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Guideline concordant opioid therapy is a key part of the concerted effort to address the opioid crisis in the United States. The study aimed to compare the rates of guideline concordant care between veterans who solely used VA services (mono users) and veterans who used both VA services and community care (dual-system users). We used electronic health record data from the Washington DC and Baltimore VA Medical Centers from 2015 to 2019. We provided descriptive statistics as well as generalized estimating equations models to find associations between mono vs. dual-system users and each guideline outcome, controlling for demographic factors and comorbid conditions. The study found that overall rates of guideline concordant care were high in both mono and dual-system users with over 90% adherence rates for the majority of recommendations. However, there were variations in adherence to specific guidelines, with urine drug screening at initiation being the least commonly followed recommendation (8.9% of mono-user opioid initiators and 11.2% of dual-user initiators). This study also found that there was no consistent pattern of higher guideline adherence in mono vs. dual-system users but did show that through the course of this study (2015-2019) overall rates of guideline concordance increased. Future research will explore additional guideline recommendations and potential coordination issues among dual-system users., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

To better connect non-emergent 911 callers to appropriate care, Washington, DC, routed low-acuity callers to nurses. Nurses could provide non-emergent transportation to a health centre, recommend self-care or return callers to the traditional 911 system. Over about one year, 6,053 callers were randomized (1:1) to receive a business-as-usual response (n control  = 3,023) or further triage (n treatment  = 3,030). We report on seven of nine outcomes, which were pre-registered ( https://osf.io/xderw ). The proportion of calls resulting in an ambulance dispatch dropped from 97% to 56% (β = -1.216 (-1.324, -1.108), P < 0.001), and those resulting in an ambulance transport dropped from 73% to 45% (β = -3.376 (-3.615, -3.137), P < 0.001). Among those callers who were Medicaid beneficiaries, within 24 hours, the proportion of calls resulting in an emergency department visit for issues classified as non-emergent or primary care physician (PCP) treatable dropped from 29.5% to 25.1% (β = -0.230 (-0.391, -0.069), P < 0.001), and the proportion resulting in the caller visiting a PCP rose from 2.5% to 8.2% (β = 1.252 (0.889, 1.615), P < 0.001). Over the longer time span of six months, we failed to detect evidence of impacts on emergency department visits, PCP visits or Medicaid expenditures. From a safety perspective, 13 callers randomized to treatment were eventually diagnosed with a time-sensitive illness, all of whom were quickly triaged to an ambulance response. These short-term effects suggest that nurse-led triage of non-emergent calls can safely connect callers to more appropriate, timely care., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The inclusion of participants from underrepresented and underserved groups is lagging in dermatology clinical trials. Through dissemination of a pilot survey at a community skin health fair, knowledge, participation, and perspectives of clinical trials were evaluated in an urban, medically underserved community in Washington, DC. Clinical trial-related questions were derived from the Health Information National Trends Survey 5 Cycle 4. This cross-sectional survey analyzed responses from 39/55 attendees (71% response rate). Most respondents were female (23/37 [62.2%]), between the ages of 25 and 54 (19/38, [50.0%]), and self-identified as non-white (35/39 [89.7%]) with a majority self-identifying as Black (16/31 [41%]). Most respondents self-reported knowing "little" to "nothing" about clinical trials (26/35 [74.3%]), and even more were unaware of the federal resource clinicaltrials.gov (30/37 [81.1%]). Few respondents discussed clinical trials as a treatment option with their healthcare provider (8/35 [22.9%]), yet having a discussion was significantly correlated with clinical trial participation (p = 0.0302). Self-reported level of knowledge was not significantly associated with participation in a clinical trial (p = 0.3035). Healthcare providers were the preferred first source of clinical trial information, followed by an internet search. Respondents rarely cited mistrust or skepticism as a barrier to participation (2/34 [5.9%]). Subjective positive healthcare experiences were significantly correlated to positive expectations with clinical trial participation (p = 0.0242). The findings of this study suggest the essential role healthcare providers, including dermatologists, play in clinical trial education and recruitment of underrepresented populations, and that patient mistrust may be present but is a rarely cited barrier to clinical trial participation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The purpose of this study is to describe telehealth experiences and quality of HIV care provided to an urban population of people with HIV (PWH) in Washington, DC. We used self-reported survey data from a cohort of PWH in the DC Cohort longitudinal study linked to medical records (October 26, 2020-December 31, 2021). Analyses followed a mixed-methods approach, including prevalence estimates and multivariable logistic regression of telehealth use by demographic and HIV characteristics. We measured primary motivation, modes of engagement, and telehealth satisfaction. Qualitative responses to open-ended questions were coded using collaborative coding. A framework developed by the National Quality Forum (NQF) was applied to the results. Among 978 participants, 69% reported using telehealth for HIV care during the pandemic. High school graduates were less likely to use telehealth compared to those with college education (aOR 0.69, 95% CI 0.48, 0.98). PWH with > 1 co-morbid condition were more likely to use telehealth compared to those without (aOR 1.42, 95% CI 1.02, 1.95). The majority reported satisfaction with telehealth (81%). Qualitative analysis of telehealth satisfaction found that most responses were related to access to care and technology, effectiveness, and patient experience. PWH using telehealth during the pandemic were satisfied with their experience though use differed demographically. Telehealth was used effectively to overcome barriers to care engagement, including transportation, costs, and time. As we transition away from the emergency pandemic responses, it will be important to determine how this technology can be used in the future in an equitable manner to further strengthen HIV care engagement., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Since 2000, there have been rising rates of syphilis infections nationally with higher incidence among minorities and persons living with human immunodeficiency virus (HIV) (PLWH). The purpose of this study was to determine syphilis treatment adequacy and factors associated with treatment delay., Methods: This was a retrospective academic-public health collaboration with the District of Columbia Department of Public Health reviewing surveillance data of all primary, secondary, and early latent syphilis cases diagnosed between January 1, 2015, and December 31, 2019. Data were analyzed using multivariable logistic regression to identify factors associated with delayed treatment >14 days from diagnosis., Results: Among 1852 individuals diagnosed with early syphilis, 93% (1730/1852) were male; 48% (893/1852) were coinfected with HIV; 43% (n = 796/1852) were African American/Black, 27% (n = 492/1852) were White, and race/ethnicity was unknown for 17% (n = 318/1852) of cases. Among 679 PLWH for whom viral load (VL) was known, 41% (278/679) had a VL < 20 copies/mL, and 18% (123/679) had VL >10,000 copies/mL. Treatment adequacy overall was 96.5%. Median time to syphilis treatment was 6 days (interquartile range = 4-7). Factors associated with delay of treatment included refused/unknown race (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.00-3.79), and HIV VL > 10,000 copies/mL (aOR, 1.97; 95% CI, 1.08-3.58)., Conclusions: The factors we identified associated with delayed treatment may reflect systemic factors contributing to the increased rates of infection among key populations. This highlights the importance of targeted public health efforts with the goal of reducing transmission of both HIV and syphilis., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: The District of Columbia (DC) has striking disparities in maternal and infant outcomes comparing Black to White women and babies. Social determinants of health (SDoH) are widely recognized as a significant contributor to these disparities in health outcomes. Screening for social risk factors and referral for appropriate services is a critical step in addressing social needs and reducing outcome disparities., Methods: We conducted interviews among employees (n = 18) and patients (n = 9) across three diverse, urban clinics within a healthcare system and one community-based organization involved in a five-year initiative to reduce maternal and infant disparities in DC. Interviews were guided by the Consolidated Framework for Implementation Research to understand current processes and organizational factors that contributed to or impeded delivery of social risk factor screening and referral for indicated needs., Results: We found that current processes for social risk factor screening and referral differed between and within clinics depending on the patient population. Key facilitators of successful screening included a supportive organizational culture and adaptability of more patient-centered screening processes. Key barriers to delivery included high patient volume and limited electronic health record capabilities to record results and track the status of internal and community referrals. Areas identified for improvement included additional social risk factor assessment training for new providers, patient-centered approaches to screening, improved tracking processes, and facilitation of connections to social services within clinical settings., Conclusion: Despite proliferation of social risk factor screeners and recognition of their importance within health care settings, few studies detail implementation processes for social risk factor screening and referrals. Future studies should test implementation strategies for screening and referral services to address identified barriers to implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Brown et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aims: African Americans (AA) in the United States have a high risk of type 2 diabetes mellitus (T2DM) and suffer from disparities in the prevalence, mortality, and comorbidities of the disease compared to other Americans. The present study aimed to shed light on the molecular mechanisms of disease pathogenesis of T2DM among AA in the Washington, DC region., Methods: We performed TaqMan Low Density Arrays (TLDA) on 24 genes of interest that belong to three categories: metabolic disease and disorders, cancer-related genes, and neurobehavioural disorders genes. The 18 genes, viz. ARNT, CYP2D6, IL6, INSR, RRAD, SLC2A2 (metabolic disease and disorders), APC, BCL2, CSNK1D, MYC, SOD2, TP53 (Cancer-related), APBA1, APBB2, APOC1, APOE, GSK3B, and NAE1 (neurobehavioural disorders), were differentially expressed in T2DM participants compared to controls., Results: Our results suggest that factors including gender, smoking habits, and the severity or lack of control of T2DM (as indicated by HbA1c levels) were significantly associated with differential gene expression. APBA1 was significantly (p-value <0.05) downregulated in all diabetes participants. Upregulation of APOE and CYP2D6 genes and downregulation of the INSR gene were observed in the majority of diabetes patients., Conclusions: Tobacco smoking and gender were significantly associated with case-control differences in expression of the APBA1 and APOE genes (connected with Alzheimer's disease) and the INSR and CYP2D6 (associated with metabolic disorders). The results highlight the need for more effective management of T2DM and for tobacco smoking cessation interventions in this community, and further research on the associations of T2DM with other disease processes, including cancer and neurobehavioral pathways., (© 2022 John Wiley & Sons Ltd.)

Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Recent events have amplified the debilitating effects of systemic racism on the health of the United States. In an effort to improve population health and dismantle more than 400 years of racial injustice, retrospective examinations of policies, practices, and events that have sustained and continue to undergird racial hierarchy are necessary. In this historical review we feature Washington, D.C.-a city with a legacy of Black plurality. We begin with an overview of contemporary place-based health and socioeconomic disparities. To express the etiology of the trends and uncover opportunities to undo the damage, we reflect on the national landscape as well as on policies and events that socially, economically, and politically disenfranchised Black residents, yielding stark differences in health outcomes among Washington, D.C., populations. In the spirit of atonement in policy and practice, we hope that this approach will inspire policy makers and practitioners in communities across the nation to conduct similar examinations.

Trust in providers and health care systems (HCSs) has been associated with higher HIV antiretroviral (ART) adherence; however, most previous studies enrolled primarily men and did not concurrently assess provider trust, HCS distrust, and clinical/biological outcomes. We enrolled 239 Washington, DC Women's Interagency HIV Study (WIHS) women: 167 with HIV (WWH) and 72 without HIV. In 2006 and 2017-2018, women completed surveys on provider trust and HCS distrust. Clinical, social, and demographic covariates were obtained during the 2017-2018 WIHS study visit. Descriptive analyses included chi-squared and Mann-Whitney tests. Wilcoxon signed-rank tests assessed trust measure change over time. Logistic (provider trust) and linear (HCS distrust) models were constructed in R. The majority of women were African American/Black (76.9%) with a median age of 52 (interquartile range 48, 58) and currently insured (99.6%). In multi-variable analyses, women with HIV (WWH) had higher odds of high provider trust [adjusted odds ratio (aOR) 2.90, 95% confidence interval (CI) 1.34, 6.45], with ≥95% ART adherence associated with high provider trust among only WWH (aOR 4.13, 95% CI 1.14, 15.92). Multi-variable models also showed 3.40-point higher HCS distrust scores among WWH who reported ≥95% ART adherence ( p  = 0.03). CD4 count and HIV viral load were not associated with provider trust or HCS distrust. Provider ( p  = 0.67) and HCS ( p  = 0.65) trust did not significantly change in this population at two time points for 10 years. Self-reported antiretroviral therapy adherence significantly associated with high provider trust, yet also with high HCS distrust, revealing a nuanced relationship to providers and the HCS among WWH.

Objective: Women living with HIV (WLWH) experience psychosocial stress related to social-structural vulnerabilities. To investigate neuroendocrine pathways linking stress and increased cardiovascular disease risk among WLWH, we evaluated associations between psychosocial stress (i.e., perceived stress, posttraumatic stress, and experiences of race- and gender-based harassment) and a composite neuroendocrine biomarker index among WLWH and women without HIV., Methods: In 2019-2020, Women's Interagency HIV Study participants in Washington, DC completed a questionnaire and provided blood and 12-hour overnight urine samples for testing of serum dehydroepiandrosterone sulfate (DHEA-S) and urinary free cortisol, epinephrine, and norepinephrine. Psychosocial stress was measured using the Perceived Stress Scale, PTSD Checklist-Civilian Version, and Racialized Sexual Harassment Scale. Latent profile analysis was used to classify participants into low (38%), moderate (44%), and high (18%) stress groups. Composite biomarker index scores between 0-4 were assigned based on participants' number of neuroendocrine biomarkers in high-risk quartiles (≥75th percentile for cortisol, epinephrine, and norepinephrine and ≤25th percentile for DHEA-S). We evaluated associations between latent profile and composite biomarker index values using multivariable linear regression, adjusting for socio-demographic, behavioral, metabolic, and HIV-related factors., Results: Among 90 women, 62% were WLWH, 53% were non-Hispanic Black, and median age was 55 years. In full multivariable models, there was no statistically significant association between psychosocial stress and composite biomarker index values among all women independent of HIV status. High (vs. low) psychosocial stress was positively associated with higher mean composite biomarker index values among all monoracial Black women (adjusted β = 1.32; 95% CI: 0.20-2.43), Black WLWH (adjusted β = 1.93; 95% CI: 0.02-3.83) and Black HIV-negative women (adjusted β = 2.54; 95% CI: 0.41-4.67)., Conclusions: Despite a null association in the overall sample, greater psychosocial stress was positively associated with higher neuroendocrine biomarker concentrations among Black women, highlighting a plausible mechanism by which psychosocial stress could contribute to cardiovascular disease risk., Competing Interests: One of the authors [ML] is currently affiliated with a commercial entity, Westat. Data collection and analysis for this study occurred prior to his current affiliation with Westat, while he was affiliated with The George Washington University. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: For patients with differentiated thyroid cancer who will receive postoperative radioactive iodine, thyroid remnant uptake can be calculated and may point to the thoroughness of the surgical resection. In the United States, outcome disparities exist among ethnic/racial minorities with differentiated thyroid cancer. Data about surgical thoroughness and recurrence rates across races/ethnicities do not exist. This study compared the amount of thyroid remnant uptake and cancer recurrence rates across race/ethnicity., Methods: This was a retrospective analysis of adult patients with differentiated thyroid cancer who had postoperative radioactive iodine in 2017 and 2018 and were followed to 2020. We collected thyroid bed remnant uptake from postoperative radioactive iodine scans and analyzed it as a ratio of percent of uptake to dose of radioactive iodine received to control for varying radioactive iodine doses. Thyroid remnant, uptake to dose of radioactive iodine received, and recurrence were evaluated across race/ethnicity., Results: Of 218 patients: 61% were White, 21% Black, 11% Asian, and 7% Hispanic; 72% were female. Seventy-one percent of patients had their surgery done by a high-volume surgeon, although volume data were not available for all. In White, Black, Asian, and Hispanic patients, median uptake was 0.68%, 0.44%, 1.5%, and 0.8%, respectively (P = .13). We did not observe differences in median uptake to dose of radioactive iodine received across groups (P = .41). Recurrence rate was 17.0% among White patients, 16.7% among Black patients, 17.6% among Asian patients, and 16.7% among Hispanic patients (P = 1.00)., Conclusion: We did not observe differences across race/ethnicity in surgical thoroughness or rate of recurrence. These findings suggest that disparities may be mitigated when ethnic/racial minorities have similar access to quality surgical care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To describe outcomes of critically ill patients with COVID-19, particularly the association of renal replacement therapy to mortality., Design: A single-center prospective observational study was carried out., Setting: ICU of a tertiary care center., Patients: Consecutive adults with COVID-19 admitted to the ICU., Intervention: Renal replacement therapy., Main Variables of Interest: Demographic data, medical history, illness severity, type of oxygen therapy, laboratory data and use of renal replacement therapy to generate a logistic regression model describing independent risk factors for mortality., Results: Of the total of 166 patients, 51% were mechanically ventilated and 26% required renal replacement therapy. The overall hospital mortality rate was 36%, versus 56% for those requiring renal replacement therapy, and 68% for those with both mechanical ventilation and renal replacement therapy. The logistic regression model identified four independent risk factors for mortality: age (adjusted OR 2.8 [95% CI 1.8-4.4] for every 10-year increase), mechanical ventilation (4.2 [1.7-10.6]), need for continuous venovenous hemofiltration (2.3 [1.3-4.0]) and C-reactive protein (1.1 [1.0-1.2] for every 10mg/L increase)., Conclusions: In our cohort, acute kidney injury requiring renal replacement therapy was associated to a high mortality rate similar to that associated to the need for mechanical ventilation, while multiorgan failure necessitating both techniques implied an extremely high mortality risk., (Copyright © 2021 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

The food retail environment has been directly linked to disparities in dietary behaviors and may in part explain racial and ethnic disparities in pregnancy-related deaths. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), administered by the United States Department of Agriculture, is associated with improved healthy food and beverage access due to its requirement for minimum stock of healthy foods and beverages in WIC-eligible stores. The selection and authorization criteria used to authorize WIC vendors varies widely from state to state with little known about the specific variations. This paper reviews and summarizes the differences across 16 of these criteria enacted by 89 WIC administrative agencies: the 50 states, the District of Columbia, five US Territories, and 33 Indian Tribal Organizations. Vendor selection and authorization criteria varied across WIC agencies without any consistent pattern. The wide variations in criteria and policies raise questions about the rational for inconsistency. Some of these variations, in combination, may result in reduced access to WIC-approved foods and beverages by WIC participants. For example, minimum square footage and/or number of cash register criteria may limit vendors to larger retail operations that are not typically located in high-risk, under-resourced communities where WIC vendors are most needed. Results highlight an opportunity to convene WIC stakeholders to review variations, their rationale, and implications thereof especially as this process could result in improved policies to ensure and improve healthy food and beverage access by WIC participants. More work remains to better understand the value of state WIC vendor authorization authority, particularly in states that have provided stronger monitoring requirements. This work might also examine if and how streamlining WIC vendor criteria (or at least certain components of them) across regional areas or across the country could provide an opportunity to advance interstate commerce and promote an equitable supply of food across the food system, while ensuring the protection for local, community-oriented WIC vendors.

The goal of HIV treatment is viral suppression as it is linked with improved health outcomes and decreased risk of viral transmission. We assessed the sociodemographic, behavioral, and patient-provider interaction associations with viral suppression with an administered survey to HIV-seropositive women in the metropolitan Washington, DC, site of the Women's Interagency HIV Study (WIHS) between 2017 and 2018. Logistic and mixed models were used to explore related factors between HIV viral suppression groups and HIV treatment self-efficacy, respectively. Higher HIV treatment self-efficacy and disclosure concerns were positively associated with viral suppression, while illicit drug use had a negative association. In mixed models, more health care provider trust was associated with higher HIV treatment self-efficacy, while depressive symptoms were associated with lower HIV treatment self-efficacy. Depression, illicit substance use, and HIV treatment self-efficacy are potentially modifiable factors that can influence viral suppression. Implementation studies are needed to determine whether interventions to manage depression or self-efficacy and improve trust in health care providers will influence treatment outcomes.

In this era of effective combination antiretroviral therapy the incidence of AIDS defining cancers (ADCs) is projected to decline while the incidence of certain non-AIDS defining cancers (NADCs) increases. Some of these NADCs are potentially preventable with appropriate cancer screening. We examined cancer incidence, screening eligibility, and receipt of screening among persons actively enrolled in the DC Cohort, a longitudinal observational cohort of PLWH, between 2011 and 2017. Cancer screening eligibility was determined based on age, sex, smoking history and co-morbidity data available and published national guidelines. The incidence rate of NADCs was 12.1 (95% CI 10.7, 13.8) and ADCs 1.6 (95% CI 0.6, 4.6) per 1000 person-years. The most common incident NADCs were breast 2.6 (95% CI 0.5,1 2.1), prostate 2.3 (95% CI 1.2, 4.3), and non-melanoma skin 1.2 (95% CI 0.6, 2.3) incident diagnoses/cases per 1000 person-years. Among cohort sites where receipt of cancer screening was assessed, less than 60% of eligible participants had any ascertained anal HPV, breast, cervical, colorectal, hepatocellular carcinoma, or lung cancer screening. In this cohort of PLWH, there were more incident NADCs versus ADCs in contrast to earlier cohort studies where ADCs predominated. Despite a large eligible population there were low rates of screening. Implementation of cancer screening is an important component of care among PLWH.

Background: Little is known regarding the efficacy of immune checkpoint inhibitors (ICI) in patients with advanced large-cell neuroendocrine lung carcinoma (aLCNEC)., Methods: 125 consecutive patients with aLCNEC were identified in the electronic databases of 4 participating cancer centers. The patients were divided into group A (patients who received ICI, n=41) and group B (patients who did not receive ICI, n=84). Overall survival since advanced disease diagnosis (OS DX) and OS since ICI initiation (OS ICI) were captured., Results: With a median follow-up of 11.8 months (mo) (IQR 7.5-17.9) and 6.0mo (IQR 3.1-10.9), 66% and 76% of patients died in groups A and B, respectively. Median OS DX was 12.4mo (95% CI 10.7 to 23.4) and 6.0mo (95% CI 4.7 to 9.4) in groups A and B, respectively (log-rank test, p=0.02). For ICI administration, HR for OS DX was 0.59 (95% CI 0.38 to 0.93, p=0.02-unadjusted), and 0.58 (95% CI 0.34 to 0.98, p=0.04-adjusted for age, Eastern Cooperative Oncology Group (ECOG) performance status (PS), presence of liver metastases and chemotherapy administration). In a propensity score matching analysis (n=74; 37 patients in each group matched for age and ECOG PS), median OS DX was 12.5 mo (95% CI 10.6 to 25.2) and 8.4 mo (95% CI 5.4 to 16.9) in matched groups A and B, respectively (log-rank test, p=0.046). OS ICI for patients receiving ICI as monotherapy (n=36) was 11.0 mo (95% CI 6.1 to 19.4)., Conclusions: With the limitations of retrospective design and small sample size, the results of this real-world cohort analysis suggest a positive impact of ICI on OS in aLCNEC., Competing Interests: Competing interests: ED reported consulting fees from MSD, BMS, Astra Zeneca, Roche, Boehringer Ingelheim, Pfizer, Novartis, Takeda. MM reported consulting fees from Boehringer Ingelheim, Roche, Astra Zeneca, MSD, BMS, Abbvie, Takeda, Pomicell. CK reported research funding (to institution) from AstraZeneca, BMS, Novartis, Regeneron, Tesaro, Karyopharm, Debiopharm, Jassen, and Mirati and consulting fees from Novartis. SVL reported consulting fees from AstraZeneca, Beigene, Blueprint, Boehringer Ingelheim, Bristol-Myers Squibb, Catalyst, Celgene, Clovis, Corvus, G1 Therapeutics, Genentech, Guardant Health, Inivata, Janssen, Jazz, Lilly, LOXO, MSD, PharmaMar, Pfizer, Regeneron, and Takeda and research grants (to institution) from Alkermes, AstraZeneca, Bayer, Blueprint, Bristol-Myers Squibb, Genentech, Lilly, Lycera, Merck, Molecular Partners, Pfizer, Rain Therapeutics, RAPT, Spectrum, and Turning Point Therapeutics. DU reported consulting fees and non-financial support from BMS, Astra Zeneca, Takeda, consulting fees MSD, Roche and Boehringer Ingelheim. AZ reported grants from BMS, personal fees from Roche, MSD, BMS, Astra Zeneca, Takeda. AO reported advisory fees from MSD, BMS, Roche, Astra Zeneca, Novartis, Boehringer Ingelheim. MW reported speaker fees and funding (to institution) from Roche, MSD. JB reported grants and personal fees from MSD, Roche, BMS, Abbvie, Pfizer, Novartis, Astra Zeneca, Boehringer Ingelheim, Takeda., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Coronavirus disease 2019 (COVID-19) continues to affect all aspects of health care delivery, and neurosurgical practices are not immune to its impact. We aimed to evaluate neurosurgical practice patterns as well as the perioperative incidence of COVID-19 in neurosurgical patients and their outcomes., Methods: A retrospective review of neurosurgical and neurointerventional cases at 2 tertiary centers during the first 3 months of the first peak of COVID-19 pandemic (March 8 to June 8) as well as following 3 months (post-peak pandemic; June 9 to September 9) was performed. Baseline characteristics, perioperative COVID-19 test results, modified Medically Necessary, Time-Sensitive (mMeNTS) score, and outcome measures were compared between COVID-19-positive and-negative patients through bivariate and multivariate analysis., Results: In total, 652 neurosurgical and 217 neurointerventional cases were performed during post-peak pandemic period. Cervical spine, lumbar spine, functional/pain, cranioplasty, and cerebral angiogram cases were significantly increased in the postpandemic period. There was a 2.9% (35/1197) positivity rate for COVID-19 testing overall and 3.6% (13/363) positivity rate postoperatively. Age, mMeNTS score, complications, length of stay, case acuity, American Society of Anesthesiologists status, and disposition were significantly different between COVID-19-positive and-negative patients., Conclusions: A significant increase in elective case volume during the post-peak pandemic period is feasible with low and acceptable incidence of COVID-19 in neurosurgical patients. COVID-19-positive patients were younger, less likely to undergo elective procedures, had increased length of stay, had more complications, and were discharged to a location other than home. The mMeNTS score plays a role in decision-making for scheduling elective cases., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The authors sought to describe state-to-state variations in the scope of statutory authority granted to default surrogates who decide on mental health treatment for incapacitated patients., Methods: The authors investigated state statutes delineating the powers of default surrogates to make decisions about mental health treatment. Statutes in all 50 U.S. states and the District of Columbia were identified and analyzed independently by three reviewers. Research was conducted from August 2017 to November 2018 and updated in January 2020., Results: State statutes varied in approaches to default surrogate decision making for mental health treatment. Eight states' statutes delegate broad authority to surrogates, whereas 25 states prohibit surrogates from giving consent for specific therapies. Thirteen states are silent on whether surrogates may make decisions., Conclusions: Heterogeneity among state statutory laws contributes to complexity of treating patients without decisional capacity. This variability encumbers efforts to support surrogates and clinicians and may contribute to health disparities.

Objective: The true incidence of perioperative coronavirus disease 2019 (COVID-19) has not been well elucidated in neurosurgical studies. We reviewed the effects of the pandemic on the neurosurgical case volume to study the incidence of COVID-19 in patients undergoing these procedures during the perioperative period and compared the characteristics and outcomes of this group to those of patients without COVID-19., Methods: The neurosurgical and neurointerventional procedures at 2 tertiary care centers during the pandemic were reviewed. The case volume, type, and acuity were compared to those during the same period in 2019. The perioperative COVID-19 tests and results were evaluated to obtain the incidence. The baseline characteristics, including a modified Medically Necessary Time Sensitive (mMeNTS) score, and outcome measures were compared between those with and without COVID-19., Results: A total of 405 cases were reviewed, and a significant decrease was found in total spine, cervical spine, lumbar spine, and functional/pain cases. No significant differences were found in the number of cranial or neurointerventional cases. Of the 334 patients tested, 18 (5.4%) had tested positive for COVID-19. Five of these patients were diagnosed postoperatively. The mMeNTS score, complications, and case acuity were significantly different between the patients with and without COVID-19., Conclusion: A small, but real, risk exists of perioperative COVID-19 in neurosurgical patients, and those patients have tended to have a greater complication rate. Use of the mMeNTS score might play a role in decision making for scheduling elective cases. Further studies are warranted to develop risk stratification and validate the incidence., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Central venous catheter (CVC) complication rates reflecting the application of modern insertion techniques to a clinically heterogeneous patient populations are needed to better understand procedural risk attributable to the 3 common anatomic insertion sites: internal jugular, subclavian, and femoral veins. We sought to define site-specific mechanical and duration-associated CVC complication rates across all hospital inpatients., Methods: A retrospective chart review was conducted over 9 months at Georgetown University Hospital and Washington Hospital Center. Peripherally inserted central catheters and tunneled or fluoroscopically placed CVC's were excluded. Mechanical complications (retained guidewire, arterial injury, and pneumothorax) and duration-associated complications (deep vein thrombosis or pulmonary embolism, and central line-associated bloodstream infections) were identified., Results: In all, 1179 CVC insertions in 801 adult patients were analyzed. Approximately 32% of patients had multiple lines placed. Of 1179 CVCs, 73 total complications were recorded, giving a total rate of one or more complications occurring per CVC of 5.9%. There was no statistically significant difference between site-specific complications. A total of 19 mechanical complications were documented, with a 1.5% complication rate of one or more mechanical complications occurring. A total of 54 delayed complications were documented, with a 4.4% complication rate of 1 or more delayed complications occurring. There were no statistically significant differences between anatomic sites for either total mechanical or total delayed complications., Conclusions: These results suggest that site-specific CVC complication rates may be less common than previously reported. These data further inform on the safety of modern CVC insertion techniques across all patient populations and clinical settings.

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws. Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length). Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws. Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Background: Adherence to antiretroviral therapy (ART) is imperative for viral suppression and reducing HIV transmission, but many people living with HIV report difficultly sustaining long-term adherence. Long-acting injectable (LAI) ART has the potential to transform HIV treatment and prevention. However, little LAI ART-related behavioral research has occurred among women, particularly outside of clinical trials., Setting: Six Women's Interagency HIV Study sites: New York, Chicago, Washington DC, Atlanta, Chapel Hill, and San Francisco., Methods: We conducted 59 in-depth interviews with women living with HIV across 6 Women's Interagency HIV Study sites (10 per site; 9 at Washington DC). We interviewed women who were not included in LAI ART clinical trials but who receive care at university settings that will administer LAI ART once it is approved. Interviews were recorded, transcribed, and analyzed using thematic content analysis., Results: Most women enthusiastically endorsed monthly LAI ART and would prefer it over pills. The following 3 reasons emerged for this preference: (1) convenience and confidentiality, (2) avoiding daily reminders about living with HIV, and (3) believing that shots are more effective than pills. Challenges remain, however, specifically around (1) medical mistrust, (2) concerns about safety and effectiveness, (3) pill burden for HIV and other conditions, and (4) barriers to additional medical visits., Conclusions: Most women preferred LAI ART over daily pills given its benefits, including convenience, privacy, and perceived effectiveness. Future research should incorporate more women into LAI ART trials to better understand and align development with user concerns and preferences to enhance uptake.

Human noroviruses are a major cause of diarrheal illness, but pathogenesis is poorly understood. Here, we investigate the cellular tropism of norovirus in specimens from four immunocompromised patients. Abundant norovirus antigen and RNA are detected throughout the small intestinal tract in jejunal and ileal tissue from one pediatric intestinal transplant recipient with severe gastroenteritis. Negative-sense viral RNA, a marker of active viral replication, is found predominantly in intestinal epithelial cells, with chromogranin A-positive enteroendocrine cells (EECs) identified as a permissive cell type in this patient. These findings are consistent with the detection of norovirus-positive EECs in the other three immunocompromised patients. Investigation of the signaling pathways induced in EECs that mediate communication between the gut and brain may clarify mechanisms of pathogenesis and lead to the development of in vitro model systems in which to evaluate norovirus vaccines and treatment.

Background: This will be the largest multi-institutional study looking at incidence of and duration to symptomatic hernia formation for major abdominal operations separated by malignant and benign disease process., Methods: An IRB-approved retrospective study within the MedStar Hospital database was conducted, incorporating all isolated colectomy, hepatectomy, pancreatectomy, and gastrectomy procedures between the years 2002 and 2016. All patients were identified using ICD-9 and ICD-10 codes for relevant procedures, and then separated based on malignant or benign etiology. The rate of symptomatic incisional hernia rates was determined for each cohort based on subsequent hernia procedural codes identified., Results: During this 15-year span, a total of 6448 major abdominal operations were performed at all 10 institutions, comprising 3835 colectomies, 1122 hepatectomies, 1165 pancreatectomies, and 326 gastrectomies. Total incidence of symptomatic incisional hernia occurrence requiring repair was 325 (5.0%). Separated by group, the overall incisional hernia repair rates for patients undergoing colectomy, hepatectomy, pancreatectomy, and gastrectomy are as follows, respectively: 6.4% (247), 2.5% (28), 3.6% (42), and 2.8% (9), P < 0.0001. The subsequent median duration to hernia repair was 498 d (interquartile range [IQR]: 312-924) for colectomy, 421 d (IQR: 340-518) for hepatectomy, 378 d (IQR: 284-527) for pancreatectomy, and 630 d (IQR: 419-1204) for gastrectomy (P = 0.03401)., Conclusions: Symptomatic incisional hernia repair rates after major gastrointestinal and hepatobiliary surgery range from 2.1% to 6.4%. There was no significant increase in hernia rates in patients undergoing surgery for malignancy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Most literature describing pharmacogenetic implementations are within academic medical centers and use single-gene tests. Our objective was to describe the results and lessons learned from a multisite pharmacogenetic pilot that utilized panel-based testing in academic and nonacademic settings. This was a retrospective analysis of 667 patients from a pilot in 4 perioperative and 5 outpatient cardiology clinics. Recommendations related to 12 genes and 65 drugs were classified as actionable or not actionable. They were ascertained from Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines and US Food and Drug Administration (FDA) labeling. Patients displayed a high prevalence of actionable results (88%, 99%) and use of medications (28%, 46%) with FDA or CPIC recommendations, respectively. Sixteen percent of patients had an actionable result for a current medication per CPIC compared with 5% per FDA labeling. A systematic approach by a health system may be beneficial given the quantity and diversity of patients affected., (© 2020 The Authors. Clinical and Translational Science published by Wiley Periodicals, Inc. on behalf of the American Society for Clinical Pharmacology and Therapeutics.)

Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type., Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011 and 2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA < 50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors., Results: Among 3908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p = 0.03; ART-experienced: private 80.2% vs public 69.4%, p < 0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR = 1.59, 95% CI: 1.20, 2.12; p = 0.001)., Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Probiotic usage in food is widespread and growing. The objective of this study was to determine the percentage of probiotic food products sold in the refrigerated section of retail grocery stores in the Washington DC area that we could link to evidence of any health benefit. We surveyed refrigerated sections of eight large grocery stores representing five national chains for probiotic products. Based on declared probiotic composition (strain and count) for each product, we searched PubMed for controlled trials that provided evidence of any health benefit. Our assessment showed that 49% (22 out of 45 distinct probiotic foods) could be linked to evidence supporting a health benefit. All products indicating strain composition could be linked to evidence. Our study suggests that consumers have a reasonable likelihood of purchasing a refrigerated probiotic food with evidence, but room for improvement exists.

Background: Despite a lower percentage of primary cesareans than non-Hispanic White and Black women, Hispanic women in the United States had the highest rate of repeat cesarean deliveries (RCD) in 2016; it is unclear if reasons for differences are due to known risk factors. Our study examined the association between ethnicity/race and RCD among women with one previous cesarean and whether demographic (age, marital status, education, language, and delivery year), anthropomorphic (height, prepregnancy body mass index), obstetrical/medical (parity, gestational age, infant birth weight, gestational diabetes, labor induction or augmentation, vaginal birth after cesarean delivery history), or health system (delivery day/time, payer source, provider gender) factors accounted for any observed differences by ethnicity/race., Methods: Our retrospective cohort study used logistic regression to evaluate the relationship between ethnicity/race and RCD based on data from electronic delivery and prenatal records from 2010 to 2016, including 1800 births to Hispanic and non-Hispanic women with one previous cesarean at a District of Columbia hospital., Results: Statistically significant differences by ethnicity/race were noted after adjustment for obstetric/medical factors, particularly parity and use of induction or augmentation methods. Hispanic (adjusted odds ratio, 2.48; 95% confidence interval, 1.03-6.01) and Black women (adjusted odds ratio, 2.83; 95% confidence interval, 1.67-4.81) had higher odds of RCD than White women., Conclusions: Adjustment for parity and use of induction or augmentation methods revealed higher odds of RCD for Hispanic and Black women than White women. Demographic and anthropometric factors did not alter these results. Our work is a first step in creating effective public health policy and programs that target potentially preventable RCD by highlighting the need to evaluate risk factors beyond those included in the literature to date., (Copyright © 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A 1c (HbA 1c ), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined., Research Design and Methods: The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA 1c >9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA 1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices., Results: A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA 1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA 1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated., Conclusions: Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes., Trial Registration Number: NCT02925312., Competing Interests: Competing interests: MFM received funding on behalf of MedStar Health Research Institute during the study period from Eli Lilly for the REWIND Study, from the Patient-Centered Outcomes Research Institute (NCT-02093234), from the National Institutes of Health (NIH DK-109503) and from Mytonomy. She served as a speaker for the American Diabetes Association and for PRIMED. KMB has no interests to declare. SJF received funding on behalf of MedStar Health Research Institute during the study period from the National Institutes of Health. CMN received funding on behalf of MedStar Health Research Institute during the study period from Eli Lilly for the REWIND Study and from the Patient-Centered Outcomes Research Institute. KS received funding from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1-TR001409, the Agency for Healthcare Research and Quality and the National Institutes of Health (NIH DK-109503). GAY was a speaker for the American Diabetes Association during the study period. No other potential conflicts of interest relevant to this article were reported. C-CH, MM, ARM, PAS and SRE have no interests to declare., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Heel ulcers have a significant impact on lower-extremity morbidity and confer high risk of major amputations. Treating these ulcers is difficult because of poor tissue coverage and the bony os calcis, often leading to proximal amputation. This case series shows the vertical contour calcanectomy (VCC) as a surgical alternative in functional limb salvage. Sixteen feet (14 patients) with recalcitrant heel wounds who underwent VCC were identified. The minimum follow-up time for inclusion was 1 year. Body mass index, diabetes, renal disease, peripheral vascular disease, lymphedema/venous insufficiency, smoking status, Charcot, amputation, vascular intervention, wound recurrence, reoperation rate, and ambulatory status were evaluated. The average follow-up time was 27.1 months (range 13.5 to 51.1). At 1 year of follow-up, 56% of heel wounds (9 of 16) treated with the VCC remained closed. An average of 1.44 subsequent surgeries were required per patient. Baseline or improved ambulatory status was achieved in 69% of patients (9 of 14) at 1-year follow up and 100% of patients (8 of 8) at 2-year follow up. The overall rate of major amputation was 19%. The long-term ambulatory status of patients treated with the VCC shows promise. The VCC should be considered as an alternative, reliable, surgical limb salvage tool for heel ulcerations., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There has been a surge in synthetic cannabinoid receptor agonist (SCRA) exposures reported in recent years. The constituents of SCRA preparations are constantly evolving and rarely confirmed. We sought to characterize the constituents of reported SCRA exposures presenting to the emergency department (ED)., Methods: Patients who presented to two academic EDs in Washington, DC with reported or suspected SCRA exposure from July 2015-July 2016 were enrolled at the discretion of the treating provider. Blood and/or urine samples were obtained as part of routine clinical care and sent to the DC medical examiner's office for identification of known SCRAs with liquid chromatography-mass spectrometry-mass spectrometry. Standard toxicology screens were additionally performed to determine the presence of other drugs of abuse., Results: 128 samples were analyzed. Seventy-one (55.5%) were positive for an SCRA. The most common SCRAs detected were AB-fubinaca (28, 39.4%), ADB-fubinaca (15, 21.1%), AB-chminaca 3-methyl-butanoic acid (15, 21.1%), ADB-chminaca (14, 19.7%), and 5-flouro-PB-22 (8, 11.3%). Fifty-seven (44.5%) samples were negative for an SCRA, of which 28 (21.9%) were positive for another substance, most commonly delta-9-tetrahydrocannabinol and phencyclidine. An additional 29 (22.7%) patients had both negative SCRA and toxicology screens., Conclusions: Of patients presenting with reported SCRA intoxication, 55.5% had detectable SCRAs on analytical testing. These results suggest that in a considerable proportion of cases, clinicians are mis-attributing the effects of other drugs or medical conditions to SCRA use. The individual SCRAs detected in our study differed from compounds detected in earlier studies, suggesting there has been a change in constituents., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Student physicians are particularly prone to high rates of poor mental and physical quality of life, including depression, anxiety, and fatigue. We prospectively tested whether a structured, theory-based executive/life coaching program tailored to first year medical students in the United States was feasible, tolerable, and would be recommended by participants. Secondary goals included impact on coaching goals, resilience, and perceived stress., Methods: This single-arm intervention study evaluated a program of two group and two private coaching sessions during the first year, second semester of the Georgetown University School of Medicine Class of 2019. Survey data (global and tailored questions, Connor-Davidson resilience scale, Friedricksson-Larsson stress question) were collected from participants at baseline and post-intervention., Results: 37/40 students completed the intervention; 32 completed the pre-post surveys. Most (32/37) were willing to recommend the program (16/37 were very willing) and 29/37 recommended inclusion in the curriculum. Responses to tailored questions showed significant increases in self-efficacy regarding stress management (p < 0.001); increased awareness of thoughts about stress and management of those thoughts (p = 0.05). Reported improvements in time management (p = 0.10) and energy for relationships and school (p = 0.089) did not achieve significance. Global resilience rating was not different (p = 0.186), but significant changes were seen in control (p = 0.029) and spiritual influence (p = 0.005) factors. Although the Friedricksson-Larsson item was not significantly different (p = 0.242), 40.6% of participants reported decreased stress and 40.6% reported unchanged stress during this most challenging preclinical semester. Substantial ceiling effects were seen in study measures., Conclusions: We showed that a tailored executive/life coaching program for first year medical students in the United States is feasible, tolerable, and safe; adherence was excellent. Global utility ratings and willingness to recommend coaching provide substantial support for efficacy. Better measures and larger-scale clinical trial designs are needed for formal proof.

Objective: To examine the association of a resident-driven quality initiative with cesarean delivery surgical site infections., Methods: This was a quasi-experimental, preintervention and postintervention study of women undergoing cesarean delivery at 23 weeks of gestation or greater between January 2015 and June 2018 at a single tertiary care center. We implemented a resident-driven, evidence-based surgical bundle, excluding women who underwent emergency cesarean or had chorioamnionitis. The bundle included routine prophylactic antibiotics (both cefazolin and azithromycin), chlorhexidine alcohol skin preparation, use of clippers instead of a razor, vaginal cleansing with povidone iodine, placental removal by umbilical cord traction, subcutaneous tissue closure if wound thickness greater than 2 cm, suture skin closure, dressing removal between 24 and 48 hours, and use of postoperative chlorhexidine soap. Our primary outcome was surgical site infections (superficial incisional, deep incisional, and organ or space surgical site infections) occurring up to 6 weeks postpartum. Outcomes were compared between the preimplementation period (January 2015-August 2016) and postimplementation period (December 2016-June 2018). Coarsened Exact Matching with k-to-k solution was performed using age, race-ethnicity, body mass index, rupture of membranes, and labor., Results: In total, 1,624 underwent cesarean delivery in the preimplementation and 1,523 postimplementation periods, respectively; 1,100 women in the postimplementation period were matched to 1,100 women in the preimplementation period. The rate of surgical site infections in the unmatched cohort was significantly lower in the postimplementation period compared to those in the preimplementation period (2.2% [33/1,523] vs 4.5% [73/1,624]; odds ratio [OR] 0.47 [95% CI 0.31-0.71]; P<.001). This decrease in the rate of surgical site infections remained statistically significant after matching (1.9% [21/1,100] vs 4.1% [45/1,100]; OR 0.46 [0.27-0.77]; P<.001)., Conclusion: After implementation of a resident-driven quality initiative using a surgical bundle, we observed a significant decrease in cesarean surgical site infections.

Background: In 2014, the state of Maryland (MD) moved away from fee-for-service payments and into a global budget revenue (GBR) structure where hospitals have a fixed revenue target, independent of patient volume or services provided. We assess the effects of GBR adoption on emergency department (ED) admission decisions among adult encounters., Methods: We used hospital medical record and billing data from adult ED encounters from January 1, 2011, through December 31, 2015, with four MD hospitals and two District of Columbia (DC) hospitals within the same health system. We performed difference-in-differences analysis and calculated the effects of the GBR model on ED admission rates (inpatient and observation) using hospital fixed-effect regression adjusted for patient, hospital, and community factors. We also examined changes in the distribution of acuity among ED admissions with GBR adoption., Results: The study sample included 1,492,953 ED encounters with a mean ED admission rate of 20.5%. The ED admission rate difference pre- and post-GBR was -1.14% (95% confidence interval [CI] = -0.89 to -1.40) for MD hospitals and -0.04% (95% CI = -0.24 to 0.32) for DC hospitals with a difference-in-differences result of -1.10% (95% CI = -1.34 to -0.86). This change was attributable to a -3.3% (95% CI = -3.54 to -3.08) decline in inpatient admissions and 2.7% (95% CI = 2.53 to 2.79) increase in observation admissions. Declines in admissions were observed primarily among mild-to-moderate severity of illness encounters with a low risk of mortality., Conclusions: Within the same health system, implementation of global budgeting in MD hospitals was associated with a decline in ED admissions-particularly lower-acuity admissions-compared to DC hospitals that remained under fee-for-service payments., (© 2018 by the Society for Academic Emergency Medicine.)

Introduction: Medication histories, including knowledge of allergies and adverse drug reactions (ADRs), are a nationally recognized quality measure. Medication histories in the emergency department (ED) are often inaccurate or incomplete. Our objective was to determine the prevalence and nature of medication allergy and ADR discrepancies in an urban ED., Methods: This was a prospective observational descriptive study, enrolling a convenience sample of adults over 7 months at a single academic urban ED. Trained personnel recorded patient demographics and number of daily medications. Patients listed any prior drug allergies or non-allergic ADRs. Following the ED encounter, the patients' self-reported allergies and ADRs were compared to the electronic medical record (EMR) to identify and describe discrepancies., Results: A sample of 1014 patients, predominantly black (81%), female (60%), and in the 18- to 59-year-old range (69%), was recruited. Most patients were taking at least one daily medication (74%). Three hundred fifteen patients reported at least one allergy (31%), and 252 (25%) at least one ADR. Four hundred sixteen patients (41%) had a discrepancy between their self-report of allergy or ADR and the EMR. Omissions were the most frequent discrepancy. Full descriptions of allergies or ADR were present in 18.4% of charts. Fifty-seven patients (5.6%) were administered a medication which could have interacted with a documented allergy or ADR; none of the allergy EMR records were updated to reflected this., Conclusions: In this cross-sectional ED study, drug allergies and ADRs were both highly prevalent. There were significant discrepancies in documentation of allergies and ADRs between patient self-report and the EMR.

Results of the SPRINT study have been disputed, based on the assumption that unattended BP measurements do not correlate with usual BP measurements. In this study, the authors investigated the correlation of unattended SPRINT-like measurements with other conventional measurements. All BP measurements were taken with the patient seated in a comfortable chair with the legs uncrossed and not speaking during the procedure. For the purpose of this study, sixty-five patients, mostly male (93%), were recruited from our hypertension clinic and all were on antihypertensive medication (av 3.0 ± 1.1). Patients were at high cardiovascular risk with high rates of comorbidities, av age 68 ± 12 years, 49% with diabetes, 34% with mild CKD (CKD 1-3, average eGFR 55.0 ± 13 mL/min/1.73 m 2 ), and 20% with history of stable coronary artery disease. All BP measurements were similar with no statistically significant difference (one-way ANOVA, P = 0.621). Compared to unattended SPRINT BP values (139.77 ± 19.22/75.42 ± 11.72 mm Hg), the clinic BP measurements were numerically slightly higher but with a NS P value (P = 0.163). Similarly, unattended BP measurements were similar to values taken by the clinic physician. In a smaller cohort of 11 patients, the authors compared unobserved vs observed SPRINT-like BP measurements, and in 13 patients, the authors compared unobserved SPRINT-like BP measurements to average home BP measurements (Table 3). There were no significant differences between any of the subgroups (one-way ANOVA, P = 0.816 for systolic and P = 0.803 for diastolic). The authors conclude that unattended BP measurements taken (the SPRINT way) are similar to other conventional office blood pressure measurements., (©2018 Wiley Periodicals, Inc.)

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

This study developed and examined the reach and impact of a culturally appropriate mass media campaign pilot, designed to increase awareness about the importance of mammography screening and the available community mammography services for low-income African American women ages 40 and above. We conducted formative research using focus groups to inform campaign development, resulting in five emergent themes-good breast health, holistic views of healthiness, cancer fatalism, fear of mammogram machines, and mammogram affordability. The campaign targeted specific low-income African American communities in the District of Columbia via print ads in Metro stations and on buses, print ads in the Washington Informer, and online ads on a local TV network website. Data were collected before, during, and after campaign implementation to assess reach and impact. Reach was measured by number of impressions (number of people exposed to the campaign), while impact was assessed via online ad click-through rates, website use and referrals, and mammography center calls. The campaign was successful in reaching the target audience, with a total combined reach from all media of 9,479,386 impressions. In addition, the mammography center received significant increases in new website visitors (1482 during the campaign, compared to 24 during the preceding period) as well as 97 calls to the dedicated phone line. Further research involving a more long-term investment in terms of funding and campaign run time, coupled with a more robust evaluation, is needed to assess if culturally appropriate mass media campaigns can generate increased mammography screening rates and decrease breast-cancer-related mortality.

Quarantine is an important but often misused tool of public health. An effective quarantine requires a process that inspires trust in government, only punishes noncompliance, and promotes a culture of social responsibility. Accomplishing successful quarantine requires incentives and enabling factors, payments, job security, and a tiered enforcement plan. In this article, we examine the variation in state-level quarantine laws and assess the effectiveness of these laws and regulations. We find that most states allow for an individual to have a hearing (63%) and to have a voice in burial and cremation procedures (71%), yet are weak on all other individual rights measures. Only 20% of states have provisions to protect employment when an individual is under quarantine, and less than half have plans for safe and humane quarantines. Decision makers at the state and local levels must make a concerted effort to revise and update quarantine laws and regulations. Ideally, these laws and regulations should be harmonized so as to avoid confusion and disruption between states, and public health officials should work with populations to identify and address the factors that will support successful quarantines if they are ever required.

Background: The Georgetown University-Albert Einstein College of Medicine breast cancer simulation model (Model GE) has evolved over time in structure and function to reflect advances in knowledge about breast cancer, improvements in early detection and treatment technology, and progress in computing resources. This article describes the model and provides examples of model applications., Methods: The model is a discrete events microsimulation of single-life histories of women from multiple birth cohorts. Events are simulated in the absence of screening and treatment, and interventions are then applied to assess their impact on population breast cancer trends. The model accommodates differences in natural history associated with estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) biomarkers, as well as conventional breast cancer risk factors. The approach for simulating breast cancer natural history is phenomenological, relying on dates, stage, and age of clinical and screen detection for a tumor molecular subtype without explicitly modeling tumor growth. The inputs to the model are regularly updated to reflect current practice. Numerous technical modifications, including the use of object-oriented programming (C++), and more efficient algorithms, along with hardware advances, have increased program efficiency permitting simulations of large samples., Results: The model results consistently match key temporal trends in US breast cancer incidence and mortality., Conclusion: The model has been used in collaboration with other CISNET models to assess cancer control policies and will be applied to evaluate clinical trial design, recurrence risk, and polygenic risk-based screening.

Background: Treatment options are limited for patients with thymic carcinoma. These aggressive tumours are not typically associated with paraneoplastic autoimmune disorders, and strong PD-L1 expression has been reported in thymic epithelial tumours. We aimed to assess the activity of pembrolizumab, a monoclonal antibody that targets PD-1, in patients with advanced thymic carcinoma., Methods: We completed a single-arm phase 2 study of pembrolizumab in patients with recurrent thymic carcinoma who had progressed after at least one line of chemotherapy. This was a single-centre study performed at Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA. Key inclusion criteria were an Eastern Cooperative Oncology Group performance status of 0-2, no history of autoimmune disease or other malignancy requiring treatment or laboratory abnormality, and adequate organ function. Patients received 200 mg of pembrolizumab every 3 weeks for up to 2 years. The primary objective of the study was the proportion of patients who had achieved a response assessed with Response Evaluation Criteria in Solid Tumors version 1.1. Analysis was per protocol, in all eligible patients. The study is registered with ClinicalTrials.gov, number NCT02364076, and is closed to accrual; we report the final analysis., Findings: 41 patients were enrolled from March 12, 2015, to Dec 16, 2016, of whom 40 were eligible and evaluable and one was excluded because of elevated liver enzymes at screening. The median follow-up was 20 months (IQR 14-26). The proportion of patients who achieved a response was 22·5% (95% CI 10·8-38·5); one (3%) patient achieved a complete response, eight (20%) patients achieved partial responses, and 21 (53%) patients achieved stable disease. The most common grade 3 or 4 adverse events were increased aspartate aminotransferase and alanine aminotransferase (five [13%] patients each). Six (15%) patients developed severe autoimmune toxicity, including two (5%) patients with myocarditis. There were 17 deaths at the time of analysis, but no deaths due to toxicity., Interpretation: Pembrolizumab is a promising treatment option in patients with thymic carcinoma. Because severe autoimmune disorders are more frequent in thymic carcinoma than in other tumour types, careful monitoring is essential., Funding: Merck & Co., (Copyright © 2018 Elsevier Ltd. All rights reserved.)