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Kratom is a widely used Asian botanical that has gained popularity in the United States due to a perception that it can treat pain, anxiety, and opioid withdrawal symptoms. The American Kratom Association estimates 10–16 million people use kratom. Kratom‐associated adverse drug reactions (ADRs) continue to be reported and raise concerns about the safety profile of kratom. However, studies are lacking that describe the overall pattern of kratom‐associated adverse events and quantify the association between kratom and adverse events. ADRs reported to the US Food and Drug Administration Adverse Event Reporting System from January 2004 through September 2021 were used to address these knowledge gaps. Descriptive analysis was conducted to analyze kratom‐related adverse reactions. Conservative pharmacovigilance signals based on observed‐to‐expected ratios with shrinkage were estimated by comparing kratom to all other natural products and drugs. Based on 489 deduplicated kratom‐related ADR reports, users were young (mean age 35.5 years), and more often male (67.5%) than female patients (23.5%). Cases were predominantly reported since 2018 (94.2%). Fifty‐two disproportionate reporting signals in 17 system‐organ‐class categories were generated. The observed/reported number of kratom‐related accidental death reports was 63‐fold greater than expected. There were eight strong signals related to addiction or drug withdrawal. An excess proportion of ADR reports were about kratom‐related drug complaints, toxicity to various agents, and seizures. Although further research is needed to assess the safety of kratom, clinicians and consumers should be aware that real‐world evidence points to potential safety threats. [ABSTRACT FROM AUTHOR]

The Internet, since its inception, has been imagined as a technology that enables information to overcome barriers of language and geography. As a handful of social media platforms now dominate globally, removing most barriers of distribution; this has created unprecedented opportunities for content to gain worldwide traction, regardless of its country of origin. Yet historically with few exceptions, people generally consume content that is from or for their region. Has the Internet or social media really altered this trait? Analyzing the extent of similarities between a hundred countries' web use patterns simultaneously across their most popular websites, and country specific trends from YouTube and Twitter respectively, we find that countries which share borders or where people speak the same languages have the most similar web use patterns. Global social media usage on both YouTube and Twitter is even more heterogeneous and driven to a larger extent by language and geography than global website traffic. Neither does high prevalence of English language speakers in the two countries, nor does one of them being the United States contributes substantially to web use similarity. Global web use remains highly regional. The technical affordances of the Internet alone are thus insufficient to render a cosmopolitan world. [ABSTRACT FROM AUTHOR]

Purpose: To determine the incidence, characteristics, and costs associated with orbital hemorrhages presenting to US EDs. Patients and Methods: This was a retrospective, longitudinal study of the Nationwide Emergency Department Sample, 2006 to 2018. Medical records from patients presenting to participating hospital-owned EDs and diagnosed with primary or secondary orbital hemorrhage were examined to determine incidence, demographics, clinical characteristics, mechanism, disposition and related risk factors, and costs. Results: From 2006 to 2018, an estimated 20,762 US ED visits included an orbital hemorrhage diagnosis. Most primary diagnosis patients were elderly (35%) and male (51%), and incidence increased from 1.1 (95% CI: 0.8– 1.4) to 3.1 per million (95% CI: 2.5– 3.7, p < 0.0001). Fall was the most common mechanism (21.6%), particularly among the elderly (39.9%). Fall-related diagnoses increased from 0.03 (95% CI: − 0.01– 0.07) to 1.0 per million (95% CI: 0.7– 1.3, p < 0.0001), while overall falls increased by only 7%. Assault-related orbital hemorrhage increased from 0.1 (95% CI: 0.0– 0.2) to 0.6 per million (95% CI: 0.4– 0.7, p < 0.0001), while overall assaults decreased by 22%. Annual total ED costs increased from $463,220 (95% CI: 233,993– 692,446) to $6,117,320 (95% CI: 4,665,403– 7,569,237, p < 0.001). Inpatient admission was uncommon (9.0%), but related costs totaled $18.9 million (95% CI: 13.3– 24.5). Odds of admission were lower in fall- and objects-related injuries and higher with certain concurrent injuries. Conclusion: Orbital hemorrhages are becoming more frequent and costly. A disproportionately large increase in fall- and assault-related diagnoses highlights the need for targeted injury prevention strategies to reduce cost and morbidity. [ABSTRACT FROM AUTHOR]

Objectives: Examine the social influence of adult children on the cardiovascular-related health behaviors of older South Asian (SA) immigrants to inform lifestyle interventions. Design: This mixed-methods study used data from an ancillary study of social networks (2014–2018) in the Mediators of Atherosclerosis in South Asians Living in America cohort. Phase 1 was a quantitative analysis of self-reported diet and physical activity among SA adults (n = 448, mean age = 58 years, SD 8.4) who named at least one adult child to their social network. The Alternative Healthy Eating Index (AHEI) was used to measure parents' diet; higher numbers indicate a healthier diet (range 0–110). Phase 2 was a thematic content analysis of in-depth qualitative interviews from a subsample of these parents (n = 23, mean age = 55, SD 7.6). Results: Parents with an adult child in their network who consumed uncooked vegetables daily had mean parental AHEI score 1.5 points higher (adjusted p-value = 0.03) than those who had a child in the network who ate uncooked vegetables less often. When at least one adult child in their network ate fresh fruit daily compared to less frequently or when at least one child ate non-SA food daily compared to less frequently, mean parental AHEI scores were higher by 2.0 (adjusted p-value = 0.01) and 1.6 (adjusted p-value = 0.03) points respectively. Parents with an adult child in their network who exercised at least weekly were more likely to meet guideline-recommended physical activity levels than parents with children who exercised less often (76% v. 56%, adjusted p-value = 0.02). Adult children provided social support and were seen as 'role models' for healthy behavior, especially when adopting Western health behaviors. Conclusion: Positive role modeling and support from adult children were important facilitators of healthy behavior change in older SA immigrants and can inform health behavior interventions for SA adults. [ABSTRACT FROM AUTHOR]

Theories explaining the impacts of online media often swing between the actions of empowered individuals and the distribution structures put in place by powerful corporations. To explicate how these factors interact, we adapt the concept of audience flow to highlight the temporal dimension of web use and demonstrate how digital architectures subtly nudge masses of people into online attention flows. We identify sequential usage patterns through a network analysis of passively measured clickstreams, combined with data on website ownership and website architectures. Our sample, based on a panel of 1 million users, includes 1761 websites that reached at least 1% of Internet users in the United States. Our findings reveal previously unseen patterns of online audience formation, which have implications for studying media effects and understanding institutional power on the Internet. [ABSTRACT FROM AUTHOR]

Background: To examine the association between race and health outcomes among U.S. breast cancer (BC) survivors and explore to what extent do social and behavioral factors contribute to racial disparities for these associations. Materials and Methods: Four hundred forty-one female participants diagnosed with BC in the National Health and Nutrition Examination Survey from 2007 to 2016 were included in this study. Poisson regression with robust variance was used to estimate the prevalence ratio (PrR) and 95% confidence intervals for the associations between race, diabetes, hypertension, and other cancers. Results: The PrR for co-occurrence of diabetes and hypertension was 2.21 (p < 0.001) and 1.62 (p < 0.001) times, respectively, among African Americans (AA) compared with non-Hispanic whites. Body mass index (BMI) explained 17.5% of the association between AA race and diabetes prevalence; a smaller reduction (7.8%) was observed adjusting for type of health insurance coverage, only. A 23.5% reduction was observed in the association between AA race and diabetes prevalence with adjustment for BMI and insurance. The association between AA race and hypertension prevalence was reduced by <6% with addition of individual risk factors, including education, insurance, poverty, obesity, smoking, and physical activity, and with adjustment of the combination of these factors. Conclusions: The association between AA race and diabetes prevalence among BC survivors may be partially explained by BMI and insurance coverage to a lesser extent. Interventions to improve outcomes among AA survivors should focus on weight management strategies. [ABSTRACT FROM AUTHOR]

Introduction: There are few longitudinal studies about South Asians (SAs) and little information about recruitment and retention approaches for this ethnic group. Methods: We followed 906 SAs enrolled in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort for 5 years. Surviving participants were invited for a second clinical exam from 2015 to 2018. A new wave of participants was recruited during 2017–2018. We assessed the yields from different methods of recruitment and retention. Results: A total of 759 (83%) completed the second clinical exam, and 258 new participants were enrolled. Providing a nearby community hospital location for the study exam, offering cab/shared ride reimbursement, and conducting home visits were the most effective methods for enhancing retention. New participant recruitment targeted women and individuals with lower socioeconomic status, and we found that participant referrals and active community engagement were most effective. Mailing invitational letters to those identified by electronic health records had very low yield. Conclusion: Recruitment and retention strategies that address transportation barriers and increase community engagement will help increase the representation of SAs in health research. [ABSTRACT FROM AUTHOR]

Purpose Vascular targeted photodynamic therapy with WST11 (TOOKAD® Soluble) is a form of tissue ablation that may be used therapeutically for localized prostate cancer. To study dosing parameters and associated treatment effects we performed a prospective, multicenter, phase I/II trial of WST11 vascular targeted photodynamic therapy of prostate cancer. Materials and Methods A total of 30 men with unilateral, low volume, Gleason 3 + 3 prostate cancer were enrolled at 5 centers after local institutional review board approval. Light energy, fiber number and WST11 dose were escalated to identify optimal dosing parameters for vascular targeted photodynamic therapy hemi-ablation. Men were treated with photodynamic therapy and evaluated by posttreatment magnetic resonance imaging and biopsy. Prostate specific antigen, light dose index (defined as fiber length/desired treatment volume), toxicity and quality of life parameters were recorded. Results After dose escalation 21 men received optimized dosing of 4 mg/kg WST11 at 200 J energy. On posttreatment biopsy residual prostate cancer was found in the treated lobe in 10 men, the untreated lobe in 4 and both lobes in 1. At a light dose index of 1 or greater with optimal dosing in 15 men 73.3% had a negative biopsy in the treated lobe. Six men undergoing retreatment with the optimal dose and a light dose index of 1 or greater had a negative posttreatment biopsy. Minimal effects were observed on urinary and sexual function, and overall quality of life. Conclusions Hemi-ablation of the prostate with WST11 vascular targeted photodynamic therapy was well tolerated and resulted in a negative biopsy in the treated lobe in the majority of men. Dosing parameters and the light dose index appear related to tissue response as determined by magnetic resonance imaging and biopsy. These parameters may serve as the basis for further prospective studies. [ABSTRACT FROM AUTHOR]

Rationale: Understanding the changing incidence and impact of acute kidney injury requiring dialysis in patients with severe sepsis will allow better risk stratification, design of clinical trials, and guide resource allocation.Objectives: To assess the longitudinal incidence of acute kidney injury requiring dialysis and its impact on mortality in patients with severe sepsis.Methods: Retrospective cohort study of adults (≥20 yr) hospitalized with severe sepsis from 2000 to 2009 in the United States using a nationally representative database.Measurements and Main Results: We calculated the incidences of acute kidney injury requiring dialysis and mortality over time. We used linear regression to assess temporal trends. We used logistic regression to estimate the odds of acute kidney injury requiring dialysis and mortality. Of the estimated 5,257,907 hospitalizations with severe sepsis, 6.1% had acute kidney injury requiring dialysis. The odds of acquiring acute kidney injury requiring dialysis increased by 14% in 2009 compared with 2000. Mortality in patients with acute kidney injury requiring dialysis was higher (43.6% vs. 24.9%; P < 0.001). After multivariable adjustment, odds of mortality declined 61% by the year 2009. Acute kidney injury requiring dialysis remained an independent predictor of mortality in patients with severe sepsis, although its influence on mortality declined with time.Conclusions: Incidence of acute kidney injury requiring dialysis in patients with severe sepsis has increased over time; conversely, associated mortality has declined. The likelihood of demise from acute kidney injury requiring dialysis in patients with severe sepsis has also declined. [ABSTRACT FROM AUTHOR]

LONGSCAN was a longitudinal study of the risks and consequences of child abuse and neglect conducted between 1992 and 2012 among five sites across the US. Interviews with mothers of at-risk children began when the children were four years of age, and mothers and children from age six to age 18 years were interviewed every other year. Maltreatment reports were obtained from departments of social services, and subjects' self-reported abuse was obtained at age 12. Generalised estimating equations were used to investigate the impact of informal social control, social cohesion and trust (SCT), and caregiver depression at ages 12, 14 and 16 years on externalising behaviours, smoking and alcohol use among 18-year olds who had been neglected prior to age 12. In models controlling for child age and gender, maltreatment types other than neglect, maternal education and study site, SCT significantly reduced the impact of caregiver depression on externalising behaviour and alcohol use among the neglected children at age 18. This moderating effect was not seen among non-neglected 18-year-old children. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Messages: Child neglect is a significant predictor of adolescent health risk behaviours., Caregiver depression increases the risk of neglect and increases the adverse behavioural outcomes of neglect., Among children neglected before age 12, in the presence of caregiver depression, SCT reduce externalising behaviours and alcohol use at age 18., Identification and treatment of caregiver depression, along with supporting community cohesion and neighbourhood trust, can ameliorate some of the negative outcomes associated with child neglect. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to compare the canal transportation, canal centering ability, and time taken for preparation of curved root canals after instrumentation with ProFile GT Series X (GTX) files, Revo-S files, twisted files, and Mtwo files by using cone-beam computed tomography (CBCT). Materials and Methods: Forty mesiobuccal canals of mandibular molars with an angle of curvature ranging from 20 to 40 were divided according to the instrument used in canal preparation into four groups of 10 samples each: GTX (group I), Revo-S (group II), twisted file (group III), and Mtwo (group IV). The teeth were instrumented according to manufacturer's guidelines, with all groups being prepared to size 30, 0.06 taper master apical file. Canals were scanned using an i-CAT CBCT scanner (Imaging Science International, Hatfield, PA, USA) before and after preparation to evaluate the transportation and centering ratio at 3 mm, 5 mm, 7 mm, 9 mm, and 11 mm from the apex. The data collected were evaluated using one-way analysis of variance (ANOVA) with Tukey's honestly significant difference (HSD) test. Results: Twisted file system showed significantly least canal transportation and highest canal centering ability values as compared to GTX, Revo-S, and Mtwo file systems. Overall, GTX, Revo-S, and Mtwo showed comparable results with respect to canal transportation and centering ability. Conclusion: The innovative method of manufacturing the TF system resulted in superior shaping ability in curved canals, with the instruments remaining more centered and producing less canal transportation than GTX, Revo-S, and Mtwo file systems. [ABSTRACT FROM AUTHOR]

Abstract: Miscellaneous and electronic loads (MELs) consume about 20% of the primary energy used in U.S. buildings, and this share is projected to increase for the foreseeable future. Our understanding, however, of which devices are most responsible for this energy use is still rudimentary due to the difficulty and expense of performing detailed studies on MELs and their energy use. In order to better understand the energy use of MELs and the design of MELs field metering studies, we conducted a year-long study of MELs in an 89,500 sq. ft. (8310 m2) office building. We present insights obtained from this study using 455 wireless plug-load power meters including the study design process, the tools needed for success, and key other methodology issues. Our study allowed us to quantify, for the study buildings, how many devices we needed to inventory and meter as well as for how long we needed to collect meter data. We find that the study design of earlier work would not have yielded accurate results in our study building. This paper presents these findings along with a brief summary of the energy related results. [Copyright &y& Elsevier]

The article discusses a study which described differences in use and timeliness of procedures such as IVC filter placement and IV thrombolysis that might be less available on weekends. A nationally representative administrative data-base developed by the Agency for Healthcare Research and Quality was used. It suggests that IVC filters were less likely to be placed during the first hospital day in patients admitted over the weekend.

The article examines national trends in the frequency and outcomes of hospitalizations for severe sepsis in the U.S. between 2000 and 2007, using the Healthcare Costs and Utilization Project's Nationwide Inpatient Sample (NIS). Results suggest that a growing number of admissions for severe sepsis combined with decreasing mortality rates contribute to more individuals surviving to hospital discharge. This results in more survivors being discharged to skilled nursing facilities and homes.

The United States Environmental Protection Agency/Environmental Response Team (US EPA/ERT), in conjunction with St. John's College, Dr B R Ambedkar University, Agra, India, is conducting a study to determine mercury vapor emission rates resulting from broken compact fluorescent lamps (CFLs) in a residential setting. The overall objectives of the study are to obtain a mercury emission model and provide a homeowner with cleanup procedures and disposal options for broken CFLs. An important component in achieving these objectives is the determination of the total mercury content in CFLs for the selection of bulbs to be used in the emission study. Most of the currently available CFLs in the United States (U.S.) market are manufactured in China for U.S. companies. Several different types of CFLs were purchased from local stores and the cap and electronic parts were removed without breaking the bulb. The bulb was then placed into a 2-L polypropylene bottle containing glass stoppers or glass marbles in a mixture of nitric acid and bromine monochloride solution (BrCl). The mixture was shaken to break the lamp and allow the mercury to be completely absorbed by the BrCl. The digested samples were analyzed for mercury using standard cold vapor atomic absorption (CVAA) methods. This CFL preparation method provides excellent results for laboratory control samples (typically, 90%-110% recovery) and good repeatability for CFL bulb analyses. The sampling and analysis phases of this study are discussed in this paper. [ABSTRACT FROM AUTHOR]

Background. A rotavirus vaccine previously licensed in the United States was withdrawn because it caused intussusception. Data on background intussusception rates in developing countries are required to plan pre- and postlicensure safety studies for new rotavirus vaccines. Also, it is unclear whether natural rotavirus infection is associated with intussusception. Methods. Passive surveillance for intussusception in a large, well-defined, poor, urban population in Delhi, India, was conducted in 2 phases. Intussusception was confirmed by ultrasonography or surgery. Fecal samples obtained from patients with intussusception at study hospitals (irrespective of their residence in study areas) and healthy control subjects were tested for rotavirus with use of enzyme immunoassay. If available, resected intestinal tissue samples were tested for rotavirus with use of immunohistochemistical analysis and reverse-transcription polymerase chain reaction. Results. The incidence of intussusception requiring hospitalization was 17.7 cases per 100,000 infant-years of follow-up (95% confidence interval, 5.9-41.4 cases per 100,000 infant-years). Detection rates of rotavirus in stool samples did not differ significantly between case patients and control subjects (4 of 42 case patients vs 6 of 92 control subjects), and no evidence of rotavirus was detected in any of the 22 patients with intussusception for whom intestinal tissue samples were available. Conclusions. The incidence of intussusception among Indian infants appears to be lower than that reported in other middle- and high-income countries. Natural rotavirus infection does not appear to be a major cause of intussusception in Indian infants. [ABSTRACT FROM AUTHOR]

Investigates how a farmer-led grassroots effort added new meaning to the phrase "American made" by producing an alternative fuel and effecting public policy decisions in Minnesota. Definition of biodiesel fuel, its creation, properties and research; Discussion of federal biodiesel fuel policies; Influence of state policies in soyabean production including the creation of a biodiesel fuel industry.

This paper examines the costs and consequences of caring for boarder patients who are disproportionately represented in urban hospitals. Resource consumption, for instance, under Prospective Payment System (PPS) has created initiatives in cost-containment which have focused the attention of health-care managers more intently on the distribution costs, quantity and types of services provided to patients. During fiscal year 1989, several District of Columbia (DC) hospitals cited problems with patients who were hospitalized but did not require medical attention. Data were obtained from the financial records of eight infants who were in DC-Howard University Hospital (HUH) between July 1, 1988 and August 28, 1989. Cost analysis revealed that fifty-two percent of the total incurred for the hospitalization of the sample stemmed from providing care to the patients after they were ready for discharge. The boarders represented twenty-eight percent of the total patient days in the nursery and 1.9 percent of the stay of all patients. Indeed, the financial department at HUH found that the cost of caring for these additional patients was over five million dollars--2.5 percent of charges generated by the hospital--representing 17 percent of the total uncompensated care provided by the hospital during the 1988-89 fiscal year.

Using data from the 2000-2004 US Healthcare Cost and Utilization Project National Inpatient Sample, we found that total hospital admissions for skin and soft tissue infections increased by 29% during 2000-2004; admissions for pneumonia were largely unchanged. These results are consistent with recent reported increases in community-associated methicillin-resistant Staphylococcus aureus infections. [ABSTRACT FROM AUTHOR]

Purpose. The 90-day risk of venous thromboembolism (VTE) among medically ill patients admitted to a hospital was estimated and is discussed. Summary. Patients aged ≥40 years who were hospitalized between January 1, 1998, and June 30, 2002, for reasons other than traumatic injury, labor and delivery, mental disorder, or VTE and who did not undergo surgery were identified in a large U.S. healthcare claims database. Patients receiving anticoagulants in the 90-day period preceding hospital admission were excluded. We estimated the percentage of study subjects who developed clinical deep-vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days of hospital admission using Kaplan-Meier methods. We also estimated hazard ratios (HRs) for potential risk factors for VTE using univariate and stepwise multivariate Cox proportional hazards regression models. Among 92,162 study subjects, 1468 (1.59%) developed clinical DVT or PE within 90 days of hospital admission; 18% of these events occurred postdischarge. In multivariate analyses, significant risk factors for clinical VTE included: 1) history of cancer (HR, 1.67; 95% confidence interval [CI], 1.45-1.93); 2) history of VTE within six months of index admission (HR, 6.14; 95% CI, 4.74-7.96); 3) operating room procedure within 30 days of index admission (HR, 1.81; 95% CI, 1.47-2.24); 4) peripheral artery disease during index admission (HR, 1.68; 95% CI, 1.28-2.21); and 5) heart failure during index admission (HR, 1.72; 95% CI, 1.52-1.95). Conclusion. The risk of clinical VTE among medically ill patients admitted to a hospital, although less than that of patients undergoing major surgery, is not negligible. Patients with a history of recent VTE or surgery, those who are admitted to the intensive care unit, those with an admitting diagnosis of heart failure, and those with active cancer are at especially high risk of VTE and deserve increased consideration for prophylaxis. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to study the age-dependence of the optomechanical properties of human lenses during simulated disaccommodation in a mechanical lens stretcher, designed to determine accommodative forces as a function of stretch distance, to compare the results with in vivo disaccommodation and to examine whether differences exist between eyes harvested in the USA and India. Postmortem human eyes obtained in the USA (n =46, age=6–83years) and India (n =91, age=1day–85years) were mounted in an optomechanical lens stretching system and dissected to expose the lens complete with its accommodating framework, including zonules, ciliary body, anterior vitreous and a segmented rim of sclera. Disaccommodation was simulated through radial stretching of the sectioned globe by 2mm in increments of 0.25mm. The load, inner ciliary ring diameter, lens equatorial diameter, central thickness and power were measured at each step. Changes in these parameters were examined as a function of age, as were the dimension/load and power/load responses. Unstretched lens diameter and thickness increased over the whole age range examined and were indistinguishable from those of in vivo lenses as well as those of in vitro lenses freed from zonular attachments. Stretching increased the diameter and decreased the thickness in all lenses examined but the amount of change decreased with age. Unstretched lens power decreased with age and the accommodative amplitude decreased to zero by age 45–50. The load required to produce maximum stretch was independent of age (median 80mN) whereas the change in lens diameter and power per unit load decreased significantly with age. The age related changes in the properties of human lenses, as observed in the lens stretching device, are similar to those observed in vivo and are consistent with the classical Helmholtz theory of accommodation. The response of lens diameter and power to disaccommodative (stretching) forces decreases with age, consistent with lens nuclear stiffening. [Copyright &y& Elsevier]

Background: Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully., Research Question: What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways?, Study Design and Methods: This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy., Results: Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient's lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube placement ($40,627; P = .004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) incurred similar costs as patients receiving thoracentesis., Interpretation: Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: C. G., M. J., M. W., S. X., A. T., and E. E. are employees of Becton, Dickinson, and Company. D. E. O. is a consultant for Becton, Dickinson, and Company, and author for UpToDate, on the test writing committee for the American Board of Internal Medicine, and an intuitive surgical consultant for Johnson and Johnson., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine the prevalence of invasive bacterial infections (IBIs) and adverse events in afebrile infants with acute otitis media (AOM)., Methods: We conducted a 33-site cross-sectional study of afebrile infants ≤90 days of age with AOM seen in emergency departments from 2007 to 2017. Eligible infants were identified using emergency department diagnosis codes and confirmed by chart review. IBIs (bacteremia and meningitis) were determined by the growth of pathogenic bacteria in blood or cerebrospinal fluid (CSF) culture. Adverse events were defined as substantial complications resulting from or potentially associated with AOM. We used generalized linear mixed-effects models to identify factors associated with IBI diagnostic testing, controlling for site-level clustering effect., Results: Of 5270 infants screened, 1637 met study criteria. None of the 278 (0%; 95% confidence interval [CI]: 0%-1.4%) infants with blood cultures had bacteremia; 0 of 102 (0%; 95% CI: 0%-3.6%) with CSF cultures had bacterial meningitis; 2 of 645 (0.3%; 95% CI: 0.1%-1.1%) infants with 30-day follow-up had adverse events, including lymphadenitis (1) and culture-negative sepsis (1). Diagnostic testing for IBI varied across sites and by age; overall, 278 (17.0%) had blood cultures, and 102 (6.2%) had CSF cultures obtained. Compared with infants 0 to 28 days old, older infants were less likely to have blood cultures ( P < .001) or CSF cultures ( P < .001) obtained., Conclusion: Afebrile infants with clinician-diagnosed AOM have a low prevalence of IBIs and adverse events; therefore, outpatient management without diagnostic testing may be reasonable., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Hydroxyurea, chronic blood transfusions, and bone marrow transplantation are efficacious, disease-modifying therapies for sickle cell disease but involve complex risk-benefit trade-offs and decisional dilemma compounded by the lack of comparative studies. A patient decision aid can inform patients about their treatment options, the associated risks and benefits, help them clarify their values, and allow them to participate in medical decision making., Objective: The objective of this study was to develop a literacy-sensitive Web-based patient decision aid based on the Ottawa decision support framework, and through a randomized clinical trial estimate the effectiveness of the patient decision aid in improving patient knowledge and their involvement in decision making., Methods: We conducted population decisional needs assessments in a nationwide sample of patients, caregivers, community advocates, policy makers, and health care providers using qualitative interviews to identify decisional conflict, knowledge and expectations, values, support and resources, decision types, timing, stages and learning, and personal clinical characteristics. Interview transcripts were coded using QSR NVivo 10. Alpha testing of the patient decision aid prototype was done to establish usability and the accuracy of the information it conveyed, and then was followed by iterative cycles of beta testing. We conducted a randomized clinical trial of adults and of caregivers of pediatric patients to evaluate the efficacy of the patient decision aid., Results: In a decisional needs assessment, 223 stakeholders described their preferences, helping to guide the development of the patient decision aid, which then underwent alpha testing by 30 patients and 38 health care providers and iterative cycles of beta testing by 87 stakeholders. In a randomized clinical trial, 120 participants were assigned to either the patient decision aid or standard care (SC) arm. Qualitative interviews revealed high levels of usability, acceptability, and utility of the patient decision aid in education, values clarification, and preparation for decision making. On the acceptability survey, 72% (86/120) of participants rated the patient decision aid as good or excellent. Participants on the patient decision aid arm compared to the SC arm demonstrated a statistically significant improvement in decisional self-efficacy (P=.05) and a reduction in the informed sub-score of decisional conflict (P=.003) at 3 months, with an improvement in preparation for decision making (P<.001) at 6 months. However, there was no improvement in terms of the change in knowledge, the total or other domain scores of decisional conflicts, or decisional self-efficacies at 6 months. The large amount of missing data from survey completion limited our ability to draw conclusions about the effectiveness of the patient decision aid. The patient decision aid met 61 of 62 benchmarks of the international patient decision aid collaboration standards for content, development process, and efficacy., Conclusions: We have developed a patient decision aid for sickle cell disease with extensive input from stakeholders and in a randomized clinical trial demonstrated its acceptability and utility in education and decision making. We were unable to demonstrate its effectiveness in improving patient knowledge and involvement in decision making., Trial Registration: ClinicalTrials.gov NCT03224429; https://clinicaltrials.gov/ct2/show/NCT03224429 and ClinicalTrials.gov NCT02326597; https://clinicaltrials.gov/ct2/show/NCT02326597., (©Lakshmanan Krishnamurti, Diana Ross, Cynthia Sinha, Traci Leong, Namita Bakshi, Nonita Mittal, Divya Veludhandi, Anh-Phuong Pham, Alankrita Taneja, Kamesh Gupta, Julum Nwanze, Andrea Marie Matthews, Saumya Joshi, Veronica Vazquez Olivieri, Santhi Arjunan, Ifechi Okonkwo, Ines Lukombo, Peter Lane, Nitya Bakshi, George Loewenstein. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 04.12.2019.)

Being inherently different from any other lifesaving organ transplant, uterine transplantation does not aim at saving lives but supporting the possibility to generate life. Unlike the kidneys or the liver, the uterus is not specifically a vital organ. Given the non-lifesaving nature of this procedure, questions have been raised about its feasibility. The ethical dilemma revolves around whether it is worth placing two lives at risk related to surgery and immunosuppression, amongst others, to enable a woman with absolute uterine factor infertility to experience the presence of an organ enabling childbirth. In the year 2000, the first uterine transplantation, albeit unsuccessful, was performed in Saudi Arabia from where it has spread to the rest of the world including Sweden, the United States and now recently India. The procedure is, however, still in the preclinical stages and several ethical, legal, social and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.

Objective: Severe sepsis requires timely management and has high mortality if care is delayed. Hematopoietic stem cell transplant recipients are more likely to be immunocompromised and are predisposed to serious infections. Reports of outcomes of severe sepsis in this population are limited to data from single, tertiary care centers, and national outcomes data are missing., Design: Retrospective analysis of an administrative database., Setting: Twenty percent of community hospitals in United States, excluding federal hospitals., Subject: Patients with severe sepsis., Intervention: None., Measurements and Main Results: We used International Classification of Diseases, 9th Edition, Clinical Modification codes indicating the presence of sepsis and organ system failure to identify hospitalizations for severe sepsis between 2000 and 2008. We also used International Classification of Diseases, 9th Edition, Clinical Modification codes to identify hematopoietic stem cell transplant recipients. We compared outcomes of hematopoietic stem cell transplant recipients with severe sepsis during engraftment and subsequent admissions with a non-hematopoietic stem cell transplant cohort and excluded solid-organ transplantation from this cohort. We used mixed effect, multivariate logistic regression modeling with propensity score adjustment to examine factors associated with mortality of severe sepsis in hematopoietic stem cell transplant recipients. A total of 21,898 hematopoietic stem cell transplant recipients with severe sepsis were identified. The frequency of severe sepsis in hematopoietic stem cell transplant recipients was five times higher when compared with the non-hematopoietic stem cell transplant cohort. The unadjusted mortality was 32.9% in non-hematopoietic stem cell transplant cohort, which was similar to autologous hematopoietic stem cell transplant recipients (30.1%) and those who did not develop graft-versus-host disease (35%). Mortality was significantly higher in allogeneic transplants (55.1%, p < 0.001) and in those who developed graft-versus-host disease (47.9%, p < 0.001). After adjustment, during engraftment admission, the odds of in-hospital mortality in allogeneic hematopoietic stem cell transplant (odds ratio, 3.81; 95% CI, 2.39-6.07) and autologous hematopoietic stem cell transplant (odds ratio, 1.28; 95% CI, 1.06-1.53) recipients was significantly higher than non-hematopoietic stem cell transplant patients. Similarly, in subsequent admissions, hematopoietic stem cell transplant recipients with graft-versus-host disease (odds ratio, 2.14; 95% CI, 1.88-2.45) and without graft-versus-host disease (odds ratio, 1.35; 95% CI, 1.19-1.54) had significantly higher odds of mortality than non-hematopoietic stem cell transplant patients. Among patients with hematopoietic stem cell transplant, persons with autologous hematopoietic stem cell transplant and those without graft-versus-host disease fared better as compared with their allogeneic and graft-versus-host disease counterparts., Conclusions: Hematopoietic stem cell transplant recipients are more likely to develop severe sepsis and die following a severe sepsis episode than nontransplant patients. Autologous hematopoietic stem cell transplant recipients and those who do not develop graft-versus-host disease have significantly better outcomes than allogeneic and graft-versus-host disease patients.

Background: The current frequency of noninvasive (NIV) and invasive mechanical ventilation use in asthma exacerbations (AEs) and the relationship to outcomes are unknown., Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients discharged with a principal diagnosis of AE. For each discharge, we determined whether NIV or invasive mechanical ventilation was initiated during the first 2 hospital days. Using multivariate logistic regression to adjust for potential confounders, we determined whether use of mechanical ventilation and in-hospital mortality changed between 2000 and 2008., Results: The number of AEs increased by 15.8% from 2000 to 2008. The proportion of admissions for which invasive mechanical ventilation was used during the first 2 days decreased from 1.4% in 2000 to 0.73% in 2008, whereas NIV use increased from 0.34% to 1.9%. The adjusted mortality from AEs requiring NIV or invasive mechanical ventilation was unchanged from 2000 to 2008. The hospital stay was also unchanged., Conclusions: There was a substantial increase in the use of mechanical ventilation, accompanied by a shift from invasive mechanical ventilation to NIV. Although we could not determine the clinical reasons for this increase, hospital stay and mortality were unchanged. A randomized trial is needed to determine whether NIV can improve outcomes in AEs before widespread adoption makes it impossible to conduct such a trial.

Objective: Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care., Design: We performed a retrospective analysis of administrative database-Healthcare Costs and Utilization Project's Nationwide Inpatient Sample-to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis., Patients: None., Interventions: We used International Classification of Diseases-9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination., Measurements and Main Results: There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge., Conclusions: Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

Background: Critically ill, morbidly obese patients (BMI≥40 kg/m2) are at high risk of respiratory failure requiring invasive mechanical ventilation (IMV). It is not clear if outcomes of critically ill, obese patients are affected by obesity. Due to limited cardiopulmonary reserve, they may have poor outcomes. However, literature to this effect is limited and conflicted., Methods: We used the Nationwide Inpatient Sample from 2004 to 2008 to examine the outcomes of morbidly obese people receiving IMV and compared them to nonobese people. We identified hospitalizations requiring IMV and morbid obesity using International Classification of Diseases, 9th Revision, Clinical Modification codes. Primary outcomes studied were inhospital mortality, rates of prolonged mechanical ventilation (≥96 h), and tracheostomy. Multivariable logistic regression was used to adjust for potential confounding variables. We also examined outcomes stratified by number of organs failing., Results: Of all hospitalized, morbidly obese people, 2.9% underwent IMV. Mean age, comorbidity score, and severity of illness were lower in morbidly obese people. The adjusted mortality was not significantly different in morbidly obese people (OR 0.89; 95% CI, 0.74-1.06). When stratified by severity of disease, there was a stepwise increase in risk for mortality among morbidly obese people relative to nonobese people (range: OR, 0.77; 95% CI, 0.58-1.01 for only respiratory failure, to OR, 4.14; 95% CI, 1.11-15.3 for four or more organs failing). Rates of prolonged mechanical ventilation were similar, but rate of tracheostomy (OR 2.19; 95% CI, 1.77-2.69) was significantly higher in patients who were morbidly obese., Conclusions: Morbidly obese people undergoing IMV have a similar risk for death as nonobese people if only respiratory failure is present. When more organs fail, morbidly obese people have increased risk for mortality compared with nonobese people.

Background and Objectives: CKD and ESRD are growing burdens. It is unclear whether these conditions affect pulmonary embolism (PE) risk, given that they affect both procoagulant and anticoagulant factors. This study examined the frequency and associated outcomes of PE in CKD and ESRD., Design, Setting, Participants, & Measurements: The Healthcare Cost and Utilization Project's Nationwide Inpatient Sample was used to estimate the frequency and outcomes of PE in adults with CKD and ESRD. Hospitalizations for the principal diagnosis of PE and presence of CKD or ESRD were identified using International Classification of Diseases, Ninth Revision codes. Data from the annual US Census and US Renal Data System reports were used to calculate the number of adults with CKD, ESRD, and normal kidney function (NKF) as well as the annual incidence of PE in each group. Logistic regression modeling was used to compare in-hospital mortality among persons admitted for PE who had ESRD or CKD to those without these conditions., Results: The annual frequency of PE was 527 per 100,000, 204 per 100,000, and 66 per 100,000 persons with ESRD, CKD, and NKF, respectively. In-hospital mortality was higher for persons with ESRD and CKD (P<0.001) compared with persons with NKF. Median length of stay was longer by 1 day in CKD and 2 days in ESRD than among those with NKF., Conclusions: Persons with CKD and ESRD are more likely to have PE than persons with NKF. Once they have PE, they are more likely to die in the hospital.