The Epidemiology Of Primary Varicella And Herpes Zoster Hospitalizations In The Post-Varicella Vaccine Era: Connecticut, 1996-2012

Background: A vaccine for primary varicella (VZV) was licensed and recommended for use in children as a single dose in 1996, and as two doses in 2006. A vaccine for herpes zoster (HZ) was licensed and recommended for use in adults ≥60 years in 2006. Both vaccines have the potential to modify the epidemiology of VZV and HZ. Rates of hospitalization due to VZV and HZ were examined in the post-vaccine era to characterize the epidemiology of severe disease and to assess the possible impact of vaccination on the incidence of hospitalization. Methods: Statewide hospital discharge data in Connecticut were used to identify cases of VZV and HZ from 1994-2012. Trends in hospitalization rates were assessed using Poisson regression models or Mantel-Haenszel chi-square tests. Results: Primary varicella hospitalization rates declined 82.9% from the pre-vaccine (1994- 1995) to the 1-dose (2001-2005) era (p\u3c0.001). Rates further decreased significantly in the 2- dose era (2010-2012) only among 5 to 9 year olds. HZ hospitalization rates decreased in individuals 0-29 years and 30-39 years by 4.8%/year and 6.1%/year, respectively, from 2001- 2012. Individuals \u3c15 years experienced the largest decline, at 19.4%/year from 2001- 2012. Among individuals ≥60 years, hospitalization rates increased by 5.1%/year from 2001- 2006 but then decreased by 4.2%/year from 2007-2012. Conclusions: Introduction of the varicella vaccine appears to have had an impact on both varicella and HZ hospitalizations. Varicella hospitalization rates decreased across all age groups following vaccine introduction, though the main impact occurred during the 1-dose era. HZ hospitalization rates decreased among individuals \u3c15 years from 2001-2012, providing early evidence of varicella vaccine impact. The increase in HZ hospitalization rates among individuals ≥60 years 2001-2006 may be due to decreased varicella virus circulation and lack of immune boosting. However, the reduction in HZ morbidity from 2007-2012 suggests HZ vaccine, despite low usage rates, is offsetting the increase. Increased use of the HZ vaccine in individuals ≥60 years is needed to reduce hospitalization rates first to the levels seen prior to varicella vaccine introduction and then lower. Ongoing surveillance for HZ is needed to monitor anticipated long-term changes in disease epidemiology; hospital discharge data is a feasible method to do so

Composition, turnover, and mechanics of extracellular matrix in developing, aging, and pathological valves for application in the design of age-specific tissue engineered heart valves

Debilitating valve disease necessitating valve replacement affects patients of all ages, all of whom would benefit from a tissue engineered heart valve with immunocompatibility, the ability of the valve to remodel in response to altered hemodynamics or patient growth, and physiologic mechanics. However, there may be age-specific requirements for such a valve. The overarching goal of this thesis was to characterize the extracellular matrix in developing, aging, and pathological mitral and aortic valves (MV, AV) in order to provide design criteria for an age-specific tissue engineered heart valve. The extracellular matrix plays a vital role in valve function; not only does it comprise the bulk of the valve tissue, but it determines the material properties of the valve, is integrally involved in biological signaling processes, and is altered in a number of valve pathologies. To this end, the composition, structure, and material properties of normal MV and AV were characterized with particular attention paid to valve heterogeneity and aging-related changes. Valves from disease states such as functional mitral regurgitation, dilated cardiomyopathy, iatrogenic valve wounds, calcific aortic valve disease, and myxomatous mitral valve disease were also analyzed to provide negative design criteria for a tissue engineered heart valve. Lastly, preliminary work was performed in developing a tissue engineered heart valve using poly(ethylene) glycol (PEG) hydrogels and valve cells of different ages. In sum, this body of work provides necessary design criteria for an age-specific tissue engineered heart valve, but in the process of analyzing various aspects of normal and diseased MV and AV, this thesis additionally provides insight into a variety of aspects of normal valve physiology, such as the relationship between valve composition and material properties and the mechanical environment, as well as insight into various valve diseases, such as the role of MV remodeling in functional mitral regurgitation and disease progression, with potential clinical implications for patients with these diseases

Time Out of General Surgery Specialty training in the UK:A National Database Study

ObjectiveGeneral surgery specialty training in the United Kingdom takes 6 years and allows trainees to take time out of training. Studies from the United States have highlighted an increasing trend for taking time out of surgical training for research. This study aimed to evaluate trends in time out of training and the impact on the duration of UK general surgical specialty training.Design, setting, and participantsA cohort study using routinely collected surgical training data from the Intercollegiate Surgical Curriculum Program database for General surgery trainees registered from August 1, 2007. Trainees were classified as Completed Training or In-Training. Out of training periods were identified and time in training calculated (both unadjusted and adjusted for out of training periods) with a predicted time in training for those In-Training.ResultsOf the trainees still In-Training (n = 994), a greater proportion had taken time out of training compared with those who had completed training (n = 360; 54.5% vs 45.9%, p < 0.01). A greater proportion of the In-Training group had undertaken a formal research period compared with the Completed Training group (35.1% vs 6.1%, p < 0.01). Total unadjusted training time in the Completed Training group was a median 6.0 (interquartile range 6.0-7.0) years compared with a predicted unadjusted training time in the In-Training group, with an out of training period recorded, of a median 8.0 (interquartile range 7.0-9.0) years.ConclusionsTrainees are increasingly taking time out of surgical training, particularly for research, with a subsequent increase in total time of training. This should be considered when redesigning surgical training programs and planning the future surgical workforce

Changing Autonomy in Operative Experience Through UK General Surgery Training:A National Cohort Study

Objectives:To determine the operative experience of UK general surgery trainees and assess the changing procedural supervision and acquisition of competency assessments through the course of training.Background Summary Data: Competency assessment is changing with concepts of trainee autonomy decisions (termed entrustment decisions) being introduced to surgical training.Methods: Data from the Intercollegiate Surgical Curriculum Programme (ISCP) and the eLogbook databases for all UK General Surgery trainees registered from 1st August 2007 who had completed training were used. Total and index procedures (IP) were counted and variation by year of training assessed. Recorded supervision codes and competency assessment outcomes for IPs were assessed by year of training.Results: We identified 311 trainees with complete data. Appendicectomy was the most frequently undertaken IP during first year of training (mean procedures (mp) = 26) and emergency laparotomy during final year of training (mp = 27). The proportion of all IPs recorded as unsupervised increased through training (

Time out of general surgery specialty training in the UK: a national database study

Objective:General surgery specialty training in the UK takes 6 years and allows trainees to take time out of training. Studies from the USA have highlighted an increasing trend for taking time out of surgical training for research. This study aimed to evaluate trends in time out of training and the impact on the duration of UK general surgical specialty training. Design, setting and participants: A cohort study using routinely collected surgical training data from the Intercollegiate Surgical Curriculum Programme (ISCP) database for General Surgery trainees registered from 1st August 2007. Trainees were classified as Completed Training or In-Training. Out of training periods were identified and time in training calculated (both unadjusted and adjusted for out of training periods) with a predicted time in training for those In-Training. Results: Of the trainees still In-Training (n=994), a greater proportion had taken time out of training compared with those who had completed training (n=360) (54.5% vs 45.9%, p<0.01). A greater proportion of the In-Training group had undertaken a formal research period compared to the Completed Training group (35.1% vs 6.1%, p<0.01). Total unadjusted training time in the Completed Training group was a median 6.0 (IQR 6.0- 7.0) years compared with a predicted unadjusted training time in the In-Training group, with an out of training period recorded, of a median 8.0 (IQR 7.0- 9.0) years. Conclusions: Trainees are increasingly taking time out of surgical training, particularly for research, with a subsequent increase in total time of training. This should be considered when redesigning surgical training programmes and planning the future surgical workforce

Time out of general surgery specialty training in the UK: a national database study

Objective:General surgery specialty training in the UK takes 6 years and allows trainees to take time out of training. Studies from the USA have highlighted an increasing trend for taking time out of surgical training for research. This study aimed to evaluate trends in time out of training and the impact on the duration of UK general surgical specialty training. Design, setting and participants: A cohort study using routinely collected surgical training data from the Intercollegiate Surgical Curriculum Programme (ISCP) database for General Surgery trainees registered from 1st August 2007. Trainees were classified as Completed Training or In-Training. Out of training periods were identified and time in training calculated (both unadjusted and adjusted for out of training periods) with a predicted time in training for those In-Training. Results: Of the trainees still In-Training (n=994), a greater proportion had taken time out of training compared with those who had completed training (n=360) (54.5% vs 45.9%, p<0.01). A greater proportion of the In-Training group had undertaken a formal research period compared to the Completed Training group (35.1% vs 6.1%, p<0.01). Total unadjusted training time in the Completed Training group was a median 6.0 (IQR 6.0- 7.0) years compared with a predicted unadjusted training time in the In-Training group, with an out of training period recorded, of a median 8.0 (IQR 7.0- 9.0) years. Conclusions: Trainees are increasingly taking time out of surgical training, particularly for research, with a subsequent increase in total time of training. This should be considered when redesigning surgical training programmes and planning the future surgical workforce

Life-Expectancy Disparities Among Adults With HIV in the United States and Canada: The Impact of a Reduction in Drug- and Alcohol-Related Deaths Using the Lives Saved Simulation Model.

Improvements in life expectancy among people living with human immunodeficiency virus (PLWH) receiving antiretroviral treatment in the United States and Canada might differ among key populations. Given the difference in substance use among key populations and the current opioid epidemic, drug- and alcohol-related deaths might be contributing to the disparities in life expectancy. We sought to estimate life expectancy at age 20 years in key populations (and their comparison groups) in 3 time periods (2004-2007, 2008-2011, and 2012-2015) and the potential increase in expected life expectancy with a simulated 20% reduction in drug- and alcohol-related deaths using the novel Lives Saved Simulation model. Among 92,289 PLWH, life expectancy increased in all key populations and comparison groups from 2004-2007 to 2012-2015. Disparities in survival of approximately a decade persisted among black versus white men who have sex with men and people with (vs. without) a history of injection drug use. A 20% reduction in drug- and alcohol-related mortality would have the greatest life-expectancy benefit for black men who have sex with men, white women, and people with a history of injection drug use. Our findings suggest that preventing drug- and alcohol-related deaths among PLWH could narrow disparities in life expectancy among some key populations, but other causes of death must be addressed to further narrow the disparities

Lifestyle and Other Factors Explain One-Half of the Variability in the Serum 25-Hydroxyvitamin D Response to Cholecalciferol Supplementation in Healthy Adults

Background: Many factors have been associated with serum 25-hydroxyvitamin D [25(OH)D] concentrations in observational studies, with variable consistency. However, less information is available on factors affecting the magnitude of changes in serum 25(OH)D resulting from vitamin D supplementation

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme