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Background: Both gallstone disease and sleep disorders are important public health problems. Few studies to date have investigated the associations between sleep and gallstone disease in humans. This study aimed to assess whether sleep factors (sleep time, sleep amounts, trouble sleeping) were associated with gallstone disease in the United States adults., Methods: This was a population-based cross-sectional study of US adults, which included data of participants aged over 20 years from the National Health and Nutrition Examination Survey (NHANES) gathered between 2017 and March 2020. The assessment of gallstone disease and sleep factors was based on self-reported data. We used sample-weighted logistic regression and restricted cubic spline models to explore the associations between sleep factors and gallstone disease. Subgroup analyses were conducted to assess the interaction between trouble sleeping and interacting factors., Results: The prevalence of gallstone disease was 11% among the 9,210 adult participants. Going to bed late on weekdays (OR, 1.41; 95% CI, 1.15 to 1.74) and weekends (OR, 1.43; 95% CI, 1.14 to 1.78), and short sleep duration on weekdays (OR, 1.29; 95% CI, 1.00 to 1.68) were factors associated with increased risk of gallstone disease, and we detected dose-response associations with the restricted cubic spline model (RCS) models, after adjusting for confounders. Presenting trouble sleeping was associated with increased risk of gallstone disease (OR, 1.52; 95% CI, 1.03 to 2.23) and the association was influenced by the presence of thyroid disease (P for interaction = 0.037)., Conclusions: Our study results indicate that going to bed late, short sleep duration, and trouble sleeping were associated with increased risk of gallstone disease in a nationally representative sample of adults in the US., Competing Interests: Declarations. Ethics approval and consent to participate: The NHANES data used in this study are publicly available. As an analysis of existing, anonymized data, the present study did not require Internal Review Board approval. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Depression frequently comorbidities with cancer, adversely affecting survivors' quality of life. Liver dysfunction is also prevalent among cancer survivors. However, the association between these two conditions remains unclear. This study aimed to explore the relationship between depression and liver function biomarkers in US cancer survivors. A cross-sectional study was conducted utilizing data from the National Health and Nutrition Examination Survey (NHANES) 2005-2020. Cancer survivors were screened and depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), and 18 liver function biomarkers were included. Survey-weighted generalized linear models with multiple covariables adjusted were employed to examine the associations between depression and liver function biomarkers. A total of 4118 cancer survivors were included, representing a weighted population of 21 501 237. After adjusted with age, gender, race, marital status, education level, family income-to-poverty ratio, and number of cancer types, 8 biomarkers demonstrated positive correlations with depression in cancer survivors, included alanine aminotransferase (ALT, OR = 1.007, 95% CI: 1.000 to 1.013), alkaline phosphatase (ALP, 1.006 [1.002, 1.010]), gamma glutamyl transferase (GGT, 1.004 [1.001, 1.007]), lactate dehydrogenase (LDH, 1.004 [1.000, 1.009]), total protein (TP, 1.040 [1.009, 1.072]), globulin (GLB, 1.060 [1.030, 1.091]), total cholesterol (TC) to high-density lipoprotein cholesterol (HDL-C) ratio (1.162 [1.050, 1.286]), and low-density lipoprotein cholesterol (LDL-C) to HDL-C ratio (1.243 [1.012, 1.526]); while 4 other biomarkers exhibited negative correlations, included HDL-C (0.988 [0.980, 0.997]), total bilirubin (TBi, 0.501 [0.284, 0.883]), aspartate aminotransferase (AST) to ALT ratio (0.588 [0.351, 0.986]), albumin (ALB) to GLB ratio (0.384 [0.229, 0.642]). Following sensitivity analysis, 5 biomarkers included LDH, HDL-C, TBi, AST/ALT and LDL-C/HDL-C lost their statistical significance for the association. This study identified certain associations between 7 liver function biomarkers and depression in US cancer survivors. Further research, particularly prospective longitudinal studies, is warranted to elucidate the causal relationships and explore the potential of improving liver function for the management of depression in cancer patients., Competing Interests: Declarations Competing interests The authors declare no competing interests. Ethics approval and consent to participate All the NHANES protocols were approved by the Ethics Review Board of U.S. National Center for Health Statistics, and written informed consents were obtained from all participants of NAHNES surveys., (© 2024. The Author(s).)

Importance: Treating low back pain (LBP) often involves a combination of pharmacologic, nonpharmacologic, and interventional treatments; one approach is acupuncture therapy, which is safe, effective, and cost-effective. How acupuncture is used within pain care regimens for LBP has not been widely studied., Objective: To document trends in reimbursed acupuncture between 2010 and 2019 among a large sample of patients with LBP, focusing on demographic, socioeconomic, and clinical characteristics associated with acupuncture use and the nonpharmacologic, pharmacologic, and interventional treatments used by patients who utilize acupuncture., Design, Setting, and Participants: This cross-sectional study included insurance claims of US adults in a deidentified database. The study sample included patients diagnosed with LBP between 2010 and 2019. Data were analyzed between September 2023 and June 2024., Main Outcomes and Measures: Changes in rates of reimbursed acupuncture utilization between 2010 and 2019, including electroacupuncture use, which involves the electrical stimulation of acupuncture needles. Covariates included age, sex, race and ethnicity, income, educational attainment, region, and a chronic LBP indicator. Secondary analyses tracked other nonpharmacologic treatments (eg, physical therapy, chiropractic care), pharmacologic treatments (eg, opioids, gabapentinoids), and interventional treatments (eg, epidural steroid injections)., Results: The total sample included 6 840 497 adults with LBP (mean [SD] age, 54.6 [17.8] years; 3 916 766 female [57.3%]; 802 579 Hispanic [11.7%], 258 087 non-Hispanic Asian [3.8%], 804 975 non-Hispanic Black [11.8%], 4 974 856 non-Hispanic White [72.7%]). Overall, 106 485 (1.6%) had 1 or more acupuncture claim, while 61 503 (0.9%) had 1 or more electroacupuncture claim. The rate of acupuncture utilization increased consistently, from 0.9% in 2010 to 1.6% in 2019; electroacupuncture rates were relatively stable. Patients who were female (male: odds ratio [OR], 0.68; 99% CI, 0.67-0.70), Asian (OR, 3.26; 99% CI, 3.18-3.35), residing in the Pacific region (New England: OR, 0.26; 99% CI, 0.25-0.28), earning incomes of over $100 000 (incomes less than $40 000: OR, 0.59; 99% CI, 0.57-0.61), college educated (high school or less: OR, 0.32; 99% CI, 0.27-0.35), and with chronic LBP (OR, 2.39; 99% CI, 2.35-2.43) were more likely to utilize acupuncture. Acupuncture users were more likely to engage in other nonpharmacologic pain care like physical therapy (39.2%; 99% CI, 38.9%-39.5% vs 29.3%; 99% CI, 29.3%-29.3%) and less likely to utilize prescription drugs, including opioids (41.4%; 99% CI, 41.1%-41.8% vs 52.5%; 99% CI, 52.4%-52.5%), compared with nonusers., Conclusions and Relevance: In this cross-sectional study, we found that acupuncture utilization among patients with LBP was rare but increased over time. Demographic, socioeconomic, and clinical characteristics were associated with acupuncture utilization, and acupuncture users were more likely to utilize other nonpharmacologic treatments and less likely to utilize pharmacologic treatments.

Objectives : Osteoarthritis (OA) stands as the prevailing progressive musculoskeletal disease, serving as the primary cause of chronic pain and activity limitations among adults over 40. Flavan-3-ols, common polyphenolic compounds, are believed to harbor anti-inflammatory and anti-aging properties. This study explores the relationship between flavan-3-ol intake and osteoarthritis risk in individuals over the age of 40 in the US. Methods : This study included 7452 participants over the age of 40 from three cycles (2007-2008, 2009-2010, and 2017-2018) of the National Health and Nutrition Examination Survey. Information on OA history was obtained via home surveys. Information on flavan-3-ol monomers intake was obtained using a survey from the Food and Nutrient Database for Dietary Studies. We used a logistic regression model and restricted cubic spline to analyze the relationships between flavan-3-ol monomers and OA. Stratified analyses were also conducted in this study. Results : There were 1056 participants with OA and 6396 without OA. Compared to the first tertile (T1) group, the adjusted odds ratio with a 95% confidence interval (CI) of logistic regression model 2 for the flavan-3-ol T2 group was 1.296 (0.979-1.715) ( p = 0.068), the OR for (-)-epigallocatechin was 1.292 (1.025-1.629) ( p = 0.032), and the OR for (-)-epicatechin 3-gallate was 1.348 (1.013, 1.793) ( p = 0.042). A dose-response curve indicated a non-linear association ( p for non-linearity <0.05) between OA and total flavan-3-ol monomers (nadir point: 483.29 mg, 95% CI: 0.61-0.90). No interaction effects were found in the subgroup analysis. Conclusions : In individuals over 40 in the US, the average daily dietary intake of flavan-3-ol monomers manifests a J-shaped relationship with OA risk.

Background: Audit and feedback (A/F), which include initiatives like report cards, have an inconsistent impact on clinicians' prescribing behavior. This may be attributable to their focus on aggregate prescribing measures, a one-size-fits-all approach, and the fact that A/F initiatives rarely engage with the clinicians they target., Methods: In this study, we describe the development and delivery of a report card that summarized antipsychotic prescribing to publicly-insured youth in Philadelphia, which was introduced by a Medicaid managed care organization in 2020. In addition to measuring aggregate prescribing behavior, the report card included different elements of care plans, including whether youth were receiving polypharmacy, proper medication management, and the concurrent use of behavioral health outpatient services. The A/F initiative elicited feedback from clinicians, which we refer to as an "audit and feedback loop." We also evaluate the impact of the report card by comparing pre-post differences in prescribing measures for clinicians who received the report card with a group of clinicians who did not receive the report card., Results: Report cards indicated that many youth who were prescribed antipsychotics were not receiving proper medication management or using behavioral health outpatient services alongside the antipsychotic prescription, but that polypharmacy was rare. In their feedback, clinicians who received report cards cited several challenges related to antipsychotic prescribing, such as the logistical difficulties of entering lab orders and family members' hesitancy to change care plans. The impact of the report card was mixed: there was a modest reduction in the share of youth receiving polypharmacy following the receipt of the report card, while other measures did not change. However, we documented a large reduction in the number of youth with one or more antipsychotic prescription fill among clinicians who received a report card., Conclusions: A/F initiatives are a common approach to improving the quality of care, and often target specific practices such as antipsychotic prescribing. Report cards are a low-cost and feasible intervention but there is room for quality improvement, such as adding measures that track medication management or eliciting feedback from clinicians who receive report cards. To ensure that the benefits of antipsychotic prescribing outweigh its risks, it is important to promote quality and safety of antipsychotic prescribing within a broader care plan., (© 2024. The Author(s).)

Objective: To identify the trends of wheelchair use and physical characteristics among older people who used wheelchairs relative to those who did not., Design: Cohort and survey., Setting: General community., Participants: 7026 participants (N=7026) were selected from the 2011 cohort of the National Health and Aging Trends Study (NHATS), which is made up of Medicare beneficiaries over the age of 65. Repeated observations among participants in the 2011 cohort were analyzed in the 4 following rounds: 2013 (N=4454), 2015 (N=3327), 2017 (N=2623), and 2019 (N=2091). Participants were divided into 2 groups: those who used and did not use wheelchairs., Interventions: Not applicable., Main Outcomes Measures: Physical characteristics, including pain, strength limitation, balance problems, mobility disability, as well as the frequency of going outside., Results: The number of older adults who use wheelchairs had increased significantly from 4.7 per 100 people in 2011 to 7.1 in 2019 (P<.001). The logistic regression analysis indicated that participants who reported less frequently going out were at least 4.27 times more likely to be wheelchair users than non-wheelchair users (P<.01). Participants who reported health and physical problems were at least 2.48 times more likely to be wheelchair users than non-wheelchair users from 2011 to 2017 (P<.0001). Balance or coordination problems increased (24%-38%) significantly among non-wheelchair users from 2011 to 2019 (all P<.05)., Conclusions: Current wheelchair users reported more physical difficulties and were much less likely to go outside. This lower outdoor mobility could be due to physical difficulties or potential barriers in physical and socio-cultural environments. In addition, older adults who do not use wheelchairs showed increasing physical problems over time (including balance or coordination problems). Clinicians should consider older wheelchair users' health and physical limitations when prescribing wheelchairs., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Backgrounds: The adverse effects of long-term use of proton pump inhibitors (PPIs) have led to growing concern. The association between PPIs use and the risks of nonalcoholic fatty liver disease (NAFLD) remains controversial., Goal: The aim of this study was to investigate the association between PPIs use and the risks of NAFLD among the general adult population in the United States., Study: We performed a cross-sectional study by extracting data from the National Health and Nutrition Examination Survey of 2017 to 2018. The association between PPIs use and NAFLD risks was analyzed by weighted multivariate logistic regression., Results: Among the 4238 participants included in this study, 2167 were diagnosed with NAFLD. In the multivariate logistic regression model, PPIs use was associated with increased risks of NAFLD [odds ratio (OR): 1.318, 95% CI: 1.044-1.663; P=0.020]. This association was nonsignificant in participants taking PPIs for ˂5 years (OR: 0.846, 95% CI: 0.579-1.238; P=0.390), whereas it remained significant in participants taking PPIs for more than 5 years (OR: 2.016, 95% CI: 1.366-2.975; P=0.031). Further analysis showed that the use of PPIs was positively associated with risks of severe hepatic steatosis (OR: 1.451, 95% CI: 1.034-2.036; P=0.031) but not with mild-to-moderate steatosis (OR: 1.242, 95% CI: 0.886-1.741; P=0.208)., Conclusions: This study indicated that taking PPIs was associated with increased risks of NAFLD, especially severe hepatic steatosis. Awareness should be raised regarding the potential risks of NAFLD when prescribing PPIs., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to estimate the size of the United States candidacy pool meeting expanded Center for Medicare Services criteria for cochlear implantation., Study Design: Retrospective cross-sectional., Setting: Tertiary care center., Methods: Preimplantation audiometric data from 486 patients seen at a single academic medical center were collected retrospectively and used to generate a predictive model of AzBio score based on audiometric pure tone thresholds. This model was then used to estimate nationally representative cochlear implantation (CI)-candidacy using pure tone averages included in the National Health and Nutrition Examination Survey. Qualitative and quantitative analyses were performed., Results: We find that the estimated prevalence of CI candidacy in individuals 65 years of age or older is expected to more than double with a change in the CI candidacy criteria from ≤40% to ≤60% (from 1.42%, 95% confidence interval [1.33, 1.63] to 3.73% [2.71, 6.56]) on speech testing. We also found the greatest absolute increase in candidacy in the 80+ age group, increasing from 4.14% [3.72, 5.1] of the population meeting the ≤40% criteria to 12.12% [9.19, 18.35] meeting the ≤60% criteria., Conclusion: The United States population size meeting expanded CMS audiologic criteria for cochlear implantation is estimated to be 2.5 million adults and 2.1 million age 65 or older. Changing the CI candidacy criteria from ≤40% to ≤60% on CI testing has the greatest effect on the eligible patient population in the >65-year-old age group. The determination of utilization rates in newly eligible patients will require further study., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Using a life course approach, we examined how sexuality is related to cognitive function for partnered older adults. We utilized longitudinal data from two rounds of the National Social Life, Health, and Aging Project (NSHAP) to analyze 1,683 respondents. Cognitive function was measured using a continuous Montreal Cognitive Assessment (MoCA) score. We considered both sexual frequency and sexual quality (i.e., physical pleasure, emotional satisfaction). We estimated cross-lagged models to consider the potential reciprocal relationship between sexuality and cognitive function. Results indicated that sexuality was not related to later cognitive function in the total sample, but the pattern varied by age and gender. For adults aged 62-74, better sexual quality (i.e., feelings of physical pleasure and emotional satisfaction) was related to better cognitive functioning, while for those aged 75-90, more frequent sex was related to better cognitive functioning. Feelings of physical pleasure were related to better cognitive functioning for men but not women. There was no evidence of cognitive functioning being related to later sexuality. The findings highlight the importance of age and gender in modifying the link between sexuality and cognition in later life.

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Evidence on cardiovascular-related and all-cause mortality risks in a wide range of cancer survivors is scarce but needed to inform prevention and management. Methods: We performed a nationwide prospective cohort study using information from the Continuous National Health and Nutrition Examination Survey (NHANES) in the United States and the linked mortality follow-up files, available for public access. A propensity score-matched analysis with a 1:1 ratio was conducted to reduce the baseline differences between participants with and without cancer. The relationship between cancer status and the cardiovascular-related and all-cause mortality risk was examined using weighted Cox proportional hazards regression. Independent stratification analysis and cancer-specific analyses were also performed. Results: The study sample included 44,342 participants, aged 20-85, interviewed between 1999 and 2018. Of these, 4,149 participants had cancer. All-cause death occurred in 6,655 participants, of whom 2,053 died from cardiovascular causes. Propensity-score matching identified 4,149 matched pairs of patients. A fully adjusted Cox proportional hazards regression showed that cancer was linked to an elevated risk of cardiovascular-related and all-cause mortality both before and after propensity score matching. Stratification analysis and cancer-specific analyses confirmed robustness of results. Conclusion: Our study confirmed that cancer was strongly linked to cardiovascular-related and all-cause mortality, even after adjusting for other factors that could impact a risk, including the American Heart Association (AHA)'s Life's Simple 7 cardiovascular health score, age, sex, ethnicity, marital status, income, and education level., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Shen, Wang, Wang, Tian, Guo, Shen, Liu and Zou.)

Objective: To examine the effect of patient age on longitudinal speech understanding outcomes after cochlear implantation (CI) in bilateral hearing loss., Study Design: Retrospective cohort study., Setting: Tertiary academic center., Patients: One thousand one hundred five adult patients with bilateral hearing loss receiving a unilateral CI between 1987 and 2022InterventionsNone., Main Outcome Measures: Postoperative speech recognition outcomes, including AzBio sentences, consonant-nucleus-consonant word, and Hearing in Noise Test in quiet were analyzed at short-term (<2 yr), medium-term (2-8 y), and long-term (>8 yr) term postoperative intervals., Results: Eighty-six very elderly (>80 yr), 409 elderly (65-80 yr), and 709 nonelderly (18-65 yr) patients were included. Short-term postoperative AzBio scores demonstrated similar magnitude of improvement relative to preoperative scores in the very elderly (47.6, 95% confidence interval [CI], 28.9-66.4), elderly (49.0; 95% CI, 39.2-58.8), and nonelderly (47.9; 95% CI, 35.4-60.4). Scores for those older than 80 years remained stable after 2 years after implant, but in those 80 years or younger, scores continued to improve for up to 8 years (elderly: 6.2 [95% CI, 1.5-12.4]; nonelderly: 9.9 [95% CI, 2.1-17.7]) after implantation. Similar patterns were observed for consonant-nucleus-consonant word scores. Across all age cohorts, patients with preoperative Hearing in Noise Test scores between 40 and 60% had similar scores to those with preoperative scores of less than 40%, at short-term (82.4, 78.9; 95% CI, -23.1 to 10.0), medium-term (77.2, 83.9; 95% CI, -15.4 to 8.2), or long-term (73.4, 71.2; 95% CI, -18.2 to 12.2) follow-up., Conclusions: Patients older than 80 years gain significant and sustained auditory benefit after CI, including those meeting expanded Centers for Medicare & Medicaid Service criteria for implantation. Patients younger than 80 years demonstrated continued improvement over longer periods than older patients, suggesting a role of central plasticity in mediating CI outcomes as a function of age., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Background: A reliable risk prediction model is critically important for identifying individuals with high risk of developing lung cancer as candidates for low-dose chest computed tomography (LDCT) screening. Leveraging a cutting-edge machine learning technique that accommodates a wide list of questionnaire-based predictors, we sought to optimize and validate a lung cancer prediction model., Methods: We developed an Optimized early Warning model for Lung cancer risk (OWL) using the XGBoost algorithm with 323,344 participants from the England area in UK Biobank (training set), and independently validated it with 93,227 participants from UKB Scotland and Wales area (validation set 1), as well as 70,605 and 66,231 participants in the Prostate, Lung, Colorectal, and Ovarian cancer screening trial (PLCO) control and intervention subpopulations, respectively (validation sets 2 & 3) and 23,138 and 18,669 participants in the United States National Lung Screening Trial (NLST) control and intervention subpopulations, respectively (validation sets 4 & 5). By comparing with three competitive prediction models, i.e., PLCO modified 2012 (PLCO m2012 ), PLCO modified 2014 (PLCO all2014 ), and the Liverpool Lung cancer Project risk model version 3 (LLPv3), we assessed the discrimination of OWL by the area under receiver operating characteristic curve (AUC) at the designed time point. We further evaluated the calibration using relative improvement in the ratio of expected to observed lung cancer cases (RI EO ), and illustrated the clinical utility by the decision curve analysis., Findings: For general population, with validation set 1, OWL (AUC = 0.855, 95% CI: 0.829-0.880) presented a better discriminative capability than PLCO all2014 (AUC = 0.821, 95% CI: 0.794-0.848) (p < 0.001); with validation sets 2 & 3, AUC of OWL was comparable to PLCO all2014 (AUC PLCOall2014 -AUC OWL < 1%). For ever-smokers, OWL outperformed PLCO m2012 and PLCO all2014 among ever-smokers in validation set 1 (AUC OWL  = 0.842, 95% CI: 0.814-0.871; AUC PLCOm2012  = 0.792, 95% CI: 0.760-0.823; AUC PLCOall2014  = 0.791, 95% CI: 0.760-0.822, all p < 0.001). OWL remained comparable to PLCO m2012 and PLCO all2014 in discrimination (AUC difference from -0.014 to 0.008) among the ever-smokers in validation sets 2 to 5. In all the validation sets, OWL outperformed LLPv3 among the general population and the ever-smokers. Of note, OWL showed significantly better calibration than PLCO m2012 , PLCO all2014 (RI EO from 43.1% to 92.3%, all p < 0.001), and LLPv3 (RI EO from 41.4% to 98.7%, all p < 0.001) in most cases. For clinical utility, OWL exhibited significant improvement in average net benefits (NB) over PLCO all2014 in validation set 1 (NB improvement: 32, p < 0.001); among ever smokers of validation set 1, OWL (average NB = 289) retained significant improvement over PLCO m2012 (average NB = 213) (p < 0.001). OWL had equivalent NBs with PLCO m2012 and PLCO all2014 in PLCO and NLST populations, while outperforming LLPv3 in the three populations., Interpretation: OWL, with a high degree of predictive accuracy and robustness, is a general framework with scientific justifications and clinical utility that can aid in screening individuals with high risks of lung cancer., Funding: National Natural Science Foundation of China, the US NIH., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Ceftazidime-avibactam is an effective antibiotic combination of a β-lactam and a β-lactamase inhibitor against Klebsiella pneumoniae-carbapenemase (KPC)-producing Enterobacterales . Despite a relatively low resistance rate, reports of resistance to ceftazidime-avibactam mainly caused by the mutations in KPC have increased in recent years. Here, we report a ceftazidime-avibactam-resistant and carbapenem-susceptible Klebsiella pneumoniae strain carrying a novel KPC variant, KPC-112, which differs from KPC-2 by 4-amino-acid deletions at Ambler positions 166L/167E and 242G/243T. The isolate was identified as K. pneumoniae by a Vitek mass spectrometer (bioMérieux, France). The MICs of antimicrobial agents were determined using broth microdilution susceptibility method. The result showed that the isolate was resistant to ceftazidime-avibactam (MIC = >128 mg/L) but susceptible to imipenem (MIC = 0.5 mg/L), meropenem (MIC = 1 mg/L), and tigecycline (MIC = 2 mg/L). The carbapenemase genes were confirmed by PCR-based sequencing. Plasmid transformation assay showed that the bla KPC-112 -positive transformant increased MICs of ceftazidime-avibactam, ceftazidime, and cefepime by at least 256-fold, 128-fold, and 128-fold, respectively, compared with the recipient Escherichia coli DH5α. According to the whole-genome sequencing analysis, many common resistance genes were identified, including bla KPC-112 , bla OXA-1 , bla CTX-M-15 , bla TEM-1B , bla SHV-28 , aac(6')Ib-cr , aac(3)-IId (CRE) are one of the most serious antimicrobial resistance problems in the world, listed as an "urgent" threat by the U.S. Centers for Disease Control and Prevention. Among CRE, K. pneumoniae-carbapenemase-producing Klebsiella pneumoniae (KPC-KP) has become a significant health threat due to its rapid transmissibility and high mortality. With the wider clinical use of ceftazidime-avibactam, reports of resistance have increased in recent years even though the overall resistance rate remains relatively low. Among the reported resistance mechanisms are mainly mutations derived from the qnrS1 , catA2 , catB4 , and fosA6 , and mutations of GyrA (GyrA-83F and GyrA-87A) and ParC (ParC-80I) were also found. Overall, our study highlights the importance of monitoring susceptibility during ceftazidime-avibactam treatment and accurate detection of KPC variants. IMPORTANCE Carbapenem-resistant Enterobacterales (CRE) are one of the most serious antimicrobial resistance problems in the world, listed as an "urgent" threat by the U.S. Centers for Disease Control and Prevention. Among CRE, K. pneumoniae-carbapenemase-producing Klebsiella pneumoniae (KPC-KP) has become a significant health threat due to its rapid transmissibility and high mortality. With the wider clinical use of ceftazidime-avibactam, reports of resistance have increased in recent years even though the overall resistance rate remains relatively low. Among the reported resistance mechanisms are mainly mutations derived from the bla KPC-2 or bla KPC-3 gene. Here, we describe the characterization of a ceftazidime-avibactam-resistant bla KPC-112 -positive K. pneumoniae clinical isolate for the first time. A number of Enterobacteriaceae isolates producing these kinds of KPC variants might be missed by conventional antimicrobial susceptibility testing (AST) methods and lead to irrational drug use. So, this study of KPC-112 will help to establish the diversity of KPCs and remind researchers of the challenge of drug resistance and detection brought by the KPC variants.

Objectives: This study aimed to explore the relationship between the blood urea nitrogen/creatinine (BUN/Cre) ratio and all-cause or cause-specific mortality in the general population., Methods: Participants were enrolled from the National Health and Nutrition Examination Survey (NHANES) during 1999 to 2014. Baseline variables were acquired from questionnaires and examinations. Death status were ascertained from National Death Index records. Cox proportional hazards models with cubic spines were used to estimate hazard ratios (HRs) and 95% confidence interval (CI) of all-cause mortality, cardiovascular and cancer mortality., Results: A total of 42038 participants were enrolled in the study with a median 8.13 years of follow-up. Older people and women tend to have a higher BUN/Cre ratio. After multivariable adjustment, BUN/Cre ratio between 11.43 and 14.64 was associated with the lowest all-cause mortality compared with the participants with the lowest quartile (HR 0.83 [0.76, 0.91]; p  < 0.001). The highest quartile of BUN/Cre ratio was associated with the lowest risk of cancer mortality (HR 0.64 [0.53, 0.78]; p  < 0.001). Restricted cubic splines showed BUN/Cre was nonlinearly associated with all-cause mortality and linearly associated with cancer mortality., Conclusions: This study confirmed a U-shape relationship between BUN/Cre ratio and all-cause mortality in the general population.

BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers' Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization. DISCLOSURES: Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.

Purpose: To estimate the central tendency and dispersion for incubation period of COVID-19 and, in turn, assess the effect of a certain length of quarantine for close contacts in active monitoring., Methods: Literature related to SARS-CoV-2 and COVID-19 was searched through April 26, 2020. Quality was assessed according to Agency for Healthcare Research and Quality guidelines. Log-normal distribution for the incubation period was assumed to estimate the parameters for each study. Incubation period median and dispersion were estimated, and distribution was simulated., Results: Fifty-six studies encompassing 4095 cases were included in this meta-analysis. The estimated median incubation period for general transmissions was 5.8 days [95% confidence interval (95% CI): 5.3, 6.2]. Incubation period was significantly longer for asymptomatic transmissions (median: 7.7 days; 95% CI 6.3, 9.4) than for general transmissions (P = 0.0408). Median and dispersion were higher for SARS-CoV-2 incubation compared to other viral respiratory infections. Furthermore, about 12 in 10,000 contacts in active monitoring would develop symptoms after 14 days, or below 1 in 10,000 for asymptomatic transmissions. Meta-regression suggested that each 10-year increase in age resulted in an average 16% increment in length of median incubation (incubation period ratio, 1.16, 95% CI 1.01, 1.32; P = 0.0250)., Conclusion: This study estimated the median and dispersion of the SARS-CoV-2 incubation period more precisely. A 14-day quarantine period is sufficient to trace and identify symptomatic infections., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Objective: To investigate the holistic characteristics of patients administered or prescribed opioids to treat pain in the emergency department (ED)., Methods: We used National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2018 to examine the administration and prescribing of opioids for pain-related ED visits. Weighted logistic regression models were developed to evaluate the association between opioid administration and prescribing (OAP) in the ED and patients' pain/severity of conditions, demographic/socioeconomic factors, behavioral factors, contextual factors, and organizational factors. Then, subgroup analyses were conducted by type of pain., Results: Nearly 55% of the ED visits in 2018 involved pain as a main reason for visiting the ED. The odds of receiving opioids were 45% less in black patients than in white patients when other covariates were adjusted (OR: 0.55; CI: 0.430-0.703). Compared to patients with private insurance, Medicaid beneficiaries and uninsured/self-pay patients had a 45% (OR: 0.55; CI: 0.423-0.706) and 44% (OR: 0.56; CI: 0.386-0.813) lower chance of receiving or being prescribed opioids for a pain-related ED visit when all covariates were adjusted. Other significant predictors of OAP for pain in EDs included older age, higher pain level, ED arrival by ambulance, admission to hospital, ED arrival during a night shift, geographic region of the ED. Behavioral factors, such as ED return within 72 h and whether a patient has substance/alcohol abuse or dependence, were not significantly associated with OAP. The subgroup analysis indicated that black patients had lower odds of OAP than their white counterparts only for certain pain categories., Conclusion: Despite increasing awareness of potential implicit bias in managing pain in the ED, racial disparities in OAP still existed. More education and training on implicit bias would help with reduce the disparities. Also, our study result indicated that non-clinical factors may play a role in emergency physicians' decision making in OAP. Increased recognition of the variation and systemic efforts to address factors affecting the variability are needed., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Epigenetic alterations, including histone acetylation, contribute to the malignant transformation of hematopoietic cells and disease progression, as well as the emergence of chemotherapy resistance. Targeting histone acetylation provides new strategies for the treatment of cancers. As a pan-histone deacetylase inhibitor, panobinostat has been approved by the US Food and Drug Administration for the treatment of multiple myeloma and has shown promising antileukemia effects in acute lymphoblastic leukemia (ALL). However, the underlying drug resistance mechanism in ALL remains largely unknown. Using genome-wide Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/CRISPR-associated (Cas)9 (CRISPR/Cas9) screening, we identified mitochondrial activity as the driver of panobinostat resistance in ALL. Mechanistically, ectopic SIRT1 expression activated mitochondrial activity and sensitized ALL to panobinostat through activating mitochondria-related apoptosis pathway. Meanwhile, the transcription level of SIRT1 was significantly associated with panobinostat sensitivity across diverse tumor types and thus could be a potential biomarker of panobinostat response in cancers. Our data suggest that patients with higher SIRT1 expression in cancer cells might benefit from panobinostat treatment, supporting the implementation of combinatorial therapy with SIRT1 or mitochondrial activators to overcome panobinostat resistance., (© 2022 by The American Society of Hematology. Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permitting only noncommercial, nonderivative use with attribution. All other rights reserved.)

Background: Iron oxide nanoparticles have been approved by food and drug administration for clinical application as magnetic resonance imaging (MRI) and are considered to be a biocompatible material. Large iron oxide nanoparticles are usually used as transversal (T 2 ) contrast agents to exhibit dark contrast in MRI. In contrast, ultrasmall iron oxide nanoparticles (USPIONs) (several nanometers) showed remarkable advantage in longitudinal (T 1 )-weighted MRI due to the brighten effect. The study of the toxicity mainly focuses on particles with size of tens to hundreds of nanometers, while little is known about the toxicity of USPIONs., Results: We fabricated Fe 3 O 4 nanoparticles with diameters of 2.3, 4.2, and 9.3 nm and evaluated their toxicity in mice by intravenous injection. The results indicate that ultrasmall iron oxide nanoparticles with small size (2.3 and 4.2 nm) were highly toxic and were lethal at a dosage of 100 mg/kg. In contrast, no obvious toxicity was observed for iron oxide nanoparticles with size of 9.3 nm. The toxicity of small nanoparticles (2.3 and 4.2 nm) could be reduced when the total dose was split into 4 doses with each interval for 5 min. To study the toxicology, we synthesized different-sized SiO 2 and gold nanoparticles. No significant toxicity was observed for ultrasmall SiO 2 and gold nanoparticles in the mice. Hence, the toxicity of the ultrasmall Fe 3 O 4 nanoparticles should be attributed to both the iron element and size. In the in vitro experiments, all the ultrasmall nanoparticles (< 5 nm) of Fe 3 O 4 , SiO 2 , and gold induced the generation of the reactive oxygen species (ROS) efficiently, while no obvious ROS was observed in larger nanoparticles groups. However, the ·OH was only detected in Fe 3 O 4 group instead of SiO 2 and gold groups. After intravenous injection, significantly elevated ·OH level was observed in heart, serum, and multiple organs. Among these organs, heart showed highest ·OH level due to the high distribution of ultrasmall Fe 3 O 4 nanoparticles, leading to the acute cardiac failure and death., Conclusion: Ultrasmall Fe 3 O 4 nanoparticles (2.3 and 4.2 nm) showed high toxicity in vivo due to the distinctive capability in inducing the generation of ·OH in multiple organs, especially in heart. The toxicity was related to both the iron element and size. These findings provide novel insight into the toxicology of ultrasmall Fe 3 O 4 nanoparticles, and also highlight the need of comprehensive evaluation for their clinic application., (© 2022. The Author(s).)

Philadelphia, Pennsylvania, is an urban epicenter of the opioid epidemic, and inappropriate opioid prescribing remains a top concern. To help address this issue, the Philadelphia Medicaid Opioid Prescribing Initiative, a type of community quality collaborative, mailed thousands of local Medicaid providers an individualized prescribing report card in 2017 and 2018. The report card featured details of providers' opioid prescribing, including peer comparison measures and inappropriate prescribing measures like concomitant opioid and benzodiazepine prescribing. This case study describes the unique process of developing and distributing the opioid prescribing report cards, with a particular focus on the role of Medicaid managed care organizations. Using Medicaid pharmacy claims, the extensive variation in prescribing measures within and across specialties is also illustrated. The report card's implementation points to the potential value of collaborations between public health departments and Medicaid managed care organizations and can provide insight for other locally grown policies.

Background: Antipsychotic prescribing to Medicaid-enrolled youth has been the target of numerous policy initiatives, including prior authorization and quality monitoring programs, which often target specific populations. Whether these efforts have changed the level or composition of antipsychotic prescribing is unclear., Methods: Using 2014-2018 administrative claims data for Medicaid enrollees aged 21 years and under in Philadelphia, Pennsylvania, we measured antipsychotic prescription fills overall and for youth without an approved indication (autism, bipolar disorder, or psychosis). We then assessed whether trends differed for populations that have been targeted by policy initiatives, including younger children and foster care-enrolled youth. We also identified the most common approved and unapproved indications and examined whether the treatment duration of antipsychotic prescriptions differed based on whether the youth had an approved or unapproved indication., Results: Overall, the number of Medicaid youth with an antipsychotic prescription fill halved between 2014 and 2018. Youth aged 17 years and under and foster care-enrolled youth, who were targeted by prior authorization and quality improvement efforts, experienced larger declines. Roughly half of prescriptions were for unapproved indications in both 2014 and 2018; the most common unapproved indication was ADHD, and the treatment duration was shorter for unapproved indications compared to approved indications., Conclusions: Antipsychotic prescribing to Medicaid-enrolled youth is declining, particularly among populations that have been targeted by policy initiatives like prior authorization and quality monitoring programs. Despite the fact that these initiatives often assess diagnostic criteria, half of antipsychotic prescriptions were for unapproved indications in both 2014 and 2018. More research is needed to gauge whether this prescribing is appropriate., (© 2021. The Author(s).)

Background: As of January 2020, 18 of 50 US states comprehensively banned almost all handheld cellphone use while driving, 3 states and the District of Columbia banned calling and texting, 27 states banned texting on a handheld cellphone, and 2 states had no general cellphone ban for all drivers. However, it remains unknown whether these bans were associated with fewer traffic deaths and whether comprehensive handheld bans are more effective than isolated calling or texting bans. We evaluated whether cellphone bans were associated with fewer driver, non-driver, and total fatalities nationally., Methods: We conducted a longitudinal panel analysis of traffic fatality rates by state, year, and quarter. Population-based rate ratios and 95% CIs were estimated comparing state-quarters with and without cellphone bans., Results: From 1999 through 2016, 616,289 persons including 344,003 drivers died in passenger vehicle crashes in the United States. Relative to no ban, comprehensive handheld bans were associated with lower driver fatality rates (adjusted rate ratio aRR = 0.93, 95% CI = 0.90, 0.97) but not for non-driver fatalities (aRR = 1.01, 95% CI = 0.95, 1.07) or total fatalities (aRR = 0.98, 95% CI = 0.94, 1.01). We found no differences in driver fatalities for calling-only bans (aRR = 1.00, 95% CI = 0.97, 1.03), texting-only bans (aRR = 1.02, 95% CI = 0.99, 1.05), texting plus phone-manipulating bans (aRR = 0.99, 95% CI = 0.93, 1.04), or calling and texting bans (aRR = 0.98, 95% CI = 0.88, 1.09)., Conclusions: Comprehensive handheld bans were associated with fewer driver fatalities., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Total knee arthroplasty (TKA) has brought hope to patients with malignant knee joint diseases. Infection is one of the serious complications after TKA, and the purpose of this study was to use bibliometrics to analyze the current research status of infection after this surgery, to unmask any deficiencies with current research, and to provide references for future researchers., Methods: We used the Science Citation Index Expanded (SCI-E) database in the Web of Science Core Collection (WOSCC) as the data source, using the search terms "total knee arthroplasty" and "infection" respectively. The "And" operation was performed on the search results of the two subject terms, and the intersection of the two search results was taken as the final search result. CiteSpace software was used to analyze the results., Results: The search results consisted of 5,600 documents, with a total citation frequency of 148,871. The average number of citations for each literature was 26.58, and the h-index was 142. The top five countries in the number of publications were the United States, China, Germany, the United Kingdom, and Spain, while the top five centrally ranked countries were the United States, the Netherlands, Germany, the United Kingdom, and France. The top five institutions with the number of publications were Thomas Jefferson Univ, Mayo Clin, Hosp Special Surg, Rush Univ, and Cleveland Clin, while the top institutions for centrality were Thomas Jefferson Univ, Tel Aviv Univ, Univ Melbourne, and Rush Univ. The top five authors of the number of published articles were Parvizi J, Mont MA, Valle CJD, Chen AF, and Hanssen AD, and the top three authors for centrality were Parvizi J, Mont MA, and Valle CJD. The main journals were J Bone Joint Surg Am, Clin Orthop Relat R, J Arthroplasty, J Bone Joint Surg Br, and Int Orthop, and the top five keywords used were total knee arthroplasty, total hip arthroplasty, replacement, infection, and arthroplasty., Conclusions: There is a lack of studies with high-level evidence. The focus of related research in recent years has not changed significantly. More randomized controlled studies are required to provide evidence-based medicine.

Purpose: Previous studies have suggested that inflammatory bowel disease (IBD) occurs at higher rates among non-Hispanic Whites (NHWs) compared to other ethnicities; however, Hispanics as the largest minority in the United States remain underrepresented in IBD research and we hypothesize that they have similar rates of IBD. We examined the epidemiology, demographics, clinical presentation, and treatment of IBD in a predominantly Hispanic cohort in Los Angeles (LA) County., Methods: This was a retrospective cohort study based at Olive View-UCLA Medical Center, one of the three major safety-net hospitals in LA County. Electronic medical records from 2015 to 2018 were queried, and biopsy-proven cases of IBD (n = 170) were identified. Outcomes included the incidence and prevalence of IBD, disease distribution, treatment, and IBD-related surgery., Results: The incidence of IBD among Hispanics was 175 (95% confidence interval [CI] 127-240) and 113 (95% CI 62-200) for NHWs per 100,000 person-years. Prevalence of IBD per 100,000 people was 418 (95% CI 341-512) for Hispanics and 557 (95% CI 431-739) for NHWs. Notably, the proportion of Hispanic IBD patients with a history of smoking was 21.5% vs 50.8% in NHWs (p = 0.011). There were no significant differences between the two groups with regard to Montreal classification, pharmacotherapy, or IBD-related surgery., Conclusions: In one of the largest US studies of Hispanics with IBD, and the only one to have both clinical and histopathologic confirmation as inclusion criteria, we found the incidence and prevalence of IBD among Hispanics to be higher than previously recognized and comparable to NHWs. Additionally, Hispanic IBD patients had lower rates of smoking compared to NHWs.

Objectives : This study examines the relationship between sexual obligation and perceived stress among older adults in the United States. Methods : Using longitudinal data from three waves of the National Social Life, Health, and Aging Project (NSHAP), our sample included 1,477 partnered, sexually-active respondents aged 57 to 85 at the baseline survey. We estimated mixed-effects models to test how feelings of sexual obligation are related to changes in perceived stress score. Results : Sexual obligation was positively associated with perceived stress score. The positive relationship between sexual obligation and perceived stress score became stronger over the study period among older men, although it remained relatively stable among older women. Relationship quality only partially explains this relationship. Conclusions : Feeling more obligated to have sex had a significantly greater effect on older men's perceived level of stress over time than older women's. This association became marginally significant after relationship quality was controlled for, suggesting that relationship quality was a key explanatory factor for the gendered patterns in sexual obligation's linkage to stress. These results highlight the importance of understanding gendered sexuality among aging older adults within the context of their relationship. Clinical Implications : Older adults' feelings of sexual obligation can manifest in their daily stress experience. Clinicians seeking to lower older adults', in particular older men's, stress levels should address the context of their sexual life and if they feel obligated to have sex, along with the positive and negative aspects of their relationship, as these could elevate their stress levels over time.

Introduction: The aging population has been rapidly growing in the United States (U.S.). In line with this trend, older adults' mobility and transportation safety are an increasing priority. Many states have implemented driver licensure laws specific to older adults to limit driving among the elderly with driving skill decline. Evaluations of these laws have primarily focused on their safety benefits related to older drivers' fatal crash rate or injury rate. However, very few studies investigated licensure law effects on older adults' mobility., Objective: The objective of our study is to evaluate the association between older driver licensure laws and older adult daily traveling and passenger exposure., Methods: The 2003-2017 American Time Use Survey (ATUS) data were linked with statewide driver licensure law provisions. Adults aged 55-64 years were used as the reference group to control for the effects of non-licensure-law factors (e.g., economic trend). We used modified Poisson regressions with robust variance to estimate the relationships between licensure law provisions and the likelihoods of older men and women's daily traveling and passenger behaviors., Results: Laws requiring a vision test at in-person renewal were associated with increased daily traveling likelihood for women aged 75 years or older, primarily as a passenger. Laws requiring a knowledge test were related to a reduced daily overall traveling likelihood for women aged 75 years or older., Conclusions: In general, licensure law provisions are not strongly related to older adults' mobility, in particular for older male adults. Older female adults' daily mobility may be more likely to be influenced by the change of licensure laws than older male adults. The existence of gender-based disparities in responding to licensure laws requires future studies to account for the gender difference in estimating the effects of those traffic policies on older adults' mobility and traffic safety.

Objective: The quasi-induced exposure ( QIE ) method was developed to estimate relative crash risk exposure. A fundamental assumption often made in applying the QIE method is that not-at-fault drivers in clean two-vehicle crashes (i.e., one and only one driver is at-fault) represent the general exposure of the driving population to crash risk in the absence of the intervention being studied. Our study used direct field observation data to test the representativeness of the assumption for not-at-fault drivers obtained from the General Estimating System ( GES ) crash data, a national crash database in the United States., Methods: Distributions of driver gender, age group, vehicle type, and time-of-crash among the not-at-fault drivers in clean two-vehicle crashes ( D2 ) and the ones in two-or-more-vehicle crashes (i.e., all not-at-fault drivers) from the GES data were compared to the driving population estimated from the National Occupant Protection Use Survey ( NOPUS ), a national representative field observation survey., Results: The gender and vehicle-type distributions of D2 and all not-at-fault drivers were not statistically significantly different from the ones in the NOPUS data. Age-group distributions for both not-at-fault driving populations were marginally similar to the ones estimated from NOPUS., Conclusion: By system-wide comparisons on gender, age group, vehicle type, and period, our study suggests that the not-at-fault drivers in crash databases with crashes ranging from no injury to fatal injury reflect the general driving population when the collision occurred. Future study should evaluate the representativeness assumption among other important factors, including roadway type, road geometry, and level of urbanization. Our study supports the credibility of applying the QIE method in traffic safety research using crash databases of all crashes with all severities.

Background: Pork consumption, in particular fresh/lean-pork consumption, provides protein and other essential micronutrients that older adults need daily and may hold the potential to prevent functional limitations resulting from sub-optimal nutrition., Aim: Assess fresh/lean-pork intake in relation to functional limitations among older adults in the USA., Methods: Individual-level data came from the National Health and Nutrition Examination Survey (NHANES) 2005-2016 waves. Nineteen validated questions assessed five functional limitation domains: activities of daily living (ADLs); instrumental activities of daily living (IADLs); leisure and social activities (LSAs); lower extremity mobility (LEM); and general physical activities (GPAs). Logistic regressions were performed to examine pork, fresh-pork and fresh lean-pork intake in relation to functional limitations among NHANES older adults ( n = 6135)., Results: Approximately 21, 18 and 16% of older adults consumed pork, fresh pork and fresh lean pork, respectively. An increase in pork consumption by 1 oz-equivalent/day was associated with a reduced odds of ADLs by 12%, IADLs by 10% and any functional limitation by 7%. An increase in fresh-pork consumption by 1 oz-equivalent/day was associated with a reduced odds of ADLs by 13%, IADLs by 10%, GPAs by 8%, and any functional limitation by 8%. Similar effects were found for fresh lean-pork consumption on ADLs, IADLs, GPAs and any functional limitation., Conclusion: This study found some preliminary evidence linking fresh/lean-pork consumption to a reduced risk of functional limitations. Future studies with longitudinal/experimental designs are warranted to examine the influence of fresh/lean-pork consumption on functional limitations.

Objectives: Around the world, aging populations pose significant concerns regarding their community mobility and transportation safety. Most previous studies in the United States have focused on the associations between driver license renewal laws and crash outcomes among older adults (65 years and older). Few studies have evaluated the impact of driver license renewal laws on older adults' community mobility. This study aimed to identify the associations between driver license renewal laws and older males' and females' daily driving likelihood and duration., Method: The 2003-2017 American Time Use Survey data were merged with driver license renewal legislation using ages 55-64 to control for effects of non-licensure factors (e.g., gasoline price). Weighted Poisson and linear regression models were used to estimate the associations of various driver licensure provisions with older males' and females' daily driving likelihood and duration., Results: A shorter in-person renewal period and the presence of mandatory reporting laws for physicians were associated with a lower daily driving likelihood and shorter driving duration among females aged 75 years or older. The presence of mandatory reporting laws was also associated with reduced daily driving likelihood and duration for males aged 65-74 years., Discussion: Policymakers should be aware that males and females may respond differently to older driver licensure laws, which may require distinct interventions to preserve their mobility. Future studies should consider the gender disparities when examining the association between driver licensure policies and older adults' transportation safety and mobility., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The use of an appropriate driving exposure measure is essential to calculate traffic crash rates and risks. Commonly used exposure measures include driving distance and the number of licensed drivers. These measures have some limitations, including the unavailability of disaggregated estimates for consecutive years, low data quality, and the failure to represent the driving population when the crash occurred. However, the length of driving time, available annually from the American Time Use Survey (ATUS), can be disaggregated by age, gender, time-of-day, and day-of week, and addresses the temporal discontinuity limitation of driving distance on the United States (U.S.) national scale., Objectives: The objective of this study is to determine if the length of driving time as a driving exposure measure is comparable to driving distance by comparing distance-based and time-based fatal crash risk ratios by driver age category, gender, time-of-day, and day-of-week., Methods: The 2016-2017 National Household Travel Survey (NHTS) provided driving distance, and 2016-2017 Fatality Analysis Reporting System provided the number of drivers in fatal crashes. The distributions of driving distance and length of driving time by driver age category (16-24, 25-44, 45-64, and 65 years or older), gender, time-of-day, day-of-week were compared. Two negative binomial regression models were used to compute the distance-based and time-based fatal crash risk ratios., Results: The distributions of driving-distance were not different from the length-of-driving-time distributions by driver age category, gender, time-of-day, and day-of-week. Driving distance and the length of driving time provide similar fatal crash risk ratio estimates., Conclusions: The length of driving time can be an alternative to driving distance as a measure of driving exposure. The primary advantage of driving time over driving distance is that, starting from 2003, the disaggregated estimates of the length of driving time are available from ATUS over consecutive years, curtailing the discontinuity limitation of driving distance. Furthermore, the length of driving time is related to drivers' perceived risks about their driving conditions and as a result, may be a better exposure measure than driving distance in comparing crash risks between drivers whose likelihood of traveling in hazardous driving conditions (e.g., nighttime) varies substantially., Competing Interests: Declaration of Competing Interest The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Motor-vehicle crash is one of the leading causes of unintentional injury death in the United States. Previous studies focused on fatalities among drivers and front-seat passengers, with a limited number of studies examining rear-seat passenger fatalities. The objectives of this study were to assess trends in rear-seat passenger motor-vehicle fatalities in the United States from 2000 to 2016 and to identify demographic factors associated with being unrestrained among fatally injured rear-seat passengers., Methods: Rear-seat passenger fatality data were obtained from the Fatality Analysis Reporting System (FARS) database. The fatality rate ratios for overall rear-seat passengers and for different age and sex groups were determined by comparing fatality rates in 2000 and 2016 using random effects models. Risk ratios of being unrestrained for age and sex groups were obtained using general estimating equations., Results: Compared to 2000, the overall rear-seat passenger fatality rate in 2016 decreased by 44% (95% confidence interval [CI]: 39-49%). In particular, the fatality rate among rear-seat passengers decreased more in males than females, and passengers aged 14-19 years experienced a larger decline than all other age groups. Fatally injured male rear-seat passengers had a higher risk of being unrestrained (adjusted risk ratio: 1.06, 95% CI: 1.04-1.07) than their female counterparts, and both youngest (≤13 years) and oldest (65-85 years) passengers were less likely to be unrestrained than those aged 20-64 years., Conclusions: Overall, fatality rates among rear-seat passengers have declined, with differential degrees of improvement by age and sex. Practical Applications: Continued restraint use enforcement campaigns targeted at teenagers and males would further preserve them from fatal injuries and improve traffic safety for the overall population., (Copyright © 2020 National Safety Council and Elsevier Ltd. All rights reserved.)

Introduction: The quasi-induced exposure (QIE) method has been widely implemented into traffic safety research. One of the key assumptions of QIE method is that not-at-fault drivers represent the driving population at the time of a crash. Recent studies have validated the QIE representative assumption using not-at-fault drivers from three-or-more vehicle crashes (excluding the first not-at-fault drivers; D3&#95;other) as the reference group in single state crash databases. However, it is unclear if the QIE representativeness assumption is valid on a national scale and is a representative sample of driving population in the United States. The aims of this study were to assess the QIE representativeness assumption on a national scale and to evaluate if D3&#95;other could serve as a representative sample of the U.S. driving population., Method: Using the Fatality Analysis Reporting System (FARS) and the National Occupant Protection Use Survey (NOPUS), distributions of driver gender, age, vehicle type, time, and roadway type among the not-at-fault drivers in clean two-vehicle crashes, the first not-at-fault drivers in three-or-more-vehicle crashes, and the remaining not-at-fault drivers in three-or-more vehicle crashes were compared to the driver population observed in NOPUS., Results: The results showed that with respect to driver gender, vehicle type, time, and roadway type, drivers among D3&#95;other did not show statistical significant difference from NOPUS observations. The age distribution of D3&#95;other driver was not practically different to NOPUS observations., Conclusions: Overall, we conclude that D3&#95;other drivers in FARS represents the driving population at the time of the crash. Practical applications: Our study provides a solid foundation for future studies to utilize D3&#95;other as the reference group to validate the QIE representativeness assumption and has potential to increase the generalizability of future FARS studies., (Copyright © 2019 National Safety Council and Elsevier Ltd. All rights reserved.)

(1) Background: This study assessed the influence of beef consumption on nutrient intakes and diet quality among U.S. adults. (2) Methods: Nationally-representative sample ( n = 27,117) from 2005⁻2016 National Health and Nutrition Examination Survey was analyzed. First-difference estimator addressed confounding bias from time-invariant unobservables (e.g., eating habits, taste preferences) by using within-individual variations in beef consumption between 2 nonconsecutive 24 h dietary recalls. (3) Results: Approximately 54%, 39%, 12%, and 7% of U.S. adults consumed beef, lean beef, fresh beef, and fresh lean beef, respectively. Overall diet quality measured by the Health Eating Index-2015 (HEI-2015) score among beef, fresh beef, lean beef, and fresh lean beef consumers was lower than beef non-consumers. Regression analyses found that beef, fresh beef, lean beef, and fresh lean beef consumption was associated with higher daily intakes of total energy, protein, sodium, choline, iron, selenium, zinc, phosphorus, and multiple B vitamins. Beef, fresh beef, and lean beef consumption but not fresh lean beef consumption was associated with higher saturated fat intake. Beef consumption was not found to be associated with overall dietary quality measured by the HEI-2015 score. (4) Conclusions: Beef consumers may increase the intake of fresh and lean beef over total beef consumption to maximize the nutritional gains from beef portions while minimizing the resulting increases in energy, saturated fat, and sodium.

Objective: To investigate trends of motorcyclist fatalities and identify at-risk populations by motorcyclist demographics and crash characteristics. Methods: We used the Fatality Analysis Reporting System (FARS) database (2000-2016) to track fatality rate trends, which were quantified by using Poisson mixed-effects regression models comparing 2000-2001 and 2007-2008, as well as 2009-2010 and 2015-2016. Results: The overall fatality rate per 100,000 population increased from 2000 to 2016, defined by two trend lines-before and after the economic recession in 2008-2009. The overall fatality rate ratio between 2000-2001 and 2007-2008 was 1.60 [95% Confidence Interval (CI): 1.51-1.70], and between 2009-2010 and 2015-2016 was 1.09 (95% CI: 1.02-1.18). Fatality rates increased among all age groups, particularly for motorcyclists aged 60 and older. Those aged 18-29 had the highest fatality rates overall. Age-and-sex standardized state fatality rates were consistently highest in Wyoming, South Dakota, and South Carolina and lowest in Massachusetts, New York and New Jersey. Conclusion: Motorcycle fatality rates increased overall and across all age groups between 2000 and 2016. Fatalities for the oldest riders showed the steadiest increasing trends. Results highlight the continued public health burden of motorcyclist fatalities and, by extension, the importance of improving motorcycle safety.

Per oral endoscopic pyloromyotomy (POP) has emerged as an endoscopic intervention for refractory gastroparesis. Early experience in the United States showed exciting clinical response rate, reduced gastroparesis symptoms, improved quality of life, and decreased gastric-emptying time during midterm follow-up up to 18 months. One recent study also showed that the number of patient emergency room visits and hospitalizations decreased significantly after POP. The procedure is technically feasible and safe. As more data become available, it is important to identify patients who would benefit most from this novel procedure., (Copyright © 2018 Elsevier Inc. All rights reserved.)

A multidisciplinary team led by nursing leadership and physicians developed a plan to meet increasing demand and improve the patient experience in the ED without expanding the department's current resources. The approach included Lean tools and engaged frontline staff and physicians. Applying Lean management principles resulted in quicker service, improved patient satisfaction, increased capacity, and reduced resource utilization. Incorporating continuous daily management is necessary for sustainment of continuous improvement activities.

Computer-automated time-lapse analysis has been shown to improve embryo selection by providing quantitative and objective information to supplement traditional morphology. In this multi-centre study, the relationship between such computer-derived outputs (High, Medium, Low scores), embryo implantation and clinical pregnancy were examined. Data were collected from six clinics, including 205 patients whose embryos were imaged by the Eeva(TM) System. The Eeva scores were blinded and not considered during embryo selection. Embryos with High and Medium scores had significantly higher implantation rates than those with Low scores (37% and 35% versus 15%; P < 0.0001; P = 0.0004). Similar trends in implantation rates were observed in different IVF centres each using their own protocols. Further analysis revealed that patients with at least one High embryo transferred had significantly higher clinical pregnancy rates than those with only Low embryos transferred (51% versus 34%; P = 0.02), although patients' clinical characteristics across groups were comparable. These data, together with previous research and clinical studies, confirm that computer-automated Eeva scores provide valuable information, which may improve the clinical outcome of IVF procedures and ultimately facilitate the trend of single embryo selection., (Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

As more and more electronic clinical information is becoming easier to access for secondary uses such as clinical research, approaches that enable faster and more collaborative research while protecting patient privacy and confidentiality are becoming more important. Clinical text de-identification offers such advantages but is typically a tedious manual process. Automated Natural Language Processing (NLP) methods can alleviate this process, but their impact on subsequent uses of the automatically de-identified clinical narratives has only barely been investigated. In the context of a larger project to develop and investigate automated text de-identification for Veterans Health Administration (VHA) clinical notes, we studied the impact of automated text de-identification on clinical information in a stepwise manner. Our approach started with a high-level assessment of clinical notes informativeness and formatting, and ended with a detailed study of the overlap of select clinical information types and Protected Health Information (PHI). To investigate the informativeness (i.e., document type information, select clinical data types, and interpretation or conclusion) of VHA clinical notes, we used five different existing text de-identification systems. The informativeness was only minimally altered by these systems while formatting was only modified by one system. To examine the impact of de-identification on clinical information extraction, we compared counts of SNOMED-CT concepts found by an open source information extraction application in the original (i.e., not de-identified) version of a corpus of VHA clinical notes, and in the same corpus after de-identification. Only about 1.2-3% less SNOMED-CT concepts were found in de-identified versions of our corpus, and many of these concepts were PHI that was erroneously identified as clinical information. To study this impact in more details and assess how generalizable our findings were, we examined the overlap between select clinical information annotated in the 2010 i2b2 NLP challenge corpus and automatic PHI annotations from our best-of-breed VHA clinical text de-identification system (nicknamed 'BoB'). Overall, only 0.81% of the clinical information exactly overlapped with PHI, and 1.78% partly overlapped. We conclude that automated text de-identification's impact on clinical information is small, but not negligible, and that improved clinical acronyms and eponyms disambiguation could significantly reduce this impact., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To develop algorithms to improve efficiency of patient phenotyping using natural language processing (NLP) on text data. Of a large number of note titles available in our database, we sought to determine those with highest yield and precision for psychosocial concepts., Materials and Methods: From a database of over 1 billion documents from US Department of Veterans Affairs medical facilities, a random sample of 1500 documents from each of 218 enterprise note titles were chosen. Psychosocial concepts were extracted using a UIMA-AS-based NLP pipeline (v3NLP), using a lexicon of relevant concepts with negation and template format annotators. Human reviewers evaluated a subset of documents for false positives and sensitivity. High-yield documents were identified by hit rate and precision. Reasons for false positivity were characterized., Results: A total of 58 707 psychosocial concepts were identified from 316 355 documents for an overall hit rate of 0.2 concepts per document (median 0.1, range 1.6-0). Of 6031 concepts reviewed from a high-yield set of note titles, the overall precision for all concept categories was 80%, with variability among note titles and concept categories. Reasons for false positivity included templating, negation, context, and alternate meaning of words. The sensitivity of the NLP system was noted to be 49% (95% CI 43% to 55%)., Conclusions: Phenotyping using NLP need not involve the entire document corpus. Our methods offer a generalizable strategy for scaling NLP pipelines to large free text corpora with complex linguistic annotations in attempts to identify patients of a certain phenotype.

Information retrieval algorithms based on natural language processing (NLP) of the free text of medical records have been used to find documents of interest from databases. Homelessness is a high priority non-medical diagnosis that is noted in electronic medical records of Veterans in Veterans Affairs (VA) facilities. Using a human-reviewed reference standard corpus of clinical documents of Veterans with evidence of homelessness and those without, an open-source NLP tool (Automated Retrieval Console v2.0, ARC) was trained to classify documents. The best performing model based on document level work-flow performed well on a test set (Precision 94%, Recall 97%, F-Measure 96). Processing of a naïve set of 10,000 randomly selected documents from the VA using this best performing model yielded 463 documents flagged as positive, indicating a 4.7% prevalence of homelessness. Human review noted a precision of 70% for these flags resulting in an adjusted prevalence of homelessness of 3.3% which matches current VA estimates. Further refinements are underway to improve the performance. We demonstrate an effective and rapid lifecycle of using an off-the-shelf NLP tool for screening targets of interest from medical records.

Background: Acute sleep restriction has been shown to increase blood pressure and sympathetic nervous system activity., Methods: We investigated the relationships between sleep duration and hypertension among women whose sleep durations were self-reported in 1986 (n = 82,130) and 2000 (n = 71,658) in the Nurses' Health Study I (NHS-I) and in 2001 (n = 84,674) in the Nurses' Health Study II (NHS-II)., Results: After controlling for multiple risk factors in logistic regression models, the prevalence of hypertension was significantly higher among women in all 3 groups who slept ≤5 hours (odds ratio = 1.19, 95% confidence interval [CI] = 1.14-1.25) per night compared with 7 hours. In prospective analyses using Cox regression shorter sleep duration of ≤5 hours per night was significantly associated with a higher incidence of hypertension only in younger women (hazard ratio [HR] =1.20, 95% CI = 1.09-1.31 for those aged <50 years; HR = 1.11, 95% CI = 1.00-1.23 for those aged 50-59 years). In both prevalent and incident analyses, results were consistent with obesity acting as a partial mediator. Results were not consistent with diabetes or hypercholesterolemia acting as mediators or with shift work, snoring, menopause, or postmenopausal hormone therapy acting as effect modifiers., Conclusions: Sufficient sleep could represent a lifestyle practice worthy of investigation as an approach to reduce hypertension incidence and prevalence.

Quality measurement is an important issue for the United States Department of Veterans Affairs (VA). In this study, we piloted the use of an informatics tool, the Multithreaded Clinical Vocabulary Server (MCVS), which extracted automatically whether the VA Office of Quality and Performance measures of quality of care were met for the completion of discharge instructions for inpatients with congestive heart failure. We used a single document, the discharge instructions, from one section of the medical records for 152 patients and developed a reference standard using two independent reviewers to assess performance. When evaluated against the reference standard, MCVS achieved a sensitivity of 0.87, a specificity of 0.86, and a positive predictive value of 0.90. The automated process using the discharge instruction document worked effectively. The use of the MCVS tool for concept-based indexing resulted in mostly accurate data capture regarding quality measurement, but improvements are needed to further increase the accuracy of data extraction., (© 2012 National Association for Healthcare Quality.)

Objective: De-identification allows faster and more collaborative clinical research while protecting patient confidentiality. Clinical narrative de-identification is a tedious process that can be alleviated by automated natural language processing methods. The goal of this research is the development of an automated text de-identification system for Veterans Health Administration (VHA) clinical documents., Materials and Methods: We devised a novel stepwise hybrid approach designed to improve the current strategies used for text de-identification. The proposed system is based on a previous study on the best de-identification methods for VHA documents. This best-of-breed automated clinical text de-identification system (aka BoB) tackles the problem as two separate tasks: (1) maximize patient confidentiality by redacting as much protected health information (PHI) as possible; and (2) leave de-identified documents in a usable state preserving as much clinical information as possible., Results: We evaluated BoB with a manually annotated corpus of a variety of VHA clinical notes, as well as with the 2006 i2b2 de-identification challenge corpus. We present evaluations at the instance- and token-level, with detailed results for BoB's main components. Moreover, an existing text de-identification system was also included in our evaluation., Discussion: BoB's design efficiently takes advantage of the methods implemented in its pipeline, resulting in high sensitivity values (especially for sensitive PHI categories) and a limited number of false positives., Conclusions: Our system successfully addressed VHA clinical document de-identification, and its hybrid stepwise design demonstrates robustness and efficiency, prioritizing patient confidentiality while leaving most clinical information intact.

Objectives: Left ventricular ejection fraction (EF) is a key component of heart failure quality measures used within the Department of Veteran Affairs (VA). Our goals were to build a natural language processing system to extract the EF from free-text echocardiogram reports to automate measurement reporting and to validate the accuracy of the system using a comparison reference standard developed through human review. This project was a Translational Use Case Project within the VA Consortium for Healthcare Informatics., Materials and Methods: We created a set of regular expressions and rules to capture the EF using a random sample of 765 echocardiograms from seven VA medical centers. The documents were randomly assigned to two sets: a set of 275 used for training and a second set of 490 used for testing and validation. To establish the reference standard, two independent reviewers annotated all documents in both sets; a third reviewer adjudicated disagreements., Results: System test results for document-level classification of EF of <40% had a sensitivity (recall) of 98.41%, a specificity of 100%, a positive predictive value (precision) of 100%, and an F measure of 99.2%. System test results at the concept level had a sensitivity of 88.9% (95% CI 87.7% to 90.0%), a positive predictive value of 95% (95% CI 94.2% to 95.9%), and an F measure of 91.9% (95% CI 91.2% to 92.7%)., Discussion: An EF value of <40% can be accurately identified in VA echocardiogram reports., Conclusions: An automated information extraction system can be used to accurately extract EF for quality measurement.

Background: The increased use and adoption of Electronic Health Records (EHR) causes a tremendous growth in digital information useful for clinicians, researchers and many other operational purposes. However, this information is rich in Protected Health Information (PHI), which severely restricts its access and possible uses. A number of investigators have developed methods for automatically de-identifying EHR documents by removing PHI, as specified in the Health Insurance Portability and Accountability Act "Safe Harbor" method.This study focuses on the evaluation of existing automated text de-identification methods and tools, as applied to Veterans Health Administration (VHA) clinical documents, to assess which methods perform better with each category of PHI found in our clinical notes; and when new methods are needed to improve performance., Methods: We installed and evaluated five text de-identification systems "out-of-the-box" using a corpus of VHA clinical documents. The systems based on machine learning methods were trained with the 2006 i2b2 de-identification corpora and evaluated with our VHA corpus, and also evaluated with a ten-fold cross-validation experiment using our VHA corpus. We counted exact, partial, and fully contained matches with reference annotations, considering each PHI type separately, or only one unique 'PHI' category. Performance of the systems was assessed using recall (equivalent to sensitivity) and precision (equivalent to positive predictive value) metrics, as well as the F(2)-measure., Results: Overall, systems based on rules and pattern matching achieved better recall, and precision was always better with systems based on machine learning approaches. The highest "out-of-the-box" F(2)-measure was 67% for partial matches; the best precision and recall were 95% and 78%, respectively. Finally, the ten-fold cross validation experiment allowed for an increase of the F(2)-measure to 79% with partial matches., Conclusions: The "out-of-the-box" evaluation of text de-identification systems provided us with compelling insight about the best methods for de-identification of VHA clinical documents. The errors analysis demonstrated an important need for customization to PHI formats specific to VHA documents. This study informed the planning and development of a "best-of-breed" automatic de-identification application for VHA clinical text.