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This study aims to examine the microorganism-fighting properties of the thin layers of TiO2. These TiO2 film as synthesized through a chemical process, in which different concentrations of copper have been added. The ability of films to inhibit the growth of different types of bacteria and fungi was examined using the disk diffusion technique. TiO2 films without additives exhibited mild antibacterial action, with inhibition areas varying according to the dose and type of microorganism. In contrast, the films that received a dose of copper showed significant increases in their ability to inhibit bacterial growth. More prominent detention areas were observed when a dose of 60 µg/mL and a doping concentration of 0.1% were used. According to X-ray diffraction tests, it was revealed that the thin films of TiO2 exhibit a cubic crystalline configuration, indicating their high crystallinity and the variation in the position of the peaks due to the inclusion of copper in their composition. The effectiveness in combating bacteria increased when the size of the crystals was raised from 6.72 nm (undoped) to 8.39 nm in presence of 0.1% copper. Significant changes occurred in the external appearance, as seen in the photographs taken using scanning electron microscopy (SEM). The modifications higher concentration of Cu doping, a transformation from smooth surfaces of pure ZnS to rough and porous layers in the films doped with Cu is observed. Specifically, the study reveals that by adding copper to thin films of zinc sulfide, their effectiveness can be enhanced, paving the way for the advancement of materials with antimicrobial properties.

This research elucidates the pursuit of operational excellence in greenhouse gas emission, employing a multifaceted approach to analyze key performance indicators (KPIs), supply chain dynamics, electric vehicle, and technology integration. The investigation reveals a consistent improvement in production efficiency, with an average increase of 0.53%, reduced downtime by an average of 5 hours per month, and a marginal decrease in cycle time. Supply chain metrics exhibit commendable performance, with an average on-time delivery rate of 93.0%, order accuracy of 97.9%, and lead time of 5.5 days. Electric vehicle showcases a strategic investment with an average of 19 hours per month, leading to certifications such as Level 3 and Level 4 for advanced machine operations and programming CNC machines. The integration of advanced technologies demonstrates substantial efficiency improvements, with IoT sensors contributing to a 20% increase, automated robotics showcasing a remarkable 35% enhancement, and advanced data analytics and augmented reality (AR) each exhibiting 25% and 30% improvements, respectively. The findings collectively underscore the interconnected strategies driving operational excellence in greenhouse gas emission, providing valuable insights for organizational decision-making.

Maximizing the efficiency of solar panels is crucial for enhancing the viability of solar energy in both residential and commercial sectors. In this study, we employ Genetic Algorithms (GAs) to optimize various parameters affecting solar panel performance, such as tilt angle, azimuth angle, and environmental conditions like temperature and solar irradiance. We develop a model that simulates the efficiency of solar panels under varying conditions and apply GAs to find the optimal configuration. The results demonstrate a significant improvement in energy output, with optimized parameters yielding up to a 15% increase in solar panel efficiency. This research shows the potential of GAs in solving complex optimization problems in renewable energy systems.

This study examines the potential of polymer matrix nanocomposites for creating lightweight and sustainable automotive parts. It conducts a thorough analysis of mechanical properties, thermal properties, environmental impact, and cost considerations. A variety of nanofillers and polymer matrices were used to create nanocomposites, which were then analyzed to assess their suitability for use in automotive applications. The results indicate variations in the mechanical properties of the nanocomposites. Composite D demonstrates the highest tensile strength (95 MPa), Young's modulus (13 GPa), flexural strength (135 MPa), and impact strength (20 kJ/m^2), suggesting superior mechanical performance compared to the other nanocomposites. The analysis of thermal properties shows variations in glass transition temperature (Tg), melting temperature, thermal conductivity, and heat deflection temperature across different nanocomposites. Among them, Composite D exhibits the highest Tg (88°C) and melting temperature (160°C), along with superior thermal conductivity (0.7 W/mK) and heat deflection temperature (130°C). The assessment of environmental impact metrics reveals that Composite D has the lowest carbon footprint (8 kg CO2/kg), embodied energy (45 MJ/kg), and water usage (90 L/kg), as well as the highest recyclability (90%). These findings emphasize the potential of Composite D to minimize environmental impact and foster sustainability in the automotive manufacturing sector. There are variations in material and processing costs among nanocomposites. Composite D has the highest material cost ($25/kg) and processing cost ($18/kg). This study offers important insights into the performance, environmental impact, and cost considerations of polymer matrix nanocomposites for lightweight sustainable automotive parts. It contributes to the development of more environmentally friendly and efficient vehicles with improved performance characteristics.

A crucial component of agriculture is soil. Soil analysis is critical for optimizing agricultural practices and ensuring sustainable crop production. Traditional methods are often time-consuming and labor intensive, limiting their scalability and real-time applicability. The application of machine learning techniques in soil nutrient analysis has emerged as a promising solution. There is a lot of complicated soil data, but algorithms that use machine learning can handle it all, enabling accurate prediction and assessment of soil nutrient content. Integration with remote sensing technologies enhances the capabilities of soil nutrient analysis, allowing for rapid assessment at different scales. Machine learning facilitates personalized recommendations for fertilizer application, irrigation strategies, and soil amendments, tailored to the specific needs of learning and adaptive individual fields or crops. The continuous capabilities of machine learning models ensure up-to-date nutrient management recommendations. Challenges include the availability of representative interpretability of models. Nevertheless, the integration of machine learning in soil nutrient analysis offers improved resource utilization, enhanced crop productivity, and sustainable soil management practices. Ongoing research and collaboration with domain experts will further advance the application of machine learning in this field.

In the realm of financial markets, understanding the interplay between mutual fund investment growth and equity market performance is paramount for investors, fund managers, and policymakers alike. This empirical study embarks on a comprehensive exploration of this intricate relationship, employing advanced econometric techniques to dissect historical data and uncover underlying patterns and dynamics. Building upon hypotheses positing significant associations between mutual fund investment growth and equity market performance, the study delves into regression analysis and statistical modelling to discern causality and quantify the impact of mutual fund investments on equity market behavior. In addition, the study investigates the influence of mutual fund performance metrics, such as annualized return, on equity market returns, shedding light on the part of mutual funds in shaping market outcomes. Despite inherent limitations, including data constraints and potential endogeneity issues, the findings contribute valuable empirical evidence and actionable insights for stakeholders navigating financial markets. Through its rigorous empirical approach and robust analytical framework, this study advances financial research and informs decision-making processes, empowering stakeholders to navigate the complex landscape of investments and market participation effectively.The findings contribute to a deeper understanding of how mutual fund investments impact equity market performance, offering valuable implications for the various players in navigating financial markets.

The name “cryptography” comes from a Greek word that refers to the art of securing data by organizing it in a disorganized and unintelligible way. It combines software engineering with math. The explosive expansion of the Internet has led to a greater awareness of intriguing uncertainty concerns. Although security is the biggest concern when it comes to the internet, many apps have been developed and designed without taking confidentiality, authentication, and protection—the three essential components of data security—into account. Knowing these kinds of security problems and challenges is going to be more important as our daily activities rely more and more on data networks. Cryptography is necessary to prevent some unwanted customers or persons from gaining access to the data. This study presents a novel hybrid security cipher that combines the three most significant ciphers, such as the Caesar, Rail Fence and Vigenère ciphers. When compared to traditional ciphers, this hybrid encryption cipher offers more security.

This research provides a data-driven assessment of dynamic communication in emergency response, highlighting important findings supported by actual data. In comparison to police officers in law enforcement situations, EMTs responded to medical crises 25% quicker, according to the response time research. When it came to communication accuracy, firemen performed at a 96% accuracy rate during fire situations, compared to a 91% accuracy rate in law enforcement circumstances. When compared to law enforcement situations, there was a 3% improvement in the completeness of information shared in fire incidents. Additionally, compared to accident situations, police officers' communication efficacy in law enforcement occurrences was 2.3% greater. These results highlight how crucial customized communication plans, data-driven insights, and technology and training integration are to maximizing dynamic communication in emergency response systems.

Background: The gap between the supply of organs available for transplantation and demand is growing, especially among ethnic groups.Objective: To evaluate the effect of a video designed to address concerns of ethnic groups about organ donation.Design: Cluster randomized, controlled trial. Randomization was performed by using a random-number table with centralized allocation concealment. Participants and investigators assessing outcomes were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00870506)Setting: Twelve branches of the Ohio Bureau of Motor Vehicles in northeastern Ohio.Participants: 952 participants aged 15 to 66 years.Intervention: Video (intervention; n = 443) or usual Bureau of Motor Vehicles license practices (control; n = 509).Measurements: The primary outcome was the proportion of participants who provided consent for organ donation on a newly acquired driver's license, learner's permit, or state identification card. Secondary outcomes included willingness to make a living kidney donation to a family member in need and personal beliefs about donation.Results: More participants who viewed the video consented to donate organs than control participants (84% vs. 72%; difference, 12 percentage points [95% CI, 6 to 17 percentage points]). The video was effective among black participants (76% vs. 54%; difference, 22 percentage points [CI, 9 to 35 percentage points]) and white participants (88% vs. 77%; difference, 11 percentage points [CI, 5 to 15 percentage points]). At the end of the trial, fewer intervention than control participants reported having insufficient information about organ donation (34% vs. 44%; difference, -10 percentage points [CI, -16 to -4 percentage points]), wanting to be buried with all of their organs (14% vs. 25%; difference, -11 percentage points [CI, -16 to -6 percentage points]), and having conflicts with organ donation (7% vs. 11%; difference, -4 percentage points [CI, -8 to -2 percentage points]).Limitation: How the observed increases in consent to donate organs might translate into a greater organ supply in the region is unclear.Conclusion: Exposure to a brief video addressing concerns that ethnic groups have about organ donation just before obtaining a license, permit, or identification card increased consent to donate organs among white and black participants.Primary Funding Source: National Institutes of Health and the Robert Wood Johnson Foundation. [ABSTRACT FROM AUTHOR]

BACKGROUND: U.S. News & World Report's annual rankings of the top 50 American hospitals in 12 specialties are based on a combination of subjective and objective measures of quality. Although the rankings have been criticized for emphasizing the subjective reputation of hospitals too strongly, the role of reputation in determining the relative standings of the top 50 hospitals has not been quantified. OBJECTIVE: To quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of U.S. News & World Report's rankings. DESIGN: Cross-sectional study. SETTING: The top 50 hospitals in each of 12 specialties. MEASUREMENTS: Rankings based on the total U.S. News score and on a subjective reputation score. RESULTS: On average, rankings based on reputation score alone agreed with U.S. News & World Report's overall rankings 100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals. Hospital reputation was minimally associated with objective quality measures (mean Spearman rho(2) = 0.03). LIMITATION: The findings apply primarily to interpretations about the relative standings of the 50 top-ranked hospitals in each specialty and not necessarily to the hundreds of unranked hospitals. CONCLUSION: The relative standings of the top 50 hospitals largely reflect the subjective reputations of those hospitals. Moreover, little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals. PRIMARY FUNDING SOURCE: None. [ABSTRACT FROM AUTHOR]

Background: Optimal hydration measures to prevent contrast-induced nephropathy are controversial.Study Design: We conducted a systematic review and meta-analysis using the MEDLINE database (1966 to January 2008), EMBASE (January 2008), and abstracts from conference proceedings.Setting& Population: Adult patients undergoing contrast procedures.Selection Criteria For Studies: Randomized controlled trials comparing intravenous hydration with sodium bicarbonate with hydration with intravenous normal saline for prevention of contrast-induced nephropathy.Intervention: Hydration with intravenous sodium bicarbonate with or without N-acetylcysteine versus hydration with normal saline with or without N-acetylcysteine.Outcomes: Contrast-induced nephropathy, need for renal replacement therapy, and worsening of heart failure.Results: Twelve trials (1,854 participants) were included. Sodium bicarbonate significantly decreased the risk of contrast-induced nephropathy (12 trials, 1,652 patients; odds ratio [OR], 0.46; 95% confidence interval [CI], 0.26 to 0.82; I2 = 55.9%) without a significant difference in need for renal replacement therapy (9 trials, 1,215 patients; OR, 0.50; 95% CI, 0.16 to 1.53; I2 = 0%), in-hospital mortality (11 trials, 1,640 patients; OR, 0.51; 95% CI, 0.15 to 1.69), or congestive heart failure compared with controls. Similar results were seen for the risk of contrast-induced nephropathy when sodium bicarbonate was compared with normal saline alone (OR, 0.39; 95% CI, 0.20 to 0.77), but not when sodium bicarbonate/N-acetylcysteine combination was compared with N-acetylcysteine/normal saline combination (OR, 0.68; 95% CI, 0.34 to 1.37). A subgroup analysis limited to published trials showed similar results (OR, 0.26; 95% CI, 0.10 to 0.64; I2 = 63.3%), whereas unpublished studies showed a nonsignificant decrease (OR, 0.85; 95% CI, 0.46 to 1.57; I2 = 25.9%) in risk of contrast-induced nephropathy.Limitation: Publication bias and heterogeneity.Conclusion: Hydration with sodium bicarbonate decreases the incidence of contrast-induced nephropathy in comparison to hydration with normal saline without a significant difference in need for renal replacement therapy and in-hospital mortality. Larger studies analyzing patient-centered outcomes are needed. [ABSTRACT FROM AUTHOR]

Context: High dietary phosphorus intake has deleterious consequences for renal patients and is possibly harmful for the general public as well. To prevent hyperphosphatemia, patients with end-stage renal disease limit their intake of foods that are naturally high in phosphorus. However, phosphorus-containing additives are increasingly being added to processed and fast foods. The effect of such additives on serum phosphorus levels is unclear.Objective: To determine the effect of limiting the intake of phosphorus-containing food additives on serum phosphorus levels among patients with end-stage renal disease.Design, Setting, and Participants: Cluster randomized controlled trial at 14 long-term hemodialysis facilities in northeast Ohio. Two hundred seventy-nine patients with elevated baseline serum phosphorus levels (>5.5 mg/dL) were recruited between May and October 2007. Two shifts at each of 12 large facilities and 1 shift at each of 2 small facilities were randomly assigned to an intervention or control group.Intervention: Intervention participants (n=145) received education on avoiding foods with phosphorus additives when purchasing groceries or visiting fast food restaurants. Control participants (n=134) continued to receive usual care.Main Outcome Measure: Change in serum phosphorus level after 3 months.Results: At baseline, there was no significant difference in serum phosphorus levels between the 2 groups. After 3 months, the decline in serum phosphorus levels was 0.6 mg/dL larger among intervention vs control participants (95% confidence interval, -1.0 to -0.1 mg/dL). Intervention participants also had statistically significant increases in reading ingredient lists (P<.001) and nutrition facts labels (P = .04) but no significant increase in food knowledge scores (P = .13).Conclusion: Educating end-stage renal disease patients to avoid phosphorus-containing food additives resulted in modest improvements in hyperphosphatemia.Trial Registration: clinicaltrials.gov Identifier: NCT00583570. [ABSTRACT FROM AUTHOR]

BACKGROUND: Chronic kidney disease, undiagnosed in a significant number of adults, is a public health problem. Given the systemic inflammatory response to periodontal disease, we hypothesized that periodontal disease could be associated with chronic kidney disease. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: We identified 12,947 adults 18 years or older with information for kidney function and at least one risk factor in the Third National Health and Nutrition Examination Survey. PREDICTOR: The main predictor was periodontal status. Other nontraditional and traditional risk factors included socioeconomic status, health status, health behavior, biomarker levels, anthropometric assessment, and health care utilization. OUTCOMES & MEASUREMENTS: Chronic kidney disease was defined using the Kidney Disease Outcomes Quality Initiative stages 3 and 4 with a moderate to severe decrease in kidney function (glomerular filtration rate, 15 to 59 mL/min/1.73 m(2)). Univariable and multivariable logistic regression models assessed the associations between chronic kidney disease and periodontal disease and other nontraditional risk factors. RESULTS: Chronic kidney disease prevalence was 3.6%; periodontal disease prevalence was 6.0%; and edentulism prevalence was 10.5%. Adults with periodontal disease and edentulous adults were twice as likely to have chronic kidney disease (adjusted odds ratio, 1.60; 95% confidence interval, 1.16 to 2.21; adjusted odds ratio, 1.85; 95% confidence interval, 1.34 to 2.56, respectively) after simultaneously adjusting for other traditional and nontraditional risk factors. LIMITATIONS: Temporal association is unknown. CONCLUSIONS: Periodontal disease and its severe consequence, edentulism, were independently associated with chronic kidney disease after adjusting for other traditional and nontraditional risk factors. This model could contribute to identifying individuals at risk of chronic kidney disease and reduce its burden. Copyright © 2008 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Context: A lack of awareness about entitled health and social services may contribute to poor delivery of such services in developing countries, especially among individuals of low socioeconomic status.Objective: To determine the impact of informing resource-poor rural populations about entitled services.Design, Setting, and Participants: Community-based, cluster randomized controlled trial conducted from May 2004 to May 2005 in 105 randomly selected village clusters in Uttar Pradesh state in India. Households (548 intervention and 497 control) were selected by a systematic sampling design, including both low-caste and mid- to high-caste households.Intervention: Four to 6 public meetings were held in each intervention village cluster to disseminate information on entitled health services, entitled education services, and village governance requirements. No intervention took place in control village clusters.Main Outcome Measures: Visits by nurse midwife; prenatal examinations, tetanus vaccinations, and prenatal supplements received by pregnant women; vaccinations received by infants; excess school fees charged; occurrence of village council meetings; and development work in villages.Results: At baseline, there were no significant differences in self-reported delivery of health and social services. After 1 year, intervention villagers reported better delivery of several services compared with control villagers: in a multivariate analysis, 30% more prenatal examinations (95% confidence interval [CI], 17%-43%; P < .001), 27% more tetanus vaccinations (95% CI, 12%-41%; P < .001), 24% more prenatal supplements (95% CI, 8%-39%; P = .003), 25% more infant vaccinations (95% CI, 8%-42%; P = .004), and decreased excess school fees of 8 rupees (95% CI, 4-13 rupees; P < .001). In a difference-in-differences analysis, 21% more village council meetings were reported (95% CI, 5%-36%; P = .01). There were no improvements in visits by a nurse midwife or in development work in the villages. Both low-caste and mid- to high-caste intervention households reported significant improvements in service delivery.Conclusions: Informing resource-poor rural populations in India about entitled services enhanced the delivery of health and social services among both low- and mid- to high-caste households. Interventions that emphasize educating resource-poor populations about entitled services may improve the delivery of such services.Trial Registration: clinicaltrials.gov Identifier: NCT00421291. [ABSTRACT FROM AUTHOR]

The quality of hemodialysis care has been the focus of intense scrutiny, yet little is known about the job satisfaction of the nurses and technicians providing this care. We identified 240 nurses and technicians from 307 randomly selected American facilities and asked them about (a) specific domains of job satisfaction, (b) overall job satisfaction, and (c) self-reported patient care practices. Fewer than half of nurses and technicians were satisfied with their pay or their opportunities for advancement. Almost all subjects were satisfied with their personal delivery of patient care, their chance to do things for others, and their job security. About three-fourths of nurses and technicians expressed overall satisfaction with their jobs. Higher job satisfaction was associated with increased attention to patient psychosocial and educational needs. We urge local and national associations of nurses and technicians to collaborate with dialysis facilities, chains, and regulatory agencies to address specific aspects of job satisfaction. [ABSTRACT FROM AUTHOR]

Shortening and skipping hemodialysis treatments occur commonly and are associated with inadequate dialysis and increased mortality. These behaviors are also frequently equated with patient noncompliance. The prevalence and demographic correlates of shortening and skipping treatments have been studied extensively. However, less is known about the reasons for shortening and skipping treatments and whether patient characteristics correlate with specific reasons. Understanding the relationship between reasons and patient characteristics is essential for determining whether patient subgroups are at a disadvantage in achieving optimal dialysis and may help guide future interventions. Semistructured interviews were conducted with 168 selected patients who shortened or skipped treatments. A variety of reasons were responsible for shortening and skipping hemodialysis treatments. Content analysis of patient responses revealed five categories of reasons for shortening and skipping, including medical problems, technical problems, life tasks, transportation, and patient decisions. The most common reasons for shortening were medical problems (38%) and life tasks (24%), while the most common reasons for skipping were life tasks (33%) and transportation (22%). Furthermore, patient subgroups differed in the reasons for shortening and skipping. After multivariate adjustment for patient characteristics, technical problems were more common among women. Life tasks were more common among men, younger patients, and patients with hypertension. Transportation problems were more common among African Americans. Interventions to optimize hemodialysis treatment should identify and target patient-specific reasons for shortening and skipping and not assume noncompliance. [ABSTRACT FROM AUTHOR]

Background: Screening for depression can be challenging among hemodialysis patients due to the overlap of depressive symptoms with dialysis or kidney disease related symptoms. The aim of this study was to understand these overlapping symptoms and develop a depression screening tool for better clinical assessment of depressive symptoms in dialysis patients., Methods: We surveyed 1,085 dialysis patients between March 1, 2018 and February 28, 2023 at 15 dialysis facilities in Northeast Ohio with the 9-item patient health questionnaire (PHQ-9) and kidney disease quality of life (KDQOL) instrument. To evaluate overlap across questionnaire items, we used structural equation modeling (SEM). We predicted and transformed factor scores to create a hemodialysis-adjusted PHQ-9 (hdPHQ-9). In exploratory analysis ( N  = 173), we evaluated the performance of the hdPHQ-9 relative to the PHQ-9 that also received a Mini-International Neuropsychiatric Interview., Results: Our study sample included a high percentage of Black patients (74.6%) and 157 (14.5%) survey participants screened positive for depression (PHQ-9 ≥ 10). The magnitude of overlap was small for (respectively, PHQ-9 item with KDQOL TM item) fatigue with washed out, guilt with burden on family, appetite with nausea and movement with lightheaded. The hdPHQ-9 showed reasonably high sensitivity (0.81 with 95% confidence interval [CI] 0.58, 0.95) and specificity (0.84 with 95% CI 0.77, 0.89); however, this was not a significant improvement from the PHQ-9., Conclusion: There is little overlap between depressive symptoms and dialysis or kidney disease symptoms. The PHQ-9 was found to be an appropriate depression screening instrument for dialysis patients.

Purpose: Axicabtagene ciloleucel (axi-cel) is an autologous CD19 chimeric antigen receptor (CAR) T-cell therapy that is approved for the treatment of relapsed or refractory large B-cell lymphoma. Little is known about the long-term survivorship after CAR T-cell therapy., Methods: We previously reported the results of 298 patients who were leukapheresed with the intent to receive standard-of-care axi-cel (n = 275 infused) after two or more previous lines of therapy at a median follow-up of 12.9 months. Here, we report extended follow-up of this cohort to a median of 58 months, with a focus on late survivorship events., Results: Among axi-cel-infused patients, progression-free survival at 5 years was 29% and overall survival (OS) at 5 years was 40%. The 5-year lymphoma-specific survival was 53% with infrequent late relapses. However, the 5-year nonrelapse mortality (NRM) was 16.2%, with over half of NRM events occurring beyond 2 years. Patients who were 60 years and older had a lower risk of relapse ( P = .02), but a higher risk of NRM compared with patients younger than 60 years (NRM odds ratio, 4.5 [95% CI, 2.1 to 10.8]; P < .001). Late NRM was mainly due to infections and subsequent malignant neoplasms (SMNs). In total, SMNs occurred in 24 patients (9%), including therapy-related myeloid neoplasms (n = 15), solid tumors (n = 7), and unrelated lymphoid malignancies (n = 2)., Conclusion: In the standard-of-care setting, axi-cel exhibits outcomes consistent with those reported in clinical trials, with sustained, durable responses observed at the 5-year time point. However, late infections and the development of SMN are key survivorship issues that reduce long-term survival after CAR T-cell therapy, particularly in the elderly.

Objectives. To quantify the prevalence, correlates, and impacts of displacement because of natural disasters in the United States. Methods. We pooled data across 10 independent survey samples from the Census Bureau Household Pulse Survey from December 2022 to September 2023. Survey questions asked about displacement from home because of natural disasters, duration of displacement, and impacts of disasters. Results. In our weighted sample of 213 234 003 adults, 3 166 500 (1.5%) reported displacement in the past year because of a natural disaster. People of color, sexual and gender minority populations, and those with lower incomes, disabilities, or unfavorable social determinants of health (SDOH) such as food insecurity were more likely to report displacement. Long-term displacement was more common with fires compared with other disasters. Disaster impacts, including food and water shortage, electricity loss, unsanitary conditions, feeling isolated, and experiencing scams, were more common among people of color and individuals with lower education or income. Conclusions. Many people in the United States, particularly from health disparity populations, are displaced because of natural disasters. Addressing SDOH and other vulnerability factors may help improve disaster preparedness and mitigate postdisaster impacts. ( Am J Public Health . 2025;115(1):55-65. https://doi.org/10.2105/AJPH.2024.307854).

Background: Whether and how much past slavery affects contemporary social and economic conditions in the United States is an area of active debate. Newly available data on which members of the United States Congress are descendants of slaveholders provides an opportunity to examine this topic. This study sought to determine the relationship between slaveholder ancestry and net worth among members of Congress., Methods: Total assets and liabilities were collected from financial declarations of all members of Congress as of April 15, 2021. Net worth was estimated as the difference between total assets and liabilities. Information on slaveholder ancestry was obtained from a Reuters investigative series based on an extensive review of historical documents and verification by board-certified genealogists. Quantile regression was used to determine the association between net worth and slaveholder ancestry after adjustment for demographic factors., Results: The median net worth of the 535 members of Congress was $1.28 million (interquartile range $0.11-5.87 million). On univariate analysis, net worth was associated with increased age, White race, increased education, and number of individuals enslaved by ancestors. On multivariate analysis, net worth was independently associated with age, White race, and number enslaved. Legislators whose ancestors enslaved 16 or more individuals had a $3.93 million (95% confidence interval 2.39-5.46) higher net worth compared to legislators whose ancestors were not slave owners after adjustment for age, sex, race, ethnicity, and education., Conclusions: Past slaveholding practices are independently associated with current wealth among members of Congress. Because members of Congress are a highly selected group, further work is needed to understand how slaveholder ancestry affects current wealth in the general population to inform efforts to reduce social and economic disparities., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Sehgal, Sehgal. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This article highlights a selection of important nephrology studies published in 2023 that have relevance for nonnephrologist physicians. Four studies examined progression of chronic kidney disease or cardiovascular disease with respect to finerenone use, magnesium supplementation, iron markers, and COVID-19. Two studies examined treatments to improve specific aspects of chronic kidney disease management, including daprodustat to address anemia and patiromer to address hyperphosphatemia. One study showed that acetazolamide added to loop diuretics increased diuresis in acute decompensated heart failure across a wide range of renal function. Another study found that once-daily hydrochlorothiazide did not prevent kidney stone recurrence. Finally, an antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infection in frail older adults., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M24-0605.

Acute myeloid leukemia (AML) in older patients has a poor prognosis, low complete remission (CR) rates, and poor overall survival (OS). Preclinical studies have shown synergistic effects of epigenetic priming with hypomethylating agents followed by cytarabine. Based on these data, we hypothesized that an induction regimen using epigenetic priming with decitabine, followed by cytarabine would be effective and safe in older patients with previously untreated AML. Here, we conducted a phase 2 trial in which older patients with previously untreated AML received an induction regimen consisting of 1 or 2 courses of decitabine 20 mg/m 2 intravenously (IV) for 5 days followed by cytarabine 100 mg/m 2 continuous IV infusion for 5 days. Forty-four patients (median age 76 years) were enrolled, and CR/CRi was achieved by 26 patients (59% of all patients, 66.7% of evaluable patients). Fourteen of 21 (66.7%) patients with adverse cytogenetics achieved CR including six out of seven evaluable patients with TP53 mutations. The 4- and 8-week mortality rates were 2.3% and 9.1%, respectively, with median OS of 10.7 months. These results suggest epigenetic priming with decitabine followed by cytarabine should be considered as an option for first-line therapy in older patients with AML. This trial was registered at www.clinicaltrials.gov as # NCT01829503., (© 2024 Wiley Periodicals LLC.)

Abstract: During the manufacturing period of autologous chimeric antigen receptor (CAR) T-cell therapy, patients may experience a decline in their condition due to cancer progression. In this study, we investigated the impact of bridging therapy (BT) on the outcome of patients with relapsed/refractory large B-cell lymphoma who received antilymphoma treatment between leukapheresis and axicabtagene ciloleucel (axi-cel) infusion. We conducted our analysis using data from the multicenter US Lymphoma CAR-T Consortium, with a median follow-up of 33 months (range, 4.3-42.1). Out of the 298 patients who underwent leukapheresis, 275 patients received axi-cel. A total 52% of patients (n = 143) who received BT had a higher baseline risk profile than patients who did not receive BT, and these patients, as a group, had inferior outcomes compared with those who did not receive BT. However, after propensity score matching between the 2 groups, there were no statistically significant differences in overall response rate (77% vs 87%; P = .13), complete response rate (58% vs 70%; P = .1), progression-free survival (hazard ratio [HR], 1.25; P = .23), and overall survival (HR, 1.39; P=.09) between the BT group and the no-BT group, respectively. Analyzing the effects of BT in the whole cohort that underwent leukapheresis regardless of receiving axi-cel (intention-to-treat analysis) showed similar results. Radiation BT resulted in outcomes similar to those observed with nonradiation BT. Our findings suggest that BT may be safe without a significant impact on long-term survival for patients who require disease stabilization during the manufacturing period. Moreover, our results suggest that there is no clear advantage to using radiation-based BT over nonradiation-based BT., (© 2024 by The American Society of Hematology. Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permitting only noncommercial, nonderivative use with attribution. All other rights reserved.)

Abstract: Axicabtagene ciloleucel (axi-cel) is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for relapsed/refractory (R/R) follicular lymphoma (FL). Approval was supported by the phase 2, multicenter, single-arm ZUMA-5 study of axi-cel for patients with R/R indolent non-Hodgkin lymphoma (iNHL; N = 104), including FL and marginal zone lymphoma (MZL). In the primary analysis (median follow-up, 17.5 months), the overall response rate (ORR) was 92% (complete response rate, 74%). Here, we report long-term outcomes from ZUMA-5. Eligible patients with R/R iNHL after ≥2 lines of therapy underwent leukapheresis, followed by lymphodepleting chemotherapy and axi-cel infusion (2 × 106 CAR T cells per kg). The primary end point was ORR, assessed in this analysis by investigators in all enrolled patients (intent-to-treat). After median follow-up of 41.7 months in FL (n = 127) and 31.8 months in MZL (n = 31), ORR was comparable with that of the primary analysis (FL, 94%; MZL, 77%). Median progression-free survival was 40.2 months in FL and not reached in MZL. Medians of overall survival were not reached in either disease type. Grade ≥3 adverse events of interest that occurred after the prior analyses were largely in recently treated patients. Clinical and pharmacokinetic outcomes correlated negatively with recent exposure to bendamustine and high metabolic tumor volume. After 3 years of follow-up in ZUMA-5, axi-cel demonstrated continued durable responses, with very few relapses beyond 2 years, and manageable safety in patients with R/R iNHL. The ZUMA-5 study was registered at www.clinicaltrials.gov as #NCT03105336., (© 2024 American Society of Hematology. Published by Elsevier Inc. Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permitting only noncommercial, nonderivative use with attribution. All other rights reserved.)

Introduction/objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. However, few studies have examined how social determinants of health change over time in the same individuals., Methods: We examined patients screened by The MetroHealth System in Cleveland, Ohio for 11 social determinants of health, including food insecurity, financial strain, transportation, housing stability, utilities affordability, other housing problems, intimate partner violence, social connection, physical activity, daily stress, and digital connectivity. We determined changes in these social determinants among patients screened at baseline and again after 6 to 18 months of follow-up. We further examined correlates of changes in food insecurity, because it is a common need among our patients and leads to numerous referrals to community organizations for assistance., Results: A substantial majority of patients had no change in each social determinant. For example, among 18 038 patients screened twice for food insecurity, 13 913 (77.1%) did not screen positive for food insecurity at baseline and follow-up and 1726 (9.6%) screened positive for food insecurity at both times. A total of 1080 (6.0%) did not screen positive for food insecurity at baseline but screened positive at follow-up while 1319 (7.3%) screened positive for food insecurity at baseline but not at follow-up. Among patients screening positive for food insecurity at baseline, screening negative at follow-up was independently associated with being age ≥60 years (odds ratio [OR] = 1.46, 95% confidence interval [CI] = 1.02-2.10), not screening positive for financial strain (OR = 1.64, CI = 1.27-2.13), not screening positive for housing problems (OR = 1.65, CI = 1.28-2.13), and not screening positive for intimate partner violence (OR = 1.45, OR = 1.02-2.08). A longer duration between baseline and follow-up screening was also independently associated with not screening positive for food insecurity at follow-up. Being referred for food assistance was not associated with absence of food insecurity at follow-up (OR = 0.71, CI = 0.47-1.08)., Conclusions: Most patients report no change in specific social determinants of health over 6 to 18 months. Examining changes may identify subgroups at greatest risk for persistence of adverse determinants and help to evaluate the impact of assistance efforts., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Many low-income adults who smoke also have unmet social needs, such as food insecurity, which can serve as a barrier to smoking cessation. We developed a novel intervention to jointly address smoking cessation and food insecurity and assessed its feasibility, acceptability, and preliminary outcomes. We enrolled participants who screened for food insecurity, reported smoking daily, and were ready to quit. All participants received 3 months of resources navigation from a community health worker through monthly telephone calls for referrals and check-ins for smoking cessation and food access resources. Participants randomized to the intervention group received an economic intervention equivalent to the cost of 1 week of groceries/month for 3 months. We randomized 55 participants who were smoking on average 13 cigarettes/day. The trial was feasible and acceptable based on 3-month retention rates (80%) and end-of-study qualitative feedback (91% would recommend the study to others). At 3 months, participants in the intervention versus control group reported a longer length of abstinence from smoking and had a higher proportion of serious quit attempts. Results from this pilot study suggest the importance of attending to social needs, particularly food insecurity, as a strategy to promote smoking cessation among low-income adults who smoke., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Although medical research dissemination is intended to benefit members of society, few members of society actually participate in the process of publishing findings. This study shares findings from community members' (including patients and the public) experiences being trained as medical journal reviewers., Methods: We analyzed findings from two focus group interviews of community reviewers (N = 29) to identify themes in their experiences with the training program., Results: Community members trained as journal reviewers appreciated learning the context under which manuscript development and review occur from authors and funders, the value of the community member perspectives to science, and strengthened their critical thinking skills. A range of training tools and strategies included glossaries of research terms, creating review guides, practicing reviews, being trained by a supportive team, and working with and learning collaboratively., Conclusions: Training as a journal reviewer has a positive impact on participating community members. Programs training community members as journal reviewers should incorporate guest speakers well-versed in community engaged research, group activities, a variety of training tools and materials, and highly supportive training teams., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Community members may provide useful perspectives on manuscripts submitted to medical journals., Objective: To determine the impact of community members reviewing medical journal manuscripts., Design: Randomized controlled trial involving 578 original research manuscripts submitted to two medical journals from June 2018 to November 2021., Participants: Twenty-eight community members who were trained, supervised, and compensated., Interventions: A total of 289 randomly selected control manuscripts were reviewed by scientific reviewers only. And 289 randomly selected intervention manuscripts were reviewed by scientific reviewers and one community member. Journal editorial teams used all reviews to make decisions about acceptance, revision, or rejection of manuscripts., Main Measures: Usefulness of reviews to editors, content of community reviews, and changes made to published articles in response to community reviewer comments., Key Results: Editor ratings of community and scientific reviews averaged 3.1 and 3.3, respectively (difference 0.2, 95% confidence interval [CI] 0.1 to 0.3), on a 5-point scale where a higher score indicates a more useful review. Qualitative analysis of the content of community reviews identified two taxonomies of themes: study attributes and viewpoints. Study attributes are the sections, topics, and components of manuscripts commented on by reviewers. Viewpoints are reviewer perceptions and perspectives on the research described in manuscripts and consisted of four major themes: (1) diversity of study participants, (2) relevance to patients and communities, (3) cultural considerations and social context, and (4) implementation of research by patients and communities. A total of 186 community reviewer comments were integrated into 64 published intervention group articles. Viewpoint themes were present more often in 66 published intervention articles compared to 54 published control articles (2.8 vs. 1.7 themes/article, difference 1.1, 95% CI 0.4 to 1.8)., Conclusions: With training, supervision, and compensation, community members are able to review manuscripts submitted to medical journals. Their comments are useful to editors, address topics relevant to patients and communities, and are reflected in published articles., Trial Registration: ClinicalTrials.gov NCT03432143., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Hyperparathyroid crisis (HPTC) is a potentially lethal condition characterized by severe symptomatic hypercalcemia with calcium levels ≥14 mg/dl. We sought to determine the rate of HPTC and how it differs from hyperparathyroidism (HPT) without crisis (HPTWC)., Methods: A retrospective review of patients with surgically treated HPT from 1990 to 2022 was completed., Results: HPTC occurred in 18 (2.4%) of 783 with primary HPT. Patients with HPTC had higher preoperative calcium and parathyroid hormone levels, lower postoperative calcium levels, larger gland weights and higher rates of ectopic glands, carcinoma, recurrence and mortality compared to patients with HPTWC (all p < 0.05)., Conclusions: HPTC is a rare condition manifested by severe HPT that is associated with a higher rate of recurrence and mortality compared to HPTWC. HPTC is associated with larger parathyroid glands that are more often ectopic and malignant., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Kidney transplant (KT) is the optimal treatment for kidney failure (KF), and although completion of KT evaluation is an essential step in gaining access to transplantation, the process is lengthy, time consuming, and burdensome. Furthermore, despite similar referral rates to non-Hispanic Whites, both Hispanic/Latinos and American Indians are less likely to be wait-listed or to undergo KT., Methods: The Access to Kidney Transplantation in Minority Populations (AKT-MP) Trial compares two patient-centered methods to facilitate KT evaluation: kidney transplant fast track (KTFT), a streamlined KT evaluation process; and peer navigators (PN), a peer-assisted evaluation program that incorporates motivational interviewing. This pragmatic randomized trial will use a comparative effectiveness approach to assess whether KTFT or PN can help patients overcome barriers to transplant listing. We will randomly assign patients to the two conditions. We will track participants' medical records and conduct surveys prior to their initial evaluation clinic visit and again after they complete or discontinue evaluation., Conclusion: Our aims are to (1) compare KTFT and PN to assess improvements in kidney transplant (KT) related outcomes and cost effectiveness; (2) examine how each approach effects changes in cultural/contextual factors, KT concerns, KT knowledge, and KT ambivalence; and (3) develop a framework for widespread implementation of either approach. The results of this trial will provide key information for facilitating the evaluation process, improving patient care, and decreasing disparities in KT., Competing Interests: 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., (© 2022 The Authors.)

Background: Greenhouse gas emissions from hemodialysis treatment in the United States have not been quantified. In addition, no previous studies have examined how much emissions vary across facilities, treatments, and emission contributors., Methods: To estimate the magnitude and sources of variation in the carbon footprint of hemodialysis treatment, we estimated life-cycle greenhouse gas emissions in carbon dioxide equivalents (CO 2 -eq) associated with 209,481 hemodialysis treatments in 2020 at 15 Ohio hemodialysis facilities belonging to the same organization. We considered emissions from electricity, natural gas, water, and supply use; patient and staff travel distance; and biohazard and landfill waste., Results: Annual emissions per facility averaged 769,374 kg CO 2 -eq (95% CI, 709,388 to 848,180 kg CO 2 -eq). The three largest contributors to total emissions were patient and staff transportation (28.3%), electricity (27.4%), and natural gas (15.2%). Emissions per treatment were 58.9 kg CO 2 -eq, with a three-fold variation across facilities. The contributors with the largest variation in emissions per treatment were transportation, natural gas, and water (coefficients of variation, 62.5%, 42.4%, and 37.7%, respectively). The annual emissions per hemodialysis facility are equivalent to emissions from the annual energy use in 93 homes; emissions per treatment are equivalent to driving an average automobile for 238 km (149 miles)., Conclusions: Similar medical treatments provided in a single geographic region by facilities that are part of the same organization may be expected to have small variations in the determinants of greenhouse gas emissions. However, we found substantial variation in carbon footprints across facilities, treatments, and emission contributors. Understanding the magnitude and variation in greenhouse gas emissions may help identify measures to reduce the environmental effect of hemodialysis treatment., (Copyright © 2022 by the American Society of Nephrology.)

Tobacco use in the U.S. is increasingly concentrated among populations with socioeconomic disadvantages such as food insecurity. Building on prior studies showing that food insecurity increases odds of cigarette smoking, the current study sought to examine how food insecurity and other social needs, particularly financial strain, transportation barriers, and housing/utility insecurity, were associated with smoking status among adult patients seen in a county hospital system. We analyzed data from the electronic health record of patients from The MetroHealth System (Cleveland, Ohio, USA), covering a two-year period since implementation of social determinants of health assessments (2019-2021; N = 45,151 patients). Logistic regression analyses were used to examine associations with smoking status. Compared to the overall smoking prevalence (21 %), smoking was higher among patients screening for transportation barriers (41 %), financial strain (39 %), food insecurity (34 %), and housing/utility insecurity (27 %). Each of these social needs was independently associated with increased odds of current smoking (all p  < 0.05). Smoking prevalence increased sequentially as the number of social needs increased; with each addition of a social need, there was a dose-response association with higher odds of current smoking (adjusted ORs ranged from 1.56 to 3.76, all p  < 0.001), and current smoking specifically among ever smoking patients (adjusted ORs ranged from 1.39 to 3.01, all p  < 0.001). There was substantial overlap among several social needs and smoking status. Alongside improving access to evidence-based cessation treatments and services, the findings raise the possibility that addressing social needs might reduce barriers to quitting and thereby reduce tobacco use disparities., Competing Interests: 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., (© 2022 The Author(s).)

Rationale & Objective: Major depressive disorder (MDD) is common among hemodialysis patients, but treatment can add to their pill burden and may be limited by nonadherence. We sought to investigate the value of directly observed, once-weekly fluoxetine dosing in MDD., Study Design: Feasibility trial of adult hemodialysis patients with untreated MDD. The diagnosis of MDD was determined using the Mini International Neuropsychiatric Interview., Setting & Participants: 16 patients at 15 hemodialysis facilities in Northeast Ohio., Intervention: Patients were initially prescribed 20 mg of fluoxetine once daily for 2 weeks to assess their tolerance. The patients took this daily fluoxetine unobserved at home. They were then transitioned to 90 mg of fluoxetine once weekly for 10 weeks. The patients took this weekly fluoxetine during hemodialysis treatment and were observed by the study staff. The dose was increased to 180 mg once weekly among patients with an inadequate response based on the judgment of the prescribing clinician., Outcomes: Mini International Neuropsychiatric Interview diagnosis of MDD at the end of the trial and changes in the Patient Health Questionnaire (PHQ-9) scores over 12 weeks., Results: One patient withdrew from active treatment after 2 daily doses of 20 mg of fluoxetine because of side effects of stomach cramping, vomiting, dizziness, and lightheadedness but completed the baseline and final assessments. The remaining 15 patients received all scheduled weekly fluoxetine doses during the trial. At 12 weeks, 14 of 16 patients (87.5%) no longer met the criteria for MDD ( P  < 0.001). Among all participants, the mean PHQ-9 scores decreased from 11.3 to 6.6 ( P  = 0.002)., Limitations: Small sample size, modestly elevated baseline PHQ-9 scores, no comparison group, and short treatment duration., Conclusions: Directly observed, once-weekly fluoxetine may be an effective and well-tolerated treatment option for hemodialysis patients. Future research should investigate longer-term health outcomes of weekly fluoxetine in this population and explore the feasibility of implementing this depression treatment model in routine clinical practice., Trial Registration: This trial was registered at clinicaltrials.gov as NCT03390933., (© 2022 The Authors.)

Objective: This study described the job responsibilities and modalities of care among dialysis dietitians in the United States and their observations regarding the nutrition needs of their patients, during the COVID-19 pandemic., Design and Methods: Cross-sectional online survey captures dietitian characteristics and responsibilities, dialysis facility characteristics, and patient needs. We recruited US dialysis dietitians. We used chi-square tests to compare respondent stress and facility-level policies regarding eating/drinking and oral nutrition supplements based on facility ownership type., Results: We received 191 complete or partial survey responses. Sixty-three percent of respondents stated that their center banned eating/drinking during dialysis due to COVID-19 masking policies. DaVita and non-profit facilities were significantly more likely to still allow eating/drinking during dialysis (31% and 29%, respectively) compared to Fresenius facilities (7%). A common theme in open-ended responses regarding nutrition care for COVID-19-positive patients was providing less care to these patients. A majority of respondents admitted to stress from working in healthcare during COVID-19. The majority of respondents indicated that patients were taking precautions such as having a family member or friend grocery shop for them (69%) or going to the store less often (60%). Just over a quarter of respondents indicated that affordability of food was a concern among patients. Seventy-two percent reported that patients were cooking at home more often, 60% had observed an increase in serum phosphorus, and 72% an increase in interdialytic weight gain., Conclusions: Due to the increased risk of malnutrition and symptoms that can affect dietary intake in COVID-positive patients, and the economic conditions leading to increased rates of food insecurity, dietitians must be proactive in preventing and/or treating malnutrition through adequate protein and energy intake. Eating/drinking bans should not become permanent and dialysis centers should take precautions to allow intradialytic meals and oral nutrition supplement protocols to continue during the pandemic., (Copyright © 2021 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction/objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. However, little is known about social determinants of health among health system employees. We sought to examine the prevalence of social determinants among employees of The MetroHealth System, a large safety-net health system in Cleveland, Ohio., Methods: We invited participants in an employee wellness program to answer the same screening questions that patients answer about 9 social determinants of health, including food insecurity, financial strain, transportation difficulty, inability to pay for housing or utilities, intimate partner violence, social isolation, infrequent physical activity, daily stress, and lack of internet access. We then determined the percentage of employees who met pre-defined criteria for being at risk for each social determinant. We also examined how these percentages varied across employee job categories., Results: Of 4191 full-time employees, 1932 (46%) completed the survey. The percentage of employees at risk for each social determinant were: food insecurity (11%), financial strain (12%), transportation difficulty (4%), inability to pay for housing or utilities (10%), intimate partner violence (4%), social isolation (48%), infrequent physical activity (10%), daily stress (58%), and lack of internet access (3%). Being at risk for specific social determinants was more common among support staff compared to staff physicians and nurses. For example, the survey participants included 436 administrative support staff, a job category that includes secretaries and patient service representatives. Among this group, 20% reported food insecurity, 20% financial strain, and 17% inability to pay for housing or utilities., Conclusions: Social determinants of health are common among health system employees, especially among workers in lower paid job categories. Health systems should routinely screen employees for social determinants and adjust salaries, benefits, and assistance programs to address their social needs.

Background: Most patients with advanced-stage indolent non-Hodgkin lymphoma have multiple relapses. We assessed axicabtagene ciloleucel autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy in relapsed or refractory indolent non-Hodgkin lymphoma., Methods: ZUMA-5 is a single-arm, multicentre, phase 2 trial being conducted at 15 medical cancer centres in the USA and two medical cancer centres in France. Patients were eligible if they were aged 18 years or older, with histologically confirmed indolent non-Hodgkin lymphoma (follicular lymphoma or marginal zone lymphoma), had relapsed or refractory disease, previously had two or more lines of therapy (including an anti-CD20 monoclonal antibody with an alkylating agent), and an Eastern Cooperative Oncology Group performance score of 0 or 1. Patients underwent leukapheresis and received conditioning chemotherapy (cyclophosphamide at 500 mg/m 2 per day and fludarabine at 30 mg/m 2 per day on days -5, -4, and -3) followed by a single infusion of axicabtagene ciloleucel (2 × 10 6 CAR T cells per kg) on day 0. The primary endpoint was overall response rate (complete response and partial response) assessed by an independent review committee per Lugano classification. The primary activity analysis was done after at least 80 treated patients with follicular lymphoma had been followed up for at least 12 months after the first response assessment at week 4 after infusion. The primary analyses were done in the per-protocol population (ie, eligible patients with follicular lymphoma who had 12 months of follow-up after the first response assessment and eligible patients with marginal zone lymphoma who had at least 4 weeks of follow-up after infusion of axicabtagene ciloleucel). Safety analyses were done in patients who received an infusion of axicabtagene ciloleucel. This study is registered with ClinicalTrials.gov, NCT03105336, and is closed to accrual., Findings: Between June 20, 2017, and July 16, 2020, 153 patients were enrolled and underwent leukapheresis, and axicabtagene ciloleucel was successfully manufactured for all enrolled patients. As of data cutoff (Sept 14, 2020), 148 patients had received an infusion of axicabtagene ciloleucel (124 [84%] who had follicular lymphoma and 24 [16%] who had marginal zone lymphoma). The median follow-up for the primary analysis was 17·5 months (IQR 14·1-22·6). Among patients who were eligible for the primary analysis (n=104, of whom 84 had follicular lymphoma and 20 had marginal zone lymphoma), 96 (92%; 95% CI 85-97) had an overall response and 77 (74%) had a complete response. The most common grade 3 or worse adverse events were cytopenias (104 [70%] of 148 patients) and infections (26 [18%]). Grade 3 or worse cytokine release syndrome occurred in ten (7%) patients and grade 3 or 4 neurological events occurred in 28 (19%) patients. Serious adverse events (any grade) occurred in 74 (50%) patients. Deaths due to adverse events occurred in four (3%) patients, one of which was deemed to be treatment-related (multisystem organ failure)., Interpretation: Axicabtagene ciloleucel showed high rates of durable responses and had a manageable safety profile in patients with relapsed or refractory indolent non-Hodgkin lymphoma., Funding: Kite, a Gilead Company., Competing Interests: Declaration of interests CAJ has received support for the present manuscript from Kite, a Gilead Company; has received consulting fees from Novartis, Bristol-Myers Squibb, Precision Biosciences, Nkarta, Bluebird Bio, AbbVie, Lonza, and Ipsen; and has received payment or honoraria from Novartis, Bristol-Myers Squibb, Bluebird Bio, and Epizyme. JCC reports consulting fees from Novartis Kite, a Gilead Company, AbbVie, Janssen, ADC Therapeutics, and Karyoplasm, and payment or honoraria from Morphosys, BeiGene, Epizyme, Bristol-Myers Squibb, and AstraZeneca. ARS reports support to their institution from Kite, a Gilead Company for the present manuscript and clinical trial support from Bristol-Myers Squibb. BMW reports consulting fees for an advisory board from Bristol-Myers Squibb. JM has received consulting fees from AbbVie, Bayer, Kite, a Gilead Company, Pfizer, Janssen, Bristol-Myers Squibb, Kyowa, Alexion, Fosunkite, Innovent, SeaGen, Debiopharm, Karyopharm, Genmab, ADC Therapeutics, Epizyme, BeiGene, and Servier; honoraria from Targeted Oncology, OncView, Curio Sciences, Kyowa, Physicians' Education Resource, and SeaGen; honoraria for speaker's bureaus from Kite, a Gilead Company, Kyowa, Bayer, Janssen, SeaGen, Acrotech/Aurobindo, BeiGene, Verastem, AstraZeneca, Bristol-Myers Squibb, and Genentech/Roche; and research funding from Bayer, Kite, a Gilead Company, Bristol-Myers Squibb, Merck, Portola, Incyte, Genentech, Pharmacyclics, SeaGen, Janssen, and Millennium. GS reports support from Kite, a Gilead Company for the present manuscript; consulting fees from Bristol-Myers Squibb, Incyte, Ipsen, Janssen, Kite, a Gilead Company, Loxo, Lilly, Milteniy, Morphosys, Novartis, and Rapt; payment or honoraria from AbbVie, Amgen, Bayer, Epizyme, Regeneron, Roche, Morphosys, Kite, a Gilead Company, and Novartis; and participation on a data safety monitoring board or advisory board at AbbVie, Beigene, Bristol-Myers Squibb, Debiopharm, Epizyme, Genentech/Roche, Genmab, Incyte, Kite, a Gilead Company, Milteniy, Morphosys, Takeda, and Velosbio. PNM reports payment or honoraria for a speaker's bureau from Kite, a Gilead Company and Incyte, and stock or stock options from Amgen. CC reports research funding from Veristem, Gilead, Bristol-Myers Squibb, and Genentech. DGM reports research funding from Bristol-Myers Squib and Kite, a Gilead Company; rights to royalties from Fred Hutch for patents licensed to Bristol-Myers Squibb; honoraria for advisory boards from Amgen, Bristol-Myers Squibb, Genentech, Gilead Sciences, Incyte, Janssen, Kite, a Gilead Company, Legend Biotech, MorphoSys, Mustang Bio, Novartis, Pharmacyclics, and Umoja; has participated on a data safety monitoring board or steering committee for Bioline RX, Bristol-Myers Squibb, and Genentech; has held a leadership role at Bristol-Myers Squibb and Genentech; and has had honoraria and stock options from A2 Biotherapeutics and Navan Technologies, Inc. SdV has participated on an advisory board with BeiGene. RR reports support from Gilead for the present manuscript; consulting fees from Gilead, Novartis, Bristol-Myers Squibb, Synthekine, TScan, Regeneron, and Atara; payment for expert testimony for Bayer; travel and meeting support from Gilead; and participation on a data safety monitoring board or advisory board at the University of Pennsylvania. LAL has received consulting fees from AbbVie, AstraZeneca, Merck, TG Therapeutics, Janssen, Epizyme, Kite, a Gilead Company, and Bristol-Myers Squibb; has received payment or honoraria for speaker's bureaus from Kite, a Gilead Company, Beigene, Janssen, AstraZeneca, SeaGen, TG therapeutics, Epizyme, Karyopharm; has participated on advisory boards with TG therapeutics, AbbVie, Janssen, AstraZeneca, SeaGen, ADC Therapeutics; and has a leadership role at the Leukemia/lymphoma Society and the Lymphoma Research Foundation. IY-A has received consulting fees from Kite, a Gilead Company and Novartis; payment or honoraria from Bristol-Myers Squibb, Janssen, and Kite, a Gilead Company; and meeting and travel support from Kite, a Gilead Company. OOO reports consulting fees from Kite, a Gilead Company, Pfizer, Novartis, and Janssen, and honoraria from Kite, a Gilead Company. HCHF has received consulting fees from Pfizer, Genzyme, BeiGene, Jazz pharmaceuticals, and Alexion, and has received payment or honoraria for speaker's bureaus and lectures from Bristol-Myers Squibb, AstraZeneca, Janssen, karyopharm, Kite, a Gilead Company, Takeda, Amgen, AbbVie, and Genentech. JR reports support for the current manuscript from Kite, a Gilead Company; grants from Synergys and Biograph55; planned patents with Synergys; leadership at the American Association for Cancer Research, American Society of Hematology, and the American Society of Clinical Oncology, and stock options with ISK. JMR reports employment with Kite, a Gilead Company and equity ownership in Kite, a Gilead Company in support of the present manuscript. LG and RV report employment with and equity ownership with Kite, a Gilead Company. VP reports travel and meeting support from Kite, a Gilead Company and equity ownership in Gilead. MPA reports employment with Kite, a Gilead Company and equity ownership in Gilead. SSN reports support from Kite, a Gilead Company for the present manuscript; grants or contracts from Kite, a Gilead Company, Merck, Bristol-Myers Squibb, Cellectis, Poseida, Karus, AstraZeneca, Allogene, Unum Therapeutics, Precision Biosciences, and Adicet Bio; royalties from Takeda; consulting fees from Kite, a Gilead Company, Merck, Bristol-Myers Squibb, Novartis, Unum Therapeutics, Pfizer, Precision Biosciences, Cell Medica/Kuur, Allogene, Incyte, Legend Biotech, Adicet Bio, Calibr, and Bluebird Bio; payment or honoraria from Medscape, Aptitude Health, Bio Ascend, and MJH Life Sciences; and patents pending related to cell therapy. YY declares no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction/objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community organizations for assistance. Understanding how social determinants cluster together may help guide assistance programs., Methods: This study examined patients screened by The MetroHealth System in Cleveland, Ohio for 9 social determinants, including food insecurity, financial strain, transportation limitations, inability to pay for housing or utilities, intimate partner violence, social isolation, infrequent physical activity, daily stress, and lack of internet access. Clustering analyses were performed to determine which combination of social determinants occurred together more often than would be expected if each determinant were independent of each other., Results: Among 23 161 screened patients, there were 19 dyads, 13 triads, and one tetrad of social determinants that clustered together. The most prevalent triad of food insecurity, social isolation, and inability to pay for housing or utilities occurred among 1095 patients but would be expected to occur among 284 patients, for an observed/expected ratio of 3.85 (95% confidence interval 3.64-4.07). In multivariate analyses, younger, Black, and lower income patients were 2 to 3 times more likely to have this triad compared to older, White, and wealthier patients., Conclusions: Social determinants of health frequently cluster together, and such clustering is associated with patient demographic characteristics. Further work is needed to determine how social determinant clusters impact health and cost outcomes and to develop programs that can address multiple co-existing social needs.

Background: Child trafficking is a pervasive public health problem in the United States, with significant health consequences for survivors. Previous studies demonstrated that survivors face barriers to healthcare, though much of the literature has not solely focused on domestic child trafficking., Objective: To identify barriers to healthcare faced by survivors of child trafficking in the United States, and to characterize the landscape of available trauma-informed medical services., Participants: 62 adult survivors of child trafficking (83% female, 10% male, 7% transgender; 90% sex trafficking, 25% labor trafficking; median age of entry 16) and 37 community agency professionals who work with trafficked children., Setting: The United States of America., Methods: The Barriers to Care Questionnaire (BCQ) was adapted, piloted with a focus group, and disseminated to participants., Results: A statistically significant increase in survivors seeking healthcare after compared to before trafficking was demonstrated (p < 0.05). Eighteen consequential barriers to healthcare were identified. The marginalization domain, representing the individual's perception of negative experiences with the healthcare system, had the highest number of consequential barriers. The majority of survivor and agency participants felt the physical and mental health needs of survivors are not being met, but would seek out trauma-informed healthcare if it were available in their community., Conclusions: Survivors of child trafficking in the U.S. experience a wide range of barriers to healthcare, and a lack of available trauma-informed healthcare. This study identified barriers to healthcare that can be considered by providers hoping to provide accessible and truama-informed services to trafficked children., (Copyright © 2021. Published by Elsevier Ltd.)

Rationale & Objective: The impact of prostate cancer on mortality in patients with end-stage kidney disease may be different from the general population. Prostate cancer may also delay the kidney transplant but has not been studied in a population-based cohort. We examined how prostate cancer influenced time to kidney transplant and death in a dialysis population., Study Design: Retrospective population-based, risk-set propensity score-matched cohort study., Setting & Participants: Men, 40-79 years old, who were dialysis-dependent Medicare beneficiaries without prior documented prostate cancer, from the United States Renal Data System., Exposures: Incident prostate cancer, identified using International Classification of Disease, Ninth Revision , Clinical Modification system diagnosis code 185., Outcomes: Time to kidney transplant and death., Analytical Approach: Propensity-based risk-set matching to reduce bias between cases and controls. Cox proportional hazards model for time to death, and Fine-Gray competing risk model for time to kidney transplant., Results: Among a total of 588,478 male dialysis patients who met the eligibility criteria, 18,162 had claims for prostate cancer. After propensity-based risk-set matching, 15,554 pairs of prostate cancer cases and controls were identified. Among the matched pairs, survival rates were 76%, 48%, and 30% at 1, 3, and 5 years in the prostate cancer group, compared with 80%, 51%, and 33% in the control group, with relative mortality of 95%, 94%, and 91% respectively (log-rank test P  < 0.001). Prostate cancer was associated with a 22% lower likelihood of kidney transplant (HR: 0.78; 95% CI: 0.72-0.85) and 11% higher likelihood of death (HR: 1.11; 95% CI: 1.08-1.14) compared with controls. Kidney transplant was associated with a 4-fold improvement in overall survival, both in patients with and without prostate cancer (HR: 0.20; 95% CI: 0.18-0.21)., Limitations: Retrospective registry study., Conclusions: Prostate cancer is associated with a modest increase in the risk of death and time to transplant in patients with end-stage kidney disease. Kidney transplant is associated with the same degree of survival benefit among those with pretransplant prostate cancer as those without., (© 2021 The Authors.)

BACKGROUND: This study examined interview data from the National Health and Nutrition Examination Survey from 2005 to 2016. AIM: To determine national trends in self-reported depressive symptoms. METHOD: Depressive symptoms were assessed using self-reported data on the nine-item Patient Health Questionnaire (PHQ-9), with a total score ≥10 and an individual item score of 2 or 3, indicating greater severity. RESULTS: A total of 31,191 individuals contributed PHQ-9 data from 2005 to 2016. The absolute proportion of individuals with total PHQ-9 score ≥10 increased from 6.2% to 8.1%. After adjustment for participant demographic characteristics and comorbid conditions, the odds ratio for high PHQ-9 score at the end versus the beginning of the study interval was 1.27 (95% confidence interval [CI: 1.07, 1.50]). Anhedonia, guilt/worthlessness, appetite, and hypoactivity/hyperactivity had the largest increases in individual item risk after adjusting for demographic and comorbid characteristics. CONCLUSIONS: There were sizeable increases in the prevalence of self-reported depressive symptoms in the United States over an 11-year period. Further work is needed to understand the reasons for and implications of this increase. However, the results suggest greater efforts should be made by health care providers to screen for depressive symptoms that may warrant further assessment, treatment, or referral to mental health services as needed.

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers.

Background: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and use systems that effectively manage the demand for services., Methods: This was a cohort study using electronic health records at a health care system in northeast Ohio that examined the effectiveness of the first 5 weeks of a 24/7 physician-staffed COVID-19 hotline including social care referrals for patients required to self-isolate. We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing., Participants: In 5 weeks, 10,112 patients called the hotline (callers). Of these, 4213 (42%) were referred for a physician telehealth visit (telehealth patients). Mean age of callers was 42 years; 67% were female, 51% white, and 46% were on Medicaid/uninsured., Results: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 patients (7%) had a subsequent emergency department visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported, with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency department use (odds ratio = 4.73, 95% confidence interval = 1.37-16.39, P = .014). Only older age was associated with having a positive test result. Patients with social needs and interest in receiving help were offered services to meet their needs including food deliveries (n = 92), behavioral health telephone visits (n = 49), and faith-based comfort calls from pastoral care personnel (n = 37)., Conclusions and Relevance: Robust, physician-directed telehealth services can meet a wide range of clinical and social needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers., (© Copyright 2021 by the American Board of Family Medicine.)