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Introduction Smoking and smoke exposure among pregnant women remain persistent public health issues. Recent estimates suggest that approximately one out of four nonsmokers have measurable levels of cotinine, a marker indicating regular exposure to secondhand smoke. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy. However, most of these studies have relied upon self-reported measures of smoking. Aims and Methods To more accurately assess smoke exposure resulting from both smoking and secondhand exposure in mothers during pregnancy, we used Bayesian regression models to estimate the association of cotinine levels with tobacco retail outlet (TRO) exposure and a neighborhood deprivation index (NDI) in six counties in North Carolina centered on Durham County. Results Results showed a significant positive association between TRO exposure (β = 0.008, 95% credible interval (CI) = [0.003, 0.013]) and log cotinine after adjusting for individual covariates (eg, age, race/ethnicity, education, marital status). TRO exposure was not significant after including the NDI, which was significantly associated with log cotinine (β = 0.143, 95% CI = [0.030, 0.267]). However, in a low cotinine stratum (indicating secondhand smoke exposure), TRO exposure was significantly associated with log cotinine (β = 0.005, 95% CI = [0.001, 0.009]), while in a high cotinine stratum (indicating active smoking), the NDI was significantly associated with log cotinine (β = 0.176, 95% CI = [0.005, 0.372]). Conclusions In summary, our findings add to the evidence that contextual factors are important for active smoking during pregnancy. Implications In this study, we found several significant associations that suggest a more nuanced understanding of the potential influence of environmental- and individual-level factors for levels of prenatal smoke exposure. Results suggested a significant positive association between TRO exposure and cotinine levels, after adjusting for the individual factors such as race, education, and marital status. Individually, NDI was similarly positively associated with cotinine levels as well. However, when combining TRO exposure alongside NDI in the same model, TROs were no longer significantly associated with overall cotinine levels.

Leukemia is the most common childhood cancer in industrialized countries, and the increasing incidence trends in the US suggest that environmental exposures play a role in its etiology. Neighborhood socioeconomic status (SES) has been found to be associated with many health outcomes, including childhood leukemia. In this paper, we used a Bayesian index model approach to estimate a neighborhood deprivation index (NDI) in the analysis of childhood leukemia in a population-based case-control study (diagnosed 1999 to 2006) in northern and central California, with direct indoor measurements of many chemicals for 277 cases and 306 controls

(1) Purpose: To assess the survival benefit for different times to adjuvant chemotherapy after a radical cystectomy. (2) Materials and Methods: We systematically searched PubMed®, Cochrane Central®, Scopus®, and Web of Science® library databases for original articles that looked at timing to adjuvant chemotherapy after radical cystectomy. Primary endpoints were five-year survival, progression free survival, and overall survival. Available multivariable hazard ratios and corresponding 95% CIs were included in the qualitative analysis. The risk of bias was completed for nonrandomized studies. (3) Results: Using PRISMA guidelines, our electronic search resulted in a total of 1862 records. After a detailed review, we selected four studies that addressed the impact of the timing of adjuvant chemotherapy for patients who underwent radical cystectomy. (4) Conclusion: A survival benefit was seen with an earlier administration of adjuvant chemotherapy, albeit a benefit persists for delayed chemotherapy post-radical cystectomy. A safe and ethical approach at this time would be to administer adjuvant chemotherapy as early in the postoperative period as possible, given the known survival benefit of such therapy (9–11% absolute survival benefit at five years).

The exposome is an ideal in public health research that posits that individuals experience risk for adverse health outcomes from a wide variety of sources over their lifecourse. There have been increases in data collection in the various components of the exposome, but novel statistical methods are needed that capture multiple dimensions of risk at once. We introduce a Bayesian index low-rank kriging (LRK) multiple membership model (MMM) to simultaneously estimate the health effects of one or more groups of exposures, the relative importance of exposure components, and cumulative spatial risk over time using residential histories. The model employs an MMM to consider all residential locations for subjects weighted by duration and LRK to increase computational efficiency. We demonstrate the performance of the Bayesian index LRK-MMM through a simulation study, showing that the model accurately and consistently estimates the health effects of one or several group indices and has high power to identify a region of elevated spatial risk due to unmeasured environmental exposures. Finally, we apply our model to data from a multicenter case-control study of non-Hodgkin lymphoma (NHL), finding a significant positive association between one index of pesticides and risk for NHL in Iowa. Additionally, we find an area of significantly elevated spatial risk for NHL in Los Angeles. In conclusion, our Bayesian index LRK-MMM represents a step forward toward bringing the ideals of the exposome into practice for environmental risk analyzes.

Electronic health records (EHRs) have provided physicians with a systematic framework for collecting patient data, organizing notes from the healthcare team, and managing the daily workflow in the modern era of healthcare. Despite these advantages, EHRs have proven to be problematic for clinicians. The burdensome regulations requiring increased documentation with the EHR paradigm have led to inefficiencies from data-entry requirements forcing physicians to spend an inordinate amount of time on it, affecting the time available for direct patient care as well as leading to professional burnout. As a result, new modalities such as speech recognition, medical scribes, pre-made EHR templates, and digital scribes [a form of artificial intelligence (AI) based on ambient speech recognition] are increasingly being used to reduce charting time and increase the time available for patient care. The purpose of our review is to provide an up-to-date review of the literature on these modalities including their benefits and shortcomings, to help physicians and other medical professionals choose the best methods to document their patient-care encounters efficiently and effectively.

Anna H Green,1 Julianne M Forlizzi,2 Joseph Boyle,3 Wilfrido J Castillo,3 Daniel Mascarenhas,1 Meizhen Yao,4 Geza Kiss,5 Carlos Sagebien1 1Department of Orthopedic Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USA; 2Department of Orthopedic Surgery, OrthoConnecticut, Norwalk, CT, USA; 3Rutgers Robert Wood Johnson University School of Medicine, New Brunswick, NJ, USA; 4Rutgers University Biostatistics and Epidemiology Services Center, New Brunswick, NJ, USA; 5Department of Anesthesiology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ, USACorrespondence: Anna H Green, Department of Orthopedic Surgery, Rutgers Robert Wood Johnson University Hospital, 1 RWJ Place, MEB 422A, New Brunswick, NJ, 08901, USA, Tel +1 571 228 2234, Fax +1 732 235 6002, Email annagreen7@gmail.comPurpose: To estimate the risk of hospital-acquired COVID-19 transmission in a population of orthopaedic trauma patients during the first wave of the pandemic.Patients and Methods: This is a retrospective cohort study of 109 patients who underwent an emergent orthopedic procedure by a single orthopedic traumatologist between March 1, 2020 and May 15, 2020 during the first peak of the pandemic. After applying inclusion and exclusion criteria, a total of 82 patients (67 inpatients and 15 ambulatory) were identified for final analysis. The primary outcome measured was postoperative Coronavirus (COVID-19) status. Secondary outcome measures included length of stay and discharge disposition.Results: The mean age and length of stay in the hospital group was 59.5 years (± 21.7) and 4.3 days (± 4.6), respectively, versus 47.9 years (± 9.8) in the ambulatory group. 7.3% (6/82) of the inpatients subsequently tested or screened positive for COVID-19 at 2 weeks post-operatively, compared to 0/15 ambulatory patients (P=0.58). Of the 6 inpatients who tested positive, 4 (66.7%) were discharged to a rehabilitation center. Diabetes (P=0.05), hypertension (P=0.02), and congestive heart failure (P=0.005) were associated with transmission.Conclusion: In this analysis, there was a nosocomial transmission rate of 7% compared to zero in the ambulatory surgery center, however this was not found to be statistically significant. This data supports the use of precautions such as frequent screening, hand washing, and masks to reduce transmission when COVID-19 rates are high. There is a lower risk of nosocomial COVID-19 transmission for patients treated as an outpatient and elective surgical procedures may be safer in this setting.Keywords: coronavirus, pandemic, infection, hospital transmission

Many health outcomes result from accumulated exposures to one or more environmental factors. Accordingly, spatial risk studies have begun to consider multiple residential locations of participants, acknowledging that participants move and thus are exposed to environmental factors in several places. However, novel methods are needed to estimate cumulative spatial risk for disease while accounting for other risk factors. To this end, we propose a Bayesian model (LRK-MMM) that embeds a multiple membership model (MMM) into a low-rank kriging (LRK) model in order to estimate cumulative spatial risk at the point level while allowing for multiple residential locations per subject. The LRK approach offers a more computationally efficient means to analyze spatial risk in case-control study data at the point level compared with a Bayesian generalized additive model, and as increased precision in spatial risk estimates by analyzing point locations instead of administrative areas. Through a simulation study, we demonstrate the efficacy of the model and its improvement upon an existing multiple membership model that uses area-level spatial random effects to estimate risk. The results show that our proposed method provides greater spatial sensitivity (improvements ranging from 0.12 to 0.54) and power (improvements ranging from 0.02 to 0.94) to detect regions of elevated risk for disease across a range of exposure scenarios. Finally, we apply our model to case-control data from the New England bladder cancer study to estimate cumulative spatial risk while adjusting for many covariates.

More than 30% of cancer related deaths are related to tobacco or alcohol use. Controlling and restricting access to these cancer-causing products, especially in communities where there is a high prevalence of other cancer risk factors, has the potential to improve population health and reduce the risk of specific cancers associated with these substances in more vulnerable population subgroups. One policy-driven method of reducing access to these cancer-causing substances is to regulate where these products are sold through the placement and density of businesses selling tobacco and alcohol. Previous work has found significant positive associations between tobacco, alcohol, and tobacco and alcohol retail outlets (TRO, ARO, TARO) and a neighborhood disadvantage index (NDI) using Bayesian shared component index modeling, where NDI associations differed across outlet types and relative risks varied by population density (e.g., rural, suburban, urban). In this paper, we used a novel Bayesian index model with spatially varying effects to explore spatial nonstationarity in NDI effects for TROs, AROs, and TAROs across census tracts in North Carolina. The results revealed substantial variation in NDI effects that varied by outlet type. However, all outlet types had strong positive effects in one coastal area. The most important variables in the NDI were percent renters, Black racial segregation, and the percentage of homes built before 1940. Overall, more disadvantaged areas experienced a greater neighborhood burden of outlets selling one or both of alcohol and tobacco.

As we look to the current conflict in Ukraine, our service members deploy to periphery Northern Atlantic Treaty Organization countries. At the same time, we see an increase in high-kinetic wounding patterns in the United States. We look to the important underrepresented topic of urologic trauma in combat casualties to prepare for the wounds of modern warfare. Genitourinary wounds are increasingly frequent and affect both military and civilian casualties; civilian urologists and deployed surgeons require proficiency in treating these wounds. We present this review of urologic trauma in Afghanistan and Iraq to inform considerations for urologic surgeons and first responders.

Despite years of advisories against the behavior, smoking among pregnant women remains a persistent public health issue in the United States. Recent estimates suggest that 9.4% of women smoke before pregnancy and 7.1% during pregnancy in the United States. Epidemiological research has attempted to pinpoint individual-level and neighborhood-level factors for smoking during pregnancy, including educational attainment, employment status, housing conditions, poverty, and racial demographics. However, most of these studies have relied upon self-reported measures of smoking, which are subject to reporting bias. To more accurately and objectively assess smoke exposure in mothers during pregnancy, we used Bayesian index models to estimate a neighborhood deprivation index (NDI) for block groups in Durham County, North Carolina and its association with cotinine, a marker of smoke exposure, in pregnant mothers (n=887 enrolled 2005–2011). Results showed a significant positive association between NDI and log cotinine (beta = 0.20, 95% credible interval = [0.11, 0.29]) after adjusting for individual covariates (e.g. race/ethnicity and education). The two most important variables in the NDI according to the estimated index weights were percent females without a high school degree and percent Black population. At the individual level, Hispanic and other race/ethnicity were associated with lowered cotinine compared with non-Hispanic Whites. Higher education levels were also associated with lowered cotinine. In summary, our findings provide stronger evidence that the socio-geographic variables of educational attainment and neighborhood racial composition are important factors for smoking and secondhand smoke exposure during pregnancy and can be used to target intervention efforts.

Many spatial analysis methods have been used to identify potential geographic clusters of disease in case-control studies. Low-rank kriging (LRK) models reduce the computational burden in generalized additive models by using a set of knot locations instead of the observed subject locations for estimating spatial risk. However, there is little guidance regarding selection of the number and location of the knots in case-control studies. We perform an extensive simulation study that compares a commonly-used method of knot selection in LRK models with two proposed methods and varies the number of knots. We find the commonly-used method is vastly outperformed by those that consider the locations of cases. We find that the Teitz and Bart heuristic allows the highest spatial sensitivity and power to detect zones of elevated risk, and recommend its use with a number of knots as close to the number of case locations as computation time will allow.

Background: Inadequate vitamin D levels may increase the risk of caries during childhood. The purpose of this study was to investigate the association between 25-hydroxyvitamin D (25(OH)D) status and severe early childhood caries (S-ECC) in preschool children. Methods: Data were obtained from children p-value of ≤0.05 was significant. Results: Data were available for 200 children with S-ECC and 144 caries-free controls. Children with S-ECC had significantly lower 25(OH)D levels than those who were caries-free (p < 0.001), and children with deficient 25(OH)D levels were 10 times more likely to have S-ECC (p < 0.001). Multiple logistic regression revealed that having higher 25(OH)D and calcium concentrations (p = 0.019 and p < 0.0001, respectively), as well as being breastfed in infancy (p < 0.001), were significantly and independently associated with lower odds of S-ECC, while dental insurance (p = 0.006) was associated with higher odds of S-ECC. Conclusions: This study provides additional evidence of an association between nutritional status, specifically vitamin D and calcium levels, and S-ECC.

Currently, the majority of dementia care is provided at home by informal caregivers. Most informal caregivers share a routine with their loved ones and change their activity patterns to adapt to a new routine of persons with dementia (PWDs). Given the dementia caregiving context, caregivers’ mobility behaviors and PWDs’ mobility may be positively associated. This study aimed to characterize patterns of GPS-derived community mobility in dementia dyads and examine relationships between PWDs’ and caregivers’ mobility patterns. Six dyads wore a GPS data logger inside and outside the home for 8-11 days. Twelve participants generated valid GPS track files (N=110). Four temporal and spatial mobility metrics were derived from GPS data (total distance, time use, median speed, and convex hull area). Then we calculated Pearson correlation coefficients between PWDs and their caregivers over all tracks. All dyads made active out-of-home trips, indicated by mean daily distance (range: 6,198 - 115,592m for PWDs; 5,125 - 108,857m for caregivers). Median speed of movement ranged from 0.09 to 1.29 km/hour for PWDs, and from 0.21 to 0.97 km/hour for caregivers. The mean size of convex hull over the monitoring period indicates a limited space usage level in both PWDs and caregivers, meaning restricted community mobility despite relatively large distance trips. The correlation coefficient was positive and significant for each metric (r = 0.70-0.97, p < .001). These results suggest substantial agreement in the mobility metrics between PWD and their caregivers, indicating a high level of dyadic effects of a partner’s experience of community mobility.

Tobacco causes 29% of cancer-related deaths while alcohol causes 5.5% of cancer-related deaths. Reducing the consumption of these cancer-causing products is a special priority area for the National Cancer Institute. While many factors are linked to tobacco and alcohol use, the placement and density of retail outlets within neighborhoods may be one community-level risk factor contributing to greater use of these products. To elucidate associations between tobacco, alcohol, and tobacco and alcohol retail outlets (TRO, ARO, and TARO) and neighborhood disadvantage over a large geographic area, we employed a novel Bayesian index modeling approach to estimate a neighborhood disadvantage index (NDI) and its associations with rates of the three types of retailers across block groups in the state of North Carolina. We used a novel extension of the Bayesian index model to include a shared component for the spatial pattern common to all three types of outlets and NDI effects that varied by outlet type. The shared component identifies areas that are elevated in risk for all outlets. The results showed significant positive associations between neighborhood disadvantage and TROs (relative risk (RR) = 1.12, 95% credible interval (CI = 1.09, 1.14)) and AROs (RR = 1.15, 95% CI = 1.11, 1.17), but the association was greatest for TAROs (RR = 1.21, 95% CI = 1.18, 1.24). The most important variables in the NDI were percent renters (i.e., low home ownership), percent of homes built before 1940 (i.e., old housing stock), and percent without a high school diploma (i.e., low education).

OBJECTIVE To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home. DESIGN, SETTING, PARTICIPANTS A cross-sectional analysis of patients admitted to an academic medical center. MEASUREMENTS Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources. RESULTS Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76). CONCLUSIONS Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.

After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT.The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups.Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P .0001) and 6 months (8.8; P .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups.Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

Objective Much of the extant literature on women with serious mental illness (SMI) has focused on the risks associated with motherhood, including violence, custody loss, poverty, and homelessness. The present study was conducted to characterize women's broader experiences surrounding the parenting role. Method Twenty women with SMI, both those with and without children, were interviewed. Qualitative data were analyzed using grounded theory approach. Results Five themes pertaining to the topic of motherhood emerged from the data: motherhood declined, motherhood derailed, motherhood disabled, motherhood reimagined, and mattering through motherhood. Conclusions and implications for practice Women with SMI face a number of challenges in their relationship to the role of mother. Clinicians can support women with SMI in their decision-making process with regard to having children or not, emphasizing self-determination and evaluation of the resources that might be needed to manifest this goal. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The refusal or withdrawal of nutrition and hydration to patients unable to provide it for themselves must not be tantamount to intentional killing, nor to bringing about death as a side-effect unless the decision not to help is fully justified morally so as to take proper account of that bad side effect. Moreover, the decision must not be tantamount to intentionally causing suffering or allowing it as a side effect unless the decision not to assist is fully justified morally so as to take proper account of this bad side-effect. Likewise the human solidarity offended by refusing to help to feed another, or to provide nutrition and hydration by way of medical actions must also be respected. The person denied must not be intentionally abandoned; the human good that binds those called to assist with those needing help must not be simply ignored. I will argue that applying these considerations to the variety of possible situations where there is some reason to refuse assistance shows that cases can arise in which refusing this assistance is permissible, but that there are also cases, thought by many to be permissible, that in fact are impermissible.

During the 20th century some versions of just war doctrine came to restrict the condition of just cause to defense, that is, these just war doctrines now hold it to be a necessary condition for the moral justifiability of any war that it be undertaken for defensive purposes. These purposes need not be self – defensive but may be defensive of the welfare and legitimate rights of other polities and groups. Some reasons for war are obviously not defensive, for example, the acquisition of territory or the assertion of imperialist control. But the boundaries of defensive warfare are unclear. I will consider two important cases in which this lack of clarity is proving to be morally significant: namely, preventive and punitive warfare undertaken for the sake of the goal of defense. I will argue that the normative rationale for limiting just cause to defense does not allow these as legitimate forms of defense. That rationale moves towards the view that one should not intend the deaths of enemies but only...

In this short response to Peter Clarke's thorough and interesting tracing of the developments in Richard McCormick's approach to moral questions, I take a perspective external to the concerns of Clarke's paper. I propose to look at the developments in McCormick's approach not so much from the perspective of contemporary Catholic moral theology but from that of the impact on the practices and beliefs of the Catholic community. From that perspective, the really important events in McCormick's theological development are his rejection of the received teaching on contraception and his closely connected embracing of a moral theory that implies that there are no moral absolutes, namely, proportionalism.

This is a response to James Dubois’ “Is anesthesia intrinsically wrong?” I do not address many of the claims in this article but only DuBois’ use of the moral evaluation of the medical use of anesthesia as a counter example to two lines of reasoning developed to defend the traditional Catholic prohibition of contraception. Elizabeth Anscombe's dialectical defense of this teaching does not imply that such a defense must logically apply to the use of anesthesia. John Finnis’ defense of this teaching on the basis of a natural law argument does not imply that consciousness is a basic human good.

IN this article, I will articulate a traditional version of just war theory and apply it to the case of a polity’s response to terrorist actions by groups that are not themselves polities. I will argue that, according to just war theory, defending against this sort of terrorism is a just cause; that within significant constraints sovereign political authorities can have authority to undertake military actions for the sake of this just cause, notwithstanding the nature of organization of the terrorists; and that a political community can pursue such a cause with right intention, even though in the world as it is military efforts to defend against terrorism may well not meet this condition. In this introduction I will define key terms; in the second section I will provide a formulation of just war theory, and in the last section I will apply its conditions for the permissibility of waging war to the case of responding to terrorism by groups that are not states. Traditional just war theory has some potential to illumine issues raised by the response to terrorism because, on the one hand, it is related historically and conceptually to the forms of just war thinking embedded in international law, and on the other, it is rooted in a normatively richer and distinctive conception of practical life than is current just war doctrine. The difference pointed to by my distinguishing current from traditional just war doctrine is in the rationale for the judgments made within each. There will certainly be disagreements about theory and particular judgments in both; but in current just war theory, the project of seeking agreement within the common moral world by careful casuistry from broadly acceptable paradigms, often embodied in international law and agreements, is central. By contrast, in traditional just war doctrine, the consensus is not so central, and the project of determining a war’s justice by application of a conception of morally good social living to the bellicose The Journal of Political Philosophy: Volume 11, Number 2, 2003, pp. 153–170