Surgical Oncology

Response to: "Intact Excision of Breast Lesions Using BLES™: Is There a Clinical Indication Yet?"

ASO Author Reflections: Neoadjuvant Therapy for Borderline Resectable Pancreatic Cancer: Is Combined Radiotherapy Necessary?

Staging for Ampullary Carcinoma: Is Less Actually More?

Laparoscopic Left Lateral Sectionectomy Using the Extrahepatic Glissonean Approach: A Secure Option for Achieving a Negative Margin for Lesions with Ductal Extension Abstract Introduction In patients with liver lesions with ductal extension, the corresponding Glissonean pedicle should be divided at its origin to achieve a negative ductal margin; however, during laparoscopic hepatectomy, it is difficult to precisely transect the liver and divide the Glissonean pedicle as planned. Methods We present a video of a laparoscopic left lateral sectionectomy using the extrahepatic Glissonean approach for a lesion with ductal extension. Results A 76-year-old woman presented with a cystic neoplasm in the liver segment 3 bile duct (B3). The preoperative workup suggested biliary extension of the lesion towards the origin of B3. A decision was made to perform laparoscopic left lateral sectionectomy with division of the segment 3 Glissonean pedicle (G3) at its origin, and, additionally, left hepatectomy if the B3 ductal margin turned out to be positive. During the procedure, prior to parenchymal transection, the Arantius' ligament was dissected, and G2 and G3 were extrahepatically taped. The ischemic border was visualized by clamping the isolated pedicle, and was also clearly demonstrated by indocyanine green fluorescence. After transecting the liver towards the tape, G3 was divided at its origin, and the frozen section of the ductal margin was negative for tumors. Conclusion The extrahepatic Glissonean approach can help to obtain a maximal ductal margin for liver lesions with possible biliary extension, although the technique potentially poses the risk of bleeding and/or biliary injury, and requires expertise in hepatobiliary surgery. Further studies with larger sample sizes are warranted to validate the feasibility and efficacy of this strategy.

Minimally Invasive Lymphadenectomy for Biliary Tumors: Stepwise Progress

Liver Resection with In Situ Hypothermic Perfusion: An Old but Effective Method Abstract Background More than 40 years ago, patients with tumors infiltrating the confluence of the hepatic veins were deemed unresectable; however, in situ hypothermic perfusion, first described by Fortner et al. (Ann Surg 180(4):644–652, 1974), allowed resection of these tumors. In order to prevent liver ischemia after total vascular exclusion, the liver was flushed with a cooled organ preservation solution. The surgeon was able to resect the tumor and reconstruct the hepatic veins with occlusion of the hepatic inflow and outflow. Methods A 55-year-old female suffering from a leiomyosarcoma of the inferior vena cava (IVC) presented to our clinic. Three years ago, the IVC was replaced with a synthetic graft. During the patient's follow-up, a computed tomography (CT) scan revealed three hepatic metastases of the sarcoma. A central metastasis in Segment 8 infiltrated the right hepatic vein (RHV), and two additional metastases were located in the left lateral segments. We used Fortner's technique to resect these tumors. Results The postoperative course of the patient was prolonged due to a hematoma that partially compressed the new RHV graft. A re-laparotomy was performed and drains were placed. On the 15th postoperative day, the patient was discharged in good health. Conclusions Although nowadays patients with these unfortunate tumor locations can, to some extent, be managed non-operatively, surgery remains an option with a chance of cure. Azoulay et al. (Ann Surg 262(1):93–104, 2015) were able to show satisfactory 5-year-survival in 77 patients (30.4%), however 90-day mortality was high (19.5%). Therefore, patients need to be selected carefully. In the era of minimally invasive liver surgery, these old techniques should not vanish from the armamentarium of liver surgeons.

Does Sidedness Matter in Unresectable Colorectal Cancer?

Perioperative Therapy for Borderline Resectable Pancreatic Cancer: What and When?

The Value of Commission on Cancer Accreditation: Improving Survival Outcomes by Enhancing Compliance with Quality Measures

Living Donor Liver Transplant for Hepatocellular Carcinoma

Trauma and Acute Care Surgery

FAILURE TO RESCUE IN SURGICAL PATIENTS: A REVIEW FOR ACUTE CARE SURGEONS The Failure to Rescue (FTR) rate is defined as the mortality rate among patients who experience one or more complications. It has been used as an outcome metric for approximately 25 years, primarily in elective surgery populations, and has been shown to be associated with factors that are modifiable on the institutional level. Although the FTR metric was derived in elective surgical populations, modifications have been made in attempts to refine the metric and apply it to broader populations, including medical patients and non-elective surgical patients. However, study among emergency general surgery patients has been limited. In this review, we summarize the current knowledge surrounding FTR, including established risk factors and potential limitations of the metric in emergency general surgery (EGS) populations. We then discuss a conceptual model for FTR events and review strategies to minimize rates. Finally, we provide a brief overview of current areas of study and potential future directions in acute care surgery. Study Type Review article Corresponding author and requests for reprint requests: Justin Hatchimonji, MD MBE, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 4 Maloney, Cell: 267-408-5825, justin.hatchimonji@uphs.upenn.edu Conflicts of Interest and Source of Funding: No authors have conflicts to declare. DNH is currently supported by a training grant through the National Heart, Lung, and Blood Institute. (K08HL131995) © 2019 Lippincott Williams & Wilkins, Inc.

Answer: Letter of the Editor Management of Devastating Duodenal Injuries No abstract available

Pneumatosis Not Created Equally: A case report No abstract available

Response to Letter to the editor: Article: TA501611 No abstract available

#EAST4ALL: An Introduction to the EAST Equity, Quality, and Inclusion Task Force Background The Eastern Association for the Surgery of Trauma (EAST) is an inclusive and supportive organization that focuses on development of the junior trauma surgeon. In 2019, there continues to be bias based on gender, race, ethnicity, religion, sexual orientation in our profession and society at large. We believe that EAST is uniquely positioned to investigate, quantify/categorize, and search for productive and effective solutions to these issues that affect our colleagues, profession, and patients. The EAST Equity, Quality and Inclusion Task Force, or #EAST4ALL, was thus created, with the goal of addressing these issues together as a community. Methods A series of Task Force meetings and teleconferences was held to collect subjective and objective data and experiences related to bias and equity issues and experiences. A uniquely structured #EAST4ALL Plenary Session was created to both introduce this initiative and to couple real-world experiential descriptives with related reviews of the relevant literature and the concept of "implicit bias". Results We share anecdotal and evidence-based examples of bias in trauma surgery presented at the inaugural #EAST4ALL Plenary Session along the axes of: i) childbearing & family concerns, ii) micro & macroaggressions, iii) gender, iv) race & ethnicity, iv) religion or country of origin, v) sexual orientation & gender identity. We then share our proposal and suggested courses of action for member-based solutions based on our various workgroups: a) Assessment & Research; b) Education; c) Guidelines & Processes; d) Mentorship, Dialogue & Collaboration. Conclusions Inequities and bias in the field of trauma surgery may have profound and deleterious impacts, lifelong for some, that we must acknowledge and eradicate. The dignity and respect we afford our patients, must be extended to each other. Our EAST Equity, Quality and Inclusion Task Force, with membership input, hopes to create a future that is truly an #EAST4ALL. Study type Original Article Level of evidence Level V Stephanie Bonne: Stephanie.bonne@rutgers.edu Brian H. Williams: brian@brianwilliamsmd.com Matthew Martin: traumadoc22@gmail.com Haytham Kaafarani: HKAAFARANI@mgh.harvard.edu William Weaver: wweaver07@gmail.com Rishi Rattan: rrattan@miami.edu Patricia Byers: pbyers@med.miami.edu D'Andrea Joseph: d'andrea.joseph@nyulangone.org Paula Ferrada: paula.ferrada@vcuhealth.org Bellal Joseph: bjoseph@surgery.arizona.edu Ariel Santos: Ariel.Santos@ttuhsc.edu Robert Winfield: rwinfield@kumc.edu Sandra DiBrito: dibrito@jhmi.edu Andrew Bernard: andrew.bernard@uky.edu Tanya L. Zakrison: tzakrison@icloud.com Correspondence: Stephanie Bonne, MD, FACS Rutgers New Jersey Medical School 150 Bergen Street, M-228 Newark, NJ 07103 The authors declare no conflicts of interest. Presented at the 32nd Eastern Association for the Surgery of Trauma Annual Scientific Assembly, January 15-19th, 2019, in Austin, TX. This work is unfunded. © 2019 Lippincott Williams & Wilkins, Inc.

Unplanned Readmission After Traumatic Injury: A Long-Term Nationwide Analysis Introduction Long-term outcomes after trauma admissions remains understudied. We analyzed the characteristics of inpatient readmissions within six-months of an index hospitalization for traumatic injury. Methods Using the 2010-2015 Nationwide Readmissions Database, which captures data from up to 27 U.S. States, we identified patients at least 15-years-old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within one-, three-, and six-months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. Results Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within one-month, 21.6% within six-months, and 29.8% within six-months, with limited variability by year. After adjustment, the following were associated with all-cause six-months inpatient readmissions: male sex (adjusted odds ratio [aOR] 1.10 [95%-CI: 1.09-1.10]), comorbidities (aOR 1.21 [1.21-1.22]), low (first and second) income quartiles (aOR 1.08 [1.07-1.10] and aOR 1.04 [1.03-1.06] respectively), Medicare (aOR 1.65 [1.62-1.69]), Medicaid (aOR 1.51 [1.48-1.53]), being treated at private, investor owned hospitals (aOR 1.15 [1.12-1.18]), longer hospital length of stay (aOR 1.01 [1.01-1.01]) and patient disposition to short-term hospital (aOR 1.55 [1.49-1.62]), skilled nursing facility (aOR 1.43 [1.42-1.45]), home health care (aOR 1.27 [1.25-1.28]), or leaving against medical advice (aOR 1.85 [1.78-1.92]). Conclusion Unplanned readmission after trauma is high and remains this way six months after discharge. Understanding the factors that increase the odds of readmissions within one-, three-, and six-months offer a focus for quality improvement and have important implications for hospital benchmarking. Level of Evidence Level 3, Epidemiological Corresponding author: Joseph V. Sakran, MD, MPH, MPA Department of Surgery, Division of Acute Care Surgery Sheikh Zayed Tower, Suite 6107 Baltimore, MD 21287 Email: jsakran1@jhmi.edu Nicole Lunardi MSPH1 – nlunard1@jhmi.edu Ambar Mehta MD, MPH2 - amehta25@jhmi.edu Hiba Ezzeddine MD3 - hezzedd1@jhmi.edu Sanskriti Varma BS1 - sanvarma@jhmi.edu Robert Winfield MD4 – rwinfield@kumc.edu Alistair Kent MD3 - alistair.kent@jhmi.edu Joseph K Canner MHS3 - jcanner1@jhmi.edu Avery B Nathens MD, MPH, PhD5 -anathens@facs.org Bellal A Joseph MD4 - bjoseph@surgery.arizona.edu David T. Efron MD3 - defron1@jhmi.edu Joseph V. Sakran MD, MPH, MPA3 - jsakran1@jhmi.edu Disclosures: None. 32nd Annual Meeting of EAST AAST and Clinical Congress of Acute Care Surgery, January, 15-19 2019 in Austin, TX © 2019 Lippincott Williams & Wilkins, Inc.

Preventable death and interpersonal violence in the United States: who can be saved? Background: Public health initiatives to reduce mortality from penetrating trauma have largely developed from patterns of injury observed in military casualties, with a focus on hemorrhage control and use of tourniquets. Recent efforts show that injury patterns differ between civilian mass casualty events and combat settings, and no studies characterize wounding patterns in all types of civilian homicide. We hypothesize that many homicide deaths are due to non-survivable injuries, and that an effective strategy to reduce mortality must focus on both primary prevention as well as improvement in trauma pre-hospital care. Methods: We analyzed homicides from the National Violent Death Reporting System from 2012 to 2015. We excluded deaths due to poisoning, intentional neglect, or unknown weapon. Deaths were classified as "Dead on Scene (DOS)", "Dead on Arrival (DOA)", or "Dead at or After Hospital (DAH)" if the patient was admitted to a hospital. Injury patterns for penetrating weapons (firearms and sharp instruments) were further categorized. Results: We included 18,051 homicides, the vast majority of which were due to firearms (n=12901 or 71.5%) or sharp instruments (n=2265 or 12.5%). The most common injury patterns included wounds to the chest or head, with isolated extremity injuries representing a minority of both firearms deaths (n=397 of 12901, 3.1%) and deaths from sharp instruments (n=50 of 2265, 2.2%). Furthermore, over half of all deaths occurred pre-hospital, with only 13.3% of victims admitted prior to death. Conclusions: The vast majority of deaths from interpersonal violence are due to firearm injuries. Few deaths appear to be related to extremity hemorrhage alone, and over half of all fatally injured died at the scene. Strategies to decrease mortality from interpersonal violence must go beyond treating injuries that have already occurred, and must address violence prevention directly. Corresponding Author: Catherine G. Velopulos 12631 East 17th Ave., Mail Stop C313 Aurora, CO 80045 The authors have no conflicts of interest to declare and there is no funding source for the work presented. This work was presented at the 32nd Annual Meeting of the Eastern Association of the Surgery of Trauma, January 15-18, 2019 in Austin, Texas. Conflicts of Interest: The authors have no conflicts of interest to declare. Funding: There is no external funding source for the work presented. All authors are salaried at their respective institutions. © 2019 Lippincott Williams & Wilkins, Inc.

Protocols for Documentation of Electrical Injuries for Electrical Safety Inspectors and Emergency Medical Practitioners Type of Study This is a paper providing guidelines for medico-legal reporting. Background Electric shocks are common, and victims report difficulty in finding practitioners with knowledge of the injury. Medical Practitioners, especially in private practice, report lack of knowledge of the injury and lack of expertise in assessing and treating the injury. The authors are often requested to suggest investigation protocols, assessment protocols, and treatment protocols, and to provide educational information. Methods The international body establishing electrical standards on the effects of current on the body (International Electrotechnical Commission, Maintenance Team 4 (MT4) of Technical Committee 64 (TC64)) have established protocols for the factors which require documentation and reporting of the injury. This paper provides a narrative approach to using these protocols in accord with the standards (IEC 60479). The level of evidence is Level III (US/Canada classification). Type This paper collects together and collates physical and medical aspects of investigating electric shocks, and summarises those of importance, and which are potentially forgotten. The thoroughness of initial assessment is emphasised. Substance Summaries are set out to guide first attenders and emergency medical personnel as to findings and observations which must be recorded for later comprehensive medico-legal reporting and which are often overlooked. Conclusions Wider teaching in the nature of electric shocks will enhance assessment of victims and thorough recording of pertinent information and thus will enhance later medico-legal reporting. Many such factors are initially overlooked and lead to inadequate reporting for forensic purposes. Conflict of Interest Statement There are no conflicts of interest for either author in the preparation of this paper. Funding No funding has been received for the publication of this paper. © 2019 Lippincott Williams & Wilkins, Inc.

Rapid point-of-care detection and classification of direct-acting oral anticoagulants (DOACs) with the TEG® 6s: implications for trauma and acute care surgery Background The trauma patient on direct oral anticoagulant (DOAC) therapy pre-injury presents a challenge in trauma and acute care surgery. Our understanding of these patients is extrapolated from vitamin K antagonists. However, DOACs have different mechanisms of action, effects on laboratory coagulation assays, and reversal strategies. Rapid identification of DOACs in the blood will allow timely reversal of factor Xa inhibitors and direct thrombin inhibitors when necessary. The present study evaluated viscoelastic testing to detect and classify DOACs in patient blood samples. Methods This observational, prospective, open-label, multi-center study used point-of-care viscoelastic testing to analyze blood samples taken from patients with and without DOAC treatment, and healthy volunteers. Anti-factor Xa (AFXa) and direct thrombin inhibition (DTI) assays were used to establish reference ranges for viscoelastic testing parameters on the TEG® 6s system. These ranges were applied to produce a DOAC identification algorithm for patient blood samples. Internal consistency of the measurements as well as algorithm sensitivity and specificity were evaluated. Results Using the TEG® 6s system, the R parameter reference range was 0.6–1.5 minutes for the AFXa assay and 1.6–2.5 minutes for the DTI assay. Our identification algorithm using these ranges for ≤2.5 minutes has sensitives of 98.3% and 100% for factor Xa inhibitor and direct thrombin inhibitor detection, respectively. Specificity was 100%. Both classes of DOAC were detectable, even when samples were collected during the "trough" between doses of medication. Conclusions Point-of-care viscoelastic testing with TEG® 6s can detect and classify DOACs with high sensitivity and specificity. This tool can be employed to better determine the need for reversal in trauma and acute care surgery patients and guide optimal surgical timing in the acute setting. Level of Evidence Level II, prognostic and epidemiological study Correspondence: João Dias Signy Center, P.O.Box. 262, 1274 Signy-Centre, Switzerland jdias@haemonetics.com Presentations: Preliminary portions of this work were presented at the 64th annual meeting of the Scientific Standardization Committee of the International Society on Thrombosis and Haemostasis and at the European Society of Cardiology Congress. Conflict of interest statement: This study was supported by Haemonetics Corporation (Braintree, Massachusetts). JD, CL, JI, HH, FZ, AM, JH, HA were employees of Haemonetics Corporation at the time of the study. The authors have no other relevant financial interest in the products or companies described in this article. We have no disclosures of funding from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; and the Howard Hughes Medical Institute (HHMI). © 2019 Lippincott Williams & Wilkins, Inc.

EAST Presidential Address: EAST-A Legacy of Inclusion No abstract available

Radiology

May 14, 2019 Don't miss the latest Radiology podcast in which Dr. David Bluemke, Editor ofRadiology, discusses recently published research. Latest Articles Original Research Breast Imaging   Breast Cancer Conspicuity on Simultaneously Acquired Digital Mammographic Images versus Digital Breast Tomosynthesis Images   Cancers visible at only one mammographic view are more often seen at the craniocaudal view than the mediolateral oblique view for both digital mammography and digital breast tomosynthesis.   Katrina E. Korhonen, Emily F. Conant...Susan P. Weinstein Genitourinary Imaging   Components of Radiologic Progressive Disease Defined by RECIST 1.1 in Patients with Metastatic Clear Cell Renal Cell Carcinoma   As assessed by RECIST 1.1 criteria, unequivocal progression of non–target disease (when target lesions are stable or partially responding, and no new lesions are present) occurs in almost one out of five patients with clear cell renal cell carcinoma and is associated with a shorter progression-free survival.   Heidi J. Coy, Michael L. Douek...Steven S. Raman  Editorial RECIST Needs Revision: A Wake-up Call for Radiologists Christiane K. Kuhl Obstetric Imaging   Echo-planar FLAIR Sequence Improves Subplate Visualization in Fetal MRI of the Brain   Echo-planar fluid-attenuated inversion recovery MRI of the fetal brain enables a better visualization of brain lamination compared with T2-weighted single-shot fast spin-echo MRI, allowing insight into in vivo imaging of brain development.   Mariana C. Diogo, Daniela Prayer...Gregor Kasprian  Editorial EPI-FLAIR: A New Color on the Fetal Brain MRI Palette Andrea Rossi Thoracic Imaging   CT-guided Lung Biopsy: Effect of Biopsy-side Down Position on Pneumothorax and Chest Tube Placement   Positioning the patient biopsy side down during percutaneous CT-guided lung biopsy reduces the incidence of pneumothorax without affecting the chest tube insertion rate or the incidence of hemoptysis.   Orla Drumm, Eimear A. Joyce...Peter Beddy Iodine Maps from Subtraction CT or Dual-Energy CT to Detect Pulmonary Emboli with CT Angiography: A Multiple-Observer Study   Subtraction CT shows comparable diagnostic performance to that of dual-energy CT in the detection of pulmonary embolism at similar radiation dose, without the need for dedicated hardware.   Dagmar Grob, Ewoud Smit...Monique Brink Reviews and Commentary Review   Digital Breast Tomosynthesis: Concepts and Clinical Practice   This article highlights the current concepts of digital breast tomosynthesis imaging, including synthetic mammography, that are relevant to contemporary breast imaging; the quasi three-dimensional information and the improved lesion conspicuity gained with tomosynthesis are associated with improvements in patient outcomes and efficiency in mammographic imaging.   Alice Chong, Susan P. Weinstein...Emily F. Conant Images in Radiology   Topsy-Turvy Heart: Volume-rendered CT Angiography   Rania H. Zakaria Having trouble viewing? View web version RSNA.org | RSNA News™ | RSNA Journals | Contact Us   © 2019 Radiological Society of North America | 820 Jorie Blvd | Oak Brook, IL 60523-2251  TEL U.S. & Canada: 1-888-600-0064 | TEL Outside U.S. & Canada: 1-630-590-7770  Privacy Policy  To update your e-mail preferences, click here.

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AIDS and Behavior

Men's Beliefs About the Likelihood of Serodiscordance in Couples with an HIV-Positive Partner: Survey Evidence from Rural Uganda Abstract Few studies in sub-Saharan Africa have assessed men's knowledge about the likelihood of serodiscordance in couples with an HIV-positive partner and how this is affected by antiretroviral therapy (ART). Using a Likert scale and probabilistic scale, we elicited beliefs of 2532 rural Ugandan men about the likelihood of seroconcordance in married couples with an HIV-positive female partner who is either taking ART or not taking ART. Logistic regression analyses explored associations between beliefs and various health behaviors. Probabilistic scale responses were consistent with Likert scale responses. Seroconcordance was believed to be likely in the scenarios without ART and with ART, with mean seroconcordance likelihood of 8.1 and 6.6, respectively, on a scale of 0–10. The majority of participants (57%) believed the likelihood of seroconcordance was lower in the scenario with ART. The results suggest a need for enhanced education among men about serodiscordance in stable relationships and about the preventive effects of ART.

Changes in Characteristics and Behavior Among African American Men Who Have Sex with Men and Women in the Context of Reductions in HIV Diagnoses Among Women Abstract Men who have sex with men and women (MSMW) connect lower prevalence populations of women to higher prevalence populations of men who have sex with men only. We hypothesize that HIV testing and treatment among MSMW have increased in recent years, and this increase can help explain the declining rates of new HIV diagnoses among African American women. We analyzed data from 2008, 2011, and 2014 of the National HIV Behavioral Surveillance system. African American men who have sex with men (MSM) were surveyed from 19 United States cities using venue-based sampling and tested for HIV infection. We used generalized estimating equations, using year of survey as an independent variable, adjusting for age, to determine differences for selected outcomes regarding healthcare and risk behaviors over time. Among the 1299 African American MSMW interviewed, significant increases were observed in the percent of men who had an HIV test in the previous 12 months (2008: 54%, 2011: 69%, and 2014: 68%, p-value < 0.001). Among HIV-positive men, the percentage of men who were aware of their infection at the time of the interview increased significantly over time (26, 35, and 48%, p-value = 0.002). Among those men, the percentage who reported currently being on antiretroviral therapy also increased significantly over time (46, 69, and 72%, p-value = 0.050). The percentage of men reporting high-risk sexual risk behaviors increased or remained stable. Our findings support the hypothesis that HIV testing and treatment has increased among African American MSM from 2008 to 2014. Additional research is needed to fully explore the population-level impact it has on HIV transmission among women.

Mental health, social support, and HIV-related sexual risk behaviors among HIV-negative adolescent sexual minority males: three U.S. cities, 2015 Abstract We examined the association between mental health issues, social support, and HIV among adolescent sexual minority males (SMM), who are disproportionally affected by HIV. National HIV Behavioral Surveillance among Young Men Who Have Sex with Men (NHBS-YMSM) data among SMM aged 13–18 years were collected in three cities (Chicago, New York City, and Philadelphia). Separate log-linked Poisson regression models were used to estimate associations between mental health issues and social support (general and family), and 3 HIV-related sexual risk behavior outcomes: past-year condomless anal intercourse (CAI) with a male partner, past-year sex with ≥ 4 partners, and first vaginal or anal sex before age 13. Of 547 adolescent SMM, 22% reported ever attempting suicide and 10% reported past-month suicidal ideation. The majority (52%) reported depression and anxiety. Thirty-nine percent reported CAI, 29% reported ≥ 4 sex partners and 22% reported first sex before age 13. Ever attempting suicide, suicidal ideation, and depression and anxiety were associated with CAI. Separately, ever attempting suicide and lack of family support were associated with  ≥ 4 sex partners. None of the mental health or support measures were associated with having sex before age 13. General social support was not associated with any sexual risk behaviors. Mental health issues are common among adolescent SMM and associated with sexual risk behaviors. Including mental health support in comprehensive HIV prevention for adolescent SMM could potentially reduce HIV risk in this population.

Interest in Pre-exposure Prophylaxis (PrEP) for HIV is Limited Among Women in a General Obstetrics & Gynecology Setting Abstract Pre-exposure prophylaxis (PrEP) is an important tool for reducing the risk of HIV acquisition, but identifying eligible and interested female patients remains difficult. We collected 144 surveys at urban Obstetrics & Gynecology clinics in Louisiana to assess interest in PrEP. Study participants were predominantly African–American (61.8%) and 45.1% had incomes of less than $20,000 per year. 84.7% of participants estimated their risk of HIV acquisition to be low. Initial interest in PrEP was moderate at 37.5% of the population. Number of partners, condom use, and self-perceived risk of HIV acquisition were associated with initial interest. After receiving more information about side effects and compliance requirements, only four of 144 (7.8% of initially interested, 2.8% of total) women remained interested in using PrEP. Concern about side effects was the major barrier to persistent interest. Further study is needed to determine how best to identify PrEP candidates in Obstetrics & Gynecology settings.

Limited Knowledge and Lack of Screening for Acute HIV Infection at Primary Care Clinics in High-Prevalence Communities of New York City Abstract Diagnosis and treatment of acute HIV infection (AHI) is crucial for ending the HIV epidemic. Individuals with AHI, who have high viral loads and often are unaware of their infection, are more likely to transmit HIV to others than those with chronic infection. In preparation for an educational intervention on AHI in primary health care settings in high HIV-prevalence areas of New York City, 22 clinic directors, 313 clinic providers, and 220 patients were surveyed on their knowledge and awareness of the topic from 2012–2015. Basic HIV knowledge was high among all groups while knowledge of AHI was partial among providers and virtually absent among patients. Inadequate knowledge about this crucial phase of HIV may be impeding timely identification of cases in the primary care setting.

Association of HIV Infection with Epilepsy and Other Comorbid Conditions Abstract Here, we aimed to investigate the associations of comorbidities in HIV patients given antiepileptic drugs. HIV patients given antiepileptic drugs for at least 6 months were considered. Comorbidities of the epileptic, HIV-positive patients were stratified according to patients' age and causes of epilepsy. Seventy-four of the 97 HIV patients identified had at least one comorbidity. Patients more than 50-years old had more comorbidities (1.9 ± 1.5 vs. 1.1 ± 1.2, p < 0.01) compared with younger subjects. The distribution of the psychiatric disorders was comparable between age-related categories. A marginally significant trend for higher frequency of psychiatric disorders was observed in patients with idiopathic epilepsy versus other causes of epilepsy (43% vs. 24%), Because the presence of comorbid disorders is a major driver for premature mortality both in HIV infection and epilepsy, strategies aimed at favoring prevention, early identification, and adequate treatment in these clinical settings should be pursued at all levels of care.

Computer-Based Substance Use Reporting and Acceptance of HIV Testing Among Emergency Department Patients Abstract More than 10 years after the Centers for Disease Control and Prevention recommended routine HIV testing for patients in emergency departments (ED) and other clinical settings, as many as three out of four patients may not be offered testing, and those who are offered testing frequently decline. The current study examines how participant characteristics, including demographics and reported substance use, influence the efficacy of a video-based intervention designed to increase HIV testing among ED patients who initially declined tests offered by hospital staff. Data from three separate trials in a high volume New York City ED were merged to determine whether patients (N = 560) were more likely to test post-intervention if: (1) they resembled people who appeared onscreen in terms of gender or race; or (2) they reported problem substance use. Chi Square and logistic regression analyses indicated demographic concordance did not significantly increase likelihood of accepting an HIV test. However, participants who reported problem substance use (n = 231) were significantly more likely to test for HIV in comparison to participants who reported either no problem substance use (n = 190) or no substance use at all (n = 125) (x2 = 6.830, p < 0.05). Specifically, 36.4% of patients who reported problem substance use tested for HIV post-intervention compared to 30.5% of patients who did not report problem substance use and 28.8% of participants who did not report substance use at all. This may be an important finding because substance use, including heavy alcohol or cannabis use, can lead to behaviors that increase HIV risk, such as sex with multiple partners or decreased condom use.

The Relationship Between Discrimination and Missed HIV Care Appointments Among Women Living with HIV Abstract Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women's Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.

Alone But Supported: A Qualitative Study of an HIV Self-testing App in an Observational Cohort Study in South Africa Abstract HIV self-testing has the potential to improve test access and uptake, but concerns remain regarding counselling and support during and after HIV self-testing. We investigated an oral HIV self-testing strategy together with a mobile phone/tablet application to see if and how it provided counselling and support, and how it might impact test access. This ethnographic study was nested within an ongoing observational cohort study in Cape Town, South Africa. Qualitative data was collected from study participants and study staff using 33 semi-structured interviews, one focus group discussion, and observation notes. The app provided information and guidance while also addressing privacy concerns. The flexibility and support provided by the strategy gave participants more control in choosing whom they included during testing. Accessibility concerns included smartphone access and usability issues for older and rural users. The adaptable access and support of this strategy could aid in expanding test access in South Africa.

The Impacts of Residential Location on the Risk of HIV Virologic Failure Among ART Users in Durban, South Africa Abstract Using a case–control study of patients receiving antiretroviral treatment (ART) in 2010–2012 at McCord Hospital in Durban, South Africa, we sought to understand how residential locations impact patients' risk of virologic failure (VF). Using generalized estimating equations to fit logistic regression models, we estimated the associations of VF with socioeconomic status (SES) and geographic access to care. We then determined whether neighborhood-level poverty modifies the association between individual-level SES and VF. Automobile ownership for men and having non-spouse family members pay medical care for women remained independently associated with increased odds of VF for patients dwelling in moderately and severely poor neighborhoods. Closer geographic proximity to medical care was positively associated with VF among men, while higher neighborhood-level poverty was positively associated with VF among women. The programmatic implications of our findings include developing ART adherence interventions that address the role of gender in both the socioeconomic and geographical contexts.

Maternal and Child Health

Associations Between Maternity Care Practices and 2-Month Breastfeeding Duration Vary by Race, Ethnicity, and Acculturation Abstract Objectives This study examines the associations between specific maternity care practices and breastfeeding duration for Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White women. Methods We analyzed data from the 2012–2014 New Mexico Pregnancy Risk Assessment Monitoring System. We used survey language as a proxy measure of acculturation and categorized women as Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White. We conducted bivariate analyses to compare rates of breastfeeding at 2 months and experiences of maternity care practices and logistic regression analysis to estimate the effects of these practices on breastfeeding duration for each group. Results Hispanic women were less likely than non-Hispanic women to breastfeed for at least 2 months (67.9% vs. 76.6%; p = 0.000); however, this varied significantly by acculturation level: 78.1% of Spanish-speaking Hispanic women compared to 66.1% of English-speaking Hispanic women breastfed for at least 2 months (p = 0.000). The effects of specific maternity care practices on duration varied across groups. Among non-Hispanic White, Native American, and English-speaking Hispanic women, breastfeeding while at the hospital had the strongest effect (AOR 2.09, 95% CI 1.67–2.61; AOR 2.71, 95% CI 2.08–3.52; and AOR 1.99, 95% CI 1.76–2.25, respectively). Among Spanish-speaking Hispanic women, being encouraged to breastfeed on demand had the strongest effect (AOR 5.179, 95% CI 3.86–6.94). Conclusions for Practice The effects of maternity care practices on breastfeeding duration vary by race, ethnicity, and acculturation level. Health care systems must acknowledge the diversity of their patient populations when seeking to develop and implement breastfeeding-friendly practices.

Intimate Partner Violence Screening in the Prenatal Period: Variation by State, Insurance, and Patient Characteristics Abstract Objective To measure the proportion of women screened for IPV during prenatal care; to assess the predictors of prenatal IPV screening. Methods We use the CDC's 2012 Pregnancy Risk Assessment Monitoring System, representative of births in 24 states and New York City (N = 28,581). We calculated descriptive and logistic regressions, weighted to deal with state-clustered observations. Results 49.2% of women in our sample reported being screened for IPV while pregnant. There were higher screening rates among women of color, and those who had not completed high school, never been married, received WIC benefits, initiated prenatal care in the first trimester, and were publicly insured. State screening rates varied (29.9–62.9%). Among states, mandated perinatal depression screening or training was positively associated with IPV screening. 3.6% of women in our sample reported prenatal IPV but were not screened during pregnancy. Conclusions for Practice Current efforts have not led to universal screening. We need to better understand when and why providers do not screen pregnant patients for IPV.

Male Partner Involvement in the Utilization of Hospital Delivery Services by Pregnant Women Living with HIV in Sub Saharan Africa: A Systematic Review and Meta-analysis Abstract Objective The level of male partner involvement in hospital delivery by pregnant women living with HIV in sub Saharan Africa (SSA) is low. We conducted a systematic review and meta-analysis to identify the approaches that are used in improving male partner involvement and their impact on the utilization of hospital delivery services by pregnant women living with HIV in SSA. Methods Ovid Medline, Embase, PsycINFO, Cochrane library, ClinicalTrials.gov, Web of Science and Current Controlled Trials were searched. Only studies carried out in SSA that reported an approach used in involving male partners and the impact on the uptake of hospital delivery services irrespective of the language and date of publication were included. Odds ratios were extracted or calculated from studies and combined in a meta-analysis using the statistical package Stata version 11.0. A forest plot was used to show the impact of various male involvement approaches. A funnel plot was used to report publication bias. Results From an initial 2316 non-duplicate articles, 08 articles were included in the systematic review and meta-analysis. The overall pooled OR was 1.56 (95% CI 1.45–1.68). After stratification, the odds ratios were: 1.51 (95% CI 1.38–1.65), 1.58 (95% CI 1.38–1.80), 3.47 (95% CI 2.16–5.58) for complex community interventions without community health workers (CHWs), complex community interventions with community health workers, and verbal encouragement respectively. The overall I-square was 91.0% but after stratification into the three different approaches, the I-squared within the complex community intervention without CHWs group was 0.0%. Conclusions for Practice Complex community interventions and verbal encouragement increase the utilization of hospital delivery services by pregnant women living with HIV in SSA. The overall heterogeneity was high but very low for studies that used complex community interventions without CHWs. More well conducted studies (including randomized controlled trials) are needed in future to add to the quality of evidence.

The South Carolina Multigenerational Linked Birth Dataset: Developing Social Mobility Measures Across Generations to Understand Racial/Ethnic Disparities in Adverse Birth Outcomes in the US South Abstract Objectives To describe the creation of a multigenerational linked dataset with social mobility measures for South Carolina (SC), as an example for states in the South and other areas of the country. Methods Using unique identifiers, we linked birth certificates along the maternal line using SC birth certificate data from 1989 to 2014, and compared the subset of records for which linking was possible with two comparison groups on sociodemographic and birth outcome measures. We created four multi-generational social mobility measures using maternal education, paternal education, presence of paternal information, and a summary score incorporating the prior three measures plus payment source for births after 2004. We compared social mobility measures by race/ethnicity. Results Of the 1,366,288 singleton birth certificates in SC from 1989 to 2014, we linked 103,194, resulting in 61,229 unique three-generation units. Mothers and fathers were younger and had lower education, and low birth weight was more common, in the multigenerational linked dataset than in the two comparison groups. Based on the social mobility summary score, only 6.3% of White families were always disadvantaged, compared to 30.4% of Black families and 13.2% of Hispanic families. Moreover, 32.8% of White families were upwardly mobile and 39.1% of Black families were upwardly mobile, but only 29.9% of Hispanic families were upwardly mobile. Conclusions for Practice When states are able to link individuals, birth certificate data may be an excellent source for examining population-level relationships between social mobility and adverse birth outcomes. Due to its location in the Deep South, the multigenerational SC dataset may be particularly useful for understanding racial/ethnic difference in social mobility and birth outcomes.

How Does the Healthfulness of the US Food Supply Compare to International Guidelines for Marketing to Children and Adolescents? Abstract Objectives Food marketing to children is pervasive and linked to increased preference and intake of unhealthy foods. The World Health Organization (WHO) developed the only multi-country nutrient criteria, and Chile recently released the world's most comprehensive regulation to identify foods that should not be marketed to children. Our objective was to examine the proportion of US packaged food and beverage products eligible for marketing to children under the WHO Europe Nutrient Profile Model (NPM) and the 2019 Chilean regulation. Methods Data for this study are from Label Insight's 2017 Open Access branded food database. Each product was assigned to one of 13 food categories, and nutritional content compared to both the NPM and Chilean criteria. The proportion of US products meeting criteria for marketing to children using both schemes was examined overall and by category. Agreement between the two criteria was examined using Cohen's Kappa. Results Of 17,740 US products, 21% were eligible to be marketed to children using the WHO criteria and 26% using the Chilean criteria. 'Egg and egg products' and 'Seafood' had the highest proportion of products eligible for marketing to children under both schemes. 'Confectionery' and 'Snack foods' had the lowest proportion eligible. Conclusions for practice The WHO NPM and Chilean criteria both restrict less healthy items from being marketed to children. Regulatory agencies in the US developing policies should consider the implementation of nutrient criteria to restrict the marketing of less healthy foods and beverages to children and adolescents.

Homelessness in Childhood and Adverse Childhood Experiences (ACEs) Abstract Objectives Research on adverse childhood experiences (ACEs) has provided a valuable framework for understanding associations between childhood maltreatment and family dysfunction and later poor health outcomes. However, increasing research suggests the number and types of childhood adversities measured warrants further examination. This study examines ACE exposure among adults who experienced homelessness in childhood, another type of childhood adversity. Methods This cross-sectional, descriptive study used the 2016 South Carolina (SC) Behavioral Risk Factor Surveillance System (BRFSS) survey and additional ACE modules to examine ACE exposure among SC adults and childhood homelessness. Standard descriptive statistics were calculated for each variable. Bivariate analysis compared types and number of ACEs by childhood homeless status. All analyses used survey sampling weights that accounted for the BRFSS sampling strategy. Results Data from 7490 respondents were weighted for analyses. Among the 215 respondents who reported homelessness in childhood, 68.1% reported experiencing four or more ACEs. In contrast, only 16.3% of respondents who reported no homelessness in childhood reported experiencing four or more ACEs. The percent of respondents was significantly higher for each of 11 ACEs among those who reported childhood homelessness, compared to those who did not. Conclusions for Practice Adults who reported homelessness in childhood also reported significantly greater exposure to higher numbers and types of ACEs than adults reporting no childhood homelessness. Study findings can be important in informing additional indicators important to the assessment of ACEs and to program developers or organizations that provide housing assistance to at-risk families and children.

Engaging Intergenerational Hispanics/Latinos to Examine Factors Influencing Childhood Obesity Using the PRECEDE–PROCEED Model Abstract Introduction Hispanics/Latinos are disproportionately affected by obesity in the U.S. Multiple factors place Hispanic/Latino children at risk for overweight, warranting guidance of a socio-ecologic approach to examine causes of obesity. The purpose of this study was to increase understanding of the factors that influence Hispanic/Latino childhood obesity through an intergenerational lens including children, parents/caregivers, and grandparents. Methods Eight focus groups were conducted with Hispanics/Latinos (N = 68 adults, N = 22 youth), using a semi-structured moderator's guide. Audio-recordings were transcribed, and thematically analyzed. Findings were categorized within the PRECEDE–PROCEED planning model. Results Adult participants were middle-aged (M = 37.8 ± 9.8 years) and youth were between the ages of 10–17 (M = 14.0 ± 1.8 years). Six themes emerged: eating habits, cultural perceptions of weight, acculturation, childhood obesity perceptions, economic issues, and generational differences. The major parental influence was lack of time to provide healthy meals due to socio-economic factors: long work hours and availability of nearby fast food options. Youth shared that childhood obesity is due to sedentary behaviors, permissive parenting and lack of parental modeling (the latter two factors often exacerbated by extended work schedules). Discussion Discordant perceptions about unhealthy eating habits emerged. Adults expressed a lack of nutritional knowledge and skills to prepare healthy meals; while adolescents emphasized permissive parenting styles and lack of discipline lead to unhealthy lifestyles in Hispanic families. Findings emphasize involving parents/caregivers and youth to understand discordant perceptions that can inform the development of prevention programs.

Leveraging Public Health Research to Inform State Legislative Policy that Promotes Health for Children and Families Abstract Purpose Engagement in policy is an essential public health service, with state legislatures serving as important arenas for activity on issues affecting children and families. However, a gap in communication often exists between policymakers and public health researchers who have the research knowledge to inform policy issues. We describe one tool for researchers to better leverage public health research to inform state legislative policymaking on issues of relevance to children and families. Description The Oregon Family Impact Seminar (OFIS), adapted from the Policy Institute for Family Impact Seminars, applies a systematic process to bring a synthesis of research findings on public health issues to state legislators using a six-step process: (1) identify candidate topics, (2) recruit legislative champions, (3) select the topic, (4) identify and prepare speakers, (5) host the presentations, and (6) develop and disseminate a research brief as a follow-up contact. Assessment Use of this model in Oregon has produced policy impact; for example, the 2015 presentation, "Two-Generation Approaches to Reduce Poverty," prompted ongoing dialogue culminating in a new statute to increase Earned Income Tax Credit for parents with young children. This approach also has strengthened relationships among researchers and legislators, which serves to streamline the OFIS process. Conclusion This model is an effective vehicle for leveraging public health research findings to inform state-level policy. This model also serves to connect researchers with opportunities to engage with policymakers to address significant public health problems, particularly those addressing social, economic, and environmental determinants of health for children and families.

Using Infant Mortality Data to Improve Maternal and Child Health Programs: An Application of Statistical Process Control Techniques for Rare Events Abstract Introduction The infant mortality rate (IMR) in the United States remains higher than most developed countries. To understand this public health issue and support state public health departments in displaying and analyzing data in ways that support learning, states participating in the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN) created statistical process control (SPC) charts for rare events. Methods State vital records data on live births and infant deaths was used to create U, T and G charts for Kansas and Alaska, two states participating in the IM CoIIN who sought methods to more effectively analyze IMR for subsets of their populations with infrequent number of deaths. The IMR and the number of days and number of births between infant deaths was charted for Kansas Non-Hispanic black population and six Alaska regions for the time periods 2013–2016 and 2011–2016, respectively. Established empirical patterns indicated points of special cause variation. Results The T and G charts for Kansas and G charts for Alaska depict points outside the upper control limit. These points indicate special cause variation and an increased number of days and/or births between deaths at these time periods. Discussion T and G charts offer value in examining rare events, and indicate special causes not detectable by U charts or other more traditional analytic methods. When small numbers make traditional analysis challenging, SPC has potential in the MCH field to better understand potential drivers of improvements in rare outcomes, inform decision making and take interventions to scale.

An Evaluation of Healthcare Use and Child Morbidity 4 Years After User Fee Removal in Rural Burkina Faso Abstract Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of user fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). ResultsWe estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI  1.0–9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0–26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9–31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that user fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.