Development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to HIV viral suppression in the Deep South.

BACKGROUND: Achieving early and sustained viral suppression (VS) following diagnosis of HIV infection is critical to improving outcomes for persons with HIV (PWH). The Deep South of the United States (US) is a region that is disproportionately impacted by the domestic HIV epidemic. Time to VS, defined as time from diagnosis to initial VS, is substantially longer in the South than other regions of the US. We describe the development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to VS in the Deep South. METHODS: Representatives of state health departments, the Centers for Disease Control and Prevention (CDC), and the academic partner met to establish core objectives and procedures at the beginning of the project. Importantly, this project used the CDC-developed Enhanced HIV/AIDS Reporting System (eHARS) through a distributed data network model that maintained the confidentiality and integrity of the data. Software programs to build datasets and calculate time to VS were written by the academic partner and shared with each public health partner. To develop spatial elements of the eHARS data, health departments geocoded residential addresses of each newly diagnosed individual in eHARS between 2012-2019, supported by the academic partner. Health departments conducted all analyses within their own systems. Aggregate results were combined across states using meta-analysis techniques. Additionally, we created a synthetic eHARS data set for code development and testing. RESULTS: The collaborative structure and distributed data network have allowed us to refine the study questions and analytic plans to conduct investigations into variation in time to VS for both research and public health practice. Additionally, a synthetic eHARS data set has been created and is publicly available for researchers and public health practitioners. CONCLUSIONS: These efforts have leveraged the practice expertise and surveillance data within state health departments and the analytic and methodologic expertise of the academic partner. This study could serve as an illustrative example of effective collaboration between academic institutions and public health agencies and provides resources to facilitate future use of the US HIV surveillance system for research and public health practice.

The Safety and Immunologic Effectiveness of the Live Varicella-Zoster Vaccine in Patients Receiving Tumor Necrosis Factor Inhibitor Therapy : A Randomized Controlled Trial.

BACKGROUND: The safety and effectiveness of live virus vaccines, such as the varicella-zoster vaccine, are unknown in patients with inflammatory diseases receiving immunomodulatory therapy such as tumor necrosis factor inhibitors (TNFis). OBJECTIVE: To evaluate the safety and immunogenicity of the live attenuated zoster vaccine (ZVL) in patients receiving TNFis. DESIGN: Randomized, blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT02538341). SETTING: Academic and community-based rheumatology, gastroenterology, and dermatology practices. PATIENTS: Adults aged 50 years or older receiving TNFis for any indication. INTERVENTION: Random assignment to ZVL versus placebo. MEASUREMENTS: Glycoprotein enzyme-linked immunosorbent assay (gpELISA) and enzyme-linked immunosorbent spot (ELISpot) from serum and peripheral blood mononuclear cells measured at baseline and 6 weeks after vaccination. Suspected varicella infection or herpes zoster was clinically assessed using digital photographs and polymerase chain reaction on vesicular fluid. RESULTS: Between March 2015 and December 2018, 617 participants were randomly assigned in a 1:1 ratio to receive ZVL (n = 310) or placebo (n = 307) at 33 centers. Mean age was 62.7 years (SD, 7.5); 66.1% of participants were female, 90% were White, 8.2% were Black, and 5.9% were Hispanic. The most common TNFi indications were rheumatoid arthritis (57.6%) and psoriatic arthritis (24.1%); TNFi medications were adalimumab (32.7%), infliximab (31.3%), etanercept (21.2%), golimumab (9.1%), and certolizumab (5.7%). Concomitant therapies included methotrexate (48.0%) and oral glucocorticoids (10.5%). Through week 6, no cases of confirmed varicella infection were found; cumulative incidence of varicella infection or shingles was 0.0% (95% CI, 0.0% to 1.2%). At 6 weeks, compared with baseline, the mean increases in geometric mean fold rise as measured by gpELISA and ELISpot were 1.33 percentage points (CI, 1.17 to 1.51 percentage points) and 1.39 percentage points (CI, 1.07 to 1.82 percentage points), respectively. LIMITATION: Potentially limited generalizability to patients receiving other types of immunomodulators. CONCLUSION: This trial informs safety concerns related to use of live virus vaccines in patients receiving biologics. PRIMARY FUNDING SOURCE: The National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American College of Rheumatology.

COVID-19 Vaccine Knowledge, Attitudes, and Practices in Alabama: The Case for Primary Health Care Providers.

OBJECTIVE: To examine knowledge, attitudes, and practices about COVID-19 in Alabama, with a primary focus on vaccination perception and utilization. DESIGN: We used a COVID-19 Knowledge, Attitudes, and Practices survey and recruited adult Alabama residents in April-May 2021. PARTICIPANTS: Initial surveys from 1324 Alabamian participants were considered for analysis; after careful review of incomplete responses, 953 were ultimately included for analysis. MAIN OUTCOME MEASURE: Vaccine behavior and hesitancy comprise a self-reported response contained in the survey instrument. Three primary vaccine groups were used to assess differences in demographic characteristics, health status, perception of susceptibility and severity of COVID-19, sources of information, and trust about COVID-19. RESULTS: Of the 953 survey participants included for analysis, 951 had self-identified vaccine status in which 153 (16.1%) reported to have received the vaccine at the time of the survey, 375 (39.4%) were very likely or somewhat likely to get an approved COVID-19 vaccine if it was offered, and 423 (44.5%) were somewhat unlikely or very unlikely to get an approved COVID-19 vaccine. Health care providers were the most trusted sources of information, regardless of vaccine status. For participants unlikely to receive a vaccine, social media and local news sources were consistently more trusted and utilized than those who were vaccinated or were likely to be. CONCLUSIONS: The perceptions among unvaccinated participants are actionable and provide teachable opportunities to decrease vaccine apprehension.

Tissue-Resident Macrophages Promote Renal Cystic Disease.

BACKGROUND: Mutations affecting cilia proteins have an established role in renal cyst formation. In mice, the rate of cystogenesis is influenced by the age at which cilia dysfunction occurs and whether the kidney has been injured. Disruption of cilia function before postnatal day 12-14 results in rapid cyst formation; however, cyst formation is slower when cilia dysfunction is induced after postnatal day 14. Rapid cyst formation can also be induced in conditional adult cilia mutant mice by introducing renal injury. Previous studies indicate that macrophages are involved in cyst formation, however the specific role and type of macrophages responsible has not been clarified. METHODS: We analyzed resident macrophage number and subtypes during postnatal renal maturation and after renal injury in control and conditional Ift88 cilia mutant mice. We also used a pharmacological inhibitor of resident macrophage proliferation and accumulation to determine the importance of these cells during rapid cyst formation. RESULTS: Our data show that renal resident macrophages undergo a phenotypic switch from R2b (CD11clo) to R2a (CD11chi) during postnatal renal maturation. The timing of this switch correlates with the period in which cyst formation transitions from rapid to slow following induction of cilia dysfunction. Renal injury induces the reaccumulation of juvenile-like R2b resident macrophages in cilia mutant mice and restores rapid cystogenesis. Loss of primary cilia in injured conditional Ift88 mice results in enhanced epithelial production of membrane-bound CSF1, a cytokine that promotes resident macrophage proliferation. Inhibiting CSF1/CSF1-receptor signaling with a CSF1R kinase inhibitor reduces resident macrophage proliferation, R2b resident macrophage accumulation, and renal cyst formation in two mouse models of cystic disease. CONCLUSIONS: These data uncover an important pathogenic role for resident macrophages during rapid cyst progression.

Intimate Partner Violence Experiences Among Men Living with HIV in Rural Appalachia.

There has been limited study of the syndemic link between HIV and intimate partner violence (IPV) among rural populations in the United States. We utilized the Revised Conflict Tactics Scale-2 to examine the past year prevalence, type (psychological aggression, physical assault, and sexual assault), and the impact of IPV on HIV clinical outcomes among men living with HIV in rural Appalachia. Approximately 39% of participants experienced some type of IPV in the preceding year, with 67% of those individuals experiencing more than 1 type of IPV. Approximately 77% of participants endorsing IPV exposure experienced psychological aggression. Most participants exposed to psychological aggression (70%) and/or physical assault (57%) were both victims and perpetrators, and those experiencing sexual assault reported being exclusively victims (65%). There were no significant differences in clinical outcomes including viral load and CD4 count, which may be secondary to small sample size derived from a clinic population with a high rate of virologic suppression (94%). This study demonstrates the need to assess IPV exposure in men living with HIV and further highlights the intricacies of relationship violence in these individuals.

Longitudinal Ultrasound Curriculum Incorporation at West Virginia University School of Medicine: A Description and Graduating Students' Perceptions.

OBJECTIVES: Sonography is a clinical tool being incorporated in multiple medical specialties with evidence of improved patient care and cost. Some schools have begun implementing ultrasound curricula. We hope to build upon that foundation and provide another potential framework of incorporation. There are several barriers, including curricular space, equipment and physical space, adequate faculty, and performing assessment. METHODS: At West Virginia University, we began a longitudinal ultrasound curriculum in 2012 with incorporation of didactic and practical sessions into gross anatomy, our systems-based second-year curriculum, physical diagnosis course, and clinical rotations. We included both written and practical assessment from the onset. After the initial 4 years, the first graduates were surveyed on their perceptions of the curriculum. Responses were correlated with specialty choice and clinical campus site. RESULTS: Based on our survey (90% response rate), students felt sonography was useful for anatomical understanding and patient care. Overall, 93% of our respondents reviewed the curriculum favorably. Qualitative feedback was very positive, with students desiring more ultrasound education and more required components, specifically in clinical rotations. CONCLUSIONS: Based on these results, some changes have already been implemented, including decreased student-to-instructor ratios, more open scan time, and more required components. The breadth of formal assessment has increased. Multiple pilot programs for clinical rotations are being developed. There is an ongoing need for faculty development and continued assessment of ultrasound competency.

Human papillomavirus vaccine beliefs and intentions Post-COVID-19 vaccine release among mothers in Alabama.

PURPOSE: The current study sought to determine if the release of COVID-19 vaccines influenced Alabama mothers' attitudes and behaviors regarding HPV vaccination of their adolescent children. METHODS: A social media survey was conducted August - September 2022 among mothers of adolescents ages 9-18, who self-identified as Alabama residents and their child(ren)'s primary medical decision maker. The survey assessed demographics, vaccine knowledge and opinions, vaccination history, influences on vaccination decisions, and how COVID-19 vaccine release affected vaccine opinions. Univariable and multivariable analyses were conducted. RESULTS: Of 241 responses, most participants were white (82.0 %, n = 196), non-Hispanic (96.6 %, n = 230), and privately insured (64.5 %, n = 151), with annual household incomes ≥$61,000 (45.4 %, n = 103). The majority (60.8 %) reported that their child either had or planned to receive the HPV vaccine. The release of COVID-19 vaccines did not change the majority of parental opinions towards HPV, with 78.5 % (n = 161) reporting no change. Among those who experienced a change, 25 % (n = 5) reported an increased likelihood of having their child vaccinated for HPV and 75 % (n = 15) reported a decrease in likelihood. Moderate and high HPV knowledge scores were associated in multivariable analysis with increased likelihood of having their child vaccinated for HPV ("moderate" knowledge AOR: 12.4, 95 % CI: 1.98-78.1; "high" knowledge AOR: 12.8, 95 % CI: 2.00-82.1). Positive HPV opinion scores in the univariable analysis similarly showed increased odds (AOR = 1.5). CONCLUSIONS: These findings indicate that, in this population, COVID-19 vaccine release did not significantly impact subsequent HPV vaccination decision making. Parental perceptions regarding vaccination are critical to informing future interventions.

The Neuromechanics of Inspiratory Muscles in Mechanical Ventilation Liberation Success and Failure.

BACKGROUND: Assessing the neuromechanical coupling of inspiratory muscles during mechanical ventilation (MV) could reveal the physiological mechanism of MV failure. This study examined the respiratory neuromechanical characteristics between MV liberation success and failure. METHODS: This is an observational prospective study that included patients during their ventilator liberation process. Assessment of surface electromyography (sEMG) of inspiratory muscles, including the diaphragm and extra-diaphragmatic (scalene, sternocleidomastoid, and parasternal) muscles, was performed 15 minutes after the initiation of spontaneous breathing trials. Neuromechanical efficiency of the diaphragm (NMEDia) and extra-diaphragmatic muscles (NMEExtra) were compared in patients who were successfully liberated from MV with those who failed MV liberation within 72 hours after extubation. RESULTS: A total of 45 patients were enrolled and 28 were female (67%). The sample median age was 63 (IQR 47, 69) years old. One-third of patients failed MV liberation within 72 hours of their spontaneous breathing trials (SBTs). NMEDia was significantly lower in patients who failed MV liberation with a root mean square of (M 0.27), (IQR 0.21, 0.37) compared with (M 0.371), (IQR 0.3, 0.631) for the success group (p=0.0222). The area under the curve for NMEDia was lower in the failure group (M 0.270), (IQR 0.160, 0.370) and (M 0.485), (IQR 0.280, 0.683) for the success group (p=0.024). However, NMEExtra was not statistically different between the two groups. CONCLUSION: Reduced NMEDia is a predictor of MV liberation failure. NMEExtra was not a major contributor to MV liberation outcomes. Further studies should assess the performance of inspiratory muscles NME indices to predict MV liberation outcomes.

Community-Based Services for Hospitalized Patients With Serious Injection-Related Infections in Alabama: A Brief Report.

Injection-related infections continue to rise, particularly in the South. People who inject drugs are increasingly utilizing hospital services for serious injection-related infections but may be discharged to areas without harm reduction services. We explored the availability and travel time to services for HIV and substance use in Alabama.

Hospitalization is a missed opportunity for HIV screening, pre-exposure prophylaxis, and treatment.

BACKGROUND: Hospitalization is a "reachable moment" for people who inject drugs (PWID), but preventive care including HIV testing, prevention and treatment is rarely offered within inpatient settings. METHODS: We conducted a multisite, retrospective cohort study of patients with opioid use disorder with infectious complications of injection drug use hospitalized between 1/1/2018-12/31/2018. We evaluated HIV care continuum outcomes using descriptive statistics and hypothesis tests for intergroup differences. RESULTS: 322 patients were included. Of 300 patients without known HIV, only 2 had a documented discussion of PrEP, while only 1 was prescribed PrEP on discharge. Among the 22 people with HIV (PWH), only 13 (59%) had a viral load collected during admission of whom all were viremic and 10 (45%) were successfully linked to care post-discharge. Rates of readmission, Medicaid or uninsured status, and unstable housing were high in both groups. DISCUSSION: We observed poor provision of HIV testing, PrEP and other HIV services for hospitalized PWID across multiple U.S. medical centers. Future initiatives should focus on providing this group with comprehensive HIV testing and treatment services through a status neutral approach.

Implementation of a safer conception programme for HIV-affected men and women in rural Uganda.

We integrated safer conception care into a Ugandan HIV clinic. People with HIV (PWH), or partnered with a PWH, and desiring children were eligible for the Healthy Families Clinic Program. Clients completed quarterly safer conception counselling visits and questionnaires to provide information around method preferences and outcomes (partner pregnancy, partner seroconversion). We used clinic level data to evaluate longitudinal viral suppression among PWH. Between November 2016 and January 2020, 361 clients (53% men) accessed services. 75% were PWH (51% women, 96% men): 99% were on antiretroviral therapy (ART) and most reported HIV-sero-different partnerships (97%). Frequently selected safer conception methods included ART (86%), timed condomless sex (74%), and PrEP (40%) with important differences by HIV-serostatus and gender. 22.5% reported pregnancy. Most (97%) PWH were virally suppressed at enrolment and 81% of non-virally suppressed PWH were virally suppressed at 15 months. Two HIV-negative clients (2%) had HIV seroconversion. There is demand for safer conception care in a public sector HIV-clinic in Uganda. Men and women have unique safer conception care preferences. The majority of clients engaged in safer conception care had viral suppression at follow up.

Oral preexposure prophylaxis uptake, adherence, and persistence during periconception periods among women in South Africa.

OBJECTIVE: We developed the Healthy Families-PrEP intervention to support HIV-prevention during periconception and pregnancy. We evaluated preexposure prophylaxis (PrEP) use with three objective measures. DESIGN: This single-arm intervention study enrolled women in KwaZulu-Natal, South Africa, who were HIV-uninfected, not pregnant, in a relationship with a partner with HIV or unknown-serostatus, and with pregnancy plans. PrEP was offered as part of a comprehensive HIV prevention intervention. Participants were followed for 12 months. METHODS: We evaluated periconception PrEP uptake and adherence using quarterly plasma tenofovir concentrations. We modeled factors associated with PrEP uptake and high plasma tenofovir (past day dosing). Patterns of use were analyzed using electronic pillcap data. Dried blood spots to measure intracellular tenofovir product (past 2 months dosing) were analyzed for a subset of women. RESULTS: Three hundred thirty women with median age 24 (IQR: 22-27) years enrolled. Partner HIV-serostatus was unknown by 96% ( N  = 316); 60% (195) initiated PrEP. High plasma tenofovir concentrations were seen in 35, 25, 22, and 20% of samples at 3, 6, 9, and 12 months, respectively. Similar adherence was measured by pillcap and dried blood spots. In adjusted models, lower income, alcohol use, and higher HIV stigma were associated with high plasma tenofovir. Eleven HIV-seroconversions were observed (incidence rate: 4.04/100 person-years [95% confidence interval: 2.24-7.30]). None had detectable plasma tenofovir. CONCLUSION: The Healthy Families-PrEP intervention supported women in PrEP use. We observed high interest in periconception PrEP and over one-third adhered to PrEP in the first quarter; one-fifth were adherent over a year. High HIV incidence highlights the importance of strategies to reduce HIV incidence among periconception women. CLINICAL TRIAL NUMBER: NCT03194308.

Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis.

Background: Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention. Methods: We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use. Results: A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum. Conclusions: The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.

Biological Effective Radiation Dose for Multiple Myeloma Palliation.

Purpose: Various radiation therapy (RT) dose/fractionation schedules are acceptable for palliation in multiple myeloma. Nine years of single-institution RT experience were reviewed to determine the influence of dose/fractionation and other factors pertinent to individualizing therapy. Methods and Materials: In total, 152 items were identified from Current Procedural Terminology codes for multiple myeloma treatment from 2012 through June 30, 2021. After exclusions, 205 sites of radiation in 94 patients were reviewed. Data were captured from treatment planning and clinical records. To statistically assess the association between biological effective dose (BED10) and variables of interest, BED was first dichotomized to <24 Gy versus ≥24 Gy. Multivariate analysis used SAS software and a generalized estimating equation approach to account for multiple observations per patient. Results: Fractions of 1.8 to 8 Gy were used in 1 to 25 fractions. Most patients had no significant toxicity. Grade 1 toxicity was more likely with greater BED radiation courses, as expected (20% vs 12% for BED <24 Gy). Pain relief was complete or very good for most sites, with <3% reporting no pain relief. Eleven sites in 9 patients required retreatment. All retreatment sites had palliation that was lasting, with a median of 22 months to last follow-up or death after repeat course (range, 0.5-106 months). There was a trend for better pain control and less risk of fracture retreatment with BED ≥24 Gy. Conclusions: Most patients had good palliation without toxicity. BED ≥24 Gy caused 8% greater risk of grade 1 toxicity and trended toward better pain control plus reduced risk of fracture retreatment.

Geospatial Analysis of Time to Human Immunodeficiency Virus (HIV) Diagnosis and Adult HIV Testing Coverage Highlights Areas for Intervention in the US Southeast.

Background: In the United States (US), 44% of people with human immunodeficiency virus (PWH) live in the Southeastern census region; many PWH remain undiagnosed. Novel strategies to inform testing outreach in rural states with dispersed HIV epidemics are needed. Methods: Alabama state public health HIV testing surveillance data from 2013 to 2017 were used to estimate time from infection to HIV diagnosis using CD4 T-cell depletion modeling, mapped to county. Diagnostic HIV tests performed during 2013-2021 by commercial testing entities were used to estimate HIV tests per 100 000 adults (aged 15-65 years), mapped to client ZIP Code Tabulation Area (ZCTA). We then defined testing "cold spots": those with <10% adults tested plus either (1) within or bordering 1 of the 13 counties with HIV prevalence >400 cases per 100 000 population or (2) within a county with average time to diagnosis greater than the state average to inform testing outreach. Results: Time to HIV diagnosis was a median of 3.7 (interquartile range [IQR], 0-9.2) years across Alabama, with a range of 0.06-12.25 years. Approximately 63% of counties (n = 42) had a longer time to diagnosis compared to national US estimates. Six hundred forty-three ZCTAs tested 17.3% (IQR, 10.3%-25.0%) of the adult population from 2013 to 2017. To prioritize areas for testing outreach, we generated maps to describe 47 areas of HIV-testing cold spots at the ZCTA level. Conclusions: Combining public health surveillance with commercial testing data provides a more nuanced understanding of HIV testing gaps in a state with a rural HIV epidemic and identifies areas to prioritize for testing outreach.

Resveratrol and exercise combined to treat functional limitations in late life: A pilot randomized controlled trial.

PURPOSE: To evaluate the safety and feasibility of combining exercise (EX) and resveratrol to treat older adults with physical function limitations. METHODS: Three-arm, two-site pilot randomized, controlled trial (RCT) for community-dwelling adults (N = 60), 71.8 ± 6.3 years of age with functional limitations. Participants were randomized to receive either 12 weeks of (1) EX + placebo [EX0], (2) EX + 500 mg/day resveratrol [EX500], or (3) EX + 1000 mg/day resveratrol [EX1000]. EX consisted of two sessions a week for 12 weeks of center-based walking and whole-body resistance training. Safety was assessed through adverse events and feasibility through exercise session and supplement (placebo, or resveratrol) protocol adherence. Outcome measures included a battery of indices of physical function as well as skeletal muscle mitchondrial function. Data were adjusted for age and gender using the Intent-To-Treat approach. RESULTS: Adverse event frequency and type were similar between groups (n = 8 EX0, n = 12 EX500, and n = 7 EX1000). Overall, 85% of participants met the supplement adherence via pill counts while 82% met the exercise session adherence. Adjusted within group mean differences (95% confidence interval) from week 0 to 12 for gait speed ranged from -0.04 (EX0: -0.1, 0.03) m/s to 0.04 (EX1000: -0.02, 0.11) and the six-minute walk test mean differences were 9.45 (EX0: -9.02, 27.7), 22.9 (EX500: 4.18, 41.6), and 33.1 (EX1000: 13.8, 52.4) meters. Unadjusted mean differences for citrate synthase were -0.80 (EX0: -15.45, 13.84), -1.38 (EX500: -12.16, 9.39), and 7.75 (EX1000: -4.68, 20.18) mU/mg. COX activity mean within group changes ranged from -0.05 (EX0) to 0.06 (EX500) k/s/mg. Additional outcomes are detailed in the text. CONCLUSION: The pilot RCT indicated that combined EX + resveratrol was safe and feasible for older adults with functional limitations and may improve skeletal muscle mitochondrial function and mobility-related indices of physical function. A larger trial appears warranted and is needed to formally test these hypotheses.

"Effect of very dense artifacts on Hologic and general electric bone densitometry results".

Very dense artifacts confound bone density measurement. Hologic and GE densitometers exclude artifact density and GE also excludes associated area. Consequently, BMD is decreased with Hologic software. Despite different manufacturers' approaches, when dense artifacts overlay the spine, the affected vertebral body should be excluded from the reported BMD. PURPOSE: Very dense objects, such as lead bullets are described as "black hole" artifacts on Hologic densitometers. Whether similar results occur on GE scanners is not reported. We hypothesized that dense artifacts confound both brands of densitometers. METHODS: Three lead bullets of varying size were placed overlying or adjacent to L3 on anthropomorphic and encapsulated aluminum spine phantoms. Three scans were acquired with and without projectiles on a Hologic Discovery W, GE iDXA, and Prodigy densitometer. RESULTS: Lead bullets are measured as having high bone mineral content (BMC); they appear black in dual-energy mode on Hologic scanners and are colored blue on GE scanners. On Hologic scanners, BMC of a dense artifact over bone is excluded, but the bone area is not altered. Consequently, bone mineral density (BMD) of the affected vertebra, and of L1-4, is decreased. For example, a .45 caliber bullet over L3 decreased BMD (p < 0.05) by 48.3% and L1-4 by 9.1%. GE scanners excluded associated BMC and area covered by the artifact, thereby minimizing impact on BMD. Dense artifacts over soft tissue on a phantom do not substantially affect BMD on either manufacturer's densitometer when scanned. CONCLUSION: Densitometer manufacturers handle very dense artifacts differently. GE software removes artifact BMC and area with resultant minimal impact on BMD, Hologic removes only BMC, not area, thereby decreasing BMD. Regardless of this difference, when dense artifacts overlay the spine, it is best to exclude the affected vertebral body. Finally, the BMD stability observed with artifacts over soft tissue may not be replicated in humans.

Translating School Physical Education and Activity Policies into Practice: A Case Study.

BACKGROUND: Public health experts recommend school-based policies as a population based approach to increase youth physical activity. The purpose of this case study is to describe one, largely rural, state's efforts to translate this recommendation into practice. Details about the genesis, implementation and evolution of two state level policies (physical education and physical activity), as well as in-house efforts of a State Department of Education to monitor policy compliance and challenges encountered are described. Two specific years are highlighted, due to policy and monitoring enhancements made during those particular time periods. METHODS: Data for this paper come from the West Virginia Department of Education for two time periods: 2013-2014 and 2014-2015 (n=369 elementary schools). Descriptive statistics for quantitative data and content analysis for qualitative data were used to document school level compliance and provide context for implementation challenges. RESULTS: Greater than 70% of school principals reported achievement of physical education and physical activity policy expectations for each year. Limited staff was the predominant explanation for nonfulfillment of physical education expectations, followed by lack of time and facilities. Recess and classroom-based physical activity were the primary strategies used to comply with the physical activity expectations. PE and PA policy compliance varied significantly by certain school characteristics in each school year studied. CONCLUSIONS: Further investigation is warranted on how states translate public health policy recommendations into practice, including how physical education and physical activity policies are developed and monitored at the state level and how to support states and schools with monitoring and implementation challenges.

Gender Differences in Sexual Health Knowledge Among Emerging Adults in Acute-Care Settings.

CONTEXT: Emerging adults (aged 18-25 years) are increasingly seeking evaluation in acute-care clinics for sexual health-related concerns to receive treatment and education. OBJECTIVE: To assess the sexual health knowledge of emerging adult patients by gender at acute-care health centers. METHODS: A prospective, self-administered survey was distributed from August 2014 through May 2016 to patients aged 18 to 24 years who presented to 1 of 4 acute-care locations in a university town in a mid-Atlantic state. Analyses included descriptive statistics, as well as χ2 and Fisher exact test crosstabulations to determine differences between genders. RESULTS: A total of 388 patients aged 18 to 24 years responded to the survey, with 81% of the sample identifying themselves as students and 64% identifying as female. Women were more likely than men to state that they sought sexual health advice at an urgent-care or walk-in clinic (70.3% vs 52.1%; P<.05). Human papillomavirus knowledge among women was significantly greater than among men (P<.0001). Open-ended responses were widespread and often incorrect, specifically with regard to the human papillomavirus vaccine and routine testing for sexually transmitted infections. CONCLUSION: Women were more knowledgeable about sexual health than men. However, both genders were not as knowledgeable overall on sexual health topics as hypothesized. A stronger emphasis on gender-specific programming for sexual health education via community- and school-based programs throughout adolescence, supplemented with greater emphasis on routine preventive health care during adolescence and emerging adulthood, is encouraged.

Environmental perfluoroalkyl acid exposures are associated with liver disease characterized by apoptosis and altered serum adipocytokines.

Exposures to perfluoroalkyl substances (PFAS) including perfluoroalkyl acids (PFAAs) are associated with increased liver enzymes in cohort studies including the C8 Health Study. In animal models, PFAAs disrupt hepatic lipid metabolism and induce apoptosis to cause nonalcoholic fatty liver disease (NAFLD). PFAAs are immunotoxic and inhibit pro-inflammatory cytokine release from stimulated leukocytes in vitro. This cross-sectional study tests the hypothesis that environmental PFAAs are associated with increased hepatocyte apoptosis and decreased pro-inflammatory cytokines in serum. Biomarkers previously associated with PFAS exposures and/or NAFLD were evaluated as secondary endpoints. Two hundred adult C8 Health Study participants were included. Measured serum biomarkers included: perfluorohexane sulfonate (PFHxS); perfluorooctanoic acid (PFOA); perfluorooctane sulfonate (PFOS); perfluorononanoic acid (PFNA); cytokeratin 18 M30 (CK18 M30, hepatocyte apoptosis); adipocytokines; insulin; and cleaved complement 3 (C3a). Confounder-adjusted linear regression models determined associations between PFAS and disease biomarkers with cut-offs determined by classification and regression tree analysis. CK18 M30 was positively associated with PFHxS (ß = 0.889, p = 0.042); PFOA (ß = 2.1, p = 0.005); and PFNA (ß = 0.567, p = 0.03). Tumor necrosis factor α (TNFα) was inversely associated with PFHxS (ß = -0.799, p = 0.001); PFOA (ß = - 1.242, p = 0.001); and PFOS (ß = -0.704, p < 0.001). Interleukin 8 was inversely associated with PFOS and PFNA. PFAAs were also associated with sexually dimorphic adipocytokine and C3a responses. Overall, PFAA exposures were associated with the novel combination of increased biomarkers of hepatocyte apoptosis and decreased serum TNFα. These data support previous findings from cohorts and experimental systems that PFAAs may cause liver injury while downregulated some aspects of the immune response. Further studies of PFAAs in NAFLD are warranted and should evaluate sex differences.