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Significant nuclear reductions by the United States can affect other states in one of five ways: by directly altering their strategic calculations and postures; by indirectly altering their strategic calculations and postures by affecting the behavior of third-party states; by undermining formal US deterrence commitments; by eroding the United States's perceived ability to provide “informal” deterrence through the maintenance of an active global presence; and by creating normative pressure for states to emulate US nuclear reductions. Only the erosion of “informal” deterrence is likely to affect South Asia; to the extent that significant US nuclear reductions affect South Asia, then, their impact is likely to be destabilizing. [ABSTRACT FROM PUBLISHER]

This paper is one of two papers that will review various previous research and present results from a study conducted on measurement of physical and climatic conditions that occur inside refrigerated ISO inter-modal containers. This first paper covers shipments of packaged and palletized fruit from refrigerated packing houses in South America in refrigerated ISO intermodal containers from Brazil to United States across the Atlantic Ocean. The study measured vibration and temperature levels in a containerized shipment where recorders measured the acceleration levels and temperature data while the instrumented and loaded containers traveled on truck and ship. Measured data shows that extreme vibration levels occur while containers travel on trucks on poor road conditions followed by rail and ship travel. It also shows that good temperature control is possible with loading packages so that good air flow is permissible in the perimeter of the load. Lowest vibration levels and temperature variation occurs when they are loaded on a ship and are traveling on sea. [ABSTRACT FROM AUTHOR]

Cirrhosis is the 12th leading cause of death in the United States. It accounted for 29,165 deaths in 2007, with a mortality rate of 9.7 per 100,000 persons. Alcohol abuse and viral hepatitis are the most common causes of cirrhosis, although non alcoholic fatty liver disease is emerging as an increasingly important cause. Primary care physicians share responsibility with specialists in managing the most common complications of the disease, screening for hepatocellular carcinoma, and preparing patients for referral to a transplant center. Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every six to 12 months. Causes of hepatic encephalopathy include constipation, infection, gastrointestinal bleeding, certain medications, electrolyte imbalances, and noncompliance with medical therapy. These should be sought and managed before instituting the use of lactulose or rifaximin, which is aimed at reducing serum ammonia levels. Ascites should be treated initially with salt restriction and diuresis. Patients with acute episodes of gastrointestinal bleeding should be monitored in an intensive care unit, and should have endoscopy performed within 24 hours. Physicians should also be vigilant for spontaneous bacterial peritonitis. Treating alcohol abuse, screening for viral hepatitis, and controlling risk factors for nonalcoholic fatty liver disease are mechanisms by which the primary care physician can reduce the incidence of cirrhosis. [ABSTRACT FROM AUTHOR]

By deemphasizing the role of nuclear weapons in US security policy, the 2010 Nuclear Posture Review (NPR) could lead India to slow or halt the growth of its nuclear weapons capabilities and to adopt a less assertive nuclear doctrine; however, the NPR is unlikely to have this effect on India's nuclear program. This is the case for two reasons. First, Indian leaders do not seek to emulate US nuclear behavior; they formulate policy based primarily on their assessment of the security threats facing India. Second, Indians do not think that the NPR augurs major changes in US nuclear policy. Thus, it will not alter the international strategic environment sufficiently to enable India to relax its nuclear posture. In fact, Indian strategists believe that the new US policy fails even to match India's current degree of nuclear restraint. Therefore, according to Indian experts, the NPR will have little impact on India. [ABSTRACT FROM AUTHOR]

Fresh-cut fruit accounted for nearly $300 at retail in the U.S. in 2004, with projected sales ranging between $1 and $2 billion by 2008. The choice of packaging materials and the atmospheric conditions both inside and outside the package contribute significantly to the shelf-life of these products. This study evaluated quality changes such as firmness, color, total soluble solids (TSS), titratable acidity (TA), sensory quality, and microbial safety of fresh-cut mangoes, pineapples, melons, and mixes of these fruits. Chemical treatments to reduce browning, firmness loss, and decay for these fruits were also investigated. The most effective treatments for fresh-cut mangoes, pineapples, and melons were 0.1 M ascorbic acid, 0.2 M ascorbic acid, and 0.2 M ascorbic acid plus 0.2 M calcium chloride, respectively. These fresh-cut tropical fruits were packaged in three semi-rigid containers made of polyethylene terephthalate (PET), oriented polystyrene (OPS), and oriented poly(lactide) (OPLA). Gas composition in the package headspace and the time to reach steady-state conditions were observed to vary among fresh-cut packaging systems and affected their quality and shelf-life. The effects of package permeability, with regards to O2 and CO2, on quality and shelf-life of the fresh-cut products are discussed in this paper. Extended shelf-life was observed in fresh-cut mangoes, pineapples, and mixes packaged in PET due to reduced O2 and elevated CO2 atmosphere. Modified atmosphere of 6% 02 and 14% CO2 achieved in PET extended the shelf-life of fresh-cut pineapples from 6 to 13 days. The results suggest that shelf-life of fresh-cut fruit could be extended using appropriate semi-rigid containers. [ABSTRACT FROM AUTHOR]

The United States and India are enjoying increasingly close relations. This rep- resents a transformation of the two countries' past relationship, which was characterized by suspicion and distrust. This change, which began with the end of the Cold War, has resulted from a convergence of structural, domestic, and individual leadership factors. [ABSTRACT FROM AUTHOR]

Scholars attribute conventional violence in a nuclear South Asia to a phenomenon known as the "stability/instability paradox." According to this paradox, the risk of nuclear war makes it unlikely that conventional conflict will escalate to the nuclear level, thereby making conventional conflict more likely. Although this phenomenon encouraged U.S.-Soviet violence during the Cold War, it does not explain the dynamics of the ongoing conflict between India and Pakistan. Recent violence has seen Pakistan or its proxies launching limited attacks on Indian territory, and India refusing to retaliate in kind. The stability/instability paradox would not predict such behavior. A low probability of conventional war escalating to the nuclear level would reduce the ability of Pakistan's nuclear weapons to deter an Indian conventional attack. Because Pakistan is conventionally weaker than India, this would discourage Pakistani aggression and encourage robust Indian conventional retaliation against Pakistani provocations. Pakistani boldness and Indian restraint have actually resulted from instability in the strategic environment. A full-scale Indo-Pakistani conventional conflict would create a significant risk of nuclear escalation. This danger enables Pakistan to launch limited attacks on India while deterring all-out Indian conventional retaliation and attracting international attention to the two countries' dispute over Kashmir. Unlike in Cold War Europe, in contemporary South Asia nuclear danger facilitates, rather than impedes, conventional conflict. [ABSTRACT FROM AUTHOR]

In the 1995-96 and 1996-97 school years, 37 elementary schools in Memphis, TN began implementation of 1 of 8 comprehensive school reform designs. The effectiveness and mobility of teachers at these schools were examined longitudinally relative to teachers at 63 nonrestructuring schools. Analyses of teacher effectiveness scores, derived from student "value-added" achievement scores, indicate that the 1995 reform cohort only showed significantly greater gains in effectiveness relative to the nonrestructuring group. This pattern was most strongly pronounced for highly experienced teachers. Teacher mobility was found to increase minimally as a function of restructuring, largely due to district policy changes. [ABSTRACT FROM AUTHOR]

Discusses the restructuring of the University of Maryland at Baltimore's Information Services (IS). IS as an umbrella organization; Addressing cost-containment cuts; Reengineering the business procedures.

The present Standards Rating Committee of American Accounting Association was appointed in 1949 for a period of five years upon the authorization of the Executive Committee of the Association Committee. The present committee was officially constituted and began functioning on January 1, 1949. Meetings of the committee have been held at intervals throughout the last five years. After extended discussion and rewriting over a period of two years this committee published an interim report in the January 1951, issue of Accounting Review. Full publicity was given to this interim report; suggestions, comments, and criticisms were solicited. Several members of the Association and other interested persons responded to the invitation. This committee appreciates the excellent suggestions made by correspondents. Their recommendations have been reviewed carefully along with the further thinking of the committee members themselves. After further weighing for about a year the problems confronting the committee, it was decided in early 1953 to prepare a final report in order to bring its current activities to a conclusion. Following this decision the committee has quite actively pursued its objectives and the present report represents the culmination of its efforts for the past five years.

While there have been few spectacular happenings during the year 1950, steady progress is evident on all sides. There has been a substantial increase in the membership and the financial condition of the American Accounting Association continues to be satisfactory. The Association owns sufficient securities to enable it to survive a period of stress caused by war or other conditions. Nearly 500 members and guests attended the annual convention held at the University of Denver. This was one of the largest groups ever to attend a convention of the Association. The periodical "The Accounting Review," under the editorship of Frank P. Smith, has continued to serve instructors, students and practitioners with a series of significant and helpful articles, book reviews, solutions to Certified Public Accountant examination problems and news items of members of the Association. It has an impressive international reputation as a scholarly publication in the field of accounting. One of the greatest satisfactions received is from the splendid cooperation of committee members. Around one hundred and sixty members of the Association have contributed generously of their time in the conduct of its committee activities.

The elementary course in accounting, as it is taught in most instances today, is specifically designed to provide a base upon which to build a structure of accounting knowledge. This base consists to some extent of the broad principles of accounting, but often, to a much larger extent, of detailed methods of technique and procedure. At the outset several questions are bound to arise concerning any changes in the elementary course. It has been the writer's experience that sixty to eighty per cent of the first year accounting students are merely fulfilling requirements for a degree and have no intention of taking additional accounting courses. If such is the case, the needs of so large a majority cannot be reasonably ignored. Students often have no intention of taking more than the minimum of accounting until they have completed the first year course. Thus, students taking the non-accounting major course frequently find an interest kindled which leads them on to the advanced accounting courses. The elementary course, however taught, is not sufficient to make the student an expert accountant. It does provide him with the basic mechanics of recording, classifying and summarizing the usual transactions of business. It does not provide him with an adequate basis for interpreting and analyzing the accountant's work.

The article presents information about the industrial accounting courses that are being conducted in the U.S. as a part of the Engineering, Science, and Management Defense Training Program (better known as ESMDT). The U.S. Congress inaugurated this program in July 1941. It may be observed that the ESMDT program is in reality just an expansion of the university extension adult education programs, which have been set up by many institutions in the years past. The program involves a definite innovation, however, in that the Federal government hitherto has limited its financial assistance to vocational level courses. Several educational authorities have expressed certain misgivings as to the implications underlying this move. It is felt by some that the ESMDT represents a type of Federally sponsored higher education which may have permanent and wide repercussions even after the present war is over. Little attention has been given to this important matter up to the present time, as the national and local administrators have been too busy with problems involved in setting up the institutional programs to deal adequately with the long-term aspects of this type of adult education. As the program gains headway over the next few months, more thought will naturally have to be devoted to the relative permanency of the organization, and also to its coordination with the now existing extension activities of the universities and colleges of the country.

The article presents the author's views regarding school reform and how while some solutions seem promising they are never whole answers. Standards and accountability reformers like the author failed to build professional capacity in order for teachers and schools to perform. The fascination of improving instruction comes at the cost of denying parental involvement and school management. The author lists some reforms backed by exaggerated claims including phonics, whole language, and multiple intelligences. Despite efforts to reform schools, some achievement gaps never slim and students needs often go unmet. However, progress is being made in American schools as reformers realize the complexity of the challenges and continue to meet them with observation and perseverance.

On January 27, 2017, President Donald J. Trump signed an Executive Order that attempted to bar citizens and refugees from seven countries from entering the U.S. for a certain time period. One of the contexts most directly affected by this order was higher education. This study examined college and university communicative responses to the order from a public relations perspective. We qualitatively determined a range of responses from U.S. universities then quantitatively determined variables of particular colleges and universities that had a correlation to the nature of the responses. Responses were then assessed using public relations best practices. The data suggest variables with relationships to type of institutional response were number of international students and political stance of the state where the institution is located. While there was no single “correct” type of response, best practices suggest two options for appropriate responses to the order. [ABSTRACT FROM AUTHOR]

Background: Home-time is an emerging, patient-centered outcome that represents the amount of time a patient spends alive and outside of health care facility settings, comprising of hospitals, skilled nursing facilities, and acute rehabilitation centers. Studies evaluating home-time in the context of heart failure are limited, and the impact of quality improvement interventions on home-time has not been studied., Methods: Medicare beneficiaries aged 65 years or older who were hospitalized for heart failure in the Get With the Guidelines-Heart Failure registry between 2019 and 2021 were included. Postdischarge home-time, mortality, and readmission rates at 30 days and 1 year were calculated with the goal of establishing baseline metrics before the initiation of IMPLEMENT-HF, a multicenter quality improvement program aimed at improving heart failure management., Results: Overall, 66 019 patients were included across 437 sites. Median 30-day and 1-year home-time were 30 (18-30) and 333 (139-362) days, respectively. Only 22.1% of patients experienced 100% home-time in the year after discharge. Older patients spent significantly less time at home, with a median 1-year home-time of 302 (86-359) compared with 345 (211-365) days in patients over 85 and those between 65 and 74 years old, respectively ( P <0.001). Black patients also experienced the least amount of home-time with only 328 (151-360) days at 1-year follow-up. Rates of heart failure readmission and all-cause mortality 1-year post-discharge were high at 29.8% and 37.0%, respectively., Conclusions: In this contemporary multicenter cohort, patients hospitalized with heart failure spent a median of 91.2% of their time in the year after discharge alive and at home, largely driven by high mortality rates. These findings serve as a preimplementation baseline for IMPLEMENT-HF, which will evaluate the impact of targeted heart failure initiatives on home-time and other clinical outcomes., Competing Interests: Dr Greene has received research support from the Duke University Department of Medicine Chair’s Research Award, the American Heart Association, Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Cytokinetics, Merck, Novartis, Pfizer, and Sanofi; has served on advisory boards or as a consultant for Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Corcept, Corteria Pharmaceuticals, CSL Vifor, Cytokinetics, Lilly, Lexicon, Merck, Novo Nordisk, Otsuka, Roche Diagnostics, Sanofi, scPharmaceuticals, Tricog Health, and Urovant Pharmaceuticals; and has received speaker fees from Bayer, Boehringer Ingelheim, Cytokinetics, Lexicon, and Roche Diagnostics. Dr Butler has consulted for Abbott, American Regent, Amgen, Applied Therapeutics, AskBio, Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardiac Dimension, Cardiocell, Cardior, CSL Behring, CVRx, Cytokinetics, Daxor, Edwards, Element Science, Faraday, Foundry, G3P, Innolife, Impulse Dynamics, Imbria, Inventiva, Ionis, Lexicon, Lilly, LivaNova, Janssen, Medtronic, Merck, Occlutech, Owkin, Novartis, Novo Nordisk, Pharmacosmos, Pharmain, Pfizer, Prolaio, Regeneron, Renibus, Roche, Salamandra, Sanofi, SC Pharma, Secretome, Sequana, SQ Innovation, Tenex, Tricog, Ultromics, Vifor, and Zoll. Dr Lewis has received grants from the American Heart Association and Merck and has consulted for AstraZeneca, Intellia, and Merck. Dr Fonarow has consulted for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson & Johnson, Medtronic, Merck, Novartis, and Pfizer.

Background: This study aimed to assess the implementation and access to telehealth-delivered pediatric weight management (PWM) during the initial phase of the COVID-19 pandemic at six US PWM programs (PWMP) using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: The COVID-19 period (COVID) was defined in this retrospective, multisite study as the time when each site closed in-person care during 2020. The Pre-COVID period (Pre-COVID) was an equivalent time frame in 2019. Patients were stratified by visit completion status. Patient characteristics for COVID and Pre-COVID were compared to examine potential changes/disparities in access to care. Results: There were 3297 unique patients included across the six sites. On average, telehealth was initiated 4 days after in-person clinic closure. Compared with Pre-COVID, COVID (mean duration: 9 weeks) yielded fewer total completed visits (1300 vs. 2157) and decreased revenue (mean proportion of nonreimbursed visits 33.30% vs. 16.67%). Among the completed visits, COVID included a lower proportion of new visits and fewer patients who were male, non-English speaking, Hispanic, or Asian and more patients who were Black or lived ≥20 miles from the program site ( p  < 0.05 for all). Among no-show/canceled visits, COVID included more patients who had private insurance, older age, or a longer time since the last follow-up. Conclusion: Rapid implementation of telehealth during COVID facilitated continuity of PWM care. Clinic volume and reimbursement were lower during COVID and differences in the patient population reached by telehealth emerged. Further characterization of barriers to telehealth for PWM is needed.

Background: Robust physical mobility is the key to healthy independent aging. Although the association between socioeconomic status and health is well documented, it is unclear whether there is a relationship between mobility and income, because income data are not readily available., Questions/purposes: (1) Do individuals with better mobility have higher incomes? (2) Does maintaining mobility over time allow individuals to keep working? (3) Is exercise associated with higher mobility over time?, Methods: We obtained longitudinal income and health data from the nationally representative Health and Retirement Study. Three cohorts were used. First, we studied the relationship between household income and mobility (on a 6-point index of walking impairment) in 19,430 adults who were assessed in 2016 (representing 93% of the 20,805-person total cohort). We measured the association of mobility and household income in a multivariate linear regression analysis of age, gender, health conditions, and education. We then identified a second group of 1094 individuals with unrestricted mobility in the year 2000 and compared differences in income and working rates between those who maintained mobility and those who lost mobility after 10 years. Finally, we identified a third group of 7063 individuals who were 60 to 80 years old in 2012, divided the group by how often they engaged in exercise, and observed differences in mobility after 4 years., Results: After adjusting for covariates, a drop of one level of mobility was associated with a USD 3410 reduction in annual household income (95% CI USD 2890 to USD 3920; p < 0.001). After 10 years, individuals who maintained their mobility had incomes that were USD 6500 higher than that of individuals who were not working (95% CI USD 2300 to USD 10,300; p < 0.001) and were more likely to be working (40% versus 34.5%; p < 0.001). Exercising at least once per week was associated with better mobility 4 years later (mobility score 4.46 ± 0.08 versus 3.66 ± 0.08; p < 0.001)., Conclusion: Better mobility was associated with more than USD 3000 in annual income. Regular exercise and other interventions that improve mobility may have meaningful returns on investment., Clinical Relevance: Because greater mobility is strongly associated with higher income, orthopaedic interventions may be undervalued., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

The number of people who report to be of minoritised sexual or gender identities in the USA, including lesbian, gay, bisexual, transgender, queer, and other sexuality-diverse and gender-diverse identities, has been increasing in the past decade. This diverse and unique population continues to experience not only health disparities but also psychosocial, economic, and legal disparities in accessing and receiving health care, including liver transplantations. As liver transplantation is life-saving for people with end-stage liver disease, understanding the factors that can affect access to and quality of liver transplantation care in people of minoritised sexual and gender identities in the USA, including differential social supports, insurance coverage, and medical and psychiatric comorbidities, is crucial. Actions, such as collecting sexual orientation and gender identity data, implementing inclusive language, recognising implicit biases, building diverse teams, providing a safer environment, and supporting further research to understand the unique health challenges are needed to ensure equitable access to high-quality liver transplantation care for people of minoritised sexual and gender identities., Competing Interests: Declaration of interests T-HL receives speaker honoraria from Mayo Clinic Arizona and the University of Washington and is a member of the LGBTQ Task Force at the American Association for the Study of Liver Diseases, of the executive board of Rainbows in Gastro, of the Liver and Intestinal Community of Practice, of the American Society of Transplantation, and of the Diversity, Equity, and Access to Life Committee of the American Society of Transplantation. ND is an executive board member of Rainbows in Gastro. KS receives funding from the US National Institutes of Health (K08 DK132509–01A1); receives speaker honorarium from Satellite Healthcare; is a board member of the American Living Organ Donor Fund; and holds stock in GE Healthcare, Gilead, and Johnson & Johnson. DAS receives consulting fees, paid to their institution, from Mallinckrodt and BioVie; holds patent 18/151,673; and is a member of the executive board of Rainbows in Gastro. SP receives funding from Intercept, Target PharmaSolutions, and Genfit; is a member of the Diversity, Equity, and Inclusion Committee of the American Gastroenterological Association, of the diversity committee of the American College of Gastroenterology, of the LGBTQ Task Force of the American Association for the Study of Liver Diseases, and of the executive board of Rainbows in Gastro., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: To provide new information about the reasons why persons with and without disabilities were not working during the coronavirus pandemic., Design: Secondary analysis of the Household Pulse Survey conducted between April 14, 2021, and May 9, 2022., Setting: The United States., Participants: 876,865 people with and without disabilities aged 18-64 years (N=876,865)., Intervention: N/A., Main Outcome Measures: Reasons for not working such as "Sick with coronavirus symptoms or caring for someone who was sick with coronavirus symptoms", "Concerned about getting or spreading the coronavirus", "Sick (not coronavirus related) or disabled", "Laid off or furloughed due to coronavirus pandemic", "Employer closed temporarily due to the coronavirus pandemic", "Caring for children not in school or daycare", "Caring for an elderly person", "Retired", "Did not have transportation to work", and "other" reasons., Results: The number of people with disabilities and people without disabilities in the sample was 82,703 and 794,162, respectively. People with disabilities were more likely to report that they were laid off or furloughed and less likely to report that they did not want employment than people without disabilities. Working-age adults with disabilities were more likely to report health or disability reasons not related to coronavirus than working-age adults without disabilities as a reason for not working. Caring for children not in school or daycare was 1 of the most cited reasons for both people with and without disabilities. Women, among both the groups, were more likely to not work primarily due to caregiving responsibilities. People with disabilities were more likely to report getting or spreading the coronavirus and less likely to report being retired as a reason for not working than people without disabilities., Conclusion: Analyzing reasons why people with disabilities were not working during the pandemic is crucial for successful employment policymaking in a post-pandemic world., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Little is known about hearing loss and tinnitus associated with neurotoxic chemotherapy. Study evaluated for differences in occurrence rates and effects of hearing loss and tinnitus in survivors who received a platinum alone, a taxane alone or a platinum and taxane containing regimen., Methods: Total of 273 survivors with breast, gastrointestinal, gynaecological or lung cancer completed self-report measures of hearing loss and tinnitus and had an audiometric assessment that obtained pure tone air conduction thresholds bilaterally at frequencies of between 0.25 kHz to 16.0 kHz. To adjust for age-related and gender-related changes in hearing, each survivor's audiogram was evaluated using the National Health and Nutrition Examination Survey-modified Occupational Safety and Health Administration standards. Survivor was classified as having hearing loss if at any frequency they scored poorer than the 50th percentile for their age and gender. Survivors were categorised as having tinnitus if they reported that for > 10% of their time awake, they were consciously aware of their tinnitus. Differences among the chemotherapy groups were evaluated using parametric and non-parametric tests., Results: For most of the demographic and clinical characteristics, no differences were found among the three chemotherapy groups. Occurrence rates for audiogram-confirmed hearing loss ranged from 52.3% to 71.4%. Occurrence rates for tinnitus ranged from 37.1% to 40.0%. No differences were found among the three chemotherapy groups in the occurrence rates or effects of hearing loss and tinnitus., Conclusion: These findings suggest that regardless of the chemotherapy regimen common mechanistic pathway(s) may underlie these two neurotoxicities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Nonalcoholic steatohepatitis (NASH) continues to increase in frequency as an indication for liver transplantation (LT). Data on long-term outcomes for these patients are limited. We aimed to compare long-term patient and graft survival in patients undergoing LT for NASH in the United States to other indications., Methods: We analyzed data from the Scientific Registry of Transplant Recipients of adult patients who underwent primary deceased-donor LT from January 1, 2005, to December 31, 2019., Results: NASH has increased as an indication for LT by 4.5-fold, from 5.2% in 2005 to 23.4% in 2019. Patient (61.2%) and graft survival (59.2%) at 10 y are significantly poorer for NASH than for all other indications other than alcohol. Patients transplanted for NASH have higher body mass index (32.2 versus 27.6) and greater frequency of diabetes (13% versus 11.6%) than any other indication ( P < 0.001). Portal vein thrombosis, location in intensive care unit, dialysis, and pre-LT diabetes ( P < 0.001 for all) are independently predictive of patient death and graft loss. Body mass index is not predictive. NASH patients undergoing simultaneous liver kidney have markedly worse 10-y patient and graft survival than liver-only (52.3% versus 62.1%). Graft loss was attributed to recurrence of NASH in <1% of patients., Conclusions: LT for NASH is associated with relatively poor long-term patient and graft survival when compared with patients transplanted for other indications, NASH patients undergoing simultaneous liver kidney have the worst long-term outcomes., Competing Interests: S.P. received research/grant funding from Intercept, Target PharmaSolutions, and Genfit. M.C. has consulted for Gilead, AbbVie, Bristol Myers, AMRA, Terns, Madrigal, Novartis, Lipocene, Metacrine, NGM Bio, and Intercept. The other authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: While avalanche fatalities have remained relatively steady per year, data suggest a possible increase in sidecountry use and snowmobile fatalities. Limited information is known regarding the accident details and preparedness among different groups of backcountry users including snowmobiles, sidecountry, and backcountry skiers, and what specific factors could contribute to their fatalities., Methods: Avalanche fatality reports covering all US states posted by the Colorado Avalanche Information Center available online for 10 seasons (2009-2010 through 2018-2019 seasons) were analyzed for group size, specific equipment carried, burial depth, burial time, and other details. Only reports in the 3 following categories were included in the analysis: backcountry ski/snowboard, sidecountry ski/snowboard, and snowmobile/snowbike. These aspects were compared among the 3 tourer types using statistical analyses (ANOVA)., Results: Two hundred and five fatalities were analyzed (n=32 sidecountry, n=91 skier/snowboard, n=82 snowmobile/snowbike). Using 2 preparedness scores, the ski/snowboard group had the greatest distribution of high scores when evaluated by equipment carried and group size, with significant differences per group (P<0.01). Of the fatalities that were buried, burial time was related to the tourer group (P=0.04), with the ski/snowboard group having the highest proportion of burials <15 min. Burial depth was significantly different among the 3 tourer groups, with snowmobiles buried the deepest on average (P<0.01)., Conclusions: Despite limited data available on fatalities, an analysis of preparedness suggests that backcountry skiers and snowboarders are more prepared for avalanche accidents compared to snowmobiles and sidecountry users when evaluated by equipment carried and group size., (Copyright © 2022 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Background: Recent studies show that human gut microbial composition can determine whether a patient is a responder or non-responder to immunotherapy but have not identified a common microbial signal shared by responding patients. The functional relationship between immunity, intestinal microbiota, and NSCLC response to immune checkpoint inhibitor/inhibition (ICI) in an American cohort remains unexplored., Methods: RNAlater-preserved fecal samples were collected from 65 pre-treatment (baseline) and post-treatment stage III/IV NSCLC patients undergoing ICI therapy, categorized as responders or non-responders according to RECIST criteria. Pooled and individual responder and non-responder microbiota were transplanted into a gnotobiotic mouse model of lung cancer and treated with ICIs. 16S rDNA and RNA sequencing was performed on patient fecal samples, 16S rDNA sequencing on mouse fecal samples, and flow cytometric analysis on mouse tumor tissue., Results: Responder patients have both a different microbial community structure than non-responders (P = 0.004) and a different bacterial transcriptome (PC2 = 0.03) at baseline. Taxa significantly enriched in responders include amplicon sequence variants (ASVs) belonging to the genera Ruminococcus, Akkermansia, and Faecalibacterium. Pooled and individual responder microbiota transplantation into gnotobiotic mice decreased tumor growth compared to non-responder colonized mice following ICI (P = 0.023, P = 0.019, P = 0.008, respectively). Responder tumors showed an increased anti-tumor cellular phenotype following ICI treatment. Responder mice are enriched with ASVs belonging to the genera Bacteroides, Blautia, Akkermansia, and Faecalibacterium. Overlapping taxa mapping between human and mouse cohorts correlated with tumor size and weight revealed a network highlighting responder-associated ASVs belonging to the genera Colidextribacter, Frisingicoccus, Marvinbryantia, and Blautia which have not yet been reported., Conclusions: The role of isolate-specific function and bacterial gene expression in gut microbial-driven responsiveness to ICI has been underappreciated. This work supports further investigation using isolate-driven models to characterize the mechanisms underlying this phenomenon., (© 2022. The Author(s).)

Background Higher circulating fibroblast growth factor 23 (FGF23) associates with greater risk of cardiovascular disease (CVD) and mortality in older adults. The association of FGF23 with cardiovascular outcomes in younger populations has been incompletely explored. Methods and Results We measured C-terminal FGF23 (cFGF23) and intact FGF23 (iFGF23) in 3151 middle-aged adults (mean age, 45±4) who participated in the year 20 examination of the CARDIA (Coronary Artery Risk Development in Young Adults) study. We used separate Cox proportional hazards models to examine the associations of cFGF23 and iFGF23 with incident CVD and mortality, adjusting models sequentially for sociodemographic, clinical, and laboratory factors. A total of 157 incident CVD events and 135 deaths occurred over a median 7.6 years of follow-up (interquartile range, 4.1-9.9). In fully adjusted models, there were no statistically significant associations of FGF23 with incident CVD events (hazard ratio per doubling of cFGF23: 1.14, 95%CI 0.97,1.34; iFGF23: 0.76, 95%CI 0.57,1.02) or all-cause mortality (hazard ratio per doubling of cFGF23, 1.17; 95% CI, 1.00-1.38; iFGF23, 0.86; 95% CI, 0.64-1.17). In analyses stratified by CVD subtypes, higher cFGF23 was associated with greater risk of heart failure hospitalization (hazard ratio per doubling of cFGF23, 1.52; 95% CI, 1.18-1.96) but not coronary heart disease or stroke, whereas iFGF23 was not associated with CVD subtypes in any model. Conclusions In middle-aged adults with few comorbidities, higher cFGF23 and iFGF23 were not independently associated with greater risk of CVD events or death. Higher cFGF23 was independently associated with greater risk of heart failure hospitalization.

Black women carry a disproportionate number of new HIV infections in the USA. Studies that have assessed HIV risk perception along with HIV prevention interventions for Black women have primarily focused on Black women of low socioeconomic status. Few studies have assessed HIV risk perceptions and sexual behavior among college-educated Black women of higher socioeconomic status despite their high risk of HIV. College-educated Black women are most likely to acquire HIV while in college, and there has been a marked absence of research assessing the environmental and cultural influences present throughout college-campuses, coupled with evaluating how these factors shape sexual behaviors. We conducted surveys with Black female students attending a historically Black college and Black female students attending a predominately White university, and compared baseline differences in sexual behaviors among both populations. Results showed that for participants attending the historically Black college certain sociocultural elements, such as music and media, had a significantly stronger influence on sexuality and sexual behaviors compared with students attending predominately White universities. The development of future HIV prevention interventions for Black women necessitates an understanding of the diverse microcultures that Black women come from. This research is high priority for college-educated Black women given this population's lack of inclusion in HIV prevention research., (© 2020. W. Montague Cobb-NMA Health Institute.)

Objective: Using data from the monthly Current Population Survey, this paper provides monthly employment and unemployment statistics for people with and without disabilities in the United States before and during the coronavirus disease 2019 pandemic to date (January 2021)., Design: Cross-sectional analysis of the Current Population Survey., Setting: The United States., Participants: People with and without disabilities ages 16-64 years., Intervention: N/A MAIN OUTCOME MEASURES: Percentage employed, percentage unemployed, percentage not in labor force, percentage on temporary layoff, percentage looking for work., Results: Estimates show that, like workers without disabilities, workers with disabilities experienced increases in unemployment at the beginning of the pandemic but continued to remain engaged in the labor force. Our analysis finds that employment rates dropped from 74.8% to 63.2% for those without disabilities and from 31.1% to 26.4% for those with disabilities between February 2020 and April 2020 but gradually improved in the succeeding months., Conclusions: As the pandemic continued, the percentage of unemployed people with and without disabilities on temporary layoff decreased and those looking for work increased., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Medical-refractory severe alcoholic hepatitis (AH) has a high mortality. The national frequency, longer term outcomes and regional practices of AH liver transplantation (LT) in the United States are not well described, despite the increasing mortality from alcohol-associated liver disease. We analyzed the trends in frequency and outcomes of UNOS data on 39 455 adult patients who underwent LT from 2014 to 2019, including AH LT recipients. LTs for AH increased 5-fold, from 28 in 2014 to 138 in 2019, varying 8-fold between UNOS regions. Three transplant centers accounted for 50%-90% of AH LTs within each region. The number of transplant centers performing AH LTs increased from 14 in 2014 to 47 in 2019. AH patients were younger (mean = 39.4 years), had higher MELD scores (mean = 36.8), and were more often on dialysis (46.0%) and in ICU (38.4%), compared to other indications (all P < .05). One- and 5-year graft survivals for AH LT recipients were 91.7% and 81.9%, respectively. The frequency of AH LT is increasing rapidly, with excellent medium-term outcomes. An impact of AH recurrence on patient or graft survival is not apparent in this national analysis. There are marked geographic variations in practices, highlighting the lack of selection criteria standardization., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

To safely resume sports, college and university athletic programs and regional athletic conferences created plans to mitigate transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Mitigation measures included physical distancing, universal masking, and maximizing outdoor activity during training; routine testing; 10-day isolation of persons with COVID-19; and 14-day quarantine of athletes identified as close contacts* of persons with confirmed COVID-19. Regional athletic conferences created testing and quarantine policies based on National Collegiate Athletic Association (NCAA) guidance (1); testing policies varied by conference, school, and sport. To improve compliance with quarantine and reduce the personal and economic burden of quarantine adherence, the quarantine period has been reduced in several countries from 14 days to as few as 5 days with testing (2) or 10 days without testing (3). Data on quarantined athletes participating in NCAA sports were used to characterize COVID-19 exposures and assess the amount of time between quarantine start and first positive SARS-CoV-2 test result. Despite the potential risk for transmission from frequent, close contact associated with athletic activities (4), more athletes reported exposure to COVID-19 at social gatherings (40.7%) and from roommates (31.7%) than they did from exposures associated with athletic activities (12.7%). Among 1,830 quarantined athletes, 458 (25%) received positive reverse transcription-polymerase chain reaction (RT-PCR) test results during the 14-day quarantine, with a mean of 3.8 days from quarantine start (range = 0-14 days) until the positive test result. Among athletes who had not received a positive test result by quarantine day 5, the probability of having a positive test result decreased from 27% after day 5 to <5% after day 10. These findings support new guidance from CDC (5) in which different options are provided to shorten quarantine for persons such as collegiate athletes, especially if doing so will increase compliance, balancing the reduced duration of quarantine against a small but nonzero risk for postquarantine transmission. Improved adherence to mitigation measures (e.g., universal masking, physical distancing, and hand hygiene) at all times could further reduce exposures to SARS-CoV-2 and disruptions to athletic activities because of infections and quarantine (1,6)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Kimberly G. Harmon reports grant support from Quidel, outside the submitted work. No other potential conflicts of interest were disclosed.

Kidney transplant program performance in the United States is commonly measured by posttransplant outcomes. Inclusion of pretransplant measures could provide a more comprehensive assessment of transplant program performance and necessary information for patient decision-making. In this study, we propose a new metric, the waitlisting rate, defined as the ratio of patients who are waitlisted in a center relative to the person-years referred for evaluation to a program. Furthermore, we standardize the waitlisting rate relative to the state average in Georgia, North Carolina, and South Carolina. The new metric was used as a proof-of-concept to assess transplant-program access compared to the existing transplant rate metric. The study cohorts were defined by linking 2017 United States Renal Data System (USRDS) data with transplant-program referral data from the Southeastern United States between January 1, 2012 and December 31, 2016. Waitlisting rate varied across the 9 Southeastern transplant programs, ranging from 10 to 22 events per 100 patient-years, whereas the program-specific waitlisting rate ratio ranged between 0.76 and 1.33. Program-specific waitlisting rate ratio was uncorrelated with the transplant rate ratio (r = -.15, 95% CI, -0.83 to 0.57). Findings warrant collection of national data on early transplant steps, such as referral, for a more comprehensive assessment of transplant program performance and pretransplant access., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Variability in transplant access exists, but barriers to referral and evaluation are underexplored due to lack of national surveillance data. We examined referral for kidney transplantation evaluation and start of the evaluation among 34 857 incident, adult (18-79 years) end-stage kidney disease patients from 690 dialysis facilities in the United States Renal Data System from January 1, 2012 through August 31, 2016, followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariable-adjusted competing risk analysis examined each outcome. The median within-facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%-43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non-Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18-1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88-0.98), vs white non-Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background: Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population., Methods: We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics., Results: In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality., Conclusion: We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The incidence of anal cancer in HIV-positive women is a growing public health concern where they have a 7.8-fold increased risk for anal cancer than women in the general population. We examined knowledge of anal cancer, anal cancer screening, and HPV in HIV-positive women and high-risk HIV-negative women. Women were recruited from the Women's Interagency HIV Study and completed an adapted Knowledge of Anal Cancer and HPV Scale. Correlations among anal cancer knowledge and sociodemographic and risk factors were assessed using Pearson's or Spearman's rho r test. Student's t test or chi-square tests identified significant differences between groups by HIV status or risk factors. Among 155 women, 72% (n = 113) correctly identified the purpose of an anal Pap test. However, only 42% (n = 65) identified HIV as a risk factor for anal cancer. HIV-positive women were more knowledgeable about anal cancer than high risk HIV-negative women (t = 2.104, p = .037). Women with a history of an abnormal cervical Pap test (t = 2.137, p = .034), younger age (t = 3.716, p = .000), reported history of anal sex (t = 3.284, p = .001), some college education or higher (t = -2.005, p = .047), and non-smokers (t = 2.425, p = .016) were significantly more knowledgeable about HPV. Although most women were knowledgeable about anal cancer, many women could not identify important risk factors for anal cancer, such as HIV infection. Patient educational interventions tailored to HIV-positive women are warranted to improve knowledge and awareness of risk for anal cancer.

Introduction: Human immunodeficiency virus (HIV) patients are living longer due to the availability of antiretroviral therapies, and non-AIDS-defining cancers are becoming more prevalent in this patient population. A paucity of data remains on post-operative outcomes following resection of non-AIDS-defining cancers in the HIV population., Methods: The National Inpatient Sample was utilized to identify patients who underwent surgical resection for malignancy from 2005 to 2015 (HIV, N = 52,742; non-HIV, N = 11,885,184). Complications were categorized by international classification of disease (ICD)-9 diagnosis codes. Cohorts were matched on insurance, household income, zip code and urban/rural setting. Logistic regression assessed whether HIV was an independent predictor of post-operative complications., Results: Descriptive statistics found HIV patients to have an increased rate of complications following select oncologic surgical resections. Univariate and multivariate logistic regression found HIV to only be an independent predictor of complications following pulmonary lobectomy (p = 0.011; OR 2.93, 95% CI 1.29-6.73). Length of stay was statistically longer following colectomy (2.61 days, 95% CI 1.98-3.44) in those with HIV., Conclusions: Our findings are hypothesis generating and highlight the potential safety of major cancer surgery in the HIV population. However, care providers need be cognizant of the potential increased risk of post-operative complications following pulmonary lobectomy and the potential for increased length of stay. These findings are an initial insight into quality of care and outcomes metrics on HIV patients undergoing major cancer operations.

Objective: Limited information is available based on single-center studies on trends of incidence and outcomes in gastrointestinal (GI) bleed with shock., Methods: We analyzed data from 2002 to 2013 National Inpatient Sample. Using ICD-9 codes we identified 6.4 million hospital discharges of GI bleed from National Inpatient Sample database. Events were analyzed based on type of GI bleed, in-hospital mortality, hemodynamic status, and use of blood products., Results: GI bleed with shock results in higher hospital mortality (20.77% with shock vs. 2.6% without shock). Between 2002 and 2013, there has been an increase in the percentage of upper and lower GI bleed with shock (1.35% to 4.92% and 1.49% to 3.06%) along with a reduction in mortality in both upper GI bleed with shock (26.9% to 13.8%) and lower GI bleed with shock (54.7% to 19.7%). Consistent with the rise in GI bleed with shock was an increase in blood product utilization. Packed red blood cell (pRBC) transfusion was associated with reduction in mortality in both nonvariceal upper GI bleed with shock (18.3% without pRBC vs. 13.9% receiving pRBC) and lower GI bleed with shock (36.05% without pRBC vs. 22.13% receiving pRBC), but did not affect mortality in variceal upper GI bleed with shock (31.79% vs. 32.22%)., Conclusions: GI bleed with shock carries a higher mortality and have been steadily increasing from 2002 to 2013. pRBC transfusion was associated in improved mortality in GI bleed with shock except variceal bleed.

Highly effective direct-acting antiviral (DAA) therapy has transformed outcomes of liver transplantation in hepatitis C virus (HCV) patients. We examined longer-term outcomes in HCV-positive recipients in the DAA era and analyzed the Scientific Registry of Transplant Recipients for primary adult, single-organ, nonfulminant liver transplant recipients in the United States from January 1, 2008 to June 30, 2018. Graft loss was compared among HCV-positive liver transplant recipients who received either an HCV-negative or HCV-positive donor (donor [D]-/recipient [R]+; D+/R+) and HCV-negative liver transplant recipients who received a HCV-negative donor (D-/R-). The groups were further divided between the pre-DAA and DAA eras. There were 52,526 patients included: 31,193 were D-/R- patients; 18,746 were D-/R+ patients; and 2587 were D+/R+ patients. The number of D-/R+ transplants decreased from 2010 in 2008 to 1334 in 2017, with this decline particularly noticeable since 2015. D-/R+ patients in the DAA era (n = 7107) were older, had higher rates of hepatocellular carcinoma, and lower Model for End-Stage Liver Disease scores than those in the pre-DAA era. Graft survival improved for all recipients in the DAA era but improved most dramatically in HCV-positive recipients: D-/R+ 1-year survival was 92.4% versus 88.7% and 3-year survival was 83.7% versus 77.7% (DAA versus pre-DAA era, respectively) compared with D-/R- 1-year survival of 92.7% versus 91.0% and 3-year survival of 85.7% versus 84.0% (DAA versus pre-DAA era, respectively). The magnitude of improvement in 3-year graft survival was almost 4-fold greater for D-/R+ patients. The 3-year survival for D+/R+ patients was similar to HCV-negative patients. In conclusion, the number of liver transplants for HCV has decreased by more than one-third over the past decade. Graft survival among HCV-positive recipients has increased disproportionately in the DAA era with HCV-positive recipients now achieving similar outcomes to non-HCV recipients., (Copyright © 2019 by the American Association for the Study of Liver Diseases.)