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Burn care remains among the most complex of the time-sensitive treatment interventions in medicine today. An enormous quantity of specialized resources are required to support the critical and complex modalities needed to meet the conventional standard of care for each patient with a critical burn injury. Because of these dependencies, a sudden surge of patients with critical burn injuries requiring immediate and prolonged care following a burn mass casualty incident (BMCI) will place immense stress on healthcare system assets, including supplies, space, and an experienced workforce (staff). Therefore, careful planning to maximize the efficient mobilization and rational use of burn care resources is essential to limit morbidity and mortality following a BMCI. The U.S. burn care profession is represented by the American Burn Association (ABA). This paper has been written by clinical experts and led by the ABA to provide further clarity regarding the capacity of the American healthcare system to absorb a surge of burn-injured patients. Furthermore, this paper intends to offer responders and clinicians evidence-based tools to guide their response and care efforts to maximize burn care capabilities based on realistic assumptions when confronted with a BMCI. This effort also aims to align recommendations in part with those of the Committee on Crisis Standards of Care for the Institute of Medicine, National Academies of Sciences. Their publication guided the work in this report, identified here as "conventional, contingency, and crisis standards of care." This paper also includes an update to the burn Triage Tables- Seriously Resource-Strained Situations (v.2). [ABSTRACT FROM AUTHOR]

Methadone has several unique characteristics that make it an attractive option for pain relief in serious illness, but the safety of methadone has been called into question after reports of a disproportionate increase in opioid-induced deaths in recent years. The American Pain Society, College on Problems of Drug Dependence, and the Heart Rhythm Society collaborated to issue guidelines on best practices to maximize methadone safety and efficacy, but guidelines for the end-of-life scenario have not yet been developed. A panel of 15 interprofessional hospice and palliative care experts from the U.S. and Canada convened in February 2015 to evaluate the American Pain Society methadone recommendations for applicability in the hospice and palliative care setting. The goal was to develop guidelines for safe and effective management of methadone therapy in hospice and palliative care. This article represents the consensus opinion of the hospice and palliative care experts for methadone use at end of life, including guidance on appropriate candidates for methadone, detail in dosing, titration, and monitoring of patients' response to methadone therapy. [ABSTRACT FROM AUTHOR]

The number of undocumented migrants in high-income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health-care system for undocumented migrants on health-care utilization, health-care system perceptions, and self-reported health in a high-income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health-care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self-assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health-care coverage for targeted groups, such as the United Kingdom and the United States. [ABSTRACT FROM AUTHOR]

Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

This paper calls for a critical reframing of masculinity as an intersectional construct in the HIV epidemic and in public health. In-depth qualitative interviews were conducted with a sample of 56 Black men who have sex with men and women in the San Francisco Bay Area. Men described their sexual identities and practices via complex narratives of masculinity that drew on subordinated and resourceful adaptations to the structural effects of racism, economic marginalisation and homophobia. By focusing on men whose experience of masculinity operates outside fixed identity categories, the paper draws attention to the intersectionality that is, by necessity, constitutive of men's lived experiences. Findings suggest the value of an integrative framework for understanding Black masculinities as processes and practices simultaneously informed by structural inequalities (racism, economic marginalisation and/or homophobia, in particular) and cultural meanings of gender. By utilising an intersectional approach, public health and sociology can better understand the concurrent resilience and vulnerability of masculinities, while building an interdisciplinary understanding of the symbolic role of Black masculinities in the USA, as well as a means by which to promote health and well-being in and through these gendered contexts. [ABSTRACT FROM AUTHOR]

Rationale: Several new drugs for idiopathic pulmonary fibrosis (IPF) are in development. Tools are needed to assess whether these drugs benefit patients on outcomes that matter most to them. Health-related quality of life (HRQL) is one such outcome. It is influenced by many factors, but symptoms and their impacts are two strong drivers.Objectives: To develop a questionnaire to assess symptoms, disease impacts, and HRQL specifically for patients with IPF.Methods: Working with the U.S. Food and Drug Administration through the Drug Development Tool Qualification process, focus groups, concept elicitation, and cognitive debriefing interviews were conducted to inform the development of a 44-item pilot questionnaire. The pilot paper-and-pen questionnaire was migrated to an equivalent electronic version and field-tested in a 14-day study. Response data were subjected to psychometric testing, including exploratory factor analysis, item calibration using item response theory models, test-retest reliability, and validity testing.Measurements and Main Results: A total of 125 patients with IPF (62.4% men) completed the longitudinal study. The mean ± SD age of the cohort was 69 ± 7.60 years, and the mean FVC% predicted was 71 ± 20.0. After factor and item analyses, 35 items were retained, and these comprise the two modules (symptoms and impacts) of the Living with IPF (L-IPF) questionnaire. The L-IPF yields five scales demonstrating good psychometric properties, including correlation with concurrently collected FVC% predicted and the ability to discriminate between patients with differing levels of IPF severity.Conclusions: The L-IPF is a new questionnaire that assesses symptoms, disease impacts, and HRQL in patients with IPF. [ABSTRACT FROM AUTHOR]

Objectives: The United States health system is challenged to improve patient and population health, enhance patients' experience of care, and reduce health care costs. Value-based health care (VBHC) models are proposed to address these issues. Medical health systems are making strides toward VBHC, whereas dental care systems lag behind. The aims of this paper are to a) present study findings of an interprofessional practice model integrating oral health and primary care in a dental practice setting, and b) discuss practice and research implications for advancing VBHC approaches in oral health.Methods: A nonexperimental research method was employed to evaluate the Nurse Practitioner-Dentist Model for Primary Care (NPD Model) at the Harvard Dental Center. Pretest/post-test design was used to assess clinical patient outcomes for a convenience cohort of Medicare beneficiaries (n = 31) with a reported diagnosis of hypertension and/or type 2 diabetes. Clinical outcome measures included: blood pressure, weight, body mass index (BMI), and Hemoglobin A1c.Results: Positive and significant improvements in biometrics (blood pressure, body weight, BMI, HbA1c) were found.Conclusions: The NPD Model is an early prototype for interprofessional VBHC in oral health and holds promise for improving patient and population health outcomes. Integration of interprofessional VBHC in oral health is an imperative for achieving the Triple Aim to improve the overall health of our nation. [ABSTRACT FROM AUTHOR]

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity. [ABSTRACT FROM AUTHOR]

Purpose: We wanted to evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, US Preventive Services Task Force recommendations about prostate cancer screening (from 2012) and mammography screening for women aged 40 to 49 years (from 2009).Methods: We created recorded vignettes of physician-patient discussions about prostate cancer screening and mammography, accompanied by illustrative slides, based on principles derived from preceding qualitative work and behavioral science literature. We conducted a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At entry and after seeing each intervention, they were surveyed about screening intentions, perceptions of benefits and harm, and decisional conflict.Results: Changes in screening intentions were analyzed without regard to order of intervention after an initial analyses showed no evidence of an order effect. At baseline, 69% of men and 86% of women reported wanting screening, with 31% and 6%, respectively, unsure. Mean change on a 3-point, yes, unsure, no scale was -0.93 (P = <.001) for men and -0.50 (P = <.001) for women after seeing the video interventions vs 0.0 and -0.06 (P = .75) after seeing the print interventions. At the study end, 33% of men and 49% of women wanted screening, and 11% and 20%, respectively, were unsure.Conclusions: Our novel, persuasive video interventions significantly changed the screening intentions of substantial proportions of viewers. Our approach needs further testing but may provide a model for helping patients to consider and accept evidence-based, counterintuitive recommendations. [ABSTRACT FROM AUTHOR]

Child birth order (CBO) in the family has received little attention in the field of prevention science. CBO is relevant to early interventionists from a public health perspective, as the most widely disseminated home-visiting program has traditionally targeted mothers and their first-born children. The current paper revisits a previous publication by Shaw et al. (2009) on the effectiveness of the Family Check-Up (FCU) to evaluate CBO (firstborn vs. middle vs. youngest) as a moderator of treatment effects of the FCU in relation to improvements in parenting, maternal depressive symptoms, and child outcomes from ages 2 to 4 in a sample of low-income, ethnically diverse families (N = 709) with multiple children. Results suggest that the FCU elicited improvements in observed parenting from ages 2 to 3 primarily for target children who were the youngest or middle children, but not for firstborns. Findings are discussed in the context of implications for prevention science research, dissemination, and public policy. [ABSTRACT FROM AUTHOR]

Few prior studies have examined the extent to which the behavior and characteristics of political extremists are related to their position within radical groups. In this paper we concentrate on one of the most fundamental distinctions in groups: That between leaders and followers. Our main goal is to investigate the comparative propensity of leaders and followers to engage in political violence. In a sample of individuals who have committed ideologically motivated political crimes in the United States (N = 1,331). we found that even though leaders were more ideologically committed to the group's goals and ideologies, they were at the same time less likely to engage in violent acts. Moreover, we found that leaders in radical criminal organizations shared many characteristics with leaders in noncriminal organizations. Specifically, in comparison to followers, they were more often male, older, and they were more likely to belong to an ethnic majority. We consider implications for future research and policy of the fundamental conclusion that compared to leaders, followers in terrorist organizations are more likely to engage in violent acts. [ABSTRACT FROM AUTHOR]

At the request of French Regulatory Authorities, a new formulation of Levothyrox® was licensed in France in 2017, with the objective of avoiding the stability deficiencies of an existing licensed formulation. Before launching the new formulation, an average bioequivalence (ABE) trial was conducted, having enrolled 204 subjects and selected for interpretation a narrow a priori bioequivalence range of 0.90-1.11. Bioequivalence was concluded. In a previous publication, we questioned the ability of an ABE trial to guarantee the switchability within patients of the new and old levothyroxine formulations. It was suggested that the two formulations should be compared using the conceptual framework of individual bioequivalence. The present paper is a response to those claiming that, despite the fact that ABE analysis does not formally address the switchability of the two formulations, future patients will nevertheless be fully protected. The basis for this claim is that the ABE study was established in a large trial and analyzed using a stringent a priori acceptance interval of equivalence. These claims are questionable, because the use of a very large number of subjects nullifies the implicit precautionary intention of the European guideline when, for a Narrow Therapeutic Index drug, it recommends shortening the a priori acceptance interval from 0.80-1.25 to 0.90-1.11. [ABSTRACT FROM AUTHOR]

The paper from Jagtap et al. in this issue of I Endoscopy i compares the respective value of European Society of Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) criteria for predicting choledocholithiasis [1]. Both ESGE and ASGE recommendations for the management of common bile duct (CBD) stones were published in 2019 [2][3]. Therefore, in all cases, the patient should be informed about the exact risk of excessive investigation or of missing a CBD stone according to the high/intermediate/low likelihood criteria of ESGE/ASGE guidelines. [Extracted from the article]

Purpose: Different health state utility (HSU) instruments produce different utilities for the same individuals, thereby compromising the intended comparability of economic evaluations of health care interventions. When developing crosswalks, previous studies have indicated nonlinear relationships. This paper inquires into the degree of nonlinearity across the four most widely used HSU-instruments and proposes exchange rates that differ depending on the severity levels of the health state utility scale.Methods: Overall, 7933 respondents from six countries, 1760 in a non-diagnosed healthy group and 6173 in seven disease groups, reported their health states using four different instruments: EQ-5D-5L, SF-6D, HUI-3 and 15D. Quantile regressions investigate the degree of nonlinear relationships between these instruments. To compare the instruments across different disease severities, we split the health state utility scale into utility intervals with 0.2 successive decrements in utility starting from perfect health at 1.00. Exchange rates (ERs) are calculated as the mean utility difference between two utility intervals on one HSU-instrument divided by the difference in mean utility on another HSU-instrument.Results: Quantile regressions reveal significant nonlinear relationships across all four HSU-instruments. The degrees of nonlinearities differ, with a maximum degree of difference in the coefficients along the health state utility scale of 3.34 when SF-6D is regressed on EQ-5D. At the lower end of the health state utility scale, the exchange rate from SF-6D to EQ-5D is 2.11, whilst at the upper end it is 0.38.Conclusion: Comparisons at different utility levels illustrate the fallacy of using linear functions as crosswalks between HSU-instruments. The existence of nonlinear relationships between different HSU-instruments suggests that level-specific exchange rates should be used when converting a change in utility on the instrument used, onto a corresponding utility change had another instrument been used. Accounting for nonlinearities will increase the validity of the comparison for decision makers when faced with a choice between interventions whose calculations of QALY gains have been based on different HSU-instruments. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to describe the Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) study, a cooperative implementation science initiative involving the National Institute on Drug Abuse, six research centers, a coordinating center, and Juvenile Justice Partners representing seven US states. While the pooling of resources across centers enables a robust implementation study design involving 36 juvenile justice agencies and their behavioral health partner agencies, co-producing a study protocol that has potential to advance implementation science, meets the needs of all constituencies (funding agency, researchers, partners, study sites), and can be implemented with fidelity across the cooperative can be challenging. This paper describes (a) the study background and rationale, including the juvenile justice context and best practices for substance use disorders, (b) the selection and use of an implementation science framework to guide study design and inform selection of implementation components, and (c) the specific study design elements, including research questions, implementation interventions, measurement, and analytic plan.Methods/design: The JJ-TRIALS primary study uses a head-to-head cluster randomized trial with a phased rollout to evaluate the differential effectiveness of two conditions (Core and Enhanced) in 36 sites located in seven states. A Core strategy for promoting change is compared to an Enhanced strategy that incorporates all core strategies plus active facilitation. Target outcomes include improvements in evidence-based screening, assessment, and linkage to substance use treatment.Discussion: Contributions to implementation science are discussed as well as challenges associated with designing and deploying a complex, collaborative project.Trial Registration: NCT02672150 . [ABSTRACT FROM AUTHOR]

Background: Lone parents and their children experience higher than average levels of adverse health and social outcomes, much of which are explained by high rates of poverty. Many high income countries have attempted to address high poverty rates by introducing employment requirements for lone parents in receipt of welfare benefits. However, there is evidence that employment may not reduce poverty or improve the health of lone parents and their children.Methods: We conducted a systematic review of qualitative studies reporting lone parents' accounts of participation in welfare to work (WtW), to identify explanations and possible mechanisms for the impacts of WtW on health and wellbeing. Twenty one bibliographic databases were searched. Two reviewers independently screened references and assessed study quality. Studies from any high income country that met the criteria of focussing on lone parents, mandatory WtW interventions, and health or wellbeing were included. Thematic synthesis was used to investigate analytic themes between studies.Results: Screening of the 4703 identified papers and quality assessment resulted in the inclusion of 16 qualitative studies of WtW in five high income countries, USA, Canada, UK, Australia, and New Zealand, covering a variety of welfare regimes. Our synthesis found that WtW requirements often conflicted with child care responsibilities. Available employment was often poorly paid and precarious. Adverse health impacts, such as increased stress, fatigue, and depression were commonly reported, though employment and appropriate training was linked to increased self-worth for some. WtW appeared to influence health through the pathways of conflict and control, analytical themes which emerged during synthesis. WtW reduced control over the nature of employment and care of children. Access to social support allowed some lone parents to manage the conflict associated with employment, and to increase control over their circumstances, with potentially beneficial health impacts.Conclusion: WtW can result in increased conflict and reduced control, which may lead to negative impacts on mental health. Availability of social support may mediate the negative health impacts of WtW. [ABSTRACT FROM AUTHOR]

The widespread adoption of science-based prevention requires local infrastructures for prevention service delivery. Communities That Care (CTC) is a tested prevention service delivery system that enables a local coalition of community stakeholders to use a science-based approach to prevention and improve the behavioral health of young people. This paper uses data from the Community Youth Development Study (CYDS), a community-randomized trial of CTC, to examine the extent to which better internal team functioning of CTC coalitions increases the community-wide adoption of science-based prevention within 12 communities, relative to 12 matched comparison communities. Specifically, this paper examines the potential of both a direct relationship between coalition functioning and the community-wide adoption of science-based prevention and a direct relationship between functioning and the coalition capacities that ultimately enable the adoption of science-based prevention. Findings indicate no evidence of a direct relationship between four dimensions of coalition functioning and the community-wide adoption of a science-based approach to prevention, but suggest a relationship between coalition functioning and coalition capacities (building new member skills and establishing external linkages with existing community organizations) that enable science-based prevention. [ABSTRACT FROM AUTHOR]

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation. [ABSTRACT FROM AUTHOR]

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran. [ABSTRACT FROM AUTHOR]

Background: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.Objective: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).Design: Qualitative study using semi-structured formative evaluation interviews.Participants: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.Interventions: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.Approach: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.Key Results: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.Conclusion: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals. [ABSTRACT FROM AUTHOR]

Mediation analysis allows the examination of effects of a third variable in the pathway between an exposure and an outcome. The general multiple mediation analysis method, proposed by Yu et al, improves traditional methods (eg, estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. In this paper, we extend the method for time-to-event outcomes and apply the method to explore the racial disparity in breast cancer survivals. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite improvement of survival rates of breast cancer in the US, a significant difference between white and black women remains. Previous studies have found that more advanced and aggressive tumors and less than optimal treatment may explain the lower survival rates for black women as compared to white women. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study to examine the determinants of racial disparities in breast cancer survival using a novel multiple mediation analysis. Using the proposed method, we applied the Cox hazard model and multiple additive regression trees as predictive models and found that all racial disparity in survival among Louisiana breast cancer patients were explained by factors included in the study. [ABSTRACT FROM AUTHOR]

The article discusses the effects of short pregnancy spacing on maternal nutrition and adverse pregnancy outcomes such as preterm birth for women in the U.S. According to the author, the use of contraception has been recommended to women and family planning providers by the Centers for Disease Control and Prevention (CDC).

This paper presents longitudinal data representing federal funding for health services research and discusses the observed trends in the larger context of overall funding for research and development in the United States. By putting into context public and private funding trends, the authors examine how these trends effect the supply and demand of the health services research workforce. [ABSTRACT FROM AUTHOR]

Objectives: To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions.Data Source/study Setting: Primary data (ratings) were reported from 58 stakeholder organizations.Study Design: An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016.Data Collection/extraction Methods: Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2).Principal Findings: In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3).Conclusions: There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group. [ABSTRACT FROM AUTHOR]

Introduction: Bicalutamide (BIC), a non-steroidal anti-androgen, is FDA-indicated for use in combination with a luteinizing hormone-releasing hormone (LHRH) analog for treatment of Stage D2 metastatic carcinoma of the prostate. Lack of consensus exists regarding the clinical benefit of BIC use, either alone or combined use of BIC with an LHRH analog or antagonist (combined androgen blockade or CAB), versus treatment with androgen deprivation therapy (ADT) alone.Methods: The SEER-Medicare database was used to identify prostate cancer patients aged ≥ 66 years diagnosed between 2007 and 2011 and who filled at least one prescription for BIC. Duration of BIC treatment was assessed in relation to ADT use; either alone (monotherapy), as part of CAB only, and as part of CAB followed by monotherapy. Additionally, we assessed use of BIC during or outside a potential testosterone flare prevention period (initiation within 2 months of an LHRH agonist).Results: A total of 7521 prostate cancer patients who filled a prescription for BIC were identified. Eighteen percent of the cohort used BIC alone, over half the patients (54%) used BIC as part of CAB and 27% used BIC as part of CAB followed by monotherapy. Among men treated with BIC as part of CAB, 58% received BIC only within the potential flare period.Conclusions: Although there is no FDA indication for BIC use as monotherapy, > 44% of patients in this study used BIC alone or as part of CAB followed by monotherapy. Further research is necessary to understand the outcomes of BIC utilization in these settings, particularly compared with newer second-generation anti-androgens.Funding: Medivation LLC, a Pfizer company, and Astellas, Pharma, Inc. [ABSTRACT FROM AUTHOR]

Objectives: Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral 'blips' above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics.Methods: This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women.Results: Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%).Conclusions: A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections.Trial Registration Number: NCT02044484, completed. [ABSTRACT FROM AUTHOR]

Purpose: Building research capacity and increasing scholarly productivity are identified needs of the specialty of family medicine. The Accreditation Council for Graduate Medical Education (ACGME) has increased the scholarly requirements for residency programs, placing even more pressure on faculty to be productive in the scholarly realm. The Council of Academic Family Medicine Educational Research Alliance (CERA) was created by volunteer members of the specialty with shared interests in overcoming barriers and increasing scholarly production.Methods: CERA has developed the infrastructure and expertise to regularly conduct omnibus surveys of key family medicine educational leaders. Proposals are centrally collected and competitively chosen. The omnibus survey process includes collaboration with experienced mentors, centralized institutional review board clearance, pilot testing, and centralized data collection. The survey results are disseminated back to research teams for presentation and publication of the findings.Results: To date, over 115 research teams have had their projects included in CERA omnibus surveys. Projects have been led by research teams from across the country and with a wide variety of research experience. This collaborative work has resulted in more than 75 scientific presentations and over 55 peer-reviewed papers in the medical literature. The raw data are now available online and serve as a repository for future secondary analysis and as an educational resource.Conclusions: The CERA infrastructure has allowed a large number of research teams to conduct meaningful scholarship at a fraction of the typical cost in terms of time and energy. CERA has expanded family medicine research by removing barriers for teams with limited experience or resources. [ABSTRACT FROM AUTHOR]

Drug-drug interactions (DDIs) are a common cause of adverse drug events (ADEs). The electronic medical record (EMR) database and the FDA's adverse event reporting system (FAERS) database are the major data sources for mining and testing the ADE associated DDI signals. Most DDI data mining methods focus on pair-wise drug interactions, and methods to detect high-dimensional DDIs in medical databases are lacking. In this paper, we propose 2 novel mixture drug-count response models for detecting high-dimensional drug combinations that induce myopathy. The "count" indicates the number of drugs in a combination. One model is called fixed probability mixture drug-count response model with a maximum risk threshold (FMDRM-MRT). The other model is called count-dependent probability mixture drug-count response model with a maximum risk threshold (CMDRM-MRT), in which the mixture probability is count dependent. Compared with the previous mixture drug-count response model (MDRM) developed by our group, these 2 new models show a better likelihood in detecting high-dimensional drug combinatory effects on myopathy. CMDRM-MRT identified and validated (54; 374; 637; 442; 131) 2-way to 6-way drug interactions, respectively, which induce myopathy in both EMR and FAERS databases. We further demonstrate FAERS data capture much higher maximum myopathy risk than EMR data do. The consistency of 2 mixture models' parameters and local false discovery rate estimates are evaluated through statistical simulation studies. [ABSTRACT FROM AUTHOR]

Introduction: Over the past few decades, tobacco control efforts have made great strides in making smoke-free air the norm; 30 states in the United States have implemented 100% smoke-free laws. Despite this progress, the evolution of the measurement of secondhand smoke (SHS) exposure has lagged.Methods: Cognitive testing was used to explore the functioning and limitations of current SHS surveillance items; many items are frequently used for statewide or national surveillance. A total of 20 nonsmokers and 17 smokers participated in a cognitive interview.Results: Overreporting of SHS was evidenced in our analysis as thirdhand smoke exposure was being included in the assessment of SHS exposure, likely due to the successful implementation of indoor smoking bans. Also asking about locations of SHS exposure outside of work, home, or a personal vehicle is important because these alternative locations were sometimes the only incidence of SHS exposure.Conclusions: Survey questions about SHS should: (1) reduce the ambiguity in words and phrases of items; (2) measure location of exposure; (3) measure duration of exposure; and (4) consider alternative strategies for asking smokers questions about SHS. Assessing location and duration of exposure can inform decision-makers about future SHS programming and policy work.Implications: Commonly accepted survey measures of SHS exposure need to be reevaluated to assure that the intended interpretation of them is still accurate given significant policy and social norm change. This paper assesses current SHS surveillance items and provides recommendations for revisions. [ABSTRACT FROM AUTHOR]

Background: Outside of the United States, international perspectives on normative data for neuropsychological test performance, within diverse populations, have been scarce. The neuropsychological test battery from the Uniform Data Set (UDS) of the Alzheimer's Disease Centers (ADC) program of the United States National Institute on Aging (NIA) is one of the most sensitive batteries for the evaluation of both normal cognitive aging and pathological cognitive decline.Objective: This study aimed to determine the feasibility of the Czech Neuropsychological Test Battery from the Uniform Data Set (UDS-Cz 2.0), while also evaluating the results obtained from an international perspective.Methods: This paper describes data from 520 cognitively normal participants. Regression analyses were used to describe the influence of demographic variables on UDS-Cz test performance.Results: Cognitive performance on all measures declined with age, with patient education level serving as a protective factor. Therefore, the present study provides normative data for the UDS-Cz, adjusted for the demographic variables of age and education.Conclusion: The present study determines the psychometric properties of the UDS-Cz and establishes normative values in the aging Czech population, which can be used in clinical settings. [ABSTRACT FROM AUTHOR]

Purpose Although incarceration may have life-long negative health effects, little is known about associations between child incarceration and subsequent adult health outcomes. The paper aims to discuss this issue. Design/methodology/approach The authors analyzed data from 14,689 adult participants in the National Longitudinal Study of Adolescent to Adult Health (Add Health) to compare adult health outcomes among those first incarcerated between 7 and 13 years of age (child incarceration); first incarcerated at>or=14 years of age; and never incarcerated. Findings Compared to the other two groups, those with a history of child incarceration were disproportionately black or Hispanic, male, and from lower socio-economic strata. Additionally, individuals incarcerated as children had worse adult health outcomes, including general health, functional limitations (climbing stairs), depressive symptoms, and suicidality, than those first incarcerated at older ages or never incarcerated. Research limitations/implications Despite the limitations of the secondary database analysis, these findings suggest that incarcerated children are an especially medically vulnerable population. Practical implications Programs and policies that address these medically vulnerable children's health needs through comprehensive health and social services in place of, during, and/or after incarceration are needed. Social implications Meeting these unmet health and social service needs offers an important opportunity to achieve necessary health care and justice reform for children. Originality/value No prior studies have examined the longitudinal relationship between child incarceration and adult health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Little is known on how to communicate messages on tobacco constituents to tobacco users. This study manipulated three elements of a message in the context of a theory-based communication campaign about tobacco constituents: (1) latency of response efficacy (how soon expected health benefits would accrue), (2) self-efficacy (confidence about quitting), and (3) interrogative cue ("Ready to be tobacco-free?").Methods: Smokers (N = 1669, 55.4% women) were recruited via an online platform, and were randomized to a 3 (Latency of response efficacy) × 2 (Self-efficacy) × 2 (Interrogative cue) factorial design. The dependent variables were believability, credibility, perceived effectiveness of the communication message, and action expectancies (likelihood of seeking additional information and help with quitting).Results: Latency of response efficacy influenced believability, perceived effectiveness, credibility, and action expectancies. In each case, scores were higher when specific health benefits were said to accrue within 1 month, as compared to general health benefits occurring in a few hours. The interrogative cue had a marginal positive effect on perceived effectiveness. The self-efficacy manipulation had no reliable effects, and there were no significant interactions among conditions.Conclusions: Smokers appear less persuaded by a communication message on constituents where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, smokers appeared to be more persuaded by messages with an interrogative cue. Such findings may help design more effective communication campaigns on tobacco constituents to smokers.Implications: This paper describes, for the first time, how components of tobacco constituent messages are perceived. We now know that smokers appear to be less persuaded by communication messages where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, including an interrogative cue ("Ready to be tobacco free?") may make messages more effective, whereas the self-efficacy manipulation designed to increase confidence about quitting had no effect. While messages were universally impactful across smoker subpopulations, everyday smokers and smokers with less trust in the government may be less receptive to communication campaigns. [ABSTRACT FROM AUTHOR]

Purpose: This paper evaluated the impact of cleft-related surgery on the oral health-related quality of life (OHRQoL) of youth with cleft over time.Methods: Data were derived from a 5-year, multi-center, prospective, longitudinal study of 1196 youth with cleft lip and/or palate and their caregivers. Eligible youth were between 7.5 and 18.5 years old, spoke English or Spanish, and were non-syndromic. During each observational period, which included baseline, and 1- and 2-year post-baseline follow-up visits, youths and their caregivers completed the Child Oral Health Impact Profile, a validated measure of OHRQoL. Multilevel mixed-effects models were used to analyze the effects of receipt of craniofacial surgery on OHRQoL over time.Results: During the course of this study a total of 516 patients (43 %) received at least one surgery. Youth in the surgery recommendation group had lower self- (β = -2.18, p < 0.05) and proxy-rated (β = -2.92, p < 0.02) OHRQoL when compared to non-surgical self- and proxy-rated OHRQoL at baseline. Both surgical and non-surgical youth (β = 3.73, p < 0.001) and caregiver (β = 1.91, p < 0.05) ratings of OHRQoL improved over time. There was significant incremental improvement (time × surgery interaction) in self-reported OHRQoL for youth postsurgery (β = 1.04, p < 0.05), but this postsurgery increment was not seen in the caregiver proxy ratings.Conclusions: Surgical intervention impacts OHRQoL among youth with cleft. Youth who were surgical candidates had lower baseline self- and caregiver-rated OHRQoL when compared to non-surgical youth. Youth who underwent cleft-related surgery had significant incremental improvements in self-rated but not caregiver (proxy)-rated OHRQoL after surgery. [ABSTRACT FROM AUTHOR]

Background: Incorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO).Methods: This Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2 years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview.Results: No case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet.Conclusions: This project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet.Trial Registration: ClinicalTrials.gov NCT01430741. [ABSTRACT FROM AUTHOR]

Home hemodialysis (HD) was first introduced in the 1960s with a rapid increase in its use due to inability of dialysis units to accommodate patient demand. A sharp decline was subsequently seen with expanding outpatient dialysis facilities and changes in reimbursement policies. In the last decade, with emerging reports of benefits with home HD and more user-friendly equipment, there has been resurgence in home HD. However, home HD remains underutilized with considerable variations between and within countries. This paper will review the history of home HD, elaborate on its established benefits, identify some of the barriers in uptake of this modality and expand on potential strategies to overcome these barriers. [ABSTRACT FROM AUTHOR]

The term latent tuberculosis (TB) was coined two centuries ago to describe post-mortem tuberculous pathology in the absence of ante-mortem tuberculosis manifestations. However, the meaning of the term has changed with each passing century, engendering confusion. In the early 20th century, with the advent of microbiological assays for live tubercle bacteria, latent TB switched from the host to refer to the bacteria from post-mortem tissues of nontuberculous hosts. Then in the late 20th century, the definition of latent TB infection returned to the host, this time referring to those with immunoreactivity to Mycobacterium tuberculosis antigens. Based on this new definition, latent TB infection is unique among bacterial infectious diseases, in that supportive evidence of the infection state is sought by the absence of the causative bacterium and its clinical manifestations. The use of indirect bedside and laboratory tests to denote infection creates clinical and research confusion, as the tests for immunoreactivity suffer from recognized limitations in sensitivity and specificity. We propose that the concept of latent TB infection be separated from that of tuberculous immunoreactivity in the interest of correct diagnosis and focused treatment, correct formulation and interpretation of research questions and better allocation of programmatic resources for TB elimination. To this end, we suggest new terminology to course-correct our thinking about tuberculous infection (TBI) which is subdivided into tuberculous infection-no disease (TBInd) and the long-accepted term for the disease, tuberculosis (TB). [ABSTRACT FROM AUTHOR]

Introduction: In the United States, firearm suicide represents a major cause of preventable, premature death among veterans. The purpose of this systematic review was to characterize the body of literature on veteran firearm suicide and identify areas for future research, which may facilitate the development of firearm suicide interventions in Veterans Health Administration (VHA) and non-Veterans Health Administration clinical settings.Materials and Methods: All randomized controlled trials, quasi-experimental, naturalistic, observational, and case study designs published between January 1, 1990 and February 21, 2019 were included in our review. Following title and abstract review, 65 papers were included in our full-text review and 37 studies were included in our analysis. We based our approach on a modification of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies were grouped into broad, nonmutually exclusive categories: (1) heterogeneity of datasets and veteran status determination for inclusion, (2) service histories, (3) firearm ownership, storage, behaviors, and risk perceptions, (4) patient and clinician attitudes toward firearm restriction interventions, (5) firearm suicide risk factors by study population, and (6) assessments of clinical firearm interventions.Results: This body of literature consists predominately of cross-sectional studies with mixed definitions and validation of veteran status, which revealed high concordance of increased risk of firearm suicide compared with nonveterans. Veterans have higher rates of firearm ownership than the general population, primarily citing personal protection as the reason for gun ownership. Veterans often exhibit risky firearm usage and storage behaviors but tend to favor measures that limit access to firearms by at-risk individuals. Despite this, there remains persistent hesitation among clinicians to screen and counsel veterans on firearm safety.Conclusions: This systematic review highlights an urgent need to produce higher quality evidence and new data with standard definitions that are critical to inform clinical practice and enhance public health measures to reduce firearm suicide among veterans. [ABSTRACT FROM AUTHOR]

Objective: Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased.Methods: Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics.Results: Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support.Conclusions: Clinical effects of the CCM may wane after cessation of active implementation support. [ABSTRACT FROM AUTHOR]

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is a key component of Medicaid policy intended to define an essential set of services provided to patients younger than age 21. Given increasing attention to social determinants of health in pediatric health care, this qualitative review examines the extent to which EPSDT might be used to implement structured screening to identify environmental and social factors affecting children's health. Themes derived from semistructured interviews conducted in 2017 were triangulated with a review of the recent literature to describe how states currently consider the EPSDT benefit with respect to social determinants of health screening. Our findings suggest that, with sufficient stakeholder advocacy given the evidence supporting social determinants of health screening as "medically necessary," EPSDT benefits could be considered as a funding source to incentivize the incorporation of social determinants of health screening into the basic package of well-child care. [ABSTRACT FROM AUTHOR]

Objectives: Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans' reproductive needs, and the effect of training on documentation in a women's primary care clinic in Salt Lake City, Utah.Methods: We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits.Results: Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling.Conclusions: Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals. [ABSTRACT FROM AUTHOR]

Background: The scale and scope of medical tourism have expanded rapidly over the last few decades. Turkey is becoming an important player in this market because of its relatively better service quality and large comparative cost advantage.Methods: This paper compares cost, quality and effectiveness of in-vitro fertilization (IVF) in the USA and in Turkey. The data from Turkey were obtained from a hospital specializing in IVF services and the US data came from secondary sources. Package price offered by the dominant IVF-service provider to international patients in Turkey was used as a measure of cost for Turkey while IVF-specific service prices were used to estimate the cost for USA. To compare quality and effectiveness of IVF services, a number of general clinical quality indicators and IVF success rate were used.Results: Indicators of quality, cost and success rate in the Turkish hospital were found to be better than the corresponding indicators in US hospitals. The cost difference of IVF services between USA and Turkey is so significant that the overall cost of obtaining the service from Turkey remains lower even with additional expenses for travel and accommodation.Conclusions: Cost-effectiveness ratio of IVF treatment per successful clinical pregnancy was much lower in Turkey than in the USA. It appears that cost and quality are the two most important factors affecting demand for health care services by international patients in Turkey. Like other important players in the medical tourism market, Turkey should be able to take advantage of its success in IVF, a highly specialized niche market, to transform its health system into an important exporter of general health services. [ABSTRACT FROM AUTHOR]

Background: Prevalence of multiple health risk behaviors is growing, and obesity and smoking are costly. Weight gain associated with quitting smoking is common and can interfere with quit success. Efficacy of adding weight management to tobacco cessation treatment has been tested with women in group sessions over an extended period of time, but has never been tested in real-world settings with men and women seeking help to quit. This paper describes the Best Quit study which tests the effectiveness of delivering tobacco and weight control interventions via existing quitline infrastructures.Methods: Eligible and consenting smokers (n = 2550) who call a telephone quitline will be randomized to one of three groups; the standard quitline or standard quitline plus a weight management program added either simultaneously or sequentially to the tobacco program. The study aims to test: 1) the effectiveness of the combined intervention on smoking cessation and weight, 2) the cost-effectiveness of the combined intervention on cessation and weight and 3) theoretically pre-specified mediators of treatment effects on cessation: reduced weight concerns, increased outcome expectancies about quitting and improved self-efficacy about quitting without weight gain. Baseline, 6 month and 12 month data will be analyzed using multivariate statistical analyses and groups will be compared on treatment adherence, quit rates and change in weight among abstinent participants. To determine if the association between group assignment and primary outcomes (30-day abstinence and change in weight at 6 months) is moderated by pre-determined baseline and process measures, interaction terms will be included in the regression models and their significance assessed.Discussion: This study will generate information to inform whether adding weight management to a tobacco cessation intervention delivered by phone, mail and web for smokers seeking help to quit will help or harm quit rates and whether a simultaneous or sequential approach is better at increasing abstinence and reducing weight gain post quit. If proven effective, the combined intervention could be disseminated across the U.S. through quitlines and could encourage additional smokers who have not sought cessation treatment for fear of gaining weight to make quit attempts.Trial Registration: Clinicaltrials.gov NCT01867983 . Registered: May 30, 2013. [ABSTRACT FROM AUTHOR]

Worldwide, the fat composition of spreads and margarines (“spreads”) has significantly changed over the past decades. Data on fat composition of US spreads are limited and outdated. This paper compares the fat composition of spreads sold in 2013 to that sold in 2002 in the USA. The fat composition of 37 spreads representing >80% of the US market sales volume was determined by standard analytical methods. Sales volume weighted averages were calculated. In 2013, a 14 g serving of spread contained on average 7.1 g fat and 0.2 g trans-fatty acids and provided 22% and 15% of the daily amounts recommended for male adults in North America of omega-3 α-linolenic acid and omega-6 linoleic acid, respectively. Our analysis of the ingredient list on the food label showed that 86% of spreads did not contain partially hydrogenated vegetable oils (PHVO) in 2013. From 2002 to 2013, based on a 14 g serving, total fat and trans-fatty acid content of spreads decreased on average by 2.2 g and 1.5 g, respectively. In the same period, the overall fat composition improved as reflected by a decrease of solid fat (from 39% to 30% of total-fatty acids), and an increase of unsaturated fat (from 61% to 70% of total-fatty acids). The majority of US spreads no longer contains PHVO and can contribute to meeting dietary recommendations by providing unsaturated fat. [ABSTRACT FROM PUBLISHER]

In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response. [ABSTRACT FROM AUTHOR]

Background: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?Methods: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.Results: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.Conclusions: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes. [ABSTRACT FROM AUTHOR]

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature. [ABSTRACT FROM AUTHOR]

Introduction: Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. The Center for Disease Control Advisory Committee on Immunization Practices (ACIP) has recognized the potential benefits of immunizing young men beginning at age 11 or 12 years and continuing through age 21 years. The maximum age of immunization is extended through age 26 for men who have sex with men, transgender individuals, and immunocompromised men. In spite of these recommendations, vaccination of young men is currently limited by numerous patient and provider variables. The authors sought to delineate these variables as they pertain to members of the U.S. Air Force in order to guide future interventions.Methods: The study consisted of two cross-sectional surveys at a single Air Force Base in California. The protocol was approved by the Institutional Review Board at David Grant Medical Center. The physician survey consisted of 10 questions that were formatted and designed to assess physicians' knowledge about the quadrivalent HPV vaccine (Gardasil) and 6 questions that were formatted and designed to assess physicians' counseling practices regarding Gardasil. The physician survey was distributed electronically via email in January 2017 to all 48 Family Medicine physicians, including both residents and staff, within the Family Medicine Residency Clinic at Travis Air Force Base. The email contained a link via Microsoft Share-point to an anonymous online survey. The patient survey was distributed in paper form to all male service members between the ages of 18 and 30 years who attended Commander's Calls over a 90-day period between January 2017 and March 2017. The patient survey included the primary outcome: proportion of respondents who had completed the HPV vaccination series. Descriptive statistics, including frequencies and percentages, were used to summarize the data. Contingency tables were constructed and the chi-square test or Fisher's Exact Test were performed to determine if particular demographic variables were associated with correct answers to individual knowledge questions.Results: The majority of the Family Medicine physicians surveyed have adequate knowledge of HPV and the vaccine but do not routinely offer the vaccine to their male patients. Inadequate time during the office visit was cited as the major limitation to vaccine promotion. Of the Active Duty Air Force males surveyed, only 27% completed the vaccine series. A lack of knowledge regarding the personal benefits of the vaccine and failure to remember to receive subsequent doses were cited as barriers to completion. Only one-quarter of all surveyed males were interested in speaking with a healthcare provider about HPV and/or the HPV vaccine.Conclusion: Deficiencies in public knowledge and insufficient provider practices are likely contributing to the suboptimal rates of HPV vaccination among eligible males. Additionally, eligible males are not interested in speaking with their healthcare providers about either HPV or the HPV vaccine. If the rates of HPV vaccination within the male population are to increase, health educators, public health proponents, and vaccine advocates need to devise a more effective approach to disseminate this information to eligible male recipients. [ABSTRACT FROM AUTHOR]

Background: Increasing knowledge on suicide prevention has been shown to be important for suicide prevention. This paper exams the accomplishment of research on suicide and examine how those research activities contribute to the change of suicide rates.Methods: Data of the publications relating to suicide from 1990 to 2018 were retrieved from the Web of Science and Scopus. Bibliographic information was analyzed and the relationships between suicide rates with the number of publications per million population and the average article citations per year were examined.Results: From 1990 to 2018, globally, publications on suicide have increased significantly. The United States ("USA") had the greatest number of publications. Research collaborations among different countries/regions have been flourishing and multinational centers have become more common than ever. Nonetheless, in some countries/regions with high rates of suicide, suicide research was scarce. It was found that the number of publications per million population and the average article citations per year were negatively correlated with the suicide rates at the global level (r = - 0.96, p < 0.001; r = -0.91, p < 0.001, respectively), but not in the higher SDI regions (r = -0.05, p = 0.81; r = 0.02, p = 0.91, respectively). Furthermore, research focusing on suicide intervention was also relatively limited.Limitation: The origins of the publications were only based on the corresponding authors' regions.Conclusions: There is significant imbalance in the amount of research effort especially in the regions with high suicide rates. In the higher socioeconomic level regions, the quantity and quality of publications sometimes do not transpire in the reduction of suicide rates. A better connection between the fundamental and practical suicide research should be established. More resources should be made available to the low- and middle-income countries/regions with higher suicide risks, then the effect of suicide prevention might be much more significant. [ABSTRACT FROM AUTHOR]

The United States is in the midst of a multifaceted public health crisis, marked by increasing midlife mortality rates among nearly all racial and ethnic groups.[[1]] The burden of this crisis has fallen most heavily among vulnerable populations, particularly individuals with lower levels of income and education.[[2]] Patterns of rising mortality - which vary across time, space, and causes of death - suggest a complex set of underlying causes, many of which may have been operative for decades.[2] How do the findings speak to the potential consequences of other trends in urban housing, in particular gentrification, whose relationship to evictions and health outcomes has thus far been shown to be mixed? America's declining well-being, health, and life expectancy: not just a white problem. 33 Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. [Extracted from the article]