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Background: The study’s objective was to explore the factors associated with loss to follow up among women with abnormal cervical cancer screening results in Iquitos, Peru from women’s perspectives. Methods: In-depth interviews were conducted with 20 screen-positive women who were referred for follow-up care but for whom evidence of follow up was not found. Results: All interviewed women were highly motivated to complete the continuum of care but faced numerous barriers along the way, including cognitive barriers such as a lack of knowledge about cervical cancer and poor communication from health professionals regarding the process, structural barriers such as challenges with scheduling appointments and unavailability of providers, and financial barriers including out-of-pocket payments and costs related to travel or missing days of work. With no registry to ensure the continuum of care, we found fragmentation between primary and hospital-level care, and often, registration of women’s follow up care was missing altogether, preventing women from being able to receive proper care and providers from ensuring that women receive care and treatment as needed. Conclusions: The challenges elucidated demonstrate the complexity of implementing a successful cervical cancer prevention program and indicate a need for any such program to consider the perspectives of women and multiple levels in the system to improve follow up after a positive screening test.

Highlights • This is the first study on the co-administration of typhoid conjugate vaccine (TCV) in West Africa. • Co-administration of TCV with routine vaccines in a typhoid-endemic country was successful. • TCV was safely co-administered at nine months with yellow fever and measles-rubella vaccines. • Single-dose TCV was immunogenic in 9-month-old children. • There was no safety signal related to TCV vaccination or co-administration., Objectives In 2017, the World Health Organisation (WHO) pre-qualified a single-dose typhoid conjugate vaccine (TCV) and identified TCV co-administration studies as a research priority. Accordingly, we tested co-administration of Typbar TCV® (Bharat Biotech International) with measles-rubella (MR) and yellow fever (YF) vaccines. Methods We conducted a randomized, double-blind, and controlled, phase 2 trial in Ouagadougou, Burkina Faso. Healthy children aged 9–11 months were randomized 1:1 to receive TCV (Group 1) or control vaccine (inactivated polio vaccine (IPV), Group 2). Vaccines were administered intramuscularly with routine MR and YF vaccines. Safety was assessed by (1) local and systemic reactions on days 0, 3, and 7; (2) unsolicited adverse events within 28 days; and (3) serious adverse events (SAEs) within six months after immunization. Results We enrolled, randomized, and vaccinated 100 eligible children (49 Group 1 and 51 Group 2). Safety outcomes occurred with similar frequency in both groups: local/solicited reactions (Group 1: 1/49, Group 2: 3/50), systemic/solicited reactions (Group 1: 4/49, Group 2: 9/50), unsolicited adverse events (Group 1: 26/49, Group 2: 33/51), and SAEs (Group 1: 2/49, Group 2: 3/51). TCV conferred robust immunogenicity without interference with MR or YF vaccines. Conclusion TCV can be safely co-administered with MR and YF vaccines to children at the 9-month vaccination visit.

Background: The World Health Organization (WHO) has called for a systems thinking approach to health systems strengthening to increase adoption of evidence-based interventions (EBI). The Integrative Systems Praxis for Implementation Research (INSPIRE) methodology operationalizes the WHO systems thinking framework to meet cervical cancer elimination–early detection and treatment (CC-EDT) goals. Methods: Using a systems thinking approach and grounded in the consolidated framework for implementation research, INSPIRE integrates multiple research methodologies and evaluation frameworks into a multilevel implementation strategy. Results: In phase I (creating a shared understanding), soft systems methodology and pathway analysis are used to create a shared visual understanding of the CC-EDT system, incorporating diverse stakeholder perspectives of the “what, how, and why” of system behavior. Phase II (finding leverage) facilitates active stakeholder engagement in knowledge transfer and decision-making using deliberative dialogues and multiple scenario analyses. Phase III (acting strategically) represents stakeholder-engaged implementation planning, using well-defined implementation strategies of education, training, and infrastructure development. In phase IV (learning and adapting), evaluation of key performance indicators via a reach, effectiveness, adoption, implementation, and maintenance framework is reviewed by stakeholder teams, who continuously adapt implementation plans to improve system effectiveness. Conclusions: The INSPIRE methodology is a generalizable approach to context-adapted implementation of EBIs. Impact: Replacing static dissemination of implementation “roadmaps” with learning health systems through the integration of systems thinking and participatory action research, INSPIRE facilitates the development of scalable and sustainable implementation strategies adapted to local contexts.

The coronavirus disease 2019 (COVID-19) pandemic has cast a bright light on the importance of science and evidence (1). Epidemiologists have provided public health advice informed by experience with epidemics and are sharing best practices for halting the spread of the virus. Biomedical scientists are researching how the virus works, testing treatments, and racing to develop a safe and effective vaccine. This work reinforces previous calls from the National Academies and others for strong investments in science and mathematics education; science, engineering, and medicine research; and the translation of new knowledge into products and processes that improve public health, spur economic growth, and maintain national security (2⇓–4). Recent events have shined a bright light on intractable inequalities in US society. The science enterprise is far from immune. Although there has been progress, the science community can do much more. Image credit: Shutterstock/Tverdokhlib. Although its high level of contagion means that everyone is vulnerable to the virus, the pandemic has also shined a bright light on intractable inequalities in our society. Several months ago, we, along with others, advocated for release of COVID-19 case data by race, arguing that we could not understand the impact of the virus unless we could see how it affected communities differently. When data were finally made available, the disparities were clear. Elderly and low-income Americans, African Americans, Native Americans, and Hispanics are infected by and dying from the virus in disproportionate numbers. Ibram Kendi has shown that the African American community has been particularly hard hit because of structural racism, economic inequalities, and health disparities (5). To paraphrase others, these differences provided the kindling and police brutality the match for the widespread fire of racial protest that has called for broad policy changes to address structural racism in America. The pandemic … [↵][1]1To whom correspondence may be addressed. Email: hrabowsk{at}umbc.edu. [1]: #xref-corresp-1-1

Multiple studies show an increased prevalence of gambling disorder among African Americans compared to whites. However, few studies take an analytic approach to understanding differences in risk factors by race/ethnicity. Income is inversely associated with gambling disorder; we hypothesized that this association would vary by race/ethnicity. The main objective was to evaluate whether the association between income and gambling disorder varies by race/ethnicity. With data from the baseline visit of a prospective cohort study, Prevention and Etiology of Gambling Addiction Study in the United States, we used multivariable logistic regression analysis to determine whether the association between income and gambling disorder varies by race/ethnicity. 1164 participants were included in the final analyses. Measures included: demographics (age, sex, race/ethnicity, education, employment, annual household income), veteran status, marital status, homelessness, smoking, substance abuse, alcohol abuse, marijuana use, and lifetime gambling disorder diagnosis as derived from Alcohol Use Disorder and Associated Disabilities Interview Schedule. There was no evidence of effect modification by race/ethnicity in the association between income and gambling disorder (global p value = 0.17). Income was associated with increased odds of gambling disorder, but only for those with low income (

Forward progress in cancer treatment has resulted in fewer adverse consequences of cancer during and after treatment, offering employed cancer patients the possibility of continuing to work during treatment, returning to work after treatment, or implementing a combination of strategies to manage the cancer–work interface. Yet, much of the research on cancer and employment examines return to work as the primary outcome, neglecting to consider the circumstances of survivors who maintain employment while engaged in active treatment. We introduce the Cancer–Work Management Framework (CWMF), a conceptual framework for understanding the cancer and job demands survivors who continue to work during active treatment experience and how cancer and job resources and strategies could promote cancer–work fit and ultimately optimize employment and health outcomes. We provide an overview of the research describing the cancer–work management experiences of survivors who maintain employment during active treatment and summarize the theories that informed the CWMF including ecological systems, boundary-spanning, and job demands and resources theories. The paper presents a description of the components of the CWMF which include cancer demands, cancer care resources and strategies, work demands, and workplace resources. We also describe a process—cancer–work fit—that reflects the interplay between demands and resources influence employment and health outcomes. Future research directions for developing knowledge about the cancer–work management process are proposed with suggestions for study of how cancer and job demands influence cancer treatment and employment decisions.

Background Typhoid fever is an acute infection characterized by prolonged fever following the ingestion and subsequent invasion of Salmonella enterica serovar Typhi (S. Typhi), a human-restricted pathogen. The incidence of typhoid fever has been most reported in children 5-15 years of age, but is increasingly recognized in children younger than 5 years old. There has been a recent expansion of multidrug-resistant typhoid fever globally. Prior typhoid vaccines were not suitable for use in the youngest children in countries with a high burden of disease. This study aims to determine the efficacy of a typhoid conjugate vaccine (TCV) that was recently prequalified by the World Health Organization, by testing it in children 9 months through 12 years of age in Blantyre, Malawi. Methods In this Phase III, individually randomized, controlled, double-blind trial of the clinical efficacy of TCV, 28 000 children 9 months through 12 years of age will be enrolled and randomized in a 1:1 ratio to receive either Vi-TCV or a meningococcal serogroup A conjugate vaccine. A subset of 600 of these children will be further enrolled in an immunogenicity and reactogenicity sub-study to evaluate the safety profile and immune response elicited by Vi-TCV. Recruiting began in February 2018. Results All children will be under passive surveillance for at least 2 years to determine the primary outcome, which is blood culture-confirmed S. Typhi illness. Children enrolled in the immunogenicity and reactogenicity sub-study will have blood drawn before vaccination and at 2 timepoints after vaccination to measure their immune response to vaccination. They will also be followed actively for adverse events and serious adverse events. Conclusions The introduction of a single-dose, efficacious typhoid vaccine into countries with high burden of disease or significant antimicrobial resistance could have a dramatic impact, protecting children from infection and reducing antimicrobial usage and associated health inequity in the world's poorest places. This trial, the first of a TCV in Africa, seeks to demonstrate the impact and programmatic use of TCVs within an endemic setting. Clinical trials registration NCT03299426.

Background Typhoid fever has been endemic on the island nation of Samoa (2016 population, 195 979) since the 1960s and has persisted through 2019, despite economic development and improvements in water supply and sanitation. Methods Salmonella enterica serovar Typhi isolates from the 2 hospitals with blood culture capability and matched patient demographic and clinical data from January 2008 through December 2019 were analyzed. Denominators to calculate incidence by island, region, and district came from 2011 and 2016 censuses and from 2017–2019 projections from Samoa’s Bureau of Statistics. Data were analyzed to describe typhoid case burden and incidence from 2008 to 2019 by time, place, and person. Results In sum, 53–193 blood culture-confirmed typhoid cases occurred annually from 2008 to 2019, without apparent seasonality. Typhoid incidence was low among children age Conclusions Typhoid has been endemic in Samoa in the period 2008–2019. Interventions, including mass vaccination with a Vi-conjugate vaccine coadministered with measles vaccine are planned.

Telemedicine has shown promise in inflammatory bowel disease (IBD). The objective of this study was to compare disease activity and quality of life (QoL) in a 1 year randomized trial of IBD patients receiving telemedicine versus standard care. Patients with worsening symptoms in the prior 2 years were eligible for randomization to telemedicine (monitoring via texts EOW or weekly) or standard care. The primary outcomes were the differences in change in disease activity and QoL between the groups; change in health care utilization among groups was a secondary aim. 348 participants were enrolled (117 control group, 115 TELE-IBD EOW, and 116 TELE-IBD weekly). 259 (74.4%) completed the study. Age was 38.9 ± 12.3 years, 56.6% were women, 91.9% were Caucasian, 67.9% had Crohn’s disease (CD) and 42.5% had active disease at baseline. In CD, all groups experienced a decrease in disease activity (control −5.2 ± 5.0 to 3.7 ± 3.6, TELE-IBD EOW 4.7 ± 4.1 to 4.2 ± 3.9, and TELE-IBD weekly 4.2 ± 4.2 to 3.2 ± 3.4, p

Background Depression is common in patients with inflammatory bowel disease (IBD) and is known to be associated with poor adherence in the usual care setting. In the last decade, there has been an increase in the use of information technology (IT) for the delivery of IBD care, but the association between depressive symptoms (DS) and adherence to self-testing in this context is not known. We aimed to investigate this association among IBD patients managed via a text messaging-based telemedicine system. Methods This was a prospective study of participants in the 2 intervention arms of the Telemedicine for Patients with IBD (TELE-IBD) trial. Depressive symptoms were measured at baseline, and then participants received periodic text messages to initiate IBD-specific self-testing. Treatment plans were similarly conveyed, and adherence to self-testing was evaluated at the end of 1 year. Regression analyses were performed, and age-stratified models were constructed to evaluate for effect modification. Results Of the 193 study participants, 48% had DS at baseline. Overall, there was no significant association between DS and adherence to self-testing. However, upon stratification by age, adherence increased with depressive symptoms in those that were 40 years and younger (P = 0.02), but there was no association between depressive symptoms and adherence in the older group (P = 0.53). Conclusions Younger IBD patients with DS have high adherence when managed in a text messaging-based telemedicine program. Telemedicine interventions have the potential to improve health outcomes in this demographic-a group that is often thought to be difficult to manage due to nonadherence.

Background Effective treatments are available for patients with inflammatory bowel disease (IBD); however, suboptimal outcomes occur and are often linked to patients’ limited disease knowledge. The aim of this analysis was to determine if delivery of educational messages through a telemedicine system improves IBD knowledge. Methods TELEmedicine for Patients with IBD (TELE-IBD) was a randomized controlled trial with visits at baseline, 6 months, and 12 months; patient knowledge was a secondary aim of the study. Patients were randomized to receive TELE-IBD every other week (EOW), weekly (TELE-IBD W), or standard of care. Knowledge was assessed at each visit with the Crohn’s and Colitis Knowledge (CCKNOW) survey. The primary outcome was change in CCKNOW score over 1 year compared between the TELE-IBD and control groups. Results This analysis included 219 participants. Participants in the TELE-IBD arms had a greater improvement in CCKNOW score compared with standard care (TELE-IBD EOW +2.4 vs standard care +1.8, P = 0.03; TELE-IBD W +2.0 vs standard care +1.8, P = 0.35). Participants with lower baseline CCKNOW scores had a greater change in their score over time (P < 0.01). However, after adjusting for race, site, and baseline knowledge, there was no difference in CCKNOW score change between the control and telemedicine arms. Conclusions Telemedicine improves IBD-specific knowledge through text messaging, although the improvement is not additive with greater frequency of text messages. However, after adjustment for confounding variables, telemedicine is not superior to education given through standard visits at referral centers. Further research is needed to determine if revised systems with different modes of delivery and/or frequency of messages improve disease knowledge.

To review the scientific literature examining gambling behavior in military veterans in order to summarize factors associated with gambling behavior in this population. Database searches were employed to identify articles specifically examining gambling behavior in military veterans. Cumulative search results identified 52 articles (1983-2017) examining gambling behavior in veteran populations. Articles generally fell into one or more of the following categories: prevalence, psychological profiles and psychiatric comorbidities, treatment evaluations, measurement, and genetic contributions to gambling disorder. Results from reviewed articles are presented and implications for future research discussed. Research to date has provided an excellent foundation to inform potential screening, intervention and research activities going forward. The authors suggest that a public health approach to future research endeavors would strengthen the evidence base regarding gambling in veteran populations and better inform strategies for screening, prevention and treatment.

Background Utilization of patient-reported outcome tools allows a more accurate assessment of the efficacy of treatment, which is critical to comparative effectiveness research. Objectives The Maryland Orthopaedic Registry (MOR) was established to assess post-surgical outcomes related to patients’ pain, functional status, met expectations, and satisfaction using an electronic data collection system. Secondary aims of the registry include assessment of patient expectations of treatment, activity level, and general health status. Methods Adult patients enrolled in this prospective observational study completed self-report measures assessing pre-operative pain, function, treatment expectations, and activity levels during the perioperative period. MOR utilizes the Patient-Reported Outcomes Measurement Information System (PROMIS ® )‘computer adaptive testing for physical function, pain interference, fatigue, social satisfaction, anxiety, and depression. Perioperative data is extracted from the medical record. Results 300 patients (40% of eligible) have been enrolled into the initial cohort. Most patients (94.1%) were aged 18–65, and 57% were male. Fifty-seven percent of enrollees were White, 33% Black, and 4% Asian. PROMIS physical function and social satisfaction were both more than half a standard deviation below the population mean. Participants reported PROMIS anxiety scores that were half a standard deviation above the population mean and pain interference scores that were more than a standard deviation above the mean. Physical function scores were significantly worse among participants with lower extremity orthopaedic issues, but scores on other measures were similar between participants undergoing lower or upper extremity surgery. Conclusions MOR provides a comprehensive assessment of patients undergoing orthopaedic surgery. The utilization of electronic clinical assessment tools as well as computer adaptive testing allows for time-efficient data collection. The diverse population is a particular strength of MOR.

Objective The purpose of this paper is to report the baseline characteristics of EMPOWER participants—a group of newly diagnosed breast cancer survivors—and describe differences in hourly and salaried wage women’s experiences regarding cancer and work management in the three months following breast cancer diagnosis. Design and setting The EMployment and Potential Outcomes of Working through canceER (EMPOWER) project is a prospective longitudinal, mixed methods pilot study designed to evaluate how employment influences treatment decisions among women diagnosed with breast cancer. Participants were women diagnosed with new breast cancer and treated at one of two clinical sites of the University of Maryland Medical System. Women were enrolled in the study within three months of first breast cancer diagnosis. Study visits occurred every three months for one year. This paper reports data from for the baseline and three-month visit which had been completed by all enrollees. Methods Trained research personnel collected demographic information, medical history and health status, social history, employment data, cancer-related data, psychosocial adjustment, and financial wellbeing at the baseline enrollment visit. A semi-structured qualitative interview was administered at the three-month study visit to assess employment decisions and the impact of job demands, cancer care, and cancer-work fit during the three months following diagnosis. Result Fifty women with new, primary diagnosis of breast cancer were enrolled in the study. Mean age of participants was 51 years, and 46% identified their race as Black or other. The majority of women disclosed their diagnosis to their employer and nearly all maintained some level of employment during the first three to six months of treatment. Women with hourly wage jobs were similar to those with salaried wage jobs with respect to demographic and social characteristics. Women with hourly wage jobs were more likely to report working in physically demanding jobs and taking unpaid leave. They were also more likely to experience side effects that required physical restrictions at work, to leave their jobs due to demands of treatment, and to report managing cancer and work concurrently as very difficult. Women in salaried wage jobs were more likely to report falling behind or missing work and working remotely as a cancer-management strategy. Women in hourly jobs more often reported difficulty managing the competing demands of cancer and work. Conclusion While further study is needed, these results suggest that women in hourly and salaried workers reported similar experiences managing cancer and work, with a few key exceptions. These exceptions pertain to the nature of hourly-wage work. Cancer survivors employed in hourly jobs may be more vulnerable to poor employment outcomes due to limited access to paid time off and workplace flexibility, and challenges related to managing physical aspects of cancer and employment.

Background. The World Health Organization (WHO) pre-qualified a single-dose typhoid conjugate vaccine (TCV) in December 2017. WHO requested data on co-administration of TCV with Expanded Programme on Immunisation vaccines in typhoid-endemic countries. We tested co-administration of Typbar TCV® [Bharat Biotech International] with routine group A meningococcal conjugate vaccine (MCV-A) and measles-rubella (MR) vaccine. Methods: We conducted a double-blind, randomised, controlled trial at Schiphra Protestant Hospital outpatient paediatric clinic, Ouagadougou, Burkina Faso. Children recruited at routine 15-month vaccination visits were randomly assigned (1:1:1) to intramuscularly receive: Group 1) TCV plus control vaccine (inactivated polio vaccine) and MCV-A 28 days later; Group 2) TCV and MCV-A; or, Group 3) MCV-A and control vaccine. Routine MR vaccine was administered subcutaneously at day 0 to all participants. The primary outcome was safety, assessed by local and systemic reactions at 0, 3, and 7 days after immunisation; and unsolicited adverse events and serious adverse events 28 days and 6 months after immunisation, respectively. Primary analysis included all participants receiving at least one intramuscular vaccine. Immunogenicity was assessed as a secondary endpoint. ClinicalTrials.gov identifier NCT03614533. Findings: Between December 3, 2018 and February 18, 2019, we recruited and vaccinated 150 children: Group 1 (n=49), Group 2 (n=50), and Group 3 (n=51). Solicited local and systemic symptoms were infrequent and similar for TCV and control recipients, as were adverse events (Group 1: 61·2%, 95% CI 46·2-74·8; Group 2: 64·0%, 95% CI 49·2-77·1; Group 3: 68·6%, 95% CI 54·1-80·9) and serious adverse events (Group 1: 2·0%, 95% CI 0·1-10·9; Group 2: 8·0%, 95% CI 2·2-19·2; Group 3: 5·9%, 95% CI 1·2-16·2). No serious adverse events were related to vaccination. TCV generated robust immunity without interference with MCV-A or MR vaccine. Interpretation: TCV can be safely co-administered with routine MCV-A and MR vaccine. Trial Registration: y. The trial is registered at ClinicalTrials.gov, Identifier NCT03614533. Funding: Bill & Melinda Gates Foundation. Declaration of Interests: The authors have no competing interests to declare. Ethics Approval Statement: The study was approved by ethics committees in Burkina Faso (Comite d’Ethique pour la Recherche en Sante [CERS], Ouagadougou, Burkina Faso) and Maryland, USA (Institutional Review Board, University of Maryland, Baltimore), and by the Regulatory Authority in Burkina Faso (L’Agence Nationale de Regulation Pharmaceutique, Ouagadougou, Burkina Faso).

Background Depression is common in patients with inflammatory bowel disease (IBD) and contributes to poor quality of life (QoL). The use of information technology for the remote management of patients with IBD is growing, but little is known about its impact on depressive symptoms (DS) and QoL. We aimed to evaluate the impact of telemedicine on DS and generic QoL in IBD patients. Methods We analyzed data from the Telemedicine for Patients with IBD (TELE-IBD) study. During this 12-month clinical trial, patients were randomized to receive text message-based telemedicine weekly (TELE-IBD W), every other week (TELE-IBD EOW), or to standard care. Depressive symptoms and QoL were assessed over time with the Mental Health Inventory 5 (MHI-5) and the Short Form 12 (SF-12), respectively. We compared the change in MHI-5 and SF-12 (with separate physical (PCS) and mental component summary (MCS) scores) between the study arms. Results A total of 217 participants were included in this analysis. After 1 year, there was no significant difference in the change in MHI-5 (TELE-IBD W +3.0 vs TELE-IBD EOW +0.7 vs standard care +3.4; P = 0.70), MCS (TELE-IBD W +1.4 vs TELE-IBD EOW +1.0 vs standard care +2.5; P = 0.89), and PCS scores (TELE-IBD W +0.4 vs TELE-IBD EOW +0.6 vs standard care +3.7; P = 0.06) between the groups. Conclusions Text message-based telemedicine does not improve DS or QoL when compared with standard care in IBD patients treated at tertiary referral centers. Further studies are needed to determine whether telemedicine improves DS or QoL in settings with few resources., Lay Summary This study showed that, in patients with inflammatory bowel disease, the use of information technology to deliver care via text messaging did not improve depressive symptoms or quality of life when compared with usual healthcare.

The Iowa Gambling Task (IGT) provides a framework to evaluate an individual decision-making process through a simulated card game where the risks and rewards vary by the decks chosen. Participants are expected to understand the logic behind the allocation of gains and losses over the course of the test and adapt their pattern of choices accordingly. This review explores the scientific work on studying problem gambling via the IGT while employing neuroimaging techniques. We first concentrate on the historical evolution of the IGT as a mechanism for studying gamblers’ behavioral patterns. Our research will also discuss the prefrontal cortex as this region of the brain is most affected by changes in behavioral patterns. In this review, we describe a number of features that may be useful in investigating decision-making patterns that lead to gambling addiction. We discuss the evidence base to date including experiments involving gambling behavior in different groups of participants (e.g., males and females, adults and minors, patients and controls) and alterations to experiment conditions that provide more thorough understanding of thought patterns in potential gamblers. We conclude that psychological testing combined with functional imaging provide powerful tools to further examine the relationships between functional impairment of the brain and a person’s ability to objectively anticipate the end results of their decisions.

Advances in breast cancer screening and treatment have led to an overall 5-year survival rate of 90%. Many of these cancer cases are diagnosed in working women. Few studies have explicitly examined the cancer–work interface, as experienced by low-wage earning women with breast cancer. This study uses in-depth, semistructured interviews with 24 low-wage breast cancer survivors to identify employment decisions and factors that influenced or enabled these decisions, and examine the individual strategies and workplace supports used to manage the cancer–work interface among a subset of women (n = 13) who continued to work. Future research areas and clinical implications are discussed.

Many states have legalized casino gambling, and casinos create increased vehicle traffic, but the strength of the association between casino construction and vehicle crashes is unknown.Retrospective analyses of motor vehicle crashes (MVCs) occurring within Anne Arundel County, Maryland (2010-2014) were conducted. The ratio of crashes within one mile of the casino's location after it was opened were compared to the ratio occurring in the same area before it was opened to determine how the incidence of MVCs near the casino changed with time. Logistic regression was used to determine how crash characteristics may have influenced the incidence of MVCs near the casino after it opened.101,860 persons were involved in 43,328 MVCs in Anne Arundel County during the study period; 29,476 (68.0 %) had an at-fault driver ≥21 years of age and complete data. MVCs proximal to the casino occurred most commonly during the day (N = 421, 76.6 %) and involved drivers40 years of age (N = 366, 66.6 %) and male (N = 316, 57.4 %). After adjustment for impairment and day of the week, there was a significant association with crashes close to the casino after it opened (ORIn this single-site study the opening of a casino was associated with an increase in crashes nearby. The generalizability of this finding should be confirmed with analysis of MVC data near other gambling venues.

INTRODUCTION: Limitations in inflammatory bowel disease (IBD) care necessitate greater patient activation and self-efficacy, measures associated with positive health outcomes. METHODS: We assessed change in patient activation and general self-efficacy from baseline to 12 months through our TELEmedicine for IBD trial, a multicenter, randomized controlled trial consisting of a web-based monitoring system that interacts with participants via text messaging. A total of 222 adults with IBD who had experienced an IBD flare within 2 years prior to the trial were randomized into either a control arm that received standard care (SC) or an intervention arm that completed self-testing through the TELE-IBD system every other week (EOW) or weekly (W). RESULTS: Changes in self-efficacy scores were not significantly different between control and experimental groups. Patient activation scores were significantly different between standard care and the TELE-IBD EOW group only (p = 0.03). CONCLUSIONS: Use of remote monitoring did not improve self-efficacy or patient activation compared to routine care.

J Kathleen Tracy,1,2 Derek Falk,1,3 Rebecca J Thompson,4 Lily Scheindlin,1 Fiyinfolu Adetunji,1 Jennifer E Swanberg1–3,5 1Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA; 2University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, Baltimore, MD, USA; 3University of Maryland School of Social Work, Baltimore, MD, USA; 4Management Department, Gettysburg College, Gettysburg, PA, USA; 5Department of Health Policy and Management, School of Professional Studies, Providence College, Providence, RI, USA Objective: This study assessed differences in employment outcomes among cancer survivors using data from a nationally representative sample.Methods: The 2011 Medical Expenditure Panel Survey (MEPS) data and the 2011 MEPS Experiences with Cancer Survivorship Supplement representing 3,360,465 people in the US population were analyzed to evaluate factors associated with unemployment among cancer survivors during the 5years following diagnosis and treatment. The sample included adults 1) diagnosed with cancer within 5years prior to survey completion and 2) engaged in paid employment since diagnosis. Individuals diagnosed with nonmelanoma skin cancer (n=33) were excluded from analyses.Results: Data of 221 cancer survivors were used to identify factors associated with employment status at the time respondents were employed (n=155) vs unemployed (n=66). Results of bivariate analyses indicated that unemployed survivors were older, more likely to be women, more likely to be uninsured at the time of cancer diagnosis, and to report lower incomes than cancer survivors who continue to be employed. Unemployed survivors were more likely than employed survivors to have had anxiety about being forced to retire or quit early when they were employed because of cancer and to report cancer-related interference with physical and mental aspects of their job tasks; unemployed survivors also took less paid time off and were less likely to change to a flexible job schedule when they were employed. In multiple logistic regression analyses, worry about being forced to retire (protective), worry that cancer recurrence will interfere with home or work responsibilities (risk), and change to a flexible work schedule (risk) following cancer diagnosis were associated with unemployment after controlling for demographic differences between employed and unemployed cancer survivors.Conclusion: Findings of this study highlight the extent to which the challenges of managing the cancer–work interface create challenges to employment among cancer survivors and may lead to long-term unemployment among cancer survivors. Future studies should evaluate the strategies that the survivors could use to manage the cancer–work interface during cancer treatment to attain medical, psychological, social, and employment outcomes. Keywords: work, employment, cancer-work-management, survivor&nbsp

Background Inflammatory bowel diseases (IBD), comprised of ulcerative colitis and Crohn's disease, are chronic disorders characterized by worsening of symptoms followed by symptom-free periods. Symptoms have a profound negative impact on quality of life and are associated with increased health care utilization. Despite effective treatments, outcomes are suboptimal secondary to nonadherence, medication intolerance, inconsistent monitoring, poor patient knowledge and limited access to care. Objectives Compare disease activity and quality of life over 1 year in a randomized trial of IBD patients receiving standard care versus telemedicine. Methods Patients evaluated at 3 IBD referral centers with worsening symptoms within the last 2 years are eligible for randomization to one of two interventions or standard care. The interventions consist of either every other week or weekly assessment of symptoms, side effects, weight and delivery of medication prompts and education via texts to the participant's mobile phone. Individualized alerts and action plans are created on a secure portal. Participants in the standard care group undergo routine and urgent follow-up visits and telephone calls. The primary outcomes group comparisons of changes in disease activity and quality of life scores from baseline to 6 and 12 months. Conclusions Methods such as telemedicine are needed to improve monitoring, adherence, self-efficacy, and patient knowledge in IBD. If effective, telemedicine should decrease symptoms, improve quality of life, and decrease health care utilization. The burden associated with use of telemedicine for patients and providers needs to be assessed. The trial is ongoing and will be completed in July 2016.

Maladaptive decision making is associated with several neuropsychiatric disorders, including problem gambling and suicidal behavior. The prevalence of these disorders is higher in men vs women, suggesting gender-dependent regulation of their pathophysiology underpinnings. We assessed sex differences in decision making using the rat version of the Iowa gambling task. Female rats identified the most optimal choice from session 1, whereas male rats from session 5. Male, but not female rats, progressively improved their advantageous option responding and surpassed females. Estrus cycle phase did not affect decision making. To test whether pharmacological manipulations targeting the dopaminergic and stress systems affect decision making in a sex-dependent manner, male and female rats received injections of a dopamine D2 receptor (D2R) antagonist (eticlopride), D2R agonist (quinpirole), corticotropin-releasing factor 1 (CRF1) antagonist (antalarmin), and α2-adrenergic receptor antagonist (yohimbine; used as a pharmacological stressor). Alterations in mRNA levels of D2R and CRF1 were also assessed. Eticlopride decreased advantageous responding in male, but not female rats, whereas quinpirole decreased advantageous responding specifically in females. Yohimbine dose-dependently decreased advantageous responding in female rats, whereas decreased advantageous responding was only observed at higher doses in males. Antalarmin increased optimal choice responding only in female rats. Higher Drd2 and Crhr1 expression in the amygdala were observed in female vs male rats. Higher amygdalar Crhr1 expression was negatively correlated with advantageous responding specifically in females. This study demonstrates the relevance of dopaminergic- and stress-dependent sex differences to maladaptive decision making.

This manuscript is a secondary analysis of a large multicenter randomized controlled trial. The primary study is Cross RK et al., A Randomized Controlled Trial of TELEmedicine for patients with Inflammatory Bowel Disease (TELE-IBD). Am J Gastroenterol, 2019 Mar.

This prognostic study compares standard readmission risk assessment scores with a machine learning score, the Baltimore score, for predicting 30-day unplanned hospital readmissions calculated in real time., Key Points Question Does a machine learning score better predict hospital readmissions than standard readmission scores? Findings In this prognostic study including 14 062 individual patients and 16 649 discharges from 3 hospitals, a machine learning score (the Baltimore score) was better able to predict hospital readmissions compared with standard readmission scores. Area under the receiver operating characteristic curve for the Baltimore score at discharge was 25.5% to 54.9% more efficient compared with commonly used scores with the difference between scores being statistically significant. Meaning The findings suggest that an individual hospital-tailored, machine learning–based score better predicts readmissions compared with standard methods., Importance Hospital readmissions are associated with patient harm and expense. Ways to prevent hospital readmissions have focused on identifying patients at greatest risk using prediction scores. Objective To identify the type of score that best predicts hospital readmissions. Design, Setting, and Participants This prognostic study included 14 062 consecutive adult hospital patients with 16 649 discharges from a tertiary care center, suburban community hospital, and urban critical access hospital in Maryland from September 1, 2016, through December 31, 2016. Patients not included as eligible discharges by the Centers for Medicare & Medicaid Services or the Chesapeake Regional Information System for Our Patients were excluded. A machine learning rank score, the Baltimore score (B score) developed using a machine learning technique, for each individual hospital using data from the 2 years before September 1, 2016, was compared with standard readmission risk assessment scores to predict 30-day unplanned readmissions. Main Outcomes and Measures The 30-day readmission rate evaluated using various readmission scores: B score, HOSPITAL score, modified LACE score, and Maxim/RightCare score. Results Of the 10 732 patients (5605 [52.2%] male; mean [SD] age, 54.56 [22.42] years) deemed to be eligible for the study, 1422 were readmitted. The area under the receiver operating characteristic curve (AUROC) for individual rules was 0.63 (95% CI, 0.61-0.65) for the HOSPITAL score, which was significantly lower than the 0.66 for modified LACE score (95% CI, 0.64-0.68; P

Although screening for pre-cancerous cervical lesions and human papilloma virus (HPV) vaccination are accepted and effective means to prevent cervical cancer, women in Mali have limited access to these interventions. In addition, cervical cancer prevention by HPV vaccination has been controversial in some settings. To reduce cervical cancer prevalence and increase HPV vaccine uptake, it is important to understand the level of knowledge about cervical cancer screening and practices related to vaccination in at-risk populations. In this study, the level of knowledge about HPV and cervical cancer and attitudes towards vaccination were assessed among 301 participants (male and female, adults and adolescents) in a house-to-house survey in two urban neighborhoods in Bamako, Mali. The survey was combined with a brief educational session on HPV. Prior to the education session, overall knowledge of HPV infection and cervical cancer was very low: only 8% knew that HPV is a sexually transmitted infection (STI). Less than 20% of women had ever consulted a gynecologist and less than 3% had ever had cervical cancer screening. After hearing a description of HPV vaccine, more than 80% would accept HPV vaccination; fathers and husbands were identified as primary decisions makers and local clinics or the home as preferred sites for vaccination. This study provides information on STI knowledge and vaccine acceptance in Bamako, Mali in 2012, prior to the introduction of HPV vaccination.

The Makah Tribe of Neah Bay, Washington, has historically relied on the subsistence harvest of coastal seafood, including shellfish, which remains an important cultural and ceremonial resource. Tribal legend describes visitors from other tribes that died from eating shellfish collected on Makah lands. These deaths were believed to be caused by paralytic shellfish poisoning, a human illness caused by ingestion of shellfish contaminated with saxitoxins, which are produced by toxin-producing marine dinoflagellates on which the shellfish feed. These paralytic shellfish toxins include saxitoxin, a potent Na+ channel antagonist that binds to the pore region of voltage gated Na+ channels. Amino acid mutations in the Na+ channel pore have been demonstrated to confer resistance to saxitoxin in softshell clam populations exposed to paralytic shellfish toxins present in their environment. Because of the notion of resistance to paralytic shellfish toxins, the study aimed to determine if a resistance strategy was possible in humans with historical exposure to toxins in shellfish. We collected, extracted and purified DNA from buccal swabs of 83 volunteer Makah tribal members and sequenced the skeletal muscle Na+ channel (Nav1.4) at nine loci to characterize potential mutations in the relevant saxitoxin binding regions. No mutations of these specific regions were identified after comparison to a reference sequence. This study suggests that any resistance of Makah tribal members to saxitoxin, if present, is not a function of Nav1.4 modification, but may be due to mutations in neuronal or cardiac sodium channels, or some other mechanism unrelated to sodium channel function.

This study systematically reviews research on child maltreatment and risk of gambling problems in adulthood. It also reviews adult problem gamblers’ risk of abusing or neglecting their own children. Multiple database searches were conducted using pre-defined search terms related to gambling and child abuse and neglect. We identified 601 unique references and excluded studies if they did not report original research, or did not specifically measure child maltreatment or gambling. Twelve studies that included multivariable analysis of childhood maltreatment exposure and problem gambling were identified. Six of seven studies examining childhood sexual abuse and four of five examining physical abuse showed a significant positive association between abuse and later gambling problems (odds ratios for sexual abuse 2.01–3.65; physical abuse 2.3–2.8). Both studies examining psychological maltreatment and two of three examining neglect identified positive associations with problem gambling. In most studies, risks were reduced or eliminated when controlling for other mental health disorders. The three studies measuring risk of child abuse and neglect among current problem gamblers suggest an increased risk for child physical abuse and medical conditions indicative of neglect although there is a considerable amount of variation among studies. Child abuse is associated with increased risk of gambling problems – gambling treatment providers should ask about maltreatment history as part of their clinical assessment. Problem gamblers may be more likely to physically abuse or neglect their children, but data here are more limited. Child welfare professionals should consider asking questions about parental gambling when assessing family risk.

Several infections are associated with increased risk of developing cancer. For example, persistent infection with high-risk strains of human papillomavirus causes cervical cancer. Our understanding of the association between infection and cancer in lesbian, bisexual and transgender (LBT) women is hampered by an absence of population-based data for LBT women. Formal epidemiologic studies of cancer, in general, and infection-associated cancer, in particular, among LBT individuals are lacking. This absence of robust epidemiologic data makes our understanding of infection-related cancer in the LBT women limited and speculative. This chapter attempts to summarize available epidemiologic data for infection-associated cancers in LBT women, highlight gaps in our knowledge, review interventions that have been used to reduce risk for infection-associated cancers in LBT women, and discuss challenges to research and policy that must be addressed in order prevent infection-associated cancers and reduce cancer disparities experienced by LBT women.

The first casino with slot machines in Baltimore City opened in August of 2014. Slot machines have been available in Baltimore City for years, however, under the euphemism “For Amusement Only.” Since 2011, Baltimore City has granted licenses for “simulated slot machines” under the condition that the machines not pay out winnings to the players. In this report, we investigate the number and geospatial patterns of these licensed simulated slot machines. The number of machines began decreasing prior to the opening of the new casino, dropping by as much as 50% over 7 years. These machines tend to be in low-income White neighborhoods and are positively correlated with property crime rates. Understanding the historical context of slot machine play in Baltimore City is important for investigating the impact of the introduction of state-sanctioned slot play in an urban environment.