Clinical and Genomic Characterization of a Cohort of Patients With Klebsiella pneumoniae Bloodstream Infection.

BACKGROUND: The clinical and microbial factors associated with Klebsiella pneumoniae bloodstream infections (BSIs) are not well characterized. Prior studies have focused on highly resistant or hypervirulent isolates, limiting our understanding of K. pneumoniae strains that commonly cause BSI. We performed a record review and whole-genome sequencing to investigate the clinical characteristics, bacterial diversity, determinants of antimicrobial resistance, and risk factors for in-hospital death in a cohort of patients with K. pneumoniae BSI. METHODS: We identified 562 patients at Massachusetts General Hospital with K. pneumoniae BSIs between 2016 and 2022. We collected data on comorbid conditions, infection source, clinical outcomes, and antibiotic resistance and performed whole-genome sequencing on 108 sequential BSI isolates from 2021 to 2022. RESULTS: Intra-abdominal infection was the most common source of infection accounting for 34% of all BSIs. A respiratory tract source accounted for 6% of BSIs but was associated with a higher in-hospital mortality rate (adjusted odds ratio, 5.4 [95% confidence interval, 2.2-12.8]; P < .001 for comparison with other sources). Resistance to the first antibiotic prescribed was also associated with a higher risk of death (adjusted odds ratio, 5.2 [95% confidence interval, 2.2-12.4]; P < .001). BSI isolates were genetically diverse, and no clusters of epidemiologically and genetically linked cases were observed. Virulence factors associated with invasiveness were observed at a low prevalence, although an unexpected association between O-antigen type and the source of infection was found. CONCLUSIONS: These observations demonstrate the versatility of K. pneumoniae as an opportunistic pathogen and highlight the need for new approaches for surveillance and the rapid identification of patients with invasive antimicrobial-resistant K. pneumoniae infection.

Is Abstinence from Alcohol and Smoking Associated with Less Anxiety and Depressive Symptoms Among People with HIV?

Achieving abstinence from alcohol, tobacco, or both may improve mental health, but is understudied in people with HIV (PWH). The St PETER HIV randomized clinical trial compared varenicline, cytisine, and nicotine replacement therapy on alcohol and smoking behavior among 400 PWH in Russia. The primary exposure was thirty-day point prevalence abstinence (PPA) from (1) alcohol, (2) smoking, (3) both, or (4) neither and was assessed at 1, 3, 6 and 12-months as were the study outcomes of anxiety (GAD-7) and depressive (CES-D) symptoms. The primary aim was to examine the association between smoking and/or alcohol abstinence and subsequent symptoms of depression and anxiety. Primary analysis used repeated measures generalized linear modeling to relate PPA with mental health scores across time. In secondary analyses, Kruskal-Wallis tests related PPA with mental health scores at each timepoint. Primary analyses did not identify significant differences in anxiety or depressive symptoms between exposure groups over time. Secondary analyses found CES-D scores across PPA categories were similar at 1-month (11, 10, 11, 11) and 6-months (10, 10, 11, 11) but differed at 3-months (9, 11, 10, 12; p = 0.035) and 12-months (10, 6, 11, 10; p = 0.019). GAD-7 scores did not vary across PPA categories at any time point. While abstinence was associated with fewer depressive symptoms at times, findings were not consistent during follow-up, perhaps reflecting intermittent relapse. PWH with polysubstance use and mental health comorbidity are complex, and larger samples with sustained abstinence would further elucidate effects of abstinence on mental health.

Psychometric assessment of the Runyankole-translated Marlowe-Crowne Social Desirability Scale among persons with HIV in Uganda.

BACKGROUND: Social desirability can negatively affect the validity of self-reported measures, including underreporting of stigmatized behaviors like alcohol consumption. The Marlowe-Crowne Social Desirability Scale (SDS) is widely implemented and comprised of Denial and Attribution Domains (i.e., tendencies to deny undesirable traits or attribute socially desirable traits to oneself, respectively). Yet, limited psychometric research has been conducted in sub-Saharan Africa, where the prevalence of unhealthy alcohol consumption is high as well as religiosity and hierarchical social norms. To address this gap, we (a) conducted an exploratory study assessing certain psychometric properties of the 28-item SDS (Runyankole-translated) among persons with HIV (PWH) in Uganda, and (b) examined the relationship between social desirability and self-reported alcohol use. METHODS: We pooled baseline data (N = 1153) from three studies of PWH engaged in alcohol use from 2017 to 2021. We assessed the translated scale's construct validity (via confirmatory factor analysis), internal consistency, item performance, differential item functioning by gender, concurrent validity with the DUREL religiosity index domains, and the association between social desirability and self-reported alcohol use. RESULTS: Participants had a mean age of 40.42 years, 63% were men, and 91% had an undetectable HIV viral load. The 28-item SDS had satisfactory construct validity (Model fit indices: RMSEA = 0.07, CFI = 0.84, TLI = 0.82) and internal consistency (Denial Domain ΩTotal = 0.82, Attribution Domain ΩTotal = 0.69). We excluded Item 14 ("I never hesitate to help someone in trouble") from the Attribution Domain, which mitigated differential measurement error by gender and slightly improved the construct validity (Model fit indices: RMSEA = 0.06, CFI = 0.86, TLI = 0.85) and reliability (Attribution Domain ΩTotal = 0.72) of the 27-item modified SDS. Using the 27-item SDS, we found that social desirability was weakly correlated with religiosity and inversely associated with self-reported alcohol use after adjusting for biomarker-measured alcohol use and other confounders (ß = -0.05, 95% confidence interval: -0.09 to -0.01, p-value = 0.03). CONCLUSIONS: We detected and mitigated measurement error in the 28-item Runyankole-translated SDS, and found that the modified 27-item scale had satisfactory construct validity and internal consistency in our sample. Future studies should continue to evaluate the psychometric properties of the Runyankole-translated SDS, including retranslating Item 14 and reevaluating its performance.

Hospital Academic Status and the Volume-Outcome Association in Postoperative Patients Requiring Intensive Care: Results of a Nationwide Analysis of Intensive Care Units in the United States.

Objective: To determine whether the outcomes of postoperative patients admitted directly to an intensive care unit (ICU) differ based on the academic status of the institution and the total operative volume of the unit. Methods: This was a retrospective analysis using the eICU Collaborative Research Database v2.0, a national database from participating ICUs in the United States. All patients admitted directly to the ICU from the operating room were included. Transfer patients and patients readmitted to the ICU were excluded. Patients were stratified based on admission to an ICU in an academic medical center (AMC) versus non-AMC, and to ICUs with different operative volume experience, after stratification in quartiles (high, medium-high, medium-low, and low volume). Primary outcomes were ICU and hospital mortality. Secondary outcomes included the need for continuous renal replacement therapy (CRRT) during ICU stay, ICU length of stay (LOS), and 30-day ventilator free days. Results: Our analysis included 22,180 unique patients; the majority of which (15,085[68%]) were admitted to ICUs in non-AMCs. Cardiac and vascular procedures were the most common types of procedures performed. Patients admitted to AMCs were more likely to be younger and less likely to be Hispanic or Asian. Multivariable logistic regression indicated no meaningful association between academic status and ICU mortality, hospital mortality, initiation of CRRT, duration of ICU LOS, or 30-day ventilator-free-days. Contrarily, medium-high operative volume units had higher ICU mortality (OR = 1.45, 95%CI = 1.10-1.91, p-value = 0.040), higher hospital mortality (OR = 1.33, 95%CI = 1.07-1.66, p-value = 0.033), longer ICU LOS (Coefficient = 0.23, 95%CI = 0.07-0.39, p-value = 0.038), and fewer 30-day ventilator-free-days (Coefficient = -0.30, 95%CI = -0.48 - -0.13, p-value = 0.015) compared to their high operative volume counterparts. Conclusions: This study found that a volume-outcome association in the management of postoperative patients requiring ICU level of care immediately after a surgical procedure may exist. The academic status of the institution did not affect the outcomes of these patients.

Plasma Soluble Suppression of Tumorigenicity-2 Associates with Ventilator Liberation in Acute Hypoxemic Respiratory Failure.

Rationale: Standard physiologic assessments of extubation readiness in patients with acute hypoxemic respiratory failure (AHRF) may not reflect lung injury resolution and could adversely affect clinical decision-making and patient outcomes. Objectives: We hypothesized that elevations in inflammatory plasma biomarkers sST2 (soluble suppression of tumorigenicity-2) and IL-6 indicate ongoing lung injury in AHRF and better inform patient outcomes compared with standard clinical assessments. Methods: We measured daily plasma biomarkers and physiologic variables in 200 patients with AHRF for up to 9 days after intubation. We tested the associations of baseline values with the primary outcome of unassisted breathing at Day 29. We analyzed the ability of serial biomarker measurements to inform successful ventilator liberation. Measurements and Main Results: Baseline sST2 concentrations were higher in patients dead or mechanically ventilated versus breathing unassisted at Day 29 (491.7 ng/ml [interquartile range (IQR), 294.5-670.1 ng/ml] vs. 314.4 ng/ml [IQR, 127.5-550.1 ng/ml]; P = 0.0003). Higher sST2 concentrations over time were associated with a decreased probability of ventilator liberation (hazard ratio, 0.80 per log-unit increase; 95% confidence interval [CI], 0.75-0.83; P = 0.03). Patients with higher sST2 concentrations on the day of liberation were more likely to fail liberation compared with patients who remained successfully liberated (320.9 ng/ml [IQR, 181.1- 495.6 ng/ml] vs. 161.6 ng/ml [IQR, 95.8-292.5 ng/ml]; P = 0.002). Elevated sST2 concentrations on the day of liberation decreased the odds of successful liberation when adjusted for standard physiologic parameters (odds ratio, 0.325; 95% CI, 0.119-0.885; P = 0.03). IL-6 concentrations did not associate with outcomes. Conclusions: Using sST2 concentrations to guide ventilator management may more accurately reflect underlying lung injury and outperform traditional measures of readiness for ventilator liberation.

Validating Data-Driven Methods for Identifying Transgender Individuals in the Veterans Health Administration of the US Department of Veterans Affairs.

We sought to operationalize and validate data-driven approaches for identifying transgender individuals in the Veterans Health Administration (VHA) of the US Department of Veterans Affairs (VA) through a retrospective analysis using VA administrative data from 2006-2018. Besides diagnoses of gender identity disorder (GID), a combination of non-GID data elements was used to identify potentially transgender veterans, including 1) an International Classification of Diseases (Ninth or Tenth Revision) code of endocrine disorder, unspecified or not otherwise specified; 2) receipt of sex hormones not associated with the sex documented in the veteran's records (gender-affirming hormone therapy); and 3) a change in the veteran's administratively recorded sex. Both GID and non-GID data elements were applied to a sample of 13,233,529 veterans utilizing the VHA of the VA between January 2006 and December 2018. We identified 10,769 potentially transgender veterans. Based on a high positive predictive value for GID-coded veterans (83%, 95% confidence interval: 77, 89) versus non-GID-coded veterans (2%, 95% confidence interval: 1, 11) from chart review validation, the final analytical sample comprised only veterans with a GID diagnosis code (n = 9,608). In the absence of self-identified gender identity, findings suggest that relying entirely on GID diagnosis codes is the most reliable approach for identifying transgender individuals in the VHA of the VA.

Associations Between Disability and Breast or Cervical Cancers, Accounting for Screening Disparities.

INTRODUCTION: Studies suggest that women with disability experience disparities in routine, high-value screening services, including mammograms and Papanicolaou (Pap) tests. However, few studies have explored whether women with disability have higher risks than other women of developing breast or cervical cancers. METHODS: The authors analyzed 2010, 2013, 2015, and 2018 National Health Interview Surveys, which involved civilian, noninstitutionalized US residents, and included supplemental surveys on cancer screening. The authors used self-reported functional status limitations to identify women without disability and women with movement difficulties (MDs) or complex activity limitations (CAL) predating breast or cervical cancer diagnoses. Multivariable models evaluated associations of disability status to cancer diagnosis, adjusting for other variables. Analyses used sampling weights, producing national estimates. RESULTS: The sample included 66,641 women; 24.4% reported MD and 14.5% reported CAL. Compared with women without disability, women with pre-existing MD or CAL had significantly higher rates of breast cancer (2.2% vs. 3.5% and 3.6%, respectively) and cervical cancer (0.6% vs. 0.8% and 1.0%, respectively). Women with disability had significantly lower recent mammography and Pap test rates than women without disability. After adjusting for all covariates, the values for odds ratio (95% confidence interval) of pre-existing CAL for cancer diagnoses were 1.21 (1.01-1.46; P=0.04) for breast cancer and 1.43 (1.04-1.99; P=0.03) for cervical cancer. CONCLUSIONS: Pre-existing disability is associated with a higher likelihood of breast and cervical cancer diagnoses, raising the urgency of eliminating disability disparities in mammography and Pap testing. Further research will need to explore the causes of these higher cancer rates.

Intersection of HIV and Anemia in women of reproductive age: a 10-year analysis of three Zimbabwe demographic health surveys, 2005-2015.

BACKGROUND: Women of reproductive age 15-49 are at a high risk of iron-deficiency anemia, which in turn may contribute to maternal morbidity and mortality. Common causes of anemia include poor nutrition, infections, malaria, HIV, and treatments for HIV. We conducted a secondary analysis to study the prevalence of and associated risk factors for anemia in women to elucidate the intersection of HIV and anemia using data from 3 cycles of Zimbabwe Demographic and Health Survey (ZDHS) conducted in 2005, 2010, and 2015. METHODS: DHS design comprises of a two-stage cluster-sampling to monitor and evaluate indicators for population health. A field hemoglobin test was conducted in eligible women. Anemia was defined as hemoglobin < 11.0 g/dL in pregnant women; < 12.0 in nonpregnant women. Chi-squared test and multivariable logistic regression analysis accounting for complex survey design were used to determine the prevalence and risk factors associated with anemia. RESULTS: Prevalence (95% confidence interval (CI)) of anemia was 37.8(35.9-39.7), 28.2(26.9-29.5), 27.8(26.5-29.1) in 2005, 2010, and 2015, respectively. Approximately 9.4, 7.2, and 6.1%, of women had moderate anemia; (Hgb 7-9.9) while 1.0, 0.7, and 0.6% of women had severe anemia (Hgb < 7 g/dL)), in 2005, 2010, and 2015, respectively. Risk factors associated with anemia included HIV (HIV+: 2005: OR (95% CI) = 2.40(2.03-2.74), 2010: 2.35(1.99-2.77), and 2015: 2.48(2.18-2.83)]; Residence in 2005 and 2010 [(2005: 1.33(1.08-1.65), 2010: 1.26(1.03-1.53)]; Pregnant or breastfeeding women [2005: 1.31(1.16-1.47), 2010: 1.23(1.09-1.34)]; not taking iron supplementation [2005: 1.17(1.03-1.33), 2010: 1.23(1.09-1.40), and2015: 1.24(1.08-1.42)]. Masvingo, Matebeleland South, and Bulawayo provinces had the highest burden of anemia across the three DHS Cycles. Manicaland and Mashonaland East had the lowest burden. CONCLUSION: The prevalence of anemia in Zimbabwe declined between 2005 and 2015 but provinces of Matebeleland South and Bulawayo were hot spots with little or no change HIV positive women had higher prevalence than HIV negative women. The multidimensional causes and drivers of anemia in women require an integrated approach to help ameliorate anemia and its negative health effects on the women's health. Prevention strategies such as promoting iron-rich food and food fortification, providing universal iron supplementation targeting lowveld provinces and women with HIV, pregnant or breastfeeding are required.

Cross-Sectional Analysis of the Associations Between Four Common Cancers and Disability.

BACKGROUND: Approximately 61 million Americans have a disability. Little research has explored whether disability is associated with subsequent diagnosis of cancer, the second-leading cause of death in the United States. The objective of this study was to explore associations between cancer and disability, focusing on 4 cancers that may present with nonspecific symptoms that could be conflated with aspects of disability, thus delaying cancer diagnoses. An analysis of a nationally representative survey using sampling weights to produce national estimates was performed. METHODS: Civilian, noninstitutionalized US residents responding to the 2010-2017 National Health Interview Surveys totaling 259,392 Sample Adult Core survey respondents were included. We used self-reported functional status limitations to identify persons with movement difficulties (MD), complex activity limitations (CAL), and no disability. Multivariable regressions predicting cancer diagnosis included sociodemographic characteristics, tobacco use, body mass index, access to care indicators, and disability status. RESULTS: Persons with preexisting disability had significantly higher rates of cancer (ranging from 0.40 [SE, 0.05] for ovarian to 3.38 [0.14] for prostate) than did those without disability (0.20 [0.02] and 1.26 [0.04] for the same cancers; all P<.0001). Multivariable analyses found strong associations of preexisting MD and CAL with colorectal cancer, with adjusted odds ratios (aORs) of 1.5 (95% CI, 1.2-1.9) and 1.9 (1.5-2.4), respectively. For non-Hodgkin's lymphoma, the aOR for CAL was 1.5 (1.1-2.1). For prostate cancer, aORs for MD were 1.2 (1.0-1.3) and 1.1 (1.0-1.3) for CAL. Using cross-sectional survey data, we could only identify statistical associations, not causality. CONCLUSIONS: Our population-based analyses suggest that persons with disability may constitute a high-risk population, with higher cancer incidence. Optimizing appropriate screening and fully investigating new signs and symptoms are therefore critical for patients with disability.

Primary caregiver education level and sleep problems in children with autism spectrum disorder.

In children with autism spectrum disorder, there have been equivocal results regarding primary caregiver education level and its influence on sleep. Thus, we assessed if lower primary caregiver education level is associated with more sleep problems. We evaluated 4,636 children with autism spectrum disorder in the Autism Speaks Autism Treatment Network's United States and Canadian registry, whose caregivers completed the Children's Sleep Habits Questionnaire. Using regression analysis, there was an association between lower primary caregiver education level and more sleep problems. Secondary analyses demonstrated that younger age, Hispanic ethnicity, higher IQ, autism diagnosis and lower adaptive function were also associated with more sleep problems. The finding that lower primary caregiver education level was associated with increased sleep problems in a large sample of children with autism spectrum disorder highlights the importance of screening for risk factors affecting sleep to help moderate sleep problems.

Oral rehydration solution coverage in under 5 children with diarrhea: a tri-country, subnational, cross-sectional comparative analysis of two demographic health surveys cycles.

BACKGROUND: More than 3 million children under 5 years in developing countries die from dehydration due to diarrhea, a preventable and treatable disease. We conducted a comparative analysis of two Demographic Health Survey (DHS) cycles to examine changes in ORS coverage in Zimbabwe, Zambia and Malawi. These surveys are cross-sectional conducted on a representative sample of the non-institutionalized individuals. METHODS: The sample is drawn using a stratified two-stage cluster sampling design with census enumeration areas, typically, selected first as primary sampling units (PSUs) and then a fixed number of households from each PSU. We examined national and sub-regional prevalence of ORS use during a recent episode of diarrhea (within 2 weeks of survey) using DHSs for 2007-2010 (1st Period), and 2013-2016 (2nd Period). Weighted proportions of ORS were obtained and multivariable- design-adjusted logistic regression analysis was used to obtain Odds Ratios (aORs) and 95% confidence intervals (CIs) and weighted proportions of ORS coverage. RESULTS: Crude ORS coverage increased from 21.0% (95% CI: 17.4-24.9) in 1st Period to 40.5% (36.5-44.6) in 2nd Period in Zimbabwe; increased from 60.8% (56.1-65.3) to 64.7% (61.8-67.5) in Zambia; and decreased from 72.3% (68.4-75.9) to 64.6% (60.9-68.1) in Malawi. The rates of change in coverage among provinces in Zimbabwe ranged from 10.3% over the three cycles (approximately 10 years) in Midlands to 44.2% in Matabeleland South; in Zambia from - 9.5% in Eastern Province to 24.4% in Luapula; and in Malawi from - 16.5% in the Northern Province to - 3.2% in Southern Province. The aORs for ORS use was 3.95(2.66-5.86) for Zimbabwe, 2.83 (2.35-3.40) for Zambia, and, 0.71(0.59-0.87) for Malawi. CONCLUSION: ORS coverage increased in Zimbabwe, stagnated in Zambia, but declined in Malawi. Monitoring national and province-level trends of ORS use illuminates geographic inequalities and helps identify priority areas for targeting resource allocation.. Provision of safe drinking-water, adequate sanitation and hygiene will help reduce the causes and the incidence of diarrhea. Health policies to strengthen access to appropriate treatments such as vaccines for rotavirus and cholera and promoting use of ORS to reduce the burden of diarrhea should be developed and implemented.

Burden and changes in HIV/AIDS morbidity and mortality in Southern Africa Development Community Countries, 1990-2017.

BACKGROUND: The 16 Southern Africa Development Community (SADC) countries remain the epicentre of the HIV/AIDS epidemic with the largest number of people living with HIV/AIDS. Anti-retroviral treatment (ART) has improved survival and prevention of mother-to-child transmission (PMTCT) of HIV, but the disease remains a serious cause of mortality. We conducted a descriptive epidemiological analysis of HIV/AIDS burden for the 16 SADC countries using secondary data from the Global Burden of Diseases, Injuries and Risk Factor (GBD) Study. METHODS: The GBD study is a systematic, scientific effort by the Institute for Health Metrics and Evaluation (IHME) to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geographies for specific points in time. We analyzed the following outcomes: mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to HIV/AIDS for SADC. Input data for GBD was extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service utilisation, disease notifications, and other sources. Country- and cause-specific HIV/AIDS-related death rates were calculated using the Cause of Death Ensemble model (CODEm) and spatiotemporal Gaussian process regression (ST-GPR). Deaths were multiplied by standard life expectancy at each age-group to calculate YLLs. Cause-specific mortality was estimated using a Bayesian meta-regression modelling tool, DisMod-MR. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases to calculate YLDs. Crude and age-adjusted rates per 100,000 population and changes between 1990 and 2017 were determined for each country. RESULTS: In 2017, HIV/AIDS caused 336,175 deaths overall in SADC countries, and more than 20 million DALYs. This corresponds to a 3-fold increase from 113,631 deaths (6,915,170 DALYs) in 1990. The five leading countries with the proportion of deaths attributable to HIV/AIDS in 2017 were Botswana at the top with 28.7% (95% UI; 23.7-35.2), followed by South Africa 28.5% (25.8-31.6), Lesotho, 25.1% (21.2-30.4), eSwatini 24.8% (21.3-28.6), and Mozambique 24.2% (20.6-29.3). The five countries had relative attributable deaths that were at least 14 times greater than the global burden of 1.7% (1.6-1.8). Similar patterns were observed with YLDs, YLLs, and DALYs. Comoros, Seychelles and Mauritius were on the lower end, with attributable proportions less than 1%, below the global proportion. CONCLUSIONS: Great progress in reducing HIV/AIDS burden has been achieved since the peak but more needs to be done. The post-2005 decline is attributed to PMTCT of HIV, resources provided through the US President's Emergency Plan For AIDS Relief (PEPFAR), and behavioural change. The five countries with the highest burden of HIV/AIDS as measured by proportion of death attributed to HIV/AIDS and age-standardized mortaility rate were Botswana, South Africa, Lesotho, eSwatini, and Mozambique. SADC countries should cooperate, work with donors, and embrace the UN Fast-Track approach, which calls for frontloading investment from domestic or other sources to prevent and treat HIV/AIDS. Robust tracking, testing, and early treatment are required, as well as refinement of individual treatment strategies for transient individuals in the region.

Evaluating the effect of care around labor and delivery practices on early neonatal mortality in the Global Network's Maternal and Newborn Health Registry.

BACKGROUND: Neonatal deaths in first 28-days of life represent 47% of all deaths under the age of five years globally and are a focus of the United Nation's (UN's) Sustainable Development Goals. Pregnant women are delivering in facilities but that does not indicate quality of care during delivery and the postpartum period. The World Health Organization's Essential Newborn Care (ENC) package reduces neonatal mortality, but lacks a simple and valid composite index that measures its effectiveness. METHODS: Data on 5 intra-partum and 3 post-partum practices (indicators) recommended as part of ENC, routinely collected in NICHD's Global Network's (GN) Maternal Newborn Health Registry (MNHR) between 2010 and 2013, were included. We evaluated if all 8 practices (Care around Delivery - CAD), combined as an index was associated with reduced early neonatal mortality rates (days 0-6 of life). RESULTS: A total of 150,848 live births were included in the analysis. The individual indicators varied across sites. All components were present in 19.9% births (range 0.4 to 31% across sites). Present indicators (8 components) were associated with reduced early neonatal mortality [adjusted RR (95% CI):0.81 (0.77, 0.85); p < 0.0001]. Despite an overall association between CAD and early neonatal mortality (RR < 1.0 for all early mortality): delivery by skilled birth attendant; presence of fetal heart and delayed bathing were associated with increased early neonatal mortality. CONCLUSIONS: Present indicators (8 practices) of CAD were associated with a 19% reduction in the risk of neonatal death in the diverse health facilities where delivery occurred within the GN MNHR. These indicators could be monitored to identify facilities that need to improve compliance with ENC practices to reduce preventable neonatal deaths. Three of the 8 indicators were associated with increased neonatal mortality, due to baby being sick at birth. Although promising, this composite index needs refinement before use to monitor facility-based quality of care in association with early neonatal mortality. Trial registration The identifier of the Maternal Newborn Health Registry at ClinicalTrials.gov is NCT01073475.

The Clinical Impact and Cost-effectiveness of Measles-Mumps-Rubella Vaccination to Prevent Measles Importations Among International Travelers From the United States.

BACKGROUND: Measles importations and the subsequent spread from US travelers returning from abroad are responsible for most measles cases in the United States. Increasing measles-mumps-rubella (MMR) vaccination among departing US travelers could reduce the clinical impact and costs of measles in the United States. METHODS: We designed a decision tree to evaluate MMR vaccination at a pretravel health encounter (PHE), compared with no encounter. We derived input parameters from Global TravEpiNet data and literature. We quantified Riskexposure to measles while traveling and the average number of US-acquired cases and contacts due to a measles importation. In sensitivity analyses, we examined the impact of destination-specific Riskexposure, including hot spots with active measles outbreaks; the percentage of previously-unvaccinated travelers; and the percentage of travelers returning to US communities with heterogeneous MMR coverage. RESULTS: The no-encounter strategy projected 22 imported and 66 US-acquired measles cases, costing $14.8M per 10M travelers. The PHE strategy projected 15 imported and 35 US-acquired cases at $190.3M per 10M travelers. PHE was not cost effective for all international travelers (incremental cost-effectiveness ratio [ICER] $4.6M/measles case averted), but offered better value (ICER <$100 000/measles case averted) or was even cost saving for travelers to hot spots, especially if travelers were previously unvaccinated or returning to US communities with heterogeneous MMR coverage. CONCLUSIONS: PHEs that improve MMR vaccination among US international travelers could reduce measles cases, but are costly. The best value is for travelers with a high likelihood of measles exposure, especially if the travelers are previously unvaccinated or will return to US communities with heterogeneous MMR coverage.

Histologic and clinical cross-sectional study of chronic hair loss in patients with cutaneous chronic graft-versus-host disease.

BACKGROUND: While scalp alopecia represents a distinctive feature of chronic graft-versus-host disease (cGVHD), little is known about the clinical and histologic presentation of hair loss. OBJECTIVES: We sought to classify the clinical presentations and histologic findings of chronic hair loss in patients with cutaneous cGVHD. METHODS: A prospective cohort of 17 adult hematopoietic cell transplantation (HCT) recipients with cutaneous cGVHD was enrolled. Dermatologic examinations were performed, and punch biopsy specimens of the scalp were obtained. Biopsy specimens were analyzed with hematoxylin-eosin and immunohistochemical stains in all cases and fluorescence in situ hybridization analyses in specific cases. RESULTS: Clinically, 4 patterns of hair loss were described-patchy nonscarring (41.2%), diffuse nonscarring (11.8%), diffuse sclerotic (11.8%), and patchy sclerotic (5.9%). The location of the inflammatory infiltrate on hematoxylin-eosin-stained specimens correlated with the hair loss pattern patients had clinically, with cell populations around the bulb and bulge in nonscarring and sclerotic cases, respectively. Fluorescence in situ hybridization studies in female cGVHD patients with male donors demonstrated green Y chromosomes limited to the area of the hair follicle affected by inflammatory cells. CONCLUSION: This study describes the various clinical and histologic subtypes of long-standing alopecia in adult cGVHD patients and suggests that this alopecia may be a direct manifestation of cGVHD of the hair follicle.

Quality Comes with the (Anatomic) Territory: Evaluating the Impact of Surgeon Operative Mix on Patient Outcomes After Pancreaticoduodenectomy.

BACKGROUND: Recent support for centralization of complex operations, such as pancreaticoduodenectomy (PD), is based on surgeon-specific volume-outcome relationships. This study examined whether volume of anatomically related operations (operative mix), besides PD, is also independently associated with postoperative outcomes after PD. METHODS: The study queried the Nationwide Inpatient Sample (2004-2009) for surgeons performing PD. Operative mix (OM) was defined as the year-specific number of other pancreatic, hepatic, biliary, and gastric operations performed by individual surgeons. Regression models included surgeon and hospital PD volume, adjusted for other hospital- and patient-specific factors. RESULTS: Among 1747 surgeons, 88.3% had low PD volume (≤ 5 cases/year), 8.9% had moderate PD volume (6-16 cases/year), and 2.8% had high PD volume (≥ 17 cases/year). Low-PD-volume surgeons with high OM (≥ 21 cases/year) (4.4%), moderate-PD-volume surgeons with high OM (3.4%), and high-PD-volume surgeons with high OM (2.7%) each had lower mortality than low-PD-volume surgeons with low OM (9.3%; all p ≤ 0.02). The frequency of prolonged hospitalization among low-PD/high-OM surgeons (45.3%) was lower than among low-PD/low-OM surgeons (61.6%; p < 0.001). Increasing OM volume was associated with decreased inpatient mortality, shorter hospital stay, and lower likelihood of any postoperative complication, using unadjusted regression (all p < 0.001). Adjusted regression results indicated that increasing OM volume is a significant predictor of decreased odds of a prolonged hospital stay (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.73-0.90; p < 0.001). CONCLUSIONS: Surgeon PD volume is an important predictor of outcomes after PD. However, surgeon OM volume identifies a subset of lower-PD-volume surgeons with more favorable outcomes.

Oral and Maxillofacial Surgery Resident Perception of Personal Achievement and Anxiety: A Cross-Sectional Analysis.

PURPOSE: Anxiety is prevalent among medical residents and is associated with fatigue, psychological dysfunction, and burnout. A low personal achievement level is a characteristic of burnout, which-if unaddressed-may lead to medical error and decrease the quality of patient care. This study aimed to assess both personal achievement levels and anxiety levels in current oral and maxillofacial surgery (OMS) residents and to discern a relationship between anxiety severity and perceived personal achievement level among residents. MATERIALS AND METHODS: An anonymous 20-question cross-sectional online survey was developed using the anxiety component of the Hospital Anxiety and Depression Scale and the personal Maslach Burnout Inventory. The survey was sent to all the OMS residents enrolled in programs affiliated with the American Association of Oral and Maxillofacial Surgeons in 2017. Univariate and bivariate analyses were conducted to obtain summary measures of the predictor (anxiety) and the outcome (personal achievement) stratified by age, gender, marital status, program type (4- or 6-year program), and year of residency. Multinomial logistic regression models were obtained to evaluate the association between anxiety and personal achievement. A 2-sided P < .05 was considered statistically significant. RESULTS: We received 238 responses (20% response rate); 58% of respondents had moderate or severe levels of anxiety, and nearly half of respondents reported moderate or low levels of personal achievement. Women were more likely to have severe anxiety than men (60% vs 37%, P < .01). Residents with severe anxiety were 91% more likely to report low levels of personal achievement than residents with low anxiety (odds ratio, 0.09; 95% confidence interval, 0.03 to 0.22; P < .0001). The results suggest the presence of an inverse relationship between personal achievement level and anxiety. CONCLUSIONS: More than half of OMS residents in the United States report moderate to severe anxiety. Higher levels of anxiety are associated with lower personal achievement levels. It is important to understand the negative impact anxiety has on trainees, including the unintended consequences.

Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations.

Background: Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers. Objective: To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine. Design: Observational study in U.S. pretravel clinics. Setting: 24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-funded consortium. Patients: Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014). Measurements: Structured questionnaire completed by traveler and provider during pretravel consultation. Results: 40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]). Limitation: These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity. Conclusion: Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus. Primary Funding Source: Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award.

Characteristics of US Travelers to Zika Virus-Affected Countries in the Americas, March 2015-October 2016.

Zika virus has recently been introduced to the Americas and is spreading rapidly. We evaluated the characteristics of US travelers to Zika virus-affected countries who were seen at Global TravEpiNet sites during March 2015-October 2016. Nearly three quarters of travelers were men or women of reproductive age.

Share2Quit: Online Social Network Peer Marketing of Tobacco Cessation Systems.

INTRODUCTION: Although technology-assisted tobacco interventions (TATIs) are effective, they are underused due to recruitment challenges. We tested whether we could successfully recruit smokers to a TATI using peer marketing through a social network (Facebook). METHODS: We recruited smokers on Facebook using online advertisements. These recruited smokers (seeds) and subsequent waves of smokers (peer recruits) were provided the Share2Quit peer recruitment Facebook app and other tools. Smokers were incentivized for up to seven successful peer recruitments and had 30 days to recruit from date of registration. Successful peer recruitment was defined as a peer recruited smoker completing the registration on the TATI following a referral. Our primary questions were (1) whether smokers would recruit other smokers and (2) whether peer recruitment would extend the reach of the intervention to harder-to-reach groups, including those not ready to quit and minority smokers. RESULTS: Overall, 759 smokers were recruited (seeds: 190; peer recruits: 569). Fifteen percent (n = 117) of smokers successfully recruited their peers (seeds: 24.7%; peer recruits: 7.7%) leading to four recruitment waves. Compared to seeds, peer recruits were less likely to be ready to quit (peer recruits 74.2% vs. seeds 95.1%), more likely to be male (67.1% vs. 32.9%), and more likely to be African American (23.8% vs. 10.8%) (p < .01 for all comparisons). CONCLUSIONS: Peer marketing quadrupled our engaged smokers and enriched the sample with not-ready-to-quit and African American smokers. Peer recruitment is promising, and our study uncovered several important challenges for future research. IMPLICATIONS: This study demonstrates the successful recruitment of smokers to a TATI using a Facebook-based peer marketing strategy. Smokers on Facebook were willing and able to recruit other smokers to a TATI, yielding a large and diverse population of smokers.