUMMARY Systemic racism in all its forms continues to influence disparities at all stages of kidney transplantation. This paper highlights recent findings that shed light on how racism contributes to racial disparities in kidney transplantation. Using these findings to identify targets and strategies for mitigation, relevant interventions and policies that show promise are detailed.

Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery. Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and > 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores. One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI > 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p > 0.05). The RSI > 13 group had more female patients (80 vs 52%, p = 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking. In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.

INTRODUCTION: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS: Data from a single institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014–2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of one year. GERD-HRQL scores improved from 22.4 (SD±10.1) preoperatively to 4.2 (±6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p=0.01) and Toupet fundoplication (vs. Nissen; p=0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.

Nucleic acid nanoparticles (NANPs) have become powerful new platforms as therapeutic and diagnostic tools due to the innate biological ability of nucleic acids to identify target molecules or silence genes involved in disease pathways. However, the clinical application of NANPs has been limited by factors such as chemical instability, inefficient intracellular delivery, and the triggering of detrimental inflammatory responses following innate immune recognition of nucleic acids. Here, we have studied the effects of altering the chemical composition of a circumscribed panel of NANPs that share the same connectivity, shape, size, charge and sequences. We show that replacing RNA strands with either DNA or chemical analogs increases the enzymatic and thermodynamic stability of NANPs. Furthermore, we have found that such composition changes affect delivery efficiency and determine subcellular localization, effects that could permit the targeted delivery of NANP-based therapeutics and diagnostics. Importantly, we have determined that altering NANP composition can dictate the degree and mechanisms by which cell immune responses are initiated. While RNA NANPs trigger both TLR7 and RIG-I mediated cytokine and interferon production, DNA NANPs stimulate minimal immune activation. Importantly, incorporation of 2′F modifications abrogates RNA NANP activation of TLR7 but permits RIG-I dependent immune responses. Furthermore, 2′F modifications of DNA NANPs significantly enhances RIG-I mediated production of both proinflammatory cytokines and interferons. Collectively this indicates that off-target effects may be reduced and/or desirable immune responses evoked based upon NANPs modifications. Together, our studies show that NANP composition provides a simple way of controlling the immunostimulatory potential, and physicochemical and delivery characteristics, of such platforms.

Silicon carbide (SiC) is an inert material with excellent biocompatibility properties. A major issue that limits its use as a medical device is the difficult processing technique that requires hot pressing at a temperature (>2,000o C) and pressure (1,000-2,000 atm). In the present study, we developed a protocol to synthesize a porous SiC scaffold by pressing the powder at 50 MPa and heating at 900o C/2 hr. The surface of SiC was chemically modified by NaOH to facilitate sintering and induce bioactivity. Porous discs with 51.51 ± 3.17% porosity and interconnected pores in the size range from 1 to 1,000 μm were prepared using 40% PEG. The average compressive strength and Young's modulus of the scaffolds were 1.94 ± 0.70 and 169.2 ± 0.08 MPa, respectively. FTIR analysis confirmed the formation of biomimetic hydroxyapatite layer after 2 hr of immersion in simulated body fluid. The Ca/P ratio was dependent on the concentration of the silanol groups created on the material surface. Increasing the atomic % of silicon on the SiC surface from 33.27 ± 9.53% to 45.13 ± 4.74% resulted in a 76% increase in the osteocalcin expression by MC3T3-E1 cells seeded on the material after 7 days. The cells colonized the entire thickness of the template and filled the pores with mineralized extracellular matrix after 14 days. Taken all together, the porous SiC scaffolds can serve as a bone graft for tissue reconstruction and cell delivery in trauma surgery.

Background and objective: Veterans’ Affairs (VA) healthcare providers perceive that Veterans expect and base visit satisfaction on receiving antibiotics for upper respiratory tract infections (URIs). No studies have tested this hypothesis. We sought to determine whether receiving and/or expecting antibiotics were associated with Veteran satisfaction with URI visits. Methods: This cross-sectional study included Veterans evaluated for URI January 2018–December 2019 in an 18-clinic ambulatory VA primary-care system. We evaluated Veteran satisfaction via the Patient Satisfaction Questionnaire Short Form (RAND Corporation), an 18-item 5-point Likert scale survey. Additional items assessed Veteran antibiotic expectations. Antibiotic receipt was determined via medical record review. We used multivariable regression to evaluate whether antibiotic receipt and/or Veteran antibiotic expectations were associated with satisfaction. Subgroup analyses focused on Veterans who accurately remembered antibiotic prescribing during their URI visit. Results: Of 1,329 eligible Veterans, 432 (33%) participated. Antibiotic receipt was not associated with differences in mean total satisfaction (adjusted score difference, 0.6 points; 95% confidence interval [CI], −2.1 to 3.3). However, mean total satisfaction was lower for Veterans expecting an antibiotic (adjusted score difference −4.4 points; 95% CI −7.2 to −1.6). Among Veterans who accurately remembered the visit and did not receive an antibiotic, those who expected an antibiotic had lower mean satisfaction scores than those who did not (unadjusted score difference, −16.6 points; 95% CI, −24.6 to −8.6). Conclusions: Veteran expectations for antibiotics, not antibiotic receipt, are associated with changes in satisfaction with outpatient URI visits. Future research should further explore patient expectations and development of patient-centered and provider-focused interventions to change patient antibiotic expectations.

Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period. Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome. Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes. POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.

There has been a surge of research on Home Children in the past several decades, as the phenomenon previously unknown to many came into the spotlight. However, much of the historical research has focused on either the psychological and physical impacts on the children at the hands of their new “families” (there were many reports of child abuse and neglect) or the ways they were saved from their poverty in Britain by being sent to the colonies. This article will put this existing historical research into conversation with theories of settler colonialism, considering Home Children as a tool of domestication for the social reproduction of Canadian white settler society, which was paired with the forced removal of Indigenous peoples from their lands. This analysis stems from and is intertwined with personal reflections on my own family history as a white settler woman descending from a Home Child to explore the gendered labour of social reproduction as a crucial pillar in creating and maintaining settler colonial Canada. Following Lorenzo Veracini’s argument that settler colonialism is a distinct structure that uses domestication as one of its key tenets and relies on its “regenerative capacity”, this paper will explore how British Home Children were a key component of settler colonialism in Canada and how this history has manifested in the current gendered, racialized, and classed politics of “settling”.

Background HIV+ donor (HIV D+) to HIV+ recipient (HIV R+) transplantation involves ethical considerations related to safety, consent, stigma, and privacy, which could be better understood through studying patients' actual experiences. Methods We interviewed kidney and liver transplant recipients enrolled in clinical trials evaluating HIV D+/R+ transplantation at 4 centers regarding their decision-making process, the informed consent process, and posttransplant experiences. Participants were interviewed at-transplant (≤3 wk after transplant), posttransplant (≥3 mo after transplant), or both time points. Interviews were analyzed thematically using constant comparison of inductive and deductive coding. Results We conducted 35 interviews with 22 recipients (15 at-transplant; 20 posttransplant; 13 both time points; 85% participation). Participants accepted HIV D+ organs because of perceived benefits and situational factors that increased their confidence in the trials and outweighed perceived clinical and social risks. Participants reported positive experiences with the consent process and the trial. Some described HIV-related stigma and emphasized the need for privacy; others believed HIV D+/R+ transplantation could help combat such stigma. There were some indications of possible therapeutic misestimation (overestimation of benefits or underestimation of risks of a study). Some participants believed that HIV+ transplant candidates were unable to receive HIV-noninfected donor organs. Conclusions Despite overall positive experiences, some ethical concerns remain that should be mitigated going forward. For instance, based on our findings, targeted education for HIV+ transplant candidates regarding available treatment options and for transplant teams regarding privacy and stigma concerns would be beneficial.

BackgroundAntibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to MethodsFrom January to December 2018, community-based outpatient clinics’ 6 months’ average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan–do–study–act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data.ResultsThe AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward.ConclusionsOperational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.

e12572 Background: Current NCCN guidelines do not recommend sentinel node biopsy (SLNB) for the treatment of DCIS, except in the setting of a mastectomy. The extent of utilization of SLNB in patients undergoing mastectomy for DCIS and which factors are associated with a higher likelihood of SLNB use is unknown. The objective of this study is to evaluate the use of SLNB in patients undergoing mastectomy for DCIS and determine predictors of SLNB utilization. Methods: A retrospective cohort analysis was performed using the NCDB. Women diagnosed with DCIS who underwent a unilateral or bilateral mastectomy from 2012-2017 were included. Patient, tumor, and treatment variables were compared between patients who received a SLNB and those who did not. A multivariate logistic regression model was then used to identify factors predictive of SLNB utilization. Results: A total of 29,962 patients met inclusion criteria. Of these, 25,734 (85.9%) underwent SLNB and 4,228 (14.1%) had no surgical axillary staging. Most patients were age 50-69 (52.0%), non-Hispanic white (71.7%), and had private insurance (65.9%). In those who underwent SLNB, only 10 (

Laryngopharyngeal reflux (LPR) symptoms are often present in patients with Gastroesophageal reflux disease (GERD). Whereas antireflux surgery (ARS) provides predictably excellent results in patients with typical GERD, those with atypical symptoms have variable outcomes. The goal of this study was to characterize the response of LPR symptoms to antireflux surgery.Patients who underwent ARS between January 2009 and May 2020 were prospectively identified from a single institutional database. Patient-reported information on LPR symptoms was collected at standardized time points (preoperative and 2 weeks, 8 weeks, and 1 year postoperatively) using a validated Reflux Symptom Index (RSI) questionnaire. Patients were grouped by preoperative RSI score: ≤ 13 (normal) and 13 (abnormal). Baseline characteristics were compared between groups using chi-square test or t-test. A mixed effects model was used to evaluate improvement in RSI scores.One hundred and seventy-six patients fulfilled inclusion criteria (mean age 57.8 years, 70% female, mean BMI 29.4). Patients with a preoperative RSI ≤ 13 (n = 61) and RSI 13 (n = 115) were similar in age, BMI, primary reason for evaluation, DeMeester score, presence of esophagitis, and hiatal hernia (p 0.05). The RSI 13 group had more female patients (80 vs 52%, p = 0.001), higher mean GERD-HRQL score, lower rates of PPI use, and normal esophageal motility. The RSI of all patients improved from a mean preoperative value of 19.2 to 7.8 (2 weeks), 6.1 (8 weeks), and 10.9 (1 year). Those with the highest preoperative scores (RSI 30) had the best response to ARS. When analyzing individual symptoms, the most likely to improve included heartburn, hoarseness, and choking.In our study population, patients with LPR symptoms achieved a rapid and durable response to antireflux surgery. Those with higher preoperative RSI scores experienced the greatest improvement. Our data suggest that antireflux surgery is a viable treatment option for this patient population.

Chemical injuries from household products cause significant morbidity and mortality annually in pediatric patients. We present a rare case of a 21-month-old male with significant esophageal and cutaneous chemical burns secondary to non-accidental trauma. Given the unique challenges associated with multiple burn types we describe this case and provide a current review of the literature on the management of these potentially devastating injuries.

The unknown immune stimulation by nucleic acid nanoparticles (NANPs) has become one of the major impediments to a broad spectrum of clinical developments of this novel technology. Having evolved to defend against bacterial and viral nucleic acids, mammalian cells have established patterns of recognition that are also the pathways through which NANPs can be processed. Explorations into the immune stimulation brought about by a vast diversity of known NANPs have shown that variations in design correlate with variations in immune response. Therefore, as the mechanisms of stimulation are further elucidated, these trends are now being taken into account in the design phase to allow for development of NANPs that are tailored for controlled immune activation or quiescence.

Background High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. Purpose This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. Method An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. Findings A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. Discussion A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period.Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome.Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes.POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.

Background: Antibiotics are not recommended but are often prescribed for upper respiratory-tract infections (URIs). Prescribers cite patient expectation as a driver of inappropriate antibiotic prescribing; prior literature has demonstrated higher satisfaction scores in patients who receive antibiotics compared to those who do not. We assessed whether veteran satisfaction at URI visits was associated with antibiotic receipt or with reported expectation for antibiotics. Methods: We surveyed veterans with documented URI encounters in the Veterans’ Affairs Tennessee Valley Healthcare System between January 1, 2018, and December 31, 2019. Patients not evaluated in person, with documented dementia, or who died prior to the study start date were excluded. Veterans were asked to recall their URI visit and to complete the Patient Safety Questionnaire (PSQ)-18 (Rand Corporation) and questions assessing antibiotic expectations. The PSQ-18, an 18-item survey that assesses patient satisfaction, uses a 5-point Likert scale (ie, strongly disagree, disagree, uncertain, agree, strongly agree), yielding a composite score of 18–90. Higher scores represent more satisfaction with care. Demographic and visit-specific information were extracted via chart review. We used multivariable linear regression to assess differences in composite PSQ-18 satisfaction scores between those who did and did not receive an antibiotic, adjusted for patient and visit characteristics, and to assess differences in satisfaction scores for those who did and did not report expecting antibiotics, adjusted for antibiotic receipt. Results: We identified 1,435 patients seen for URI at 17 sites. After exclusions, 1,343 veterans were eligible for chart abstraction. After excluding 42 responders who responded after study close or returned blank surveys, the final analytic cohort included 432 (32.2%) of 1,343 responders; 225 (52.1%) received an antibiotic and 207 (47.9%) did not. Mean total satisfaction for veterans who received an antibiotic was 67.8 (SD, ±9.4) compared to 66.7 (SD, ±9.7) for those who did not (Figure 1). Increased total satisfaction was not significantly associated with antibiotic receipt (0.65; 95% CI, −2.0 to 3.3). Most veterans (72.0%) disagreed that visit satisfaction depended on antibiotic receipt. However, only 30.8% reported that they would not expect an antibiotic for URI visits. A significant reduction in total satisfaction (−4.1; 95% CI, −6.3 to −1.9) was associated with expecting compared to not expecting an antibiotic. Conclusions: Our findings suggest that prescribing an antibiotic is not associated with increased veteran satisfaction for URI visits but is associated with expecting an antibiotic. Future work will evaluate methods to change veteran antibiotic expectations.Funding: NoDisclosures: None

Objective: To compare outcomes after bariatric surgery between Medicaid and non-Medicaid patients and assess whether differences in social determinants of health were associated with postoperative weight loss. Background: The literature remains mixed on weight loss outcomes and healthcare utilization for Medicaid patients after bariatric surgery. It is unclear if social determinants of health geocoded at the neighborhood level are associated with outcomes. Methods: Patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2008 to 2017 and had ≥1 year of follow-up within a large health system were included. Baseline characteristics, 90-day and 1-year outcomes, and weight loss were compared between Medicaid and non-Medicaid patients. Area deprivation index (ADI), urbanicity, and walkability were analyzed at the neighborhood level. Median regression with percent total body weight (TBW) loss as the outcome was used to assess predictors of weight loss after surgery. Results: Six hundred forty-seven patients met study criteria (191 Medicaid and 456 non-Medicaid). Medicaid patients had a higher 90-day readmission rate compared to non-Medicaid patients (19.9% vs 12.3%, P < 0.016). Weight loss was similar between Medicaid and non-Medicaid patients (23.1% vs 21.9% TBW loss, respectively; P = 0.266) at a median follow-up of 3.1 years. In adjusted analyses, Medicaid status, ADI, urbanicity, and walkability were not associated with weight loss outcomes. Conclusions: Medicaid status and social determinants of health at the neighborhood level were not associated with weight loss outcomes after bariatric surgery. These findings suggest that if Medicaid patients are appropriately selected for bariatric surgery, they can achieve equivalent outcomes as non-Medicaid patients., Mini-abstract: The relationship among Medicaid status, social determinants of health, and bariatric surgery outcomes is unclear. Using electronic health record data and social determinant variables geocoded at the neighborhood level, we found that Medicaid status, socioeconomic deprivation, household location (rural vs urban), and neighborhood walkability were not associated with weight loss outcomes after bariatric surgery. However, Medicaid patients had higher readmission rates within 90 days of surgery. Supplemental Digital Content is available in the text.

Recent studies have indicated weekly patterns of health behaviors and information seeking in areas such as diet and smoking cessation, but little information is available on whether similar patterns may exist in HIV. If such patterns do exist, there could be important implications for the timing of interventions for both prevention and care. This review provides a summary of the available literature on weekly patterns in HIV-relevant behaviors and existing interventions (including prevention and antiretroviral therapy [ART] adherence), and provides recommendations for additional research. Data were collected from published reports indexed from database inception through December 2014 and identified through PubMed and EBSCO. Only English language reports were included. Evidence of weekly patterns was found in information-seeking behaviors, risk behaviors, screening and care, and structuring of existing interventions, including ART adherence interventions. These patterns included increased interest in HIV-related information early in the week, weekend patterns of risk behavior among some populations, and interest in weekend and evening clinic hours. Literature on text messaging for ART adherence indicates that weekly short message service messages are the most effective. Implications for prevention and adherence interventions are discussed, and recommendations for future research are given.

Evidence for widespread nonuniform vertical mixing of dust in Mars's tropical atmosphere (in the form of features called “detached dust layers” or DDLs) is a challenge for atmospheric modeling. We characterize the seasonal, diurnal, and geographic variability of DDL activity in retrievals from observations by the Mars Climate Sounder onboard Mars Reconnaissance Orbiter. We find that dust injection above the boundary layer, which forms DDLs, is a spatially ubiquitous phenomenon in the tropics during the daytime, implying that it has a significant nontopographic component. DDL formation is more intense in northern spring and summer than in southern spring and summer but is still common when the zonal average dust distribution appears uniformly mixed. DDLs do not appear to follow the upwelling associated with Mars's Hadley circulation or the extant climatology of local dust storm activity in the tropics. Geographic variability in the nightside vertical dust distribution does not always correlate with the dayside vertical dust distribution, implying that there is spatial and seasonal variability in the efficiency of dust deposition/removal processes. Nighttime dust removal is especially efficient over the Tharsis Montes during northern spring and summer, which suggests some association between water ice clouds and removal. Intense injection combined with efficient removal results in a high amplitude of diurnal variability in the dust distribution at 15–30 km above the surface of the tropics during much of the Martian year.

In 2004, the North Carolina Division of Public Health initiated the Rapid Response Project to incorporate geographic information system (GIS) technology into public health preparedness and response. In 2007, 17 local health departments (LHDs) received funding, training, and equipment from federal preparedness grant funds to increase epidemiology capacity through the spatial analysis and centralization of public health data.This article describes training and exercises associated with implementing mobile GIS technology at LHDs and presents evaluation findings from associated trainings and exercises. Participant surveys were used to conduct formative, process, and outcome evaluations to assess the effectiveness of training and exercise activities. Pretraining and post-training and exercise surveys were given to LHD staff who received equipment and attended a training course or participated in the statewide exercise. Differences in means between pretraining and post-training and pre-exercise and postexercise were evaluated using t tests. A total of 96 LHD staff completed the pretraining and posttraining evaluation. Fifty-two participants completed the pre-exercise and postexercise evaluation. After attending the 2-day training, participants reported significant improvements in knowledge and comfort using GIS-enabled computers for field data collection and accessing data and map layers from the state’s database (p < 0.05). Following the exercise, participants reported significant improvements in their ability to use GIS-enabled computers to respond to a natural disaster, bioterrorist attack, chemical spill, or a disease outbreak, as well as to perform a routine community health assessment. Enhancement of mobile GIS/global positioning system capacities of LHDs should improve the readiness of North Carolina in public health emergencies. Handheld computers with GIS were highly acceptable to LHD staff for use during routine assessments and emergency responses. Despite limited experience, LHD staff reported feeling more prepared to use mobile and wireless technology for sample selection, mapping, and data collection.

Observers consciously prefer Mondrian’s paintings in their original orientation compared with a rotated position—the “oblique effect” (Latto, Brain, & Kelly, 2000). However, this finding’s premise, that all vertical–horizontal orientations of the thick black lines in Mondrian’s oeuvre are preferred, overlooks the fact that the overall balance of these images is also altered when they are reoriented. Thus, balance may regulate the oblique effect, which might influence conscious aesthetic preferences. To address this issue, we explore Hess’s (1965, 1972) claim that observers will unconsciously increase their pupil diameter to pleasing images and constrict it to unpleasant images. We overcame Hess’s methodological limitation of not keeping his images’ luminances and contrast constant across conditions by presenting eight Mondrian paintings (1921–1944) to 30 observers on a CRT for 20 s each in either their original or seven rotated positions. Simultaneously, we measured their pupil size while asking them to report how (dis)pleasing they found each image. We found both evidence for the oblique effect (where image rotation hampers preference) and a correlation between this consciously reported aesthetic preference and unconsciously derived pupil size.

Anti-TAG-72 monoclonal antibodies target the tumor-associated glycoprotein (TAG)-72 in various solid tumors. This study evaluated the use of anti-TAG-72 monoclonal antibodies, both murine CC49 and humanized CC49 (HuCC49deltaCH2), for near-infrared fluorescent (NIR) tumor imaging in colorectal cancer xenograft models. The murine CC49 and HuCC49deltaCH2 were conjugated with Cy7 monofunctional N-hydroxysuccinimide ester (Cy7-NHS). Both in vitro and in vivo anti-TAG-72 antibody binding studies were performed. The in vitro study utilized the human colon adenocarcinoma cell line LS174T that was incubated with Cy7, antibody-Cy7 conjugates, or excessive murine CC49 followed by the antibody-Cy7 conjugates and was imaged by fluorescence microscopy. The in vivo study utilized xenograft mice, bearing LS174T subcutaneous tumor implants, that received tail vein injections of Cy7, murine CC49-Cy7, HuCC49deltaCH2-Cy7, or nonspecific IgG-Cy7 and were imaged by the Xenogen IVIS 100 system from 15 min to 288 h. The biodistribution of the fluorescence labeled antibodies was determined by imaging the dissected tissues. The in vitro study revealed that the antibody-Cy7 conjugates bound to LS174T cells and were blocked by excessive murine CC49. The in vivo study demonstrated that murine CC49 achieved a tumor/blood ratio of 15 at 96 h postinjection. In comparison, HuCC49deltaCH2-Cy7 cleared much faster than murine CC49-Cy7 from the xenograft mice, and HuCC49deltaCH2-Cy7 achieved a tumor/blood ratio of 12 at 18 h postinjection. In contrast, Cy7 and Cy7 labeled nonspecific IgG resulted in no demonstrable tumor accumulation. When mice were injected with excessive unlabeled murine CC49 at 6 h before the injection of murine CC49-Cy7 or HuCC49deltaCH2-Cy7, both the intensity and retention time of the fluorescence from the tumor were reduced. In summary, the Cy7 labeled murine CC49 and HuCC49deltaCH2 demonstrate tumor-targeting capabilities in living colorectal cancer xenograft mice and provide an alternative modality for tumor imaging.

Spirulina may increase people’s ability to resist mental and physical fatigue. This study tested that hypothesis in a randomized, double blinded, placebo controlled study in men. After 1 week, a 3 g/day dose of spirulina produced a small, but statistically significant increase in exercise output (Kcals consumed in 30 min exercise on a cross trainer machine). A mathematical based mental fatigue test showed improved performance 4 h after the first time of supplementation as well as 8 weeks later. Similarly, a subjective survey for a sense of physical and mental fatigue showed improvement within 4 h of the first supplementation as well as 8 weeks later. These results show that spirulina intake can affect fatigue in men.

In the past few years, the study of therapeutic RNA nanotechnology has expanded tremendously to encompass a large group of interdisciplinary sciences. It is now evident that rationally designed programmable RNA nanostructures offer unique advantages in addressing contemporary therapeutic challenges such as distinguishing target cell types and ameliorating disease. However, to maximize the therapeutic benefit of these nanostructures, it is essential to understand the immunostimulatory aptitude of such tools and identify potential complications. This paper presents a set of 16 nanoparticle platforms that are highly configurable. These novel nucleic acid based polygonal platforms are programmed for controllable self-assembly from RNA and/or DNA strands via canonical Watson-Crick interactions. It is demonstrated that the immunostimulatory properties of these particular designs can be tuned to elicit the desired immune response or lack thereof. To advance the current understanding of the nanoparticle properties that contribute to the observed immunomodulatory activity and establish corresponding designing principles, quantitative structure-activity relationship modeling is conducted. The results demonstrate that molecular weight, together with melting temperature and half-life, strongly predicts the observed immunomodulatory activity. This framework provides the fundamental guidelines necessary for the development of a new library of nanoparticles with predictable immunomodulatory activity.

Therapeutic nucleic acids (TNAs) can be engineered to deliver functional moieties such as siRNAs to target cells. An additional benefit of TNAs is that they can be complexed with amphiphilic molecules for delivery into sites such as the central nervous system (CNS) that are difficult to access due to the blood-brain barrier. However, previous TNA constructs have failed clinical trials due to the induction of severe systemic inflammatory responses. We have developed a new generation of TNAs in which immunomodulatory activity, in addition to chemical and thermodynamic stability, can be engineered. In this study, we have assessed the immunomodulatory activity of various TNAs on human CNS cell types. We have determined the ability of 16 TNAs of differing nucleic acid composition and polygon type to elicit cytokine and chemokine production by transfected human microglia and astrocyte-like cells. Our results indicate that, in general, our TNA formulations do not elicit immune responses in human astrocyte-like cells, but do induce significant release of the type I interferon, IFN-β, by cultured microglia with minimal release of the inflammatory cytokine IL-6 and the chemokine IL-8. Interestingly, we observed that the TNA nucleic acid composition and polygon type affect the immune mediator amount and profile released by human microglia-like cells. Specifically, IFN-β responses to TNAs composed of RNA are robust while those composed of DNA are minimal. Furthermore, triangle and pentagon TNA structures stimulate more IFN-β release than square and hexagon compositions. Together these results suggest these novel TNAs may be specifically engineered to minimize detrimental inflammatory responses while promoting beneficial host immunity.

We have previously demonstrated that murine microglia and astrocytes express the neurokinin-1 high affinity receptor (NK-1R) for the neuropeptide substance P. Importantly, we have also shown that substance P/NK-1R interactions augment the inflammatory responses of isolated murine glia to bacterial challenge and exacerbate in vivo neuroinflammatory damage within the central nervous system in mouse models of meningitis. Here, we show the constitutive expression of NK-1R in acutely isolated non-human primate (NHP) brain tissue and ex vivo brain slices. Interestingly, NK-1R protein levels were increased in brain tissue as rapidly as 4 hours following ex vivo infection with Borrelia burgdorferi, the causative agent of Lyme neuroborreliosis. Furthermore, we observed higher NK-1R protein levels in NHP brain tissue at 2 and 4 weeks following in vivo infection, increases that correlated with decreases in the expression of glial fibrillary acidic protein. These in vivo changes were prevented by treatment with a specific NK-1R antagonist suggesting a key role for substance P/NK-1R interactions in these effects. We then investigated the expression of NK-1R in human glial cells. While human microglia showed robust NK-1R expression at rest, astrocytes constitutively expressed only low levels. However, challenge with bacteria or their products elicited rapid increases in whole cell and cell surface NK-1R protein expression by primary human astrocytes and cell lines. Together, these data indicate that human microglia and astrocytes show constitutive and/or inducible expression of the substance P receptor and may therefore be susceptible to this pro-inflammatory neuropeptide.

BACKGROUND: 18 F-fluorodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) scanning is a widely accepted preoperative tumor imaging modality. Herein, we evaluate the becquerel (Bq) as a potential novel quantitative PET measure for application of surgical specimen imaging. METHODS: Retrospectively, PET-avid lesions that could be followed from preoperative imaging, confidently identified in the operating room, imaged ex vivo, and correlated with histopathology were included in this study. Bq counts from both in vivo (preoperative) and ex vivo (surgical specimen) PET/CT images were measured and correlated with histopathology. RESULTS: Fifty-five PET-avid lesions in 37 patients were included. Forty-six of 55 PET-avid lesions identified were found to contain malignancy on histopathology. Mean Bq counts for the PET-avid lesions were significantly higher that the adjacent PET-nonavid areas (background) within both in vivo and ex vivo imaging (P < .001 and P < .001, respectively). When analyzing all 55 lesions, we found significant increases in Bq levels. PET-avid lesions from in vivo to ex vivo images (P < .001) without significant increases in Bq levels in PET-nonavid lesions from in vivo to ex vivo images (P = .06). When comparing Bq levels between the 2 groups (malignant and benign), we found significantly higher Bq counts in the malignant group on in vivo imaging (P = .02) as well as significantly lower Bq counts in FDG-nonavid areas on ex vivo imaging (P = .04) within the malignant group. Significant differences in PET-avid to PET-nonavid Becquerels ratios within both in vivo and ex vivo images (P = .004, P = .002 respectively) were found, with ex vivo ratio being significantly higher (P < .001). CONCLUSIONS: 18 F-FDG PET/CT imaging using Bqs is the potential to discern malignant lesions from benign tissues within both in vivo and ex vivo scans.

18 F-fluorodeoxyglucose positron emission tomography–computed tomography is integral to the staging of lung cancer. We describe the combined use of diagnostic preoperative 18 F-fluorodeoxyglucose positron emission tomography–computed tomography, intraoperative 18 F-fluorodeoxyglucose handheld gamma probe detection, and immediate postoperative 18 F-fluorodeoxyglucose positron emission tomography–computed tomography patient and specimen imaging for improved staging and determination of adequacy of mediastinal lymph node dissection.

A letter to the editor is presented in response to the article "Real Men Don't: Constructions of Masculinity and Inadvertent Harm in Public Health Interventions" by P.J. Fleming, J.G. Lee, and S.L. Dworkin which appears in a 2014 issue of the journal.

Background 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) is widely used in diagnostic cancer imaging. However, the use of 18F-FDG in PET-based imaging is limited by its specificity and sensitivity. In contrast, anti-TAG (tumor associated glycoprotein)-72 monoclonal antibodies are highly specific for binding to a variety of adenocarcinomas, including colorectal cancer. The aim of this preliminary study was to evaluate a complimentary determining region (CDR)-grafted humanized CH2-domain-deleted anti-TAG-72 monoclonal antibody (HuCC49deltaCH2), radiolabeled with iodine-124 (124I), as an antigen-directed and cancer-specific targeting agent for PET-based imaging. Methods HuCC49deltaCH2 was radiolabeled with 124I. Subcutaneous tumor implants of LS174T colon adenocarcinoma cells, which express TAG-72 antigen, were grown on athymic Nu/Nu nude mice as the xenograft model. Intravascular (i.v.) and intraperitoneal (i.p.) administration of 124I-HuCC49deltaCH2 was then evaluated in this xenograft mouse model at various time points from approximately 1 hour to 24 hours after injection using microPET imaging. This was compared to i.v. injection of 18F-FDG in the same xenograft mouse model using microPET imaging at 50 minutes after injection. Results At approximately 1 hour after i.v. injection, 124I-HuCC49deltaCH2 was distributed within the systemic circulation, while at approximately 1 hour after i.p. injection, 124I-HuCC49deltaCH2 was distributed within the peritoneal cavity. At time points from 18 hours to 24 hours after i.v. and i.p. injection, 124I-HuCC49deltaCH2 demonstrated a significantly increased level of specific localization to LS174T tumor implants (p = 0.001) when compared to the 1 hour images. In contrast, approximately 50 minutes after i.v. injection, 18F-FDG failed to demonstrate any increased level of specific localization to a LS174T tumor implant, but showed the propensity toward more nonspecific uptake within the heart, Harderian glands of the bony orbits of the eyes, brown fat of the posterior neck, kidneys, and bladder. Conclusions On microPET imaging, 124I-HuCC49deltaCH2 demonstrates an increased level of specific localization to tumor implants of LS174T colon adenocarcinoma cells in the xenograft mouse model on delayed imaging, while 18F-FDG failed to demonstrate this. The antigen-directed and cancer-specific 124I-radiolabled anti-TAG-72 monoclonal antibody conjugate, 124I-HuCC49deltaCH2, holds future potential for use in human clinical trials for preoperative, intraoperative, and postoperative PET-based imaging strategies, including fused-modality PET-based imaging platforms.

This study investigates cross-border collaboration between beef organisations in Australia and Singapore. It aims to identify factors impacting trust and technology diffusion by gauging gaps between expected importance and perceived performance rating of the factors. The research presents results of a survey comprising 69 beef organisations from Australia and Singapore. The research identifies critical gaps using two methods of analysis; validity analysis and performance gap analysis. Each method comprises two types of tests. The WarpPLS software is used to perform the validity analysis. Results indicate gaps in level of responsiveness. The research concludes that the success of cross-border collaboration between organisations in both Australia and Singapore can be better achieved through the establishment of information exchange relationships, rather than through the use of technology alone, and by ensuring compatibility between business partners.