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Among people who inject drugs (PWID), 60% have HCV and 50-90% of HIV-infected PWID are co-infected with HCV. Data comparing adherence to direct-acting antiviral (DAA) therapy among HCV mono-infected and HIV/HCV co-infected PWID is limited. The impact of HCV treatment initiation on HIV antiretroviral therapy (ART) adherence is also poorly understood. We assessed DAA adherence in HCV mono-infected and HIV/HCV co-infected PWID and examined changes in ART adherence and HIV outcomes following HCV treatment. Study was conducted in three Medication for Opioid use Disorder (MOUD) programs in Bronx, New York. HCV treatment adherence was measured using electronic blister packs. 2-week DAA adherence rates were compared and controlled for study arm, psychiatric illness and alcohol intoxication within the past 30 days. ART adherence was measured using participant self-report and dichotomized to "excellent" or "other". ART adherence, CD4 count, and HIV viral load were identified six months prior to, during, and six months after HCV treatment. Statistical significance was assessed with mixed-effects regression linear or logistic models. Overall DAA adherence rates among HCV mono-infected and HIV/HCV co-infected PWID were 74% (95% CI=71-78%) and 76% (95%CI=70-83%), respectively (p=.55). There were no significant changes in ART adherence, CD4 counts, or HIV viral loads prior to, during, or after HCV treatment. This is the first study assessing the impact of DAA therapy on ART adherence and HIV treatment outcomes among PWID. It is one of the first to compare DAA adherence among HCV and HIV/HCV co-infected PWID. Our data demonstrate no significant difference in DAA adherence and no significant impact of HCV treatment on ART adherence or HIV outcomes.

In the seven years since the HIV Organ Policy Equity (HOPE) Act made HIV-positive organ donation to HIV-positive recipients legally permissible in the United States, there have been fewer HIV-positive organ donations than expected. Organ procurement organizations (OPOs) play a key role in the transplant system and barriers at OPOs may be partly responsible for the relatively low number of HIV-positive donors. To understand potential OPO barriers, we conducted semi-structured interviews with 20 OPO staff members. Interviews were recorded, transcribed, and analyzed using a conventional content analytic approach with two coders. OPO staff had high levels of knowledge about HOPE. Many had evaluated referrals of HIV-positive donors and approached families for authorization. Barriers to HIV-positive organ recovery identified included obtaining authorization for donation, potentially disclosing HIV status to next-of-kin, and fear of HIV infection among those engaged in organ recovery. Strategies to overcome these barriers include providing continuing education about the specific tasks required to procure organs from HIV-positive donors, implementing targeted interventions to reduce fear of infection, and developing partnerships with HIV advocacy and care organizations. Given the central role OPOs play, HIV-positive donations are unlikely to occur in significant numbers unless these barriers can be overcome.

Chyle leak after living donor nephrectomy is a rare complication and is associated with a significant postoperative burden. To the best of our knowledge, only 1 case of chyle leak after robotic living donor nephrectomy has been reported in the literature. In this study, we present our experience with 2 cases of chyle leak: 1 after and 1 during robotic donor nephrectomy. We discuss previously published studies and man - agement options of chyle leak in kidney donors.

To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013.In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open.For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P .05).Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

This descriptive study reports caregiver experiences with GnRH agonist implants among a cohort of youth followed in a pediatric hospital-based gender clinic. We administered a survey to 36 of 55 eligible caregivers ascertaining demographics and satisfaction, with a medical record review of any surgical complications. The overwhelming majority (97.1%) reported satisfaction with the procedure and would undergo the implant procedure again (94.4%). The most frequent challenges noted were about affordability (39.8%) and insurance denials (39.8%). Implantable GnRH agonist can be used successfully in pediatric patients with gender dysphoria. Future policy should seek to address concerns regarding insurance approval and reimbursement.

In addition to combat trauma, childhood and adult non-military, interpersonal trauma exposures have been linked to a range of psychiatric symptoms (e.g., alcohol use problems, posttraumatic stress disorder [PTSD], depression symptoms) in veterans. However, few studies simultaneously explore the associations between these civilian and combat trauma types and mental health outcomes. Using a sample of combat-exposed veterans who were previously deployed to Iraq and Afghanistan ( N = 302), this study sought to (a) understand the independent associations of civilian interpersonal trauma (i.e., childhood trauma and non-military adult trauma) and combat-related trauma with post-deployment alcohol use, PTSD symptoms, and depressive symptoms, respectively and (b) to examine the interactive effects of trauma type to test whether childhood and non-military adult trauma moderate the association of combat trauma with these outcomes. A path analytic framework was used to allow for the simultaneous prediction of these associations. In the final model non-military adult trauma and combat trauma were found to be significantly associated with PTSD symptoms and depression symptoms, but not average amount of drinks consumed per drinking day. Childhood trauma was not associated with any outcomes (i.e., PTSD symptoms, depression symptoms, average amount of drinks consumed per day). Only combat trauma was significantly associated with average amount of drinks consumed per day. Results underscore the importance of assessing multiple trauma types and considering trauma as a non-specific risk factor, as different trauma types may differentially predict various mental health outcomes other than PTSD. Further, results highlight the noteworthiness of considering co-occurring outcomes within the veteran community. Limitations, future directions, and implications of diversity are discussed.

En bloc kidney transplant is a surgical treatment option that increases available donor organs and has excellent graft survival for patients with end-stage renal disease. Herein, we report a case of dissection of the external iliac artery that occurred during en bloc kidney transplant in an adult recipient. The en bloc kidneys were removed, flushed, and then reimplanted after restoring the blood flow to the lower limb. To our knowledge, this is the first case of dissection of the external iliac artery managed successfully during en bloc kidney transplant.

The coronavirus disease 2019 (COVID-19) pandemic necessitated using telehealth to bridge the clinical gap, but could increase health disparities. This article reports on a chart review of diabetes telehealth visits occurring before COVID-19, during shelter-in-place orders, and during the reopening period. Visits for children with public insurance and for those who were non-English speaking were identified. Telehealth visits for children with public insurance increased from 26.2% before COVID-19 to 37.3% during shelter-in-place orders and 34.3% during reopening. Telehealth visits for children who were non-English speaking increased from 3.5% before COVID-19 to 17.5% during shelter-in-place orders and remained at 15.0% during reopening. Pandemic-related telehealth expansion included optimization of workflows to include patients with public insurance and those who did not speak English. Increased participation by those groups persisted during the reopening phase, indicating that prioritizing inclusive telehealth workflows can reduce disparities in access to care.

Liver transplantation (LT) from donors-with-HIV to recipients-with-HIV (HIV D+/R+) is permitted under the HOPE Act. There are only three international single-case reports of HIV D+/R+ LT, each with limited follow-up. We performed a prospective multicenter pilot study comparing HIV D+/R+ to donors-without-HIV to recipients-with-HIV (HIV D-/R+) LT. We quantified patient survival, graft survival, rejection, serious adverse events (SAEs), human immunodeficiency virus (HIV) breakthrough, infections, and malignancies, using Cox and negative binomial regression with inverse probability of treatment weighting. Between March 2016-July 2019, there were 45 LTs (8 simultaneous liver-kidney) at 9 centers: 24 HIV D+/R+, 21 HIV D-/R+ (10 D- were false-positive). The median follow-up time was 23 months. Median recipient CD4 was 287 cells/µL with 100% on antiretroviral therapy; 56% were hepatitis C virus (HCV)-seropositive, 13% HCV-viremic. Weighted 1-year survival was 83.3% versus 100.0% in D+ versus D- groups (p = .04). There were no differences in one-year graft survival (96.0% vs. 100.0%), rejection (10.8% vs. 18.2%), HIV breakthrough (8% vs. 10%), or SAEs (all p .05). HIV D+/R+ had more opportunistic infections, infectious hospitalizations, and cancer. In this multicenter pilot study of HIV D+/R+ LT, patient and graft survival were better than historical cohorts, however, a potential increase in infections and cancer merits further investigation.

Background and Aims Lumen-apposing metal stents (LAMSs) provide an endoscopic method for management of walled-off necrosis (WON) and a gateway for the performance of endoscopic necrosectomy (EN). However, bleeding may occur in up to 20% of EN procedures. Predictive factors for bleeding in this patient population are unknown, and there is no agreed-upon algorithm for management of bleeding. The aim of this study was to evaluate preprocedural risk factors for bleeding in patients undergoing endoscopic drainage or EN for WON. Methods A retrospective cohort of patients undergoing EN for WON was reviewed. Demographics, comorbidities, concurrent medications, and etiology of pancreatitis were recorded. Pre-, peri-, and postprocedural clinical variables were compared using Chi-squared test and independent t-test. Results Between June 2014 and October 2020, 536 EN were performed in 151 patients. Intraprocedural bleeding occurred during 28 procedures (5.2%) in 18 patients (11.9%.) Endoscopic hemostasis was attempted in 8 patients (10 procedures). Eight patients (10 procedures) in total were treated by IR. Thrombocytopenia (p = 0.006) and cirrhosis (p = 0.049) were associated with intraprocedural bleeding, although thrombocytopenia was present in only one patient. Identification of a vessel within the cavity endoscopically was also associated with bleeding (p Conclusions EN for WON was associated with a 5.2% per procedure risk of bleeding and an 11.9% per-patient bleeding risk. Identification of a vessel within the cavity during endoscopy is predictive of bleeding during EN. Patients who require more transfusions before endoscopy may require earlier intervention by IR.

BACKGROUND & AIMS: A non-endoscopic approach to Barrett’s esophagus (BE) surveillance after radiofrequency ablation (RFA) would offer a less invasive method for monitoring. We assessed the test characteristics and cost-effectiveness of the Cytosponge® in post-RFA patients. METHODS: We performed a multicenter study of dysplastic BE patients after at least one round of RFA. A positive Cytosponge® before endoscopy was defined as intestinal metaplasia (IM) on cytological assessment and/or TFF3 immunohistochemistry. Sensitivity, specificity, and receiver operator characteristic (ROC) curves were calculated. Multivariable regression was used to estimate the odds of a positive Cytosponge® in BE. A microsimulation cost-effectiveness model was performed to assess outcomes of various surveillance strategies: endoscopy-only, Cytosponge®-only, and alternating endoscopy/Cytosponge®. RESULTS: Of 234 patients, Cytosponge® adequately sampled the distal esophagus in 175 (75%). Of the 142 with both endoscopic and histologic data, 19 (13%) had residual/recurrent BE. For detecting any residual Barrett’s, Cytosponge® had a sensitivity of 74%, specificity of 85%, accuracy of 84%, and ROC curve showed an area under the curve of 0.74. The adjusted odds of a positive Cytosponge® in BE were 17.1 (95% CI: 5.2–55.9). Cytosponge®-only surveillance dominated all the surveillance strategies, being both less costly and more effective. Cytosponge®-only surveillance required

People living with HIV (PLWH) have increased prevalence of comorbid conditions including insulin resistance and at-risk alcohol use. Circulating microRNAs (miRs) may serve as minimally invasive indicators of pathophysiological states. We aimed to identify whether alcohol modulates circulating miR associations with measures of glucose/insulin dynamics in PLWH. PLWH ( n = 96; 69.8% males) enrolled in the Alcohol & Metabolic Comorbidities in PLWH: Evidence-Driven Interventions (ALIVE-Ex) study were stratified into negative phosphatidylethanol (PEth < 8 ng/mL, n = 42) and positive PEth (PEth ≥ 8 ng/mL, n = 54) groups. An oral glucose tolerance test (OGTT) was administered, and total RNA was isolated from fasting plasma to determine absolute miR expression. Circulating miRs were selected based on their role in skeletal muscle (miR-133a and miR-206), pancreatic β-cell (miR-375), liver (miR-20a), and adipose tissue (miR-let-7b, miR-146a, and miR-221) function. Correlation and multiple regression analyses between miR expression and adiponectin, 2 h glucose, insulin, and C-peptide values were performed adjusting for body mass index (BMI) category, age, sex, and viral load. miR-133a was negatively associated with adiponectin ( P = 0.002) in the negative PEth group, and miR-20a was positively associated with 2 h glucose ( P = 0.013) in the positive PEth group. Regression analyses combining miRs demonstrated that miR-133a ( P < 0.001) and miR-221 ( P = 0.010) together predicted adiponectin in the negative PEth group. miR-20a ( P < 0.001) and miR-375 ( P = 0.002) together predicted 2 h glucose in the positive PEth group. Our results indicate that associations between miRs and measures of glucose/insulin dynamics differed between PEth groups, suggesting that the pathophysiological mechanisms contributing to altered glucose homeostasis in PLWH are potentially modulated by alcohol use.

Objective To separately compare the long-term risk of mortality among bariatric surgical patients undergoing either RYGB or SG to large, matched, population-based cohorts of patients with severe obesity who did not undergo surgery. Background Bariatric surgery has been associated with reduced long-term mortality compared to usual care for severe obesity which is particularly relevant in the COVID-19 era. Most prior studies involved the Roux-en-Y gastric bypass (RYGB) operation and there is less long-term data on the sleeve gastrectomy (SG). Methods In this retrospective, matched cohort study, patients with a body mass index ≥35 kg/m2 who underwent bariatric surgery from January 2005 to September 2015 in three integrated health systems in the United States were matched to nonsurgical patients on site, age, sex, body mass index, diabetes status, insulin use, race/ethnicity, combined Charlson/Elixhauser comorbidity score, and prior health care utilization, with follow-up through September 2015. Each procedure (RYGB, SG) was compared to its own control group and the two surgical procedures were not directly compared to each other. Multivariable-adjusted Cox regression analysis investigated time to all-cause mortality (primary outcome) comparing each of the bariatric procedures to usual care. Secondary outcomes separately examined the incidence of cardiovascular-related death, cancer related-death, and diabetes related-death. Results Among 13,900 SG, 17,258 RYGB, and 87,965 nonsurgical patients, the 5-year follow-up rate was 70.9%, 72.0%, and 64.5%, respectively. RYGB and SG were each associated with a significantly lower risk of all-cause mortality compared to nonsurgical patients at 5-years of follow-up (RYGB: HR = 0.43; 95% CI: 0.35,0.54; SG: HR = 0.28; 95% CI: 0.13,0.57) Similarly, RYGB was associated with a significantly lower 5-year risk of cardiovascular- (HR = 0.27; 95% CI: 0.20, 0.37), cancer- (HR = 0.54; 95% CI: 0.39, 0.76), and diabetes-related mortality (HR = 0.23; 95% CI:0.15, 0.36). There was not enough follow-up time to assess 5-year cause-specific mortality in SG patients, but at 3-years follow up, there was significantly lower risk of cardiovascular- (HR = 0.33; 95% CI:0.19, 0.58), cancer- (HR = 0.26; 95% CI:0.11, 0.59), and diabetes-related (HR = 0.15; 95% CI:0.04, 0.53) mortality for SG patients. Conclusion This study confirms and extends prior findings of an association with better survival following bariatric surgery in RYGB patients compared to controls and separately demonstrates that the SG operation also appears to be associated with lower mortality compared to matched control patients with severe obesity that received usual care. These results help to inform the trade-offs between long-term benefits and risks of bariatric surgery.

BACKGROUND The currently utilized International Neuroblastoma Risk Group (INRG) staging system developed in 2009 uses image-defined risk factors as a measure of surgical risk, separating resectable neuroblastoma from those best preceded by chemotherapy. The previous International Neuroblastoma Staging System was based primarily on surgical findings. We hypothesized there would be a change to the role of the surgeon in neuroblastoma treatment in the more recent decade. METHODS This is a single center 20-year retrospective analysis of 104 patients with International Classification of Diseases-9 and -10 codes for neuroblastoma. Patient demographics, tumor site, cancer treatment modality, survival, biopsy technique, surgical intervention, and pathology staging were collected. Data was analyzed by analysis of variance (ANOVA) and Student's t test. RESULTS There was a decrease in open surgeries for extra-adrenal neuroblastomas in the later decade (77%, 31%, P = 0.01). There was a narrowing of the time interval to surgery in the later cohort, likely as a result of uniformity in surgical timing on treatment protocols relying on INRG staging. CONCLUSIONS Our findings mirror changes in practice patterns globally. We found an increase in minimally invasive approaches but did not find a difference in the role of the surgeon under the INRG staging system.

The treatment of functional neurological disorder (FND), previously referred to as conversion disorder, can be challenging. Despite these challenges and with increased understanding of this condition, new treatment options are emerging. One such treatment is hypnosis, which has a long history of use in the treatment of FND. Jean-Martin Charcot, considered by many to be the father of modern neurology, used therapeutic hypnosis as early as the 19th century. In this report, we discuss the novel use of a hypno-anesthetic technique (the magic glove) for treatment of FND presenting as diplegia. We illustrate the use of the technique with the case of a 9-year-old girl who suffered from chronic pain and lower extremity weakness secondary to FND. With the magic glove technique, she improved rapidly and was free of symptoms by her sixth month follow-up visit. We review the current literature on FND interventions and emphasize the need for continued research in this field.

Purpose Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU. Materials and methods We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014–June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR). Results We included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29–1.71), hospital readmission (RR 1.49, 95%CI 1.34–1.66), ICU readmission (RR 2.64, 95%CI 1.55–4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00–1.71) six-months post-ICU discharge. Conclusion Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.

Partial breast irradiation (PBI) and ultra-hypofractionated whole breast irradiation (uWBI) are contemporary alternatives to conventional and standard hypofractionated whole breast irradiation (WBI), which shorten treatment from 3 to 6 weeks to 1-2 weeks for select patients. PBI and accelerated PBI (APBI) can be delivered with external beam radiation (3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT)), intraoperative radiation (IORT), or brachytherapy. These new radiation techniques offer the advantage of convenience and lower cost, which ultimately improves access to care. Globally, the COVID 19 pandemic has accelerated APBI/PBI and ultra-hypofractionated regimens into routine practice for carefully selected patients. Recent long-term data from randomized controlled trials (RCTs) have demonstrated these techniques are safe and effective in suitable patients demonstrating equivalent or improved local recurrence, acute/late toxicity, and cosmesis. PBI and APBI should be limited to low risk unifocal invasive ductal carcinoma and ductal carcinoma in situ with tumor size

Purpose: Gastropexy during laparoscopic gastrostomy tube (GT) insertion can be technically challenging. T-fasteners are an effective method of gastropexy. However, the use of external bolsters requ...

Bochdalek hernias are the most common congenital diaphragmatic hernias and are usually diagnosed during childhood1. They can present in adulthood and, in uncommon circumstances, result in gastric herniation with strangulation. We present a case of an adult Bochdalek hernia resulting in total gastric necrosis necessitating Roux-en-Y esophagojejunostomy in an otherwise healthy 39-year-old male. This case highlights the potential morbidity associated with unrepaired congenital diaphragmatic hernias and the need for appropriate referral.

The aim of this study was to describe the utilization patterns of brain tissue oxygen (PbtO2) monitoring following severe traumatic brain injury (TBI) and determine associations with mortality, health care use, and pulmonary toxicity. We conducted a retrospective cohort study of patients from United States trauma centers participating in the American College of Surgeons National Trauma Databank between 2008 and 2016. We examined patients with severe TBI (defined by admission Glasgow Coma Scale score ≤ 8) over the age of 18 years who survived more than 24 h from admission and required intracranial pressure (ICP) monitoring. The primary exposure was PbtO2 monitor placement. The primary outcome was hospital mortality, defined as death during the hospitalization or discharge to hospice. Secondary outcomes were examined to determine the association of PbtO2 monitoring with health care use and pulmonary toxicity and included the following: (1) intensive care unit length of stay, (2) hospital length of stay, and (3) development of acute respiratory distress syndrome (ARDS). Regression analysis was used to assess differences in outcomes between patients exposed to PbtO2 monitor placement and those without exposure by using propensity weighting to address selection bias due to the nonrandom allocation of treatment groups and patient dropout. A total of 35,501 patients underwent placement of an ICP monitor. There were 1,346 (3.8%) patients who also underwent PbtO2 monitor placement, with significant variation regarding calendar year and hospital. Patients who underwent placement of a PbtO2 monitor had a crude in-hospital mortality of 31.1%, compared with 33.5% in patients who only underwent placement of an ICP monitor (adjusted risk ratio 0.84, 95% confidence interval 0.76–0.93). The development of the ARDS was comparable between patients who underwent placement of a PbtO2 monitor and patients who only underwent placement of an ICP monitor (9.2% vs. 9.8%, adjusted risk ratio 0.89, 95% confidence interval 0.73–1.09). PbtO2 monitor utilization varied widely throughout the study period by calendar year and hospital. PbtO2 monitoring in addition to ICP monitoring, compared with ICP monitoring alone, was associated with a decreased in-hospital mortality, a longer length of stay, and a similar risk of ARDS. These findings provide further guidance for clinicians caring for patients with severe TBI while awaiting completion of further randomized controlled trials.

Adults with Down syndrome (DS) are at risk for Alzheimer’s disease. Despite sharing trisomy 21, however, there is variability in the age of disease onset. This variability may mean that other factors, such as lifestyle, influence cognitive aging and disease timing. The present study assessed the association between everyday life physical activity using an actigraph accelerometer and cognitive functioning and early Alzheimer’s disease pathology via positron emission tomography amyloid-β and tau and diffusion tension imaging measures of white matter integrity in 61 non-demented adults with DS. Percent time in sedentary behavior and in moderate-to-vigorous activity were associated (negatively and positively, respectively) with cognitive functioning (r = −.472 to .572, p

BACKGROUND AND OBJECTIVES Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations. METHODS This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children’s hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing. RESULTS Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events. CONCLUSION Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.

The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology.We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes.Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS.We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure and define practical criteria for CSTS recommendations.

Background Patients who require readmission to an intensive care unit (ICU) after transfer to a lower level of care (“bounceback”) suffer from increased mortality and longer hospital stays. We aimed to create a multifaceted standardized transfer process for patients moving from the neurointensive care unit (neuro-ICU) to a lower level of care. We hypothesized that this process would lead to improvement in provider-rated safety and a decreased rate of bouncebacks to the neuro-ICU after transfer. Methods The study took place at the Hospital of the University of Pennsylvania from October 2018 to October 2020. A standardized five-step transfer process was created and implemented for transferring patients from the neuro-ICU to a lower level of care. Patient care providers completed a survey before and after implementation of the protocol to assess a variety of components related to safety concerns when transferring patients. The rate of bouncebacks pre and post intervention was calculated by using a two-sample Wilcoxon rank-sum test, and disposition at discharge was calculated by using Fisher’s exact test. Results Of the 1176 total patient transfers out of the neuro-ICU, 29 patients bounced back within 48 h. The average age of patients who bounced back was 63.3 years old, with a similar distribution among men and women. The most common reason for bounceback was respiratory distress, followed by cardiac arrhythmia, stroke, and sepsis. Implementation of the standardized process led to a decrease in provider-rated concern of overall safety (5 to 3, p = 0.008). There was improvement in transfer delays due to bed availability (3 to 4.5, p = 0.020), identification of high-risk patients (5 to 6, p = 0.021), patient assignment to the appropriate level of care (5 to 6, p = 0.019), and use of the electronic medical record handoff indicator (5 to 6, p = 0.003). There was no statistically significant difference in terms of patient bounceback rate after implementation of the process (2.4% vs. 2.5%, p = 1.00) or patient disposition at discharge (p = 0.553). Conclusions Patients who bounceback to the neuro-ICU within 48 h had an increased length of hospital stay, had an increased length of ICU stay, and were more likely to be intubated for more than 96 h. Implementation of a standardized five-step transfer process from the neuro-ICU to a lower level of care resulted in improvement in multiple provider-rated safety outcomes and identification of high-risk patients but led to no difference in the patient bounceback rate or patient disposition at discharge. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01385-z.

Background Indigenous populations have a high prevalence of Human Papillomavirus (HPV) infection and a high incidence of HPV associated cancers, such as cervical and oropharyngeal cancer. There is an effective HPV vaccination program in almost all developed countries to prevent the incidence of cervical cancer, but reports suggest that the uptake of these vaccinations by Indigenous populations is low. The objective of this qualitative systematic review was to explore the knowledge and beliefs of global Indigenous populations regarding HPV vaccines. This review was performed to identify the barriers faced by Indigenous peoples and to provide evidence for more effective and acceptable execution of vaccination policies for Indigenous peoples. Methods Two investigators independently searched MEDLINE, PubMed, SCOPUS, and Web of Science databases using a pre-specified search strategy to identify qualitative studies on narratives of Indigenous peoples regarding HPV vaccine awareness, knowledge and experiences across all geographic and income-level settings. Results After performing the literature search and quality appraisals 5 papers were included in the final review. Three core synthesised findings were identified: reasons for acceptance or hesitancy, and areas for improvement. Lack of correct knowledge and mistrust in the healthcare system were important categories observed in all papers included in the review. Other categories within the conceptual model included prioritising disease prevention, health professional guidance, family support and supportive community environment. Conclusion Qualitative systematic reviews are an excellent means of exploring the gaps in current healthcare practices. Indigenous healthcare research should be grounded in community experiences and feedback. This review provides insights into HPV vaccination understanding and acceptance amongst Indigenous populations, from which recommendations for increasing resonance of vaccination strategies with Indigenous communities can be formed.

Background The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection. Methods In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ − 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days. Results We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4–42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were “Feeling nervous, anxious or on edge” (96.0% [95%CI 85.2–99.0]); “Not being able to stop or control worrying” (88.0% [95%CI 75.6–94.5]; “Worrying too much about different things” and “Feeling afraid as if something awful might happen” (84.0% [95%CI 71.0–91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report “Worrying too much about different things” more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04–4.91]; Sour Seven, OR 2.28 [95%CI 1.00–5.23]). Conclusions Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients. Trial registration This study is registered on ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03379129).

Objective While adjuvant treatment regimens have been modified for older patients with glioblastoma (GBM), surgical strategies have not been tailored. Methods Clinical data of 48 consecutive patients aged 70 years or older, who underwent surgical resection for GBM with intraoperative ultrasonography (IoUS) alone or combination with intraoperative MRI (IoMRI) at Yale New Haven Hospital were retrospectively reviewed. Variables were analyzed, and comparative analyses were performed. Results The addition of IoMRI was not superior to IoUS alone in terms of overall survival (OS) (P = 0.306), Karnofsky Performance Score (KPS) at postoperative 6 weeks (P = 0.704) or extent of resection (P = 0.263). Length of surgery (LOSx), however, was significantly longer (P = 0.0002) in the IoMRI group. LOSx (P = 0.015) and hospital stay (P = 0.025) were predictors of postoperative complications. Increased EOR (GTR or NTR) (P = 0.030), postoperative adjuvant treatment (P < 0.0001) and postoperative complications (P = 0.006) were predictive for OS. Patients with relatively lower preoperative KPS scores ( Conclusions Aggressive management with surgical resection should be considered in older patients with GBM, even those with relatively poor KPS. The use of ioMRI in this population does not appear to confer any measurable benefit over ioUS in experienced hands, but prolongs the length of surgery significantly, which is a preventable prognostic factor for impeding care.

OBJECTIVES Clinical assessment of uterine artery (UtA) hemodynamics is currently limited to Doppler ultrasound (US) velocimetry. We have demonstrated previously the feasibility of applying four-dimensional (4D) flow magnetic resonance imaging (MRI) to evaluate UtA hemodynamics during pregnancy, allowing flow quantification of the entire course of the vessel. In this study, we sought to further validate the physiological relevance of 4D flow MRI measurement of UtA blood flow by exploring its association with pregnancy outcome relative to US-based metrics. METHODS Recruited into this prospective, cross-sectional study were 87 women with a singleton pregnancy who underwent 4D flow MRI between May 2016 and April 2019 to measure the UtA pulsatility index (MRI-PI) and blood flow rate (MRI-flow, in mL/min). UtA-PI was also measured using US (US-PI). The primary outcome was a composite (COMP) of pre-eclampsia (PE) and/or small-for-gestational-age (SGA) neonate, and secondary outcomes were PE and SGA neonate individually. We assessed the ability of MRI-flow, MRI-PI and US-PI to distinguish between outcomes, and evaluated whether MRI-flow changed as gestation progressed. RESULTS Following 4D flow postprocessing and exclusions from the analysis, 74 women had 4D flow MRI data analyzed for both UtAs. Of these, 18 developed a COMP outcome: three developed PE only, 11 had a SGA neonate only and four had both. A comparison of the COMP group vs the no-COMP group found no differences in maternal age, body mass index, nulliparity, gravidity or race. For 66 of the 74 subjects, US data were also available. In these subjects, both median MRI-PI (0.95 vs 0.70; P

BACKGROUND: The declaration of Coronavirus disease 2019 (COVID-19) as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 required rapid implementation of early investigations to inform appropriate national and global public health actions. METHODS: The suite of existing pandemic preparedness generic epidemiological early investigation protocols was rapidly adapted for COVID-19, branded the 'UNITY studies' and promoted globally for the implementation of standardized and quality studies. Ten protocols were developed investigating household (HH) transmission, the first few cases (FFX), population seroprevalence (SEROPREV), health facilities transmission (n = 2), vaccine effectiveness (n = 2), pregnancy outcomes and transmission, school transmission, and surface contamination. Implementation was supported by WHO and its partners globally, with emphasis to support building surveillance and research capacities in low- and middle-income countries (LMIC). RESULTS: WHO generic protocols were rapidly developed and published on the WHO website, 5/10 protocols within the first 3 months of the response. As of 30 June 2021, 172 investigations were implemented by 97 countries, of which 62 (64%) were LMIC. The majority of countries implemented population seroprevalence (71 countries) and first few cases/household transmission (37 countries) studies. CONCLUSION: The widespread adoption of UNITY protocols across all WHO regions indicates that they addressed subnational and national needs to support local public health decision-making to prevent and control the pandemic.

Background Sentinel events are negative health-related events that trigger change in risky health behaviors. Despite its presumed major role in behavior change, the sentinel event effect has received little empirical attention. Through analysis of qualitative interviews, we explored how sentinel events trigger behavior change. Methods Thematic analysis and concept mapping were used to develop a preliminary model of the sentinel event effect among a sample of 24 adult heavy drinking Mexican-origin men previously admitted to a hospital due to injury. The model was checked against cases that did versus did not report change in alcohol use following an alcohol-related negative event. Results Findings suggest that sentinel events may arouse negative emotional reactions, encourage reflection on the negative consequences of drinking, and cause reevaluation of the severity and significance of drinking. These processes may increase motivation to change. Conclusions Findings support the concept of the sentinel event as a natural intervention, and identifies potential social-cognitive and motivational mechanisms through which it influences change. Findings stand to inform research on mechanisms underlying brief intervention effects, and research that seeks to identify treatment targets.

Background Assistive devices provide balance and stability to those who require a greater base of support, especially during ambulation or in tasks essential to functional daily living. In ambulatory assistive device use, center of pressure (COP) movement as one of the measurements of postural control is a factor when assessing fall risk, with an overall goal of maintaining postural equilibrium. There is a lack of research on assistive devices, such as walkers, regarding measurable outcome variables related to fall risk. The purpose of this study was to determine how much the postural control in single limb stance during a balance perturbance is affected by utilizing three different walker types designed to promote stability: the standard walker, the front-wheeled walker with straight wheels and the front-wheeled walker with caster wheels. Research question Is postural sway control in single limb stance during a balance perturbance affected by walker type? Methods Twenty-three healthy adults participated and gave consent. The NeuroCom® SMART EquiTest® system was utilized to simulate forward falls. Subjects stood on the system’s force plate, which was tipped backwards quickly, forcing subjects to attempt to maintain balance. Each participant experienced 18 simulated perturbations, during which they were asked to maintain balance while using one of three walkers in single-limb stance. Each trial was completed using random assignment of three different walker types. Leg dominance of the stance leg was also randomized for each trial. Results The type of walker and the leg dominance in the standing limb significantly affected postural control in a balance perturbance in the A-P direction. The walker type significantly affected the COP maximum displacement in anterior-posterior (AP) direction. However, the leg dominance significantly affected COP maximum displacement in AP and medio-lateral (ML) directions and COP velocity in AP direction. Significance The findings suggest that when fully grounded, a standard walker is more stable than the front-wheeled walker. However, this does not indicate that the standard walker is more stable than other types of walkers when it is being picked up and moved forward during normal use.

Background and Aims EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. Methods We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. Results Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. Conclusions Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

OBJECTIVES: Metastatic cancer has historically been considered fatal; however, there is a paucity of evidence characterizing the epidemiology of incidence, treatment, and outcomes in these patients. MATERIALS AND METHODS: Incidence rates, annual percent change (APC), descriptive epidemiological statistics, and odds ratios for survival were calculated using registry data from the Surveillance, Epidemiology, and End Results (SEER) and the National Cancer Database (NCDB), 1998 to 2015. RESULTS: There were a total of 1,055,860 patients with metastatic cancer. The most frequent primary cancers were lung (42.6%), colorectal (9.5%), and ovarian (5.5%). Metastatic lung and colorectal cancer incidence decreased, APC: -1.57 (P

Although numerous studies have established advanced patient age as a risk factor for poor outcomes following intracranial meningioma resection, large-scale evaluation of frailty for preoperative risk assessment has yet to be examined. Weighted discharge data from the National Inpatient Sample were queried for adult patients undergoing benign intracranial meningioma resection from 2015 to 2018. Complex samples multivariable logistic regression models and receiver operating characteristic curve analysis were performed to evaluate adjusted associations and discrimination of frailty, quantified using the 11-factor modified frailty index (mFI), for clinical endpoints. Among 20,250 patients identified (mean age 60.6 years), 35.4% (n = 7170) were robust (mFI = 0), 34.5% (n = 6985) pre-frail (mFI = 1), 20.1% (n = 4075) frail (mFI = 2), and 10.0% (n = 2020) severely frail (mFI ≥ 3). On univariable analysis, these sub-cohorts stratified by increasing frailty were significantly associated with the development of Clavien–Dindo grade IV (life-threatening) complications (inclusive of those resulting in mortality) (1.3% vs. 3.1% vs. 6.5% vs. 9.4%, p

Over the past decade, nontypeable Haemophilus influenzae (NTHi) has gained recognition as a major opportunistic pathogen of the respiratory tract that imposes a substantial global burden of disease, owing to a high rate of morbidity and ensuing complications. Further amplifying the global impact of NTHi infections is the increasing spectrum and prevalence of antibiotic resistance, leading to higher rates of treatment failure with first- and second-line antibiotics regimes. The threat of antibiotic resistance was recognised by the World Health Organization in 2017, listing NTHi as a priority pathogen for which new therapies are urgently needed. Despite significant efforts, there are currently no effective vaccine strategies available that can slow the growing burden of NTHi disease. Consequently, alternative preventative or therapeutic approaches that do not rely on antibiotic susceptibility or stable vaccine targets are becoming more attractive. The nutritional dependency for haem at all stages of NTHi pathogenesis exposes a vulnerability that may be exploited for the development of such therapies. This article will discuss the therapeutic potential of strategies that limit NTHi access to this vital nutrient, with particular focus on a novel bacteriotherapeutic approach under development.

Background Presence in the neonatal intensive care unit (NICU) is a vital step for caregivers initiating involvement, such as skin-to-skin contact, holding or singing/reading to their newborn. Little is known about caregiver presence and involvement in Canadian NICU's context by caregiver type (mother, father, other), and the association between maternal presence and key maternal and newborn characteristics. Purpose The primary objective was to examine the presence and involvement of family caregivers in the NICU. The secondary objective was to examine the relationship between maternal presence and maternal and newborn characteristics. Design and methods A prospective observational cohort study in an open bay setting of an Eastern Canadian NICU. Presence (physically present at the newborn's bedside) and involvement (e.g., skin-to-skin, singing/reading) were tracked daily by families in the NICU until discharge. Demographic information was also collected. Results Participants included 142 mothers and their newborns. Mothers were present 8.7 h/day, fathers were present 4.1 h/day, and other caregivers were present 1.8 h/day in the NICU in the first 34 days. Mothers were involved in care activities 50% of the time they were present in the NICU, whereas fathers and other caregivers were spending 20% and 6% of their time respectively. Regression identified maternal age, distance to home, parity, birthweight, and length of stay to be statistically significant variables related to maternal presence. Conclusions There is variation in presence and involvement by caregiver type. Targeted interventions to maintain and increase mothers, fathers and other caregivers' presence and involvement in care throughout their stay in the NICU are recommended.

In rodents and humans, the gut bacteria-derived metabolite trimethylamine N-oxide (TMAO) has been implicated in the progression of cardiovascular disease, chronic kidney disease, fatty liver, and insulin resistance; however, the effects of TMAO on dairy cattle health and milk production have not been defined. We aimed to determine whether intravenous TMAO infusion modifies measures of liver health, glucose tolerance, and milk production in early-lactation cows. Eight early-lactation Holstein cows (30.4 ± 6.41 d in milk; 2.88 ± 0.83 lactations) were enrolled in a study with a replicated 4 × 4 Latin square design. Cows were intravenously infused TMAO at 0 (control), 20, 40, or 60 g/d for 6 d. Washout periods lasted 9 d. Intravenous glucose tolerance tests (GTT) occurred on d 5. Blood was collected daily. Milk was collected on d -1, 0, 5, and 6. Urine was collected on d -1 and 6. Circulating metabolites, milk components, and TMAO concentrations in milk, urine, and plasma were quantified. Data were analyzed using a mixed model that included the fixed effects of treatment. Concentrations of TMAO in plasma, milk, and urine increased linearly with increasing dose. Dry matter intake and milk production were not modified by treatment. Daily plasma triacylglycerol, fatty acid (FA), and glucose concentrations were not modified. Serum albumin, total protein, globulin, total bilirubin, direct bilirubin, aspartate aminotransferase, γ-glutamyl transferase, and glutamate dehydrogenase concentrations were also not modified by treatment. Serum GTT glucose, FA, and insulin concentrations were not modified by treatment. Plasma total, reduced, and oxidized glutathione concentrations were also not modified by treatment. We conclude that a 6-d intravenous infusion of TMAO does not influence measures of liver health, glucose tolerance, or milk production in early-lactation dairy cows.

Introduction Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America. Methods We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test. Results Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities. Conclusions Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.

Background Extended contact interventions delivered via text messaging are a low-cost option for promoting the long-term continuation of behavior change. This secondary analysis of a text message–delivered extended contact intervention (‘Get Healthy, Stay Healthy’ (GHSH)) explores the extent to which changes in physical activity, dietary behaviors and body weight were associated with the frequency of text messages (dose) and contact between the health coach and participant (engagement). Methods Following a telephone coaching program, participants were randomised to receive extended contact via tailored text messages (GHSH, n = 114) or no additional contact (n = 114) over a 6-month period. Message dose, timing, and content were based on participant preferences, ascertained during two tailoring telephone calls. All incoming and outgoing messages were recorded. At baseline and 6 months, participants self-reported body weight and dietary behaviors (fruit and vegetable servings/day). Moderate-vigorous physical activity (MVPA) was assessed via accelerometry. Results Median dose (25th, 75th percentile) was 53 (33, 72) text messages in total across six months. Mean fortnightly dose in weeks 1–2 was 5.5 (95 % CI: 4.3, 6.6) text messages, and remained stable (with the exception of planned decreases in weeks involving additional intervention contacts). Offset against the average fortnightly dose of goal checks (1.6, 95 % CI: 1.3, 2.0 and 1.5, 95 % CI: 1.2, 1.8, for physical activity and diet respectively), mean replies to goal checks were highest in weeks 1–2 (1.4, 95 % CI: 1.4, 1.5 and 1.3, 95 % CI: 1.2, 1.4, respectively) and tended to become lower in most weeks thereafter. Greater weight loss was positively associated with text message dose (P = 0.022), with a difference of 1.9 kg between participants receiving the most and fewest texts. There was no association between engagement and changes in outcome measures. Conclusions A fixed dose of texts does not seem suitable to meet participants’ individual preferences. Higher self-selected text doses predicted better weight outcomes. However, greater participant engagement through text replies does not predict more favourable outcomes, despite being a suggested facilitator of successful behavior change maintenance. Trial registration Australian New Zealand Clinical Trials Registry number: ACTRN12613000949785. Date registered: 27 August 2013. Retrospectively registered. http://www.anzctr.org.au/.

The standard of care for treatment of sino-orbital mucormycosis involves aggressive surgical debridement and liposomal amphotericin, and the roles of adjunctive and topical therapies are less clear. Here we describe a case of severe refractory sino-orbital mucormycosis in an immunocompetent patient who responded to combination therapy with liposomal amphotericin, isavuconazole, micafungin, and topical amphotericin deoxycholate after failing to achieve negative surgical margins.

There is an increasing number of case reports of COVID-19 reinfection. The mechanism of reinfection is poorly understood and evolving. Prevention of the transmission of severe acute respiratory syndrome coronavirus 2 for those with a serious mental illness (SMI) living in a congregate setting presents unique challenges. In this case report, we describe an individual with an SMI in a long-term inpatient psychiatric care hospital who was initially diagnosed in June 2020 with COVID-19 infection via a polymerase chain reaction test. Approximately 6 months later, the patient presented with a COVID-19 reinfection and more severe COVID-like symptoms.

BACKGROUND: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

We utilized a mixed methods approach to assess student attitudes towards tobacco use and campus tobacco policies. Interviews (N = 21), focus groups (N = 2 groups, 4-5 participants each), and an online survey (N = 636) were conducted among a sample of students attending a 4-year, urban, public university in the Mid-Atlantic region of the United States. In interviews and focus groups, students expressed skepticism about a tobacco-free campus policy due to perceived violations of personal rights and challenges with enforcement. Of the sample surveyed, 9.2% and 20.6% had used cigarettes or e-cigarettes within the past 30 days. The majority of students agreed that colleges have a responsibility to adopt tobacco-free policies that reduce the risk of tobacco addiction (62.4%) and ensure smoke-free air to breathe (81.5%). However, more than half (56.3%) also indicated that a policy allowing for designated smoking areas for cigarettes was best for campus, which runs counter to a comprehensive tobacco-free policy. Academic year, gender, and race/ethnicity were significant factors associated with support for tobacco-free policies. Current smokers and vapers were less likely to support tobacco-free policies that reduce the risk of tobacco addiction (OR = 0.3, 95% CI 0.1, 0.7 for smokers; OR = 0.3, 95% CI 0.1, 0.6 for vapers), but not policies that ensure smoke-free air to breathe. E-cigarettes pose a unique obstacle to tobacco-free policies, as students perceived e-cigarettes to be less harmful than cigarettes. To implement a tobacco-free campus policy, students suggested educational campaigns that focus on the potential health benefits of a tobacco-free campus.

Background Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. Methods We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. Results Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL Conclusion The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor–based regimens is rare, which is reassuring regarding safety.

Antithrombotic therapies include anticoagulants and antiplatelet agents. It is increasingly recognized that combined dual antithrombotic (DAT, which consists of an oral anticoagulant and a single antiplatelet) and triple antithrombotic therapies (TAT, which consists of an oral anticoagulant and two antiplatelets) increase bleeding risk. Additionally, the benefit of aspirin for primary prevention has been called into question by a number of randomized controlled trials over the last few years. As such, several recent clinical trials have explored de-escalated antithrombotic regimens that have resulted in less bleeding with similar efficacy. Our study was a retrospective, observational investigation assessing the effect of a systematic antithrombosis stewardship intervention implemented in outpatient, pharmacy-driven antithrombosis clinics on the number of patients receiving potentially inappropriate combined antithrombotic therapy. Pharmacists identified anticoagulation patients on concomitant antiplatelet therapy, assessed for appropriateness, and performed interventions if needed. Of the 875 patients included, 261 (29.8%) were on combined antithrombotic therapy, 48 (18.4%) of which were deemed inappropriate at baseline. By the end of the intervention period, 45 (93%) of these patients had a de-escalation in combined therapy (p

To understand and summarize the breadth of knowledge on comfort-holding in pediatric intensive care units (PICUs).This scoping review was conducted using PRISMA methodology. A literature search was conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials. Search strategies were developed with a medical librarian and revised through a peer review of electronic search strategies. All databases were searched from inception to 14 April 2020. Only full-text articles available in English were included. All identified articles were reviewed independently and in duplicate using predetermined criteria. All study designs were eligible if they reported on comfort-holding in a PICU. Data were extracted independently and in duplicate.Of 13,326 studies identified, 13 were included. Comfort-holding was studied in the context of end-of-life care, developmental care, mobilization, and as a unique intervention. Comfort-holding is common during end-of-life care with 77.8% of children held, but rare during acute management (51% of childrenthree years,5% of children ≥ three years). Commonly reported outcomes included child outcomes (e.g., physiologic measurements), safety outcomes (e.g., accidental line removal), parent outcomes (e.g., psychological symptoms), and frequency of holding.There is a paucity of literature on comfort-holding in PICUs. This scoping review identifies significant gaps in the literature, including assessment of child-based outcomes of comfort-holding or safety assessment of comfort-holding, and highlights core outcomes to consider in future evaluations of this intervention including child-based outcomes, parent-based outcomes, and safety of the intervention.RéSUMé: OBJECTIF: Comprendre et résumer l’étendue des connaissances sur la pratique des étreintes de réconfort dans les unités de soins intensifs pédiatriques (USIP).Cette étude de portée a été réalisée en utilisant la méthodologie PRISMA. Une recherche de la littérature a été menée dans les bases de données MEDLINE, EMBASE, PsycINFO, CINAHL et dans le registre Cochrane CENTRAL d’études contrôlées. Les stratégies de recherche ont été élaborées avec un bibliothécaire médical et révisées au moyen d’un examen par les pairs des stratégies de recherche électronique. Toutes les bases de données ont été passées en revue de leur création au 14 avril 2020. Seuls les articles en texte intégral disponibles en anglais ont été inclus. Tous les articles identifiés ont été révisés indépendamment et en double à l’aide de critères prédéterminés. Tous les types de plans d’étude étaient admissibles s’ils abordaient le thème des étreintes de réconfort dans une USIP. Les données ont été extraites indépendamment et en double.Sur les 13 326 études identifiées, 13 ont été incluses. Les étreintes de réconfort ont été étudiées dans le contexte des soins de fin de vie, des soins développementaux, de la mobilisation et en tant qu’intervention unique. Les étreintes de réconfort sont une approche courante dans le cadre de soins de fin de vie, durant lesquels 77,8 % des enfants sont étreints, mais plus rares pendant la prise en charge aiguë (51 % des enfantstrois ans,5 % des enfants ≥ trois ans). Les résultats couramment rapportés comprenaient les issues pour les enfants (p. ex. mesures physiologiques), les issues en matière de sécurité (p. ex. retrait accidentel d’une ligne), les issues pour les parents (p. ex. symptômes psychologiques) et la fréquence des étreintes.Il n’existe que très peu de littérature s’intéressant aux étreintes de réconfort dans les USIP. Cette étude de portée identifie d’importantes lacunes dans la littérature, notamment l’évaluation des issues pour l’enfant suite à une étreinte de réconfort ou l’évaluation de la sécurité de telles étreintes, et met en évidence les issues principales dont il faudra tenir compte dans les évaluations futures de cette intervention, y compris les issues axées sur l’enfant, les issues basées sur les parents et la sécurité de l’intervention.