Losartan in hospitalized patients with COVID-19 in North America: An individual participant data meta-analysis.

BACKGROUND: Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) have been hypothesized to benefit patients with COVID-19 via the inhibition of viral entry and other mechanisms. We conducted an individual participant data (IPD) meta-analysis assessing the effect of starting the ARB losartan in recently hospitalized COVID-19 patients. METHODS: We searched ClinicalTrials.gov in January 2021 for U.S./Canada-based trials where an angiotensin-converting enzyme inhibitors/ARB was a treatment arm, targeted outcomes could be extrapolated, and data sharing was allowed. Our primary outcome was a 7-point COVID-19 ordinal score measured 13 to 16 days post-enrollment. We analyzed data by fitting multilevel Bayesian ordinal regression models and standardizing the resulting predictions. RESULTS: 325 participants (156 losartan vs 169 control) from 4 studies contributed IPD. Three were randomized trials; one used non-randomized concurrent and historical controls. Baseline covariates were reasonably balanced for the randomized trials. All studies evaluated losartan. We found equivocal evidence of a difference in ordinal scores 13-16 days post-enrollment (model-standardized odds ratio [OR] 1.10, 95% credible interval [CrI] 0.76-1.71; adjusted OR 1.15, 95% CrI 0.15-3.59) and no compelling evidence of treatment effect heterogeneity among prespecified subgroups. Losartan had worse effects for those taking corticosteroids at baseline after adjusting for covariates (ratio of adjusted ORs 0.29, 95% CrI 0.08-0.99). Hypotension serious adverse event rates were numerically higher with losartan. CONCLUSIONS: In this IPD meta-analysis of hospitalized COVID-19 patients, we found no convincing evidence for the benefit of losartan versus control treatment, but a higher rate of hypotension adverse events with losartan.

Distress During the COVID-19 Pandemic Among Local Public Health Workers in New York State.

OBJECTIVE: Understanding the challenges public health workers have faced is critical to reinforcing, revitalizing, and strengthening the public health workforce. We measured and identified the level and causes of psychological distress among public health workers during the COVID-19 pandemic in New York State. METHODS: We used a knowledge, attitudes, beliefs, and behaviors survey to ask public health workers at local health departments about their experiences working in public health during the pandemic, including questions relating to harassment from the public, workload, and work/life balance. We used the Kessler-6 scale to measure participants' psychological distress using a 5-point Likert scale, with higher scores indicating greater psychological distress. We calculated descriptive statistics and conducted a regression analysis to determine the factors associated with public health worker psychological distress, and we coded open-ended comments for qualitative analysis. RESULTS: During September 7-20, 2021, 231 public health workers from 38 local health departments completed the survey. Respondents were predominantly non-Hispanic White (89.6%), female (82.1%), full-time employees (95.1%), and located in Upstate New York. On a bivariate level, the strongest predictor of distress was job satisfaction (-0.388), followed closely by COVID-19 fatigue (0.386) and feeling bullied or harassed by the public (0.331). In the regression analysis, 2 additional factors were associated with distress: considering leaving their job due to the pandemic and concerns about exposure. Themes from the qualitative analysis strongly supported these findings. CONCLUSIONS: Understanding the challenges public health workers have faced during the pandemic is critical to inform the actions needed-stronger state laws protecting against harassment, workforce incentives, and commensurate funding-to reinforce and revitalize our frontline public health workforce.

Impact of pet dog or cat exposure during childhood on mental illness during adolescence: a cohort study.

BACKGROUND: In our prior study of 643 children, ages 4-11 years, children with pet dogs had lower anxiety scores than children without pet dogs. This follow-up study examines whether exposure to pet dogs or cats during childhood reduces the risk of adolescent mental health (MH) disorders. METHODS: Using a retrospective cohort study design, we merged our prior study database with electronic medical record (EMR) data to create an analytic database. Common MH diagnoses (anxiety, depression, ADHD) occurring from the time of prior study enrollment to 10/27/21 were identified using ICD-9 and ICD-10 codes. We used proportional hazards regression to compare time to MH diagnoses, between youths with and without pets. From 4/1/20 to 10/27/21, parents and youth in the prior study were interviewed about the amount of time the youth was exposed to a pet and how attached s/he was to the pet. Exposure included having a pet dog at baseline, cumulative exposure to a pet dog or cat during follow-up, and level of pet attachment. The main outcomes were anxiety diagnosis, any MH diagnosis, and MH diagnosis associated with a psychotropic prescription. RESULTS: EMR review identified 571 youths with mean age of 14 years (range 11-19), 53% were male, 58% had a pet dog at baseline. During follow-up (mean of 7.8 years), 191 children received a MH diagnosis: 99 were diagnosed with anxiety (52%), 61 with ADHD (32%), 21 with depression (11%), 10 with combined MH diagnoses (5%). After adjusting for significant confounders, having a pet dog at baseline was associated with lower risk of any MH diagnosis (HR = 0.74, p = .04) but not for anxiety or MH diagnosis with a psychotropic prescription. Among the 241 (42%) youths contacted for follow-up, parent-reported cumulative exposure to pet dogs was borderline negatively associated with occurrence of any MH diagnosis (HR = 0.74, p = .06). Cumulative exposure to the most attached pet (dog or cat) was negatively associated with anxiety diagnosis (HR = 0.57, p = .006) and any MH diagnosis (HR = 0.64, p = .013). CONCLUSION: Cumulative exposure to a highly attached pet dog or cat is associated with reduced risk of adolescent MH disorders.

Comparison of antibody response durability of mRNA-1273, BNT162b2, and Ad26.COV2.S SARS-CoV-2 vaccines in healthcare workers.

OBJECTIVES: There are limited comparative immunologic durability data post COVID-19 vaccinations. METHODS: Approximately 8.4 months after primary COVID-19 vaccination, 647 healthcare workers completed surveys about COVID-19 vaccinations/infections and blood draws. The groups included participants vaccinated with mRNA-1273 (n = 387), BNT162b2 (n = 212), or Ad26.COV2.S (n = 10) vaccines; unvaccinated participants (n = 10); and participants who received a booster dose (n = 28). The primary outcome was immunoglobin anti-spike titer. Secondary/tertiary outcomes included neutralizing antibodies (enzyme-linked immunosorbent assay-based pseudoneutralization) and vaccine effectiveness (VE). Antibody levels were compared using analysis of variance and linear regression. RESULTS: Mean age was 49.7 and 75.3% of the participants were female. Baseline variables were balanced except for immunosuppression, previous COVID-19 infection, and post-primary vaccination time. Unadjusted median (interquartile range [IQR]) anti-spike titers (AU/ml) were 1539.5 (876.7-2626.7) for mRNA-1273, 751.2 (422.0-1381.5) for BNT162b2, 451.6 (103.0-2396.7) for Ad26.COV2.S, 113.4 (3.7-194.0) for unvaccinated participants, and 31898.8 (21347.1-45820.1) for participants administered with booster dose (mRNA-1273 vs BNT162b2, P <.001; mRNA-1273, BNT162b2, or boosted vs unvaccinated, P <.006; mRNA-1273, BNT162b2, Ad26.COV2.S, or unvaccinated vs boosted, P <.001). Unadjusted median (IQR) pseudoneutralization was as follows: 90.9% (80.1-95.0) for mRNA-1273, 77.2% (59.1-89.9) for BNT162b2, 57.9% (36.6-95.8) for Ad26.COV2.S, 40.1% (21.7-60.6) for unvaccinated, and 96.4% (96.1-96.6) for participants administered with booster dose (mRNA-1273 vs BNT162b2, P <.001; mRNA-1273, BNT162b2, or boosted vs unvaccinated, P <.028; mRNA-1273, BNT162b2, Ad26.COV2.S, or unvaccinated vs boosted, P <.001). VE was 87-89% for participants administered mRNA-1273 vaccine, BNT162b2 vaccine, and booster dose, and 33% for Ad26.COV2.S (none significantly different). CONCLUSION: Antibody responses 8.4 months after primary vaccination were significantly higher with mRNA-1273 than those observed with BNT162b2.

COVIDMED - An early pandemic randomized clinical trial of losartan treatment for hospitalized COVID-19 patients.

Objectives: To assess the efficacy and safety of losartan for COVID-19 patients. Methods: COVIDMED was a double-blinded, placebo-controlled platform RCT. Enrollees were randomized to standard care plus hydroxychloroquine, lopinavir/ritonavir, losartan, or placebo. Hydroxychloroquine and lopinavir/ritonavir arms were discontinued early. We report losartan data vs. combined (lopinavir-ritonavir and placebo) and prespecified placebo-only controls. The primary endpoint was the mean COVID-19 Ordinal Severity Score (COSS) slope of change. Slow enrollment prompted early termination. Results: Fourteen patients were included in our final analysis (losartan [N = 9] vs. control [N = 5] [lopinavir/ritonavir [N = 2], placebo [N = 3]]). Most baseline parameters were balanced. Losartan treatment was not associated with a difference in mean COSS slope of change vs. combined (p = 0.4) or placebo-only control (p = 0.05) (trend favoring placebo). 60-day mortality and overall AE/SAE rates were insignificantly higher with losartan. Conclusion: In this small RCT in hospitalized COVID-19 patients, losartan did not improve outcome and was associated with adverse safety signals.

COVID-19 vaccine hesitancy and political ideation among college students in Central New York: The influence of differential media choice.

COVID-19 vaccine hesitancy is context specific and highly dynamic in the United States. The objective of this study was to examine the underlying causes of COVID-19 vaccine use and hesitancy among students at two colleges in Central New York (USA) in order to better understand how to promote vaccination in this demographic. A Knowledge, Attitudes, Beliefs & Behaviors survey was designed to measure the relationship between gender, political ideology, media consumption, beliefs, mental health and anxiety, and pandemic-related behaviors. The survey was distributed by email to students in April 2021. Of 8,894 eligible respondents, 627 students completed the survey. Structural Equation Modeling was utilized to explore both direct and indirect relationships. Modeling suggests that the effect of political ideology (being more conservative) is to promote the consumption of right wing news, which in turn tends to increase vaccine hesitancy. Conservative political ideology does not directly lead to vaccine hesitancy, but it does encourage the consumption of news from sources that promote fear and hesitation about the vaccines. News sources significantly contribute to vaccine attitudes among this demographic.

Tick magnets: The occupational risk of tick-borne disease exposure in forestry workers in New York.

BACKGROUND: Outdoor workers, such as forestry workers, are at an increased risk for contracting tick-borne diseases due to their prolonged time spent in tick habitats. Although well studied in Europe, no studies have been conducted with forestry workers in the Northeastern United States since 1990s. METHODS: Full-time forestry workers and two comparison groups (volunteer firefighter/first responders and indoor/healthcare workers) within New York State Department of Environmental Conservation Regions 3, 4, 5, 6, and 7 were recruited for this cross-sectional seroprevalence study. Blood draws were conducted to test for antibodies to Lyme, anaplasmosis, babesiosis, and ehrlichiosis. Surveys were administered to determine personal risk factors and protective behaviors. RESULTS: Between November 2020 and May 2021, 256 (105 forestry, 101 firefighter/first responder, and 50 indoor/healthcare) workers participated in this study. Forestry workers had a probability of testing positive nearly twice as high for any tick-borne disease (14%) compared to firefighter/first responders (8%) and to indoor workers (6%); however, this difference was not statistically significant (P = .140). Forestry workers were more likely to find embedded ticks on themselves (f = 33.26, P < .0001 vs both comparison groups) and to have been previously diagnosed with a tick-borne disease (P = .001 vs firefighter/first responders, P = .090 vs indoor/healthcare workers). CONCLUSIONS: This pilot study suggests a higher proportion of tick-borne disease risk among forestry workers compared to firefighters/first responders and indoor/healthcare workers with lesser exposure. A larger study to confirm or refute this pilot data could help optimize mitigation/prevention strategies.

Full agonist opioid prescribing by primary care clinicians after buprenorphine training.

BACKGROUND: While primary care clinicians are being trained to use buprenorphine for the treatment of Opioid Use Disorder (OUD) in order to increase access to addiction treatment, it is not known what impact such training and subsequent experience treating patients with OUD has on full agonist opioid prescribing.Methods: This retrospective cohort study compares the full agonist opioid prescribing patterns of Drug Addiction Treatment Act (DATA)-waivered ("X-waivered") primary care clinicians to non-trained, non-waivered clinicians in a rural health network. X-waivered clinicians also received Project ECHO training and telementoring support for one year. Using prescriber data generated by an electronic medical record system, opioid prescribing and morphine milligram equivalents (MME) per day per patient were calculated. A between-group analysis was used to compare the study groups six months pre-versus post-training.Results: Although the mean number of full agonist opioid prescriptions per clinician and per 100 patient encounters decreased among all clinicians, there was no change in full agonist opioid prescribing MME. As expected, buprenorphine prescribing by X-waivered, trained clinicians increased significantly post-training.Conclusions: X-waivers plus Project ECHO support for the treatment of OUD using buprenorphine had no effect on full agonist opioid prescribing by primary care clinicians.

Project ECHO and primary care buprenorphine treatment for opioid use disorder: Implementation and clinical outcomes.

Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.

Evaluating the Evolution of Social Networks: A Ten-Year Longitudinal Analysis of an Agricultural, Fishing and Forestry Occupational Health Research Center.

As part of our evaluation of the NIOSH-funded Northeast Center for Occupational Health and Safety: Agriculture, Forestry and Fishing (NEC), we present methodology, findings and the potential implications of a sequential social network analysis (SNA) conducted over ten years. Assessing the effectiveness of the center's scientific projects was our overarching evaluation goal. The evaluation design employed SNA to (a) look at changes to the center's network over time by visualizing relationships between center collaborators annually, (b) document collaborative ties and (c) identify particularly strong or weak areas of the network. Transdisciplinary social network criteria were applied to the SNA to examine the collaboration between center personnel, their partners and the industry groups they serve. SNA participants' perspectives on the utility of the SNA were also summarized to assess their interest in ongoing SNA measures. Annual installments of the SNA (2011-2020) showed an expansion of the network with a 30% increase in membership from baseline, as well as an increase in total relational ties (any type of contact). SNA measures also indicated significant increases in co-publication, cross-sector and transdisciplinary ties. Overall, SNA is an effective tool in visualizing and sustaining an occupational safety and health research and outreach network. Its utility is limited by how ties are characterized, grant cycle timeframes and how SNA metrics relate to productivity.

Prevalence and Risk Factors for Nonsuicidal Self-Injury in Transgender and Gender-Expansive Youth at a Rural Gender Wellness Clinic.

Purpose: Transgender and gender-expansive (TGE) populations are at increased risk for nonsuicidal self-injury (NSSI). Rural TGE populations are understudied and underserved in terms of mental health services. The purpose of this study was to determine lifetime prevalence of NSSI among TGE youth at a rural gender wellness clinic and identify demographic and clinical characteristics associated with NSSI. Methods: The Gender Wellness Center Pediatric Patient Registry, a comprehensive database of 185 TGE youth ≤25 years of age, provided an estimate of the lifetime prevalence of NSSI. Univariate logistic regression models were utilized to test associations between patient demographic and clinical characteristics and NSSI. Variables that met the threshold for significance in the univariate analyses (p<0.05) were entered into a multivariate logistic regression model. All statistical analyses were conducted in SAS v.9.4. Results: Prevalence of NSSI in the sample was 36.8% (n=68). In unadjusted logistic regression models, risk factors for NSSI included female assigned sex at birth, transmasculine spectrum gender identity, history of mood disorder, history of suicidal ideation (SI) or attempt, and history of abuse (p<0.05). In the adjusted model, variables significantly associated with NSSI included female assigned sex at birth, history of mood disorder, and history of SI or attempt. Conclusion: NSSI was highly prevalent in this sample of rural TGE youth, confirming the need for screening and early interventions that target the unique vulnerabilities of TGE youth. The complex interplay of sex assigned at birth, mood disorders, and NSSI requires further research.

Bone marrow biopsy and aspiration: a departmental financial comparison in a rural hospital.

OBJECTIVE: The purpose of this study was to compare the charges and payments associated with bone marrow aspiration and biopsies performed by hematology/oncology specialists versus interventional radiology specialists at Bassett Medical Center located in a rural area of New York State. Charges pertained to what the hospital charged for the procedure and payment refers to the reimbursement the hospital received. Our secondary objectives were to compare specimen quality by procedure and to determine whether body mass index was associated with which specialist performed the procedure. RESULTS: The median charge was significantly higher in the interventional radiology group ($5254 USD) compared to the hematology/oncology group ($413 USD), p < 0.0001. Median payments were also higher in the interventional radiology ($1392 USD) compared to the hematology/oncology group ($1109 USD), p < 0.0001. Adequacy of the samples obtained by either profession was similar. Disease process was not associated with adequacy of the sample. There was no statistically significant difference in the proportion of males and females in the respective groups or in the mean age. However, the patients' in the interventional radiology group had a significantly higher mean BMI (34.3) compared to those in the hematology/oncology group (28.6), p = 0.0014.

Worry and Wisdom: A Qualitative Study of Transgender Elders' Perspectives on Aging.

Purpose: While lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) elders face a multitude of barriers to healthy aging, little is known about needs and concerns specific to transgender elders, except that they face many self-perceived challenges to healthy aging, which exist at the individual, community, and institutional levels. To further understand these needs, we explored the perspectives of transgender individuals aged 65 and older on health care, expectations of aging, concerns for the future, and advice for young transgender people. Methods: We performed 19 semistructured interviews with individuals who identify as transgender elders, 10 transgender women and 9 transgender men. Interviews were transcribed and coded by three investigators to generate salient themes via thematic analysis. Results: We identified 7 major themes that exemplify the concerns and experiences of this sample of the aging transgender community: fear of mistreatment in elder care, isolation and loneliness exacerbated by transgender identity, increased vulnerability to financial stressors, perceived lack of agency, health care system and provider inclusivity, giving back to one's community, and embracing self-truth as a path to fulfillment. Conclusion: While some of these concerns, such as fear of mistreatment, are common among elders, the concerns of transgender elders are heightened due to stigma compounded by being both transgender and elderly. Health care providers, nursing home staff, and social workers must be sensitized to these needs and fears to provide appropriate, affirming, and respectful care and support to transgender elders.

Longitudinal Use of the Consolidated Framework for Implementation Research to Evaluate the Creation of a Rural Center of Excellence in Transgender Health.

BACKGROUND: Transgender people face numerous barriers to accessing care, particularly in rural settings. Transportation, travel time, a lack of providers offering transgender care, and discrimination all contribute to these barriers. The Gender Wellness Center was established in New York State, USA, to fill a gap in rural transgender care and was subsequently awarded a Robert Wood Johnson Foundation grant to establish a Center of Excellence. This study examined the implementation of the Center of Excellence, a complex intervention, to assess barriers and facilitators to implementation over 18 months. METHODS: The Consolidated Framework for Implementation Research (CFIR) was used to develop baseline and follow-up surveys. These were distributed to members of the core implementation team at the Gender Wellness Center at the midpoint and conclusion of the Robert Wood Johnson Foundation grant. Responses were largely open-ended and analyzed qualitatively. RESULTS: Results are presented in terms of CFIR domains and constructs, as well as the relative outlook (positive or negative) of implementation. Overall, there were improvements over time, with more encouraging feedback and examples of success at follow-up. Though true, organizational culture and individual beliefs about the provision of transgender care challenged implementation of the Center of Excellence throughout the project. CONCLUSIONS: This study highlights the importance of organizational culture on implementation efforts, as well as the need for complex, multifaceted interventions to overcome such challenges in order to improve care for marginalized populations.

A pilot study of an online produce market combined with a fruit and vegetable prescription program for rural families.

Despite being surrounded by farms, rural families are often at risk for diet-related diseases because of food disparities. Barriers such as distance and transportation to a full service grocery store, lack of cooking knowledge and skills, and the cost of fresh produce, force families to shop at convenience stores that carry predominantly unhealthy, processed foods. We combined a Fruit and Vegetable Prescription Program (F&VRx) with family cooking/nutrition classes and a pilot online produce shopping to promote lifestyle dietary changes in rural families. In 2 rural upstate New York communities school health staff referred low income families with one or more children at risk for chronic disease related to obesity for this pilot program. Each family was given a weekly online produce credit for 5 months, September/October 2017 through January/February 2018. Two monthly nutrition/cooking lessons were provided for the entire family. Evaluation was done using pre and post program surveys and Photovoice. Families took photos in response to the question "How has the F&VRx program affected my family?". Redemption of online produce credit was 94% and class attendance was 80%. Fruit and vegetable consumption rose for children. Confidence, culinary skills, and food literacy increased slightly. Three months after program completion, 60% of the families continued weekly online produce shopping without the F&VRx. Healthy behaviors for shopping, preparing, and consuming fruits and vegetables can be increased using a F&VRx, online produce ordering, and family cooking classes.

Health-related quality of life among transgender and gender expansive youth at a rural gender wellness clinic.

PURPOSE: To address a critical gap in the existing Health-Related Quality of Life (HRQOL) literature by quantifying and describing HRQOL among transgender and gender expansive (TG/GE) youth at a rural gender clinic and comparing the HRQOL of these youth to age-stratified United States (U.S.) population standards. METHODS: This cross-sectional study includes results of the baseline HRQOL assessment of 141 TG/GE patients enrolled in the Gender Wellness Center (GWC) Pediatric Patient Registry. HRQOL was assessed using the Child Health Questionnaire-Child Form 87 (CHQ-CF87; ages < 18) and the Short Form-36 (SF-36v2; ages 18-21). Mean subscale scores were compared to the most current U.S. population standards available. RESULTS: On all but one of the CHQ-CF87 subscales, TG/GE youth scored significantly lower than 2015-2016 U.S. general population youth and youth with two chronic conditions. On the SF-36v2, TG/GE youth scored significantly higher than 2009 U.S. standards on all physical health domains but lower on all but one of the mental health domains. CONCLUSIONS: Cross-sectional HRQOL data from a registry of TG/GE youth indicate significantly poorer mental health measures as compared with the U.S. general population. Longitudinal assessments are needed to evaluate whether HRQOL improves with gender-affirming care. Future studies should aim to identify sociocultural factors at the intersection of rurality and health that contribute to diminished HRQOL among rural TG/GE youth.

Evaluating the Placebo Status of Nebulized Normal Saline in Patients With Acute Viral Bronchiolitis: A Systematic Review and Meta-analysis.

Importance: In therapeutic trials for acute viral bronchiolitis, consistent clinical improvement in groups that received nebulized normal saline (NS) as placebo raises the question of whether nebulized NS acts as a treatment rather than a placebo. Objective: To measure the short-term association of nebulized NS with physiologic measures of respiratory status in children with bronchiolitis by analyzing the changes in these measures between the use of nebulized NS and the use of other placebos and the changes before and after nebulized NS treatment. Data Sources: MEDLINE and Scopus were searched through March 2019, as were bibliographies of included studies and relevant systematic reviews, for randomized clinical trials evaluating nebulized therapies in bronchiolitis. Study Selection: Randomized clinical trials comparing children 2 years or younger with bronchiolitis who were treated with nebulized NS were included. Studies enrolling a treatment group receiving an alternative placebo were included for comparison of NS with other placebos. Data Extraction and Synthesis: Data abstraction was performed per PRISMA guidelines. Fixed- and random-effects, variance-weighted meta-analytic models were used. Main Outcomes and Measures: Pooled estimates of the association with respiratory scores, respiratory rates, and oxygen saturation within 60 minutes of treatment were generated for nebulized NS vs another placebo and for change before and after receiving nebulized NS. Results: A total of 29 studies including 1583 patients were included. Standardized mean differences in respiratory scores for nebulized NS vs other placebo (3 studies) favored nebulized NS by -0.9 points (95% CI, -1.2 to -0.6 points) at 60 minutes after treatment (P < .001). There were no differences in respiratory rate or oxygen saturation comparing nebulized NS with other placebo. The standardized mean difference in respiratory score (25 studies) after nebulized NS was -0.7 (95% CI, -0.7 to -0.6; I2 = 62%). The weighted mean difference in respiratory scores using a consistent scale (13 studies) after nebulized NS was -1.6 points (95% CI, -1.9 to -1.3 points; I2 = 72%). The weighted mean difference in respiratory rate (17 studies) after nebulized NS was -5.5 breaths per minute (95% CI, -6.3 to -4.6 breaths per minute; I2 = 24%). The weighted mean difference in oxygen saturation (23 studies) after nebulized NS was -0.4% (95% CI, -0.6% to -0.2%; I2 = 79%). Conclusions and Relevance: Nebulized NS may be an active treatment for acute viral bronchiolitis. Further evaluation should occur to establish whether it is a true placebo.

Key factors for successful implementation of the National Rollover Protection Structure Rebate Program: A correlation analysis using the consolidated framework for implementation research.

Objectives On US farms, tractor overturns are the leading cause of death; however, these fatalities are preventable with the use of a rollover protection structure (ROPS). A ROPS rebate program was established in New York in 2006 to address these fatalities. Due to its success, the program expanded to six additional states before being implemented as the National ROPS Rebate Program (NRRP) in 2017. The aim of this study was to evaluate the success of the NRRP implementation using short- and long-term ROPS outcome measures and identify which components of the consolidated framework for implementation research (CFIR) correlate with these outcomes. Methods Stakeholders involved in the NRRP implementation were surveyed at four time points, beginning at the time of the NRRP launch and then every six months. These surveys measured 14 relevant CFIR constructs. Correlations between CFIR survey items (representing constructs) and three outcome measures (intakes, funding progress, and retrofits) were used to identify CFIR survey items that are predictive of the outcomes. Results Eight CFIR survey items were highly correlated (rho ≥0.50) with at least one of the three outcome measures. These eight CFIR survey items included four constructs: access to knowledge and information, leadership engagement, engaging (in fundraising and funding requests), and reflecting and evaluating. Conclusions The results of this study provide important guidance for continuing the implementation of the NRRP. Similarly, these findings can inform the evaluation of other similarly structured implementation efforts and the application of CFIR in a variety of settings.

Building a Pediatric Patient Registry to Study Health Outcomes Among Transgender and Gender Expansive Youth at a Rural Gender Clinic.

Purpose: Significant knowledge gaps regarding outcomes of gender-affirming therapy in transgender (TG) and gender expansive (GE) youth impede an evidence-based approach to these patients. The Gender Wellness Center (GWC) Pediatric Patient Registry was established in 2017 to enable systematic, longitudinal research to describe the physical, mental, and quality-of-life outcomes of these youth. Methods: All TG/GE youth, ages 8-21 years, presenting to the GWC were recruited on site. Ten research questions guided the creation of data fields. The following 131 variables were abstracted from electronic medical records: demographics, weight, height, body mass index, gender identity, sexual orientation, coexisting diagnoses, substance use, Tanner stage, sexual activity, medications, fertility preservation, Gonadotropin Releasing Hormone (GnRH) analog use, hormone therapy, surgery, and related outcomes. Health-related quality of life is assessed using the Child Health Questionnaire-87 for ages <18 and the Short Form-36 for ages 18-21. Results: To date, 139 TG and GE youth (90% white and 93% non-Hispanic), have enrolled in the registry. Average age at enrollment was 17.5 years (±3.1, range: 8-21). Two-thirds of youth identified on the trans masculine spectrum (n=90), 28.8% identified on the trans feminine spectrum (n=40), and 6.5% identified as nonbinary/gender nonconforming (n=9). Nearly, all youth had socially transitioned (n=121, 87.7%) and were medically transitioning (n=123, 89.1%). Conclusion: As one of the first rural-based registries, the GWC Registry has helped to delineate health outcomes attributable to gender-affirming care in a unique patient population of TG/GE youth. Our results will be used to describe treatment outcomes that will contribute to evidence-based guidelines.