Search

Importance: Clinicians are a key component of preexposure prophylaxis (PrEP) care. Yet, no prior studies have quantitatively investigated how PrEP adherence differs by clinician specialty., Objective: To understand the association between prescribing clinician specialty and patients not picking up (reversal/abandonment) their initial PrEP prescription., Design, Setting, and Participants: This cross-sectional study of patients who were 18 years or older used pharmacy claims data from 2015 to 2019 on new insurer-approved PrEP prescriptions that were matched with clinician data from the US National Plan and Provider Enumeration System. Data were analyzed from January to May 2022., Main Outcomes and Measures: Clinician specialties included primary care practitioners (PCPs), infectious disease (ID), or other specialties. Reversal was defined as a patient not picking up their insurer-approved initial PrEP prescription. Abandonment was defined as a patient who reversed and still did not pick their prescription within 365 days., Results: Of the 37 003 patients, 4439 (12%) were female and 32 564 (88%) were male, and 77% were aged 25 to 54 years. A total of 24 604 (67%) received prescriptions from PCPs, 3571 (10%) from ID specialists, and 8828 (24%) from other specialty clinicians. The prevalence of reversals for patients of PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively, and for abandonments was 12%, 12%, and 20%, respectively. After adjusting for confounding, logistic regression models showed that, compared with patients who were prescribed PrEP by a PCP, patients prescribed PrEP by ID specialists had 10% lower odds of reversals (odds ratio [OR], 0.90; 95% CI, 0.81-0.99) and 12% lower odds of abandonment (OR, 0.88; 95% CI, 0.78-0.98), while patients prescribed by other clinicians had 33% higher odds of reversals (OR, 1.33; 95% CI, 1.25-1.41) and 54% higher odds of abandonment (OR, 1.54; 95% CI, 1.44-1.65)., Conclusion: The results of this cross-sectional study suggest that PCPs do most of the new PrEP prescribing and are a critical entry point for patients. PrEP adherence differs by clinician specialties, likely due to the populations served by them. Future studies to test interventions that provide adherence support and education are needed.

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV. Several different developments in the US either threaten to increase or promise to decrease PrEP out-of-pocket costs and access in the coming years. In a sample of 58,529 people with a new insurer-approved PrEP prescription, we estimated risk-adjusted percentages of patients who abandoned (did not fill) their initial prescription across six out-of-pocket cost categories. We then simulated the percentage of patients who would abandon PrEP under hypothetical changes to out-of-pocket costs, ranging from $0 to more than $500. PrEP abandonment rates of 5.5 percent at $0 rose to 42.6 percent at more than $500; even a small increase from $0 to $10 doubled the rate of abandonment. Conversely, abandonment rates that were 48.0 percent with out-of-pocket costs of more than $500 dropped to 7.3 percent when those costs were cut to $0. HIV diagnoses were two to three times higher among patients who abandoned PrEP prescriptions than among those who filled them. These results imply that recent legal challenges to the provision of PrEP with no cost sharing could substantially increase PrEP abandonment and HIV rates, upending progress on the HIV/AIDS epidemic.

Background: Drinking water is a common source of exposure to inorganic arsenic. In the US, the Safe Drinking Water Act (SDWA) was enacted to protect consumers from exposure to contaminants, including arsenic, in public water systems (PWS). The reproductive effects of preconception and prenatal arsenic exposure in regions with low to moderate arsenic concentrations are not well understood., Objectives: This study examined associations between preconception and prenatal exposure to arsenic violations in water, measured via residence in a county with an arsenic violation in a regulated PWS during pregnancy, and five birth outcomes: birth weight, gestational age at birth, preterm birth, small for gestational age (SGA), and large for gestational age (LGA)., Methods: Data for arsenic violations in PWS, defined as concentrations exceeding 10 parts per billion, were obtained from the Safe Drinking Water Information System. Participants of the Environmental influences on Child Health Outcomes Cohort Study were matched to arsenic violations by time and location based on residential history data. Multivariable, mixed effects regression models were used to assess the relationship between preconception and prenatal exposure to arsenic violations in drinking water and birth outcomes., Results: Compared to unexposed infants, continuous exposure to arsenic from three months prior to conception through birth was associated with 88.8 g higher mean birth weight (95% CI: 8.2, 169.5), after adjusting for individual-level confounders. No statistically significant associations were observed between any preconception or prenatal violations exposure and gestational age at birth, preterm birth, SGA, or LGA., Conclusions: Our study did not identify associations between preconception and prenatal arsenic exposure, defined by drinking water exceedances, and adverse birth outcomes. Exposure to arsenic violations in drinking water was associated with higher birth weight. Future studies would benefit from more precise geodata of water system service areas, direct household drinking water measurements, and exposure biomarkers., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Per- and polyfluoroalkyl substances (PFAS) are persistent and ubiquitous chemicals associated with risk of adverse birth outcomes. Results of previous studies have been inconsistent. Associations between PFAS and birth outcomes may be affected by psychosocial stress., Objectives: We estimated risk of adverse birth outcomes in relation to prenatal PFAS concentrations and evaluate whether maternal stress modifies those relationships., Methods: We included 3,339 participants from 11 prospective prenatal cohorts in the Environmental influences on the Child Health Outcomes (ECHO) program to estimate the associations of five PFAS and birth outcomes. We stratified by perceived stress scale scores to examine effect modification and used Bayesian Weighted Sums to estimate mixtures of PFAS., Results: We observed reduced birth size with increased concentrations of all PFAS. For a 1-unit higher log-normalized exposure to perfluorooctanoic acid (PFOA), perfluorooctanesulfonic acid (PFOS), perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS), we observed lower birthweight-for-gestational-age z-scores of β = - 0.15 [95% confidence interval (CI): - 0.27 , - 0.03 ], β = - 0.14 (95% CI: - 0.28 , - 0.002 ), β = - 0.22 (95% CI: - 0.23 , - 0.10 ), β = - 0.06 (95% CI: - 0.18 , 0.06), and β = - 0.25 (95% CI: - 0.37 , - 0.14 ), respectively. We observed a lower odds ratio (OR) for large-for-gestational-age: OR PFNA = 0.56 (95% CI: 0.38, 0.83), OR PFDA = 0.52 (95% CI: 0.35, 0.77). For a 1-unit increase in log-normalized concentration of summed PFAS, we observed a lower birthweight-for-gestational-age z-score [ - 0.28 ; 95% highest posterior density (HPD): - 0.44 , - 0.14 ] and decreased odds of large-for-gestational-age ( OR = 0.49 ; 95% HPD: 0.29, 0.82). Perfluorodecanoic acid (PFDA) explained the highest percentage (40%) of the summed effect in both models. Associations were not modified by maternal perceived stress., Discussion: Our large, multi-cohort study of PFAS and adverse birth outcomes found a negative association between prenatal PFAS and birthweight-for-gestational-age, and the associations were not different in groups with high vs. low perceived stress. This study can help inform policy to reduce exposures in the environment and humans. https://doi.org/10.1289/EHP10723.

Background: Food insecurity is a complex public health problem affecting many individuals in the United States. Digital health interventions that promote behavior change and provide access to affordable and healthy food may help to alleviate food insecurity., Objective: The aim of this study was to characterize food-insecure users of Foodsmart, a telehealth and nutrition platform with meal planning, food ordering, nutrition education, budgeting, and grocery discount features, and to evaluate changes in diet and food insecurity., Methods: We retrospectively analyzed data collected from 4595 adults who used the Foodsmart platform between February and October 2021. Participants self-reported their diet, demographics, biometrics, and food insecurity status in a 56-item questionnaire. Participants were reported to be food insecure if they answered "sometimes" or "often" to the question "How often does the food you buy not last and you don't have money to get more?" from the United States Department of Agriculture's Household Food Security survey. We examined baseline characteristics of participants by food insecurity status, associations between characteristics and baseline food insecurity, and changes in diet quality and food insecurity status. To evaluate potential causes of reversing food insecurity, the use of 6 Foodsmart features was compared between food-insecure participants who achieved food security versus food-insecure participants who remained food insecure, based on their last response to the food insecurity question., Results: We found that 16% (742/4595) of participants were food insecure at baseline. Participants who were food insecure at baseline were more likely to be obese, to have at least one chronic condition, to have a lower diet quality, to cook less frequently at home, to think healthy food is too expensive, and less likely to order takeout or eat at a restaurant. Among participants who were food insecure at baseline, 61% (451/742) improved their nutrition and 29% (217/742) responded that they were food secure at follow-up, with an increasing percentage achieving food security with longer enrollment time. Using a multivariable logistic regression model, we found that age, diabetes, prediabetes, BMI categories, and diet quality at baseline were statistically significantly associated with the likelihood of being food insecure at baseline. Among those who were food insecure at baseline, there was a higher relative proportion of participants who achieved food security and used the "deals" (28.6% higher), "CookItNow" (36.4% higher), and "telenutrition" (27.5% higher) features compared to those who remained food insecure., Conclusions: This study assesses the characteristics of individuals enrolled on the Foodsmart platform who answered the food insecurity question. We found that a significant number of participants who were food insecure at enrollment achieved food security. This finding shows that telehealth and nutrition platforms may potentially help users improve household food security., (©Shivani Bakre, Benjamin Shea, Kaylee Ortega, Jared Scharen, Jason Langheier, Emily Hu. Originally published in JMIR Formative Research (https://formative.jmir.org), 25.10.2022.)

Objectives: We sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement., Methods: Patients ( N = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Patients who were determined to be good candidates for shunts ( N = 71, 31.7%) took another MoCA assessment following shunt insertion. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared., Results: All nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline ( p = 0.88) or have better improvement in MoCA scores after the tap test ( p = 0.17). Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion ( p = 0.019; p = 0.03, respectively)., Conclusions: In patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wesner, Etzkorn, Bakre, Chen, Davis, Zhang, Yasar, Rao, Luciano, Wang and Moghekar.)

Importance: Medicare accountable care organizations (ACOs) that disproportionately care for patients of racial and ethnic minority groups deliver lower quality care than those that do not, potentially owing to differences in out-of-network primary care among them., Objective: To examine how organizational quality is associated with out-of-network primary care among ACOs that care for high vs low proportions of patients of racial and ethnic minority groups., Design Setting and Participants: A retrospective cohort study was conducted between March 2019 and October 2021 using claims data (2013 to 2016) from a national sample of Medicare beneficiaries. Among beneficiaries who were assigned to 1 of 528 Medicare ACOs, a distinction was made between those treated by organizations that cared for high (vs low) proportions of patients of racial and ethnic minority groups. For each ACO, the amount of out-of-network primary care that it delivered annually was determined. Multivariable models were fit to evaluate how the quality of care that beneficiaries received varied by the proportion of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care., Exposures: The degree of care provided to patients of racial and ethnic minority groups by the ACO and its amount of out-of-network primary care., Main Outcomes and Measures: The ACO quality assessed with 5 preventive care services and 4 utilization metrics., Results: Among 3 955 951 beneficiary-years (2 320 429 [58.7%] women; 71 218 [1.8%] Asian, 267 684 [6.8%] Black, 44 059 [1.1%] Hispanic, 4922 [0.1%] North American Native, and 3 468 987 [87.7%] White individuals and 56 157 [1.4%] of Other race and ethnicity), those assigned to ACOs serving many patients of racial and ethnic minority groups at the mean level of out-of-network primary care were less likely than those assigned to ACOs serving fewer patients of racial and ethnic minority groups to receive diabetic retinal examinations (predicted probability, 49.4% [95%CI, 49.0%-49.7%] vs 51.6% [95% CI, 51.5%-51.8%]), glycated hemoglobin testing (predicted probability, 58.5% [95% CI, 58.2%-58.5%] vs 60.4% [95% CI, 60.3%-60.6%]), or low-density lipoprotein cholesterol testing (predicted probability, 85.2% [95% CI, 85.0%-85.5%] vs 86.0% [95% CI, 85.9%-86.1%]). They were also more likely to experience all-cause 30-day readmissions (predicted probability, 16.4% [95% CI, 16.1%-16.7%] vs 15.7% [95% CI, 15.6%-15.8%]). However, as the level of out-of-network primary care decreased, these gaps closed substantially, such that beneficiaries at ACOs that served many and fewer patients of racial and ethnic minority groups in the lowest percentile of out-of-network primary care received care of comparable quality., Conclusions and Relevance: This large cohort study found that quality performance among ACOs serving many patients of racial and ethnic minority groups was negatively associated with their level of out-of-network primary care., Competing Interests: Conflict of Interest Disclosures: Dr Herrel reported grants from the National Cancer Institute outside the submitted work. Dr Hollingsworth reported grants from National Institute on Aging (R01AG068074) during the conduct of the study. No other disclosures were reported., (Copyright 2022 Bakre S et al. JAMA Health Forum.)

Background: While there is a strong association between adhering to a healthy dietary pattern and reductions in blood pressure, adherence remains low. New technologies aimed to help facilitate behavior change may have an effect on reducing blood pressure among individuals with hypertension., Objective: This study aims to evaluate characteristics of participants with stage 2 hypertension who used Foodsmart and to assess changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP)., Methods: We analyzed demographic, dietary, and clinical characteristics collected from 11,934 adults with at least two blood pressure readings who used the Foodsmart platform. Stage 2 hypertension was defined as SBP ≥140 mmHg or DBP ≥90 mmHg. We calculated mean changes in blood pressure among participants with stage 2 hypertension and stratified by length of follow-up and the covariates associated with achieving blood pressure levels below stage 2 hypertension. We compared changes in diet quality and weight between participants with stage 2 hypertension at baseline who achieved stage 1 hypertension or below and those who did not., Results: We found that 10.63% (1269/11,934) of participants had stage 2 hypertension at baseline. Among Foodsmart participants with stage 2 hypertension at baseline, SBP and DBP decreased, on average, by 5.7 and 4.0 mmHg, respectively; 33.02% (419/1269) of participants with stage 2 hypertension at baseline achieved blood pressure levels below stage 2 hypertension (SBP <140 mmHg and DBP <90 mmHg). Using a multivariable ordinal logistic regression model, changes in Nutriscore (P=.001) and weight (P=.04) were statistically significantly associated with changes in blood pressure categories for users with stage 2 hypertension at baseline. Using a multivariable logistic regression model, we found that baseline Nutriscore, change in Nutriscore, and change in weight were associated with greater likelihood of users with stage 2 hypertension at baseline achieving a lower blood pressure category., Conclusions: This study evaluated changes in SBP and DBP among users (with hypertension) of the Foodsmart platform and found that those with stage 2 hypertension, on average, improved their blood pressure levels over time., (©Shivani Bakre, Benjamin Shea, Jason Langheier, Emily A Hu. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.03.2022.)

Ratiometric delivery of combination chemotherapy can achieve therapeutic efficacy based on synergistic interactions between drugs. It is critical to design such combinations with drugs that complement each other and reduce cancer growth through multiple mechanisms. Using hyaluronic acid (HA) as a carrier, two chemotherapeutic agents-doxorubicin (DOX) and camptothecin (CPT)-were incorporated and tested for their synergistic potency against a broad panel of blood-cancer cell lines. The pair also demonstrated the ability to achieve immunogenic cell death by increasing the surface exposure levels of Calreticulin, thereby highlighting its ability to induce apoptosis via an alternate pathway. Global proteomic profiling of cancer cells treated with HA-DOX-CPT identified pathways that could potentially predict patient sensitivity to HA-DOX-CPT. This lays the foundation for further exploration of integrating drug delivery and proteomics in personalized immunogenic chemotherapy.

Aims: Urinary incontinence (UI) in women is a dynamic condition with numerous risk factors yet most studies have focused on examining its prevalence at a single time. The objective of this study was to describe the long-term time course of UI in women with type 1 diabetes (T1D)., Methods: Longitudinal data in women with T1D were collected from 568 women in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, the observational follow-up of the Diabetes Control and Complications Trial (DCCT) cohort. Over a 12-year period, participants annually responded to whether they had experienced UI in the past year., Results: We identified four categories of UI in this population over time: 205 (36.1%) women never reported UI (no UI), 70 (12.3%) reported it one or two consecutive years only (isolated UI), 247 (43.5%) periodically changed status between UI and no UI (intermittent UI), and 46 (8.1%) reported UI continuously after the first report (persistent UI). Compared to women reporting no/isolated UI, women displaying the intermittent phenotype were significantly more likely to be obese (OR: 1.86, 95% CI 1.15, 3.00) and report prior hysterectomy (OR: 2.57, 95% CI: 1.39, 4.77); whereas women with persistent UI were significantly more likely to have abnormal autonomic function (OR: 2.36, 95% CI: 1.16-4.80)., Conclusions: UI is a dynamic condition in women with T1D. Varying risk factors observed for the different phenotypes of UI suggest distinctive pathophysiological mechanisms. These findings have the potential to be used to guide individualized interventions for UI in women with diabetes., (© 2021 Wiley Periodicals LLC.)

In present world almost all industrial systems are based on wireless communication, as it has many advantages. The development of a fully Automated Energy Meter which is having capabilities like remote monitoring and controlling of energy meter will lead to transparency in the energy meter reading and billing system. This system avoids the human intervention in power management. If the customer does not pay the bill in time, the user is informed through SMS system using GSM. If still customer does not pay the bill then as per designed late consideration, one alert message will be sent then automatically the power connection is disconnected from the remote server. The purpose of this project is the remote monitoring and control of the domestic energy meter; its aims includes: to design a circuit which continuously monitors the meter reading and sends message to electricity company, programming of the GSM MODEM with AT (Attention)command sequence, interfacing the programmable chip with the personal computer, interfacing the programmable chip with the energy meter, interfacing of GSM MODEM with the programmable chip, sending messages from the remote phone to control device. [ABSTRACT FROM AUTHOR]

Background: Diabetes-related costs are the highest across all chronic conditions in the United States, with type 2 diabetes accounting for up to 95% of all cases of diabetes. A healthy diet is strongly associated with lowering glycated hemoglobin A 1c (HbA 1c ) levels among individuals with diabetes, which can help curtail other health complications. Digital health platforms can offer critical support for improving diet and glycemic control among individuals with diabetes. Less is known about the characteristics of people with diabetes who use digital health platforms (specifically, a platform that integrates personalized healthy meal plans and food ordering) and changes in their HbA 1c levels., Objective: The aim of this study is to characterize Foodsmart users with diabetes and evaluate the longitudinal impact of Foodsmart-a personalized digital nutrition platform with meal planning, food ordering, and nutrition education features-on changes in HbA 1c levels., Methods: We retrospectively analyzed data collected from 643 adults with at least two self-reported HbA 1c entries in the Foodsmart platform between January 2016 and June 2021. Participants self-reported their HbA 1c levels, height, weight, health conditions, and diet in a 53-item food frequency questionnaire. Diabetes was defined as HbA 1c ≥6.5%. We analyzed distributions of characteristics by baseline diabetes status and examined the association of characteristics with the likelihood of having diabetes at baseline. To evaluate the change in HbA 1c levels among Foodsmart users, we calculated mean changes (absolute and percent) in HbA 1c among participants with diabetes and by length of follow-up. We also compared changes in HbA 1c and weight between participants with diabetes at baseline who achieved a normal HbA 1c level and those who did not., Results: We found that 43.5% (280/643) of the participants with at least two HbA 1c level entries had diabetes at baseline. Participants with diabetes at baseline were more likely to be male, have a higher weight and BMI, report high blood pressure, and have a poorer diet in comparison to participants without diabetes. Using a multivariable logistic regression model, we found that being male and obese were statistically significantly associated with baseline diabetes. Among participants with diabetes at baseline, HbA 1c was reduced, on average, by 0.46%. In addition, 21.4% (60/280) of participants with diabetes achieved a normal HbA 1c level (<6.5%) in their last HbA 1c level entry; this percentage increased with longer follow-up time (39% [7/18] at >24 months). In a sensitivity analysis, users with an HbA 1c ≥7.0% at baseline had an average absolute change of -0.62% and 31.2% (62/199) of these participants achieved HbA 1c levels of less than 7.0%., Conclusions: This study assessed characteristics of individuals enrolled on the Foodsmart platform with HbA 1c levels and found that users with diabetes had lower HbA 1c levels over time and a sizable percentage of participants were successful in achieving normal levels., (©Benjamin Shea, Shivani Bakre, Keaton Carano, Jared Scharen, Jason Langheier, Emily A Hu. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 18.10.2021.)

Skin cancer is one of the most common types of cancer in the United States and worldwide. Topical products are effective for treating cancerous skin lesions when surgery is not feasible. However, current topical products induce severe irritation, light-sensitivity, burning, scaling, and inflammation. Using hyaluronic acid (HA), we engineered clinically translatable polymer-drug conjugates of doxorubicin and camptothecin termed, DOxorubicin and Camptothecin Tailored at Optimal Ratios (DOCTOR) for topical treatment of skin cancers. When compared to the clinical standard, Efudex, DOCTOR exhibited high cancer-cell killing specificity with superior safety to healthy skin cells. In vivo studies confirmed its efficacy in treating cancerous lesions without irritation or systemic absorption. When tested on patient-derived primary cells and live-skin explants, DOCTOR killed the cancer with a selectivity as high as 21-fold over healthy skin tissue from the same donor. Collectively, DOCTOR provides a safe and potent option for treating skin cancer in the clinic., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

Background and Objectives: Despite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare's fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned., Design, Setting, Participants, & Measurements: In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics., Results: During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397)., Conclusions: There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician., (Copyright © 2020 by the American Society of Nephrology.)

Background : Lorazepam use in the treatment of alcohol withdrawal syndrome (AWS) is not without risk. Objective : This study compares AWS outcomes using a standard, symptom-triggered lorazepam dosing protocol (control group) and symptom-triggered lorazepam dosing augmented with a gabapentin loading dose and taper (GABA group). Methods : Consecutive, non-randomized adults (n = 982; 64.0% male) undergoing treatment for AWS were included in this retrospective, open-label study. Symptom-triggered lorazepam dosing was informed by scores on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar). Gabapentin augmentation utilized an initial loading dose (900 mg) and a three-day taper. Outcomes included average symptom severity per treatment hour and average lorazepam dose per treatment hour. Average time in the protocol by group, stratified by highest CIWA-Ar score, was examined as a secondary outcome. A priori group differences were controlled statistically. Results : GABA patients were older and exhibited somewhat more severe withdrawal symptoms than controls. After controlling for confounders, gabapentin augmentation did not significantly lower average lorazepam dosing per treatment hour or withdrawal symptom severity per treatment hour. Compared to controls, overall withdrawal symptoms diminished somewhat more rapidly for GABA patients experiencing low or moderate-level withdrawal symptoms; however, severe withdrawal symptoms remitted more slowly in the GABA group. Results should be interpreted in light of the uncontrolled nature of group assignment and other confounders. Conclusions : Compared to symptom-triggered lorazepam dosing alone, gabapentin augmentation did not produce better outcomes during treatment of acute AWS. These results do not support the use of scheduled gabapentin as an augmentation to benzodiazepines during inpatient treatment of AWS.

Purpose of Review: Environmental chemical exposures may disrupt child development, with long-lasting health impacts. To date, U.S. studies of early environmental exposures have been limited in size and diversity, hindering power and generalizability. With harmonized data from over 60,000 participants representing 69 pregnancy cohorts, the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) Program is the largest study of U.S. children's health. Here, we: (1) review ECHO-wide studies of chemical exposures and maternal-child health; and (2) outline opportunities for future research using ECHO data., Recent Findings: As of early 2024, in addition to over 200 single-cohort (or award) papers on chemical exposures supported by ECHO, ten collaborative multi-cohort papers have been made possible by ECHO data harmonization and new data collection. Multi-cohort papers have examined prenatal exposure to per- and polyfluoroalkyl substances (PFAS), phthalates, phenols and parabens, organophosphate esters (OPEs), metals, melamine and aromatic amines, and emerging contaminants. They have primarily focused on describing patterns of maternal exposure or examining associations with maternal and infant outcomes; fewer studies have examined later child outcomes (e.g., autism) although follow up of enrolled ECHO children continues. The NICHD's Data and Specimen Hub (DASH) database houses extensive ECHO data including over 470,000 chemical assay results and complementary data on priority outcome areas (pre, peri-, and postnatal, airway, obesity, neurodevelopment, and positive health), making it a rich resource for future analyses. ECHO's extensive data repository, including biomarkers of chemical exposures, can be used to advance our understanding of environmental influences on children's health. Although few published studies have capitalized on these unique harmonized data to date, many analyses are underway with data now widely available., (© 2024. The Author(s).)

Presents a study which observed the magneto microwave Kerr effect in the Voigt configuration on polycrystalline magnesium-manganese ferrite samples at x-band frequency. Background on the magneto microwave Kerr effect; Computational approach; Results and discussion.

A method for determination of selected organophosphorus pesticides (OPs) along with their degradation products in post mortem tissues is reported in the paper. Malathion, Dimethoate and Phorate are frequently found organophosphates in homicidal or suicidal poisoning cases. The separation of these pesticides along-with their oxon degradation products Malaoxon, Omethoate and Phorate-sulfone respectively is achieved by a programmed temperature capillary column gas chromatography coupled with a nitrogenphosphorus detector (NPD). Prior to analysis, pesticide residues were extracted by QuEChERS extraction method. Matrix matched calibration curves were linear with coefficients of correlation better than 0.995 for concentration range from 0.5 to 20 μg/gm while the limits of detection ranged from 0.05 to 0.85 μg/gm for all compounds. The method is simple, rapid and was used to detect the oxon degradation products of the original OP which otherwise were not detectable by other conventional methods used for routine analysis of post-mortem tissues in poisoning cases. [ABSTRACT FROM AUTHOR]

The article discusses a comparative study of pounding forces obtained from several models of impact simulation. Topics covered include pounding models' uncertainty in collision properties that alter a structure's final response, damage resulting from pounding between adjacent structures in densely populated cities, and the mathematical formulation of gap element spring properties. The linear single degree of freedom (SDOF) system in each adjacent structure in a system is also mentioned.

The optimum parameters of multiple tuned mass dampers (MTMD) for suppressing the dynamic response of a base-excited damped main system are investigated by a numerical searching technique. The criterion selected for the optimality is the minimization of the steady state displacement of the main system under harmonic base acceleration. The parameters of the MTMD that are optimized include: the damping ratio, the tuning frequency ratio and the frequency bandwidth. The optimum parameters of the MTMD system and corresponding displacement are obtained for different damping ratios of the main system and different mass ratios of the MTMD system. The explicit formulas for the optimum parameters of the MTMD (i.e. damping ratio, bandwidth and tuning frequency) are then derived using a curve-fitting scheme that can readily be used in engineering applications. The error in the proposed explicit expressions is investigated and found to be negligible. The effectiveness of the optimally designed MTMD system is also compared with that of the optimum single tuned mass damper. It is observed that the optimally designed MTMD system is more effective for vibration control than the single tuned mass damper. Further, the damping in the main system significantly influences the optimum parameters and the effectiveness of the MTMD system. [ABSTRACT FROM AUTHOR]

The global population is increasing at an alarming pace, leading to a rapid surge in industrialization and concomitant environmental degradation. In light of the present circumstances, it is crucial to find sustainable solutions to mitigate pollution and ensure a safe and clean environment for the present and future society. One promising solution is photocatalysis, which utilizes solar energy to address environmental issues while providing a renewable and sustainable energy source. Herein, a TiO2-based multi-layer thin film photocatalyst was developed, and its hydrogen generation and Rhodamine 6G dye degradation properties were analysed. As TiO2 undergoes excitation in the UV region, in order to shift the absorbance towards the visible region, bandgap engineering was performed with Fe and Ag doping. As a consequence, the band gap effectively reduces, and Fe and Ag doping result in the least gap energies measuring 2.7 eV and 2.85 eV, respectively. DFT band structure study was performed, which shows the presence of additional electronic states that lie in the conduction and valence energy bands of TiO2 owing to the doping of elements. Additionally, the effect of the number of thin film layers on photocatalysis was investigated. To confirm the presence of structural distortions and oxygen vacancies, different characterizations were performed. [ABSTRACT FROM AUTHOR]

Introduction: Drug-resistant Neisseria gonorrhoeae is an urgent threat to public health. Novel prevention and treatment strategies are emerging, including immunizations, pharmacologic post-exposure prophylaxis, rapid molecular resistance assays, and novel antibiotics. However, where and how such strategies are optimally implemented remains unclear. Methods: We conducted a retrospective interrupted time series analysis of gonorrhea cases reported to the Massachusetts Department of Public Health. We collected names of treating providers from 2011 (n = 100) and 2022 (n = 108), and cross-referenced provider names with publicly available records from the Massachusetts Boards of Registration in Medicine and Nursing to identify provider type, specialty, year of terminal degree or licensure, and clinic type. Results: Of 208 providers, 111 (53.4%) were advanced care practitioners. Providers treated cases predominantly in community health centers (n = 65, 31.3%) and emergency departments or urgent care centers (n = 60, 28.8%). Only 11 (12.4%) of 89 physicians were trained in either adult or pediatric infectious diseases. Conclusion: Our results indicate that the majority of gonorrhea cases in the Massachusetts are treated in non-specialty settings. The time is now to plan for implementation of the emerging strategies to avoid underutilization and assure uptake of interventions in settings positioned to reach persons diagnosed with gonorrhea who will benefit most. [ABSTRACT FROM AUTHOR]

This review highlights the significant role of nanodrug delivery systems (NDDS) in enhancing the efficacy of tumor immunotherapy. Focusing on the integration of NDDS with immune regulation strategies, it explores their transformative impacts on the tumor microenvironment and immune response dynamics. Key advancements include the optimization of drug delivery through NDDS, targeting mechanisms like immune checkpoint blockade and modulating the immunosuppressive tumor environment. Despite the progress, challenges such as limited clinical efficacy and complex manufacturing processes persist. The review emphasizes the need for further research to optimize these systems, potentially revolutionizing cancer treatment by improving delivery efficiency, reducing toxicity and overcoming immune resistance. Graphical Abstract Article highlights Tumor immunotherapy & nanodrug delivery system Immunotherapy Essential for addressing tumor growth, evasion and metastasis, with key roles played by immune evasion processes. Mechanisms Involves activation of T-cell immune response, with antigen-presenting cells playing a pivotal role in activating effector T-cells which target tumor cells. Approaches Distinguishes between passive and active immunotherapies, including the use of immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. Challenges Includes immune-related adverse effects, drug resistance and the immunosuppressive tumor microenvironment (TME). Drug delivery systems Focuses on nanomedicine for targeted drug delivery, enhancing drug efficacy and minimizing toxicity, crucial for overcoming immunotherapy challenges. Nanodrug delivery system in tumor immunotherapy Immunogenic cell death inducement Describes the role of NDDS in promoting immunogenic cell death through delivery of chemotherapy drugs and photosensitizers. Regulation of TME Outlines strategies for targeting immune suppressive cells in the TME, including macrophages and neutrophils, to enhance immune response. Elimination of tumor cell immune escape Discusses the utilization of NDDS to block immune escape mechanisms effectively, enhancing the efficacy of immunotherapy. Enhancement of peripheral immune function Highlights the use of nanoparticles to target lymph nodes and spleen for improving the activation of the immune system against tumors. Challenges & future directions Drug delivery challenges Discusses limitations like poor tumor penetrability and the complexity of the TME which hinder the efficacy of NDDS. Clinical applications Notes the limited clinical application of NDDS due to tumor heterogeneity and differences between preclinical models and human conditions. Future research Emphasizes the need for humanized animal models, identification of biomarkers for personalized treatment and advances in nanotechnology to enhance the effectiveness and safety of NDDS in tumor immunotherapy. [ABSTRACT FROM AUTHOR]

Product inhibition poses a persistent challenge in catalysis, adversely affecting reaction rates and selectivity, leading to substantial economic losses in industrial settings. This phenomenon is particularly pronounced in sustainable hydrogen production, where byproduct-induced inhibition often obstructs catalyst regeneration and sustained catalytic activity. Despite numerous reports highlighting the issues associated with product inhibition, studies directly addressing this critical problem while maintaining a high turnover frequency (TOF) of the catalyst throughout the cycle remain unexplored. In this work, we have engineered a unique catalyst comprising Ru atomic clusters (ACs) installed on the surface of Co–Co2B (10% RuACs/Co–Co2B) that remarkably combats product inhibition by borates during ammonia borane (AB) dehydrogenation, while sustaining the catalyst's efficacy in hydrogen production throughout the reaction cycle. The hydrogen generation proceeds with a superior rate (26559.14 ± 169.67 mL min−1 gcat−1) and a high TOF (1032.2 ± 114.6 molH2 molRu−1 min−1) that dehydrogenates AB in only 9 s. Through a comprehensive analysis combining detailed experimental evidence, computational studies, and successive half-life analyses, we have uncovered significant charge reorganization between the Ru atomic clusters and the Co–Co2B support, which cooperatively facilitates rapid kinetics and greatly enhances the removal of the byproduct, ammonium tetramethoxyborate (AMB), from the catalyst's surface. This unique chemistry to combat product inhibition without compromising high rate and TOF distinguishes the 10% RuACs/Co–Co2B catalyst from others reported in the literature. Our findings not only hold significant promise for a sustainable hydrogen economy but open up avenues for the fundamental engineering of atomically clustered multitasking catalysts capable of addressing product inhibition in various crucial reactions. [ABSTRACT FROM AUTHOR]

A pilot study was carried out to determine the yeast species associated with sugar cane peels recovered from three separate dumping sites found in Ojo, a typical market town in Nigeria. Species identities were determined by 26S ribosomal DNA (rDNA) sequencing. By using this method, a total of 6 different yeasts were identified, with Candida tropicalis, a recognised human yeast pathogen, being the species most frequently isolated from these dumping sites. The implications of this and other findings of the study, the apparent first of its kind, are discussed in detail.

Traffic is an important pollution factor causing environmental damages such as soil, water and atmospheric pollution, greenhouse effect, and climate change. Effects of traffic pollution on various organisms enlightened with various studies. In this study, it was aimed to examine the effects of traffic-based pollution on Auchenorrhyncha (Insecta: Hemiptera) species in apple orchards and their potential as biomonitor for heavy metal pollution. The Auchenorrhyncha specimens were collected from the apple orchards near the Amasya-Samsun motorway in Türkiye. The heavy metal concentrations were determined by ICP-OES. Five Auchenorrhyncha species were determined from three sites from each of three different distance. Empoasca decipiens specimens were collected only from 0 m while others found in all localities. Heavy metal concentrations in insect specimens tended to decrease with the increasing distance from the motorway. These differences were clearly indicated in Psammotettix provincialis and Phlepsius intricatus, which were found in all localities. Except for Ni, Fe and Mn for Phlepsius intricatus, all examined heavy metals significantly varied in both species. Results showed that heavy metals tended to accumulate in the body of Auchenorrhyncha specimens and because of this they may be evaluated as a biomonitor for heavy metal pollution. [ABSTRACT FROM AUTHOR]

Growing concerns about seismic events enforced structural engineers and architects to embrace the hazardous effect of ground motion in design. To address this, researchers have developed various base isolation (BI) techniques. This study comprehensively reviews BI system types, techniques, and implementation. Exploring the dynamic response of three-dimensional BI devices and the mutual effects of isolation devices and soil-structure interaction during strong ground motion, the paper covers topics such as seismic isolation of nuclear power plants, cost analysis, and various optimization techniques. Furthermore, the paper investigates the behavior of isolation devices in beyond-design events, including blast and aircraft impact loading. In general, the seismic isolation and control device response is demonstrated through shaking table tests and computational analysis. The study sheds light on the functions of seismic isolation system by comparing them with fixed base structures. Additionally, the paper presents codal recommendations, recent advancements, and current practices, aligning them with historical developments and past reviews of different BI techniques, along with their advantages and disadvantages. In conclusion, the closing remarks emphasize the future research prospects in this field. [ABSTRACT FROM AUTHOR]

BACKGROUND: Estimates for the effects of environmental exposures on health outcomes, including secondhand smoke (SHS) exposure, often present considerable variability across studies. Knowledge of the reasons behind these differences can aid our understanding of effects in specific populations as well as inform practices of combining data from multiple studies. OBJECTIVES: This study aimed to assess the presence of effect modification by measured sociodemographic characteristics on the effect of SHS exposure during pregnancy on birth weights that may drive differences observed across cohorts. We also aimed to quantify the extent to which differences in the cohort mean effects observed across cohorts in the Environmental influences on Child Health Outcomes (ECHO) consortium are due to differing distributions of these characteristics. METHODS: We assessed the presence of effect modification and transportability of effect estimates across five ECHO cohorts in a total of 6,771 mother–offspring dyads. We assessed the presence of effect modification via gradient boosting of regression trees based on the H-statistic. We estimated individual cohort effects using linear models and targeted maximum likelihood estimation (TMLE). We then estimated transported effects from one cohort to each of the remaining cohorts using a robust nonparametric estimation approach relying on TMLE estimators and compared them to the original effect estimates for these cohorts. RESULTS: Observed effect estimates varied across the five cohorts, ranging from significantly lower birth weight associated with exposure [-167.3 g; 95% confidence interval (CI): -270.4, -64.1] to higher birth weight with wide CIs, including the null (42.4 g; 95% CI: -15.0, 99.8). Transported effect estimates only minimally explained differences in the point estimates for two out of the four cohort pairs. DISCUSSION: Our findings of weak to moderate evidence of effect modification and transportability indicate that unmeasured individual-level and contextual factors and sources of bias may be responsible for differences in the effect estimates observed across ECHO cohorts. [ABSTRACT FROM AUTHOR]

Per- and polyfluoroalkyl substances (PFAS) are widely used, and their fluorinated state contributes to unique uses and stability but also long half-lives in the environment and humans. PFAS have been shown to be toxic, leading to immunosuppression, cancer, and other adverse health outcomes. Only a small fraction of the PFAS in commerce have been evaluated for toxicity using in vivo tests, which leads to a need to prioritize which compounds to examine further. Here, we demonstrate a prioritization approach that combines human biomonitoring data (blood concentrations) with bioactivity data (concentrations at which bioactivity is observed in vitro) for 31 PFAS. The in vitro data are taken from a battery of cell-based assays, mostly run on human cells. The result is a Bioactive Concentration to Blood Concentration Ratio (BCBCR), similar to a margin of exposure (MoE). Chemicals with low BCBCR values could then be prioritized for further risk assessment. Using this method, two of the PFAS, PFOA (Perfluorooctanoic Acid) and PFOS (Perfluorooctane Sulfonic Acid), have BCBCR values < 1 for some populations. An additional 9 PFAS have BCBCR values < 100 for some populations. This study shows a promising approach to screening level risk assessments of compounds such as PFAS that are long-lived in humans and other species. [ABSTRACT FROM AUTHOR]