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Interim Estimates of 2023-24 Seasonal Influenza Vaccine Effectiveness - United States
No full textIn the United States, annual influenza vaccination is recommended for all persons aged ≥6 months. Using data from four vaccine effectiveness (VE) networks during the 2023-24 influenza season, interim influenza VE was estimated among patients aged ≥6 months with acute respiratory illness-associated medical encounters using a test-negative case-control study design. Among children and adolescents aged 6 months-17 years, VE against influenza-associated outpatient visits ranged from 59% to 67% and against influenza-associated hospitalization ranged from 52% to 61%. Among adults aged ≥18 years, VE against influenza-associated outpatient visits ranged from 33% to 49% and against hospitalization from 41% to 44%. VE against influenza A ranged from 46% to 59% for children and adolescents and from 27% to 46% for adults across settings. VE against influenza B ranged from 64% to 89% for pediatric patients in outpatient settings and from 60% to 78% for all adults across settings. These findings demonstrate that the 2023-24 seasonal influenza vaccine is effective at reducing the risk for medically attended influenza virus infection. CDC recommends that all persons aged ≥6 months who have not yet been vaccinated this season get vaccinated while influenza circulates locally
Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial
No full textBackground: Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ( ROAD Home ) on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.
Methods: This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a stewardship as usual control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.
Discussion: Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.
Trial registration: Clinicaltrials.gov NCT06106204 on 10/30/23.
Keywords: Antibiotic stewardship; Facilitation; Hospital discharge; Integrated Promoting Action on Research Implementation in Health Services Research (i-PARIHS) framework; Pneumonia; Tailoring; Transitions of care; Urinary tract infection
IL-10 Differentially Promotes Mast Cell Responsiveness to IL-33, Resulting in Enhancement of Type 2 Inflammation and Suppression of Neutrophilia
No full textMast cells (MCs) play critical roles in the establishment of allergic diseases. We recently demonstrated an unexpected, proinflammatory role for IL-10 in regulating MC responses. IL-10 enhanced MC activation and promoted IgE-dependent responses during food allergy. However, whether these effects extend to IgE-independent stimuli is not clear. In this article, we demonstrate that IL-10 plays a critical role in driving IL-33-mediated MC responses. IL-10 stimulation enhanced MC expansion and degranulation, ST2 expression, IL-13 production, and phospho-relA upregulation in IL-33-treated cells while suppressing TNF-α. These effects were partly dependent on endogenous IL-10 and further amplified in MCs coactivated with both IL-33 and IgE/Ag. IL-10\u27s divergent effects also extended in vivo. In a MC-dependent model of IL-33-induced neutrophilia, IL-10 treatment enhanced MC responsiveness, leading to suppression of neutrophils and decreased TNF-α. In contrast, during IL-33-induced type 2 inflammation, IL-10 priming exacerbated MC activity, resulting in MC recruitment to various tissues, enhanced ST2 expression, induction of hypothermia, recruitment of eosinophils, and increased MCPT-1 and IL-13 levels. Our data elucidate an important role for IL-10 as an augmenter of IL-33-mediated MC responses, with implications during both allergic diseases and other MC-dependent disorders. IL-10 induction is routinely used as a prognostic marker of disease improvement. Our data suggest instead that IL-10 can enhance ST2 responsiveness in IL-33-activated MCs, with the potential to both aggravate or suppress disease severity depending on the inflammatory context
Blood pressure difference between pre and post-menopausal women and age-matched men: A cross-sectional study at a tertiary center
No full textHypertension is a prominent risk factor for cardiovascular and cerebrovascular diseases. Gender differences and menopausal status contribute to blood pressure changes across the lifespan which have not been completely characterized. Our study aims to explore the impact of multiple factors on blood pressure levels in previously healthy women and men. Factors of interest included gender, menopausal status, age, and body mass index. Healthy women and men were recruited through healthcare facility announcements. Detailed menopausal history was obtained from females. The authors measured each participant\u27s systolic and diastolic blood pressure at our outpatient clinics twice on the same day, and two different days, one week apart, and the authors included the mean of the averaged two readings for each participant. The study sample consisted of 313 participants. Female gender was a significant predictor of lower systolic and diastolic blood pressure (p \u3c .001), while age significantly correlated with higher systolic blood pressure readings (p = .004). Although systolic blood pressure levels were significantly higher in postmenopausal females (124 mmHg) compared to premenopausal females (116 mmHg), our multiple linear regression analysis revealed that postmenopausal status did not significantly predict changes in either systolic or diastolic blood pressure. Our study demonstrates significant associations between blood pressure levels and various factors such as gender and age. This could emphasize the intricate interplay of demographic and clinical factors in blood pressure variations among individuals, highlighting the importance of a holistic approach to diagnosing hypertension, which considers various individual factors, including gender and age
The relationship between felt stigma and non-fatal overdose among rural people who use drugs
No full textBackground: Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.
Methods: Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.
Results: 6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).
Conclusions: Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.
Keywords: Opioids; Overdose; People who use drugs; Rural health; Self-stigma; Stigma
What Every Colorectal Surgeon Needs to Know about the Proposed Limitations to Noncompete Clauses
No full textRacial Disparities in Surgical Treatment of Uterine Fibroids During the COVID-19 Pandemic
No full textObjective: Analyze the association between race and surgery performed for uterine fibroids during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Retrospective exploratory cross-sectional study of patients with fibroids who underwent surgery during the COVID-19 pandemic. We compared the type of surgery performed (minimally invasive hysterectomy [MIH], uterine-sparing procedure [USP], or total abdominal hysterectomy [TAH]) by White versus non-White patients. Absolute percentage differences were estimated with multinomial logistic regression adjusting for age, body mass index (BMI), parity, comorbidities, and maximum fibroid diameter. Results: Of 350 subjects, the racial composition was 1.7% Asian, 23.4% Black, and 74.9% White. Non-White patients had greater fibroid burden by mean maximum fibroid diameter, mean uterine weight, and mean fibroid weight. Although MIH occurred more frequently among White patients (7.5% points higher [95% confidence interval (CI) = -3.1 to 18.2]), USP and TAH were more commonly conducted for non-White patients (3.4% points higher [95% CI = -10.4 to 3.6] and 4.2% points higher [95% CI = -13.2 to 4.8], respectively). The overall complication rate was 18.6%, which was 6% points lower (95% CI = -15.8 to 3.7) among White patients. Conclusion: During the COVID-19 pandemic at a single-site institution, non-White patients were more likely to undergo a uterine-sparing procedure for surgical treatment of uterine fibroids, abdominal procedures, including both hysterectomy and myomectomy, and experience surgery-related complications.
Keywords: minimally invasive; racial disparities; surgery; uterine fibroids
Validation of the PediBIRN-7 clinical prediction rule for pediatric abusive head trauma
No full textBackground: The PediBIRN-7 clinical prediction rule incorporates the (positive or negative) predictive contributions of completed abuse evaluations to estimate abusive head trauma (AHT) probability after abuse evaluation. Applying definitional criteria as proxies for AHT and non-AHT ground truth, it performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.88 (95 % CI: 0.85-0.92) in its derivation study.
Objective: To validate the PediBIRN-7\u27s AHT prediction performance in a novel, equivalent, patient population.
Participants and settings: Consecutive, acutely head-injured children \u3c3 years hospitalized for intensive care across eight sites between 2017 and 2020 with completed skeletal surveys and retinal exams (N = 342).
Methods: Secondary analysis of an existing, cross-sectional, prospective dataset, including assignment of patient-specific estimates of AHT probability, calculation of AHT prediction performance measures (ROC-AUC, sensitivity, specificity, predictive values), and completion of sensitivity analyses to estimate best- and worst-case prediction performances.
Results: Applying the same definitional criteria, the PediBIRN-7 performed with sensitivity 0.74 (95 % CI: 0.66-0.81), specificity 0.77 (95 % CI: 0.70-0.83), and ROC-AUC 0.83 (95 % CI: 0.78-0.88). The reduction in ROC-AUC was statistically insignificant (p = .07). Applying physicians\u27 final consensus diagnoses as proxies for AHT and non-AHT ground truth, the PediBIRN-7 performed with sensitivity 0.73 (95 % CI: 0.66-0.79), specificity 0.87 (95 % CI: 0.82-0.90), and ROC-AUC 0.90 (95 % CI: 0.87-0.94). Sensitivity analyses demonstrated minimal changes in rule performance.
Conclusion: The PediBIRN-7\u27s overall AHT prediction performance has been validated in a novel, equivalent, patient population. Its patient-specific estimates of AHT probability can inform physicians\u27 AHT-related diagnostic reasoning after abuse evaluation.
Keywords: Abusive head trauma; Child physical abuse; Clinical prediction rule; Likelihood ratio
County-Level Cardiac Rehabilitation and Broadband Availability: Opportunities for Hybrid Care in the United States
No full textPurpose: Cardiac rehabilitation (CR) improves patient outcomes and quality of life and can be provided virtually through hybrid CR. However, little is known about CR availability in conjunction with broadband access, a requirement for hybrid CR. This study examined the intersection of CR and broadband availability at the county level, nationwide.
Methods: Data were gathered and analyzed in 2022 from the 2019 American Community Survey, the Centers for Medicare & Medicaid Services, and the Federal Communications Commission. Spatially adaptive floating catchments were used to calculate county-level percent CR availability among Medicare fee-for-service beneficiaries. Counties were categorized: by CR availability, whether lowest (ie, CR deserts), medium, or highest; and by broadband availability, whether CR deserts with majority-available broadband, or dual deserts. Results were stratified by state. County-level characteristics were examined for statistical significance by CR availability category.
Results: Almost half of US adults (n = 116 325 976, 47.2%) lived in CR desert counties (1691 counties). Among adults in CR desert counties, 96.8% were in CR deserts with majority-available broadband (112 626 906). By state, the percentage of the adult population living in CR desert counties ranged from 3.2% (New Hampshire) to 100% (Hawaii and Washington, DC). Statistically significant differences in county CR availability existed by race/ethnicity, education, and income.
Conclusions: Almost half of US adults live in CR deserts. Given that up to 97% of adults living in CR deserts may have broadband access, implementation of hybrid CR programs that include a telehealth component could expand CR availability to as many as 113 million US adults
Nitrous Oxide Use for Pain in Labor, Conversion to Neuraxial Anesthesia and Birth Outcome
No full textIntroduction: A variety of labor pain management options is essential to patients and their care providers. Inhaled, patient controlled nitrous oxide (N2O) is a valuable addition to these options. The purpose of this study was to examine laboring patient, newborn, and provider characteristics associated with N2O use for pain relief in labor and to examine the association between N2O, conversion to neuraxial analgesia, and cesarean birth.
Methods: This was a retrospective observational cohort study of the first year of N2O use in one large academic medical center. Patients at least 37 weeks\u27 gestation who were admitted for labor with intended vaginal birth from August 1, 2018, to June 30, 2019, were included (N = 2605). Laboring patient and newborn factors and their relationship to N2O use were calculated as unadjusted and adjusted relative risks (RRs). Poisson regression was used to model the association between N2O use and subsequent use of neuraxial analgesia and type of birth for both nulliparous and multiparous patients.
Results: Overall, 20.2% of patients used N2O during labor. Multiparous patients were 24% less likely to use N2O than nulliparous patients (RR, 0.76; 95% CI, 0.69-0.84). Use of N2O did not differ significantly between patients cared for by midwives compared with patients cared for by physicians (RR, 0.95; 95% CI, 0.90-1.00). In multivariable modeling, N2O use in multiparous patients was associated with a 17% decrease in use of neuraxial analgesia (RR, 0.83; 95% CI, 0.73-0.94). There was no association between N2O use and use of neuraxial analgesia in nulliparous patients (RR, 0.99; 95% CI, 0.93-1.06). N2O use was not associated with cesarean birth in either group.
Discussion: N2O is an important pain management option for laboring patients and those who care for them. Study results may assist midwives, physicians, and nurses in counseling patients about analgesia options.
Keywords: intrapartum pain; labor analgesia; neuraxial analgesia; nitrous oxide