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Abstract: Objective: To prospectively characterize the prevalence, course, and impact of acute sleep abnormality among traumatic brain injury (TBI) neurorehabilitation admissions. Design: Prospective observational study. Setting: Freestanding rehabilitation hospital. Participants: Primarily severe TBI (median emergency department Glasgow Coma Scale [GCS] score=7; N=205) patients who were mostly men (71%) and white (68%) were evaluated during acute neurorehabilitation. Interventions: None. Main Outcome Measure: Delirium Rating Scale-Revised-98 (DelRS-R98) was administered weekly throughout rehabilitation hospitalization. DelRS-R98 item 1 was used to classify severity of sleep-wake cycle disturbance (SWCD) as none, mild, moderate, or severe. SWCD ratings were analyzed both serially and at 1 month postinjury. Results: For the entire sample, 66% (mild to severe) had SWCD at 1 month postinjury. The course of the SWCD using a subset (n=152) revealed that 84% had SWCD on rehabilitation admission, with 63% having moderate to severe ratings (median, 24d postinjury). By the third serial exam (median, 35d postinjury), 59% remained with SWCD, and 28% had moderate to severe ratings. Using general linear modeling and adjusting for age, emergency department GCS score, and days postinjury, presence of moderate to severe SWCD at 1 month postinjury made significant contributions in predicting duration of posttraumatic amnesia (P<.01) and rehabilitation hospital length of stay (P<.01). Conclusions: Results suggest that sleep abnormalities after TBI are prevalent and decrease over time. However, a high percent remained with SWCD throughout the course of rehabilitation intervention. Given the brevity of inpatient neurorehabilitation, future studies may explore targeting SWCD to improve early outcomes, such as cognitive functioning and economic impact, after TBI. [Copyright &y& Elsevier]

Abstract: Ottomanelli L, Goetz LL, Suris A, McGeough C, Sinnott PL, Toscano R, Barnett SD, Cipher DJ, Lind LM, Dixon TM, Holmes SA, Kerrigan AJ, Thomas FP. Effectiveness of supported employment for veterans with spinal cord injuries: results from a randomized multisite study. Objective: To examine whether supported employment (SE) is more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI). Design: Prospective, randomized, controlled, multisite trial of SE versus TAU for vocational issues with 12 months of follow-up data. Setting: SCI centers in the Veterans Health Administration. Participants: Subjects (N=201) were enrolled and completed baseline interviews. In interventional sites, subjects were randomly assigned to the SE condition (n=81) or the TAU condition (treatment as usual–interventional site [TAU-IS], n=76). In observational sites where the SE program was not available, 44 subjects were enrolled in a nonrandomized TAU condition (treatment as usual–observational site [TAU-OS]). Interventions: The intervention consisted of an SE vocational rehabilitation program called the Spinal Cord Injury Vocational Integration Program, which adhered as closely as possible to principles of SE as developed and described in the individual placement and support model of SE for persons with mental illness. Main Outcome Measures: The primary study outcome measurement was competitive employment in the community. Results: Subjects in the SE group were 2.5 times more likely than the TAU-IS group and 11.4 times more likely than the TAU-OS group to obtain competitive employment. Conclusions: To the best of our knowledge, this is the first and only controlled study of a specific vocational rehabilitation program to report improved employment outcomes for persons with SCI. SE, a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI. [Copyright &y& Elsevier]

Summary: Bronchiolitis Obliterans Syndrome (BOS) complicates the course of many lung transplant recipients. It carries significant risk of morbidity and mortality, but its course is difficult to characterize. We evaluated the prognostic utility of the 6min walk test (6MWT) obtained after the onset of BOS in 42 patients. This was compared to the prognostic significance of changes in the FEV1. The median time between the onset of BOS and the 6MWT was 109 days. The median decline in the FEV1 from baseline to BOS onset was 25.7%, while the median change over the ensuing 3 months was 12.5%. Neither of these was predictive of subsequent mortality. The 6MWT yielded averages in the resting saturation, lowest saturation, distance walked and maximal Borg scores of 97%, 90.2%, 323m and 2.35, respectively. The best of these parameters in discriminating survival was the distance. Patients who walked further than 330m had a median survival of 1178 days versus 263 days for those who walked less (p <0.0001). We conclude that the 6MWT provides important prognostic information in patients with BOS and might perform better than spirometry. Use of this test might allow different clinical phenotypes to be discerned. [Copyright &y& Elsevier]

Objectives: Percutaneous intervention for coronary revascularization is associated with an increased risk of repeat revascularization, especially in patients with diabetes mellitus. In this study we sought to examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome and intermediate-term survival in patients undergoing coronary artery bypass surgery. Methods: Between January 1, 2001, and December 31, 2006, 1758 consecutive patients with diabetes mellitus who underwent first-time isolated coronary artery bypass surgery were identified. Survival and major perioperative complications for 1537 patients who did not have prior percutaneous intervention (group 1) were compared with those in 221 patients with prior percutaneous intervention (group 2) after adjusting for baseline risk factors. Vital status was determined by using the National Death Index and Social Security Death Index. Age-adjusted survival at 2 years'' follow-up was calculated with the Cox singular proportional hazards model. Results: At baseline, group 2 patients had higher incidences of hypercholesterolemia and myocardial infarction. Compared with group 1 patient, group 2 patients had significantly higher operative mortality (adjusted odds ratio, 4.05; 95% confidence interval, 1.41–11.63), perioperative major adverse cardiac events (adjusted odds ratio, 2.72; 95% confidence interval, 1.08–6.85), and atrial fibrillation (adjusted odds ratio, 1.97; 95% confidence interval, 1.29–3.01). Group 2 patients had worse age-adjusted survival at 2 years'' follow-up (93.4% vs 87.4%, P < .017). Conclusions: Patients with diabetes mellitus and a history of percutaneous coronary stenting before coronary artery bypass surgery were found to have an increased risk of operative death, increased perioperative complications, and decreased age-adjusted survival at 2 years'' follow-up. [Copyright &y& Elsevier]

Background: Complications after open-heart surgery result in an increased length of stay and greater financial burdens for all. The purpose of this study was to measure the additive costs of postoperative complications for selected subgroups of patients after coronary artery bypass grafts in the Commonwealth of Virginia. Methods: A multiyear statewide data repository with clinical and billing data was used to measure outcomes for the period 2004 to 2007. The Society of Thoracic Surgeons records matched with Universal Billing (UB-04) charge data for all payers were used to estimate the additive costs of cardiac surgical outcomes using cost-to-charge ratios. Additive cost was defined as the difference between the baseline cost of an average case with no complications and one with a postoperative morbidity or mortality. Multivariate analysis was used to account for important covariates and apportion incremental costs. Results: The baseline cost of isolated coronary artery bypass grafting (CABG) cases with no complications during the study period was $26,056. Isolated atrial fibrillation was the most frequently cited complication and had the lowest additive cost ($2,574). Additive costs for isolated CABG patients were greatest for those cases involving prolonged ventilation ($40,704), renal failure ($49,128), mediastinitis ($62,773), and operative mortality ($49,242). Conclusions: Additive costs can serve as an indicator for pursuing quality improvement initiatives. Our results suggest additive costs vary according to type of postoperative complication and comorbidities. Regional collaborations of multidisciplinary groups in cardiac surgery are an effective means to implement quality guidelines and drive down additive costs. [Copyright &y& Elsevier]

Objective: The surgical treatment of valvular heart disease has changed significantly in the past decade with more mitral valves being repaired and tissue valves implanted in the aortic position. The National Inpatient Sample was used to document national trends of primary isolated aortic and mitral valve surgical procedures. Methods: Subjects were adult patients who had an isolated aortic or mitral valve repair or replacement in the United States. Estimated institution cost and total billed charges data were provided by the Centers for Medicare and Medicaid Services. Results: From 1998 to 2005, an estimated 330,000 aortic or mitral valve procedures were performed in the United States (repair, n = 46,342; replacement, n = 287,989). Since 1998, annual valve repair or replacement procedures increased 186.6% and 12.6%, respectively. Aortic valve repair or replacement procedures increased 102.5% and 28.0%, respectively, with an increased percentage for repairs from 2.0% in 1998 to 3.1% in 2005. Mitral valve repair procedures increased from18.9% in 1998 to 45.8% in 2005, with mitral replacements decreasing 17.2% over the same period. Since 1998, the total hospital billed charges for aortic valve repair procedures increased 80.6% and aortic valve replacement procedures 90.4%; mitral valve repair procedures increased from 37.8%, replacement 42.0%. Annual increases in estimated institution cost increased for both aortic and mitral procedures on average 8% to 9%. Conclusion: During the last decade the practice of valve surgery has changed significantly. The surgical treatment for mitral disease has transitioned to primarily one of repair, not replacement, with the use of bioprostheses more than doubled. For the aortic position, the primary procedure remained valve replacement with bioprosthesis being the valve of choice. Regardless of valve disease, institutional costs and charges for the surgical treatment have greatly outpaced physician reimbursement. [Copyright &y& Elsevier]

The article presents the results of a study on the experience of two health care centers in New York in the management of patients with sarcoidosis-associated pulmonary arterial hypertension (PAH). According to the authors, 22 patients with sarcoidosis treated with PAH-specific therapies experienced an increase in their mean six-minute walk distance, a greater increment in exercise capacity, and reduce in mean pulmonary artery pressure. They add that the survival rates of one- and three-year transplant free patients ranged from 74 to 90 percent.

Objectives: Preoperative atrial fibrillation has been associated with less favorable outcomes in patients undergoing coronary artery bypass grafting. However, it was never investigated in a large cohort of patients using a national database. This study aims to (1) identify the effect of atrial fibrillation on operative mortality and morbidity in patients undergoing isolated coronary artery bypass grafting and (2) identify the potential effect of atrial fibrillation on patients with decreased left ventricular ejection fraction (≤40%). Methods: The Society of Thoracic Surgeons National Adult Cardiac Surgery Database was used for patients with coronary artery disease undergoing isolated coronary artery bypass grafting (n = 281,567). The association between atrial fibrillation and outcomes was estimated within 3 categories of low (ejection fraction, <40%), moderate (ejection fraction, 40%–55%), or normal (ejection fraction, >55%) systolic function. Results: Patients with atrial fibrillation were found to be older and have a higher incidence of comorbidities. A higher incidence of all major complications and mortality after surgical intervention was documented. An interaction between atrial fibrillation and an ejection fraction of greater than 40% for mortality, stroke, prolonged ventilation, and prolonged length of stay was identified. Conclusions: Our findings suggest that preoperative atrial fibrillation is associated with an increased risk for perioperative mortality and morbidity in patients undergoing coronary artery bypass grafting. The negative effect of atrial fibrillation might be more significant in patients undergoing coronary artery bypass grafting with an ejection fraction of greater than 40%. Both the EuroSCORE and, until recently, the Society of Thoracic Surgeons risk calculator do not include atrial fibrillation as a potential risk modifier; however, based on this study, it should be identified as a variable to be investigated and incorporated into future risk calculators. [Copyright &y& Elsevier]

Eight hundred thirty-six patients who had open-heart surgery were available for analysis of health-related quality of life (HRQL) data and survival at the 1-year follow-up. Elective open-heart surgery patients with decreasing HRQL at 1 year following surgery may experience a survival disadvantage in comparison with those patients experiencing positive gains. Clinical care should extend beyond the immediate postoperative period. [ABSTRACT FROM AUTHOR]

The article presents a study on the association between early outcome, health-connected quality of life, and survival after elective open-heart surgery. This research investigated the effect of perioperative complications on patients' health-related quality of life (HRQL) and intermediate-term survival after cardiac surgery. It is identified that perioperative complications had minimal effect on HRQL a year after cardiac surgery.

Background: Idiopathic pulmonary fibrosis (IPF) is a disease with very high mortality. Objective: We sought to characterize serial changes in pulmonary artery pressures (PAP) in patients with advanced IPF who survive to transplant. Methods: Retrospective analysis of IPF patients comparing mean PAP at the time of initial evaluation for transplan- tation (mPAPbaseline) with mPAP at the time of transplant (mPAPfollow-up). The measurements were correlated with New York Heart Association (NYHA) functional class and oxygen requirements. Results: The final cohort consisted of 44 patients with serial right heart catheterization data. The mean mPAPbaseline and mPAPfollow-up were 22.5 and 32.7 mm Hg, respectively. 38.6% (17/44) of the patients had pulmonary hypertension (PH) at baseline. The majority of the non-PH patients developed PH during the serial time interval with a subsequent incidence of 77.8%. At the time of transplant, 86.4% of the patients had PH. There was a significant association between transplant NYHA class, severity of PH and oxygen requirements. Transplant NYHA class IV patients had a higher rate of mPAP change. The severity of PH at the time of transplant did not affect transplant outcomes. Conclusion: PH is common and progressive in patients with advanced IPF who are transplant candidates. Serial change and severity of PAP elevations have a significant association with oxygen requirements and functional status, but not transplant outcomes. Whether or not progressive PH has a significant impact on outcomes without transplantation requires further study. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The benefits of cardiac rehabilitation following a major cardiac event are without question. Less well known, however, is the association of age with improved quality of life following rehabilitation. Subjects (n = 300) completed a 3-month phase II cardiac rehabilitation program following either a coronary artery bypass graft or a valve procedure. There were similar gains in health-related quality of life across all age groups; our results suggest that there needs to be a greater focus on emotional needs among our younger patients. [ABSTRACT FROM AUTHOR]

The article presents the study which examines the relationship between pulmonary function tests (PFTs), including the composite physiologic index and percentage of predicted total lung capacity. This study is composed of 118 idiopathic pulmonary fibrosis (IPF) patients who are reviewed over an 8-year interval in whom both PFT and right-heart catheterization data are available. The findings revealed that pulmonary hypertension is common in patients with IPF.

The Rapid After Bypass Back Into Telemetry program is based on a simple clinical algorithm to predict same-day transfer of patients to the cardiac telemetry unit following cardiac surgery. This program proved to be an excellent predictor for decreased postoperative complications, shorter intensive care unit and hospital stay, and lower costs. We believe that any candidate for cardiac surgery should be screened for eligibility to participate in the program with special focus on female patients to further improve their outcomes. [ABSTRACT FROM AUTHOR]

Objective: The maze procedure is recognized as the most effective surgical treatment of atrial fibrillation. In the last few years, new surgical ablation techniques were developed involving the left atrium only and modifications of the maze procedure in ablating both atria. For this study, we evaluated the evidence regarding the effectiveness of the surgical ablation procedures (biatrial and left atrial) in reducing postoperative atrial fibrillation and subsequent survival. Methods: MEDLINE was searched for English-language studies using the terms “maze,” “atrial fibrillation,” and “surgical treatment” for 1995 through August 2005. Primary outcomes of interest were postoperative survival and postoperative freedom from atrial fibrillation. Survival data were collected at 1-, 2-, and 3-year intervals. Freedom from atrial fibrillation was collected at 3 months and at 1-, 2-, and 3-year intervals. Results: Sixty-nine studies were included in this analysis. Five thousand eight hundred eighty-five total patients were involved. Patients undergoing surgical ablation (range, 90.4-85.4) demonstrated significantly greater rates of freedom from atrial fibrillation compared with those seen in control patients (range, 47.2-60.9). Survival rates among patients with biatrial surgical procedures (range, 94.9-92.8) were similar to those who had left atrial procedures only (range, 93.9-89.4). However, patients undergoing biatrial ablation (range, 92.0-87.1 vs 86.1-73.4) demonstrated superior freedom from atrial fibrillation at all time points. Conclusion: Biatrial ablation surgical procedures were more effective in controlling atrial fibrillation than procedures confined to the left atrium. To encourage the use of future meta-analysis within the surgical literature, we suggest the more frequent reporting of either through Kaplan-Meier survival analyses and the reporting of rates for specific time intervals. [Copyright &y& Elsevier]

The purpose of this study was to develop a simple, single-page measurement tool that evaluates risk of skin breakdown in the pediatric population and apply it to the acutely hospitalized child. Data were collected over a 15-month period from 347 patients on four in-patient units (PICU, medical-surgical, oncology, and adolescents) on skin breakdown using the AHCPR staging guidelines and compared to the total score on the Starkid SkinScale in order to determine its ability to predict skin breakdown. The inter-rater reliability of the Starkid Skin Scale was r² = 0.85 with an internal reliability of 0.71. The sensitivity of the total score was low (17.5%) but highly specific (98.5%). The prevalence of skin breakdown in the acutely hospitalized child was 23%, the majority (77.5%) occurring as erythema of the skin. Buttocks, perineum, and occiput were the most common locations of breakdown. Occiput breakdown was more common in critically ill (PICU) patients while diaper dermatitis was more common in the general medical-surgical population. [ABSTRACT FROM AUTHOR]

The article presents information on the prevalence and outcomes of pulmonary arterial hypertension (PAH) in advanced idiopathic pulmonary fibrosis (IPF). PAH is very common in advance cases of ICF and this affects survival significantly. It is reported that several forms of diffuse parenchymal lung disease can cause PAH, thus a better understanding of the prevalence of PAH in patients with IPF is significant. PAH is found in almost one third of patients, who have advance IPF. Moreover, PAH is also associated with increase in mortality in patients with chronic obstructive pulmonary disease.

Topic: This report summarizes the first studies on individual placement and support (IPS) in the field of physical medicine and rehabilitation (PM&R) and discusses adaptation of the model. Purpose: Research related to the implementation and evaluation of the use of IPS in the VA System of Spinal Cord Injury Care is reviewed. Results suggest that IPS was more effective than traditional vocational rehabilitation. With physical disabilities, the model needs adaptation with respect to integration, disclosure, and job development while following the core principles. Special consideration is needed with respect to caseload size and transportation issues. Sources Used: Published results from the Spinal Cord Injury Vocational Integration Program (SCI-VIP) study and clinical field observations. Conclusions and Implications for Practice: IPS can be successfully adapted to physical medicine and rehabilitation. [ABSTRACT FROM AUTHOR]

Background and Purpose: Diabetic nephropathy is a common complications related to high morbidity and mortality in type 2 diabetes. We investigated the action of the dual modulator, PTUPB, a soluble epoxide hydrolase and cyclooxygenase-2 inhibitor against diabetic nephropathy.Experimental Approach: Sixteen-week-old type 2 diabetic and proteinuric obese ZSF1 rats were treated with vehicle, PTUPB or enalapril for 8 weeks. Measurements were made of epoxyeicosatrienoic acids, thromboxane B2 (TBX2 ) and prostaglandin E2 (PGE2 ) in the kidney of these and lean ZSF1 rats along with their blood pressure.Key Result: Obese ZSF1 rats were diabetic with fivefold higher fasting blood glucose levels and markedly higher HbA1c levels compared with lean ZSF1 rats. PTUPB nor enalapril reduced fasting blood glucose or HbA1c but alleviated the development of diabetic nephropathy. In PTUPB-treated obese ZSF1 rats, glomerular nephrin expression was preserved. Enalapril also alleviated diabetic nephropathy. Diabetic renal injury in obese ZSF1 rats was accompanied by renal inflammation with six to sevenfold higher urinary MCP-1 (CCR2) level and renal infiltration of CD-68 positive cells. PTUPB and enalapril significantly reduced urinary MCP-1 levels and renal mRNA expression of cytokines. Both PTUPB and enalapril lowered blood pressure. PTUPB but not enalapril decreased hyperlipidaemia and liver injury in obese ZSF1 rats.Conclusion and Implications: Overall, the dual modulator PTUPB does not treat hyperglycaemia but can effectively alleviate hypertension, diabetic nephropathy, hyperlipidaemia and liver injury in type 2 diabetic rats. Our data further demonstrate that the renal actions of PTUPB are comparable with a current standard diabetic nephropathy treatment. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor concerning the findings of C.M. Magro and associates published in a previous issue of "CHEST" journal and their implications for a report on a high rate of pulmonary embolism in patients with idiopathic pulmonary fibrosis after lung transplantation.

The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing. We aimed to estimate the pooled global NAFLD incidence. We performed a systematic review and meta-analysis of cohort studies of adults without NAFLD at baseline to evaluate the global incidence of ultrasound-diagnosed NAFLD. A total of 63 eligible studies (1,201,807 persons) were analyzed. Studies were from Mainland China/Hong Kong (n = 26), South Korea (n = 22), Japan (n = 14), other (n = 2, Sri Lanka, Israel); 63.8% were clinical center studies; median study year 2000 to 2016; 87% were good quality. Among the 1,201,807 persons at risk, 242,568 persons developed NAFLD, with an incidence rate of 4,612.8 (95% CI 3,931.5-5,294.2) per 100,000 person-years and no statistically significant differences by study sample size (p = 0.90) or study setting (p = 0.055). Males had higher incidence vs. females (5,943.8 vs. 3,671.7, p = 0.0013). Both the obese (vs. non-obese) and the overweight/obese groups (vs. normal weight) were about threefold more likely to develop NAFLD (8,669.6 vs. 2,963.9 and 8,416.6 vs. 3,358.2, respectively) (both p < 0.0001). Smokers had higher incidence than non-smokers (8,043.2 vs. 4,689.7, p = 0.046). By meta-regression, adjusting for study year, study setting, and study location, study period of 2010 or after and study setting were associated with increased incidence (p = 0.010 and p = 0.055, respectively). By country, China had a higher NAFLD incidence compared to non-China regions (p = 0.012) and Japan a lower incidence compared to non-Japan regions (p = 0.005). NAFLD incidence is increasing with a current estimate of 4,613 new cases per 100,000 person-years. Males and overweight/obese individuals had significantly higher incidence rates compared to females and those of normal weight. Public health interventions for prevention of NAFLD are needed with a special emphasis on males, overweight/obese individuals, and higher risk regions. Non-alcoholic fatty liver disease (NAFLD) affects approximately 30% of people worldwide and appears to be increasing, but data to estimate the incidence rate are limited. In this meta-analytic study of over 1.2 million people, we estimated an incidence rate of NAFLD of 46.13 per 1,000 person-years with significant differences by sex, BMI, geography, and time-period. As treatment options for NAFLD remain limited, prevention of NAFLD should remain the focus of public health strategies. Studies such as these can help policy makers in determining which and whether their interventions are impactful. [Display omitted] • Global NAFLD incidence was found to be 4,613 per 100,000 person-years. • NAFLD incidence was higher in men and in those who were overweight or obese. • Incidence rate has increased more than 3-fold between 2000 and 2015. • Among countries with available data, the NAFLD incidence rate was highest in Mainland China and lowest in Japan. [ABSTRACT FROM AUTHOR]

This study uses data from the 2005 Department of Defense Survey of Health-Related Behaviors Among Military Personnel to examine relationships between family stress and posttraumatic stress symptoms across 4 subgroups of Operation Iraqi Freedom-deployed (i.e., war in Iraq) or Operation Enduring Freedom-deployed (i.e., war in Afghanistan) active-duty military service members. Results suggest the following: (a) the greatest positive correlation of family stressors with posttraumatic stress symptoms was found within the military health care officer group, and (b) these military health care officers differed in family stressors mediating posttraumatic stress with divorce and financial problems accounting for significant and unique portions of the variance. Implications for care of service members and their families are discussed. [Copyright &y& Elsevier]

Context.--The data in College of American Pathologists cancer protocols have to be presented effectively to health care providers. There is no consensus on the format of those protocols, resulting in various designs among pathologists. Cancer protocols are independently created by site-specific experts, so there is inconsistent wording and repetition of data. This lack of standardization can be confusing and may lead to interpretation errors. Objectives.--To define a synopsis format that is effective in delivering essential pathologic information and to evaluate the aesthetic appeal and the impact of varying format styles on the speed and accuracy of data extraction. Design.--We queried individuals from several health care backgrounds using varying formats of the fallopian tube protocol of the College of American Pathologists without content modification to investigate their aesthetic appeal, accuracy, efficiency, and readability/complexity. Descriptive statistics, an item difficulty index, and 3 tests of readability were used. Results.--Columned formats were aesthetically more appealing than justified formats (P, .001) and were associated with greater accuracy and efficiency. Incorrect assumptions were made about items not included in the protocol. Uniform wording and short sentences were associated with better performance by participants. Conclusions.--Based on these data, we propose standardized protocol formats for cancer resections of the fallopian tube and the more-familiar colon, employing headers, short phrases, and uniform terminology. This template can be easily and minimally modified for other sites, standardizing format and verbiage and increasing user accuracy and efficiency. Principles of human factors engineering should be considered in the display of patient data. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of this study was to determine predictors of clinical leadership skill (CLS) for RNs with 24 months of clinical experience or less. BACKGROUND: New graduate nurse transition programs (NGNTPs) have been proposed as a strategy to increase CLS. CLS is associated with positive patient outcomes. METHOD: Method used was hierarchical regression modeling to evaluate predictors of CLS among individual characteristics of RNs and characteristics of NGNTPs. RESULTS: Perceived overall quality of an NGNTP was the strongest predictor of CLS (R2 = 0.041, P < .01). Clinical experience and NGNTP characteristics accounted for 6.9% of the variance in CLS and 12.6% of the variance among RNs with assigned mentors (P < .01). RNs participating in NGNTPs for more than 24 weeks were 21 times more likely to remain employed within the organization when compared with NGNTPs of 12 weeks or less, a significant cost-benefit to the organization. CONCLUSION: Although perceived overall quality of a NGNTP was the strongest predictor of CLS, much of the variance in CLS remains unexplained. [ABSTRACT FROM AUTHOR]

Post‐hemorrhagic hydrocephalus (PHH) is a severe complication of intraventricular hemorrhage (IVH) in very preterm infants. PHH monitoring and treatment decisions rely heavily on manual and subjective two‐dimensional measurements of the ventricles. Automatic and reliable three‐dimensional (3D) measurements of the ventricles may provide a more accurate assessment of PHH, and lead to improved monitoring and treatment decisions. To accurately and efficiently obtain these 3D measurements, automatic segmentation of the ventricles can be explored. However, this segmentation is challenging due to the large ventricular anatomical shape variability in preterm infants diagnosed with PHH. This study aims to (a) propose a Bayesian U‐Net method using 3D spatial concrete dropout for automatic brain segmentation (with uncertainty assessment) of preterm infants with PHH; and (b) compare the Bayesian method to three reference methods: DenseNet, U‐Net, and ensemble learning using DenseNets and U‐Nets. A total of 41 T2‐weighted MRIs from 27 preterm infants were manually segmented into lateral ventricles, external CSF, white and cortical gray matter, brainstem, and cerebellum. These segmentations were used as ground truth for model evaluation. All methods were trained and evaluated using 4‐fold cross‐validation and segmentation endpoints, with additional uncertainty endpoints for the Bayesian method. In the lateral ventricles, segmentation endpoint values for the DenseNet, U‐Net, ensemble learning, and Bayesian U‐Net methods were mean Dice score = 0.814 ± 0.213, 0.944 ± 0.041, 0.942 ± 0.042, and 0.948 ± 0.034 respectively. Uncertainty endpoint values for the Bayesian U‐Net were mean recall = 0.953 ± 0.037, mean negative predictive value = 0.998 ± 0.005, mean accuracy = 0.906 ± 0.032, and mean AUC = 0.949 ± 0.031. To conclude, the Bayesian U‐Net showed the best segmentation results across all methods and provided accurate uncertainty maps. This method may be used in clinical practice for automatic brain segmentation of preterm infants with PHH, and lead to better PHH monitoring and more informed treatment decisions. [ABSTRACT FROM AUTHOR]

Ventricular assist device (VAD) patients often experience infections, which increase the risk of stroke and mortality. Using the definitions of the International Society for Heart and Lung Transplantation (ISHLT), we have characterized differences in clinical outcomes for categories of infection: VAD-specific (e.g., pump component related); VAD-related (e.g., bloodstream infection, BSI); and non-VAD infections (e.g., pneumonia). Querying of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) identified 16,597 continuous-flow VAD recipients. Categories of infection were tested in multivariate models to determine the risk of stroke and death. After implant, 7,046 patients (42%) developed an infection at a median of 69 (interquartile range 12 to 272) days. A majority were non-VAD infections (49%), followed by VAD-related (26%) and VAD-specific infections (25%). BSIs were the most common form of VAD-related infection (92%), and the majority (59%) had no associated infection, that is, idiopathic bacteremia. Internal pump component infections were rare (0.003 event per patient-year [EPPY]). Infected VAD patients had a higher prevalence of stroke compared to patients without an infection (18% vs 11%, p < 0.001). The lowest stroke rate occurred after a VAD-specific infection (0.11 EPPY) compared with VAD-related (0.17 EPPY) and non-VAD infections (0.15 EPPY, p < 0.001). Hemorrhagic strokes were more common than ischemic strokes in all infection groups and highest after a VAD-related infection (0.13 EPPY). One-year survival after an infection was 87% in VAD-specific infections, as compared with VAD-related (71%) and non-VAD infections (72%, p < 0.001). The ISHLT categorization of VAD infections unveils notable differences in associated risk of stroke and mortality. A re-assessment of transplant prioritization for eligible infected VAD patients may be useful to increase transplant-related survival benefit. [ABSTRACT FROM AUTHOR]

Background: Cardiogenic shock (CS) is a multifactorial, hemodynamically complex syndrome associated with high mortality. Despite advances in reperfusion and mechanical circulatory support, management remains highly variable and outcomes poor.Objectives: This study investigated whether a standardized team-based approach can improve outcomes in CS and whether a risk score can guide clinical decision making.Methods: A total of 204 consecutive patients with CS were identified. CS etiology, patient demographic characteristics, right heart catheterization, mechanical circulatory support use, and survival were determined. Cardiac power output (CPO) and pulmonary arterial pulsatility index (PAPi) were measured at baseline and 24 h after the CS diagnosis. Thresholds at 24 h for lactate (<3.0 mg/dl), CPO (>0.6 W), and PAPi (>1.0) were determined. Using logistic regression analysis, a validated risk stratification score was developed.Results: Compared with 30-day survival of 47% in 2016, 30-day survival in 2017 and 2018 increased to 57.9% and 76.6%, respectively (p < 0.01). Independent predictors of 30-day mortality were age ≥71 years, diabetes mellitus, dialysis, ≥36 h of vasopressor use at time of diagnosis, lactate levels ≥3.0 mg/dl, CPO <0.6 W, and PAPi <1.0 at 24 h after diagnosis and implementation of therapies. Either 1 or 2 points were assigned to each variable, and a 3-category risk score was determined: 0 to 1 (low), 2 to 4 (moderate), and ≥5 (high).Conclusions: This observational study suggests that a standardized team-based approach may improve CS outcomes. A score incorporating demographic, laboratory, and hemodynamic data may be used to quantify risk and guide clinical decision-making for all phenotypes of CS. [ABSTRACT FROM AUTHOR]

Objective: To determine the association between neighborhood disadvantage (ND) and functional brain development of in utero fetuses., Study Design: We conducted an observational study using Social Vulnerability Index (SVI) scores to assess the impact of ND on a prospectively recruited sample of healthy pregnant women from Washington, DC. Using 79 functional magnetic resonance imaging scans from 68 healthy pregnancies at a mean gestational age of 33.12 weeks, we characterized the overall functional brain network structure using a graph metric approach. We used linear mixed effects models to assess the relationship between SVI and gestational age on 5 graph metrics, adjusting for multiple scans., Results: Exposure to greater ND was associated with less well integrated functional brain networks, as observed by longer characteristic path lengths and diminished global efficiency (GE), as well as diminished small world propensity (SWP). Across gestational ages, however, the association between SVI and network integration diminished to a negligible relationship in the third trimester. Conversely, SWP was significant across pregnancy, but the relationship changed such that there was a negative association with SWP earlier in the second trimester that inverted around the transition to the third trimester to a positive association., Conclusions: These data directly connect ND and altered functional brain maturation in fetuses. Our results suggest that, even before birth, proximity to environmental stressors in the wider neighborhood environment are associated with altered brain development., Competing Interests: Declaration of Competing Interest Supported by the National Institutes of Health, NHLBI R01-HL116585 (C.L.), NICHD T32-HD098066 (K.M.C.), the Canadian Institutes of Health Research MOP-81116 (C.L.), and the A. James & Alice B. Clark Foundation's Parent-Child Health Initiative. The authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: There is a limited evidence-base describing clinical features of delirium in youth. What is known is largely extrapolated from studies of adults or samples with heterogeneous etiologies. It is unclear if the symptoms experienced by adolescents differ from those experienced by adults, or the degree to which delirium impacts the ability of adolescents to return to school or work., Objective: To describe delirium symptomatology among adolescents following a severe traumatic brain injury (TBI). Symptoms were compared by adolescent delirium status and across age groups. Delirium and its relationship with adolescent employability 1 year post-injury was also examined., Design: Exploratory secondary analysis of prospectively collected data., Setting: Free-standing rehabilitation hospital., Patients: Severely injured TBI Model Systems neurorehabilitation admissions (n = 243; median Glasgow Coma Scale = 7). The sample was divided into three age groups (adolescents, 16-21 years, n = 63; adults 22-49 years, n = 133; older adults ≥50 years, n = 47)., Interventions: Not applicable., Measures: We assessed patients using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria and the Delirium Rating Scale-Revised 98 (DRS-R-98). The employability item from the Disability Rating Scale was the primary 1-year outcome., Results: Most items on the DRS-R-98 differentiated delirious from non-delirious adolescents. Only "delusions" differed among age groups. Among adolescents, delirium status 1 month post-TBI provided acceptable classification of employability prediction 1 year later (area under the curve [AUC]: 0.80, 95% confidence interval [CI]: 0.69-0.91, p < .001). Delirium symptom severity (AUC: 0.86, 95% CI: 0.68-1.03, SE: 0.09; p < .001) and days of post-traumatic amnesia (AUC: 0.85, 95% CI: 0.68-1.01, SE: 0.08; p < .001) provided excellent prediction of outcomes for TBI patients in delirium., Conclusions: Delirium symptomatology was similar among age groups and useful in differentiating the delirium status within the adolescent TBI group. Delirium and symptom severity at 1 month post-TBI were highly predictive of poor outcomes. Findings from this study support the utility of DRS-R-98 at 1 month post-injury to inform treatment and planning., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Preterm labor leading to preterm birth is the leading cause of infant morbidity and mortality. At the present time, nothing can reliably halt labor once it begins. The knowledge that agonists of the β2 adrenergic receptor relax airway smooth muscle and are effective in the treatment of asthma led to the notion that β2 mimetics would prevent preterm birth by relaxing uterine smooth muscle. The activation of cAMP-dependent protein kinase by β2 receptors is unable to provide meaningful tocolysis. The failure of β2 agonists such as ritodrine and terbutaline to prevent preterm birth suggests that the regulation of uterine smooth muscle is disparate from that of airway. Other smooth muscle quiescent-mediating molecules, such as nitric oxide, relax vascular smooth muscle in a cGMP-protein kinase G-dependent manner; however, nitric oxide activation of protein kinase G fails to explain the relaxation of the myometrium to nitric oxide. Moreover, nitric oxide-mediated relaxation is blunted in preterm labor, and thus, for this reason and because of the fall in maternal blood pressure, nitric oxide cannot be employed as a tocolytic. The β3 adrenergic receptor-mediated relaxation of the human myometrium is claimed to be cAMP-dependent protein kinase-dependent. This is scientifically displeasing given the failure of β2 agonists as tocolytics and suggests a non-canonical signaling role for β3AR in myometrium. The addition of the β3 agonist mirabegron to pregnant human myometrial strips in the tissue bath relaxes oxytocin-induced contractions. Mirabegron stimulates nitric oxide production in myometrial microvascular endothelial cells, and the relaxation of uterine tissue in vitro is partially blocked by the addition of the endothelial nitric oxide synthase blocker Nω-Nitro-L-arginine. Recent data suggest that both endothelial and smooth muscle cells respond to β3 stimulation and contribute to relaxation through disparate signaling pathways. The repurposing of approved medications such as mirabegron (Mybetriq™) tested in human myometrium as uterine tocolytics can advance the prevention of preterm birth.

Preterm labor, delivery prior to 37 completed weeks of gestation, is the leading cause of infant morbidity and mortality. β3 adrenergic receptor protein expression is increased in the myometrium during pregnancy, and the agonist, mirabegron, relaxes the myometrium making the β3 adrenergic receptor a potential therapeutic target in PTL. β3 adrenergic receptor has been shown to activate the tyrosine kinase, Src, which can down regulate connexin 43, a contractile associated protein which promotes the formation of gap junctions that create an electrical syncytium. We hypothesize that mirabegron downregulates connexin 43, imparting quiescence effects on the myometrium. Employing contractile studies, we demonstrate that Src is involved in the mirabegron-induced relaxation of contracting pregnant human myometrial tissue strips. Western blot analysis demonstrates that Src kinase expression is decreased in both preterm and term laboring myometrial tissue. Imaging revealed that mirabegron stimulation of the β3 adrenergic receptor phosphorylates tyrosine at position Y265 on connexin 43 in pregnant human uterine myocytes. Western blot analysis and immunofluorescent imaging indicate that mirabegron decreases the expression of connexin 43 and mediates relaxation over a 24-h exposure period, suggesting that mirabegron has long lasting quiescent effects on the human myometrium. The relationship between the β3 adrenergic receptor and down regulation of the contractile associated protein connexin 43 through activation of Src kinase suggests that mirabegron may be useful in combination tocolysis., Competing Interests: Declaration of Competing Interest Authors have no conflicts of interests with the article., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Approximately 10% of US births deliver preterm before 37 weeks of completed gestation. Premature infants are at risk for life-long debilitating morbidities and death, and spontaneous preterm labour explains 50% of preterm births. In all cases existing treatments are ineffective, and none are FDA approved. The mechanisms that initiate preterm labour are not well understood but may result from dysfunctional regulation of quiescence mechanisms. Human pregnancy is accompanied by large increases in blood flow, and the uterus must enlarge by orders of magnitude to accommodate the growing fetus. This mechanical strain suggests that stretch-activated channels may constitute a mechanism to explain gestational quiescence. Here we identify for the first time that Piezo1, a mechanosensitive cation channel, is present in the uterine smooth muscle and microvascular endothelium of pregnant myometrium. Piezo is downregulated during preterm labour, and stimulation of myometrial Piezo1 in an organ bath with the agonist Yoda1 relaxes the tissue in a dose-dependent fashion. Further, stimulation of Piezo1 while inhibiting protein kinase A, AKT, or endothelial nitric oxide synthase mutes the negative inotropic effects of Piezo1 activation, intimating that actions on the myocyte and endothelial nitric oxide signalling contribute to Piezo1-mediated contractile dynamics. Taken together, these data highlight the importance of stretch-activated channels in pregnancy maintenance and parturition, and identify Piezo1 as a tocolytic target of interest. KEY POINTS: Spontaneous preterm labour is a serious obstetric dilemma without a known cause or effective treatments. Piezo1 is a stretch-activated channel important to muscle contractile dynamics. Piezo1 is present in the myometrium and is dysregulated in women who experience preterm labour. Activation of Piezo1 by the agonist Yoda1 relaxes the myometrium in a dose-dependent fashion, indicating that Piezo1 modulation may have therapeutic benefits to treat preterm labour., (© 2022 The Authors. The Journal of Physiology published by John Wiley & Sons Ltd on behalf of The Physiological Society.)

Background: Fetal growth restriction (FGR) is a risk factor for neurodevelopmental problems, yet remains poorly understood. We sought to examine the relationship between intrauterine development and neonatal neurobehavior in pregnancies diagnosed with antenatal FGR., Methods: We recruited women with singleton pregnancies diagnosed with FGR and measured placental and fetal brain volumes using MRI. NICU Network Neurobehavioral Scale (NNNS) assessments were performed at term equivalent age. Associations between intrauterine volumes and neurobehavioral outcomes were assessed using generalized estimating equation models., Results: We enrolled 44 women diagnosed with FGR who underwent fetal MRI and 28 infants underwent NNNS assessments. Placental volumes were associated with increased self-regulation and decreased excitability; total brain, brainstem, cortical and subcortical gray matter (SCGM) volumes were positively associated with higher self-regulation; SCGM also was positively associated with higher quality of movement; increasing cerebellar volumes were positively associated with attention, decreased lethargy, non-optimal reflexes and need for special handling; brainstem volumes also were associated with decreased lethargy and non-optimal reflexes; cerebral and cortical white matter volumes were positively associated with hypotonicity., Conclusion: Disrupted intrauterine growth in pregnancies complicated by antenatally diagnosed FGR is associated with altered neonatal neurobehavior. Further work to determine long-term neurodevelopmental impacts is warranted., Impact: Fetal growth restriction is a risk factor for adverse neurodevelopment, but remains difficult to accurately identify. Intrauterine brain volumes are associated with infant neurobehavior. The antenatal diagnosis of fetal growth restriction is a risk factor for abnormal infant neurobehavior., (© 2022. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Preterm labor leading to preterm birth is the leading cause of infant morbidity and mortality. Although β2 adrenergic agonists fail to provide adequate tocolysis, the expression of the β3 adrenergic receptor in myometrium and its unique signaling suggest a role for β3 agonist in the management of preterm labor. Western blot analysis showed that the β3 adrenergic receptor expression increased in human pregnancy myometrium compared to nonpregnant tissues (p < 0.0001). There was no difference in β3 adrenergic receptor expression throughout pregnancy (p > 0.05). The addition of the β3 agonist mirabegron in the tissue bath relaxed oxytocin contracted myometrium with an EC 50 of 41.5 µM. Relaxation was partially blocked by the addition of the eNOS blocker Nω-nitro-L-arginine, or the large conductance potassium channel blocker paxilline. Combination of Nω-nitro-L-arginine and paxilline prevented mirabegron-mediated relaxation. Imaging revealed that the β3 adrenergic receptors are expressed by both myocyte and microvascular endothelial cells isolated from human myometrium. Nitric oxide production measured by 4-amino-5-methylamino-2',7'-difluorofluorescein diacetate revealed that mirabegron stimulated nitric oxide production in myometrial endothelial cells. These data suggest that both endothelial and smooth muscle cells contribute to relaxation through disparate signaling pathways. Repurposing of approved medications tested in human myometrium as uterine tocolytics can advance prevention of preterm birth. These data argue that further examination of β3 adrenergic receptor signaling in myometrium may reveal mirabegron as a useful tocolytic in combination tocolysis regimens., (© 2022. The Author(s).)

Aims: This study investigated mental health reactions to dealing with COVID-19 in a population of nurses working in a variety of settings. The study attempted to expand our current understanding of the psychological reactions unique to nurses working during the highly stressful period of the COVID-19 pandemic., Design: The study used an online questionnaire design., Methods: Nurses were recruited using social media via an electronic link between July and September 2020. Of them, 112 nursing professionals completed the 66-item questionnaire., Results: Significant findings included the presence of moderate or greater levels of anxiety (62%), depression (31%), and posttraumatic stress disorder (15%) and with significantly greater intrusive thoughts and memories for nurses who provided direct patient care than those who did not. Nurses with a prior history of anxiety or depression were found to be at greater risk for psychological distress. Results further highlighted concerns and fears related to coronavirus in both their daily personal and professional lives., Conclusion: The use of standard, commonly used, measures of psychological disorders allow for a more precise comparison among studies both for this population at the time of the survey and over a period of time., Impact: Suggestions for helping nursing professionals identify nurses at risk and improved ways to cope and deal with adverse psychological effects are discussed., (© 2022 John Wiley & Sons Ltd.)

Background: Brain injury is a serious and common complication of critical congenital heart disease (CHD). Impaired autonomic development (assessed by heart rate variability (HRV)) is associated with brain injury in other high-risk neonatal populations., Objective: To determine whether impaired early neonatal HRV is associated with pre-operative brain injury in CHD., Methods: In infants with critical CHD, we evaluated HRV during the first 24 h of cardiac ICU (CICU) admission using time-domain (RMS 1, RMS 2, and alpha 1) and frequency-domain metrics (LF, nLF, HF, nHF). Pre-operative brain magnetic resonance imaging (MRI) was scored for injury using an established system. Spearman's correlation coefficient was used to determine the association between HRV and pre-operative brain injury., Results: We enrolled 34 infants with median birth gestational age of 38.8 weeks (IQR 38.1-39.1). Median postnatal age at pre-operative brain MRI was 2 days (IQR 1-3 days). Thirteen infants had MRI evidence of brain injury. RMS 1 and RMS 2 were inversely correlated with pre-operative brain injury., Conclusions: Time-domain metrics of autonomic function measured within the first 24 h of admission to the CICU are associated with pre-operative brain injury, and may perform better than frequency-domain metrics under non-stationary conditions such as critical illness., Impact: Autonomic dysfunction, measured by heart rate variability (HRV), in early transition is associated with pre-operative brain injury in neonates with critical congenital heart disease. These data extend our earlier findings by providing further evidence for (i) autonomic dysfunction in infants with CHD, and (ii) an association between autonomic dysfunction and brain injury in critically ill neonates. These data support the notion that further investigation of HRV as a biomarker for brain injury risk is warranted in infants with critical CHD., (© 2021. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Background: Elevated maternal psychological distress during pregnancy is linked to adverse outcomes in offspring. The potential effects of intensified levels of maternal distress during the COVID-19 pandemic on the developing fetal brain are currently unknown., Methods: We prospectively enrolled 202 pregnant women: 65 without known COVID-19 exposures during the pandemic who underwent 92 fetal MRI scans, and 137 pre-pandemic controls who had 182 MRI scans. Multi-plane, multi-phase single shot fast spin echo T2-weighted images were acquired on a GE 1.5 T MRI Scanner. Volumes of six brain tissue types were calculated. Cortical folding measures, including brain surface area, local gyrification index, and sulcal depth were determined. At each MRI scan, maternal distress was assessed using validated stress, anxiety, and depression scales. Generalized estimating equations were utilized to compare maternal distress measures, brain volume and cortical folding differences between pandemic and pre-pandemic cohorts., Results: Stress and depression scores are significantly higher in the pandemic cohort, compared to the pre-pandemic cohort. Fetal white matter, hippocampal, and cerebellar volumes are decreased in the pandemic cohort. Cortical surface area and local gyrification index are also decreased in all four lobes, while sulcal depth is lower in the frontal, parietal, and occipital lobes in the pandemic cohort, indicating delayed brain gyrification., Conclusions: We report impaired fetal brain growth and delayed cerebral cortical gyrification in COVID-19 pandemic era pregnancies, in the setting of heightened maternal psychological distress. The potential long-term neurodevelopmental consequences of altered fetal brain development in COVID-era pregnancies merit further study., Competing Interests: Competing interestsThe authors declare no competing interests., (© The Author(s) 2022.)

Importance: Prenatal maternal psychological distress is associated with disturbances in fetal brain development. However, the association between altered fetal brain development, prenatal maternal psychological distress, and long-term neurodevelopmental outcomes is unknown., Objective: To determine the association of fetal brain development using 3-dimensional magnetic resonance imaging (MRI) volumes, cortical folding, and metabolites in the setting of maternal psychological distress with infant 18-month neurodevelopment., Design, Setting, and Participants: Healthy mother-infant dyads were prospectively recruited into a longitudinal observational cohort study from January 2016 to October 2020 at Children's National Hospital in Washington, DC. Data analysis was performed from January 2016 to July 2021., Exposures: Prenatal maternal stress, anxiety, and depression., Main Outcomes and Measures: Prenatal maternal stress, anxiety, and depression were measured using validated self-report questionnaires. Fetal brain volumes and cortical folding were measured from 3-dimensional, reconstructed T2-weighted MRI scans. Fetal brain creatine and choline were quantified using proton magnetic resonance spectroscopy. Infant neurodevelopment at 18 months was measured using Bayley Scales of Infant and Toddler Development III and Infant-Toddler Social and Emotional Assessment. The parenting stress in the parent-child dyad was measured using the Parenting Stress Index-Short Form at 18-month testing., Results: The cohort consisted of 97 mother-infant dyads (mean [SD] maternal age, 34.79 [5.64] years) who underwent 184 fetal MRI visits (87 participants with 2 fetal studies each) with maternal psychological distress measures between 24 and 40 gestational weeks and completed follow-up infant neurodevelopmental testing. Prenatal maternal stress was negatively associated with infant cognitive performance (β = -0.51; 95% CI, -0.92 to -0.09; P = .01), and this association was mediated by fetal left hippocampal volume. In addition, prenatal maternal anxiety, stress, and depression were positively associated with all parenting stress measures at 18-month testing. Finally, fetal cortical local gyrification index and sulcal depth were negatively associated with infant social-emotional performance (local gyrification index: β = -54.62; 95% CI, -85.05 to -24.19; P < .001; sulcal depth: β = -14.22; 95% CI, -23.59 to -4.85; P = .002) and competence scores (local gyrification index: β = -24.01; 95% CI, -40.34 to -7.69; P = .003; sulcal depth: β = -7.53; 95% CI, -11.73 to -3.32; P < .001)., Conclusions and Relevance: In this cohort study of 97 mother-infant dyads, fetal cortical local gyrification index and sulcal depth were associated with infant 18-month social-emotional and competence outcomes, and fetal left hippocampal volume mediated the association between prenatal maternal stress and infant cognitive outcome. These findings suggest that altered prenatal brain development in the setting of elevated maternal distress has adverse infant sociocognitive outcomes, and identifying early biomarkers associated with long-term neurodevelopment may assist in early targeted interventions.

Background and Aims: Chronic hepatitis B (CHB) affects >290 million persons globally, and only 10% have been diagnosed, presenting a severe gap that must be addressed. We developed logistic regression (LR) and machine learning (ML; random forest) models to accurately identify patients with HBV, using only easily obtained demographic data from a population-based data set., Approach and Results: We identified participants with data on HBsAg, birth year, sex, race/ethnicity, and birthplace from 10 cycles of the National Health and Nutrition Examination Survey (1999-2018) and divided them into two cohorts: training (cycles 2, 3, 5, 6, 8, and 10; n = 39,119) and validation (cycles 1, 4, 7, and 9; n = 21,569). We then developed and tested our two models. The overall cohort was 49.2% male, 39.7% White, 23.2% Black, 29.6% Hispanic, and 7.5% Asian/other, with a median birth year of 1973. In multivariable logistic regression, the following factors were associated with HBV infection: birth year 1991 or after (adjusted OR [aOR], 0.28; p < 0.001); male sex (aOR, 1.49; p = 0.0080); Black and Asian/other versus White (aOR, 5.23 and 9.13; p < 0.001 for both); and being USA-born (vs. foreign-born; aOR, 0.14; p < 0.001). We found that the ML model consistently outperformed the LR model, with higher area under the receiver operating characteristic values (0.83 vs. 0.75 in validation cohort; p < 0.001) and better differentiation of high- and low-risk persons., Conclusions: Our ML model provides a simple, targeted approach to HBV screening, using only easily obtained demographic data., (© 2021 American Association for the Study of Liver Diseases.)

Objective: The purpose of this study was to examine variables predictive of post-SCI return to employment and current employment among a large cohort of veterans with Spinal Cord Injury (SCI) treated within the Veterans Health Administration (VHA) SCI System of Care. Design: Cross sectional analysis of data obtained during in-person baseline interviews and follow-up phone interviews. Setting: Seven SCI Centers within Veteran Affairs Medical Centers. Participants: 1047 veterans with SCI receiving inpatient or outpatient care in VHA. Results: Only 29.8% were employed post-SCI, 27.9% reported employment within the immediate 5 years before the baseline interview, but only 9.2% reported current employment at the time of the baseline interview. Significant predictors of current employment among these veterans with SCI included recent employment experience, history of legal problems, duration of SCI, education, and life satisfaction. Conclusions: The baseline employment rate following SCI of a large, representative sample, was 29.8%. Greater duration of SCI predicted unemployment, likely due to the older age of this population. Additional years of education promoted current and post-SCI employment, while a history of legal problems was a barrier to employment.