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Objective: The objective of this study was to examine the associations between active, passive, and manual therapy interventions with the escalation-of-care events following physical therapist care for veterans with low back pain (LBP)., Methods: A retrospective cohort study was conducted in 3618 veterans who received physical therapist care for LBP between January 1, 2015 and January 1, 2018. The Department of Veterans Affairs (VA) Corporate Data Warehouse was utilized to identify LBP-related physical therapist visits and procedures, as well as opioid prescription and non-physical therapy clinic encounters. The association between physical therapist interventions with 1-year escalation-of-care events were assessed using adjusted odds ratios from logistic regression., Results: Nearly all veterans (98%) received active interventions, but only a minority (31%) received manual therapy. In the 1-year follow-up period, the odds of receiving an opioid prescription were 30% lower for those who received manual therapy in addition to active interventions, as compared with patients who received only active interventions. Moreover, the odds of receiving primary care, specialty care, and diagnostic testing were 30% to 130% higher for patients who received electrical stimulation or more than 1 passive intervention in addition to active treatments, as compared with patients who received only active interventions., Conclusion: The use of manual therapy along with active interventions was associated with reduced prescription of opioids, while utilization of specific passive interventions such as electrical stimulation or multiple modalities in conjunction with active interventions resulted in increased escalation-of-care events., Impact: The use of active interventions, which is supported by most clinical practice guidelines, was the cornerstone of physical therapist care for veterans with LBP. However, the use of clinical practice guideline-recommended manual therapy interventions was low but associated with reduced opioid prescriptions. The use of 2 or more different passive interventions along with active interventions was common (34%) and associated with less-than-optimal escalation-of-care outcomes., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To examine case logs reported by general surgery residents and identify potential disparities in operative experience., Background: A recent study of 21 institutions noted significant differences between the number of cases reported during general surgery residency by trainees who are underrepresented in medicine (URiM) versus trainees who are not URiM (non-URiM). This study also identified differences between female residents and male residents. We partnered with the Accreditation Council for Graduate Medical Education to examine case logs reported from all accredited general surgery programs in the United States. This is the first time these data have been examined nationally., Methods: We examined total case logs submitted by graduating residents between 2017 and 2022. Group differences in mean reported case logs were examined using paired t tests for female versus male and URiM versus non-URiM overall case numbers., Results: A total of 6458 residents submitted case logs from 319 accredited programs. Eight-hundred fifty-four (13%) were URiM and 5604 (87%) were non-URiM. Over the 5-year study period, URM residents submitted 1096.95 (SD ± 160.57) major cases versus 1115.96 (±160.53) for non-URiM residents (difference = 19 cases, P = 0.001). Case logs were submitted by 3833 (60.1%) male residents and 2625 (39.9%) female residents over the 5-year study period. Male residents reported 1128.56 (SD ± 168.32) cases versus 1091.38 (±145.98) cases reported by females (difference = 37.18, P < 0.001). When looking at surgeon chief and teaching assistant cases, there was no significant difference noted between cases submitted by URiM versus non- URiM residents. However, male residents reported significantly more in both categories than their female peers ( P < 0.001)., Conclusions: Overall, URiM residents submitted fewer cases in the 5-year study period than their non-URiM peers. The gap in submitted cases between male and female residents was more pronounced, with male residents submitting significantly more cases than their female counterparts. This finding was consistent and statistically significant throughout the entire study period, in most case categories, and without narrowing of difference over time. A difference of 30 to 40 cases can amount to 1 to 3 months of surgical training and is a concerning national trend deserving the attention of every training program and our governing institutions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

A report entitled Say Her Name: Resisting Police Brutality against Black Women underscores the paucity of research examining police violence toward Black women. This study focused on how valuing a White police officer and symbolic racism moderate reactions when the officer fatally shoots a Black or White woman during a traffic stop. At high levels of officer valuing, symbolic racism was positively associated with perceptions the victim presented a threat to the officer, but negatively associated with support for punishing the officer and perceived victim compliance; these associations were stronger when the victim was Black relative to White. At low officer valuing levels, there was no variability in the link between symbolic racism and the outcome variables as a function of victim race. Implications for bias in judicial outcomes for the victim and officer are discussed., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale & Objective: Although functional impairment is common among older adults with chronic kidney disease (CKD), functional reserve before an acute health event and physical resilience after the event have not been characterized in this population. The purpose of this study was to identify distinct patterns of physical function before and after an acute health event among older veterans with stage 4 CKD., Study Design: Prospective cohort study., Setting & Participants: National sample of veterans≥70 years of age with an estimated glomerular filtration rate (eGFR) of<30mL/min/1.73m 2 who had an acute care encounter (emergency department visit or hospitalization) during the follow-up period (n = 272)., Predictors: Demographic characteristics, eGFR, basic and instrumental activities of daily living (ADL/IADL) difficulty, symptom burden, cognition, depressive symptoms, social support., Outcome: Function measured using the life-space mobility assessment obtained by telephone survey before and after an acute care encounter., Analytical Approach: General growth mixture models to identify classes of functional trajectories. Calculation of percentages for demographic characteristics and means for eGFR, ADL/IADL difficulty, symptom burden, cognition, depressive symptoms, and social support by trajectory class., Results: Four trajectory classes were identified and characterized by different levels of life-space mobility before (reserve) and change in life-space mobility after (resilience) an acute care encounter: (1) low reserve, low resilience (n=91), (2) high reserve, high resilience (n=23), (3) moderate reserve, moderate resilience (n=89), and (4) high reserve, low resilience (n=69). Mean levels of ADL/IADL difficulty, symptom burden, cognition, and depressive symptoms, but not demographic characteristics, eGFR, or social support, differed by trajectory class., Limitations: Veteran cohort was primarily male., Conclusions: Among older adults with stage 4 CKD, physical function trajectories before and after an acute health event vary. Integrating reserve and resilience into care for this population may be useful for anticipating changes in function and developing tailored treatment plans., (Published by Elsevier Inc.)

Background: The Statin Use in Persons with Diabetes (SUPD) measure is a Star measure by the Center for Medicare & Medicaid Services. The Duke Population Health Management Office has a team of pharmacists and pharmacy students who conduct targeted outreach to patients at risk of failing statin quality measures. Pharmacy services are embedded in select primary care clinics and other clinics are supported remotely., Objectives: The primary objective of this review is to compare the initiation rates of recommended statin prescriptions between embedded pharmacist versus remote pharmacist versus remote student pharmacist outreach groups, all of which have different levels of autonomy within pharmacy practice. The secondary objectives are to identify the barriers to the implementation of statin therapy and to assess the statin drugs and intensity of the statins prescribed., Methods: A single-center, retrospective chart review was performed for SUPD patients with Medicare insurance. SUPD patients included patients between 40 and 75 years of age, diagnosed with type 2 diabetes, and were not dispensed at least 1 statin medication of any intensity during the 6-month measurement period. The primary outcome was the initiation of recommended statin medications prescribed, or pended for the primary care provider to prescribe, for qualifying patients by embedded, remote, and remote student pharmacists. Secondary outcomes included the reasons for the nonimplementation of statin recommendations, reasons statin therapy was not prescribed to patients contributing to the SUPD measure gap, and statin drug and dose prescribed for appropriateness., Results: A total of 189 patients were included in the evaluation. In this study, 34.9% of the patients filled the prescribed or pended statin prescription and 83.3% of patients filled the prescribed or pended statin prescription at the recommended intensity according to the American College of Cardiology/American Hospital Association guidelines, effectively closing the SUPD measure gap. The initiation rates of recommended statin prescriptions between the embedded pharmacist, remote pharmacist, and remote student pharmacist outreach were numerically different at 36.7%, 28.2%, and 36.7%, respectively, even though not statistically different (P = 0.61)., Conclusion: Remote student pharmacists' performance was equal to that of the embedded pharmacists when comparing the initiation rates of statin medications prescribed or pending the primary care provider's approval. The most common reason for nonimplementation of statin therapy is that the statin was refused by the patient. Atorvastatin and rosuvastatin were the two most commonly prescribed statins., Competing Interests: Disclosure The author declares no relevant conflicts of interest or financial relationships., (Copyright © 2024 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Rationale: Airway tree morphology varies in the general population and may modify the distribution and uptake of inhaled pollutants. Objectives: We hypothesized that smaller airway caliber would be associated with emphysema progression and would increase susceptibility to air pollutant-associated emphysema progression. Methods: MESA (Multi-Ethnic Study of Atherosclerosis) is a general population cohort of adults 45-84 years old from six U.S. communities. Airway tree caliber was quantified as the mean of airway lumen diameters measured from baseline cardiac computed tomography (CT) (2000-2002). Percentage emphysema, defined as percentage of lung pixels below -950 Hounsfield units, was assessed up to five times per participant via cardiac CT scan (2000-2007) and equivalent regions on lung CT scan (2010-2018). Long-term outdoor air pollutant concentrations (particulate matter with an aerodynamic diameter ⩽2.5 μm, oxides of nitrogen, and ozone) were estimated at the residential address with validated spatiotemporal models. Linear mixed models estimated the association between airway tree caliber and emphysema progression; modification of pollutant-associated emphysema progression was assessed using multiplicative interaction terms. Measurements and Main Results: Among 6,793 participants (mean ± SD age, 62 ± 10 yr), baseline airway tree caliber was 3.95 ± 1.1 mm and median (interquartile range) of percentage emphysema was 2.88 (1.21-5.68). In adjusted analyses, 10-year emphysema progression rate was 0.75 percentage points (95% confidence interval, 0.54-0.96%) higher in the smallest compared with largest airway tree caliber quartile. Airway tree caliber also modified air pollutant-associated emphysema progression. Conclusions: Smaller airway tree caliber was associated with accelerated emphysema progression and modified air pollutant-associated emphysema progression. A better understanding of the mechanisms of airway-alveolar homeostasis and air pollutant deposition is needed.

Background: Mental health conditions are highly prevalent among US veterans. The Veterans Health Administration (VHA) is committed to enhancing mental health care through the integration of measurement-based care (MBC) practices, guided by its Collect-Share-Act model. Incorporating the use of remote mobile apps may further support the implementation of MBC for mental health care., Objective: This study aims to evaluate veteran experiences with Mental Health Checkup (MHC), a VHA mobile app to support remote MBC for mental health., Methods: Our mixed methods sequential explanatory evaluation encompassed mailed surveys with veterans who used MHC and follow-up semistructured interviews with a subset of survey respondents. We analyzed survey data using descriptive statistics. We then compared responses between veterans who indicated having used MHC for ≥3 versus <3 months using χ 2 tests. We analyzed interview data using thematic analysis., Results: We received 533 surveys (533/2631, for a 20% response rate) and completed 20 interviews. Findings from these data supported one another and highlighted 4 key themes. (1) The MHC app had positive impacts on care processes for veterans: a majority of MHC users overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed or strongly agreed that using MHC helped them be more engaged in their health and health care (169/262, 65%), make decisions about their treatment (157/262, 60%), and set goals related to their health and health care (156/262, 60%). Similarly, interviewees described that visualizing progress through graphs of their assessment data over time motivated them to continue therapy and increased self-awareness. (2) A majority of respondents overall, and a greater proportion who had used MHC for ≥3 months (versus <3 months), agreed/strongly agreed that using MHC enhanced their communication (112/164, 68% versus 51/98, 52%; P=.009) and rapport (95/164, 58% versus 42/98, 43%; P=.02) with their VHA providers. Likewise, interviewees described how MHC helped focus therapy time and facilitated trust. (3) However, veterans also endorsed some challenges using MHC. Among respondents overall, these included difficulty understanding graphs of their assessment data (102/245, 42%), not receiving enough training on the app (73/259, 28%), and not being able to change responses to assessment questions (72/256, 28%). (4) Interviewees offered suggestions for improving the app (eg, facilitating ease of log-in, offering additional reminder features) and for increasing adoption (eg, marketing the app and its potential advantages for veterans receiving mental health care)., Conclusions: Although experiences with the MHC app varied, veterans were positive overall about its use. Veterans described associations between the use of MHC and engagement in their own care, self-management, and interactions with their VHA mental health providers. Findings support the potential of MHC as a technology capable of supporting the VHA's Collect-Share-Act model of MBC., (©Robin T Higashi, Bella Etingen, Eric Richardson, Jennifer Palmer, Mark S Zocchi, Felicia R Bixler, Bridget Smith, Nicholas McMahon, Kathleen L Frisbee, John C Fortney, Carolyn Turvey, Jennifer Evans, Timothy P Hogan. Originally published in JMIR Mental Health (https://mental.jmir.org), 10.05.2024.)

Context: It is unknown if US residency applicants of different educational backgrounds (US allopathic [MD], Doctor of Osteopathic Medicine [DO], and international medical graduates [IMG]) but comparable academic performance have similar match success., Objectives: Our objective was to compare match probabilities between applicant types after adjusting for specialty choice and United States Medical Licensing Examination (USMLE) Step 1 scores., Methods: We performed a secondary analysis of published data in National Resident Matching Program (NRMP) reports from 2016, 2018, 2020, and 2022 for US MD seniors, DO seniors, and IMGs (US citizens and non-US citizens). We examined the 10 specialties with the most available spots in 2022. Average marginal effects from a multiple variable logistic regression model were utilized to estimate each non-MD senior applicant type's probability of matching into their preferred specialty compared to MD seniors adjusting for specialty choice, Step 1 score, and match year., Results: Each non-MD applicant type had a lower adjusted percent difference in matching to their preferred specialty than MD seniors, -7.1 % (95 % confidence interval [CI], -11.3 to -2.9) for DO seniors, -45.6 % (-50.6 to -40.5) for US IMGs, and -56.6 % (-61.5 to -51.6) for non-US IMGs. Similarly, each non-MD applicant type had a lower adjusted percent difference in matching than MD seniors across almost all Step 1 score ranges, except for DO seniors with Step 1 scores <200 (-2.0 % [-9.5 to 5.5])., Conclusions: After adjusting for specialty choice, Step 1 score, and match year, non-US MD applicants had lower probabilities of matching into their preferred specialties than their US MD colleagues., (© 2024 the author(s), published by De Gruyter, Berlin/Boston.)

Competing Interests: Conflicts of interest Dr Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, DermTech, Dr Reddy's Laboratories, Eli Lilly, EPI Health, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Pfizer, Regeneron, Samsung Bioepis, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health. Authors Kam, George, Osborne, Smith, Thacker, Vo, and Wescott have no conflicts of interest to declare.

Context/objective: Online patient portals like the Veteran Health Administration's (VA) My Health e Vet (MHV) may be particularly useful for Veterans with spinal cord injuries/disorders (SCI/D), many of whom experience barriers to care. The objective of this analysis was to examine MHV use among Veterans with SCI/D., Design: Retrospective database analysis., Setting: VA SCI/D System of Care., Participants: Veterans with SCI/D who utilize VA care., Interventions: N/A., Outcome Measures: MHV registration and use of key portal features among Veterans who newly registered for MHV. Veteran characteristics associated with registration and use of portal features using multiple logistic regression., Results: 14.6% of Veterans with SCI/D in our sample registered to use MHV. 48.7% used the medication refill feature, 28.7% used the appointment view feature, 25.0% sent or read at least one secure message and 10.8% used the Blue Button feature. Adjusted analyses indicate that having a C5-8 (OR: 1.36, CI95%: 1.06-1.76, P < 0.05) or T1-S5 (OR: 1.41, CI95%: 1.13-1.78, P < 0.01) (vs. C1-C4), having (vs. not having) neurogenic bladder (OR: 1.45, CI95%: 1.18-1.77, P < 0.01), being married (vs. not married) (OR: 2.00, CI95%: 1.67-2.39, P < 0.01), and increased healthcare utilization in the third (OR: 1.71, CI95%: 1.31-2.24, P < 0.01) and fourth (OR: 1.73, CI95%: 1.27-2.34, P < 0.01) quartiles (vs. first quartile) were associated with increased odds of MHV registration. We also identified factors associated with use of key MHV features., Conclusions: Our results suggest that MHV registration and use of key portal features was limited among Veterans with SCI/D. Effort to increase portal use in this population are warranted.

Competing Interests: Conflict of interest Dr Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Bausch Health, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, DermTech, Dr. Reddy's Laboratories, Eli Lilly, EPI Health, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Pfizer, Regeneron, Samsung Bioepis, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health. Dr Han is or has been an investigator, consultant/advisor, or speaker for AbbVie, Athenex, Boehringer Ingelheim, Bond Avillion, Bristol Myers Squibb, Celgene Corporation, Dermavant, Eli Lilly, Janssen, LEO Pharma, MC2, Novartis, Ortho Dermatologics, PellePharm, Pfizer, Regeneron, Sanofi/Genzyme, SUN Pharmaceutical, and UCB. Authors Smith, Engel, and Javadi have no conflicts of interest to declare.

Competing Interests: Conflicts of interest Dr Ferris is a consultant for DermTech and an investigator for Castle Biosciences, SkinAnalytics, and DermTech. Author Smith, Author Smith, and Dr Demanelis have no conflicts of interest to declare.

Competing Interests: Conflicts of interest Dr Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Bausch Health, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, DermTech, Dr. Reddy's Laboratories, Eli Lilly, EPI Health, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Pfizer, Regeneron, Samsung Bioepis, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health. Dr Maul has served as advisor and/or received speaking fees and/or participated in clinical trials sponsored by AbbVie, Almirall, Amgen, BMS, Celgene, Eli Lilly, LEO Pharma, Janssen-Cilag, MSD, Novartis, Pfizer, Pierre Fabre, Roche, Sanofi, UCB. Authors Smith, Engel, Devjani, Javadi, and Collier have no conflicts of interest to declare.

Background: Drug testing is widely implemented as a work-based prevention strategy for employee substance use. However, it has raised concerns about its potential use as a punitive measure in the workplace where racialized/ethnic workers are over-represented. This study examines the rates of exposure to workplace drug testing among ethnoracial workers in the United States and the potential differences in the employers' responses to positive test results., Methods: A nationally-representative sample of 121,988 employed adults was examined using the 2015-2019 National Survey on Drug Use and Health data. The rates of exposure to workplace drug testing were estimated separately for ethnoracial workers. Then we used multinomial logistic regression to test differences in employers' responses to the first positive drug test results across ethnoracial subgroups., Results: Since 2002, Black workers reported 15-20% points higher rates of having a workplace drug testing policy than Hispanic or White workers. When tested positive for drug use, Black and Hispanic workers were more likely to be fired than White workers. When tested positive, Black workers were more likely to be referred to treatment/counseling services while Hispanic workers were less likely to be referred compared to White workers., Conclusion: Black workers' disproportionate exposure to drug testing and punitive responses in the workplace may potentially place individuals with substance use problems out of the workforce, limiting their access to treatment/other resources available via their workplaces. Also, Hispanic workers' limited accessibility to treatment and counseling services when tested positive for drug use requires attention to address unmet needs., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: Financial toxicity is of increasing concern in the United States. The Comprehensive Score for Financial Toxicity (COST) is a validated measure; however, it has not been widely utilized among low-income patients and may not fully capture financial toxicity in this population. Furthermore, the relationships between financial toxicity, quality of life (QOL), and patient well-being are poorly understood. We describe the experience of financial toxicity among low-income adults receiving cancer care. We hypothesized that higher financial toxicity would be associated with less income and lower quality of life. Qualitative interviews focused on the financial impact of cancer treatment., Method: This study was conducted at a cancer clinic in Central Texas. Quantitative and qualitative data were collected in Fall and Spring 2018, respectively. The quantitative sample ( N = 115) was dichotomized by annual income (<$15,000 vs. >$15,000). Outcomes included financial toxicity (COST), quality of life (FACT-G), and patient well-being (PROMIS measures: Anxiety, Depression, Fatigue, Pain Interference, and Physical Function). Associations between quality of life, patient well-being, and financial toxicity were evaluated using linear regression. Sequential qualitative interviews were conducted with a subsample of 12 participants., Results: Patients with <$15k had significantly lower levels of QOL and patient well-being such as depression and anxiety compared to patients with >$15k across multiple measures. A multivariate linear regression found QOL ( Β = 0.17, 95% CI = 0.05, 0.29, p = 0.008) and insurance status ( Β = -3.79, 95% CI = -7.42, -0.16, p = 0.04), but not income, were significantly associated with financial toxicity. Three qualitative themes regarding patient's access to cancer care were identified: obtaining healthcare coverage, maintaining financial stability , and receiving social support ., Significance of Results: Low-income patients with cancer face unique access barriers and are at risk for forgoing treatment or increased symptom burdens. Comprehensive assessment and financial navigation may improve access to care, symptom management, and reduce strain on social support systems.

Background : Stigma and discrimination during the coronavirus (COVID-19) pandemic have increased precipitously worldwide. This multinational study examines how stigma, blaming groups for virus spread, concern regarding contracting the virus, resource loss, life satisfaction, and protective behaviors that help control the spread of COVID-19 are associated with post-traumatic stress and vaccine intent in Mongolia, India, and the United States. Method : 1429 people in Mongolia, India, and the United States completed measures assessing stigma during the COVID-19 pandemic, post-traumatic stress, blame, protective behaviors, and vaccine intent. Results : Mean post-traumatic stress scores in all three countries exceeded the cut-off that is commonly used to determine probable post-traumatic stress. Post-traumatic stress was associated with COVID-19 stigma experience, personal behavior change due to COVID-19 stigma, blaming groups for the spread of COVID-19, fear of COVID-19, and resource loss. In India and the United States, personal behavior change due to COVID-19 stigma, anger at individuals spreading COVID-19, and perceived susceptibility to illness were positively associated with vaccine intent. Conclusions : Stigma is a collateral stressor during the pandemic. The findings underscore the importance of prompt action to address stigma as a deleterious consequence of the pandemic. The findings illuminate potential barriers to receiving the vaccine and provide direction for future research to address barriers.

Background: Third time liver transplantation is a technically demanding exercise with variable outcomes in single center series. There has been no national level description of survival following third time liver transplant in the US in the MELD era., Methods: Third time liver transplants between March 1, 2002 and January 1, 2018 in the UNOS dataset were analyzed., Results: Patient survival among the 240 third time liver transplant recipients in the study at 1, 3, 5, and 10 years (71.8%, 62.4%, 59.1%, 49.5%) was significantly worse compared to primary liver transplant (90.6%, 83.9%, 78.8%, 67.6%; p < 0.001) and retransplant (77.1%, 70.3%, 65.6%, 54.9%; p = 0.014). Recipients who were under 43 years old, not on dialysis, without diabetes, and over 1 month out from their second transplant had acceptable survival at 1, 3, 5, and 10 years (88.5%, 78.4%, 73.6%, 69.7%)., Conclusions: While redo-redo transplant remains a challenging endeavor, appropriate patient selection can yield acceptable results., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Staphylococcus aureus remains a leading cause of skin and soft tissue infections (SSTIs) globally. In the United States, many of these infections are caused by isolates classified as USA300. Our understanding of the success of USA300 as a human pathogen is due in part to data obtained from animal infection models, including rabbit SSTI models. These animal models have been used to study S. aureus virulence and pathogenesis and to gain an enhanced understanding of the host response to infection. Although significant knowledge has been gained, the need to use a relatively high inoculum of USA300 (1 × 10 8 to 5 × 10 8 CFU) is a caveat of these infection models. As a step toward addressing this issue, we created mutations in USA300 that mimic those found in S. aureus strains with naturally occurring rabbit tropism-namely, single nucleotide polymorphisms in dltB and/or deletion of rot . We then developed a rabbit SSTI model that utilizes an inoculum of 10 6 USA300 CFU to cause reproducible disease and tested whether primary SSTI protects rabbits against severe reinfection caused by the same strain. Although there was modest protection against severe reinfection, primary infection and reinfection with rabbit-tropic USA300 strains failed to increase the overall level of circulating anti-S. aureus antibodies significantly. These findings provide additional insight into the host response to S. aureus. More work is needed to further develop a low-inoculum infection model that can be used to better test the potential of new therapeutics or vaccine target antigens. IMPORTANCE Animal models of S. aureus infection are important for evaluating bacterial pathogenesis and host immune responses. These animal infection models are often used as an initial step in the testing of vaccine antigens and new therapeutics. The extent to which animal models of S. aureus infection approximate human infections remains a significant consideration for translation of results to human clinical trials. Although significant progress has been made with rabbit models of S. aureus infection, one concern is the high inoculum needed to cause reproducible disease. Here, we generated USA300 strains that have tropism for rabbits and developed a rabbit SSTI model that uses fewer CFU than previous models.

Purpose: This study evaluated risk factors predicting unplanned 30-day acute service utilization among adults subsequent to hospitalization for a new diagnosis of leukemia, lymphoma, or myeloma. This study explored the prevalence of medical complications (aligned with OP-35 measure specifications from the Centers for Medicare & Medicaid Services [CMS] Hospital Outpatient Quality Reporting Program) and the potential impact of psychosocial factors on unplanned acute care utilization., Methods: This study included 933 unique patients admitted to three acute care inpatient facilities within a nonprofit community-based health care system in southern California from 2012 to 2017. Integrated comprehensive data elements from electronic medical records and facility oncology registries were leveraged for univariate statistics, predictive models constructed using multivariable logistic regression, and further exploratory data mining, with predictive accuracy of the models measured with c-statistics., Results: The mean age of study participants was 65 years, and 55.1% were male. Specific diagnoses were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days postdischarge, and over half of these patients presented with one or more symptoms associated with the CMS medical complication measure. The predictive models, with c-statistics ranging from 0.7 and above for each type of hematologic malignancy, indicated good predictive qualities with the impact of psychosocial functioning on the use of acute care services ( P values < .05), including lack of consult for social work during initial admission (lymphoma or myeloma), history of counseling or use of psychotropic medications (lymphoma), and past substance use (myeloma)., Conclusion: This study provides insights into patient-related factors that may inform a proactive approach to improve health outcomes, such as enhanced care transition, monitoring, and support interventions., Competing Interests: Joyce C. LaMoriEmployment: Janssen Scientific AffairsStock and Other Ownership Interests: Johnson & Johnson Besa SmithEmployment: ICON Clinical ResearchStock and Other Ownership Interests: ICON plcResearch Funding: ICON Clinical ResearchTravel, Accommodations, Expenses: ICON plc Tyler SmithEmployment: ICON Clinical Research (I)No other potential conflicts of interest were reported.

Background: There are little data to compare the post-transplant survival between lung-liver transplant (LLT) and liver-alone recipients. This study was undertaken to compare survival between LLT and liver-alone transplant., Methods: UNOS data for patients undergoing LLT from 2002 to 2017 was analyzed. LLT recipients (n = 81) were matched 1:4 to liver-alone recipients (n = 324) by propensity score and patient survival was compared in the matched cohorts., Results: Unadjusted 1, 3, and 5-year patient survival in the matched cohort was significantly worse in the LLT (82.5%, 72.2%, and 62.2%) versus liver-alone (92.2%, 82.8%, and 80.9%; p = 0.005). This difference persisted after adjusting for covariates with residual imbalance (HR 2.05, 95% CI 1.37-3.08; p = 0.001)., Conclusion: LLT has significantly worse survival than liver-alone transplant. With an increasing organ shortage, medical necessity criteria such as those developed for simultaneous liver-kidney transplantation should be developed for simultaneous lung-liver transplants to assure liver allografts are only allocated when truly needed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Poor adherence to the 2011 American Society for Radiation Oncology (ASTRO) evidence-based guideline on whole-breast irradiation (WBI) has been reported. We utilized theMednet to assess the views of the updated 2018 guideline among radiation oncologists (ROs)., Methods: We identified 11 questions asked by community ROs on theMednet, a web-based platform, between October 27, 2014 and May 2, 2017 that were updated in the 2018 guideline. New answers provided by senior authors of the 2018 guideline, cited guidelines, and polls to survey ROs were disseminated in 3 theMednet's newsletters between March 16, 2018 and May 1, 2018. Any question with less than 60% consensus was resubmitted on October 9, 2019 and assessed on February 13, 2020., Results: A total of 792 ROs responded to the initial surveys. In each survey, the answer choice(s) that received the majority of the votes aligned with the 2018 guideline. The strongest consensus was for the use of hypofractionated (HF)-WBI regardless of histology (97%), followed by HF-WBI boost dose (92%), molecular subtype (90%), grade (88%), and concurrent use of trastuzumab (87%). The least consensus was for age at which HF-WBI should be offered with 53% of respondents, specifically 73% of academic ROs versus 47% of community ROs (P = .001), agreeing with the guideline. The re-submitted survey 19 months later showed 77% of 287 new respondents now agreed with the guideline regarding age., Conclusion: The majority of ROs concur with the 2018 WBI guideline in theMednet surveys, with better agreement among academic ROs than community ROs for certain components of the guideline. Further research into the different practice patterns may optimize patient care., (Copyright © 2021. Published by Elsevier Inc.)

Background: Direct bronchial spread of tuberculosis was extensively described in pre-antibiotic human pathology literature but this description has been overlooked in the post-antibiotic era, in which most pathology data come from animal models that emphasise the granuloma. Modern techniques, such as [ 18 F]2-fluoro-2-deoxy-D-glucose (FDG) PET-CT scans, might provide further insight. Our aim was to understand normal early tuberculosis resolution patterns on pulmonary PET-CT scans in treated patients with tuberculosis who were subsequently cured., Methods: In this observational analysis, we analysed data from PredictTB, an ongoing, prospective, randomised clinical trial that examined sequential baseline and week 4 FDG-PET-CT scans from participants successfully treated (sputum culture negative 18 months after enrolment) for drug-susceptible pulmonary tuberculosis in South Africa and China. Participants who were aged 18-75 years, GeneXpert MTB/RIF positive for tuberculosis and negative for rifampicin resistance, had not yet started tuberculosis treatment, had not been treated for active tuberculosis within the previous 3 years, and met basic safety laboratory criteria were included and participants with diabetes, HIV infection, or with extrapulmonary tuberculosis including pleural tuberculosis were excluded. Scans were assessed by two readers for the location of tuberculosis lesions (eg, cavities and consolidations), bronchial thickening patterns, and changes from baseline to week 4 of treatment., Findings: Among the first 124 participants (enrolled from June 22, 2017, to Sept 27, 2018) who were successfully treated, 161 primarily apical cavitary lesions were identified at baseline. Bronchial thickening and inflammation linking non-cavitary consolidative lesions to cavities were observed in 121 (98%) of 124 participants' baseline PET-CT scans. After 4 weeks of treatment, 21 (17%) of 124 participants had new or expanding lesions linked to cavities via bronchial inflammation that were not present at baseline, particularly participants with two or more cavities at baseline and participants from South Africa., Interpretation: In participants with pulmonary tuberculosis who were subsequently cured, the location of cavitary and non-cavitary lesions at baseline and new lesions at week 4 of treatment suggest a cavitary origin of disease and bronchial spread through the lungs. Bronchial spread from cavities might play a larger role in the spread of pulmonary tuberculosis than has been appreciated. Elucidating cavity lesion dynamics and Mycobacterium tuberculosis viability within cavities might better explain treatment outcomes and why some patients are cured and others relapse., Funding: Bill & Melinda Gates Foundation, European and Developing Countries Clinical Trials Partnership, China Ministry of Science and Technology, National Natural Science Foundation of China, and National Institutes of Health., Translations: For the Chinese, Afrikaans and Xhosa translations of the abstract see Supplementary Materials section., Competing Interests: RJW is supported by Francis Crick Institute, which receives funding from UK Research and Innovation (FC0010218), Wellcome (FC0010218), and Cancer Research UK (FC0010218). RJW also receives support from Wellcome (104803, 203135), the European and Developing Countries Clinical Trials Partnership (EDCTP; SRIA2015-1065), and US National Institutes of Health (NIH; AI115940). GW receives funding from the South African Research Chair Initiative from the National Research Foundation (86535). STM receives grants from the South African Medical Research Council (grant number CDF1576). KA is employed by the Bill & Melinda Gates Medical Research Institute which is a grantee of the Bill & Melinda Gates Foundation but a separate legal entity. All other authors declare no competing interests., (© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Objective: The aim of this study is to describe the current state of robotic surgery training among Otolaryngology-Head and Neck Surgery (OHNS) residency programs in the United States., Methods: This is a national survey study among OHNS residents. All OHNS residency programs were identified via the Accreditation Council for Graduate Medical Education website. A total of 64/127 (50.3%) of OHNS programs were selected based on a random number generator. The main outcome measure was the number of OHNS residents with access to robotic surgery training and assessment of operative experience in robotic surgery among those residents., Results: A total of 140 OHNS residents participated in the survey, of which 59.3% (n = 83) were male. Response rate was 40.2%. Respondents came from middle 50.0% (n = 70), southern 17.8% (n = 25), western 17.8% (n = 25), and eastern sections 14.3% (n = 20). Most respondents (94.3%, n = 132) reported that their institution utilized a robot for head and neck surgery. Resident experience at the bedside increased in the junior years of training and console experience increased across the years particularly for more senior residents. However, 63.4% of residents reported no operative experience at the console. Only 11.4% of programs have a structured robotics training program., Conclusion: This survey indicated that nearly all OHNS residencies utilize robotic surgery in their clinical practice with residents receiving little formal education in robotics or experience at the console. OHNS residencies should aim to increase access to training opportunities in order to increase resident competency., Level of Evidence: IV.

Background: The seroprotection rate (SPR) of hepatitis B vaccination in adults is suboptimal. The aim of this study was to compare the SPR of a tri-antigenic hepatitis B vaccine (TAV), with a mono-antigenic vaccine (MAV) in adults of all ages., Methods: This was a multicentre, double-blind, phase 3, randomised controlled trial (PROTECT) comparing the immunogenicity and safety of TAV with MAV in 28 community and hospital sites in the USA, Finland, Canada, and Belgium. Adults (aged ≥18 years) seronegative for hepatitis B virus (HBV), including those with well-controlled common chronic conditions, were randomly assigned (1:1) and stratified by study centre and age according to a web-based permuted blocked randomisation. Participants received either TAV or MAV which were administered as an intramuscular dose (1 mL) of TAV (10 μg; Sci-B-Vac, VBI Vaccines [SciVac, Rehovot, Israel]) or MAV (20 μg; Engerix-B [GlaxoSmithKline Biologicals, Rixensart, Belgium]) on days 0, 28, and 168 with six study visits and 24 weeks of follow-up after the third vaccination. Participants, investigators, and those assessing outcomes were masked to group assignment. The co-primary outcomes were to show non-inferiority of the SPRs 4 weeks after the third vaccination with TAV versus MAV in adults aged 18 years and older, as well as superiority in adults aged 45 years and older. SPR was defined as the percentage of participants attaining anti-HBs titres of 10 mIU/mL or higher. Non-inferiority of TAV to MAV was concluded if the lower limit of the 95% CI for the between-group difference was greater than -5%. Non-inferiority was assessed in the per-protocol set of participants (aged ≥18 years) and superiority was assessed in all participants (aged ≥45 years) who received at least one vaccination and had at least one evaluable immunogenicity sample after baseline (full analysis set). Safety analyses were a secondary outcome and included all participants who received at least one injection. This trial is registered at Clinicaltrials.gov (NCT03393754) and EudraCT (2017-001819-36) and is closed to new participants., Findings: Between Dec 13, 2017, and April 8, 2019, 1607 participants (796 allocated to TAV and 811 allocated to MAV) were randomly assigned and distributed across age cohorts of 18-44 years (299 of 1607; 18·6%), 45-64 years (716 of 1607; 44·6%), and 65 years and older (592 of 1607; 36·8%). In participants aged 18 years and older, SPR was 91·4% (656 of 718) in the TAV group versus 76·5% (553 of 723) in the MAV group (difference 14·9%, 95% CI 11·2-18·6), showing non-inferiority in the per-protocol set. In participants aged 45 years and older, SPR was 89·4% (559 of 625) in the TAV group versus 73·1% (458 of 627) in the MAV group (difference 16·4%, 95% CI 12·2-20·7), showing superiority in the full analysis set. TAV was associated with higher rates of mild or moderate injection site pain (63·2% [503 of 796] in TAV vs 36·3% [294 of 811] in MAV), tenderness (60·8% [484 of 796] in TAV vs 34·8% [282 of 811] in MAV), and myalgia (34·7% [276 of 796] vs 24·3% [197 of 811] in MAV). Otherwise, the safety profile of TAV was similar to that of MAV., Interpretation: The safety and efficacy of TAV shows its usefulness for the prevention of HBV infection in adults, including those with stable and controlled chronic conditions., Funding: VBI Vaccines., Competing Interests: Declaration of interests JNS, NM, BY-R, DA, VP, and FDM are employees of VBI Vaccines. TV, JML, NS, BJW, CC, GP, BS, SG, JEM, MD, PvD, IL-R, and GL-R received funding from VBI Vaccines for the conduct of the study., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose Although tinnitus is highly prevalent among patients receiving audiology services, the extent to which most audiologists are trained in tinnitus management is not well documented. The extent and type of instruction in tinnitus clinical care provided by audiology graduate (AuD) programs is not clear, nor is it known whether training programs are consistent in their recommendations. It is certainly true that widely accepted standards do not exist to ensure that all tinnitus clinical services are supported by adequate scientific evidence, which may result in unsatisfactory outcomes and unnecessary expense for patients. The purpose of this clinical focus article is to describe the results of an informal survey of AuD programs to determine their level of training for tinnitus management. Method A short survey was sent to all 75 American Speech-Language-Hearing Association-accredited AuD programs to assess the extent and type of tinnitus training their students receive. Conclusions The 32 AuD programs that responded to our survey provide tinnitus training using a variety of settings and methods. Further research could explore in more detail the extent of training in specific methods provided by these programs, and aim to elicit responses from a greater number of programs and from the students themselves.

Purpose: Obesity is a risk factor for the development of acute kidney injury but its effect on the need for dialysis in trauma has not been elucidated. Additionally, the contribution that obesity has towards risk of mortality in trauma is unclear. We hypothesized that patients with a higher body mass index (BMI) will have a higher risk for need of dialysis and mortality after trauma., Methods: This is a retrospective analysis using the National Trauma Data Bank. All patients ≥ 8 years old were grouped based on BMI: normal (18.5-24.99 kg/m 2 ), obese (30-34.99 kg/m 2 ), severely obese (35-39.99 kg/m 2 ) and morbidly obese (≥ 40 kg/m 2 ). The primary outcome was hemodialysis initiation. The secondary outcome was mortality during the index hospitalization., Results: From 988,988 trauma patients, 571,507 (57.8%) had a normal BMI, 233,340 (23.6%) were obese, 94,708 (9.6%) were severely obese, and 89,433 (9.0%) were morbidly obese. The overall rate of hemodialysis was 0.3%. After adjusting for covariates, we found that obese (OR 1.36, CI 1.22-1.52, p < 0.001), severely obese (OR 1.89, CI 1.66-2.15, p < 0.001) and morbidly obese (OR 2.04, CI 1.82-2.29, p < 0.001) patients had a stepwise increased need for hemodialysis after trauma. Obese patients had decreased (OR 0.92, CI 0.88-0.95, p < 0.001), severely obese had similar (OR 1.02, CI 0.97-1.08, p = 0.50) and morbidly obese patients had increased (OR 1.06, CI 1.01-1.12, p = 0.011) risk of mortality after trauma., Conclusions: Obesity was associated with an increased risk for dialysis after trauma. Mortality risk was reduced in obese, similar in severely obese, and increased in morbidly obese trauma patients suggesting an inflection threshold BMI for risk of mortality in trauma.

Objectives: To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex., Design: Retrospective cross-sectional design., Setting: National VA Polytrauma System of Care outpatient settings., Participants: Veterans with a confirmed TBI event (N=6065)., Interventions: Not applicable., Main Outcome Measure(s): Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis., Results: The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item., Conclusions: There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex., (Published by Elsevier Inc.)

Background: A large-scale epidemiological study of 6088 individuals with cystic fibrosis (CF) and 4102 caregivers in nine countries documented elevated symptoms of depression and anxiety, leading to international guidelines for annual screening and follow-up. To facilitate national implementation, 84 CF programs funded a mental health coordinators (MHC). Implementation was evaluated after 1 year using the consolidated framework for implementation research (CFIR) to identify facilitators and barriers., Methods: A 45-item internet survey was developed to assess relevant CFIR implementation steps. Surveys were completed in 2016. It assessed five domains tailored to study aims: (a) Intervention characteristics, (b) outer setting, (c) inner setting, (d) characteristics of individuals, and (e) process of implementation., Results: Response rate was 88%, with pediatric and adult programs equally represented. A majority of MHCs were social workers (54.1%) and psychologists (41.9%); 41% had joined the team in the past year. Facilitators across the five domains included universal uptake of screening tools, greater awareness and detection of psychological symptoms, reduced stigma, and positive feedback from patients and families. Barriers included limited staff time, space, and logistics., Discussion: This is the largest systematic effort to integrate mental health screening and treatment into the care of individuals with a serious, chronic illness and their caregivers. MHCs implementing screening, interpretation and follow-up reported positive results, and significant barriers. This national implementation effort demonstrated that depression and anxiety can be efficiently evaluated and treated in a complex, chronic disease. Future efforts include recommending the addition of screening scores to national CF Registries and examining their effects on health outcomes., (© 2020 Wiley Periodicals LLC.)

Background: Patients seek care across multiple health care settings. One coordination issue is the unnecessary duplication of laboratory across different health care settings. This analysis examined the association between patient portal use and duplication of laboratory testing among Veterans who are dual users of Veterans Affairs (VA) and non-VA providers. Materials and Methods: A national sample of Veterans who were newly authenticated users of the portal during fiscal year (FY) 2013 who used Blue Button at least once were compared with a random sample of Veterans who were not registered to use the portal. From these two groups, Veterans who were also Medicare-eligible users in FY2014 were identified. Duplicate testing was defined as receipt of more than five HbA1c (hemoglobin A1c) in 1 year. Results: Use of the Blue Button decreased the odds of duplicate HbA1c testing in VA and Medicare-covered facilities across three comparisons: (1) overall between users and nonusers: portal users were less likely to have duplicate testing; (2) pre-post comparison: there was a trend toward lower duplicate testing in both groups across time; and (3) pre-post comparisons accounting for use of the portal: the trend toward lower duplicate testing was greater in Blue Button users. Conclusion: Duplicate HbA1c testing was significantly lower in dual users of VA and Medicare services who used the Blue Button feature of their VA patient portal. Non-VA providers encounter barriers to access of complete information about Veterans who also use VA health care. Provider endorsement of consumer-mediated health information exchange could help further this model of sharing information.

Background: Although mother-to-child human immunodeficiency virus (HIV) transmission has dramatically decreased with maternal antiretroviral therapy, breast milk transmission accounts for most of the 180 000 new infant HIV infections annually. Broadly neutralizing antibodies (bNAb) may further reduce transmission., Methods: A Phase 1 safety and pharmacokinetic study was conducted: a single subcutaneous (SC) dose of 20 or 40 mg/kg (Dose Groups 1 and 2, respectively) of the bNAb VRC01 was administered to HIV-exposed infants soon after birth. Breastfeeding infants (Dose Group 3) received 40 mg/kg SC VRC01 after birth and then 20 mg/kg/dose SC monthly. All infants received appropriate antiretroviral prophylaxis., Results: Forty infants were enrolled (21 in the United States, 19 in Africa). Subcutaneous VRC01 was safe and well tolerated with only mild-to-moderate local reactions, primarily erythema, which rapidly resolved. For multiple-dose infants, local reactions decreased with subsequent injections. VRC01 was rapidly absorbed after administration, with peak concentrations 1-6 days postdose. The 40 mg/kg dose resulted in 13 of 14 infants achieving the serum 50 micrograms (mcg)/mL target at day 28. Dose Group 3 infants maintained concentrations greater than 50 mcg/mL throughout breastfeeding., Conclusions: Subcutaneous VRC01 as single or multiple doses is safe and well tolerated in very young infants and is suitable for further study to prevent HIV transmission in infants., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Introduction: Excessive alcohol use (EAU), a harmful pattern of drinking that includes binge drinking and heavy use, occurs in 25% (binge) and 6% (heavy use) of the US population, respectively. Little is known about alcohol use in individuals with cystic fibrosis (CF). The objective of this investigation is to examine alcohol consumption patterns in individuals with CF using a health survey administered from a social media platform., Methods: Individuals with CF, 18 years of age or older, were recruited for participation through social media and internet-based platforms., Results: 1135 individuals initially participated in the survey and 84% (n = 952) were eligible and completed the survey. Of the respondents, 77% (n = 729) currently consume alcohol, 18% (n = 171) formerly consumed alcohol, and 5% (n = 52) never consumed alcohol. Amongst the people with CF who currently consume alcohol, 54% (N = 391) met criteria for EAU. Thirty percent of current drinkers experienced symptoms of harmful alcohol use. Of those who met criteria for EAU, 7% wore oxygen, 6% had a lung transplant, 10% had liver disease and 32% had diabetes. Those with EAU reported more hospitalizations than those without EAU [244 (62%) vs 182 (54%), p = .034]. Characteristics associated with EAU after multivariable adjustment included younger age, unmarried status, male gender and younger age at initiation of drinking., Conclusion: EAU is occurring at a much higher proportion in individuals with CF. A substantial percentage of CF individuals with EAU also have medical co-morbidities. Screening, brief intervention, and referral to treatment for EAU in CF clinics is warranted., Competing Interests: Conflict of interest statement None of the authors of this manuscript have any personal or financial relationships to disclose., (Copyright © 2019 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Importance: In general surgery, women earn less money and hold fewer leadership positions compared with their male counterparts., Objective: To assess whether differences exist between the perspectives of male and female general surgery residents on future career goals, salary expectations, and salary negotiation that may contribute to disparity later in their careers., Design, Setting, and Participants: This study was based on an anonymous and voluntary survey sent to 19 US general surgery programs. A total of 606 categorical residents at general surgery programs across the United States received the survey. Data were collected from August through September 2017 and analyzed from September through December 2017., Main Outcomes and Measures: Comparison of responses between men and women to detect any differences in career goals, salary expectation, and perspectives toward salary negotiation at a resident level., Results: A total of 427 residents (70.3%) responded, and 407 responses (230 male [58.5%]; mean age, 30.0 years [95% CI, 29.8-30.4 years]) were complete. When asked about salary expectation, female residents had lower expectations compared with men in minimum starting salary ($249 502 [95% CI, $236 815-$262 190] vs $267 700 [95% CI, $258 964-$276 437]; P = .003) and in ideal starting salary ($334 709 [95% CI, $318 431-$350 987] vs $364 663 [95% CI, $351 612-$377 715]; P < .001). Women also had less favorable opinions about salary negotiation. They were less likely to believe they had the tools to negotiate (33 of 177 [18.6%] vs 73 of 230 [31.7%]; P = .03) and were less likely to pursue other job offers as an aid in negotiating a higher salary (124 of 177 [70.1%] vs 190 of 230 [82.6%]; P = .01). Female residents were also less likely to be married (61 of 177 [34.5%] vs 116 of 230 [50.4%]; P = .001), were less likely to have children (25 of 177 [14.1%] vs 57 of 230 [24.8%]; P = .008), and believed they would have more responsibility at home than their significant other (77 of 177 [43.5%] vs 35 of 230 [15.2%]; P < .001). Men and women anticipated working the same number of hours, expected to retire at the same age, and had similar interest in holding leadership positions, having academic careers, and pursuing research., Conclusions and Relevance: This study found no difference in overall career goals between male and female residents; however, female residents' salary expectations were lower, and they viewed salary negotiation less favorably. Given the current gender disparities in salary and leadership within surgery, strategies are needed to help remedy this inequity.

Aim: Hemocompatibility-related adverse events (HRAE) are a major cause of readmissions in patients with left ventricular assist devices (LVAD). The impact of aortic insufficiency (AI) on HRAE remains uncertain. We aimed to investigate the impact of AI on HRAE., Methods and Results: Patients who underwent LVAD implantation between August 2014 and July 2017 and had echocardiograms 3 months post-LVAD implantation were enrolled. AI severity was assessed by measuring the systolic/diastolic ratio of flow and the rate of diastolic flow acceleration using Doppler echocardiography of the outflow cannula. Regurgitation fraction was derived from these parameters. Significant AI was defined as regurgitation fraction > 30%. Among 105 patients (median age, 56 years; 76% male), 36 patients (34%) had significant AI. Baseline characteristics were statistically not significantly different between those with and without significant AI except for higher rates of ischemic etiology and atrial fibrillation in the significant AI group (P < 0.05 for both). One-year survival free from HRAE was 44% in patients with AI compared to 67% in patients without significant AI (P = 0.018). The average hemocompatibility score, which defines the net burden of HRAE, was higher in the AI group (1.72 vs 0.64; P = 0.009), due mostly to higher tier I (mild HRAE; P = 0.034) and tier IIIB scores (severe HRAE; P = 0.011)., Conclusion: Significant AI, as assessed by Doppler echocardiographic parameters, was associated with HRAE during LVAD support., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Online patient portals may be effective for engaging patients with mental health conditions in their own health care. This retrospective database analysis reports patient portal use among Veterans with mental health diagnoses. Unadjusted and adjusted odds of portal feature use was calculated using logistic regressions. Having experienced military sexual trauma or having an anxiety disorder, post-traumatic stress disorder, or depression were associated with increased odds of portal use; bipolar, substance use, psychotic and adjustment disorders were associated with decreased odds. Future research should examine factors that influence portal use to understand diagnosis-level differences and improve engagement with such tools.

The National Diabetes Prevention Program lifestyle change program demonstrated health benefits and potential for health care cost-savings. For many states, employers, and insurers, there is a strong business case for paying for type 2 diabetes prevention, which will likely result in medical and nonmedical cost-savings as well as improved quality of life after a few years. Using an iterative feedback process with multiple stakeholders, the Centers for Disease Control and Prevention developed the Diabetes Prevention Impact Tool kit, https://nccd.cdc.gov/toolkit/diabetesimpact, which forecasts the cost impact the lifestyle change program can have for states, employers, and health insurers. We conducted key informant interviews and a qualitative analysis to evaluate the tool kit. We found that end users recognized its utility for decision making. They valued the detail of the tool kit's underlying calculations and appreciated the option of either using the default settings or revising assumptions based on their own data. The Diabetes Prevention Impact Tool kit can be a helpful tool for organizations that wish to forecast the economic costs and benefits of implementing or covering the National Diabetes Prevention Program lifestyle change program.

Importance: While air pollutants at historical levels have been associated with cardiovascular and respiratory diseases, it is not known whether exposure to contemporary air pollutant concentrations is associated with progression of emphysema., Objective: To assess the longitudinal association of ambient ozone (O3), fine particulate matter (PM2.5), oxides of nitrogen (NOx), and black carbon exposure with change in percent emphysema assessed via computed tomographic (CT) imaging and lung function., Design, Setting, and Participants: This cohort study included participants from the Multi-Ethnic Study of Atherosclerosis (MESA) Air and Lung Studies conducted in 6 metropolitan regions of the United States, which included 6814 adults aged 45 to 84 years recruited between July 2000 and August 2002, and an additional 257 participants recruited from February 2005 to May 2007, with follow-up through November 2018., Exposures: Residence-specific air pollutant concentrations (O3, PM2.5, NOx, and black carbon) were estimated by validated spatiotemporal models incorporating cohort-specific monitoring, determined from 1999 through the end of follow-up., Main Outcomes and Measures: Percent emphysema, defined as the percent of lung pixels less than -950 Hounsfield units, was assessed up to 5 times per participant via cardiac CT scan (2000-2007) and equivalent regions on lung CT scans (2010-2018). Spirometry was performed up to 3 times per participant (2004-2018)., Results: Among 7071 study participants (mean [range] age at recruitment, 60 [45-84] years; 3330 [47.1%] were men), 5780 were assigned outdoor residential air pollution concentrations in the year of their baseline examination and during the follow-up period and had at least 1 follow-up CT scan, and 2772 had at least 1 follow-up spirometric assessment, over a median of 10 years. Median percent emphysema was 3% at baseline and increased a mean of 0.58 percentage points per 10 years. Mean ambient concentrations of PM2.5 and NOx, but not O3, decreased substantially during follow-up. Ambient concentrations of O3, PM2.5, NOx, and black carbon at study baseline were significantly associated with greater increases in percent emphysema per 10 years (O3: 0.13 per 3 parts per billion [95% CI, 0.03-0.24]; PM2.5: 0.11 per 2 μg/m3 [95% CI, 0.03-0.19]; NOx: 0.06 per 10 parts per billion [95% CI, 0.01-0.12]; black carbon: 0.10 per 0.2 μg/m3 [95% CI, 0.01-0.18]). Ambient O3 and NOx concentrations, but not PM2.5 concentrations, during follow-up were also significantly associated with greater increases in percent emphysema. Ambient O3 concentrations, but not other pollutants, at baseline and during follow-up were significantly associated with a greater decline in forced expiratory volume in 1 second per 10 years (baseline: 13.41 mL per 3 parts per billion [95% CI, 0.7-26.1]; follow-up: 18.15 mL per 3 parts per billion [95% CI, 1.59-34.71])., Conclusions and Relevance: In this cohort study conducted between 2000 and 2018 in 6 US metropolitan regions, long-term exposure to ambient air pollutants was significantly associated with increasing emphysema assessed quantitatively using CT imaging and lung function.

Improving the ability to predict which patients are at increased risk for readmission can lead to more effective interventions and greater compliance with CMS Hospital Readmissions Reduction Program (HRRP) requirements. This study evaluated the performance of a risk model that used data from a health system's electronic medical record (EMR) to predict all-cause readmission among adult inpatients with acute medical conditions, with a specific focus on the impact of including behavioral health screening data. The study included 39,155 unique adult patients admitted during 2015 to 4 acute care inpatient facilities within a nonprofit community-based health care system. The risk model integrated a comprehensive set of data elements including demographics, psychosocial characteristics, medical history, assessment results, and clinical events. Predictive models were constructed using a multivariable logistic regression with a stepwise selection approach. Among study participants, the mean age was 62.9 years, 48.0% were male, 31.2% had comorbid psychiatric conditions, and 6986 had medical conditions/procedures subject to HRRP penalties. Results from exploratory predictive analyses demonstrated that any patients with a Serious Mental Illness (SMI) diagnosis were 28% more likely to be readmitted within 30 days, and the likelihood of readmission associated with SMI increased to 56% for patients with medical conditions subject to HRRP penalties. As health care systems face increasing pressures to reduce readmissions and avoid CMS HRRP financial penalties, study results indicate the importance of including behavioral health data from EMRs and screening assessments for all inpatients to improve discharge planning and patient outcomes.

Background: Physical therapy (PT) and other exercise-based interventions are core components of care for knee osteoarthritis (OA), but both are underutilized, and some patients have limited access to PT services. This clinical trial is examining a STepped Exercise Program for patients with Knee OsteoArthritis (STEP-KOA). This model of care can help to tailor exercise-based interventions to patient needs and also conserve higher resource services (such as PT) for patients who do not make clinically relevant improvements after receiving less costly interventions., Methods / Design: Step-KOA is a randomized trial of 345 patients with symptomatic knee OA from two Department of Veterans Affairs sites. Participants are randomized to STEP-KOA and Arthritis Education (AE) Control groups with a 2:1 ratio, respectively. STEP-KOA begins with 3 months of access to an internet-based exercise program (Step 1). Participants not meeting response criteria for clinically meaningful improvement in pain and function after Step 1 progress to Step 2, which involves bi-weekly physical activity coaching calls for 3 months. Participants not meeting response criteria after Step 2 progress to in-person PT visits (Step 3). Outcomes will be assessed at baseline, 3, 6 and 9 months (primary outcome time point). The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and secondary outcomes are objective measures of physical function. Linear mixed models will compare outcomes between the STEP-KOA and AE control groups at follow-up. We will also evaluate patient characteristics associated with treatment response and conduct a cost-effectiveness analysis of STEP-KOA., Discussion: STEP-KOA is a novel, efficient and patient-centered approach to delivering exercise-based interventions to patients with knee OA, one of the most prevalent and disabling health conditions. This trial will provide information on the effectiveness of STEP-KOA as a novel potential model of care for treatment of OA., Trial Registration: Clinicaltrials.gov, NCT02653768 (STepped Exercise Program for Knee OsteoArthritis (STEP-KOA)), Registered January 12, 2016.

The purpose of this study is to characterize and describe the relationships between symptoms and functional impairment following mild traumatic brain injury (mTBI) and behavioral health conditions (BHCs) in order to inform evidence-based theories on why symptoms and functional impairments persist in some individuals but not others. This is a retrospective, multi-site, cross-sectional study utilizing data collected from a total of 289 Operation Iraqi Freedom/Operation Enduring Freedom Veterans who were classified into diagnostic groups using the symptom attribution and classification algorithm and the VA clinical reminder and comprehensive traumatic brain injury evaluation. The Neurobehavioral Symptom Inventory was used to assess mTBI symptom number and severity. The World Health Organization Disability Assessment Schedule 2.0 was used to assess functional impairment. Symptom profiles differed between diagnostic groups irrespective of symptom attribution method used. Veterans with both mTBI and BHCs and those with BHCs alone had consistently greater number of symptoms and more severe symptoms relative to no symptom and symptoms resolved groups. Symptom number and severity were significantly associated with functional impairment. Both symptom number and functional impairment were significantly associated with the number of mTBI exposures. Together, these results informed evidence-based theories on understanding why symptoms and functional impairment persist among some OEF/OIF Veterans., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Mucormycosis outbreaks have been linked to contaminated linen. We performed fungal cultures on freshly-laundered linens at 15 transplant and cancer hospitals. At 33% of hospitals, the linens were visibly unclean. At 20%, Mucorales were recovered from >10% of linens. Studies are needed to understand the clinical significance of our findings., (Published by Oxford University Press for the Infectious Diseases Society of America 2018.)

Objective: Health care disparities are noted between different socioeconomic groups; it is crucial to recognize and correct disparities, if present, that extend to children with hearing loss. The objective of the study is to evaluate the effect of socioeconomic status (SES) on access to hearing rehabilitation and speech and language therapy and outcomes in children with hearing loss., Methods: Retrospective Chart Review of children diagnosed with hearing loss at 3 tertiary care academic centers from 2010 to 2012. Two hundred patients were then randomly selected from each institution for analysis. International and self-pay patients were excluded. They were separated into two groups based on SES using insurance coverage as proxy for financial status (private insurance versus Medicaid). Main outcome measures included number of hearing aid evaluations recommended andcompleted, compliance with hearing aids use, diagnosis on speech therapy evaluations, participation in speech therapy, and outcomes noted on the last speech therapy session in patients' medical record at time of study completion., Results: 600 patients were identified by random selection out of total of 3679 patients. 18 were excluded because they were international pay or self-pay. Of 582 patients, 299 (51.4%) had private insurance and 283 (48.6%) had Medicaid. The pure tone average (PTA) at initial diagnosis did not differ between the two populations (left ear p = 0.74, right ear p = 0.68). There was no significant difference in the number of hearing aid evaluations recommended (p = 0.49), hearing aid evaluation completed (p = 0.68), or documented hearing aid compliance (p = 0.68) between the two populations. Similarly, there was no significant difference in the presence of speech delay (p = 0.62), the receipt of speech therapy (p = 0.49), or speech language outcomes between the two groups (p = 0.45)., Conclusions: This study suggests that despite lower socioeconomic status, in children with hearing loss, Medicaid allows equivalent access to hearing rehabilitation and speech therapy as their privately insured counterparts and children achieve similar speech and language outcomes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Little is known about mental health (MH) emergencies in atopic dermatitis (AD) and their financial burden. We sought to determine hospitalization rates and costs of MH disorders in AD patients. We analyzed data from the Nationwide Inpatient Sample from 2002 to 2012, containing a representative 20% sample of US hospitalizations. Overall, 835 AD (1.36%) and 2,434,703 non-AD (0.75%) patients had a primary admission for an MH disorder. Atopic dermatitis patients admitted for MH disorders were more likely to be younger, Asian, of black race, and in a higher income quartile and have an increasing number of chronic conditions. In multivariable logistic regression models adjusting for demographics, AD was associated with a primary admission for MH disorders in adults, including mood disorders, schizophrenia, and developmental disorders. Atopic dermatitis was not associated with a primary admission for an MH disorder in children. There were an estimated US $183,821,629 excess costs of care annually for MH disorders in inpatients with versus without AD. In conclusion, AD was associated with higher odds of hospitalization for all MH disorders and substantial excess costs of inpatient care.

Introduction: Little information is available on state-specific financial burdens of diabetes in the Medicaid population, yet such information is essential for state Medicaid programs to plan diabetes care and evaluate the benefits of diabetes prevention. We estimated medical expenditures associated with diabetes among adult Medicaid enrollees in 8 states., Methods: We analyzed the latest available 2012 CMS Medicaid claims data for 1,193,811 adult enrollees aged 19-64 years in 8 states: Alabama, California, Connecticut, Florida, Illinois, Iowa, New York, and Oklahoma. For each state, we stratified the study population by Medicaid eligibility criteria: disability and nondisability. For each group, we estimated per capita annual medical expenditures on outpatient care, inpatient care, and prescription drugs by using a 2-part model, adjusted for age, sex, race/ethnicity, and comorbidities. We calculated the expenditures associated with diabetes as the difference in predicted expenditures for enrollees with and without diabetes. Analyses were done in 2017., Results: For disability-based enrollees, the estimated total per capita annual diabetes expenditures ranged from $6,183 in Alabama to $15,319 in New York (all P < .001). For nondisability-based enrollees, the corresponding estimates ranged from $4,985 in Alabama to $15,366 in New York (all P < .001). The proportion of individual components varied by state and eligibility criteria., Conclusion: Medical expenditures associated with diabetes among adults on Medicaid were substantial and varied across studied states. Our estimates can be used by the 8 state Medicaid programs to prepare health care resources needed for diabetes care and assess the financial benefits of diabetes prevention programs.