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ObjectiveCrisis services are undergoing an unprecedented expansion in the United States, but research is lacking on crisis system design. This study describes how individuals flow through a well-established crisis system and examines factors associated with reutilization of such services.MethodsThis cross-sectional study used Medicaid claims to construct episodes describing the flow of individuals through mobile crisis, specialized crisis facility, emergency department, and inpatient services. Claims data were merged with electronic health record (EHR) data for the subset of individuals receiving care at a crisis response center. A generalized estimating equation was used to calculate adjusted odds ratios for demographic, clinical, and operational factors associated with reutilization of services within 30 days of an episode's end point.ResultsOf 41,026 episodes, most (57.4%) began with mobile crisis services or a specialized crisis facility rather than the emergency department. Of the subset (N=9,202 episodes) with merged EHR data, most episodes (63.3%) were not followed by reutilization. Factors associated with increased odds of 30-day reutilization included Black race, homelessness, stimulant use, psychosis, and episodes beginning with mobile crisis services or ending with inpatient care. Decreased odds were associated with depression, trauma, and involuntary legal status. Most (59.3%) episodes beginning with an involuntary legal status ended with a voluntary status.ConclusionsCrisis systems can serve a large proportion of individuals experiencing psychiatric emergencies and divert them from more restrictive and costly levels of care. Understanding demographic, clinical, and operational factors associated with 30-day reutilization may aid in the design and implementation of crisis systems.

Abstract Background Understanding the cause vs consequence relationship of gut inflammation and microbial dysbiosis in inflammatory bowel diseases (IBD) requires a reproducible mouse model of human-microbiota-driven experimental colitis. Results Our study demonstrated that human fecal microbiota transplant (FMT) transfer efficiency is an underappreciated source of experimental variability in human microbiota-associated (HMA) mice. Pooled human IBD patient fecal microbiota engrafted germ-free (GF) mice with low amplicon sequence variant (ASV)-level transfer efficiency, resulting in high recipient-to-recipient variation of microbiota composition and colitis severity in HMA Il-10 −/− mice. In contrast, mouse-to-mouse transfer of mouse-adapted human IBD patient microbiota transferred with high efficiency and low compositional variability resulting in highly consistent and reproducible colitis phenotypes in recipient Il-10 −/− mice. Engraftment of human-to-mouse FMT stochastically varied with individual transplantation events more than mouse-adapted FMT. Human-to-mouse FMT caused a population bottleneck with reassembly of microbiota composition that was host inflammatory environment specific. Mouse-adaptation in the inflamed Il-10 −/− host reassembled a more aggressive microbiota that induced more severe colitis in serial transplant to Il-10 −/− mice than the distinct microbiota reassembled in non-inflamed WT hosts. Conclusions Our findings support a model of IBD pathogenesis in which host inflammation promotes aggressive resident bacteria, which further drives a feed-forward process of dysbiosis exacerbated by gut inflammation. This model implies that effective management of IBD requires treating both the dysregulated host immune response and aggressive inflammation-driven microbiota. We propose that our mouse-adapted human microbiota model is an optimized, reproducible, and rigorous system to study human microbiome-driven disease phenotypes, which may be generalized to mouse models of other human microbiota-modulated diseases, including metabolic syndrome/obesity, diabetes, autoimmune diseases, and cancer. Video Abstract

Abstract Image‐based analyses from an online repository on rhino horns asserted that declines in size over time could be the consequence of poaching and hunting. We provide reflections on whether the sample was representative enough to make generalizations, the study adequately accounted for the main sources of horn‐size variation and the statistical methods were adequate to be confident in the results. The sample had a limited representation, most coming from zoo animals. We highlight several sources of variance in horn size that such a sample could not evaluate robustly using linear regressions, both for establishing a proxy for horn size corrected for size of a rhino and assessing trends over time. Nevertheless, horn poaching continues to be the key threat to rhinos. Addressing the underlying drivers of poaching and trafficking are key priorities for responsible public debate, policy making and interventions. Read the free Plain Language Summary for this article on the Journal blog.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

ABSTRACT Sexual selection is not a single process. Instead, multiple processes of sexual selection can interact with respect to a given phenotype, in either reinforcing, independent, or conflicting directions. Here we consider how different processes of sexual selection interact in the seed bug Lygaeus simulans. This species is characterised by limited pre‐copulatory sexual selection, but the potential for rather strong post‐copulatory sexual selection. In particular, mating failure is common in this species, with around 40%–60% of copulations failing to result in the successful transfer of sperm. Mating failure is negatively correlated with female size, with smaller females being less likely to end up inseminated. We have recently argued that this pattern is best explained by cryptic male mate choice for large, more fecund females. Males therefore preferentially inseminate larger females. Here we explore how this potential cryptic male choice interacts with another component of post‐copulatory sexual selection: sperm competition. We first manipulated male and female size variation, generating large and small, male and female, size classes. Using a visible mutant marker to assign paternity, we then double‐mated females with males, in all combinations of male and female size. Our results showed that sperm competition outcomes were primarily driven by copulation duration, with longer copulations leading to greater paternity share for a male. We also confirmed that larger females are more likely to produce offspring than smaller females, as predicted by cryptic male choice for large females. This effect was again linked to copulation duration, with longer copulations less likely to lead to mating failure. While larger males tended to be more successful in sperm competition, especially if copulating second, female size had little effect on paternity, suggesting that cryptic male choice and sperm competition are acting relatively independently in this species.

Abstract One yet unresolved question in the study of mating system evolution is the occurrence of mating failure, when individuals go through their lives without successfully mating. This includes the failure to produce offspring even following copulation, for instance due to insemination or fertilisation failure. Copulations are costly in a variety of ways, but also a fundamental route to fitness in sexual species, and so we should expect that engaging in copulations that generate no offspring should be strongly selected against. Nonetheless, it has become apparent that mating failure is quite common in nature. Here we consider post‐copulatory sexual selection in Lygaeus simulans seed bugs to test the hypothesis that the high levels of mating failure found in this species (approximately 40%–60%) are caused by cryptic male choice (i.e. males choosing not to inseminate a female during copulation). In our first experiment, we found that mating failure depended on female size, but not male size, with smaller females experiencing mating failure more frequently. Mechanistically this is likely to be due to copulation duration, as shorter copulations were more likely to lead to mating failure. Likewise, copulations with smaller females were shorter. In our second and third experiments, rates of mating failure decreased when pairs were allowed to repeatedly interact with the same partner over longer durations (hours through to days), implying that mating failure is not primarily caused by infertility or chronic mechanical failure. Instead, our results strongly suggest cryptic male choice as the cause of mating failure in this species.

Abstract Organism condition plays an important role in sexual selection. Sexual ornaments and displays can be condition‐dependent, reflecting either underlying genetic quality, experience of environmental stressors, or both. As such, the phenotypic expression of such traits, and the resulting patterns of mate choice acting on them, may be shaped by intrinsic genetic quality and the environment. Moreover, condition may also influence the choosing individual in mate choice, influencing their ability to invest in mate discrimination, or changing what traits of the chosen, including resources, are most preferred. Here we consider sexual selection and condition in the seed bug Lygaeus simulans, a species characterised by strong post‐copulatory sexual selection, but rather limited pre‐copulatory discrimination. We manipulated short‐term condition in both males and females by restricting access to water for 24 h. Water is particularly important in these bugs, given their feeding ecology and physiology. We found that water‐deprived males proved less likely to mate, while copulation duration with water‐deprived females was significantly reduced. Given the importance of copulation duration for the successful transfer of sperm by males to females, the data suggest cryptic male choice acting against water‐deprived females. These data add to those suggesting that cryptic male choice for fecund females plays an important role in sexual selection in this species. More generally, our results support the widespread importance of condition in terms of mating dynamics and sexual selection.

Background: Hospitalized neonates are vulnerable to infection and have high rates of antibiotic utilization. Methods: Fourteen South African neonatal units (seven public, seven private sector) assembled multidisciplinary teams involving neonatologists, microbiologists, pharmacists, and nurses to implement prospective audit and feedback neonatal antimicrobial stewardship (NeoAMS) interventions. The teams attended seven online training sessions. Pharmacists conducted weekday antibiotic prescription reviews in the neonatal intensive care unit and/or neonatal wards providing feedback to the clinical teams. Anonymized demographic and NeoAMS interventions data were aggregated for descriptive purposes and statistical analysis. Findings: During the 20-week NeoAMS intervention in 2022, 565 neonates were enrolled. Pharmacists evaluated seven hundred antibiotic prescription episodes; rule-out sepsis (180; 26%) and culture-negative sepsis (138; 20%) were the most frequent indications for antibiotic prescription. For infection episodes with an identified pathogen, only 51% (116/229) of empiric treatments provided adequate antimicrobial coverage. Pharmacists recommended 437 NeoAMS interventions (0·6 per antibiotic prescription episode), with antibiotic discontinuation (42%), therapeutic drug monitoring (17%), and dosing (15%) recommendations most frequent. Neonatal clinicians’ acceptance rates for AMS recommendations were high (338; 77%). Mean antibiotic length of therapy decreased by 24% from 9·1 to 6·9 days (0·1 day decrease per intervention week; P = 0·001), with the greatest decline in length of therapy for culture-negative sepsis (8·2 days (95% CI 5·7-11·7) to 5·9 days (95% CI 4·6-7·5); P = 0·032). Interpretation: This neonatal AMS programme was successfully implemented in heterogenous and resource-limited settings. Pharmacist-recommended AMS interventions had high rates of clinician acceptance. The NeoAMS intervention significantly reduced neonatal antibiotic use, particularly for culture-negative sepsis. Funding: A grant from Merck provided partial support.

Abstract Although patients experiencing food insecurity commonly screen positive for a myriad of social determinants of health (SDOH) needs and chronic medical conditions influenced by diet, few studies have investigated associations within both uninsured and food insecure populations. We screened patients for food insecurity using the USDA six-item short form between October 2021 and April 2022. We then evaluated associations of food security status with nine separate SDOH needs and eight chronic medical conditions. In this cross-sectional study, of the 190 patients seen at a student-run free clinic serving patients without health insurance, 135 (71%) completed the SDOH survey. We identified chronic medical conditions via retrospective chart review and analyzed associations using multivariable logistic regressions adjusted for age and sex. Uninsured participants experiencing food insecurity (n = 22,16.3%) requested more support for: medications (adjusted odds ratio [AOR] = 7.28; 95% Confidence Interval [95% CI] = 2.33–23.2); p-value [P] =