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Descriptive statistics of the demographic characteristics of the general study population (n = 222), 18–29-year-old population (n = 48), and population identifying as women (n = 122) Variable General Population n (%) 18-29-Year-Old Population n (%) Women n (%) Categorical Age  18–29 48 (21.6) 48 (100.0) 28 (23.0)  30–39 15 (6.8) - 11 (9.0)  40–49 30 (13.5) - 13 (10.7)  50–59 53 (23.9) - 34 (27.9)  60 and older 42 (18.9) - 19 (15.6)  Unknown 34 (15.3) - 17 (13.9) Gender Identity  Man 97 (43.7) 20 (41.7) -  Woman 122 (55.0) 28 (58.3) 122 (100.0)  Unknown 3 (1.4) 0 (0.0) - Race  Black/African American 4 (1.8) 1 (2.1) 3 (2.5)  White/Caucasian 209 (94.1) 45 (93.8) 116 (95.1)  Unknown 9 (4.1) 2 (4.2) 3 (2.5) Ethnicity  Hispanic or Latino 7 (3.2) 1 (2.1) 3 (2.5)  Not Hispanic or Latino 149 (67.1) 35 (72.9) 86 (70.5)  Unknown 66 (29.7) 12 (25.0) 33 (27.0) SASTP (Self-Assessed Skin Tone)  A: 1–3 115 (51.8) 27 (56.3) 64 (52.5)  B: 1–3 101 (45.5) 20 (41.7) 55 (45.1)  C: 1–3 6 (2.7) 1 (2.1) 3 (2.5) [See PDF for image] Fig. 1 Bar graphs of the survey answers by study population. (a) Positive association between categorical age and the number of sun protection methods (p < 0.001). (b) Individuals 18–23 years old (n = 23) used significantly fewer sun protection methods than 24–29-year-olds (n = 25) (p = 0.001). (c) Positive association between categorical age and sunscreen use (p < 0.001). Material preparation, data collection and analysis were performed by Ryan Murphy, Camille Moeckel, Jill Stachowski, Amy Longenecker, and Charlene Lam, MD. The first draft of the manuscript was written by Ryan Murphy, Camille Moeckel, and Jill Stachowski, and all authors commented on previous versions of the manuscript. Ethics approval Deemed exempt research by the Penn State College of Medicine Institutional Review Board; study ID:

To evaluate the efficacy of a femtosecond laser assisted astigmatic keratotomy (AK) nomogram (FemtoAK.com) for correction of astigmatism during cataract surgery. Consecutive patients underwent cataract extraction with AKs and insertion of a non-toric intraocular lens. Eyes with greater than 0.5 D of against-the-rule (ATR) or 1.0 D of with-the-rule (WTR) or oblique (OBL) astigmatism were treated in accordance with the nomogram. Optical biometry and manifest refraction were checked pre- and one-month post-operatively. Outcome measures included correction index (CI), index of success (IOS), and proportion of eyes with less than 0.5 and 1.0 D of astigmatism. Ninety-five eyes from 69 patients were included, of which 41 had ATR, 35 had WTR, and 19 had OBL astigmatism. Corneal CI (ATR = 0.86, WTR = 0.27) indicated a small and large under-correction of ATR and WTR astigmatism, respectively, while refractive CI revealed a near-ideal correction of WTR (ATR = 0.87, WTR = 1.02). The proportion of eyes with less than 0.5 and 1.0 D of refractive astigmatism increased from 28% and 54% pre-operatively to 56% and 92% post-operatively, respectively. The FemtoAK nomogram is effective at reducing corneal astigmatism at the time of cataract surgery. Astigmatic correction was more precise when evaluated by refractive rather than corneal measures.

Hidradenitis Suppurativa (HS) is a chronic, scarring, inflammatory skin disease affecting hair follicles in axillae, inguinal, and anogenital regions. Dysbiosis in HS patients compared to healthy subjects is documented. However, whether dysbiosis is specific to particular body sites or skin niches is unknown. We investigated the follicular and skin surface microbiome of the axilla and groin of HS patients (n=11) and healthy individuals (n=10) using 16S rRNA gene sequencing (V3-V4). We sampled non-lesional (HSN) and lesional skin (HSL) of HS patients. β-diversity was significantly decreased (p<0.05) in HSN and HSL skin compared to normal skin with loss of body site and skin niche heterogeneity in HS samples. The relative bacterial abundance of specific microbes was also significantly different between normal and HSN (15 genera) or HSL (21 genera) skin. Smoking and alcohol use influenced the β-diversity (p<0.08) in HS skin. We investigated metabolic profiles of bacterial communities in HS and normal skin using a computational approach. Metabolism, Genetic Information Processing, and Environmental Information Processing were significantly different between normal and HS samples. Altered metabolic pathways associated with dysbiosis of HS skin suggest mechanisms underlying the disease pathology and information about treatment with drugs targeting those pathways.

To address workforce shortages and expand access to care, we developed a telemedicine program incorporating existing infrastructure for delivery of cardiovascular care in Gulu, Northern Uganda. Our study had three objectives: 1) assess feasibility and clinical impact 2) evaluate patient/parent satisfaction and 3) estimate costs. All cardiology clinic visits during a two-year study period were included. All patients received an electrocardiogram and echocardiogram performed by a local nurse in Gulu which were stored and transmitted to the Uganda Heart Institute in the capital of Kampala for remote consultation by a cardiologist. Results were relayed to patients/families following cardiologist interpretation. The following telemedicine process was utilized: 1) clinical intake by nurse in Gulu; 2) ECG and echocardiography acquisition in Gulu; 3) echocardiography transmission to the Uganda Heart Institute in Kampala, Uganda; 4) remote telemedicine consultation by cardiologists in Kampala; and 5) communication of results to patients/families in Gulu. Clinical care and technical aspects were tracked. Diagnoses and recommendations were analyzed by age groups (0-5 years, 6-21 years, 22-50 years and > 50 years). A mixed methods approach involving interviews and surveys was used to assess patient satisfaction. Healthcare sector costs of telemedicine-based cardiovascular care were estimated using time-driven activity-based costing. Normal studies made up 47%, 55%, 76% and 45% of 1,324 patients in the four age groups from youngest to oldest. Valvular heart disease (predominantly rheumatic heart disease) was the most common diagnosis in the older three age groups. Medications were prescribed to 31%, 31%, 24%, and 48% of patients in the four age groups. The median time for consultation was 7 days. A thematic analysis of focus group transcripts displayed an overall acceptance and appreciation for telemedicine, citing cost- and time-saving benefits. The cost of telemedicine was $29.48/visit. Our data show that transmission and interpretation of echocardiograms from a remote clinic in northern Uganda is feasible, serves a population with a high burden of heart disease, has a significant impact on patient care, is favorably received by patients, and can be delivered at low cost. Further study is needed to better assess the impact relative to existing standards of care and cost effectiveness.

Background Cardiology care may be beneficial for risk factor management in people living with HIV (PLWH), yet limited information is available about the referral process from the perspectives of HIV specialists and cardiologists. Methods We conducted 28 qualitative interviews at academic medical centers in the United States from December 2019 to February 2020 using components of the Specialty Referral Process Framework: referral decision, entry into referral care, and care integration. We analyzed the data using applied thematic analysis. Results Reasons for cardiology referral most commonly included secondary prevention, uncontrolled risk factors, cardiac symptoms, and medication management. Facilitators in the referral process included ease of referral, personal relationships between HIV specialists and cardiologists, and close proximity of the clinic to the patient’s home. Barriers included lack of transportation, transportation costs, insurance coverage gaps, stigma, and patient reluctance. Conclusions Our results will inform future studies on implementation strategies aimed at improving the specialty referral process for PLWH. Trial Registration ClinicalTrials.gov Identifier: NCT04025125 .

Rheumatic fever, an immune sequela of untreated streptococcal infections, is an important contributor to global cardiovascular disease. The goal of this study was to describe trends, characteristics, and cost burden of children discharged from hospitals with a diagnosis of RF from 2000 to 2012 within the United States. Using the Kids' Inpatient Database, we examined characteristics of children discharged from hospitals with the diagnosis of rheumatic fever over time including: overall hospitalisation rates, age, gender, race/ethnicity, regional differences, payer type, length of stay, and charges. The estimated national cumulative incidence of rheumatic fever in the United States between 2000 and 2012 was 0.61 cases per 100,000 children. The median age was 10 years, with hospitalisations significantly more common among children aged 6-11 years. Rheumatic fever hospitalisations among Asian/Pacific Islanders were significantly over-represented. The proportion of rheumatic fever hospitalisations was greater in the Northeast and less in the South, although the highest number of rheumatic fever admissions occurred in the South. Expected payer type was more likely to be private insurance, and the median total hospital charges (adjusted for inflation to 2012 dollars) were $16,000 (interquartile range: $8900-31,200). Median length of stay was 3 days, and the case fatality ratio for RF in the United States was 0.4%. Rheumatic fever persists in the United States with an overall downwards trend between 2003 and 2012. Rheumatic fever admissions varied considerably based on age group, region, and origin.

Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1-19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.

ObjectivesRheumatic heart disease (RHD) remains a major driver of cardiovascular morbidity and mortality in low-resource settings. Registry-based care for RHD has been advocated as a powerful tool to improve clinical care and track quality metrics. Data collected through an RHD registry may also reveal epidemiological and geospatial trends, as well as insight into care utilisation. Uganda established a central RHD registry at the country’s only tertiary cardiac centre in 2010. In 2014 RHD care and registry enrolment expanded to the Western region and in 2015 to the North. Here, we examine the geographical distribution of RHD cases in Uganda and the impact of registry expansion.MethodsA retrospective search of the Ugandan national RHD registry was preformed to capture all cases of acute rheumatic fever or clinical RHD from January 2010 through July 2016. A geospatial analysis revealed that the density of detected cases (cases/100 000 district residents) reflected proximity to an RHD registry enrolment centre. Regionalisation improved the number of cases detected in the regions of expansion and improved retention of patients in care.Results and conclusionsRHD appears to have uniform distribution throughout Uganda with geographical clustering surrounding RHD registry enrolment centres reflecting access to care, rather than differences in prevalence. Higher rates of case detection and improved retention in care with regionalisation highlight the urgent need for decentralisation of cardiovascular services. Future studies should examine sustainable models for cardiovascular care delivery, including task shifting of clinical care and echocardiography and use of telemedicine.