Temporary Financial Assistance for Housing Expenditures and Mortality and Suicide Outcomes Among US Veterans.

INTRODUCTION: It is unclear whether interventions designed to increase housing stability can also lead to improved health outcomes such as reduced risk of death and suicide morbidity. The objective of this study was to estimate the potential impact of temporary financial assistance (TFA) for housing-related expenses from the US Department of Veterans Affairs (VA) on health outcomes including all-cause mortality, suicide attempt, and suicidal ideation. METHODS: We conducted a retrospective national cohort study of Veterans who entered the VA Supportive Services for Veteran Families (SSVF) program between 10/2015 and 9/2018. We assessed the association between TFA and health outcomes using a multivariable Cox proportional hazards regression approach with inverse probability of treatment weighting. We conducted these analyses on our overall cohort as well as separately for those in the rapid re-housing (RRH) and homelessness prevention (HP) components of SSVF. Outcomes were all-cause mortality, suicide attempt, and suicidal ideation at 365 and 730 days following enrollment in SSVF. RESULTS: Our analysis cohort consisted of 41,969 unique Veterans with a mean (SD) duration of 87.6 (57.4) days in the SSVF program. At 365 days following SSVF enrollment, TFA was associated with a decrease in the risk of all-cause mortality (HR: 0.696, p < 0.001) and suicidal ideation (HR: 0.788, p < 0.001). We found similar results at 730 days (HR: 0.811, p = 0.007 for all-cause mortality and HR: 0.881, p = 0.037 for suicidal ideation). These results were driven primarily by individuals enrolled in the RRH component of SSVF. We found no association between TFA and suicide attempts. CONCLUSION: We find that providing housing-related financial assistance to individuals facing housing instability is associated with improvements in important health outcomes such as all-cause mortality and suicidal ideation. If causal, these results suggest that programs to provide housing assistance have positive spillover effects into other important aspects of individuals' lives.

Condition-Dependent and Dynamic Impacts of Indoor Masking Policies for Coronavirus Disease 2019 Mitigation: A Nationwide, Interrupted Time-Series Analysis.

BACKGROUND: The effectiveness and sustainability of masking policies as a pandemic control measure remain uncertain. Our aim was to evaluate different masking policy types on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) incidence and to identify factors and conditions impacting effectiveness. METHODS: Nationwide, retrospective cohort study of US counties from 4/4/2020-28/6/2021. Policy impacts were estimated using interrupted time-series models with the masking policy change date (eg, recommended-to-required, no-recommendation-to-recommended, no-recommendation-to-required) modeled as the interruption. The primary outcome was change in SARS-CoV-2 incidence rate during the 12 weeks after the policy change; results were stratified by coronavirus disease 2019 (COVID-19) risk level. A secondary analysis was completed using adult vaccine availability as the policy change. RESULTS: In total, N = 2954 counties were included (2304 recommended-to-required, 535 no-recommendation-to-recommended, 115 no-recommendation-to-required). Overall, indoor mask mandates were associated with 1.96 fewer cases/100 000/week (cumulative reduction of 23.52/100 000 residents during the 12 weeks after policy change). Reductions were driven by communities with critical and extreme COVID-19 risk, where masking mandated policies were associated with an absolute reduction of 5 to 13.2 cases/100 000 residents/week (cumulative reduction of 60 to 158 cases/100 000 residents over 12 weeks). Impacts in low- and moderate-risk counties were minimal (<1 case/100 000 residents/week). After vaccine availability, mask mandates were not associated with significant reductions at any risk level. CONCLUSIONS: Masking policy had the greatest impact when COVID-19 risk was high and vaccine availability was low. When transmission risk decreases or vaccine availability increases, the impact was not significant regardless of mask policy type. Although often modeled as having a static impact, masking policy effectiveness may be dynamic and condition dependent.

Multidrug-Resistant Bacterial Infections in U.S. Hospitalized Patients, 2012-2017.

BACKGROUND: Multidrug-resistant (MDR) bacteria that are commonly associated with health care cause a substantial health burden. Updated national estimates for this group of pathogens are needed to inform public health action. METHODS: Using data from patients hospitalized in a cohort of 890 U.S. hospitals during the period 2012-2017, we generated national case counts for both hospital-onset and community-onset infections caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase (ESBL) production, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant acinetobacter species, and MDR Pseudomonas aeruginosa. RESULTS: The hospital cohort in the study accounted for 41.6 million hospitalizations (>20% of U.S. hospitalizations annually). The overall rate of clinical cultures was 292 cultures per 1000 patient-days and was stable throughout the time period. In 2017, these pathogens caused an estimated 622,390 infections (95% confidence interval [CI], 579,125 to 665,655) among hospitalized patients. Of these infections, 517,818 (83%) had their onset in the community, and 104,572 (17%) had their onset in the hospital. MRSA and ESBL infections accounted for the majority of the infections (52% and 32%, respectively). Between 2012 and 2017, the incidence decreased for MRSA infection (from 114.18 to 93.68 cases per 10,000 hospitalizations), VRE infection (from 24.15 to 15.76 per 10,000), carbapenem-resistant acinetobacter species infection (from 3.33 to 2.47 per 10,000), and MDR P. aeruginosa infection (from 13.10 to 9.43 per 10,000), with decreases ranging from -20.5% to -39.2%. The incidence of carbapenem-resistant Enterobacteriaceae infection did not change significantly (from 3.36 to 3.79 cases per 10,000 hospitalizations). The incidence of ESBL infection increased by 53.3% (from 37.55 to 57.12 cases per 10,000 hospitalizations), a change driven by an increase in community-onset cases. CONCLUSIONS: Health care-associated antimicrobial resistance places a substantial burden on patients in the United States. Further work is needed to identify improved interventions for both the inpatient and outpatient settings. (Funded by the Centers for Disease Control and Prevention.).

Cost of Care for Patients With Cirrhosis.

INTRODUCTION: There are limited longitudinal data on the cost of treating patients with cirrhosis, which hampers value-based improvement initiatives. METHODS: We conducted a retrospective cohort study of patients with cirrhosis seen in the Veterans Affairs health care system from 2011 to 2015. Patients were followed up through 2019. We identified a sex-matched and age-matched control cohort without cirrhosis. We estimated incremental annual health care costs attributable to cirrhosis for 4 years overall and in subgroups based on severity (compensated, decompensated), cirrhosis complications (ascites, encephalopathy, varices, hepatocellular cancer, acute kidney injury), and comorbidity (Deyo index). RESULTS: We compared 39,361 patients with cirrhosis with 138,964 controls. The incremental adjusted costs for caring of patients with cirrhosis were $35,029 (95% confidence interval $32,473-$37,585) during the first year and ranged from $14,216 to $17,629 in the subsequent 3 years. Cirrhosis complications accounted for most of these costs. Costs of managing patients with hepatic encephalopathy (year 1 cost, $50,080) or ascites ($50,364) were higher than the costs of managing patients with varices ($20,488) or hepatocellular cancer ($37,639) in the first year. Patients with acute kidney injury or those who had multimorbidity were the most costly at $64,413 and $66,653 in the first year, respectively. DISCUSSION: Patients with cirrhosis had substantially higher health care costs than matched controls and multimorbid patients had even higher costs. Cirrhosis complications accounted for most of the excess cost, so preventing complications has the largest potential for cost saving and could serve as targets for improvement.

How Does the Effect of the Comprehensive Care for Joint Replacement Model Vary Based on Surgical Volume and Costs of Care?

BACKGROUND: The Center for Medicare and Medicaid Innovation revised the comprehensive Care for Joint Replacement (CJR) program, a mandatory 90-day bundled payment for lower extremity joint replacement, in December 2017, retaining 34 of the original 67 metropolitan statistical areas with higher volume and historic episode payments. OBJECTIVES: We describe differences in costs, quality, and patient selection between hospitals that continued to participate compared with those that withdrew from CJR before and after the implementation of CJR. RESEARCH DESIGN: We used a triple difference approach to compare the magnitude of the policy effect for elective admissions between hospitals that were retained in the CJR revision or not, before and after the implementation of CJR, and compared with hospitals in nonparticipant metropolitan statistical areas. SUBJECTS: 694,275 Medicare beneficiaries undergoing elective lower extremity joint replacement from January 1, 2013 to August 31, 2017. MEASURES: The treatment effect heterogeneity of CJR. RESULTS: Hospitals retained in the CJR policy revision had a greater reduction in 90-day episode-of-care cost compared with those that were allowed to discontinue (-$846, 95% CI: -$1,338, -$435) and had greater cost reductions in the more recent year (2017). We also found evidence that retained CJR hospitals disproportionately reduced treating patients who were older than 85 years. CONCLUSIONS: Hospitals that continued to participate in CJR after the policy revision achieved a greater cost reduction. However, the cost reductions were partly attributed to avoiding potential higher - cost patients, suggesting that a bundled payment policy might induce disparities in care delivery.

Change in Homeless and Health Services Use Following Migration Among Veterans with Experience of Homelessness.

BACKGROUND: Homelessness is associated with poor health outcomes, including lack of access to care. Homelessness experienced in rural areas is understudied but likely associated with difficulty accessing needed services. Prior studies have assessed the extent to which Veterans experiencing homelessness in rural areas "migrate" to urban areas, but have not focused on changes in services utilization following migration. OBJECTIVE: To determine whether Veterans with a history of homelessness experience changes in the use of homeless and health services following a migration from a rural to urban residence, and vice versa, and to assess the magnitude of those changes. DESIGN: Longitudinal retrospective analysis of services use among Veterans identified as experiencing homelessness and migrating at least 40 miles or from an urban to a rural area or vice versa. PARTICIPANTS: A total of 81,620 Veterans with incident homelessness who experienced a migration and for whom we could establish 2 quarters of both pre-migration and post-migration service utilization. MAIN MEASURES: In addition to sociodemographic and health-related factors, we assessed index location and destination using geographic descriptors both residential address and Veteran Affairs (VA) facility where Veterans were identified as experiencing homelessness. Outcomes included continuous measures of homeless services and outpatient care and dichotomous measures of emergency department use and inpatient admissions. KEY RESULTS: Regardless of a Veteran's index location, migration to or within a rural area was associated with a significant decrease in the number of homeless and outpatient services and reduced risk of emergency department use or inpatient admission relative to migration to or within an urban area. CONCLUSION: Controlling for sociodemographic and health-related factors, Veterans experiencing homelessness who had a residential migration to or within a rural area had a significant reduction in their use of VA health and homeless services compared to those who migrated to or within an urban area.

A Cluster Randomized Trial of a Family Health History Platform to Identify and Manage Patients at Increased Risk for Colorectal Cancer.

BACKGROUND: Obtaining comprehensive family health history (FHH) to inform colorectal cancer (CRC) risk management in primary care settings is challenging. OBJECTIVE: To examine the effectiveness of a patient-facing FHH platform to identify and manage patients at increased CRC risk. DESIGN: Two-site, two-arm, cluster-randomized, implementation-effectiveness trial with primary care providers (PCPs) randomized to immediate intervention versus wait-list control. PARTICIPANTS: PCPs treating patients at least one half-day per week; patients aged 40-64 with no medical conditions that increased CRC risk. INTERVENTIONS: Immediate-arm patients entered their FHH into a web-based platform that provided risk assessment and guideline-driven decision support; wait-list control patients did so 12 months later. MAIN MEASURES: McNemar's test examined differences between the platform and electronic medical record (EMR) in rates of increased risk documentation. General estimating equations using logistic regression models compared arms in risk-concordant provider actions and patient screening test completion. Referral for genetic consultation was analyzed descriptively. KEY RESULTS: Seventeen PCPs were randomized to each arm. Patients (n = 252 immediate, n = 253 control) averaged 51.4 (SD = 7.2) years, with 83% assigned male at birth, 58% White persons, and 33% Black persons. The percentage of patients identified as increased risk for CRC was greater with the platform (9.9%) versus EMR (5.2%), difference = 4.8% (95% CI: 2.6%, 6.9%), p < .0001. There was no difference in PCP risk-concordant action [odds ratio (OR) = 0.7, 95% CI (0.4, 1.2; p = 0.16)]. Among 177 patients with a risk-concordant screening test ordered, there was no difference in test completion, OR = 0.8 [0.5,1.3]; p = 0.36. Of 50 patients identified by the platform as increased risk, 78.6% immediate and 68.2% control patients received a recommendation for genetic consultation, of which only one in each arm had a referral placed. CONCLUSIONS: FHH tools could accurately assess and document the clinical needs of patients at increased risk for CRC. Barriers to acting on those recommendations warrant further exploration. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02247336 https://clinicaltrials.gov/ct2/show/NCT02247336.

Scale-Up of HIV Antiretroviral Therapy and Estimation of Averted Infections and HIV-Related Deaths - Uganda, 2004-2022.

On January 28, 2003, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease in history, was announced.* In April 2004, the first person in the world to receive PEPFAR-supported antiretroviral therapy (ART) was a man aged 34 years in Uganda. Effective ART reduces morbidity and mortality among persons with HIV infection (1) and prevents both mother-to-child transmission (MTCT) (2) and sexual transmission once viral load is suppressed to undetectable levels (<200 viral copies/mL) (3). By September 2022, more than 1.3 million persons with HIV infection in Uganda were receiving PEPFAR-supported ART, an increase of approximately 5,000% from September 2004. As indicators of the ART program's effectiveness, a proxy MTCT rate decreased 77%, from 6.4% in 2010 to 1.5% in 2022, and the viral load suppression rate (<1,000 viral copies/mL) increased 3%, from 91% in 2016 to 94% in September 2022. During 2004-2022, ART scale-up helped avert nearly 500,000 HIV infections, including more than 230,000 infections among HIV-exposed infants, and approximately 600,000 HIV-related deaths. Going forward, efforts will focus on identifying all persons with HIV infection and rapidly linking them to effective ART. PEPFAR remains committed to continued strong partnership with the Government of Uganda, civil society, and other development partners toward sustainable solutions aligned with the Joint United Nations Programme on HIV/AIDS (UNAIDS) fast-track strategy to ending the global AIDS epidemic by 2030† and safeguarding impact achieved in the long term.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis.

PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.

Mortality, Length of Stay, and Healthcare Costs Associated With Multidrug-Resistant Bacterial Infections Among Elderly Hospitalized Patients in the United States.

BACKGROUND: This study reports estimates of the healthcare costs, length of stay, and mortality associated with infections due to multidrug-resistant bacteria among elderly individuals in the United States. METHODS: We conducted a retrospective cohort analysis of patients aged ≥65 admitted for inpatient stays in the Department of Veterans Affairs healthcare system between 1/2007-12/2018. We identified those with positive cultures for multidrug-resistant bacteria and matched each infected patient to ≤10 control patients. We then performed multivariable regression models to estimate the attributable cost and mortality due to the infection. We also constructed multistate models to estimate the attributable length of stay due to the infection. Finally, we multiplied these pathogen-specific attributable cost, length of stay, and mortality estimates by national case counts from hospitalized patients in 2017. RESULTS: Our cohort consisted of 87 509 patients with infections and 835 048 matched controls. Costs were higher for hospital-onset invasive infections, with attributable costs ranging from $22 293 (95% confidence interval: $19 101-$24 485) for methicillin-resistant Staphylococcus aureus (MRSA) to $57 390 ($34 070-$80 710) for carbapenem-resistant (CR) Acinetobacter. Similarly, for hospital-onset invasive infections, attributable mortality estimates ranged from 14.2% (12.2-16.2%) for MRSA to 24.1% (12.1-36.0%) for CR Acinetobacter. The aggregate cost of these infections was an estimated $1.9 billion ($1.3 billion-$2.5 billion) with 11 852 (8719-14 985) deaths and 448 224 (354 513-541 934) inpatient days in 2017. CONCLUSIONS: Efforts to prevent these infections due to multidrug-resistant bacteria could save a significant number of lives and healthcare resources.

Identification of a Proline-Kinked Amphipathic α-Helix Downstream from the Methyltransferase Domain of a Potexvirus Replicase and Its Role in Virus Replication and Perinuclear Complex Formation.

Characterized positive-strand RNA viruses replicate in association with intracellular membranes. Regarding viruses in the genus Potexvirus, the mechanism by which their RNA-dependent RNA polymerase (replicase) associates with membranes is understudied. Here, by membrane flotation analyses of the replicase of Plantago asiatica mosaic potexvirus (PlAMV), we identified a region in the methyltransferase (MET) domain as a membrane association determinant. An amphipathic α-helix was predicted downstream from the core region of the MET domain, and hydrophobic amino acid residues were conserved in the helical sequences in replicases of other potexviruses. Nuclear magnetic resonance (NMR) analysis confirmed the amphipathic α-helical configuration and unveiled a kink caused by a highly conserved proline residue in the α-helix. Substitution of this proline residue and other hydrophobic and charged residues in the amphipathic α-helix abolished PlAMV replication. Ectopic expression of a green fluorescent protein (GFP) fusion with the entire MET domain resulted in the formation of a large perinuclear complex, where virus replicase and RNA colocated during virus infection. Except for the proline substitution, the amino acid substitutions in the α-helix that abolished virus replication also prevented the formation of the large perinuclear complex by the respective GFP-MET fusion. Small intracellular punctate structures were observed for all GFP-MET fusions, and in vitro high-molecular-weight complexes were formed by both replication-competent and -incompetent viral replicons and thus were not sufficient for replication competence. We discuss the roles of the potexvirus-specific, proline-kinked amphipathic helical structure in virus replication and intracellular large complex and punctate structure formation. IMPORTANCE RNA viruses characteristically associate with intracellular membranes during replication. Although virus replicases are assumed to possess membrane-targeting properties, their membrane association domains generally remain unidentified or poorly characterized. Here, we identified a proline-kinked amphipathic α-helix structure downstream from the methyltransferase core domain of PlAMV replicase as a membrane association determinant. This helical sequence, which includes the proline residue, was conserved among potexviruses and related viruses in the order Tymovirales. Substitution of the proline residue, but not the other residues necessary for replication, allowed formation of a large perinuclear complex within cells resembling those formed by PlAMV replicase and RNA during virus replication. Our results demonstrate the role of the amphipathic α-helix in PlAMV replicase in a perinuclear complex formation and virus replication and that perinuclear complex formation by the replicase alone will not necessarily indicate successful virus replication.

One-Year Costs Associated With the Veterans Affairs National TeleStroke Program.

OBJECTIVES: Access to timely care is important for patients with stroke, where rapid diagnosis and treatment affect functional status, disability, and mortality. Telestroke programs connect stroke specialists with emergency department staff at facilities without on-site stroke expertise. The objective of this study was to examine healthcare costs for patients with stroke who sought care before and after implementation of the US Department of Veterans Affairs National TeleStroke Program (NTSP). METHODS: We identified 471 patients who had a stroke and sought care at a telestroke site and compared them to 529 patients with stroke who received stroke care at the same sites before telestroke implementation. We examined patient costs for 12 months before and after stroke, using a linear model with a patient-level fixed effect. RESULTS: NTSP was associated with significantly higher rates of patients receiving guideline concordant care. Compared with control patients, those treated by NTSP were 14.3 percentage points more likely to receive tissue plasminogen activator and 4.3 percentage points more likely to receive a thrombectomy (all P < .0001). NTSP was associated with $4821 increased costs for patients with stroke in the first 30 days after the program (2019 dollars). There were no observed savings over 12 months, and the added costs of care were attributable to higher rates of guideline concordant care. CONCLUSIONS: Telestroke programs are unlikely to yield short-term savings because optimal stroke care is expensive. Healthcare organizations should expect increases in healthcare costs for patients treated for stroke in the first year after implementing a telestroke program.

A terrestrial planet candidate in a temperate orbit around Proxima Centauri.

At a distance of 1.295 parsecs, the red dwarf Proxima Centauri (α Centauri C, GL 551, HIP 70890 or simply Proxima) is the Sun's closest stellar neighbour and one of the best-studied low-mass stars. It has an effective temperature of only around 3,050 kelvin, a luminosity of 0.15 per cent of that of the Sun, a measured radius of 14 per cent of the radius of the Sun and a mass of about 12 per cent of the mass of the Sun. Although Proxima is considered a moderately active star, its rotation period is about 83 days (ref. 3) and its quiescent activity levels and X-ray luminosity are comparable to those of the Sun. Here we report observations that reveal the presence of a small planet with a minimum mass of about 1.3 Earth masses orbiting Proxima with a period of approximately 11.2 days at a semi-major-axis distance of around 0.05 astronomical units. Its equilibrium temperature is within the range where water could be liquid on its surface.

Directly Measured Costs of Severe Maternal Morbidity Events during Delivery Admission Compared with Uncomplicated Deliveries.

OBJECTIVE: To estimate the actual excess costs of care for delivery admissions complicated by severe maternal morbidity (SMM) compared with uncomplicated deliveries. STUDY DESIGN: This is a retrospective cohort study of all deliveries between October 2015 and September 2018 at a single tertiary academic center. Pregnant individuals ≥ 20 weeks' gestation who delivered during a hospital admission (i.e., a "delivery admission") were included. The primary exposure was SMM, as defined by Centers for Disease Control and Prevention (CDC) criteria, CDC criteria excluding blood transfusion, or by validated hospital-defined criteria (intensive care unit admission or ≥ 4 units of blood products). Potential SMM events identified via administrative and blood bank data were reviewed to confirm SMM events had occurred. Primary outcome was total actual costs of delivery admission derived from time-based accounting and acquisition costs in the institutional Value Driven Outcomes database. Cost of delivery admissions with SMM events was compared with the cost of uncomplicated delivery using adjusted generalized linear models, with separate models for each of the SMM definitions. Relative cost differences are reported due to data restrictions. RESULTS: Of 12,367 eligible individuals, 12,361 had complete cost data. Two hundred and eighty individuals (2.3%) had confirmed SMM events meeting CDC criteria. CDC criteria excluding transfusion alone occurred in 1.0% (n = 121) and hospital-defined SMM in 0.6% (n = 76). In adjusted models, SMM events by CDC criteria were associated with a relative cost increase of 2.45 times (95% confidence interval [CI]: 2.29-2.61) the cost of an uncomplicated delivery. SMM by CDC criteria excluding transfusion alone was associated with a relative increase of 3.26 (95% CI: 2.95-3.60) and hospital-defined SMM with a 4.19-fold (95% CI: 3.64-4.83) increase. Each additional CDC subcategory of SMM diagnoses conferred a relative cost increase of 1.60 (95% CI: 1.43-1.79). CONCLUSION: SMM is associated with between 2.5- and 4-fold higher cost than uncomplicated deliveries. KEY POINTS: · Severe maternal morbidity as defined by CDC criteria confers a 2.5-fold increase in delivery hospitalization costs.. · Intensive care unit admission or ≥ 4 units of blood products confer a fourfold increase in cost.. · Costs of maternal morbidity may motivate SMM review..

Paediatric Cavernous Malformation of the Trigeminal Nerve: Case Report and Review of the Literature.

INTRODUCTION: Intradural, extra-axial cerebral cavernous malformations (CCMs) are rare entities and are mostly reported in relation to the optic apparatus or the facial/vestibulocochlear complex. Cranial nerve CCMs tend to follow a clinically aggressive course, with a tendency to progressive neurological dysfunction following intra-lesional haemorrhage or less commonly due to the effects of subarachnoid haemorrhage. CASE PRESENTATION: We report the first case of a trigeminal CCM presenting in a child with otalgia and left-sided headaches. The patient was initially managed with radiological surveillance but required surgical management following deterioration. We describe the successful treatment of the lesion with microsurgical resection. CONCLUSION: A CCM should be considered in the differential diagnosis of mass lesions arising in the region of the trigeminal nerve. Surgical resection is recommended to prevent neurological deterioration and may result in significant symptomatic improvement.

Criminal legal involvement among recently separated veterans: Findings from the LIMBIC study.

OBJECTIVE: This study investigated individual-level and neighborhood-level predictors of criminal legal involvement of veterans during the critical transition period from military to civilian life. HYPOTHESES: We hypothesized that substance use, mental health, and personality disorders will increase the incidence of criminal legal involvement, which will be highest among veterans living in socioeconomically disadvantaged neighborhoods after military discharge. METHOD: We analyzed data from a longitudinal cohort study of 418,624 veterans who entered Department of Veterans Affairs (VA) health care after leaving the military. Department of Defense (DoD) data on clinical diagnoses, demographics, and military history were linked to VA data on neighborhood of residence and criminal legal involvement. RESULTS: Criminal legal involvement in the 2 years following military discharge was most strongly predicted by younger age, substance use disorder, and being male. Other predictors included the military branch in which veterans served, deployment history, traumatic brain injury, serious mental illness, personality disorder, having fewer physical health conditions, and living in socioeconomically disadvantaged neighborhoods. These factors combined in multivariable analysis yielded a very large effect size for predicting criminal legal involvement after military separation (area under the curve = .82). The incidence of criminal legal involvement was 10 times higher among veterans with co-occurring substance use disorder, serious mental illness, and personality disorder than among veterans with none of these diagnoses, and these rates were highest among veterans residing in more socioeconomically disadvantaged neighborhoods. CONCLUSIONS: To our knowledge, this is the largest longitudinal study of risk factors for criminal legal involvement in veterans following military discharge. The findings supported the hypothesis that veterans with co-occurring mental disorders living in socioeconomically disadvantaged neighborhoods were at higher risk of criminal legal involvement, underscoring the complex interplay of individual-level and neighborhood-level risk factors for criminal legal involvement after veterans leave the military. These results can inform policy and programs, such as the DoD Transition Assistance Program (TAP) and the VA Military to Civilian Readiness Pathway program (M2C Ready), to enhance community reintegration and prevent criminal legal involvement among veterans transitioning from military to civilian life. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Economic Considerations in Infectious Diseases Emergency Response Preparedness: It's All About the Point of View.

Outbreaks and emergence of novel pathogens present a challenge in economic evaluations of prevention strategies, due to unusually high levels of risk aversion and uncertainty. Here, we discuss cost-effectiveness investigations and interpretation of economic analyses in the context of outbreak planning and containment, and outline considerations for providers, administrators, patients, and policy makers for infection emergency preparedness response.

Economic Evaluations of New Antibiotics: The High Potential Value of Reducing Healthcare Transmission Through Decolonization.

BACKGROUND: Antibiotics designed to decolonize carriers of drug-resistant organisms could offer substantial population health benefits, particularly if they can help avert outbreaks by interrupting person-to-person transmission chains. However, cost effectiveness of an antibiotic is typically evaluated only according to its benefits to recipients, which can be difficult to demonstrate for carriers of an organism that may not pose an immediate health threat to the carrier. METHODS: We developed a mathematical transmission model to quantify the effects of 2 hypothetical antibiotics targeting carbapenem-resistant Enterobacteriaceae (CRE) among long-term acute care hospital inpatients: one assumed to decrease the death rate of patients with CRE bloodstream infections (BSIs) and the other assumed to decolonize CRE carriers after clinical detection. We quantified the effect of each antibiotic on the number of BSIs and deaths among patients receiving the drug (direct effect) and among all patients (direct and indirect effect) compared to usual care. We applied these results to a cost-effectiveness analysis with effectiveness outcome of life-years gained and assumed costs for antibiotic doses and for CRE BSI. RESULTS: The decolonizing antibiotic, once indirect effects were included, produced increased relative effectiveness and decreased relative costs compared to both usual care and the BSI treatment antibiotic. In fact, in most scenarios, the decolonizing drug was the dominant treatment strategy (ie, less costly and more effective). CONCLUSIONS: Antibiotics that decolonize carriers of drug-resistant organisms can be highly cost-effective when considering indirect benefits within populations vulnerable to outbreaks. Public health could benefit from finding ways to incentivize development of decolonizing antibiotics in the US, where drugs with unclear direct benefits to recipients would pose difficulties in achieving FDA approval and financial benefit to the developer.

Matching Methods to Problems: Using Data Science and Transmission Modeling to Combat Antimicrobial Resistance.

Antimicrobial resistance is a growing worldwide crisis, declared by the World Health Organization as "one of the principal threats to global public health today." The emergence and spread of antimicrobial resistance is a multifaceted problem that spans all aspects of healthcare, and research efforts to advance the field must likewise employ investigators with a diverse set of expertise and a variety of approaches and study designs who recognize and address the unique challenges of infectious-disease and antimicrobial-resistance research. An understanding of transmission dynamics and externalities, both positive and negative, is critical to any assessment of the impact of an intervention or policy related to infectious disease, infection prevention, or antimicrobial stewardship, in order to create a more comprehensive and accurate estimate of the costs and outcomes associated with an intervention. These types of advanced studies are necessary if we are to significantly alter the course of this crisis and improve the outlook for our future.

Effectiveness of 3 Versus 6 ft of Physical Distancing for Controlling Spread of Coronavirus Disease 2019 Among Primary and Secondary Students and Staff: A Retrospective, Statewide Cohort Study.

BACKGROUND: National and international guidelines differ about the optimal physical distancing between students for prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission; studies directly comparing the impact of ≥3 versus ≥6 ft of physical distancing policies in school settings are lacking. Thus, our objective was to compare incident cases of SARS-CoV-2 in students and staff in Massachusetts public schools among districts with different physical distancing requirements. State guidance mandates masking for all school staff and for students in grades 2 and higher; the majority of districts required universal masking. METHODS: Community incidence rates of SARS-CoV-2, SARS-CoV-2 cases among students in grades K-12 and staff participating in-person learning, and district infection control plans were linked. Incidence rate ratios (IRRs) for students and staff members in traditional public school districts with ≥3 versus ≥6 ft of physical distancing were estimated using log-binomial regression; models adjusted for community incidence are also reported. RESULTS: Among 251 eligible school districts, 537 336 students and 99 390 staff attended in-person instruction during the 16-week study period, representing 6 400 175 student learning weeks and 1 342 574 staff learning weeks. Student case rates were similar in the 242 districts with ≥3 versus ≥6 ft of physical distancing between students (IRR, 0.891; 95% confidence interval, .594-1.335); results were similar after adjustment for community incidence (adjusted IRR, 0.904; .616-1.325). Cases among school staff in districts with ≥3 versus ≥6 ft of physical distancing were also similar (IRR, 1.015, 95% confidence interval, .754-1.365). CONCLUSIONS: Lower physical distancing requirements can be adopted in school settings with masking mandates without negatively affecting student or staff safety.