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Background: The use of a watch and wait management strategy following a complete clinical response to neoadjuvant therapy for rectal cancer is increasing. However, insights into implementation, treatments, and outcomes, on a United States national level, are limited., Objective: To investigate and report on watch & wait management practices and outcomes in the US., Design: Retrospective study., Setting: Multicenter., Patients: Stage II or III rectal cancer patients who underwent intentional watch & wait management between January 2015 and August 2022., Main Outcome Measures: Patient and tumor characteristics, neoadjuvant treatment and response, local cancer regrowth and metastasis, salvage surgery, overall and disease-specific survival., Results: Among 545 patients from 33 centers, follow-up was 21 months (range, 9-37). Total neoadjuvant therapy or other types of neoadjuvant were used in 395 (72%) and 150 (28%) of patients, respectively. Estimated 3-year local regrowth rate was 23.8% (95% CI: 19.1-29.4%). Patients with local regrowth had higher distant metastases incidence (14.2% vs. 3.5%, p < 0.001). Salvage surgery was performed in 74/84 (88%) patients with local regrowth and included rectal resection in 66 (89%), and local excision in 8 (11%). Of 64 salvage resections with known pathology results, 58 (91%) were margin-negative. Overall, 3-year overall survival was 94.8% (95% CI: 90.5 - 97.2%) and 3-year disease specific survival 96.2% (95% Cl 91.8 - 98.2%). Patients with and without local regrowth exhibited 3-year overall survival of 83.6% (95% Cl 68.4 - 91.9%), and 97.7% (95% CI: 93.3 - 99.2%), respectively., Limitations: Retrospective study., Conclusion: This multicenter study indicates that the watch & wait approach for locally advanced rectal cancer is feasible with acceptable outcomes across a variety of geographical regions and practice settings in the US. Local regrowth and distant metastasis rates were within published norms and salvage surgery proved effective. See Video Abstract., (Copyright © The ASCRS 2024.)

Background: Opioid substitution therapy (also known as 'opioid agonist therapy' or 'medication treatment of opioid use disorder') is associated with improved health and social outcomes for people who use heroin and other illicit opioids. It is typically managed in the community and is not always continued when people are admitted to hospital. This causes opioid withdrawal, patient-directed discharge, and increased costs. We are establishing a project called iHOST (improving hospital opioid substitution therapy) to address these problems. This is an applied health research project in which we will develop and evaluate an intervention that aims to improve opioid substitution therapy in three acute hospitals in England. The intervention was developed in collaboration with stakeholders including people who use opioids, hospital staff, and other professionals who work with this group. It includes five components: (1) a card that patients can use to help hospital clinicians confirm their opioid substitution therapy, (2) a helpline for patients and staff, (3) an online training module for staff, (4) a clinical guideline for managing opioid withdrawal in hospital, and (5) 'champion' roles at each hospital., Methods: We will do a mixed-methods study including a quasi-experimental quantitative study and a qualitative process evaluation. The primary outcomes for the quantitative study are patient-directed discharge and emergency readmission within 28 days. We will do a difference-in-difference analysis comparing changes in these outcomes for patients at iHOST sites with changes for patients at control hospitals. The process evaluation will use in-depth interviews, focus groups, and site observations with people who use opioids and staff. We will assess acceptability of the intervention, barriers and facilitators to implementation, and contextual factors impacting outcomes., Impact: We anticipate that iHOST will improve care for hospital patients who use illicit opioids and/or are receiving community-based opioid substitution therapy. Depending on the results, we will promote the intervention at hospitals across the UK. Dissemination, including through publication, will inform hospital-based services for people who use drugs both in the UK and other countries., Competing Interests: Competing interests: AH is conducting a PhD funded by the Medical Research Council, grants MR/W006308/1 and MR/X018636/1; he is Co-Chair of the Faculty of Public Health Drugs Special Interest Group; volunteers for the Loop (a drug checking organisation); is a member of the Drug Science Enhanced Harm Reduction Working Group (EHRWG); and in the last three years was Associate Director of International Doctors for Healthier Drug Policies., (Copyright: © 2024 Lewer D et al.)

Background: Between 2006 and 2016 the prevalence of overweight and obesity among children and adolescents aged 5-19 years in Peru increased from 22.7 to 27.0%. This investment case quantifies the economic impacts of childhood and adolescent overweight and obesity in Peru. It identifies and quantifies the potential impact of a set of new or expanded interventions that can strengthen current national efforts to prevent and reduce child and adolescent overweight and obesity., Methods: A deterministic Markov cohort model with a societal cost perspective estimated reductions in mortality and morbidity from implementing interventions to prevent and reduce child and adolescent overweight and obesity and the impact in savings in healthcare costs and gains in wages and productivity. Interventions identified through a review of published literature includes a school-based social marketing campaign, exclusive breastfeeding promotion and support, a healthy food and drink policy for school premises, and a 20% subsidy on fruits and vegetables for people living below the national poverty line. The return on investment (ROI) was calculated along with the estimated cost savings associated with the interventions. Analysis was conducted to test ROI sensitivity to changes in the key parameters and assumptions., Results: Between 2025 and 2092, the expected combined direct and indirect healthcare costs attributable to child and adolescent overweight and obesity in Peru are 210.6 billion USD. The direct healthcare costs are 1.8 billion USD, and the indirect costs are 208.8 billion USD. Expected savings for all interventions combined is 13.9 billion USD with a per-person savings of 12,089.8 USD. The expected ROI of the four interventions combined is 39.3 USD (30-years), 64.6 USD (50-years), and 164.1 USD (66-years) per one USD invested., Conclusions: The overweight and obesity epidemic among children and adolescents in Peru requires wide-ranging and expanded implementation of policies to achieve long-term reductions in prevalence. This study's findings show that the four priority interventions have high ROIs and can be used to guide policy to address the complex interplay of factors that contribute to the obesogenic environment., (© 2024. The Author(s).)

Background: Unnecessary antibiotic prescriptions in primary care are common and contribute to antimicrobial resistance in the population. Audit and feedback (A&F) on antibiotic prescribing to primary care can improve the appropriateness of antibiotic prescribing, but the optimal approach is uncertain. We performed two pragmatic randomized controlled trials of different approaches to audit and feedback. The trial results showed that A&F was associated with significantly reducing antibiotic prescribing. Still, the effect size was small, and the modifications to the A&F interventions tested in the trials were not associated with any change. Herein, we report a theory-informed qualitative process evaluation to explore potential mechanisms underlying the observed effects., Methods: Ontario family physicians in the intervention arms of both trials who were sent A&F letters were invited for one-on-one interviews. Purposive sampling was used to seek variation across interested participants in personal and practice characteristics. Qualitative analysis utilized inductive and deductive techniques informed by the Clinical Performance Feedback Intervention Theory., Results: Modifications to the intervention design tested in the trial did not alter prescribing patterns beyond the changes made in response to the A&F overall for various reasons. Change in antibiotic prescribing in response to A&F depended on whether it led to the formation of specific intentions and whether those intentions translated to particular behaviours. Those without intentions to change tended to feel that their unique clinical context was not represented in the A&F. Those with intentions but without specific actions taken tended to express a lack of self-efficacy for avoiding a prescription in contexts with time constraints and/or without an ongoing patient relationship. Many participants noted that compared to overall prescribing, A&F on antibiotic prescription duration was perceived as new information and easily actionable., Conclusion: Our findings indicate that contextual factors, including the types of patients and the setting where they are seen, affect how clinicians react to audit and feedback. These results suggest a need to test tailored feedback reports that reflect the context of how, where, and why physicians prescribe antibiotics so that they might be perceived as more personal and more actionable., Trial Registration: Clinical Trial registration IDs: NCT04594200, NCT05044052., (© 2024. The Author(s).)

Background: Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment., Objective: To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment., Design: This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services., Setting: The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017., Participants: We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not., Exposures: HPE emergency Medicaid approval at the time of hospitalization., Main Outcomes and Measures: The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval., Results: Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enroll in Medicaid (aOR 0.77, P <0.001). Surgical intervention (aOR 1.10, P <0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P <0.001)., Conclusion: California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Diabetes care remains unavailable and unaffordable for many people. Adapting models of care to low-income and middle-income country contexts is a priority. Digital technology offers substantial potential yet must surmount health system, technological and acceptability issues. This formative research aimed to identify the potential for a digital technology solution (Diabetes Compass) to address diabetes care gaps in primary healthcare., Design: Qualitative research was conducted in selected districts of Sri Lanka and Tanzania with practitioners, patients and family members. In-depth interviews assessed how digital solutions may improve diabetes care, acceptability and usability; contextual and clinical observations identified practitioner clinical competencies, strengths and weaknesses, and the influence of the care environment on service delivery; and workshop discussions explored strategies to encourage digital solution uptake and sustain use., Setting: The research was undertaken in 2022 at nine health facilities in Sri Lanka's Southern Province (Galle), and 16 health facilities in Tanzania's Lindi and Pwani Regions., Participants: Participants included primary and secondary care practitioners, facility managers, patients and family members., Results: There was striking concordance in the diabetes care gaps and potential for digital solutions in the two countries, and between practitioners, patients and family members. Five main gaps were practitioner training; health information systems and data; service delivery; infrastructure, equipment and medication; and community awareness and knowledge. Practitioners, patients and family members saw strong potential for digital solutions to improve early detection, diagnosis, secondary prevention of complications and improve patients' and families' experience of living with diabetes. They identified specific design and implementation considerations to enable the Diabetes Compass to realistically meet these needs and overcome challenges., Conclusion: There was a strong appetite among practitioners, patients and family members for a digital solution to strengthen diabetes care. Their experience of challenges and practical recommendations informed the Diabetes Compass design., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While communication is an essential skill for providing effective medical care, it is infrequently taught or directly assessed, limiting targeted feedback and behavior change. We sought to evaluate the impact of a multi-departmental longitudinal residency communication coaching program. We hypothesized that program implementation would result in improved confidence in residents' communication skills and higher-quality faculty feedback., Methods: The program was implemented over a 3-year period (2019-2022) for surgery and neurology residents at a single institution. Trained faculty coaches met with assigned residents for coaching sessions. Each session included an observed clinical encounter, self-reflection, feedback, and goal setting. Eligible residents completed baseline and follow-up surveys regarding their perceptions of feedback and communication. Quantitative responses were analyzed using paired t-tests; qualitative responses were analyzed using content analysis., Results: The baseline and follow-up survey response rates were 90.0% (126/140) and 50.5% (46/91), respectively. In a paired analysis of 40 respondents, residents reported greater confidence in their ability to communicate with patients (inpatient: 3.7 vs. 4.3, p < 0.001; outpatient: 3.5 vs. 4.2, p < 0.001), self-reflect (3.3 vs. 4.3, p < 0.001), and set goals (3.6 vs. 4.3, p < 0.001), as measured on a 5-point scale. Residents also reported greater usefulness of faculty feedback (3.3 vs. 4.2, p = 0.001). The content analysis revealed helpful elements of the program, challenges, and opportunities for improvement. Receiving mentorship, among others, was indicated as a core program strength, whereas solving session coordination and scheduling issues, as well as lowering the coach-resident ratio, were suggested as some of the improvement areas., Conclusions: These findings suggest that direct observation of communication in clinical encounters by trained faculty coaches can facilitate long-term trainee growth across multiple core competencies. Future studies should evaluate the impact on patient outcomes and workplace-based assessments., (© 2024. The Author(s).)

Background: Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation., Methods: An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data., Results: A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel., Conclusion: Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Entrustable professional activities (EPAs) are a widely used framework for curriculum and assessment, yet the variability in emergency medicine (EM) training programs mandates the development of EPAs that meet the needs of the specialty as a whole. This requires eliciting and incorporating the perspectives of multiple stakeholders (i.e., faculty, residents, and patients) in the development of EPAs. Without a shared understanding of what a resident must be able to do upon graduation, we run the risk of advancing ill-prepared residents that may provide inconsistent care., Methods: In an effort to address these challenges, beginning in February 2020, the authors assembled an advisory board of 25 EM faculty to draft and reach consensus on a final list of EPAs that can be used across all training programs within the specialty of EM. Using modified Delphi methodology, the authors came to consensus on an initial list of 22 EPAs. The authors presented these EPAs to faculty supervisors, residents, and patients for refinement. The authors collated and analyzed feedback from focus groups of residents and patients using thematic analysis. The EPAs were subsequently refined based on this feedback., Results: Stakeholders in EM residency training endorsed a final revised list of 22 EPAs. Stakeholder focus groups highlighted two main thematic considerations that helped shape the finalized list of EM EPAs: attention to the meaningful nuances of EPA language and contextualizing the EPAs and viewing them developmentally., Conclusions: To foreground all key stakeholders within the EPA process for EM, the authors chose within the development process to draft; come to consensus; and refine EPAs for EM in collaboration with relevant faculty, patient, and resident stakeholders. Each stakeholder group contributed meaningfully to the content and intended implementation of the EPAs. This process may serve as a model for others in developing stakeholder-responsive EPAs., Competing Interests: The authors declare no conflicts of interest., (© 2024 Society for Academic Emergency Medicine.)

Introduction: Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-d emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-d HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow and (2) facilitators and barriers to HPE approval to understand process improvement opportunities., Material and Methods: We conducted semi-structured interviews between September-December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement., Results: Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics., Conclusions: This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer., Summary Background Data: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions., Methods: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White., Results: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics., Conclusions: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity., Competing Interests: Disclosures: The authors report no conflicts of interest related to this work. The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s (CDC) National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute’s Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: A retrospective cross-sectional study., Objective: To identify who prescribes outpatient antibiotics among a primary care spinal cord injury (SCI) cohort., Setting: ICES databases in Ontario, Canada., Methods: A cohort of individuals with SCI were retrospectively identified using a tested-algorithm and chart reviews in a primary care electronic medical records database. The cohort was linked to a drug dispensing database to obtain outpatient antibiotic prescribing information, and prescriber details were obtained from a physician database., Results: Final cohort included three hundred and twenty individuals with SCI. The average annual number of antibiotic courses dispensed for the SCI cohort was 2.0 ± 6.2. For dispensed antibiotics, 58.9% were prescribed by rostered-primary care practice physicians, compared to 17.9% by emergency and non-rostered primary care physicians, 17.4% by specialists and 6.1% by non-physician prescribers. Those who lived in urban areas and rural areas, compared to those who lived in suburban areas, were more likely to receive antibiotics from emergency and non-rostered primary care physicians than from rostered-primary care practice physicians., Conclusion: Although individuals with SCI received outpatient antibiotic prescriptions from multiple sources, physicians from an individual's rostered-primary care practice were the main antibiotic prescribers. As such, interventions to optimize antibiotics use in the SCI population should target the primary care practice., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse., Methods: CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021)., Results: Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention)., Conclusions: Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger., Level of Evidence: Level II., Type of Study: Study of Diagnostic Test., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists., Background: Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity, and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice., Methods: An American Surgical Association Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A strength, weakness, opportunities, threats analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies., Results: Taskforce recommendations: (1) SURGEONS: Growth mindset : identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set : align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair : mentor-mentee matching/regular meetings/accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (eg, relative value unit equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee : enthusiastic/eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (eg, T-/P-grants), leveraging of institutional resources, negotiation of formalized/formulaic funds flow investment from academic medical center toward science, philanthropy; (4) STRUCTURAL/STRATEGIC SUPPORT: Structural: grants administrative support, biostats/bioinformatics support, clinical trial and research support, regulatory support, shared departmental laboratory space/equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention/ recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses/mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (eg, endowed chairs), promotion friendly toward surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator status, surgeon representation on study section, focused award strategies for professional societies/foundations., Conclusions: Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists toward advancements of science., Competing Interests: S.H.F. reports past compensation to her institution from Novartis, Randox, and Transplant Genomics. S.H.F. also serves as an Editor-in-Chief for American Journal of Transplantation and a member of Editorial Board for New England Journal of Medicine . W.E.G. reports ongoing compensation to his institution from National Cancer Institute, Leidos Biomedical, and 1440 Foundation. E.A.M. reports compensated service on scientific advisory boards for Astra Zeneca, BioNTech and Merck; uncompensated service on steering committees for Bristol Myers Squibb and Roche/Genentech; and institutional research support from Roche/Genentech (via SU2C grant) and Gilead. E.A.M. also reports research funding from Susan Komen for the Cure for which she serves as a Scientific Advisor, and uncompensated participation as a member of the American Society of Clinical Oncology Board of Directors. J.K.S. receives consultant fees from Deciphera, Aadi and Grand Rounds, serves as a consultant for CureMatch, received speaker’s fees from Deciphera, La-Hoffman Roche, Foundation Medicine, Merck, QED, and Daiichi Sankyo; and owns stock in Personalis and CureMatch. L.G.W. reports ongoing compensation to her institution from Perimeter Medical and compensated services from Elucent Medical. D.L.F. reports compensated services from Briopryme and Artemis Cures; uncompensated services as a consultant for the National Institutes of Health; and research funding from California Institute for Regenerative Medicine (CIRM). The other authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Fibromyalgia (FM) affects 2% to 8% of the general population. FM patients often experience self-stigma and feel rejected by healthcare providers and families, resulting in isolation and distressing symptoms of pain, fatigue, and poor cognitive functioning, increasing the risk of depressive symptoms. Major Depressive Disorder (MDD) is the most common comorbidity in FM patients (Any depression: 43%; MDD: 32%). Genome-wide association studies (GWAS) have identified a common genetic risk loci for major depression and fibromyalgia. Given that even minor symptoms of depression worsen the outcomes of FM patients, clinicians are challenged to identify and manage depression in these patients. However, due to overlapping symptoms, limited screening, and contamination bias, MDD often goes undiagnosed and presents a critical challenge. Unrecognized and untreated MDD in FM patients can exacerbate fatigue, sleep disturbances, and pain, reduce physical functioning, and increase the risk of developing comorbid conditions, such as substance abuse and cardiovascular disease. These comorbidities are associated with a lower treatment response rate, a higher dropout rate, and a greater risk of relapse. Clinicians may effectively identify and treat MDD in FM patients with appropriate pharmacologic agents combined with aerobic exercise and cognitive-behavioral therapies for core FM symptoms, thus significantly reducing symptom severity for both MDD and FM. Such a comprehensive approach will result in a much-improved quality of life. MedLine content was searched via PubMed to identify eligible articles between 1995 and 2023 using search terms fibromyalgia, major depressive disorder, and treatment of depression in fibromyalgia, and the most current information is presented. In this primer for clinicians caring for FM patients, we describe clinically relevant pharmacologic and non-pharmacologic management approaches for treating MDD in FM patients., Competing Interests: Declaration of conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives., Methods: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8)., Results: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care., Conclusion: Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program., Level of Evidence: Economic And Value Based Evaluations; Level II., (Copyright © 2023 American Association for the Surgery of Trauma.)