Revisiting the effects of state anesthesia policy interventions: A comprehensive look at certified registered nurse anesthetist service provision in U.S. hospitals from 2010 to 2021.

AIMS: Rural hospitals in the United States often rely on nonphysician providers such as advanced practice nurses to care for their patients. One important role that is served by advanced practice nurses is that of anesthesia provider (certified registered nurse anesthetist or CRNA). In 2001, Centers for Medicare & Medicaid Services (CMS) passed an opt-out law affording state governors the right to loosen physician supervision requirements on CRNAs in their respective states, thus potentially improving access in targeted areas. Since then, 24 states have adopted these opt-out provisions. We aim to understand the extent to which the CMS opt-out law has resulted in increased CRNA service provision in hospitals, especially in rural areas. DESIGN: The study used a longitudinal design. We compiled 2010-2021 American Hospital Association data, which includes 4,464 unique U.S. hospitals observed an average of 8 times annually (35,863 total hospital-year observations). METHODS: We model CRNA services provision at the hospital level using longitudinal mixed effects generalized linear models that incorporate state, county, and hospital control variables. RESULTS: Using descriptive statistics and mixed effects generalized linear models, we discovered that adopting opt-out provisions does not universally result in increased CRNA service provision in U.S. hospitals. Notably, opt-out provisions do not improve access in rural counties. However, in supplemental analysis, we discover some of the conditions under which the likelihood of CRNA service provision is influenced. CONCLUSIONS: Hospitals often utilize CRNAs to staff their hospitals. However, many hospitals use both CRNAs and physician anesthesiologists; this can be a potential source of contention and confusion, given the lack of uniformity in the scope of practice policies. We offer some suggestions with regard to the effects of state interventions into the field, and how they might impact this dispute. Lastly, policymakers should consider additional measures to address rural access limitations, as the opt-out policy does not seem to be working as intended.

Reconstruction of American Women in State and Territorial Legislative Offices, 1895-1995.

This data paper presents a reconstruction of American women who have served in state and territorial legislatures (female legislators). The dataset spans from 1895 to 1995 and is reported at an annual basis. For all 6,466 women, individual information on each female legislator is provided, including their name, surname, party affiliation, city and county of residence, and the state they represented. Data for the Senate and House are reported separately. The data was extracted from the encyclopedia titled ``Women State and Territorial Legislators, 1895-1995. A State-by-State Analysis, with Rosters of 6,000 Women'' [1]. The dataset can be used to study patterns in political representation, assessing the involvement of women in government, and delving into significant themes such as the intersection between women legislators and the historical, cultural, and political dynamics of their era. The categorization of women according to their city/county of residence enables researchers to seamlessly integrate this data with other spatio-temporal databases. Additionally, the dataset includes the FIPS county codes corresponding to each woman's residence, facilitating convenient linkage with other datasets, such as census data, using the FIPS code.

Association between family economic situation and serum PFAS concentration in American adults with hypertension and hyperlipemia.

Although there is an association between income status and concentration of perfluoroalkyl and polyfluoroalkyl substance (PFAS), the association remains uncertain in patients with hypertension, hyperlipidemia, and comorbidities. Data from the 2013-2016 National Health and Nutrition Examination Survey were analyzed. A total of 2665 adults were included, and the data included participants' serum PFAS (perfluorooctanoic acid [PFOA], perfluorononaic acid, perfluorodecanoic acid, perfluoroundecanoic acid, perfluorohexane sulfonic acid, and perfluorooctane sulfonic acid) levels and selected covariates. Multivariate linear regression models were used to examine the association between the ratio of family income to poverty (PIR) and individual serum PFAS concentrations in the hypertensive and/or hyperlipidemia groups after adjusting for covariates. The potential effects of sex and age on the results were explored using stratified analysis. A mediating effect model was used to explore the mediating effects of body mass index (BMI) and waist circumference on the association results. After adjusting for potential confounders, for hyperlipidemia and comorbidities (hypertension and hyperlipidemia), serum levels of multiple common PFAS increased by 0.09% (95%Confidence interval [CI] 0.02-0.15%) to 0.13% (95%CI 0.08-0.19%) and 0.10% (95%CI 0.02-0.17%) to 0.12% (95%CI 0.06-0.18%), respectively, with each 1% increase in PIR. The covariate model and stratified analyses results suggested the potential effects of different covariates such as age and sex, leading to changes in the statistical significance of the association results. BMI significantly mediated the effect of PIR on PFOA in hyperlipidemia (13%, P < 0.001). Household income in adults with hyperlipidemia and comorbidities positively correlated with serum PFAS concentration in the United States. Obesity played an indispensable mediating role in the association between economic income and PFAS concentration.

Seeing Bradycardia: How Ultrasound Improves Medical Decision-Making.

There is a broad differential for new-onset cardiac dysrhythmia, and the rapid identification of the underlying cause of these cardiac emergencies can be lifesaving. Identifying wall motion abnormalities on point-of-care ultrasound (POCUS) is not a core echocardiography application for Emergency Medicine (EM) physicians. However, ruling in a regional wall motion abnormality can expedite patient-centered care and assist the busy EM physician in high-risk cases.

Resiliency among United States Air Force personnel: The direct and interactive influence of cognitive fitness and confidence in social connections.

The United States (U.S.) military has focused on increasing service members' (SM) mental and social fitness to bolster resiliency (successful role performance). The Resiliency Model of Role Performance posits that individual assets and social connections account for SM's differential success in meeting military demands and personal obligations. We used a U.S. Air Force (AF) active-duty dataset to test for a direct, positive relationship between cognitive fitness and both formal and informal social connections, and the impact on successful role performance. We also tested for potential moderating influences of formal and informal social connections on role performance among SMs with low vs. high cognitive fitness. Data were collected from a non-probability purposive sample of AF SMs and civilians (N = 59,094) who completed the Support and Resiliency Inventory between November 4, 2011 and January 7, 2014. We focused on the married active-duty subsample (n = 29,387). We employed multivariate hierarchical regression analysis across three models to explore the direct and interactive influence of cognitive and social fitness on resiliency. Controlling for military demographic characteristics, we found a positive linear relationship between cognitive fitness and resiliency and between informal and formal support and resiliency. Informal social support moderated the association between cognitive fitness and resiliency, compensating for resiliency among SMs with lower cognitive fitness. Study findings support current military resilience-building initiatives and underline the importance of prioritizing informal social support in U.S. military settings.

Comparison of the Efficacy Between Ultrasound-Guided Paravertebral Block and Erector Spinae Block for Postoperative Analgesia in Percutaneous Nephrolithotomy Using Levobupivacaine: A Prospective and Randomized Study.

Introduction Various techniques have been developed in the current era of regional anesthesia practice. With the advent of ultrasound, the visualization of needle and pleura in real time enables a better outcome with negligible adverse events. This study was designed to compare the efficacy between ultrasound-guided erector spinae plane block (ESPB) and paravertebral block (PVB) in percutaneous nephrolithotomy (PCNL) for the duration of postoperative analgesia with levobupivacaine, a local anesthetic with higher lipid solubility, making it more potent and resulting in a longer duration of action. Methods This prospective randomized single-blinded study enrolled 50 patients of ASA grades I and II, aged between 20 and 60 years, who were scheduled for PCNL under general anesthesia. Patients were divided into two groups of 25 each: group ESPB and group PVB, and 25 mL of 0.25% levobupivacaine was administered to both groups. They were primarily evaluated for the duration of postoperative analgesia. Total rescue analgesic requirements, hemodynamic parameters, and any adverse effects were also assessed. Results Both ESPB and PVB provided a significant duration of analgesia postoperatively. Demographic characteristics in both groups were comparable. The duration of postoperative analgesia in group ESPB was 746 ± 58.6 minutes when compared to group PVB, which is 768 ± 68.6 minutes (p = 0.08). Intravenous (IV) paracetamol was used as a rescue analgesic. The doses used were also comparable in both groups, with the visual analog score (VAS) being high after around 12 hours of surgery. The total rescue analgesic requirement was similar in both groups (group ESPB, 2.0 ± 1.6; group PVB, 2.2 ± 1.4; p = 0.51). There were no significant hemodynamic or other adverse effects in either group. Conclusion We conclude that both ESPB and PVB using isobaric levobupivacaine 0.25% as a local anesthetic are equally efficacious in providing effective postoperative analgesia in patients undergoing PCNL under general anesthesia.

Innovative Multiplex PCR Assay for Detection of tlh, trh, and tdh Genes in Vibrio parahaemolyticus with Reference to the U.S. FDA's Bacteriological Analytical Manual (BAM).

Vibrio parahaemolyticus is an important foodborne bacterium that causes severe gastroenteritis following the consumption of contaminated seafood. To identify V. parahaemolyticus and determine its pathogenicity, the U.S. Food and Drug Administration (FDA)'s Bacteriological Analytical Manual (BAM) recommends a multiplex polymerase chain reaction (PCR) protocol to simultaneously detect the species-specific thermolabile hemolysin (tlh) gene and the pathogenic thermostable-related hemolysin (trh) and thermostable-direct hemolysin (tdh) genes. However, this assay has shown two limitations: difficulty in separating the amplicons of the trh (486 bp) and tlh (450 bp) genes due to their highly similar sizes, and the weaker band exhibited by the tdh gene amplicon (270 bp). The present study aimed to improve the BAM's multiplex PCR assay by separating the three amplicons with similar intensity. A new primer set was applied for the tlh gene (369 bp) alongside the existing primers for the trh and tdh genes. The amplicons for the three genes were effectively separated by electrophoresis on a 2% tris-borate-EDTA (TBE) agarose gel within 45 min. Primer concentrations of 0.25 µM for three genes produced a significant amount of amplicons among various combinations of primer concentrations with 35 PCR cycles. This assay exhibited a detection limit of 10 pg of bacterial DNA, demonstrating its high sensitivity. It did not display amplicons from nine Vibrio species known to be human pathogens or from 18 well-documented foodborne pathogens. Therefore, the present multiplex PCR protocol could help overcome the limitations of existing assays and provide a more reliable method for detecting the three genes of V. parahaemolyticus.

Association between age and onset of daptomycin-induced adverse events using the U.S. food and drug administration adverse event reporting system.

BACKGROUND: Daptomycin is a lipopeptide antibiotic with a broad spectrum of activity against gram-positive bacteria. Although information on daptomycin-induced adverse events can be found in clinical trials, data regarding the impact of age on these events are insufficient. Therefore, we evaluated whether age affects the occurrence of daptomycin-induced adverse events using adverse drug event reports in post-marketing stages provided by the U.S. Food and Drug Administration (FDA). METHODS: A total dataset of 7307 reports of patients treated with daptomycin in the FDA's Adverse Event Reporting System were analyzed. The patients were divided into seven age groups: 0-28 days, >28 days-23 months, 2-11 years, 12-17 years, 18-64 years, 65-80 years, and >80 years. A disproportionality analysis was conducted to calculate the reporting odds ratio, with a 95 % confidence interval. The univariate regression analysis was conducted using the percentage of each adverse event and age groups. RESULTS: Compared with the number of reports aged 18-64 years, there were significantly increased reports of eosinophilic pneumonia in patients aged 65-80 years and >80 years, anaphylactic reaction and pseudomembranous colitis in patients aged 12-17 years, and acute renal failure in patients aged 65-80 years. The regression coefficient for the reporting proportion of eosinophilic pneumonia was significantly positive. CONCLUSIONS: Our findings revealed age-related trends in daptomycin-induced adverse events, supporting the idea that implementing age-dependent follow-up and supportive care helps in the continuation of daptomycin therapy.

Trends in Disability and Limitations among U.S. Adults Age 18-44, 2000-2018.

Understanding disability trends is critical for health care and social policy. Although trends in disability and limitations have been studied extensively among older and middle-aged adults, little is known about trends in younger Americans, despite their importance for current and future population health. We present the first comprehensive evidence on disability trends among U.S. adults age 18-44. We analyze 20 measures of disability and limitations collected in the nationally representative National Health Interview Survey 2000-2018 (N=261,505). Robust Poisson models estimate age- and sex-adjusted trends and their covariates. Over one quarter (27.4%) reported at least one disability or limitation; the age-adjusted prevalence increased by 5% from 2000 to 2018. However, trends for specific disabilities and limitations varied tremendously. ADL and IADL limitations, cognitive, and social disabilities increased steeply (by 65-89% over the study period). Mobility limitations were generally unchanged or increased modestly. Hearing and 'other' limitations decreased significantly (25-48% decrease). The trends are only partly explained by education, health behaviors, chronic conditions, and other covariates. Disability trends research must not be limited to older adults. Researchers and policy makers interested in health care policy, planning, and caregiving should pay attention to disability trends among young adults in the United States.

"Honesty, Communication and Trust Are What Bring Peace of Mind": Narratives of HIV Risk Among Hispanic/Latino Men Who Have Sex with Men in the Southern United States.

For Hispanic/Latino MSM (HLMSM) in the South, HIV burden remains high, and HIV elimination is a national priority. Between July and September 2016, using a strengths-based approach informed by resilience theory, we conducted qualitative interviews with HIV-negative HLMSM in five southern cities in the United States with elevated HIV prevalence. We analyzed data using a qualitative content analysis approach, assessing for interrater reliability. A brief behavioral survey was also conducted. We enrolled 51 HLMSM (mean age = 33 years, range = 15-63). HLMSM discussed the climate of fear about HIV and homosexuality impeding HIV prevention, including the impact of stigma and taboo. Three main strengths-based strategies emerged for preventing HIV: assessing partner risk, establishing boundaries for sexual interactions, and self-education. Future HIV prevention efforts may benefit from balancing risk-based approaches with those that emphasize resilience, address partner trustworthiness and safety, and focus on providing novel outlets for HIV prevention education.

Structural Racism Conceptualization and Operationalization for Research for the U.S. HIV Epidemic: Findings from a Scoping Review and Implications for Advancing Research for Structural Interventions.

In the U.S., inequities by race/ethnicity in health outcomes, such as in the HIV epidemic, are long standing but have come to the forefront during the COVID-19 pandemic. There is growing recognition of the role of structural racism in racialized health inequities, yet the conceptualization and operationalization of structural racism in HIV research lags. We conducted a scoping review of existing published literature, between 1999-April 2024, conceptualizing and measuring structural racism's impact among people living with or at risk for HIV in the U.S. Our initial search yielded 236 unique articles, which after title and abstract screening yielded ten articles meeting full text review criteria. We then extracted key parameters, such as conceptualization, method of measurement of structural racism, study aims, design, and findings. Three of the articles were qualitative studies that conceptualized structural racism using (1) the social network model, (2) individual and structural intersectionality and (3) critical race theory. Operationalization of structural racism within the seven quantitative studies fell into three categories: (1) structural level, (2) a scale of experiences of racism, including structural racism, and (3) using explanatory demographic factors as downstream measures of the effects of structural racism. The variance in the conceptualization and operationalization of structural racism highlights the different interpretations of structural racism in its applications to the field of HIV research. Given the vast racial/ethnic inequities in HIV, we propose three overarching suggestions for next steps in improving the conduct of research on structural racism in HIV: (1) we must prioritize measuring racism past the individual and interpersonal levels to consider systemic factors at a societal level that manifest as structural racism to improve HIV outcomes in the U.S., (2) consider intergenerational effects of structural racism through the use of longitudinal data, and (3) broaden the agenda of structural racism to incorporate other systems of oppression. Additionally, broadening the scope of funding and inclusion of more researchers and individuals with lived experiences to support structural racism research to drive the scientific agenda and design of structural-level interventions will not only bolster achieving the U.S. Ending the HIV Epidemic goals but will do so by addressing inequities.

Intramuscular Cyst in the Vastus Intermedius Muscle: A Rare Presentation of a Hydatid Cyst.

Echinococcosis, or hydatid disease, is a parasitic infection caused by a cestode from the Taeniidae family, mainly by Echinococcus multilocularis or granulosus. It is predominantly seen in the lungs or the liver. The hydatid disease rarely manifests as a palpable mass in the muscles. This study reports a case of a 70-year-old male who has presented with a swelling in the anterolateral aspect of his right upper thigh, which was progressive over the past two years. The swelling was initially painless and is now associated with pain. The clinical diagnosis of an abscess was suspected. The diagnosis of his swelling was later made as a hydatid cyst in a muscle of the thigh based on the imaging modalities, the ultrasound, and an MRI. The patient underwent surgical excision of the cyst, following which the diagnosis of a hydatid cyst was confirmed on the biopsy.

Isolated Renal Hydatid Cyst: A Rare Case.

Hydatid disease is a parasitic infection caused by a cestode from the Taeniidae family, by Echinococcus multilocularis or Echinococcus granulosus, predominantly occurring in the lungs and liver. Although the kidney can be involved in hydatid cysts, isolated kidney hydatidosis is very rare. Most cases present with non-specific complaints or remain asymptomatic for years. Hence, imaging is very useful in the diagnosis. Here, we report an isolated hydatid cyst involving the right kidney.

Deployed at sea amidst the pandemic: Insights from 30 United States Navy nurses.

BACKGROUND: Coronavirus disease 2019 (COVID-19) presented unique challenges to the United States Navy given that the major components of controlling an infectious disease outbreak are not easily achieved on ships. PURPOSE: To understand shipboard Navy nurses' activities during the COVID-19 pandemic. METHODS: Virtual semistructured interviews were conducted in 2021 with 30 Navy nurses who deployed to sea during the pandemic. Data were coded using directed content analyses whereby remarks were categorized according to 16 public health interventions (PHIs) of the Minnesota Department of Health Intervention Wheel. Data were also coded via conventional content analysis. DISCUSSION: Multiple PHIs were utilized to improve the public health of those on Navy ships during the height of the pandemic. Also, four themes were constructed via conventional content analysis. CONCLUSION: Shipboard Navy nurses overcame unprecedented challenges to protect the health of their crew, all the while preserving operational readiness during the COVID-19 pandemic.

Minor Trauma, Major Discovery: The Ultrasound Identification of a Sternal Fracture Missed by Computed Tomography in an Older Patient Presenting With Acute Chest Pain.

This case report presents the diagnostic difficulties encountered by a 96-year-old woman with osteoporosis who experienced acute chest pain following minor trauma, eventually diagnosed with a sternal fracture. It highlights the nuanced presentation and diagnostic challenges associated with sternal fractures in older patients. Despite the prevalent use of chest radiography and computed tomography in acute trauma assessments, this case emphasizes their limitations, as both modalities initially failed to detect the sternal fracture. The successful identification of the fracture using ultrasound (US) underscores the utility of this modality in detecting subtle yet clinically significant injuries. This report advocates for a high index of suspicion for sternal fractures in older patients presenting with chest pain after minor trauma and suggests that US is a valuable, less invasive diagnostic tool. By illuminating the potential for minor trauma to cause major injury and the critical role of US in diagnosis, this case provides valuable insights into the management of sternal fractures in the geriatric population, urging clinicians to consider atypical presentations in diagnostic evaluations.

Healthcare system variability and inpatient maternal mortality in the United States.

OBJECTIVE: To examine the association of inpatient maternal mortality with variability in healthcare services delivery such as hospital size, urban/rural designation, teaching/non-teaching status, regional location, and insurance coverage. METHODS: This is a pooled, cross-sectional analysis of the National Inpatient Sample (2012-2014). Information on maternal demographics, clinical conditions, and birth outcomes were identified using respective ICD9-CM codes. Bivariate and multivariate analysis using logistic regression models were used to describe maternal characteristics and to calculate the risk of mortality with each independent variable. RESULTS: The weighted sample included 12,409,939 hospital records (82.6% are 18-34-year-old and 49.5% are Caucasians). Maternal death during hospitalization occurred in 1310 cases (12/100,000 live birth). Women with cardiovascular disorders, hemorrhage or sepsis were 33.6, 4.7, and 5.4 times more likely to suffer inpatient maternal mortality. Compared to small-sized hospitals, delivery at medium or large size hospitals is associated with higher mortality, adjusted odds ratios (aOR) 1.8 (1.4-2.3), and 2.2 (1.8-2.8), respectively. Adjusted OR for inpatient maternal mortality in urban non-teaching or urban teaching compared to rural hospitals were 2.2 (1.7-3.0) and 2.9 (2.2-3.9), respectively. Women in the South have higher maternal mortality compared to Northeast, aOR 1.7 (1.5-2.1). Women coved with public insurance experience higher inpatient maternal mortality compared to those with private insurance, aOR: 2.6 (2.1-3.2) and 1.9 (1.6-2.1), respectively. CONCLUSION: Factors related to variability in healthcare delivery may play a role in inpatient maternal mortality. Some could be explained by the case mix and the clinical conditions affecting birthing outcomes. A qualitative analysis is needed to explore how these factors relate to increased maternal mortality in certain hospital settings.

Beyond the Dichotomy: Creation and Validation of a Continuous Statewide Index of U.S. Honor Culture.

Honor cultures are characterized by a heightened sensitivity to reputation threats and strong expectations for the defense of honor. U.S. states vary in the extent to which they express the cultural norms of honor, but researchers have frequently relied upon a dichotomous classification that differentiates states as honor or dignity states. We created and validated a continuous, six-item index of honor norms and values across all U.S. states (Study 1). In Study 2, our honor index was correlated with historical variables theoretically associated with the genesis of honor cultures. In Study 3, we validated our honor index further by showing that it predicted several race-/ethnicity-specific outcomes that prior research has connected with honor (e.g., homicide rates, suicide rates). This new index equips researchers with a more nuanced understanding of U.S. honor cultures and a measure that can be used in future investigations.

Impact of Climate Policy Uncertainty (CPU) and global Energy Uncertainty (EU) news on U.S. sectors: The moderating role of CPU on the EU and U.S. sectoral stock nexus.

This article accounts for the impact of positive and negative shocks of the news-related Climate Policy Uncertainty (CPU) and the novel Economist Intelligence Unit's report-based global Energy Uncertainty (EU) on the U.S. sectoral stock returns by using the ARDL and NARDL approaches with dynamic multiplier simulations. We also utilize both the DCC-GARCH and ADCC-GARCH approaches to extract the symmetric and asymmetric dynamic conditional correlations between the EU and the U.S. sectoral stock returns and then regress these conditional correlation series on the CPU through series of quantile regressions. Overall, the findings suggest that only the positive CPU shocks negatively impact the U.S. sectoral stock returns of Consumer Services, Financials, Industries, Telecommunication and Utilities in the long-term, whereas the negative CPU shocks insignificantly predict the U.S. sectoral returns. The findings also report that only the negative EU shocks increase the U.S. sectoral stock returns of Consumer Services, Financials, Health Care, Industries, Moreover, the positive (negative) EU shocks cause the U.S. sectoral returns of Materials and Technology to decrease (increase) in the long-term. Portfolio managers may consider diversifying their portfolios to include sectors least susceptible to negative impacts from the CPU and EU shocks such as Health Care and Oil & Gas. Our findings also show that CPU shocks moderate the dynamic conditional correlations between the EU and the U.S. sectoral returns of Consumer Services, Materials, Health Care, Telecommunication, Oil and Gas and Utility. Fund managers should contemplate augmenting the allocations to the Financials, Industrials, and Technology sectors owing to their diminished interconnectivity with the EU during periods of heightened CPU.

Effect of Social Vulnerability on Cocaine-Related Mortality Rates in U.S. Counties.

Cocaine-related mortality rates have risen sharply since 2013 and social vulnerability is a crucial indicator for drug-related mortality rates. Therefore, the purpose of this study was to investigate the relationship between social vulnerability and cocaine-related mortality rates in U.S. counties. The Data were collected from the CDC WONDER, CDC's Social Vulnerability Index (CDC's SVI), and American Community Survey (ACS). The Data were analyzed by spatial autoregression models. According to present results, first, counties with social vulnerability (socioeconomic) were positively related to higher rates of cocaine overdose death (spatial lag: B = 0.323, p < .05; spatial error: B = 0.513, p < .01). Second, counties with social vulnerability (minority status & language) were negatively related to higher rates of cocaine overdose death (spatial lag: B = -0.233, p < .05). Third, counties with social vulnerability (housing type & transportation) were positively related to higher rates of cocaine overdose death (spatial lag: B = 0.413, p < .001; spatial error: B = 0.378, p < .001). In conclusion, the spread of cocaine overdose on U.S. counties with social vulnerabilities demonstrated a disproportionate burden of cocaine-related mortality.