Social Determinants of Health Among Persons Living with HIV Impact Important Health Outcomes in Michigan.

Addressing social determinants of health (SDOH) is a national priority for improving quality of life and addressing obstacles to accessing care for people living with HIV (PLWH). Utilizing the Oregon Social Determinants of HIV Health Index and CDC's Medical Monitoring Project, we examined the association between social determinants of health and various HIV clinical outcomes and quality of life indicators, including stigma and mental health, for people living with HIV in Michigan. We calculated estimates of SDOHs, clinical outcomes, stigma, and mental health using weighted percentages and prevalence ratios with predicted marginal means, adjusting for age, race/ethnicity, and gender/sexual orientation. Compared with PLWH reporting 0-1 SDOH challenges, those reporting ≥ 4 SDOH challenges were more likely to miss ≥ 1 HIV care appointment (aPR: 2.57, 95% CI 1.70-3.88), have symptoms of depression (aPR: 4.03, 95% CI 2.68-6.05) and anxiety (aPR: 3.55, 95% CI 2.25-5.61), and less likely to have 100% antiretroviral therapy (ART) adherence (aPR: 0.62, 95% CI 0.50-0.78) and sustained viral suppression (aPR: 0.77, 95% CI 0.65-0.90). Stigma scores were highest for those reporting ≥ 4 SDOH challenges. Our findings indicate significant associations between SDOH and adverse HIV health and quality of life outcomes which can inform and direct federal, state, and local strategies aimed at improving these outcomes. Linking PLWH to social support services and providing mental health screening and care services could benefit their mental and emotional well-being, leading to better healthcare outcomes.

An Inpatient Geriatrics Program with a Focus on Any Type of Cognitive Impairment Reduces Mortality.

BACKGROUND: No matter what type of cognitive impairment an older hospitalized patient has, the risk of mortality is increased. OBJECTIVES: To describe a hospital-based geriatrics program with a focus on any type of cognitive impairment and to determine whether this program was associated with reduced mortality over time. DESIGN, PARTICIPANTS AND SETTING: Retrospective chart review of all patients age 70+ admitted during a 3-year period (2017-2019, N=20,401), to a 500-bed community-based hospital (Level 1 Trauma Center and Stroke Center). INTERVENTION: A multicomponent geriatrics program was developed and implemented throughout 2018 and included: geriatric consultation, data collection, review of the data with hospital leaders, a geriatrics task force, clinician education and a Delirium Unit. MAIN OUTCOMES AND MEASURES: Monthly mortality rates for patients with and without cognitive impairment over the 3-year period. To control for other variables associated with mortality, pre-post implementation analyses were performed (2017 versus 2019). RESULTS: A linear regression analysis showed a significant downward trend in mortality over time for patients with cognitive impairment [R2=0.4, P<.0001, (correlation coefficient -0.6, 95% CI, -0.8 to -0.4)] but not among patients without cognitive impairment [R2=0.0, P=0.829, (correlation coefficient 0.0, 95% CI, -0.3 to 0.3)]. When controlling for other variables, there was still a decrease in mortality risk among patients with cognitive impairment. CONCLUSION: Although there are limitations to this study, a multicomponent geriatrics program with an emphasis on any type of cognitive impairment, may be associated with improved mortality.

HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities.

Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.

Toward two-dimensional photon echo spectroscopy with 200 nm laser pulses.

Knowledge of elementary relaxation processes in small molecules and proteins motivates the extension of two-dimensional photon echo (2DPE) spectroscopy further into the UV wavelength range. Here, we describe our development of a four-wave mixing spectrometer employing 200 nm laser pulses. Filamentation of laser beams in both air and argon yields 200 nm pulses with 60 fs durations. These 200 nm pulses are used to probe dynamics initiated at 267 nm in transient grating and 2DPE experiments conducted on adenosine. This study demonstrates that these femtosecond spectroscopies may indeed be carried out at the shortest wavelengths feasible in aqueous solutions.

Interplay between vibrational energy transfer and excited state deactivation in DNA components.

Femtosecond laser spectroscopies are used to examine a thymine family of systems chosen to expose the interplay between excited state deactivation and two distinct vibrational energy transfer (VET) pathways: (i) VET from the base to the deoxyribose ring; (ii) VET between neighboring units in a dinucleotide. We find that relaxation in the ground electronic state accelerates markedly as the molecular sizes increase from the nucleobase to the dinucleotide. This behavior directly reflects growth in the density of vibrational quantum states on the substituent of the base. Excited state lifetimes are studied at temperatures ranging from 100 to 300 K to characterize the thermal fluctuations that connect the Franck-Condon geometries and the conical intersections leading back to the ground state. An Arrhenius analysis yields an approximate excited state energy barrier of 13 meV in the thymine dinucleotide. In addition, we find that the transfer of vibrational energy from the base to the substituent suppresses thermal fluctuations across this energy barrier. The possibility that the solvent viscosity imposes friction on the reaction coordinate is examined by comparing thymine and adenine systems. Experiments suggest that the solvent viscosity has little effect on barrier crossing dynamics in thymine because the conical intersection is accessed through relatively small out-of-plane atomic displacements. Overall, we conclude that the transfer of vibrational quanta from thymine to the deoxyribose ring couples significantly to the internal conversion rate, whereas the neighboring unit in the dinucleotide serves as a secondary heat bath. In natural DNA, it follows that (local) thermal fluctuations in the geometries of subunits involving the base and deoxyribose ring are most important to this subpicosecond relaxation process.

Two-Dimensional Electronic Spectroscopy in the Ultraviolet Wavelength Range.

Coherent two-dimensional (2D) spectroscopies conducted at visible and infrared wavelengths are having a transformative impact on the understanding of numerous processes in condensed phases. The extension of 2D spectroscopy to the ultraviolet spectral range (2DUV) must contend with several challenges, including the attainment of adequate laser bandwidth, interferometric phase stability, and the suppression of undesired nonlinearities in the sample medium. Solutions to these problems are motivated by the study of a wide range of biological systems whose lowest-frequency electronic resonances are found in the UV. The development of 2DUV spectroscopy also makes possible the attainment of new insights into elementary chemical reaction dynamics (e.g., electrocyclic ring opening in cycloalkenes). Substantial progress has been made in both the implementation and application of 2DUV spectroscopy in the past several years. In this Perspective, we discuss 2DUV methodology, review recent applications, and speculate on what the future will hold.

Communication: uncovering molecule-TiO2 interactions with nonlinear spectroscopy.

Femtosecond transient grating experiments are used to investigate electronic structures and transport mechanisms in dye-sensitized nanocrystalline TiO(2) films. This study examines two molecular sensitizers spanning the weak (a phosphonated Ruthenium complex) and strong (catechol) molecule-TiO(2) coupling regimes. It is shown that strong molecule-TiO(2) interactions give rise to photoinduced vibrational coherences at the interface between species. We suggest that the amplitudes of these coherences reflect the molecule-TiO(2) coupling strength and signify the delocalization of excited state wavefunctions.

Influence of temperature on thymine-to-solvent vibrational energy transfer.

At the instant following the non-radiative deactivation of its ππ* electronic state, the vibrational modes of thymine possess a highly non-equilibrium distribution of excitation quanta (i.e., >4 eV in excess energy). Equilibrium is re-established through rapid (5 ps) vibrational energy transfer to the surrounding solvent. The mechanisms behind such vibrational cooling (VC) processes are examined here using femtosecond transient grating and two-dimensional photon echo spectroscopies conducted at 100 K and 300 K in a mixture of methanol and water. Remarkably, we find that this variation in temperature has essentially no impact on the VC kinetics. Together the experiments and a theoretical model suggest three possible mechanisms consistent with this behavior: (i) vibrational energy transfer from the solute to solvent initiates (directly) in intramolecular modes of the solute with frequencies >300 cm(-1); (ii) the relaxation induced increase in the temperature of the environment reduces the sensitivity of VC to the temperature of the equilibrium system; (iii) the time scale of solvent motion approaches 0.1 ps even at 100 K. Mechanism (i) deserves strong consideration because it is consistent with the conclusions drawn in earlier studies of isotope effects on VC in hydrogen bonding solvents. Our model calculations suggest that mechanism (ii) also plays a significant role under the present experimental conditions. Mechanism (iii) is ruled out on the basis of long-lived correlations evident in the photon echo line shapes at 100 K. These insights into photoinduced relaxation processes in thymine are made possible by our recent extension of interferometric transient grating and photon echo spectroscopies to the mid UV spectral region.

Probing ultrafast dynamics in adenine with mid-UV four-wave mixing spectroscopies.

Heterodyne-detected transient grating (TG) and two-dimensional photon echo (2DPE) spectroscopies are extended to the mid-UV spectral range in this investigation of photoinduced relaxation processes of adenine in aqueous solution. These experiments are the first to combine a new method for generating 25 fs laser pulses (at 263 nm) with the passive phase stability afforded by diffractive optics-based interferometry. We establish a set of conditions (e.g., laser power density, solute concentration) appropriate for the study of dynamics involving the neutral solute. Undesired solute photoionization is shown to take hold at higher peak powers of the laser pulses. Signatures of internal conversion and vibrational cooling dynamics are examined using TG measurements with signal-to-noise ratios as high as 350 at short delay times. In addition, 2DPE line shapes reveal correlations between excitation and emission frequencies in adenine, which reflect electronic and nuclear relaxation processes associated with particular tautomers. Overall, this study demonstrates the feasibility of techniques that will hold many advantages for the study of biomolecules whose lowest-energy electronic resonances are found in the mid-UV (e.g., DNA bases, amino acids).

Influence of vibronic coupling on band structure and exciton self-trapping in α-perylene.

Exciton sizes influence transport processes and spectroscopic phenomena in molecular aggregates and crystals. Thermally driven nuclear motion generally localizes electronic states in equilibrium systems. Exciton sizes also undergo dynamic changes caused by nonequilibrium relaxation in the lattice structure local to the photoexcitations (i.e., self-trapping). The α-phase of crystalline perylene is particularly well-suited for fundamental studies of exciton self-trapping mechanisms. It is generally agreed that a subpicosecond self-trapping process in α-perylene localizes photoexcited excitons onto pairs of closely spaced molecules (i.e., dimers), which then relax through excimer emission. Here, electronic relaxation dynamics in α-perylene single crystals are investigated using a variety of nonlinear optical spectroscopies in conjunction with a Frenkel exciton model. Linear absorption and photon echo spectroscopies suggest that excitons are delocalized over less than four unit cells (16 molecules) at 78 K prior to self-trapping. Stimulated Raman spectroscopies conducted on and off electronic resonance reveal significant vibronic coupling in a mode at 104 cm(-1), which corresponds to the displacement between perylene molecules comprising a dimer. Strong vibronic coupling in this mode suggests that motion along the interdimer axis is instrumental in driving the self-trapping process. The results are discussed in the context of our recent study of tetracene and rubrene single crystals in which similar experiments and models were employed.

Assaultive eye injury and enucleation.

An especially dangerous behavior observed in some forensic and security hospital populations is assaultive eye gouging. Although a number of case reports in the literature concern auto-enucleation, gouging out the eyes of another is virtually unmentioned. We present a case series of eye gougers (n = 10) gathered through clinical contributions from several forensic populations in the United States and Russia. Four subjects were psychotic during the eye-gouging episode, one was only mentally retarded, and five, who were neither psychotic nor retarded, deliberately injured victims' eyes during acts of extreme sexual violence.

Comparative mechanical properties of spinal cable and wire fixation systems.

STUDY DESIGN: Surgical spinal cable and wire fixation systems were tested mechanically using standardized methodologies. OBJECTIVES: To compare the relative mechanical properties and biomechanical performances of the different commercially available spinal wire and cable fixation devices, and to provide information that will help in selecting different cables for different clinical applications. SUMMARY OF BACKGROUND DATA: Spinal cables have become extensively used for spinal fixation; however, there are few published accounts delineating their mechanical properties. No reports have compared the relative properties of different cable systems. METHODS: Nine spinal cable and wire fixation systems were mechanically tested to compare their static tensile strength, stiffness, fatigue strength, creep, conformance, and abrasion properties. Titanium and stainless steel Codman cable, Danek cable, and AcroMed cable, polyethylene Smith & Nephew cable, and 20- and 22-gauge stainless steel monofilament Ethicon wire were tested using identical methodologies. The cable or wire was connected into loops with methods that simulated in vivo clinical applications. RESULTS: Under static tensile testing, titanium cables had 70% to 90% of the ultimate tensile strength of the comparable steel cables; the different cables were 100% to 600% stronger than monofilament wire; the ultimate strength of the polyethylene cable was similar to that of the strongest available steel cable. Fatigue testing delineated important differences among the different materials. For a given manufacturer, titanium cables were always more susceptible to fatigue than stainless steel cables of comparable diameter. Polyethylene cable withstood cyclical loading without breaking better than all of the metal cables and wires. The mechanisms of failure differed substantially among materials and types of tests. Polyethylene cables exhibited significant stretching or "creep" at loads that were much lower than the static failure loads. In contrast, no wire cable demonstrated creep. Monofilament wires demonstrated little creep. Polyethylene cables failed by elongating and loosening; wire cables failed by breaking. Monofilament wire and cables conformed least to a solid surface; polyethylene cable conformed the most and flattened out against solid surfaces. Abrasion properties depended on the surface characteristics of the implants. Polyethylene cable was abraded by (and eventually failed by wearing against) the simulated bone, a result that did not occur with any metal cables or wires. The steel and titanium cables and the monofilament wires all had an ability to abrade through simulated bone. CONCLUSIONS: Titanium, steel, and polyethylene cable systems all behave substantially differently mechanically compared with monofilament wire. The relative advantages and disadvantages of each particular products should be considered when selecting an implant for a specific clinical use.

An apparatus for applying pure nonconstraining moments to spine segments in vitro.

STUDY DESIGN: This article reports on the design and use of a new apparatus for creating and monitoring pure, relatively nonconstraining moments to induce flexion/extension, lateral bending, and axial rotation in cadaveric spine segments of two or more vertebrae. OBJECTIVE: The apparatus was designed to take advantage of the precision and control available in a servo-hydraulic testing frame to efficiently create and monitor testing moments. SUMMARY OF BACKGROUND DATA: Other laboratories have reported methods of flexibility testing that also use cables and pulleys. However, instead of loading the cables and pulleys using a mechanical testing frame, previous systems have used pneumatic actuators or dead weights. METHODS: Force from a uniaxial mechanical testing frame is converted to torque applied to the specimen through a system of cables and pulleys. The cable orientation is monitored to ensure that pure moments are created. Applied moments are recorded using one or two load cells. RESULTS: Sketches of the apparatus are presented and its operation is described. CONCLUSION: Because the materials required to build this apparatus are inexpensive and the equipment needed for its operation is common in mechanical testing labs, this design may be useful for researchers interested in beginning in vitro spine flexibility testing with minimal expenditure.

Biomechanical effects of transoral odontoidectomy.

The acute biomechanical effects of transoral odontoidectomy were studied by using qualitative and quantitative methods to assess atlantoaxial motion. In vitro biomechanical testing was performed on the upper cervical spines of eight baboon and five human cadaveric specimens. Using an unconstrained testing apparatus, we performed a flexibility method of testing. Physiological range loading was applied to atlantoaxial specimens, and three-dimensional motion was analyzed with stereophotogrammetry. Force-deformation relationships were delineated in intact specimens and again after surgical removal of the anterior C1 arch, odontoid process, and transverse atlantal ligament. We studied the total range of rotational and linear motions, the behavior of the neutral zone and elastic zone, the flexibility coefficients, and the instantaneous axes of rotation during flexion, extension, bilateral lateral bending, and bilateral axial rotation. Odontoidectomy produced several distinct alterations in motion and in force-deformation responses at C1-C2 that were almost identical in the baboon and human specimens. After odontoidectomy, the atlas developed significantly increased translational movements, which were most prominent in the anteroposterior direction. The total angular range of motion increased significantly during flexion, extension, and lateral bending but not during axial rotation. When the total range of motion was altered, the neutral zone was affected selectively and the elastic zone was spared. Surgery produced mobile, widely spread, unconstrained instantaneous axes of rotation that were in a constrained, fixed position in intact specimens. Clinically, transoral odontoidectomy may predispose patients to spinal instability. Even if acute spinal instability is not apparent, the patients may be susceptible to the delayed effects of the surgery because of the altered anatomy and biomechanical responses.

Morphology and kinematics of the baboon upper cervical spine. A model of the atlantoaxial complex.

STUDY DESIGN: Quantitative and qualitative analyses were performed to compare the anatomy and biomechanics of baboon and human upper cervical spines. OBJECTIVES: This study examined the baboon as a potential model for in vivo and in vitro atlantoaxial research. SUMMARY OF BACKGROUND DATA: A variety of animal models have been used for spine research; however, no species have been used for C1-C2 research. Most species have remarkably different C1-C2 morphology compared with that of humans. METHODS: Twenty baboon and seven human normal adult cadaveric upper cervical spines were studied morphologically. C1-C2 motion segments were analyzed biomechanically using a flexibility method of testing with physiologic range, nondestructive loading. Motion and load-deformation relationships were studied during flexion, extension, bilateral lateral bending, and bilateral axial rotation. RESULTS: The bones and ligaments of the baboon and human upper cervical vertebrae have similarly proportioned structures, identical individual components, and similar geometric configurations. The average size of the baboon vertebrae was 50% to 60% of the human specimens. There were several minor anatomical differences. Baboons had more horizontal C2-C3 facet joints and more vertical C1-C2 articular surfaces; the vertebral arteries were encased in a continuous bony canal in C1. Biomechanical testing demonstrated that baboons and humans had similarly proportioned neutral zones and elastic zones. Compared with humans, baboons had a 2 degrees to 9 degrees wider range of motion in all directions. CONCLUSIONS: The baboon and human upper cervical anatomy and biomechanics are similar. The baboon may be useful to study atlantoaxial biomechanics and pathology.

The effects of pedicle screw fit. An in vitro study.

STUDY DESIGN: The effects of pedicle screw size (major diameter and length) on fixation stiffness in osteoporotic and nonosteoporotic vertebrae were evaluated in vitro. METHODS: Lumbar vertebrae were obtained from two fresh frozen human spines. Bone mineral densities were determined using dual energy radiograph absorptiometry, followed by nondestructive mechanical testing of the specimens instrumented with pedicle screws. A loading technique was used that more closely mimics loading of pedicle screws in vivo. RESULTS: Testing revealed that for good quality bone, screw size had a significant effect on fixation stiffness, but the effect of penetration depth depended on pedicle fill, and vice versa. In nonosteoporotic bone, the use of a longer screw increased fixation stiffness if the screw filled up the pedicle by 70% or more. The use of wider screws increased the fixation stiffness if the penetration depth was 80% or more. CONCLUSION: Screw size had little or no effect on fixation stiffness in osteoporotic bone.

Rising violence in ERs cause hospitals to redesign security.

A growing number of problems caused by drugs, alcohol, gang violence and domestic quarrels are spilling over into emergency departments, creating security challenges for the nation's hospitals. In response, facilities are stepping up security measures, including redesigning emergency departments, installing airport-type metal detectors and broadening staff training.

5-Fluorouracil, cyclophosphamide, and vincristine for adenoid cystic carcinoma of the head and neck.

Twenty-one patients with adenoid cystic carcinoma of the head and neck were treated with intravenous boluses of cyclophosphamide and vincristine and 5-day continuous intravenous infusions of 5-fluorouracil (CVF) every 4 weeks. Eight patients received CVF as palliation for recurrent or metastatic disease. A sustained complete response (107+ months) was observed in one patient; one partial response and one mixed response each also were observed. In four patients disease stabilized, and in one disease progressed. Thirteen patients received six courses of CVF in the adjuvant setting after surgery and radiation for either primary or locoregional recurrent disease. Recurrences developed in two of seven patients with primary disease and three of six patients with recurrent disease with a median follow-up 45 months (range, 20-108+). Recurrence rate and time interval to recurrence were comparable to those of well-matched historical controls. Distant metastases have not developed in patients treated with CVF in the adjuvant setting, whereas distant metastases had developed in historical controls within comparable periods of follow-up. Serious toxicities were not encountered in any patient. The authors conclude that CVF is a well-tolerated combination chemotherapy program with activity in adenoid cystic carcinoma of the head and neck. This regimen, however, has not had a major impact in the adjuvant setting in preventing recurrent disease.

Pain in the head and neck cancer patient: changes over treatment.

The incidence, severity, and location of pain was evaluated in 30 head and neck cancer patients prior to treatment after the first phase of their treatment and upon the completion of treatment. The incidence of pain was relatively high (40%-70%) and tended to increase slightly over treatment. Patients having advanced disease (stage III or IV) had a higher incidence of pain. Pain severity ratings were stable over treatment. Pain was located close to tumor or incision sites, and a trend for patients to report a greater number of pain sites over treatment was noted. While medical status variables (disease stage and site) were found to predict pain status after the initial phase of cancer treatment, initial pain measurements were more likely to predict pain status at the completion of treatment.