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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 Information on slaveholder ancestry was obtained from a Reuters investigative series based on an extensive review of historical documents and verification by board-certified genealogists.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.

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: 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.

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.

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.

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.)

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.

Introduction/objectives: Many health systems screen patients for social determinants of health and refer patients with social needs to community service organizations for assistance. We developed a framework based on sequential steps to evaluate this process., Methods: We reviewed efforts by The MetroHealth System in Cleveland, Ohio and identified 6 sequential steps: patient screened, has social needs, consents to referral to a service organization, referral placed, referral accepted, and referral outcome. Referral outcomes were categorized as resolved (organization provided requested service or patient self-resolved problem), or unresolved (patient unable to be contacted or declined assistance). We then determined the numbers of patients with food insecurity who completed each step, how completion differed by patient characteristics and service organization, and reasons for failure to complete specific steps., Results: We used the framework to evaluate screening and assistance steps among 5741 patients who attended a COVID-19 vaccine clinic from February 15-March 31, 2021 and were followed through April 30, 2021. The percentage of patients who completed each step ranged from 17-98%. Step completion differed by patient age, patient race, and clinic. Of 360 referrals accepted by community organizations, 98 (27%) were resolved. The most common reasons for unresolved referrals were inability of service organization to contact patients (151), no reason stated (71), and patients declined service (30)., Conclusions: A framework based on sequential steps may be used to evaluate social determinants of health screening and assistance programs. Further work is needed to address reasons for failure to complete steps, to include patient perspectives, and to determine long-term outcomes.

Objective: The antidepressant medication fluoxetine at 90 mg dosed weekly is as effective and safe as standard formulation fluoxetine 20 mg dosed daily in patients with major depressive disorder. Weekly fluoxetine has not been well studied in hemodialysis patients, and doses beyond 90 mg/week have not been described in this population. This case series, derived from a larger study on depression in hemodialysis patients, describes the use of weekly fluoxetine at dosages beyond 90 mg/week., Method: Hemodialysis patients with depressive symptom severity scored ≥10 on the 9-item Patient Health Questionnaire and major depressive disorder confirmed with Mini International Neuropsychiatric Interview were initially prescribed daily fluoxetine for two weeks and then transitioned to weekly fluoxetine. Dosage titration was made at the discretion of the prescribing clinician. Fluoxetine was continued for a total of 12 weeks., Results: Four women, aged 24 to 65 years, on hemodialysis for 1 to 18 years, were started on weekly fluoxetine that was increased over several weeks up to 180 mg. Side effects included restlessness, dry mouth, sedation, and lightheadedness. Two patients ultimately had their weekly fluoxetine decreased back to 90 mg. However, all four continued weekly fluoxetine as part of poststudy aftercare and no longer met diagnostic criteria for major depressive disorder, current episode., Conclusions: Weekly fluoxetine at doses of 180 mg may be a reasonable treatment consideration for hemodialysis patients who have partial or insufficient antidepressant response. Side effects may limit tolerance of the 180 mg dose in some individuals. Future research should investigate longer term health outcomes of weekly fluoxetine in this population.

Background: The aim of this study was to determine whether patients undergoing thyroidectomy and parathyroidectomy have similar postoperative pain if managed with an opioid-sparing regimen versus an opioid-containing regimen. We hypothesized that an opioid-sparing regimen would provide equivalent analgesia., Methods: We performed a prospective, randomized trial (clinicaltrials.govNCT03640247) comparing non-narcotic and narcotic postoperative pain regimens after discharge. Patients ≥18 y undergoing thyroidectomy or parathyroidectomy were eligible for inclusion. Patients were excluded if they were taking a narcotic. Patients in the nonnarcotic arm of the study received acetaminophen, alternating with ibuprofen, and patients in the narcotic arm received the same medications plus a narcotic., Results: Of 126 patients, 64 patients were in the nonnarcotic group and 62 were in the narcotic group. The mean age was 54 ± 14 y, and 108 (86%) patients were female. Median pain scores were similar on postoperative day #0 (narcotic group 7 versus nonnarcotic group 7.5), postoperative day #1 (narcotic group 6 versus nonnarcotic group 6), postoperative day #2 (narcotic group 5 versus nonnarcotic group 5), postoperative day #3 (narcotic group 4 versus nonnarcotic group 4), postoperative day #4 (narcotic group 3 versus nonnarcotic 3) and postoperative day #5 (narcotic group 2.5 versus nonnarcotic group 2, all P > .1). A total of 31 (50%) patients in the narcotic group did not take a narcotic. A total of 8 (12.5%) patients in the nonnarcotic group and of 31 (50%) patients in the narcotic group took a median total of 2 narcotic tablets., Conclusion: An opioid-sparing pain medication regimen provides effective analgesia for most patients after thyroidectomy and parathyroidectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Fatigue is a prevalent symptom associated with decreased quality of life and increased mortality in individuals with end stage renal disease (ESRD), yet causes of fatigue in individuals with ESRD remain poorly understood. We examined gene expression of Neuronal PAS Domain Protein 2 (NPAS2) in relation to patient-reported fatigue in 122 individuals with ESRD. Independent samples t-tests were used to examine NPAS2 gene expression profiles of: non-fatigue versus fatigue. Multivariable regression analyses were used to examine the relationship between fatigue and numerous variables including depression. Participants were approximately 58 years old (+/- 13.2 years), 78% African American ( n = 95), and 72% male ( n = 88). The phenotype of fatigue was not significantly associated with gene expression of NPAS2 but was significantly associated with depression ( p < .001). This study suggests that further research should examine the causal mechanism between depression and fatigue in order to identify genetic factors that could explain the high comorbidity of depression and fatigue.

Background: News media and policy makers frequently discuss deaths from firearms, drug overdoses, and motor vehicle accidents. However, this information is generally presented as absolute numbers or annual rates. Cumulative lifetime risk may be an additional useful metric for understanding the impact of these causes of death., Methods: Data on all-cause firearm, drug overdose, and motor vehicle accident deaths were obtained from the US Centers for Disease Control and Prevention (CDC) for the year 2018. Age-specific death rates were used to estimate the cumulative risk of firearm, drug overdose, and motor vehicle accident deaths from birth to age 85 after accounting for other causes of death., Results: The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents was 0.93% (95% confidence interval [CI], 0.92%-0.94%), 1.52% (95% CI, 1.51%-1.53%), and 0.92% (95% CI, 0.91%-0.93%), respectively. Black males had a 2.61% (95% CI, 2.55%-2.66%) lifetime risk of firearm death, indicating that 1 out of 38 black males will die from firearms if current death rates persist. Residents of West Virginia had a 3.54% lifetime risk of drug overdose death, equivalent to 1 out of every 28 residents dying from overdoses., Conclusions: The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents is substantial and varies greatly across demographic subgroups and states., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Major depression consists of multiple phenotypic traits. Our objective was to characterize depressive phenotypes in the patient health questionnaire (PHQ)-9 using the Research Domain Criteria (RDoC) research framework. Cross-sectional data were examined from the 2013-2014 (N = 5397) and 2015-2016 (N = 5164) National Health and Nutrition Examination Survey, a large, nationally representative U.S. sample. Using both factor analysis and qualitative analysis in mapping scale items along RDoC domains, a four factor model was found to be theoretically appropriate and had an excellent model fit for the PHQ-9. The factor structure consisted of phenotypes describing Negative Valence Systems and Externalizing (anhedonia and depression), Negative Valence Systems and Internalizing (depression, guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue and appetite) and Cognitive and Sensorimotor Systems (concentration and psychomotor). High correlation between these phenotypes did indicate screening and monitoring for depression study population using a single depression score is likely useful in most circumstances. In multiple indicator multiple cause analysis, differences in the means of the phenotypic traits were found by age, race/ethnicity, sex, and number of comorbidities. Future research should explore whether phenotype expression derived from readily available self-rated depression scales can help to inform more personalized care., Competing Interests: Declaration of Competing Interest Author DG reports a book royalty agreement with Taylor Francis Publishing. Author MS has received grant support from Otsuka, Alkermes, Janssen, the National Institutes of Health, the Centers for Disease Control and Prevention and the International Society for Bipolar Disorders. She has served as a consultant to Bracket, Otsuka, Janssen, Alkermes, Neurocrine and Health Analytics and receives royalties from Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate. All other authors declare no conflicts of interest with the research or writing of this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The purpose of this study was to evaluate the consistency of 3 commonly used direct-to-consumer genetic testing kits. Genetic testing kits are widely marketed by several companies but the consistency of their results is unclear. Because identical twins share the same DNA, their genetic testing results should provide insight into test consistency., Methods: Forty-two identical twins (21 pairs) provided samples for 3 testing companies. Outcomes were concordance of ancestry results when twin pairs were tested by the same company and the same participant was tested by different companies. Concordance of 8 self-reported traits with 23andMe genetic analyses were also examined., Results: Concordance of ancestry results when twin pairs were tested by the same company was high, with mean percentage agreement ranging from 94.5% to 99.2%. Concordance of ancestry results when participants were tested by 2 different companies was lower, with mean percentage agreement ranging from 52.7% to 84.1%. Concordance of trait results was variable, ranging from 34.1% for deep sleep and detached earlobes to 90.2% for cleft chin., Conclusion: The consistency of consumer genetic testing is high for ancestry results within companies but lower and more variable for ancestry results across companies and for specific traits. These results raise questions about the usefulness of such testing., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian., Methods: This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others)., Results: The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94)., Conclusion: About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: Organ donation and other altruistic behaviors may be influenced by multiple factors, such as demographic characteristics, religious beliefs, and social norms., Research Question: What is the role of genetic factors on altruism in identical and fraternal twin pairs?, Design: Twins attending a twin festival (N = 296) completed an organ donation and altruistic behavior survey., Results: Concordance for stage of change for organ donation was 65% among identical twin pairs versus 33% among fraternal twin pairs ( P = .004). Concordance was higher among identical versus fraternal twin pairs for several altruistic behaviors, including giving directions to a stranger (63% vs 24%, P < .001), giving money to a stranger (51% vs 29%, P = .048), donating goods to charity (46% vs 16%, P = .005), and offering a seat on the bus (46% vs 24%, P = .04)., Discussion: We conclude that genetic factors may play a role in decisions about organ donation and other altruistic behaviors.

Fatigue is a subjective overwhelming feeling of tiredness at rest, exhaustion with activity, lack of energy that impedes daily tasks, lack of endurance, or a loss of vigor. Individuals with end stage renal disease (ESRD) experience a high rate and severity of fatigue. Symptom management of fatigue in this population is critical, since fatigue has been linked with lower quality of life and higher mortality rates. In this article, we present a definition and overview of fatigue, a review of factors contributing to fatigue, and ways to manage fatigue in individuals with ESRD., Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Background: Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality., Objective: The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts., Design: A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments., Participants/setting: Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH., Main Outcome Measure: HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research., Analysis: Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P<0.05 and P<0.10 because of modest sample sizes in each community., Results: Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (β=.295, Cleveland; β=.297, Columbus, P<0.05) and distance traveled to primary food store (β=.111, Cleveland, P<0.10; β=.175, Columbus, P<0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (β=-.125, P<0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R 2 =.282 and R 2 =.152, respectively)., Conclusions: Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away., (Copyright © 2019 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The efficacy of video interventions to increase organ donation willingness remains unclear., Methods: Three-arm web-based randomized controlled trial involving 2261 students at 3 northeastern Ohio universities. Intervention students watched a live-action (n = 755) or animated (n = 753) donation video. Control students (n = 753) viewed wellness information from the Centers for Disease Control and Prevention (CDC). The primary outcome was proportion of students who visited their state electronic donor registry to consent. The secondary outcome was intervention quality. Logistic regression assessed the effects of interventions on visiting the state registry to provide donation consent while controlling for baseline variables., Results: Students in the live-action video arm visited their state registry more frequently than students in the CDC arm (OR = 1.86, 95% CI = 1.20-2.88). There was no difference between students in the animated video and CDC arms (OR = 1.10, 95% CI = 0.69-1.76). The quality of the live-action video was rated lower than the animated video and the CDC text (75% ± 18, 84% ± 16, 80% ± 16, respectively; P < 0.001)., Conclusion: Students who watched the live-action video were more willing to visit their electronic donor registry to register as organ donors, but rated it lower in satisfaction. Future work should identify the most potent components of organ donation interventions., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Interventions aimed at improving access to healthy food in low-income communities should consider the preferences of residents. Household food shoppers in two urban, low-income communities were asked about their preferences for vendors at, and qualities of, a potential nearby food hub. Universally, participants preferred availability of whole foods, primarily fruits and vegetables. They also favored cleanliness, quality, and affordability. The demographics and preferences of potential customers raise central issues that would need to be integrated into the development of a food hub, namely affordability (likely through subsidization), attention to accommodation and cultural accessibility, and programming that builds community.

Background: Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis., Methods: We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals., Results: Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters., Conclusions: Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps., (© 2019 S. Karger AG, Basel.)

Background and Objectives: Many patients with ESKD face barriers in completing the steps required to obtain a transplant. These eight sequential steps are medical suitability, interest in transplant, referral to a transplant center, first visit to center, transplant workup, successful candidate, waiting list or identify living donor, and receive transplant. This study sought to determine the effect of navigators on helping patients complete these steps., Design, Setting, Participants, & Measurements: Our study was a cluster randomized, controlled trial involving 40 hemodialysis facilities and four transplant centers in Ohio, Kentucky, and Indiana from January 1, 2014 to December 31, 2016. Four trained kidney transplant recipients met regularly with patients on hemodialysis at 20 intervention facilities, determined their step in the transplant process, and provided tailored information and assistance in completing that step and subsequent steps. Patients at 20 control facilities continued to receive usual care. Primary study outcomes were waiting list placement and receipt of a deceased or living donor transplant. An exploratory outcome was first visit to a transplant center., Results: Before the trial, intervention (1041 patients) and control (836 patients) groups were similar in the proportions of patients who made a first visit to a transplant center, were placed on a waiting list, and received a deceased or living donor transplant. At the end of the trial, intervention and control groups were also similar in first visit (16.1% versus 13.8%; difference, 2.3%; 95% confidence interval, -0.8% to 5.5%), waitlisting (16.3% versus 13.8%; difference, 2.5%; 95% confidence interval, -1.2% to 6.1%), deceased donor transplantation (2.8% versus 2.2%; difference, 0.6%; 95% confidence interval, -0.8% to 2.1%), and living donor transplantation (1.2% versus 1.0%; difference, 0.1%; 95% confidence interval, -0.9% to 1.1%)., Conclusions: Use of trained kidney transplant recipients as navigators did not increase first visits to a transplant center, waiting list placement, and receipt of deceased or living donor transplants., (Copyright © 2018 by the American Society of Nephrology.)

Objective: Patient to staff ratios vary based on facility characteristics, and therefore have been proposed as an explanatory factor for the variation in dialysis facility outcomes. This analysis tested that hypothesis., Design and Methods: Observational study using Dialysis Facility Report data. Reported staff numbers from the Annual Facility Survey were converted to full time equivalents (FTE). Subsequently, ratios were created for patients per FTE registered dietitian (RD), social worker, nurse, and patient care technician. Bivariate associations and structural equation modeling (SEM) were used to explore relationships between these ratios and patient outcomes: standardized mortality ratio and standardized hospitalization rate, when also considering the impact of non-modifiable facility characteristics (region, chain, profit status). Our focus was on RD staffing; therefore we also included serum phosphorus and normalized protein catabolic ratio in the model, and also conducted a sub-analysis of the 198 facilities that exceeded the KDOQI maximum of 150 patients:FTE RD., Subjects: Dialysis centers in the US with at least 30 adult patients and no pediatric patients. 4035 facilities had complete data for the proposed variables., Main Outcome Measure: Standardized mortality ratio and standardized hospitalization rate were the primary outcomes., Results: The mean and standard deviation for patients per FTE staff were 90.0 ± 34.0, 88.7 ± 32.8, 17.1 ± 20.5 and 11.9 ± 7.0 for RDs, social workers, nurses, and technicians, respectively. Facility characteristics impacted staffing in bivariate analyses and SEM. The only significant paths from staffing ratio to outcomes were for patient:FTE social worker to SMR (standardized beta = -0.09, 95% CI -0.13, -0.04) and Patients:FTE RD to SHR Days (standardized beta = 0.04, 95% CI 0.001, 0.09). In the sub-analysis, there were no significant paths from staffing to outcomes., Conclusions: This study did not provide evidence that patient per staff ratios explain variation in dialysis facility outcomes. While there are some important bivariate relationships, these disappear in more complex models. Future research should investigate the impacts of staffing ratios on individual patients, to overcome the possible ecological fallacy., (Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Chronic localized pain and decreased upper extremity mobility commonly occur following breast cancer surgery and may persist despite use of pain medication and physical therapy., Purpose: We sought to determine the value of myofascial massage to address these pain and mobility limitations., Setting: The study took place at a clinical massage spa in the U.S. Midwest. The research was overseen by MetroHealth Medical Center's Institutional Review Board and Case Center for Reducing Health Disparities research staff., Participants: 21 women with persistent pain and mobility limitations 3-18 months following breast surgery., Research Design: We conducted a pilot randomized controlled trial where intervention patients received myofascial massages and control patients received relaxation massages., Intervention: Intervention participants received 16 myofascial massage sessions over eight weeks that focused on the affected breast, chest, and shoulder areas. Control participants received 16 relaxation massage sessions over eight weeks that avoided the affected breast, chest, and shoulder areas. Participants completed a validated questionnaire at the beginning and end of the study that asked about pain, mobility, and quality of life., Main Outcome Measures: Outcome measures include change in self-reported pain, self-reported mobility, and three quality-of-life questions., Results: At baseline, intervention and control participants were similar in demographic and medical characteristics, pain and mobility ratings, and quality of life. Compared to control participants, intervention participants had more favorable changes in pain (-10.7 vs. +0.4, p < .001), mobility (-14.5 vs. -0.8, p < .001), and general health (+29.5 vs. -2.5, p = .002) after eight weeks. All intervention and control participants reported that receiving massage treatments was a positive experience., Conclusions: Myofascial massage is a promising treatment to address chronic pain and mobility limitations following breast cancer surgery. Further work in several areas is needed to confirm and expand on our study findings., Competing Interests: CONFLICT OF INTEREST NOTIFICATION The authors declare there are no conflicts of interest.

Background and Objectives: Transplant centers may accept or refuse deceased-donor kidneys that are offered to their patients at the top of the waiting list. We sought to determine the outcomes of deceased-donor kidney offers and their association with characteristics of waitlisted patients and organ donors., Design, Setting, Participants, & Measurements: We examined all 7 million deceased-donor adult kidney offers in the United States from 2007 to 2012 that led to eventual transplantation. Data were obtained from the national organ allocation system through the United Network of Organ Sharing. The study cohort consisted of 178,625 patients waitlisted for a deceased-donor kidney transplant and 31,230 deceased donors. We evaluated offers made to waitlisted patients and their outcomes (transplantation or specific reason for refusal)., Results: Deceased-donor kidneys were offered a median of seven times before being accepted for transplantation. The most common reasons for refusal of an offer were donor-related factors, e.g. , age or organ quality (3.2 million offers, 45.0%), and transplant center bypass, e.g. , minimal acceptance criteria not met (3.2 million offers, 44.0%). After adjustment for characteristics of waitlisted patients, organ donors, and transplant centers, male (odds ratio [OR], 0.93; 95% confidence interval [95% CI], 0.91 to 0.95) and Hispanic (OR, 0.96; 95% CI, 0.93 to 0.99) waitlisted patients were less likely to have an offer accepted than female and white patients, respectively. The likelihood of offer acceptance varied greatly across transplant centers (interquartile ratio, 2.28)., Conclusions: Transplant centers frequently refuse deceased-donor kidneys. Such refusals differ by patient and donor characteristics, may contribute to disparities in access to transplantation, and vary greatly across transplant centers., Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017&#95;07&#95;27&#95;Huml.mp3., (Copyright © 2017 by the American Society of Nephrology.)

Objective: Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey., Design: Cross-sectional study., Setting: Twelve grocery stores in Northeast Ohio., Main Outcome Measure: Availability and cost of food items in 12 categories., Results: The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74)., Conclusion: The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases., (Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: This study describes the design, operation and evaluation of a community-based research (CBR) consult service within the setting of a Clinical and Translational Science Award (CTSA) institution. To our knowledge, there are no published evaluations of a CBR consult service at a CTSA hub., Methods: A community-based research Consult Service was created to support faculty, health care providers/research coordinators, trainees, community-based organizations and community members. A framework was developed to assess the stages of client engagement and to foster clear articulation of client needs and challenges. A developmental evaluation system was integrated with the framework to track progress, store documents, continuously improve the consult service and assess research outcomes., Results: This framework provides information on client numbers, types, services used and successful outreach methods. Tracking progress reveals reasons that prevent clients from completing projects and facilitates learning outcomes relevant to clients and funding agencies. Clients benefit from the expert knowledge, community connections and project guidance provided by the Consult Service team, increasing the likelihood of study completion and achieving research outcomes., Conclusion: This study offers a framework by which CTSA institutions can expand their capacity to conduct and evaluate community-based research while addressing challenges that inhibit community engagement., Competing Interests: Conflicts: The authors have no conflicts of interest.

This descriptive study examines the prevalence of comorbid physical and mental health issues among young clients at a large mental health agency. Health status data was collected from the intake process of youth seeking mental health services at a Northeast Ohio agency ( n = 1,076). The results show a higher prevalence of asthma and obesity among clients with known mental health diagnoses at this agency compared to national averages. The results could help the agency develop strategies for implementation of an integrated care model to better meet the complex needs of the clients served.