De-escalation of Disease-Modifying Therapy for People with Multiple Sclerosis Due to Safety Considerations: Characterizing 1-Year Outcomes in 25 People Who Switched from Ocrelizumab to Diroximel Fumarate.

INTRODUCTION: Switching disease-modifying therapy (DMT) may be considered for relapsing-remitting multiple sclerosis (RRMS) if a patient's current therapy is no longer optimal. This was particularly important during the recent COVID-19 pandemic because of considerations around immune deficiency and impaired vaccine response associated with B cell-depleting DMTs. This real-world, single-center study aimed to evaluate change or decline in functional ability and overall disease stability in people with RRMS who were switched from B cell-depleting ocrelizumab (OCRE) to diroximel fumarate (DRF) because of safety concern related to the COVID-19 pandemic. METHODS: Adults with RRMS were included if they had been clinically stable for ≥ 1 year on OCRE. Data collected at baseline and 1 year post switch included relapse rate, magnetic resonance imaging (MRI), blood work for assessment of peripheral immune parameters, the Cognitive Assessment Battery (CAB), optical coherence tomography (OCT), and patient-reported outcomes (PROs). RESULTS: Participants (N = 25) had a mean (SD) age of 52 (9) years, and a mean (SD) duration of 26 (8) months' treatment with OCRE before the switch to DRF. Median washout duration since the last OCRE infusion was 7 months (range 4-18 months). No participants relapsed on DRF during follow-up, and all remained persistent on DRF after 1 year. There were no significant changes in peripheral immune parameters, other than an increase in the percentage of CD19+ cells 1 year after switching (p < 0.05). Similarly, there were no significant changes in CAB, OCT, and PROs. CONCLUSION: These preliminary findings suggest that transition to DRF from OCRE may be an effective treatment option for people with RRMS who are clinically stable but may need to switch for reasons unrelated to effectiveness. Longer follow-up times on larger samples are needed to confirm these observations.

Current challenges and future of agricultural genomes to phenomes in the USA.

Dramatic improvements in measuring genetic variation across agriculturally relevant populations (genomics) must be matched by improvements in identifying and measuring relevant trait variation in such populations across many environments (phenomics). Identifying the most critical opportunities and challenges in genome to phenome (G2P) research is the focus of this paper. Previously (Genome Biol, 23(1):1-11, 2022), we laid out how Agricultural Genome to Phenome Initiative (AG2PI) will coordinate activities with USA federal government agencies expand public-private partnerships, and engage with external stakeholders to achieve a shared vision of future the AG2PI. Acting on this latter step, AG2PI organized the "Thinking Big: Visualizing the Future of AG2PI" two-day workshop held September 9-10, 2022, in Ames, Iowa, co-hosted with the United State Department of Agriculture's National Institute of Food and Agriculture (USDA NIFA). During the meeting, attendees were asked to use their experience and curiosity to review the current status of agricultural genome to phenome (AG2P) work and envision the future of the AG2P field. The topic summaries composing this paper are distilled from two 1.5-h small group discussions. Challenges and solutions identified across multiple topics at the workshop were explored. We end our discussion with a vision for the future of agricultural progress, identifying two areas of innovation needed: (1) innovate in genetic improvement methods development and evaluation and (2) innovate in agricultural research processes to solve societal problems. To address these needs, we then provide six specific goals that we recommend be implemented immediately in support of advancing AG2P research.

Characterizing opioid overdose hotspots for place-based overdose prevention and treatment interventions: A geo-spatial analysis of Rhode Island, USA.

OBJECTIVE: Examine differences in neighborhood characteristics and services between overdose hotspot and non-hotspot neighborhoods and identify neighborhood-level population factors associated with increased overdose incidence. METHODS: We conducted a population-based retrospective analysis of Rhode Island, USA residents who had a fatal or non-fatal overdose from 2016 to 2020 using an environmental scan and data from Rhode Island emergency medical services, State Unintentional Drug Overdose Reporting System, and the American Community Survey. We conducted a spatial scan via SaTScan to identify non-fatal and fatal overdose hotspots and compared the characteristics of hotspot and non-hotspot neighborhoods. We identified associations between census block group-level characteristics using a Besag-York-Mollié model specification with a conditional autoregressive spatial random effect. RESULTS: We identified 7 non-fatal and 3 fatal overdose hotspots in Rhode Island during the study period. Hotspot neighborhoods had higher proportions of Black and Latino/a residents, renter-occupied housing, vacant housing, unemployment, and cost-burdened households. A higher proportion of hotspot neighborhoods had a religious organization, a health center, or a police station. Non-fatal overdose risk increased in a dose responsive manner with increasing proportions of residents living in poverty. There was increased relative risk of non-fatal and fatal overdoses in neighborhoods with crowded housing above the mean (RR 1.19 [95 % CI 1.05, 1.34]; RR 1.21 [95 % CI 1.18, 1.38], respectively). CONCLUSION: Neighborhoods with increased prevalence of housing instability and poverty are at highest risk of overdose. The high availability of social services in overdose hotspots presents an opportunity to work with established organizations to prevent overdose deaths.

Humoral immune response after Ad26.COV2.S vaccination in patients with multiple sclerosis treated with natalizumab.

The immunomodulatory effects of disease-modifying therapies for multiple sclerosis might affect the immune response to vaccines for severe acute respiratory syndrome coronavirus 2. We analyzed the severe acute respiratory syndrome coronavirus 2-specific antibody response and lymphocyte profile before and after Ad26.COV2.S (Johnson & Johnson) vaccination in natalizumab-treated patients with multiple sclerosis. There was a 72-fold increase in mean anti-severe acute respiratory syndrome coronavirus 2 spike immunoglobulin G levels 4 weeks after vaccination and a 137-fold increase after 6 months. Other immune signals were within normal ranges. Natalizumab-treated patients with multiple sclerosis had a robust immune response to Ad26.COV2.S vaccine, and other immune signals were not significantly affected.

Advancing Equity in Graduate Medical Education Recruitment Through a Diversity Equity and Inclusion (DEI) Toolkit for Program Directors.

Objectives: To increase diversity and inclusion in graduate medical education (GME), the Accreditation Council for Graduate Medical Education (ACGME) issued new diversity standards requiring programs to engage in practices that focus on systematic recruitment and retention of a diverse workforce of trainees and faculty. The literature on how program directors (PDs) can incorporate and prepare for this standard is limited. Methods: We developed a diversity, equity, and inclusion (DEI) toolkit for PDs as an example of an institutional GME-led effort to promote inclusive recruitment and DEI awareness among residency and fellowship programs at a large academic center. Results: A survey was sent to 80 PDs before the launch of the toolkit and 6 months afterwards with response rates of 27% (22/80) and 97% (78/80), respectively. At baseline, 45% (10/22) anticipated that the DEI toolkit might provide better resources than those currently available to them and 41% (9/22) perceived that the toolkit might improve recruitment outcomes. At 6 months, 63% (49/78) found the toolkit helpful in the 2021-2022 recruitment season. By contrast, 2% (2/78) of PDs did not find the toolkit helpful, and 33% (26/78) said they did not access the toolkit. When asked if a PD changed their program's recruitment practices because of the toolkit, 31% (24/78) responded yes. Programs that changed recruitment practices started to require unconscious bias training for all faculty and residents involved in the residency interviews and ranking. Others worked on creating a standardized scoring rubric for interviews focused on four main domains: Experiences, Attributes, Competencies, and Academic Metrics. Conclusion: There is a need to support PDs in their DEI journey and their work to recruit a diverse workforce in medicine. Utilizing a DEI toolkit is one option to increase DEI knowledge, skills, awareness, and self-efficacy among PDs and can be adopted by other institutions and leaders in academic medicine.

Impact of an Online Question Bank on Resident In-Training Exam Performance.

OBJECTIVE: In-training exams (ITEs) are administered annually to Obstetrics and Gynecology (OBGYN) residents and have been demonstrated to correlate with success on licensing examinations. Our study objective was to determine the impact of a question bank and mock exam on the performance of Council on Resident Education in Obstetrics and Gynecology (CREOG) ITEs. Secondarily, we investigated the correlation between the extent of question bank usage and performance on the exam. METHODS: Pre-post intervention study of resident performance on CREOG ITE before and after implementation of the question bank and mock ITE at Indiana University in 2018. Performance was measured as year-to-year improvement in percent correct on ITE exams. Scores were excluded if a resident did not have a prequestion bank score report or if they did not sit for all eligible ITE exams. RESULTS: There were 51 OBGYN residents at Indiana University during the study period, with 38 available for analysis (75%). Before implementation, average year-to-year improvement for PGY1-2, PGY2-3 and PGY3-4 classes were 0.60%, 1.0% and -1.6%, respectively. After implementation, all resident classes had significant improvements in ITE scores of 6.6% (P < .01), 9.0% (P < .01), and 7.2% (P < .01), respectively. There was a moderate program-wide correlation between the number of questions completed and the percent improvement on the ITE of R = 0.36 (P = .046). CONCLUSIONS: Our study demonstrated that access to a question bank and mock ITE significantly improved CREOG ITE performance of OBGYN residents at Indiana University.

Morphological, ultrastructural, genetic characteristics and remarkably low prevalence of macroscopic Sarcocystis species isolated from sheep and goats in Kurdistan region, Iraq.

Introduction: Sarcocystis is a genus of cyst-forming parasites that infest both humans and livestock. Some parasites cause clinical and subclinical diseases in their hosts, resulting in economic losses. Methods: Esophagus, diaphragm, and skeletal muscle from slaughtered sheep and goats were examined macroscopically, microscopically, and ultrastructurally and subjected to DNA analysis. Results: We isolated macrocysts of S. gigantea and of S. caprafelis moulei from naturally infected sheep (Ovis aries) and goats (Capra hircus). The macrocyst wall thickness was 18.9 µm in sheep and 15.3 µm in goats, and consisted of an inner Periodic acid Schiff- (PAS) negative primary wall and an outer glycoconjugates containing i.e. PAS-positive secondary wall. The walls inner surface was compartmentalized and filled with bradyzoites. In S. gigantea the bradyzoites were approximently 12.3 x 2.6 µm in size, while in S. caprafelis moulei they were 13.9 x 4.4 µm. Ultrastructurally, both species have nearly identical morphology: cauliflower-like protrusions with numerous microtubules and often dendritic-like filaments, branching from the primary wall. The 18S rRNA gene in S. gigantea was 85.9% identical to that in S. medusiformis and 80.4% to the S. caprafelis moulei gene. The 28S rRNA gene in S. gigantea was 94.6% identical to that in S. medusiformis and 97.3% to the S. caprafelis moulei. Conclusion: This study is the first to (i) detail the ultrastructure of the macrocyst wall of S. caprafelis moulei, (ii) identify S. medusiformis in Iraqi sheep, and (iii) compare the prevalence of macroscopic Sarcocystis at different time periods within the same region. A positive finding was the reduction of macroscopic sarcocystosis occurrences (0.01% in sheep and 0.02% in goats) compared to our previous data from 1992 (4.1%: sheep, 33.6%: goats).

Resident Research Mentoring Teams: A Support Program to Increase Resident Research Productivity.

Background: Scholarly activity is a requirement for most graduate medical education training programs. However, barriers exist for residents to accomplish projects. Objective: To evaluate the correlation between a resident research mentoring team (RRMT) program and meeting presentations and publications of resident research projects. We further plan to report feasibility of the RRMT. Methods: We performed a before-and-after study of meeting presentations and/or publication of resident research projects before institution of the RRMT (2004-2011) and post-RRMT implementation (2016-2019). The RRMT is a diverse group of faculty, statisticians, and research staff who meet regularly with residents to provide guidance for their research studies. It is part of overall research support from the department, which also includes biostatistics, database and regulatory help, travel funds, and project budget funds. Data on meeting presentations and publications were collected from Google Scholar, PubMed, Scopus, and the IUPUI ScholarWorks institutional repository, using resident and faculty names and titles of projects. Comparisons of pre- and post-RRMT groups were made. Results: Seventy-four residents were in the pre-RRMT group and 40 were in the post-RRMT group. Post-RRMT residents published, presented, and combined published or presented their projects more frequently than those in pre-RRMT group (57.5% vs 28.4%, P=.002; 50% vs 16.2%, P=.001; 67.5% vs 37.8%, P=.002). Controlling for winning a Research Day award and pursuing a fellowship, being in the post-RRMT group was independently associated with presentation or publication of the resident research project (OR 3.62, 95% CI 1.57-8.83). Conclusions: Support of resident scholarly activity, such as thorough implementation of a program like the RRMT, is associated with increased presentations and publications of research projects.

Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study.

Background: As opioid overdoses surge, medications for opioid use disorder (MOUD) remain underutilized. MOUD is rarely offered in correctional facilities although individuals involved in the criminal justice system have higher rates of OUD and mortality relative to the general population. Methods: A retrospective cohort design examined the effect of MOUD while incarcerated on 12 months post-release treatment engagement and retention, overdose mortality, and recidivism. Individuals (N = 1600) who participated in the Rhode Island Department of Corrections (RIDOC) MOUD program (the United States' first statewide program) and were released from incarceration from December 1, 2016, to December 31, 2018, were included. The sample was 72.6% Male (27.4% female) and 80.8% White (5.8% Black, 11.4% Hispanic, 2.0% another race). Findings: 56% were prescribed methadone, 43% buprenorphine, and 1% naltrexone. During incarceration, 61% were continued on MOUD from the community, 30% were inducted onto MOUD upon incarceration, and 9% were inducted pre-release. At 30 days and 12 months post-release, 73% and 86% of participants engaged in MOUD treatment, respectively, and those newly inducted had lower post-release engagement than those who continued from the community. Reincarceration rates (52%) were similar to the general RIDOC population. Twelve overdose deaths occurred during the 12-month follow-up, with only one overdose death during the first two weeks post-release. Interpretations: Implementing MOUD in correctional facilities, with seamless linkage to community care is a needed life-saving strategy. Funding: Rhode Island General Fund, the NIH of Health HEAL Initiative, the NIGMS, and the NIDA.

Childhood Victimization and Adult Incarceration: A Review of the Literature.

A growing body of work estimates the prevalence of childhood victimization among incarcerated people. The present study seeks to descriptively and quantitatively summarize this abundant literature by reviewing studies that report childhood victimization prevalence among people incarcerated in the United States. The review includes any study of childhood victimization that uses a sample of incarcerated adults (age eighteen or older) and that reports the proportion of the sample that experienced child abuse and/or neglect. Sixty-seven studies met these criteria and were analyzed, encompassing 1,187,044 incarcerated individuals. The studies vary in sample characteristics, methodological features, and employ an exceedingly wide range of victimization measures. Meta-analyses for pooled prevalence rates revealed that the inter-study heterogeneity was too great to draw conclusive summary estimates of childhood victimization from this literature, even when disaggregating by victimization type. Exploratory t-tests and correlation analyses suggest that a study's sample size, racial, ethnic, and gender composition, and variation in victimization measurement can influence reported child abuse and neglect, but more research is needed to fully assess how study characteristics influence reported victimization prevalence. Understanding the extensiveness of childhood victimization histories among incarcerated people emphasizes the need for robust screening and treatment for people within correctional facilities, as well as improved community prevention and intervention efforts.

Long-term effect of field triage on times to endovascular treatment for emergent large vessel occlusion.

BACKGROUND: Delays to endovascular therapy (EVT) for stroke may be mitigated with direct field triage to EVT centers. We sought to compare times to treatment over a 5.5 year span between two adjacent states, one with field triage and one without, served by a single comprehensive stroke center (CSC). METHODS: During the study period, one of the two states implemented severity-based triage for suspected emergent large vessel occlusion, while in the other state, patients were transported to the closest hospital regardless of severity. We compared times to treatment and clinical outcomes between these two states. We also performed a matched pairs analysis, matching on date treated and distance from field to CSC. RESULTS: 639 patients met the inclusion criteria, 407 in State 1 (with field triage) and 232 in State 2 (without field triage). In State 1, scene to EVT decreased 6% (or 8.13 min, p=0.0004) every year but no decrease was observed for State 2 (<1%, p=0.94). Cumulatively over 5.5 years, there was a reduction of 43 min in time to EVT in State 1, but no change in State 2. Lower rates of disability were seen in State 1, both for the entire cohort (all OR 1.22, 95% CI 1.07 to 1.40, p=0.0032) and for those independent at baseline (1.36, 95% CI 1.15 to 1.59, p=0.0003). CONCLUSIONS: Comparing adjacent states over time, the implementation of severity-based field triage significantly reduced time to EVT.

Increasing Diversity in Residency Training Programs.

Improving diversity in the healthcare workforce holds promise in improving the health outcomes of our diverse patient population. Attracting, recruiting, and retaining physicians from races and ethnicities that are historically underrepresented in medicine are vital in this effort. Increasing diversity at the graduate medical education level has the potential to positively reshape our physician personnel. In this editorial, we discuss the current state of diversity-oriented recruitment strategies for residency programs and present opportunities for future efforts.

Treatment With Nimodipine or FK506 After Facial Nerve Repair Neither Improves Accuracy of Reinnervation Nor Recovery of Mimetic Function in Rats.

Purpose: Nimodipine and FK506 (Tacrolimus) are drugs that have been reported to accelerate peripheral nerve regeneration. We therefore tested these substances aiming to improve the final functional outcome of motoric reinnervation after facial nerve injury. Methods: In 18 female rats, the transected facial nerve was repaired by an artificial nerve conduit. The rats were then treated with either placebo, nimodipine, or FK506, for 56 days. Facial motoneurons were pre-operatively double-labeled by Fluoro-Gold and again 56 days post-operation by Fast-Blue to measure the cytological accuracy of reinnervation. The whisking motion of the vibrissae was analyzed to assess the quality of functional recovery. Results: On the non-operated side, 93-97% of those facial nerve motoneurons innervating the vibrissae were double-labeled. On the operated side, double-labeling only amounted to 38% (placebo), 40% (nimodipine), and 39% (FK506), indicating severe misdirection of reinnervation. Regardless of post-operative drug or placebo therapy, the whisking frequency reached 83-100% of the normal value (6.0 Hz), but whisking amplitude was reduced to 33-48% while whisking velocity reached 39-66% of the normal values. Compared to placebo, statistically neither nimodipine nor FK506 improved accuracy of reinnervation and function recovery. Conclusion: Despite previous, positive data on the speed and quantity of axonal regeneration, nimodipine and FK506 do not improve the final functional outcome of motoric reinnervation in rats.

Risk Factors and Clinical Presentation in Dogs with Increased Serum Pancreatic Lipase Concentrations-A Descriptive Analysis.

Limited data exist regarding the full array of clinical signs seen in dogs with pancreatitis and potential risk factors for the disease. Laboratory submissions from the Gastrointestinal Laboratory at Texas A&M University were retrospectively reviewed for dogs with an increased serum pancreatic lipase immunoreactivity (cPLI) concentration (≥400 µg/L), and an internet-based survey was distributed to the attending veterinarian and/or technician on each case. The survey contained questions related to (i) clinical signs, (ii) prior gastrointestinal upset, (iii) comorbidities, (iv) pre-existing medical therapies, and (v) dietary history. One hundred and seventy (170) survey responses were recorded. The top three clinical signs reported were inappetence (62%), diarrhea (53%), and vomiting (49%). Abdominal pain was noted in only 32% of dogs, likely associated with poor pain detection. Additionally, the majority of dogs (71%) had prior episodes of gastrointestinal upset within the past 12 months, lending support for the commonality of recurrent acute pancreatitis, or acute on chronic disease. Hepatobiliary abnormalities (24%) were the most common concurrent disease, and endocrine disorders were seen in a low proportion of respondents (5-8%). Adult maintenance diets (65%), dog treats (40%), and human foods (29%) were commonly consumed by dogs prior to the discovery of increased cPLI concentration.

Improving Resident Knowledge of Ergonomics Guidelines.

OBJECTIVE: To improve resident knowledge of ergonomics guidelines for surgery, vaginal deliveries and repairs, and documentation. PROJECT SUMMARY: We consulted with a licensed occupational therapist at our institution regarding our difficulties with maintaining proper ergonomics while operating, performing deliveries, and documenting. We conducted two separate sessions: one in the obstetrics workroom regarding techniques to improve the ergonomics of our documentation and one in the operating room and labor and delivery unit to address techniques to avoid injury and promote long-term wellness. The sessions were conducted during morning report at our institution, and the obstetrics and gynecology teams attended both sessions. The sessions were available by videoconference for the entire residency program. Handouts were created to present basic ergonomics guidelines and were provided at the conclusion of the sessions. The handouts summarized the information provided during the sessions and included recommendations for adjustments that could be made in the workroom, operating room, and delivery room. The sessions were conducted during ACOG Wellness Week. OUTCOME: Adjustments were made in the obstetric and gynecology team workrooms to improve ergonomic function. Sessions improved resident knowledge of ergonomics recommendations for vaginal deliveries. Recommendations included guidelines for arm and shoulder position, tucked chins, and appropriate bed height (sitting vs standing). Adjustments were made in the workroom to position the top of the monitor just below eye level and arm's length away, and chairs were adjusted so that the keyboard and mouse height were just below elbow height. Residents were encouraged to keep arms and wrists in a relaxed, neutral position and to sit all the way back in the chair with back supported and feet firmly on the floor. Residents improved their knowledge of ergonomics guidelines and increased awareness of posture and positioning both on the labor and delivery unit and in the operating room. RELEVANCE TO WOMENS HEALTH OR PHYSICIANS IN PRACTICE: Work-related musculoskeletal disorders are prevalent among surgeons and can have a significant effect on productivity and career longevity. If we are able to implement evidence-based guidelines developed by high-quality ergonomics research, we can potentially protect obstetricians and gynecologists from injury and improve overall wellness.

Beyond HIV outbreaks: protocol, rationale and implementation of a prospective study quantifying the benefit of incorporating viral sequence clustering analysis into routine public health interventions.

INTRODUCTION: HIV continues to have great impact on millions of lives. Novel methods are needed to disrupt HIV transmission networks. In the USA, public health departments routinely conduct contact tracing and partner services and interview newly HIV-diagnosed index cases to obtain information on social networks and guide prevention interventions. Sequence clustering methods able to infer HIV networks have been used to investigate and halt outbreaks. Incorporation of such methods into routine, not only outbreak-driven, contact tracing and partner services holds promise for further disruption of HIV transmissions. METHODS AND ANALYSIS: Building on a strong academic-public health collaboration in Rhode Island, we designed and have implemented a state-wide prospective study to evaluate an intervention that incorporates real-time HIV molecular clustering information with routine contact tracing and partner services. We present the rationale and study design of our approach to integrate sequence clustering methods into routine public health interventions as well as related important ethical considerations. This prospective study addresses key questions about the benefit of incorporating a clustering analysis triggered intervention into the routine workflow of public health departments, going beyond outbreak-only circumstances. By developing an intervention triggered by, and incorporating information from, viral sequence clustering analysis, and evaluating it with a novel design that avoids randomisation while allowing for methods comparison, we are confident that this study will inform how viral sequence clustering analysis can be routinely integrated into public health to support the ending of the HIV pandemic in the USA and beyond. ETHICS AND DISSEMINATION: The study was approved by both the Lifespan and Rhode Island Department of Health Human Subjects Research Institutional Review Boards and study results will be published in peer-reviewed journals.

Statewide Longitudinal Trends in Transmitted HIV-1 Drug Resistance in Rhode Island, USA.

BACKGROUND: HIV-1 transmitted drug resistance (TDR) remains a global challenge that can impact care, yet its comprehensive assessment is limited and heterogenous. We longitudinally characterized statewide TDR in Rhode Island. METHODS: Demographic and clinical data from treatment-naïve individuals were linked to protease, reverse transcriptase, and integrase sequences routinely obtained over 2004-2020. TDR extent, trends, impact on first-line regimens, and association with transmission networks were assessed using the Stanford Database, Mann-Kendall statistic, and phylogenetic tools. RESULTS: In 1123 individuals, TDR to any antiretroviral increased from 8% (2004) to 26% (2020), driven by non-nucleotide reverse transcriptase inhibitor (NNRTI; 5%-18%) and, to a lesser extent, nucleotide reverse transcriptase inhibitor (NRTI; 2%-8%) TDR. Dual- and triple-class TDR rates were low, and major integrase strand transfer inhibitor resistance was absent. Predicted intermediate to high resistance was in 77% of those with TDR, with differential suppression patterns. Among all individuals, 34% were in molecular clusters, some only with members with TDR who shared mutations. Among clustered individuals, people with TDR were more likely in small clusters. CONCLUSIONS: In a unique (statewide) assessment over 2004-2020, TDR increased; this was primarily, but not solely, driven by NNRTIs, impacting antiretroviral regimens. Limited TDR to multiclass regimens and pre-exposure prophylaxis are encouraging; however, surveillance and its integration with molecular epidemiology should continue in order to potentially improve care and prevention interventions.