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OBJECTIVES: Incidental small renal masses (SRMs) now account for the majority of new diagnoses of renal cancers. Although there are established management guidelines, referral and management patterns can vary. We aimed to explore identification, practice patterns, and management of identified SRMs in an integrated health system. STUDY DESIGN: Retrospective analysis. METHODS: We identified patients with a newly diagnosed SRM measuring 3 cm or less from January 1, 2013, to December 31, 2017, at Kaiser Permanente Southern California. These patients were flagged at the time of radiographic identification to ensure adequate notification of findings. Diagnostic modality, referral, and treatment patterns were analyzed. RESULTS: Of 519 patients with SRMs, 65% were found on abdominal CT and 22% on renal/abdominal ultrasounds. Within 6 months, 70% of patients consulted with a urologist. Initial management patterns were as follows: active surveillance (60%), partial/radical nephrectomy (18%), and ablation (4%). Among 312 patients on surveillance, 14% eventually received treatment. The majority of patients (69.4%) did not receive guideline-recommended chest imaging for initial staging. Urologist visit within 6 months of SRM diagnosis was associated with increased adherence to staging (P = .003) and subsequent surveillance imaging (P < .001). CONCLUSIONS: In this contemporary analysis of an integrated health system's experience, referral to a urologist was associated with guideline-concordant staging and surveillance imaging. Frequent utilization of active surveillance with a low rate of progression to active treatment was noted in both groups. These findings shed light on care patterns upstream of urologic evaluation and support the need for clinical pathways to be implemented at the time of radiologic diagnosis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Timely receipt of surgery should be available for all patients. Few studies have examined differences in the treatment of symptomatic cholelithiasis (SC), a common surgical problem, based on race/ethnicity or insurance status. This study aimed to identify differences in repeat emergency department (ED) use and wait time to cholecystectomy for SC. STUDY DESIGN: Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Repeat ED use and wait time to elective and nonelective cholecystectomy after ED discharge were examined using logistic and negative binomial regression models. RESULTS: The final cohort analyzed 13,596 patients who underwent cholecystectomy within 1 year from index ED visit for SC. In adjusted analysis, non-Hispanic Black patients had higher odds for repeat ED use for biliary-related conditions before elective surgery and experienced longer waits for cholecystectomy (across several measures of wait times) compared with non-Hispanic White patients. Similar findings were seen for Medicaid and self-pay compared with privately insured patients. For example, self-pay patients had more than double the odds of experiencing repeat ED use while waiting for elective cholecystectomy compared with privately insured patients (adjusted odds ratio 2.49, 95% CI 1.88-3.31). CONCLUSION: Patients with SC receiving cholecystectomy within 1 year from index ED visit were more likely to have repeat ED use and longer waits to surgery based on their race/ethnicity and insurance status, even after adjusting for other measures of access. We identify a vulnerable population at risk for differences in treatment for a common surgical pathology. [ABSTRACT FROM AUTHOR]

This case series describes the rate and time to return to sport following nonoperative management of abdominal muscle strain in the National Collegiate Athletic Association Division I. Twenty-seven overhead athletes were included, and each participated in a rehabilitation flexibility program as well as interventions addressing hip and thoracic rotational deficits. To our knowledge, this is the first study to report on the rates of abdominal injury in overhead athletes and their return to sport at a National Collegiate Athletic Association Division I institution. Volleyball athletes were disproportionately affected by abdominal injuries in the present study, and these injuries have been reported to account for up to 22.2% of muscle injuries in elite volleyball athletes. Similar to the finding in the present study, two baseball studies demonstrated that the abdominal musculature on the opposite side of the dominant arm (lead side) was usually affected. [ABSTRACT FROM AUTHOR]

Background: Nonventilator hospital--acquired pneumonia (NV-HAP) is a common hospital-acquired condition that is amenable to basic nursing care interventions. Purpose: The purpose of this study was to determine the incidence of NV-HAP in a California community hospital and to identify the patient and nursing care factors including missed nursing care associated with its development. Methods: A retrospective study identified possible NV-HAP cases with ICD-10 (International Classification of Diseases, Tenth Revision) codes and then validated cases using Centers for Disease Control and Prevention confirmatory criteria. Results: The incidence of NV-HAP in our hospital was 0.64 cases per 1000 patient-days. Patient factors most strongly associated with NV-HAP were age (each year of increased age was associated with a 4% increased likelihood of developing NV-HAP) (OR = 1.04-1.07) and the presence of underlying disease, which reduced odds of developing NV-HAP by 36% (OR = 0.36; 95% CI, 0.12-0.98). Head-of-bed elevation reduced by 26% the odds of developing NV-HAP (OR = 0.26; 95% CI, 0.07-0.08). Conclusions: NV-HAP can be predicted and potentially prevented. Paradoxically, the presence of underlying disease was not positively associated with the development of NV-HAP in this study. [ABSTRACT FROM AUTHOR]

Objective: Due to physiological and metabolic immaturity, prematurely born infants are at increased risk because of maternal separation in many neonatal intensive care units (NICUs). The stress induced from maternal–infant separation can lead to well-documented short-term physiologic instability and potentially lifelong neurological, sociological, or psychological sequelae. Based on previous studies of kangaroo mother care (KMC) that demonstrated improvement in physiologic parameters, we examined the impact of KMC on physiologic measures of stress (abdominal temperature, heart rate, oxygen saturation, perfusion index, near-infrared spectrometry), oxidative stress, and energy utilization/conservation in preterm infants. Methods: In this randomized, stratified study of premature neonates, we compared the effects on urinary concentrations of biomarkers of energy utilization and oxidative stress of 1 hr of KMC versus incubator care on Day 3 of life in intervention-group babies (n = 26) and control-group babies (n = 25), respectively. On Day 4, both groups received 1 hr of KMC. Urinary samples were collected 3 hr before and 3 hr after intervention/incubator care on both days. Energy utilization was assessed by measures of adenosine triphosphate (ATP) degradation (i.e., hypoxanthine, xanthine, and uric acid). Oxidative stress was assessed using urinary allantoin. Mixed-models analysis was used to assess differences in purine/allantoin. Results: Mean allantoin levels over Days 3 and 4 were significantly lower in the KMC group than in the control group (p =.026). Conclusions: Results provide preliminary evidence that KMC reduces neonatal oxidative stress processes and that urinary allantoin could serve as an effective noninvasive marker for future studies. [ABSTRACT FROM AUTHOR]

BACKGROUND: We sought to describe adverse events associated with unplanned extubation (UE) and to explore risk factors for serious adverse events post-UE among infants who experienced UE. METHODS: Data were prospectively collected on all infants who had a UE event at a single institution over a 4-y period. Demographic information and information on outcomes were obtained retrospectively. We described the frequency of post-UE adverse events: success or failure of extu- bation trial if offered, rate of re-intubation, post-UE changes in ventilator settings, and serious adverse events post-UE (eg, need for cardiopulmonary resuscitation, clinical sepsis, and death or tracheostomy prior to discharge). We used a multivariate logistic regression model to identify the risk factors associated with serious adverse events. RESULTS: There were 134 documented UE events. Agitation was the most common known cause. After UE, 49% of the subjects were given a trial of extubation, and 65% of the trials were successful at 48 h. Cardiopulmonary resuscitation (CPR) was performed in 13% of cases. In subjects requiring immediate re-intubation, mean airway pressure (...) and oxygen requirement increased in 33% and 55% of the subjects, respectively. Post-UE clinical sepsis occurred in 17% of subjects. Higher pre-UE ... and difficult re-intubation were associated with a need for CPR. Subjects who received CPR had increased odds (3.7 X) of developing clinical sepsis. CONCLUSION: UE can result in serious adverse events, including hemodynamic instability and possibly an increased risk for clinical sepsis. Difficult re-intubation was associated with a higher risk of needing CPR and, later, tracheostomy and death. [ABSTRACT FROM AUTHOR]

Immigrants account for a significant proportion of the nursing workforce in the United States (U.S.). Although different cultural backgrounds may affect immigrant nurses' perceptions of work and occupational health risks, little research has been conducted. Defining immigrant nurses as those who received initial nursing education in foreign countries, this study examined the differences in work-related perceptions and experiences of musculoskeletal (MS) symptoms and injuries between U.S.-educated and foreign-educated nurses. We analyzed data from a cross-sectional study using a statewide random sample of 419 California registered nurses. Foreign-educated nurses reported a more positive safety climate (p =.017) and perceived their jobs as less demanding (p =.008) than did U.S.-educated nurses. The prevalence of work-related MS symptoms was significantly lower in foreign-educated nurses than in U.S.-educated nurses (p =.044), but the difference was not significant in the multivariable analyses. Positive safety climate was significantly associated with a decreased risk of work-related MS symptoms and injuries, and this relationship was greater among U.S.-educated nurses than among foreign-educated nurses. Our findings suggest that immigrant nurses may have different perceptions about safety climate and job demand, which may modify their occupational health risks. [ABSTRACT FROM AUTHOR]

BACKGROUND: High risk for readmission in patients with heart failure (HF) is associated with Hispanic ethnicity, multimorbidity, smaller hospitals, and hospitals serving low-socioeconomic or heavily Hispanic regions and those with limited cardiac services. Information for hospitals caring primarily for such high-risk patients is lacking. OBJECTIVE: The aim of this study was to identify factors associated with 30-day HF readmission after HF hospitalization in a rural, primarily Hispanic, low-socioeconomic, and underserved region. METHODS: Electronic medical records for all HF admissions within a 2-year period to a 107-bed hospital near the California-Mexico border were reviewed. Logistic regression was used to identify independent predictors of readmission. RESULTS: A total of 189 unique patients had 30-day follow-up data. Patientswere primarily Hispanic (71%),male (58%), and overweight or obese (82.5%)with 4 or more chronic conditions (83%) and a mean age of 68 years. The 30-day HF readmission rate was 5.3%. Early readmission was associated with history of HF, more previous emergency department (ED) and hospital visits, higher diastolic blood pressure and hypokalemia at presentation, shorter length of stay, and higher heart rate, diastolic blood pressure, and atrial fibrillation (AF) at discharge. Using logistic regression, previous 6-month ED visits (odds ratio, 1.5; P = .009) and AF at discharge (odds ratio, 5.7; P = .039) were identified as independent predictors of 30-day HF readmission. CONCLUSIONS: Previous ED use and AF at discharge predicted early HF readmission in a high-risk, primarily Hispanic, rural population in a low-socioeconomic region. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with cancer often experience prominent deficiencies in cancer care in the immediate period following initial cancer diagnosis. OBJECTIVES: This article aims to determine whether the inclusion of a gastrointestinal (GI) oncology nurse navigator (ONN) on the multidisciplinary cancer care team is associated with improved quality of care for patients. METHODS: This retrospective study compared randomly selected patients with GI cancer with and without an ONN. Two endpoints, the time from diagnosis to treatment and the average number of missed appointments, were evaluated through a review of healthcare records using the Epic electronic health records system. FINDINGS: Patients with an ONN had a shorter time lapse between diagnosis and treatment commencement (p < 0.001). In this group, the average time spent between initial diagnosis and the start of treatment was 15.15 days, compared to 42.93 days for patients who were not part of the multidisciplinary cancer care model. [ABSTRACT FROM AUTHOR]

Background: Cartilage repair algorithms use lesion size to choose surgical techniques when selecting a cartilage repair procedure. The association of fresh osteochondral allograft (OCA) size with graft survivorship and subjective patient outcomes is still unknown. Purpose: To determine if lesion size (absolute or relative) affects outcomes after OCA transplantation. Study Design: Cohort study; Level of evidence, 3. Methods: The study included 156 knees in 143 patients who underwent OCA transplantation from 1998 to 2014 for isolated femoral condyle lesions. The mean age was 29.6 ± 11.4 years, and 62.9% were male. The majority of patients (62.2%) presented for cartilage repair because of osteochondritis dissecans. The mean graft area, used as a surrogate for absolute size of the lesion, was 6.4 cm2 (range, 2.3-11.5 cm2). The relative size of the lesion was calculated as the tibial width ratio (TWR; ratio of graft area to tibial width) and affected femoral condyle ratio (AFCR; ratio of graft area to affected femoral condyle width) using preoperative radiographs. All patients had a minimum follow-up of 2 years. Further surgical procedures were documented, and graft failure was defined as revision OCA transplantation or conversion to arthroplasty. International Knee Documentation Committee (IKDC) pain, function, and total scores were obtained. Satisfaction with OCA transplantation was assessed. Results: The mean follow-up among patients with grafts remaining in situ was 6.0 years (range, 1.9-16.5 years). The OCA failure rate was 5.8%. Overall survivorship of the graft was 97.2% at 5 years and 93.5% at 10 years. No difference in postoperative outcomes between groups was found in absolute or relative size. Change in IKDC scores (from preoperative to latest follow-up) was greater for knees with large lesions compared to knees with small lesions, among all measurement methods. Overall satisfaction with the results of OCA transplantation was 89.8%. Conclusion: The size of the lesion, either absolute or relative, does not influence outcomes after OCA transplantation for isolated femoral condyle lesions of the knee. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine whether the presence of a birth plan was associated with mode of delivery, obstetrical interventions, and patient satisfaction. Methods: This was a prospective cohort study of singleton pregnancies greater than 34 weeks’ gestation powered to evaluate a difference in mode of delivery. Maternal characteristics, antenatal factors, neonatal characteristics, and patient satisfaction measures were compared between groups. Differences between groups were analyzed using chi‐squared for categorical variables, Fisher exact test for dichotomous variables, and Wilcoxon rank sum test for continuous or ordinal variables. Results: Three hundred women were recruited: 143 (48%) had a birth plan. There was no significant difference in the risk of cesarean delivery for women with a birth plan compared with those without a birth plan (21% vs 16%, adjusted odds ratio [adjOR] 1.11 [95% confidence interval (CI) 0.61‐2.04]). Women with a birth plan were 28% less likely to receive oxytocin (P < .01), 29% less likely to undergo artificial rupture of membranes (P < .01), and 31% less likely to have an epidural (P < .01). There was no difference in the length of labor (P = .12). Women with a birth plan were less satisfied (P < .01) and felt less in control (P < .01) of their birth experience than those without a birth plan. Conclusion: Women with and without a birth plan had similar odds of cesarean delivery. Though they had fewer obstetrical interventions, they were less satisfied with their birth experience, compared with women without birth plans. Further research is needed to understand how to improve childbirth‐related patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Femoroacetabular impingement (FAI) can lead to hip pain and early joint degeneration. There have been few reports to date on the outcomes of hip arthroscopy for the treatment of FAI in the military population. Purpose/Hypothesis: The purpose of this study was to compare patient demographics with postoperative outcomes after hip arthroscopy for symptomatic FAI and to identify preoperative risk factors for poor outcomes. The hypothesis was that certain preoperative patient characteristics will be predictive of poorer outcomes and that lower outcomes scores will be associated with a higher likelihood of medical separation from the military. Study Design: Case series; Level of evidence, 4. Methods: Retrospective chart review of active-duty and dependent patients older than 18 years who underwent hip arthroscopy for symptomatic FAI from 2009 to 2014 at a single institution. Results: A total of 469 (309 males and 160 females) surgeries were performed on 456 active-duty personnel and 13 dependent civilians, with a mean 2.5-year follow-up. Overall, 39% (n = 179) were able to return to duty (RTD), 18% (n = 82) were medically cleared to return to normal daily activities but did not remain on active duty, and 43% (n = 195) required referral to the Disability Evaluation System (DES). Increasing rank and male sex were positive predictors and Axis 1 psychiatric diagnosis, revision surgery, concomitant psoas tenotomy, multiple medical comorbidities, and complaints of generalized pelvic pain were negative predictors for returning to duty. US Marine Infantry and Special Forces showed improved RTD rates (50%-86%) compared with administrative, more sedentary, occupations (22%). On average, Single Alpha Numeric Evaluation (SANE) and visual analog scale (VAS) scores improved after surgery, with SANE scores improving 37 ± 28 points and VAS scores improving 2.6 ± 2.5 points. The mean postoperative SANE and VAS scores differed significantly between the RTD group and those not returning to duty; 87 and 1.2 points compared with 69 and 3.6 points, respectively (P < .0001). Conclusion: Hip arthroscopy for the treatment of symptomatic FAI effectively improves pain symptoms and self-reported overall function but shows a much lower than expected return to full, unrestricted active duty in the general active-duty military population. Underlying psychiatric diagnoses, female sex, and more sedentary occupations are associated with lower RTD rates. Furthermore, lower postoperative SANE and VAS scores are associated with lower RTD rates. Only the more active and elite components of the military study population showed RTD rates consistent with previously reported outcomes of return to competitive sports after hip arthroscopy for FAI. [ABSTRACT FROM AUTHOR]

Background: Homeless female ex-offenders (homeless female offenders) exiting jail and prison are at a critical juncture during reentry and transitioning into the community setting. Objective: The purpose of the study was to compare the effect of a dialectical behavioral therapy-case management (DBT-CM) program with a health promotion (HP) program on achieving drug and alcohol abstinence among female parolees/probationers residing in the community. Methods: We conducted a multicenter parallel randomized controlled trial with 130 female parolees/probationers (aged 19-64 years) residing in the community randomly assigned to either DBT-CM (n = 65) or HP (n = 65). The trial was conducted in four community-based partner sites in Los Angeles and Pomona, California, from February 2015 to November 2016. Treatment assignment was carried out using a computer-based urn randomization program. The primary outcome was drug and alcohol use abstinence at 6-month follow up. Results: Analysis was based on data from 116 participants with complete outcome data. Multivariable logistic regression revealed that the DBT-CM program remained an independent positive predictor of decrease in drug use among the DBT-CM participants at 6 months (p = .01) as compared with the HP program participants. Being non-White (p < .05) and having higher depressive symptom scores (p < .05) were associated with lower odds of drug use abstinence (i.e., increased the odds of drug use) at 6 months. Discussion: DBT-CM increased drug and alcohol abstinence at 6-month follow-up, compared to an HP program. [ABSTRACT FROM AUTHOR]

Aims and objectives To evaluate the effect of an 'insulin introduction' group visit on insulin initiation and A1C in adults with type 2 diabetes. Background The clinical course of type 2 diabetes involves eventual beta-cell failure and the need for insulin therapy. Patient psychological insulin resistance, provider-related delays and system barriers to timely initiation of insulin are common. Group visits are widely accepted by patients and represent a potential strategy for improving insulin initiation. Design A single two-hour group visit in English or Spanish, facilitated by advanced practice nurses, addressed psychological insulin resistance and encouraged mock injections to overcome needle anxiety. Methods A retrospective review of 273 patients referred from 2008-2012, determined characteristics of group attenders, rates of mock self-injection, rates of insulin initiation and changes in A1C from baseline to 2-6 and 7-12 months postgroup. Change in A1C was compared to patients referred to the group who did not attend ('nonattenders'). Results Of 241 patients eligible for analysis, 87·6% were racial/ethnic minorities with an average A1C of 9·99%. Group attendance rate was 66%; 92% performed a mock injection, 55% subsequently started insulin. By 2-6 months, A1C decreased by 1·37% among group attenders, and by 1·6% in those who did a mock injection and started insulin. Fewer nonattenders started insulin in primary care (40%), experiencing an A1C reduction of 0·56% by 2-6 months. A1C improvements were sustained by 7-12 months among group attenders and nonattenders who started insulin. Relevance to clinical practice Nurses can effectively address patient fears and engage patients in reframing insulin therapy within group visits. Conclusions This one-time nurse-facilitated group visit addressing psychological barriers to insulin in a predominantly minority patient population resulted in increased insulin initiation rates and clinically meaningful A1C reductions. [ABSTRACT FROM AUTHOR]

Background and aims Treatment for opioid use disorders (OUD) reduces the risk of mortality and infectious disease transmission; however, opportunities to quantify the potential economic benefits of associated decreases in drug-related crime are scarce. This paper aimed to estimate the costs of crime during and after periods of engagement in publicly funded treatment for OUD to compare total costs of crime during a hypothetical 6-month period following initiation of opioid agonist treatment (OAT) versus detoxification. Design Retrospective, administrative data-based cohort study with comprehensive information on drug treatment and criminal justice systems interactions. Setting Publicly funded drug treatment facilities in California, USA (2006-10). Participants A total of 31 659 individuals admitted for the first time to treatment for OUD, and who were linked with criminal justice and mortality data, were followed during a median 2.3 years. Median age at first treatment admission was 32, 35.8% were women and 37.1% primarily used prescription opioids. Measurements Daily costs of crime (US$2014) were calculated from a societal perspective and were composed of the costs of policing, court, corrections and criminal victimization. We estimated the average marginal effect of treatment engagement in OAT or detoxification adjusting for potential fixed and time-varying confounders, including drug use and criminal justice system involvement prior to treatment initiation. Findings Daily costs of crime during treatment compared with after treatment were $126 lower for OAT [95% confidence interval (CI) = $116, $136] and $144 lower for detoxification (95% CI = $135, $154). Summing the costs of crime during and after treatment over a hypothetical 6-month period using the observed median durations of OAT (161 days) and detoxification (19 days), we estimated that enrolling an individual in OAT as opposed to detoxification would save $17 550 ($16 840, $18 383). Conclusions In publicly funded drug treatment facilities in California, USA, engagement in treatment for opioid use disorders is associated with lower costs of crime in the 6 months following initiation of treatment, and the economic benefits were far greater for individuals receiving time-unlimited treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: In June 2010, Kaiser Permanente Northern California replaced all abstract 7-valent pneumococcal conjugate vaccine (PCV7) vaccines with the 13-valent pneumococcal conjugate vaccine (PCV13). Our objectives were to compare the incidence of bacteremia in children 3 to 36 months old by 3 time periods: pre-PCV7, post-PCV7/pre-PCV13, and post-PCV13. METHODS: We designed a retrospective review of the electronic medical records of all blood cultures collected on children 3 to 36 months old at Kaiser Permanente Northern California from September 1, 1998 to August 31, 2014 in outpatient clinics, in emergency departments, and in the first 24 hours of hospitalization. RESULTS: During the study period, 57 733 blood cultures were collected in the population of children 3 to 36 months old. Implementation of routine immunization with the pneumococcal conjugate vaccine resulted in a 95.3% reduction of Streptococcus pneumoniae bacteremia, decreasing from 74.5 to 10 to 3.5 per 100 000 children per year by the post- PCV13 period. As pneumococcal rates decreased, Escherichia coli, Salmonella spp, and Staphylococcus aureus caused 77% of bacteremia. Seventy-six percent of all bacteremia in the post-PCV13 period occurred with a source. CONCLUSIONS: In the United States, routine immunizations have made bacteremia in the previously healthy toddler a rare event. As the incidence of pneumococcal bacteremia has decreased, E coli, Salmonella spp, and S aureus have increased in relative importance. New guidelines are needed to approach the previously healthy febrile toddler in the outpatient setting. [ABSTRACT FROM AUTHOR]

Background: Prenatal alcohol exposure results in a broad range of cognitive and behavioral impairments. Because of the long-lasting problems that are associated with fetal alcohol spectrum disorders (FASDs), the development of effective treatment programs is critical. Preclinical animal studies have shown that choline, which is an essential nutrient, can attenuate the severity of alcohol-related cognitive impairments. Objective: We aimed to translate preclinical findings to a clinical population to investigate whether choline supplementation can ameliorate the severity of memory, executive function, and attention deficits in children with FASDs. Design: In the current study, which was a randomized, double-blind, placebo-controlled clinical trial, we explored the effectiveness of a choline intervention for children with FASDs who were aged 5-10 y. Fifty-five children with confirmed histories of heavy prenatal alcohol exposure were randomly assigned to either the choline (n = 29) or placebo (n = 26) treatment arms. Participants in the choline group received 625 mg choline/d for 6 wk, whereas subjects in the placebo group received an equivalent dose of an inactive placebo treatment. Primary outcomes, including the performance on neuropsychological measures of memory, executive function, and attention and hyperactivity, were assessed at baseline and postintervention. Results: Compared with the placebo group, participants in the choline group did not differentially improve in cognitive performance in any domain. Treatment compliance and mean dietary choline intake were not predictive of treatment outcomes. Conclusions: Findings of the current study do not support that choline, administered at a dose of 625 mg/d for 6 wk, is an effective intervention for school-aged (5-10 y old) children with FASDs. This research provides important information about choline's therapeutic window. Combined with other studies of choline and nutritional interventions in this population, this study emphasizes a further need for the continued study of the role of nutritional status and supplementation in children with FASDs and the contributions of nutrition to neurocognition. This trial was registered at clinicaltrials.gov as NCT01911299. [ABSTRACT FROM AUTHOR]

Although vaccination against the Human Papilloma Virus (HPV) reduces the risk of related morbidities, the vaccine uptake remains low in adolescents. This has been attributed to limited parental knowledge and misconceptions. In this cross sectional study, we assessed the (1) clarity of educational material informing Hispanic mothers about HPV, cervical cancer and the HPV vaccine, (2) determined vaccination acceptability and (3) identified predictors of vaccine acceptance in an underserved health setting. 418 Hispanic mothers received the educational material and completed an anonymous survey. 91 % of participants understood most or all of the information provided. 77 % of participants reported vaccine acceptance for their children; this increased to 84 % when only those with children eligible to receive vaccination were included. Significant positive predictors of maternal acceptance of the HPV vaccine for their children were understanding most or all of the provided information, older age and acceptance of the HPV vaccine for themselves. Concerns about safety and general dislike of vaccines were negatively associated with HPV vaccine acceptance. Prior knowledge, level of education, previous relevant gynecologic history, general willingness to vaccinate and other general beliefs about vaccines were not significantly associated with HPV vaccine acceptance. The majority of participants reported understanding of the provided educational material. Vaccine acceptability was fairly high, but was even higher among those who understood the information. This study documents a cost-effective way to provide Hispanic mothers with easy-to-understand HPV-related information that could increase parental vaccine acceptability and future vaccine uptake among their children. [ABSTRACT FROM AUTHOR]

Although poor clinic attendance is associated with increased morbidity and mortality among HIV-infected individuals, less is known about predictors of retention and the acceptability of targeted interventions to increase regular clinic attendance. To better understand which patients are at risk for irregular clinic attendance and to explore interventions to aid in retention to care, we surveyed patients attending two outpatient HIV clinics affiliated with the University of California, San Francisco. A total of 606 participants were surveyed, and the analysis was restricted to the 523 male respondents. Of this group, 45% (N= 299) reported missing at least one visit a year. Missing a clinic visit was associated with being African American (aOR = 1.99; 95%CI 1.12–3.52), being a man who has sex with both men and women (aOR=2.72; 95%CI 1.16–6.37), and reporting at least weekly methamphetamine use (aOR=5.79; 95%CI 2.47–13.57). Participants who reported a monthly income greater than $2000 were less likely to miss an appointment (aOR = 0.56; 95%CI 0.34–0.93). Regarding possible retention interventions, most patients preferred phone calls over other forms of support. These findings support the need for ongoing engagement support with particular attention to at-risk sub-groups. [ABSTRACT FROM PUBLISHER]

Context.--Molecular diagnostics allow for rapid identification and detection of resistance markers of bloodstream infection, with a potential for accelerated antimicrobial optimization and improved patient outcomes. Although the impact of rapid diagnosis has been reported, studies in pediatric patients are scarce. Objective.--To determine the impact of a molecular blood-culture assay that identifies a broad-spectrum of pathogens and resistance markers in pediatric patients with gram-positive bloodstream infections. Design.--Data on the time to antimicrobial optimization, the length of hospitalization, and the hospital cost following implementation of a rapid assay were prospectively collected and compared with corresponding preimplementation data. Results.--There were 440 episodes from 383 patients included, 221 preimplementation episodes and 219 post-implementation episodes. Overall time to antimicrobial optimization was shortened by 12.5 hours (P = .006), 11.9 hours (P = .005) for bloodstream infections of Staphylococcus aureus specifically. Duration of antibiotics for those with probable blood-culture contamination with coagu-lase-negative staphylococci was reduced by 36.9 hours (P < .001). Median length of stay for patients admitted to general pediatric units was 1.5 days shorter (P = .04), and median hospital cost was $3757 (P = .03) less after implementation. For S aureus bloodstream infections, median length of stay and hospital cost were decreased by 5.6 days (P = .01) and $13 341 (P = .03), respectively. Conclusions.--Implementation of molecular assay for the detection of gram-positive pathogens and resistance markers significantly reduced time to identification and resistance detection, resulting in accelerated optimization of therapy, shorter length of stay, and decreased health care cost. [ABSTRACT FROM AUTHOR]

Background Reduction in mitral regurgitation ( MR) after transcatheter aortic valve replacement ( TAVR) has previously been reported. However, the hemodynamic effects of TAVR in patients with MR have not been previously evaluated. Methods We analyzed 571 patients who underwent TAVR from December 2010 to December 2013. We studied 20 patients with moderate or severe preprocedural functional mitral regurgitation ( FMR) who also had a follow-up transthoracic echocardiography ( TTE) examination between 90 and 360 days (median 213 days) after TAVR (Significant FMR Group). We also studied age- and gender-matched 20 patients with mild or lesser MR (Nonsignificant MR Group). Left ventricular functional measurements were assessed using echocardiography before and after TAVR. Left ventricular outflow tract stroke volume measurements using pulsed-wave Doppler ( SVLVOT) were calculated as a representative of systolic forward flow, and stroke volume by the Simpson's method (SVSimpson) was calculated as a parameter of degree of LV contraction. Results MR grade improved in 22 of 40 patients after TAVR. In both groups, BNP level decreased, left ventricular ejection fraction increased, and SVLVOT increased after TAVR. SVSimpson increased in the Nonsignificant MR Group and remained unchanged in the Significant FMR Group. Vena contracta width of MR ( MRVC) decreased in the Significant FMR Group. Using multivariable analysis in the Significant FMR Group, the increase in SVLVOT significantly correlated with the decrease in MRVC (P < 0.05). Conclusions SVLVOT increased significantly after TAVR in patients with FMR. In these patients, increase in SVLVOT after TAVR was associated with decrease in severity of MR. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the compliance with and tolerability of daily cranberry capsule ingestion for asymptomatic bacteriuria (ASB) prevention in pregnancy. Design: A total of 49 pregnant women from two sites were randomly assigned to cranberry or matching placebo, two doses daily, at gestational ages less than 16 weeks. Patients were followed monthly for urinary tract infection until delivery. Up to seven monthly visits were scheduled for each patient. Delivery data were evaluated. Results: Of 38 evaluable patients, the mean compliance rate over the study period was 82% (range, 20%-100%). This compliance rate and the 74% of patients achieving good (≥75%) compliance were similar between those who received cranberry capsules and placebo. Compliance evaluation revealed that most patients stopped capsule consumption after 34-38 weeks of participation. Multivariate logistic regression and longitudinal analysis showed a significant interaction time effect with cranberry treatment. However, cranberry consumption was not a significant predictor of gastrointestinal intolerance or study withdrawal. Although 30% of patients withdrew for various reasons, only 1 withdrew because of intolerance to the cranberry capsules. Loss to follow-up was mostly due to provider change (9 of 49 [18%]) and therapy disinterest (4 of 49 [8%]). Seven cases of ASB occurred in 5 patients: 2 of 24 (8%) in the cranberry group and 3 of 25 (12%) in the placebo group. No cases of cystitis or pyelonephritis were observed. Conclusion: One third of pregnant women could not complete the study protocol for various reasons. Compliance with and tolerability of cranberry capsule ingestion appear good; these capsules provide a potentially effective means to prevent ASB in pregnancy. Further studies with large samples are necessary to confirm the findings. [ABSTRACT FROM AUTHOR]

Background Atrioventricular nodal reentrant tachycardia (AVNRT) typically occurs in adolescents and adults with limited data regarding AVNRT in young children. Methods All patients with AVNRT who underwent electrophysiology study and ablation between 2005 and 2012 were retrospectively studied. Patients were stratified by age <10 years (young AVNRT) or ≥10 years (older AVNRT). Young AVNRT patients were also compared to age-matched patients with orthodromic reentrant tachycardia (ORT). Results A total of 275 studies in 272 patients were evaluated including 38 young AVNRT patients (7.7 ± 1.5 years) and 202 older AVNRT patients (14.9 ± 2.1 years). An atrial-His jump ≥50 ms was demonstrated in 56% of young and 64% of older patients. Slow pathway modification was attempted in all but one older patient with acute ablation success achieved in all. RF ablation was the primary ablation modality with cryoablation used in 10 patients (three young and seven older). Recurrences were rare (zero young and three older patients) despite residual AVNRT echo beats postablation in 34% of young and 40% of older patients. One older AVNRT patient (0.5%) required a pacemaker for heart block while no complications occurred in the young patients. Electrophysiologic parameters were comparable to the 35 age-matched young ORT group (7.7 ±1.7 years) in whom supraventricular tachycardia was more inducible. Concusions Slow pathway modification for AVNRT in children resulted in high success and low complication rates, regardless of age. Recurrence of tachycardia was infrequent despite persistence of AVNRT echo beats in 34-40% of patients following slow pathway modification. [ABSTRACT FROM AUTHOR]

Primary gastrointestinal non-Hodgkin's lymphoma (PGINHL) is a heterogeneous family of tumors, with treatment modalities including chemotherapy, surgery, and radiotherapy. Because the role of surgery in PGINHL remains disputed, this study aims to assess the impact of operative resection on survival. We used a pathology database to identify all cases of PGINHL diagnosed at a single academic-affiliated medical center from 1988 to 2013. Demographic and clinical data were abstracted from the medical record. We summarized the clinical courses of patients with PGINHL and then performed a survival analysis to compare overall and disease-free survival, stratified by demographic and clinical variables. We identified 33 patients diagnosed with PGINHL during the study period. Of 29 who subsequently received treatment at the institution, 15 initially underwent chemotherapy, 10 underwent surgical resection, and 4 underwent surgery for other reasons such as diagnosis without resection or management of disease complications. Three patients suffered surgical complications and two of these patients died. We found no difference in overall survival between patients receiving surgical resection and patients managed initially with chemotherapy. This case series supports a continued role for surgical resection in the management of patients with PGINHL, though anticipated benefits should be weighed against the risk of complications. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: High bilirubin levels are associated with sensorineural hearing loss (SNHL). However, few large studies of relative and excess risk exist. We sought to quantify the risk of SNHL in newborns who had bilirubin levels at or above American Academy of Pediatrics exchange transfusion thresholds (ETT). METHODS: Infants born at ≥35 weeks gestation in 15 Kaiser Permanente Northern California hospitals from 1995-2011 were eligible (N = 525 409). We used a nested double cohort design. The exposed cohort included subjects with ≥1 bilirubin level at or above ETT. The unexposed cohort was a 3.6% random sample of subjects with all bilirubin levels below ETT (10 unexposed per exposed). An audiologist, blinded to bilirubin levels, reviewed the charts of children in whom SNHL had been diagnosed before age 8 years to confirm the diagnosis. We calculated Cox proportional hazard ratios for time to diagnosis of SNHL. RESULTS: SNHL was confirmed in 11 (0.60%) of the 1834 exposed subjects and in 43 (0.23%) of the 19 004 unexposed. Only bilirubin levels ≥10 mg/dL above ETT were associated with a statistically significant increased risk of SNHL (hazard ratio: 36 [95% confidence interval (CI): 13 to 101]). Likewise, only bilirubin levels ≥35 mg/dL were associated with a statistically significant increased risk of SNHL (hazard ratio: 91 [95% CI: 32 to 255]). For subjects with total serum bilirubin levels 0 to 4.9 mg/dL above ETT, the upper limit of the 95% CI for excess risk was 0.5%. CONCLUSIONS: Only bilirubin levels well above ETT were associated with SNHL. At lower bilirubin levels, the excess risk of SNHL was low. [ABSTRACT FROM AUTHOR]

Objective This study aims to compare the effects of early and late (routine) initiation of caffeine in nonintubated preterm neonates. Study Design A total of 21 neonates < 29 weeks gestational age were randomized to receive intravenous caffeine citrate (20 mg/kg) or placebo either before 2 hours of age (early) or at 12 hours of age (routine). This was an observational trial to determine the power needed to reduce the need for endotracheal intubation by 12 hours of age. Other outcomes included comparisons of cerebral oxygenation, systemic and pulmonary blood flow, hemodynamics, hypotension treatment, oxygen requirement, and head ultrasound findings. Results There was no difference in the need for intubation (p = 0.08), or vasopressors (p = 0.21) by 12 hours of age. Early caffeine was associated with improved blood pressure (p = 0.03) and systemic blood flow (superior vena cava flow, p = 0.04 and right ventricular output, p = 0.03). Heart rate, left ventricular output, and stroke volume were not significantly affected. Cerebral oxygenation transiently decreased 1 hour after caffeine administration. There were no differences in other outcomes. Conclusion This pilot study demonstrated the feasibility of conducting such a trial in extremely preterm neonates. We found that early caffeine administration was associated with improved hemodynamics. Larger studies are needed to determine whether early caffeine reduces intubation, intraventricular hemorrhage, and related long-term outcomes. [ABSTRACT FROM AUTHOR]

The National Postbaccalaureate Collaborative (NPBC) is a partnership of Postbaccalaureate Programs (PBPs) dedicated to helping promising college graduates from disadvantaged and underrepresented backgrounds get into and succeed in medical school. This study aims to determine long-term program outcomes by looking at PBP graduates, who are now practicing physicians, in terms of health care service to the poor and underserved and contribution to health care workforce diversity. Methods. We surveyed the PBP graduates and a randomly drawn sample of non-PBP graduates from the affiliated 10 medical schools stratified by the year of medical school graduation (1996-2002). Results. The PBP graduates were more likely to be providing care in federally designated underserved areas and practicing in institutional settings that enable access to care for vulnerable populations. Conclusion. The NPBC graduates serve a critical role in providing access to care for underserved populations and serve as a source for health care workforce diversity. [ABSTRACT FROM AUTHOR]

Associations linking HIV infection to violence and abuse are well documented; however, little is known about how violence/abuse is related to HIV testing behavior, particularly among undergraduate university students, who test at lower rates compared to non-student peers in the United States. We assessed history of HIV testing in an ethnically diverse sample of undergraduates in California (n = 1,210); and examined potential associations between testing and various forms of violence/abuse, while controlling for covariates. Whereas 73.4 % of students were sexually active in the past year, only 26.3 % had ever tested for HIV. At the bivariate level, testing was associated with experiencing verbal abuse and sexual violence/coercion, and perpetrating verbal abuse. Experiencing verbal abuse remained significant in multivariate analysis. We discuss findings in a syndemics framework, considered in combination with social psychology-based health behavior theories. Enhanced HIV testing scale-up initiatives for undergraduates are needed and should consider integration with violence prevention programs. [ABSTRACT FROM AUTHOR]

Purpose. To evaluate the effectiveness of the Pharmacist-Managed Telephone Tobacco Cessation Clinic (PMTTCC) compared to the standard of care (SOC) at the Veterans Affairs San Diego Healthcare System. Method. A retrospective cohort study was performed investigating the proportion of veterans who quit smoking at 6 months while enrolled in the PMTTCC. Chart review was performed using the Veterans Affairs Computerized Patient Record System. The PMTTCC group included patients who had received medication and counseling from the tobacco cessation pharmacists. The cohort was compared to a matched SOC group who did not receive counseling, only tobacco cessation medication therapy through a primary care provider. The primary outcome for this study was patient-reported tobacco cessation at 6 months. Secondary outcomes were abstinence at 1 and 3 months. Results. A total of 1,006 patients were included in the analysis, 503 patients from the PMTTCC and 503 patients from SOC. The overall study population was 54 years old on average, 92.5% male, 70.0% Caucasian, 45.5% with history of psychiatric conditions, and had an average smoking history of 33-pack years. Patients in the PMTTCC group had statistically significant improvements in abstinence at 6 months versus the SOC group (81/503, 16.1% vs. 48/503, 9.5%; p < .0001). Quitters were older on average versus non-quitters (56.03 vs. 53.65 years; p = .01). Conclusion. Patients enrolled in the PMTTCC had improved tobacco abstinence rates at 6 months compared to SOC. Although the study was not designed to test for causality, the results lend support for using intensive tobacco cessation management in veteran population. [ABSTRACT FROM PUBLISHER]