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Hypertensive disorders of pregnancy are a major contributor to maternal morbidity and mortality in the United States and include chronic and gestational hypertension, preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, eclampsia, and chronic hypertension with superimposed preeclampsia. For patients with chronic hypertension, oral antihypertensive therapy should be initiated or titrated at a blood pressure threshold of 140/90 mm Hg or greater. Gestational hypertension and preeclampsia without severe features can be managed with blood pressure monitoring, laboratory testing for disease progression, antenatal testing for fetal well-being, and delivery at 37 weeks' gestation. The use of antihypertensive drugs to control nonsevere hypertension in the setting of gestational hypertension and preeclampsia does not improve outcomes and is not recommended. Antihypertensive therapy should be initiated expeditiously for acute-onset severe hypertension to prevent hemorrhagic stroke. Preeclampsia with severe features requires immediate stabilization and inpatient treatment with magnesium sulfate for seizure prophylaxis and antenatal corticosteroids (if preterm). Patients in the preterm period should receive antenatal corticosteroids without delaying delivery to complete courses. Hypertensive disorders of pregnancy can worsen or initially present after delivery and account for up to 44% of pregnancy-related deaths in the first six days postpartum. Patients should be monitored closely in the early postpartum period. Hypertensive disorders of pregnancy are linked to poor long-term maternal and fetal outcomes, including increased maternal lifetime risk of cardiovascular disease. Daily low-dose aspirin therapy starting at 12 to 16 weeks' gestation is safe and effective for reducing the risk of preeclampsia for patients with risk factors. (Am Fam Physician. 2024; 109(3):251–260. Copyright © 2024 American Academy of Family Physicians.) Hypertensive disorders of pregnancy are a major contributor to maternal morbidity and mortality in the United States and include chronic and gestational hypertension, preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, eclampsia, and chronic hypertension with superimposed preeclampsia. For patients with chronic hypertension, oral antihypertensive therapy should be initiated or titrated at a blood pressure threshold of 140/90 mm Hg or greater. Gestational hypertension and preeclampsia without severe features can be managed with blood pressure monitoring, laboratory testing for disease progression, antenatal testing for fetal well-being, and delivery at 37 weeks' gestation. The use of antihypertensive drugs to control nonsevere hypertension in the setting of gestational hypertension and preeclampsia does not improve outcomes and is not recommended. Antihypertensive therapy should be initiated expeditiously for acute-onset severe hypertension to prevent hemorrhagic stroke. Preeclampsia with severe features requires immediate stabilization and inpatient treatment with magnesium sulfate for seizure prophylaxis and antenatal corticosteroids (if preterm). Patients in the preterm period should receive antenatal corticosteroids without delaying delivery to complete courses. Hypertensive disorders of pregnancy can worsen or initially present after delivery and account for up to 44% of pregnancy-related deaths in the first six days postpartum. Patients should be monitored closely in the early postpartum period. Hypertensive disorders of pregnancy are linked to poor long-term maternal and fetal outcomes, including increased maternal lifetime risk of cardiovascular disease. Daily low-dose aspirin therapy starting at 12 to 16 weeks' gestation is safe and effective for reducing the risk of preeclampsia for patients with risk factors. [ABSTRACT FROM AUTHOR]

The rise in suicide by African Americans in the United States is directly attributable to the dramatic, nearly three-fold increase in suicide rates of African American males. Gibbs (1997) hypothesized high social support, religiosity, and southern residence are protective factors against suicidality for Black people. This hypothesis was tested among 5,125 participants from the National Comorbidity Survey; 299 were African American males. In this study we hypothesized that there would be significantly lower suicidality in the South, and social support and religiosity would mediate this relationship. Our results indicate that Southern region is indeed a significant predictor of suicidal symptoms in African American men, such that suicidal symptoms were lower in the South, but religiosity and social support did not account for this effect. Other potential mediators were also examined.

Background: Incarceration is linked to risk of sexually transmitted infection (STI) postrelease among women. There has been little examination of incarceration's association with related sexual and reproductive outcomes such as pelvic inflammatory disease (PID) and pregnancy loss, or the role of STI in this relationship and whether these relationships differ between Black and White women. Methods: Using data from the National Longitudinal Study of Adolescent to Adult Health, we examined cross-sectional associations between incarceration (Wave IV; 2007–2008; ages 24–34) and history of STI and PID (n = 5,968), and longitudinal associations between incarceration and later pregnancy loss in mid-adulthood (Wave V; 2016–2018; ages 34–43) among women who had ever been pregnant (n = 2,353); we estimated racial differences. Using causal mediation, we explored whether STI mediated associations with pregnancy loss. Results: Incarceration was associated with a history of STI (White adjusted prevalence ratio [APR]: 1.54, 95% confidence interval [CI] 1.14–2.06; Black APR: 1.26, 95% CI 1.02–1.56); the association between incarceration and PID was null among White women (APR: 0.99, 95% CI 0.47–2.09) and elevated among Black women (APR: 2.82, 95% CI 1.36–5.83). Prior incarceration did not appear associated with pregnancy loss among White women (APR: 1.01, 95% CI 0.70–1.45), but was associated among Black women (APR: 1.38, 95% CI: 0.97–1.97), with STI appearing to partially mediate. Conclusions: Pregnancy loss may be elevated among Black women who have been incarcerated, and incarceration-related increases in STI may account for some of this association. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated costs and healthcare utilization associated with a culturally‐sensitive, medical and education program for pediatric Latino patients with type 1 diabetes. Research Design and Methods: Program participants included Latino children ages 1–20 years old diagnosed with type 1 diabetes (n = 57). Control subjects with type 1 diabetes were matched by age, sex, and zip code to intervention participants from the Colorado All Payer Claims Database. Data included emergency department (ED) visits, hospitalizations, demographic information, and health insurance claims data 180 days prior to program start/index date through 1 year after program start/index date. We tracked program staff time and estimated costs for healthcare utilization using data from the scientific literature. Generalized Estimating Equation (GEE) models with logit link were used to estimate group differences in probabilities of ED visits and hospitalizations over 6‐month periods pre/post‐study, accounting for correlation of within‐subject data across time points. Sensitivity analyses modeled longer‐term cost differences under different assumptions. Results: The intervention group had fewer hospitalizations, 2% versus 12% of controls (p = 0.047,OR = 0.13;95%CI: 0.02–0.97) for 6 months following start date. The intervention group had fewer ED visits, 19% versus 32% in controls (n.s.; p = 0.079,OR = 0.52;95%CI:0.25–1.08) and significantly fewer hospitalizations, 4% versus 15% of controls (p = 0.039,OR = 0.21;95%CI: 0.05–0.93) 6–12 months post‐start date. One‐year per‐patient program costs of $633 and healthcare cost savings of $2710 yielded total per‐patient savings of $2077, or a 5‐year cost savings of $14,106. Conclusion: This unique type 1 diabetes management program altered health service utilization of program participants, reducing major healthcare cost drivers, ED visits, and hospitalizations. [ABSTRACT FROM AUTHOR]

Objective: Psychotropic medication use in youth with eating disorders (EDs) is poorly understood despite high co‐occurrence of psychiatric disorders. This study examined characteristics associated with medication use in treatment‐seeking youth with EDs. Method: Youth up to age 18 reported on medication use when presenting to an academic medical center outpatient ED service in the United States. Data presented were collected between 1998–2015. Results: The sample (N = 604) was predominantly female (90.6%) with a mean age of 15.3 years (SD = 2.3). Approximately one‐third (30%, n = 173) were taking psychotropic medications (40%, n = 70, were taking multiple medications). Antidepressant use was most common (26%, n = 152), followed by atypical antipsychotics (8%, n = 43). Adjusting for co‐occurring psychiatric disorders, non‐Hispanic Whites who had received prior treatment (psychotherapy, hospitalization) were significantly more likely to be using medication. Longer illness duration and prior treatment were associated with greater antidepressant use. For atypical antipsychotics, prior hospitalization was associated with greater use. Conclusions: Findings confirm moderate psychotropic medication use among young patients with EDs despite a lack of clarity regarding optimally effective pharmacologic interventions in this population. Pharmacological trials examining the efficacy of medications for young patients with EDs are warranted to inform future prescribing practice. [ABSTRACT FROM AUTHOR]

The SIU (Société Internationale d'Urologie)-ICUD (International Consultation on Urologic Diseases) working group on systemic therapy for metastatic bladder cancer has summarized the most recent findings on the aforementioned topic and came to conclusions and recommendations according to the evidence published. In Europe and the United States, treatment for metastatic UC has changed a great deal recently, mainly involving a move from chemotherapy to immune checkpoint blockers. This is particularly true in platinum-refractory disease, where supportive randomized data exist. Five checkpoint blockers have been approved in this setting by the FDA: avelumab, atezolizumab, durvalumab, nivolumab, and pembrolizumab. Nivolumab, pembrolizumab, and atezolizumab have been approved in Europe. [ABSTRACT FROM AUTHOR]

Objective. To assess the pain prevalence, pain intensity, and pain medication use in older patients with a diagnosed subtype of dementia, mild cognitive impairment (MCI), or subjective cognitive impairment (SCI). Design. Cross-sectional. Setting. Outpatient memory clinics. Subjects. In total, 759 patients with Alzheimer's disease (AD), vascular dementia, mixed AD and vascular pathology (MD), frontotemporal dementia, dementia with Lewy Bodies, MCI, or SCI. Methods. Self-reported presence and intensity of pain, prescribed medication, and related descriptive variables were given for each group. To compare groups on prevalence of pain, logistic regression analyses were adjusted for age, gender, and mood. Differences in pain intensity were tested using a Kruskall-Wallis test, and differences in analgesic use with chi-square analyses. Results. Pain prevalence ranged from 34% in MD to 50% in SCI. AD (odds ratio [OR]=0.56, 95% confidence interval [CI]=0.34-0.93) and MD (OR=0.45, CI=0.20-0.98) patients were less likely to report pain than SCI patients. The self-reported pain intensity did not differ between groups. In total, 62.5% of patients did not use any analgesic medication despite being in pain, which did not differ significantly between groups. Conclusion. Outpatient memory clinic patients with mild to moderate AD and MD are less likely to report pain than patients with SCI. No difference in selfreported pain intensity was present. The high percentage of patients with and without dementia who do not use analgesics when in pain raises the question of whether pain treatment is adequate in older patients. [ABSTRACT FROM AUTHOR]

Abstract: American Association of Physical Anthropologists (AAPA) membership surveys from 1996 and 1998 revealed significant gender disparities in academic status. A 2014 follow‐up survey showed that gender equality had improved, particularly with respect to the number of women in tenure‐stream positions. However, although women comprised 70% of AAPA membership at that time, the percentage of women full professors remained low. Here, we continue to consider the status of women in biological anthropology by examining the representation of women through a quantitative analysis of their participation in annual meetings of the AAPA during the past 20 years. We also review the programmatic goals of the AAPA Committee on Diversity Women's Initiative (COD‐WIN) and provide survey results of women who participated in COD‐WIN professional development workshops. Finally, we examine the diversity of women's career paths through the personal narratives of 14 women biological anthropologists spanning all ranks from graduate student to Professor Emeritus. We find that over the past 20 years, the percentage of women first authors of invited symposia talks has increased, particularly in the sub‐disciplines of bioarchaeology, genetics, and paleoanthropology. The percentage of women first authors on contributed talks and posters has also increased. However, these observed increases are still lower than expected given the percentage of graduate student women and women at the rank of assistant and associate professor. The personal narratives highlight first‐hand the impact of mentoring on career trajectory, the challenges of achieving work‐life satisfaction, and resilience in the face of the unexpected. We end with some suggestions for how to continue to improve equality and equity for women in biological anthropology. [ABSTRACT FROM AUTHOR]

Purpose: To test the effects of employer subsidies on employee enrollment, attendance, and weight loss in a nationally available weight management program.Design: A randomized trial tested the impact of employer subsidy: 100%; 80%, 50%, and a hybrid 50% subsidy that could become a 100% subsidy by attaining attendance targets.Trial Registration: NCT01756066.Setting and Participants: Twenty three thousand twenty-three employees of 2 US companies.Measures: The primary outcome was the percentage of employees who enrolled in the weight management program. We also tested whether the subsidies were associated with differential attendance and weight loss over 12 months, as might be predicted by the expectation that they attract employees with differing degrees of motivation. Analysis and Results: Enrollment differed significantly by subsidy level ( P < .0001). The 100% subsidy produced the highest enrollment (7.7%), significantly higher than each of the lower subsidies (vs 80% subsidy: 6.2%, P = .002; vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Enrollment in the 80% subsidy group was significantly higher than both lower subsidy groups (vs 50% subsidy: 3.9%, P < .0001; vs hybrid: 3.7%, P < .0001). Among enrollees, there were no differences among the 4 groups in attendance or weight loss.Conclusion: This pragmatic trial, conducted in a real-world workplace setting, suggests that higher rates of employer subsidization help individuals to enroll in weight loss programs, without a decrement in program effectiveness. Future research could explore the cost-effectiveness of such subsidies or alternative designs. [ABSTRACT FROM AUTHOR]

BACKGROUND: Loss-of-control (LOC) eating is common in adults undergoing bariatric surgery and is associated with poorer weight outcomes. Its long-term course in adolescent bariatric surgery patients and associations with weight outcomes are unclear. METHODS: Adolescents (n = 234; age range = 13-19 years) undergoing bariatric surgery across 5 US sites were assessed for postsurgery follow-up at 6 months and 1, 2, 3, and 4 years. Descriptive statistics and generalized linear mixed models were used to describe the prevalence of LOC eating episodes involving objectively large amounts of food and continuous eating, respectively. Generalized linear mixed models investigated the association of any LOC eating with short- and long-term BMI changes. results: At baseline, objectively large LOC eating was reported by 15.4% of adolescents, and continuous LOC eating by 27.8% of adolescents. Both forms of LOC eating were significantly lower at all postsurgical time points relative to presurgery (range = 0.5%-14.5%; Ps < .05). However, both behaviors gradually increased from 6-month to 4-year follow-up (Ps < .05). Presurgical LOC eating was not related to percent BMI change over follow-up (P = .79). However, LOC eating at 1-, 2-, and 3-year follow-up was associated with lower percent BMI change from baseline at the next consecutive assessment (Ps < .05). CONCLUSIONS: Although presurgical LOC eating was not related to relative weight loss after surgery, postoperative LOC eating may adversely affect long-term weight outcomes. Rates of LOC eating decreased from presurgery to 6-months postsurgery but increased thereafter. Therefore, this behavior may warrant additional empirical and clinical attention. [ABSTRACT FROM AUTHOR]

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7). [ABSTRACT FROM AUTHOR]

Changing demographics in the population will have far-reaching effects on the labor force, the economy, and employment over the 2016-26 decade. The overall labor force participation rate is projected to decline as older workers leave the labor force, constraining economic growth. The aging baby-boomer segment of the population will drive demand for healthcare services and related occupations. [ABSTRACT FROM AUTHOR]

Domestic relations law has struggled with feminism for decades, and it has never truly found a place in the family law arena. The crux of the problem, no doubt, is that family law has always had a difficult time defining feminism in context. From an economic perspective, is it feminist to provide economic assistance to women, who studies continue to show suffer far more than do their male counterparts in the wake of divorce? Or does feminism instead require a recognition of the ability of women to make equivalent financial contributions to a marriage as men, and thereby accept only pure equality of treatment? A series of incongruent doctrines makes it clear that family law truly does not know what feminism should mean. Consequently, the system of family law largely fails to achieve one of feminism's most fundamental tenets: empowerment. This Article will sample a diverse cross-section of family law and analyze it from a feminist perspective. Part I will consider the state of a woman's decision-making authority in the reproductive context. Parts II and III will explore the modern proliferation of domestic violence related legislation, analyzing state law schemes that provide for both punitive damage recoveries and permanent spousal support. Part IV will address marital property regimes around the country. Across all contexts, the Article will demonstrate that, often despite the best intentions of legislators and jurists, family law wholly fails to empower women. [ABSTRACT FROM AUTHOR]

Background Obesity continues to be a serious public health challenge. Rates are increasing worldwide, with nearly 70% of the US adults overweight or obese, leading to increased clinical and economic burden. While successful approaches for achieving weight loss have been identified, techniques for long-term maintenance of initial weight loss have largely been unsuccessful. Financial incentive interventions have been shown in several settings to be successful in motivating participants to adopt healthy behaviors. Purpose Keep It Off is a three-arm randomized controlled trial that compares the efficacy of a lottery-based incentive, traditional direct payment incentive, and control of daily feedback without any incentive for weight-loss maintenance. This design allows comparison of a traditional direct payment incentive with one based on behavioral economic principles that consider the underlying psychology of decision-making. Methods Participants were randomized in a 2:1 ratio for each active arm relative to control, with a targeted 188 participants in total. Eligible participants were those aged 30–80 who lost at least 11 lb (5 kg) during the first 4 months of participation in Weight Watchers, a national weight-loss program, with whom we partnered. The interventions lasted 6 months (Phase I); participants were followed for an additional 6 months without intervention (Phase II). The primary outcome is weight change from baseline to the end of Phase I, with the change at the end of Phase II a key secondary endpoint. Keep It Off is a pragmatic trial that recruited, consented, enrolled, and followed patients electronically. Participants were provided a wireless weight scale that electronically transmitted daily self-monitored weights. Weights were verified every 3 months at a Weight Watchers center local to the participant and electronically transmitted. Results Using the study web-based platform, we integrated recruitment, enrollment, and follow-up procedures into a digital platform that required little staff effort to implement and manage. We randomized 191 participants in less than 1 year. We describe the design of Keep It Off and implementation of enrollment. Lessons Learned We demonstrated that our pragmatic design was successful in rapid accrual of participants in a trial of interventions to maintain weight loss. Limitations Despite the nationwide reach of Weight Watchers, the generalizability of study findings may be limited by the characteristics of its members. The interventions under study are appropriate for settings where an entity, such as an employer or health insurance company, could offer them as a benefit. Conclusions Keep It Off was implemented and conducted with minimal staff effort. This study has the potential to identify a practical and effective weight-loss maintenance strategy. [ABSTRACT FROM AUTHOR]

Purpose: To test whether employer matching of employees' monetary contributions increases employees' (1) participation in deposit contracts to promote weight loss and (2) weight loss.Design: A 36-week randomized trial.Setting: Large employer in the northeast United States.Participants: One hundred thirty-two obese employees.Interventions: Over 24 weeks, participants were asked to lose 24 pounds and randomized to monthly weigh-ins or daily weigh-ins with monthly opportunities to deposit $1 to $3 per day that was not matched, matched 1:1, or matched 2:1. Deposits and matched funds were returned to participants for each day they were below their goal weight.Measures: Rates of making ≥1 deposit, weight loss at 24 weeks (primary outcome), and 36 weeks.Analysis: Deposit rates were compared using χ(2) tests. Weight loss was compared using t tests.Results: Among participants eligible to make deposits, 29% made ≥1 deposit and matching did not increase participation. At 24 weeks, control participants gained an average of 1.0 pound, whereas 1:1 match participants lost an average of 5.3 pounds (P = .005). After 36 weeks, control participants gained an average of 2.1 pounds, whereas no match participants lost an average of 5.1 pounds (P = .008).Conclusion: Participation in deposit contracts to promote weight loss was low, and matching deposits did not increase participation. For deposit contracts to impact population health, ongoing participation will need to be higher. [ABSTRACT FROM AUTHOR]

Background: The "Why Try" phenomenon, a consequence of self-stigma, is a sense of futility that occurs when people believe they are unworthy or incapable of achieving personal goals because they apply the stereotypes of mental illness to themselves. Aims: This study examines a four-stage model of self-stigma (aware, agree, apply, and self-stigma harm) and examines the "why try" effect as a result. We do that by testing a measure of "why try." Method: Two hypothetical path models were tested. In the first, applying stereotypes to oneself leads to diminished self-respect and a sense of "why try". In the second, the effect of applying stereotypes on "why try" is mediated by diminished self-respect. Participants completed the "why try" measure along with measures of self-stigma, public stigma, recovery, and empowerment. Results: Results show application of stereotypes to oneself predicts diminished self-respect and "why try". "Why try" was significantly associated with agreement with public stigma, depression, and diminished sense of personal recovery. Conclusions: Findings from this study reveal the complex impact of self-stigma demonstrating its emotional and behavioral consequences. Implications for impacting self-stigma are discussed. [ABSTRACT FROM AUTHOR]

Objective: To examine characteristics potentially associated with school lunch fruit and vegetable waste, both overall and pre/post implementation of the Healthy, Hunger-Free Kids Act.Design: Multi-year (2010-2013) cross-sectional study using pre- and post-meal digital photographs of students' school lunch trays to estimate fruit and vegetable availability and consumption. Fruit and vegetable items were categorized for factors suspected to impact waste: prior farm to school years, placement (main menu, salad bar), procurement (local, conventional), preparation (cooked, raw) and meal component (entrée, side, topping). Analyses to assess within-category differences in waste volume were performed using a Tobit model.Setting: Wisconsin elementary schools participating in farm to school programmes, USA.Subjects: Children in third to fifth grade.Results: Many within-factor differences were detected overall and/or across time. Cooked fruits were wasted less than raw, while cooked vegetables were wasted more than raw. Where identified, locally sourced items were wasted more than conventionally sourced (+0·1 cups, P<0·0001) and salad bar items more than main menu items (+0·01 cups, P<0·0001). Increasing prior farm to school years decreased waste (-0·02 cups, P<0·0001). Items previously tried were wasted at the same volume whether reported as liked or not. New school lunch meal pattern requirement implementation did not uniformly impact fruit and vegetable waste across all categories and there was no change in waste for seven of fifteen assessed categories.Conclusions: Many factors impact elementary students' school lunch waste. These factors may be helpful for school food-service authorities to consider when planning school menus. [ABSTRACT FROM AUTHOR]

The article discusses the problems associated with unsuccessful adoptions in the U.S., and it mentions legal protections for biological parents, as well as issues related to child abuse and neglect. Disruptions involving families in America are mentioned, along with the efforts of child welfare workers and children who are part of the U.S. foster care system. Adoptions of older children and kids with special needs are examined, as well as research regarding Reactive Attachment Disorder .

Background: Long-term care settings provide care to a large proportion of predominantly older, highly disabled adults across the United States and Canada. Managing and improving quality of care is challenging, in part because staffing is highly dependent on relatively non-professional health care aides and resources are limited. Feedback interventions in these settings are relatively rare, and there has been little published information about the process of feedback intervention. Our objectives were to describe the key components of uptake of the feedback reports, as well as other indicators of participant response to the intervention. Methods: We conducted this project in nine long-term care units in four facilities in Edmonton, Canada. We used mixed methods, including observations during a 13-month feedback report intervention with nine post-feedback survey cycles, to conduct a process evaluation of a feedback report intervention in these units. We included all facility-based direct care providers (staff) in the feedback report distribution and survey administration. We conducted descriptive analyses of the data from observations and surveys, presenting this in tabular and graphic form. We constructed a short scale to measure uptake of the feedback reports. Our analysis evaluated feedback report uptake by provider type over the 13 months of the intervention. Results: We received a total of 1,080 survey responses over the period of the intervention, which varied by type of provider, facility, and survey month. Total number of reports distributed ranged from 103 in cycle 12 to 229 in cycle 3, although the method of delivery varied widely across the period, from 12% to 65% delivered directly to individuals and 15% to 84% left for later distribution. The key elements of feedback uptake, including receiving, reading, understanding, discussing, and reporting a perception that the reports were useful, varied by survey cycle and provider type, as well as by facility. Uptake, as we measured it, was consistently high overall, but varied widely by provider type and time period. Conclusions: We report detailed process data describing the aspects of uptake of a feedback report during an intensive, longitudinal feedback intervention in long-term care facilities. Uptake is a complex process for which we used multiple measures. We demonstrate the feasibility of conducting a complex longitudinal feedback intervention in relatively resource-poor long-term care facilities to a wider range of provider types than have been included in prior feedback interventions. [ABSTRACT FROM AUTHOR]

Patient falls are considered a significant safety risk, but little evidence regarding the significance of falls in children is available. A multisite, observational study of fall events occurring in pediatric inpatients (younger than 18 years of age) from Child Health Corporation of America member hospitals was conducted to determine the prevalence and significance of falls. Fall prevalence was 0.84 per 1,000 patient days with 48% classified as preventable. Injuries occurred in 32%, but only two falls resulted in an increased length of stay; none resulted in permanent disability or death. Only 47% of the children who fell were identified to be at risk for fall. Alert mechanisms were used in 60% and preventive measures in 23%. These findings suggest that while inpatient pediatric fall rates are lower than those of adults, greater diligence in identification and risk reduction may further reduce the prevalence of falls and the proportion of fall-related injuries. [ABSTRACT FROM AUTHOR]

Abstract: This study was undertaken to determine if increasing maternal iodine intake through single dose tablets will decrease breast milk concentrations of the iodine-uptake inhibitor, perchlorate, through competitive inhibition. We also sought to determine if the timing of supplementation influences the fraction of iodine excreted in milk versus urine and to compare the effectiveness of iodized salt as a means of providing iodine to breastfed infants. Thirteen women who did not use supplements, seven of whom used iodized salt and six of whom used non-iodized salt, submitted four milk samples and a 24-h urine collection daily for three days. Women repeated the sampling protocol for three more days during which ~150μg of iodine were taken in the evening and again for three days with morning supplementation. Samples were analyzed using isotope-dilution inductively-coupled plasma-mass spectrometry for iodine and isotope-dilution ion chromatography-tandem mass spectrometry for perchlorate. No statistically significant differences were observed in milk iodine or perchlorate concentrations during the two treatment periods. Estimated perchlorate intake was above the U.S. National Academy of Sciences suggested reference dose for most infants. Single daily dose iodine supplementation was not effective in decreasing milk perchlorate concentrations. Users of iodized salt had significantly higher iodine levels in milk than non-users. Iodized salt may be a more effective means of iodine supplementation than tablets. [Copyright &y& Elsevier]

Background: Although colorectal cancer (CRC) is the second leading cause of cancer death among adults in the US and colonoscopy is efficacious in reducing morbidity and mortality from CRC, screening rates are sub-optimal. Understanding the socioeconomic, cultural, and health care context within which decisions about colonoscopy are made allows physicians to address patients' most salient beliefs and values and other constraints when making screening recommendations.Objective: To evaluate the direct and interactive effects of socioeconomics, health care variables, psychological characteristics, and cultural values on colonoscopy use.Design, Setting, Participants: National survey completed between January-August 2009 in a random sample of African American, white, and Hispanic adults ages 50-75 without cancer (n = 582).Main Measure: Self-reported colonoscopy use.Key Results: Only 59% of respondents reported having a colonoscopy. The likelihood of colonoscopy increased with having health insurance (OR = 2.82, 95% CI = 1.24, 6.43, p = 0.004), and increasing age (OR = 1.40, 95% CI = 1.11, 1.77, p = 0.001). In addition, respondents with greater self-efficacy were more likely to have a colonoscopy (OR = 2.41, 95% CI = 1.35, 4.29, p = 0.003).Conclusions: Programs that help patients to overcome access and psychological barriers to screening are needed. [ABSTRACT FROM AUTHOR]

Tropical cyclone intensity change remains a forecasting challenge with important implications for such vulnerable areas as the U.S. coast along the Gulf of Mexico. Analysis of 1979-2008 Gulf tropical cyclones during their final two days before U.S. landfall identifies patterns of behavior that are of interest to operational forecasters and researchers. Tropical storms and depressions strengthened on average by about 7 kt for every 12 h over the Gulf, except for little change during their final 12 h before landfall. Hurricanes underwent a different systematic evolution. In the net, category 1-2 hurricanes strengthened, while category 3-5 hurricanes weakened such that tropical cyclones approach the threshold of major hurricane status by U.S. landfall. This behavior can be partially explained by consideration of the maximum potential intensity modified by the environmental vertical wind shear and hurricane-induced sea surface temperature reduction near the storm center associated with relatively low oceanic heat content levels. Linear least squares regression equations based on initial intensity and time to landfall explain at least half the variance of the hurricane intensity change. Applied retrospectively, these simple equations yield relatively small forecast errors and biases for hurricanes. Characteristics of most of the significant outliers are explained and found to be identifiable a priori for hurricanes, suggesting that forecasters can adjust their forecast procedures accordingly. [ABSTRACT FROM AUTHOR]

Objective: Some advocates argue that the word "stigma" is itself stigmatizing and contributes to further denigration of people with mental illness. This brief report presents results of a nationwide survey comparing terminology related to stigma in regard to mental illness.Methods: A total of 340 Amazon Mechanical Turk survey takers read variations of a vignette depicting an individual with schizophrenia and then completed a brief stigma measure. The vignette varied in a single sentence in which three different words-"stigma," "prejudice," and "reactions"-were used to describe coworkers' possible attitudes toward the depicted individual.Results: Stigma ratings did not differ by vignette group. "Reactions" was viewed as significantly less disrespectful than both "stigma" and "prejudice" (p<.001).Conclusions: Further research is needed to support replacing the word "stigma" in public arenas. Current efforts to remove the word may unnecessarily distract advocates and policy makers from the primary mission of erasing stigma. [ABSTRACT FROM AUTHOR]

Background & Aims: In patients with chronic liver disease, race plays a role in the rate of survival after transplantation. It is not known how race and ethnicity influence the presentation, etiology, and outcomes in patients with acute liver failure (ALF). Methods: A retrospective cohort study was conducted using the ALF Study Group database to assess differences between racial and ethnic groups in subjects with ALF. Results: In the cohort of 927 subjects (81.8% white, 12.8% black, and 5.4% Asian), enrolled between January 1998 and March 2006, age, sex, and level of education were comparable among the groups. Differences were found in the prevalence of psychiatric illness and the use of medications. Racial groups also differed with respect to etiology of ALF. Whites presented more frequently with acetaminophen toxicity (51% vs 27%; P < .001). By day 21, 228 (30%) whites, 46 (39%) blacks, and 11 (22%) Asians had died. There were no significant differences found in the overall mortality rate after adjustment for potential confounders including etiology of ALF, encephalopathy, age, sex, admission laboratory values, and region. The odds of liver transplantation were higher among Asians and Hispanics; however, this finding was attenuated after adjustment for the previously-described confounders (adjusted odds ratio, 1.50; 95% confidence interval, 0.72–3.13; and adjusted odds ratio, 1.89; 95% confidence interval, 1.08–3.30, respectively). Conclusions: In patients with ALF, there were no significant differences in survival or rate of liver transplantation among racial and ethnic groups except for transplantation in Hispanics. [Copyright &y& Elsevier]

Background: Smoking is the leading preventable cause of premature death in the United States. Previous studies of financial incentives for smoking cessation in work settings have not shown that such incentives have significant effects on cessation rates, but these studies have had limited power, and the incentives used may have been insufficient. Methods: We randomly assigned 878 employees of a multinational company based in the United States to receive information about smoking-cessation programs (442 employees) or to receive information about programs plus financial incentives (436 employees). The financial incentives were $100 for completion of a smoking-cessation program, $250 for cessation of smoking within 6 months after study enrollment, as confirmed by a biochemical test, and $400 for abstinence for an additional 6 months after the initial cessation, as confirmed by a biochemical test. Individual participants were stratified according to work site, heavy or nonheavy smoking, and income. The primary end point was smoking cessation 9 or 12 months after enrollment, depending on whether initial cessation was reported at 3 or 6 months. Secondary end points were smoking cessation within the first 6 months after enrollment and rates of participation in and completion of smoking-cessation programs. Results: The incentive group had significantly higher rates of smoking cessation than did the information-only group 9 or 12 months after enrollment (14.7% vs. 5.0%, P<0.001) and 15 or 18 months after enrollment (9.4% vs. 3.6%, P<0.001). Incentive-group participants also had significantly higher rates of enrollment in a smoking-cessation program (15.4% vs. 5.4%, P<0.001), completion of a smoking-cessation program (10.8% vs. 2.5%, P<0.001), and smoking cessation within the first 6 months after enrollment (20.9% vs. 11.8%, P<0.001). Conclusions: In this study of employees of one large company, financial incentives for smoking cessation significantly increased the rates of smoking cessation. (ClinicalTrials.gov number, NCT00128375.) N Engl J Med 2009;360:699-709. [ABSTRACT FROM AUTHOR]

Background: Anatomic distribution of melanoma, thought to be different between men and women, has not been studied in the United States since the 1970s, although lifestyle and clothing habits have changed since then. Objective: To determine whether the anatomic distribution of melanoma varied between men and women at our institution in 2004 and in the 1970s, and to assess whether the anatomic distribution has changed over time. Methods: We recorded the body location of initial primary cutaneous melanomas and assessed other variables of interest for 152 patients seen in our clinic in 2004 and in 397 patients seen between 1972 and 1977. Logistic regression was used for analysis. Results: For the 2004 patients, males had an increased relative risk compared to females of developing a melanoma on their head and neck (relative risk ratio [RRR] = 3.33; P = .01). For the 1970s patients, this difference was not found, but males in the 1970s had higher odds of developing melanoma on their upper back, chest, and abdomen, while females in the 1970s had higher odds of developing melanoma on the upper extremity and lower extremity, particularly the lower legs and feet. Examining differences over time, we found that women in 2004 had a decreased relative risk of developing a melanoma on the lower extremities as opposed to the trunk as compared to the 1970s (RRR = 0.42; P < .01). We also found that women had increased odds of developing a melanoma on the chest in 2004 compared to the 1970s (OR = 2.65; P = .04), while men had increased odds of developing a melanoma on their lower legs in 2004 compared to the 1970s (OR = 3.18; P = .02). Limitations: The study was performed at a single academic center and the results may not generalize to all melanoma populations. There may be important unexamined confounders. Conclusions: There were significant differences between men and women in the anatomic distribution of melanoma in 2004 patients and in 1970s patients, but the nature of those differences changed over time. [Copyright &y& Elsevier]

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Background: Sunburn is a major preventable risk factor for skin cancer. Objective: We investigated risk factors for sunburn in the United States based on the 2003 Behavioral Risk Factor Surveillance System. Design and methods: A random sample of 207,776 respondents provided data for the population-based survey. The main outcome measure was any report of sunburn within the previous 12 months. Results: Overall, 39% of respondents had at least one sunburn. The strongest factors associated with sunburn were age and socioeconomic factors. Sunburn prevalence was greatest in respondents 18 to 24 years old (61%). This group was more likely to have a sunburn than respondents 45 to 54 years of age (odds ratio [OR] = 2.76). Higher income and higher levels of education were positively associated with sunburn (OR 1.67 and 1.63, respectively). Individuals reporting recent binge drinking had a higher prevalence of sunburn (OR = 1.33). Limitations: The Behavioral Risk Factor Surveillance System does not include data on skin type or sun protection behavior; therefore the impact of these factors was not assessed. Conclusion: Sunburn occurs at a very high rate in the United States. [Copyright &y& Elsevier]

More than four years after September 11, 2001, bioterrorism preparedness remains a high priority for federal, state, and local governments. With reasonably flexible federal funding, communities have strengthened their ability to respond to public health emergencies, according to assessments by stakeholders and market observers. Collaborative relationships developed for bioterrorism preparedness have proved useful in addressing other threats, such as natural disasters and infectious disease outbreaks. Major ongoing challenges include funding constraints, inadequate surge capacity, public health workforce shortages, competing priorities, and jurisdictional issues. [ABSTRACT FROM AUTHOR]

Numerous state and federal programs and policies aim to improve rural health care. This study compares access to and quality of medical care in urban and rural areas from the perspective of physicians and patients, using a broad set of indicators taken from the 2000-2001 Community Tracking Study (CTS) Physician and Household Surveys. Across most dimensions examined, access and quality in rural areas-even rural counties not adjacent to metropolitan areas-were either equivalent or superior to that provided in urban areas. However, rural residents have greater difficulty obtaining mental health services and generally face greater financial barriers to care. [ABSTRACT FROM AUTHOR]

Since the terrorist attacks of 11 September 2001, emergency preparedness has become a top priority in metropolitan areas, and some of these areas have received considerable federal funding to help support improvements. Although much progress has been made, preparedness still varies across communities, with the larger ones exhibiting stronger response capabilities, and some weaknesses are evident, particularly in the areas of communications and workforce education. Experience with other public health emergencies, strong leadership, successful collaboration, and adequate funding contributed to high states of readiness. Important challenges include a shortage of funding, delay in the receipt of federal funding, and staffing shortages. [ABSTRACT FROM AUTHOR]

Purpose: Personal assistance care is a Medicaid benefit in New York, but few data are available on its prevalence and contribution to home care. We examined these issues in a New York City sample by assessing older adults' reports of weekly home core hours and Medicaid billing records. Design and Methods: With help from New York City's Human Resources Administration, we identified all respondents in an ongoing population-based survey of Medicare enrollees who were receiving Medicaid-reimbursed personal assistance care in 1996. Results: Of respondents in the sample, 10.3% (185 of 1,902 alive through 1996) had Medicaid claims for personal assistance care. The mean was 46.1 hr/ week for reported hours and 40.1 hr/week for administrative claims. Accuracy of reported hours was evident in a high correlation (r= .91; p < .001) between respondent reports and authorized claims, and a consistently high and mostly constant ratio of billed to reported hours across all categories of activities of daily living disability. Implications: In this urban, low income, and mostly minority sample, older adults' reports of weekly formal care hours were valid when matched against administrative records. Respondent reports of formal care hours were valid even in complex care situations. [ABSTRACT FROM AUTHOR]

Studies how adults in the U.S. communicate their end-of-life preferences. Use of face-to-face interviews; Major barriers impeding support of individuals' end-of-life preferences; Preferences' lack of clarity and detail needed by significant others; Percent of respondents who use living wills to make their preferences clear.

Grandparents are returning to the role of parents in ever-increasing numbers. Custodial grandparents often find themselves isolated from sources of support as they face unique emotional, physical, and financial challenges on a daily basis. Nearly half are grandparents without partners and the majority are caring for two or more young children. Children in the care of grandparents are more likely to experience cognitive, emotional, and physical challenges. Their early traumatic experiences may lead to difficulties in communication and forming attachments. The Parent Topics Questionnaire is a standardized assessment measure designed to provide parent education group facilitators with specific information about needs, desires, and expectations of participants. Administration of this instrument to four parent groups revealed a high readiness for information among the custodial grandparent population. Based on information obtained from this measure, a holistic program was developed which simultaneously provided services to caregiving grandparents, their young grandchildren, and educational professionals. Grandparent and grandchildren's groups met weekly and emphasized topics and activities aimed at meeting common needs within these populations. Educational professionals participated in a series of inservice meetings aimed at increasing awareness of needs and strengths of grandparent- headed families, modifying curriculum to more effectively meet grandchildren's needs, and enhancing knowledge of existing resources. Pre- and post-test analysis demonstrate significant positive effects for all involved populations. Grandparents were found to increase in parenting knowledge, perceived levels of social support, willingness to utilize existing resources, and enjoyment of time with their grandchildren. Levels of isolation and perceived depression were decreased. Participating grandchildren demonstrated increased abilities to interact effectively with peers and adults and perceived their interactions with grandparents more positively. Educational professionals reported feeling more informed about custodial grandparent family issues, more confident about interacting with grandparents, and more knowledgeable about existing resources. [ABSTRACT FROM PUBLISHER]

Asserts that grandparent-headed households in the United States often result from drugs, divorce, desertion and death. Statistics on the growth of the trend; Need for educational professionals to acquire information about custodial grandparents' particular circumstances; Feeling common to grandparented children; Importance of the professional educator's role in rearing grandparented children.

The article focuses on the impact of basketball player Magic Johnson's announcement of being HIV positive on adolescents in the U.S. Johnson's announcement has raised awareness among teenagers of the dangers of heterosexual sex. They are becoming more concerned about HIV infections and are willing to interact with infected individuals. Magic, in his announcement, emphasized repeatedly that he was HIV-positive but did not have AIDS and did not feel ill. Adolescents appeared to derive different lessons from his story and encountered different reactions to it from parents, teachers, and friends that may have modulated their own responses. However, Johnson's announcement does not appear to be strong enough to finally convinced young people that they might get infected by it. It is expected that Magic Johnson's continuing efforts to educate youth about AIDS can help to reduce rates of infection, particularly among the young black males. It remains the case that coverage of AIDS by the media and AIDS public service announcements can make an important contribution to AIDS education.

Significant funding of health programs in low-income countries comes from external sources, mainly private donors and national development agencies of high-income countries. How these external funds are allocated remains a subject of ongoing debate, as studies have revealed that external funding may misalign with the underlying disease burden. One determinant of the priorities set by both private donors and development agencies is the perceptions of populations living in high-income countries about which diseases are legitimate for global health intervention. While research has been conducted on the priorities expressed by recipient communities, relatively less has been done to assess those of the donating country. To investigate people's beliefs about the disease burden in high-income countries, we compared publicly available data from U.S. surveys of people's perceptions of the leading causes of death in developing countries against measures of the actual disease burden from the World Health Organization. We found little correlation between the U.S. public's perception and the actual disease burden, measured as either mortality or disability-adjusted life years. While there is potential for reverse causality, so that donor programs drive public perceptions, these findings suggest that increasing the general population's awareness of the true global disease burden could help better align global health funding with population health needs. [ABSTRACT FROM AUTHOR]

Background: Sleep difficulties are common among older adults, and clinical management of sleep difficulties commonly includes sleep medication (pharmacological and non-pharmacological). Our research examines sleep medication use and incident dementia over 8 years using nationally representative data from older adults ages 65 years and older in the United States.Methods: We used data collected from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of Medicare beneficiaries. Routine sleep medication use (pharmacological and non-pharmacological) was defined as use "most nights" or "every night." Participants were screened for dementia with validated instruments that assessed memory, orientation, and executive function. We conduct prospective analyses to examine the relationship between routine sleep medication use and incident dementia using Cox proportional hazards modeling and estimated survival curves. Analyses controlled for age, sex, marital status, education, and chronic conditions.Results: Among respondents at baseline (n = 6373), most participants (21%) were age 70-74 years of age. Participants were 59% female and the sample comprised non-Hispanic White (71%). At baseline, 15% of our study sample reported using sleep medication routinely, which is representative of 4.6 million older adults in the US. Covariate adjusted proportional hazard models revealed that routinely using sleep medication was associated with incident dementia (HR = 1.30, 95%CI: 1.10 to 1.53, p < 0.01).Conclusions: Our study observed, in a nationally representative study of older adults in the US across 8 years of data that 15% of older adults report routinely using sleep medication, yet routine use of sleeping medication was associated with incident dementia across the follow-up interval. Future research may examine behavioral approaches to improving sleep among older adults. [ABSTRACT FROM AUTHOR]

Examines a case of granular parakeratosis in an Afro-American boy. Prevalence of the disease in children; Histopathology of the disease; Therapeutic approaches.

Perchlorate has been considered by some a potential threat to human health, especially to developing infants and children because it may inhibit iodide uptake by the sodium iodide symporter (NIS) of the thyroid. In the United States, during the last several decades, environmental perchlorate has had three recognized sources stemming from (a) its use as an oxidizer (including in rocket propellants), (b) its presence in Chilean nitrate fertilizer (CNF), and (c) natural production. An analysis of the relative source strengths and how they may influence entry into the food chain has not been conducted. Averaged over the last ∼60 years, we estimate that the source strengths have been (a) 10.6, (b) 0.75, and (c) 0.13–0.64 Gg/y for the United States as a whole. Of this, while (b) and (c) represent actual dispersed amounts, the figure in (a) is the amount of perchlorate produced and only a fraction (f) of it has been dispersed and often in a more localized fashion. In addition, dispersal of (b) has taken place only over agricultural land. Considering that the total land area in the United States is 5.5x the arable land area, in terms of incorporation into the food chain, the figure cited in (b) has a proportionately greater impact. Most estimates of f will thus suggest that over the considered period, the contribution of CNF to incorporation of perchlorate in the food chain has likely been comparable to oxidizer perchlorate, with natural production being a lesser source. Fireworks presently constitute a potentially important source of increasing importance but a quantitative impact cannot yet be assessed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate survival times for dogs with previously untreated. peripheral nodal, intermediate- or large-cell Iymphoma treated with prednisone alone. ANIMALS: 109 client-owned dogs recruited from 15 institutions in the United States. PROCEDURES: Dogs were treated with prednisone at a dosage of 40 mg/m², PO. once daily for 7 days and at a dosage of 20 mg/m², PO, once daily thereafter. Quality of life (QOL) was assessed by owners with a visual analog scale when treatment was started (day 0), I and 2 weeks after treatment was started, and every 4 weeks thereafter. The primary outcome of interest was survival time as determined by the Kaplan-Meier method. Factors potentially associated with survival time were examined. RESULTS: Median overall survival time was 50 days (95% CL 41 to 59 days). Factors associated with survival time included substage (a vs b) and immunophenotype (B cell vs T cell). Owner-assigned QOL scores on days 0 and 14 were significantly positively correlated with survival time. When QOL score was dichotomized, dogs with day 0 or day 14 QOL scores 2 50 had significantly longer survival times, compared with dogs with day 0 or day 14 QOL scores < 50. No variables were predictive of long-term (> 120 days) survival. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that survival times were short for dogs with previously untreated, peripheral nodal, intermediate- or large-cell Iymphoma treated with prednisone alone. Owner-perceived QOL and clinician-assigned substage were both associated with survival time. Findings provide potentially important information for clinicians to discuss with owners of dogs with Iymphoma at the time treatment decisions are made. [ABSTRACT FROM AUTHOR]

There is a high prevalence of overweight among U.S. young adults and the intergenerational implications of excess weight gain at this life stage are great. We used Project EAT (Eating and Activity in Teens and Young Adults) study data to identify personal, behavioral, and environmental factors that predicted healthy weight maintenance during the transition from adolescence to adulthood and as individuals progressed from the third to fourth decade of life. The sample included 1120 young adults who were secondary school students in Minneapolis-St. Paul at Time 1 (1998–1999) and responded at follow-ups in 2008–2009 and 2015–2016. Results showed individual factors and multiple environmental factors contribute to maintenance. The most consistent findings suggest that having higher body satisfaction and avoiding unhealthy weight control behaviors (e.g., skipping meals) and dieting are protective against excess weight gain for women and men. For example, the odds ratio associated with a one standard deviation increase in the probability of using an extreme weight control behavior from adolescence and adulthood was 0.67 (CI: 0.54, 0.84) among women and 0.34 (CI: 0.12, 0.96) among men indicating decreased odds of maintaining a healthy weight. Social support for healthy eating and physical activity were protective whereas close relationships with individuals who were dieting (e.g., parents, significant others) reduced the likelihood of maintaining a healthy weight. Primary prevention strategies should continue beyond adolescence and involve peer social support to encourage young people at a healthy weight to be satisfied with their shape/size and avoid restrictive weight control behaviors. [ABSTRACT FROM AUTHOR]

Background: The approval of anti-programmed death ligand 1 (PD-L1) and anti-programmed death 1 agents has expanded treatment options for patients with locally advanced or metastatic urothelial carcinoma. Avelumab, a human monoclonal anti-PD-L1 antibody, has shown promising antitumour activity and safety in this disease. We aimed to assess the safety profile in patients (both post-platinum therapy and cisplatin-naive) treated with avelumab and to assess antitumour activity of this drug in post-platinum patients.Methods: In this pooled analysis of two cohorts from the phase 1 dose-expansion JAVELIN Solid Tumor study, patients aged 18 years and older with histologically or cytologically confirmed locally advanced or metastatic urothelial carcinoma that had progressed after at least one previous platinum-based chemotherapy were enrolled from 80 cancer treatment centres or hospitals in the USA, Europe, and Asia. Eligible patients had adequate end-organ function, an Eastern Cooperative Oncology Group performance status of 0 or 1, life expectancy of at least 3 months, and at least one measurable lesion. Cisplatin-ineligible patients who might have been previously treated in the perioperative setting, including platinum-naive patients, were also eligible. Patients unselected for PD-L1 expression received avelumab (10 mg/kg, 1 h intravenous infusion) every 2 weeks until confirmed disease progression, unacceptable toxicity, or other criterion for withdrawal. The primary endpoint for this efficacy expansion cohort was confirmed best overall response (according to RECIST version 1.1), adjudicated by independent review. Safety analysis was done in all patients who received at least one dose of avelumab. Antitumour activity was assessed in post-platinum patients who received at least one dose of avelumab. This trial is registered with ClinicalTrials.gov, number NCT01772004; enrolment in this cohort of patients with metastatic urothelial carcinoma is closed and the trial is ongoing.Findings: Between Sept 3, 2014, and March 15, 2016, 329 patients with advanced metastatic urothelial carcinoma were screened for enrolment into this study; 249 patients were eligible and received treatment with avelumab for a median of 12 weeks (IQR 6·0-19·7) and followed up for a median of 9·9 months (4·3-12·1). Safety and antitumour activity were evaluated at data cutoff on June 9, 2016. In 161 post-platinum patients with at least 6 months of follow-up, a best overall response of complete or partial response was recorded in 27 patients (17%; 95% CI 11-24), including nine (6%) complete responses and 18 (11%) partial responses. The most frequent treatment-related adverse events (any grade in ≥10% patients) were infusion-related reaction (73 [29%]; all grade 1-2) and fatigue (40 [16%]). Grade 3 or worse treatment-related adverse events occurred in 21 (8%) of 249 patients, the most common of which were fatigue (four [2%]), and asthenia, elevated lipase, hypophosphataemia, and pneumonitis in two (1%) patients each. 19 (8%) of 249 patients had a serious adverse event related to treatment with avelumab, and one treatment-related death occurred (pneumonitis).Interpretation: Avelumab showed antitumour activity in the treatment of patients with platinum-refractory metastatic urothelial carcinoma; a manageable safety profile was reported in all avelumab-treated patients. These data provide the rationale for therapeutic use of avelumab in metastatic urothelial carcinoma and it has received accelerated US FDA approval in this setting on this basis.Funding: Merck KGaA, and Pfizer Inc. [ABSTRACT FROM AUTHOR]