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Children with cancer in low- and middle-income countries were disproportionately impacted by the COVID-19 pandemic, but little is known about how adolescents and young adults (AYAs) with cancer were affected. Sixty-seven physicians and nonphysician providers were interviewed about their experiences caring for AYAs with cancer in Latin America. Quotes related to the COVID-19 pandemic were identified and grouped into themes. Barriers from the COVID-19 pandemic included limited space, restrictions on travel, reduced funding, limited staff, limited services, and changes to treatment. However, improvements to care that arose from the COVID-19 pandemic included better access to distance learning and telemedicine.

Decades of disparities in health between infants born to Black and White mothers have persisted in recent years, despite policy initiatives to improve maternal and reproductive health for Black mothers. Although scholars have increasingly recognized the critical role that structural racism plays in driving health outcomes for Black people, measurement of this relationship remains challenging. This study examines trends in preterm birth and low birth weight between 2007 and 2018 separately for births to Black and White mothers. Using a multivariate regression model, we evaluated potential factors, including an index of racialized disadvantage as well as community- and individual-level factors that serve as proxy measures for structural racism, that may contribute to White-Black differences in infant health. Finally, we assessed whether unequal effects of these factors may explain differences in birth outcomes. We found that differences in the effects of these factors appear to explain about half of the underlying disparity in infant health., Competing Interests: Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Gold nanoparticles (Au-NPs) are used as catalysts for a diverse range of industrial applications. Currently, Au-NPs are synthesized chemically, but studies have shown that plants fed Au deposit, this element naturally as NPs within their tissues. The resulting plant material can be used to make biomass-derived catalysts. In vitro studies have shown that the addition of specific, short (∼10 amino acid) peptide/s to solutions can be used to control the NP size and shape, factors that can be used to optimize catalysts for different processes. Introducing these peptides into the model plant species, Arabidopsis thaliana ( Arabidopsis ), allows us to regulate the diameter of nanoparticles within the plant itself, consequently influencing the catalytic performance in the resulting pyrolyzed biomass. Furthermore, we show that overexpressing the copper and gold COPPER TRANSPORTER 2 (COPT2) in Arabidopsis increases the uptake of these metals. Adding value to the Au-rich biomass offers the potential to make plant-based remediation and stabilization of mine wastes financially feasible. Thus, this study represents a significant step toward engineering plants for the sustainable recovery of finite and valuable elements from our environment.

Importance: Studies suggest that early neurodevelopmental assessments are beneficial for identifying cerebral palsy, yet their effectiveness in practical scenarios and their ability to detect cognitive impairment are limited., Objective: To assess the effectiveness of early neurodevelopmental assessments in identifying cerebral palsy and cognitive and other neurodevelopmental impairments, including their severity, within a multidisciplinary clinic., Design, Setting, and Participants: This diagnostic study was conducted at Monash Children's Hospital, Melbourne, Australia. Participants were extremely preterm infants born at less than 28 weeks' gestation or extremely low birth weight infants less than 1000 g and term encephalopathic infants who received therapeutic hypothermia, attending the early neurodevelopmental clinic between January 2019 and July 2021. Data were analyzed from December 2023 to January 2024., Exposures: Early cerebral palsy or high risk of cerebral palsy, the absence of fidgety movements, and Hammersmith Infant Neurological Examination (HINE) scores at corrected age (CA) 3 to 4 months. Early cerebral palsy or high risk of cerebral palsy diagnosis was based on absent fidgety movements, a low HINE score (<57), and medical neurological examination., Main Outcome and Measures: The outcomes of interest were cerebral palsy, cognitive and neurodevelopmental impairments and their severity, diagnosed at 24 to 36 months' CA., Results: A total of 116 infants (median [IQR] gestational age, 27 [25-29] weeks; 65 [56%] male) were included. Diagnosis of early cerebral palsy or high risk of cerebral palsy demonstrated a sensitivity of 92% (95% CI, 63%-99%) and specificity of 84% (95% CI, 76%-90%) for predicting cerebral palsy and 100% (95% CI, 59%-100%) sensitivity and 80% (95% CI, 72%-87%) specificity for predicting moderate to severe cerebral palsy. Additionally, the accuracy of diagnosis of early cerebral palsy or high risk of cerebral palsy was 85% (95% CI, 77%-91%) for predicting cerebral palsy and 81% (95% CI, 73%-88%) for predicting moderate to severe cerebral palsy. Similarly, the absence of fidgety movements had an 81% (95% CI, 73%-88%) accuracy in predicting cerebral palsy, and HINE scores exhibited good discriminatory power with an area under the curve of 0.88 (95% CI, 0.79-0.97) for cerebral palsy prediction. However, for cognitive impairment, the predictive accuracy was 44% (95% CI, 35%-54%) for an early cerebral palsy or high risk of cerebral palsy diagnosis and 45% (95% CI, 36%-55%) for the absence of fidgety movements. Similarly, HINE scores showed poor discriminatory power for predicting cognitive impairment, with an area under the curve of 0.62 (95% CI, 0.51-0.73)., Conclusions and Relevance: In this diagnostic study of infants at high risk for cerebral palsy or other cognitive or neurodevelopmental impairment, early neurodevelopmental assessments at 3 to 4 months' CA reliably predicted cerebral palsy and its severity at 24 to 36 months' CA, signifying its crucial role in facilitating early intervention. However, for cognitive impairment, longer-term assessments are necessary for accurate identification.

Background: Patients and their families face financial hardship during cancer treatment, which may intensify at end of life (EOL) due to increased symptoms and care needs. We undertook a narrative literature review to describe the current understanding of the causes, impacts and factors associated with financial hardship at EOL. We identify gaps in research, policy and clinical practice and propose steps to mitigate financial hardship for patients and caregivers at EOL., Methods: We conducted a Medline search to identify US studies since 2000 that examined EOL financial hardship for patients with cancer and their caregivers., Results: Twenty-seven adult and four paediatric studies met review criteria. Adults with cancer and their caregivers face significant financial hardship at EOL and in bereavement, especially due to employment changes and informal caregiving time costs. Financial hardship may be higher for younger caregivers and for patients who are uninsured, low income, rural, with high symptom burdens or with certain cancer types. The few paediatric studies showed high financial hardship and employment impact lasting well beyond a child's death., Conclusions: There is limited literature examining financial hardship at EOL in the USA, especially in paediatrics. Priorities for future research include longitudinal studies in diverse populations of patients with cancer and informal caregivers using standardised financial hardship measures. Policies to address financial hardship at EOL, especially with hospice care, should include insurance coverage for family caregiving and medical leave policies. There is need for increased financial hardship screening at EOL and in bereavement and a need for financial navigation interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Severe brain injury (SBI), including severe intraventricular haemorrhage (sIVH) and cystic periventricular leukomalacia, poses significant challenges for preterm infants, yet recent data and trends are limited., Methods: Analyses were conducted using the Australian and New Zealand Neonatal Network data on preterm infants born &lt;32 weeks' gestation admitted at Monash Children's Hospital, Australia, from January 2014 to April 2021. The occurrence and trends of SBI and sIVH among preterm infants, along with the rates and trends of death and neurodevelopmental impairment (NDI) in SBI infants were assessed., Results: Of 1,609 preterm infants, 6.7% had SBI, and 5.6% exhibited sIVH. A total of 37.6% of infants with SBI did not survive to discharge, with 92% of these deaths occurring following redirection of clinical care. Cerebral palsy was diagnosed in 65.2% of SBI survivors, while 86.4% of SBI survivors experienced NDI. No statistically significant differences were observed in the temporal trends of SBI (adjusted OR [95% CI] 1.08 [0.97-1.20]; p = 0.13) or sIVH (adjusted OR [95% CI] 1.09 [0.97-1.21]; p = 0.11). Similarly, there was no statistically significant difference noted in the temporal trend of the composite outcome, which included death or NDI among infants with SBI (adjusted OR [95% CI] 0.90 [0.53-1.53]; p = 0.71)., Conclusion: Neither the rates of SBI nor its associated composite outcome of death or NDI improved over time. A notable proportion of preterm infants with SBI faced redirection of care and subsequent mortality, while most survivors exhibited adverse neurodevelopmental challenges. The development of better therapeutic interventions is imperative to improve outcomes for these vulnerable infants., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Objective: To provide pharmacists and other health care professionals with the knowledge required to minimize the risk of prolonged opioid use following total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Data Sources: A literature search of PubMed and Embase was performed, and included the search terms: (opioid OR opiate OR opium) AND (risk factor OR predict*) AND (arthroplasty OR replacement) NOT shoulder., Study Selection and Data Extraction: Randomized control trials, cohort studies (both prospective and retrospective), systematic reviews, and meta-analyses were included if risk ratios (RRs) or odds ratios (ORs) were reported and published within the last 5 years., Data Synthesis: ]Twenty studies met inclusion criteria, including 2 meta-analyses and 2 prospective studies. There were several risk factors that overlapped between studies and presented clinically significant risks for prolonged opioid use following THA and TKA surgery. Of these, age < 65 (RRs: 1.15-9.36), preoperative opioid use (RRs: 1.09-7.81), larger quantities of opioids prescribed at discharge (RRs: 1.26-8.81), and TKA surgery (RRs: 1.73-6.07) were the most significant. Several risk factors were recently described, including migraines (RRs: 1.14-5.11) and fibromyalgia (RRs: 1.1-2.3) that may be of interest for further research., Relevance to Patient Care and Clinical Practice: This review presents a discussion of the factors associated with prolonged opioid use following THA and TKA surgeries, which are among the most common orthopedic surgeries., Conclusions: Prescribers should carefully consider patient-specific factors when prescribing opioids as there are several factors, including age, surgery type, and medical conditions that can predispose patients to prolonged opioid use.

In the early stages of treating patients with SARS-CoV-2, limited information was available to guide antimicrobial stewardship interventions. The COVID-19 Task Force and Antimicrobial Stewardship Committee, at a 988-bed academic medical center, implemented the use of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab polymerase chain reaction (PCR) testing to assist with the de-escalation of anti-MRSA therapy in patients with suspected superimposed bacterial pneumonia in COVID-19. A retrospective study was conducted to evaluate the impact of MRSA nasal swab PCR testing on the rate of anti-MRSA therapy between 13 April 2020 and 26 July 2020. A total of 122 patients were included in the analysis. Of the patients included in the final analysis, 58 (47.5%) had anti-MRSA therapy discontinued and 41 (33.6%) avoided anti-MRSA therapy completely due to a negative swab result. With the implementation of MRSA nasal swab PCR testing in COVID-19 patients, anti-MRSA therapy was reduced in 81% of patients in this study. In patients who continued with anti-MRSA therapy, nasal swabs were either positive for MRSA or an alternative indication for anti-MRSA therapy was noted. Only three patients in the cohort had MRSA identified in a sputum culture, all of whom had anti-MRSA therapy continued. MRSA nasal swab PCR testing may serve as an effective antimicrobial stewardship tool in COVID-19 pneumonia.

Background: Existing evidence suggests that while the coronavirus disease 2019 (COVID-19) pandemic triggered quit attempts among many smokers, it led some to smoke more and others to relapse back to smoking. These diverse effects have the potential to have a long-term impact on individuals' smoking and vaping behaviors., Aims and Methods: This study explored the effect of COVID-19 on smokers and vapers, vape shops (VS), and stop smoking services (SSS). A total of 39 semi-structured interviews were conducted with stop-smoking practitioners, tobacco control leads, smokers and/or vapers, and vape shop owners. Interviews were transcribed verbatim and analyzed thematically., Results: Four themes were identified: Lockdown as a barrier to becoming or remaining smoke-free; COVID as a catalyst for quitting and remaining smoke-free; changes in vaping and challenges for vapers and VS; and changes and challenges for stop smoking support. Fear of COVID resulting in severe health implications for smokers facilitated behavior change; however, the boredom and monotony of lockdown and associated stress created difficulties in remaining a smoke free. Results showed that the enforced switch from face-to-face to the remote provision of SSS was beneficial for improving engagement, particularly for vulnerable groups such as pregnant women. Stop smoking professionals and vapers disagreed with the forced closure of VS because it created unnecessary difficulties for vapers to access supplies., Conclusions: COVID-19 was both a barrier and facilitator for smoking cessation. Remote provision of SSS implemented due to lockdown was beneficial for hard-to-reach groups; services should look to incorporate these changes into day-to-day practice., Implications: This study is one of the first to explore how the COVID-19 pandemic directly affected smokers, vapers, SSS, tobacco control leads, and VS. It provides evidence for the continued use of the remote provision of smoking cessation services to increase engagement among hard-to-reach groups and provides information on how pandemics can be a catalyst for health behavior change. This study is unique in that it incorporates the views of different stakeholders., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Adequate pain management is important in patients' recovery from total hip arthroplasty (THA) and total knee arthroplasty (TKA)., Objective: To determine whether risk factors for prolonged opioid use are considered when discharge prescriptions for postoperative pain are written following THA and TKA., Methods: Opioid prescriptions written between June 14 and July 9, 2021, for patients who underwent THA or TKA were analyzed. Data were also collected on the patients' age, sex, type of surgery, type of anesthesia (regional or general), preoperative use of opioids, and preoperative use of antidepressants., Results: Among the 59 patients included in the study, the most common prescriptions were for hydromorphone 2 mg ( n = 15, 25%) and hydromorphone 1 mg ( n = 15, 25%). At discharge, patients received a median of 400 morphine milligram equivalents (MMEs). There was no significant difference in the quantity of opioids (MMEs) prescribed at discharge in relation to surgery type ( p = 0.63), sex ( p = 0.44), preoperative antidepressant use ( p = 0.22), or preoperative opioid use ( p = 0.97). There also appeared to be no correlation between a patient's age and MMEs at discharge ( p = 0.21; r 2 = 0.028). None of these variables could be used to predict which patients would receive more than 400 MMEs., Conclusions: Patient-specific factors appeared not to be taken into consideration when opioids were prescribed for postoperative pain among patients who underwent THA or TKA., Competing Interests: Competing interests: None declared., (2022 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Objectives: In December 2020, Derbyshire County Council in England introduced 'walk-in' asymptomatic community COVID-19 testing sites. Our study aimed to explore people's views of the newly established COVID-19 community testing (CT) sites among those who attended and those who did not attend them, alongside gathering individuals' experiences of attending a CT site to complete a lateral flow test., Setting: This qualitative research study comprised of one-to-one interviews with those attending a COVID-19 CT sites in Derbyshire and those from the surrounding area who did not attend., Participants: A combination of purposive and convenience sampling was used to recruit those who had (n=18) and those who had not attended (n=15) a walk-in asymptomatic CT site., Results: Employers played a key role in raising awareness of the testing sites, with most attending CT at the request of their workplace. The experience of attending a CT site was overwhelmingly positive and those who got tested spoke about the reassurance a negative result offered, knowing they were not passing on the virus when going about their daily lives. However, there was a perception that awareness of CT sites was low across the county and some confusion about who was eligible to attend and under what circumstances. Individuals linked this to low level of advertising they had seen, in addition to a lack of clarity in the information provided., Conclusions: People's experience of attending a 'walk-in' asymptomatic CT site in Derbyshire was generally very positive; however, ensuring clear communication for future testing programmes is essential to maximise their uptake., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Context: Children with serious illness deserve high-quality pediatric palliative care (PPC). With expansion of PPC provision, it is important to understand the quality improvement (QI) activities of PPC clinicians and programs., Objectives: To describe the 1) background, education/training, and activities in QI and 2) perceived barriers to QI efforts among PPC clinicians and programs nationally., Methods: An electronic survey was sent to members of the Pediatric Palliative Improvement Network, the National Coalition for Hospice and Palliative Care Pediatric Task Force, and the PPC Research Network as part of a study to develop hospital-based, primary PPC quality measures. Surveys queried participants' background, education/training, individual/team QI efforts, and barriers to QI work. Results were summarized descriptively., Results: Of the 95 respondents; most were female (84 [88%]) and/or white (84 [88%]). The majority (57 [54%]) were physicians, although participants represented a variety of clinical disciplines, researchers (10 [9%]), and administrators (6 [6%]). One-quarter (25 [26%]) reported having <10 hours total of training in QI, yet two-third (63 [66%]) participated in QI work. About one-third (35 [37%]) reported that their program had no dedicated staff for QI activities, yet over half (56 [59%]) of participants reported that their team participated in QI work. Participants reported that lack of personnel/time, standardized measures/tools, education/training/mentoring in QI, systems to promote QI work, and financing/grants were barriers., Conclusion: Over half of PPC participants in this study reported involvement in QI activities despite limited staffing/time, QI training, and standardized measures, which presents challenges to this work., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Telehealth can reduce the gap between developmental concern and diagnosis. Evaluation of telehealth methods is needed for providers to make decisions about using telediagnostic assessments., Aim: This systematic review examined telehealth in facilitating a diagnosis for children with developmental concerns and assessed 1) study characteristics and type of diagnostic evaluation; 2) comparison of telehealth technologies to in-person diagnostic methods; 3) feasibility and acceptability of telehealth technologies; and 4) methodological quality., Method and Procedures: Peer-reviewed studies from PsycINFO, CINAHL, Web of Science, PubMed, Embase, and Cochrane published January 2000-July 2021 were searched using "telehealth" AND "developmental concern" AND "diagnosis". Data extraction included study characteristics, diagnostic evaluation, technology, diagnostic accuracy, feasibility, and acceptability. Methodological quality was assessed using NHLBI tools., Outcomes and Results: Nine studies met inclusion. Children with suspected FAS, social-emotional concerns, suspected genetic conditions, and failed hearing screenings received a telediagnosis. Evaluations included dysmorphology, feeding, neurological, developmental, audiological, and psychiatric. Seven studies used videoconferencing in real-time and two used Store-and-Forward methods. High diagnostic agreement occurred between face-to-face and remote methods. Stakeholders reported high satisfaction and feasibility. Many of the studies were rated as fair quality., Conclusions and Implications: Findings underscore partnership models between local providers and remote specialists. Rigorous study designs with larger samples covering a wider range of developmental domains are needed to provide a stronger empirical base for providers., (Published by Elsevier Ltd.)

Children with heart disease often experience symptoms and medically intense end-of-life care. Our study explored bereaved parents' perceptions of a "good death" via a mail survey to 128 parents of children with heart disease who died in two centers. Parental perceptions of end-of-life circumstances were assessed by closed-ended questions including level of agreement with the question: "would you say your child experienced a good death?" and open-ended comments were contributed. Medical therapies at end-of-life and mode of death were retrieved through chart review. Of 50 responding parents, 44 (response rate: 34%) responded to the "good death" question; 16 (36%) agreed strongly, 15 (34%) agreed somewhat, and 30% disagreed (somewhat: 7, 16%; strongly: 6, 14%). Half the children were on mechanical support and 84% intubated at death. Of children with cardiopulmonary resuscitation (CPR) at end-of-life, 71% of parents disagreed with the "good death" question compared with 22% of parents whose child died following discontinuation of life-sustaining therapy or comfort measures (OR 9.1, 95% CI 1.3, 48.9, p < 0.01). Parent-reported circumstances associated with disagreement with the "good death" question included cure-oriented goals-of-care (OR 16.6, 95% CI 3.0, 87.8, p < 0.001), lack of advance care planning (ACP) (OR 12.4 95% CI 2.1, 65.3 p < 0.002), surprise regarding timing of death (OR 11.7, 95% CI 2.6, 53.4 p < 0.002), and experience of pain (OR 42.1, 95% CI 2.3, 773.7 p < 0.02). Despite high medical intensity, many bereaved parents of children with cardiac disease agree a "good death" was experienced. A "good death" was associated with greater preparedness, ACP, non-cure-oriented goals-of-care, pain control, and CPR avoidance., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Ewing sarcoma (EWS) and osteosarcoma (OS) require multidisciplinary treatment. Care at specialized cancer centers (SCC: Children's Oncology Group affiliated and/or National Cancer Institute-designated cancer center) has been found to improve outcomes in patients with leukemia, but studies have not considered location of care and outcomes in EWS and OS patients, an ideal group to evaluate given their specialized multidisciplinary treatment needs., Methods: Patients hospitalized with primary EWS and OS (2000-2014) were identified using the California Cancer Registry linked with hospitalization data. Patients were divided into age groups (0-18, 19-39, ≥40 years), and classified on whether they received all versus part/none of their inpatient treatment at a SCC within 1 year of diagnosis. Multivariable Cox proportional hazards regression identified factors associated with survival., Results: There were 531 ES and 959 OS patients. Five-year overall survival was better for patients with EWS (all: 63% vs. part/none: 42%) and OS (all: 64% vs. part/none: 47%) who received all of their treatment at a SCC. After adjusting for sociodemographic and clinical factors, receiving all inpatient cancer treatment at a SCC was associated with superior overall survival (EWS HR: 0.49, CI 0.37-0.67; OS HR: 0.78, CI 0.63-0.97)., Conclusion: Our results suggest that treatment for EWS and OS at a SCC is associated with significantly improved survival even after adjustment for known prognostic factors. The superior survival among those treated at SCCs may be due to having greater access to clinical trials and services at SCCs., (© 2021 Wiley Periodicals LLC.)

Expressive language and communication are among the key targets of interventions for individuals with autism spectrum disorder (ASD), and natural language samples provide an optimal approach for their assessment. Currently, there are no protocols for collecting such samples that cover a wide range of ages or language abilities, particularly for children/adolescents who have very limited spoken language. We introduce a new protocol for collecting language samples, eliciting language samples for analysis (ELSA), and a novel approach for deriving basic measures of verbal communicative competence from it that bypasses the need for time-consuming transcription. Study 1 presents ELSA-adolescents (ELSA-A), designed for minimally and low-verbal older children/adolescents with ASD. The protocol successfully engaged and elicited speech from 46 participants across a wide range of ages (6;6-19;7) with samples averaging 20-25 min. The collected samples were segmented into speaker utterances (examiner and participant) using real-time coding as one is listening to the audio recording and two measures were derived: frequency of utterances and conversational turns per minute. These measures were shown to be reliable and valid. For Study 2, ELSA was adapted for younger children (ELSA-Toddler [ELSA-T]) with samples averaging 29 min from 19 toddlers (2;8-4;10 years) with ASD. Again, measures of frequency of utterances and conversational turns derived from ELSA-T were shown to have strong psychometric properties. In Study 3, we found that ELSA-A and ELSA-T were equivalent in eliciting language from 17 children with ASD (ages: 4;0-6;8), demonstrating their suitability for deriving robust objective assessments of expressive language that could be used to track change in ability over time. We introduce a new protocol for collecting expressive language samples, ELSA, that can be used with a wide age range, from toddlers (ELSA-T) to older adolescents (ELSA-A) with ASD who have minimal or low-verbal abilities. The measures of language and communication derived from them, frequency of utterances, and conversational turns per minute, using real-time coding methods, can be used to characterize ability and chart change in intervention research. LAY SUMMARY: We introduce a new protocol for collecting expressive language samples, ELSA, that can be used with a wide age range, from toddlers (ELSA-T) to older adolescents (ELSA-A) with autism spectrum disorder who have minimal or low-verbal abilities. The measures of language and communication derived from them, frequency of utterances and conversational turns per minute, using real-time coding methods, can be used to characterize ability and chart change in intervention research., (© 2020 International Society for Autism Research and Wiley Periodicals LLC.)

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.

Absolute neutrophil count (ANC) cut-offs for antimicrobial prophylaxis in veterinary cancer chemotherapy patients are empirical and vary between institutions. Evidence based cut-offs are vital for antimicrobial stewardship, particularly as global antimicrobial resistance rises. The primary objectives of this study were to evaluate the tolerability of a <0.75 × 10 9 /l ANC cut-off for antimicrobial prophylaxis in dogs after receiving chemotherapy and its impact on antimicrobial prescription. Predicted nadir ANCs (pnANCs) were stratified into six groups (<0.75 × 10 9 /l [receiving antimicrobial prophylaxis], 0.75-0.99 × 10 9 /l, 1-1.49 × 10 9 /l, 1.5-1.99 × 10 9 /l, 2.0-3.59 × 10 9 /l and 3.6-12 × 10 9 /l [reference interval]). The incidences of post-nadir febrile neutropenia (FN) and non-haematological toxicity (NHT) were compared between groups. Five hundred and eighty-six pnANCs were recorded for 181 dogs. There were four episodes of post-nadir FN and 90 episodes of post-nadir NHT. There was no significant difference in incidence of post-nadir FN (P = .063) or post-nadir NHT (P = .084) between pnANC groups. Antimicrobial prophylaxis was prescribed following 8.8% of the chemotherapy administrations; had cut-off values of <1.0 × 10 9 /l or <1.5 × 10 9 /l been used it would have been prescribed in 15.3% and 25.8% of cases respectively. An ANC cut-off of <0.75 × 10 9 /l for antimicrobial prophylaxis appears to be well tolerated and minimizes the prescription of antimicrobials., (© 2019 John Wiley & Sons Ltd.)

This study used bivariate and regression-adjusted analyses of participant-level survey and medical data to investigate prevalence of depression among pregnant Medicaid participants, correlates of depression, and the relationship between depression and pregnancy outcomes. The sample included Medicaid participants with a single gestation and valid depression data who were enrolled in Strong Start for Mothers and Newborns 2, a national preterm birth prevention program, from 2013 to 2017 (N = 37,287; 85% of total enrollment). Depression rates in Strong Start were high (27.5%). Depression was associated with being black; having other children, an unplanned pregnancy, or challenges accessing prenatal care; not having a co-resident spouse or partner; and experiencing intimate partner violence. After these and other risk factors were controlled for, depression remained associated with higher rates of preterm birth. Systematic screening and holistic approaches to prenatal care that address depression and associated risks could help reduce rates of preterm birth and other poor pregnancy outcomes.

The federal Strong Start for Mothers and Newborns initiative supported alternative approaches to prenatal care, enhancing service delivery through the use of birth centers, group prenatal care, and maternity care homes. Using propensity score reweighting to control for medical and social risks, we evaluated the impacts of Strong Start's models on birth outcomes and costs by comparing the experiences of Strong Start enrollees to those of Medicaid-covered women who received typical prenatal care. We found that women who received prenatal care in birth centers had lower rates of preterm and low-birthweight infants, lower rates of cesarean section, and higher rates of vaginal birth after cesarean than did the women in the comparison groups. Improved outcomes were achieved at lower costs. There were few improvements in outcomes for participants who received group prenatal care, although their costs were lower in the prenatal period, and no improvements in outcomes for participants in maternity care homes.

This article was migrated. The article was marked as recommended. Preventable chronic disease is a leading cause of death and disability in the United States and around the world. Training in wellness and disease prevention is provided to varying degrees in medical education leading to low levels of counseling on prevention-related topics in clinical care. Colleges of osteopathic medicine are in a unique position to lead the way in training future physicians in community health and prevention topics. Integrating community health and wellness throughout the curriculum allows osteopathic medical students to learn the scientific basis for prevention recommendations and learn to apply them to future patient care. We are incorporating these topics across the first two years of medical school in a new college of osteopathic medicine in the USA. This will address local disparities and train physicians prepared to care for patients at the individual and population health levels., (Copyright: © 2020 Goldgraben S et al.)

Objective: We assessed factors related to the integration of an office-based diet quality screener: nutrition counselling, cardiometabolic risk factors and patient/physician satisfaction., Methods: We evaluated the impact of a 10-item diet quality measure (self-rated diet quality question and a 9-item Mediterranean Diet Score (MDS)) prior to the cardiology visit on assessment of nutrition counselling, cardiometabolic risk factors and patient/provider satisfaction. Study staff trained the nine participating physicians on the purpose and use of the screener. To assess physician uptake of the diet quality screener, we reviewed all charts having a documented dietitian referral or visit and a 20% random sample of remaining participants that completed the screener at least once to determine the proportion of notes that referenced the diet quality screener and documented specific counselling based on the screener., Results: Between December 2017 and August 2018, 865 patients completed the diet quality screener. Mean age was 59 (SD 16) years, 54% were male and mean body mass index was 27.4 (SD 6.0) kg/m 2 . Almost one-fifth (18.5%) of participants rated their diet as fair or poor, and mean MDS (range 0-9) was moderate (mean 5.6±1.8 SD). Physicians referred 22 patients (2.5%) to a dietitian., Conclusion: Integrating the screener into the electronic health record did not increase dietitian referrals, and improvements in screener scores were modest among the subset of patients completing multiple screeners. Future work could develop best practices for physicians in using diet quality screeners to allow for some degree of standardisation of nutrition referral and counselling received by the patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To describe infant deaths where a u-shaped pillow was under or around an infant and to describe cases classified as Explained Suffocation., Methods: We examined demographics and circumstances of 141 infant deaths during 2004-2015 in the US National Fatality Review Case Reporting System with u-shaped pillows in the sleep environment., Results: Most infants were < 6 months old (92%), male (58%), non-Hispanic White (53%), and of the nine explained suffocation deaths, four occurred when the u-shaped pillow obstructed the infant's airway; five occurred when the infant rolled off the pillow and their airway was obstructed by another object., Conclusions for Practice: Although infrequent, infant deaths with u-shaped pillows have occurred. Health care providers may include discussion of the importance of caregivers following infant product packaging precautions and warning labels for commonly used consumer products, such as u-shaped pillows in their advice to caregivers.

Background: Dynamic nutrition education strategies may help prepare physicians to provide nutrition guidance to patients., Activity: We pilot tested a nutrition-focused iBook chapter with a group of medical students and residents (June 2017) through pre and post-test Qualtrics surveys., Results: All 29 respondents recognized the role of nutrition in medical care. Two-thirds reported some nutrition training in their medical education; nearly 90% reported this training was inadequate. Few (17%) reported reading scholarly nutrition articles; 84% reported they would recommend the iBook to their peers., Conclusions: An iBook is a resource that could be used to teach nutrition to medical trainees., Competing Interests: Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest.

Background: Approximately 700 women die from pregnancy-related complications in the United States every year., Methods: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors., Results: For 2011-2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care., Conclusions: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable., Implications for Public Health Practice: Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. David Goodman reports that the Building U.S. Capacity to Review and Prevent Maternal Deaths initiative was supported in part by funding from Merck, through an award agreement with its Merck for Mothers program. No other potential conflicts of interest were disclosed.

Purpose of Review: Recent studies have documented that diet quality in the US is poor and linked to higher rates of cardiovascular disease (CVD), other non-communicable diseases, and total mortality. As a result, nutrition counseling in clinical practice is an evidence-based strategy endorsed by numerous stakeholders. However, medical nutrition education (MNE) in the US has been inadequate, and physician knowledge, competencies, and practices related to diet counseling have been documented to be insufficient. National scientific meetings and conferences offer opportunities to translate new scientific evidence, guidelines, and competencies to clinicians in attendance and to publicize this evidence widely. This review assessed the adequacy of, and trends in, nutrition education provided at recent major US scientific meetings that offer continuing medical education (CME), with a focus on CVD-related conferences., Recent Findings: The authors found no reviews that have assessed the scope and type of nutrition-related educational programming at major conferences. We therefore investigated nutrition-related programming at CVD-related CME conferences in the US from 2013 to 2018. National scientific CVD-related conferences in the USA have offered variable amounts of programming related to practical applications of nutrition science. We did not observe an increase in nutrition-related offerings, despite the increase in diet-related diseases and the growing evidence base for the role of nutrition in the prevention and management of chronic disease. Increasing nutrition-related CME programming at national scientific meetings can lead to greater translation of nutrition evidence to patients by healthcare providers and improved health outcomes in the population.

The original version of this article unfortunately contained a mistake in the order of authors. The co-author "Sarah Benatar" should be the second author and "Brigette Courtot" should be the third author of the article.

Morbidity and mortality associated with cardiovascular disease can be significantly modified through lifestyle interventions, yet there is little emphasis on nutrition and lifestyle in medical education. Improving nutrition education for future physicians would likely lead to improved preparedness to counsel patients on lifestyle interventions. An online anonymous survey of medical residents, cardiology fellows, and faculty in Internal Medicine and Cardiology was conducted at New York University Langone Health assessing basic nutritional knowledge, self-reported attitudes and practices. A total of 248 physicians responded (26.7% response rate). Nutrition knowledge was fair, but few (13.5%) felt adequately trained to discuss nutrition with patients. A majority (78.4%) agreed that additional training in nutrition would allow them to provide better clinical care. Based on survey responses, a dedicated continuing medical education (CME) conference was developed to improve knowledge and lifestyle counseling skills of healthcare providers. In postconference evaluations, attendees reported improved knowledge of evidence-based lifestyle interventions. Most noted that they would prescribe a Mediterranean or plant-based diet and would make changes to their practice based on the conference. An annual CME conference on diet and lifestyle can effectively help interested providers overcome barriers to lifestyle change in clinical practice through improved nutrition knowledge., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives Strategies to prevent preterm birth are limited. 17 Alpha-Hydroxyprogesterone Caproate (17P) injections have been shown to be effective, but the intervention is under-used. This mixed methods study investigates barriers and facilitators to 17P administration among Medicaid and CHIP participants enrolled in Strong Start for Mothers and Newborns, a federal preterm birth prevention program. Methods Twenty-seven awardees with more than 200 sites in 30 states, the District of Columbia, and Puerto Rico enrolled approximately 46,000 women in Strong Start from 2013 to 2016. Participant data, including data on preterm birth and 17P, was collected for each woman. Intensive interviews (n = 211) conducted with Strong Start program staff and providers (n = 314) included questions about 17P provision. Results Of women whose data included a valid response regarding 17P initiation, 3919 had a prior preterm birth and current singleton pregnancy; 14.95% received 17P. Barriers to 17P administration include late entry to prenatal care, administrative burden of preauthorization, cost risks to providers, limits in scope of practice for non-physician providers, and social barriers among participants. Facilitators for provision include streamlined work flows and the option of home administration. Conclusions for Practice A universal insurance authorization process could mitigate many barriers to 17P use. Providers need continuing education regarding the effectiveness of 17P, and expanding scope of practice for non-physician prenatal care providers would increase access. Targeted program interventions can help to overcome social barriers Medicaid participants face in accessing care. Streamlined work processes and the option of home health services are two effective program-based facilitators for providing 17P to a Medicaid population.

Purpose: Intensity of end-of-life care receives much attention in oncology because of concerns that high-intensity care is inconsistent with patient goals, leads to worse caregiver outcomes, and is expensive. Little is known about such care in those undergoing allogeneic hematopoietic cell transplantation (HCT), a population at high risk for morbidity and mortality., Patients and Methods: We conducted a population-based analysis of patients who died between 2000 and 2013, within 1 year of undergoing an inpatient allogeneic HCT using California administrative data. Previously validated markers of intensity were examined and included: hospital death, intensive care unit (ICU) admission, and procedures such as intubation and cardiopulmonary resuscitation at end of life. Multivariable logistic regression models determined clinical and sociodemographic factors associated with: hospital death, a medically intense intervention (ICU admission, cardiopulmonary resuscitation, hemodialysis, intubation), and ≥ two intensity markers., Results: Of the 2,135 patients in the study population, 377 were pediatric patients (age ≤ 21 years), 461 were young adults (age 22 to 39 years), and 1,297 were adults (age ≥ 40 years). The most common intensity markers were: hospital death (83%), ICU admission (49%), and intubation (45%). Medical intensity varied according to age, underlying diagnosis, and presence of comorbidities at time of HCT. Patients with higher-intensity end-of-life care included patients age 15 to 21 years and 30 to 59 years, patients with acute lymphoblastic leukemia, and those with comorbidities at time of HCT., Conclusion: Patients dying within 1 year of inpatient allogeneic HCT are receiving medically intense end-of-life care with variations related to age, underlying diagnosis, and presence of comorbidities at time of HCT. Future studies need to determine if these patterns are consistent with patient and family goals.

Objective: To examine the perspectives of family medicine preceptors and residents, including their interest and intent to participate in and their knowledge and willingness to teach or learn about medical assistance in dying (MAID)., Design: Two anonymous surveys were distributed via e-mail using a Dillman approach to residents and preceptors. Responses were collected between August 23 and November 29, 2016. Data were analyzed using descriptive and inferential statistics., Setting: The large, 4-site Queen's University family medicine residency program in southeastern Ontario., Participants: A total of 71 preceptors and 62 residents., Main Outcome Measures: Physician and resident knowledge of and experience, comfort, and confidence with MAID; willingness to participate in MAID; perspectives on the effect of MAID on team relationships; and the importance, desired content, and delivery of MAID education., Results: Overall, 45.2% of preceptors and 33.3% of residents responded. A low proportion of both preceptors and residents felt competent or comfortable discussing and exploring MAID with a patient, with preceptors feeling significantly more competent and comfortable than residents ( P < .001 and P < .01, respectively). Paradoxically, significantly more residents than preceptors were willing to be part of a clinical team providing MAID through oral or intravenous routes ( P < .001). In spite of this willingness to be involved, significantly fewer residents felt safe discussing personal perspectives on MAID in various clinical environments ( P < .001). Most participants from both groups believed it was important to include MAID in the core family medicine residency curriculum and identified specific curriculum content and delivery strategies., Conclusion: Family medicine preceptors and residents are willing and want to learn about MAID. Our research demonstrates a need to integrate MAID into the family medicine residency curriculum, with faculty development and continuing professional development for preceptors., (Copyright© the College of Family Physicians of Canada.)

Understanding the factors influencing mosquito distribution is important for effective surveillance and control of nuisance and disease vector mosquitoes. The goal of this study was to determine how trap height and distance to the city center influenced the abundance and species of mosquitoes collected in Adelaide, South Australia. Mosquito communities were sampled at two heights (<2 m and ~10 m) along an urban-rural gradient. A total of 5,133 mosquitoes was identified over 176 trap nights. Aedes notoscriptus, Ae. vigilax, and Culex molestus were all more abundant in lower traps while Cx. quinquefasciatus (an ornithophilic species) was found to be more abundant in high traps. Distance to city center correlated strongly with the abundance of Ae. vigilax, Ae. camptorhynchus, Cx. globocoxitus, and Cx. molestus, all of which were most common at the sites farthest from the city and closest to the saltmarsh. Overall, the important disease vectors in South Australia (Ae. vigilax, Ae. camptorhynchus, Ae. notoscriptus, and Cx. annulirostris) were more abundant in low traps farthest from the city and closest to the saltmarsh. The current mosquito surveillance practice of setting traps within two meters of the ground is effective for sampling populations of the important disease vector species in South Australia., (© 2014 The Society for Vector Ecology.)

Anaplasma phagocytophilum (Dumler et al.) is the bacterial agent of human granulocytic anaplasmosis, an emerging infectious disease. The main vector of A. phagocytophilum in the United States is the blacklegged tick (Ixodes scapularis (Say)) and various small and medium-sized mammals are reservoirs. Previous studies indicate that birds are exposed to A. phagocytophilum; however, because no studies have directly investigated avian susceptibility, reservoir competence, and morbidity for A. phagocytophilum, uncertainty remains as to what role birds could play in its transmission ecology. In a controlled laboratory study, we tested whether two species, the American robin (Turdus migratorius (L.)) and the gray catbird (Dumetella carolinensis (L.)), can become infected with and then transmit A. phagocytophilum to feeding ticks, and whether exposed birds develop disease. Wild caught, seronegative birds (n = 10 per species) were exposed to A. phagocytophilum-infected I. scapularis nymphs (day 0). Transmission was assessed by xenodiagnosis on days 7, 14, 42, and 77; blood was assayed for bacteremia and serology. A. phagocytophilum was detected using quantitative polymerase chain reaction targeting the 16s rRNA gene. One robin infected 2 of 13 larval ticks (15%) on day 7; no other birds were found to infect feeding ticks at any time. Birds did not develop bacteremia, specific antibodies or significant illness because of exposure. Mouse controls became bacteremic, infected feeding ticks, and seroconverted. Our results suggest that these two avian species are unlikely to play a significant role in the maintenance of the agent of human granulocytic anaplasmosis and that avian serosurveys may not be a reliable indicator of A. phagocytophilum exposure.

Objective: This study assessed a potential relationship between elevated carboxyhemoglobin (COHb) levels and the presence of acute mountain sickness (AMS) at 4300 m on Denali and evaluated the relationship between COHb levels, AMS, and climber characteristics and behaviors. Building on our research done in 2004, in this article we report further data gathered during the 2005 climbing season and evaluate the combined results., Methods: Participants were screened for AMS using the Lake Louise Self-Report Questionnaire and answered questions focusing on AMS symptoms, AMS prevention, and previous history of altitude illness. Carboxyhemoglobin levels were measured by serum co-oximetry. Additional questions assessed stove practices, climbing practices, and climber behaviors. Nonparametric statistical analyses were performed to examine potential relationships between COHb levels, AMS symptoms, and climber behaviors across the 2 years and with years combined., Results: Overall, 317 climbers participated in the 2-year study. As in 2004, the combined data demonstrated no relationship between positive carbon monoxide (CO) exposure and positive criteria for AMS (P = .276). Climbers in 2005 were 1.92 times more likely to meet positive criteria for AMS, compared to climbers in 2004 (P = .028). On the contrary, climbers in 2004 were 3.93 times more likely to be CO exposed than climbers in 2005 (P = .003). Overall, climbers descending the mountain were more likely to be positive for CO exposure (5.56 times more likely than ascending climbers, P = .002) and to have higher overall mean COHb levels (2.26% descending vs 0.93% ascending, P = .006). The previous association between increased stove use and climbers who met positive criteria for AMS was not observed in the 2005 or in the combined data (P = .715). A relationship was observed between increased hours of operating stoves and increased COHb levels (P = .002). Female climbers were 2.041 times more likely to meet criteria for AMS (P = .043)., Conclusions: No relationship between AMS symptoms and CO exposure was observed. As found in our initial study, descending climbers had higher overall COHb levels and an increased risk of CO exposure (COHb of >3% in nonsmokers and >10% in smokers). Also, increased hours of stove operation was linked to climbers who had elevated COHb levels.

Objective: This exploratory study assessed a potential relationship between elevated carboxyhemoglobin (COHb) levels and acute mountain sickness (AMS) at 4300 m on Denali. Additional analysis assessed the relationship among COHb levels, AMS, and climber characteristics and behaviors., Methods: Participants were screened for AMS with the Lake Louise Self-Report questionnaire and answered questions focusing on AMS symptoms, prevention, and previous altitude illness. Levels of COHb were measured by serum cooximetry. Additional questions assessed stove practices, climbing practices, and climber behaviors. Nonparametric statistical analyses were performed to examine potential relationships among COHb levels, AMS symptoms, and climber behaviors., Results: A total of 146 climbers participated in the study. Eighteen climbers (12.5%) were positive for carbon monoxide (CO) exposure and 20 (13.7%) met criteria for AMS. No significant relationship was observed between positive CO exposure and positive criteria for AMS. Climbers descending the mountain were 3.6 times more likely to meet the study criteria for positive CO exposure compared with those ascending the mountain (P = .42). In addition, COHb levels were significantly higher for those descending the mountain (P = .012) and for those taking prophylactic medications (P = .010). Climbers meeting positive criteria for AMS operated their stoves significantly longer (P = .047)., Conclusions: No significant relationship between AMS symptoms and CO exposure was observed. This may have been affected by the low percentage of climbers reporting AMS symptoms, as well as limited power. Descending climbers had a 3.6 times increased risk of CO exposure compared with ascending climbers and had significantly higher COHb scores. Increased hours of stove operation was significantly linked to climbers who also met criteria for AMS.