Background: Wildfire events are increasing in prevalence in the western United States. Research has found mixed results on the degree to which exposure to wildfire smoke is associated with an increased risk of mortality. Methods: We tested for an association between exposure to wildfire smoke and non-traumatic mortality in Washington State, USA. We characterized wildfire smoke days as binary for grid cells based on daily average PM 2.5 concentrations, from June 1 through September 30, 2006-2017. Wildfire smoke days were defined as all days with assigned monitor concentration above a PM 2.5 value of 20.4 μg/m 3 , with an additional set of criteria applied to days between 9 and 20.4 μg/m 3. We employed a case-crossover study design using conditional logistic regression and time-stratified referent sampling, controlling for humidex. Results: The odds of all-ages non-traumatic mortality with same-day exposure was 1.0% (95% CI: − 1.0-4.0%) greater on wildfire smoke days compared to non-wildfire smoke days, and the previous day's exposure was associated with a 2.0% (95% CI: 0.0-5.0%) increase. When stratified by cause of mortality, odds of same-day respiratory mortality increased by 9.0% (95% CI: 0.0-18.0%), while the odds of same-day COPD mortality increased by 14.0% (95% CI: 2.0-26.0%). In subgroup analyses, we observed a 35.0% (95% CI: 9.0-67.0%) increase in the odds of same-day respiratory mortality for adults ages 45-64. Conclusions: This study suggests increased odds of mortality in the first few days following wildfire smoke exposure. It is the first to examine this relationship in Washington State and will help inform local and state risk communication efforts and decision-making during future wildfire smoke events.

Nitrogen oxides ( NO x ) are ubiquitous pollutants in outdoor and indoor air. However, epidemiologic studies that evaluate health effects associated with NO x commonly rely upon outdoor concentrations of NO x , nitrogen dioxide ( NO 2 ), or residence characteristics as surrogates for personal exposure. In this study, personal exposures ( 48 h ) and corresponding indoor and outdoor concentrations of nitric oxide ( NO ), NO 2 , and NO x were measured ( July -September ) in 39 adults and 9 children from 23 households in Richmond, Virginia, using Ogawa passive NO x monitors. Demographic, time -activity patterns, and household data were collected by questionnaire and used to develop exposure prediction models. Adults had higher NO 2 , NO, and NO x exposures ( means: 16, 63, and 79 ppb, respectively ) than children ( 13, 49, and 62 ppb ). Measurements taken in bedrooms ( 18, 57, and 75 ppb ) and living rooms ( 19, 65, and 84 ppb ) surpassed measurements taken outdoors ( 15, 21, and 36 ppb ). In indoor locations, NO x concentrations were influenced largely by NO, and consequently, personal exposure prediction models for NO x were reflective of models for NO. Statistical models that best predicted personal exposures included indoor measurements; outdoor measurements contributed relatively little to personal exposure. Close to 70% of the variation in personal NO 2 and NO x exposure was explained by two variable models ( bedroom NO 2 and time spent in other indoor locations; bedroom NO x and time spent in kitchen ). Given appropriate resources, measurement error in epidemiologic studies can be reduced significantly with the use of personal exposure measurements or prediction models developed from indoor measurements and survey data.

Cardiorespiratory symptoms precede gastrointestinal symptoms of intestinal dysfunction. Targeting signs and symptoms in an early warning tool to identify intestinal dysfunction can impact NEC severity progression.

Chronic liver disease is increasingly prevalent and, as the population ages, geriatricians will see an increasing burden. We present an overview of the investigation and management of older adults with chronic parenchymal liver disease and highlight the potential roles of transjugular intrahepatic portosytemic shunts and orthotopic liver transplantation.

Background Human milk–based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk–based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines. Methods Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population. Results Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution’s size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution. Conclusions The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.