Community-Level Factors are Predictors of Severe Maternal Morbidity Among American Indian and Alaska Native Pregnant People in the Pacific Northwest in a Multilevel Logistic Regression.

INTRODUCTION: American Indian/Alaska Native (AI/AN) pregnant people face barriers to health and healthcare that put them at risk of pregnancy complications. Rates of severe maternal morbidity (SMM) among Indigenous pregnant people are estimated to be twice that of non-Hispanic White (NHW) pregnant people. METHODS: Race-corrected Oregon Hospital Discharge and Washington Comprehensive Hospital Abstract Reporting System data were combined to create a joint dataset of births between 2012 and 2016. The analytic sample was composed of 12,535 AI/AN records and 313,046 NHW records. A multilevel logistic regression was used to assess the relationship between community-level, individual and pregnancy risk factors on SMM for AI/AN pregnant people. RESULTS: At the community level, AI/AN pregnant people were more likely than NHW to live in mostly or completely rural counties with low median household income and high uninsured rates. They were more likely to use Medicaid, be in a high-risk age category, and have diabetes or obesity. During pregnancy, AI/AN pregnant people were more likely to have insufficient prenatal care (PNC), gestational diabetes, and pre-eclampsia. In the multilevel model, county accounted for 6% of model variance. Hypertension pre-eclampsia, and county rurality were significant predictors of SMM among AI/AN pregnant people. High-risk age, insufficient PNC and a low county insured rate were near-significant at p < 0.10. DISCUSSION: Community-level factors are significant contributors to SMM risk for AI/AN pregnant people in addition to hypertension and pre-eclampsia. These findings demonstrate the need for targeted support in pregnancy to AI/AN pregnant people, particularly those who live in rural and underserved communities.

What is already known on this subject? American Indian and Alaska Native pregnant people face higher rates of severe maternal morbidity and mortality, and the risk is exacerbated for rural Indigenous pregnant people.What this study adds? This publication uses a multilevel model to assess the contribution of community-level factors in severe maternal morbidity risk for American Indian and Alaska Native pregnant people. This analysis highlights the important role that rurality, prenatal care adequacy and access to insurance play in maternal morbidity risk and discusses how those risks are disproportionately felt by American Indian and Alaska Native pregnant people in the Pacific Northwest.

Characterizing observable COVID-19 controls in Pacific Northwest grocery stores.

Utilizing a longitudinal, observational study, grocery store health and safety controls implemented during the COVID-19 pandemic across stores in two cities were characterized. Sixteen stores between Seattle, WA (n = 9) and Portland, OR (n = 7) were visited monthly by the study team from May 2020 to January 2021, and observations of controls were recorded using a standardized checklist in REDCap. The checklist included questions on the presence or absence of controls such as physical barriers, social distancing markers, required masking of customers, cleaning of check-out stands, and closures of store areas. Descriptive analyses were conducted to determine the proportion of stores with a certain control each month. Mixed-effects logistic regression was used to explore how controls changed over time, and whether differences were observed between cities or by income of the area the store serves. Source control (e.g., mask requirements) and engineering controls (e.g., physical barriers at checkout) were the most common and consistent controls observed across stores and over the study period. Controls such as having special hours for vulnerable populations, demarcations on aisles for directionality, and cleaning check-out stands between customers varied significantly over time (p < 0.05 in the mixed-effects model). Having an employee present to clean baskets and carts, as well as physical barriers between self-checkouts, were significantly more common in stores in areas above the median income (p < 0.05 in the mixed-effects model). To best protect workers and shoppers from infectious agents, controls should be evidence-based, consistently implemented across grocery stores, and coupled with administrative practices and policies to promote worker wellbeing.

COVID-19-related institutional betrayal associated with trauma symptoms among undergraduate students.

Individuals are dependent on institutions (e.g., universities, governments, healthcare systems) to protect their safety and advocate for their needs. When institutions harm the individuals who depend on them, they commit institutional betrayal, which has been associated with numerous negative outcomes in prior research. Throughout the COVID-19 pandemic, students have entrusted universities to protect both their health and their educational opportunities. However, many universities have failed to meet these expectations, and it is likely that many students experience COVID-19-related institutional betrayal. In two similar studies, we examined the prevalence and correlates of institutional betrayal among undergraduate students at a large, public university in the Northwest United States during the fall 2020 and winter 2021quarters. In both studies, more than half of students endorsed at least one type of COVID-19-related institutional betrayal, and higher institutional betrayal ratings were significantly correlated with both current trauma symptoms and COVID-19-related avoidance and intrusion cognitions. In Study 2, the relationship between COVID-19-related institutional betrayal and current trauma symptoms remained significant, even when controlling for gender, personal and familial COVID-19 infection, and past trauma history. These results indicate that COVID-19 institutional betrayal is common and may be uniquely associated with distress among undergraduate students. We suggest it would behoove university institutions to reduce COVID-19-related institutional betrayal.

Heat-Related Emergency Department Visits During the Northwestern Heat Wave - United States, June 2021.

Record high temperatures are occurring more frequently in the United States, and climate change is causing heat waves to become more intense (1), directly impacting human health, including heat-related illnesses and deaths. On average, approximately 700 heat-related deaths occur in the United States each year (2). In the northwestern United States, increasing temperatures are projected to cause significant adverse health effects in the coming years (3). During June 25-30, 2021, most of Oregon and Washington were under a National Weather Service excessive heat warning.* Hot conditions persisted in parts of Oregon, Washington, or Idaho through at least July 14, 2021. The record-breaking heat had the largest impact in Oregon and Washington, especially the Portland metropolitan area, with temperatures reaching 116°F (46.7°C), which is 42°F (5.6°C) hotter than the average daily maximum June temperature.

Clinical and pathologic findings in an outbreak in rabbits of natural infection by rabbit hemorrhagic disease virus 2 in the northwestern United States.

Rabbit hemorrhagic disease virus 2 (RHDV2) causes an often-fatal disease of rabbits that has resulted in outbreaks in rabbitries in Europe, Africa, Australia, and Asia. RHD has historically been characterized as a foreign animal disease in the United States. In July 2019, RHDV2 was detected in rabbits on Orcas Island along the northwestern coast of Washington (WA) State following reports of deaths in multiple feral and domestic rabbits. We document and highlight here the unique clinical presentation and gross and histologic lesions observed in this recent WA outbreak. Affected rabbits died without premonitory signs or displayed hyporexia and/or lethargy for ≤1 d prior to death. The most consistent pathologic finding was random, multifocal hepatocellular necrosis, often with concurrent multifocal-to-diffuse splenic necrosis. The lack of significant clinical signs in conjunction with the random distribution of hepatic necrosis in the WA outbreak contrasts with previous reports of RHDV2 disease progression.

Genetic characterization of Flavobacterium columnare isolates from the Pacific Northwest, USA.

Flavobacterium columnare is the causative agent of columnaris disease. Previous work has demonstrated a high degree of genetic variability among F. columnare isolates, identifying 4 genetic groups (GGs) with some host associations. Herein, a total of 49 F. columnare isolates were characterized, the majority of which were collected from 15 different locations throughout the US Pacific Northwest. Most isolates were collected from 2015-2018 and originated from disease outbreaks in salmonid hatcheries and rearing ponds, sturgeon hatcheries and ornamental fish. Other isolates were part of collections recovered from 1980-2018. Initial identification was confirmed by F. columnare species-specific qPCR. Study isolates were further characterized using a multiplex PCR that differentiates between the 4 currently recognized F. columnare GGs. Multiplex PCR results were supported by repetitive sequence-mediated PCR fingerprinting and gyrB sequence analysis. F. columnare GG1 was the most prevalent (83.7%, n = 41/49), represented by isolates from salmonids (n = 32), white sturgeon (n = 2), channel catfish (n = 1), ornamental goldfish (n = 1), koi (n = 3), wild sunfish (n = 1) and 1 unknown host. Six isolates (12.2%, n = 6/49) were identified as GG3, which were cultured from rainbow trout (n = 3) and steelhead trout (n = 3). Two isolates were identified as GG2 (4.1%, n = 2/49) and were from ornamental fish. No GG4 isolates were cultured in this study. The biological significance of this genetic variability remains unclear, but this variation could have significant implications for fish health management. The results from this study provide baseline data for future work developing strategies to ameliorate columnaris-related losses in the US Pacific Northwest.

Rates of delayed hemolytic transfusion reactions observed in a trauma center.

BACKGROUND: Delayed hemolytic transfusion reactions (DHTRs) are reported to be rare occurrences but may be more frequently observed in the trauma setting where patients are heavily transfused, followed over long inpatient admissions, and have frequent subsequent blood counts as they undergo multiple surgical interventions. STUDY DESIGN AND METHODS: We examined the rates of DHTRs on a per transfusion and per patient basis in an academic county hospital with a level 1 trauma center serving a four-state region and over a 3-year period. DHTRs were entered sequentially into a registry as they were observed, and a retrospective review of all new alloantibodies detected was performed to identify any additional DHTRs. The number of units of red blood cells (RBCs), the number of unique patients, types of alloantibodies, and number of transfusions were extracted from blood bank records. RESULTS: Twenty-nine DHTRs were observed from January 1, 2017, through December 31, 2019, from newly observed alloantibodies after a median of 12 red blood cells (RBCs) transfusions per patient. These reactions occurred in response to 24,633 unique transfusions in 6905 unique patients, so the observed rates were about 1:849 RBC transfusions and 1:238 transfused patients. Evidence of delayed hemolysis was seen in five additional patients who were transfused during emergency resuscitation and later found to have had known RBC antibodies. DISCUSSION: We report a higher rate of DHTRs than previously described to demonstrate that DHTRs are not rare in trauma centers.

Virulence and Infectivity of UC, MD, and L Strains of Infectious Hematopoietic Necrosis Virus (IHNV) in Four Populations of Columbia River Basin Chinook Salmon.

Infectious Hematopoietic Necrosis Virus (IHNV) infects juvenile salmonid fish in conservation hatcheries and aquaculture facilities, and in some cases, causes lethal disease. This study assesses intra-specific variation in the IHNV susceptibility of Chinook salmon (Oncorhynchus tshawytscha) in the Columbia River Basin (CRB), in the northwestern United States. The virulence and infectivity of IHNV strains from three divergent virus genogroups are measured in four Chinook salmon populations, including spring-run and fall-run fish from the lower or upper regions of the CRB. Following controlled laboratory exposures, our results show that the positive control L strain had significantly higher virulence, and the UC and MD strains that predominate in the CRB had equivalently low virulence, consistent with field observations. By several experimental measures, there was little variation in host susceptibility to infection or disease. However, a small number of exceptions suggested that the lower CRB spring-run Chinook salmon population may be less susceptible than other populations tested. The UC and MD viruses did not differ in infectivity, indicating that the observed asymmetric field prevalence in which IHNV detected in CRB Chinook salmon is 83% UC and 17% MD is not due to the UC virus being more infectious. Overall, we report little intra-species variation in CRB Chinook salmon susceptibility to UC or MD IHNV infection or disease, and suggest that other factors may instead influence the ecology of IHNV in the CRB.

Interactions Between Ticks and Lyme Disease Spirochetes.

Borrelia burgdorferi sensu lato causes Lyme borreliosis in a variety of animals and humans. These atypical bacterial pathogens are maintained in a complex enzootic life cycle that primarily involves a vertebrate host and Ixodes spp. ticks. In the Northeastern United States, I. scapularis is the main vector, while wild rodents serve as the mammalian reservoir host. As B. burgdorferi is transmitted only by I. scapularis and closely related ticks, the spirochete-tick interactions are thought to be highly specific. Various borrelial and arthropod proteins that directly or indirectly contribute to the natural cycle of B. burgdorferi infection have been identified. Discrete molecular interactions between spirochetes and tick components also have been discovered, which often play critical roles in pathogen persistence and transmission by the arthropod vector. This review will focus on the past discoveries and future challenges that are relevant to our understanding of the molecular interactions between B. burgdorferi and Ixodes ticks. This information will not only impact scientific advancements in the research of tick- transmitted infections but will also contribute to the development of novel preventive measures that interfere with the B. burgdorferi life cycle.

Lung Cancer Survival in Patients With Autoimmune Disease.

Importance: Patients with autoimmune disease and lung cancer pose a multidisciplinary treatment challenge, particularly with the advent of immunotherapy. However, the association between autoimmune disease and lung cancer survival is largely unknown. Objective: To determine the association between autoimmune disease and lung cancer survival. Design, Setting, and Participants: Retrospective cohort study between 2003 and 2019 at a single academic medical center (Northwestern University). A query of the Northwestern Medicine Enterprise Data Warehouse identified 349 patients with lung cancer and several autoimmune diseases. Types of lung cancers included small cell, adenocarcinoma, squamous cell carcinoma, non-small cell not otherwise specified, and large cell carcinoma. Autoimmune diseases included rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, mixed connective tissue disease, myositis, and Sjögren syndrome. Inclusion criteria were biopsy-confirmed lung cancer, autoimmune diagnosis confirmed by a rheumatologist, and death or an encounter listed in the electronic medical record within 2 years of study end. A control group of patients with biopsy-proven lung cancer but without autoimmune disease was identified. Data analysis was conducted from March to July 2020. Exposure: Presence of autoimmune disease. Main Outcomes and Measures: Overall survival and progression-free survival in patients with autoimmune disease. The hypothesis was that patients with autoimmune disease would have worse progression-free survival and overall survival compared with patients in the control group. Results: Of the original 349 patients, 177 met inclusion criteria. Mean (SD) age at lung cancer diagnosis was 67.0 (10.0) years and 136 (76.8%) were women. Most common autoimmune diseases were rheumatoid arthritis (97 [54.8%]), systemic sclerosis (43 [24.3%]), and systemic lupus erythematous (15 [8.5%]). Most common lung cancers were adenocarcinoma (99 [55.9%]), squamous cell carcinoma (29 [16.4%]), and small cell lung cancer (17 [9.6%]). A total of 219 patients (mean [SD] age at diagnosis, 65.9 [4.1] years; 173 [79.0%]) were identified as having lung cancer without autoimmune disease and included in the control cohort. Compared with patients in the control group, patients with autoimmune disease experienced no difference in overall survival (log-rank P = .69). A total of 126 patients (69.5%) with autoimmune disease received standard of care vs 213 patients (97.3%) in the control group (P < .001). No individual autoimmune disease was associated with worse prognosis, even among patients with underlying interstitial lung disease. Conclusions and Relevance: Compared with institutional controls, patients with autoimmune disease experienced no difference in survival despite the fact that fewer patients in this group received standard-of-care treatment. No individual autoimmune disease was associated with worse prognosis. Future multicenter prospective trials are needed to further evaluate autoimmune disease and lung cancer survival.

Temporal Trends in the Incidence of Anogenital Warts: Impact of Human Papillomavirus Vaccination.

BACKGROUND: Studies in countries with high human papillomavirus (HPV) vaccination coverage have demonstrated marked reductions in anogenital wart (AGW) incidence. Our goal was to assess the impact of HPV vaccination in a population with suboptimal coverage by comparing AGW incidence trends in the years before and after vaccine introduction. METHODS: We conducted a retrospective analysis of AGW incidence trends using an ecologic study design among 11- through 39-year-olds enrolled at Kaiser Permanente Northwest. We defined incidence as the proportion of persons who had a new AGW diagnosis for each calendar year in the prevaccine periods (2000 through 2006 for female individuals, 2000 through 2010 for male individuals) and the postvaccine periods (2007 through 2016 for female individuals, 2011 through 2016 for male individuals). We also described cumulative HPV vaccination coverage. RESULTS: The average annual AGW incidence rates in the prevaccine periods were 27.8 per 10,000 in female individuals and 26.9 per 10,000 in male individuals. In the postvaccine periods, AGW incidence rates decreased by 31% (P < 0.001) in female individuals and 10% (P = 0.006) in male individuals; the largest reductions were observed in 15- to 19-year-old female individuals (67%, P < 0.001) and male individuals (45%, P < 0.001). Three dose HPV coverage rates were less than 50% in all age groups and both sexes. CONCLUSIONS: In a population of young adults with moderate HPV vaccination coverage, we observed declines in AGW incidence among both female and male year after the introduction of HPV vaccination. The largest incidence reductions were observed in 15- to 19-year-olds who were most likely to have been vaccinated.

The Disease Ecology, Epidemiology, Clinical Manifestations, and Management of Emerging Cryptococcus gattii Complex Infections.

Cryptococcus neoformans, a soil-dwelling fungus found worldwide, can cause cryptococcosis, an opportunistic fungal infection of the lungs and central nervous system. One former member of the C neoformans complex, Cryptococcus gattii, has caused meningitis in immunosuppressed and immunocompetent persons in endemic regions in Africa and Asia. Between 1999 and 2004, C gattii caused outbreaks of human cryptococcosis in unexpected, nonendemic, nontropical regions on Vancouver Island, Canada, and throughout the US Pacific Northwest and California. C gattii was recognized as an emerging species with several genotypes and a unique environmental relationship with trees that are often encountered in the wilderness and in landscaped parks. Because C gattii infections have a high case-fatality rate, wilderness medicine clinicians should be aware of this emerging pathogen, its disease ecology and risk factors, its expanding geographic distribution in North America, and its ability to cause fatal disease in both immunosuppressed and immunocompetent persons.

Hepatitis C-Related Mortality Among American Indian/Alaska Native Persons in the Northwestern United States, 2006-2012.

OBJECTIVE: American Indian and Alaska Native (AI/AN) persons are commonly misclassified in epidemiologic and administrative data sets. The race-corrected hepatitis C virus (HCV)-related mortality rate among AI/AN persons in the Northwest United States (Idaho, Oregon, and Washington State) is unknown. We quantified the disparity in HCV-related mortality between AI/AN persons and non-Hispanic white (NHW) persons in the Northwest during 2006-2012 after correcting misclassified AI/AN race. METHODS: After conducting probabilistic record linkage between death records and the Northwest Tribal Registry, we calculated HCV-related mortality rates for AI/AN and NHW persons by using National Center for Health Statistics bridged-race estimates standardized to the US 2000 standard population. RESULTS: The 2006-2012 aggregate age-adjusted HCV-related mortality rate per 100 000 population in the Northwest was 19.6 (95% confidence interval [CI], 17.3-22.2) for AI/AN persons and 5.9 (95% CI, 5.7-6.1) for NHW persons (rate ratio [RR] = 3.3; 95% CI, 3.0-3.8). The disparity was larger among females (RR = 4.6; 95% CI, 3.8-5.5) than among males (RR = 2.9; 95% CI, 2.5-3.4). CONCLUSION: The disproportionate rate of HCV-related mortality among AI/AN persons in the Northwest highlights the need to expand HCV education, screening, and treatment among this population.

Spatial analysis of drug poisoning deaths in the American west: A comparison study using profile regression to adjust for collinearity and spatial correlation.

BACKGROUND: The USA has seen dramatic increases in drug poisoning deaths (DPD) recently. State-level rates have responded to federal and state initiatives, yet the counties with the highest rates are stable. Spatial analysis enables investigators to identify the highest risk counties and most important risk factors, although results are often confounded by spatial autocorrelation and multicollinearity. METHODS: Profile regression (PR) is an integrated method for cluster and regression analysis, which adjusts for spatial-autocorrelation and multi-collinearity. RESULTS: With PR, three clusters were identified in the Western USA with most of NM, NV and UT and several counties in AZ, CO, ID and WY being high-risk. Cluster analysis in a previous study only identified high-risk counties in northern CA, NM and NV. Elevation, suicide and LDS population were positively, and population density was negatively linked with DPD for PR and standard regression (SR) showing differences between the mountain west and coastal areas. Complex relationships between DPD and several variables were identified by PR which was not possible with SR. CONCLUSIONS: Statistically principled methods like PR are needed for appropriate identification of the highest risk counties and important risk factors given the complex relationships with DPD. Funding for prevention, education and medical services should be targeted at rural, mountain communities in the west which have high %LDS and suicide rates. Counties with high %poverty and %Hispanic were also at high-risk. Individual-level studies are needed to confirm important risk factors in high-risk counties.

Acceptability of Cell and Gene Therapy for Curing HIV Infection Among People Living with HIV in the Northwestern United States: A Qualitative Study.

Multiple strategies to cure HIV infection are under investigation, including cell and gene therapy (C>) approaches. Research, and ultimately treatment, with these novel strategies will require patients' willingness to participate. To elicit the perspectives of people living with HIV specific to these novel approaches, we conducted 4 focus group discussions with a diverse group of 19 English-speaking men and women living with HIV in care at a large academic HIV clinic in the northwestern United States. Thematic analysis indicated participants expressed initial fear about C> research. They articulated specific concerns about risks, including analytical treatment interruptions, and thought only a person in desperate straits would participate. They voiced significant mistrust of research in general and believed there was already a cure from HIV that was being withheld from the poor. Overall, they were satisfied with their health and quality of life on antiretroviral therapy. These findings suggest the importance of community engagement and educational efforts about C> for HIV cure to ensure optimal collaborative partnerships.

High Prevalence of Maternal Serum 25-Hydroxyvitamin D Deficiency Is Not Associated With Poor Birth Outcomes Among Healthy White Women in the Pacific Northwest.

OBJECTIVE: To quantify vitamin D status among pregnant women in the Pacific Northwest (Portland, OR, and Seattle, WA) and examine pregnancy and newborn outcomes in relationship to maternal serum blood samples obtained during pregnancy. DESIGN: A retrospective cohort design. SETTING: Data from 2009 to 2013 were abstracted from the health records of two out-of-hospital midwifery practices in the Pacific Northwest. PARTICIPANTS: Women with recorded serum blood samples for vitamin D during pregnancy were included. We reviewed health records of 663 women, and 357 met criteria. METHODS: We extracted demographic, biometric, and pregnancy outcome data from participants' records and analyzed them using regression models. RESULTS: Mean serum 25-hydroxy vitamin D (25[OH]D) was 29.96 ± 10.9 ng/ml; 45.5% of participants were sufficient (≥30 ng/ml), and 55.5% were insufficient or deficient (<29 ng/ml). Lower vitamin D levels were predicted by Seattle location, greater prepregnancy body mass index, and blood samples drawn during the winter. Vitamin D status was not a predictor of spontaneous abortion, glucose tolerance test result, cesarean birth, infant birth weight, or any other outcome investigated. CONCLUSION: Although there is a high prevalence of vitamin D insufficiency and deficiency in pregnant women in the Pacific Northwest, adverse health effects were not observed. This may be attributable to the overall healthy profile of the women in our sample. Further research on maternal vitamin D status should focus on identification of optimal vitamin D levels in pregnancy and long-term outcomes among offspring of women who are vitamin D deficient, particularly those from high-risk, vulnerable populations.

At Work in the Woods: Occupational Hazards of Harvesting Non-Timber Forest Products in the Pacific Northwest.

Harvesting timber for lumber produces is among the most dangerous occupations in the United States. While not exhaustive, the literature on these dangers is substantial. However, several other smaller harvesting forest based industries put workers at risk in unique ways. Relatively little research has been published on these activities, but preliminary exploratory research, summarized here, suggests that besides the risks inherent in being in the forest, workers face some unique workplace risks, the frequency and consequences of which are augmented by the social determinants that characterize the workforce. This paper provides a brief overview of the workplace safety risks to forest green and mushroom harvesters and cedar block cutters in the Northwest. We also point out the social characteristics of these workforces that potentially aggravate these risks and the health impacts therefrom.

Atrial fibrillation is highly prevalent yet undertreated in patients with biopsy-proven nonalcoholic steatohepatitis.

BACKGROUND & AIMS: Nonalcoholic steatohepatitis (NASH) is associated with increased cardiovascular disease. Atrial fibrillation is a prominent risk marker for underlying cardiovascular disease with a prevalence of 2% in patients <65 years old. Atrial fibrillation prevalence in NASH is unknown. We sought to assess the prevalence and impact of atrial fibrillation on healthcare utilization in NASH. METHODS: Patients were identified from a tertiary care centre Electronic Database from 2002 to 2015. International Classification of Diseases 9 (ICD9) codes identified comorbidities and atrial fibrillation. Descriptive statistics were used to compare characteristics between patients with NASH with and without atrial fibrillation. RESULTS: Of 9108 patients with ICD9 diagnosis of NASH, 215 (2.3%, mean age 57 years, 32% male) had biopsy-proven NASH. Atrial fibrillation prevalence was 4.6%. Patients with NASH and atrial fibrillation had a higher prevalence of heart failure (54.5% vs 8.8%, P < 0.001) and cerebrovascular (27.3% vs 2.0%, P < 0.001) or vascular disease (54.5% vs 13.2%, P = 0.002), compared to NASH without atrial fibrillation. All patients with NASH and atrial fibrillation had a CHA2DS2VASc score ≥2 indicating high stroke risk and need for anticoagulation. Eight of 10 patients were eligible for anticoagulation and 5 of 8 (62.5%) received appropriate therapy. CONCLUSION: Atrial fibrillation prevalence is two-fold higher in patients with NASH compared to the general population. Patients with NASH have a high risk of stroke; however, many do not receive appropriate guideline-directed therapy. Future studies are needed to identify whether guideline-based management of atrial fibrillation in NASH reduces cardiovascular morbidity and mortality.

Timing the Origin of Cryptococcus gattii sensu stricto, Southeastern United States.

We conducted molecular clock analysis of whole-genome sequences from a set of autochthonous isolates of Cryptococcus gattii sensu stricto from the southeastern United States. Our analysis indicates that C. gattii arrived in the southeastern United States approximately 9,000-19,000 years ago, long before its arrival in the Pacific Northwest.