Search

Rationale: Although obstructive sleep apnea is associated with physiological perturbations that increase risk of hypertension and are proatherogenic, it is uncertain whether sleep apnea is associated with increased stroke risk in the general population.Objectives: To quantify the incidence of ischemic stroke with sleep apnea in a community-based sample of men and women across a wide range of sleep apnea.Methods: Baseline polysomnography was performed between 1995 and 1998 in a longitudinal cohort study. The primary exposure was the obstructive apnea-hypopnea index (OAHI) and outcome was incident ischemic stroke.Measurements and Main Results: A total of 5,422 participants without a history of stroke at the baseline examination and untreated for sleep apnea were followed for a median of 8.7 years. One hundred ninety-three ischemic strokes were observed. In covariate-adjusted Cox proportional hazard models, a significant positive association between ischemic stroke and OAHI was observed in men (P value for linear trend: P = 0.016). Men in the highest OAHI quartile (>19) had an adjusted hazard ratio of 2.86 (95% confidence interval, 1.1-7.4). In the mild to moderate range (OAHI, 5-25), each one-unit increase in OAHI in men was estimated to increase stroke risk by 6% (95% confidence interval, 2-10%). In women, stroke was not significantly associated with OAHI quartiles, but increased risk was observed at an OAHI greater than 25.Conclusions: The strong adjusted association between ischemic stroke and OAHI in community-dwelling men with mild to moderate sleep apnea suggests that this is an appropriate target for future stroke prevention trials. [ABSTRACT FROM AUTHOR]

Abstract Background Many critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS). Discrepancies between the medical history documented by a health professional and the patient's own report may therefore have important health consequences. Methods Medical histories of 117 patients with an ACS were documented. A questionnaire assessing the patient's health history was then completed by 62 eligible patients. Information about 13 health conditions with relevance to ACS management was obtained from the questionnaire and the medical record. Concordance between these two sources and reasons for discordance were identified. Results There was significant variation in agreement, from very poor in angina (kappa < 0) to almost perfect in diabetes (kappa = 0.94). Agreement was substantial in cerebrovascular accident (kappa = 0.76) and hypertension (kappa = 0.73); moderate in cocaine use (kappa = 0.54), smoking (kappa = 0.46), kidney disease (kappa = 0.52) and congestive heart failure (kappa = 0.54); and fair in arrhythmia (kappa = 0.37), myocardial infarction (kappa = 0.31), other cardiovascular diseases (kappa = 0.37) and bronchitis/pneumonia (kappa = 0.31). The odds of agreement was 42% higher among individuals with at least some college education (OR = 1.42; 95% CI, 1.00 - 2.01, p = 0.053). Listing of a condition in medical record but not in the questionnaire was a common cause of discordance. Conclusion Discrepancies in aspects of the medical history may have important effects on the care of ACS patients. Future research focused on identifying the most effective and efficient means to obtain accurate health information may improve ACS patient care quality and safety.

Introduction: This study addresses the lack of methods to quantify driver familiarity with roadways, which poses a higher risk of crashes., Method: We present a new approach to assessing driving route diversity and familiarity using data from the DrivingApp, a smartphone-based research tool that collects trip-level information, including driving exposure and global positioning system (GPS) data, from young novice drivers (15-19 years old) to older drivers (67-78 years old). Using these data, we developed a GPS data-based algorithm to analyze the uniqueness of driving routes. The algorithm creates same route trip (SRT) arrays by comparing each trip of an identified user, employing statistically determined thresholds for GPS coordinate proximity and trip overlap. The optimal thresholds were established using a General Linear Model (GLM) to examine distance, and repeated observations. The Adjusted Breadth-First Search method is applied to the SRT arrays to prevent double counting or trip omission. The resulting list is classified as geographically distinct routes, or unique routes (URs)., Results: Manual comparison of algorithm output with geographical maps yielded an overall precision of 0.93 and accuracy of 0.91. The algorithm produces two main outputs: a measure of driving diversity (number of URs) and a measure of route-based familiarity derived from the Rescorla-Wagner model. To evaluate the utility of these measures, a Gaussian mixture model clustering algorithm was used on the young novice driver dataset, revealing two distinct groups: the low-frequency driving group with lower route familiarity when having higher route diversity, whereas the high-frequency driving group with the opposite pattern. In the older driver group, there was a significant correlation found between the number of URs and Geriatric Depression Score, or walking gait speed., Practical Applications: These findings suggest that route diversity and familiarity could complement existing measures to understand driving safety and how driving behavior is related to physical and psychological outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

In this randomized, double-blind, sham-controlled trial of Cerebellar Stimulation for Aphasia Rehabilitation (CeSAR), we will determine the effectiveness of cathodal tDCS (transcranial direct current stimulation) to the right cerebellum for the treatment of chronic aphasia (>6 months post stroke). We will test the hypothesis that cerebellar tDCS in combination with an evidenced-based anomia treatment (semantic feature analysis, SFA) will be associated with greater improvement in naming untrained pictures (as measured by the change in Philadelphia Picture Naming Test), 1-week post-treatment, compared to sham plus SFA. We will also evaluate the effects of cerebellar tDCS on naming trained items as well as the effects on functional communication, content, efficiency, and word-retrieval of picture description, and quality of life. Finally, we will identify imaging and linguistic biomarkers to determine the characteristics of stroke patients that benefit from cerebellar tDCS and SFA treatment. We expect to enroll 60 participants over five years. Participants will receive 15, 25-minute sessions of cerebellar tDCS (3-5 sessions per week) or sham tDCS combined with 1 hour of SFA treatment. Participants will be evaluated prior to the start of treatment, one-week post-treatment, 1-, 3-, and 6-months post-treatment on primary and secondary outcome variables. The long-term aim of this study is to provide the basis for a Phase III randomized controlled trial of cerebellar tDCS vs sham with concurrent language therapy for treatment of chronic aphasia. Trial registration: The trial is registered with ClinicalTrials.gov NCT05093673., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Lammers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In initial COVID-19 clinical trials, menstrual health was not formally monitored, yet anecdotal reports of menstruation changes surfaced on social media. This study aims to assess the association between COVID-19 vaccines and menstruation using Clue, a period-tracking application., Study Design: A survey assessing demographics, menstrual health, stress levels, and COVID-19 vaccination was sent to Clue users between 12/7/2021 and 2/9/2022. Inclusion criteria were (1) 18 years or older (2) currently menstruating (3) not pregnant or breastfeeding since 1/2020. Menstrual data was collected for each participant. Users with cycle lengths more than 90 days were excluded. Cycle lengths were calculated for the 6-month average pre-vaccination (PRIOR), the cycle during which vaccination was administered (DURING), the cycle following DURING (AFTER1), and the cycle following AFTER1 (AFTER2). For periods, individuals were stratified based on whether vaccination was received during their menstrual period (DURING). Period lengths were additionally calculated for the 6-month average pre-vaccination (PRIOR), the first period following vaccination (AFTER1), and the period following AFTER1 (AFTER2). For unvaccinated participants, an index date (4/1/2022) was used to similarly designate menstrual cycles and periods. For each participant, cycle length changes for DURING, AFTER1, and AFTER2 compared to PRIOR were determined. Student's t -test compared the mean of these changes between vaccinated and unvaccinated groups., Results: Of 7,559 participants, 6,897 (91 %) were vaccinated. Compared to PRIOR, individuals vaccinated during their menstrual period demonstrated a statistically significant increase in the DURING period length, but not AFTER1 (p = 0.463) and AFTER2 (p = 0.692). No statistically significant changes were observed in period lengths of those vaccinated in between periods or in cycle lengths overall., Conclusion: A small but statistically significant change in period length was observed only in individuals vaccinated for COVID-19 during their menstrual period. Providers can better counsel menstruating individuals to reduce vaccine misinformation., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mostafa Borahay reports financial support was provided by National Institute of Child Health and Human Development. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Pulmonary vasodilator treatment can improve hemodynamics, right ventricular function, symptoms, and survival in pediatric pulmonary hypertension (PH). However, clinical trial data are lacking due to many constraints. One major limitation is the lack of relevant trial endpoints reflective of hemodynamics or functional status in patients in whom standard exercise testing is impractical, unreliable, or not reproducible. The Kids Mod PAH trial (Mono- vs. Duo Therapy for Pediatric Pulmonary Arterial Hypertension) is an ongoing multicenter, Phase III, randomized, open-label, pragmatic trial to compare the safety and efficacy of first-line combination therapy (sildenafil and bosentan) to first-line monotherapy (sildenafil alone) in 100 pediatric patients with PH across North America. Investigators will measure participants' physical activity with a research-grade, wrist-worn actigraphy device at multiple time points as an exploratory secondary outcome. Vector magnitude counts per minute and activity intensity will be compared between the treatment arms. By directly and noninvasively measuring physical activity in the ambulatory setting, we aim to identify a novel, simple, inexpensive, and highly reproducible approach for quantitative assessment of exercise tolerance in pediatric PH. These data will increase the field's understanding of the effect of pulmonary vasodilator treatment on daily activity - a quantitative measure of functional status and wellbeing in pediatric PH and a potential primary outcome for future clinical trials in children with cardiopulmonary disorders., Competing Interests: The authors declare no conflict of interest., (© 2024 The Authors. Pulmonary Circulation published by John Wiley & Sons Ltd on behalf of Pulmonary Vascular Research Institute.)

Motor vehicle crashes are a leading cause of death in the United States, and disproportionately impact communities of color. Replacing human control with automated vehicles (AVs) holds the potential to reduce crashes and save lives. The benefits of AVs, including automated shuttles, buses, or cars could extend beyond safety to include improvements in congestion, reductions in emissions, and increased access to mobility, particularly for vulnerable populations. However, AVs have not attained the level of public trust that has been expected, given their potential to save lives and increase access to mobility. Public opinion surveys have highlighted safety and security concerns as reasons for this lack of confidence. In this study, we present the findings of an experiment we conducted to actively shift mindsets on AVs toward advancing health equity. We demonstrate through a nationally representative sample of 2265 U.S. adults that the public support for AVs can be improved by expanding their scope of application to include advancing social benefit. The survey began with questions on respondent's support for AVs based on a priori knowledge and beliefs. Consistent with prior surveys, baseline support (strong support and some degree of support) was low at 26.4% (95% confidence interval 24.0-29.0). After introducing information about how AVs could be used to provide mobility for older adults, those with limited income, or the vision-impaired, respondents were asked to reassess their support for AVs. Support significantly increased to include the majority of respondents. By prioritizing the deployment of AVs to serve individuals and communities in greatest need of mobility, AVs would not only demonstrate compelling social value by reducing disparities but would also gain widespread public support among the U.S. public., Competing Interests: No competing financial interests exist., (© Johnathon P. Ehsani et al., 2024; Published by Mary Ann Liebert, Inc.)

Background: The incidence of endometrial cancer (EC) in the United States continues to rise, driven mainly by the obesity epidemic. We sought to determine overweight and obese women's cancer risk knowledge and preferences regarding diagnostic endometrial biopsy (EMB) for EC detection., Methods: An online survey was administered to overweight and obese women without EC recruited through the electronic medical record's online patient portal. Baseline questions queried gynecologic history, cancer risk knowledge, and factors potentially influencing decision-making for EMB. We used the threshold survey technique to identify the minimum acceptable risk (MAR) threshold at which each respondent would be willing to undergo an EMB to detect EC., Results: Of 357 respondents (median age 45 years (interquartile range [IQR]: 38-54); median BMI 39 [IQR: 36.0-44.6]), fewer than half (48.7 %) were aware that obesity is a risk factor for EC, and 10 % considered their risk of EC to be high. Almost half (42 %) of respondents reported MAR thresholds characterized as very low (0-1 %), and these were more common among respondents with higher BMIs. Forty percent identified their weight as a factor influencing their MAR threshold decision, while 76 % identified their perceived personal risk as a factor. Less than half cited immediate risks of the procedure., Conclusion: Many patients reported being willing to undergo an EMB at very low risk thresholds for EC. Perceived personal risk is a stronger factor in decision-making than immediate procedural risks. Providers should focus on communicating patients' risk to motivate EMB to detect EC where appropriate., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Malaria is initiated when infected anopheline mosquitoes inoculate sporozoites as they probe for blood. It is thought that all infected mosquitoes are equivalent in terms of their infectious potential, with parasite burden having no role in transmission success. In this study, using mosquitoes harboring the entire range of salivary gland sporozoite loads observed in the field, we demonstrate a strong and highly significant correlation between mosquito parasite burden and inoculum size. We then link the inoculum data to oocyst counts, the most commonly-used metric to assess mosquito infection in the field, and determine the efficiency with which oocyst sporozoites enter mosquito salivary glands. Taken together our data support the conclusion that mosquitoes with higher parasite burdens are more likely to initiate infection and contribute to onward transmission. Overall these data may account for some of the unexplained heterogeneity in transmission and enable more precise benchmarks for transmission-blocking interventions., (© 2024. The Author(s).)

Pulmonary hypertension (PH) is a significant health problem that contributes to high morbidity and mortality in diverse cardiac, pulmonary, and systemic diseases in children. Evidence-based advances in PH care have been challenged by a paucity of quality endpoints for assessing clinical course and the lack of robust clinical trial data to guide pharmacologic therapies in children. While the landmark adult AMBITION trial demonstrated the benefit of up-front combination PH therapy with ambrisentan and tadalafil, it remains unknown whether upfront combination therapy leads to more rapid and sustained clinical benefits in children with various categories of PH. In this article, we describe the inception of the Kids Mod PAH Trial, a multicenter Phase III trial, to address whether upfront combination therapy (sildenafil and bosentan vs. sildenafil alone) improves PH outcomes in children, recognizing that marked differences between the etiology and therapeutic response between adults and children exist. The primary endpoint of this study is WHO functional class (FC) 12 months after initiation of study drug therapy. In addition to the primary outcome, secondary endpoints are being assessed, including a composite measure of time to clinical worsening, WHO FC at 24 months, echocardiographic assessment of PH and quantitative assessment of right ventricular function, 6-min walk distance, and NT-proBNP levels. Exploratory endpoints include selected biomarkers, actigraphy, and assessments of quality of life. This study is designed to pave the way for additional clinical trials by establishing a robust infrastructure through the development of a PPHNet Clinical Trials Network., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Pulmonary Circulation published by Wiley Periodicals LLC on behalf of the Pulmonary Vascular Research Institute.)

Background: A birth companion is a simple and low-cost intervention that can improve both maternal and newborn health outcomes. The evidence that birth companionship improves labor outcomes and experiences of care has been available for many years. Global and national policies exist in support of birth companions. Many countries including Ethiopia, Kenya, and Nigeria have not yet incorporated birth companions into routine practice in health facilities. This paper presents the protocol for a trial that aims to assess if a package of interventions that addresses known barriers can increase the coverage of birth companions., Methods: This two parallel arm cluster randomized controlled trial will evaluate the impact of a targeted intervention package on scale-up of birth companionship at public sector health facilities in Ethiopia (five study sites encompassing 12 facilities), Kenya (two sites encompassing 12 facilities in Murang'a and 12 facilities in Machakos counties), and Nigeria (two sites encompassing 12 facilities in Kano and 12 facilities in Nasarawa states). Baseline and endline assessments at each site will include 744 women who have recently given birth in the quantitative component. We will interview a maximum of 16 birth companions, 48 health care providers, and eight unit managers quarterly for the qualitative component in each country., Discussion: Ample evidence supports the contribution of birth companions to positive health outcomes for mothers and newborns. However, limited data are available on effective strategies to improve birth companion coverage and inform scale-up efforts. This trial tests a birth companion intervention package in diverse clinical settings and cultures to identify possible barriers and considerations to increasing uptake of birth companions. Findings from this study may provide valuable evidence for scaling up birth companionship in similar settings., Trial Registration: Trial is registered with ClinicalTrials.gov with identifier: NCT05565196, first posted 04/10/ 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: There are persistent racial and ethnic health disparities in end-of-life health outcomes in the United States. African American patients are less likely than White patients to access palliative care, enroll in hospice care, have documented goals of care discussions with their healthcare providers, receive adequate symptom control, or die at home. We developed Community Health Worker Intervention for Disparities in Palliative Care (DeCIDE PC) to address these disparities. DeCIDE PC is an integrated community health worker (CHW) palliative care intervention that uses community health workers (CHWs) as care team members to enhance the receipt of palliative care for African Americans with advanced cancer. The overall objectives of this study are to (1) assess the effectiveness of the DeCIDE PC intervention in improving palliative care outcomes amongst African American patients with advanced solid organ malignancy and their informal caregivers, and (2) develop generalizable knowledge on how contextual factors influence implementation to facilitate dissemination, uptake, and sustainability of the intervention., Methods: We will conduct a multicenter, randomized, assessor-blind, parallel-group, pragmatic, hybrid type 1 effectiveness-implementation trial at three cancer centers across the United States. The DeCIDE PC intervention will be delivered over 6 months with CHW support tailored to the individual needs of the patient and caregiver. The primary outcome will be advance care planning. The treatment effect will be modeled using logistic regression. The secondary outcomes are quality of life, quality of communication, hospice care utilization, and patient symptoms., Discussion: We expect the DeCIDE PC intervention to improve integration of palliative care, reduce multilevel barriers to care, enhance clinic and patient linkage to resources, and ultimately improve palliative care outcomes for African American patients with advanced cancer. If found to be effective, the DeCIDE PC intervention may be a transformative model with the potential to guide large-scale adoption of promising strategies to improve palliative care use and decrease disparities in end-of-life care for African American patients with advanced cancer in the United States., Trial Registration: Registered on ClinicalTrials.gov (NCT05407844). First posted on June 7, 2022., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: To examine incidence of child marriage among displaced and host populations in humanitarian settings., Design: Cross-sectional surveys., Setting: Data were collected in Djibouti, Yemen, Lebanon and Iraq in the Middle East and in Bangladesh and Nepal in South Asia., Participants: Adolescent girls aged 10-19 in the six settings and age cohort comparators., Outcome Measures: Cumulative incidence of marriage by age 18., Results: In Bangladesh and Iraq, the hazard of child marriage did not differ between internally displaced populations (IDPs) and hosts (p value=0.25 and 0.081, respectively). In Yemen, IDPs had a higher hazard of child marriage compared with hosts (p value<0.001). In Djibouti, refugees had a lower hazard of child marriage compared with hosts (p value<0.001). In pooled data, the average hazard of child marriage was significantly higher among displaced compared with host populations (adjusted HR (aHR) 1.3; 95% CI 1.04 to 1.61).In age cohort comparisons, there was no significant difference between child marriage hazard across age cohorts in Bangladesh (p value=0.446), while in Lebanon and Nepal, younger cohorts were less likely to transition to child marriage compared with older comparators (p value<0.001). Only in Yemen were younger cohorts more likely to transition to child marriage, indicating an increase in child marriage rates after conflict (p value=0.034). Pooled data showed a downward trend, where younger age cohorts had, on average, a lower hazard of child marriage compared with older cohorts (aHR 0.36; 95% CI 0.29 to 0.4)., Conclusions: We did not find conclusive evidence that humanitarian crises are associated with universal increases in child marriage rates. Our findings indicate that decision-making about investments in child marriage prevention and response must be attuned to the local context and grounded in data on past and current trends in child marriage among communities impacted by crisis., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anxiety and depression are common in the perinatal period and negatively affect the health of the mother and baby. Our group has developed "Happy Mother-Healthy Baby" (HMHB), a cognitive behavioral therapy-based psychosocial intervention to address risk factors specific to anxiety during pregnancy in low- and middle-income countries (LMICs)., Objective: The purpose of this study is to examine biological mechanisms that may be linked to perinatal anxiety in conjunction with a randomized controlled trial of HMHB in Pakistan., Methods: We are recruiting 120 pregnant women from the Holy Family Hospital, a public facility in Rawalpindi, Pakistan. Participants are assessed for at least mild anxiety symptoms using the Hospital Anxiety and Depression Scale (ie, a score ≥8 on the anxiety scale is necessary for inclusion in the anxiety groups and <8 for inclusion in the healthy control group). Women who meet the criteria for an anxiety group are randomized into either the HMHB intervention group or an enhanced usual care (EUC) control group. Participants receive HMHB or EUC throughout pregnancy and undergo blood draws at 4 time points (baseline, second trimester, third trimester, and 6 weeks post partum). We will assess peripheral cytokine concentrations using a multiplex assay and hormone concentrations using gas chromatography and mass spectrometry. The statistical analysis will use generalized linear models and mixed effects models to assess the relationships across time among anxiety, immune dysregulation, and hormone levels, and to assess whether these biological factors mediate the relationship between anxiety and birth and child development outcomes., Results: Recruitment started on October 20, 2020, and data collection was completed on August 31, 2022. The start date for recruitment for this biological supplement study was delayed by approximately half a year due to the COVID-19 pandemic. The trial was registered at ClinicalTrials.gov (NCT03880032) on September 22, 2020. The last blood samples were shipped to the United States on September 24, 2022, where they will be processed for analysis., Conclusions: This study is an important addition to the HMHB randomized controlled trial of an intervention for antenatal anxiety. The intervention itself makes use of nonspecialist providers and, if effective, will represent an important new tool for the treatment of antenatal anxiety in LMICs. Our biological substudy is one of the first attempts to link biological mechanisms to antenatal anxiety in an LMIC in the context of a psychosocial intervention, and our findings have the potential to significantly advance our knowledge of the biological pathways of perinatal mental illness and treatment efficacy., Trial Registration: ClinicalTrials.gov NCT03880032; https://clinicaltrials.gov/ct2/show/NCT03880032., International Registered Report Identifier (irrid): DERR1-10.2196/43193., (©Morgan L Sherer, Abid Malik, Lauren M Osborne, Armaan A Rowther, Ahmed Zaidi, Najia Atif, Atif Rahman, Lubna E Kahloon, Muhammad Salman, Gayane Yenokyan, Pamela J Surkan. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 11.04.2023.)

Introduction: Supervised practice during the learner stage of graduated driver licensing is required in all U.S. states and some international jurisdictions. Several U.S. states require driving hours to be recorded in a paper logbook, making it susceptible to errors or falsification. A smartphone app that operates as an electronic logbook could serve as an alternative. The purpose of this study was to measure the impact of the logbook format (i.e., paper versus electronic) on self-reported driving behavior., Design: Parent‒teen dyads were enrolled and assigned to electronic ( n =147) and paper ( n =131) logbook groups using a block design., Setting/participants: This study was conducted in Maryland. Data were collected for 6 continuous months while teenagers held a learner permit between January 2020 and December 2021., Intervention: Electronic logbook to measure practice driving., Outcome Measure: Self-reported driving between the electronic and paper logbook groups. For those using electronic logbooks, an agreement between self-reported trips and electronic logbook trips and perceptions of using an electronic logbook to measure driving., Results: There were no statistically significant differences in any measures of self-reported practice driving by logbook type (electronic versus paper). Agreement between self-reported and electronic logbook‒recorded trips ranged between 68.6% and 79.0% (allowing a difference of 2 trips per week). User satisfaction with the electronic logbook was high, with 93.0% of teenagers and 91.9% of parents stating that they would recommend the app to a friend., Conclusions: An electronic logbook is a viable approach to measuring practice driving. Eventually, it could become part of a system where practice requirements are verified, allowing states to move toward performance-based graduated driver licensing., (© 2022 The Author(s).)

Background: There is limited data to assess, track, or quantify accessibility and disability inclusion across universities., Objective: This cross-sectional study assessed disability inclusion and accessibility at the top 50 National Institutes of Health (NIH)-funded undergraduate programs in the United States. We hypothesized that there is no association between NIH funding and the University Disability Inclusion Score., Methods: A novel tool, the University Disability Inclusion Score assessed disability inclusion and accessibility using 10 indicators spanning 4 categories: (1) accessibility of built and virtual environment, (2) public image of disability inclusion, (3) accommodations processes and procedures, and (4) grievance policy. Based upon the total points (out of a total score of 100), each university was assigned a letter grade (A-F)., Results: Of the top 50 NIH-funded institutions, 6% received an A grade on the Score, while 60% received D or F. The mean scores were 15.2 (SD = 5) for accessibility of built and virtual environment (20 points), 10 (SD = 3) for public image of disability inclusion (20 points), 30.6 (SD = 10) for accommodations processes and procedures (50 points), and 8.1 (SD = 3) for grievance policy (10 points)., Conclusions: Our findings suggest room for improvement in disability inclusion and accessibility among top university recipients of NIH funding. To provide an equitable academic experience, universities must prioritize disability inclusion., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Campanile et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster-randomized controlled trial, all adult non-intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real-time, electronic alert-triggered, patient-centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre- versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57-0.71]). Nonadministration decreased significantly ( P <0.001) in both arms: patient-centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48-0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62-0.84]). Patient refusal decreased significantly in both arms: patient-centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37-0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59-0.86]). No differential effect occurred on medical versus surgical units. The patient-centered education bundle was significantly more effective in reducing all nonadministered ( P =0.03) and refused doses ( P =0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0-1.61]; P =0.03 for interaction). Conclusions Information technology strategies like the alert-triggered, targeted patient-centered education bundle, and nurse-focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03367364.

Objective: The American Indian/Alaska Native (AI/AN) population in the U.S. is thriving in spite of settler colonialist efforts of erasure. AI/AN people, however, continue to experience persistent health disparities including a disproportionate burden of substance use and sexually transmitted diseases/infections (STDs/STIs), as well as a disproportionate lack of public health STD screening services and STD prevention interventions grounded in AI/AN social contexts, experiences, and epistemologies. The present study explored how stressors and protective factors based on the Indigenist Stress Coping framework predict STD screening outcomes among Native adults., Methods: We analyzed baseline self-report data from 254 Native adults ages 18-55 years with recent binge substance use who were enrolled in an evaluation of "EMPWR," a two-session STD risk reduction program in a rural, reservation-based community in the U.S. Southwest. Logistic regression models with robust variance were used to estimate odds ratios of lifetime STD testing for the theoretical stressors and cultural buffers., Results: A little over half the sample were males (52.5%, n = 136), with a mean age of 33.6 years (SD = 8.8). The majority (76.7%, n = 195) reported having ever been screened for STD in their life. Discrimination score were significantly associated with lifetime STD testing: The higher discrimination was associated with lower odds of STD testing in the fully adjusted model (aOR = 0.40, 95%CI: 0.18, 0.92). The effects of AI/AN-specific cultural buffer such as participation in traditional practices on STD testing outcomes was in the expected positive direction, even though the association was not statistically significant. Household size was significantly associated with STD screening: The higher the number of people lived together in the house, the higher the odds of STD testing in the fully adjusted model (aOR = 1.19, 95%CI: 1.04, 1.38)., Conclusion: Our findings suggest that STD prevention programs should take into consideration AI/AN-specific historical traumatic stressors such as lifetime discrimination encounters and how these interact to drive or discourage sexual health services at local clinics. In addition, larger household size may be a protective factor functioning as a form of social support, and the extended family's role should be taken into consideration. Future research should consider improvement in measurements of AI/AN enculturation constructs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Magarati, Chambers, Yenokyan, Rosenstock, Walls, Slimp, Larzelere, Lee, Pinal and Tingey.)

Background: Diagnostic outcomes for fever of unknown origin (FUO) remain with notable numbers of undiagnosed cases. A recent systemic review and meta-analysis of studies reported geographic variation in FUO-related infectious diseases. Whether geography influences types of FUO noninfectious diagnoses deserves examination., Methods: We systematically searched Medline (PubMed), Embase, Scopus, and Web of Science databases using medical subject headings published from January 1, 1997 to March 31, 2021. Prospective clinical studies investigating participants meeting adult FUO defining criteria were selected if they assessed final diagnoses. Meta-analyses were based on the random-effects model according to World Health Organization (WHO) geographical regions., Results: Nineteen studies with significant heterogeneity were analyzed, totaling 2667 participants. Noninfectious inflammatory disorders had a pooled estimate at 20.0% (95% confidence interval [CI], 17.0%-23.0%). Undiagnosed illness had a pooled estimate of 20.0% (95% CI, 14.0%-26.0%). The pooled estimate for cancer was 15.0% (95% CI, 12.0%-18.0%). Miscellaneous conditions had a pooled estimate of 6.0% (95% CI, 4.0%-8.0%). Noninfectious inflammatory disorders and miscellaneous conditions were most prevalent in the Western Pacific region with a 27.0% pooled estimate (95% CI, 20.0%-34.0%) and 9.0% (95% CI, 7.0%-11.0%), respectively. The highest pooled estimated for cancer was in the Eastern Mediterranean region at 25.0% (95% CI, 18.0%-32.0%). Adult-onset Still's disease (114 [58.5%]), systemic lupus (52 [26.7%]), and giant-cell arteritis (40 [68.9%]) predominated among the noninfectious inflammatory group. Lymphoma (164 [70.1%]) was the most common diagnosis in the cancer group., Conclusions: In this systematic review and meta-analysis, noninfectious disease diagnostic outcomes varied among WHO-defined geographies. Evaluations for FUO should include local variations in disease prevalence., Competing Interests: Potential Conflicts of interest. W. F. W reports no conflicts of interest. G. Y. is funded in part by a grant from the NCATS. P. G. A. has worked as a consultant for Pfizer, Humanigen, and EMD Serono, and has equity holdings in Johnson and Wellstat, all outside the submitted work., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Fever of unknown origin (FUO) investigations yield a substantial number of patients with infectious diseases. This systematic review and meta-analysis aimed to quantify more common FUO infectious diseases etiologies and to underscore geographic variation., Methods: Four databases (PubMed, Embase, Scopus, and Web of Science) were searched for prospective studies reporting FUO rates among adult patients from 1 January 1997 to 31 March 2021. The pooled proportion for infectious diseases etiology was estimated using the random-effects meta-analysis model., Results: Nineteen prospective studies were included with 2667 total cases. No studies were available for Africa or the Americas. Overall, 37.0% (95.0% confidence interval [CI], 30.0%-44.0%) of FUO patients had an infectious disease etiology. Infections were more likely from Southeastern Asia (pooled proportion, 0.49 [95% CI, .43-.55]) than from Europe (pooled proportion, 0.31 [95% CI, .22-.41]). Among specifically reported infectious diseases (n = 832), Mycobacterium tuberculosis complex predominated across all geographic regions (n = 285 [34.3%]), followed by brucellosis (n = 81 [9.7%]), endocarditis (n = 62 [7.5%]), abscesses (n = 61 [7.3%]), herpesvirus (eg, cytomegalovirus and Epstein-Barr virus) infections (n = 60 [7.2%]), pneumonia (n = 54 [6.5%]), urinary tract infections (n = 54 [6.5%]), and enteric fever (n = 40 [4.8%])., Conclusions: FUO patients from Southeastern Asia were more likely to have an infectious diseases etiology when compared to other regions. The predominant factor for this finding appears to be differences in disease prevalence among various geographical locations or other factors such as access to timely care and diagnosis. Noting epidemiological disease factors in FUO investigations could improve diagnostic yields and clinical outcomes., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Cervical cancer is the fourth most common cancer in the world, affecting mainly women residing in low- and middle-income countries. Progression from a pre-invasive phase to that of an invasive phase generally takes years and provides a window of opportunity to screen for and treat precancerous lesions., Methods: This study is being conducted at four sites in north Karnataka, India. Community sensitization activities have been organized in the study areas to create awareness among stakeholders, including elected representatives, physicians, health care workers, and potential participants. Organized community based as well as hospital-based screening is being conducted using visual inspection with acetic acid (VIA). Screen positive women are referred to respective study hospitals for colposcopy and directed biopsy. Participants with confirmed high-grade cervical dysplasia (high-grade squamous intraepithelial lesions or HSIL) who fit all other eligibility criteria will be recruited to the study and will receive cryotherapy using CryoPop®, an innovative new cryotherapy device., Discussion: There is a need to develop an inexpensive, simple, and effective cryotherapy device for use by frontline health care providers at locations where screening and timely treatment can be given, accelerating access to cervical cancer prevention services and minimizing loss to follow-up of women with precancerous lesions who need treatment., Trial Registration: Clinical Trial Registry - India CTRI/2019/01/017289 ClinicalTrials.Gov number NCT04154644 . Registered on November 6, 2019., (© 2021. The Author(s).)

Background: While current estimates suggest that up to three million additional surgical procedures are needed to meet the needs of forcibly displaced populations, literature on surgical care for refugee or forced migrant populations has often focused on acute phase and war-related trauma or violence with insufficient attention to non-war related pathologies. To our knowledge, no study has compared refugee versus host population utilization of surgical services in a refugee camp-based hospital over such an extended period of twenty years. The aim of this paper is to first describe the patterns of surgical care by comparing refugee and host population utilization of surgical services in Nyarugusu refugee camp between 2000 and 2020, then evaluate the impact of a large influx of refugees in 2015 on refugee and host population utilization., Methods: The study was based on a retrospective review of surgical logbooks in Nyarugusu refugee camp (Kigoma, Tanzania) between 2000 and 2020. We utilized descriptive statistics and multiple group, interrupted time series methodology to assess baseline utilization of surgical services by a host population (Tanzanians) compared to refugees and trends in utilization before and after a large influx of Burundian refugees in 2015., Results: A total of 10,489 operations were performed in Nyarugusu refugee camp between 2000 and 2020. Refugees underwent the majority of procedures in this dataset (n = 7,767, 74.0%) versus Tanzanians (n = 2,722, 26.0%). The number of surgeries increased over time for both groups. The top five procedures for both groups included caesarean section, bilateral tubal ligation, herniorrhaphy, exploratory laparotomy and hysterectomy. In our time series model, refugees had 3.21 times the number of surgeries per quarter at baseline when compared to Tanzanians. The large influx of Burundian refugees in 2015 impacted surgical output significantly with a 38% decrease (IRR = 0.62, 95% CI 0.46-0.84) in surgeries in the Tanzanian group and a non-significant 20% increase in the refugee group (IRR = 1.20, 95% CI 0.99-1.46). The IRR for the difference-in-difference (ratio of ratios of post versus pre-intervention slopes between refugees and Tanzanians) was 1.04 (95% CI 1.00-1.07), and this result was significant (p=0.028)., Conclusions: Surgical care in conflict and post-conflict settings is not limited to war or violence related trauma but instead includes a large burden of obstetrical and general surgical pathology. Host population utilization of surgical services in Nyarugusu camp accounted for over 25% of all surgeries performed, suggesting some host population benefit of the protracted refugee situation in western Tanzania. Host population utilization of surgical services was apparently different after a large influx of refugees from Burundi in 2015., (© 2021. The Author(s).)

Objectives: Fat quality and quantity may affect health similarly or differently. Fat quality can be assessed by measuring fat density on CT scan (greater density = smaller, higher quality adipocytes). We assessed the effects of tesamorelin, a growth hormone-releasing hormone analogue that reduces visceral fat (VAT) quantity in some people living with HIV (PWH), on fat density., Design: Participants from two completed, placebo-controlled, randomized trials of tesamorelin for central adiposity treatment in PWH were included if they had either a clinical response to tesamorelin (VAT decrease ≥8%, ≈70% of participants) or were placebo-treated., Methods: CT VAT and subcutaneous fat (SAT) density (Hounsfield Units, HU) were measured by a central blinded reader., Results: Participants (193 responders, 148 placebo) were 87% male and 83% white. Baseline characteristics were similar across arms, including VAT (-91 HU both arms, P = 0.80) and SAT density (-94 HU tesamorelin, -95 HU placebo, P = 0.29). Over 26 weeks, mean (SD) VAT and SAT density increased in tesamorelin-treated participants only [VAT: +6.2 (8.7) HU tesamorelin, +0.3 (4.2) HU placebo, P < 0.0001; SAT: +4.0 (8.7) HU tesamorelin, +0.3 (4.8) HU placebo, P < 0.0001]. The tesamorelin effects persisted after controlling for baseline VAT or SAT HU and area, and VAT [+2.3 HU, 95% confidence interval (4.5-7.3), P = 0.001) or SAT (+3.5 HU, 95% confidence interval (2.3-4.7), P < 0.001] area change., Conclusion: In PWH with central adiposity who experienced VAT quantity reductions on tesamorelin, VAT and SAT density increased independent of changes in fat quantity, suggesting that tesamorelin also improves VAT and SAT quality in this group., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study was undertaken to identify clinical factors associated with seizure freedom after magnetic resonance-guided laser interstitial thermal therapy (MRgLiTT) in temporal lobe epilepsy patients with unilateral mesial temporal sclerosis (MTS)., Methods: We identified 56 patients with magnetic resonance imaging-defined MTS who underwent MRgLiTT with at least 1 year of follow-up. Primary outcome was seizure freedom at 1 year. We examined the association of seizure freedom and the following clinical factors: age at surgery, gender, history of febrile seizures, history of focal to bilateral tonic-clonic seizures, duration of epilepsy at the time of surgery, frequency of interictal epileptiform discharges (IEDs), seizure frequency, and presence of bilateral IEDs., Results: Thirty-five (62.5%) patients were seizure-free at 1 year. The presence of bilateral IEDs and age at surgery were associated with 1-year seizure freedom after MRgLiTT. The presence of bilateral IEDS was associated with lower odds of seizure freedom (odds ratio [OR] = .05, 95% confidence interval [CI] = .01-.46, p = .008), whereas increasing age at surgery was associated with increased odds of seizure freedom (OR = 1.10, 95% CI = 1.03-1.19, p = .009)., Significance: This study demonstrates associations between presence of bilateral IEDs and age at surgery and seizure freedom at 1 year after MRgLiTT., (© 2021 International League Against Epilepsy.)

Background: Inpatient colonoscopy bowel preparation (ICBP) is frequently inadequate and can lead to adverse events, delayed or repeated procedures, and negative patient outcomes. Guidelines to overcome the complex factors in this setting are not well established. Our aims were to use health systems engineering principles to comprehensively evaluate the ICBP process, create an ICBP protocol, increase adequate ICBP, and decrease length of stay. Our goal was to provide adaptable tools for other institutions and procedural specialties., Methods: Patients admitted to our tertiary care academic hospital that underwent inpatient colonoscopy between July 3, 2017 to June 8, 2018 were included. Our multi-disciplinary team created a protocol employing health systems engineering techniques (i.e., process mapping, cause-effect diagrams, and plan-do-study-act cycles). We collected demographic and colonoscopy data. Our outcome measures were adequate preparation and length of stay. We compared pre-intervention (120 ICBP) vs. post-intervention (129 ICBP) outcomes using generalized linear regression models. Our new ICBP protocol included: split-dose 6-L polyethylene glycol-electrolyte solution, a gastroenterology electronic note template, and an education plan for patients, nurses, and physicians., Results: The percent of adequate ICBPs significantly increased with the intervention from 61% pre-intervention to 74% post-intervention (adjusted odds ratio of 1.87, p value = 0.023). The median length of stay decreased by approximately 25%, from 4 days pre-intervention to 3 days post-intervention (p value  = 0.11)., Conclusions: By addressing issues at patient, provider, and system levels with health systems engineering principles, we addressed patient safety and quality of care provided by improving rates of adequate ICBP.

Context: In vitro and in vivo evidence has supported the role of angiotensin II blockade in reducing leiomyoma cell proliferation and growth. However, no population-based study to date has investigated this potential association., Objective: This work aims to determine whether prior angiotensin-converting enzyme inhibitor (ACEi) use is associated with a reduced odds of leiomyoma development., Design: A nested case-control study was conducted., Setting: The population was assembled from the Truven Health MarketScan Research Database, which includes private health insurance claims from January 1, 2012 to December 31, 2017., Patients or Other Participants: We included (n = 353 917) women age 18 to 65 with hypertension. Cases (n = 13 108) with a leiomyoma diagnosis were matched to controls (n = 340 808) with no such diagnosis at a 1:26 ratio by age and region of origin within the United States., Intervention: Prior ACEi use was determined from outpatient drug claims., Main Outcome Measure: Leiomyoma development was indicated by a first-time diagnosis code., Results: Women on an ACEi experienced a 31.8% reduced odds of developing clinically recognized leiomyoma compared to nonusers (odds ratio [OR] 0.68; 95% CI, 0.65-0.72). This association was significant for each age group: 30 to 39 years (OR 0.86; 95% CI, 0.74-0.99), 40 to 49 years (OR 0.71; 95% CI, 0.66-0.76), 50 to 59 years (OR 0.63; 95% CI, 0.58-0.69), and 60 to 65 years (OR 0.58; 95% CI, 0.50-0.69). Of the ACEis, lisinopril (OR 0.67; 95% CI, 0.64-0.71), quinapril (OR 0.62; 95% CI, 0.41-0.92), and ramipril (OR 0.35; 95% CI, 0.23-0.50) demonstrated a significant association with reduced leiomyoma incidence., Conclusions: ACEi use was associated with a reduced odds of developing clinically recognized leiomyoma in adult hypertensive women., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The Three Delays Model has been commonly used to understand and prevent maternal mortality but has not been systematically applied to emergency medical conditions more generally. The objective of this study was to identify delays in emergency medical care seeking and delivery in rural Bangladesh and factors contributing to these delays by using the Three Delays Model as a framework., Design: A qualitative approach was used. Data were collected through focus group discussions and in-depth interviews using semistructured guides. Two analysts jointly developed a codebook iteratively and conducted a thematic analysis to triangulate results., Setting: Six unions in Raiganj subdistrict of Bangladesh., Participants: Eight focus group discussions with community members (n=59) and eight in-depth interviews with healthcare providers., Results: Delays in the decision to seek care and timely receipt of care on reaching a health facility were most prominent. The main factors influencing care-seeking decisions included ability to recognise symptoms and decision-making power. Staff and resource shortages and lack of training contributed to delays in receiving care. Delay in reaching care was not perceived as a salient barrier. Both community members and healthcare providers expressed interest in receiving training to improve management of emergency conditions., Conclusions: The Three Delays Model is a practical framework that can be useful for understanding barriers to emergency care and developing more tailored interventions. In rural Bangladesh, training community members and healthcare providers to recognise symptoms and manage acute conditions can reduce delays in care seeking and receiving adequate care at health facilities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Olfactory dysfunction has been well documented in individuals with temporal lobe epilepsy, but its use in presurgical planning has yet to be examined. We assessed the role of preoperative odor identification in mesial onset seizure localization utilizing stereoelectroencephalography (S-EEG) and magnetic resonance-guided laser interstitial thermal therapy (MRgLiTT) outcome., Methods: We identified 30 patients who had typical seizures captured during S-EEG monitoring or MRgLiTT of mesial temporal structures (n = 17 S-EEG, n = 13 MRgLiTT); seizure onset zone was classified as unilateral mesial seizure onset, or multifocal with unilateral mesial onset and nonmesial onset. Odor identification ability was assessed using the Sniffin' Sticks Odor Identification Test (SSOIT). Patients also completed measures of confrontation naming and auditory-verbal learning/memory using the Boston Naming Test and Hopkins Verbal Learning Test-Revised, respectively., Results: Overall, patients with intractable focal epilepsy exhibited poor olfactory performance (median [M] = 10.4, interquartile range [IQR] = 9.4-11.8). Of 19 patients who underwent MRgLiTT, 10 patients (52.6%) were seizure-free at last follow-up (M = 13 months, IQR =10-18). Patients who were seizure-free after MRgLiTT (n = 10) had poorer odor identification scores (M = 9, IQR = 7-13) compared to patients with seizure reoccurrence (M = 13, IQR = 12.5-15). Odor identification score was inversely associated with seizure freedom, with odds ratio = 0.60 (95% confidence interval [CI] = 0.38-0.95, P = .03). Receiver operating characteristic analysis revealed that an SSOIT score of 12 was the ideal cutoff for predicting favorable seizure outcome (area under the curve = 0.84, 95% CI = 0.64-1.0). Sensitivity was 88.9% and specificity was 78.9%, with a likelihood ratio of 2.9 of seizure failure in patients who had an odor identification score ≥ 12., Significance: Interictal olfactory dysfunction is commonly seen in patients with intractable focal epilepsy. Odor identification is a novel, noninvasive presurgical biomarker to distinguish who may or may not benefit from MRgLiTT of mesial temporal structures., (© 2020 International League Against Epilepsy.)

Background: The epidemic of nonmedical use of prescription opioids (NMUPOs) has been fueled in part by the availability of leftover, legitimately prescribed opioids. In children, outpatient urological procedures are among the most common surgeries performed, but data are lacking to guide appropriate postoperative opioid prescribing. The aim of this study was to compare the amount of prescribed opioid medication to the amount taken for acute pain after minor pediatric urological surgery and to determine the disposition of excess opioid. In addition, we explored whether distinct patient characteristics and procedure type influenced opioid prescribing and consumption., Methods: Of the 139 families of pediatric patients enrolled, 115 were interviewed within 48 hours and/or 10-14 days of discharge to determine the amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid., Results: The most common procedures performed were circumcision (n = 58) and orchiopexy (n = 40). Most patients (98%) were male, and 77% were <8 years of age. All opioid prescriptions were for oxycodone dosed every 4 hours as needed (PRN). Median number of doses prescribed was 30 (interquartile range [IQR], 23-31; n = 138) for both respondents who reported doses remaining (IQR, 29-31; n = 83) and those who did not (IQR, 22-32; n = 55). Among those reporting doses remaining, median number of doses consumed was 4.2 (IQR, 0-14). Multivariable linear regression showed no significant association between doses consumed and patient age, type of procedure, discharge pain score, or use of adjuvant analgesics. Median duration of opioid therapy was 2 days (IQR, 0-5; n = 83) with each additional day of opioid use corresponding to an average increase in consumption of 2.3 doses (95% confidence interval [CI], 1.8-2.8). An estimated 75% (95% CI, 69%-81%) of opioid dispensed was not consumed, and 86% (72/83) of patients took ≤18 doses. Forty-four of 65 (68%) families reported receiving no disposal instructions for leftover opioid, and only 7 families disposed of leftover medication., Conclusions: For minor pediatric urological surgeries in young boys, a 3-day supply (18 doses) of opioid was sufficient to adequately treat acute postoperative pain in most patients. Adjusting opioid dispensing to align with consumption and better educating patients and families on opioid disposal can be used to potentially decrease availability of leftover opioids in homes and communities.

Background: The aim of this study was to compare health workers knowledge and skills competencies between those trained using the onsite simulation-based, low-dose, high frequency training plus mobile mentoring (LDHF/m-mentoring) and the ones trained through traditional offsite, group-based training (TRAD) approach in Kogi and Ebonyi states, Nigeria, over a 12-month period., Methods: A prospective cluster randomized controlled trial was conducted by enrolling 299 health workers who provided healthcare to mothers and their babies on the day of birth in 60 health facilities in Kogi and Ebonyi states. These were randomized to either LDHF/m-mentoring (intervention, n = 30 facilities) or traditional group-based training (control, n = 30 facilities) control arm. They received Basic Emergency Obstetrics and Newborn Care (BEmONC) training with simulated practice using anatomic models and role-plays. The control arm was trained offsite while the intervention arm was trained onsite where they worked. Mentorship was done through telephone calls and reminder text messages. The multiple choice questions (MCQs) and objective structured clinical examinations (OSCEs) mean scores were compared; p-value < 0.05 was considered statistically significant. Qualitative data were also collected and content analysis was conducted., Results: The mean knowledge scores between the two arms at months 3 and 12 post-training were equally high; no statistically significant differences. Both arms showed improvements in composite scores for assessed BEmONC clinical skills from around 30% at baseline to 75% and above at end line (p < 0.05). Overall, the observed improvement and retention of skills was higher in intervention arm compared to the control arm at 12 months post-training, (p < 0.05). Some LDHF/m-mentoring approach trainees reported that mentors' support improved their acquisition and maintenance of knowledge and skills, which may have led to reductions in maternal and newborn deaths in their facilities., Conclusion: The LDHF/m-mentoring intervention is more effective than TRAD approach in improving health workers' skills acquisition and retention. Health care managers should have the option to select the LDHF/m-mentoring learning approach, depending on their country's priorities or context, as it ensures health workers remain in their place of work during training events thus less disruption to service delivery., Trial Registration: The trial was retrospectively registered on August 24, 2017 at ClinicalTrials.Gov: NCT03269240.

Plasmodium sporozoites are the infective stage of the malaria parasite. Though this is a bottleneck for the parasite, the quantitative dynamics of transmission, from mosquito inoculation of sporozoites to patent blood-stage infection in the mammalian host, are poorly understood. Here we utilize a rodent model to determine the probability of malaria infection after infectious mosquito bite, and consider the impact of mosquito parasite load, blood-meal acquisition, probe-time, and probe location, on infection probability. We found that infection likelihood correlates with mosquito sporozoite load and, to a lesser degree, the duration of probing, and is not dependent upon the mosquito's ability to find blood. The relationship between sporozoite load and infection probability is non-linear and can be described by a set of models that include a threshold, with mosquitoes harboring over 10,000 salivary gland sporozoites being significantly more likely to initiate a malaria infection. Overall, our data suggest that the small subset of highly infected mosquitoes may contribute disproportionally to malaria transmission in the field and that quantifying mosquito sporozoite loads could aid in predicting the force of infection in different transmission settings., Competing Interests: The authors have no competing interests.

Background: Airway obstruction remains a preventable cause of death on the battlefield. Surgical cricothyroidotomy is an essential skill for immediate airway management in trauma. Training for surgical cricothyroidotomy has been undertaken using simulators, cadavers or animal models. The ideal approach to training for this low volume and high-risk procedure is unknown. We hypothesized that current simulation technology provides an equal or better education for surgical cricothyroidotomy when compared with animal tissue training., Methods: We performed a prospective randomized controlled study comparing training for surgical cricothyroidotomy using hands-on training on swine versus inanimate manikin. We enrolled medical students who had never performed or had formal instruction on surgical cricothyroidotomy. We randomized their instruction to use either a swine model or the inanimate version of the Operative Experience Inc. advanced surgical manikin. Participants' skills were then evaluated on human cadavers and on an advanced robotic manikin. Tests were scored using checklists modified from Objective Structured Assessment of Technical Skills and Tactical Combat Casualty Care. We compared scores between the groups using Wilcoxon rank sum tests and generalized linear models., Results: Forty-eight participants were enrolled and trained; 30 participants completed the first testing session; 25 completed the second testing session. The mean time to establish an airway from the incision until the cuff was blown up was 95±52 s. There were no significant differences in any of the outcome measures between the two training groups., Discussion: Measured performance was not different between subjects trained to perform surgical cricothyroidotomy on an animal model or a high fidelity manikin. The use of an advanced simulator has the potential to replace live tissue for this procedure mitigating concerns over animal rights., Levels of Evidence: I., Competing Interests: Competing interests: VP has received two research grants from National Institutes of Health. The first grant is through the Nursing Institute of Nursing Research to assess symptoms and screen for laryngeal injury postextubation in intensive care unit settings (R01NR017433-01A1). The second grant is funded through the National Institute of Aging to evaluate the effectiveness of a novel arm restraint for intubated patients with cognitive impairment to reduce agitation, sedation and immobility (R42AG059451). ERH is/was primary investigator of contracts from PCORI entitled 'Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology' (CE-12-11-4489) and 'Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis' (DI-1603-34596). ERH is primary investigator of a grant from the Agency for Healthcare Research and Quality (1R01HS024547) entitled 'Individualized Performance Feedback on Venous Thromboembolism Prevention Practice' and is a coinvestigator on a grant from the National Institute of Health/National Heart, Lung, and Blood Institute (R21HL129028) entitled 'Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis'. ERH is supported by a contract from The Patient-Centered Outcomes Research Institute (PCORI), 'A Randomized Pragmatic Trial Comparing the Complications and Safety of Blood Clot Prevention Medicines Used in Orthopedic Trauma Patients' (PCS-1511-32745). ERH receives royalties from Lippincott, Williams, Wilkins for a book 'Avoiding Common ICU Errors'. ERH was the paid author of a paper commissioned by the National Academies of Medicine titled 'Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making', which was used to support the report titled 'A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury'., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Racial disparities are common in healthcare. Venous thromboembolism (VTE) is a leading cause of preventable harm, and disparities observed in prevention practices. We examined the impact of a patient-centered VTE education bundle on the non-administration of preventive prophylaxis by race., Methods: A post-hoc, subset analysis (stratified by race) of a larger nonrandomized trial. Pre-post comparisons analysis were conducted on 16 inpatient units; study periods were October 2014 through March 2015 (baseline) and April through December 2015 (post-intervention). Patients on 4 intervention units received the patient-centered, nurse educator-led intervention if the electronic health record alerted a non-administered dose of VTE prophylaxis. Patients on 12 control units received no intervention. We compared the conditional odds of non-administered doses of VTE prophylaxis when patient refusal was a reason for non-administration, stratified by race., Results: Of 272 patient interventions, 123 (45.2%) were white, 126 (46.3%) were black, and 23 (8.5%) were other races. A significant reduction was observed in the odds of non-administration of prophylaxis on intervention units compared to control units among patients who were black (OR 0.61; 95% CI, 0.46-0.81, p<0.001), white (OR 0.57; 95% CI, 0.44-0.75, p<0.001), and other races (OR 0.50; 95% CI, 0.29-0.88, p = 0.015)., Conclusion: Our finding suggests that the patient education materials, developed collaboratively with a diverse group of patients, improved patient's understanding and the importance of VTE prevention through prophylaxis. Quality improvement interventions should examine any differential effects by patient characteristics to ensure disparities are addressed and all patients experience the same benefits., Competing Interests: Mr. Lau, and Drs. Streiff and Haut are supported by a grant from the AHRQ (1R01HS024547) entitled “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice,” a contract from PCORI entitled “Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis,” and a grant from the NIH/NHLBI (R21HL129028) entitled “Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis.” Mr. Lau is supported by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant and a contract (AD-1306-03980) from PCORI entitled “Patient Centered Approaches to Collect Sexual Orientation/Gender Identity Information in the Emergency Department.” Ms. Hobson has given expert witness testimony in various medical malpractice cases. Dr. Streiff has received research funding from Boehringer-Ingelheim, Janssen, Portola and Roche and consulted for Janssen and Portola and has given expert witness testimony in various medical malpractice cases. Dr. Haut is a paid consultant and speaker for the “Preventing Avoidable Venous Thromboembolism— Every Patient, Every Time” VHA/Vizient IMPERATIV® Advantage Performance Improvement Collaborative. Dr. Haut receives royalties from Lippincott, Williams, & Wilkins for a book - “Avoiding Common ICU Errors.” Dr. Haut was the paid author of a paper commissioned by the National Academies of Medicine titled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” All remaining authors report no disclosures. All other authors report no disclosures. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages ("nudges") that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors., Methods/design: In total, 40 young adults who are African-American, aged 18-24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group ("comparison") will receive text messages with information on job openings. The second group ("experimental") will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention., Discussion: This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population., Trial Registration: ClinicalTrials.gov, NCT03766165 . Registered on 4 December 2018.

Postpartum depression is a serious illness affecting up to 15% of women worldwide after childbirth, and our understanding of its biology is limited. Postpartum anxiety is perhaps more prevalent and less understood. Prior studies indicate that allopregnanolone, a metabolite of progesterone, may play a role in reproductive mood disorders, including postpartum depression, but the exact nature of that role is unclear. Our own prior study in a group of psychiatrically ill women found that low allopregnanolone in the second trimester predicted the development of postpartum depression. In the present study, in both healthy and mood- and anxiety-disordered women who remained well throughout the perinatal period, we found that second trimester allopregnanolone predicted postpartum anxiety symptoms, with a similar trend toward the prediction of postpartum depressive symptoms (though without statistical significance). Both concurrent sleep and prior histories of mood and anxiety disorders contributed to the variance in mood and anxiety scores at 6 weeks postpartum. These findings confirm the importance of pregnancy allopregnanolone in postpartum psychiatric symptoms and point to future directions that may determine other important contributing factors.