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Objectives To conduct a nationwide evaluation of student and program director (PD) perspectives of virtual subinternships that took place during the COVID-19 pandemic. Methods In December 2020, we distributed anonymous surveys to all 534 urology residency applicants and 161 urology PDs at academic medical centers across the United States to evaluate virtual subinternships. Surveys assessed curriculum composition, goals, satisfaction, barriers, and future reusability. The primary outcome was overall satisfaction with the subinternship, evaluated on a 5-point Likert scale. Results The survey was completed by 174 students (33%) and 82 PDs (51%), including 81 students (47%) and 32 PDs (41%) who participated in virtual subinternships at 29 institutions. Overall, 77% of students and 78% of PDs rated the electives "excellent" or "very good." On ordinal logistic regression, higher student ratings were associated with duration ≥3 weeks (OR 4.64, p=0.003) and class size ≤4 students (OR 3.33, p=0.015). Higher PD ratings were associated with full-time electives (OR 11.18, p=0.019), class size ≤4 students (OR 13.99, p=0.042), and utilization of the standardized Guidebook from the Society of Academic Urologists (OR 11.89, p=0.038). The most commonly reported challenge to the subinternship's efficacy was lack of hands-on learning (87% of students and 81% of PDs). Looking forward, 45% of students and 66% of PDs recommended incorporating virtual components into future electives. Conclusions The virtual subinternship was a coordinated nationwide initiative to provide urologic education to medical students during a pandemic. The most successful courses were structured with longer duration, full-time commitment, and small class size.

Objective To develop an item response theory (IRT)–calibrated, patient-reported outcome measure (the PROMIS Cancer Function Brief 3D Profile) of physical function, including associations with fatigue and social participation, in cancer rehabilitation patients. Design Large-scale field testing, graded response model IRT analyses, and multivariate regression analysis. Setting Six cancer rehabilitation clinics associated with cancer centers across the United States. Participants Adults (N=616) treated in outpatient cancer rehabilitation medicine clinics. Intervention Not applicable. Main Outcome Measures: The PROMIS(r) Cancer Function 3D Profile (including existing items from PROMIS(r) item banks). Results A total of 616 patients completed 21 items in the initial item pool. Nine items were removed because of comparatively lower information that they provide according to the IRT item calibrations, low item-total correlations, or bimodal distributions. The remaining items generated a 12-item short form. Regression analyses determined that the items were responsive to and representative of the patient population across trait ranges and multiple domains and subdomains of function. Conclusions This psychometric investigation supports the use of the PROMIS Cancer Function Brief 3D Profile for evaluating function in outpatient cancer rehabilitation patients.

Perceptual aliasing challenges reinforcement learning agents. They struggle to learn stable policies through failing to identify and disambiguate perceptually identical states in the environment that require different actions to reach a goal. As the agent often has only a local frame-of-reference it cannot represent the global environment. Frame-of-reference based learning is a feature of vertebrate intelligence that allows multiple simultaneous representations of an environment at different levels of abstraction. This enables the resolution of patterns that are madeup of patterns that are madeup of features. The evolutionary computation technique of learning classifier systems has shown promise in learning nested patterns in singlestep domains. This work uses the frame-of-reference concept within a learning classifier system to learn stable policies in non-Markov multi-step domains. Considering aliased states at a constituent level enables the system to place them appropriately in holistic-level policies. Instead of enumerating a huge search space, evolution computation empowers the novel system to evolve fitter rules and policies. Experimental results show that the novel system effectively solves complex aliasing patterns in non-Markov environments that have been challenging to artificial agents. For example, the novel system utilizes only 6:5, 3:71, and 3:22 steps to resolve Maze10, Littman57, and Woods102, respectively.

We explored gender diverse youth’s experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.

Introduction: Relative to the general population, patients with schizophrenia or schizoaffective disorder have higher rates of suicide attempts and mortality from COVID-19 infection. Therefore, determining whether a history of suicide attempt is associated with COVID-19 in patients with schizophrenia or schizoaffective disorder has implications for COVID-19 vulnerability stratification in this patient population. Methods: We carried out cross-sectional analyses of electronic health records of veterans with a diagnosis of schizophrenia or schizoaffective disorder that received treatment at any United States Veterans Affairs Medical Center between January 1, 2020, and January 31, 2021. We used logistic regression to estimate unadjusted and adjusted (including age, sex, race, marital status, body mass index (BMI), and a medical comorbidity score) odds ratios (ORs) for COVID-19 positivity in suicide attempters relative to nonattempters. Results: A total of 101,032 veterans (mean age 56.67 ± 13.13 years; males 91,715 [90.8%]) were included in the analyses. There were 2,703 (2.7%) suicide attempters and 719 (0.7%) patients were positive for COVID-19. The association between history of suicide attempt and COVID-19 positivity was modified by age and BMI, such that the relationship was only significant in patients younger than 59 years, and in obese (BMI ≥30) patients (adjusted OR 3.42, 95% CI 2.02–5.79 and OR 2.85, 95% CI 1.65–4.94, respectively). Conclusions: Higher rates of COVID-19 in young or obese suicide attempters with a diagnosis of schizophrenia or schizoaffective disorder might be due to the elevated risk for the infection in this subgroup of patients.

There is a continuing debate concerning “adjustments” to heart period variability [i.e., heart rate variability (HRV)] for the heart period [i.e., increases inter-beat-intervals (IBI)]. To date, such arguments have not seriously considered the impact a demographic variable, such as gender, can have on the association between HRV and the heart period. A prior meta-analysis showed women to have greater HRV compared to men despite having shorter IBI and higher heart rate (HR). Thus, it is plausible that men and women differ in the association between HRV and HR/IBI. Thus, the present study investigates the potential moderating effect of gender on the association between HRV and indices of cardiac chronotropy, including both HR and IBI. Data from 633 participants (339 women) were available for analysis. Cardiac measures were assessed during a 5-min baseline-resting period. HRV measures included the standard deviation of inter-beat-intervals, root mean square of successive differences, and autoregressive high frequency power. Moderation analyses showed gender significantly moderated the association between all HRV variables and both HR and IBI (each p

Background: COVID-19 restrictions and alterations to daily living (e.g. working from home, caregiving responsibilities) necessitated changes in physical activity (PA) behavior. Purpose: The purpose of this study is to understand how PA within specific domains and behavior settings changed during the COVID-19 pandemic. Methods: An e-survey, conducted April-June 2020, examined changes in PA across domains and settings in a national sample of adults (N=805; M age=38.7 ± 14.9 yrs; 78.0% female). Results: Respondents reported domain-specific increases in household and recreational PA, but decreases in active transportation, occupational PA, and public transportation use. Weekly minutes of PA changed significantly across all behavior settings, with reported increases in home-based, neighborhood, parks/trails, and total PA, and decreases in PA through recreational sports and fitness facilities. Total weekly PA minutes increased by 10.6% (Z= 4.428, p < .000). Those with caregiving responsibilities reported increases in household PA (2=9.82, p=0.007) and PA frequency (2=8.21, p=0.02). Those without caregiving responsibilities were more likely to report increases in sitting (2=20.55, p

Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection carries substantial risk for all-cause mortality and liver-related morbidity and mortality, yet many persons coinfected with HIV/HCV remain untreated for HCV. We explored demographic, clinical, and sociodemographic factors among participants in routine HIV care associated with prescription of direct-acting antivirals (DAAs). The HIV Outpatient Study (HOPS) is an ongoing longitudinal cohort study of persons with HIV in care at participating clinics since 1993. There are currently eight study sites in six US cities. We analyzed medical records data of HOPS participants diagnosed with HCV since June 2010. Sustained virological response (SVR) was documented with first undetectable HCV viral load (VL). We assessed factors associated with being prescribed DAAs by multi-variable logistic regression and described the cumulative rate of SVR. Among 306 eligible participants, 131 (43%) were prescribed DAA therapy. Factors associated with greater odds of being prescribed DAA were older age, private health insurance, higher CD4 cell count, being a person who injects drugs, and receiving care at publicly funded sites (

Increasing rates of Anthropocene biodiversity extinctions suggest a possible sixth mass extinction event. Conservation planners are seeking effective ways to protect species, hotspots of biodiversity, and dynamic ecosystems to reduce and eventually eliminate the degradation and loss of diversity at the scale of genes, species, and ecosystems. While well-established, adequately enforced protected areas (PAs) increase the likelihood of preserving species and habitats, traditional placement methods are frequently inadequate in protecting biodiversity most at risk. Consequently, the Key Biodiversity Area (KBA) Partnership developed a set of science-based criteria and thresholds that iteratively identify sites where biodiversity is most in need of protection. KBA methodology has been rarely applied in the marine realm, where data are often extremely limited. We tested the feasibility of KBA population metrics in the Greater Caribbean marine region using occurrence and population data and threat statuses for 1669 marine vertebrates. These data identified areas where site-specific conservation measures can effectively protect biodiversity. Using KBA criteria pertaining to threatened and irreplaceable biodiversity, we identified 90 geographically unique potential KBAs, 34 outside and 56 within existing PAs. These provide starting points for local conservation managers to verify that KBA thresholds are met and to delineate site boundaries. Significant data gaps, such as population sizes, life history characteristics, and extent of habitats, prevent the full application of the KBA criteria to data-poor marine species. Increasing the rate and scope of marine sampling programs and digital availability of occurrence datasets will improve identification and delineation of KBAs in the marine environment.

The health benefits of physical activity and spending time in nature are well established. However, children and adults in the United States are not participating in sufficient levels of physical activity and are not spending much time outdoors. Recently, increased access to nature for the health and wellness of all populations has seen growing public health attention, though a specific focus on nature-based physical activity has been limited. The purpose of this scoping review is to operationalize the health benefits of nature-based physical activity to provide guidance to program administrators, advocates, and researchers for nature-based physical activity to facilitate collaborations. Peer-reviewed literature was searched in PubMed, Medline, Web of Science, and Google Scholar as well as in published reviews of the literature. The literature was divided into three categories of: 1) amount and location of nature-based components and physical activity; 2) added health benefits of exposure to nature-based components and physical activity; and 3) nature-based components and physical activity effect on non-white, marginalized, and vulnerable populations. This review supports and encourages multiple strategies to increase nature-based physical activity as this provides even greater benefit to health and wellness than exposure to nature or physical activity alone. Although many of the physical and mental health benefits of nature and physical activity are well established, additional research is needed to better understand the relationship between exposure to nature and nature-based physical activity. However, the existing information justifies the promotion of nature-based physical activities in public health initiatives.

This study sought to theorize the crisis coverage gap, a new way of understanding the divide between public information needs and local digital news coverage during a crisis, through the context of...

BACKGROUND The Pediatric Trauma Society (PTS) is a multidisciplinary organization, with scientific presentations at its annual meeting addressing trauma care from prehospital through rehabilitation. OBJECTIVE The purpose of this study was to identify and describe the scholarly areas of focus of presentations at the annual meeting over the society's first 5 years and evaluate research dissemination. METHODS Data were collected on abstracts presented between 2014 and 2018, including titles, authors, and abstract classification. PubMed and Google Scholar searches identified abstracts that resulted in publications. Journal impact factors were identified. RESULTS Over 5 years, 491 of 635 (77.3%) abstracts were accepted. The number of submitted and accepted abstracts increased, but the acceptance rate was stable (range = 72.1%-81.2%, p = NS [nonsignificant]). The most frequently accepted categories included "Epidemiology," "Abdominal or Thoracic Trauma," and "Neurosurgery or Traumatic Brain Injury (TBI)," whereas "Trauma Nursing" and "Quality Improvement" were less common. Among the 2014-2016 abstracts, 55.4% of podium and 24.3% of poster presentations were published. Abstracts categorized as "Epidemiology," "Education & Injury Prevention," and "Neurosurgery or TBI" were commonly presented but uncommonly published. The median journal impact factor of publications was 2.1 and 2.0 for podium and poster presentations, respectively (ranging from 0.11 to 10.25). CONCLUSION Most of the scholarly effort presented at the PTS remains unpublished. Published work is mainly in low-impact factor journals. Mentorship in the publication process and encouragement of multidisciplinary collaboration within the society are needed to address limitations in the number and potential impact of the scientific content of the annual meeting. This type of analysis is relevant not only to the PTS but also to any professional society seeking to improve its impact.

Objective Healthcare agencies recommend limited use of aerosol‐generating procedures to mitigate disease (COVID‐19) transmission. However, total dispersion patterns of aerosols, particularly respirable droplets, via dental ultrasonic units is unclear. The purpose of this study was to characterize and map total spatter, droplet and aerosol dispersion during ultrasonic scaling in simulated and clinical contexts. Methods Ultrasonic scaling was performed on dental simulation units using methylene blue dye‐stained water. All resultant stain profiles were photoanalysed to calculate droplet size and travel distance/direction. Airborne particle concentrations were also documented 0–1.2 m (0–4ft.) and 1.2–2.4 m (4–8ft.) from patients during in vivo ultrasonic scaling with a saliva ejector. Results Stain profiles showed droplets between 25 and 50µm in diameter were most common, with smaller droplets closer to the mouth. In‐vivo particle concentrations were uniformly low. The smallest (10 µm, PM10+) particles were most common, especially within 1.2 m (4ft.) of the patient. Respirable particles (PM2.5) were uncommon. Conclusions Tests showed the highest concentration of small droplets in zones nearest the patient. While uncommon, particles were detected up to 2.4 m (8ft.) away. Furthermore, observed particle sizes were consistent with those that can carry infectious agents. Efforts to mitigate the spread of inhalable aerosols should emphasize proximate regions nearest the procedure, including personal protective equipment and the use of evacuation devices.

Accumulation of cytotoxic bile acids (BAs) during cholestasis can result in liver failure. Glucuronidation, a phase II metabolism pathway responsible for BA detoxification, is regulated by peroxisome proliferator–activated receptor alpha (PPARα). This study investigates the efficacy of adjunct fenofibrate therapy to up‐regulate BA‐glucuronidation and reduce serum BA toxicity during cholestasis. Adult patients with primary biliary cholangitis (PBC, n = 32) and primary sclerosing cholangitis (PSC, n = 23), who experienced an incomplete response while receiving ursodiol monotherapy (13‐15 mg/kg/day), defined as serum alkaline phosphatase (ALP) ≥ 1.5 times the upper limit of normal, received additional fenofibrate (145‐160 mg/day) as standard of care. Serum BA and BA‐glucuronide concentrations were measured by liquid chromatography–mass spectrometry. Combination therapy with fenofibrate significantly decreased elevated serum ALP (−76%, P, Combination therapy with fenofibrate favorably alters BA‐glucuronidation as a PPARa‐mediated mechanism to reduce elevated serum BAs in patients with PBC and PSC who are incomplete responders to Ursodiol monotherapy. This study also identifies serum BA‐glucuronides and their respective metabolic ratios as indicators of response to therapy. Serum BA‐glucuronides may serve as mechanistically relevant secondary endpoints in clinical trials for PBC and PSC with anti‐cholestatic agents.

BACKGROUND AND OBJECTIVES Drug courts provide an array of substance use treatments and community-based services for probationers struggling with substance use disorders. We assessed substance use treatment services utilization and related expenditures and relapse and recidivism outcomes and identified predictors of cost of provision of substance use treatment services in a matched cohort of Massachusetts probationers in drug courts and traditional courts. METHODS This was an observational quasi-experimental study with 542 propensity-score-matched probationers initiating drug court between August 1, 2015 and February 28, 2018 and a minimum 6-month follow-up period. RESULTS A significantly greater proportion of probationers in drug courts were female, self-reported opioids as their primary drug of choice, had a history of substance use treatment, and a high and very high risk of recidivism than their counterparts in traditional courts. We estimated that the provision of substance use treatment services was $1498 more expensive for probationers in drug courts than traditional courts (p = .054). There were no statistically significant differences in relapse or recidivism rates between court systems. DISCUSSION AND CONCLUSIONS Probationer's age, gender, risk of recidivism at court intake, and enrollment length were strong predictors of expenditures on substance use treatment services. SCIENTIFIC SIGNIFICANCE This was the first study to assess substance use treatment services utilization and outcomes among probationers in drug courts and traditional courts. Drug courts served the needs of probationers disproportionally impacted by nonserious drug-related offenses struggling with substance use disorders who were at a high and very high risk of recidivism at court intake.

DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To evaluate information provided by residency and fellowship programs to graduates of Accreditation Council for Pharmacy Education-accredited doctor of pharmacy programs holding F-1 visas who are seeking postgraduate training opportunities. METHODS A 2-phase review of all US-based postgraduate year 1 (PGY1) residency and fellowship programs was conducted. In phase 1, program eligibility criteria were reviewed from the residency and fellowship directories published by the American Society of Health-System Pharmacists (ASHP) and American College of Clinical Pharmacy (ACCP). In phase 2, the postgraduate programs' official websites were reviewed for additional information. Each program was evaluated to determine the eligibility of international students with F-1 visa or Optional Practical Training (OPT) status, visa sponsorship and work authorization opportunities, and citizenship requirements. Programs were classified as eligible or noneligible to international students or as not providing sufficient information. Descriptive statistics were used to summarize the data. RESULTS A total of 1,455 ASHP PGY1 programs and 69 fellowship programs were included in our analysis. In phase 1, there were 3 eligible programs accepting applicants with F-1/OPT status and 377 noneligible programs. In phase 2, there were 10 eligible programs accepting applicants with F-1/OPT status or providing H-1B sponsorship and 410 noneligible programs. Over 70% of programs (phase 1, n = 1,075; phase 2, n = 1,035) were classified as providing no information. None of the fellowship programs were classified as eligible in our review. CONCLUSION Most residency and fellowship programs did not provide clear eligibility criteria for students with F-1/OPT status. Only a few programs clearly stated that they would accept applicants with F-1/OPT status or provide visa sponsorship to graduates holding F-1 visas.

To examine changes in Social Media (SoMe) use among urology residency applicants before and after the COVID-19 pandemic.We distributed surveys to individuals who applied to our residency program for application cycles ending in 2018, 2019, and 2021. The surveys included questions about applicants' SoMe use and perceptions of programs' SoMe use during the application process, both before (2018/2019) and after (2021) the COVID-19 pandemic. The primary outcome was SoMe use for professional purposes.We received survey responses from 33% (162 of 496) and 29% (84 of 294) of applicants from the 2018/2019 and 2021 cohorts, respectively. There was a significant increase in professional SoMe use in the 2021 cohort (80%) compared with the 2018/2019 cohort (44%) (P.001). In 2021 compared to 2018/2019, more applicants used SoMe to connect directly with residents (69% vs 34%, P.001) and with faculty members (65% vs 15%, P.001). Applicants in 2021 compared to 2018/2019 more often found SoMe to be useful for making decisions about applying to (33% vs 10%), interviewing at (26% vs 7%), and ranking programs (20% vs 9%) (all P.05). Twitter was the most common platform for applicants to access program information, increasing from 38% to 71%.The COVID-19 pandemic ushered in a period of unprecedented SoMe usage among urology applicants, who used it to learn about and connect with residency programs in new ways. The use of SoMe by residency programs has become an important component of trainee recruitment and is likely to continue in the future.

Steatosis is the most important prognostic histologic feature in the setting of liver procurement. The currently utilized diagnostic methods, including gross evaluation and frozen section examination, have important shortcomings. Novel techniques that offer advantages over the current tools could be of significant practical utility. The aim of this study is to evaluate the accuracy of surface color spectrophotometry in the quantitative assessment of steatosis in a murine model of fatty liver. C57BL/6 mice were divided into a control group receiving normal chow (n = 19), and two steatosis groups receiving high-fat diets for up to 20 weeks—mild steatosis (n = 10) and moderate-to-severe steatosis (n = 19). Mouse liver surfaces were scanned with a hand-held spectrophotometer (CM-600D; Konica-Minolta, Osaka, Japan). Spectral reflectance data and color space values (L*a*b*, XYZ, L*c*h*, RBG, and CMYK) were correlated with histopathologic steatosis evaluation by visual estimate, digital image analysis (DIA), as well as biochemical tissue triglyceride measurement. Spectral reflectance and most color space values were very strongly correlated with histologic assessment of total steatosis, with the best predictor being % reflectance at 700 nm (r = 0.91 [0.88–0.94] for visual assessment, r = 0.92 [0.88–0.95] for DIA of H&E slides, r = 0.92 [0.87–0.95] for DIA of oil-red-O stains, and r = 0.78 [0.63–0.87] for biochemical tissue triglyceride measurement, p

Using species distribution models (SDMs), we predicted the distribution of 170 plant species under different climatic scenarios (current and future climatic conditions) and used this information to create invasion risk maps to identify potential invasion hot spots in California. The risk of invasion by individual species was also assessed using species’ predicted area in combination with some biological traits associated with invasiveness (growth form, reproduction mechanisms, and age of maturity). A higher number of species would find suitable climatic conditions along the coast; the Central Western (CW) and South Western (SW) were ecoregions where a higher number of species were predicted. Overall, hot spots of species distribution were similar under current and future climatic conditions; however, individual species’ predicted area (increase or decrease) was variable depending on the climate change scenario and the greenhouse gas emission. Out of the 170 species assessed, 22% ranked as high-risk species, with herbs, grasses, and vines accounting for 78% within this risk class, and a high proportion (67%) of Asteraceae species ranked as high risk. This study suggests that current climatic conditions of the central and south coastal regions of California would be considered as hot spots of new invasions, and for some species this risk might increase with hotter and drier future climatic conditions.

Hateful content online is a concern for social media platforms, policymakers, and the public. This has led high-profile content platforms, such as Facebook, to adopt algorithmic content-moderation systems; however, the impact of algorithmic moderation on user perceptions is unclear. We experimentally test the extent to which the type of content being removed (profanity vs hate speech) and the explanation given for its removal (no explanation vs link to community guidelines vs specific explanation) influence user perceptions of human and algorithmic moderators. Our preregistered study encompasses representative samples ( N = 2870) from the United States, the Netherlands, and Portugal. Contrary to expectations, our findings suggest that algorithmic moderation is perceived as more transparent than human, especially when no explanation is given for content removal. In addition, sending users to community guidelines for further information on content deletion has negative effects on outcome fairness and trust.

Background Opioid use disorder (OUD) is a major public health issue in the United States. Medications for OUD (MOUD), which combines the use of approved medications with counseling and behavioral therapies, represents an evidence-based approach to treat individuals living with an OUD. However, MOUD has not kept up with increased demand and new treatment approaches are needed. One approach is injectable naltrexone, an approved and effective MOUD treatment, provided by pharmacists, who are more geographically accessible and have legal authority to administer it in some states. Objectives To explore how different community pharmacists provide injectable naltrexone treatment and identify best practices. Methods An exploratory sequential mixed-methods design was used to investigate pharmacy-based naltrexone injection practices, involving a pharmacist questionnaire and interviews with pharmacists, prescribers, and community stakeholders. An inductive/iterative content analysis approach, guided by an initial straw model, was used to identify and explore conceptual categories for the interviews. Results The final sample included 68 pharmacy surveys and 14 total interviews with pharmacists (n = 9), prescribers (n = 3), and community stakeholders (n = 2). Pharmacies providing naltrexone injections reported administering over 700 injections in the past year. Interviews revealed benefits and barriers to pharmacist-provided injections and the importance of the prescriber-pharmacist relationship in OUD treatment. Three pharmacy treatment delivery models were identified, compared to the initial straw model, and informed development of a best practices checklist for community pharmacies interested in establishing or expanding a naltrexone injection service. Conclusions The study demonstrates how community pharmacies developed and implemented a naltrexone injection service. Pharmacists' and prescribers' feedback clearly suggests an untapped interest, as well as resources, in realizing pharmacists’ roles as providers of injectable naltrexone treatment. Implementation research could inform the development and evaluation of an intervention based on these best practices to further explore the utility of community pharmacy-based naltrexone injection services.

Purpose: Proline Rich 12 (PRR12) is a gene of unknown function with suspected DNA-binding activity, expressed in developing mice and human brains. Predicted loss-of-function variants in this gene are extremely rare, indicating high intolerance of haploinsufficiency. Methods: Three individuals with intellectual disability and iris anomalies and truncating de novo PRR12 variants were described previously. We add 21 individuals with similar PRR12 variants identified via matchmaking platforms, bringing the total number to 24. Results: We observed 12 frameshift, 6 nonsense, 1 splice-site, and 2 missense variants and one patient with a gross deletion involving PRR12. Three individuals had additional genetic findings, possibly confounding the phenotype. All patients had developmental impairment. Variable structural eye defects were observed in 12/24 individuals (50%) including anophthalmia, microphthalmia, colobomas, optic nerve and iris abnormalities. Additional common features included hypotonia (61%), heart defects (52%), growth failure (54%), and kidney anomalies (35%). PrediXcan analysis showed that phecodes most strongly associated with reduced predicted PRR12 expression were enriched for eye- (7/30) and kidney- (4/30) phenotypes, such as wet macular degeneration and chronic kidney disease. Conclusion: These findings support PRR12 haploinsufficiency as a cause for a novel disorder with a wide clinical spectrum marked chiefly by neurodevelopmental and eye abnormalities. Graphic Abstract: [Figure not available: see fulltext.]

Posttraumatic stress disorder (PTSD) has been associated with an increase in risk of cardiovascular disease (CVD). The goal of this study was to determine if peripheral vascular dysfunction, a precursor to CVD, was present in young adults with PTSD, and if an acute antioxidant (AO) supplementation could modify this potential PTSD-induced vascular dysfunction. Thirteen individuals with PTSD were recruited for this investigation and were compared with 35 age- and sex-matched controls (CTRL). The PTSD group participated in two visits, consuming either a placebo (PTSD-PL) or antioxidants (PTSD-AO; vitamins C and E; α-lipoic acid) before their visits, whereas the CTRL subjects only participated in one visit. Upper and lower limb vascular functions were assessed via flow-mediated dilation and passive leg movement technique. Heart rate variability was utilized to assess autonomic nervous system modulation. The PTSD-PL condition, when compared with the CTRL group, reported lower arm and leg microvascular function as well as sympathetic nervous system (SNS) predominance. After acute AO supplementation, arm, but not leg, microvascular function was improved and SNS predominance was lowered to which the prior difference between PTSD group and CTRL was no longer significant. Young individuals with PTSD demonstrated lower arm and leg microvascular function as well as greater SNS predominance when compared with age- and sex-matched controls. Furthermore, this lower vascular/autonomic function was augmented by an acute AO supplementation to the level of the healthy controls, potentially implicating oxidative stress as a contributor to this blunted vascular/autonomic function.

BACKGROUND Assessment of patient satisfaction is central to understanding and improving system performance with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) national standard survey. However, no large, multi-institutional study exists, which examines the role of nurses in trauma patient satisfaction. OBJECTIVE To assess the impact of nurses on trauma patient satisfaction. METHODS This retrospective, descriptive study of Level I-IV trauma centers in a multistate hospital system evaluated patients 18 years and older admitted with at least an overnight stay. Data were obtained electronically for patients discharged in 2018-2019 who returned an HCAHPS survey. Surveys were linked by an honest broker to demographic and injury data from the trauma registry, and then anonymized prior to analysis. Patients were categorized as "trauma" per the National Trauma Data Standard (NTDS) definition or as "medical" or "surgical" per the HCAHPS definition. RESULTS Of 112,283 surveys from 89 trauma centers, "trauma" patients (n = 5,126) comprised 4.6%, "surgical" 39.0% (n = 43,763), and "medical" 56.5% (n = 63,394). Nurses had an overwhelming impact on "trauma" patient satisfaction, accounting for 63.9% (p < .001) of the variation (adjusted R2) in the overall score awarded the institution-larger than for "surgery" (59.6%; p < .001) or "medical" (58.4%; p < .001) patients. The most important individual domain contributor to the overall rating of a facility was "nursing communication." CONCLUSIONS The magnitude of the effect of trauma nurses was noteworthy, with their communication ability being the single biggest driver of institutional ratings. These data provide insight for future performance benchmark development and emphasize the critical impact of trauma nurses on the trauma patient experience.

Background and Aim: Avian influenza (AI), which is one of the major respiratory diseases of poultry, and Escherichia coli (E. coli) have caused major economic losses around the world, including in Egypt. Therefore, in this study, we aimed to produce a vaccine from E. coli O157 and AI H5N1 formulated with Montanide ISA70 for the protection of poultry against both diseases. Materials and Methods: We divided one hundred 3-week-old chicks into four groups: Group 1 was vaccinated with prepared inactivated AI H5N1formulated with Montanide ISA70, Group 2 was vaccinated with inactivated E. coli formulated with Montanide ISA70, Group 3 was vaccinated with combined E. coli and AI H5N1 formulated with Montanide ISA70, and Group 4 was an unvaccinated control group. We measured the immune response using the HI (hemagglutination inhibition) test, enzyme-linked immunosorbent assay (ELISA), and the challenge test. Results: We found the three vaccines to be safe and sterile during all periods of examination and observation. The HI test showed that Group 1 exhibited specific antibody titers of 2.3 log2, 4.3 log2, 7.5 log2, 7.8 log2, 8 log2, and 8.1 log2 from week 2 to week 7, respectively, post-vaccination. Group 3 exhibited antibody titers of 3.3 log2, 5.8 log2, 7.8 log2, 8 log2, 8.3 log2, and 8.3 log2 from week 2 to week 7, respectively, post-vaccination. The immune response in both groups reached a high titer at week 6. The combined inactivated E. coli and AI H5N1 vaccine generated a higher immune response than the inactivated AI H5N1 vaccine, and a significant difference exists between the two groups. For Groups 2 and 3, the ELISA antibody titer exhibited its lowest value, 1996.5 and 2036.7, respectively, at week 1 post-vaccination; whereas, both groups exhibited the highest titers, 2227.7 (for Group 2) and 2287.3 (for Group 3), in week 3 post-booster. The ELISA for the combined inactivated E. coli and AI H5N1 vaccine had a higher titer than did the inactivated E. coli vaccine, and a significant difference exists between the two groups. Moreover, the protection rate was higher in Group 3, with 100% for E. coli and 90% for the AI H5N1 vaccine. Conclusion: Our findings demonstrate that producing a combined vaccine using E. coli and AI H5N1 formulated with Montanide ISA70 is recommended for protection against both diseases.

Introduction Longer prehospital times were associated with increased odds for survival in trauma patients. The purpose of this study was to determine how the COVID-19 pandemic affected emergency medical services (EMS) prehospital times for trauma patients. Methods This retrospective cohort study compared trauma patients transported via EMS to six US level I trauma centers admitted 1/1/19–12/31/19 (2019) and 3/16/20–6/30/20 (COVID-19). Outcomes included: total EMS pre-hospital time (dispatch to hospital arrival), injury to dispatch time, response time (dispatch to scene arrival), on-scene time (scene arrival to scene departure), and transportation time (scene departure to hospital arrival). Fisher's exact, chi-squared, or Kruskal-Wallis tests were used, alpha = 0.05. All times are presented as median (IQR) minutes. Results There were 9400 trauma patients transported by EMS: 79% in 2019 and 21% during the COVID-19 pandemic. Patients were similar in demographics and transportation mode. Emergency room deaths were also similar between 2019 and COVID-19 [0.6% vs. 0.9%, p = 0.13].There were no differences between 2019 and during COVID-19 for total EMS prehospital time [44 (33, 63) vs. 43 (33, 62), p = 0.12], time from injury to dispatch [16 (6, 55) vs. 16 (7, 77), p = 0.41], response time [7 (5, 12) for both groups, p = 0.27], or on-scene time [16 (12−22) vs. 17 (12,22), p = 0.31]. Compared to 2019, transportation time was significantly shorter during COVID-19 [18 (13, 28) vs. 17 (12, 26), p = 0.01]. Conclusion The median transportation time for trauma patients was marginally significantly shorter during COVID-19; otherwise, EMS prehospital times were not significantly affected by the COVID-19 pandemic.

Objective To assess the association between commonly obtained endoscopic and serologic data and bronchoalveolar lavage pepsin assay (BAL) results in children with chronic cough. Study design We performed a retrospective chart review of seventy-two children with a BAL pepsin obtained through our Aerodigestive Center over an 18-month period. BAL outcomes include evidence of viral, bacterial, or fungal infection, presence of lipid laden macrophages, and cytology (eosinophils, neutrophils, and lymphocytes). Gastrointestinal outcomes include esophagogastroduodenoscopy (EGD) and pH impedance probe findings. Other characteristics include serum eosinophil, neutrophils, and lymphocytes; spirometry; FeNO; and IgE. Results Seventy-two patients underwent BAL pepsin testing. Median age was 4.9 years, 30.6% had severe persistent asthma, and 59.2% were on reflux medication. There was an association between positive BAL pepsin assay and positive viral panel (p=0.002) or fungal culture (p=0.027). No significant association found between positive BAL bacterial culture; BAL cytology; presence of BAL lipid laden macrophages; IgE; spirometry; FeNO; CBC neutrophil, eosinophil, or lymphocytes; pH impedance testing parameters; or EGD pathology. Conclusions BAL pepsin is associated with a positive BAL viral PCR or fungal culture. Lack of correlation between pepsin-positivity and pH-impedance parameters or EGD pathology suggests microaspiration may be due to an acute event (such as a respiratory infection) rather than chronic GERD. This may be especially true in the presence of a positive viral panel or fungal culture when a BAL pepsin is obtained. This article is protected by copyright. All rights reserved.

Background/Objective Newborn infant skin is functional but immature, and diapering products can play a significant role in infant diapered skin health. Previous work demonstrated a regimen consisting of a diaper with an emollient and apertures on the inner liner (topsheet) with an acidic, pH‐buffered wipe (Regimen A) lowered newborn skin pH and reduced the enzymatic activity on skin post‐stool cleaning versus a regimen without these features (Regimen B). This study extends these findings to determine the impact of Regimen A on diaper area erythema severity over a 2‐week use period. Methods This IRB‐approved, blinded, randomized, crossover study enrolled newborn infants >7 days and ≤8 weeks. Participants exclusively used two unique diaper and wipe combinations, Regimen A and Regimen B (non‐emollient, non‐aperture containing topsheet and wipe with limited buffering capacity), each for 14 days and preceded by a 3‐day washout regimen. Results Diapered skin pH was reduced during Regimen A use to values similar to that of a non‐diapered control site (chest), while use of Regimen B was associated with a more alkaline skin pH. Regimen A resulted in significantly fewer severe erythema episodes. At the site of highest erythema, the perianal space, the average erythema score was significantly lower and more newborns were free of erythema while using Regimen A vs. Regimen B (P

Background Triple-negative breast cancer (TNBC) is a heterogeneous disease and we have previously shown that rapid relapse of TNBC is associated with distinct sociodemographic features. We hypothesized that rapid versus late relapse in TNBC is also defined by distinct clinical and genomic features of primary tumors. Methods Using three publicly-available datasets, we identified 453 patients diagnosed with primary TNBC with adequate follow-up to be characterized as ‘rapid relapse’ (rrTNBC; distant relapse or death ≤2 years of diagnosis), ‘late relapse’ (lrTNBC; > 2 years) or ‘no relapse’ (nrTNBC: > 5 years no relapse/death). We explored basic clinical and primary tumor multi-omic data, including whole transcriptome (n = 453), and whole genome copy number and mutation data for 171 cancer-related genes (n = 317). Association of rapid relapse with clinical and genomic features were assessed using Pearson chi-squared tests, t-tests, ANOVA, and Fisher exact tests. We evaluated logistic regression models of clinical features with subtype versus two models that integrated significant genomic features. Results Relative to nrTNBC, both rrTNBC and lrTNBC had significantly lower immune signatures and immune signatures were highly correlated to anti-tumor CD8 T-cell, M1 macrophage, and gamma-delta T-cell CIBERSORT inferred immune subsets. Intriguingly, lrTNBCs were enriched for luminal signatures. There was no difference in tumor mutation burden or percent genome altered across groups. Logistic regression mModels that incorporate genomic features significantly outperformed standard clinical/subtype models in training (n = 63 patients), testing (n = 63) and independent validation (n = 34) cohorts, although performance of all models were overall modest. Conclusions We identify clinical and genomic features associated with rapid relapse TNBC for further study of this aggressive TNBC subset.

Introduction Black women are at disproportionately greater risk for HIV and sexually transmitted infections than women of other ethnic/racial backgrounds. Alcohol use may further elevate the risk of HIV/sexually transmitted infection acquisition and transmission. Study Design A random-assignment parallel-group comparative treatment efficacy trial was conducted with random assignment to 1 of 3 conditions. Setting/participants The sample comprised 560 Black or African American women aged 18–24 years who reported recent unprotected vaginal or anal sex and recent alcohol use. Participants were recruited from community settings in Atlanta, Georgia, from January 2012 to February 2014. Intervention A Group Motivational Enhancement Therapy module was designed to complement a Centers for Disease Control and Prevention–designated evidence-based intervention (Horizons) to reduce sexual risk behaviors, alcohol use, and sexually transmitted infections, with 3 comparison groups: (1) Horizons + Group Motivational Enhancement Therapy intervention, (2) Horizons + General Health Promotion intervention, and (3) enhanced standard of care. Main outcome measures Outcome measures included safe sex (abstinence or 100% condom use); condom nonuse; proportion of condom use during sexual episodes; incident chlamydia, gonorrhea, and trichomonas infections; and problematic alcohol use measured by Alcohol Use Disorders Identification Test score. Treatment effects were estimated using an intention-to-treat protocol‒generalized estimating equations with logistic regression for binomial outcomes and Poisson regression for count outcomes. Analyses were conducted between October 2018 and October 2019. Results Participants assigned to Horizons + Group Motivational Enhancement Therapy had greater odds of safe sex (AOR=1.45, 95% CI=1.04, 2.02, p=0.03), greater proportion of condom use (AOR=1.68, 95% CI=1.18, 2.41, p=0.004), and lower odds of condom nonuse (AOR=0.57, 95% CI=0.38, 0.83, p=0.004). Both interventions had lower odds of problematic alcohol use (Horizons: AOR=0.57, 95% CI=0.39, 0.85, p=0.006; Horizons + Group Motivational Enhancement Therapy: AOR=0.61, 95% CI=0.41, 0.90, p=0.01). Conclusions Complementing an evidence-based HIV prevention intervention with Group Motivational Enhancement Therapy may increase safer sexual behaviors and concomitantly reduce alcohol use among young Black women who consume alcohol. Trial registration This study is registered at www.clinicaltrials.gov NCT01553682.

Introduction:Sustaining resident education efforts during the height of the COVID-19 pandemic required innovative, virtual didactic programs. This article reviews the authors’ collaborative...

Background Trauma and emergency surgery patients are unique with regard to the sudden and unexpected nature of their hospitalization and this can adversely affect patient satisfaction, but, to our knowledge, no large study exists examining this issue. The purpose of this study was to investigate the major factors that affect satisfaction scores in trauma and emergency surgery patients. Study Design Consumer Assessment of Healthcare Providers and Systems, Hospital Version survey data from patients discharged in 2018-2019 from facilities in a national hospital system were obtained. Patients were categorized as trauma, emergency surgery, or direct admit surgery (elective surgery). Individual Consumer Assessment of Healthcare Providers and Systems, Hospital Version question scores were regressed on the score for “overall rating” to determine the primary, secondary, and tertiary satisfaction drivers. Results There were 186,779 patients from 168 hospitals included. As expected, the primary determinant of patient satisfaction was nursing communication for all groups. However, trauma and emergency surgery patients differed from elective surgery patients in that physician communication was the second most important factor in patient satisfaction, accounting for 12.0% (trauma) and 8.6% (emergency surgery) of the total variability in the overall rating beyond the variability explained by the primary driver. If physician communication received low ratings, it was unlikely that high scores in other metrics could compensate to bring the overall score above the 50th percentile. Conclusions Acute care surgeons appear to play a uniquely important role in support of Consumer Assessment of Healthcare Providers and Systems, Hospital Version scores. These data emphasize the importance of physician communication, particularly when a prehospital physician-patient relationship does not exist. Future research should explore specific mechanisms by which physicians effectively communicate with patients.

Background Since the national stay-at-home order for COVID-19 was implemented, clinicians and public health authorities worldwide have expressed growing concern about the potential repercussions of drug and alcohol use due to social restrictions. We explored the impact of the national stay-at-home orders on alcohol or drug use and screenings among trauma admissions. Methods This was a retrospective cohort study at six Level I trauma centers across four states. Patients admitted during the period after the onset of the COVID-19 restrictions (defined as March 16, 2020-May 31, 2020) were compared with those admitted during the same time period in 2019. We compared 1) rate of urine drug screens and blood alcohol screens; 2) rate of positivity for drugs or alcohol (blood alcohol concentration ≥ 10 mg/dL); 3) characteristics of patients who were positive for drug or alcohol, by period using chi-squared tests or Fisher’s exact tests, as appropriate. Two-tailed tests with an alpha of p Results There were 4762 trauma admissions across the study period; 2602 (55%) in 2019 and 2160 (45%) in 2020. From 2019 to 2020, there were statistically significant increases in alcohol screens (34% vs. 37%, p = 0.03) and drug screens (21% vs. 26%, p p = 0.007), while the rate of drug positive patients was unchanged (57% vs. 52%, p = 0.13). Of the 1025 (22%) patients who were positive for alcohol or drugs, there were significant increases in a history of alcoholism (41% vs. 26%, p Conclusions Our first wave of COVID-19 data suggests that trauma centers were admitting significantly more patients who were alcohol positive, as well those with substance use disorders, potentially due to the impact of social restrictions and guidelines. Further longitudinal research is warranted to assess the alcohol and drug positive rates of trauma patients over the COVID-19 pandemic.

Black youth face significant disparities in HIV/sexually transmitted infection (STI) disease burden—statistics among heterosexual Black youth are concerning. Mental illness and emotion regulation are documented contributors to HIV/STI risk, yet the majority of HIV/STI prevention interventions do not address these factors. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually-active Black youth aged 14 to 17 (N = 108). Participants were recruited from outpatient mental health treatment programs and general community settings via community partner referrals, face-to-face encounters, flyers and social media. Assessments were conducted pretest, immediate posttest, and at 3-, 6-, and 12-month follow-up. Although there were no statistically significant differences in behavior change from baseline, there were practically significant effect sizes among HIV condition participants when compared to the general health condition (e.g., increased proportion of condom use for vaginal sex at 3 months, fewer sexual partners at 6 months). An increase in theoretical mediators (e.g., condom use negotiation beliefs, pro-Black ethnic identity) was sustained at 12 months. HIV condition participants also reported lower depressive symptom severity, with statistical significance noted at immediate post and at 3 months. The findings highlight the importance and challenges of engaging Black youth in culturally and contextually relevant, developmentally and psychologically appropriate HIV/STI prevention interventions. Future work is needed to avoid unnecessary health complications in this demographic.

Platelet-derived growth factor receptor-beta (PDGFRβ) is a receptor tyrosine kinase found in cells of mesenchymal origin such as fibroblasts and pericytes. Activation of this receptor is dependent on paracrine ligand induction, and its preferred ligand PDGFB is released by neighboring epithelial and endothelial cells. While expression of both PDGFRβ and PDGFB has been noted in patient breast tumors for decades, how PDGFB-to-PDGFRβ tumor–stroma signaling mediates breast cancer initiation, progression, and metastasis remains unclear. Here we demonstrate this paracrine signaling pathway that mediates both primary tumor growth and metastasis, specifically, metastasis to the brain. Elevated levels of PDGFB accelerated orthotopic tumor growth and intracranial growth of mammary tumor cells, while mesenchymal-specific expression of an activating mutant PDGFRβ (PDGFRβD849V) exerted proproliferative signals on adjacent mammary tumor cells. Stromal expression of PDGFRβD849V also promoted brain metastases of mammary tumor cells expressing high PDGFB when injected intravenously. In the brain, expression of PDGFRβD849V was observed within a subset of astrocytes, and aged mice expressing PDGFRβD849V exhibited reactive gliosis. Importantly, the PDGFR-specific inhibitor crenolanib significantly reduced intracranial growth of mammary tumor cells. In a tissue microarray comprised of 363 primary human breast tumors, high PDGFB protein expression was prognostic for brain metastases, but not metastases to other sites. Our results advocate the use of mice expressing PDGFRβD849V in their stromal cells as a preclinical model of breast cancer–associated brain metastases and support continued investigation into the clinical prognostic and therapeutic use of PDGFB-to-PDGFRβ signaling in women with breast cancer. Significance: These studies reveal a previously unknown role for PDGFB-to-PDGFRβ paracrine signaling in the promotion of breast cancer brain metastases and support the prognostic and therapeutic clinical utility of this pathway for patients. See related article by Wyss and colleagues, p. 594

Objectives To compare the efficacy and safety of algenpantucel-L (HAPa; IND# 12311) immunotherapy combined with standard of care (SOC) chemotherapy and chemoradiation to SOC chemotherapy and chemoradiation therapy alone in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (PDAC). Summary background data To date, immunotherapy has not been shown to benefit patients with borderline resectable or locally advanced unresectable PDAC. HAPa is a cancer vaccine consisting of allogeneic pancreatic cancer cells engineered to express the murine α(1,3)GT gene. Methods A multicenter, phase 3, open label, randomized (1:1) trial of patients with borderline resectable or locally advanced unresectable PDAC. Patients received neoadjuvant SOC chemotherapy (FOLFIRINOX or gemcitabine/nab-paclitaxel) followed by chemoradiation (standard group) or the same standard neoadjuvant regimen combined with HAPa immunotherapy (experimental group). The primary outcome was overall survival. Results Between May 2013 and December 2015, 303 patients were randomized from 32 sites. Median (IQR) overall survival was 14.9 (12.2-17.8) months in the standard group (N=158) and 14.3 (12.6-16.3) months in the experimental group (N = 145) (hazard ratio [HR] 1.02, 95% CI 0.66-1.58; P = 0.98). Median progression-free survival was 13.4 months in the standard group and 12.4 months in the experimental group (HR 1.33, 95% CI 0.72-1.78; P = 0.59). Grade 3 or higher adverse events occurred in 105 of 140 patients (75%) in the standard group and in 115 of 142 patients (81%) in the experimental group (P > 0.05). Conclusions Algenpantucel-L immunotherapy did not improve survival in patients with borderline resectable or locally advanced unresectable PDAC receiving SOC neoadjuvant chemotherapy and chemoradiation. Trial registration ClinicalTrials.gov Identifier: NCT01836432.

In this review, we examine the current literature regarding the use of cranberry and other complimentary methods for the prevention of catheter-associated urinary tract infections (CAUTIs). Some studies have suggested cranberry products may have a positive effect in reducing the incidence of CAUTIs in patients with normal bladder function receiving short-term catheterization, while other studies have failed to show the benefits of cranberry products for the reduction of CAUTIs. While there is some data suggesting cranberry-derived products may reduce CAUTIs in specific patient populations, there is currently overall insufficient clinical data to recommend broad usage of cranberry products for the reduction of CAUTIs. Many of the studies reviewed have significant limitations in size, design, and lack standardization.

In this article, we review the potential for adverse impacts on the clinician following a medical error or poor clinical outcome. Second victim syndrome, its symptoms, risk factors, natural history, and possible outcomes are described. We also discuss the important role of organizational leadership and culture and highlight possible programmatic interventions designed to support clinicians following an adverse event.

Purpose: Visitor restrictions during the COVID-19 pandemic limit in-person family meetings for hospitalized patients. We aimed to evaluate the quantity of family meetings by telephone, video and in-person during the COVID-19 pandemic by manual chart review. Secondary outcomes included rate of change in patient goals of care between video and in-person meetings, the timing of family meetings, and variability in meetings by race and ethnicity. Methods: A retrospective cohort study evaluated patients admitted to the intensive care unit at an urban academic hospital between March and June 2020. Patients lacking decision-making capacity and receiving a referral for a video meeting were included in this study. Results: Most patients meeting inclusion criteria (N = 61/481, 13%) had COVID-19 pneumonia (n = 57/61, 93%). A total of 650 documented family meetings occurred. Few occurred in-person (n = 70/650, 11%) or discussed goals of care (n = 233/650, 36%). For meetings discussing goals of care, changes in patient goals of care occurred more often for in-person meetings rather than by video (36% vs. 11%, p = 0.0006). The average time to the first goals of care family meeting was 11.4 days from admission. More documented telephone meetings per admission were observed for White (10.5, SD 9.5) and Black/African-American (7.1, SD 6.6) patients compared to Hispanic or Latino patients (4.9, SD 4.9) (p = 0.02). Conclusions: During this period of strict visitor restrictions, few family meetings occurred in-person. Statistically significant fewer changes in patient goals of care occurred following video meetings compared to in-person meetings, providing support limiting in-person meetings may affect patient care.

Objective To evaluate the effectiveness of a contraceptive decision aid in reducing decisional conflict among women seeking reversible contraception. Study Design We conducted a randomized trial of a computer-based decision aid compared to a control group for women presenting for reversible contraception at two clinics affiliated with an academic medical center. The primary outcome was change in decisional conflict, measured before and after the healthcare visit using the validated Decisional Conflict Scale. We hypothesized the decision aid would reduce the decisional conflict score by 10 points on a 100-point scale (0 = no conflict, 100 = high conflict) compared to the control group. Secondary outcomes included contraceptive method chosen and satisfaction with the healthcare visit. Results We enrolled and randomized 253 women, and 241 had complete data for our primary outcome. Overall, pre-visit decisional conflict scores were low, reflecting low levels of decisional conflict in our sample; median score 15 (range 0–80) in the decision aid and 10 (0–85) in the control group (p = 0.45). Both groups had a similar reduction in median decisional conflict after the healthcare visit: −10 (−80 to 25) and −10 (−60 to 5) in the decision aid and control groups respectively (p = 0.99). Choice of contraception (p = 0.23) and satisfaction with healthcare provider (p = 0.79) also did not differ by study group. Conclusions Decisional conflict around contraception was low in both groups at baseline. Use of a computerized contraceptive decision aid did not reduce decisional conflict, alter method choice, or impact satisfaction compared to the control group among women choosing reversible contraception. Implications Use of a computerized contraceptive decision aid did not reduce decisional conflict or alter method choice compared to the control group among women choosing reversible contraception. Future studies could focus on testing the decision aid in different clinical settings, especially where barriers to providing comprehensive contraceptive counseling exist.

Background: Bovine tuberculosis (BTB) and brucellosis are associated with devastating losses in the livestock sector in Colombia and even in developed countries. Real-time disease surveillance is a key strategy to control and eradicate infectious disease outbreaks. Objective: To design an epidemiological tool for monitoring BTB and brucellosis in Colombia. Methods: An interactive platform for disease mapping of BTB and brucellosis during an observation period between years 2004 and 2019 was designed. Results: Our analysis showed that the provinces of Cundinamarca and Valle del Cauca are regions affected by BTB and brucellosis epidemics, respectively (p

Background: Health care providers (HCPs) promoting physical activity (PA) through programs such as Park Prescriptions (ParkRx) are gaining momentum. However, it is difficult to realize provider PA practices and program interest, and differences in program success exist by provider type (eg, primary vs secondary). This study explored HCPs’ (1) PA counseling practices, (2) knowledge/interest in ParkRx, (3) barriers and resources needed to implement PA counseling and ParkRx programs, and (4) differences in primary versus secondary HCPs. Methods: An e-survey administered in Spring/Summer 2018 to HCPs in 3 states examined study objectives. Results: Respondents (n = 278) were mostly primary (58.3%) HCPs. The majority asked about patient PA habits and offered PA counseling (mean = 5.0, SD = 1.5; mean = 4.8, SD = 1.5), but few provided written prescriptions (mean = 2.5, SD = 1.6). Providers were satisfied with their PA counseling knowledge (mean = 3.8, SD = 1.0) but not with prescribing practices (mean = 3.2, SD = 1.1). Secondary HCPs placed higher importance (P = .012) and provided significantly more written PA prescriptions (P = .005). Time was a common barrier to prescribing PA (mean = 3.4, SD = 1.2), though more so for primary HCPs (P = .000). Although few HCPs knew about ParkRx programs, 81.6% expressed interest. Access to park information and community partnerships was an important resource for program implementation. Conclusions: HCPs underutilize PA prescriptions. Despite little awareness, HCPs were interested in ParkRx programs.

The study put forth a new concept, which we call engagement moderation, that is defined as community managers or journalists interacting with commenters to improve the comment threads, rather than ...

Resilience is defined as the ability and process to transform adversity into opportunities for growth and adaptation. Resilience may be especially important for people living with HIV (PLWH), who are susceptible to anxiety and depressive disorders, which are commonly linked to risk behaviors (i.e., alcohol and drug abuse), poor adherence to medical regimens, increased risk of morbidity and mortality, and related stigma and discrimination. To date, few studies have examined the impact of resilience on health-related behaviors and outcomes among PLWH, particularly among minority women living with HIV (WLWH) who are dealing with multiple stressors impacting their health. This study used a convergent parallel mixed-methods design to collect, analyze, and integrate qualitative and quantitative data from a subsample of WLWH enrolled in the Women's Interagency HIV Study (WIHS). The aims of the study were to (1) qualitatively examine the resilience perspectives of 76 marginalized WLWH, and; (2) quantitatively assess the associations of resilience with HIV health outcomes—adherence to antiretroviral therapy and viral suppression—in the context of differing levels of internalized HIV-related stigma and depressive symptoms (n = 420). Findings from this mixed-methods study suggest that resilience is an important resource that can aid WLWH in coping constructively with adversity by capitalizing on intrapersonal traits and states, interpersonal and institutional resources, and spiritual and/or religious practices. Given the complex medical and social needs of marginalized WLWH, intervention strategies should focus on mitigating psychosocial burdens of stigma and depression, in addition to building resilience.

Background The incidence of mucinous appendiceal adenocarcinomas (MAA) has increased over the past three decades. Advanced stage tumor diagnosis is likely attributable to non-specific findings. Here we describe advanced stage appendiceal MAA presenting as inguinal ulcers, scrotal abscesses, and other nonspecific symptoms. To our knowledge, this is the first report of MAA presenting as inguinal pain with inflamed phlegmonous tissue and scrotal abscess. Case presentation A 67-year-old male presented to a rural facility complaining of weight-loss, fatigue, hematuria, dysuria, painful right inguinal ulceration, and right scrotal abscess drainage. Computed tomography of the abdomen and pelvis revealed a distended appendix (> 1.3 cm) and a fistula between the appendix, urinary bladder, right scrotum, and right groin. Laparoscopic appendectomy was performed and diagnosed as MAA. After a right hemicolectomy, the MAA was staged as pT3b pN0 M0 G2. Conclusion This case highlights a unique presentation of late stage appendiceal MAA. Due to the increased incidence of appendiceal MAAs, reports of unique clinical features are needed to facilitate early diagnosis and intervention, especially in rural settings with limited access to specialists.

BACKGROUND: Circulating tumor DNA (ctDNA) harboring tumor-specific genetic and epigenetic aberrations allows for early detection and real-time monitoring of tumor dynamics. In this study, we aimed to evaluate the potential of parallel serial assessment of somatic mutation and methylation profile in monitoring the response to osimertinib of epidermal growth factor receptor (EGFR) T790M-positive advanced lung adenocarcinoma patients. METHODS: Parallel somatic mutation and DNA methylation profiling was performed on a total of 85 longitudinal plasma samples obtained from 8 stage IV osimertinib-treated EGFR T790M-positive lung adenocarcinoma patients. RESULTS: Our results revealed a significant correlation between the by-patient methylation level with the maximum allele fraction (maxAF, P=0.0002). The methylation levels were significantly higher in the plasma samples of patients with detectable somatic mutations than patients without somatic mutations (P=0.0003) and healthy controls (P=0.0018). Moreover, analysis of both the DNA methylation level and maxAF revealed four trends of treatment response. Collectively, the decrease in methylation level and maxAF reflected treatment efficacy, while the gradual increase reflected impending disease progression (PD). Elevated methylation levels and maxAF were observed in 6 and 5 patients in an average lead-time of 3.0 and 1.9 months, respectively, prior to evaluation of PD using radiological imaging. CONCLUSIONS: DNA methylation profiling has the potential to predict disease relapse prior to evaluation through radiological modalities, suggesting that serial assessment of methylation level in combination with somatic mutation profiling are reliable methods for treatment monitoring. These methods should thus be incorporated with imaging modalities for a more comprehensive work-up of treatment response, particularly for patients treated with targeted therapies.

ObjectiveTo determine the joint role of ideal cardiovascular health (CVH) and genetic risk on risk of dementia.MethodsWe categorized CVH on the basis of the American Heart Association Ideal CVH Index and genetic risk through a genetic risk score (GRS) of common genetic variants and the APOE ε4 genotype in 1,211 Framingham Heart Study (FHS) offspring cohort participants. We used multivariable Cox proportional hazards regression models to examine the association between CVH, genetic risk, and incident all-cause dementia with up to 10 years of follow-up (mean 8.4 years, 96 incident dementia cases), adjusting for age, sex, and education.ResultsWe observed that a high GRS (>80th percentile) was associated with a 2.6-fold risk of dementia (95% confidence interval [CI] of hazard ratio [HR] 1.23–5.29; p = 0.012) compared with having a low GRS (APOE ε4 allele was associated with a 2.3-fold risk of dementia compared with not carrying an APOE ε4 allele (95% CI of HR 1.49–3.53; p = 0.0002), and having a favorable CVH showed a 0.45-fold lower risk of dementia (95% CI of HR 0.20–1.01; p = 0.0527) compared to having an unfavorable CVH when all 3 components were included in the model. We did not observe an interaction between CVH and GRS (p = 0.99) or APOE ε4 (p = 0.16).ConclusionsWe observed that both genetic risk and CVH contribute additively to dementia risk.

Objectives: Chronic recalcitrant cough is present in 2/3 of pediatric patients evaluated in our tertiary-care multidisciplinary aerodigestive clinic (ADC). This study aimed to determine the impact of chronic cough and efficacy of ADC treatment using the validated Pediatric-Cough Quality-of-Life-27 tool (PC-QOL-27). Methods: The PC-QOL-27 survey was administered to ADC patients with chronic cough at initial clinic visit and 6 to 12 weeks after cough management. Pre and post survey scores, demographic data, treatment and evaluation season were collected over 16 months. Results: Twenty parents completed pre and post PC-QOL-27 surveys (mean 12.1 weeks later). Patient median age was 6.04 years (IQR: 2.2-10.44 years). A total of 65% were males and 65% were African American. Management was tailored based on clinical assessment and diagnostic studies, including direct laryngoscopy/bronchoscopy (4), pulmonary function tests (PFT’s 9), esophagogastroduodenoscopy (9), and flexible bronchoscopy/lavage (9). Following ADC management, changes in physical, social and psychological domain scores of the PC-QOL-27 each met the threshold for minimal clinical important difference (MCID) indicating a clinically meaningful improvement. Improvements were most notable in the physical domain where post survey scores significantly improved from pre-survey scores ( P = .009) regardless of age, gender, ethnicity, history of endoscopy and season. Conclusions: The physical impact of chronic cough in pediatric patients who failed prior management by a single specialist was lessened by an ADC team approach to management.

Introduction. Hip fracture is a major cause of morbidity and mortality in older adults. Intertrochanteric hip fractures often are treated surgically using cephalomedullary nails (CMN), in either a short or long length. Their outcomes are documented in the literature; however, outcomes of the intermediate-length CMN have not been well described. Methods. A retrospective review was conducted of older adults with intertrochanteric hip fractures that were treated with cephalomedullary nail fixation using an intermediate-length (235 mm Synthes Trochanteric Fixation® nail or 240 mm Stryker Gamma 3®) nail. Outcome data were collected during the inpatient stay and 16 months post-operatively. Results. Seventy-seven patients met inclusion criteria and were reviewed during inpatient stay; however, only 42 had documented post-operative outcomes. Of those, two patients died post-discharge and were not included in the 16-month follow-up. Comparison of results to published literature suggested that intermediate-length nails are comparable to short-length nails with regard to time in the operating room and estimated blood loss. The rate of blood transfusion was lower and length of hospital stay was shorter than in comparable studies of both short- and long-length nails. There were no post-operative periprosthetic fractures in the 16-month follow-up. This rate was lower than published rates for short and long nails. The hardware failure rate (3/42, 7.1%) of intermediate-length nails was higher than comparison studies of both short- and long-length nails. Conclusions. Patient outcomes for intermediate-length nails were similar to outcomes of shorter length nails. Utilization of the intermediate-length nail appears to be an effective treatment option for repair of intertrochanteric femur fractures. However, direct comparison is difficult since periprosthetic fracture rate may increase over time and nail length and hardware failure are not defined consistently in the literature. Further study is needed with a larger sample size followed over a longer period of time to confirm our findings.