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Importance: Macrolides of different ring sizes are critically important antimicrobials for human medicine and veterinary medicine, though the widely used 15-membered ring azithromycin in humans is not approved for use in veterinary medicine. We document here the emergence of azithromycin-resistant Salmonella among the NARMS culture collections between 2011 and 2021 in food animals and retail meats, some with co-resistance to ceftriaxone or decreased susceptibility to ciprofloxacin. We also provide insights into the underlying genetic mechanisms and genomic contexts, including the first report of a novel combination of azithromycin resistance determinants and the characterization of multidrug-resistant plasmids. Further, we highlight the emergence of a multidrug-resistant Salmonella Newport clone in food animals (mainly cattle) with both azithromycin resistance and decreased susceptibility to ciprofloxacin. These findings contribute to a better understating of azithromycin resistance mechanisms in Salmonella and warrant further investigations on the drivers behind the emergence of resistant clones., Competing Interests: The authors declare no conflict of interest.

Vietnamese Americans experience significant health disparities compared with other groups, but their health care utilization is suboptimal. Boat People SOS (BPSOS), a nationwide Vietnamese-serving community-based organization, implemented a community health worker and community-clinical linkage electronic referral system to improve health care utilization. Three sites (in Alabama, California, and Virginia) received the intervention; Mississippi was the comparison site. The intervention included bridging between communities and health systems, culturally appropriate health education, informal counseling and social support, advocating for individual and community needs, direct services, and building individual and community capacity through partnerships with service providers. Compared with the comparison site, clients at the intervention sites reported better overall perceived health after the intervention. Past-year medical checkups declined in both groups during the COVID-19 pandemic but declined less in the treatment group. The intervention did not reduce emergency room visits. Findings suggest that this intervention can improve health care utilization and health status among Vietnamese Americans.

Importance: The potential role of living alone in either facilitating or hampering access to and use of services for older adults with cognitive impairment is largely unknown. Specifically, it is critical to understand directly from health care and social services professionals how living alone creates barriers to the access and use of supportive health care and social services for racially and ethnically diverse patients with cognitive impairment., Objective: To identify the potential role of living alone in the access and use of health care and social services for diverse patients with cognitive impairment by investigating professionals' perceptions of caring for such patients who live alone in comparison with counterparts living with others., Design, Setting, and Participants: This qualitative study of 76 clinicians, social workers, and other professionals used semistructured interviews conducted between February 8, 2021, and June 8, 2022, with purposively sampled professionals providing services to diverse patients with cognitive impairment in Michigan, California, and Texas., Main Outcomes and Measures: Clinicians, social workers, and other professionals compared serving patients with cognitive impairment and living alone vs counterparts living with others. An inductive content analysis was used to analyze the interview transcripts., Results: A total of 76 professionals were interviewed (mean [SD] age, 49.3 [12.7] years); 59 were female (77.6%), 8 were Black or African American (11%), and 35 were White (46%). Participants included physicians, nurses, social workers, and home-care aides, for a total of 20 professions. Participants elucidated specific factors that made serving older adults living alone with cognitive impairment more challenging than serving counterparts living with others (eg, lacking an advocate, incomplete medical history, requiring difficult interventions), as well as factors associated with increased concerns when caring for older adults living alone with cognitive impairment, such as isolation and a crisis-dominated health care system. Participants also identified reasons for systematic unmet needs of older adults living alone with cognitive impairment for essential health care and social services, including policies limiting access and use to public home-care aides., Conclusions and Relevance: In this qualitative study of professionals' perspectives, findings suggest that living alone is a social determinant of health among patients with cognitive impairment owing to substantial barriers in access to services. Results raised considerable concerns about safety because the US health care system is not well equipped to address the unique needs of older adults living alone with cognitive impairment.

The most prevalent modifiable risk factor for skin cancer is cumulative lifetime exposure to ultraviolet (UV) radiation, supporting the development of interventions promoting the early adoption of sun-protection behaviors. This systematic review summarizes behavioral interventions designed to promote sun-protection behaviors and reduce harmful UV exposure among U.S. adolescents. Ten studies describing 15 intervention arms were ultimately included in this review and comprised seven cross-sectional studies, a cohort study, a quasi-experimental study, and a randomized controlled trial. Most interventions included in this review were effective in increasing awareness of skin cancer and knowledge of the risk factors for skin cancer, but knowledge did not correlate with self-reported frequency of sun-protection behaviors in this population., (© 2023 Wiley Periodicals LLC.)

Chronic hepatitis B viral (HBV) infection is associated with significant morbidity and mortality with endemic areas carrying most of the global burden of HBV disease. Current HBV screening rates in the United States are suboptimal. We aimed to improve HBV screening rates at regional family health centers serving high-risk refugee populations by 20% over 2 years. We used quality improvement (QI) methodology and implemented interventions providing electronic medical record (EMR)-enabled HBV screening tools within known clinical workflows. EMR tools captured country-of-origin data to identify persons from HBV-endemic regions with provision of a laboratory order set to ensure performance of appropriate HBV screening tests. The project was initiated prior to the COVID pandemic but continued during the pandemic with imposed social isolation measures. We nevertheless demonstrated 4 statistical process control chart shifts and achieved our QI smart aim. Further, we demonstrated a high HBV detection rate (8.2%-12.8%) among persons identified for screening., Competing Interests: This investigator-initiated and designed study was funded by Gilead Sciences, Inc. J.S.H. also receives payment for grants unrelated to the current work from Janssen, AbbVie, and Ferring. K.B.S. receives funding from the National Institutes of Health for the Hepatitis B Research Network, Gilead, and Albireo (unrelated to current work). The remaining authors report no conflicts of interest., (Copyright © 2023 by European Society for European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Purpose: The social vulnerability index (SVI), developed by the Centers for Disease Control and Prevention, is a novel composite measure encompassing multiple variables that correspond to key social determinants of health. The objective of this review was to investigate innovative applications of the SVI to oncology research and to employ the framework of the cancer care continuum to elucidate further research opportunities., Methods: A systematic search for relevant articles was performed in five databases from inception to 13 May 2022. Included studies applied the SVI to analyze outcomes in cancer patients. Study characteristics, patent populations, data sources, and outcomes were extracted from each article. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines., Results: In total, 31 studies were included. Along the cancer care continuum, five applied the SVI to examine geographic disparities in potentially cancer-causing exposures; seven in cancer diagnosis; fourteen in cancer treatment; nine in treatment recovery; one in survivorship care; and two in end-of-life care. Fifteen examined disparities in mortality., Conclusion: In highlighting place-based disparities in patient outcomes, the SVI represents a promising tool for future oncology research. As a reliable geocoded dataset, the SVI may inform the development and implementation of targeted interventions to prevent cancer morbidity and mortality at the neighborhood level., (© 2023. The Author(s).)

Background & Aims: Gastric cancer (GC) remains a leading cause of mortality among certain racial, ethnic, and immigrant groups in the United States (US). The majority of GCs are diagnosed at advanced stages, and overall survival remains poor. There exist no structured national strategies for GC prevention in the US., Methods: On March 5-6, 2020 a summit of researchers, policy makers, public funders, and advocacy leaders was convened at Stanford University to address this critical healthcare disparity. After this summit, a writing group was formed to critically evaluate the effectiveness, potential benefits, and potential harms of methods of primary and secondary prevention through structured literature review. This article represents a consensus statement prepared by the writing group., Results: The burden of GC is highly inequitably distributed in the US and disproportionately falls on Asian, African American, Hispanic, and American Indian/Alaskan Native populations. In randomized controlled trials, strategies of Helicobacter pylori testing and treatment have been demonstrated to reduce GC-specific mortality. In well-conducted observational and ecologic studies, strategies of endoscopic screening have been associated with reduced GC-specific mortality. Notably however, all randomized controlled trial data (for primary prevention) and the majority of observational data (for secondary prevention) are derived from non-US sources., Conclusions: There exist substantial, high-quality data supporting GC prevention derived from international studies. There is an urgent need for cancer prevention trials focused on high-risk immigrant and minority populations in the US. The authors offer recommendations on how strategies of primary and secondary prevention can be applied to the heterogeneous US population., (Copyright © 2022 AGA Institute. All rights reserved.)

All known group A streptococci [GAS] are susceptible to β-lactam antibiotics. We recently identified an invasive GAS (iGAS) variant ( emm43.4 /PBP2x-T553K) with unusually high minimum inhibitory concentrations (MICs) for ampicillin and amoxicillin, although clinically susceptible to β-lactams. We aimed to quantitate PBP2x variants, small changes in β-lactam MICs, and lineages within contemporary population-based iGAS. PBP2x substitutions were comprehensively identified among 13,727 iGAS recovered during 2015-2021, in the USA. Isolates were subjected to antimicrobial susceptibility testing employing low range agar diffusion and PBP2x variants were subjected to phylogenetic analyses. Fifty-five variants were defined based upon substitutions within an assigned PBP2x transpeptidase domain. Twenty-nine of these variants, representing 338/13,727 (2.5%) isolates and 16 emm types, exhibited slightly elevated β-lactam MICs, none of which were above clinical breakpoints. The emm43.4 /PBP2x-T553K variant, comprised of two isolates, displayed the most significant phenotype (ampicillin MIC 0.25 μg/ml) and harbored missense mutations within 3 non-PBP genes with known involvement in antibiotic efflux, membrane insertion of PBP2x, and peptidoglycan remodeling. The proportion of all PBP2x variants with elevated MICs remained stable throughout 2015-2021 (<3.0%). The predominant lineage ( emm4 /PBP2x-M593T/ ermT ) was resistant to macrolides/lincosamides and comprised 129/340 (37.9%) of isolates with elevated β-lactam MICs. Continuing β-lactam selective pressure is likely to have selected PBP2x variants that had escaped scrutiny due to MICs that remain below clinical cutoffs. Higher MICs exhibited by emm43.4 /PBP2x-T553K are probably rare due to the requirement of additional mutations. Although elevated β-lactam MICs remain uncommon, emm43.4 /PBP2x-T553K and emm4 /PBP2x-M593T/ ermT lineages indicate that antibiotic stewardship and strain monitoring is necessary.

Background: Invasive pneumococcal disease (IPD) isolates forming genomic clusters can reflect rapid disease transmission between vulnerable individuals., Methods: We performed whole genome sequencing of 2820 IPD isolates recovered during 2019 through Centers for Disease Control and Prevention's Active Bacterial Core surveillance to provide strain information (serotypes, resistance, genotypes), and 2778 of these genomes were analyzed to detect highly related genomic clusters., Results: Isolates from persons experiencing homelessness (PEH) were more often within genomic clusters than those from persons not experiencing homelessness (PNEH) (105/198 [53.0%] vs 592/2551 [23.2%]; P < .001). The 4 western sites accounted for 33.4% (929/2778) of isolates subjected to cluster analysis yet accounted for 48.7% (343/705) of clustering isolates (P < .001) and 75.8% (150/198) of isolates recovered from PEH (P < .001). Serotypes most frequent among PEH were (in rank order) 12F, 4, 3, 9N, 8, 20, and 22F, all of which were among the 10 serotypes exhibiting the highest proportions of clustering isolates among all cases. These serotypes accounted for 44.9% (1265/2820) of all IPD cases and are included within available vaccines., Conclusions: We identified serotype-specific and geographic differences in IPD transmission. We show the vulnerability of PEH within different regions to rapidly spreading IPD transmission networks representing several pneumococcal serotypes included in available vaccines., (Published by Oxford University Press for the Infectious Diseases Society of America 2022.)

The hepatitis C virus (HCV) treatment landscape is shifting given the advent of direct-acting antivirals and a global call to action by the World Health Organization. Eliminating HCV is now an issue of healthcare delivery. Treatment is limited by the complexity of the HCV care continuum, expensive therapy and competing health burdens experienced by an underserved HCV population. The objective of this literature review was to assess strategies to improve retention in HCV care, with particular focus on those implemented in the United States. We identified barriers in HCV care retention and propose solutions to increase HCV treatment delivery. The following recommendations are herein described: improving the cohesion of health services through localized care and integrated case management, expanding the supply of non-specialist HCV treatment providers, leveraging patient navigators and care coordinators, improving adherence through directly observed therapy and reducing cost barriers through value-based payment and pharmaceutical subscription models., (© 2022 John Wiley & Sons Ltd.)

(1) Background: A United States national policy advisory group (PAG) was convened to identify barriers and facilitators to expand formal long-term services and support (LTSS) for people living alone with cognitive impairment (PLACI), with a focus on equitable access among diverse older adults. The PAG's insights will inform the research activities of the Living Alone with Cognitive Impairment Project, which is aimed at ensuring the equitable treatment of PLACI. (2) Methods: The PAG identified barriers and facilitators of providing effective and culturally relevant LTSS to PLACI via one-on-one meetings with researchers, followed by professionally facilitated discussions among themselves. (3) Results: The PAG identified three factors that were relevant to providing effective and culturally relevant LTSS to PLACI: (i) better characterization of PLACI, (ii) leveraging the diagnosis of cognitive impairment, and (iii) expanding and enhancing services. For each factor, the PAG identified barriers and facilitators, as well as directions for future research. (4) Conclusions: The barriers and facilitators the PAG identified inform an equity research agenda that will help inform policy change.

Seventy percent of tuberculosis (TB) cases in the United States occur among non-US-born persons; cases usually result from reactivation of latent TB infection (LTBI) likely acquired before the person's US arrival. We conducted a prospective study among US immigrant visa applicants undergoing the required overseas medical examination in Vietnam. Consenting applicants >15 years of age were offered an interferon-γ release assay (IGRA); those 12-14 years of age received an IGRA as part of the required examination. Eligible participants were offered LTBI treatment with 12 doses of weekly isoniazid and rifapentine. Of 5,311 immigrant visa applicants recruited, 2,438 (46%) consented to participate; 2,276 had an IGRA processed, and 484 (21%) tested positive. Among 452 participants eligible for treatment, 304 (67%) initiated treatment, and 268 (88%) completed treatment. We demonstrated that using the overseas medical examination to provide voluntary LTBI testing and treatment should be considered to advance US TB elimination efforts.

County-based health care financial assistance programs offer improved access to health care for indigent populations by reducing or eliminating costs to receive care. We examined health care financial assistance programs serving the 10 most populous U.S. counties. We found that the percent enrollment in a county's program is strongly correlated with the percent uninsured (r=.86) and the percent undocumented (r=.83), and moderately correlated with the percent indigent (r=.43) in a county, suggesting the importance of health care financial assistance programs for these groups. Furthermore, the typical county-based health care financial assistance program covers the same income range (0-138% federal poverty level) and offers similar benefits (including coverage of emergency care and inpatient care) as Medicaid. Counseling services are frequently available to assist applicants. These characteristics allow them to serve as an alternative source of health care funding to those who are ineligible for Medicaid coverage.

Background: Surgical resection for sarcoma lung metastases has been associated with improved overall survival (OS)., Methods: Patients who underwent curative-intent resection of sarcoma lung metastases (2000-2016) were identified from the US Sarcoma Collaborative. Patients with extrapulmonary metastatic disease or R2 resections of primary tumor or metastases were excluded. Primary endpoint was OS., Results: Three hundred and fifty-two patients met inclusion criteria. Location of primary tumor was truncal/extremity in 85% (n = 270) and retroperitoneal in 15% (n = 49). Forty-nine percent (n = 171) of patients had solitary and 51% (n = 180) had multiple lung metastasis. Median OS was 49 months; 5-year OS 42%. Age ≥55 (HR 1.77), retroperitoneal primary (HR 1.67), R1 resection of primary (HR 1.72), and multiple (≥2) lung metastases (HR 1.77) were associated with decreased OS(all p < 0.05). Assigning one point for each factor, we developed a risk score from 0 to 4. Patients were then divided into two risk groups: low (0-1 factor) and high (2-4 factors). The low-risk group (n = 159) had significantly better 5-year OS compared to the high-risk group (n = 108) (51% vs. 16%, p < 0.001)., Conclusion: We identified four characteristics that in aggregate portend a worse OS and created a novel prognostic risk score for patients with sarcoma lung metastases. Given that patients in the high-risk group have a projected OS of <20% at 5 years, this risk score, after external validation, will be an important tool to aid in preoperative counseling and consideration for multimodal therapy., (© 2021 Wiley Periodicals LLC.)

Objective: Hospital quality ratings are intended to guide patients and payers to the highest quality hospitals. Their success in achieving this goal has been limited by inconsistencies between ratings and questionable data collection methods. Despite these shortcomings, their popularity and importance are increasing. The purpose of this review is to identify the strengths and weaknesses of the US News and World Report (USNWR) Best Children's Hospitals Report and Leapfrog Pediatric Care Survey and discuss improvement opportunities., Methods: A structured literature review was performed analyzing hospital quality surveys. Previously published criteria were used to compare the USNWR Best Children's Hospitals Report and Leapfrog Pediatric Care Survey., Results: This narrative review highlights the strengths and weakness of both the USNWR Best Children's Hospitals Report and the Leapfrog Pediatric Care Survey, including a letter grade comparison., Conclusion: Existing children's hospital rating systems are lacking. We suggest specific improvements that may better enable these reports to influence the quality of pediatric care.

Since the closure of Charity Hospital after Hurricane Katrina, New Orleans Student-Run Free Clinics have helped fill the resulting void in healthcare access for the underserved New Orleans population. To better understand the health insurance status and health outcomes of this patient population, 1036 patient records from seven New Orleans Student-Run Free Clinics were collected and analyzed between February 2017 and March 2020. Insurance status was significantly associated with gender, race, homelessness, and prior incarceration, but not with education. Substance use rehabilitation centers had low uninsured rates, while homeless shelters had higher uninsured rates. Patients on Non-Medicaid insurance were most likely to be prescribed a medication for diabetes (p = .01), hypertension (p = .21), and psychiatric conditions (p = .04), followed by those on Medicaid, and then those who were uninsured. This study demonstrates the benefits of health insurance and provides important data that can inform future health insurance enrollment efforts and health policy., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Objectives: Even before the COVID-19 pandemic, older adults with cognitive impairment living alone (an estimated 4.3 million individuals in the United States) were at high risk for negative health outcomes. There is an urgent need to learn how this population is managing during the pandemic., Research Design and Methods: This is a qualitative study of 24 adults aged 55 and older living alone with cognitive impairment from diverse racial/ethnic backgrounds. Participants' lived experiences during the pandemic were elicited via 59 ethnographic interviews conducted over the phone either in English, Spanish, or Cantonese. Using a qualitative content analysis approach, interview transcripts were analyzed to identify codes and themes., Results: Qualitative analysis of transcripts revealed 5 themes: (a) fear generated by the pandemic, (b) distress stemming from feeling extremely isolated, (c) belief in misinformation, (d) strategies for coping during the pandemic, and (e) the importance of access to essential services., Discussion and Implications: This pandemic put a spotlight on the precarity and unmet needs of older adults living alone with cognitive impairment. Findings underscore the need to expand access to home care aides and mental health services for this population., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To evaluate the difference in the number of drug therapy interventions between patients seen by pharmacists and patients seen by nonpharmacist providers during Medicare Annual Wellness Visits (AWVs)., Methods: Pharmacists completed the medication history portion of AWVs at a primary care, interdisciplinary clinic in Central Texas. Drug therapy problems were collected and compared to those identified by physicians conducting AWVs. Drug therapy problems were grouped into 4 categories: indication, effectiveness, safety, and adherence. Each category was divided into subcategories to further specify the problem., Results: Fifty patients received an AWV in each group. Pharmacists identified more drug therapy problems in all 4 categories as compared to physicians (100 vs 20 interventions, respectively) and significant differences were detected in most subcategories: indication without medication ( P = .005), suboptimal regimen ( P = .0034), drug-drug interaction ( P = .0267), warning/precaution requiring additional monitoring ( P = .0267), nonadherence ( P = .0058), and patient lack of understanding medication therapy ( P = .005)., Conclusion: Pharmacist involvement in AWVs helped identify drug therapy problems.

Background: The novel composite metric textbook outcome (TO) has increasingly been used as a quality indicator but has not been reported among patients undergoing surgical resection for retroperitoneal sarcoma (RPS) using multi-institutional collaborative data., Methods: All patients who underwent resection for RPS between 2000 to 2016 from eight academic institutions were included. TO was defined as a patient with R0/R1 resection that discharged to home and was without transfusion, reoperation, grade ≥2 complications, hospital-stay >50th percentile, or 90-day readmission or mortality. Univariate and multivariable analyses were performed., Results: Among 627 patients, 56.1% were female and the median age was 59 years. A minority of patients achieved a TO (34.9%). Factors associated with achieving a TO were tumor size <20 cm and low tumor grade, while ASA class ≥3, history of a prior cardiac event, resection of left colon/rectum, distal pancreatic resection, major venous resection and drain placement were associated with not achieving a TO (all P < .05). Achievement of a TO was associated with improved survival (median:12.7 vs 5.9 years, P < .01)., Conclusions: Among patients undergoing resection for RPS, failure to achieve TO is common and associated with significantly worse survival. The use of TO may inform patient expectations and serve as a measure for patient-level hospital performance., (© 2020 Wiley Periodicals LLC.)

Parents and friends can help facilitate the academic engagement of newcomer immigrant youth during the early post-migration years. Using an accelerated longitudinal design and the integrative risk and resilience framework, we examined how parent home involvement and friendships were directly and indirectly associated with the development of newcomer immigrant youths' academic engagement. We used data from three waves (Years 3-5) of the Longitudinal Immigrant Student Adaptation study where a culturally diverse group of immigrant youth (N = 354, ages 10-17, M timeinUS  = 3.98 years, SD = 1.39) in the United States reported on their perceptions of parent home involvement (educational values and communication) and friendship (educational values and academic support) in Year 3 and on their academic engagement (behavioural and emotional) across 3 years. Findings showed high-stable behavioural and emotional engagement and direct positive associations between perceptions of parent home involvement and initial levels of behavioural and emotional engagement and between perceptions of friend educational values and initial levels of emotional engagement. Additionally, perceptions of parents' educational values indirectly contributed to initial levels of emotional engagement through positive associations with perceptions of friends' educational values. These findings can inform family-school partnerships and school-interventions targeting newcomer immigrant youths' engagement., (© 2020 International Union of Psychological Science.)

Objectives: We aimed to provide population-based and whole-genome sequence (WGS) -based characterization of invasive pneumococcal disease isolates collected from multistate surveillance in the USA during 2017., Methods: We obtained short-read WGS from 2881 isolates with associated bioinformatics pipeline strain feature predictions. For quality control, capsular serotypes and antimicrobial MICs were also obtained conventionally from 442 isolates. Annotated WGS were provided (inclusive of serotypes, MICs, multilocus sequence types, pilus type(s)) from 2723 isolates. For 158 isolates with suboptimal WGS, antimicrobial MICs were obtained conventionally., Results: There were 127 isolates from children <5 years of age and 2754 isolates from those ≥5 years old in 2017. One of 43 different serotypes was predicted for 2877 of the 2881 isolates. Serotypes in the 13-valent conjugate vaccine together with 6C (PCV13+6C) accounted for 816 (28.3%) isolates, with PCV13 serotype 3 being the most common serotype overall. Non-PCV13-6C- serotypes accounted for 2065 (71.7%) isolates, comprising 96 (75.6%) isolates from children < 5 years old and 1969 (61.4%) isolates from those aged ≥5 years. Of 36 different categories of recently emerged serotype-switch variants, three showed marked increases relative to 2015-2016 in that the number from 2017 surpassed the number from 2015-2016 combined. Two of these included antimicrobial-resistant serotype 11A and 35B serotype-switch variants of the ST156 clonal complex., Conclusions: PCV13+6C strains are still identified in 2017 but non-PCV13-type strains impose a considerable burden. This well-annotated year 2017 WGS/strain data set will prove useful for a broad variety of analyses and improved our understanding of invasive pneumococcal disease-causing strains in the post-PCV13 era., (Published by Elsevier Ltd.)

Racial discrimination is known to harm health, but to what extent the health burden of racial discrimination is contingent on residential contexts is understudied. This study examines the moderating role of racial residential segregation in the relationship between racial discrimination and psychological distress. Nationally representative data from the 2002-2003 National Latino and Asian American Study were merged with metropolitan-level data from the U.S. Census. Logistic regression models were used to test the independent and joint contributions of racial discrimination and residential segregation to psychological distress among Asians and Latinxs, stratified by nativity status. Higher residential segregation (measured by the interaction index) is associated with lower odds of distress among U.S.-born Asians but not among other groups. As for the moderating effect, residential segregation exacerbates the positive association between discrimination and distress among foreign-born Asians (measured by the dissimilarity index) and foreign-born Latinxs (measured by the interaction index), but not among their respective U.S.-born counterparts. Taken together, the present study highlights that strategies to mitigate the psychological burden of racial discrimination need to move beyond individual-level efforts to incorporate neighborhood-based approaches. In particular, results provide empirical support for efforts to reduce residential segregation, particularly among immigrants who are discriminated against., (© 2019 Society for Community Research and Action.)

Background: CBD products have risen in popularity given CBD's therapeutic potential and lack of legal oversight, despite lacking conclusive scientific evidence for widespread over-the-counter usage for many of its perceived benefits. While medical evidence is being generated, social media surveillance offers a fast and inexpensive alternative to traditional surveys in ascertaining perceived therapeutic purposes and modes of consumption for CBD products., Methods: We collected all comments from the CBD subreddit posted between January 1 and April 30, 2019 as well as comments submitted to the FDA regarding regulation of cannabis-derived products and analyzed them using a rule-based language processing method. A relative ranking of popular therapeutic uses and product groups for CBD is obtained based on frequency of pattern matches including precise queries that entail identifying mentions of the condition, a CBD product, and some "trigger" phrase indicating therapeutic use. We validated the social media-based findings using a similar analysis on comments to the U.S. Food and Drug Administration's (FDA) 2019 request-for-comments on cannabis-derived products., Results: CBD is mostly discussed as a remedy for anxiety disorders and pain and this is consistent across both comment sources. Of comments posted to the CBD subreddit during the monitored time span, 6.19% mentioned anxiety at least once with at least 6.02% of these comments specifically mentioning CBD as a treatment for anxiety (i.e., 0.37% of total comments). The most popular CBD product group is oil and tinctures., Conclusion: Social media surveillance of CBD usage has the potential to surface new therapeutic use-cases as they are posted. Contemporary social media data indicate, for example, that stress and nausea are frequently mentioned as therapeutic use cases for CBD without corresponding evidence, that affirms or denies, in the research literature. However, the abundance of anecdotal claims warrants serious scientific exploration moving forward. Meanwhile, as FDA ponders regulation, our effort demonstrates that social data offers a convenient affordance to surveil for CBD usage patterns in a way that is fast and inexpensive and can inform conventional electronic surveys., Competing Interests: Conflict of Competing Interest Both authors do NOT have any conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Zika virus infection during pregnancy can cause congenital brain and eye abnormalities and is associated with neurodevelopmental abnormalities (1-3). In areas of the United States that experienced local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy increased in the second half of 2016 compared with the first half (4). To update the previous report, CDC analyzed population-based surveillance data from 22 states and territories to estimate the prevalence of birth defects potentially related to Zika virus infection, regardless of laboratory evidence of or exposure to Zika virus, among pregnancies completed during January 1, 2016-June 30, 2017. Jurisdictions were categorized as those 1) with widespread local transmission of Zika virus; 2) with limited local transmission of Zika virus; and 3) without local transmission of Zika virus. Among 2,004,630 live births, 3,359 infants and fetuses with birth defects potentially related to Zika virus infection during pregnancy were identified (1.7 per 1,000 live births, 95% confidence interval [CI] = 1.6-1.7). In areas with widespread local Zika virus transmission, the prevalence of birth defects potentially related to Zika virus infection during pregnancy was significantly higher during the quarters comprising July 2016-March 2017 (July-September 2016 = 3.0; October-December 2016 = 4.0; and January-March 2017 = 5.6 per 1,000 live births) compared with the reference period (January-March 2016) (1.3 per 1,000). These findings suggest a fourfold increase (prevalence ratio [PR] = 4.1, 95% CI = 2.1-8.4) in birth defects potentially related to Zika virus in widespread local transmission areas during January-March 2017 compared with that during January-March 2016, with the highest prevalence (7.0 per 1,000 live births) in February 2017. Population-based birth defects surveillance is critical for identifying infants and fetuses with birth defects potentially related to Zika virus regardless of whether Zika virus testing was conducted, especially given the high prevalence of asymptomatic disease. These data can be used to inform follow-up care and services as well as strengthen surveillance., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

In May 2018, a study of birth defects in infants born to women with diagnosed human immunodeficiency virus (HIV) infection in Botswana reported an eightfold increased risk for neural tube defects (NTDs) among births with periconceptional exposure to antiretroviral therapy (ART) that included the integrase inhibitor dolutegravir (DTG) compared with other ART regimens (1). The World Health Organization* (WHO) and the U.S. Department of Health and Human Services † (HHS) promptly issued interim guidance limiting the initiation of DTG during early pregnancy and in women of childbearing age with HIV who desire pregnancy or are sexually active and not using effective contraception. On the basis of additional data, WHO now recommends DTG as a preferred treatment option for all populations, including women of childbearing age and pregnant women. Similarly, the U.S. recommendations currently state that DTG is a preferred antiretroviral drug throughout pregnancy (with provider-patient counseling) and as an alternative antiretroviral drug in women who are trying to conceive. § Since 1981 and 1994, CDC has supported separate surveillance programs for HIV/acquired immunodeficiency syndrome (AIDS) (2) and birth defects (3) in state health departments. These two surveillance programs can inform public health programs and policy, linkage to care, and research activities. Because birth defects surveillance programs do not collect HIV status, and HIV surveillance programs do not routinely collect data on occurrence of birth defects, the related data have not been used by CDC to characterize birth defects in births to women with HIV. Data from these two programs were linked to estimate overall prevalence of NTDs and prevalence of NTDs in HIV-exposed pregnancies during 2013-2017 for 15 participating jurisdictions. Prevalence of NTDs in pregnancies among women with diagnosed HIV infection was 7.0 per 10,000 live births, similar to that among the general population in these 15 jurisdictions, and the U.S. estimate based on data from 24 states. Successful linking of data from birth defects and HIV/AIDS surveillance programs for pregnancies among women with diagnosed HIV infection suggests that similar data linkages might be used to characterize possible associations between maternal diseases or maternal use of medications, such as integrase strand transfer inhibitors used to manage HIV, and pregnancy outcomes. Although no difference in NTD prevalence in HIV-exposed pregnancies was found, data on the use of integrase strand transfer inhibitors in pregnancy are needed to understand the safety and risks of these drugs during pregnancy., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objectives: Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission., Design: Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013., Setting: LTAC hospitals., Participants: Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital., Measurements: Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation., Results: Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation., Conclusion: Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019., (© 2019 The American Geriatrics Society.)

Purpose: Stent omission after routine ureteroscopy (rtURS) is accepted by current guidelines and may result in decreased patient morbidity and treatment costs. In a value-based healthcare model, the added morbidity and cost of routine stent placement may be scrutinized. Furthermore, data are limited on urologist cost knowledge and it is effect on ureteral stent placement. As such, we seek to describe ureteral stenting practices and urologist cost knowledge amongst US and non-US-based urologists., Methods: The ureteroscopic practice patterns and cost awareness of members of the Endourological Society were surveyed using an international email listserv. Respondents were grouped by practice location (US vs non-US). Logistic regression was used to evaluate the associations of surgeon practice location with stenting practices., Results: 233 completed responses were received with a response rate of 13.5%. Results revealed that 55% and 71% of respondents reported ureteral stent insertion after rtURS more than 75% of the time for ureteral and renal stones, respectively. Reporting stent insertion following more than 75% of rtURS was more common among US participants for both ureteral and renal stones. Overall, reported cost knowledge was high, but lower among US participants. On multivariable analysis, US respondents were more likely to place ureteral stents after rtURS for ureteral stones more than 75% of the time when compared to those abroad (OR 3.43 p < 0.01)., Conclusion: Ureteral stenting after rtURS is over utilized in the US compared to other countries. While this phenomenon is multifactorial in nature, cost knowledge may be under recognized as a determinant of ureteral stent placement following rtURS.

Background and Objectives: Resection of primary retroperitoneal sarcomas (RPS) has a high incidence of recurrence. This study aims to identify patterns of recurrence and its impact on overall survival., Methods: Adult patients with primary retroperitoneal soft tissue sarcomas who underwent resection in 2000-2016 at eight institutions of the US Sarcoma Collaborative were evaluated., Results: Four hundred and ninety-eight patients were analyzed, with 56.2% (280 of 498) having recurrences. There were 433 recurrences (1-8) in 280 patients with 126 (25.3%) being locoregional, 82 (16.5%) distant, and 72 (14.5%) both locoregional and distant. Multivariate analyses revealed the following: Patient age P = .0002), tumor grade (P = .02), local recurrence (P = .0003) and distant recurrence (P < .0001) were predictors of disease-specific survival. The 1-, 3-, and 5-year survival rate for patients who recurred vs not was 89.6% (standard error [SE] 1.9) vs 93.5% (1.8), 66.0% (3.2) vs 88.4% (2.6), and 51.8% (3.6) vs 83.9% (3.3), respectively, P < .0001. Median survival was 5.3 years for the recurrence vs 11.3+ years for the no recurrence group (P < .0001). Median survival from the time of recurrence was 2.5 years., Conclusions: Recurrence after resection of RPS occurs in more than half of patients independently of resection status or perioperative chemotherapy and is equally distributed between locoregional and distant sites. Recurrence is primarily related to tumor biology and is associated with a significant decrease in overall survival., (© 2019 Wiley Periodicals, Inc.)

Background & Aims: There is controversy over the effects of direct-acting antiviral (DAA) therapies for hepatitis C virus (HCV) infection on hepatocellular carcinoma (HCC) recurrence and tumor aggressiveness. We compared HCC recurrence patterns between DAA-treated and untreated HCV-infected patients who had achieved a complete response to HCC treatment in a North American cohort., Methods: We conducted a retrospective cohort study of patients with HCV-related HCC with a complete response to resection, local ablation, transarterial chemo- or radioembolization, or radiation therapy from January 2013 through December 2017 at 31 health systems throughout the United States and Canada. Cox regression was used to examine the association between DAA therapy and time to recurrence after a complete response, with DAA therapy analyzed as a time-varying exposure. We also estimated the association between DAA therapy and risk of early HCC recurrence (defined as 365 days after complete response)., Results: Of 793 patients with HCV-associated HCC, 304 (38.3%) received DAA therapy and 489 (61.7%) were untreated. HCC recurred in 128 DAA-treated patients (42.1%; early recurrence in 52 patients) and 288 untreated patients (58.9%; early recurrence in 227 patients). DAA therapy was not associated with HCC recurrence (hazard ratio 0.90, 95% confidence interval 0.70-1.16) or early HCC recurrence (hazard ratio 0.96, 95% confidence interval 0.70-1.34) after we adjusted for study site, age, sex, Child-Pugh score, α-fetoprotein level, tumor burden, and HCC treatment modality. In DAA-treated and untreated patients, most recurrences were within the Milan criteria (74.2% vs 78.8%; P = .23). A larger proportion of DAA-treated than untreated patients received potentially curative HCC therapy for recurrent HCC (32.0% vs 24.6%) and achieved a complete or partial response (45.3% vs 41.0%) but this did not achieve statistical significance., Conclusion: In a large cohort of North American patients with complete response to HCC treatment, DAA therapy was not associated with increased overall or early HCC recurrence. HCC recurrence patterns, including treatment response, were similar in DAA-treated and untreated patients., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The management of chronic hepatitis B patients is not well characterized in real-world practice. We compared baseline characteristics of CHB patients on entecavir, the frequency of on-treatment monitoring, and the effectiveness of ETV treatment between academic and community practices., Methods: Treatment-naïve CHB patients ≥18 years old, treated with ETV for ≥12 months from 2005 to 2013, in 26 community and academic practices throughout the USA were retrospectively evaluated., Results: Of 841 patients enrolled, 658 (65% male, 83% Asian, median age 47, 9% with cirrhosis) met inclusion criteria. Half of the patients (52%) were from community practices. A lower percentage of patients in community practices had cirrhosis or liver cancer (5 vs. 14%). Community practices more often treated patients with baseline ALT < 2 × ULN. Over a median follow-up of 4 years, community practices were more likely to discontinue ETV with less frequent laboratory monitoring compared to academic practices. The 5-year cumulative probability of ALT normalization was greater among patients treated in community practices (70 vs. 50%, p < 0.001), but the 5-year cumulative probability of undetectable HBV DNA was lower (45 vs. 70%, p < 0.001) than those treated in academic practices., Conclusion: Academic practices saw CHB patients with more advanced liver disease, more often followed AASLD guidelines, and monitored patients on ETV treatment more frequently than community practices. While patients in community practices were less likely to achieve undetectable HBV DNA and more likely to achieve ALT normalization, the rates of HBeAg loss and seroconversion as well as HBsAg loss were similar.

Prevalence of gastroschisis, a serious birth defect of the abdominal wall resulting in some of the abdominal contents extending outside the body at birth, has been increasing worldwide (1,2). Gastroschisis requires surgical repair after birth and is associated with digestive and feeding complications during infancy, which can affect development. Recent data from 14 U.S. states indicated an increasing prevalence of gastroschisis from 1995 to 2012 (1). Young maternal age has been strongly associated with gastroschisis, but research suggests that risk factors such as smoking, genitourinary infections, and prescription opioid use also might be associated (3-5). Data from 20 population-based state surveillance programs were pooled and analyzed to assess age-specific gastroschisis prevalence during two 5-year periods, 2006-2010 and 2011-2015, and an ecologic approach was used to compare annual gastroschisis prevalence by annual opioid prescription rate categories. Gastroschisis prevalence increased only slightly (10%) from 2006-2010 to 2011-2015 (prevalence ratio = 1.1, 95% confidence interval [CI] = 1.0-1.1), with the highest prevalence among mothers aged <20 years. During 2006-2015, the prevalence of gastroschisis was 1.6 times higher in counties with high opioid prescription rates (5.1 per 10,000 live births; CI = 4.9-5.3) and 1.4 times higher where opioid prescription rates were medium (4.6 per 10,000 live births; CI = 4.4-4.8) compared with areas with low prescription rates (3.2 per 10,000 live births; CI = 3.1-3.4). Public health research is needed to understand factors contributing to the association between young maternal age and gastroschisis and assess the effect of prescription opioid use during pregnancy on this pregnancy outcome., Competing Interests: All authors have completed and submitted the ICMJE form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Objectives: Chronic infection with hepatitis C virus (HCV) was previously the leading indication for liver transplant (LT) in the United States. However, since 2014 the use of direct-acting antivirals (DAAs) has decreased the chronic HCV burden, while the prevalence of nonalcoholic steatohepatitis (NASH) has risen substantially through the last decade. Both gender and ethnic disparities in indications for LT have been shown in the past but no data on this have been reported since the implementation of DAAs., Methods: We assessed changes in etiologies for LT listing and in gender and ethnic differences in those listed for LT. Adult patients registered for LT in the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between January 1, 2004 and December 31, 2016 were included. Multinomial logistic regression modeling was used to test for changes in waitlist or liver transplant rates., Results: The study included 127,164 adult patients registered for LT. By 2016, alcoholic liver disease (ALD) was the leading etiology for waitlisting and LT; NASH was second; hepatocellular carcinoma (HCC) due to chronic HCV and chronic HCV alone were 3rd and 4th. NASH was the leading cause for LT for women and the 2nd leading cause for men (following ALD). NASH increased as the cause in all ethnic subgroups and was the leading cause in 2016 among Asian, Hispanic, and non-Hispanic white females. We also found that although the indication for liver transplant for hepatocellular carcinoma (HCC) due to HCV has increased over the years, this indication decreased for the first time between 2015 and 2016 in both males and females., Conclusions: NASH is currently the second leading cause for LT waitlist registration/liver transplantation overall, and in females, the leading cause. Given the rate of increase, NASH will likely rise to become the leading indication for LT in males as well.

Background: Surgical resection is the cornerstone of curative-intent therapy for patients with hilar cholangiocarcinoma (HC). The role of vascular resection (VR) in the treatment of HC in western centres is not well defined., Methods: Utilizing data from the U.S. Extrahepatic Biliary Malignancy Consortium, patients were grouped into those who underwent resection for HC based on VR status: no VR, portal vein resection (PVR), or hepatic artery resection (HAR). Perioperative and long-term survival outcomes were analyzed., Results: Between 1998 and 2015, 201 patients underwent resection for HC, of which 31 (15%) underwent VR: 19 patients (9%) underwent PVR alone and 12 patients (6%) underwent HAR either with (n = 2) or without PVR (n = 10). Patients selected for VR tended to be younger with higher stage disease. Rates of postoperative complications and 30-day mortality were similar when stratified by vascular resection status. On multivariate analysis, receipt of PVR or HAR did not significantly affect OS or RFS., Conclusion: In a modern, multi-institutional cohort of patients undergoing curative-intent resection for HC, VR appears to be a safe procedure in a highly selected subset, although long-term survival outcomes appear equivalent. VR should be considered only in select patients based on tumor and patient characteristics., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objectives: Our objective was to evaluate and exploit a whole genome sequence (WGS) bioinformatics pipeline for predicting antimicrobial resistance and capsular serotypes from invasive group B streptococci (iGBS)., Methods: For 1975 iGBS recovered during 2015 from CDC's Active Bacterial Core surveillance, we compared pipeline predictions with broth dilution testing. Fifty-six isolates from earlier surveillance were included for testing β-lactams. Conventional serotyping was compared to WGS-based assignments for 302 isolates., Results: All 28 isolates with reduced susceptibility to β-lactam antibiotics harboured one of 19 rare PBP2x types. Resistances to erythromycin/clindamycin (808/1975 isolates, 41.0%), erythromycin (235/1975, 11.9%) and lincosamide/streptogramin A/pleuromutilins (56/1975, 2.8%) were predicted by the presence of erm-methylase, mef and lsa determinants, respectively (41 of 56 lsa gene-positive isolates also contained lnu, erm and/or mef genes). Presence of both erm and lsa determinants (25 isolates) predicted non-susceptibility to quinupristin/dalfopristin. Most isolates (1680/1975, 85.1%) were tet gene-positive, although 41/1565 (2.6%) tetM-positive isolates were tetracycline-susceptible. All 53 fluoroquinolone-resistant isolates contained ParC and/or GyrA substitutions. Resistances to rifampin (eight isolates), trimethoprim, chloramphenicol and vancomycin (two isolates each) were predicted by the pipeline. Resistance to macrolides/lincosamides without pipeline prediction was rare and correlated to divergent resistance genes or rRNA A2062G substitution. A selection of 267 isolates assigned WGS-based serotypes were also conventionally serotyped. Of these, 246 (92.1%) were in agreement, with the remaining 21 (7.8%) conventionally non-serotypeable. For 32 of 1975 isolates (1.6%), WGS-based serotypes could not be assigned., Conclusion: The WGS-based assignment of iGBS resistance features and serotypes is an accurate substitute for phenotypic testing., (Published by Elsevier Ltd.)

Background: Healthcare organizations and their employees are critical role models for healthy living in their communities. The American Heart Association (AHA) 2020 impact goal provides a national framework that can be used to track the success of employee wellness programs with a focus on improving cardiovascular (CV) health. This study aimed to assess the CV health of the employees of Baptist Health South Florida (BHSF), a large nonprofit healthcare organization., Hypothesis: HRAs and wellness examinations can be used to measure the cardiovascular health status of an employee population., Methods: The AHA's 7 CV health metrics (diet, physical activity, smoking, body mass index, blood pressure, total cholesterol, and blood glucose) categorized as ideal, intermediate, or poor were estimated among employees of BHSF participating voluntarily in an annual health risk assessment (HRA) and wellness fair. Age and gender differences were analyzed using χ(2) test., Results: The sample consisted of 9364 employees who participated in the 2014 annual HRA and wellness fair (mean age [standard deviation], 43 [12] years, 74% women). Sixty (1%) individuals met the AHA's definition of ideal CV health. Women were more likely than men to meet the ideal criteria for more than 5 CV health metrics. The proportion of participants meeting the ideal criteria for more than 5 CV health metrics decreased with age., Conclusions: A combination of HRAs and wellness examinations can provide useful insights into the cardiovascular health status of an employee population. Future tracking of the CV health metrics will provide critical feedback on the impact of system wide wellness efforts as well as identifying proactive programs to assist in making substantial progress toward the AHA 2020 Impact Goal., (© 2015 Wiley Periodicals, Inc.)

For years, we have relied on population surveys to keep track of regional public health statistics, including the prevalence of non-communicable diseases. Because of the cost and limitations of such surveys, we often do not have the up-to-date data on health outcomes of a region. In this paper, we examined the feasibility of inferring regional health outcomes from socio-demographic data that are widely available and timely updated through national censuses and community surveys. Using data for 50 American states (excluding Washington DC) from 2007 to 2012, we constructed a machine-learning model to predict the prevalence of six non-communicable disease (NCD) outcomes (four NCDs and two major clinical risk factors), based on population socio-demographic characteristics from the American Community Survey. We found that regional prevalence estimates for non-communicable diseases can be reasonably predicted. The predictions were highly correlated with the observed data, in both the states included in the derivation model (median correlation 0.88) and those excluded from the development for use as a completely separated validation sample (median correlation 0.85), demonstrating that the model had sufficient external validity to make good predictions, based on demographics alone, for areas not included in the model development. This highlights both the utility of this sophisticated approach to model development, and the vital importance of simple socio-demographic characteristics as both indicators and determinants of chronic disease.

The purpose of the study is (1) to compare the effects of factors on self-rated health (SRH) among older non-Hispanic Whites (NHW), Hispanic, and Asian Californians and (2) to provide estimated influence size of each factor on SRH. This study analyzed secondary data drawn from the 2005 California Health Interview Survey. Binary logit regressions were used to analyze data with the Jackknife replication sampling weights. Significant differences were found in SRH among the three groups. Hispanics and Asians reported poorer health than NHW. Socioeconomic status, acculturation, and health access significantly accounted for an association between ethnicity and SRH. However, the magnitudes of their effects on SRH varied across the groups and by the factors examined. This study discusses and concludes with some recommendations on the opportunities presented by the Affordable Care Act and Healthy People 2020.

Background: There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior., Objective: To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers., Methods and Results: In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications., Conclusions: When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications., (©2014 Wiley Periodicals, Inc.)

Small cell, neuroendocrine tumors, and melanoma of the anus are rare. Limited data exist on the incidence and management for these rare tumors. A large, prospective, population-based database was used to determine incidence and survival patterns of rare anal neoplasms. The Surveillance, Epidemiology and End Results registry was queried to identify patients diagnosed with anal canal neoplasms. Incidence and survival patterns were evaluated with respect to age, sex, race, histology, stage, and therapy. We identified 7078 cases of anal canal neoplasms: melanoma (n = 149), neuroendocrine (n = 61), and small cell neuroendocrine (n = 26). Squamous cell carcinoma (SCC) (n = 6842) served as the comparison group. Anal melanoma (AM) demonstrated the lowest survival rate at 2.5 per cent. Neuroendocrine tumors (NETs) demonstrated similar survival as SCC (10-year survival for regional disease of 25 and 22.3%, respectively). Ten-year survival of small cell NETs resembled AM (5.3 vs 2.5%). Age 60 years or older, sex, black race, stage, and surgery were independent predictors of survival. This study presents the largest patient series of rare anal neoplasms. NETs of the anal canal demonstrate similar survival patterns to SCC, whereas small cell NETs more closely resemble AM. Accurate histologic diagnosis is vital to determine treatment and surgical management because survival patterns can differ among rare anal neoplasms.

Cigarette smoking is a serious global public health issue, and is particularly harmful to the maternal and child population. The study aimed to determine if there was an association between smoking cessation intervention during pregnancy and postpartum smoking relapse, and to define a time trend of postpartum smoking relapse after delivery. Data from the 2004-2008 pregnancy risk assessment monitoring systems of Colorado, Maine, Ohio, and Washington were analyzed. Logistic regression was used to define the association between smoking cessation intervention and postpartum smoking relapse, and to identify trend of postpartum smoking relapse. Analyses were done using SAS-Callable SUDAAN v.10.0 and Mplus v.6.0. Among the 2,938 women in the study the relapse rate was 48 %. It was 45 % among those without intervention, 58 % among those who received only counseling, and 57 % among those who received both counseling with treatment and/or referral. The rate was 42, 61, and 67 % among women whose infants were at 2-3, 4-5, and 6 months or more, respectively. Adjusted logistic regression models showed a trend of increased smoking relapse, but did not indicate an association between smoking cessation intervention and smoking relapse. Rates of smoking relapse were high and increased by time after delivery. Smoking cessation intervention during pregnancy may not be successful at preventing postpartum smoking relapse.

Objectives/hypothesis: To report tolerance and toxicity of radiotherapy (RT) with or without chemotherapy in HIV seropositive patients with squamous cell carcinoma of the head and neck (SCCHN)., Methods: This is a single institution retrospective study of 73 HIV seropositive patients with SCCHN treated from January 1997 through 2010. Stages I, II, III, and IV were 8%, 10%, 24%, and 58%, respectively. The median age at RT, HIV diagnosis. and the duration of HIV seropositive were 51 (32-72), 34 (25-50), and 11 (6-20) years, respectively. Patients were treated definitively with RT alone (35%) or concurrent chemo-RT (65%). Median dose of 70 Gy (66-70) was delivered to the gross disease. Median duration of treatment was 52 (49-64) days. Fifty patients (70%) were on HAART., Results: RT± chemotherapy induced acute toxicity was: median weight loss 20 pounds (6-40), 100% developed dysgeusia and xerostomia (grades 1-3). Acute mucositis and dysphagia/odynophagia grades ≤ 2 and 3 were 83% and 17%, respectively. Treatment breaks in excess of 10, 7, and 3 days were found in 5%, 13%, and 15% of patients, respectively. With a median follow-up of 4 years (2-12) the RT ±chemotherapy induced late dysphagia and xerostomia grades >2 were 26% and 23% of patients, respectively., Conclusion: Our data show that primary RT ±chemotherapy for HIV seropositive SCCHN is less tolerated compared to the historical data for SCCHN without HIV., Level of Evidence: 2b., (Copyright © 2013 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objective: To prospectively evaluate relationships among serum cytokine levels, innate immune responsiveness, and mortality in a multicenter cohort of critically ill children with influenza infection., Design: Prospective, multicenter, observational study., Setting: Fifteen pediatric ICUs among members of the Pediatric Acute Lung Injury and Sepsis Investigators network., Patients: Patients ≤18 yrs old admitted to a PICU with community-acquired influenza infection. A control group of outpatient children was also evaluated., Interventions: ICU patients underwent sampling within 72 hrs of ICU admission for measurement of a panel of 31 serum cytokine levels and quantification of whole blood ex vivo lipopolysaccharide-stimulated tumor necrosis factor-α production capacity using a standardized stimulation protocol. Outpatient control subjects also underwent measurement of tumor necrosis factor-α production capacity., Measurements and Main Results: Fifty-two patients (44 survivors, eight deaths) were sampled. High levels of serum cytokines (granulocyte macrophage colony-stimulating factor, interleukin-6, interleukin-8, interferon-inducible protein-10, monocyte chemotactic protein-1, and macrophage inflammatory protein-1α) were associated with mortality (p < 0.0016 for each comparison) as was the presence of secondary infection with Staphylococcus aureus (p = 0.007), particularly methicillin-resistant S. aureus (p < 0.0001). Nonsurvivors were immunosuppressed with leukopenia and markedly reduced tumor necrosis factor-α production capacity compared with outpatient control subjects (n = 21, p < 0.0001) and to ICU survivors (p < 0.0001). This association remained after controlling for multiple covariables. A tumor necrosis factor-α response <250 pg/mL was highly predictive of death and longer duration of ICU stay (p < 0.0001). Patients with S. aureus coinfection demonstrated the greatest degree of immunosuppression (p < 0.0001)., Conclusions: High serum levels of cytokines can coexist with marked innate immune suppression in children with critical influenza. Severe, early innate immune suppression is highly associated with both S. aureus coinfection and mortality in this population. Multicenter innate immune function testing is feasible and can identify these high-risk children.

According to recent studies, over 50% of the general population (and nearly 70% of military personnel) report regular use of dietary supplements (DS). Military personnel may be at greater risk for adverse reactions to DS because of operational environments and stressors (extreme heat, altitude, or sleep deprivation) associated with military deployments and training. As a recent example, the Department of Defense placed a medical hold on all DS containing the ingredient 1,3-dimethylamylamine in response to several fatalities linked to the use of this product. This study investigated product certification for DS in military commissaries (grocery stores), exchanges (department stores), and civilian retail stores. Overall, only 12% of the available products were certified by an independent scientific agency. Consumers should be aware that most over-the-counter DS do not have independent certification of product integrity. Although "third-party certification" does not ensure DS safety or effectiveness, it is important that consumers and health care providers are made aware that such product screening takes place, to help patients make more informed decisions about the purchase and use of DS.

Differences in definitions and methods of data collection on deaths occurring during or shortly after pregnancy have created confusion and challenges in evaluating research findings. The study aimed to determine if the use of enhanced linkage procedures improve data collection of deaths occurring during or shortly after pregnancy, and how different definitions of those deaths changed the results of data analysis. The study used 2000-2005 Louisiana Pregnancy Mortality Surveillance System (LPMSS) and 2000-2005 death certificates linked with 1999-2005 live birth and fetal death certificates. Five indicators of deaths occurring during or shortly after pregnancy using WHO and CDC/ACOG definitions were estimated. One-sided Spearman rank test was used to analyze maternal mortality trends from 2000 to 2005. Of 345 women who died within 1 year of pregnancy, 187 were identified through linkage; 38 of those were missed by the LPMSS. Total mortality ratios of deaths occurring within 1 year of pregnancy ranged from 13.4 to 88.9 per 100,000 live births depending on the indicator used. CDC/ACOG pregnancy-related death and pregnancy-associated death statistically increased, whereas WHO pregnancy-related death decreased between 2000 and 2005. The most common causes of death differed by indicator. Universal adoption of linkage procedures could improve data on deaths occurring during or shortly after pregnancy. Estimates, trends, and most common causes of death were markedly different depending on which indicator was used. Additionally, the use of different mortality indicators during analysis provides a more detailed picture of potential target areas for future research and interventions.

This is a prospective study to evaluate ability of a nurse care coordinator to: (1) improve ability of a pediatric clinic to meet medical home (MH) objectives and (2) improve receipt of services for families of children with special health care needs (CSHCN). A nurse was hired to provide care coordination for CSHCN in an urban, largely Medicaid pediatric academic practice. CSHCN were identified using a CSHCN Screener. Ability to meet MH criteria was determined using the MH Index (MHI). Receipt of MH services was measured using the MH Family Index (MHFI). After baseline surveys were completed, Hurricane Katrina destroyed the clinic. Care coordination was implemented for the post-disaster population. Surveys were repeated in the rebuilt clinic after at least 3 months of care coordination. The distribution of demographics, diagnoses and percent CSHCN did not significantly change pre and post Katrina. Psychosocial needs such as food, housing, mental health and education were markedly increased. Essential strategies included developing a new tool for determining complexity of needs and involvement of the entire practice in care coordination activities. MHFI showed improvement in receipt of services post care coordination and post-Katrina with P < 0.05 for 13 of 16 questions. MHI demonstrated improvement in care coordination and community outreach domains. Average cost was $36.88 per CSHCN per year. There was significant improvement in the ability of the clinic to meet care coordination and community outreach MH criteria and in family receipt of services after care coordination, despite great increase in psychosocial needs. This study provides practical strategies for implementing care coordination for families of high risk CSHCN in underserved populations.

Objective: To demonstrate the efficacy of once-daily extended release quetiapine fumarate (quetiapine XR) versus placebo in adults with acute exacerbation of schizophrenia., Methods: A 6-week, double-blind, randomized, placebo-controlled study. In- or out-patients with a DSM-IV diagnosis of schizophrenia were randomized to fixed-dose quetiapine XR 400, 600, or 800 mg/day, quetiapine immediate release (IR) 800 mg/day, or placebo. Primary endpoint was change from baseline in Positive and Negative Syndrome Scale (PANSS) total score at Week 6. Other efficacy assessments included Clinical Global Impressions (CGI) of Severity (CGI-S) and of Improvement (CGI-I) ratings. Safety assessments included adverse event (AE) reporting and laboratory measures., Results: 565 patients were randomized; 333 (58.9%) completed the study. Greater numeric improvements in PANSS total score were seen for quetiapine XR (all doses) and quetiapine IR versus placebo at Week 6; the differences were not statistically significant. Secondary efficacy endpoint results were similar. There was not a high placebo response in this study, but rather an attenuation of drug effect. In general, quetiapine XR was well tolerated over 6-weeks' treatment; there were no unexpected AEs., Conclusion: The efficacy of quetiapine XR (400, 600, and 800 mg/day) was not established at Week 6. Quetiapine IR, an agent with established efficacy in schizophrenia, also did not separate from placebo at endpoint. Therefore, this is considered a failed study and possible reasons for this are discussed. Quetiapine XR was generally well tolerated and its safety profile was consistent with the known profile of quetiapine.