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Home health aides (HHAs) are a vital workforce essential to meet the complex care needs of the persons living with dementia (PLWD) who remain at home. Care plans for PLWD in the home healthcare setting should incorporate HHAs perspectives. We sought to understand HHAs’ perspectives about their information needs in caring for PLWD, from June to August 2020, semi-structured interviews telephone interviews (n = 25) with English and Spanish-speaking HHAs with limited English proficiency in the New York metropolitan area. Interviews were audio-recorded, transcribed verbatim and transcripts were analyzed using conventional content analysis. Four key themes emerged reflective of information needs of HHAs caring for PLWD: (1) ambiguities of scope of HHA tasks related to medication management; (2) clinical information needs of HHAs; (3) dementia-related concerns; and (4) going above and beyond. Findings from this research can guide efforts to develop dementia-specific care plans, and training to support the HHA workforce caring for the growing population of PLWD.

Suicide is the second leading cause of death among adolescents in the U.S., and risk factors include child maltreatment (CM), especially physical and emotional abuse, and in-home firearm availability ('availability'). However, research examining availability among adolescent populations at-risk for CM is limited. This study examines availability in this population, the association between CM and availability, and availability among adolescents experiencing suicidal ideation. A multivariable modified Poisson regression model assessed the relationship between CM by age 12 and availability at age 14 using data from the Longitudinal Studies of Child Abuse and Neglect (n = 1,354 families). Approximately 11.61% of adolescents reported availability, and physical abuse increased the risk of availability (aRR = 1.94; 95% CI [1.22, 3.08]). Over one-quarter (27.50%) of adolescents with suicidal ideation at age 16 reported availability. Child welfare-involved families are often referred to interventions. Future research and prevention efforts should explore augmentation of these programmes with firearm safe storage guidance.

The authors present a new approach to show how interdisciplinary collaborations among a group of institutions can provide a unique opportunity for students to engage across the science-policy nexus using the framework of the Sustainable Development Goals and the United Nations Framework Convention on Climate Change. Through collaboration across seven higher education institutions in the United States and Australia, virtual student research teams worked together across disciplines.

Millions of older Americans receive nurse practitioner (NP)-provided home based primary care (HBPC). Little is known about how state scope-of- practice (SOP) laws may impact use of NP-home visits. Using 2017 Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File (PUF), we examined the impact of state SOP laws on the use of NP-home visits. The PUF file was merged with the 2017 American Community Survey to assess area-level median income. Over 4.4 million home visits were provided to 1.6 million Medicare beneficiaries. NPs represented the largest share of providers (47.5%). In states with restricted SOP laws, compared to NPs, physicians and physician assistants had higher odds of providing HBPC. In states with reduced SOP laws, compared to NPs, physicians and PAs had decreased odds of providing HBPC. Our study provides evidence that SOP restrictions are associated with decreased utilization of NP-provided HBPC.

Neurons of the enteric nervous system (ENS) have limited regenerative capacity, and damage to these cells can cause neuropathies. In a recent issue of Cell, Ahrends et al. (2021) demonstrate that muscularis macrophages integrate distinct signals from diverse intestinal infections to protect ENS neurons from subsequent pathogenic insult.

Background: While pain is the hallmark of sickle cell disease (SCD), healthcare personnel are often ill-equipped to adequately treat patients who present in vaso-occlusive crisis (VOC). Although symptom severity varies from individual to individual, SCD is characterized by intervallic pain as a result of oxygen deprivation in tissues and organs. Regardless of pain severity, SCD patients are often viewed as drug seekers by healthcare personnel who have concerns regarding patient s’ dependence on opioids which may lead to addiction. The objective was to assess the types and amount of opioids used to treat VOC in comparison to Centers for Disease Control opioid prescription guidelines. Methods: Literature search was conducted using CINAHL, PubMed, the Cochrane Library, Web of Science and hand search. Data were analyzed from 1999 to 2018. Randomized trials, observational, and case studies involved hospitalized adults with SCD who were prescribed opioids to treat VOC. Quality assessment was conducted using Downs and Black checklist. Meta-analysis was not conducted. Results: Five studies were conducted in the USA, Arabia and the Netherlands, and the USA and Canada were included. Participants were treated with either morphine or morphine milligram equivalent (MME). No study used the same method of opioid administration. Conclusions: Patients with SCD who are hospitalized secondary to VOC mostly received opioids for pain well within the Centers for Disease Control and Prevention prescription guidelines. No uniform method exists. Additional research is warranted. J Hematol. 2021;10(2):46-52 doi: https://doi.org/10.14740/jh828

Summary Hepatitis C virus (HCV) infection is a major source of morbidity and mortality in the United States. HCV is transmitted primarily through parenteral exposures to infectious blood or body fluids that contain blood, most commonly through injection drug use. No vaccine against hepatitis C exists and no effective pre- or postexposure prophylaxis is available. More than half of persons who become infected with HCV will develop chronic infection. Direct-acting antiviral treatment can result in a virologic cure in most persons with 8–12 weeks of all-oral medication regimens. This report augments (i.e., updates and summarizes) previously published recommendations from CDC regarding testing for HCV infection in the United States (Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. MMWR Recomm Rec 2012;61[No. RR-4]). CDC is augmenting previous guidance with two new recommendations: 1) hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of HCV infection is

Importance Black and Hispanic individuals experience poorer outcomes related to coronavirus disease (COVID-19), yet have alarmingly lower uptake of the COVID-19 vaccine compared to non-Hispanic White individuals. Objective To explore the perceptions of barriers and facilitators of COVID-19 vaccine acceptance among Black and Hispanic adults in the New York. Design, Setting, and Participants A qualitative study consisting of one-on-one semi-structured interviews with Black and/ or Hispanic adults in New York state was conducted. Participants were recruited from local businesses, community-based social service agencies and Black and Hispanic churches and a college. All data were collected between February and March 2021. Transcripts were analyzed using qualitative thematic analysis. Results A total of 50 individuals (32[64%] women; mean [SD] age, 42.04[15.99] years) participated. The majority of participants identified as Black (n=34, 68%), 9 (18%) identified as Hispanic, 3(6%) as Black and Hispanic, and 4(8%) as White and Hispanic. Twenty-two participants (44%) had high-school level education or less. Mistrust emerged as a central barrier to COVID-19 vaccine acceptance. Facilitators of effective COVID-19 vaccine messages include a) key informants: like me, b) personalized community outreach, c) present the facts, and d) communicate across multiple media platforms. Conclusions and Relevance This qualitative study found that among Black and Hispanic participants, receipt of reliable vaccine related information, social networks, seeing people like themselves receive the vaccination, and trusted doctors are key drivers of vaccine acceptance.

Currently, there is minimal guidance to antiepileptic dose adjustment for a patient requiring either venoarterial (VA) extracorporeal membrane oxygenation (ECMO) or plasma exchange (PLEX) therapy, and to our knowledge, there are rare guidances for a patient requiring both. Given the dangers with non-therapeutic concentrations of phenytoin, it is critical for the intensive care unit (ICU) practitioner to understand how the pharmacokinetic parameters of phenytoin change in critically ill patients requiring extracorporeal support. This case study presents a 41-year-old female transferred to the cardiovascular ICU requiring VA ECMO and PLEX for the treatment of systemic lupus erythematosus (SLE)-induced catastrophic antiphospholipid syndrome (CAPS). Free phenytoin concentrations were measured to assess the removal of phenytoin. There was no significant decrease in the free phenytoin concentrations post-PLEX and while on ECMO. Free phenytoin concentrations are not influenced in the setting of PLEX and while on ECMO.

Helminthic worms are ancestral members of the intestinal ecosystem that have been largely eradicated from the general population in industrialized countries. Immunomodulatory mechanisms induced by some helminths mediate a “truce” between the mammalian host and the colonizing worm, thus allowing for long-term persistence in the absence of immune-mediated collateral tissue damage. This concept and the geographic discrepancy between global burdens of chronic inflammatory diseases and helminth infection have sparked interest in the potential of using helminthic worms as a therapeutic intervention to limit the progression of autoimmune diseases such as multiple sclerosis (MS). Here, we present and evaluate the evidence for this hypothesis in the pre-clinical animal model of MS, experimental autoimmune encephalitis, in helminth-infected MS patients and in clinical trials of administered helminth immunotherapy (HIT).

CME/CNE Information To access the article, post-test, and evaluation online, go to http://www.cmscscholar.org.Activity Available Online: The target audience for this activity is physicians, physician assistants, nursing professionals, and other health care providers involved in the management of patients with multiple sclerosis (MS).Target Audience: Learning Objectives: Accreditation Statement: In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Delaware Media Group. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The CMSC designates this journal-based activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Physician Credit: The CMSC designates this enduring material for 1.0 contact hour (none in the area of pharmacology).Nurse Credit: Editor in Chief of the International Journal of MS Care (IJMSC), has served as Physician Planner for this activity. He has disclosed relationships with Springer Publishing (royalty), Qr8 (receipt of intellectual property rights/patent holder), Biogen (receipt of intellectual property rights/patent holder, speakers' bureau), GW Pharma (consulting fee), and Adamas Pharmaceuticals (contracted research). Laurie Scudder, DNP, NP, has served as Reviewer for this activity. She has disclosed no relevant financial relationships. Sarah J. Donkers, PT, PhD, has disclosed no relevant financial relationships. Megan C. Kirkland, MSc, has disclosed no relevant financial relationships. Marc Charabati, BSc, has disclosed no relevant financial relationships. Lisa C. Osborne, PhD, has disclosed no relevant financial relationships. The peer reviewer for IJMSC has disclosed no relevant financial relationships. The staff at IJMSC, CMSC, and Delaware Media Group who are in a position to influence content have disclosed no relevant financial relationships. Note: Financial relationships for some authors may have changed in the interval between listing these disclosures and publication of the article.Disclosures: Francois Bethoux, MD, Method of Participation: Release Date: February 1, 2020 Valid for Credit Through: February 1, 2021 In order to receive CME/CNE credit, participants must: Statements of Credit are awarded upon successful completion of the post-test with a passing score of >70% and the evaluation. There is no fee to participate in this activity. This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. CMSC and Delaware Media Group do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of CMSC or Delaware Media Group.Disclosure of Unlabeled Use: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health-care professionals without first evaluating their patients' conditions, considering possible contraindications or risks, reviewing any applicable manufacturer's product information, and comparing any therapeutic approach with the recommendations of other authorities.Disclaimer

Background The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies. Objective To determine if motor weakness and patient-reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months. Design Prospective observational cohort. Setting Outpatient academic spine practice. Participants Adults with acute radicular weakness due to disk herniation. Methods Forty patients with radiculopathy and strength deficit were followed over a 12-month period. Objective strength and performance tests as well as survey-based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado. Main outcome measurements Testing of strength was through MMT, handheld dynamometer, and performance-based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) were used to measure pain and disability outcomes. Results Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty-four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R-C]), and 9 (22%) did not have surgery and lacked at least one follow-up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R-I]). No statistically significant differences were found on baseline measures of strength deficits and SF-36 domains between the CPM&R-C, Surgery, and CPM&R-I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R-C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12-month follow-up to baseline in the CPM&R-C group. Conclusions Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year. Level of evidence II.

Hospital readmission is common after ileostomy formation and frequently associated with dehydration.This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission.This is a randomized controlled trial.This study was conducted in 3 hospitals within a single health care system.Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected.Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care.Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured.One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar.This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care.A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at http://links.lww.com/DCR/A812.

Introduction Sepsis is a complex, life-threatening condition, posing a significant burden to both NHS resources and society in general. Bacteraemia is a common presentation in surgical pathology and requires prompt investigation and treatment. Blood cultures remain the gold standard for detecting bacteraemia and providing targeted antibiotic therapy. We aimed to improve the overall use of blood cultures in pyrexial surgical patients. Method A three-loop, prospective quality improvement project was performed. Patients identified as being pyrexial were reviewed to determine when it was recorded and whether blood cultures were taken. Following a departmental presentation, two further audit cycles were performed at two months and seven months post-intervention to determine long-term response. Result A total of 56 patients were included over the three audit cycles. Blood culture adherence improved from 58.7% at baseline to 65% at 7 months. Most notably, out-of-hours compliance improved from 44.4% to 66.6%. 2-month compliance was 85%, however, this comprised of only 7 patients. Conclusions Early recognition and management of sepsis remains a key area of improvement. Whilst overall and out-of-hour blood culture compliance improved, continued education is needed to further increase this.

Background Despite their integral role, Home Health Aides (HHAs) are largely unrecognized as essential to implementing effective infection prevention and control practices in the home healthcare setting. We sought to understand the infection prevention and control needs and challenges associated with caring for patients during the pandemic from the perspective of HHAs. Methods From June to August 2020, data were collected from HHAs in the New York metropolitan area using semi-structured qualitative interviews by telephone; 12 HHAs were interviewed in Spanish. Audio-recorded interviews were transcribed, translated and analyzed using conventional content analysis. Results In total, 25 HHAs employed by 4 unique home care agencies participated. HHAs had a mean age of 49.8 (± 9.1), 24 (97%) female, 11 (44%) Black, 12 (48%) Hispanic. Three major themes related to the experience of HHA's working during the COVID-19 pandemic emerged: (1) all alone, (2) limited access to information and resources, and (3) dilemmas related to enhanced COVID-19 precautions. Hispanic HHAs with limited English proficiency faced additional difficulties related to communication. Conclusions We found that HHA communication with nursing staff, plays a key role in infection control efforts in home care. Efforts to manage COVID-19 in home care should include improving communication between HHAs and nursing staff.

Examining media coverage of what women tennis players from different places around the world wear—from the staid to the outlandish—to offering insights into media discourses about female athletes as ornamental.

Introduction Approximately 10% to 15% of people affected by sickle cell disease (SCD) in the United States are Latino, many of whom are primary Spanish speakers. A key tool for self-reported outcome measures, the Pediatric QOL Inventory (PedsQL) SCD module, was not available in Spanish. Here, we assess the linguistic validity of a Spanish translation and compare perception of disease-specific and generic quality of life (QOL) in a sample of Latino and non-Latino children with SCD and their parents. Method Following forward and backward translation, Spanish-speaking child–parent dyads linguistically validated the translated instruments. Disease-specific and generic QOL perception of 28 child–parent dyads who participated in a clinical feasibility trial, HABIT (Hydroxyurea Adherence for Personal Best in Sickle Cell Disease), were compared by ethnicity. Data were analyzed by descriptive statistics, Mann–Whitney U test, absolute score differences, and minimal clinically important differences (MCID). Results The translated questionnaire required no further language changes. QOL scores were higher for Latino children and parents compared with non-Latinos, with score differences exceeding MCIDs for total scores and the majority of subscale scores. Conclusion Spanish language PedsQL SCD instruments allow measurement of QOL in Spanish-speaking Latino children with SCD and their parents. Score differences for Latinos mostly exceeded MCIDs, suggesting that these differences are clinically meaningful. Confirmation of these findings is warranted.

Substance use is strongly associated with suicide completions. However, little is known about the patterns of substances used in suicide deaths. The purpose of this analysis is to determine latent classes of toxicology-reported substances among individuals who completed suicide. The sample consists of suicide victims in the National Violent Death Reporting System (NVDRS) during years 2003–2017 (n = 202,838). Toxicology reports were used to construct latent class analyses of substance use among suicide victims. Correlates for latent class membership included sex, race/ethnicity, previous experiences of child abuse, homelessness, and intimate partner violence (IPV) victimization. The majority of suicide victims were male (77.7%), straight/heterosexual (99.5%) and white (88.3%). The final unconditional model yielded a four-class model, including a “No substance/single substance use” class, an “Alcohol and other substance” class, a “Marijuana and other substance” class, and an “Opiate use” class. Compared to the reference class of “No substance/single substance,” females were more likely than males to be classified in the “Alcohol and other substance” class, the “Multi-substance use” class, and the “Opiate use” class. Homelessness was associated with classification in the “Marijuana and other substance” class and the “Opiate use” class compared to the “No substance/single substance” class. IPV was associated with both polysubstance use classes (“Alcohol plus other substance” and “Marijuana plus other substance”) along with the “Opiate use” class compared to the “No substance/single substance” class. These classes highlight profiles of suicide descendants and emphasize the importance of polysubstance use prevention among females, homeless individuals, and those who experience IPV.

Objectives Suicide is the second leading cause of death among adolescents in the United States, and a substantial proportion are committed with a firearm. This study identifies risk patterns among adolescent firearm suicides and examines how demographic factors relate to these patterns. Methods A latent class analysis was conducted using US National Violent Death Reporting System data, years 2007–2017. Adolescent firearm suicide decedents ages 10–17 years were included in the primary analyses (n = 2139). Factors used to identify risk patterns fell under the categories of mental health, relationship or other social problems, and substance use. Demographic factors examined in relation to risk patterns were age, race/ethnicity, and sex. Results Three risk patterns emerged: low problems (i.e., a low probability of all risk factors included in the model; n = 1075; 50.26%); high mental health problems and history of suicidal behavior, ideation, and suicide attempts (n = 742, 34.69%); and high problems at school (n = 322, 15.05%). Compared to White adolescents, Black adolescents had decreased odds of being in the “high mental health and suicidal behavior” class, compared to being in the “low problems” class (AOR, 0.53, 95% CI: 0.36, 0.79). A post hoc analysis identified four risk patterns for non-firearm suicides (n = 3319), with mental health problems featuring more prominently compared to firearm suicide patterns. Conclusions Findings indicate that half of adolescent firearm suicides are characterized by a low probability of having common risk factors for suicide. This emphasizes the importance of universal safe storage practices among firearm-owning parents. Results also indicate a need for more research on the risk factors unique to Black adolescents.

Introduction The introduction of biological and synthetic meshes has revolutionised the practice of implant-based breast reconstruction (IBBR) but evidence for effectiveness is lacking. The iBRA (implant Breast Reconstruction evAluation) study is a national trainee-led project that aims to explore the practice and outcomes of IBBR to inform the design of a future trial. We report the results of the iBRA National Practice Questionnaire (NPQ) which aimed to comprehensively describe the provision and practice of IBBR across the UK. Methods A questionnaire investigating local practice and service provision of IBBR developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Summary data for each survey item were calculated and variation between centres and overall provision of care examined. Results 81 units within 79 NHS-hospitals completed the questionnaire. Units offered a range of reconstructive techniques, with IBBR accounting for 70% (IQR:50–80%) of participating units' immediate procedures. Units on average were staffed by 2.5 breast surgeons (IQR:2.0–3.0) and 2.0 plastic surgeons (IQR:1.0–3.0) performing 35 IBBR cases per year (IQR:20-50). Variation was demonstrated in the provision of novel different techniques for IBBR especially the use of biological (n = 62) and synthetic (n = 25) meshes and in patient selection for these procedures. Conclusions The iBRA-NPQ has demonstrated marked variation in the provision and practice of IBBR in the UK. The prospective audit phase of the iBRA study will determine the safety and effectiveness of different approaches to IBBR and allow evidence-based best practice to be explored., Highlights • Implant breast reconstruction (IBBR) and the range of techniques is poorly evidence based. • We aimed to explore the current practice of IBBR in the UK to inform the design of a future definitive study. • Significant variation was demonstrated in the availability of techniques and patient selection for IBBR. • There is a need for well-designed studies to establish best practice and improve outcomes for patients considering IBBR.

Child maltreatment has long-lasting negative impacts, and interventions are needed to improve caregiver's parenting skills to prevent maltreatment. This paper reports on a randomized trial comparing the SafeCare© model to services as usual (SAU) for child-welfare referred caregivers. SafeCare is an 18-session behavioral parenting program that teaches skills in positive parent-child interactions, home safety, and child health. SAU is generally unstructured and includes support, crisis management, referrals for need, and parenting education. Teams of providers at nine sites were randomized to implement SafeCare (19 teams; 119 providers) or continue SAU (17 teams; 118 providers). Two-hundred eighty eight caregivers (193 SafeCare; 95 SAU) with children aged 0–5 who were receiving services agreed to complete a baseline and 6-month assessment. Assessments measured positive parenting behaviors, parenting stress, protective factors, and neglectful behaviors using validated scales. Participants were primarily white (74.6%), female (87.0%), and low-income (68.6%), and had a mean age of 29. Latent change score models (LCSM) using a sandwich estimator consistent with the trial design were used to examine changes in 13 outcomes. Results indicated that SafeCare had small to medium effects for improving several parenting outcomes including supporting positive child behaviors (d = 0.46), proactive parenting (d = 0.25), and two aspects of parenting stress (d = 0.28 and .30). No differential change between groups was found for other indicators, including all indicators of neglect. Parenting programs such as SafeCare offer a promising mode of intervention for child welfare systems. Scale-up of parenting programs can improve parenting, improve child outcomes, and potentially reduce maltreatment. Clinicaltrial.gov registration number NCT02549287

BACKGROUND: We examined the prevalence of and relationships between violence victimization and negative health correlates of Haitian youth exposed to the 2010 earthquake. METHODS: Participants were randomly selected 13–24 year-old youth (1457 females; 1459 males) living in Haiti following the 2010 earthquake. Data collected via Haiti’s 2012 Violence against Children Survey (VACS) were analyzed. RESULTS: Participants reported violence victimization in the past 12 months (females: 49.93%; males: 41.68%), moderate-to-severe mental distress (females: 76.56%; males: 66.41%), and suicidal ideation (females: 26.79%; males: 8.05%). Compared to participants without experiences of violence, victims of violence had significantly higher mean number of sexual partners (females: 1.99, 95% CI: 1.81–2.16, p = .02; males: 4.33, 95% CI: 3.50–5.16, p = .03), mental distress (females: 80.39%, p = .01; males: 72.95%, p = .002), and suicidal ideation (females: 36.09%, p < .0001; males: 12.02%, p < .0001). Male victims of violence were more likely to have sex without a condom (26.02%, p = .01) and female victims of violence were more likely to report histories of STIs (28.04%, p = .01), when compared to participants without history of violence. LIMITATIONS: Data were collected via self-report. Disaster exposure experiences were not assessed. Analysis was correlational and did not control for potential confounding variables. CONCLUSIONS: Disaster-exposed youth endorsed high levels of violence victimization and negative health correlates. Earthquake survivors who experienced violence were more likely to report negative health correlates. Greater attention to downstream sequelae of natural disasters is needed.

Undifferentiated febrile illnesses present diagnostic and treatment challenges in the Firm Base, let alone in the deployed austere environment. We report a series of 14 cases from Operation TRENTON in South Sudan in 2017 that coincided with the rainy season, increased insect numbers and a Relief in Place. The majority of patients had headaches, myalgia, arthralgia and back pain, as well as leucopenia and thrombocytopenia. No diagnoses could be made in theatre, despite a sophisticated deployed laboratory being available, and further testing in the UK, including next-generation sequencing, was unable to establish an aetiology. Such illnesses are very likely to present in tropical environments, where increasing numbers of military personnel are being deployed, and clinicians must be aware of the non-specific presentation and treatment, as well as the availability of Military Infection Reachback services to assist in the management of these cases.

Despite the enduring interest in motion integration, a direct measure of the space–time filter that the brain imposes on a visual scene has been elusive. This is perhaps because of the challenge of estimating a 3D function from perceptual reports in psychophysical tasks. We take a different approach. We exploit the close connection between visual motion estimates and smooth pursuit eye movements to measure stimulus–response correlations across space and time, computing the linear space–time filter for global motion direction in humans and monkeys. Although derived from eye movements, we find that the filter predicts perceptual motion estimates quite well. To distinguish visual from motor contributions to the temporal duration of the pursuit motion filter, we recorded single-unit responses in the monkey middle temporal cortical area (MT). We find that pursuit response delays are consistent with the distribution of cortical neuron latencies and that temporal motion integration for pursuit is consistent with a short integration MT subpopulation. Remarkably, the visual system appears to preferentially weight motion signals across a narrow range of foveal eccentricities rather than uniformly over the whole visual field, with a transiently enhanced contribution from locations along the direction of motion. We find that the visual system is most sensitive to motion falling at approximately one-third the radius of the stimulus aperture. Hypothesizing that the visual drive for pursuit is related to the filtered motion energy in a motion stimulus, we compare measured and predicted eye acceleration across several other target forms.SIGNIFICANCE STATEMENTA compact model of the spatial and temporal processing underlying global motion perception has been elusive. We used visually driven smooth eye movements to find the 3D space–time function that best predicts both eye movements and perception of translating dot patterns. We found that the visual system does not appear to use all available motion signals uniformly, but rather weights motion preferentially in a narrow band at approximately one-third the radius of the stimulus. Although not universal, the filter predicts responses to other types of stimuli, demonstrating a remarkable degree of generalization that may lead to a deeper understanding of visual motion processing.

When engaging with ethnographic research to understand symbols associated with a club and its fan base, researchers need to reflect on the role of the ethnographer and the extent to which we can or...

Background Family-based behavioral therapy is an efficacious approach to deliver weight management counseling to children and their parents. However, most families do not have access to in-person, evidence-based treatment. We previously developed and tested DRIVE (Developing Relationships that Include Values of Eating and Exercise), a home-based parent training program to maintain body weight among children at risk for obesity, with the intent to eventually disseminate it nationally alongside SafeCare, a parent support program that focuses on parent-child interactions. Currently the DRIVE program has only been tested independently of SafeCare. This study created the “mHealth DRIVE” program by further adapting DRIVE to incorporate digital and mobile health tools, including remotely delivered sessions, a wireless scale that enabled a child-tailored weight graph, and a pedometer. Telehealth delivery via mHealth platforms and other digital tools can improve program cost-effectiveness, deliver long-term care, and directly support both families and care providers. Objective The objective of this study was to examine preliminary acceptability and effectiveness of the mHealth DRIVE program among children and parents who received it and among SafeCare providers who potentially could deliver it. Methods Study 1 was a 13-week pilot study of a remotely delivered mHealth family-based weight management program. Satisfaction surveys were administered, and height and weight were measured pre- and post-study. Study 2 was a feasibility/acceptability survey administered to SafeCare providers. Results Parental and child satisfaction (mean of 4.9/6.0 and 3.8/5.0, respectively) were high, and children’s (N=10) BMI z-scores significantly decreased (mean –0.14, SD 0.17; P=.025). Over 90% of SafeCare providers (N=74) indicated that SafeCare families would benefit from learning how to eat healthily and be more active, and 80% of providers reported that they and the families would benefit from digital tools to support child weight management. Conclusions Pediatric mHealth weight management interventions show promise for effectiveness and acceptability by families and providers. Trial Registration Clinicaltrials.gov NCT03297541, https://clinicaltrials.gov/ct2/show/NCT03297541.

Knowledge surrounding the trillions of microbes that inhabit the human gut has bloomed exponentially in recent years, and the emerging concept of a gut-brain axis represents a major shift in how we think about neurological health. A recent workshop at the University of British Columbia, Canada brought together multi-disciplinary leaders in the field of microbiomics and brain health and aimed to serve as a springboard for future combined endeavors in these areas. This article provides the motivation for, and overview of, the workshop, and the next steps in establishing a cross-disciplinary initiative on Brain Health and the Microbiome.

BACKGROUND: Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques.METHODS: In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281.FINDINGS: Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (INTERPRETATION: Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction.FUNDING: National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Background: Children are a vulnerable population following a natural disaster, due to their age and dependence on adults. The primary presenting problem children report after disasters is posttraumatic stress symptoms (PTSS). Prior research suggests that PTSS is inversely related to social support, which is often disrupted after a disaster. Objective: This study examined the relationship between social support (from parents, teachers, and peers) and PTSS in children affected by Hurricane Katrina. The research contributes to the literature by examining the mechanisms that drive this relationship over time. Methods: In this study, 426 children were followed over four timepoints, beginning 3–7 months after Hurricane Katrina and concluding 25–27 months post-hurricane. Three path models analysed the relationship between social support (from parents, teachers, and peers, measured by the Social Support Scale for Children) and PTSS (measured by the UCLA PTSD Reaction Index). Covariates included child age, minority status, gender, perceived life threat, and actual life threat. Nonsignificant paths were trimmed from the final models. Global fit indices were examined to determine model fit. Results: In the parent and peer social support models, PTSS exhibited statistically significant effects on social support from one wave to the next. In the teacher model, this was only true between Waves 2 and 3. Social support showed a statistically significant effect on PTSS between Wave 2 and Wave 3 in the peer model (standardized estimate = −0.26, p

INTRODUCTION: The 2008 National Mastectomy and Breast Reconstruction Audit demonstrated marked variation in the practice and outcomes of breast reconstruction in the UK. To standardise practice and improve outcomes for patients, the British professional associations developed best-practice guidelines with specific guidance for newer mesh-assisted implant-based techniques. We explored the degree of uptake of best-practice guidelines within units performing implant-based reconstruction (IBBR) as the first phase of the implant Breast Reconstruction Evaluation (iBRA) study.METHODS: A questionnaire developed by the iBRA Steering Group was completed by trainee and consultant leads at breast and plastic surgical units across the UK. Simple summary statistics were calculated for each survey item to assess compliance with current best-practice guidelines.RESULTS: 81 units from 79 NHS Trusts completed the questionnaire. Marked variation was observed in adherence to guidelines, especially those relating to clinical governance and infection prevention strategies. Less than half (n = 28, 47%) of units obtained local clinical governance board approval prior to offering new mesh-based techniques and prospective audit of the clinical, cosmetic and patient-reported outcomes of surgery was infrequent. Most units screened for methicillin-resistant staphylococcus aureus prior to surgery but fewer than 1 in 3 screened for methicillin-sensitive strains. Laminar-flow theatres (recommended for IBBR) were not widely-available with less than 1 in 5 units having regular access. Peri-operative antibiotics were widely-used, but the type and duration were highly-variable.CONCLUSIONS: The iBRA national practice questionnaire has demonstrated variation in reported practice and adherence to IBBR guidelines. High-quality evidence is urgently required to inform best practice.

BACKGROUND: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. METHODS: We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). RESULTS: MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89-6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. CONCLUSIONS: MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.

Background Tranexamic acid reduces blood loss and transfusion requirements in cardiac surgery but may increase the risk of coronary graft thrombosis. We previously reported the 30-day results of a trial evaluating tranexamic acid for coronary artery surgery. Here we report the 1-year clinical outcomes. Methods Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score of less than 8. Secondary outcomes included a composite of myocardial infarction, stroke, and death from any cause through to 1 year after surgery. Results The rate of death or disability at 1 year was 3.8% in the tranexamic acid group and 4.4% in the placebo group (relative risk, 0.85; 95% confidence interval, 0.64-1.13; P = .27), and this did not significantly differ according to aspirin exposure at the time of surgery (interaction P = .073). The composite rate of myocardial infarction, stroke, and death up to 1 year after surgery was 14.3% in the tranexamic acid group and 16.4% in the placebo group (relative risk, 0.87; 95% CI, 0.76-1.00; P = .053). Conclusions In this trial of patients having coronary artery surgery, tranexamic acid did not affect death or severe disability through to 1 year after surgery. Further work should be done to explore possible beneficial effects on late cardiovascular events.

An exploration of the implosion properties and X-ray radiation pulses from tungsten-based planar wire array Z-pinch experiments is presented, with an emphasis on loads mixed with aluminum. These experiments were carried out on Zebra, the 1.0 MA pulse power generator at the Nevada Terawatt Facility. A suite of diagnostics was used to study these plasmas, including X-ray and EUV Si diodes, optical imaging, laser shadowgraphy, and time-gated and time-integrated X-ray pinhole imagers and spectrometers. Specifically, loads with relatively large inter-wire gaps where tungsten is placed in the center of a planar configuration composed primarily of aluminum showed unusual characteristics. These loads are shown to generate a “bubbling” effect in which plasma from the ablation of outer aluminum wires is temporarily hindered from converging at the center of the array where the tungsten wire is located. Reproduction of these experiments with variations to load geometry, materials, and mass distribution are also presented and discussed in an attempt to better understand the phenomenon. In addition, a theoretical model has also been applied to better understand the dynamics of the implosions of these loads. Applications of this effect to radiation pulse shaping, particularly with multi-planar arrays, are also discussed.

Pruritus ani is a common condition with multiple causes. Primary causes are thought to be fecal soiling or food irritants. Secondary causes include malignancy, infections including sexually transmitted diseases, benign anorectal diseases, systemic diseases, and inflammatory conditions. A broad differential diagnosis must be considered. A reassessment of the diagnosis is required if symptoms or findings are not responsive to therapy. The pathophysiology of itching, an overview of primary and secondary causes, and various treatment options are reviewed.

PhDObjectives: Todeterminethesexandracedifferencesassociatedwithspecific congenital heart diseases (CHDs) and the patterns of con-comitant conditions associated with eight severe, complex lesions.Methods: A 15-year Medicaid dataset (1996Y2010) from one statewas analyzed for 14,496 patients aged 17 years and younger and di-agnosedashavingaCHDononeormoreservicevisitstoapediatricianor pediatric cardiologist.Results: Controlling for all other diagnosed CHDs, boys were morelikely to be diagnosed as having transposition of the great arteries, hy-poplastic left heart syndrome, aortic stenosis, and coarctation of theaorta, whereas African Americans were more likely to be diagnosed ashaving tricuspid regurgitation, atrial septal defect sinus venosus, coro-naryarteryanomaly,andpulmonarystenosis.Ventricularseptaldefects,atrialseptaldefectssecundum,patentductusarteriosus,andpulmonarystenosis were the most prevalent isolated CHDs, whereas tetralogy ofFallot,atrioventricularcanal/endocardialcushiondefect,common/singleventricle, double outlet right ventricle, and transposition of the greatarterieswerethemostprevalentsevere,complexlesions.Thecomplexityof some severe cardiac anomalies appears to be increasing over time.Conclusions: Changes over time in pediatric CHD caseload mix mayaffectcaremanagementandresultinprognosisoroutcomedifferences.These changes present important opportunities for pediatricians andpediatric cardiologists to collaborate, especially in the care of the mostsevere anomalies.Key Words: complex lesions, congenital heart disease, prevalencerates, severe lesions

We began applying laparoscopic techniques to colon and rectal surgery at the Cleveland Clinic Florida over 25 years ago. During those years, we have refined our approach and for many years have routinely employed minimally invasive techniques for proctectomy for rectal cancer. Our operative planning begins with a thorough preoperative assessment which includes a rectal cancer protocol synoptic report, pelvic MRI, and endoscopy to locally stage the tumor as well as a CT of the chest, abdomen and pelvis. All patients meet with an enterostomal therapy nurse for counseling and stoma marking as well as a colorectal nurse for preoperative education. All patients undergo a mechanical cathartic and oral and parenteral bowel prep.

Implementation of evidence-based parenting programs is critical for parents at-risk for child maltreatment perpetration; however, widespread use of effective programs is limited in both child welfare and prevention settings. This exploratory study sought to examine whether a technology-mediated approach to SafeCare® delivery can feasibly assist newly trained providers in achieving successful implementation outcomes. Thirty-one providers working in child welfare or high-risk prevention settings were randomized to either SafeCare Implementation with Technology-Assistance (SC-TA) or SafeCare Implementation as Usual (SC-IU). SC-TA providers used a web-based program during session that provided video-based psychoeducation and modeling directly to parents and overall session guidance to providers. Implementation outcome data were collected from providers for six months. Data strongly supported the feasibility of SC-TA. Further, data indicated that SC-TA providers spent significantly less time on several activit...

In the natural world, the statistics of sensory stimuli fluctuate across a wide range. In theory, the brain could maximize information recovery if sensory neurons adaptively rescale their sensitivity to the current range of inputs. Such adaptive coding has been observed in a variety of systems, but the premise that adaptation optimizes behaviour has not been tested. Here we show that adaptation in cortical sensory neurons maximizes information about visual motion in pursuit eye movements guided by that cortical activity. We find that gain adaptation drives a rapid (, Efficient coding suggests that adapting gain to match the varying stimulus statistics should help in optimizing behaviour. Here the authors show that adaptation in motion sensitive neurons maximizes information and improves movement accuracy in pursuit eye movements.

Objectives To document the quality of initial HIV care in Canada using the Programmatic Compliance Score (PCS), to explore the association of the PCS with mortality, and to identify factors associated with higher quality of care. Methods We analysed data from the Canadian Observational Cohort Collaboration (CANOC), a multisite Canadian cohort of HIV-positive adults initiating combination antiretroviral therapy (ART) from 2000 to 2011. PCS indicators of noncompliance with HIV treatment guidelines include: fewer than three CD4 count tests in the first year of ART; fewer than three viral load tests in the first year of ART; no drug resistance testing before initiation; baseline CD4 count < 200 cells/mm3; starting a nonrecommended ART regimen; and not achieving viral suppression within 6 months of initiation. Indicators are summed for a score from 0 to 6; higher scores indicate poorer care. Cox regression was used to assess the association between PCS and mortality and ordinal logistic regression was used to explore factors associated with higher quality of care. Results Of the 7460 participants (18% female), the median score was 1.0 (Q1−Q3 1.0−2.0); 21% scored 0 and 8% scored ≥ 4. In multivariable analysis, compared with a score of 0, poorer PCS was associated with mortality for scores > 1 [score = 2: adjusted hazard ratio (AHR) 1.64; 95% confidence interval (CI) 1.13–2.36; score = 3: AHR 2.02; 95% CI 1.38–2.97; score ≥ 4: AHR 2.14; 95% CI 1.43–3.21], after adjustments for age, sex, province, ART start year, hepatitis C virus (HCV) coinfection, and baseline viral load. Women, individuals with HCV coinfection, younger people, and individuals starting ART earlier (2000−2003) had poorer scores. Conclusions Our findings further validate the PCS as a predictor of all-cause mortality. Disparities identified suggest that further efforts are needed to ensure that care is equitably accessible.

England’s Barclays Premier League is one of the most successful and widereaching sporting organizations in the world, attracting the best football players and managers from around the world as well as a global audience. Since its formation in 1992, the Premier League has focused on commercial success for both the League and its constituent clubs. This emphasis has brought tremendous change to English football as a whole. This case study analysis seeks to understand the perceptions and experiences of sports reporters tasked with covering these Premier League sides. These football journalists describe limited access brought on by the clubs’ decisions to emphasize global brands and manage their own branded content through club-run websites and material. Respondents also perceive this limited access is exacerbated by increased multiculturalism and a growing culture of suspicion that widens the gulfs between teams and the reporters who cover them.

With his purchase of Aston Villa Football Club (AVFC) in 2006, Randy Lerner joined the growing ranks of foreign—and specifically American—owners in Barclays Premier League. During a year-long investigation spanning the 2008–2009 season, we conducted extensive participant observation among fans, interviews with a variety of sources (including club officials, journalists, and fans), and fan Web-site monitoring to understand the broader implications of Lerner's takeover. A consistently recurring theme during initial data analysis was the role of public relations in creating positive perceptions of Lerner as an owner. This ran contrary to the experiences of his American counterparts at other clubs. The British press, as well as academic researchers of sport globalization, has warned against the loss of localized rituals and institutions in the wake of the “foreign invasion” (Osborne & Coombs, 2009). Critics fear that foreign ownership of culturally rooted institutions such as English football clubs will creat...

The results of the recent experiments focused on study of x-ray radiation from multicharged plasmas irradiated by relativistic (I > 1019 W/cm2) sub-ps laser pulses on Leopard laser facility at NTF/UNR are presented. These shots were done under different experimental conditions related to laser pulse and contrast. In particular, the duration of the laser pulse was 350 fs or 0.8 ns and the contrast was varied from high (10−7) to moderate (10−5). The thin laser targets (from 4 to 750 μm) made of a broad range of materials (from Teflon to iron and molybden to tungsten and gold) were utilized. Using the x-ray diagnostics including the high-precision spectrometer with resolution R ∼ 3000 and a survey spectrometer, we have observed unique spectral features that are illustrated in this paper. Specifically, the observed L-shell spectra for Fe targets subject to high intensity lasers (∼1019 W/cm2) indicate electron beams, while at lower intensities (∼1016 W/cm2) or for Cu targets there is much less evidence for an electron beam. In addition, K-shell Mg features with dielectronic satellites from high-Rydberg states, and the new K-shell F features with dielectronic satellites including exotic transitions from hollow ions are highlighted.