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Wastewater-based surveillance is a promising approach for proactive outbreak monitoring. SARS-CoV-2 is shed in stool early in the clinical course and infects a large asymptomatic population, making it an ideal target for wastewater-based monitoring. In this study, we develop a laboratory protocol to quantify viral titers in raw sewage via qPCR analysis and validate results with sequencing analysis. Our results suggest that the number of positive cases estimated from wastewater viral titers is orders of magnitude greater than the number of confirmed clinical cases and therefore may significantly impact efforts to understand the case fatality rate and progression of disease. These data may help inform decisions surrounding the advancement or scale-back of social distancing and quarantine efforts based on dynamic wastewater catchment-level estimations of prevalence. Wastewater surveillance represents a complementary approach to clinical surveillance to measure the presence and prevalence of emerging infectious diseases like the novel coronavirus SARS-CoV-2. This innovative data source can improve the precision of epidemiological modeling to understand the penetrance of SARS-CoV-2 in specific vulnerable communities. Here, we tested wastewater collected at a major urban treatment facility in Massachusetts and detected SARS-CoV-2 RNA from the N gene at significant titers (57 to 303 copies per ml of sewage) in the period from 18 to 25 March 2020 using RT-qPCR. We validated detection of SARS-CoV-2 by Sanger sequencing the PCR product from the S gene. Viral titers observed were significantly higher than expected based on clinically confirmed cases in Massachusetts as of 25 March. Our approach is scalable and may be useful in modeling the SARS-CoV-2 pandemic and future outbreaks. IMPORTANCE Wastewater-based surveillance is a promising approach for proactive outbreak monitoring. SARS-CoV-2 is shed in stool early in the clinical course and infects a large asymptomatic population, making it an ideal target for wastewater-based monitoring. In this study, we develop a laboratory protocol to quantify viral titers in raw sewage via qPCR analysis and validate results with sequencing analysis. Our results suggest that the number of positive cases estimated from wastewater viral titers is orders of magnitude greater than the number of confirmed clinical cases and therefore may significantly impact efforts to understand the case fatality rate and progression of disease. These data may help inform decisions surrounding the advancement or scale-back of social distancing and quarantine efforts based on dynamic wastewater catchment-level estimations of prevalence.

There has been increasing interest in the use of home monitoring technologies during the COVID-19 pandemic to decrease interpersonal contacts and the resultant risks of exposure for people to the coronavirus SARS-CoV-2. This Perspective explores how the accelerated development of these technologies also raises major concerns pertaining to safety and privacy. We make recommendations for needed interventions to ensure safety and review best practices and US regulatory requirements for privacy and security. We discuss, among other topics, Emergency Use Authorizations for medical devices and privacy laws of the USA and Europe. Home monitoring technologies are being rushed to market during the COVID-19 pandemic; here, safety and privacy considerations are discussed.

Purpose of ReviewTraditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP.Recent FindingsPharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively.SummaryNew and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.

Scaling Up Point-of-Care Fentanyl TestingAlthough fentanyl is now the dominant driver of the U.S. opioid epidemic, our health care system has struggled to adapt toxicology screening practices to this reality.

Smartphone-based digital phenotyping uses built-in sensors and usage patterns to passively capture behavioral and environmental data relevant to health and has been applied extensively in mental health and chronic disease contexts. This review synthesizes studies that use smartphone-based digital phenotyping, defined as approaches that rely exclusively on onboard smartphone sensors to characterize specific health conditions. To our knowledge, this work provides the most comprehensive cross-condition synthesis of smartphone-based digital phenotyping to date, spanning mental health, physical health, and substance use disorders (SUDs), and highlighting common practices, gaps, and opportunities for future research. We conducted a scoping review of English-language, peer-reviewed papers published between 2012 and 2025 in Google Scholar, IEEE Xplore, ACM Digital Library, and PubMed using terms such as \"mobile sensing\" and \"digital phenotyping.\" Eligible papers used onboard smartphone sensors to assess health and went beyond self-report. Studies that did not rely on smartphone auxiliary sensing modalities or digital phenotyping were excluded. We performed a descriptive synthesis of study characteristics, sensors, and health domains. Of 111 papers identified, 65 met inclusion criteria. Most studies were observational and relied on passive sensing. Sample sizes ranged from fewer than 10 to over 18,000 participants, with a median of 52 (IQR=26-126). Mental health conditions were most frequently examined, including depression (n=16), bipolar disorder (n=11), stress or anxiety (n=10), and schizophrenia (n=8). Less commonly studied conditions included SUDs (n=7), Parkinson disease (n=4), and sleep apnea (n=2). Sensor streams varied widely and included diverse passive smartphone data sources capturing mobility, communication, device usage, environmental context, and user interaction patterns. Ground-truth measurements most commonly relied on validated clinical scales (eg, Patient Health Questionnaire-9, Young Mania Rating Scale [YMRS], and Pittsburgh Sleep Quality Index; n=41), followed by ecological momentary assessments (n=18), clinician-confirmed diagnoses (n=9), and physiological measures such as polysomnography (n=3). Across studies, recurring methodological limitations included incomplete or inconsistent sensor descriptions, limited reporting of data quality (eg, sampling rates and missingness), and heterogeneous validation practices. These issues limit comparability and reproducibility and underscore the need for clearer reporting standards and greater data availability. This scoping review provides the first comprehensive synthesis of smartphone-only digital phenotyping studies spanning mental health, physical health, and SUDs. Unlike prior reviews, this work maps behavioral associations derived exclusively from smartphone sensors across a broad range of health domains. The primary contribution of this review lies in its consolidation of behavioral associations observed across studies, enabling researchers to correlate new findings to the existing evidence base and identify opportunities for replication, extension, or clinical translation. Collectively, these findings highlight both the promise of smartphone-based digital phenotyping in real-world settings and the need for improved standardization to support translation into clinical and public health applications.

•Semistructured interviews of patients with cancer consuming medical cannabis were analyzed using applied thematic analysis.•Preparation type, administration route, and dosing of medical cannabis vary dramatically among patients with cancer.•This study suggests the need for cannabis therapeutics educational programs and standardization of dispensary products. Medical cannabis (MC) is used by 1 in 3 patients with cancer. Scientific work suggests a disconnect between patients’ cannabis therapeutics practices and oncologists’ clinical preferences. This qualitative study explores the preferences of patients with cancer as they relate to MC formulations, administration routes, and dosing. Semistructured interviews were conducted with patients with cancer consuming MC in 8 states and examined using thematic analysis. Among study participants (N = 24), the mean age was 54 years, 67% were female, and 51% had metastatic disease. A powerful theme identified across interviews was of myriad MC dispensary product formulations, triggering astonishment and burden. Common strategies among participants included purchasing and sampling multiple store-bought formulations, modifying dispensary products, and altering intended routes of administration. Preferred dispensary products were not consistently available. Top-cited modes of administration included oral, followed by topical, sublingual, vaporization, combustion, and rectal suppository. Three-quarters of participants alternated between modes. Medical cannabis dosing imprecision represented another powerful theme due to the lack of dispensary quality assurance and accuracy in home measurements. This investigation suggests that MC preparations, dosing, and administration routes vary among patients with cancer, and that common consumption patterns (for instance, reliance on multiple routes of cannabis administration) are not rooted in science. Although these findings should be further interrogated, they suggest a need for lay-facing cannabis therapeutics education and standardization of dispensary products to strengthen cannabis-related care.

ObjectivesTo compare the impact of respirator extended use and reuse strategies with regard to cost and sustainability during the COVID-19 pandemic.DesignCost analysis.SettingUSA.ParticipantsAll healthcare workers within the USA.InterventionsNot applicable.Main outcome measuresA model was developed to estimate usage, costs and waste incurred by several respirator usage strategies over the first 6 months of the pandemic in the USA. This model assumed universal masking of all healthcare workers. Estimates were taken from the literature, government databases and commercially available data from approved vendors.ResultsA new N95 respirator per patient encounter would require 7.41 billion respirators, cost $6.38 billion and generate 84.0 million kg of waste in the USA over 6 months. One respirator per day per healthcare worker would require 3.29 billion respirators, cost $2.83 billion and generate 37.22 million kg of waste. Decontamination by ultraviolet germicidal irradiation would require 1.64 billion respirators, cost $1.41 billion and accumulate 18.61 million kg of waste. H2O2 vapour decontamination would require 1.15 billion respirators, cost $1.65 billion and produce 13.03 million kg of waste. One reusable respirator with daily disposable filters would require 18 million respirators, cost $1.24 billion and generate 15.73 million kg of waste. Pairing a reusable respirator with H2O2 vapour-decontaminated filters would reduce cost to $831 million and generate 1.58 million kg of waste. The use of one surgical mask per healthcare worker per day would require 3.29 billion masks, cost $460 million and generate 27.92 million kg of waste.ConclusionsDecontamination and reusable respirator-based strategies decreased the number of respirators used, costs and waste generated compared with single-use or daily extended-use of disposable respirators. Future development of low-cost,simple technologies to enable respirator and/or filter decontamination is needed to further minimise the economic and environmental costs of masks.

To assess the impact of winning a wishbone contest on the likelihood of subsequent goal attainment. Prospective cohort study. A large urban academic emergency department in the United States. 40 frontline emergency department clinicians including supervising and resident physicians and physician assistants. Participants were enrolled between December 8, 2023 and January 10, 2024 and followed for three months. The primary outcomes were feasibility of performing wishbone contests in the emergency department and attainment of a pre-specified wish by the end of the three-month follow-up period. Forty participants who met eligibility criteria were enrolled in the study and 37 completed follow-up at three months. Half identified as female and professional roles (resident physician, attending physician and physician assistant) were equally distributed. Overall, 38% of wishes were realized at three month follow-up. There was no association between winning the wishbone competition and realizing the wish. Participants who perceived a greater degree of control over the outcome of their wish were more likely to have their wish realized (RR1.2, 95% CI 1.05-1.37). Frontline healthcare workers will engage in luckiness-boosting wishbone contests even in a busy emergency department environment. In our study, there was no association between winning the wishbone competition and goal or wish achievement. Participants who reported and perceived a greater degree of control over the outcome of their wish, however, were more likely to have their wish realized. Holiday cheer and wishful thinking traditions may indicate the feasibility of future work in extending positive thinking among frontline healthcare workers.

A large number of medications and medical devices removed from the market by the US Food and Drug Administration over the past 4 decades specifically posed greater health risks to women. This article reviews the historical background of sex and gender in clinical research policy and describes several approved drugs and devices targeted for use in women that have caused major morbidity and mortality. The intended population for the medications and devices, population affected, approval process, and the basic and legal actions taken against the medication/drug company are also discussed. It is recognized that women are still at risk for harm from unsafe medications and devices, and continued improvements in legislation that promotes inclusion of sex and gender into the design and analysis of research will improve safety for both men and women.

Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks. A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017. 383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25%) where the route of exposure was known. Explosive devices were used in 21% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25% and 12% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0%), tear gas (20.8%), and cyanide (15.6%). Blood agent incidents declined from 32.6% before the September 11, 2001 attacks to 13.6% after 2001, while nerve agent attacks fell from 9.3% to 1.2%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7% to 48.1% and from 2.3% to 6.2% of attacks, respectively. Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.