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In 2022, liver transplant activity continued to increase in the United States, with an all-time high of 9,527 transplants performed, representing a 52% increase over the past decade (2012-2022). Of these transplants, 8,924 (93.7%) were from deceased donors and 603 (6.3%) were from living donors. Liver transplant recipients were 94.5% adult and 5.5% pediatric. The overall size of the liver transplant waiting list contracted, with more patients being removed than added, although 10,548 adult patients still remained on the waiting list at the end of 2022. Alcohol-associated liver disease continued to be the leading diagnosis among both candidates and recipients, followed by metabolic dysfunction-associated steatohepatitis. Simultaneous liver-kidney transplant was the most common multiorgan combination, with 800 liver-kidney transplants performed in 2022; in addition, there were 303 new listings for kidney transplant via the safety net mechanism. Among adults added to the liver waiting list in 2021, 39.9% received a deceased donor liver transplant within 3 months; 45.7%, within 6 months; and 54.5%, within 1 year. Pretransplant mortality decreased to 12.3 deaths per 100 patient-years in 2022, although still 15.6% of removals from the waiting list were for death or being too sick for transplant. Graft and patient survival outcomes after deceased donor liver transplant improved, approximating pre-COVID-19 pandemic levels, with 5.1% mortality observed at 6 months; 6.8%, at 1 year; 12.7%, at 3 years; 19.8%, at 5 years; and 35.7%, at 10 years. Five-year graft and patient survival rates after living donor liver transplant exceeded those of deceased donor liver transplant. Candidates receiving model for end-stage liver disease exception points for hepatocellular carcinoma constituted 15.5% of transplants performed in 2022, with similar transplant rates and posttransplant outcomes compared to cases without hepatocellular carcinoma exception. In 2022, more pediatric liver transplant candidates were added to the waiting list and underwent transplant compared with either of the preceding 2 years, with an uptick in living donor liver transplant volume. Although pretransplant mortality has improved after the recent policy change prioritizing pediatric donors for pediatric recipients, still, in 2022, 50 children died or were removed from the waiting list for being too sick to undergo transplant. Posttransplant mortality among pediatric liver transplant recipients remained notable, with death occurring in 4.0% at 6 months, 6.0% at 1 year, 8.2% at 3 years, 9.8% at 5 years, and 13.9% at 10 years. Similar to adult living donor recipients, pediatric living donor recipients had better 5-year patient survival compared with deceased donor recipients., (Copyright © 2024. Published by Elsevier Inc.)

The year 2022 had continued successes and challenges for the field of kidney transplantation, as the community adapted to ongoing surges of the COVID-19 pandemic and broader geographic organ distribution. The total number of kidney transplants in the United States reached a record count of 26,309, driven by continued growth in deceased donor kidney transplants (DDKTs). The total number of candidates listed for DDKT rose slightly in 2022 but remained below 2019 listing levels, with 12.4% of candidates having been waiting 5 years or longer. Following the height of the COVID-19 pandemic, pretransplant mortality in 2022 declined across age, race and ethnicity, sex, and blood type groups. Pretransplant mortality continued to vary substantially by donation service area. The proportion of deceased donor kidneys recovered but not used for transplant (nonuse rate) rose to a high of 26.7% overall, with greater nonuse of biopsied kidneys (39.8%), kidneys from donors aged 55 years or older (54.7%), and kidneys with a kidney donor profile index (KDPI) of 85% or greater (71.3%). Nonuse of kidneys from donors who are hepatitis C virus (HCV) antibody positive rose to 30.2% but only slightly exceeded that of HCV antibody-negative donors. Disparities in access to living donor kidney transplant (LDKT) persist, especially for non-White and publicly insured patients. Delayed graft function continues an upward trend and occurred in 26.3% of adult kidney transplants in 2022. Five-year graft survival after LDKT compared with DDKT was 90.0% versus 81.4% for recipients aged 18-34 years and 80.8% versus 67.8% for recipients aged 65 years or older, respectively. The total number of pediatric kidney transplants performed in 2022 decreased to 705, its lowest point in the past decade; 502 (71.2%) were DDKTs and 203 (28.8%) were LDKTs. Among pediatric recipients, LDKT remains low, with continued racial disparities. The rate of DDKT among pediatric candidates has decreased by almost 25% since 2011. Congenital anomalies of the kidney and urinary tract remain the leading primary kidney disease diagnosis among pediatric candidates with a reported diagnosis. Most pediatric deceased donor recipients received a kidney from a donor with a KDPI of less than 35%. The rate of delayed graft function was 5.8% in 2022 and has been stable over the past decade. Long-term graft survival continues to improve, with superior outcomes for living donor transplant recipients., (Copyright © 2024. Published by Elsevier Inc.)

For the first time since the COVID-19 pandemic, the annual number of lung transplants performed in the United States increased. The year 2022, encompassed in this report, marks the last full calendar year where the Lung Allocation Score was used for ranking transplant candidates based on their estimated transplant benefit and donor lung allocation in the United States. In March 2023, a major change in transplant allocation policy occurred with the implementation of the Composite Allocation Score. Transplant rates have increased over the past decade, although there is variability among age, diagnosis, racial and ethnic, and blood groups. Over half of candidates received a lung transplant within 3 months of placement on the waiting list, with nearly 75% of candidates accessing transplant by 1 year. Pretransplant mortality rates remained stable, with approximately 13% of lung transplant candidates dying or being removed from the waiting list within a year of listing. Posttransplant survival remained stable; however, variability exists by age, diagnosis, and racial and ethnic groups., (Copyright © 2024. Published by Elsevier Inc.)

Background: In the United States, disparities in gestational age at birth by maternal race, ethnicity, and geography are theorized to be related, in part, to differences in individual- and neighborhood-level socioeconomic status (SES). Yet, few studies have examined their combined effects or whether associations vary by maternal race and ethnicity and United States Census region., Methods: We assembled data from 34 cohorts in the Environmental influences on Child Health Outcomes (ECHO) program representing 10,304 participants who delivered a liveborn, singleton infant from 2000 through 2019. We investigated the combined associations of maternal education level, neighborhood deprivation index (NDI), and Index of Concentration at the Extremes for racial residential segregation (ICE Race ) on gestational weeks at birth using linear regression and on gestational age at birth categories (preterm, early term, post-late term relative to full term) using multinomial logistic regression., Results: After adjustment for NDI and ICE Race , gestational weeks at birth was significantly lower among those with a high school diploma or less (-0.31 weeks, 95% CI: -0.44, -0.18), and some college (-0.30 weeks, 95% CI: -0.42, -0.18) relative to a master's degree or higher. Those with a high school diploma or less also had an increased odds of preterm (aOR 1.59, 95% CI: 1.20, 2.10) and early term birth (aOR 1.26, 95% CI: 1.05, 1.51). In adjusted models, NDI quartile and ICE Race quartile were not associated with gestational weeks at birth. However, higher NDI quartile (most deprived) associated with an increased odds of early term and late term birth, and lower ICE Race quartile (least racially privileged) associated with a decreased odds of late or post-term birth. When stratifying by region, gestational weeks at birth was lower among those with a high school education or less and some college only among those living in the Northeast or Midwest. When stratifying by race and ethnicity, gestational weeks at birth was lower among those with a high school education or less only for the non-Hispanic White category., Conclusion: In this study, maternal education was consistently associated with shorter duration of pregnancy and increased odds of preterm birth, including in models adjusted for NDI and ICE Race ., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Dunlop, Burjak, Dean, Alshawabkeh, Avalos, Aschner, Breton, Charifson, Cordero, Dabelea, D’Sa, Duarte, Elliott, Eick, Ferrara, Fichorova, Ganiban, Gern, Hedderson, Herbstman, Hipwell, Huddleston, Karagas, Karr, Kerver, Koinis-Mitchell, Lyall, Madan, Marsit, McEvoy, Meeker, Oken, O’Shea, Padula, Sathyanarayana, Schantz, Schmidt, Snowden, Stanford, Weiss, Wright, Wright, Zhang and McGrath.)

Background: Anticonvulsants are frequently prescribed, and exposures are commonly reported to American Association of Poison Control Centers sites. The purpose of this study was to describe the epidemiology of fatalities associated with oral anticonvulsant use, including patient demographics, specific medications, and the circumstances surrounding the deaths., Methods: This was a retrospective analysis of cases coded with oral anticonvulsants as a single substance and associated with a fatal outcome reported to the AAPCC National Poison Data System from 2000 to 2019. Polydrug ingestions and parenteral exposures were excluded. Patient characteristics, circumstances of the ingestion, specific medication, and chronicity of use were described., Results: We identified 126 cases that were classified as fatalities associated with single anticonvulsant use. The five most implicated anticonvulsants were carbamazepine, gabapentin, lamotrigine, phenytoin, and valproic acid. The majority (68.3%) of fatal cases were suicides. Phenytoin was implicated in eight (89%) adverse reactions and seven (70%) therapeutic errors. Valproic acid caused one (11.1%) adverse reaction and was associated with one (10%) therapeutic error. Three (75%) unintentional fatalities were caused by carbamazepine. The plurality (42.1%) of fatal ingestions occurred in acute-on-chronic use. An additional 40 (31.7%) were acute. Chronic use accounted for 15 (11.9%) of fatal exposures, including 5/10 of fatalities attributed to therapeutic error. The chronicity of medication use was unknown in 18 (14.3%) of fatal ingestions. Narrative summaries were available in 14 cases. Four of the patients presented to the emergency department with minimal symptoms. The other 10 had varying degrees of central nervous system (CNS) depression. Seizures were observed in six cases. Hyperammonemia was reported in seven of nine valproic acid ingestions., Conclusions: Fatalities associated with isolated anticonvulsant use are uncommon and typically occur following intentional overdoses. Fatal adverse reactions and therapeutic errors are most associated with phenytoin use and disproportionately affect elderly patients., Competing Interests: Declaration of Competing Interest None of the authors have any financial or intellectual conflicts of interest to disclose., (Copyright © 2023 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Background and Objectives: Racial/ethnic and socioeconomic disparities are reported in sepsis, with increased mortality for minority and low socioeconomic status groups; however, these studies rely on billing codes that are imprecise in identifying sepsis. Using a previously validated algorithm to detect pediatric sepsis using electronic clinical data, we hypothesized that racial/ethnic and socioeconomic status disparities would be evident in this group., Methods: We performed a retrospective study from a large, quaternary academic center, including sepsis episodes from January 20, 2011, to May 20, 2021, identified by an algorithm indicative of bacterial infection with organ dysfunction (cardiac, respiratory, renal, or hematologic). Multivariable logistic regression was used to measure association of race/ethnicity, insurance status, and social disorganization index, with the primary outcome of mortality, adjusting for age, sex, complex chronic conditions, organ dysfunction on day 1, source of admission, and time to hospital. Secondary outcomes were ICU admission, readmission, organ dysfunction-free days, and sepsis therapies., Results: Among 4532 patient episodes, the mortality rate was 9.7%. There was no difference in adjusted odds of mortality on the basis of race/ethnicity, insurance status, or social disorganization. There was no significant association between our predictors and ICU admission. Hispanic patients and publicly insured patients were more likely to be readmitted within 1 year (Hispanic odds ratio 1.28 [1.06-1.5]; public odds ratio 1.19 [1.05-1.35])., Conclusions: Previously described disparities were not observed when using electronic clinical data to identify sepsis; however, data were only single center. There were significantly higher readmissions in patients who were publicly insured or identified as Hispanic or Latino, which require further investigation., (Copyright © 2023 by the American Academy of Pediatrics.)

The year 2021 marked both successes and challenges for the field of kidney transplantation, in the context of the ongoing COVID-19 pandemic and broader geographic organ distribution. The total number of kidney transplants in the United States reached a record count of 25,487, driven by growth in deceased donor kidney transplants. The total number of candidates listed for deceased donor kidney transplant rose slightly in 2021 but remained below 2019 listing levels, with nearly 10% of candidates having been waiting 5 years or longer. Pretransplant mortality declined slightly among candidates of Black, Hispanic, and other races, in parallel with increasing numbers of Black and Hispanic transplant recipients. In the context of broader organ sharing, there is growing disparity in pretransplant mortality among non-metropolitan compared with metropolitan residents. The proportion of deceased donor kidneys recovered but not used for transplant (nonuse rate) rose to a high of 24.6% overall, with greater nonuse among biopsied kidneys (35.9%), kidneys from donors aged 55 years or older (51.1%), and kidneys with kidney donor profile index (KDPI) of 85% or greater (66.6%). Nonuse of kidneys from donors who are hepatitis C virus (HCV) antibody positive only slightly exceeded that of HCV antibody-negative donors. Disparities in access to living donor kidney transplant persists, especially for non-White and publicly insured patients. Delayed graft function continues an upward trend and occurred in 24% of adult kidney transplants in 2021. Five-year graft survival after living compared with deceased donor transplant was 88.6% versus 80.7% for recipients aged 18-34 years, and 82.1% versus 68.0% for recipients aged 65 years or older. The total number of pediatric kidney transplants performed increased to 820 in 2021, the highest number since 2010. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities. The rate of deceased donor transplants among pediatric candidates recovered in 2021 from a low in 2020. Congenital anomalies of the kidney and urinary tract remain the leading primary kidney disease diagnosis among pediatric candidates. Most pediatric deceased donor recipients receive a kidney from a donor with KDPI less than 35%. Graft survival continues to improve, with superior outcomes for living donor transplant recipients., (Copyright © 2023. Published by Elsevier Inc.)

In 2021, liver transplant volume continued to grow, with a record 9,234 transplants performed in the United States, 8,665 (93.8%) from deceased donors and 569 (6.2%) from living donors. There were 8,733 (94.6%) adult and 501 (5.4%) pediatric liver transplant recipients. An increase in the number of deceased donor livers corresponded to an increase in the overall transplant rate and shorter waiting times, although still 10.0% of livers that were recovered were not transplanted. Alcohol-associated liver disease was the leading indication for both waitlist registration and liver transplant in adults, outpacing nonalcoholic steatohepatitis, while biliary atresia remained the leading indication for children. Related to allocation policy changes implemented in 2019, the proportion of liver transplants performed for hepatocellular carcinoma has decreased. Among adult candidates listed for liver transplant in 2020, 37.7% received a deceased donor liver transplant within 3 months, 43.8% within 6 months, and 53.3% within 1 year. Pretransplant mortality improved for children following implementation of acuity circle-based distribution. Short-term graft and patient survival outcomes up to 1 year worsened for adult deceased and living donor liver transplant recipients, which is a reversal of previous trends and coincided with the onset of the COVID-19 pandemic in early 2020. Longer-term outcomes among adult deceased donor liver transplant recipients were unaffected, with overall posttransplant mortality rates of 13.3% at 3 years, 18.6% at 5 years, and 35.9% at 10 years. Pretransplant mortality improved for children following implementation of acuity circle-based distribution and prioritization of pediatric donors to pediatric recipients in 2020. Pediatric living donor recipients had superior graft and patient survival outcomes compared with deceased donor recipients at all time points., (Copyright © 2023. Published by Elsevier Inc.)

Despite changes brought about by the 2010 Affordable Care Act (ACA), millions of individuals are still unable to access health care in the United States. Mobile medical clinics have been an invisible force of care delivery for vulnerable and marginalized populations for decades; however, little is known about their impact post-ACA. Guided by the Anderson Behavioral Model, the purpose of this article was to review and critique the state of the current literature about mobile medical clinics in the United States since 2010. Following Whittemore and Knafl's integrative review methodology, the search was conducted in 6 databases and delivered 1934 results; 341 articles were removed as duplicates. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, 2 independent reviewers screened and adjudicated the remaining titles, abstracts, and full-texts, yielding 12 articles in the final review. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the quality of the articles. Studies revealed variation in quality, study design, and location; and diversity of chronic diseases and populations addressed (eg, children with asthma, complementary alternative medicine use with children, adults with diabetes and hypertension, patients with chronic disease with an emphasis on the patient experience, utilization patterns in migrant farmers). Mobile medical clinics provide care for the prevention, treatment, and management of chronic illness and their wide geographic spread confirms their broad use across the United States. They provide a return on investment through emergency room avoidance, decreasing hospital length of stay, and improving chronic disease management.

The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. In addition, the model has the potential to negatively affect small and independent dialysis organizations disproportionately. It incentivizes home dialysis over transplant and promotes development of new home dialysis programs, rewards achievement over improvement, and places an excessive burden on small and independent dialysis organizations. Advantages of the program include the focus on self-care as an acceptable alternative to home dialysis for some patients and the potential for some organizations to make improvements in care with increased reimbursements. The authors hope that the Centers for Medicare and Medicaid Services will address many of these concerns in updated rulemaking and guidance., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

WHAT IS KNOWN ON THE SUBJECT?: There is very limited literature on the health of Middle Eastern immigrants in the United States, and the available studies were mostly conducted on small convenient samples in local communities. There is also a need to understand changes in the rates of serious psychological distress (SPD) during the 15 years after 2001, as there were negative effects on Arabs' health since the September 2001 aftermath. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: The study examined the rates of SPD, the risk of SPD and its associated factors in a national sample of Middle Eastern immigrants in the United States from 2001 to 2015. The study found that serious psychological distress rate was high among Middle Eastern immigrants. Being a female and having obesity were associated with a higher risk of reporting serious psychological distress among this population. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These outcomes necessitate mental health nursing interventions that provide culturally sensitive mental health care to immigrants For example, developing community-based prevention programmes is required to address risk factors of psychological distress and to increase awareness about psychological distress among Middle Eastern immigrants. ABSTRACT: Introduction While Middle Eastern immigrants are a fast-growing population in the United States, there is very limited literature on their mental health. Most of the available studies were conducted on small convenient samples in local communities. Aims To examine rates of serious psychological distress (SPD) and its associated factors among Middle Eastern immigrants in the United States, compared with US-born, non-Hispanic Whites. Methods Data from the National Health Interview Survey (NHIS) from 2001 to 2015 were analysed. The survey included 1,246 Middle Eastern immigrants and 232,392 US-born, non-Hispanic Whites. SPD was measured by the Kessler-6 psychological distress scale. Survey analysis procedures, sampling weights and variance estimates were conducted. Descriptive statistics and regression analyses were employed to examine differences and factors associated with SPD. Results SPD rate was the highest among Middle Eastern immigrants (5.99%) between 2006 and 2010. Among Middle Eastern immigrants, being female and obese were significantly associated with a higher risk of SPD. Discussion Middle Eastern immigrants in the United States suffered high rates of SPD. Gender and obesity were factors associated with SPD risk. Implications These outcomes indicate the need for mental health nursing interventions that provide culturally sensitive mental health care to immigrants, such as developing community-based prevention programmes., (© 2020 John Wiley & Sons Ltd.)

Importance: Merkel cell carcinoma is an aggressive, cutaneous, neuroendocrine cancer that is increasing in incidence. Understanding why the incidence of Merkel cell carcinoma is increasing through underlying factors, such as age effects, calendar period of diagnosis effects, and birth cohort effects, can help guide resource allocation and design of screening programs., Objectives: To evaluate the associations of patient age, calendar period of diagnosis, and birth cohort with the increasing incidence of Merkel cell carcinoma and to provide new incidence projections to 2030., Design, Setting, and Participants: A cross-sectional retrospective study with age-period-cohort analysis and incidence projection modeling using data from the Surveillance, Epidemiology, and End Results Program database of 9 registries from 1987 to 2016 was conducted among 3720 patients with Merkel cell carcinoma. Statistical analysis was conducted from October 20, 2019, to July 29, 2020., Exposures: Age effects (ie, physiology), period of diagnosis effects (ie, changes in diagnostics and clinical awareness), and birth cohort effects (ie, environmental risk factors) over time were assessed., Main Outcomes and Measures: Incidence rates of Merkel cell carcinoma., Results: Among the 3720 patients in the study (2200 male patients [59.1%]; median age, 77 years [interquartile range, 68-84 years]), during the period from 2012 to 2016, the age-adjusted Merkel cell carcinoma incidence rate was 0.66 per 100 000 (95% CI, 0.62-0.70), which represented a 3.5-times (95% CI, 3.0-4.2) increase from 1987 to 1991. The incidence of Merkel cell carcinoma increased with patient age across calendar periods and birth cohorts; the highest incidence rate was observed for those aged 85 years or older, with an age-adjusted rate from 2012 to 2016 of 14.6 per 100 000 for men and 5.5 per 100 000 for women. Although the birth cohort effect has continued to increase over time, the calendar period of diagnosis effect has started to plateau. It is projected that there will be 3023 new cases of Merkel cell carcinoma in 2020 and 5130 new cases in 2030, increased from an estimated 1933 cases in 2010., Conclusions and Relevance: The slowing down of the period effect (ie, changes in diagnostics and awareness) found in this longitudinal cohort study suggests that part of the initial increased incidence of Merkel cell carcinoma was associated with increased detection. However, the projected increase in incidence rate is likely associated with the aging population and increasing risk factor exposure in more recent birth cohorts.

Background: Prasugrel is a potent thienopyridine that may be preferentially used in younger patients with lower bleeding risk., Objective: We compared prasugrel use and outcomes by age from the PROMETHEUS study. We also assessed age-related trends in treatment effects with prasugrel versus clopidogrel., Methods: PROMETHEUS was a multicenter acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) registry. We compared patients in age tertiles (T1 < 60 years, T2 60-70 years, T3 > 70 years). Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke or unplanned revascularization. Data were adjusted using multivariable Cox regression for age-related risks and propensity score stratification for thienopyridine effects., Results: The study included 19,914 patients: 7045 (35.0%) in T1, 6489 (33.0%) in T2 and 6380 (32.0%) in T3. Prasugrel use decreased from T1 to T3 (29.2% vs. 23.5% vs. 7.5%, p < 0.001). Crude 1-year MACE rates were highest in T3 (17.4% vs. 16.8% vs. 22.7%, p < 0.001), but adjusted risk was similar between the groups (p-trend 0.52). Conversely, crude incidence (2.8% vs. 3.8% vs. 6.9%, p < 0.001) and adjusted bleeding risk were highest in T3 (HR 1.24, 95% CI 0.99-1.55 in T2; HR 1.83, 95% CI 1.46-2.30 in T3; p-trend < 0.001; reference = T1). Treatment effects with prasugrel versus clopidogrel did not demonstrate age-related trends for MACE (p-trend = 0.91) or bleeding (p-trend = 0.28)., Conclusions: Age is a strong determinant of clinical risk as well as prasugrel prescription in ACS PCI with much lower use among older patients. Prasugrel did not have a differential treatment effect by age for MACE or bleeding. Frequency of prasugrel use and age-related temporal risks of all-cause death and bleeding after ACS PCI.

Objective: To review current musculoskeletal (MSK) job market postings to define the listed requirements for practice in order to provide insight to guide residents pursuing fellowship training in MSK radiology to best meet the needs of potential future employers., Methods: Utilizing the ACR (American College of Radiology) Career Center, a review of the ACR job postings began 6/1/2018 focusing on jobs labeled as musculoskeletal (MSK) subspecialty. E-mail notifications from the career center were reviewed, and jobs were tracked prospectively for 1 year. Data was collected regarding the number of positions, the location, the practice type, and required skills both within musculoskeletal radiology and within the remainder of the radiology subspecialties., Results: 456 postings met the inclusion criteria. Approximately 19% were for a dedicated MSK radiologist, 25% sought a combination of MSK and a general skill set, and 56% were specifically for a general radiologist position. Approximately 29% of jobs require some combination of mammography and/or light interventional radiology (IR)., Discussion: Our results indicate that majority of job postings for musculoskeletal radiology require a practice that is not specifically limited to MSK, mirroring trends in other radiology subspecialties. Radiology trainees and program directors should be aware of the needs being demanded by the job market to help guide trainees to individualize their training to best meet the needs of their future employment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The aim of the study was to examine self-rated health (SRH) of Middle Eastern immigrants in the US compared with US-born non-Hispanic whites and to examine factors associated with fair/poor SRH among Middle Eastern immigrants in the US., Study Design: We used a cross-sectional design to analyze the National Health Interview Survey from 2001 to 2015., Methods: Secondary survey analysis procedures were conducted using the SAS program, with a total of 3,966 Middle Eastern and 731,285 US-born non-Hispanic whites. Descriptive statistics and regression analyses were used., Results: Middle Eastern immigrants had significantly higher rates of fair/poor SRH than US-born whites across the three survey waves. Reporting symptoms of serious psychological distress, older age (60+ years), current alcohol-drinking status, and having a family member with disability were the factors associated significantly with higher odds of reporting fair/poor SRH in Middle Eastern immigrants, whereas education was a protecting factor of fair/poor SRH., Conclusions: This study indicates that Middle Eastern immigrants are one of the US immigrant populations that report poor health status, which reveals the need for health policy attention to reduce health disparities., (Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Purpose: A systematic review was conducted to understand self-rated health (SRH) of Arab immigrants in the United States (U.S.)., Background: Arab immigrants are one of the fastest growing populations in the United States. There is some evidence that Arab immigrants face health issues including low SRH. However, no study has been done to synthesize research on SRH of Arab immigrants., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide this review. A search was conducted on seven databases., Results: Six studies met the systematic review criteria. The available evidence indicated that rates of fair/poor SRH among Arab immigrants ranged between 4.66% and 41%. Arabic-speaking immigrants, women, older immigrants, and socioeconomically disadvantaged immigrants had the highest rates of fair/poor SRH., Implications: Health care providers need to assess patient's SRH and identify barriers to optimal health and health practices related to SRH of Arab immigrants., (© 2019 Wiley Periodicals, Inc.)

Objective: To investigate the use of prasugrel after percutaneous coronary intervention (PCI) in African American (AA) patients presenting with acute coronary syndrome (ACS)., Background: AA patients are at higher risk for adverse cardiovascular outcomes after PCI and may derive greater benefit from the use of potent antiplatelet therapy., Methods: Using the multicenter PROMETHEUS observational registry of ACS patients treated with PCI, we grouped patients by self-reported AA or other races. Clinical outcomes at 90-day and 1-year included non-fatal myocardial infarction (MI), major adverse cardiac events (composite of death, MI, stroke, or unplanned revascularization) and major bleeding., Results: The study population included 2,125 (11%) AA and 17,707 (89%) non-AA patients. AA patients were younger, more often female (46% vs. 30%) with a higher prevalence of diabetes mellitus, chronic kidney disease, and prior coronary intervention than non-AA patients. Although AA patients more often presented with troponin (+) ACS, prasugrel use was much less common in AA vs. non-AA (11.9% vs. 21.4%, respectively, P = 0.001). In addition, the use of prasugrel increased with the severity of presentation in non-AA but not in AA patients. Multivariable logistic regression showed AA race was an independent predictor of reduced use of prasugrel (0.42 [0.37-0.49], P < 0.0001). AA race was independently associated with a significantly higher risk of MI at 90-days and 1 year after PCI., Conclusions: Despite higher risk clinical presentation and worse 1-year ischemic outcomes, AA race was an independent predictor of lower prasugrel prescription in a contemporary population of ACS patients undergoing PCI., (© 2019 Wiley Periodicals, Inc.)

We sought to investigate the utilization of prasugrel and its association with outcomes relative to clopidogrel in three typical subgroups of ACS in a real-world setting. Prasugrel is superior to clopidogrel for reducing risk of ischemic events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), but is associated with an increased risk of bleeding complications. PROMETHEUS was a retrospective multicenter observational study of 19,913 ACS patients undergoing PCI from 8 centers in the United States between 2010 and 2013. Major adverse cardiovascular events (MACE) were defined as a composite of all-cause mortality, myocardial infarction, stroke or unplanned revascularization. The study cohort included 3285 (16.5%) patients with ST-segment elevation myocardial infarction (STEMI), 5412 (27.2%) patients with NSTEMI and 11,216 (56.3%) patients with unstable angina (UA). The frequency of prasugrel use at discharge was highest in STEMI and lowest in UA patients, 27.3% versus 22.2% versus 18.9% (p < 0.001). Use of prasugrel vs clopidogrel was associated with a lower rate of MACE in STEMI, NSTEMI, or UA at 1 year, but the differences were attenuated for all groups except for patients with UA (adjusted HR 0.81, 95% CI 0.69-0.94, p = 0.006) after propensity adjusted analysis. After adjustment, there was no difference in bleeding risk between prasugrel and clopidogrel for all groups at 1 year. STEMI patients were more likely to receive prasugrel compared to NSTEMI and UA patients. Prasugrel was associated with reduced adverse outcomes compared with clopidogrel in unadjusted analyses, findings that were largely attenuated upon adjustment and suggest preferential use of prasugrel in low vs high risk patients.

Objectives: To investigate the prevalence, predictors and associations between guideline-directed medical therapy (GDMT) and clinical outcomes in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI) from eight academic centers in the United States., Background: Evidence for GDMT in patients with AMI comes from randomized controlled trials. The use of GDMT in clinical practice is unknown in this setting., Methods: PROMETHEUS is a multicenter observational registry comprising 19,914 patients with acute coronary syndrome (ACS) undergoing PCI. Patients with AMI were divided into two groups based on the prescription of GDMT or not (non-GDMT) at discharge. GDMT was defined according to American College of Cardiology/American Heart Association (ACC/AHA) class I recommendations, specifically, dual antiplatelet therapy, statin and beta-blocker for all AMI patients, and additional ACEI/ARB in patients with left ventricular ejection fraction (LVEF) less than 40%, hypertension, diabetes mellitus (DM) or chronic kidney disease (CKD). The primary endpoint was major adverse cardiovascular events (MACE) defined as a composite of all-cause death, MI, stroke or unplanned target vessel revascularization (TVR) at 1 year., Results: Out of 4,834 patients with AMI, 3,356 (69.4%) patients were discharged on GDMT. Patients receiving GDMT were more often younger and male. Compared with non-GDMT patients, GDMT patients had a significantly lower frequency of comorbidities. Predictors of greater GDMT prescription at discharge were ST-segment elevation myocardial infarction (STEMI), and increased body mass index (BMI), whereas hypertension, prior PCI, anemia and CKD were associated with less GDMT prescription. At 1 year, the use of GDMT was associated with a significantly lower incidence of MACE (13.7% vs. 22.5%; adjusted HR 0.68; 95%CI 0.58-0.80; P < 0.001), death (3.7% vs. 9.4%; adjusted HR 0.61; 95%CI 0.46-0.80; P < 0.001), and unplanned TVR (8.4% vs. 11.3%; adjusted HR 0.76; 95%CI 0.61-0.96; P = 0.020). However, there were no significant differences in the incidence of MI (4.3% vs. 7.0%; adjusted HR 0.75; 95%CI 0.56-1.01; P = 0.056), stroke (1.5% vs. 2.0%; adjusted HR 0.79; 95%CI 0.47-1.34; P = 0.384) between the two groups., Conclusion: In a contemporary practice setting in the United States, GDMT was utilized in just over two-thirds of AMI patients undergoing PCI. Predictors of GDMT prescription at discharge included STEMI, BMI and absence of hypertension, CKD, anemia or prior PCI. Use of GDMT was associated with significantly lower risk of 1-year MACE and mortality., (© 2018 Wiley Periodicals, Inc.)

Background: Clinical trial data studies suggest superiority of prasugrel over clopidogrel in patients with diabetes. However, the use, safety and efficacy profile of prasugrel in unselected diabetic patients presenting with acute coronary syndromes (ACS) remain unclear., Methods: PROMETHEUS was a prospective multicenter observational study of 19,919 ACS PCI patients enrolled between 2010 and 2013. The primary endpoint was 90-day major adverse cardiovascular events (MACE), comprising all-cause death, myocardial infarction, stroke or unplanned revascularization. The safety endpoint was bleeding requiring hospitalization., Results: We identified 7580 (38%) subjects with and 12,329 (62%) without diabetes. Diabetic patients were older and had significantly higher rates of cardiovascular risk factors. However, they were less likely to receive prasugrel (18.2% vs. 21.7%). Use of prasugrel did not increase with the severity of clinical presentation in diabetics, whereas, among non-diabetics, prescription of prasugrel was higher in NSTEMI and STEMI compared to unstable angina. The 90-day and 1-year adjusted risk of MACE was greater in diabetics (at 1 year: 22.7% vs. 16.5%; HR 1.22 [1.14-1.33], p < 0.001). At 1 year, the risk of bleeding was also higher in diabetics (4.9% vs. 4.1%, HR 1.19 [1.01-1.39], p = 0.035). After multivariable adjustment, use of prasugrel was associated with a lower risk of death in diabetic patients both at 90 days and 1 year., Conclusions: Use of prasugrel in diabetic patients with PCI-treated ACS was lower than in non-diabetics despite their high-risk profile and the severity of their clinical presentation. In diabetics, prasugrel was associated with a lower adjusted risk of 90-day death compared with clopidogrel., (Copyright © 2018 Elsevier B.V. All rights reserved.)

During recent months, the Centers for Disease Control and Prevention (CDC) announced the occurrence of three major biosafety incidents, raising serious concern about biosafety and biosecurity guideline implementation in the most prestigious agencies in the United States: the CDC, the National Institutes of Health (NIH) and the Federal Drug Administration (FDA). These lapses included: a) the mishandling of Bacillus anthracis spores potentially exposing dozens of employees to anthrax; b) the shipment of low pathogenic influenza virus unknowingly cross-contaminated with a highly pathogenic strain; and c) an inventory lapse of hundreds of samples of biological agents, including six vials of variola virus kept in a cold storage room for decades, unnoticed. In this review we present the published data on these events, report the CDC inquiry's main findings, and discuss the key lessons to be learnt to ensure safer scientific practice in biomedical and microbiological service and research laboratories.

Public health obesity prevention experts have recently emphasized a policy systems and environmental change approach. Absent, however, are studies describing how practitioners transition from policy adoption to implementation. In the realm of food policy, financing programs to incentivize healthy food retail development in communities classified as "underserved" are underway at the local, state, and national levels. Implementing these policies requires a clear definition of eligibility for program applicants and policy administrators. This article outlines a methodology to establish eligibility for healthy food financing programs by describing the work of The Food Trust to coadminister programs in 3 distinct regions. To determine program eligibility, qualitative assessments of community fit are needed and national data sources must be locally verified. Our findings have broad implications for programs that assess need to allocate limited public/private financing resources.

Background: Bevacizumab is the first in its class, vascular endothelial growth factor (VEGF) inhibitor that was initially approved by the US FDA in 2004 for the treatment of metastatic colon cancer and other solid tumors. Preapproval clinical trials, particularly for oncology drugs, are limited in their ability to detect certain adverse effects and, therefore, the FDA and pharmaceutical sponsors collect and monitor reports of adverse events (AEs) following approval., Objective: The purpose of this study was to screen the FDA's Adverse Event Reporting System (AERS) database for novel AEs that may be attributed to bevacizumab., Methods: The FDA AERS database was used to identify all AE reports for bevacizumab from February 2004 to September 2009. Disproportionality analysis was conducted for bevacizumab against all other drugs in the background by setting statistical significance at proportional reporting ratio (PRR) ≥2, observed case count ≥3 and chi-square ≥4. Subsequent clinical evaluation was performed to determine the clinical relevance of the findings and to group related events., Results: A total of 523 Preferred Terms (PTs) were disproportionally reported; following clinical review 63 (12%) were found to be both unlabelled and of clinical importance. These PTs were grouped into 15 clinical disorder groups. Among the clinical disorders, electrolyte abnormalities had the greatest number of reports (n = 426) followed by cardiovascular events (n = 421), gastrointestinal events (n = 345), nervous system disorders (n = 106) and pneumonitis (n = 96). On sensitivity analysis, a number of clinically important unlabelled disorders, such as necrotizing fasciitis, vessel wall disorders, arrhythmia and conduction disorder and autoimmune thrombocytopenia still met the statistical significance criteria., Conclusions: During the study period, out of 12 010 AE reports mentioning bevacizumab, it was listed as the suspect drug in 94.2% of the reports. Our disproportionality analysis identified many events that are already recognized as AEs of bevacizumab, but it also identified a number of clinically important unlabelled terms, which if confirmed in future studies would have potential implications for use of bevacizumab in clinical practice.

Background: Historically, four divisions of the National Institute of Allergy and Infectious Diseases (NIAID) that manage clinical trials and oversee data and safety monitoring have operated fairly autonomously with respect to their approaches to Data and Safety Monitoring Board (DSMB) operations. We recognized the need for a revised policy on DSMB operations in an effort to encourage greater harmonization of procedures across the four divisions., Purpose: The purpose of this article is to describe the considerations that motivated the development of the new policy, summarize current DSMB policies and ongoing harmonization efforts across the four divisions, and offer some recommendations for DSMB operations in the hope that other organizations may benefit from our experience., Methods: From 2005 to 2009, a working group undertook a review of DSMB responsibilities, policies, and operations. We analyzed and summarized the final policy document that the working group produced, gathered data describing current DSMB activities, and developed a tabular, cross-sectional overview highlighting how divisions are harmonizing their DSMB operations., Results: In 2010, there were 44 DSMBs in NIAID monitoring 169 protocols, and those DSMBs conducted 209 reviews of the protocols. Review and analysis of DSMB practices across the four divisions have led to recommendations for efficient and successful DSMB operations: adopt an inclusive approach, whereby the trial investigators assist in the process of forming and utilizing DSMBs; structures other than DSMBs can often provide many of the features of DSMBs but with greater flexibility in membership, access to interim data, and scheduling; the trial protocol should specify what safety and other concerns should trigger a DSMB review and what data should be included in prespecified reviews; present data in thoughtful and user-friendly ways that answer specific questions; allow sufficient time to plan for working with the DSMB., Limitations: We recognize that NIAID's specific circumstances and DSMB policy may not apply to the operation of DSMBs in every organization. Nevertheless, we believe that useful lessons can be learned from our experiences and efforts toward harmonization., Conclusions: Homogeneity in DSMB operations and management has appeal as a matter of organizational policy and efficiency. Some limited flexibility, as long as it honors fundamental principles of independence, confidentiality of interim trial results, and clear lines of reporting and approval, may be appropriate on occasion. NIAID's 2009 institute-level policy established a collective understanding of the important contribution that DSMBs make to the responsible conduct of clinical trials. Thinking will continue to evolve, leading to further policy refinements and the continued assurance of patient safety in our clinical trials.

The objective of this study is to explore risk factors associated with overweight and high blood pressure in Chinese American children. Students and their parents were recruited from Chinese language schools in the San Francisco Bay Area. Data were collected on 67 children and their mothers, and included children's weight, height, waist and hip circumferences, blood pressure, level of physical activity, dietary intake, usual food choice, knowledge about nutrition and physical activity, and self-efficacy regarding diet and physical activity. Mothers completed questionnaires on demographic data and acculturation. About 46% of children had a body mass index exceeding the 85th percentile. Lower level of maternal acculturation is a risk factor for overweight and higher waist to hip ratio. Children's unhealthy food choices were predictive of high body mass index and high systolic blood pressure, whereas older age and less physical activity in children were predictors of high diastolic blood pressure. Developing culturally sensitive and developmentally appropriate interventions to reduce overweight and high blood pressure is critical to reduce health disparities among minority children.

This article provides an update regarding individual state legislation for advanced practice psychiatric nursing, building on previous briefings. Specific attention is given to independent versus collaborative practice regulations, titling, and prescriptive authority. There is review of contemporary issues and focus on scope and standards of practice, workforce data, certification, and advanced practice regulatory models.

Introduction: Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment., Objective: To determine if there is a relationship between a paramedic's degree of occupational/organizational commitment and the following: (1) levels of education and (2) type of employment., Methods: This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associate's or bachelor's degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non-fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P < .05 was considered significant., Results: For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non-fire-based employees., Conclusion: Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored.

Objectives: The purpose of this study was to evaluate a restraint training module for paramedic students. The hypotheses were that the effect of an hour-long restraint training module on paramedic students would (1) improve their understanding of concepts about patient restraints and (2) change their likelihood to use restraint techniques on patients in emergency situations., Methods: This was a cross-sectional study. A five-person panel of highly experienced emergency medical services (EMS) personnel compiled an hour-long restraint training module based on a compiled list of important concepts. A pretest and posttest were designed to contain the following two parts: (1) a knowledge quiz consisting of ten content-based questions and (2) a questionnaire on the likelihood to use restraint techniques in emergency situations, consisting of a five-question validated scale (Video Assessment of Propensity to use Emergency Restraints Scale [VAPERS])., Results: Thirty-four paramedic students at our training institution participated. We found that the paramedic students had a significant increase in their knowledge of the content shown (66% vs. 85%, p<0.05). There was no significant overall difference between pretest scores on the VAPERS (56+/-17 on a 0-100 scale) and posttest scores (57+/-16 on a 0-100 scale)., Conclusions: Paramedic students had improved understanding of important restraint concepts following a training module. The training module did not significantly change overall likelihood to use restraint techniques.

This study compared the experiences of 39 self-identified lesbians and 39 heterosexual women who had recently been treated for breast cancer. They were matched by age, stage of disease, time since diagnosis, and ethnicity. Data were collected by a questionnaire completed at home and returned by mail. Variables assessed included emotional adjustment, thought intrusion and avoidance, perceived quality of life, concerns about breast cancer, benefit finding, relationship and sexual disruption, psychosexual adjustment, social support, and coping. Compared to the heterosexual women, lesbians reported less thought avoidance, lower levels of sexual concern, less concern about their appearance, and less disruption in sexual activity, but also substantially lower perceptions of benefit from having had cancer. Lesbians reported less social connection to family, but no group difference emerged in connection to friends. Lesbians reported less denial coping, and more use of support from friends, more venting, and more positive reframing. Better understanding of the similarities and differences between groups will help address the relevant clinical issues appropriately, in order to optimize psychosocial adjustment to breast cancer. .

Background: Many factors, including heredity, atopic status, and environment, have been implicated in the determination of asthma severity. Relatively little is known about the degree to which asthma duration influences asthma severity., Objective: The Childhood Asthma Management Program (CAMP), consisting of 1041 children (age 8. 9 +/- 2.1 years at enrollment) with mild-to-moderate asthma, offers an opportunity to examine the relationship between asthma duration and asthma severity., Methods: By using the extensive CAMP baseline cross-sectional data on asthma duration, spirometry, bronchial responsiveness, symptomatology, and markers of atopy, univariate and multivariate regression models were used to evaluate whether asthma duration is associated with asthma severity., Results: Duration of asthma in the study cohort from time of diagnosis until randomization into CAMP ranged from 0.3 to 12.1 years (mean, 5.0; SD, 2.7; median, 4.8). Asthma duration is associated in univariate analyses both with lower levels of several lung functions (P <.001), including methacholine bronchial reactivity (natural log [ln] FEV1 PC20, mg/mL; r = -0.112), prebronchodilator and postbronchodilator percent predicted FEV1 (r = -0.176 and r = -0.130, respectively), and prebronchodilator and postbronchodilator FEV1 /forced vital capacity (FVC) (%) (r = -0.237 and r = -0.211, respectively), as well as higher levels of symptoms (symptom score: r = 0.147, P <. 001) and borderline greater use of albuterol for symptoms (r = 0.058, P =.064) during a 28-day screening period before randomization. Simple linear regression detected the following differences in lung functions per year of asthma duration: ln FEV1 PC20, -0.050 mg/mL/y; prebronchodilator FEV1, -0.907 percent predicted/y; and prebronchodilator FEV1 /FVC, -0.729 percent predicted/y. After controlling for potential explanatory variables (atopy, inflammatory markers, household Der p 1 levels, anti-inflammatory medication use, and clinical center), regression models revealed that the duration of asthma remained significantly and independently associated with ln FEV1 PC20 (P =.004), prebronchodilator percent predicted FEV1 (P =.043), and prebronchodilator and postbronchodilator FEV1 /FVC (%) (P <.001), as well as being positively associated with mean daily symptom score (P <.001) and albuterol use for symptoms (P =.003) during a 28-day screening period. Duration was also found to be significantly associated with physician/nurse assessment of asthma severity and other historical measures of medication use., Conclusions: These data demonstrate that asthma duration is associated with lower lung function, greater methacholine responsiveness, more asthma symptomatology, and greater use of as-needed albuterol, which are all measures of asthma severity. As such, early diagnosis and intervention may be necessary to ameliorate these adverse effects of persistent asthma.

Purpose: To perform a cost-utility analysis utilizing a cooperative group protocol and constrasting the results with the published quality adjusted survival., Methods and Materials: A cost-utility analysis was performed on Radiation Therapy Oncology Group (RTOG) protocol 83-02. The quality-adjusted survival has been published previously. Pretreatment tests and chemotherapy costs are not considered, as these were similar across all treatment arms. Payor costs are calculated from Federal Register data for Medicare Region IV. Global charges are used to calculate the professional and technical charges. Costs are measured in relative value units (RVUs) and are tabulated assuming equal treatment complexity for all treatment arms., Results: The number of RVUs calculated for each arm were 48 Gy--166.65; 54.4 Gy--182.17; 64.8 Gy--232.53; 72.0 Gy--272.19; 76.8 Gy--287.11; and 81.6 Gy--302.63. The RVU/QALY for the <50-year-old group were 48 Gy--119.03; 54.4 Gy--100.65; 64.8 Gy--104.78; 72.0 Gy--90.73; 76.8 Gy--193.99; and 81.6 Gy--165.37. The RVU/QALY for the >50-year-old group were 48 Gy--198.39; 54.4 Gy--276.85; 64.8 Gy--426.57; 72.0 Gy--423.71; 76.8 Gy--703.70; and 81.6 Gy--519.10. Sensitivity analysis of one treatment plan, simulation, and set of blocks for the 48 Gy and 54.4 Gy arms decreased the RVU/QALY to 105.34 and 90.05, respectively., Discussion: Our analyses shows the experimental arm with the lowest RVU/QALY is also the arm with the longest quality-adjusted survival. This arm had the most efficient use of resources in this protocol. Prospective collection of all pertinent cost data is required for comparison of one treatment against another. All cooperative group protocols should have prospective quality of life and economic endpoints to allow for comparison of the most cost efficient treatment method.

Food on wheels: it's here, there and everywhere. But while some operations rev up cart expansion plans, others have shifted into low gear. Here's an update on that '90s phenomenon: mobile merchandising.

Physical frailty and fall-related injuries present two of the biggest threats to older people's functioning and quality of life. The Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials represent a set of eight different clinical trials concerning physical frailty and injuries in later life. This report documents the history and organization of the trials and provides an overview of the measures being collected at multiple sites and the analytic strategies to be used for multi-site investigations.

This article proposes the use of a role transformation model to facilitate the assumption of more progressive attitudes and more autonomous, responsible behavior by nurses. Five major areas of content which need to be addressed in the role transformation process are detailed: 1) Defining and Articulating the Nursing Domain, 2) Legitimizing the Nursing Profession, 3) Communicating in Professional rather than Non-professional Modes, 4) Negotiating Collaborative Roles, and 5) Cultivating the Organizational Network. Emphasis is placed on the responsibility of nursing educators to model and facilitate role transformation for students and nursing colleagues.