Search

Purpose. This study aimed to document the self-reported trauma-related appraisals and coping strategies of injured workers with and without symptoms of posttraumatic stress disorder (PTSD) and to explore relationships between these cognitive variables and work potential. Method. Sixty-nine (55% males) respondents previously admitted to a teaching hospital following accidental injury completed a self-report survey which included measures for PTSD, trauma-related appraisals, coping strategies and work potential approximately 8 months post-accident. Results. Nineteen percent of the sample reported symptoms consistent with a PTSD diagnosis, and these participants reported more negative appraisals about the self and the world, greater use of avoidant coping and poorer work outcomes than those without clinically significant PTSD symptoms. After partialing out the influence of PTSD symptom severity, active cognitive coping was associated with increased work potential and negative appraisals of the world was associated with reduced work potential. Conclusions. Trauma-related appraisals and coping strategies are associated with work potential following accidental injury. Although the role of negative appraisals in the maintenance of PTSD is well documented, this study identified negative appraisals of the world as being associated with work potential after controlling for PTSD symptoms. Reducing negative appraisals of the world and increasing active coping may influence work potential, however, longitudinal studies that substantiate the direction of the associations are required. [ABSTRACT FROM AUTHOR]

Purpose: To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device.Technique: After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90 degrees to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65-85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites).Conclusion: We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs. [ABSTRACT FROM AUTHOR]

This study reports findings of an online survey of 139 health professionals. Health professionals were asked about the degree and type of workplace stress they encountered, as well as general perceived stress, psychological distress, and life satisfaction. The sample comprised social workers, psychologists, occupational therapists, physiotherapists, speech pathologists, and a small number of other allied health professionals. The allied health professional groups were remarkably similar in terms of workplace stress, life satisfaction, perceived stress outside the workplace, and the depression, anxiety, and stress subscales of the Depression Anxiety and Stress Scale. There were no significant differences in these variables between those working in hospital and community settings. Compared with expectations based on normative data, more people in the present sample had Depression Anxiety and Stress Scale depression scores in the mild, moderate, severe, or very severe range. The single significant predictor of psychological distress and life satisfaction was perceived stress. In the context of an increasingly generic health care workforce, the present findings indicate that workplace stressors are also generic and that generic, interdisciplinary stress management approaches may therefore be recommended. [ABSTRACT FROM AUTHOR]

Severe ischemia of the upper extremity causing tissue necrosis occurs much less frequently than in the lower extremity. The clinical outcome of patients diagnosed with digital nonhealing ulcer or gangrene is largely unknown. A retrospective review of patients with upper extremity tissue loss was performed. Patients with ischemia from embolic disease, steal syndromes, and vasospastic or connective tissue disorders were excluded. Thirteen patients with upper extremity ischemic gangrene and/or nonhealing ulcers were treated from January 1995 to June 2002. Comorbid conditions included diabetes mellitus in 10 patients and renal failure in 11 patients. Five patients developed bilateral upper extremity ischemia during the period of evaluation, while 8 had unilateral involvement. Nine patients had dry gangrene of a digit, 5 had nonhealing ulcers, and 1 patient developed wet gangrene from an ischemic ulcer. All 13 patients received local wound care and medical treatment with anticoagulants, calcium channel blockers, or antiplatelet agents. Ischemic lesions healed in 3 of the 5 patients with conservative management. Surgical intervention was performed on 6 patients with dry gangrene, and the patient with wet gangrene underwent amputation of the hand (53.8%). Two patients underwent sympathectomy without improvement. In the remaining 3 patients, tissue loss remained stable. Seven patients died within 2 years of presentation with upper extremity ischemia, with a survival at 24 months of only 14% by lifetable analysis. The local outcome of severe upper extremity ischemia is generally favorable, with good response to either medical management or digit amputation. However, the life expectancy of the patients with upper extremity ischemia from true atherosclerotic disease is dismal. Therefore, surgical intervention should be reserved for infection control or pain relief only. [ABSTRACT FROM AUTHOR]

This study examined the usefulness of a score derived from nine items of Wolpe and Lang's (1964) Fear Survey Schedule (FSS) in predicting the number of symptoms consistent with panic reported by a large outpatient sample undertaking magnetic resonance imaging (MRI) scans. The items were those identified by Lukins, Davan, and Drummond (1997) as likely to reflect fears associated with the aversive characteristics of the MRI procedure (i.e., noise, confinement, and isolation) and were taken 1 week before the scan. The MRI-related FSS score was a better predictor of symptoms consistent with panic attack during the scan than (a) Rachman and Taylor's (1993) Claustrophobia Questionnaire, (b) a score derived from nine FSS items reflecting common community fears, or (c) a measure of state anxiety. It is suggested that the brief MRI-related FSS scale can provide information important for planning patient management during MRI scans at a time when the information can be most useful. [ABSTRACT FROM AUTHOR]

Chronic neuropathic pain is an increasingly prevalent societal issue that responds poorly to existing therapeutic strategies. The α9α10 nicotinic acetylcholine receptor (nAChR) has emerged as a potential target to treat neuropathic pain. However, challenges in expressing functional α9α10 nAChRs in mammalian cell lines have slowed the discovery of α9α10 ligands and studies into the relationship between α9α10 nAChRs and neuropathic pain. Here, we develop a cell line in the HEK293 background that stably expresses functional α9α10 nAChRs. By also developing cell lines expressing only α9 and α10 subunits, we identify distinct receptor pharmacology between homomeric α9 or α10 and heteromeric α9α10 nAChRs. Moreover, we demonstrate that incubation with nAChR ligands differentially regulates the expression of α9- or α10-containing nAChRs, suggesting a possible mechanism by which ligands may modify receptor composition and trafficking in α9- and α10-expressing cells. We then apply our α9α10 cell line in a screen of FDA-approved and investigational drugs to identify α9α10 ligands that provide new tools to probe α9α10 nAChR function. We demonstrate that one compound from this screen, diphenidol, possesses antinociceptive activity in a murine model of neuropathic pain. These results expand our understanding of α9α10 receptor pharmacology and provide new starting points for developing efficacious neuropathic pain treatments.

Background: Enhancing care integration and coordination to improve patient outcomes in opioid use disorder treatment is a growing focus in the field. Understanding of how the treatment system implements coordination and integration, particularly in the aftermath of the COVID-19 pandemic, remains limited. In this study, we explored the implementation of medications for opioid use disorder (MOUD) and the evolution of service delivery toward a more comprehensive approach. We examined providers' perspectives from high-achieving programs in Los Angeles County, the largest and most diverse U.S. county, including barriers to integrating and coordinating care and strategies for integrating MOUD service delivery., Methods: We gathered qualitative interview data from 30 high-performing programs in Los Angeles County, each represented by a manager or supervisor. High performance was defined by empirical indicators of access, retention, and program completion. Our data collection and analysis followed the constructivist grounded theory approach, explicating the social processes used by participating managers during the pandemic and subsequent organizational shifts. This approach yielded 14 major and six minor codes. Interrater reliability tests yielded a pooled Cohen's kappa statistic of 93%., Results: Expert providers exhibited a strong commitment to destigmatizing MOUD and worked to overcome obstacles in delivering care to clients by advocating its efficacy to fellow health care providers. Along with their endorsement of MOUD, they identified challenges in integrating and coordinating MOUD care. Barriers included stigma at both patient and provider levels, inadequate education about MOUD, limited access to MOUD, and the complexities of operating in a fragmented health care framework. Despite these challenges, high-performing providers used strategies to harmonize and align MOUD service delivery with health and social services. These included establishing service colocation, adopting a multidisciplinary team-based approach, forming partnerships with the community, offering telehealth services, integrating and sharing data, and embracing a harm reduction philosophy., Discussion: Through the adoption of these strategies, providers enhanced care accessibility, boosted patient engagement, sustained retention in treatment, and enhanced treatment outcomes. Even among highly skilled treatment providers in Los Angeles County, barriers to integrating and coordinating care using MOUD remain intricate and multifaceted. Addressing these challenges necessitates a comprehensive strategy involving provider education and training, increased availability of MOUD, enhanced coordination and communication among health care providers, resolution of regulatory hurdles, and addressing patient hesitancy toward MOUD., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Objective: Obtaining surgical informed consent (SIC) is a critical skill most residents are expected to learn "on-the-job." This study sought to quantify the effect of 1 year of clinical experience on performance obtaining SIC in the absence of formal informed consent education., Design: In this case-control cohort study, PGY1 and PGY2 surgical residents in an academic program were surveyed regarding their experiences and confidence in obtaining SIC; then assessed obtaining informed consent for a right hemicolectomy from a standardized patient., Setting: Single academic general surgery residency program in Buffalo, NY., Participants: Ten PGY1 and eight PGY2 general surgery residents were included in the study, after excluding residents with additional years of training., Results: PGY2 residents had significantly more experience obtaining SIC compared to PGY1 residents (median response: ">50" vs "between 6 and 15," p = 0.001), however there was no difference in self-reported confidence in ability obtaining SIC (mean 3.2/5 in PGY1 vs 3.4/5 in PGY2, p = 0.61), self-reported knowledge of SIC (mean 3.1/5 in PGY1 vs 3.6/5 in PGY2, p = 0.15), performance on a test regarding SIC (mean score 9.0/20, SD 3.9 for PGY1 vs mean score 9.6/20, SD 3.5, t = 0.387, p = 0.739) or performance during a standardized patient interview (mean 11.2/20, SD 2.78 for PGY1 vs mean 11.4/20, SD 1.51 for PGY2, p = 0.87). In the interviews all residents addressed general risks (bleeding/infection), however both groups performed worse in addressing procedure-specific risks including anastomotic leak as risk for hemicolectomy., Conclusions: A year of clinical training between PGY1 to PGY2 did not improve performance in obtaining surgical informed consent when lacking formal education, despite self-confidence in their ability. A curriculum covering the content, delivery and assessment of informed consent should be initiated for residents upon arrival to surgical training., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosures None.

Background: According to the Total Worker Health ® framework, safety culture including a reasonable workload among healthcare workers is essential to the security and well-being of patients, staff, and healthcare organizations. Evaluating the impact of the pandemic on the nursing workforce in different practice areas is critical for addressing workforce health and sustainability. The purpose of this study was to compare work and selfcare experiences among Alabama nurses between practice areas and the early pandemic years (2020 vs. 2021)., Methods: A secondary analysis of cross-sectional Alabama State Nurses Association (ASNA) survey data was conducted. Kruskal-Wallis analysis of variance, Wilcoxon rank, and false discovery rates were examined., Results: There were 1,369 and 2,458 nurse survey responses in 2020 and 2021, respectively. By 2021, nurses reported worsening staff shortages, a greater need for retired and new graduate nurses to help with the workload burden, and perceptions of heavier emergency department workloads. Lower proportions of nurses reported the ability to engage in self-care activities and satisfaction with state and federal crisis management. Intensive care nurses were more likely to report staffing shortages while also reporting the lowest ability to engage in self-care., Conclusions: Overall, the Alabama nursing workforce perceived worsening work conditions in 2021 compared to when the pandemic began. Practice areas varied greatly in their responses, with acute and intensive care areas perceiving more difficult work conditions. Total Worker Health ® programs should be designed to promote and support nurses' well-being based on their experience and the needs of specific practice areas., Competing Interests: Conflict of InterestThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Disrupting the accessibility of the mental representation of suicide may be a possible pathway to a strategy for suicide prevention. Our study aims to theoretically evaluate this perspective by examining the impact of temporarily disrupting the concept of suicide on perceptions of suicide. Using a within-subject design, we tested the effects of semantic satiation targeting the word "suicide" on the perceptual judgment of suicide-relevant pictures in 104 young adults. On each trial, participants repeated aloud one of the three words (i.e., "accident," "murder," or "suicide") either three times (priming) or 30 times (satiation) and indicated whether a subsequent picture matched with the word. Results indicated that satiation of the word "suicide" slowed the accurate categorization of pictures related to all three words, and satiation of "murder" and "accident" delayed participants' judgment of suicide-relevant pictures. Our findings support that semantic satiation can render the suicide concept temporarily less accessible, thereby providing preliminary support for the strategy of concept disruption in suicide prevention., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes., Study Design: Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared., Results: Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%)., Conclusion: Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up., (© 2023. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Social determinants have been increasingly implicated in accelerating HIV vulnerability, particularly for disenfranchised communities. Among these determinants, neighborhood factors play an important role in undermining HIV prevention. However, there has been little research comprehensively examining the impact of neighborhood factors on HIV care continuum participation in the US. To address this, we conducted a systematic review (PROSPERO registration number CRD42022359787) to determine neighborhood factors most frequently associated with diminished HIV care continuum participation. Peer-reviewed studies were included if published between 2013 - 2022, centralized in the US, and analyzed a neighborhood factor with at least one aspect of the HIV care continuum. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Study quality was guided by LEGEND (Let Evidence Guide Every New Decision) evaluation guidelines. Systematic review analysis was conducted using Covidence software. There were 3,192 studies identified for initial screening. Forty-four were included for review after eliminating duplicates, title/abstract screening, and eligibility assessment. Social and economic disenfranchisement of neighborhoods negatively impacts HIV care continuum participation among persons living with HIV. In particular, five key neighborhood factors (socioeconomic status, segregation, social disorder, stigma, and care access) were associated with challenged HIV care continuum participation. Race moderated relationships between neighborhood quality and HIV care continuum participation. Structural interventions addressing neighborhood social and economic challenges may have favorable downstream effects for improving HIV care continuum participation., (© 2023. The New York Academy of Medicine.)

Background: People with cystic fibrosis (CF) are at increased risk for bronchiectasis, and several reports suggest that CF carriers may also be at higher risk for developing bronchiectasis. The purpose of this study was to determine if CF carriers are at risk for more severe courses or complications of bronchiectasis., Methods: Using MarketScan data (2001-2021), we built a cohort consisting of 105 CF carriers with bronchiectasis and 300 083 controls with bronchiectasis but without a CF carrier diagnosis. We evaluated if CF carriers were more likely to be hospitalized for bronchiectasis. In addition, we examined if CF carriers were more likely to be infected with Pseudomonas aeruginosa or nontuberculous mycobacteria (NTM) or to have filled more antibiotic prescriptions. We considered regression models for incident and rate outcomes that controlled for age, sex, smoking status, and comorbidities., Results: The odds of hospitalization were almost 2.4 times higher (95% CI, 1.116-5.255) for CF carriers with bronchiectasis when compared with non-CF carriers with bronchiectasis. The estimated odds of being diagnosed with a Pseudomonas infection for CF carriers vs noncarriers was about 4.2 times higher (95% CI, 2.417-7.551) and 5.4 times higher (95% CI, 3.398-8.804) for being diagnosed with NTM. The rate of distinct antibiotic fill dates was estimated to be 2 times higher for carriers as compared with controls (95% CI, 1.735-2.333), and the rate ratio for the total number of days of antibiotics supplied was estimated as 2.8 (95% CI, 2.290-3.442)., Conclusions: CF carriers with bronchiectasis required more hospitalizations and more frequent administration of antibiotics as compared with noncarriers. Given that CF carriers were also more likely to be diagnosed with Pseudomonas and NTM infections, CF carriers with bronchiectasis may have a phenotype more resembling CF-related bronchiectasis than non-CF bronchiectasis., Competing Interests: Potential conflicts of interest. P. M. P. is a consultant/case adjudicator for Eli Lilly and has grant funding from Pfizer. K. L. W. served on an advisory committee for Insmed; served as a consultant for Bayer Healthcare, Bristol-Myers Squibb, Horizon, Lilly, Pfizer, and RedHill Biopharma; received research support from Bristol-Myers Squibb, Cellestis, and Insmed; and served on data safety and monitoring boards for AbbVie, Biomarin, Gilead, Roche, and UCB. All other authors report no potential conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a supplementary intervention that can be incorporated into the Pre-Exposure Prophylaxis (PrEP) Care Continuum, complementing initiatives and endeavors focused on Human Immunodeficiency Virus (HIV) prevention in clinical care and community-based work. Referencing the Transtheoretical Model of Change and the PrEP Awareness Continuum, this conceptual analysis highlights how SBIRT amplifies ongoing HIV prevention initiatives and presents a distinct chance to address identified gaps. SBIRT's mechanisms show promise of fit and feasibility through (a) implementing universal Screening (S), (b) administering a Brief Intervention (BI) grounded in motivational interviewing aimed at assisting individuals in recognizing the significance of PrEP in their lives, (c) providing an affirming and supportive Referral to Treatment (RT) to access clinical PrEP care, and (d) employing client-centered and destigmatized approaches. SBIRT is uniquely positioned to help address the complex challenges facing PrEP awareness and initiation efforts. Adapting the SBIRT model to integrate and amplify HIV prevention efforts merits further examination., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Harris, Kerr, Skidmore, Ghare, Reyes-Vega, Remenik-Zarauz, Samanapally, Anwar, Rijal, Bryant, Hall and Barve.)

Thoracic outlet syndrome (TOS) is a rare anatomic condition caused by compression of neurovascular structures as they traverse the thoracic outlet. Depending on the primary structure affected by this spatial narrowing, patients present with one of three types of TOS-venous TOS, arterial TOS, or neurogenic TOS. Compression of the subclavian vein, subclavian artery, or brachial plexus leads to a constellation of symptoms, including venous thrombosis, with associated discomfort and swelling; upper extremity ischemia; and chronic pain due to brachial plexopathy. Standard textbooks have reported a predominance of females patients in the TOS population, with females comprising 70%. However, there have been few comparative studies of sex differences in presentation, treatment, and outcomes for the various types of TOS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Chronic leg ulcers are affecting approximately 6.5 million Americans, and they are associated with significant mortality, reduced quality of life, and high treatment costs. Since many chronic ulcers have underlying vascular insufficiency, accurate assessment of tissue perfusion is critical to treatment planning and monitoring. This study introduces a dual-scan photoacoustic (PA) tomography (PAT) system that can simultaneously image the dorsal and plantar sides of the foot to reduce imaging time. To account for the unique shape of the foot, the system employs height-adjustable and articulating baseball stages that can scan along the foot's contour. In vivo results from healthy volunteers demonstrate the system's ability to acquire clear images of foot vasculature, and results from patients indicate that the system can image patients with various ulcer conditions. We also investigated various PA features and examined their correlation with the foot condition. Our preliminary results indicate that vessel sharpness, occupancy, intensity, and density could all be used to assess tissue perfusion. This research demonstrated the potential of PAT for routine clinical tissue perfusion assessment.

Background: The COVID-19 pandemic has had devasting effects on drug abuse treatment systems already stressed by the opioid crisis. Providers within opioid use disorder (OUD) outpatient treatment programs have had to adjust to rapid change and respond to new service delivery provisions such as telehealth and take-home medication. Using the COVID-19 pandemic and subsequent organizational challenges as a backdrop, this study explores providers' perspectives about strategies and policies that, if made permanent, can potentially improve access to and quality of OUD treatment., Methods: This qualitative study was conducted in Los Angeles County, which has one of the largest substance use disorder (SUD) treatment systems in the United States serving a diverse population, including communities impacted by the opioid crisis. We collected qualitative interview data from 30 high-performing programs (one manager/supervisor per program) where we based high performance on empirical measures of access, retention, and program completion outcomes. The study team completed data collection and analysis using constructivist grounded theory (CGT) to describe the social processes in which the participating managers engaged when faced with the pandemic and subsequent organizational changes. We developed 14 major codes and six minor codes with definitions. The interrater reliability tests showed pooled Cohen's kappa statistic of 93 %., Results: Our results document the impacts of COVID-19 on SUD treatment systems, their programmatic responses, and the strategic innovations they developed to improve service delivery and quality and which managers plan to sustain within their organizations., Conclusion: Providers identified three primary areas for strategic innovation designed to improve access and quality: (1) designing better medication utilization, (2) increasing telemedicine capacity, and (3) improving reimbursement policies. These strategies for system transformation enable us to use lessons from the COVID-19 pandemic to direct policy and programmatic reform, such as expanding eligibility for take-home medication and enhancing access to telehealth services., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Prior studies have demonstrated acceptable midterm outcomes with prosthetic conduits for above-knee bypass for occlusive disease in patients with inadequate segment great saphenous vein (GSV). In this study we aimed to investigate whether this holds true for open repair of popliteal artery aneurysms (PAA)., Methods: We queried the Vascular Quality Initiative data for patients who underwent open PAA repair (OPAR). We divided the cohort into three groups based on the conduit used: GSV, other autologous veins, or prosthetic graft. Study outcomes included primary patency, freedom from major amputation, amputation-free survival, and overall survival at 1 y. Kaplan-Meier survival estimates, log-rank tests and multivariable Cox regression were used to compare outcomes between study groups., Results: A total of 4016 patients underwent bypass for PAA from January 2010 to October 2021. The three cohorts were significantly different in many demographic and clinical characteristics. The adjusted odds of postoperative amputation among symptomatic patients were 3-fold higher for prosthetic conduits compared to the GSV (odds ratio, 3.20; 95% CI, 1.72-5.92; P < 0.001). For the 1-y outcomes, the adjusted risk of major amputation was almost 3-fold higher for patients with symptomatic disease undergoing bypass with prosthetic conduits (hazard ratio [HR], 2.97; 95% CI, 1.35-6.52; P = 0.007). When compared with GSV, prosthetic conduits were associated with 96% increased risk of death when used for repair in symptomatic patients (adjusted hazard ratio (aHR), 1.96; 95% CI, 1.29-2.97; P = 0.002) but no significant association with mortality in asymptomatic patients (aHR, 0.83; 95% CI, 0.37-1.87; P = 0.652). When compared with GSV, prosthetic conduits were associated with a 2-fold increased risk of 1-y major amputation or death when used for repair in symptomatic patients (aHR, 2.03; 95% CI, 1.40-2.94; P < 0.001) but no significant association with mortality in asymptomatic patients (aHR, 0.91; 95% CI, 0.42-1.98; P = 0.816). Comparing bypass with other veins to the GSV among patients with symptomatic disease, there was no statistically significant difference in major amputation risk (HR; 2.44; 95% CI, 0.55-10.82; P = 0.242) and no difference in the adjusted risk of all-cause mortality (aHR, 0.77; 95% CI, 0.26-2.44; P = 0.653). There were no differences in the adjusted risk of loss of primary patency comparing other veins to GSV (HR, 1.53; 95% CI, 0.85-2.76; P = 0.154) and prosthetic conduits to GSV (HR, 0.85; 95% CI, 0.57-1.26; P = 0.422)., Conclusions: This large study shows that among patients undergoing OPAR, 1-y primary patency does not differ between conduit types. However, prosthetic conduits are associated with significantly higher risk of amputation and death compared to GSV among symptomatic patients. Though non-GSV autologous veins are less often used for OPAR, they have comparably acceptable outcomes as GSV., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Objectives: Mentorship is critical to physician recruitment, career development, and retention. Many underrepresented in medicine (URiM) physicians experience minority taxes that can undermine their professional objectives. Use of cross-cultural mentoring skills to navigate differences between non-URiM and URiM physicians can make mentorship relationships with URiM physicians more effective. This survey examined military family physician demographics and mentorship practices., Methods: Design and Setting: Cross-sectional study using voluntary, anonymous data from the 2021 Uniformed Services Academy of Family Physicians (USAFP) Annual Meeting Omnibus Survey., Study Population: USAFP Members attending 2021 Virtual Annual Meeting., Intervention: None., Statistical Analysis: Descriptive statistics and χ2 tests., Results: The response rate to the omnibus survey was 52.9%, n=258. More than half of respondents did not have a URiM mentee and had not collaborated with a URiM colleague on a scholarly activity within the last 3 years. Only 54.7% of respondents could recognize and address minority taxes. URiM physicians were more likely to have a URiM mentee (65.4% vs 44.4%, P=.042) and to recognize and address minority taxes (84.6% vs 51.3%, P=.001). They also were more confident (84.6% vs 60.3%, P=.015) and more skilled in discussing racism (80.8% vs 58.2%, P=.026)., Conclusions: Structured programs are needed to improve knowledge and skills to support cross-cultural mentorship. Additional studies are needed to further evaluate and identify implementation strategies.

Compounding systems of marginalization differentiate and shape water-related risks. Yet, quantitative water security scholarship rarely assesses such risks through intersectionality, a paradigm that conceptualizes and examines racial, gendered, class, and other oppressions as interdependent. Using an intersectionality approach, we analyze the relationships between household head gender and self-reported socio-economic status, and water affordability (proportion of monthly income spent on water) and water insecurity (a composite measure of 11 self-reported experiences) for over 4000 households across 18 low- and middle-income countries in Central and South America, Africa, and Asia. Interaction terms and composite categorical variables were included in regression models, adjusting for putative confounders. Among households with a high socio-economic status, the proportion of monthly income spent on water differed by household head gender. In contrast, greater household water insecurity was associated with lower socio-economic status and did not meaningfully vary by the gender of the household head. We contextualize and interpret these experiences through larger systems of power and privilege. Overall, our results provide evidence of broad intersectional patterns from diverse sites, while indicating that their nature and magnitude depend on local contexts. Through a critical reflection on the study's value and limitations, including the operationalization of social contexts across different sites, we propose methodological approaches to advance multi-sited and quantitative intersectional research on water affordability and water insecurity. These approaches include developing scale-appropriate models, analyzing complementarities and differences between site-specific and multi-sited data, collecting data on gendered power relations, and measuring the impacts of household water insecurity., Competing Interests: Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Optimizing medical management and risk factor modification are underused strategies in patients with chronic limb-threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in patients with CLTI undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS), and limb salvage (LS)., Methods: Patients undergoing index PVI for CLTI between 2012 and 2016, with ≥24 months of follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t test, and logistic regression., Results: There were 12,370 PVI completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (from 29.8% to 39.0%; P < .001) and PVI performed for tissue loss (from 59.1% to 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (from 36.2% to 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45%, and P2Y12 therapy in 58% of patients not receiving these medications before PVI. Over the course of follow-up, dual antiplatelet therapy (DAPT) (from 41.1% to 48.0%; P < .001), angiotensin-converting enzyme (ACE) inhibitor (from 46.2% to 51.3%; P < .001), and statin (from 70.4% to 77.5%; P < .001) use increased. Combined DAPT, ACE inhibitor and statin use increased from 33.6% to 39.6% (P ≤ .001). Significant improvement in 24-month OS and AFS was noted (OS, from 90.9% to 93.7% [P = .002]: AFS, from 81.2% to 83.1% [P = .046]), but not LS (from 89.6% to 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE inhibitors was an independent predictor of improved OS (hazard ratio, 0.61; 95% confidence interval, 0.39-0.96; P = .034). DAPT was independent predictor of improved LS (hazard ratio, 0.83; 95% confidence interval, 0.79-0.87; P < .007)., Conclusions: Antiplatelet, ACE inhibitor, and statin use increased over the study period and was associated with improved OS and AFS. LS trends did not change significantly over time, possibly owing to the inclusion of patients with a greater disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Background: Pre-exposure prophylaxis (PrEP) demonstrates effectiveness in decreasing new cases of HIV. However, few African Americans use PrEP, despite being disproportionately impacted by HIV. Understanding the influence of sociocultural and structural factors on PrEP use among multiple priority groups of African Americans, including but not limited to men who have sex with men, may improve PrEP engagement and uptake. The social ecological model (SEM) as a framework guided the understanding of how these factors operate on multiple levels to influence PrEP use among this population., Methods: This study derived data from the Afya PrEP study consisting of eleven focus groups (N = 63) with 18-29-year-old African American sexual and gender minority and heterosexual individuals at heightened behavioral vulnerability to HIV. We employed constructivist grounded theory processes to inductively analyze the data. A pooled kappa score of 0.90 indicated excellent inter-rater agreement., Results: Factors impacting PrEP engagement among African American young adults included: (1) Community/social network influences; (2) medical mistrust; (3) stigma; (4) PrEP availability and accessibility, which had two sub-categories: (a) cost and (b) where to obtain PrEP; and (5) PrEP engagement strategies, which had two sub-categories: (a) current AIDS service organizations' PrEP engagement practices and (b) recommended future PrEP engagement strategies. Categories one through three represent sociocultural factors, and categories four and five represent structural factors that influence perceptions and attitudes of African American young adults regarding PrEP., Conclusion: Our study highlights sociocultural and structural factors that act as barriers and facilitators to PrEP engagement. The SEM guided the understanding of how these factors operated on multiple levels. One of the sociocultural factors, community/social network influences operated at the interpersonal level of the SEM; the other two, stigma and medical mistrust, operated at the community level. The structural factors (PrEP availability, accessibility, and engagement strategies) operated at the institutional/organizational level. Thus, multi-level interventions are warranted to improve PrEP engagement among various African American young adult priority groups., (© 2023. The Author(s).)

We describe two cases of wound infections of koalas (Phascolarctos cinereus), one wild and one captive, in which Lonepinella-like organisms were involved. The wild adult koala was captured with bite wound injuries, as part of a koala population management program in Queensland, Australia. In both cases, there was evidence of physical trauma causing the initial wound. The captive koala suffered injury from the cage wire, and the wild koala had injuries suggestive of intermale fighting. Gram-negative bacteria isolated from both cases proved to be challenging to identify using routine diagnostic tests. The wound in the captive koala yielded a pure culture of an organism shown by whole genome sequence (WGS) analysis to be a member of the genus Lonepinella, but not a member of the only formally described species, L. koalarum. The wound of the wild koala yielded a mixed culture of Citrobacter koseri, Enterobacter cloacae and an organism shown by WGS analysis to be Lonepinella, but again not Lonepinella koalarum. Both cases were difficult to treat; the captive koala eventually had to have the phalanges amputated, and the wild koala required removal of the affected claw. The two Lonepinella isolates from these cases have a close relationship to an isolate from a human wound caused by a koala bite and may represent a novel species within the genus Lonepinella. Wound infections in koalas linked to Lonepinella have not been reported previously. Wildlife veterinarians need to be aware of the potential presence of Lonepinella-like organisms when dealing with wound infections in koalas, and the inability of commercial kits and systems to correctly identify the isolates., (© Wildlife Disease Association 2023.)

Existing evidence suggests a link between physical pain and suicide, but the nature of this relationship remains unknown. To address this critical gap in knowledge, the present study leveraged a validated virtual reality (VR) suicide paradigm to experimentally examine the causal effects of physical pain on subsequent virtual suicidal behaviors. Based on previous findings, we hypothesized that physical pain would causally drive virtual suicidal behavior only if suicide was conceptualized as having desirable anticipated consequences (e.g., a means of escaping from current pain; an opportunity to avoid future pain). We tested this by randomizing 326 participants across four different conditions: a physical pain condition, an anticipated escape condition, an anticipated avoidance condition, and a control condition. As predicted, physical pain alone did not result in statistically significant increases in VR suicide rates; however, the anticipation that virtual suicidal behavior would result in the avoidance of future physical pain had a large causal effect on VR suicide rates (B = 1.61, p < .001, IRR = 5.01). We failed to find evidence that anticipating that VR suicide would provide an escape from currently experienced physical pain increases the likelihood of VR suicide. Our findings add to a growing body of evidence suggesting that the anticipated consequences of suicide (e.g., avoidance of future physical pain) may serve as primary causes of suicidal behavior., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

There have been 130 mass shootings in the United States from 1982 to June, 2022 according to the Mother Jones database of active shooter events. In these critical scenarios, making the right decisions while evacuating can be the difference between life and death. However, emergency evacuation is intensely stressful, which along with lack of verifiable real-time information may lead to costly incorrect decisions. In this paper, we demonstrate the effectiveness of a non-homogeneous semi-Markov-Decision-Process (NHSMDP) based naive algorithm that relies on prior knowledge about the layout of a building and uses recurring updates of the shooter's location (based on automatic processing of images from a camera network) to provide an optimized egress plan for evacuees. While emergency evacuations due to fire and natural disasters are well researched, the novelty of this work is in the response to a threat that moves either purposefully or randomly through the building and in incorporating the ability for an evacuee to wait for danger to pass before beginning egress and during the process of evacuation. This ability to include sojourn times in the optimized scheme is due to the NHSMDP formulation and is a notable augmentation to the current state-of-the-art. We show that following this algorithm can reduce casualties by 56% and the time spent by evacuees in the shooter's line of sight by 52% compared to an intuitive natural response guided by expert advice., Competing Interests: The authors declare no competing interests., (© 2023 The Author(s).)

Competing Interests: Conflicts of interest: None.

Background: Over 50% of new AIDS/HIV diagnoses are older adults and disproportionately African American people. Longstanding health inequities, driven by the enduring nature of systemic racism, pose challenges to obtaining optimal HIV services. Patient experiences and identities shape the health care experience, yet patient voices are often minimized, including their assessment of quality HIV care. Understanding these markers of care, including facilitators of and barriers to care and engagement, may help enhance the patient voice, potentially improving service delivery and eradicating HIV healthcare disparities., Method: Using a convergent mixed method design, our study identifies patient-identified markers of quality care among older African Americans (N = 35). Measurements of global stress, HIV stigma, and engagement in care were collected, and in-depth qualitative interviews explored the symbols of quality care as well as facilitators of and barriers to care., Results: We identified widespread participant awareness and recognition of quality care, the detection of facilitators and barriers across individual, clinic, and community levels. Facilitators of care include diet, health, relationships, community support, and compassionate HIV care. Barriers to care include health comorbidities, economic, food, and housing insecurity, lack of transportation, and structural racism., Conclusion: Our findings illuminate how the prominence of barriers to care often uproot facilitators of care, creating impediments to HIV service delivery as patients transition through the HIV care continuum. We offer implications for practice and policy, as well as recommendations for reducing structural barriers to care by enhancing the patient voice and for aligning services toward compassionate and inclusive care., (© 2022. W. Montague Cobb-NMA Health Institute.)

Ensuring that evidence-based practice is adopted across hospital systems is difficult. A system-wide Nursing Research Council in a large academic health care system in Maryland implemented a unique strategy to support the evidence-based practice process by collaborating with other system-wide councils. As a result, new system-wide evidence-based practices were adopted and improved organizational outcomes were seen. [ J Contin Educ Nurs . 2023;54(1):25-31.] .

Objective: We evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI)., Methods: All index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS., Results: The 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P < .001)., Conclusions: Stenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment., (Copyright © 2022 Society for Vascular Surgery. All rights reserved.)

The nuclear corepressors NCOR1 and NCOR2 interact with transcription factors involved in B cell development and potentially link these factors to alterations in chromatin structure and gene expression. Herein, we demonstrate that Ncor1/2 deletion limits B cell differentiation via impaired recombination, attenuates pre-BCR signaling and enhances STAT5-dependent transcription. Furthermore, NCOR1/2-deficient B cells exhibited derepression of EZH2-repressed gene modules, including the p53 pathway. These alterations resulted in aberrant Rag1 and Rag2 expression and accessibility. Whole-genome sequencing of Ncor1/2 DKO B cells identified increased number of structural variants with cryptic recombination signal sequences. Finally, deletion of Ncor1 alleles in mice facilitated leukemic transformation, whereas human leukemias with less NCOR1 correlated with worse survival. NCOR1/2 mutations in human leukemia correlated with increased RAG expression and number of structural variants. These studies illuminate how the corepressors NCOR1/2 regulate B cell differentiation and provide insights into how NCOR1/2 mutations may promote B cell transformation., (© 2022. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Objective: To evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques., Methods: We retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by 1 of 3 surgeons over a 10-year period and the surgeon's daily schedule., Results: The median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning vs afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (P =.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration vs scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (P =.043)., Conclusion: A variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Mega-damming, pollution and depletion endanger rivers worldwide. Meanwhile, modernist imaginaries of ordering 'unruly waters and humans' have become cornerstones of hydraulic-bureaucratic and capitalist development. They separate hydro/social worlds, sideline river-commons cultures, and deepen socio-environmental injustices. But myriad new water justice movements (NWJMs) proliferate: rooted, disruptive, transdisciplinary, multi-scalar coalitions that deploy alternative river-society ontologies, bridge South-North divides, and translate river-enlivening practices from local to global and vice-versa. This paper's framework conceptualizes 'riverhood' to engage with NWJMs and river commoning initiatives. We suggest four interrelated ontologies, situating river socionatures as arenas of material, social and symbolic co-production: 'river-as-ecosociety', 'river-as-territory', 'river-as-subject', and 'river-as-movement'., Competing Interests: No potential conflict of interest was reported by the authors., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Spoken language interpreters play a critical role in bridging the linguistic and cultural gap between refugee newcomers and service providers in resettlement countries. Little is known about the positions interpreters assume in their work with refugee newcomers and the meaning-making processes attached. Our study used constructivist grounded theory techniques and Situational Analysis to analyse interview transcripts and identify positions taken. We conducted in-depth qualitative interviews with 12 professional interpreters working in the southeastern United States. Findings suggest interpreters break the mould of the dominant training paradigm-the black box interpretation model-to support the realities of their clients' needs. We conceptualised five prominent positions interpreters take-the conduit, the clarifier, the co-clinician, the comforter, and the volunteer. Practice recommendations include incorporating identified positions into professional interpreter training and supervision agendas., (© 2022 John Wiley & Sons Ltd.)

Objective: Antiplatelet therapy is recommended in patients with peripheral arterial disease to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet therapy (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy, and DAPT on limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI)., Methods: The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between March 1, 2010 and September 30, 2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy, and DAPT. Propensity score-matched samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by χ 2 and Hosmer-Lemeshow tests. Kaplan-Meier and Cox regression were performed for OS, AFS, and LS., Results: A total of 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Median follow-up was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared with ASA monotherapy, OS (87.8% vs 85.5%l P = .026; Cox hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = .03), AFS (79.6% vs 74.8%; P < .001; Cox HR, 0.75; 95% CI, 0.65-0.86; P < .001) and LS (89.5% vs 86.8%; P = .013; Cox HR, 0.74; 95% CI, 0.60-0.91; P = .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%; P = .62; Cox HR, 0.94; 95% CI, 0.77-1.14; P = .50), AFS (79.6% vs 81.5%; P = .33; Cox HR, 0.92; 95% CI, 0.78-1.07; P = .28), and LS (91.7% vs 89.4; P = .03; Cox HR, 0.80; 95% CI, 0.64-1.00; P = .06)., Conclusions: P2Y12 monotherapy was associated with superior OS, AFS, and LS as compared with ASA monotherapy, and comparable OS, LS, and AFS with DAPT in patients undergoing PVI for CLTI. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in patients with CLTI, especially in patients with high bleeding risk., (Copyright © 2022. Published by Elsevier Inc.)

Background: People with cystic fibrosis (CF) routinely suffer from recurrent sinopulmonary infections. Such infections require frequent courses of antimicrobials and often involve multidrug-resistant organisms. The goal of this study was to identify real-world evidence for the effectiveness of elexacaftor-tezacaftor-ivacaftor (ELX/TEZ/IVA) in decreasing infection-related visits and antimicrobial use in people with CF., Methods: Using IBM MarketScan data, we identified 389 enrollees with CF who began taking ELX/TEZ/IVA before 1 December 2019 and were enrolled from 1 July 2019 to 14 March 2020. We also identified a comparison population who did not begin ELX/TEZ/IVA during the study period. We compared the following outcomes in the 15 weeks before and after medication initiation: total healthcare visits, inpatient visits, infection-related visits, and antimicrobial prescriptions. We analyzed outcomes using both a case-crossover analysis and a difference-in-differences analysis, to control for underlying trends., Results: For the case-crossover analysis, ELX/TEZ/IVA initiation was associated with the following changes over a 15-week period: change in overall healthcare visit dates, -2.5 (95% confidence interval, -3.31 to -1.7); change in inpatient admissions, -0.16 (-.22 to -.10); change in infection-related visit dates, -0.62 (-.93 to -.31); and change in antibiotic prescriptions, -0.78 (-1.03 to -.54). Results from the difference-in-differences approach were similar., Conclusions: We show a rapid reduction in infection-related visits and antimicrobial use among people with CF after starting a therapy that was not explicitly designed to treat infections. Currently, there are >30 000 people living with CF in the United States alone. Given that this therapy is effective for approximately 90% of people with CF, the impact on respiratory infections and antimicrobial use may be substantial., Competing Interests: Potential conflicts of interest. D. A. S. reports funding, outside the submitted work, from the National Institutes of Health and the Cystic Fibrosis Foundation and royalties or licensing from Exemplar Genetics (received by the University of Iowa Foundation and shared with developers of a cystic fibrosis pig model). D. B. H. reports grants or contracts, outside the submitted work, from a Cystic Fibrosis Foundation center grant (annual support) and consulting fees from MannKind. P. M. P. reports consulting fees from Eli Lily, outside the submitted work (case adjudication for a clinical trial; no payment received). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Introduction: Our goal was to describe variation in procedural benzodiazepine and post-vasectomy nonopioid pain and opioid prescription dispense events, and multilevel factors associated with the probability of an opioid refill., Methods: Patients (40,584) undergoing vasectomies in the U.S. Military Health System between January 2016-January 2020 were included in this observational retrospective study. The main outcome was the probability of being dispensed an opioid prescription refill within 30 days post-vasectomy. Bivariate analyses examined the relationships between patient- and care-level characteristics, prescription dispense and 30-day opioid prescription refill. A generalized additive mixed-effects model and sensitivity analyses examined factors associated with opioid refill., Results: There was wide variation in procedural benzodiazepine (32%) and post-vasectomy nonopioid (71%) and opioid (73%) prescription dispense patterns across facilities. Only 5% of the patients dispensed opioids received a refill. Probability of an opioid refill was associated with race (White), younger age, opioid dispense history, documented mental health or pain condition, lack of post-vasectomy nonopioid pain medication dispense events and higher dispensed post-vasectomy opioid prescription dose; albeit the effect of dose did not replicate in sensitivity analyses., Conclusions: Despite the wide variation in vasectomy-related pharmacological pathways across a large health care system, most patients do not require an opioid refill. Significant variation in prescribing practices indicated racial inequities. Given the low rates of opioid prescription refill, combined with the wide variation in opioid prescription dispense events and American Urological Association recommendations for conservative opioid prescribing after vasectomy, intervention to address excessive opioid prescribing is warranted.

Patients with acute lymphoblastic leukemia have experienced significantly improved outcomes due to the advent of chimeric antigen receptor (CAR) T cells and bispecific T-cell engagers, although a proportion of patients still relapse despite these advances. T-cell exhaustion has been recently suggested to be an important driver of relapse in these patients. Indeed, phenotypic exhaustion of CD4+ T cells is predictive of relapse and poor overall survival in B-cell acute lymphoblastic leukemia (B-ALL). Thus, therapies that counter T-cell exhaustion, such as immune checkpoint blockade, may improve leukemia immunosurveillance and prevent relapse. Here, we used a murine model of Ph+ B-ALL as well as human bone marrow biopsy samples to assess the fundamental nature of CD4+ T-cell exhaustion and the preclinical therapeutic potential for combining anti-PD-L1 based checkpoint blockade with tyrosine kinase inhibitors targeting the BCR-ABL oncoprotein. Single-cell RNA-sequence analysis revealed that B-ALL induces a unique subset of CD4+ T cells with both cytotoxic and helper functions. Combination treatment with the tyrosine kinase inhibitor nilotinib and anti-PD-L1 dramatically improves long-term survival of leukemic mice. Depletion of CD4+ T cells prior to therapy completely abrogates the survival benefit, implicating CD4+ T cells as key drivers of the protective anti-leukemia immune response. Indeed, treatment with anti-PD-L1 leads to clonal expansion of leukemia-specific CD4+ T cells with the aforementioned helper/cytotoxic phenotype as well as reduced expression of exhaustion markers. These findings support efforts to use PD1/PD-L1 checkpoint blockade in clinical trials and highlight the importance of CD4+ T-cell dysfunction in limiting the endogenous anti-leukemia response., (© 2022 by The American Society of Hematology.)

Despite increased numbers of children and adolescents seeking and receiving mental health treatment, rates of self-injurious thoughts and behaviors (SITBs) in youth are rising. In the hopes of aiding ongoing efforts to alleviate the burden of SITBs in this vulnerable population, the present study summarizes current knowledge on the efficacy of SITB interventions in children and adolescents. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing treatment effects on SITBs in child and adolescent populations. A total of 112 articles comprising 558 effect sizes were included in analyses. Nearly all interventions produced nonsignificant reductions in SITBs. For binary SITB outcomes, a nonsignificant treatment effect was detected, with an RR of 1.06 (95% CIs [0.99, 1.14]). For continuous SITB outcomes, analyses also yielded a nonsignificant treatment effect (g = - 0.04 [- 0.12, 0.05]). These patterns were largely consistent across SITB outcomes, regardless of intervention type, treatment components, sample and study characteristics, and publication year. Our findings highlight opportunities for improving SITB intervention development and implementation in child and adolescent populations. The most efficacious interventions are likely to directly target the causes of SITBs; therefore, future research is needed to identify the causal processes underlying the onset and maintenance of SITBs in youth., (© 2022. The Author(s).)