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Background: With improved survival of adults with congenital heart disease (CHD) comes a need to understand the lifelong outcomes of this population. The aim of this paper is to describe the rationale and design of Congenital Heart Disease Project to Understand Lifelong Survivor Experience (CHD PULSE), a study to determine long-term medical, neurocognitive, and psychosocial outcomes among adults with a history of intervention for CHD and to identify factors associated with those outcomes., Methods: CHD PULSE is a cross-sectional survey conducted from September 2021 to April 2023 among adults aged 18 and older with a history of at least 1 intervention for CHD at 1 of 11 participating U.S. centers in the Pediatric Cardiac Care Consortium. Participants with CHD were asked to complete a 99-question survey on a variety of topics including: demographics, surgeries, health insurance, health care, heart doctors, general health, height and weight, education and work history, reproductive health (for women only), and COVID-19. To construct a control group for the study, siblings of survey respondents were invited to complete a similar survey. Descriptive statistics for demographics, disease severity, center, and method of survey completion were computed for participants and controls. Comparisons were made between participants and non-participants to assess for response bias and between CHD participants and sibling controls to assess for baseline differences., Results: Among the 14,322 eligible participants, there were 3,133 respondents (21.9%) from 48 U.S. states with surveys returned for inclusion in the study. Sibling contact information was provided by 691 respondents, with surveys returned by 326 siblings (47.2%). The median age of participants was 32.8 years at time of survey completion, with an interquartile range of 27.2 years to 39.7 years and an overall range of 20.1 to 82.9 years. Participants were predominantly female (55.1%) and of non-Hispanic White race/ethnicity (87.1%). There were no differences between participants and non-participants regarding severity of CHD. Compared to nonparticipants, participants were more likely to be female, of older age, and be of non-Hispanic White race/ethnicity. Enrolled siblings were more likely to be female and slightly younger than participants., Conclusions: With surveys from 3,133 participants from across the U.S., CHD PULSE is poised to provide keen insights into the lifelong journey of those living with CHD, extending beyond mere survival. These insights will offer opportunities for informing strategies to enhance and improve future outcomes for this population of patients., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Cardiomyopathy (CDM) in pregnancy is associated with maternal morbidity and mortality., Objectives: To explore trends and clinical outcomes in CDM subtypes during delivery hospitalizations., Methods: We used the National Inpatient Sample database to identify delivery hospitalizations between 2005-2020 by CDM subtypes: peripartum (PPCM), dilated (DCM), hypertrophic (HCM), and restrictive (RCM). Maternal and fetal outcomes were identified using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes. Baseline characteristics and temporal trends of CDM subtypes were analyzed. Maternal cardiovascular, pregnancy, and fetal outcomes were evaluated by CDM subtype using univariate logistic regression. The primary outcome was in-hospital mortality., Results: During 2005-2020, 37,125 out of 61,811,842 delivery hospitalizations were complicated by CDM. Among CDM-related delivery hospitalizations, the most prevalent were DCM (46%), followed by PPCM (45.6%), HCM (4.6%), and RCM (3.9%). The rates of in-hospital mortality (1.7%), adverse cardiovascular events such as acute heart failure (17%), cardiogenic shock (3.4%), and cardiac arrest (3.1%), and adverse pregnancy outcomes such as preeclampsia (14.2%) and preterm labor (11%), were highest among PPCM (all p < 0.0001). The prevalence of PPCM (49.1% to 38.5%) decreased while the prevalence of HCM (2.7% to 8.8%) and DCM (48% to 52.2%) increased over time., Conclusions: Over a 15-year period, PPCM had higher rates of in-hospital mortality, cardiovascular events, and adverse pregnancy outcomes compared to other CDM subtypes. While the prevalence of PPCM decreased over time, the prevalence of HCM and DCM increased. Hence, further research on cardiomyopathies during pregnancy and prospective studies on this vulnerable patient cohort are urgently needed., Competing Interests: Declaration of competing interest Dr. Sharma is supported by the AHA grant 979,462. Dr. Ibrahim reports consulting income from Cytokinetics and honoraria from Applied Therapeutics. All other authors have no conflict of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Current hemovigilance methods generally rely on survey data or administrative claims data utilizing billing and revenue codes, each of which has limitations. We used electronic health records (EHR) linked to blood bank data to comprehensively characterize red blood cell (RBC) utilization patterns and trends in three healthcare systems participating in the U.S. Food and Drug Administration Center for Biologics Evaluation and Research Biologics Effectiveness and Safety (BEST) initiative., Methods: We used Information Standard for Blood and Transplant (ISBT) 128 codes linked to EHR from three healthcare systems data sources to identify and quantify RBC-transfused individuals, RBC transfusion episodes, transfused RBC units, and processing methods per year during 2012-2018., Results: There were 577,822 RBC units transfused among 112,705 patients comprising 345,373 transfusion episodes between 2012 and 2018. Utilization in terms of RBC units and patients increased slightly in one and decreased slightly in the other two healthcare facilities. About 90% of RBC-transfused patients had 1 (~46%) or 2-5 (~42%)transfusion episodes in 2018. Among the small proportion of patients with ≥12 transfusion episodes per year, approximately 60% of episodes included only one RBC unit. All facilities used leukocyte-reduced RBCs during the study period whereas irradiated RBC utilization patterns differed across facilities., Discussion: ISBT 128 codes and EHRs were used to observe patterns of RBC transfusion and modification methods at the unit level and patient level in three healthcare systems participating in the BEST initiative. This study shows that the ISBT 128 coding system in an EHR environment provides a feasible source for hemovigilance activities., (© 2024 AABB. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Competency-based education is increasingly being adopted across the health professions. A model for competency-based education in veterinary medicine was recently developed by a working group of the American Association of Veterinary Medical Colleges (AAVMC) and is being used in institutions worldwide. The purpose of this study was to gather information on progress in and barriers to implementing competency-based education (including use of the AAVMC competency-based veterinary education [CBVE] Model) by AAVMC member schools to inform the development of strategies to support institutions in successful implementation of the CBVE Model. A cross-sectional survey was developed and distributed to AAVMC member institutions via an AAVMC web-based communication platform. Thirty-four of 55 AAVMC member institutions responded to the survey (62% response rate). Twenty schools reported using a competency-based education framework. Eleven of these institutions had implemented the AAVMC CBVE Framework, with an additional 12 institutions anticipating implementing it over the next 3 years. Timing, resources, and change management were the most commonly reported challenges to implementation. Suggestions for development of training resources included translation of milestones to pre-clinical courses, development of assessments, guidance on making progress decisions, illustrative overviews of specific components of the CBVE Model (e.g., the AAVMC CBVE Framework, EPAs, entrustment scales, milestones), and curriculum mapping. This study assesses progress in implementing the CBVE Model in AAVMC member schools and aids in identifying key challenges and resources to support faculty and institutions in the successful adoption and implementation of this educational model.

Background: After implementation of the Lung Allocation Score in 2005, idiopathic pulmonary fibrosis (IPF) emerged as the most common indication for lung transplantation (LT) in the United States. The age and comorbidity of patients undergoing LT have since increased, and the indications for LT have evolved. However, limited data have been used to analyze more recent outcomes among the IPF population., Methods: This study analyzed LTs for the primary indication of IPF by using the United Network for Organ Sharing database. An eras-based analysis was performed, comparing patient characteristics, survival, and related outcomes during 2005 to 2009 (era 1) and 2010 to 2014 (era 2) with χ 2 , Wilcoxon rank sum, and Kaplan-Meier analyses. The study compared 1-year survival from 2005 to 2020 and survival at milestones ranging from 1 month to 5 years. Two adjusted Cox proportional hazards models were conducted: 5-year survival by era and 1-year survival annually from 2010 to 2020., Results: From era 1 (n = 1818) to era 2 (n = 3227), the median age of LT recipients increased from 61 to 63 years (P < .001). The percentage of patients in the intensive care unit before LT climbed from 7.7% to 12.1% (P < .001), and the percentage of patients with diabetes grew from 17.9% to 19.4% (P = .003). Despite increased severity of illness, 5-year survival increased from 51.9% in era 1 to 55.2% in era 2 (P = .02). Adjusted modeling indicated that LT during era 2 featured a 17% hazard reduction compared with era 1 (hazard ratio, 0.83; 95% CI, 0.76-0.91)., Conclusions: Survival is improving for patients undergoing LT for IPF, despite the challenges of transplant recipients with progressively higher risk profiles., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

The American Society of Nephrology (ASN) Task Force on the Future of Nephrology was established in April 2022 in response to requests from the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education regarding training requirements in nephrology. Given recent changes in kidney care, ASN also charged the task force with reconsidering all aspects of the specialty's future to ensure that nephrologists are prepared to provide high-quality care for people with kidney diseases. The task force engaged multiple stakeholders to develop 10 recommendations focused on strategies needed to promote: ( 1 ) just, equitable, and high-quality care for people living with kidney diseases; ( 2 ) the value of nephrology as a specialty to nephrologists, the future nephrology workforce, the health care system, the public, and government; and ( 3 ) innovation and personalization of nephrology education across the scope of medical training. This report reviews the process, rationale, and details (the "why" and the "what") of these recommendations. In the future, ASN will summarize the "how" of implementing the final report and its 10 recommendations., (Copyright © 2023 by the American Society of Nephrology.)

Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.

Background: Previous research used data through 2008 to estimate a model for the effect of the California Tobacco Control Program (CTCP) that used cumulative real per capita tobacco control expenditure to predict smoking behavior (current adult smoking prevalence and mean cigarette consumption per current smoker). Predicted changes in smoking behavior due to the CTCP were used to predict its effect on health care expenditure. This research updates the model using the most recently available data and estimates CTCP program effect through 2019., Methods: The data used in the previous research were updated, and the original model specification and a related predictive forecast model were re-estimated. The updated regression estimates were compared to those previously published and used to update estimates of CTCP program effect in 2019 dollars., Results: There was no evidence of structural change in the previously estimated model. The estimated effect of the CTCP program expenditures on adult current smoking prevalence and mean consumption per adult current smoker has remained stable over time. Over the life of the program, one additional dollar per capita of program expenditure was associated with a reduction of current adult smoking prevalence by about 0.05 percentage point and mean annual consumption per adult current smoker by about 2 packs. Using updated estimates, the program prevented 9.45 (SE 1.04) million person-years of smoking and cumulative consumption of 15.7 (SE 3.04) billion packs of cigarettes from 1989 to 2019. The program produced cumulative savings in real healthcare expenditure of $544 (SE $82) billion using the National Income and Product Accounts (NIPA), and $816 (SE $121) billion using the Center for Medicare and Medicaid Services (CMS) measure of medical costs. During this time, the CTCP expenditure was $3.5 billion., Conclusion: A simple predictive model of the effectiveness of the CTCP program remained stable and retains its predictive performance out-of-sample. The updated estimates of program effect suggest that CTCP program has retained its effectiveness over its 31-year life and produced a return on investment of 231 to 1 in direct CMS medical expenditure., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Lightwood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Surgical specialties, including oral and maxillofacial surgery (OMS), are traditionally male-dominated fields. This study aimed to analyze the proportions of female surgeons on specialty society boards and journal editorial boards in OMS in the United States and to assess whether they were proportionate with female representation in OMS academic faculty between 2011 and 2020., Methods: A retrospective cohort study was performed using information obtained from the websites of two major OMS journals and information obtained directly from six American specialty societies for OMS. The predictor variable was time. The outcome variable was gender. Temporal changes in the proportion of women on society and journal editorial boards were compared with those amongst full-time board-certified faculty. Chi-squared test and simple linear regression were used for statistical analyses., Results: Between 2011 and 2020, the proportion of women on editorial and society boards was 6.7% (31 women among 463 editorial board members) and 7.8% (43 women among 553 society board members), respectively. The proportion of women on editorial boards increased from 4.5% in 2011 to 10.6% in 2020 (β = 0.656 [95% confidence interval, 0.336-0.975], P = .001) and that of women on society boards increased from 4.3% in 2011 to 10.3% in 2020 (β = 0.645 [95% confidence interval, 0.252-1.037], P = .005). The proportion of women on editorial boards in 2011-2012 was significantly lower than that in full-time board-certified faculty positions (4.3% vs 11.0%, P = .045), whereas by 2019-2020, there was no difference between the 2 groups (9.8% vs 12.5%, P = .454). Similarly, the proportion of women on society boards in 2011-2012 tended to be lower than that in full-time board-certified faculty positions (5.6% vs 11.0%, P = .111), while in 2019-2020, no difference was observed between the 2 groups (10.4% vs 12.5%, P = .531)., Conclusion: The proportion of women on society and journal editorial boards in OMS remains low but has progressively increased from 2011 to 2020, resulting in proportionate female representation in these positions compared with the gender composition of academic faculty in recent years. The current upward trend of female representation in leadership positions will hopefully present more diverse opportunities and mentorship/role models for trainees., (Copyright © 2022 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: Chronic obstructive pulmonary disease (COPD) is underdiagnosed in primary care., Objective: To evaluate the operating characteristics of the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool for identifying US primary care patients with undiagnosed, clinically significant COPD., Design, Setting, and Participants: In this cross-sectional study, 4679 primary care patients aged 45 years to 80 years without a prior COPD diagnosis were enrolled by 7 primary care practice-based research networks across the US between October 12, 2018, and April 1, 2022. The CAPTURE questionnaire responses, peak expiratory flow rate, COPD Assessment Test scores, history of acute respiratory illnesses, demographics, and spirometry results were collected., Exposure: Undiagnosed COPD., Main Outcomes and Measures: The primary outcome was the CAPTURE tool's sensitivity and specificity for identifying patients with undiagnosed, clinically significant COPD. The secondary outcomes included the analyses of varying thresholds for defining a positive screening result for clinically significant COPD. A positive screening result was defined as (1) a CAPTURE questionnaire score of 5 or 6 or (2) a questionnaire score of 2, 3, or 4 together with a peak expiratory flow rate of less than 250 L/min for females or less than 350 L/min for males. Clinically significant COPD was defined as spirometry-defined COPD (postbronchodilator ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity [FEV1:FVC] <0.70 or prebronchodilator FEV1:FVC <0.65 if postbronchodilator spirometry was not completed) combined with either an FEV1 less than 60% of the predicted value or a self-reported history of an acute respiratory illness within the past 12 months., Results: Of the 4325 patients who had adequate data for analysis (63.0% were women; the mean age was 61.6 years [SD, 9.1 years]), 44.6% had ever smoked cigarettes, 18.3% reported a prior asthma diagnosis or use of inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10.0% reported at least 1 cardiovascular comorbidity. Among the 110 patients (2.5% of 4325) with undiagnosed, clinically significant COPD, 53 had a positive screening result with a sensitivity of 48.2% (95% CI, 38.6%-57.9%) and a specificity of 88.6% (95% CI, 87.6%-89.6%). The area under the receiver operating curve for varying positive screening thresholds was 0.81 (95% CI, 0.77-0.85)., Conclusions and Relevance: Within this US primary care population, the CAPTURE screening tool had a low sensitivity but a high specificity for identifying clinically significant COPD defined by presence of airflow obstruction that is of moderate severity or accompanied by a history of acute respiratory illness. Further research is needed to optimize performance of the screening tool and to understand whether its use affects clinical outcomes.

Background: The U.S. Food and Drug Administration (FDA) Biologics Effectiveness and Safety (BEST) Initiative conducts active surveillance of adverse events of special interest (AESI) after COVID-19 vaccination. Historical incidence rates (IRs) of AESI are comparators to evaluate safety., Methods: We estimated IRs of 17 AESI in six administrative claims databases from January 1, 2019, to December 11, 2020: Medicare claims for adults ≥ 65 years and commercial claims (Blue Health Intelligence®, CVS Health, HealthCore Integrated Research Database, IBM® MarketScan® Commercial Database, Optum pre-adjudicated claims) for adults < 65 years. IRs were estimated by sex, age, race/ethnicity (Medicare), and nursing home residency (Medicare) in 2019 and for specific periods in 2020., Results: The study included >100 million enrollees annually. In 2019, rates of most AESI increased with age. However, compared with commercially insured adults, Medicare enrollees had lower IRs of anaphylaxis (11 vs 12-19 per 100,000 person-years), appendicitis (80 vs 117-155), and narcolepsy (38 vs 41-53). Rates were higher in males than females for most AESI across databases and varied by race/ethnicity and nursing home status (Medicare). Acute myocardial infarction (Medicare) and anaphylaxis (all databases) IRs varied by season. IRs of most AESI were lower during March-May 2020 compared with March-May 2019 but returned to pre-pandemic levels after May 2020. However, rates of Bell's palsy, Guillain-Barré syndrome, narcolepsy, and hemorrhagic/non-hemorrhagic stroke remained lower in multiple databases after May 2020, whereas some AESI (e.g., disseminated intravascular coagulation) exhibited higher rates after May 2020 compared with 2019., Conclusion: AESI background rates varied by database and demographics and fluctuated in March-December 2020, but most returned to pre-pandemic levels after May 2020. It is critical to standardize demographics and consider seasonal and other trends when comparing historical rates with post-vaccination AESI rates in the same database to evaluate COVID-19 vaccine safety., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [Shayan Hobbi reports financial support was provided by US Food and Drug Administration, Timothy A Burrell reports financial support was provided by US Food and Drug Administration. Timothy A Burrell reports a relationship with IBM that includes: employment, Dr. Edwards has disclosed the following financial relationships. Grant Recipient from CDC (Vaccine Safety with COVID vaccines) Grant Recipient from NIH (Mentoring young investigators in vaccine sciences) Consultant from BioNet (pertussis vaccines) Consultant from IBM (vaccine safety networks) Consultant from Data safety and Monitoring Boards: Sanofi, X-4 Pharma, Seqirus, Moderna, Pfizer, Merck, GSK, Roche, Dr. Black has disclosed the following financial relationships: I am a consultant for CEPI through the SPEAC project and also a consultant for GSK on meeting planning, Djeneba Audrey Djibo reports financial support was provided by US Food and Drug Administration. Djeneba Audrey Djibo reports a relationship with CVS Health that includes: employment and equity or stocks, Daniel C. Beachler reports a relationship with Elevance Health Inc. that includes: employment and equity or stocks, Patricia Lloyd, Deborah Thompson, Rositsa Dimova, Joyce Obidi, Steve Anderson, Richard Forshee, Hui-Lee Wong, Azadeh Shoaibi, Cheryl N McMahill-Walraven reports financial support was provided by US Food and Drug Administration. Cheryl N McMahill-Walraven reports a relationship with CVS Health that includes: employment, John D. Seeger reports financial support was provided by Optum Inc. John D. Seeger reports a relationship with Optum that includes: employment and equity or stocks, Kandace Amend reports financial support was provided by Optum Inc. Kandace Amend reports a relationship with Optum that includes: employment and equity or stocks, Thomas MaCurdy reports financial support was provided by Acumen LLC. Thomas MaCurdy reports a relationship with Acumen LLC that includes: employment and equity or stocks]. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Purpose: To show the impact of drug-drug interactions (DDIs) associated with co-administration of enzyme-inducing (EI) antiseizure medications and oral contraceptives (OCs) on the annual number of unintended pregnancies, their outcomes, and their associated costs in the United States (US)., Methods: A Microsoft Excel pregnancy-outcomes model was developed to determine the impact of DDIs in women who take an OC as well as an EI antiseizure medication known to lower the effectiveness of the OC in preventing pregnancy. The model compared the number of unintended pregnancies, the expected pregnancy outcomes, and associated costs in women taking an OC and an EI medication with a matched cohort of women who took an OC and an enzyme-neutral (EN) antiseizure medication that is known not to interact with OCs. The model perspectives were patients and third-party payers in the US. Unintended pregnancy rates, pregnancy outcomes, and cost inputs for the model were taken from published studies., Results: The results of the analysis showed an estimated increase in the annual number of unintended pregnancies in the US of 503 (a change from 1151 to 1654), an increase of 44.7%, for the estimated 71,922 women currently taking an OC plus an EI medication in the US when compared with a matched cohort taking an OC plus an EN medication. This resulted in an estimated annual healthcare cost increase of $3 million, which is an increase of 5.5% in the annual costs for contraception and pregnancy care. A scenario analysis showed that the annual number of unintended pregnancies could be lower (575 vs 1654) for a matched cohort of women taking EI medications and using a copper intrauterine device, a highly effective and nonhormonal form of contraception, rather than an OC., Conclusions: Physicians treating women of reproductive age for epilepsy who wish to avoid pregnancy should consider the potential for DDIs that might result in unintended pregnancies. Thus, physicians should alert women using EI medications for epilepsy control to the increased potential for unintended pregnancies if they use OCs for contraception., Competing Interests: Declaration of Competing Interest Seri Anderson, Josephine Mauskopf, Sandra Talbird, Annesha White, and Meenakshi Srinivasan have no conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to examine the relationship between patient experience and readmissions by exploring whether the deviation from an ideal patient-experience profile is linked to higher readmissions. Using patient experience scores, hospitals were assigned to one of four groups based on their deviation from an ideal profile. The readmission rates for the four groups were analyzed using Profile Deviation, ANOVA, and Least Significant Difference. Patient experience is a central component of hospital performance, specifically, readmission rates. Findings indicate as patient experience scores decrease, profile deviation increases, with a corresponding increase in readmission rate. This study provides empirical support for administrators focusing on patient experience as part of an overall strategy for reducing hospital readmissions. The key feature of this research is the use of a profile deviation methodology to examine the relationship between patient experience and readmission rates.

Background: Vaccine use during pregnancy affects maternal and infant health. Many women do not receive vaccines recommended during pregnancy; conversely, inadvertent exposure to vaccines contraindicated or not recommended during pregnancy may occur. We assessed exposure to two recommended vaccines and two vaccines not recommended during pregnancy among privately and Medicaid-insured women in the United States., Methods: This study includes a retrospective cohort of pregnancies in women aged 12-55 years resulting in live birth, spontaneous abortion, or stillbirth identified in the IBM® MarketScan® Commercial, Blue Health Intelligence® (BHI®) Commercial, and IBM MarketScan Multi-State Medicaid Databases from August 1, 2016, to December 31, 2018. Gestational age at vaccination was determined using a validated algorithm. We examined vaccines (1) recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) (tetanus, diphtheria, and acellular pertussis [Tdap]; inactivated influenza) and (2) not recommended (human papillomavirus [HPV]) or contraindicated (measles, mumps, and rubella [MMR])., Results: We identified 496,771 (MarketScan Commercial), 858,961 (BHI), and 289,573 (MarketScan Medicaid) pregnancies (approximately 75% aged 20-34 years). Across these three databases, 52.1%, 50.3%, and 31.3% of pregnancies, respectively, received Tdap, most often at a gestational age of 28 weeks, and influenza vaccination occurred in 32.1%, 30.8%, and 18.0% of pregnancies, respectively. HPV vaccination occurred in < 0.2% of pregnancies, mostly in the first trimester among women aged 12-19 years, and MMR was administered in < 0.1% of pregnancies. Use of other contraindicated vaccines per ACIP (e.g., varicella, live attenuated influenza) was rare., Conclusion: Maternal vaccination with ACIP-recommended vaccines was suboptimal among privately and Medicaid-insured patients, with lower vaccination coverage among Medicaid-insured pregnancies than their privately insured counterparts. Inadvertent exposure to contraindicated vaccines during pregnancy was rare. This study evaluated only vaccinations reimbursed among insured populations and may have limited generalizability to uninsured populations., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In many correctional facilities across the United States, COVID-19 vaccine refusal rates are as high as 50%. Most women leaving jails have low SES, health literacy, and mistrust of governmental institutions, thus exacerbating existing health disparities and making women leaving jail vulnerable. Data from 25 interviews with recently released women suggest that interventions to promote vaccines to this population will have to address health education and mitigate mistrust, misinformation, and conspiracy theories., (© 2021 Wiley Periodicals, Inc.)

The Coronavirus Disease 2019 (COVID-19) pandemic has had a devastating impact on global health, and has resulted in an unprecedented, international collaborative effort to develop vaccines to control the outbreak, protect human lives, and avoid further social and economic disruption. Mass vaccination campaigns are underway in multiple countries and are expected worldwide once more vaccine becomes available. Some early candidate vaccines use novel platforms, such as mRNA encapsulated in lipid nanoparticles, and relatively new platforms, such as replication-deficient viral vectors. While these new vaccine platforms hold promise, limited safety data in humans are available. Serious health outcomes linked to vaccinations are rare, and some outcomes may occur incidentally in the vaccinated population. Knowledge of background incidence rates of these medical conditions is a critical component of vaccine safety monitoring to aid in the assessment of adverse events temporally associated with vaccination and to put these events into context with what would be expected due to chance alone. A list of 22 potential adverse events of special interest (AESI), including neurologic, autoimmune, and cardiovascular disorders, was compiled by subject matter experts at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. The most recently available U.S. background rates for these medical conditions, overall and by age, sex, and race/ethnicity (when available), were sourced from reported statistics (data published by medical panels/ associations or federal government reports), and literature reviews in PubMed. This review provides estimates of background incidence rates for medical conditions that may be monitored or studied as AESI during safety surveillance and research for COVID-19 vaccines and other new vaccines., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Importance: Understanding the effect of serum antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on susceptibility to infection is important for identifying at-risk populations and could have implications for vaccine deployment., Objective: The study purpose was to evaluate evidence of SARS-CoV-2 infection based on diagnostic nucleic acid amplification test (NAAT) among patients with positive vs negative test results for antibodies in an observational descriptive cohort study of clinical laboratory and linked claims data., Design, Setting, and Participants: The study created cohorts from a deidentified data set composed of commercial laboratory tests, medical and pharmacy claims, electronic health records, and hospital chargemaster data. Patients were categorized as antibody-positive or antibody-negative according to their first SARS-CoV-2 antibody test in the database., Main Outcomes and Measures: Primary end points were post-index diagnostic NAAT results, with infection defined as a positive diagnostic test post-index, measured in 30-day intervals (0-30, 31-60, 61-90, >90 days). Additional measures included demographic, geographic, and clinical characteristics at the time of the index antibody test, including recorded signs and symptoms or prior evidence of coronavirus 2019 (COVID) diagnoses or positive NAAT results and recorded comorbidities., Results: The cohort included 3 257 478 unique patients with an index antibody test; 56% were female with a median (SD) age of 48 (20) years. Of these, 2 876 773 (88.3%) had a negative index antibody result, and 378 606 (11.6%) had a positive index antibody result. Patients with a negative antibody test result were older than those with a positive result (mean age 48 vs 44 years). Of index-positive patients, 18.4% converted to seronegative over the follow-up period. During the follow-up periods, the ratio (95% CI) of positive NAAT results among individuals who had a positive antibody test at index vs those with a negative antibody test at index was 2.85 (95% CI, 2.73-2.97) at 0 to 30 days, 0.67 (95% CI, 0.6-0.74) at 31 to 60 days, 0.29 (95% CI, 0.24-0.35) at 61 to 90 days, and 0.10 (95% CI, 0.05-0.19) at more than 90 days., Conclusions and Relevance: In this cohort study, patients with positive antibody test results were initially more likely to have positive NAAT results, consistent with prolonged RNA shedding, but became markedly less likely to have positive NAAT results over time, suggesting that seropositivity is associated with protection from infection. The duration of protection is unknown, and protection may wane over time.

Background: The Vaccine Safety Datalink (VSD) identified a statistical signal for an increased risk of Guillain-Barré syndrome (GBS) in days 1-42 after 2018-2019 high-dose influenza vaccine (IIV3-HD) administration. We evaluated the signal using Medicare., Methods: We conducted early- and end-of-season claims-based self-controlled risk interval analyses among Medicare beneficiaries ages ≥65 years, using days 8-21 and 1-42 postvaccination as risk windows and days 43-84 as control window. The VSD conducted chart-confirmed analyses., Results: Among 7 453 690 IIV3-HD vaccinations, we did not detect a statistically significant increased GBS risk for either the 8- to 21-day (odds ratio [OR], 1.85; 95% confidence interval [CI], 0.99-3.44) or 1- to 42-day (OR, 1.31; 95% CI, 0.78-2.18) risk windows. The findings from the end-of-season analyses were fully consistent with the early-season analyses for both the 8- to 21-day (OR, 1.64; 95% CI, 0.92-2.91) and 1- to 42-day (OR, 1.12; 95% CI, 0.70-1.79) risk windows. The VSD's chart-confirmed analysis, involving 646 996 IIV3-HD vaccinations, with 1 case each in the risk and control windows, yielded a relative risk of 1.00 (95% CI, 0.06-15.99)., Conclusions: The Medicare analyses did not exclude an association between IIV3-HD and GBS, but it determined that, if such a risk existed, it was similar in magnitude to prior seasons. Chart-confirmed VSD results did not confirm an increased risk of GBS., (Published by Oxford University Press for the Infectious Diseases Society of America 2020.)

Objective: To examine the association between estimated age at first exposure (eAFE) to American football and clinical measures throughout recovery following concussion., Methods: Participants were recruited across 30 colleges and universities as part of the National Collegiate Athletic Association (NCAA)-Department of Defense Concussion Assessment, Research and Education Consortium. There were 294 NCAA American football players (age 19 ± 1 years) evaluated 24-48 hours following concussion with valid baseline data and 327 (age 19 ± 1 years) evaluated at the time they were asymptomatic with valid baseline data. Participants sustained a medically diagnosed concussion between baseline testing and postconcussion assessments. Outcome measures included the number of days until asymptomatic, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) composite scores, Balance Error Scoring System (BESS) total score, and Brief Symptom Inventory 18 (BSI-18) subscores. The eAFE was defined as participant's age at the time of assessment minus self-reported number of years playing football., Results: In unadjusted regression models, younger eAFE was associated with lower (worse) ImPACT Visual Motor Speed ( R 2 = 0.031, p = 0.012) at 24-48 hours following injury and lower (better) BSI-18 Somatization subscores ( R 2 = 0.014, p = 0.038) when the athletes were asymptomatic. The effect sizes were very small. The eAFE was not associated with the number of days until asymptomatic, other ImPACT composite scores, BESS total score, or other BSI-18 subscores., Conclusion: Earlier eAFE to American football was not associated with longer symptom recovery, worse balance, worse cognitive performance, or greater psychological distress following concussion. In these NCAA football players, longer duration of exposure to football during childhood and adolescence appears to be unrelated to clinical recovery following concussion., (© 2020 American Academy of Neurology.)

An estimated 57% of persons living with HIV (PLWH) in the United States are not connected to regular medical care or have lapsed from regular care (Centers for Disease Control and Prevention, 2018), increasing risk of HIV progression and transmission and delaying viral suppression. The state of Louisiana has consistently ranked in the top five US states for HIV case rates. We evaluated the impact of a combined data-to-care and patient navigation system that was implemented in 3 cities in Louisiana from 2013 to 2015. The program, LA Links, used a surveillance system to identify PLWH who were not in regular health care and connected them to a patient navigator. During the intervention period, persons who lapsed from care were 17% more likely to reengage in care than persons in the comparison group, and persons newly diagnosed during the intervention period were 56% more likely to link to care.

The Physician Payments Sunshine Act requires biomedical companies to report payments made to physicians and teaching hospitals to the Centers for Medicare and Medicaid Services (CMS). Despite significant attention paid to industry payments to physicians, little is known about payments to teaching hospitals, which create the potential for both benefits and institutional conflicts of interest. We examined 2018 CMS Open Payments program data to identify all nonresearch payments made by industry to teaching hospitals and determined that 91 percent of teaching hospitals received industry payments totaling $832 million in 2018. We observed substantial royalty payments, which may reflect the downstream benefits of research partnerships, as well as substantial payments for gifts and education, which raise concerns for institutional conflicts of interest. Hospital predictors of receiving payments included large bed size, major medical school affiliation, and inclusion on the U.S. News & World Report Best Hospitals Honor Roll. Financial payments from industry to teaching hospitals are common and previously underrecognized. Hospitals should strengthen policies to prevent the institutional conflicts of interest that may arise from these payments while promoting beneficial industry collaborations. We also suggest that CMS reporting requirements be broadened to all hospitals to meet the Sunshine Act's goals of encouraging transparency and preventing inappropriate industry influence.

Objective: Evaluate the rate of concussions across Big 12 Conference football programs based on (1) equipment worn, (2) contact level, (3) preseason practice versus in-season practice versus games, and (4) mechanism of injury for concussion., Design: Descriptive epidemiology study., Setting: Big 12 Conference football practices and competitions., Patients (or Participants): Big 12 Conference football teams., Assessment of Risk Factors: All Big 12 Conference institutions collected data on practice types, equipment worn, practice and game participation, and concussions during the fall, preseasons and regular seasons, from 2013 to 2016., Main Outcome Measures: Injury rates and injury rate ratios were reported with 95% confidence intervals (CIs)., Results: From 2013 to 2016, there were 375 concussions reported [0.98/1000 athlete exposures (AEs) (95% CI, 0.88-1.08)], an average of approximately 9 concussions per team per year. Concussion rates were highest in games (5.73/1000 AE), but among practices, concussion rates were highest in full-pad (1.18/1000 AEs) and live-contact (1.28/1000 AEs) practices. Concussion rates increased with increasing contact and equipment worn. Concussion rates were higher in the preseason than in the regular season, even when stratifying by contact level and equipment worn., Conclusions: Practice concussion rates are highest during fully padded and live-contact practices, supporting limitations on practice contact and equipment worn to reduce the risk associated with head-impact exposure. Higher concussion rates in the preseason and during games indicate an effect of play intensity on concussion risk, and further research is needed to evaluate the direct effect of practice contact level and equipment guidelines and restrictions on concussion incidence.

Introduction: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs., Methods: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review., Results: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved., Conclusions: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Introduction: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs., Methods: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review., Results: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved., Conclusions: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence., (© by the National Athletic Trainers' Association, Inc.)

Particularly in rural settings, there has been little research regarding the health impacts of fine particulate matter (PM 2.5 ) during the wildfire season smoke exposure period on respiratory diseases, such as influenza, and their associated outbreaks months later. We examined the delayed effects of PM 2.5 concentrations for the short-lag (1-4 weeks prior) and the long-lag (during the prior wildfire season months) on the following winter influenza season in Montana, a mountainous state in the western United States. We created gridded maps of surface PM 2.5 for the state of Montana from 2009 to 2018 using spatial regression models fit with station observations and Moderate Resolution Imaging Spectroradiometer (MODIS) aerosol optical thickness data. We used a seasonal quasi-Poisson model with generalized estimating equations to estimate weekly, county-specific, influenza counts for Montana, associated with delayed PM 2.5 concentration periods (short-lag and long-lag effects), adjusted for temperature and seasonal trend. We did not detect an acute, short-lag PM 2.5 effect nor short-lag temperature effect on influenza in Montana. Higher daily average PM 2.5 concentrations during the wildfire season was positively associated with increased influenza in the following winter influenza season (expected 16% or 22% increase in influenza rate per 1 μg/m 3 increase in average daily summer PM 2.5 based on two analyses, p = 0.04 or 0.008). This is one of the first observations of a relationship between PM 2.5 during wildfire season and influenza months later., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Out-of-sample forecasts are used to evaluate the predictive adequacy of a previously published national model of the relationship between smoking behavior and real per capita health care expenditure using state level aggregate data. In the previously published analysis, the elasticities between changes in state adult current smoking prevalence and mean cigarette consumption per adult current smoker and healthcare expenditures were 0.118 and 0.108 This new analysis provides evidence that the model forecasts out-of-sample well., Methods: Out-of-sample predictive performance was used to find the best specification of trend variables and the best model to bridge a break in survey data used in the analysis. Monte-Carlo simulation was used to calculate forecast intervals for the effect of changes in smoking behavior on expected real per capita healthcare expenditures., Results: The model specification produced good-out-of-sample forecasts and stable recursive regression parameter estimates spanning the break in survey methodology. In 2014, a 1% relative reduction in adult current smoking prevalence and mean cigarette consumption per adult current smoker decreased real per capita healthcare expenditure by 0.104% and 0.113% the following year, respectively (elasticity). A permanent relative reduction of 5% reduces expected real per capita healthcare expenditures $99 (95% CI $44, $154) in the next year and $31.5 billion for the entire US (in 2014 dollars), holding other factors constant. The reductions accumulate linearly for at least five years following annual permanent decreases of 5% each year. Given the limitations of time series modelling in a relatively short time series, the effect of changes in smoking behavior may occur over several years, even though the model contains only one lag for the explanatory variables., Conclusion: Reductions in smoking produce substantial savings in real per capita healthcare expenditure in short to medium term. A 5% relative drop in smoking prevalence (about a 0.87% reduction in absolute prevalence) combined with a 5% drop in consumption per remaining smoker (about 16 packs/year) would be followed by a $31.5 billion reduction in healthcare expenditure (in 2014 dollars)., Competing Interests: The authors have declared that no competing interests exist. SA’s involvement does not alter our adherence to PLOS ONE policies on sharing data and materials.

Parkinson's disease (PD) is the second most common neurodegenerative disease, though evidence suggests that this disorder does not affect all racial groups similarly. Research in African Americans, in particular, has been conflicting. Some studies have found similar prevalence rates in African Americans and whites whereas other studies have found much lower prevalence and incidence rates in African Americans. A few studies identify potential factors underlying these discrepancies, including biologic differences as well as disparities in healthcare access. However, African Americans remain underrepresented in research studies, which make understanding the underlying reasons for these differences difficult. The purpose of this paper is to summarize existing research in African Americans with PD, highlight some of the reasons why differences exist in diagnostic rates of PD in this population, and briefly discuss interventions that may need to be made in order to ensure adequate care is provided to these patients.

Objective: To design an Obstetrics and Gynecology (OBGYN) residency elective in global health that meets ACGME standards and simultaneously promotes health equity., Design: A 4-week elective was established for US residents in a high-volume African district hospital that served as a site for OBGYN rotations for the national internship training program. Clear clinical, operative, and teaching requirements were delineated for US OBGYN residents. Resident formal didactic outputs were incorporated into the intern OBGYN curriculum. The program was evaluated through assessment of resident experience and contribution to local training, as well as assessment of intern competency in OBGYN., Setting: Scottish Livingstone Hospital, a public district hospital in Molepolole, Botswana., Participants: Second- to fourth-year OBGYN residents from US training programs, working with Batswana medical interns under on-site faculty supervision., Results: From May 2016 to June 2018, 18 residents from 9 US OBGYN residency programs participated in the elective. Under supervision, US residents performed 116 major and 77 minor gynecologic surgeries, and teach-assisted Batswana interns and medical officers in 76 cesarean deliveries. Residents led or contributed significantly to 25 didactic education sessions as part of the formal intern OBGYN curriculum. During this period, 24 Batswana interns rotated through the hospital's department of OBGYN, and all 24 trainees met required OBGYN competencies prior to completing their internship., Conclusions: Matching US resident demand for global health experiences to equitable global health programming while maintaining ACGME training guidelines poses a challenge to OBGYN residency training programs. This elective provides a model OBGYN global health elective that addresses host-identified needs, broadens residents' skills, and meets standards for postgraduate OBGYN training. Purposeful global health electives for US residents embedded in longitudinal programs provide an opportunity for residents to contribute to broader global health efforts that promote health equity., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge., Methods: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated., Results: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29)., Conclusion: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the Centers for Disease Control and Prevention's (CDC) contraceptive effectiveness poster with a more patient-centered poster on factors affecting the likelihood of using effective contraceptives., Methods: The posters were tested in a randomized controlled trial. Women were eligible if they were aged 18-44 years, could speak and read English, were not pregnant or trying to conceive, and had engaged in vaginal intercourse in the past 3 months. An online survey administered through Amazon Mechanical Turk was used to collect baseline and immediate follow-up data on three primary outcomes: contraceptive knowledge (measured using the Contraceptive Knowledge Assessment), perceived pregnancy risk, and the effectiveness of the contraceptive the woman intended to use in the next year. Subgroup analyses were conducted in women with prior pregnancy scares, low numeracy, and no current contraceptive. Within- and between-group differences were compared for the two randomized groups., Results: From January 26 to February 13, 2018, 2,930 people were screened and 990 randomized. For the primary outcomes, the only significant result was that the patient-centered poster produced a greater improvement in contraceptive knowledge than the CDC poster (P<.001). Relative to baseline, both posters significantly improved contraceptive knowledge (CDC +3.6, patient-centered +6.4 percentage points, P<.001) and a constructed score measuring the effectiveness of the contraceptive that women intended to use in the next year (CDC and patient-centered +3 percentage points, P<.01). This is equivalent to 1-17 of every 100 women who viewed a poster changing their intentions in favor of a more effective contraceptive., Conclusion: This study suggests that both posters educate women about contraception and may reduce unplanned pregnancy risk by improving contraceptive intentions. Of the three primary outcomes, the patient-centered poster performs significantly better than the CDC poster at increasing contraceptive knowledge., Clinical Trial Registration: ClinicalTrials.gov, NCT03372369.

Objectives: To refine the Centers for Disease Control and Prevention (CDC)'s contraceptive education poster using patient-centered design., Study Design: We conducted cognitive interviews with 26 women aged 18-44 living in North Carolina who spoke and read English and had ever had sex. We interviewed women about both a CDC and a patient-centered poster in alternating order. Participants were contraceptive users and non-users that we selected purposively to have a range of characteristics that might influence their perspective: age, race/ethnicity, previous births and pregnancies, contraceptive method(s) used in the past three months, pregnancy intentions, and numeracy. The initial response rate for participants was 55%. We used cognitive theory to code interviews for comprehension, relevance, and acceptability, as well as design and overall preference. We structured the 26 interviews into four rounds and revised the patient-centered poster after each round to improve these measures., Results: By the final round, 83% of women preferred the patient-centered poster. The majority of women favored this poster's relevance (86%), and design (100%) and ease of comprehension (86%). Women raised few concerns about the acceptability of the final version of the patient-centered poster. Women identified many issues with both posters that the researchers did not anticipate, highlighting the value of patient-centered design approaches to educational materials., Conclusions: This study refined a patient-centered poster so that its language is clear and it addresses the informational needs of its target audience., Implications: The Centers for Disease Control and Prevention and the Office of Population Affairs recommend that clinicians educate women about contraception. This study developed a poster that could help clinicians follow this recommendation. Before widespread implementation, more research is needed to evaluate the poster's impact on contraceptive knowledge and behaviors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Public health practitioners can use Behavior Over Time (BOT) graphs to spur discussion and systems thinking around complex challenges. Multiple large systems, such as health care, the economy, and education, affect chronic disease rates in the United States. System thinking tools can build public health practitioners' capacity to understand these systems and collaborate within and across sectors to improve population health. BOT graphs show a variable, or variables (y axis) over time (x axis). Although analyzing trends is not new to public health, drawing BOT graphs, annotating the events and systemic forces that are likely to influence the depicted trends, and then discussing the graphs in a diverse group provides an opportunity for public health practitioners to hear each other's perspectives and creates a more holistic understanding of the key factors that contribute to a trend. We describe how BOT graphs are used in public health, how they can be used to generate group discussion, and how this process can advance systems-level thinking. Then we describe how BOT graphs were used with groups of maternal and child health (MCH) practitioners and partners (N = 101) during a training session to advance their thinking about MCH challenges. Eighty-six percent of the 84 participants who completed an evaluation agreed or strongly agreed that they would use this BOT graph process to engage stakeholders in their home states and jurisdictions. The BOT graph process we describe can be applied to a variety of public health issues and used by practitioners, stakeholders, and researchers.

Objective: To assess women's perceptions of current body mass index (BMI) category, evaluate their knowledge of medical and surgical conditions associated with obesity, and assess their previous exposure to counseling on obesity., Design: Questionnaire-based survey., Setting: Gynecology clinics in a large midwestern city., Participants: Non-pregnant women age 18 to 65 years., Methods: Descriptive design with distribution of anonymous questionnaires pertaining to demographics, current medical conditions, perceived weight, medical conditions associated with obesity, surgical complications from obesity, and previous weight loss counseling. All data were analyzed using chi-squared tests, and statistical significance was set at a p value of <.05., Results: The majority of the sample (65%) was overweight or obese, and 44% of participants underestimated their BMI categories. The relationship of perceived versus actual BMI differed significantly by race (p < .001), income (p < .05), and education (p < .05); African American women and women with less education tended to underestimate their BMI categories. Increasing actual BMI was inversely correlated with the ability to identify obesity as a risk factor for medical conditions (p < .01). Only 43% of participants discussed their weight or related concerns with medical professionals., Conclusion: A significant number of participants were unaware of their BMI status as well as the relationship between obesity and other comorbidities. Counseling and patient education efforts by health care providers are essential., (© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

This study explored how nonpromotional school changes, a potentially major event for children, were associated with 3 forms of social maladjustment: isolation/withdrawal, affiliation with maladjusted peers, and aggression toward peers. Given that school mobility frequently co-occurs with family transitions, the moderating role of these transitions was investigated. These issues were examined in 2 longitudinal samples of U.S. (N = 1,364) and Canadian (N = 1,447) elementary school children. Propensity weighted analyses controlling for premobility individual, family, and friends' characteristics indicated that children who experienced both school and family transitions were at risk of either social withdrawal (in the Canadian sample) or affiliation with socially maladjusted peers (in the U.S. sample). These findings suggest the importance of considering both the social consequences of school mobility and the context in which such mobility occurs., (PsycINFO Database Record (c) 2015 APA, all rights reserved.)

Background: This study evaluated meal bolus insulin delivery strategies and associated postprandial glucose control while using an artificial pancreas (AP) system., Subjects and Methods: This study was a multicenter trial in 53 patients, 12-65 years of age, with type 1 diabetes for at least 1 year and use of continuous subcutaneous insulin infusion for at least 6 months. Four different insulin bolus strategies were assessed: standard bolus delivered with meal (n=51), standard bolus delivered 15 min prior to meal (n=40), over-bolus of 30% delivered with meal (n=40), and bolus purposely omitted (n=46). Meal carbohydrate (CHO) intake was 1 g of CHO/kg of body weight up to a maximum of 100 g for the first three strategies or up to a maximum of 50 g for strategy 4., Results: Only three of 177 meals (two with over-bolus and one with standard bolus 15 min prior to meal) had postprandial blood glucose values of <60 mg/dL. Postprandial hyperglycemia (blood glucose level >180 mg/dL) was prolonged for all four bolus strategies but was shorter for the over-bolus (41% of the 4-h period) than the two standard bolus strategies (73% for each). Mean postprandial blood glucose level was 15.9 mg/dL higher for the standard bolus with meal compared with the prebolus (baseline-adjusted, P=0.07 for treatment effect over the 4-h period)., Conclusions: The AP handled the four bolus situations safely, but at the expense of having elevated postprandial glucose levels in most subjects. This was most likely secondary to suboptimal performance of the algorithm.

Adding patient ratings and costs to quality metrics reshapes a system's goals.

Purpose: This study compares the frequency and severity of head impacts sustained by football players on days with and without diagnosed concussion and to identify the sensitivity and specificity of single-impact severity measures to diagnosed injury., Methods: One thousand two hundred eight players from eight collegiate football teams and six high school football teams wore instrumented helmets to measure head impacts during all team sessions, of which 95 players were diagnosed with concussion. Eight players sustained two injuries and one sustained three, providing 105 injury cases. Measures of head kinematics (peak linear and rotational acceleration, Gadd severity index, head injury criteria (HIC15), and change in head velocity (Δv)) and the number of head impacts sustained by individual players were compared between days with and without diagnosed concussion. Receiver operating characteristic curves were generated to evaluate the sensitivity and specificity of each kinematic measure to diagnosed concussion using only those impacts that directly preceded diagnosis., Results: Players sustained a higher frequency of impacts and impacts with more severe kinematic properties on days of diagnosed concussion than on days without diagnosed concussion. Forty-five injury cases were immediately diagnosed after head impact. For these cases, peak linear acceleration and HIC15 were most sensitive to immediately diagnosed concussion (area under the curve = 0.983). Peak rotational acceleration was less sensitive to diagnosed injury than all other kinematic measures (P = 0.01), which are derived from linear acceleration (peak linear, HIC15, Gadd severity index, and Δv)., Conclusions: Players sustained more impacts and impacts of higher severity on days of diagnosed concussion than on days without diagnosed concussion. In addition, of historical measures of impact severity, those associated with peak linear acceleration are the best predictors of immediately diagnosed concussion.

Outbreaks of human salmonellosis associated with live poultry contact have been reported since 1955. Multiple Salmonella serotypes have been associated with these outbreaks, and specific outbreak strains have been repeatedly linked to single hatcheries over multiple years. During 2009, four multistate outbreaks of human Salmonella infections associated with direct and indirect exposure to live poultry purchased from mail-order hatcheries and agricultural feed stores were identified, resulting in 165 culture-confirmed cases in 30 states. This report describes the epidemiologic, environmental and laboratory investigations conducted by state and local health departments, state departments of agriculture, the U.S. Department of Agriculture (USDA), Animal and Plant Health Inspection Service (APHIS), National Poultry Improvement Plan (NPIP) and National Veterinary Services Laboratories (NVSL), and the Centers for Disease Control and Prevention (CDC). Case-patients were identified through PulseNet, the national molecular subtyping network for foodborne disease surveillance, and interviewed using the CDC standard live poultry contact questionnaire that asks about poultry-related exposures during the 7 days before illness onset. These outbreaks highlight the need to focus efforts on strategies to decrease and prevent human illness associated with live poultry contact through comprehensive interventions at the mail-order hatchery, agricultural feed store and consumer levels. Additional consumer education and interventions at mail-order hatcheries and venues where live poultry are sold, including agricultural feed stores, are necessary to prevent transmission of Salmonella from poultry to humans., (© 2012 Blackwell Verlag GmbH.)

Purpose: The purpose of this study was to explore the nurse practitioner (NP) experience with caring for prehypertensive patients. Lifestyle modifications are the primary recommendation for management of prehypertension. Given the historical foundation of health promotion and disease prevention as a fundamental component of NP professional identity, gaining insight into the experience of caring for prehypertensive patients in the current healthcare environment is valuable to the profession, patients, and communities. Therefore, the NP role in health promotion and disease prevention related to prehypertension was explored as well., Data Sources: Narrative inquiry was the chosen methodology to gather narrative accounts of eight NPs caring for prehypertensive patients in primary care. The three-dimensional narrative inquiry space was used to guide the researcher during data analysis., Conclusions: Three themes emerged from the NPs' narratives: realities of practice, ambiguous role identity, and bridging models. Time constraints, financial considerations, and bridging the nursing and medical models while adapting to practice environments were barriers identified as components of the NP experience caring for patients with prehypertension., Implications for Practice: This study revealed that caring for prehypertensive patients is a complex and multilayered experience., (©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.)

Purpose: To provide nurse practitioners (NPs) with an overview of prehypertension identification and management. Additionally, the article serves to highlight the prevalence and impact of prehypertension in the United States., Data Sources: A comprehensive review of the literature was conducted using multiple databases, including PubMed, Medline, CINAHL, and SAGE Health Sciences databases. The review was not limited by discipline, year of publication, or type of research. Key words used to obtain relevant articles included prehypertension, nurse practitioner, health promotion, disease prevention, hypertension, and chronic disease., Conclusions: Approximately 70 million individuals have been recognized as prehypertensive in the United States, placing them at increased risk for hypertension and cardiovascular disease. Identifying and managing prehypertension has been recognized in national health policy as a priority to improve public health. Prehypertension is managed primarily by eliminating risk factors and implementing lifestyle modification., Implications for Practice: Health promotion and disease prevention form the cornerstone of the NP role. The designation of prehypertension serves as an opportunity for NPs to assist in decreasing the burden on the health system from chronic disease and improve patient quality of life., (©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.)

This study reviews the creation and testing of a model of Therapist Personal Agency during MFT training. A model including self-efficacy, trainee developmental level, supervisor working alliance, family of origin relationships, and psychological states was supported by data collected from a national sample of MFT students. The model supported by the data was consistent with much of the previous research regarding the correlates of therapist self-efficacy. Furthermore, the model accounted for 20% of the variance in therapist performance as measured by therapist reports of the working alliance. The results also highlighted the importance of attending to the relationships, interactions, and experiences that take place within the training environment and secondly, the added value that may accrue from focusing on the trainee's extended network of family relationships. A brief case example serves to illustrate the importance of tending to Therapist Personal Agency. In sum, this study provides preliminary support for holistic training methods that focus upon the whole person of the therapist., (© 2010 American Association for Marriage and Family Therapy.)

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Fibroblast growth factor (FGF)-2 (basic) is a potent angiogenic molecule involved in tumor progression, and is one of several growth factors with a central role in ovarian carcinogenesis. We hypothesized that common single nucleotide polymorphisms (SNPs) in the FGF2 gene may alter angiogenic potential and thereby susceptibility to ovarian cancer. We analyzed 25 FGF2 tgSNPs using five independent study populations from the United States and Australia. Analysis was restricted to non-Hispanic White women with serous ovarian carcinoma (1269 cases and 2829 controls). There were no statistically significant associations between any FGF2 SNPs and ovarian cancer risk. There were two nominally statistically significant associations between heterozygosity for two FGF2 SNPs (rs308379 and rs308447; p < .05) and serous ovarian cancer risk in the combined dataset, but rare homozygous estimates did not achieve statistical significance, nor were they consistent with the log additive model of inheritance. Overall genetic variation in FGF2 does not appear to play a role in susceptibility to ovarian cancer.

Objectives: To determine whether the offspring of centenarians have personality characteristics that are distinct from the general population., Design: Case-control., Setting: Nationwide U.S. sample., Participants: Unrelated offspring of centenarians (n=246, mean age 75) were compared with published norms., Measurements: Using the NEO-Five-Factor Inventory (NEO-FFI) questionnaire, measures of the personality traits neuroticism, extraversion, openness, agreeableness, and conscientiousness were obtained. T-scores and percentiles were calculated according to sex and used to interpret the results., Results: Male and female offspring of centenarians scored in the low range of published norms for neuroticism and in the high range for extraversion. The women also scored comparatively high in agreeableness. Otherwise, both sexes scored within normal range for conscientiousness and openness, and the men scored within normal range for agreeableness., Conclusion: Specific personality traits may be important to the relative successful aging demonstrated by the offspring of centenarians. Similarities across four of the five domains between male and female offspring is noteworthy and may relate to their successful aging. Measures of personality are an important phenotype to include in studies that assess genetic and environmental influences of longevity and successful aging.

To improve the safety and quality of the care that radiologists provide, and to allow radiologists and radiology personnel to remain competitive in an increasingly complex environment, it is essential that all imaging departments establish and maintain managed, comprehensive, and effective performance improvement programs. Although the structure and focus of these programs can vary, a number of common components exist, many of which are now widely mandated by organizations that regulate the field of radiology. Basic components include patient safety, process improvement, customer service, professional staff assessment, and education, each of which requires strategies for implementing continuous programs to monitor performance, analyzing and depicting data, implementing change, and meeting regulatory requirements. All of these components are part of a comprehensive quality management system in a large academic radiology department. For smaller departments or practices, the gradual introduction of one or more of these components is useful in ensuring the safety and quality of their services., ((c) RSNA, 2009.)

Background: Schools are in a unique position to promote healthy dietary behaviors and help ensure appropriate nutrient intake. This article describes the characteristics of both school nutrition services and the foods and beverages sold outside of the school meals program in the United States, including state- and district-level policies and school practices., Methods: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n=445). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=944)., Results: Few states required schools to restrict the availability of deep-fried foods, to prohibit the sale of foods that have low nutrient density in certain venues, or to make healthful beverages available when beverages were offered. While many schools sold healthful foods and beverages outside of the school nutrition services program, many also sold items high in fat, sodium, and added sugars., Conclusions: Nutrition services program practices in many schools continue to need improvement. Districts and schools should implement more food preparation practices that reduce the total fat, saturated fat, sodium, and added sugar content of school meals. In addition, opportunities to eat and drink at school should be used to encourage greater daily consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products.