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Background: The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths occurring in the United States (US) in 2022. Overdose deaths have increasingly been polysubstance-involved, with novel substances (e.g., xylazine) complicating overdose risk and health outcomes. Understanding the effects of-and responses to-a changing drug supply among people who use drugs is critical to modifying harm reduction strategies to be more responsive to people's needs., Methods: This qualitative study draws on data collected from May to December 2022 in Rhode Island. Data include in-depth interviews with 50 people who use drugs and observational fieldwork in spaces frequented by participants (e.g., encampments, drop-in centers). Qualitative data were analyzed thematically drawing on concepts of situated rationality., Results: Participants described significant changes in the drug supply, with many attributing these transitions to COVID-19. Most participants characterized the local supply as "synthetic" with textures, color, and taste evolving. Notably, participants emphasized adverse outcomes related to available supplies, including during use (e.g., intense burning sensations) and post-consumption (e.g., heavy sedation, ongoing withdrawal, necrosis). Given the complex supply, participants highlighted the increased risk of overdose and shared how they altered their use practices to manage evolving health risks., Conclusion: Our results underscore how people who use drugs characterized the local drug supply, including perceived changes to supply contents. Implementing and scaling up harm reduction interventions that reduce risk and reinforce the agency of people who use drugs are urgently needed to effectively address the overdose crisis., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH., Methods: We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes., Results: There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality., Conclusion: Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Monocyte distribution width (MDW) is an emerging biomarker for infection. It is available easily and quickly as part of the CBC count, which is performed routinely on hospital admission. The increasing availability and promising results of MDW as a biomarker in sepsis has prompted an expansion of its use to other infectious diseases., Research Question: What is the diagnostic performance of MDW across multiple infectious disease outcomes and care settings?, Study Design and Methods: A systematic review of the diagnostic performance of MDW across multiple infectious disease outcomes was conducted by searching PubMed, Embase, Scopus, and Web of Science through February 4, 2022. Meta-analysis was performed for outcomes with three or more reports identified (sepsis and COVID-19). Diagnostic performance measures were calculated for individual studies with pooled estimates created by linear mixed-effects models., Results: We identified 29 studies meeting inclusion criteria. Most examined sepsis (19 studies) and COVID-19 (six studies). Pooled estimates of diagnostic performance for sepsis differed by reference standard (Second vs Third International Consensus Definitions for Sepsis and Septic Shock criteria) and tube anticoagulant used and ranged from an area under the receiver operating characteristic curve (AUC) of 0.74 to 0.94, with mean sensitivity of 0.69 to 0.79 and mean specificity of 0.57 to 0.86. For COVID-19, the pooled AUC of MDW was 0.76, mean sensitivity was 0.79, and mean specificity was 0.59., Interpretation: MDW exhibited good diagnostic performance for sepsis and COVID-19. Diagnostic thresholds for sepsis should be chosen with consideration of reference standard and tube type used., Trial Registry: Prospero; No.: CRD42020210074; URL: https://www.crd.york.ac.uk/prospero/., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the prevalence of cardiovascular risk-factors in patients with mesenteric panniculitis., Aims: To determine whether cardiovascular risk-factors and mesenteric panniculitis are associated., Methods: Retrospective, matched case-control study of patients referred to Meir Medical Center, Israel, 2014-2019, who underwent computerized tomography scan, were diagnosed mesenteric panniculitis by radiologic criteria. They were compared to two, matched case-control groups: hospitalized patients without mesenteric panniculitis and the general population based on Israeli Ministry of Health surveys. Patients with active malignancy, IBD or significant intra-abdominal morbidity were excluded., Results: Of 376 patients with mesenteric panniculitis diagnosed by computerized tomography, 187 were included. Compared to hospital patients, they had higher incidence of dyslipidemia (77.5%/56.7%), hypertension (52.4%/40.6%), obesity (body mass index>30) (60.4%/30.5%) and nonalcoholic fatty liver disease (42.2%/16.6%). Similar differences were observed compared to the general population. In multivariable logistic regression, dyslipidemia, obesity, and nonalcoholic fatty liver disease were independent predictors for mesenteric panniculitis., Conclusions: Patients with mesenteric panniculitis have more cardiovascular risk-factors compared to a case-control group and to the general population. This suggests that mesenteric panniculitis is clinically significant and may be part of the metabolic morbidity burden. This association should be further explored., Competing Interests: Conflict of Interest None declared., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Consuming different food groups and nutrients can have differential effects on body weight, body composition, and insulin sensitivity., Objective: The aim was to identify how food group, nutrient intake, and diet quality change relative to usual-diet controls after 16 weeks on a low-fat vegan diet and what associations those changes have with changes in body weight, body composition, and measures of metabolic health., Design: Secondary analysis of a randomized clinical trial conducted between October 2016 and December 2018 in four replications., Participants/setting: Participants included in this analysis were 219 healthy, community-based adults in the Washington, DC, area, with a body mass index (BMI) between 28 and 40, who were randomly assigned to either follow a low-fat vegan diet or make no diet changes., Intervention: A low-fat, vegan diet deriving approximately 10% of energy from fat, with weekly classes including dietary instruction, group discussion, and education on the health effects of plant-based nutrition. Control group participants continued their usual diets., Main Outcome Measures: Changes in food group intake, macronutrient and micronutrient intake, and dietary quality as measured by Alternate Healthy Eating Index-2010 (AHEI-2010), analyzed from 3-day diet records, and associations with changes in body weight, body composition, and insulin sensitivity were assessed., Statistical Analyses Performed: A repeated-measure analysis of variance model that included the factors group, subject, and time was used to test the between-group differences throughout the 16-week study. Interaction between group and time was calculated for each variable. Within each diet group, paired comparison t tests were calculated to identify significant changes from baseline to 16 weeks. Spearman correlations were calculated for the relationship between changes in food group intake, nutrient intake, AHEI-2010 score, and changes in body weight, body composition, and insulin sensitivity. The relative contribution of food groups and nutrients to weight loss was evaluated using linear regression., Results: Fruit, vegetable, legume, meat alternative, and whole grain intake significantly increased in the vegan group. Intake of meat, fish, and poultry; dairy products; eggs; nuts and seeds; and added fats decreased. Decreased weight was most associated with increased intake of legumes (r = -0.38; P < 0.0001) and decreased intake of total meat, fish, and poultry (r = +0.43; P < 0.0001). Those consuming a low-fat vegan diet also increased their intake of carbohydrates, fiber, and several micronutrients and decreased fat intake. Reduced fat intake was associated with reduced body weight (r = +0.15; P = 0.02) and, after adjustment for changes in BMI and energy intake, with reduced fat mass (r = +0.14; P = 0.04). The intervention group's AHEI-2010 increased by 6.0 points on average, in contrast to no significant change in the control group (treatment effect, +7.2 [95% CI +3.7 to +10.7]; P < 0.001). Increase in AHEI-2010 correlated with reduction in body weight (r = 0.14; P = 0.04), fat mass (r = -0.14; P = 0.03), and insulin resistance as measured by the Homeostasis Model Assessment (HOMA-IR; r = -0.17; P = 0.02), after adjustment for changes in energy intake., Conclusions: When compared with participants' usual diets, intake of plant foods increased, and consumption of animal foods, nuts and seeds, and added fats decreased on a low-fat vegan diet. Increased legume intake was the best single food group predictor of weight loss. Diet quality as measured by AHEI-2010 improved on the low-fat vegan diet, which was associated with improvements in weight and metabolic outcomes. These data suggest that increasing low-fat plant foods and minimizing high-fat and animal foods is associated with decreased body weight and fat loss, and that a low-fat vegan diet can improve measures of diet quality and metabolic health., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Purpose: Loeys-Dietz syndrome (LDS) is a connective tissue disorder affecting multiple organ systems, including bone., Methods: We defined the bone phenotype and clinical predictors of low bone density and fracture risk in 77 patients with LDS type 1 to type 5., Results: Patients with LDS had dual-energy x-ray absorptiometry (DXA) Z-scores significantly < 0, and 50% of children and 9% of adults had Z-scores < -2. Sixty percent of patients had ≥1 fracture, and 24% of patients with spinal x-rays scans showed spinal compression fractures. Lower body mass index, asthma, male sex and eosinophilic gastrointestinal disease were correlated with lower DXA Z-scores. The count of 5 LDS-associated skeletal features (scoliosis, pes planus, arachnodactyly, spondylolisthesis, and camptodactyly) in patients with LDS was correlated with DXA Z-score. Adults with ≥1 skeletal features had DXA Z-scores significantly < 0, and children with >2 features had DXA Z-score significantly < -2. Bone turnover markers suggest accelerated bone resorption. Data from 5 patients treated with bisphosphonates suggest a beneficial effect., Conclusion: All LDS types are associated with reduced bone density and increased risk of fracture, which may be due to increased bone resorption. Clinical features can predict a subgroup of patients at highest risk of low bone density and fracture risk., Competing Interests: Conflict of Interest The authors declare no conflict of interests., (Copyright © 2021. Published by Elsevier Inc.)

Background: Neurocognitive impairment (NCI) persists among women living with HIV. Food insecurity is also common among women and may be an important modifiable contributor of NCI., Objective: The goal of this study was to determine the association of food insecurity with neurocognitive function among women living with or without HIV., Methods: From 2013 to 2015, we analyzed data from a cross-sectional sample from the Women's Interagency HIV Study (WIHS). Measures included food insecurity and a comprehensive neuropsychological test battery assessing executive function, processing speed, attention/working memory, learning, memory, fluency, and motor function. We conducted multivariable linear regressions to examine associations between food insecurity and domain-specific neurocognitive performance, adjusting for relevant sociodemographic, behavioral, and clinical factors., Results: Participants (n = 1,324) were predominantly HIV seropositive (68%), Black/African-American (68%) or Hispanic (16%), and low income (48% reported <$12,000/y), with a median age of 49.6 y (IQR = 43.1, 55.5). Approximately one-third (36%, n = 479) were food insecure. Food insecurity was associated with poorer executive function (b = -1.45, SE = 0.58, P ≤ 0.01) and processing speed (b = -1.30, SE = 0.59, P ≤ 0.05). HIV serostatus modified the association between food insecurity and learning, memory, and motor function (P values <0.05). Food insecurity was positively associated with learning among women living with HIV (b = 1.58, SE = 0.77, P ≤ 0.05) and negatively associated with motor function among HIV-negative women (b = -3.57, SE = 1.08, P ≤ 0.001)., Conclusions: Food insecurity was associated with domain-specific neurocognitive function in women, and HIV serostatus modified associations. Food security may be an important point of intervention for ethnically diverse women with low socioeconomic status. Longitudinal studies are warranted to determine potential pathways by which food insecurity is associated with neurocognitive function among women living with or at risk for HIV., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: In octogenarians with carotid stenosis, data supporting the decision to intervene and choice of intervention with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) have been conflicting. The purpose of this study was to compare the perioperative outcomes of CEA and CAS in octogenarians, and to identify patients at high risk for unfavorable outcomes., Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2011-2018) was queried for patients aged ≥80 years who underwent CAS or CEA. Propensity scores were created for the odds of undergoing CAS. Patients were matched 1:1 based on propensity score and outcomes were compared after matching. Multivariable logistic regression analyses were used to identify risk factors for unfavorable postoperative outcomes., Results: In total, 15,858 and 527 patients who underwent CEA and CAS were identified. After matching, there was no difference between CEA and CAS in perioperative stroke (2.3% vs. 2.9%; P = 0.56), cardiac complications (2.3% vs. 2.3%; P = 0.99), mortality (1.1% vs. 1.7%; P = 0.44), length of stay (median [interquartile range], 2 [1-4] vs. 1 [1-4] days; P = 0.13), and 30-day readmission (11.8% vs. 11.6%; P = 0.92). On multivariable analysis, the following were predictive for postoperative stroke: urgent operation (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.68-2.69; P < 0.001), chronic obstructive pulmonary disease (COPD; OR, 1.52; 95% CI, 1.11-2.09; P = 0.009), and American Society of Anesthesiologists class > III (OR, 1.46; 95% CI, 1.15-1.86; P = 0.002). Urgent procedure (OR, 2.86; 95% CI, 2.11-3.87; P < 0.001), COPD (OR, 2.31; 95% CI, 1.61-3.32; P < 0.001), dependent functional status (OR, 2.05; 95% CI, 1.35-3.1; P < 0.001), and age ≥ 85 years (OR, 1.92; 95% CI, 1.43-2.57; P < 0.001) were predictive for 30-day mortality., Conclusions: Outcomes of CEA and CAS were similar in octogenarians. Risk factors for worse intervention outcomes were identified, which may guide risk-benefit discussions and shared decision-making., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Oral health-related quality of life (OHRQoL) is a multidimensional, perception-based measure of how oral health affects social and physical functioning and self-image. OHRQoL is important for assessing women living with HIV (WLWH) who may have unmet dental needs and experience disparities that impact dental care accessibility., Methods: In 2016, the authors conducted an assessment of OHRQoL among a national sample of 1,526 WLWH in the Women's Interagency HIV Study using the Oral Health Impact Profile instrument, which assesses the frequency of 14 oral health impact items. OHRQoL was measured using multivariable linear regression with a negative binomial distribution to assess the association between report of a recent unmet dental need and OHRQoL., Results: "Fair or poor" oral health condition was reported by 37.8% (n = 576) of WLWH. Multivariable linear regression showed that unmet dental needs had the strongest positive association with poor OHRQoL (difference in Oral Health Impact Profile mean, 2.675; P < .001) compared with not having unmet needs. The frequency of dental care utilization was not associated with higher OHRQoL. Older age, fair or poor dental condition, smoking, symptoms of anxiety and loneliness, and poor OHRQoL were also associated with worse OHRQoL., Conclusion: Self-perceived impact of oral health on social and physical function and self-image, as measured by OHRQoL, may be an easily assessable but underrecognized aspect of OHRQoL, particularly among women aging with HIV., Practical Implications: Dentists should implement OHRQoL assessments in their management of the care of patients with HIV to identify those who do have significant oral health impacts., (Copyright © 2020 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Lower extremity arteriovenous (AV) access is an alternative when upper extremity access options have been exhausted. Our goal was to assess short- and medium-term outcomes of lower extremity hemodialysis access., Methods: The Vascular Quality Initiative was reviewed for all lower extremity AV hemodialysis cases. Patient and case details were recorded. Multivariable analysis was used to analyze outcomes., Results: We identified 463 lower extremity AV access cases in the VQI registry. There were 56 AVF (12.1%) and 407 AVG (87.9%). The mean age was 56 ± 15 years, 46.9% were male, and 40.7% were Caucasian. The majority (90%) had a previous upper extremity AV access and 25.4% had a prior lower extremity access. More than one-half (57.9%) had a tunneled line at the time of the procedure. Patients undergoing an AVF vs AVG creation were younger, more often ambulatory, and less often with peripheral arterial disease. For AVF, the superficial femoral artery was more often used for access inflow (76.8% vs 49.4%; P < .001), compared with AVG, and there was no difference in using femoral vein as the main outflow (78.6% vs 82.6%; P = .466). For AVF, compared with AVG, there was no difference in wound infection (12.5% vs 9.6%; P = .571), ischemic steal (5% vs 2.2%; P = .273), or leg swelling (2.5% vs 3.3%; P = .99) at 6 months. Kaplan-Meier analysis of the overall cohort showed that freedom from loss of primary patency at 6 months was 52.9%, freedom from any reintervention at 6 months was 75.3%, and the 1-year survival was 81.9%. Survival at 5 years was 65.5%. Multivariable analysis showed no significant association of access type (AVF vs AVG) with primary patency loss or death (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.36-1.5; P = .4), any reintervention or death (HR, 1.65; 95% CI, 0.82-3.33; P = .163), or mortality (HR, 1.94; 95% CI, 0.71-5.33; P = .197). Factors independently associated with primary patency loss or death included peripheral arterial disease (HR, 1.6; 95% CI, 1.06-2.42; P = .03) and obesity (HR, 1.5; 95% CI, 1.1-2.05; P = .01). Any reintervention or death was associated with obesity (HR, 1.67; 95% CI, 1.09-2.56; P = .015). Mortality was associated with congestive heart failure (HR, 1.82; 95% CI, 1.13-2.94; P = .015) and white race (HR, 1.71; 95% CI, 1.08-2.73; P = .023)., Conclusions: In our contemporary multicenter analysis, patients undergoing lower extremity AV access creation have low primary access patency and almost 20% mortality at 1 year. These results should be considered when suggesting a lower extremity dialysis access, as well as other dialysis alternatives when available., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In hospitals and health systems across the country, patient flow bottlenecks delay care delivery-emergency department boarding and operating room exit holds are familiar examples. In other industries, such as oil, gas, and air traffic control, command centers proactively manage flow through complex systems., Methods: A systems engineering approach was used to analyze and maximize existing capacity in one health system, which led to the creation of the Judy Reitz Capacity Command Center. This article describes the key elements of this novel health system command center, which include strategic colocation of teams, automated visual displays of real-time data providing a global view, predictive analytics, standard work and rules-based protocols, and a clear chain of command and guiding tenets. Preliminary data are also shared., Results: With proactive capacity management, subcycle times decreased and allowed the health system's flagship hospital to increase occupancy from 85% to 92% while decreasing patient delays., Conclusion: The command center was built with three primary goals-reducing emergency department boarding, eliminating operating room holds, and facilitating transfers in from outside facilities-but the command center infrastructure has the potential to improve hospital operations in many other areas., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Harvesting behaviors of natural resource users, such as farmers, fishermen and aquaculturists, are shaped by season-to-season and day-to-day variability, or in other words risk. Here, we explore how risk-mitigation strategies can lead to sustainable use and improved management of common-pool natural resources. Over-exploitation of unmanaged natural resources, which lowers their long-term productivity, is a central challenge facing societies. While effective top-down management is a possible solution, it is not available if the resource is outside the jurisdictional bounds of any management entity, or if existing institutions cannot effectively impose sustainable-use rules. Under these conditions, alternative approaches to natural resource governance are required. Here, we study revenue-sharing clubs as a mechanism by which resource users can mitigate their income volatility and importantly, as a co-benefit, are also incentivized to reduce their effort, leading to reduced over-exploitation and improved resource governance. We use game theoretic analyses and agent-based modeling to determine the conditions in which revenue-sharing can be beneficial for resource management as well as resource users. We find that revenue-sharing agreements can emerge and lead to improvements in resource management when there is large variability in production/revenue and when this variability is uncorrelated across members of the revenue-sharing club. Further, we show that if members of the revenue-sharing collective can sell their product at a price premium, then the range of ecological and economic conditions under which revenue-sharing can be a tool for management greatly expands. These results have implications for the design of bottom-up management, where resource users themselves are incentivized to operate in ecologically sustainable and economically advantageous ways., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: This study assessed early and late clinical outcomes in patients who underwent aortic valve repair or an aortic valve-sparing operation and investigated predictors for failure., Methods: Of 227 consecutive patients who underwent aortic valve repair or a valve-sparing operation in our department between 2004 and 2016, 81 (36%) underwent aortic root replacement with or without cusp repair, 97 (42%) ascending aorta replacement with or without cusp repair, and 49 (22%) isolated aortic valve repair. Clinical and echocardiographic follow-up was complete., Results: One patient (0.4%) died in-hospital. Mean clinical and echocardiographic follow-up was 69 ± 40 months (range, 1 to 147 months) and 53 ± 40 months (range, 1 to 147 months), respectively. Fifteen patients (6.6%) died during follow-up, with an overall 5-year survival rate of 94.4%. Recurrent significant (≥3) aortic insufficiency developed in 20 patients (8.8%), 17 of whom underwent reoperation, with a 5-year freedom from reoperation rate of 88%. Predictors for recurrent significant aortic insufficiency or reoperation were greater preoperative aortic insufficiency (grade III to IV vs I to II; relative risk [RR], 1.97; p = 0.023), cusp repair (RR, 2.92; p = 0.001), higher European System for Cardiac Operative Risk Evaluation score (RR, 1.16; p = 0.006), and valve repair with pericardial patch augmentation (RR, 2.34; p = 0.032)., Conclusions: Aortic valve repair and valve-sparing operations can be performed with good early and late clinical outcomes. In our experience, however, the rate of recurrent aortic insufficiency was significant, especially in patients who underwent cusp augmentation with glutaraldehyde-treated autologous pericardial patch., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mortality associated with cervical cancer is a public health concern for women, particularly in HIV-seropositive women in resource-limited countries. HIV-seropositive women are at a higher risk of high-grade cervical precancer, which can eventually progress to invasive carcinoma as compared to HIV-seronegative women. It is imperative to identify effective treatment methods for high-grade cervical precursors among HIV-seropositive women., Objective: Randomized controlled trial data are needed comparing cryotherapy vs loop electrosurgical excision procedure treatment efficacy in HIV-seropositive women. Our primary aim was to compare the difference in the efficacy of loop electrosurgical excision procedure vs cryotherapy for the treatment of high-grade cervical intraepithelial neoplasia (grade ≥2) among HIV-seropositive women by conducting a randomized clinical trial., Study Design: HIV-seropositive women (n = 166) aged 18-65 years with histology-proven cervical intraepithelial neoplasia grade ≥2 were randomized (1:1) to cryotherapy or loop electrosurgical excision procedure treatment at a government hospital in Johannesburg. Treatment efficacy was compared using 6- and 12-month cumulative incidence posttreatment of: (1) cervical intraepithelial neoplasia grade ≥2; (2) secondary endpoints of histologic cervical intraepithelial neoplasia grade ≥3 and grade ≥1; and (3) high-grade and low-grade cervical cytology. The study was registered (ClinicalTrials.govNCT01723956)., Results: From January 2010 through August 2014, 166 participants were randomized (86 loop electrosurgical excision procedure; 80 cryotherapy). Cumulative cervical intraepithelial neoplasia grade ≥2 incidence was higher for cryotherapy (24.3%; 95% confidence interval, 16.1-35.8) than loop electrosurgical excision procedure at 6 months (10.8%; 95% confidence interval, 5.7-19.8) (P = .02), although by 12 months, the difference was not significant (27.2%; 95% confidence interval, 18.5-38.9 vs 18.5%; 95% confidence interval, 11.6-28.8, P = .21). Cumulative cervical intraepithelial neoplasia grade ≥1 incidence for cryotherapy (89.2%; 95% confidence interval, 80.9-94.9) did not differ from loop electrosurgical excision procedure (78.3%; 95% confidence interval, 68.9-86.4) at 6 months (P = .06); cumulative cervical intraepithelial neoplasia grade ≥1 incidence by 12 months was higher for cryotherapy (98.5%; 95% confidence interval, 92.7-99.8) than loop electrosurgical excision procedure (89.8%; 95% confidence interval, 82.1-95.2) (P = .02). Cumulative high-grade cytology incidence was higher for cryotherapy (41.9%) than loop electrosurgical excision procedure at 6 months (18.1%, P < .01) and 12 months (44.8% vs 19.4%, P < .001). Cumulative incidence of low-grade cytology or greater in cryotherapy (90.5%) did not differ from loop electrosurgical excision procedure at 6 months (80.7%, P = .08); by 12 months, cumulative incidence of low-grade cytology or greater was higher in cryotherapy (100%) than loop electrosurgical excision procedure (94.8%, P = .03). No serious adverse effects were recorded., Conclusion: Although rates of cumulative cervical intraepithelial neoplasia grade ≥2 were lower after loop electrosurgical excision procedure than cryotherapy treatment at 6 months, both treatments appeared effective in reducing cervical intraepithelial neoplasia grade ≥2 by >70% by 12 months. The difference in cumulative cervical intraepithelial neoplasia grade ≥2 incidence between the 2 treatment methods by 12 months was not statistically significant. Relatively high cervical intraepithelial neoplasia grade ≥2 recurrence rates, indicating treatment failure, were observed in both treatment arms by 12 months. A different treatment protocol should be considered to optimally treat cervical intraepithelial neoplasia grade ≥2 in HIV-seropositive women., (Copyright © 2017. Published by Elsevier Inc.)

It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. Plant-based diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage. Vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. Low intake of saturated fat and high intakes of vegetables, fruits, whole grains, legumes, soy products, nuts, and seeds (all rich in fiber and phytochemicals) are characteristics of vegetarian and vegan diets that produce lower total and low-density lipoprotein cholesterol levels and better serum glucose control. These factors contribute to reduction of chronic disease. Vegans need reliable sources of vitamin B-12, such as fortified foods or supplements., (Copyright © 2016 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Aortic valve replacement, particularly in elderly patients with small aortic annulus, could lead to patient-prosthesis mismatch. Sutureless bioprosthesis could be an ideal solution for these patients. We compared results of aortic valve replacement with sutureless versus stented bioprosthetic valves., Methods: Of the 63 patients undergoing aortic valve replacement with sutureless bioprosthesis between 2011 and 2014 in our department, 22 (20 women, 77 ± 6 years) had a small annulus less than 21 mm (sutureless group). They were matched for sex, age, body surface area, and left ventricular ejection fraction with 22 patients (20 women, 79 ± 6 years) undergoing stented bioprosthesis valve replacement (stented group). Body mass index and body surface area were 28 ± 5 kg/m(2) and 28 ± 3 kg/m(2) (p = 0.9), 1.6 ± 0.2 m(2) and 1.6 ± 0.1 m(2) (p = 0.9), in the sutureless and stented groups, respectively. Logistic EuroSCOREs were similar between groups., Results: Postoperative peak transvalvular gradient was lower in the sutureless group (15 ± 7 mm Hg versus 20 ± 11 mm Hg; p = 0.02). The indexed effective orifice area was greater in the sutureless group (1.12 ± 0.2 cm(2)/m(2) versus 0.82 ± 0.1 cm(2)/m(2); p < 0.05). Aortic cross-clamp and cardiopulmonary bypass times were 47 ± 21 and 67 ± 15 minutes, respectively (p < 0.05) in the sutureless group versus 70 ± 22 and 85 ± 21 minutes, respectively (p = 0.02) in the stented group. Intensive care unit stay, hospitalization, and major complications were not significantly different between groups. At follow-up, regression of left ventricular hypertrophy was better in the sutureless group (93 ± 21 g/m(2) versus 106 ± 14 g/m(2); p = 0.02)., Conclusions: Sutureless bioprosthetic valves demonstrate improved hemodynamic performance compared with stented valves in elderly patients with small aortic annulus, providing better regression of left ventricular hypertrophy and decreased rates of patient-prosthesis mismatch. Aortic cross-clamp and cardiopulmonary bypass times are also decreased., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patient triage is necessary to manage excessive patient volumes and identify those with critical conditions. The most common triage system used today, Emergency Severity Index (ESI), focuses on resources utilized and critical outcomes., Objective: This study derives and validates a computer-based electronic triage system (ETS) to improve patient acuity distribution based on serious patient outcomes., Methods: This cross-sectional study of 25,198 (97 million weighted) adult emergency department visits from the 2009 National Hospital Ambulatory Medical Care Survey. The ETS distributes patients by using a composite outcome based on the estimated probability of mortality, intensive care unit admission, or transfer to operating room or catheterization suite. We compared the ETS with the ESI based on the differentiation of patients, outcomes, inpatient hospitalization, and resource utilization., Results: Of the patients included, 3.3% had the composite outcome and 14% were admitted, and 2.52 resources/patient were used. Of the 90% triaged to low-acuity levels, ETS distributed patients evenly (Level 3: 30%; Level 4: 30%, and Level 5: 29%) compared to ESI (46%, 34%, and 7%, respectively). The ETS better-identified patients with the composite outcome present in 40% of ETS Level 1 vs. 17% for ESI and the ETS area under the receiver operating characteristic curve (AUC) was 0.83 vs. ESI 0.73. Similar results were found for hospital admission (ETS AUC = 0.83 vs. ESI AUC = 0.72). The ETS demonstrated slight improvements in discriminating patient resource utilization., Conclusions: The ETS is a triage system based on the frequency of critical outcomes that demonstrate improved differentiation of patients compared to the current standard ESI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In several parts of India, groundwater is the only reliable, year round source for drinking water. Prevention of fluorosis, a chronic disease resulting from excess intake of fluoride, requires the screening of all groundwater sources for fluoride in endemic areas. In this paper, the authors present a field deployable colorimetric analyzer based on an inexpensive smartphone embedded with digital camera for taking photograph of the colored solution as well as an easy-fit, and compact sample chamber (Akvo Caddisfly). Phones marketed by different smartphone makers were used. Commercially available zirconium xylenol orange reagent was used for determining fluoride concentration. A software program was developed to use with the phone for recording and analyzing the RGB color of the picture. Linear range for fluoride estimation was 0-2mgl(-1). Around 200 samples, which consisted of laboratory prepared as well as field samples collected from different locations in Karnataka, India, were tested with Akvo Caddisfly. The results showed a significant positive correlation between Ion Selective Electrode (ISE) method and Akvo Caddisfly (Phones A, B and C), with correlation coefficient ranging between 0.9952 and 1.000. In addition, there was no significant difference in the mean fluoride content values between ISE and Phone B and C except for Phone A. Thus the smartphone method is economical and suited for groundwater fluoride analysis in the field., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

With increasing global concerns about obesity and related health effects, tools to predict how urban form affects population physical activity and health are needed. However, such tools have not been well established. This article develops a computer simulation model for forecasting the health effects of urban features that promote walking. The article demonstrates the model using a proposed small-area plan for a neighborhood of 10,400 residents in Raleigh, North Carolina, one of the fastest-growing and most sprawling U.S. cities. The simulation model predicts that the plan would increase average daily time spent walking for transportation by 17 min. As a result, annual deaths from all causes are predicted to decrease by 5.5%. Annual new cases of diabetes, coronary heart disease, stroke, and hypertension are predicted to decline by 1.9%, 2.3%, 1.3%, and 1.6%, respectively. The present value of these health benefits is $21,000 per resident., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The personal choices affecting the transmission of infectious diseases include the number of contacts an individual makes, and the risk-characteristics of those contacts. We consider whether these different choices have distinct implications for the course of an epidemic. We also consider whether choosing contact mitigation (how much to mix) and affinity mitigation (with whom to mix) strategies together has different epidemiological effects than choosing each separately. We use a set of differential equation compartmental models of the spread of disease, coupled with a model of selective mixing. We assess the consequences of varying contact or affinity mitigation as a response to disease risk. We do this by comparing disease incidence and dynamics under varying contact volume, contact type, and both combined across several different disease models. Specifically, we construct a change of variables that allows one to transition from contact mitigation to affinity mitigation, and vice versa. In the absence of asymptomatic infection we find no difference in the epidemiological impacts of the two forms of disease risk mitigation. Furthermore, since models that include both mitigation strategies are underdetermined, varying both results in no outcome that could not be reached by choosing either separately. Which strategy is actually chosen then depends not on their epidemiological consequences, but on the relative cost of reducing contact volume versus altering contact type. Although there is no fundamental epidemiological difference between the two forms of mitigation, the social cost of alternative strategies can be very different. From a social perspective, therefore, whether one strategy should be promoted over another depends on economic not epidemiological factors., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Surgery in the beach chair position (BCP) may reduce cerebral blood flow and oxygenation, resulting in neurological injuries. The authors tested the hypothesis that a ventilation strategy designed to achieve end-tidal carbon dioxide (E'(CO₂)) values of 40-42 mm Hg would increase cerebral oxygenation (Sct(O₂)) during BCP shoulder surgery compared with a ventilation strategy designed to achieve E'(CO₂) values of 30-32 mm Hg., Methods: Seventy patients undergoing shoulder surgery in the BCP with general anaesthesia were enrolled in this randomized controlled trial. Mechanical ventilation was adjusted to maintain an E'(CO₂) of 30-32 mm Hg in the control group and an E'(CO₂) of 40-42 mm Hg in the study group. Cerebral oxygenation was monitored continuously in the operating theatre using near-infrared spectroscopy. Baseline haemodynamics and Sct(O₂) were obtained before induction of anaesthesia, and these values were then measured and recorded continuously from induction of anaesthesia until tracheal extubation. The number of cerebral desaturation events (CDEs) (defined as a ≥20% reduction in Sct(O₂) from baseline values) was recorded., Results: No significant differences between the groups were observed in haemodynamic variables or phenylephrine interventions during the surgical procedure. Sct(O₂) values were significantly higher in the study 40-42 group throughout the intraoperative period (P<0.01). In addition, the incidence of CDEs was lower in the study 40-42 group (8.8%) compared with the control 30-32 group (55.6%, P<0.0001)., Conclusions: Cerebral oxygenation is significantly improved during BCP surgery when ventilation is adjusted to maintain E'(CO₂) at 40-42 mm Hg compared with 30-32 mm Hg., Clinical Trial Registration: ClinicalTrials.gov NCT01546636., (© The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Few data exist regarding the effect of hormonal contraception (HC) on incidence and progression of cervical disease (e.g., cervical dysplasia, squamous intraepithelial lesions, cervical intraepithelial neoplasia) in HIV-infected African women., Study Design: We conducted an observational study of HIV-seropositive women in Johannesburg, South Africa. The effect of individual HC types on the incidence and progression of cervical disease was determined using Poisson regression to obtain adjusted incidence rate ratios., Results: We evaluated 594 HIV-infected women, with median follow-up time of 445 days; 75 of these women were receiving some form of HC (largely DMPA, NET-EN, or COCs) at baseline. Risks of incidence and progression of cervical disease were similar comparing women not receiving HCs to women receiving DMPA, NET-EN, or COCs both individually by HC-type and considering all HC together., Conclusions: There was no statistically significant effect of particular HC methods or of HC use in general on rates of incidence or progression of cervical disease in this study. These results should reassure us that use of HC is unlikely to substantially increase risks of cervical disease among HIV-positive women., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Venous cystic adventitial disease is an exceedingly rare vascular disorder, with 12 cases reported in the past decade. A 60-year-old woman presented with a painful, palpable groin mass without leg swelling. She was initially thought to have a nonreducible inguinal hernia. A computed tomography scan was obtained that revealed a cystic mass involving the right common femoral vein. Previous imaging revealed that the mass had enlarged over time. In the operating room, the cyst wall was excised without compromising vein integrity. The patient had an uneventful recovery and her pain resolved. We review the presentation, diagnosis, and treatment of this condition. We believe that the rapid evolution of this lesion suggests that an unknown inciting factor triggers its onset and growth., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Pseudoaneurysms of the common carotid arteries are rare and have been associated with both penetrating and blunt trauma. Intervention is warranted in most cases to avert the sequelae of rupture or embolization. Treatments are tailored to the specific patient on a case by case basis. This report describes an unusual case of common carotid artery pseudoaneurysm after minor blunt trauma and reviews the diagnostic and treatment modalities available., (Copyright © 2013 Elsevier Inc. All rights reserved.)

This paper examines the role of other-regarding behavior as a mechanism for the establishment and maintenance of cooperation in resource use under variable social and environmental conditions. By coupling resource stock dynamics with social dynamics concerning compliance to a social norm prescribing non-excessive resource extraction in a common pool resource, we show that when reputational considerations matter and a sufficient level of social stigma affects the violators of a norm, sustainable outcomes are achieved. We find large parameter regions where norm-observing and norm-violating types coexist, and analyze to what extent such coexistence depends on the environment., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objectives: Menkes disease, an X linked recessive neurodegenerative disorder, results from a mutation in the gene coding for the copper transporting ATPase (ATP7A). Epilepsy is a major clinical feature of this disorder. We describe the clinical presentation, evolution of epilepsy and explore the biological underpinnings of epileptogenesis in Menkes disease., Methods: Longitudinal case study illustrating the natural history of epilepsy and results of subcutaneous cupric chloride supplementation in a patient with Menkes disease and literature review., Results: The onset and evolution of epilepsy in Menkes disease is marked by different stages. Early presentations typically involve focal seizures, with progression to epileptic spasms and a chronic late stage of epilepsy characterized by tonic seizures, myoclonic jerks, and multifocal epileptiform activity on the EEG. Morphological correlates in the brain include evidence of atrophy of grey matter, ventriculomegaly, tortuous intracranial vasculature, and white matter signal changes consistent with loss of myelin and axons. The presence of significant lactic acidosis in brain and cerebrospinal fluid suggests widespread disturbance in oxidative metabolism. Molecular consequences of the pathogenic ATP7A gene mutation lead to impairment in copper transport, which in turn causes deficiencies of key copper containing enzymes (dopamine β hydroxylase and cytochrome c oxidase). Microarray studies suggest widespread effects in dysregulation of genes involved in cellular responses to oxidative stress, ribosomal translation, signal transduction, mitochondrial function, and immune responses. Impairment of copper mediated NMDA receptor function further enhances neuronal excitability, excitotoxic neuronal injury, setting up a cascade that creates conditions for epileptogenesis to follow., Conclusion: Neurological manifestations are likely related to perturbations in copper dependent enzymatic pathways involved in neurotransmitter and energy metabolism. Early diagnosis and institution of copper supplementation has been shown to be beneficial particularly in patients with residual ATP7A activity., (Copyright © 2011 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.)

Background: More than 50,000 people participated in the rescue and recovery work that followed the Sept 11, 2001 (9/11) attacks on the World Trade Center (WTC). Multiple health problems in these workers were reported in the early years after the disaster. We report incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examine their associations with occupational exposures, and quantify physical and mental health comorbidities., Methods: In this longitudinal study of a large cohort of WTC rescue and recovery workers, we gathered data from 27,449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. We used the Kaplan-Meier procedure to estimate cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud)., Findings: 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastro-oesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders., Interpretation: 9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasise the need for continued monitoring and treatment of the WTC rescue and recovery population., Funding: Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Tumor-associated macrophages can potentially kill tumor cells via the high concentrations of nitric oxide (NO) produced by inducible nitric oxide synthase (iNOS); however, tumor-associated macrophages actually support tumor growth, as they are skewed toward M2 activation, which is characterized by low amounts of NO production and is proangiogenic. We show that the mouse renal cell carcinoma cell line, RENCA, which, on stimulation, expresses high levels of iNOS mRNA, loses its ability to express the iNOS protein. This effect is mediated by the microRNA miR-146a, as inhibition of RENCA cells with anti-miR- 146a restores iNOS expression and NO production (4.8 ± 0.4 versus 0.3 ± 0.1 μmol/L in uninhibited cells, P < 0.001). In vivo, RENCA tumor cells do not stain for iNOS, while infiltrating tumor-associated macrophages showed intense staining, and both cell types expressed iNOS mRNA. Restoring iNOS protein expression in RENCA cells using anti-miR-146a increases macrophage-induced death of RENCA cells by 73% (P < 0.01) in vitro and prevents tumor growth in vivo. These results suggest that, in addition to NO production by macrophages, tumor cells must produce NO to induce their own deaths, and some tumor cells may use miR-146a to reduce or abolish endogenous NO production to escape macrophage-mediated cell death. Thus, inhibiting miR-146a may render these tumor cells susceptible to therapeutic strategies, such as adoptive transfer of M1-activated macrophages.

We propose a (time) multiscale method for the coarse-grained analysis of collective motion and decision-making in self-propelled particle models of swarms comprising a mixture of 'naïve' and 'informed' individuals. The method is based on projecting the particle configuration onto a single 'meta-particle' that consists of the elongation of the flock together with the mean group velocity and position. We find that the collective states can be associated with the transient and asymptotic transport properties of the random walk followed by the meta-particle, which we assume follows a continuous time random walk (CTRW). These properties can be accurately predicted at the macroscopic level by an advection-diffusion equation with memory (ADEM) whose parameters are obtained from a mean group velocity time series obtained from a single simulation run of the individual-based model., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Tinnitus distress can be reduced by means of cognitive-behavior therapy (CBT), and the treatment can be delivered in different ways. The most recent format is Internet-based self-help. The aim of this study was to compare this treatment (n= 26) with standard group-based CBT (n=25) in a randomized controlled trial. Outcomes on self-report inventories measuring tinnitus distress were evaluated immediately after and 1 year after treatment. Results showed that both groups had improved, and there were few differences between them. The effect size for the Internet treatment was d=0.73 (95% CI=0.16-1.30) and for the group treatment was d=0.64 (95% CI=0.07-1.21). The Internet treatment consumed less therapist time and was 1.7 times as cost-effective as the group treatment. At pretreatment patients rated the Internet treatment as less credible than the group treatment. In conclusion, Internet treatment for tinnitus distress merits further investigation, as the outcomes achieved are promising.

Microbes require multiple essential elements that they acquire from the environment independently. Here we investigate how microbial stoichiometry and uptake rates depend on the conditions in which they grow. We modify a recent model of growth based on a multinutrient extension of the Droop model to allow a trade-off between ability to acquire two essential resources. In a static analysis, we show that the optimal allocation strategy is the one that results in co-limitation by both nutrients. We then add a dynamic equation to model the physiological acclimation uptake rates in changing conditions. This dynamic model predicts that the response of organismal stoichiometry to nutrient supply ratio can vary over time. The response of organismal stoichiometry and growth rate to a nutrient pulse depends on the speed at which cells adapt their uptake rates. In a variable environment, very fast or very slow acclimation may be better strategies than intermediate speed acclimation. We suggest experimental tests of the model and avenues for future model development.

Study Objectives: To characterize respiratory abnormalities in a convenience sample of ironworkers exposed at the World Trade Center (WTC) disaster site for varying lengths of time between September 11, 2001, and February 8, 2002., Design: Cross-sectional study., Setting: The Mount Sinai Medical Center, a large tertiary hospital., Participants: Ninety-six ironworkers engaged in rescue and recovery with exposure onset between September 11, 2001, and September 15, 2001, who responded to an invitation to undergo respiratory evaluation., Measurements: Medical and exposure history, physical examination, spirometry, forced oscillation (FO), and chest radiographs. The relationships of prevalence of respiratory symptoms and presence of obstructive physiology to smoking, exposure on September 11, duration of exposure, and type of respiratory protection were examined using univariate and linear and logistic regression analyses., Results: Seventy-four of 96 workers (77%) had one or more respiratory symptoms (similar in smokers [49 of 63 subjects, 78%] and nonsmokers [25 of 33 subjects, 76%]). Cough was the most common symptom (62 of 96 subjects, 65%), and was associated with exposure on September 11. Chest examination and radiograph findings were abnormal in 10 subjects (10%) and 19 subjects (20%), respectively. FO revealed dysfunction in 34 of 64 subjects tested (53%), while spirometry suggested obstruction in only 11 subjects (17%). Lack of a respirator with canister was a risk factor for large airway dysfunction, and cigarette smoking was a risk factor for small airway dysfunction. No other relationships reached statistical significance., Conclusions: Respiratory symptoms occurred in the majority of ironworkers at the WTC disaster site and were not attributable to smoking. Exposure on September 11 was associated with a greater prevalence of cough. Objective evidence of lung disease was less common. Spirometry underestimated the prevalence of lung function abnormalities in comparison to FO. Continuing evaluation of symptoms, chest radiographs, and airway dysfunction should determine whether long-term clinical sequelae will exist.

We evaluated the feasibility of recruiting overweight adults with diabetes, living in rural, medically underserved communities, to a weight management intervention consisting of a 12-month clinical trial of two weight management programs and usual care. The sampling frame consisted of adults ages 45 years and older with clinically diagnosed diabetes from two community health centers. The recruitment process included medical record review, prescreening telephone call, two screening visits, and a randomization visit. Over 1,400 medical records were reviewed; 78.6% met eligibility criteria; 60.1% were contacted for telephone prescreening, and 35.5% remained eligible and were interested in participating. Of these, 187 completed visit 1, 164 completed visit 2, and 143 were randomized. Forty-six people were randomized who entered the study as walk-ins at screening visit 1, resulting in 189 subjects. The final yield was 21.5%. Subject mean age was 60.4 years, mean body mass index was 36.4 kg/m(2), 80% were African-American, and 46.6% had less than a high school education. Retention at 12 months was 81.5%. Successful strategies included partnering with community health centers, positive reinforcement and social supportiveness, monitoring progress, and free transportation. This work provides a useful example of an academic-community partnership designed to reach groups previously considered hard to reach.