Epidemiological investigations of the foodborne parasitic illness cyclosporiasis can be aided by molecular techniques that enable the identification of genetically related clusters of Cyclospora isolates. At the Centers for Disease Control and Prevention (CDC), routine Cyclospora genotyping for the purpose of informing epidemiological outbreak investigations has occurred since 2018 using clinical stool specimens from case patients diagnosed with cyclosporiasis. This approach involves targeted amplicon deep sequencing of eight genotyping markers, followed by bioinformatic processing through a custom clustering algorithm. However, not all stool specimens submitted to the CDC for genotyping successfully amplify for at least five of the eight genotyping markers, the minimum required to be bioinformatically processed through the clustering algorithm. In this study, we utilized information from clinical stool specimens sent to the CDC from the years 2019 to 2023 to assess if the type of preservative, the age of the specimen, or the method used to diagnose the patient influenced the probability of successfully genotyping parasites from a fecal specimen. Additionally, we assessed the analytical specificity of the Cyclospora genotyping workflow by analyzing samples positive for other intestinal parasites, including closely related non-human infecting Cyclospora species and other coccidia. We found that stool specimens stored in preservatives had a greater likelihood of sequencing success over time relative to specimens without preservatives or those stored in non-nutritive transport media. Additionally, stool specimens from case patients diagnosed via microscopy-based methods were more likely to yield DNA of sufficient quality and quantity for genotyping compared to PCR or multiplex panels. Lastly, we determined that the genotyping workflow has an analytical specificity of 100%, as no non-human-infecting Cyclospora or other parasites yielded sequence data at >1 of the genotyping markers. This knowledge will help strengthen the quality of Cyclospora genotyping data produced in the future, improving the utility of this data for supporting epidemiological investigations.IMPORTANCEDetermining the genetic relatedness among parasites causing foodborne illness, such as Cyclospora, is a valuable tool to complement outbreak investigations. However, this molecular genotyping approach is limited by the quality and quantity of genetic data obtained from the samples being investigated. In this study, we demonstrate that the storage conditions of clinical stool specimens are correlated to the quality of sequence data produced for Cyclospora genotyping. Our insights can be used to guide storage recommendations for stool specimens, which can improve the quality of foodborne illness outbreak investigations conducted in the future. Additionally, we showed that the current Cyclospora genotyping tool used by the Centers for Disease Control (CDC) is highly specific to human-infecting Cyclospora parasites; this valuable information indicates that the CDC's Cyclospora investigations are not negatively impacted by false-positive detections.

BACKGROUND: Drowning causes more than 4500 deaths annually and is the leading cause of death among children aged 1-4 years old in the USA. Isolation pool fencing (ie, four-sided fencing to limit access from all adjoining areas including residences and yards) and use of US Coast Guard-approved life jackets while boating can prevent drowning, but preventable deaths still occur. This study aimed to estimate the annual health and economic burden of drowning likely attributable to inadequate pool fencing and not wearing life jackets while boating to highlight the unrealised value of these known prevention strategies. METHODS: A simple mathematical model used the most recent annual number of drowning deaths by decedent age in combination with previous study data to estimate the number of drowning deaths that might have been prevented through: (1) adequate isolation fencing for swimming pools among children aged <5 years old and (2) use of life jackets while boating for people of all ages. Prevention effectiveness estimates of pool fencing and life jackets were based on previous studies. Unit costs for drowning-related medical spending and avoidable mortality using the value of statistical life were from existing sources. RESULTS: Proper use of swimming pool isolation fencing and always wearing a life jacket while boating could prevent an estimated 348 US drowning deaths and an economic cost of US$4.5 billion per year. CONCLUSIONS: Highlighting the effectiveness of drowning prevention strategies can help inform public attention to this issue and support cost-effective public health decision-making.

INTRODUCTION: This paper is a systematic review of evidence from economic evaluations of family-based interventions that was recommended by the Community Preventive Services Task Force (CPSTF) to prevent substance use among youth. METHODS: The search covered studies published from inception of databases through October 2023 and was limited to those based in the United States (U.S.) and other high-income countries. The present review reports results from peer-reviewed studies and government reports as separate sources of evidence. Analyses were conducted during June 2023 through September 2024. Monetary values are in 2023 U.S. dollars. RESULTS: The search yielded 11 peer-reviewed studies and two government reports, one from the Washington State Institute for Public Policy (WSIPP) that evaluated 14 programs and one from the Substance Abuse and Mental Health Administration (SAMHSA) that evaluated 8 programs. The median intervention cost ranged from $655 to $1,672 per family and $677 to $753 per youth or participant across the 3 sources of evidence. The median benefit to cost ratio were 5.8, 3.9, and 8.9 from peer-reviewed studies, WSIPP, and SAMHSA, respectively, with all three estimates indicating that benefits exceed cost. SAMHSA's report found some interventions to be cost-saving and the others to have a median cost per quality-adjusted life years (QALY) gained of $21,426. DISCUSSION: CPSTF determined cost-benefit evidence across the three sources showed societal benefits exceeded cost of family-based interventions to prevent substance use among youth. CPSTF determined there were not enough peer-reviewed studies to reach a conclusion about cost-effectiveness.

Global risk maps are an important tool for assessing the global threat of mosquito and tick-transmitted arboviral diseases. Public health officials increasingly rely on risk maps to understand the drivers of transmission, forecast spread, identify gaps in surveillance, estimate disease burden, and target and evaluate the impact of interventions. Here, we describe how current approaches to mapping arboviral diseases have become unnecessarily siloed, ignoring the strengths and weaknesses of different data types and methods. This places limits on data and model output comparability, uncertainty estimation and generalisation that limit the answers they can provide to some of the most pressing questions in arbovirus control. We argue for a new generation of risk mapping models that jointly infer risk from multiple data types. We outline how this can be achieved conceptually and show how this new framework creates opportunities to better integrate epidemiological understanding and uncertainty quantification. We advocate for more co-development of risk maps among modellers and end-users to better enable risk maps to inform public health decisions. Prospective validation of risk maps for specific applications can inform further targeted data collection and subsequent model refinement in an iterative manner. If the expanding use of arbovirus risk maps for control is to continue, methods must develop and adapt to changing questions, interventions and data availability.

Parabens are widely used preservatives with endocrine-disrupting properties, but their role in glucose metabolism during pregnancy is unclear. This study examines prospective associations between urinary concentrations of four parabens in early and mid-pregnancy and gestational diabetes (GDM). A matched case-control study nested within a diverse longitudinal pregnancy cohort (PETALS) with universal GDM screening matched GDM cases to two controls (111 cases; 222 controls). Urine samples collected 2015-2017 in early (14 ± 2.3 weeks) and mid-pregnancy (20 ± 2.4 weeks) were analyzed for paraben concentrations with mass spectrometry. Area-under-the-time-concentration-curve (AUC) assessed cumulative exposure. Conditional logistic regression models evaluated associations between paraben concentrations and GDM, adjusting for covariates. We a priori examined effect modification by Asian/Pacific Islander (A/PI) race/ethnicity due to the case-control matching and GDM prevalence highest among A/PI. Participants were 31 ± 5 years old and 40 % A/PI, 33 % Hispanic, 14 % White and 9 % Black. Methylparaben and propylparaben had >94 % detection, while ethylparaben and butylparaben ranged from 22 %-51 %. Paraben exposure was not associated with GDM overall. Among A/PI, higher methylparaben concentrations exhibited higher odds of GDM: early-pregnancy OR 1.14 per IQR (95 % CI: 0.89,1.45) and AUC 1.07 (0.89,1.30) compared to non-A/PI (early-pregnancy 0.81 [0.62,1.06] and AUC 0.70 [0.44,1.12]; P(interaction) = 0.01 and 0.03, respectively). A/PI mid-pregnancy ethylparaben exposure (detectable vs non-detectable) was linked to higher GDM odds (2.00 [0.84,4.76] vs. non-A/PI 0.47 [0.17,1.27]; P(interaction) = 0.04) as was mid-pregnancy propylparaben exposure (Tertile 2 vs. 1: 3.67 [1.21,11.1] vs. non-A/PI 0.70 [0.22, 2.25]; P(interaction) = 0.04). Although overall paraben exposure was not associated with GDM, interactions by A/PI race/ethnicity suggested potential increased odds of GDM related to propylparaben, methylparaben, and ethylparaben exposure. Future studies should explore paraben exposure in diverse populations.

BACKGROUND: Surveillance of traumatic brain injury (TBI) in the USA has historically relied on healthcare administrative datasets, but these methods likely undercount the true burden of TBI. Self-report measures may help obtain more comprehensive estimates. A fundamental question is whether TBI prevalence estimated through self-report varies by whether and how TBI signs and symptoms are ascertained in the survey question(s). METHODS: Self-report data were collected from 4303 adults in the summer wave of Porter Novelli's 2023 ConsumerStyles survey. Respondents were randomised to receive a question about their 12-month experience of head injury and a grouped list of TBI signs/symptoms or a question about their 12-month experience of head injury and an option to select individual TBI signs and symptoms that resulted from the head injury. All respondents who indicated they experienced a head injury received a set of follow-up questions. RESULTS: A significantly higher percentage of people who received the 'individual signs/symptoms' question self-reported a TBI (8.3%) than those who received the 'grouped signs/symptoms' question (4.3%) χ(2)=19.6, p<0.0001. Among TBI cases identified, there were no statistical differences between question type in relation to whether the respondent reported being evaluated for or diagnosed with a TBI, nor any demographic differences. CONCLUSIONS: These results demonstrate that how TBI is ascertained in a survey can meaningfully impact reporting of TBI prevalence and provides evidence that question wording and structure affect estimates on national surveys.

PURPOSE: Surveillance of traumatic brain injury (TBI) in the United States has historically relied on healthcare administrative datasets, but these sources likely underestimate the true burden of TBI. Surveys that ask individuals to self- or proxy-report their experiences with their injuries are an alternative source for surveillance. This paper provides results from a large national survey that ascertained TBI among sampled adults and children. METHODS: Data from the 2023 National Health Interview Survey, a nationally representative household survey of the civilian non-institutionalized US population, were examined. Descriptive and bivariate statistics of demographic and injury characteristics of children and adults who sustained a TBI in the past 12 months were calculated. RESULTS: Analyses reveal that 3.0% (n=9,757,000) of Americans (3.3% of adults and 2.2% of children (aged ≤17 years)) reported a TBI in the past year. Among children who sustained a TBI in the past year, over half (55.5%) sustained their TBI during a sport or recreational activity, and 62.4% were evaluated by a medical professional. The prevalence of TBI and injury characteristics varied by select demographics. CONCLUSION: These findings demonstrate that TBI affects a large number of Americans and highlight the value of TBI surveillance through nationally representative surveys, providing a broad picture of prevalence, healthcare utilization, and setting of injury.

OBJECTIVES: This manuscript describes traumatic brain injury (TBI)-related mortality in the United States during 2021, by geography, sociodemographic characteristics, mechanism of injury, and injury intent. METHOD: Multivariable modeling of TBI mortality was performed to assess the simultaneous effect of multiple factors (geographic region, sex, race and ethnicity, and age) included in the model. Authors analyzed multiple-cause-of-death data from the National Vital Statistics System and included records when an International Classification of Diseases, Tenth Revision (ICD-10) underlying cause of death injury code, and a TBI-related ICD-10 diagnosis code were both listed. RESULTS: During 2021, there were 69,473 TBI-related deaths. Rates were highest among older adults, males, and non-Hispanic American Indian/Alaska Native persons. A large proportion of all TBI-related deaths were attributed to unintentional falls and suicides. Model-based rates of TBI mortality revealed a divergent pattern with increasing rates by age group, while rate ratios simultaneously declined with age among specific racial/ethnic groups when compared with non-Hispanic White persons. CONCLUSION: Findings indicate unintentional falls and suicides remain a common cause of fatal TBI and specific groups are disproportionally affected by such injuries. Health care providers can play a role by assessing patients at increased risk for TBI and providing referrals for care and culturally tailored interventions when warranted.

More than 60 percent of US adults report that they had adverse childhood experiences (ACEs). For this study of 930,000 children born during the period 1999-2003, we used linked administrative, survey, and criminal justice data to measure the association between ACEs (parental death; separation; incarceration; or criminal charge for intimate partner violence, substance use disorder, or child sexual or nonsexual abuse) and socioeconomic disadvantages at ages 18-22 during 2017-21. After childhood socioeconomic status was controlled for, young adults with ACEs were more likely to have been charged with felonies, have become teenage parents, live in a household with poverty or housing assistance, be enrolled in Medicaid, and be employed, and were less likely to be enrolled in an educational institution. These outcomes were most likely among young adults with multiple ACEs or lower childhood socioeconomic status. Using new linked data opportunities, this study provides large-scale, person-level longitudinal evidence of the long-lasting and substantial societal cost of ACEs.

BACKGROUND: Widespread use of pneumococcal conjugate vaccines (PCVs) has reduced vaccine-type invasive pneumococcal disease (IPD). We describe the serotype distribution of IPD after extensive use of ten-valent PCV (PCV10; Synflorix, GSK) and 13-valent PCV (PCV13; Prevenar 13, Pfizer) globally. METHODS: IPD data were obtained from surveillance sites participating in the WHO-commissioned Pneumococcal Serotype Replacement and Distribution Estimation (PSERENADE) project that exclusively used PCV10 or PCV13 (hereafter PCV10 and PCV13 sites, respectively) in their national immunisation programmes and had primary series uptake of at least 70%. Serotype distribution was estimated for IPD cases occurring 5 years or more after PCV10 or PCV13 introduction (ie, the mature period when the serotype distribution had stabilised) using multinomial Dirichlet regression, stratified by PCV product and age group (<5 years, 5-17 years, 18-49 years, and ≥50 years). FINDINGS: The analysis included cases occurring primarily between 2015 and 2018 from 42 PCV13 sites (63 362 cases) and 12 PCV10 sites (6806 cases) in 41 countries. Sites were mostly high income (36 [67%] of 54) and used three-dose or four-dose booster schedules (44 [81%]). At PCV10 sites, PCV10 serotypes caused 10·0% (95% CI 6·3-12·9) of IPD cases in children younger than 5 years and 15·5% (13·4-19·3) of cases in adults aged 50 years or older, while PCV13 serotypes caused 52·1% (49·2-65·4) and 45·6% (40·0-50·0), respectively. At PCV13 sites, PCV13 serotypes caused 26·4% (21·3-30·0) of IPD cases in children younger than 5 years and 29·5% (27·5-33·0) of cases in adults aged 50 years or older. The leading serotype at PCV10 sites was 19A in children younger than 5 years (30·6% [95% CI 18·2-43·1]) and adults aged 50 years or older (14·8% [11·9-17·8]). Serotype 3 was a top-ranked serotype, causing about 9% of cases in children younger than 5 years and 14% in adults aged 50 years or older at both PCV10 and PCV13 sites. Across all age and PCV10 or PCV13 strata, the proportion of IPD targeted by higher-valency PCVs beyond PCV13 was 4·1-9·7% for PCV15, 13·5-36·0% for PCV20, 29·9-53·8% for PCV21, 15·6-42·0% for PCV24, and 31·5-50·1% for PCV25. All top-ten ranked non-PCV13 serotypes are included in at least one higher-valency PCV. INTERPRETATION: The proportion of IPD due to serotypes included in PCVs in use was low in mature PCV10 and PCV13 settings. Serotype distribution differed between PCV10 and PCV13 sites and age groups. Higher-valency PCVs target most remaining IPD and are expected to extend impact. FUNDING: Bill & Melinda Gates Foundation as part of the WHO Pneumococcal Vaccines Technical Coordination Project.

BACKGROUND: Traumatic brain injury (TBI) is a common injury in children. Though research on youth TBI has largely focused on high school students, this study describes selected school outcomes after TBI in the past 12 months among children aged 5-17 years. METHODS: Data from parent-proxy respondents from the pilot administration of the National Concussion Surveillance System (a random-digit-dial telephone survey with over 10,000 adult respondents) were examined. Descriptive statistics of demographic and injury characteristics of children who sustained a TBI were calculated. The association between TBI signs/symptoms and selected school outcomes were determined by multinomial logistic regressions. RESULTS: Among the 3557 children sampled via parent-proxy-reporting, 9.9% sustained a TBI in the past year. Changes in sleep or being more tired than usual, trouble concentrating, sensitivity to light or noise, and difficulty learning or remembering new things were associated with a greater risk of worse school outcomes following a TBI. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: To promote a positive return to learn (RTL) experience among children following TBI, school districts may prioritize accommodations (e.g., breaks in learning, extra time for assignments) and implement existing ascending levels of academic support where warranted. CONCLUSION: These findings may inform stakeholders seeking to enhance RTL and provide needed support or services for school-aged children who sustain a TBI.

PURPOSE: To investigate differences in teen-reported and parent-reported lifetime prevalence estimates of traumatic brain injury (TBI) symptoms, TBI evaluation, and TBI diagnosis among a nationally representative sample of teenagers aged 12-17 years old and their parents. METHODS: Parent-reported data from the 2021 to 2022 National Health Interview Survey linked with teen-reported data from the National Health Interview Survey-Teen July 2021-December 2022 (n = 1,153) were analyzed. Lifetime prevalence estimates for TBI symptoms (e.g., selected symptoms as a result of a blow or jolt to the head), history of evaluation by health professional for TBI (i.e., TBI evaluation), and TBI diagnosis stratified by sociodemographic characteristics and reporter type were produced, and z-tests were conducted to test for differences. Concordance measures were calculated to assess agreement between teen and parent survey responses to TBI measures. RESULTS: Lifetime prevalence of TBI symptoms varied by reporter type across all sociodemographic characteristics with teen-report consistently producing higher estimates. Estimates of TBI evaluation varied by reporter type only among older teens, non-Hispanic teens, and teens who participated in sports; there was no difference for TBI diagnosis. Percent agreement between the 2 reporters ranged from 73% to 95%, prevalence-adjusted bias-adjusted kappa ranged from 0.45 to 0.90, and Cohen's kappa ranged from 0.22 to 0.63. DISCUSSION: There was general agreement for observable outcomes TBI evaluation and TBI diagnosis, but discordance existed in reports of TBI symptoms. These findings suggest that youth self-report of TBI symptoms may enhance surveillance efforts.

INTRODUCTION: Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) experience cognitive problems with attention, information processing speed, working memory, learning efficiency, and executive function. Commonly, patients report worsening of cognitive symptoms over time after physical and/or cognitive challenges. To determine, monitor, and manage longitudinal decrements in cognitive function after such exposures, it is important to be able to screen for cognitive dysfunction and changes over time in clinic and also remotely at home. The primary objectives of this paper were: (1) to determine whether a brief computerized cognitive screening battery will detect differences in cognitive function between ME/CFS and Healthy Controls (HC), (2) to monitor the impact of a full-day study visit on cognitive function over time, and (3) to evaluate the impact of exercise testing on cognitive dysfunction. METHODS: This cognitive sub-study was conducted between 2013 and 2019 across seven U.S. ME/CFS clinics as part of the Multi-Site Clinical Assessment of ME/CFS (MCAM) study. The analysis included 426 participants (261 ME/CFS and 165 HC), who completed cognitive assessments including a computerized CogState Brief Screening Battery (CBSB) administered across five timepoints (T0-T4) at the start of and following a full day in-clinic visit that included exercise testing for a subset of participants (182 ME/CFS and 160 HC). Exercise testing consisted of ramped cycle ergometry to volitional exhaustion. The primary outcomes are performance accuracy and latency (performance speed) on the computerized CBSB administered online in clinic (T0 and T1) and at home (T2-T4). RESULTS: No difference was found in performance accuracy between ME/CFS and HCs whereas information processing speed was significantly slower for ME/CFS at most timepoints with Cohen's d effect sizes ranging from 0.3-0.5 (p < 0.01). The cognitive decline over time on all CBSB tasks was similar for patients with ME/CFS independent of whether exercise testing was included in the clinic visit. CONCLUSION: The challenges of a clinic visit (including cognitive testing) can lead to further cognitive deficits. A single short session of intense exercise does not further reduce speed of performance on any CBSB tasks.

IMPORTANCE: Many recent advances in pediatric concussion care are implemented by specialists; however, children with concussion receive care across varied locations. Thus, it is critical to identify which children have access to the most up-to-date treatment strategies. OBJECTIVE: To evaluate differences in the sociodemographic and community characteristics of pediatric patients who sought care for concussion across various points of entry into a regional health care network. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included children seen for concussions across a regional US health care network from January 1, 2017, to August 4, 2023. Pediatric patients aged 0 to 18 years who received an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification code for concussion were included. The study took place at emergency department (ED) and outpatient (primary care [PC] and specialty care [SC]) settings. EXPOSURES: Age at visit, biological sex, parent-identified race and ethnicity, payer type, median income and percentage of adults with a bachelor's degree for home zip code, and overall and subdomain Child Opportunity Index (COI) score based on patient address. MAIN OUTCOMES AND MEASURES: The association of exposures with point of entry of ED, PC, and SC were examined in both bivariate analysis and a multinomial logistic regression. RESULTS: Overall, 15 631 patients were included in the study (median [IQR] age, 13 [11-15] years; 7879 [50.4%] male; 1055 [6.7%] Hispanic, 2865 [18.3%] non-Hispanic Black, and 9887 [63.7%] non-Hispanic White individuals). Race and ethnicity were significantly different across settings (1485 patients [50.0%] seen in the ED were non-Hispanic Black vs 1012 [12.0%] in PC and 368 [8.7%] in SC; P < .001) as was insurance status (1562 patients [52.6%] seen in the ED possessed public insurance vs 1624 [19.3%] in PC and 683 [16.1%] in SC; P < .001). Overall and individual COI subdomain scores were also significantly different between settings (overall COI median [IQR]: ED, 30 [9-71]; PC, 87 [68-95]; SC, 87 [69-95]; P < .001). Race, insurance status, and overall COI had the strongest associations with point of entry in the multivariable model (eg, non-Hispanic Black patients seen in the ED compared with non-Hispanic White patients: odds ratio, 2.03; 95% CI, 1.69-2.45). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, children with concussion seen in the ED setting were more likely to be non-Hispanic Black, have public insurance, and have a lower Child Opportunity Index compared with children cared for in the PC or SC setting. This highlights the importance of providing education and training for ED clinicians as well as establishing up-to-date community-level resources to optimize care delivery for pediatric patients with concussion at high risk of care inequities.

This cohort study examines the association of reuse of N95 filtering facepiece respirators and N95 filtration efficiency. | eng

BACKGROUND: Chronic overlapping pain conditions (COPCs), pain-related conditions that frequently occur together, may occur in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and could impact illness severity. This study aimed to identify comorbid COPCs in patients with ME/CFS and evaluate their impact on illness severity. METHODS: We used data from 923 participants in the Multi-Site Clinical Assessment of ME/CFS study, conducted in seven U.S. specialty clinics between 2012 and 2020, who completed the baseline assessment (595 ME/CFS and 328 healthy controls (HC)). COPCs included chronic low back pain (cLBP), chronic migraine/headache (cMHA), fibromyalgia (FM), interstitial cystitis/irritable bladder (IC/IB), irritable bowel syndrome (IBS), temporomandibular disorder (TMD). Illness severity was assessed through questionnaires measuring symptoms and functioning. Multivariate analysis of variance and analysis of covariance models were used for analyses. Log-binomial regression analyses were used to compute prevalence of COPCs and prevalence ratios (PR) between groups with 95% confidence intervals. Both unadjusted and adjusted results with age and sex are presented. RESULTS: 76% of participants with ME/CFS had at least one COPCs compared to 17.4% of HC. Among ME/CFS participants, cMHA was most prevalent (48.1%), followed by FM (45.0%), cLBP (33.1%), and IBS (31.6%). All individual COPCs, except TMD, were significantly more frequent in females than males. The unadjusted PR (ME/CFS compared to HC) was highest for FM [147.74 (95% confidence interval (CI) = 20.83-1047.75], followed by cLBP [39.45 (12.73-122.27)], and IC/IB [13.78 (1.88-101.24)]. The significance and order did not change after age and sex adjustment. The COPC comorbidities of cLBP and FM each had a significant impact on most health measures, particularly in pain attributes (Cohen's d effect size 0.8 or larger). While the impact of COPC comorbidities on non-pain attributes and quality of life measures was less pronounced than that on pain, statistically significant differences between ME/CFS participants with and without COPCs were still evident. CONCLUSIONS: More than 75% of ME/CFS participants had one or more COPCs. Multiple COPCs further exacerbated illness severity, especially among females with ME/CFS. Assessment and management of COPCs may help improve the health and quality of life for patients with ME/CFS.

This economic evaluation uses nationwide public health data to evaluate incidence and economic costs of homicides and nonfatal assault injuries among US adults aged 60 years or older. | eng

CONTEXT: International Classification of Diseases (ICD) codes are used for billing but also for surveillance for injuries such as traumatic brain injuries (TBI). While specificity is possible in the ICD-10-CM scheme, use of the code for unspecified injury of head (SO9.9) remains high. OBJECTIVES: This process evaluation sought to understand medical ICD-10-CM coding behaviors for TBI in emergency department (ED) settings. DESIGN: Semi-structured interviews explored the processes that facilitate or hinder ED physicians from selecting specific ICD codes for TBI and potential points of intervention for increased coding specificity and reducing the use of unspecified codes. SETTING: Video interviews were conducted with a nationwide sample in the United States. PARTICIPANTS: A purposive snowball sampling strategy was used to recruit 26 ED physicians with experience diagnosing TBI. INTERVENTION: Semi-structured interviews identified factors related to the selection of specific ICD codes for head injury. MAIN OUTCOME MEASURE: Thematic analysis of transcribed data. RESULTS: Four main themes emerged from the data: the impact of training and expertise, factors related to diagnosis, unclear connections with medical coders, and actionable recommendations. Interviews underscored the context surrounding "unspecified" codes for TBI, including demands from patient care, time pressures, issues around how a diagnosis may impact patient management decisions, and considerations related to mapping within the electronic medical record (EMR) where options may default to an unspecified code. CONCLUSIONS: Findings from this analysis indicate that ED providers may benefit from more robust training on how documentation can better support ICD-10-CM coding for this type of trauma. Revised EMR structures could support efficient coding specificity and clarity.

BACKGROUND: Alcohol-exposed pregnancies, which can lead to fetal alcohol spectrum disorders (FASDs), is one of the most common preventable causes of lifelong intellectual and developmental disabilities in the U.S. Healthcare teams can play a critical role in preventing FASDs; however, they are currently unprepared to do so. Training can remediate this problem. This article explores the different approaches to the education and training of healthcare providers around FASD prevention used by six Centers for Disease Control (CDC)-funded programs, and how they have been adapted to (1) the specific needs of the healthcare professionals and/or the clinical setting and (2) the challenges posed by the COVID-19 pandemic. METHODS: This article offers an in-depth description and comparison of the models utilized by the programs described, detailing the challenges of each model as well as the adaptations made. Interdisciplinary collaboration and review highlights these models and offers a variety of solutions and lessons learned that can be implemented in similar practice settings and/or educational initiatives. RESULTS: Based on organizational structure (i.e., national organization, educational institution, and clinical settings) and program purpose, different methods were employed for FASD education. Some programs were focused on FASD prevention through staff training and alcohol screening and brief intervention/clinical intervention and others were focused on broadscale professional education and awareness. Improvements were made on an ongoing basis as challenges related to COVID-19, staff shortages, and patient and clinician discomfort were identified, resulting in modifications to content and delivery modality (e.g., online forums and use of social media). CONCLUSION: FASD prevention education is wrought with a variety of challenges related to stigma, discomfort, and misinformation, which these programs encountered in a variety of ways.

CONTEXT: In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the "unspecified head injury" code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED. OBJECTIVE: This evaluation explores medical coders' perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED. DESIGN: This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders' perspectives, processes, and coding determinations for head injuries in the ED. SETTING: Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023. PARTICIPANTS: Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15 years of experience. MAIN OUTCOMES: Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders' assumptions and code determination processes. RESULTS: Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes. CONCLUSIONS: This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.

OBJECTIVE: Surveillance of traumatic brain injury (TBI), including concussion, in the United States has historically relied on healthcare administrative datasets, but these methods likely underestimate the true burden of TBI. The Centers for Disease Control and Prevention (CDC) has recently added TBI prevalence questions to several national surveys. The objective of this article is to summarize their recent efforts and report TBI prevalence estimates. SETTING: Surveys. PARTICIPANTS: Adult and youth respondents to a series of national surveys. DESIGN: Recent nationally representative surveys with either 12-month or lifetime TBI prevalence questions were identified. MAIN MEASURES: For each data source, survey methodology, TBI definition, question wording, and prevalence estimates were examined. RESULTS: TBI prevalence varied depending on the question wording and data source. Overall 12-month prevalence of concussion/TBI among adults ranged from 2% to 12% while overall lifetime prevalence of concussion or TBI ranged from 19% to 29%. Overall 12-month prevalence of concussion/TBI among children and adolescents was 10% while 12-month prevalence of sports- and recreation-related concussion for youth ranged from 7% to 15%. Overall lifetime prevalence of TBI among youth ranged from 6% to 14%. CONCLUSION: Survey data based on self-reported concussions and TBIs resulted in larger prevalence estimates than would be expected based on traditional surveillance methods. Analyses of the various surveys shows that how the questions are asked and what terminology is used can notably affect the estimates observed. Efforts can be made to optimize and standardize data collection approaches to ensure consistent measurement across settings and populations.

OBJECTIVE: Injuries and poisoning are leading causes of US morbidity and mortality. This study aimed to update medical and work loss cost estimates per injured person. METHODS: Injuries treated in emergency departments (ED) during 2019-2020 were analysed in terms of mechanism (eg, fall) and intent (eg, unintentional), as well as traumatic brain injury (TBI) (multiple mechanisms and intents). Fatal injury medical spending was based on the Nationwide Emergency Department Sample and National Inpatient Sample. Non-fatal injury medical spending and workplace absences (general, short-term disability and workers' compensation) were analysed among injury patients with commercial insurance or Medicaid and matched controls during the year following an injury ED visit using MarketScan databases. RESULTS: Medical spending for injury deaths in hospital EDs and inpatient settings averaged US$4777 (n=57 296) and US$45 678 per fatality (n=89 175) (2020 USD). Estimates for fatal TBI were US$5052 (n=5363) and US$47 952 (n=37 184). People with ED treat and release visits for non-fatal injuries had on average US$5798 (n=895 918) in attributable medical spending and US$1686 (11 missed days) (n=116 836) in work loss costs during the following year, while people with non-fatal injuries who required hospitalisation after an ED injury visit had US$52 246 (n=32 976) in medical spending and US$7815 (51 days) (n=4473) in work loss costs. Estimates for non-fatal TBI were US$4529 (n=25 792), US$1503 (10 days) (n=1631), US$51 241 (n=3030) and US$6110 (40 days) (n=246). CONCLUSIONS AND RELEVANCE: Per person costs of injuries and violence are important to monitor the economic burden of injuries and assess the value of prevention strategies.

Cross jurisdictional collaboration efforts and emergency vaccine plans that are consistent with Tribal sovereignty are essential to public health emergency preparedness. The widespread adoption of clearly written federal, state, and local vaccine plans that address fundamental assumptions in vaccine distribution to Tribal nations is imperative for future pandemic response.

INTRODUCTION: Concussions sustained during sports and recreational activities are a concern for young athletes. The purpose of this study was to estimate past 12-month sport- and recreation-related (SRR) traumatic brain injuries (TBIs) among a sample of children. METHODS: Pilot data from the Centers for Disease Control and Prevention's National Concussion Surveillance System were analyzed. National Concussion Surveillance System utilized a cross-sectional random-digit-dial telephone survey using computer-assisted telephone interviewing to collect self/proxy-reported data from 2018 to 2019. Adults with children aged 5-17 in the household were asked about head injuries sustained by their children. Estimates were stratified by sociodemographic and injury circumstance characteristics. Data analysis occurred from April 2022 to July 2023. RESULTS: Utilizing a tiered case definition developed by the Centers for Disease Control and Prevention, an estimated 6.9% (95% confidence interval [CI], 6.0%-7.8%) of the sample's 5-17-year-old children sustained at least one probable or possible SRR-TBI in the previous 12 months; 3.3% (95% CI, 2.7%-4.0%) of the children sustained at least one probable SRR-TBI. An estimated 63.6% (95% CI, 58.1%-69.0%) of all reported TBIs were attributed to SRR activities. Of the SRR-TBIs reported, 41.1% (95% CI, 33.0%-49.2%) were experienced while playing contact sports. Symptoms did not resolve for 8 or more days or had not resolved at the time of the interview for 18.1% (95% CI, 13.0%-23.1%) of the children's most recent SRR-TBI. CONCLUSIONS: Many proxy-reported TBIs among children aged 5-17 years were due to sports and recreational activities. Athletic trainers and healthcare providers can play a role in the prevention, identification, and management of SRR-TBIs in their respective environments.

Recent cyclosporiasis outbreaks associated with fresh produce grown in the United States highlight the need to better understand C. cayetanensis prevalence in U.S. agricultural environments. In this study, C. cayetanensis occurrence was assessed in municipal wastewater sludge, on-farm portable toilets, irrigation pond water, and spent packing house dump tank water in a Southeastern Georgia growing region over two years. Detection of the C. cayetanensis 18S rRNA qPCR gene target in pond samples was 0%, 28%, and 42% (N=217) depending on the detection definition used, and ≤ 1% in dump tank samples (N=46). However, no qPCR detections were confirmed by sequencing, suggesting false detection occurred due to cross-reactions. C. cayetanensis qPCR detections were confirmed in 9% of wastewater sludge samples (N=76). The human-specific fecal markers HF183 and crAssphage were detected in 33% and 6% of pond samples, respectively and 4% and 0% of dump tank samples, respectively. Despite community Cyclospora shedding and evidence of human fecal contamination in irrigation water, there was no correlation between C. cayetanensis and HF183 qPCR detections, further supporting that 18S gene target qPCR amplifications were due to cross reactions. When evaluating C. cayetanensis qPCR environmental detection data, the impact of assay specificity and detection criteria should be considered. Moreover, additional sequence-based testing may be needed to appropriately interpret Cyclospora qPCR environmental data.

BACKGROUND: Reports of fluconazole-resistant Candida parapsilosis bloodstream infections are increasing. We describe a cluster of fluconazole-resistant C parapsilosis bloodstream infections identified in 2021 on routine surveillance by the Georgia Emerging Infections Program in conjunction with the Centers for Disease Control and Prevention. METHODS: Whole-genome sequencing was used to analyze C parapsilosis bloodstream infections isolates. Epidemiological data were obtained from medical records. A social network analysis was conducted using Georgia Hospital Discharge Data. RESULTS: Twenty fluconazole-resistant isolates were identified in 2021, representing the largest proportion (34%) of fluconazole-resistant C parapsilosis bloodstream infections identified in Georgia since surveillance began in 2008. All resistant isolates were closely genetically related and contained the Y132F mutation in the ERG11 gene. Patients with fluconazole-resistant isolates were more likely to have resided at long-term acute care hospitals compared with patients with susceptible isolates (P = .01). There was a trend toward increased mechanical ventilation and prior azole use in patients with fluconazole-resistant isolates. Social network analysis revealed that patients with fluconazole-resistant isolates interfaced with a distinct set of healthcare facilities centered around 2 long-term acute care hospitals compared with patients with susceptible isolates. CONCLUSIONS: Whole-genome sequencing results showing that fluconazole-resistant C parapsilosis isolates from Georgia surveillance demonstrated low genetic diversity compared with susceptible isolates and their association with a facility network centered around 2 long-term acute care hospitals suggests clonal spread of fluconazole-resistant C parapsilosis. Further studies are needed to better understand the sudden emergence and transmission of fluconazole-resistant C parapsilosis.

Cyclospora cayetanensis is a foodborne parasite that causes cyclosporiasis, an enteric illness in humans. Genotyping methods are used to genetically discriminate between specimens from cyclosporiasis cases and can complement source attribution investigations if the method is sufficiently sensitive for application to food items. A very sensitive targeted amplicon sequencing (TAS) assay for genotyping C. cayetanensis encompassing 52 loci was recently designed. In this study, we analyzed 66 genetically diverse clinical specimens to assess the change in phylogenetic resolution between the TAS assay and a currently employed eight-marker scheme. Of the 52 markers, ≥50 were successfully haplotyped for all specimens, and these results were used to generate a hierarchical cluster dendrogram. Using a previously described statistical approach to dissect hierarchical trees, the 66 specimens resolved into 24 and 27 distinct genetic clusters for the TAS and an 8-loci scheme, respectively. Although the specimen composition of 15 clusters was identical, there were substantial differences between the two dendrograms, highlighting the importance of both inclusion of additional genome coverage and choice of loci to target for genotyping. To evaluate the ability to genetically link contaminated food samples with clinical specimens, C. cayetanensis was genotyped from DNA extracted from raspberries inoculated with fecal specimens. The contaminated raspberry samples were assigned to clusters with the corresponding clinical specimen, demonstrating the utility of the TAS assay for traceback efforts.

BACKGROUND: Children aged 0-4 years have the highest rate of emergency department (ED) visits for traumatic brain injury (TBI); falls are the leading cause. Infants younger than 2 years are more likely to sustain a fractured skull after a fall. OBJECTIVE: This study examined caregiver actions and products associated with ED visits for fall-related fractured skulls in infants aged 0-4 months. METHODS: Data were analyzed from the 2001-2017 National Electronic Injury Surveillance System-All Injury Program. Case narratives of infants aged 0-4 months who visited an ED for a fall-related skull fracture were examined to code caregiver actions preceding the fall. Product codes determined fall location and product type involved (e.g., flooring, bed, or stairs). All national estimates were weighted. RESULTS: There were more than 27,000 ED visits (weighted estimate) of infants aged 0-4 months for a nonfatal fall-related fractured skull between 2001 and 2017. Most were younger than 2 months (46.7%) and male (54.4%). Falls occurred primarily in the home (69.9%) and required hospitalization (76.4%). Primary caregiver actions coded involved placing (58.6%), dropping (22.7%), and carrying an infant (16.6%). Floor surfaces were the most common product (mentioned in 24.0% of the cases). CONCLUSIONS: Fall-related fractured skulls are a health and developmental concern for infants, highlighting the importance of a comprehensive assessment at the time of the injury to better understand adult actions. Findings indicated the need to develop prevention messages that include safe carrying and placement of infants.

Per- and polyfluoroalkyl substances (PFAS) are related to various adverse health outcomes, and food is a common source of PFAS exposure. Dietary sources of PFAS have not been adequately explored among U.S. pregnant individuals. We examined associations of dietary factors during pregnancy with PFAS concentrations in maternal plasma and human milk in the New Hampshire Birth Cohort Study. PFAS concentrations, including perfluorohexane sulfonate (PFHxS), perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), perfluorononanoate (PFNA), and perfluorodecanoate (PFDA), were measured in maternal plasma collected at ~28 gestational weeks and human milk collected at ~6 postpartum weeks. Sociodemographic, lifestyle and reproductive factors were collected from prenatal questionnaires and diet from food frequency questionnaires at ~28 gestational weeks. We used adaptive elastic net (AENET) to identify important dietary variables for PFAS concentrations. We used multivariable linear regression to assess associations of dietary variables selected by AENET models with PFAS concentrations. Models were adjusted for sociodemographic, lifestyle, and reproductive factors, as well as gestational week of blood sample collection (plasma PFAS), postpartum week of milk sample collection (milk PFAS), and enrollment year. A higher intake of fish/seafood, eggs, coffee, or white rice during pregnancy was associated with higher plasma or milk PFAS concentrations. For example, every 1 standard deviation (SD) servings/day increase in egg intake during pregnancy was associated with 4.4 % (95 % CI: 0.6, 8.4), 3.3 % (0.1, 6.7), and 10.3 % (5.6, 15.2) higher plasma PFOS, PFOA, and PFDA concentrations respectively. Similarly, every 1 SD servings/day increase in white rice intake during pregnancy was associated with 7.5 % (95 % CI: -0.2, 15.8) and 12.4 % (4.8, 20.5) greater milk PFOS and PFOA concentrations, respectively. Our study suggests that certain dietary factors during pregnancy may contribute to higher PFAS concentrations in maternal plasma and human milk, which could inform interventions to reduce PFAS exposure for both birthing people and offspring.