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Data that inform preexposure prophylaxis (PrEP) implementation for women involved in criminal justice (WICJ) systems are scarce. In a survey of PrEP attitudes, acceptability, and barriers across the criminal justice system, incarcerated women (n = 48) were more likely than WICJ on probation (n = 125) to be eligible for PrEP (29% vs. 15%; p = .04) and willing to take PrEP if offered (94% vs. 78%; p = .01). In multivariate models, PrEP eligibility directly correlated with being incarcerated (adjusted odds ratio [aOR] 4.81, 95% confidence interval [CI] 1.76–13.1) and inversely correlated with Hispanic/Latina ethnicity (aOR 0.31; 95% CI 0.10–0.96). Recent partner violence exposure was associated with PrEP eligibility (aOR 3.29; 95% CI 1.54–7.02) and discordant risk perception (aOR 2.36; 95% CI 1.18–4.70). Findings demonstrate high potential for PrEP for all WICJ, though implementation efforts will need to address partner violence.

Supplemental Digital Content is available in the text., Patients on left ventricular assist device (LVAD) support may be susceptible to severe disease and complications from coronavirus disease-19 (COVID-19). The purpose of this study was to describe the clinical course of COVID-19 in LVAD patients. A retrospective review was performed at our center; 28 LVAD patients who developed COVID-19 between March 2020 and March 2021, and six patients with a prior COVID-19 infection who underwent LVAD implantation, were identified and examined. Of the 28 patients, nine (32%) died during the study period, five (18%) during their index hospitalization for COVID-19. Two patients (7%) presented with suspected pump thrombosis. In a nonadjusted binary regression logistic analysis, admission to the intensive care unit (unadjusted odds ratio, 7.6 [CI, 1.2–48], P = 0.03), and the need for mechanical ventilation (unadjusted odds ratio 14 [CI, 1.3–159], P = 0.03) were associated with mortality. The six patients who previously had COVID-19 and subsequently received a LVAD were on intra-aortic balloon pump and inotropic support at time of surgery. All six experienced a complicated and prolonged postoperative course. Three patients (50%) suffered from ischemic stroke, and there was one (17%) 30 day mortality. We observed an increased risk of morbidity and mortality in LVAD patients with COVID-19.

Background and objectives: Little is known about outcome improvements and disparities in cardiac arrest and active cancer. We performed the first known AI and propensity score (PS)-augmented clinical, cost-effectiveness, and computational ethical analysis of cardio-oncology cardiac arrests including left heart catheterization (LHC)-related mortality reduction and related disparities. Materials and methods: A nationally representative cohort analysis was performed for mortality and cost by active cancer using the largest United States all-payer inpatient dataset, the National Inpatient Sample, from 2016 to 2018, using deep learning and machine learning augmented propensity score-adjusted (ML-PS) multivariable regression which informed cost-effectiveness and ethical analyses. The Cardiac Arrest Cardio-Oncology Score (CACOS) was then created for the above population and validated. The results informed the computational ethical analysis to determine ethical and related policy recommendations. Results: Of the 101,521,656 hospitalizations, 6,656,883 (6.56%) suffered cardiac arrest of whom 61,300 (0.92%) had active cancer. Patients with versus without active cancer were significantly less likely to receive an inpatient LHC (7.42% versus 20.79%, p < 0.001). In ML-PS regression in active cancer, post-arrest LHC significantly reduced mortality (OR 0.18, 95%CI 0.14–0.24, p < 0.001) which PS matching confirmed by up to 42.87% (95%CI 35.56–50.18, p < 0.001). The CACOS model included the predictors of no inpatient LHC, PEA initial rhythm, metastatic malignancy, and high-risk malignancy (leukemia, pancreas, liver, biliary, and lung). Cost-benefit analysis indicated 292 racial minorities and $2.16 billion could be saved annually by reducing racial disparities in LHC. Ethical analysis indicated the convergent consensus across diverse belief systems that such disparities should be eliminated to optimize just and equitable outcomes. Conclusions: This AI-guided empirical and ethical analysis provides a novel demonstration of LHC mortality reductions in cardio-oncology cardiac arrest and related disparities, along with an innovative predictive model that can be integrated within the digital ecosystem of modern healthcare systems to improve equitable clinical and public health outcomes.

Background People who have been incarcerated have high rates of cardiovascular risk factors, such as hypertension and smoking, and cardiovascular disease (CVD) is a leading cause of hospitalizations and mortality in this population. Despite this, little is known regarding what pathways mediate the association between incarceration exposure and increased rates of CVD morbidity and especially what incarceration specific factors are associated with this risk. The objective of this study is to better understand CVD risk in people exposed to incarceration and the pathways by which accumulate cardiovascular risk over time. Methods and Analysis The Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study is a prospective cohort study of individuals released from incarceration with known cardiovascular risk factors. We are recruiting 500 individuals within three months after release from jail/prison. At baseline we are assessing traditional risk factors for CVD, including diet, exercise, and smoking, and exposure to incarceration-related policies, psychosocial stress, and self-efficacy. Cardiovascular risk factors are measured at baseline through point of care testing. We are following these individuals for the 12 months following the index release from incarceration with re-evaluation of psychosocial factors and clinical risk factors every 6 months. Using these data, we will estimate the direct and indirect latent effects of incarceration on cardiovascular risk factors and the paths via which these effects are mediated. We will also model the anticipated 10-year burden of CVD incidence, health care use, and mortality associated with incarceration. Discussion Our study will identify factors associated with CVD risk factor control among people released from incarceration. Our measurement of incarceration-related exposures, psychosocial factors, and clinical measures of cardiovascular risk will allow for identification of unique targets for intervention to modify CVD risk in this vulnerable population.

IntroductionIncarceration is associated with decreased cancer screening rates and a higher risk for hospitalisation and death from cancer after release from prison. However, there is a paucity of data on the relationship between incarceration and cancer outcomes and quality of care. In the Incarceration and Cancer-Related Outcomes Study, we aim to develop a nuanced understanding of how incarceration affects cancer incidence, mortality and treatment, and moderates the relationship between socioeconomic status, structural racism and cancer disparities.Methods and analysisWe will use a sequential explanatory mixed-methods study design. We will create the first comprehensive linkage of data from the Connecticut Department of Correction and the statewide Connecticut Tumour Registry. Using the linked dataset, we will examine differences in cancer incidence and stage at diagnosis between individuals currently incarcerated, formerly incarcerated and never incarcerated in Connecticut from 2005 to 2016. Among individuals with invasive cancer, we will assess relationships among incarceration, quality of cancer care and mortality, and will assess the degree to which incarceration status moderates relationships among race, socioeconomic status, quality of cancer care and cancer mortality. We will use multivariable logistic regression and Cox survival models with interaction terms as appropriate. These results will inform our conduct of in-depth interviews with individuals diagnosed with cancer during or shortly after incarceration regarding their experiences with cancer care in the correctional system and the immediate postrelease period. The results of this qualitative work will help contextualise the results of the data linkage.Ethics and disseminationThe Yale University Institutional Review Board (#2000022899) and the Connecticut Department of Public Health Human Investigations Committee approved this study. We will disseminate study findings through peer-reviewed publications and academic and community presentations. Access to the deidentified quantitative and qualitative datasets will be made available on review of the request.

Hemodynamic support with continuous-flow left ventricular assist device (CF-LVAD) therapy has proven a reliable treatment for advanced heart failure. Although modern LVADs are highly durable, device failure and infection can be resolved with surgical exchange of pump components. In this study, we investigated the incidence and outcomes of LVAD exchange with the HeartMate II and HeartWare HVAD. Data were obtained from 677 patients who underwent CF-LVAD implantation between 2005 and 2016. Patients who underwent a device exchanged were included. The primary outcomes were length of hospital stay and mortality. Of the 677 patients included in this study, 72 (10.6%) required LVAD exchange. Thirty-day and 1-year mortality rates were comparable to primary LVAD implantation: 4.3% vs. 3.49%, p = 0.727 and 20.3% vs. 20.7%, p = 0.989, respectively. Thirty-one patients (4.5%) underwent exchange with ongoing infection. Kaplan-Meier analysis indicated significant differences in survival between groups based on indication for exchange. Patients who underwent exchange after more than 150 days of active infection suffered worse postexchange survival than those who underwent exchanged earlier (P = 0.007). While exchange was required only in 10.6% of patients undergoing LVAD implantation, our results show device exchange may be executed safely and effectively, with long-term outcomes similar to primary LVAD implantation. The indication for device exchange impacts postexchange outcomes, and those exchanged with LVAD infection tend to fare worse than those exchanged for device malfunction or thrombus. Patients who are exchanged with active infection have better postoperative survival if the exchange is performed expeditiously after medical management has failed.

This paper describes and reflects on a seminar series in linguistically responsive instruction across academic disciplines, providing faculty in different institutions a model for faculty development in working with international students.

People transitioning from prisons or jails have high mortality, but data are scarce for people with HIV and no studies have integrated data from both criminal justice and community settings. We aimed to assess all-cause mortality in people with HIV released from an integrated system of prisons and jails in Connecticut, USA.We linked pharmacy, custodial, death, case management, and HIV surveillance data from Connecticut Departments of Correction and Public Health to create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut between 2007 and 2014. We compared the mortality rate of adults with HIV released from incarceration with the general US and Connecticut populations, and modelled time-to-death from any cause after prison release with Cox proportional hazard models.We identified 1350 people with HIV who were released after 24 h or more of incarceration between 2007 and 2014, of whom 184 (14%) died after index release; median age was 45 years (IQR 39-50) and median follow-up was 5·2 years (IQR 3·0-6·7) after index release. The crude mortality rate for people with HIV released from incarceration was 2868 deaths per 100 000 person-years, and the standardised mortality ratio showed that mortality was higher for this cohort than the general US population (6·97, 95% CI 5·96-7·97) and population of Connecticut (8·47, 7·25-9·69). Primary cause of death was reported for 170 individuals; the most common causes were HIV/AIDS (78 [46%]), drug overdose (26 [15%]), liver disease (17 [10%]), cardiovascular disease (16 [9%]), and accidental injury or suicide (13 [8%]). Black race (adjusted hazard ratio [HR] 0·52, 95% CI 0·34-0·80), having health insurance (0·09, 0·05-0·17), being re-incarcerated at least once for 365 days or longer (0·41, 0·22-0·76), and having a high percentage of re-incarcerations in which antiretroviral therapy was prescribed (0·08, 0·03-0·21) were protective against mortality. Positive predictors of time-to-death were age (≥50 years; adjusted HR 3·65, 95% CI 1·21-11·08), lower CD4 count (200-499 cells per μL, 2·54, 1·50-4·31;200 cells per μL, 3·44, 1·90-6·20), a high number of comorbidities (1·86, 95% CI 1·23-2·82), virological failure (2·76, 1·94-3·92), and unmonitored viral load (2·13, 1·09-4·18).To reduce mortality after release from incarceration in people with HIV, resources are needed to identify and treat HIV, in addition to medical comorbidities, psychiatric disorders, and substance use disorders, during and following incarceration. Policies that reduce incarceration and support integrated systems of care between prisons and communities could have a substantial effect on the survival of people with HIV.US National Institutes of Health.

Summary Background Incarceration provides an opportunity for engagement in HIV care but is associated with poor HIV treatment outcomes after release. We aimed to assess post-release linkage to HIV care (LTC) and the effect of transitional case management services. Methods To create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut, USA (2007–14), we linked administrative custody and pharmacy databases with mandatory HIV/AIDS surveillance monitoring and case management data. We examined time to LTC (defined as first viral load measurement after release) and viral suppression at LTC. We used generalised estimating equations to show predictors of LTC within 14 days and 30 days of release. Findings Among 3302 incarceration periods for 1350 individuals between 2007 and 2014, 672 (21%) of 3181 periods had LTC within 14 days of release, 1042 (34%) of 3064 had LTC within 30 days of release, and 301 (29%) of 1042 had detectable viral loads at LTC. Factors positively associated with LTC within 14 days of release are intermediate (31–364 days) incarceration duration (adjusted odds ratio 1·52; 95% CI 1·19–1·95), and transitional case management (1·65; 1·36–1·99), receipt of antiretroviral therapy during incarceration (1·39; 1·11–1·74), and two or more medical comorbidities (1·86; 1·48–2·36). Reincarceration (0·70; 0·56–0·88) and conditional release (0·62; 0·50–0·78) were negatively associated with LTC within 14 days. Hispanic ethnicity, bonded release, and psychiatric comorbidity were also associated with LTC within 30 days but reincarceration was not. Interpretation LTC after release is suboptimal but improves when inmates' medical, psychiatric, and case management needs are identified and addressed before release. People who are rapidly cycling through jail facilities are particularly vulnerable to missed linkage opportunities. The use of integrated programmes to align justice and health-care goals has great potential to improve long-term HIV treatment outcomes. Funding US National Institutes of Health.

Community evidenced-based diabetes self-management education (DSME) models have not been examined for feasibility, acceptability or effectiveness among incarcerated persons transitioning to independent DSM. In a non-equivalent control group design with repeated measures, we examined the feasibility, acceptability and preliminary effect of a 6-week 1-hour per week diabetes survival skills (DSS) intervention on diabetes knowledge, distress, self-efficacy and outcome expectancy for transitioning incarcerated males. Of the 92 participants (84% T2D, 83% using insulin, 40% black, 20% white,30% Latino, 66% high school or less, mean age 47.3 years, 84% length of incarceration ≤4 years), 41 completed the study (22 Control/19 intervention (TX). One-way repeated measures ANOVAs revealed significant changes in diabetes knowledge within each group (C, p=.002; TX, p=.027) at all time points; however, a two-way repeated measures ANOVA showed no differences between groups. Additionally, both groups showed improvement in diabetes-related distress and outcome expectancy with the treatment group experiencing greater and sustained improvement at the 12-week time point. Analysis of focus group data (Krippendorf) revealed acceptance of and enthusiasm for the DSS training and low literacy education materials, and the need for skill demonstration, and ongoing support throughout incarceration and before release. Our results highlight the complexity of working with incarcerated populations. We observed information-gathering strategies among incarcerated persons that may account for overall increases in diabetes knowledge. Due to high attrition, the power to detect effects was limited. Yet, results suggest that the intervention is feasible and acceptable with an increased sample size and refined recruitment procedure. Disclosure L.A. Reagan: None. R.A. Laguerre: None. C. Gallagher: None. Funding American Nurses Foundation

BackgroundHealth systems can be integral to addressing population health, including persons with incarceration exposure. Few studies have comprehensively integrated state-wide data to assess how the primary care system can impact criminal justice outcomes. We examined whether enhanced primary care can decrease future contact with the criminal justice system among individuals just released from prison.MethodsWe linked administrative data (2013–2016) of Connecticut Department of Correction, Department of Mental Health and Addiction Services, Department of Social Service, Court Support Services Division, and Department of Public Health to conduct a quasi-experimental study using propensity score matching of 94 participants who received enhanced primary care in Transitions Clinic to 94 controls not exposed to the programme. The propensity score included 23 variables, which encompassed participants’ medical and incarceration history and service utilisation. The main outcomes were reincarceration rates and days incarcerated in the first year from the index date, which was either enrolment in the Transitions Clinic programme or release from prison in the control group.ResultsThe odds of reincarceration, including arrests and new convictions, were similar for the two groups, but Transitions Clinic participants had lower odds of returning to prison for a parole or probation technical violation (adjusted OR: 0.38; 95% CI 0.16 to 0.93) compared with the control group. Further, Transitions Clinic participants had fewer incarceration days (incidence rate ratio: 0.55; 95% CI 0.35 to 0.84) compared with the control group.ConclusionsEnhanced primary care for individuals just released from prison can reduce reincarceration for technical violations and shorten time spent within correctional facilities. This study shows how community health systems may play a role in current strategies to reduce prison populations.

Despite modifications and a procedure to externally replace the distal portion of the percutaneous lead, damage to the wiring insulation causing an electrical short to ground, referred to as a short to shield (STS), has become an important factor in the longevity of the HeartMate II left ventricular assist device (LVAD). Device exchange has been the suggested treatment option. The aim of this study was to evaluate the long-term clinical outcomes of patients with an STS supported on an ungrounded cable. A retrospective review of all patients (n = 479) implanted with a HeartMate II at our center between January 2008 and December 2017 was performed. Patients with a documented STS maintained on an ungrounded cable were examined. Patient characteristics, time from device implantation to STS, treatment strategies, and duration of support on an ungrounded cable were summarized. The association between support with an ungrounded cable and clinical outcomes was evaluated. A total of 53 (11% of 479) patients (83% males and 81% destination therapy) with an STS were supported on an ungrounded cable for a median duration of 195 days (range 2 days to 3.3 years). Patients were more active (New York Heart Association [NYHA] p < 0.001, 6 minute walk test [6MWT] p = 0.003) and had a trend toward increased weight gain (p = 0.055) from time of implant to STS. Duration of support before the STS was 1.9 years (range 165 days to 8.6 years). Twenty-two patients were treated directly with an ungrounded cable and 31 patients underwent an external driveline repair and still required an ungrounded cable within 2 days (range 0 days to 1.3 years). During the study period, 38 patients were maintained on an ungrounded cable: 21 patients were ongoing for 299 days (range 114 days to 2.8 years), 11 patients transplanted after 79 days (range 7-295 days), four patients died because of comorbid conditions after 1.6 years (range 141 days to 3.2 years), one patient exchanged for thrombosis after 229 days, and one patient explanted after 279 days. The other 15 patients developed a phase-to-phase electrical short after 51 days (range 2 days to 3.3 years): 14 patients underwent a successful pump exchange and one patient transplanted within 2 days. No patients died because of support with an ungrounded cable or worsening lead damage necessitating device exchange. With extended durations of support, some patients with a HeartMate II LVAD will experience device failure in the form of an STS. Select patients with an STS can be safely supported on an ungrounded cable for several years with close monitoring. This treatment approach should be considered before a device exchange.

Purpose The ENDURANCE trial demonstrated noninferiority of the intrapericardial centrifugal-flow HeartWare HVAD compared to the axial-flow HeartMate II left ventricular assist device (LVAD) regarding survival in patients with advanced heart failure ineligible for heart transplantation, but stroke was more common. Most recently, the MOMENTUM 3 trial demonstrated superiority of the intrathoracic, fully magnetically levitated centrifugal-flow HeartMate 3 (HM3) LVAD compared to the HeartMate II. A clinical trial evaluating the HM3 and HVAD has not been performed, therefore the purpose of this study was to compare outcomes between these two devices. Methods We retrospectively reviewed all destination therapy patients enrolled in the MOMENTUM 3 trial with a HM3 (n = 23) and Endurance Supplemental Trial with a HVAD (n = 22) at a single center with a selected study cutoff date of October 2017, to allow for 2 years of postoperative follow up on all patients. Baseline characteristics, clinical outcomes, and major adverse events using the MOMENTUM 3 trial definitions were compared for all HM 3 and HVAD patients. Results Patients implanted with a HM3 were older (70 ± 8 vs. 62 ± 11, p = .017), and experienced more hypertension (p = .001) and tricuspid regurgitation (p = .023) than the HVAD population. Cardiac arrhythmias (p = .007), major infection (p = .019), and device thrombosis (p = .032) occurred more often in the HVAD group. HVAD patients had shorter operative times (p = .067) and more VAD specific infections (p = .069), respiratory failure (p = .082), device exchange (p = .101), hospital admissions (.127), neurological dysfunction (p = .130), renal dysfunction (p = .140), and right heart failure (p = .181) at 2 years. Conclusion Patients supported with a HM3 had significantly less cardiac arrhythmias, pump thrombosis and major infection compared to HVAD patients at 2 years. Although there were no differences in survival, functional status or quality of life, the HVAD was associated with a higher morbidity compared to the HM 3.

Purpose Left ventricular assist device (LVAD) exchange for source control of infection has been suggested as a treatment option for LVAD-associated infections (LVADI). However, there are limited data regarding the efficacy and outcomes of these patients. We reviewed the clinical outcomes of patients undergoing a device exchange in the presence of persistent and severe VAD-specific and VAD-related infections. Methods We retrospectively reviewed all patients (n=80) at our center who underwent a CF-LVAD exchange between January 2005 and October 2016. Patients with a LVADI, defined using the International Society of Heart and Lung Transplant criteria were further evaluated. The primary outcomes included freedom from recurrent or new LVADI and survival at 1 and 2 years following pump exchange. Results A total of 31 (39% of 80) patients had a LVADI at time of device exchange. Median age was 59 years, 25 (81%) male, 26 (84%) HeartMate 2, and 29 (94%) destination therapy. Indication for exchange was 9 (29%) infection, 10 (32%) hemolysis, and 12 (39%) device failure. Median duration of support prior to infection was 1.1 years (range, 4 days - 4.4 years). The most common pathogens were S. aureus (23%), Pseudomonas (19%), and coagulase negative staphylococci (13%). Overall median duration from onset of LVADI to exchange was 270 days (range, 4 days - 2.4 years). The median time from onset of LVADI to exchange was shorter in patients with no recurrence of LVADI compared to patients with recurrence (140 vs. 348 days). At one-year post-exchange; ten (32%) patients had recurrence with the same pathogen after a median duration of 25 days, 6 (19%) with a new pathogen after a median duration of 90 days, and 12 (39%) were infection free. The 30-day mortality was 3 (10%) patients. Overall, 16 (51%) patients had recurrent or new LVADI at 1 year and 19 (62%) at 2 years post-exchange. Survival at 1 and 2 years was 52% and 36% and cause of death in most patients was HCVA at 42% and 50%, respectively. Conclusion For patients receiving a pump exchange with a LVADI, this study suggests a lower incidence of recurrent LVADI with earlier device exchange. While device exchange should remain a consideration for difficult LVADI, it is associated with significant risk of morbidity and mortality at 1 and 2 years. Additional studies are needed to better define management strategies in patients undergoing a device exchange for the control of infection.

In the United States, the phenomenon of mass incarceration has created a public health crisis. One strategy for addressing this crisis involves developing a correctional agency - academic institution partnership tasked with augmenting the quality and quantity of evidence-based healthcare delivered in state prisons and attracting a greater number of health professionals to the field of correctional health research. Using a Connecticut correctional agency - academic institution partnership as a case example, the present paper examines some of the key challenges encountered over the course of a 3-year capacity-building initiative. Particular attention is given to agency and institution characteristics both at the structural level and in terms of divergent stakeholder perspectives. The authors find that future partnership development work in this area will likely benefit from close attention to predictable sources of temporal variation in agency capability to advance project-related aims.

Blood stream infections (BSIs) are an important cause of morbidity and mortality in patients with left ventricular assist devices (LVADs). The aim of this study was to examine the correlation between hemorrhagic cerebrovascular accident (CVA) and BSI after implantation of LVAD for advanced heart failure (HF). This was a retrospective descriptive review of 87 patients with end-stage HF, who underwent implantation of HeartMate II continuous-flow LVAD over a 4 year period. Blood stream infections were diagnosed by serial blood cultures, and suspected neurological complications including CVAs were confirmed by neuroimaging. Extensive patient chart review was performed, and descriptive characteristics were analyzed using SPSS statistical software. The mean age of our study population was 62.3 ± 12.8 years, and the majority of our patients were males (n = 75, 86.2%). The baseline characteristics were comparable in the patients with and without CVAs. Patients with BSI had a much greater incidence of CVA compared to patients without BSI (n = 13, 43.3% vs. n = 5, 10.0%; p0.0001). There was an increased mortality in patients with BSI than those without (n = 57, 65.5% vs. n = 30, 34.5%; p = 0.003). The risk of all CVAs (hemorrhagic/ischemic) was eightfold (odds ratio [OR] = 7.9; 95% confidence interval [CI] = 2.4-25.5; p = 0.001] in patients with BSI. Patients with BSI had a20-fold risk of hemorrhagic CVA (OR = 24; 95% CI = 2.8-201.1; p = 0.03). Advanced HF patients with LVAD support who developed BSI need urgent evaluation and close monitoring for suspected neurological complications, particularly hemorrhagic CVA.

Background The HeartMate II (Thoratec Corp, Pleasanton, CA) continuous-flow left ventricular assist device (LVAD) improved survival in destination therapy (DT) patients during a randomized trial compared with pulsatile-flow LVADs. This study documented changes in cognitive performance in DT patients from that trial to determine if there were differences between continuous-flow and pulsatile-flow support. Methods Data were collected in a sub-study from 96 HeartMate II continuous-flow and 30 HeartMate XVE pulsatile-flow LVAD patients from 12 of the 35 trial sites that followed the same serial neurocognitive (NC) testing protocol at 1, 3, 6, 12, and 24 months after LVAD implantation. Spatial perception, memory, language, executive functions, and processing speed were the domains assessed with 10 standard cognitive measures. Differences over time and between LVAD type were evaluated with linear mixed-effects modeling. Results From 1 to 24 months after LVAD implantation, changes in NC functions were stable or showed improvement in all domains, and there were no differences between the continuous-flow and pulsatile-flow groups. Data at 24 months were only available from patients with the continuous-flow LVAD due to the limited durability of the HeartMate XVE device. There was no decline in any NC domain over the time of LVAD support. Missing data not collected from patients who died could have resulted in a bias toward inflated study results. Conclusions The NC performance of advanced heart failure patients supported with continuous-flow and pulsatile-flow LVADs shows stabilization or improvement during support for up to 24 months.

Background Improving the survival and quality of life of patients with end-stage heart failure is the primary goal of using a ventricular assist device, generally known as mechanical circulatory support. Ventricular assist devices are a practical long-term surgical option for a select group of patients with end-stage heart failure. Method A case study is used to demonstrate the process of selection and evaluation of patients with end-stage heart failure for ventricular assist device therapy. Also, a detailed description of all aspects of care of patients before, during, and after implantation of a ventricular assist device is presented. Conclusion A ventricular assist device is a superior therapeutic option for patients with end-stage heart failure who have become intolerant to medical therapy or in whom medical therapy has been unsuccessful. Advances in device technology through the development of nonpulsatile continuous flow devices are showing favorable long-term outcomes for patients with a ventricular assist device by minimizing complications and enhancing quality of life.

Background This implementation study examined the impact of an organizational process improvement intervention (OPII) on a continuum of evidence based practices related to assessment and community reentry of drug-involved offenders: Measurement/Instrumentation, Case Plan Integration, Conveyance/Utility, and Service Activation/Delivery. Methods To assess implementation outcomes (staff perceptions of evidence-based assessment practices), a survey was administered to correctional and treatment staff ( n = 1509) at 21 sites randomly assigned to an Early- or Delayed-Start condition. Hierarchical linear models with repeated measures were used to examine changes in evidence-based assessment practices over time, and organizational characteristics were examined as covariates to control for differences across the 21 research sites. Results Results demonstrated significant intervention and sustainability effects for three of the four assessment domains examined, although stronger effects were obtained for intra- than inter-agency outcomes. No significant effects were found for Conveyance/Utility. Conclusions Implementation interventions such as the OPII represent an important tool to enhance the use of evidence-based assessment practices in large and diverse correctional systems. Intra-agency assessment activities that were more directly under the control of correctional agencies were implemented most effectively. Activities in domains that required cross-systems collaboration were not as successfully implemented, although longer follow-up periods might afford detection of stronger effects.

Background One in six people living with HIV (PLH) in the USA transition through prison or jail annually. During incarceration, people may engage in HIV care, but transition to the community remains challenging. Linkage to care (LTC) post-release and retention in care (RIC) are necessary to optimizing HIV outcomes, but have been incompletely assessed in prior observational studies. Methods We created a retrospective cohort of all PLH released from a Connecticut jail or prison (2007–2014) by linking Department of Correction demographic, pharmacy, and custody databases with Department of Public Health HIV surveillance monitoring and case management data. We assessed time to LTC, defined as time from release to first community HIV-1 RNA test, and viral suppression status at time of linkage. We used generalized estimating equations to identify correlates of LTC within 14 or 30 days after release. We also described RIC over three years following an initial release, comparing recidivists to non-recidivists. Results Among 3,302 incarceration periods from 1,350 unique PLH, 21% and 34% had LTC within 14 and 30 days, respectively, of which >25% had detectable viremia at time of linkage. Independent correlates of LTC at 14 days included incarceration periods >30 days (adjusted odds ratio [AOR] = 1.6; P Conclusion For incarcerated PLH, both LTC and RIC as well as viral suppression are suboptimal after release. PLH who receive case management are more likely to have timely LTC. Targeted interventions and integrated programming aligning health and criminal justice goals may improve post-release HIV treatment outcomes. Disclosures All authors: No reported disclosures.

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

Changes in the trends in the material composition of domestic and imported automobiles and the increasing cost of landfilling the non-recyclable portion of automobiles (automobile shredder residue or ASR) pose questions about the future of automobile recycling in the United States. In response to these challenges, new and innovative approaches to automobile recycling are being developed. This paper presents the findings of a recent study to examine the impacts of these changes on the life cycle energy consumption of automobiles and on the quantity of waste that must be disposed of. Given the recycle status quo, trends in material composition and the viability of recycling the non-metallic components of the typical automobile are of secondary importance when compared to the energy consumed during the life of the automobile. The energy savings resulting from small changes in the fuel efficiency of a vehicle overshadow potential energy losses associated with the adoption of new and possibly non-recyclable materials. Under status quo conditions, the life cycle energy consumed by the typical automobile is projected to decrease from 599 million Btus in 1992 to 565 million Btus in 2000. Energy consumed during the manufacture of the typical car will increase from about 120 to 140 million Btus between 1992 and 2000, while energy used during vehicle operation will decrease from 520 to 480 million Btus. This study projects that energy saved at the recycle step will increase from 41 million Btus in 1992 to 55 million Btus in 2000. This study also investigated the energy impacts of several potential changes to the recycle status quo, including the adoption of technologies to retrieve the heat value of ASR by incineration and the recycle of some or all thermoplastics in the typical automobile. The study estimates that under optimistic conditions —i.e., the recycling of all thermoplastics and the incineration with heat recovery of all remaining ASR —about 8 million Btus could be saved per automobile —i.e., an increase from about 55 to 63 million Btus. In the more realistic scenario —i.e., the recycling of easy-to-remove thermoplastic components (bumper covers and dash-boards) —the potential energy savings are about 1 million Btus per vehicle. It is estimated that the annual quantity of ASR in the United States could be reduced from about 5 billion pounds to as little as 1 billion pounds of ash if all ASR is incinerated. Alternatively, ASR quantity could be reduced to about 4 billion pounds if all thermoplastics in automobiles are recycled. However, in the case of recycling only thermoplastic bumper covers and dashboards, the quantity of ASR would be reduced by only 0.2 billion pounds. A significant reduction or increase in the size of the ASR waste stream will not in itself have a large impact on the solid waste stream in the United States.

Background Continuous flow left ventricular assist devices (CF-LVADs) have emerged as the standard of care for patients in advanced heart failure (HF) requiring long-term mechanical circulatory support. Gastrointestinal (GI) bleeding has been frequently reported within this population. Methods A retrospective analysis of 101 patients implanted with the Heart Mate II from January 2005 to August 2011 was performed to identify incidence, etiology, and management of GI bleeding. Univariate and multivariate regression analysis was conducted to identify related risk factors. Results A significant incidence of GI bleeding (22.8%) occurred in our predominantly destination therapy (DT) (93%) population. Fifty-seven percent of the patients with bleeding episodes bled from the upper GI (UGI) tract (with 54% bleeding from gastric erosions and 37% from ulcers/angiodysplasias), whereas 35% of patients bled from the lower GI (LGI) tract. Previous history of GI bleeding (odds ratio [OR], 22.7; 95% CI, 2.2−228.6; p = 0.008), elevated international normalized ratio (INR) (OR, 3.9; CI, 1.2−12.9; p = 0.02), and low platelet count (OR, −0.98; CI, 0.98 −0.99; p = 0.001) were independent predictors of GI hemorrhage. Recurrent bleeding was more common in older patients (mean, 70 years; p = 0.01). The majority of bleeders (60%) rebled from the same site. Management strategies included temporarily withholding anticoagulation, decreasing the speed of LVADs, and using octreotide. Octreotide did not impact the amount of packed red blood cells used, rebleeding rates, length of hospital stay, or all-cause mortality. Only 1 patient died as a direct consequence of GI bleeding. Conclusions Multiple factors account for GI bleeding in patients on CF-VADs. A previous history of bleeding increases risk significantly and warrants careful monitoring.