Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction.

With high success rates of autologous breast reconstruction, the focus has shifted from flap survival to improved patient outcomes. Historically, a criticism of autologous breast reconstruction has been the length of hospital stay. Our institution has progressively shortened the length of stay after deep inferior epigastric artery perforator (DIEP) flap reconstruction and began discharging select patients on postoperative day 1 (POD1). The purpose of this study was to document our experience with POD1 discharges and to identify preoperative and intraoperative factors that may identify patients as candidates for earlier discharge. Methods: An institutional review board-approved, retrospective chart review of patients undergoing DIEP flap breast reconstruction from January 2019 to March 2022 at Atrium Health was completed, consisting of 510 patients and 846 DIEP flaps. Patient demographics, medical history, operative course, and postoperative complications were collected. Results: Twenty-three patients totaling 33 DIEP flaps were discharged on POD1. The POD1 group and the group of all other patients (POD2+) had no difference in age, ASA score, or comorbidities. BMI was significantly lower in the POD1 group (P = 0.039). Overall operative time was significantly lower in the POD1 group, and this remained true when differentiating into unilateral operations (P = 0.023) and bilateral operations (P = 0.01). No major complications occurred in those discharged on POD1. Conclusions: POD1 discharge after DIEP flap breast reconstruction is safe for select patients. Lower BMI and shorter operative times may be predictive in identifying patients as candidates for earlier discharge.

Waterborne exposure during non-consumptive domestic use of surface water: a population study across WASH service levels in rural India.

Exposure to pathogens from domestic use of surface water is understudied. In many low- and middle-income countries, surface water is used for hygiene, sanitation, amenity, and recreational purposes. In this study, self-reported use of and structured observations at community ponds were collected to measure waterborne exposure across water and sanitation service levels in a rural population of Khorda District, India. Overall, 86% of households (n = 200) reported using ponds on a regular basis. Among observed people (n = 765), 82% put water into their mouth at least once, with a median frequency of five occurrences per visit. Reported and observation data were combined to estimate the proportion (p) of the population that put water in their mouth at least once per day, and their mean daily rate of oral exposure (OE). These were highest for individuals with neither safely managed water nor basic sanitation access (p = 93%, OE = 14 day-1), but still high among those with both (p = 67%, OE = 6 day-1). The results suggest widespread exposure to waterborne pathogens in settings where non-potable surface water bodies continue to be used for domestic purposes, even among households with access to safely managed drinking water.

Vaccine Hesitancy in Mississippi: Does Political Ideology Muddy the Waters?

During the SARS-CoV2 pandemic vaccines were made available at a rapid pace in the United States (US) with support from the government. In Mississippi, vaccine hesitancy was marked. Across the country many areas of the US demonstrated reduced uptake regarding this specific vaccine due to a variety of reasons. Even with the efficacy of the vaccine indicative of a significant level of protection from mortality and serious morbidity, vaccine uptake and hesitancy were a significant concern. This study surveyed Mississippians on their willingness to take the vaccine or not, and in particular, investigated political ideology as a reason for vaccine hesitancy. Data was collected via an online survey and 589 adults (>18 years) responded. Those self-identifying as "Republican" were more than twice as likely to disagree that not getting the vaccine was a risk to their health and others (OR = 2.07, 95% CI 1.70, 2.54) as those who identified as "Democrat or independent" voters. Future health promotion efforts should specifically attempt to address this group in a more effective manner.

Genetic and phenotypic parameter estimates for selection within Ugandan indigenous chickens.

The high genetic variation within indigenous chickens (IC) which provides an opportunity to select superior stock for sustainable production and conservation is under-exploited. This study is aimed at estimating heritability and genetic and phenotypic correlation coefficients of productive and reproductive traits of Ugandan IC as a basis for selection. Data on traits were collected across two consecutive generations, weight (W) and shank length (SL) of chicks at hatching (HW) as well as at 2 (W2; SL2), 4 (W4; SL4), 6 (W6; SL6), 8 (W8; SL8), and 12 (W12; SL12) weeks of growth. Body weights at onset of lay (WFE) were also measured. In addition, egg number (EN-60), egg weight (EW), clutch number (CLN-60), and clutch size (CLS-60) over a period of 60 days were recorded. Genetic parameters were estimated using the univariate animal model analysis with restricted maximum likelihood procedure using the variability package of R, version 4.1.1. Heritability of traits ranged from 0.30 and 0.72 except SL4 (0.02), SL12 (0.14), and EN-60 (0.17). The traits EN-60 and W4 were negatively phenotypically correlated (- 0.49). Body weight at first egg was highly genetically correlated (0.99) with SL8. Egg number was significantly, negatively, and genetically correlated (- 0.96) with SL12. In conclusion, shank length is a potential phenotypic marker when selecting for live weight at onset of lay and egg yield. The shank length could, therefore, permit selection of superior chickens at an early age.

Addressing Food Insecurity: A Qualitative Study of Undergraduate Students' Perceptions of Food Access Resources.

Food insecurity has emerged as a leading health care problem in the United States, impacting college students' health, well-being, and academic performance. The aims of this study were: (1) to assess the prevalence of food insecurity, (2) to identify college students' perceptions about food access resources, and (3) to explore students' expressed needs from the university in improving food security status. A mixed-methods approach was used to assess the quantitative and qualitative aspects of the study aims. An online survey to gather demographic information and assess food security status using the 6-item version of the US Household Food Security Scale Module (HFSSM) was administered. Next, qualitative focus groups with subsets of participants was conducted to gain further insight into the perceptions, coping mechanisms, and resource utilization issues related to food insecurity. This study found 34.1% of undergraduate college students to be food insecure and demonstrates that students with a meal plan are less likely to be food insecure (p = 0.012; OR = 0.68; 95% CI = 0.489, 0.918). Qualitative data identified key influencers of food insecurity: (1) personal beliefs, (2) life skills, and (3) the university. The results of this study contribute to the literature focused on food insecurity prevalence in college students and presents insight from the college student perspective. Findings may support the development of relevant interventions that are congruent with students' needs, enhancing resource utilization to increase food security status among college students.

l-Carnitine therapy improves right heart dysfunction through Cpt1-dependent fatty acid oxidation.

Pulmonary arterial hypertension (PAH) is a fatal vasculopathy that ultimately leads to elevated pulmonary pressure and death by right ventricular (RV) failure, which occurs in part due to decreased fatty acid oxidation and cytotoxic lipid accumulation. In this study, we tested the hypothesis that decreased fatty acid oxidation and increased lipid accumulation in the failing RV is driven, in part, by a relative carnitine deficiency. We then tested whether supplementation of l-carnitine can reverse lipotoxic RV failure through augmentation of fatty acid oxidation. In vivo in transgenic mice harboring a human BMPR2 mutation, l-carnitine supplementation reversed RV failure by increasing RV cardiac output, improving RV ejection fraction, and decreasing RV lipid accumulation through increased PPARγ expression and augmented fatty acid oxidation of long chain fatty acids. These findings were confirmed in a second model of pulmonary artery banding-induced RV dysfunction. In vitro, l-carnitine supplementation selectively increased fatty acid oxidation in mitochondria and decreased lipid accumulation through a Cpt1-dependent pathway. l-Carnitine supplementation improves right ventricular contractility in the stressed RV through augmentation of fatty acid oxidation and decreases lipid accumulation. Correction of carnitine deficiency through l-carnitine supplementation in PAH may reverse RV failure.

Food Insecurity and Depression among US Adults: NHANES 2005-2016.

A growing body of evidence suggests that food insecurity is associated with adverse mental health outcomes such as depression and anxiety. In this study, the relationship between food insecurity and depression was examined using data from the 2005−2016 National Health and Nutrition Examination Survey (NHANES). Food insecurity was assessed with the 18-item United States Food Security Survey Module with zero affirmative responses indicating high food security, 1 or 2 affirmative responses indicating marginal food security, and ≥3 affirmative responses indicating food insecurity. Depression was assessed with the Patient Health Questionnaire-9 with scores ≥10 indicating depression. Data were analyzed from 28,448 adult participants aged 20 or older. Food insecurity was present in 19.2% of the sample population (n = 5452). Food security status was significantly associated with gender, race, education level, marital status, smoking status, and BMI (Rao-Scott chi-square, p < 0.05). Fully food secure and very low food security adults experienced depression at a rate of 5.1% and 25.8%, respectively (Rao-Scott chi-square, p < 0.0001). Participants with very low food security had a significantly greater odds of depression than food secure adults, OR = 3.50 (95% CI: 2.98, 4.12). These findings suggest that food insecurity is a significant risk factors for depression in US adults over 20 years of age. To address this issue in our citizenry, police initiatives and public health interventions addressing both food access and mental health should be prioritized.

COVID-19 Infectious Disease Prevention and Mitigation Practices by Chiropractic Physicians and Licensed Massage Therapists in Mississippi: A Needs Assessment to Inform Health Education and Promotion.

Objective: The purpose of this study was to assess self-reported infection prevention processes and their effect on businesses of chiropractic doctors (DCs) and licensed massage therapists (LMTs) in Mississippi during the COVID-19 pandemic. Methods: We developed a survey that was electronically delivered to all licensed DCs and LMTs in Mississippi between August and September 2020. Assessments were made using Qualtrics software, with data management and subsequent analysis including Pearson's χ2 test. Results: Responses were based on 32 of 323 DCs and 69 of 934 LMTs that were still seeing patients through the pandemic (n = 101, response rate 8%). The DC and LMT practitioners (94%) used treatment table and/or surface sanitizing (91.8%) and hand washing and/or sanitizing (89.8%) between all patients. Female practitioners reported practicing handwashing for at least 20 seconds, whereas male practitioners reported practicing handwashing for at least 15 seconds (P < .001). DCs were more likely to report using gloves for personal protective equipment, and LMTs were more likely to report using face masks (P < .001). Other COVID-19 procedures included limiting practice to acute care (82.5%), checking all patient temperatures (62.9%), sign-in and wait in the car (53.2% LMT vs 6.5% DC, P < .001), and prohibiting all nonpatient visitors (87.7% LMTs vs 9.4% DCs, P < .001). DCs (96.9%) and LMTs (89.9%) reported making referrals for COVID-19 testing or treatment when indicated. LMTs (82.3%) reported seeing fewer patients (P = .03), and older practitioners reported the most economic impact (P = .003) by the pandemic. Patient concerns and LMTs needing more time to perform infection control (P = .04) were reasons cited by practitioners for the reduced number of visits seen. Conclusion: Most respondents had moderate to high compliance with guidelines on recommended infection prevention processes during fall 2020 of the COVID-19 pandemic. This assessment of compliance may be used to help guide future health education and promotion research of disease prevention and mitigation as well as physical and economic burdens faced by DCs and LMTs in Mississippi during a pandemic.

Evaluation of intravitreal topotecan dose levels, toxicity and efficacy for retinoblastoma vitreous seeds: a preclinical and clinical study.

BACKGROUND: Current melphalan-based intravitreal regimens for retinoblastoma (RB) vitreous seeds cause retinal toxicity. We assessed the efficacy and toxicity of topotecan monotherapy compared with melphalan in our rabbit model and patient cohort. METHODS: Rabbit experiments: empiric pharmacokinetics were determined following topotecan injection. For topotecan (15 µg or 30 µg), melphalan (12.5 µg) or saline, toxicity was evaluated by serial electroretinography (ERG) and histopathology, and efficacy against vitreous seed xenografts was measured by tumour cell reduction and apoptosis induction. PATIENTS: retrospective cohort study of 235 patients receiving 990 intravitreal injections of topotecan or melphalan. RESULTS: Intravitreal topotecan 30 µg (equals 60 µg in humans) achieved the IC90 across the rabbit vitreous. Three weekly topotecan injections (either 15 µg or 30 µg) caused no retinal toxicity in rabbits, whereas melphalan 12.5 µg (equals 25 µg in humans) reduced ERG amplitudes 42%-79%. Intravitreal topotecan 15 µg was equally effective to melphalan to treat WERI-Rb1 cell xenografts in rabbits (96% reduction for topotecan vs saline (p=0.004), 88% reduction for melphalan vs saline (p=0.004), topotecan vs melphalan, p=0.15). In our clinical study, patients received 881 monotherapy injections (48 topotecan, 833 melphalan). Patients receiving 20 µg or 30 µg topotecan demonstrated no significant ERG reductions; melphalan caused ERG reductions of 7.6 µV for every injection of 25 µg (p=0.03) or 30 µg (p<0.001). Most patients treated with intravitreal topotecan also received intravitreal melphalan at some point during their treatment course. Among those eyes treated exclusively with topotecan monotherapy, all eyes were salvaged. CONCLUSIONS: Taken together, these experiments suggest that intravitreal topotecan monotherapy for the treatment of RB vitreous seeds is non-toxic and effective.

Efficacy, Toxicity, and Pharmacokinetics of Intra-Arterial Chemotherapy Versus Intravenous Chemotherapy for Retinoblastoma in Animal Models and Patients.

Purpose: Through controlled comparative rabbit experiments and parallel patient studies, our purpose was to understand mechanisms underlying differences in efficacy and toxicity between intra-arterial chemotherapy (IAC) and intravenous chemotherapy (IVC). Methods: In rabbits, ocular tissue drug levels were measured following IAC and IVC. Retinal toxicity was assessed using electroretinography, fluorescein angiography, optical coherence tomography (OCT) and OCT angiography. Efficacy to eradicate retinoblastoma orthotopic xenografts was compared. In IAC and IVC patients, we measured blood carboplatin pharmacokinetics and compared efficacy and toxicity. Results: In rabbits receiving IAC, maximum carboplatin levels were 134 times greater in retina (P = 0.01) and 411 times greater in vitreous (P < 0.001), and total carboplatin (area under the curve) was 123 times greater in retina (P = 0.005) and 131 times greater in vitreous (P = 0.02) compared with IVC. Melphalan levels were 12 times greater (P = 0.003) in retina and 26 times greater in vitreous (P < 0.001) for IAC. Blood levels were not different. IAC melphalan (but not IV melphalan or IV carboplatin, etoposide, and vincristine) caused widespread apoptosis in retinoblastoma xenografts but no functional retinal toxicity or cytopenias. In patients, blood levels following IVC were greater (P < 0.001) but, when adjusted for treatment dose, were not statistically different. Per treatment cycle in patients, IVC caused higher rates of anemia (0.32 ± 0.29 vs. 0.01 ± 0.04; P = 0.0086), thrombocytopenia (0.5 ± 0.42 vs. 0.0 ± 0.0; P = 0.0042), and neutropenia (0.58 ± 0.3 vs. 0.31 ± 0.25; P = 0.032) but lower treatment success rates (P = 0.0017). Conclusions: The greater efficacy and lower systemic toxicity with IAC appear to be attributable to the greater ocular-to-systemic drug concentration ratio compared with IVC. Translational Relevance: Provides an overarching hypothesis for a mechanism of efficacy/toxicity to guide future drug development.

[Electrohysterography, a promising alternative for uterine monitoring: 5 years later]. / Elektrohysterografie veelbelovend alternatief voor weeënregistratie.

Electrohysterography monitors the electrical activity of the uterine muscle through electrodes on the maternal abdominal wall. It is a non-invasive method for uterine contraction monitoring and has a strong correlation with the invasive intra-uterine pressure catheter. A prospective validation study showed a significant higher sensitivity of electrohysterography compared to external tocodynamometry for uterine contraction detection (p-value < 0.001). Moreover, the sensitivity of electrohysterography appears to be less affected by maternal obesity compared to external tocodynamometry. A clinical pilotstudy comparing electrohysterography and external tocodynamometry during labor, showed no negative effect of electrohysterography on labor outcomes. Recently, technical improvements have been made and electrohysterography has become available in an adhesive electrode patch together with fetal and maternal electrocardiography. Therefore, we expect a successful implementation of electrohysterography in the near future.

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Geographical and linguistic structure in the people of Kenya demonstrated using 21 autosomal STRs.

Kenya is a diverse and populous nation that employs DNA evidence in its criminal justice system, and therefore requires reliable information on autosomal STR allele frequency variation across the country and in its many ethnic groups. In order to provide reference data and to assess population structure, we analysed the 21 autosomal STRs in the GlobalFiler multiplex in a sample of 510 indigenous Kenyans representing the country's eight former provinces, 43 of its 47 counties, three main linguistic families and all 29 ethnic groups that each comprise >0.5% of the 2019 census population. The indigenous population originated from successive migrations of Cushitic, Nilotic and Bantu speaking groups who settled in regions that suited their distinctive sustenance lifestyles. Consequently, they now largely reside in a patchwork of communities with strong associations with particular counties and provinces and limited degrees of inter-group marriage, as shown by DNA donors' ancestry details. We found significant genetic differentiation between the three Nilotic language sub-families, with Western Nilotes (the Luo ethnic group) showing greater similarity to the Bantu than the Southern and Eastern Nilotes which themselves showed closer affinity to the Cushitic speakers. This concurs with previous genetic, linguistic and social studies. Comparisons with other African populations also showed that linguistic affiliation is a stronger factor than geography. This study revealed several rare off-ladder alleles whose structure was determined by Sanger sequencing. Among the unusual features that could affect profile interpretation were a deletion of Amelogenin Y but no other forensic marker (autosomal or Y-chromosomal), a triallelic pattern at TPOX and an extremely short SE33 allele falling within the expected size range of D7S820. Compared with the currently implemented Identifiler multiplex, Random Match Probabilities decreased from 6.4 × 10-19 to 3.9 × 10-27. The appreciation of local population structure provided by the geographically and ethnically representative sample in this study highlights the structured genetic landscape of Kenya.

Gestational weight gain in 4 low- and middle-income countries and associations with birth outcomes: a secondary analysis of the Women First Trial.

BACKGROUND: Adequate gestational weight gain (GWG) is essential for healthy fetal growth. However, in low- and middle-income countries, where malnutrition is prevalent, little information is available about GWG and how it might be modified by nutritional status and interventions. OBJECTIVE: We describe GWG and its associations with fetal growth and birth outcomes. We also examined the extent to which prepregnancy BMI, and preconception and early weight gain modify GWG, and its effects on fetal growth. METHODS: This was a secondary analysis of the Women First Trial, including 2331 women within the Democratic Republic of Congo (DRC), Guatemala, India, and Pakistan, evaluating weight gain from enrollment to ∼12 weeks of gestation and GWG velocity (kg/wk) between ∼12 and 32 weeks of gestation. Adequacy of GWG velocity was compared with 2009 Institute of Medicine recommendations, according to maternal BMI. Early weight gain (EWG), GWG velocity, and adequacy of GWG were related to birth outcomes using linear and Poisson models. RESULTS: GWG velocity (mean ± SD) varied by site: 0.22 ± 0.15 kg/wk in DRC, 0.30 ± 0.23 in Pakistan, 0.31 ± 0.14 in Guatemala, and 0.39 ± 0.13 in India, (P <0.0001). An increase of 0.1 kg/wk in maternal GWG was associated with a 0.13 cm (95% CI: 0.07, 0.18, P <0.001) increase in birth length and a 0.032 kg (0.022, 0.042, P <0.001) increase in birth weight. Compared to women with inadequate GWG, women who had adequate GWG delivered newborns with a higher mean length and weight: 47.98 ± 2.04 cm compared with 47.40 ± 2.17 cm (P <0.001) and 2.864 ± 0.425 kg compared with 2.764 ± 0.418 kg (P <0.001). Baseline BMI, EWG, and GWG were all associated with birth length and weight. CONCLUSIONS: These results underscore the importance of adequate maternal nutrition both before and during pregnancy as a potentially modifiable factor to improve fetal growth.

COVID-19 Case Investigation and Contact Tracing Efforts from Health Departments - United States, June 25-July 24, 2020.

Case investigation and contact tracing are core public health tools used to interrupt transmission of pathogens, including SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19); timeliness is critical to effectiveness (1,2). In May 2020, CDC funded* 64 state, local, and territorial health departments† to support COVID-19 response activities. As part of the monitoring process, case investigation and contact tracing metrics for June 25-July 24, 2020, were submitted to CDC by 62 health departments. Descriptive analyses of case investigation and contact tracing load, timeliness, and yield (i.e., the number of contacts elicited divided by the number of patients prioritized for interview) were performed. A median of 57% of patients were interviewed within 24 hours of report of the case to a health department (interquartile range [IQR] = 27%-82%); a median of 1.15 contacts were identified per patient prioritized for interview§ (IQR = 0.62-1.76), and a median of 55% of contacts were notified within 24 hours of identification by a patient (IQR = 32%-79%). With higher caseloads, the percentage of patients interviewed within 24 hours of case report was lower (Spearman coefficient = -0.68), and the number of contacts identified per patient prioritized for interview also decreased (Spearman coefficient = -0.60). The capacity to conduct timely contact tracing varied among health departments, largely driven by investigators' caseloads. Incomplete identification of contacts affects the ability to reduce transmission of SARS-CoV-2. Enhanced staffing capacity and ability and improved community engagement could lead to more timely interviews and identification of more contacts.

Therapeutic Use of Acetaminophen and Light to Moderate Alcohol: Are There Early Disparate Risks for Kidney Disease?

Introduction: Acetaminophen (APAP) is the most common medication taken in the United States. Using the 2003-2004 U.S. National Health and Nutrition Examination Survey (NHANES), the authors previously explored and reported the relationship of concomitant consumption of light to moderate alcohol (LMA) and therapeutic doses of APAP to early risk of renal dysfunction among adults in the United States. Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and LMA by adjusting for hypertension, diabetes, and obesity. In this study the authors explored further on of potential disparities in the above relationship in the population. The relationship was verified with the 2009 Chronic Kidney Disease-Epidemiology Collaboration creatine-based estimated Glomerular Filtration Rate (GFR). Methods: Subgroup logistic regression analyses to assess disparities based on gender, race, age, education, and income were performed for renal dysfunction measured in terms of serum creatinine (SCr) directly as well as self-report using NHANES 2003-2004 data. Results: Early stage renal dysfunction, as determined by self-reports, and SCr and GFR values may occur among those who concomitantly ingested therapeutic doses of APAP and described alcohol use when compared to those who do not. Risks were more profound among females, particularly in minority racial groups, below legal drinking age of 21, and with household income below $25K. Conclusion: Potential risks for renal dysfunction are apparent in a disparate manner resulting in possible health inequity. Further research could increase the sample size of minority groups and specifically assess for effect modifiers that NHANES does not include for assessment.

Urinary metabolites and risk of coronary heart disease: A prospective investigation among urban Chinese adults.

BACKGROUND AND AIMS: Studies have linked several metabolites to the risk of coronary heart disease (CHD) among Western populations, but prospective studies among Asian populations on the metabolite-CHD association remain limited. METHODS AND RESULTS: We evaluated the association of urinary metabolites with CHD risk among Chinese adults in a nested case-control study of 275 incident cases and 275 matched controls (127 pairs of men and 148 pairs of women). Fifty metabolites were measured by a predefined metabolomics panel and adjusted using urinary creatinine. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). After adjusting for traditional CHD risk factors, urinary tryptophan showed a positive association with incident CHD: OR (95% CI) for the highest vs. lowest quartiles was 2.02 (1.15-3.56) among all study participants (p-trend = 0.02). The tryptophan-CHD association was more evident among individuals with dyslipidemia than among those without the condition (OR [95% CI] for the highest vs. lowest quartiles = 3.90 [1.86-8.19] and 0.74 [0.26-2.06], respectively; p-interaction<0.01). Other metabolites did not show significant associations with CHD risk among all study participants. However, a positive association of methionine with CHD risk was observed only among women (OR [95% CI] for the highest vs. lowest quartiles = 2.77 [1.17-6.58]; p-interaction = 0.03), and an inverse association of inosine with CHD risk was observed only among men (OR [95% CI] for the highest vs. lowest quartiles = 0.29 [0.11-0.81]; p-interaction = 0.04). CONCLUSION: Elevated urinary tryptophan may be related to CHD risk among Chinese adults, especially for those with dyslipidemia.

Provision of STD Services in Community Settings After the Loss and Return of State Funding to Support Service Provision: Observations From Select Providers in Massachusetts, 2010 and 2013.

CONTEXT: In 2008, the $1.2 M sexually transmitted disease (STD) services line item supporting STD clinical services by the Massachusetts Department of Public Health was eliminated, forcing the cessation of all state-supported STD service delivery. OBJECTIVE: To determine the impact on community provision of STD services after the elimination of state funds supporting STD service provision. DESIGN AND SETTING: Rapid ethnographic assessments were conducted in May 2010 and September 2013 to better understand the impact of budget cuts on STD services in Massachusetts. The rapid ethnographic assessment teams identified key informants through Massachusetts's STD and human immunodeficiency virus programs. PARTICIPANTS: Fifty providers/clinic administrators in 19 sites (15 unique) participated in a semistructured interview (community health centers [n = 10; 53%], hospitals [n = 4; 21%], and other clinical settings [n = 5; 26%]). RESULTS: Results clustered under 3 themes: financial stability of agencies/clinics, the role insurance played in the provision of STD care, and perceived clinic capacity to offer appropriate STD services. Clinics faced hard choices about whether to provide care to patients or refer elsewhere patients who were unable or unwilling to use insurance. Clinics that decided to see patients regardless of ability to pay often found themselves absorbing costs that were then passed along to their parent agency; the difficulty and financial strain incurred by a clinic's parent agency by providing STD services without support by state grant dollars emerged as a primary concern. Meeting patient demand with staff with appropriate training and expertise remained a concern. CONCLUSIONS: Provision of public health by private health care providers may increase concern among some community provision sites about the sustainability of service provision absent external funds, either from the state or from the third-party billing. Resource constraints may be felt across clinic operations. Provision of public health in the for-profit health system involves close consideration of resources, including those: leveraged, used to provide uncompensated care, or available for collection through third-party billing.

Urinary Levels of Trimethylamine-N-Oxide and Incident Coronary Heart Disease: A Prospective Investigation Among Urban Chinese Adults.

Background Trimethylamine-N-oxide ( TMAO ), a diet-derived, gut microbial-host cometabolite, has been associated with adverse cardiovascular outcomes in patient populations; however, evidence is lacking from prospective studies conducted in general populations and non-Western populations. Methods and Results We evaluated urinary levels of TMAO and its precursor metabolites (ie, choline, betaine, and carnitine) in relation to risk of coronary heart disease ( CHD ) among Chinese adults in a nested case-control study, including 275 participants with incident CHD and 275 individually matched controls. We found that urinary TMAO , but not its precursors, was associated with risk of CHD . The odds ratio for the highest versus lowest quartiles of TMAO was 1.91 (95% CI, 1.08-3.35; Ptrend=0.008) after adjusting for CHD risk factors including obesity, diet, lifestyle, and metabolic diseases and 1.75 (95% CI, 0.96-3.18; Ptrend=0.03) after further adjusting for potential confounders or mediators including central obesity, dyslipidemia, inflammation, and intake of seafood and deep-fried meat or fish, which were associated with TMAO level in this study. The odds ratio per standard deviation increase in log- TMAO was 1.30 (95% CI, 1.03-1.63) in the fully adjusted model. A history of diabetes mellitus modified the TMAO - CHD association. A high TMAO level (greater than or equal to versus lower than the median) was associated with odds ratios of 6.21 (95% CI, 1.64-23.6) and 1.56 (95% CI, 1.00-2.43), respectively, among diabetic and nondiabetic participants ( Pinteraction=0.02). Diabetes mellitus status also modified the associations of choline, betaine, and carnitine with risk of CHD ; significant positive associations were found among diabetic participants, but null associations were noted among total and nondiabetic participants. Conclusions Our study suggests that TMAO may accelerate the development of CHD , highlighting the importance of diet-gut microbiota-host interplay in cardiometabolic health.

Light to moderate drinking and therapeutic doses of acetaminophen: An assessment of risks for renal dysfunction.

This study investigated the potential effect of therapeutic doses of acetaminophen (APAP) in combination with light-moderate amounts of alcohol on kidney functions controlling for factors such as hypertension, diabetes and obesity that may predispose the kidney to APAP and/or alcohol toxicity. Secondary analysis of the 2003-2004 National Health and Nutrition Examination Survey data was performed using SAS 9.4. Odds ratios (OR) and 95% confidence intervals (CI) comparing the likelihood that individuals who ingested therapeutic doses of APAP and light-moderate amount of alcohol, compared to those who did not, would have kidney dysfunction were generated from multiple logistics regression models by further controlling for potential predisposing factors namely hypertension, diabetes and obesity. Kidney dysfunction was defined based on self-reports and laboratory examination of serum creatinine (SCr), blood urea nitrogen (BUN), glomerular filtration rate (GFR) and albumin creatinine ratio (ABCR). Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and light-moderate amount of alcohol [OR(95% CI) = 1.64(1.28-2.10) self-report, 2.18(1.81-2.63) SCr, 4.60(3.03-7.00) BUN, 3.14(2.42-4.07) GFR, and 1.71(1.36-2.14) ALBCR)] even after adjusting for hypertension, diabetes and obesity [Adjusted OR (95% CI) = 1.78 (1.22-2.58) self-report, 2.05 (1.07-3.92) GFR]. The toxic effects of APAP and alcohol on the kidney were hypothesized. The threshold doses at which these effects begin to occur are unknown. The findings of this study suggest that even therapeutic doses of APAP and light-moderate amount of alcohol could be health problematic if consumed concomitantly.