Implementation of single-port robotic urologic surgery: experience at a large academic center.

The Single-Port (SP) robotic system is increasingly being implemented in the United States, allowing for several minimally invasive urologic procedures to be performed. The present study aims to describe our single-center experience since the adoption of the SP platform. We retrospectively collected and analyzed consecutive SP cases performed at a major teaching hospital in the Midwest (Rush University Medical Center) from December 2020 to December 2023. Demographic variables were collected. Surgical and pathological outcomes were analyzed in the overall cohort and for each type of procedure. The study timeframe was divided into two periods to assess the evolution of SP technical features over time. In total, 160 procedures were performed, with robot-assisted radical prostatectomy (RARP) being the most common (49.4%). Overall, 54.4% of the procedures were extraperitoneal, with a significantly higher adoption of this approach in the second half of the study period (30% vs 74.3%, p < 0.001). A "plus one" assistant port was adopted in 38.1% of cases, with a shift towards a "pure" single-port surgery in the most recent procedures (21.1% vs 76.7%, p < 0.001). The median LOS was 33.5 h (30-48), with a rate of any grade and CD ≥ 3 postoperative complications of 9.4% and 2.5%, respectively, and a 30-day readmission rate of 1.9%. SP robotic surgery can be safely and effectively implemented for various urologic procedures. With increasing experience, the SP platform allows shifting away from transperitoneal procedures, potentially minimizing postoperative pain, and shortening hospital stay and postoperative recovery.

A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial.

INTRODUCTION: Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain. METHODS: The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months. RESULTS: Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting. CONCLUSIONS: A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Impact of Injection-Based Delivery Parameters on Local Distribution Volume of EthylCellulose Ethanol Gel in Tissue and Tissue Mimicking Phantoms.

: Local drug delivery aims to minimize systemic toxicity by preventing off-target effects; however, injection parameters influencing depot formation of injectable gels have yet to be thoroughly studied. We explored the effects of needle characteristics, injection depth, rate, volume, and polymer concentration on gel ethanol distribution in both tissue and phantoms. METHODS: The polymer ethyl cellulose (EC) was added to ethanol to form an injectable gel to ablate cervical precancer and cancer. Tissue mimicking phantoms composed of 1% agarose dissolved in deionized water were used to establish overall trends between various injection parameters and the resulting gel distribution. Additional experiments were performed in excised swine cervices with a CT-imageable injectate formulation, which enabled visualization of the distribution without tissue sectioning. RESULTS: Needle type and injection rate had minimal impact on gel distribution, while needle depths ≥13 mm yielded significantly larger distributions. Needle gauge and EC concentration impacted injection pressure with maximum gel distribution achieved when the pressure was 70-250 kPa. Injection volumes ≤3 mL of 6% ECethanol minimized fluid leakage away from the injection site. Results guided the development of a speculum-compatible handheld injector to deliver gel ethanol into the cervix. CONCLUSION: Needle depth, gauge, and polymer concentration are critical to consider when delivering injectable gels. SIGNIFICANCE: This study addressed key questions related to the impact of injection-based parameters on gel distribution at a scale relevant to human applications including: 1) how best to deliver EC-ethanol into the cervix and 2) general insights about injection protocols relevant to the delivery of injectable gels in tissue.

"It Is A Carrot-Stick Model": A Qualitative Study of Rural-Serving Clinician and Rural-Residing Veteran Perceptions of Requirements to Quit Smoking prior to Elective Surgery.

Introduction: Some medical centers and surgeons require patients to stop smoking cigarettes prior to elective orthopaedic surgeries in an effort to decrease surgical complications. Given higher rates of smoking among rural individuals, rural patients may be disproportionately impacted by these requirements. We assessed the perceptions and experiences of rural-residing Veterans and clinicians related to this requirement. Methods: We conducted qualitative semistructured one-on-one interviews of 26 rural-residing veterans, 10 VA orthopaedic surgery staff (from two Veterans Integrated Services Networks), 24 PCPs who serve rural veterans (14 VA; 10 non-VA), and 4 VA pharmacists. Using the knowledge, attitudes, and behavior framework, we performed conventional content analysis. Results: We found three primary themes across respondents: (1) knowledge of and the evidence base for the requirement varied widely; (2) strong personal attitudes toward the requirement; and (3) implementation and possible implications of this requirement. All surgery staff reported knowledge of requirements at their institution. VA PCPs reported knowledge of requirements but typically could not recall specifics. Most patients were unaware. The majority of respondents felt this requirement could increase motivation to quit smoking. Some PCPs felt a more thorough explanation of smoking-related complications would result in increased quit attempts. About half of all patients reported belief that the requirement was reasonable regardless of initial awareness. Respondents expressed little concern that the requirement might increase rural-urban disparities. Most PCPs and patients felt that there should be exceptions for allowing surgery, while surgical staff disagreed. Discussion. Most respondents thought elective surgery was a good motivator to quit smoking; but patients, PCPs, and surgical staff differed on whether there should be exceptions to the requirement that patients quit preoperatively. Future efforts to augment perioperative smoking cessation may benefit from improving coordination across services and educating patients more about the benefits of quitting.

Dexamethasone Suppression Testing in a Contemporary Cohort with Adrenal Incidentalomas in Two U.S. Integrated Healthcare Systems.

Autonomous cortisol secretion (ACS) from an adrenal adenoma can increase the risk for comorbidities and mortality. The dexamethasone suppression test (DST) is the standard method to diagnose ACS. A multi-site, retrospective cohort of adults with diagnosed adrenal tumors was used to understand patient characteristics associated with DST completion and ACS. Time to DST completion was defined using the lab value and result date; follow-up time was from the adrenal adenoma diagnosis to the time of completion or censoring. ACS was defined by a DST > 1.8 µg/dL (50 nmol/L). The Cox proportional hazards regression model assessed associations between DST completion and patient characteristics. In patients completing a DST, a logistic regression model evaluated relationships between elevated ACS and covariates. We included 24,259 adults, with a mean age of 63.1 years, 48.1% obese, and 28.7% with a Charlson comorbidity index ≥ 4. Approximately 7% (n = 1768) completed a DST with a completion rate of 2.36 (95% CI 2.35, 2.37) per 100 person-years. Fully adjusted models reported that male sex and an increased Charlson comorbidity index were associated with a lower likelihood of DST completion. Current or former smoking status and an increased Charlson comorbidity index had higher odds of a DST > 1.8 µg/dL. In conclusion, clinical policies are needed to improve DST completion and the management of adrenal adenomas.

In Vivo Evaluation of Safety and Efficacy of Ethyl Cellulose-Ethanol Tissue Ablation in a Swine Cervix Model.

Current therapies for treating cervical dysplasia are often inaccessible in low and middle-income countries (LMICs), highlighting the need for novel low-cost therapies that can be delivered at the point of care. Ethanol ablation is a low-cost therapy designed to treat locoregional cancers, which we augmented into an ethyl cellulose (EC)-ethanol gel formulation to enhance its efficacy. Here, we evaluated whether EC-ethanol ablation is able to safely achieve an ablation zone comparable to thermocoagulation, a commonly used therapy for cervical dysplasia. The study was performed in 20 female Yorkshire pigs treated with either a single 500 µL injection of EC-ethanol into the 12 o'clock position of the cervix or a single application of thermocoagulation at 100 °C for 20 s. The average temperature, heart rate, respiratory rate, and blood oxygen remained within normal ranges throughout the EC-ethanol procedure and were similar to the thermocoagulation group. No major side effects were observed. The reproductive tracts were excised after 24 h to examine ablation zones. Comparable depths of necrosis were seen for EC-ethanol (18.6 ± 1.6 mm) and thermocoagulation (19.7 ± 4.1 mm). The volumes of necrosis induced by a single injection of EC-ethanol (626.2 ± 122.8 µL) were comparable to the necrotic volumes induced by thermocoagulation in the top half of the cervices (664.6 ± 168.5 µL). This suggests that two EC-ethanol injections could be performed (e.g., at the 12 and 6 o'clock positions) to achieve comparable total necrotic volumes to thermocoagulation and safely and effectively treat women with cervical dysplasia in LMICs. This is the first study to systematically evaluate EC-ethanol ablation in a large animal model and compare its safety and efficacy to thermocoagulation, a commonly used ablative therapy for cervical dysplasia.

Associations Between Characteristics of Individuals With Fontan Circulation With Blood and Urine Biomarkers of Kidney Injury and Dysfunction.

Background Fontan circulation is associated with kidney injury and dysfunction, often unappreciated until Fontan circulatory failure. We hypothesized that cystatin C-estimated glomerular filtration rate (eGFR) would identify chronic kidney disease more frequently and that urine kidney injury biomarkers would be higher with declining Fontan physiological features. Methods and Results We enrolled 100 ambulatory individuals. Blood and urinary laboratory measurements were compared with demographics and clinically obtained data. Different eGFR equations were used for individuals aged ≥19 years and <19 years. Chronic kidney disease was defined as eGFR <90 mL/min per 1.73 m2. Median (25th-75th percentile) age was 19 (14-26) years, and 43% were female patients. Cystatin C eGFR detected chronic kidney disease (37%) in more patients than creatinine eGFR (11%). Cystatin C eGFR was positively associated, and skeletal muscle mass was negatively associated, with creatinine eGFR in both univariate (cystatin C eGFR ß=0.44±0.12, P=0.0006; skeletal muscle mass ß=-0.72±0.32, P=0.03) and multivariable analysis (cystatin C eGFR ß=0.43±0.12, P=0.0005; skeletal muscle mass ß=-0.69±0.29, P=0.02). Urine neutrophil gelatinase-associated lipocalin concentration correlated with Fontan pressure (r=0.28; P=0.04), ventricular end-diastolic pressure (r=0.28; P=0.04), and body fat mass (r=0.26; P=0.03). Conclusions Cystatin C eGFR identified more kidney dysfunction, likely attributable to creatinine eGFR being confounded by skeletal muscle mass. Elevated urine neutrophil gelatinase-associated lipocalin was associated with worse Fontan hemodynamics and higher percentage body fat, suggesting that higher venous pressure and higher adiposity are associated with ongoing kidney injury.

Implementation fidelity to HIV assisted partner services (aPS) during scale-up in western Kenya: a convergent mixed methods study.

BACKGROUND: HIV assisted partner services (aPS) is an intervention to improve HIV status awareness among sex and drug-injecting partners of people newly diagnosed with HIV (index clients). Implementation fidelity-the degree to which an intervention is conducted as intended - is critical to effectiveness, but there are limited data about aPS fidelity when delivered by HIV testing service (HTS) providers. We explored factors affecting implementation fidelity to aPS in two high-HIV prevalence counties in western Kenya. METHODS: We used convergent mixed methods adapting the conceptual framework for implementation fidelity within the aPS scale-up project. This was an implementation study examining scale-up of APS within HTS programs in Kisumu and Homa Bay counties that recruited male sex partners (MSPs) of female index clients. We defined implementation fidelity as the extent to which HTS providers followed the protocol for phone and in-person participant tracing at six expected tracing attempts. Quantitative data were collected from tracing reports in 31 facilities between November 2018 and December 2020, and in-depth interviews (IDIs) were conducted with HTS providers. Descriptive statistics were used to describe tracing attempts. IDIs were analyzed using thematic content analysis. RESULTS: Overall, 3017 MSPs were mentioned of whom 98% (2969/3017) were traced, with most tracing attempts being successful (2831/2969, 95%). Fourteen HTS providers participated in the IDIs-mostly females (10/14, 71%) with a median age of 35 years (range 25-52), who all had post-secondary education (14/14, 100%). The proportion of tracing attempts occurring by phone ranged from 47 to 66%, with the highest proportion occurring on the first attempt and lowest on the sixth attempt. Contextual factors either enhanced or impeded implementation fidelity to aPS. Positive provider attitudes towards aPS and conducive work environment factors promoted implementation fidelity, while negative MSP responses and challenging tracing conditions impeded it. CONCLUSION: Interactions at the individual (provider), interpersonal (client-provider), and health systems (facility) levels affected implementation fidelity to aPS. As policymakers prioritize strategies to reduce new HIV infections, our findings highlight the importance of conducting fidelity assessments to better anticipate and mitigate the impact of contextual factors during the scale-up of interventions.

Real-world impact of integrating HIV assisted partner services into 31 facilities in Kenya: a single-arm, hybrid type 2 implementation-effectiveness study.

BACKGROUND: Assisted partner services (APS), or exposure notification and HIV testing for sexual partners of individuals diagnosed with HIV (index clients), have been shown to be safe and effective in clinical trials. We assessed the real-world effectiveness of APS when integrated into HIV clinics in western Kenya. METHODS: In this single-arm, hybrid type 2 implementation science study, we facilitated APS implementation in 31 health facilities in Kenya by training existing health-care staff. We focused on male partner outcomes to assess the impact of APS in reaching male individuals in sub-Saharan Africa, who have lower rates of HIV testing than female individuals. Female individuals (aged ≥18 years or emancipated minor) who tested positive for HIV at participating facilities in Kenya were offered APS; consenting female participants provided contact information for all male sexual partners in the past 3 years. Male partners were notified of their potential HIV exposure and offered a choice of community-based or facility-based HIV testing services (HTS). Female index clients and male partners with HIV were followed up at 6 weeks, 6 months, and 12 months after enrolment, to assess linkage to antiretroviral treatment. Viral load was assessed at 12 months. FINDINGS: Between May 1, 2018, and March 31, 2020, 32 722 female individuals received HTS; 1910 (6%) tested positive for HIV, of whom 1724 (90%) received APS. Female index clients named 5137 male partners (median 3 per index [IQR 2-4]), of whom 4422 (86%) were reached with exposure notification and HTS. 524 (12%) of the male partners tested were newly diagnosed with HIV and 1292 (29%) reported a previous HIV diagnosis. At 12 months follow-up, 1512 (88%) female index clients and 1621 (89%) male partners with HIV were taking ART, with few adverse events: 25 (2%) female index clients and seven (<1%) male partners reported intimate partner violence, and 60 (3%) female index clients and ten (<1%) male partners reported relationship dissolution. INTERPRETATION: Evidence from this real-world APS scale-up project shows that APS is a safe, acceptable, and effective strategy to identify males with HIV and retain them in care. FUNDING: The US National Institutes of Health.

Regionalization or Access to Care? A Joint Pediatric Heart Care Program That Achieves Both: One Program-Two Sites.

Background: Regionalization of care for children with congenital heart disease has been proposed as a method to improve outcomes. This has raised concerns about limiting access to care. We present the details of a joint pediatric heart care program (JPHCP) which utilized regionalization and actually improved access to care. Methods: In 2017, Kentucky Children's Hospital (KCH) launched the JPHCP with Cincinnati Children's Hospital Medical Center (CCHMC). This unique satellite model was the product of several years of planning, leading to a comprehensive strategy with shared personnel, conferences, and a robust transfer system; "one program-two sites." Results: Between March 2017 and the end of June 2022, 355 operations were performed at KCH under the auspices of the JPHCP. As of the most recent published Society of Thoracic Surgeons (STS) outcome report (through the end of June 2021), for all STAT categories, the JPHCP at KCH outperformed the STS overall in postoperative length of stay, and the mortality rate was lower than expected for the case mix. Of the 355 operations, there were 131 STAT 1, 148 STAT 2, 40 STAT 3, and 36 STAT 4 operations, with two operative mortalities: an adult undergoing surgery for Ebstein anomaly, and a premature infant who died from severe lung disease many months after aortopexy. Conclusions: With a select case mix, and by affiliating with a large volume congenital heart center, the creation of the JPHCP at KCH was able to achieve excellent congenital heart surgery results. Importantly, access to care was improved for those children at the more remote location utilizing this one program-two sites model.

HIV self-testing acceptability among injured persons seeking emergency care in Nairobi, Kenya.

BACKGROUND: Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations. OBJECTIVES: This study sought to understand the injury patient acceptability of ED-HIVST. METHODS: Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains. RESULTS: Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they 'Agree Completely' with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36-2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27-2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72-4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41-2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01-2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38-2.33) had greater odds of agreeing completely. CONCLUSIONS: ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya.

Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study.

HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.

Isolated Optic Disc Granuloma as a Presenting Sign of Sarcoidosis.

PURPOSE: To report a case of an optic disc granuloma secondary to sarcoidosis in the absence of any systemic symptoms nor evident signs of intraocular inflammation at the time of presentation. METHODS: Retrospective case report. RESULTS: A 59-year-old Caucasian woman with previously unrevealing systemic work up was referred to the uveitis service for persistent optic disc edema of the right eye for over 1 year. Fundoscopic examination revealed an optic disc granuloma with associated hyper-reflectivity on OCT and high surface reflectivity with medium internal reflectivity on B-scan ultrasound. CT chest was negative, however, a PET scan demonstrated extensive FDG activity in the mediastinum and bilateral hilum, consistent with a diagnosis of sarcoidosis. CONCLUSION: Optic nerve head granulomas can rarely present as the only clinical sign of sarcoidosis. In these cases, additional imaging modalities may be needed to make the appropriate diagnosis.

Sex Differences in Adult Facial Three-Dimensional Morphology: Application to Gender-Affirming Facial Surgery.

Background: Gender-affirming facial surgery (GFS) is pursued by transgender individuals who desire facial features that better reflect their gender identity. Currently, there are a few objective guidelines to justify and facilitate effective surgical decision making. Objective: To quantify the effect of sex on adult facial size and shape through an analysis of three-dimensional (3D) facial surface images. Materials and Methods: Facial measurements were obtained by registering an atlas facial surface to 3D surface scans of 545 males and 1028 females older than 20 years of age. The differences between male and female faces were analyzed and visualized for a set of predefined surgically relevant facial regions. Results: On average, male faces are 7.3% larger than female faces (Cohen's D = 2.17). Sex is associated with significant facial shape differences (p < 0.0001) in the entire face as well as in each sub-region considered in this study. The facial regions in which sex has the largest effect on shape are the brow, jaw, nose, and cheek. Conclusions: These findings provide biologic data-driven anatomic guidance and justification for GFS, particularly forehead contouring cranioplasty, mandible and chin alterations, rhinoplasty, and cheek modifications.

Acceptability and uptake of HIV self-testing in emergency care settings: A systematic review and meta-analysis.

BACKGROUND: Emergency departments (ED) interface with large numbers of patients that are often missed by conventional HIV testing approaches. ED-based HIV self-testing (HIVST) is an innovative engagement approach which has potential for testing gains among populations that have failed to be reached. This systematic review and meta-analysis evaluated acceptability and uptake of HIVST, as compared to standard provider-delivered testing approaches, among patients seeking care in ED settings. METHODS: Six electronic databases were systematically searched (Dates: January 1990-May 2021). Reports with data on HIVST acceptability and/or testing uptake in ED settings were included. Two reviewers identified eligible records (κ= 0.84); quality was assessed using formalized criteria. Acceptability and testing uptake metrics were summarized, and pooled estimates were calculated using random-effects models with assessments of heterogeneity. RESULTS: Of 5773 records identified, seven met inclusion criteria. The cumulative sample was 1942 subjects, drawn from three randomized control trials (RCTs) and four cross-sectional studies. Four reports assessed HIVST acceptability. Pooled acceptability of self-testing was 92.6% (95% confidence interval [CI]: 88.0%-97.1%). Data from two RCTs demonstrated that HIVST significantly increased testing uptake as compared to standard programs (risk ratio [RR] = 4.41, 95% CI: 1.95-10.10, I2  = 25.8%). Overall, the quality of evidence was low (42.9%) or very low (42.9%), with one report of moderate quality (14.2%). CONCLUSIONS: Available data indicate that HIVST may be acceptable and may increase testing among patients seeking emergency care, suggesting that expanding ED-based HIVST programs could enhance HIV diagnosis. However, given the limitations of the reports, additional research is needed to better inform the evidence base.

Emergency Department Presentation of Retinal Artery Occlusion.

PURPOSE: To determine how frequently patients who present to an emergency department (ED) with a retinal artery occlusion (RAO) undergo brain imaging and cardiovascular testing and are hospitalized. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Patients who presented to an ED with an RAO in the National Emergency Department Sample (NEDS), a nationally representative United States database. METHODS: The NEDS was queried to identify patients who presented to an ED with the primary diagnosis of RAO between 2006 and 2014. Patient and hospital characteristics were evaluated, and a multivariable regression was performed to determine predictors of hospitalization. Testing was categorized into 3 groups: (1) brain imaging performed using computed tomography or magnetic resonance; (2) carotid imaging performed using ultrasound, computed tomography, or magnetic resonance; and (3) cardiac testing performed using electrocardiogram or echocardiogram. The number of tests performed for each category was recorded. MAIN OUTCOME MEASURES: Proportions of patients undergoing brain imaging, carotid imaging, or cardiac testing. Rate and predictors of hospitalization. RESULTS: Among 259 343 582 ED visits, 2802 had a primary diagnosis of RAO. Patients were mostly aged ≥65 years (59%) and male (54%). Hypertension (59%), dyslipidemia (36%), and diabetes (20%) were the most common preexisting cardiovascular diseases. Brain imaging, carotid imaging, and cardiac testing were performed in 20.3%, 7.1%, and 23.8% of the patients, respectively; at least 1 test from each of these 3 categories was performed in 4.1% of the patients. Half of the patients were hospitalized. Factors that increased the chances of hospitalization included the following (P < 0.05): age of <45 years; female sex; a history of smoking; presenting to a metropolitan hospital and having giant cell arteritis, carotid artery disease, atrial fibrillation, cardiac valve disease, obesity, dyslipidemia, hypertension, diabetes, and chronic ischemic heart disease. CONCLUSIONS: Most patients who presented to an ED with an RAO did not receive emergency brain imaging, carotid imaging, or basic cardiac testing. A multidisciplinary approach is needed to raise awareness that RAOs should be treated as a precursor of stroke or a stroke equivalent.

High Acceptance and Completion of HIV Self-testing Among Diverse Populations of Young People in Kenya Using a Community-Based Distribution Strategy.

Oral HIV self-testing (HIVST) may expand access to testing among hard-to-reach reach adolescents and young adults (AYA). We evaluated community-based HIVST services for AYA in an urban settlement in Kenya. Peer-mobilizers recruited AYA ages 15-24 through homes, bars/clubs, and pharmacies. Participants were offered oral HIVST, optional assistance and post-test counseling. Outcomes were HIVST acceptance and completion (self-report and returned kits). Surveys were given at enrollment, post-testing, and 4 months. Log-binomial regression evaluated HIVST preferences by venue. Among 315 reached, 87% enrolled. HIVST acceptance was higher in bars/clubs (94%) than homes (86%) or pharmacies (75%). HIVST completion was 97%, with one confirmed positive result. Participants wanted future HIVST at multiple locations, include PrEP, and cost ≤ $5USD. Participants from bars/clubs and pharmacies were more likely to prefer unassisted testing and peer-distributers compared to participants from homes. This differentiated community-based HIVST strategy could facilitate engagement in HIV testing and prevention among AYA.

Medicina del Estilo de Vida: El Momento es Ahora / Lifestyle Medicine: The Time is Now

El momento de la medicina del estilo de vida es ahora. Necesitamos la medicina de estilo de vida para ayudar a manejar los brotes en curso de las condiciones crónicas relacionadas con el estilo de vida como la diabetes, la obesidad, la demencia y las enfermedades del corazón que continúan plagando nuestro mundo hoy, y necesitamos la medicina de estilo de vida para ayudar a manejar la pandemia mundial creada por el COVID-19. Mozafarrian y sus colegas señalaron que entre las 900.000 hospitalizaciones por enfermedad coronaria en 2019 hasta el 18 de noviembre de 2020, se estima que el 63,5% de ellas se atribuyen a cuatro condiciones cardiometabólicas: obesidad, hipertensión, diabetes e insuficiencia cardíaca.

The time for lifestyle medicine is now. We need lifestyle medicine to help manage the ongoing outbreaks of lifestyle related chronic conditions like diabetes, obesity, dementia, and heart disease that continue to plague our world today, and we need lifestyle medicine to help handle the worldwide pandemic created by COVID-19. Mozafarrian and colleagues noted that among the 900,000 coronavirus disease hospitalizations in 2019 through November 18, 2020, 63.5% of them were estimated to be attributed to four cardiometabolic conditions: obesity, hypertension, diabetes, and heart failure.