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Burn survivors experience barriers to returning to work. For those who do return to work, little is known regarding whether they achieve preinjury productivity (i.e., equivalent or gain in income compared to preinjury income). Identifying patients at risk of not achieving preinjury productivity is important for targeting services that support this population. They extracted occupational and income data through 24 months postinjury from the multicenter, longitudinal Burn Model System National Database. Annual income was reported in six groups: 199k. Participants were classified by change in income at each follow-up (i.e., gain, loss, and equivalent). Explanatory variables included demographics, injury characteristics, insurance payer, employment status, and job type. Multilevel, multivariable logistic regression was used to model return to productivity. Four hundred fifty-three participants provided complete income data at discharge and follow-up. Of the 302 participants employed preinjury, 180 (60%) returned to work within 24 months postinjury. Less than half (138) returned to productivity (46% of participants employed preinjury; 77% of those who returned to work). Characteristics associated with return to productivity included older age (median 46.9 vs 45.9 years, OR 1.03, P = .006), Hispanic ethnicity (24% vs 11%, OR 1.80, P = 0.041), burn size >20% TBSA (33.7% vs 33.0%, OR 2.09, P = 0.045), and postinjury employment (54% vs 26%, OR 3.41, P < 0.001). More than half of employed people living with burn injury experienced loss in productivity within 24 months postinjury. Even if they return to work, people living with burn injuries face challenges returning to productivity and may benefit from vocational rehabilitation and/or financial assistance.

Patient-reported outcomes are important for understanding recovery after burn injury, benchmarking service delivery and measuring the impact of interventions. Patient-Reported Outcomes Measurement Information System (PROMIS)-29 domains have been validated for use among diverse populations though not among burn survivors. The purpose of this study was to examine validity and reliability of PROMIS-29 scores in this population.The PROMIS-29 scores of physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social roles, and pain interference were evaluated for validity and reliability in adult burn survivors. Unidimensionality, floor and ceiling effects, internal consistency, and reliability were examined. Differential item functioning was used to examine bias with respect to demographic and injury characteristics. Correlations with measures of related constructs (Community Integration Questionnaire, Satisfaction with Life Scale, Post-Traumatic Stress Checklist-Civilian, and Veteran's Rand-12) and known-group differences were examined.Eight hundred and seventy-six burn survivors with moderate to severe injury from 6 months to 20 years postburn provided responses on PROMIS-29 domains. Participants' ages ranged from 18 years to 93 years at time of assessment; mean years since injury was 3.4. All PROMIS domain scores showed high internal consistency (Cronbach's α = 0.87-0.97). There was a large ceiling effect on ability to participate in social roles (39.7%) and physical function (43.3%). One-factor confirmatory factor analyses supported unidimensionality (all comparative fit indices0.95). We found no statistically significant bias (differential item functioning). Reliability was high (0.9) across trait levels for all domains except sleep, which reached moderate reliability (0.85). All known-group differences by demographic and clinical characteristics were in the hypothesized direction and magnitude except burn size categories.The results provide strong evidence for reliability and validity of PROMIS-29 domain scores among adult burn survivors. Reliability of the extreme scores could be increased and the ceiling effects reduced by administering PROMIS-43, which includes six items per domain, or by administering by computerized adaptive testing.Diagnostic Test or Criteria, level III.

Background We aimed to analyze the impact of the Affordable Care Act’s Medicaid Expansion on clinical outcomes and patient disposition after burn injury. We hypothesized that increased insurance coverage results in improved outcomes and higher rates of discharge to inpatient rehabilitation. Methods We reviewed the University of Washington Regional Burn Center registry data for patients admitted from 2011 to 2018. Patients were grouped into two categories: before (2011–2013) and after (2015−2018) Medicaid expansion; we excluded 2014 data to serve as a washout period. Outcomes assessed included length of hospital stay, patient disposition, and mortality. Multivariable logistic and linear regression models with covariates for sex, age, burn size, ethnicity ethnicity, distance from burn center, etiology of burn, and presence of inhalation injury were used to determine the impact of Medicaid expansion on outcomes. Results Rates of uninsured patients decreased while Medicaid coverage increased. Despite increased median burn size after Medicaid expansion, inpatient mortality rates did not change, but average acute care length of stay increased. More patients were discharged to rehabilitation centers. Conclusions Our study corroborates prior findings of increased insurance coverage since Medicaid expansion. Increased insurance coverage is associated with higher rates of discharge to inpatient rehabilitation programs after burn injury.

Cytochrome c oxidase subunit II (COX2) is one of the three mitochondrially encoded proteins of the complex IV of the respiratory chain that catalyses the reduction of oxygen to water. The

Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities.To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems.This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022.Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being.Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35).This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Introduction Previous reports suggest that many factors impact recovery from burn injury. To improve our understanding of these factors, we queried adult burn survivors using a mixed method design during the first year after injury. Methods An anonymous, 2-page survey was developed and administered to adult burn survivors during routine outpatient clinic follow-up visits at a regional burn center. Participants rated issues of concern and their impacts on return to pre-burn activity levels. Both quantitative and qualitative data were obtained. Descriptive statistics were used to analyze quantitative data and thematic analysis was used to identify, analyze and report patterns from open-ended responses. Results Over seven months in 2016, 187 patients completed the anonymous survey. Study participants were predominantly male, white, and non-Hispanic. Participants who had not yet returned to pre-burn function reported worse outcomes for all issues queried compared to those who had. Burn survivors from racial and ethnic minority groups reported greater difficulty with accessing medical care and information about their injury as well as higher levels of self-identified posttraumatic stress, issues related to appearance and concerns for loss of strength. Several themes and sub-themes were identified that had both negative and positive impact on early recovery. Such themes included: healing process, psychological recovery and emotional health, and community reintegration/employment. Conclusions Several themes from responses provided insight into challenges as well as key support systems during the first year of recovery after injury. Collectively, these findings can be used to direct clinical outpatient care, patient education and psychosocial support services.

Preburn comorbidities increase the risk of death in the acute phase, and negatively impact quality of life among survivors. Investigations to date have only evaluated comorbidities as indices, limiting the ability to target conditions and develop strategies for risk reduction. Therefore, we aimed to evaluate the differential effects of specific conditions on long-term, patient-reported outcomes after burn injury. A prospectively maintained trauma registry was merged with a longitudinal database of patient-reported outcomes from a regional burn center from 2007 to 2018. Demographic data, injury-specific information, and the prevalence of 20 comorbidities were systematically documented. The impact of comorbidities on responses to Short Form-12/Veterans RAND 12 (SF/VR-12) health surveys at 6, 12, and 24 months postinjury was evaluated with generalized linear models. The merged dataset included 493 adult participants. Median age was 46 years (interquartile range, IQR 32–57 years), and 72% were male. Median burn size was 14% TBSA (IQR 5–28%). Seventy percent of participants had ≥1 comorbidity (median 1 comorbidity/participant; IQR 0–2 comorbidities). SF/VR-12 mental component summary scores at 6 and 12 months postinjury were negatively associated with mental illness (P < .001, P = .013). SF/VR-12 physical component summary (PCS) scores were negatively associated with smoking (P = .019), diabetes (P = .001), and alcohol use disorder (P = .001) at 6-month follow-up. Twelve-month SF/VR-12 PCS scores were negatively associated with prior trauma admission (P = .001) and diabetes (P = .042). Twenty-four-month SF/VR-12 PCS scores were negatively associated with mental illness (P = .003). Smoking, alcohol use disorder, and diabetes were associated with lower PCS scores 6 months after injury; diabetes persisted as a negatively associated covariate at 12 months. Mental component summary scores were negatively associated with mental illness 6 and 12 months postinjury. Integrated models of postdischarge comorbidity management need to be tested in burn patients.

Background Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. Methods We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. Results The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. Conclusions Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements. Electronic supplementary material The online version of this article (10.1007/s00268-020-05428-y) contains supplementary material, which is available to authorized users.

This research was funded by Discovery grants from the Natural Sciences and Engineering Research Council of Canada (NSERC) to D.T.S. (grant number 217175) and S.B. (grant number 435656). E.E.C. was funded by the European Union's Horizon 2020 research and innovation programme under the Marie Skodowska-Curie grant agreement No713750, carried out with the financial support of the Regional Council of Provence- Alpes-Cote d'Azur and with the financial support of the A*MIDEX (n degrees ANR- 11-IDEX-0001-02), funded by the Investissements d'Avenir project funded by the French Government, managed by the French National Research Agency [ANR]. B.M.R. was supported by an NSERC CGS-D award, Killam Predoctoral Scholarship, and a NS Graduate Scholarship. M.A.G.-R. was supported by a Harrison McCain Visiting Professorship Award at Acadia University from the Harrison McCain Foundation., Doubly uniparental inheritance (DUI) of mitochondrial DNA (mtDNA) in bivalve mollusks is one of the most notable departures from the paradigm of strict maternal inheritance of mtDNA among metazoans. Recently, work on the Mediterranean mussel Mytilus galloprovincialis suggested that a nucleotide motif in the control region of this species, known as the sperm transmission element (STE), helps protect male-transmitted mitochondria from destruction during spermatogenesis. Subsequent studies found similar, yet divergent, STE motifs in other marine mussels. Here, we extend the in silico search for mtDNA signatures resembling known STEs. This search is carried out for the large unassigned regions of 157 complete mitochondrial genomes from within the Mytiloida, Veneroida, Unionoida, and Ostreoida bivalve orders. Based on a sliding window approach, we present evidence that there are additional putative STE signatures in the large unassigned regions of several marine clams and freshwater mussels with DUI. We discuss the implications of this finding for interpreting the origin of doubly uniparental inheritance in ancestral bivalve mollusks, as well as potential future in vitro and in silico studies that could further refine our understanding of the early evolution of this unusual system of mtDNA inheritance., Natural Sciences and Engineering Research Council of Canada (NSERC) 217175 435656, European Commission 713750, Region Provence-Alpes-Cote d'Azur, French National Research Agency (ANR) ANR- 11-IDEX-0001-02 NSERC CGS-D award, Killam Predoctoral Scholarship, NS Graduate Scholarship, Harrison McCain Visiting Professorship Award at Acadia University from the Harrison McCain Foundation

PURPOSE: To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120–275/100,000). RESULTS: An estimated 17,418 [95% uncertainty interval (UI) 8,154–26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2–99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully-trained surgeons, but nonetheless performed 38% of district-level hernia operations. CONCLUSIONS: The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully-trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly-important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

INTRODUCTION. The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark. METHODS. Data on operations performed for elderly patients over a 1-year period in 2014–5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) vs. other according to The World Bank’s Disease Control Priority project (DCP-3). Data from New Zealand’s National Minimum Dataset were used to derive a benchmark operation rate for the elderly. RESULTS. 16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95%UI: 1440–2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category. CONCLUSIONS. The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana’s elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.

Objective The primary aim of the study was to determine levels of literacy in both oral health and orthodontics in an adult population. The secondary study aim was to investigate differences in literacy between males and females. Methods Participants included individuals 18 years or older seeking dental treatment at the East Carolina University (ECU) School of Dental Medicine. To determine levels of oral health literacy (OHL) and orthodontic literacy (OrthoL), validated instruments were administered, including the Rapid Estimate of Adult Literacy in Medicine and Dentistry, the Oral Health Literacy Instrument and its separate scales, and a questionnaire on orthodontic literacy. Summary statistics were computed, and statistical significance was set at 0.05. Results One hundred seventy-two individuals participated in the study and had a mean age of 55.03 (range:18–88). Greater than 70% of the sampled population exhibited inadequate or marginal oral health knowledge. Additionally, greater than 70% of the sample possessed no more than an 8th grade reading level, with regard to basic medical and dental terms. Higher education was weakly associated with higher OrthoL and OHL. Higher age was also weakly associated with lower OrthoL and OHL. Males on average exhibited significantly higher OHL (p < .05) but there were no OrthoL differences between males and females. Dental visit frequency was not associated with OrthoL or OHL. Conclusion Low levels of OrthoL and OHL were observed in the study. While males demonstrated a higher level of OHL than females, neither age nor the occurrence of dental appointments significantly influenced levels of literacy.

People living with burn injury often report temperature sensitivity. However, its epidemiology and associations with health-related quality of life (HRQOL) are unknown. We aimed to characterize temperature sensitivity and determine its impact on HRQOL to inform patient education after recovery from burn injury. We used the multicenter, longitudinal Burn Model System National Database to assess temperature sensitivity at 6, 12, and 24 months after burn injury. Chi-square and Kruskal–Wallis tests determined differences in patient and injury characteristics. Multivariable, multilevel generalized linear regression models determined the association of temperature sensitivity with Satisfaction with Life (SWL) scale scores and Veterans RAND 12 (VR-12) physical and mental health summary component (MCS) scores. The cohort comprised 637 participants. Two thirds (66%) experienced temperature sensitivity. They had larger burns (12% TBSA, interquartile range [IQR] 4–30 vs 5% TBSA, IQR 2–15; P < .0001), required more grafting (5% TBSA, IQR 1–19 vs 2% TBSA, IQR 0–6; P < .0001), and had higher intensity of pruritus at discharge (11% severe vs 5% severe; P = .002). After adjusting for confounding variables, temperature sensitivity was strongly associated with lower SWL (odds ratio [OR] −3.2, 95% confidence interval [CI] −5.2, −1.1) and MCS (OR −4.0, 95% CI −6.9, −1.2) at 6 months. Temperature sensitivity decreased over time (43% at discharge, 4% at 24 months) and was not associated with poorer HRQOL at 12 and 24 months. Temperature sensitivity is common after burn injury and associated with worse SWL and MCS during the first year after injury. However, temperature sensitivity seems to improve and be less intrusive over time.

The Lancet Commission on Global Surgery (LCoGS) recommended an annual surgical rate at which low- and middle-income countries (LMICs) could achieve most of the population-wide benefits of surgery. However, condition-specific guidelines were not proposed. To inform rates of surgery for cancer, we sought to assess the current met and unmet need for oncologic surgery in Ghana. Data on all operations performed in Ghana over a one-year period (2014–15) were obtained from representative samples of 48/124 first-level and 12/16 referral hospitals and scaled-up for nationwide estimates. Procedures for cancer were identified by indication. Using modified LCoGS methodology with disease prevalence, Ghana’s annual rate of cancer surgery was compared to that of New Zealand to quantify current unmet needs. 232,776 surgical procedures were performed in Ghana; 2,562 procedures (95%UI 1878–3255) were for cancer. Of these, 964 (37%) were surgical biopsies. The annual rate of procedures treating cancer was 2115 surgeries/100,000 cancer cases, or 21% of the New Zealand benchmark. Cervical, breast, and prostate cancer were found to meet 2.1%, 17.2%, and 32.1% of their respective surgical need. There is a large unmet need for cancer surgery in Ghana. Cancer surgery constitutes under 2% of the total surgeries performed in Ghana, an important proportion of which are used for biopsies. Therapeutic operative rate is deficient across most cancer types, and may lag behind improvements in screening efforts. As cancer prevalence and diagnosis increase in LMICs, cancer-specific surgical capacity must be increased to meet these evolving needs.

BACKGROUND: We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels. METHODS: In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality. RESULTS: Among 6,431 burn patients (38% female; 62% male), females less frequently received surgical treatment during index hospitalization (49% vs 56%, p

A previously healthy 68-year-old man rapidly developed a severe melancholic depression following influenza infection. There is an evolving understanding of the complex and possibly bidirectional relationship between depression and inflammation. We review the literature concerning this relationship in the context of viral infection and discuss possible implications for treatment.

To examine agreement between pediatric burn survivor self- and caregiver proxy-report on multiple PROMIS domains and examine factors associated with differences between self- and proxy-reports. Children 8–17 years of age and their caregivers completed PROMIS measures (physical function, depression, peer relationships, pain interference, and anger) between 6 months and 15 years after injury. Self- and proxy-report scores were compared using Wilcoxon sign rank test, Cohen’s effect size, and intraclass correlation coefficients (ICC) and by agreement across severity of symptoms based on recommended cutoffs. Ordinary least squares regression analyses examined child- (self-report score, age, gender, and ethnicity) and proxy-related (relationship to child) factors associated with score differences. Two hundred and seventy four child-caregiver pairs completed the PROMIS measures. Mean child age was 13.0 (SD:3) years. Caregivers reported significantly worse scores than the child on physical function, pain, and anger (all p ≤ 0.01). The effect sizes were small across all domains except physical function. Similarly, ICCs were all of moderate agreement. The percentage of dyads in agreement by severity groups was high with only 5%-9% of pairs discordant. Only higher self-report score was associated (all p

BACKGROUND: We aimed to determine the incidence of childhood burn injuries in rural Ghana and describe modifiable household risk factors to inform prevention initiatives. METHODS: We performed a cluster-randomized, population-based survey of caregivers of children in a rural district in Ghana, representing 2713 households and 14,032 children. Caregivers were interviewed regarding childhood burn injuries within the past 6 months and household risk factors. RESULTS: 357 households were sampled. Most used an open fire with biomass fuel for cooking (85.8%). Households rarely cooked in a separate kitchen (10%). Stove height was commonly within reach of children under five years (

Background Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients’ involvement in their care. However, little is known about the pathways through which portals may help patients engage in their care. Objective Our objective is to understand how an electronic patient portal facilitates patient engagement among individuals with diabetes. Methods This qualitative study employed semistructured telephone interviews of 40 patients living with diabetes since at least 2011, who had experienced uncontrolled diabetes, and had used secure messaging through a portal at least 4 times over 18 months. The interviews were recorded, transcribed, coded, and analyzed using primarily an inductive approach to identify how patients living with diabetes use an online health portal to support diabetes self-management. Results Overall, patients who used the portal reported feeling engaged in their health care. We identified four pathways by which the portal facilitates patient engagement and some challenges. The portal provides a platform that patients use to (1) better understand their health by asking questions about new symptoms, notes, or labs, (2) prepare for medical appointments by reviewing labs and notes, (3) coordinate care between VA (Veterans Affairs) and non-VA health care teams, and (4) reach out to providers to request help between visits. Several patients reported that the portal helped improve the patient-provider relationship; however, aspects of the portal design may hinder engagement for others. Patients reported challenges with both secure messaging and access to medical records that had negative impacts on their engagement. Benefits for patient engagement were described by many types of portal users with varying degrees of diabetes control. Conclusions Patient portals support engagement by facilitating patient access to their health information and by facilitating patient-provider communication. Portals can help a wide range of users engage with their care.

Background Vein conduit is known to have better patency than prosthetic for infrainguinal bypass. Here we explore if racial disparities exist in infrainguinal bypass vein conduit use amid preoperative patient and systemic factors. Methods Retrospective Society for Vascular Surgery Vascular Quality Initiative data for 23,959 infrainguinal bypasses between 2003 and 2017 for occlusive disease were analyzed. For homogeneity, only infrainguinal bypasses originating from the common femoral artery were included. Demographics of patients receiving vein vs prosthetic were compared and logistic regression analyses were performed with race and preoperative factors to evaluate for predictors of vein conduit use. Results Adjusted regression models demonstrated black patients were 76% as likely ( p Conclusion Racial disparities exist in conduit use for infrainguinal bypass, with black and Hispanic patients less likely to receive vein bypasses. However, the contribution of race to conduit selection is small in adjusted and unadjusted models. Overall, pre-operative variables in the Vascular Quality Initiative poorly predicted vein conduit use for infrainguinal bypass.

Highlights • There are few tools to facilitate shared decision-making after burn injury. • Mortality prognostication scores are thought to reflect long-term quality of life. • Higher rBaux and Ryan scores are negatively correlated with long-term physical health, but not mental health. • Burn size and mortality prognostication scores poorly explained the variance quality of life. • More accurate scores are needed to predict long-term quality of life, Objective Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury. Methods We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994–2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined. Results The analysis included 1606 respondents (median age 42 years, IQR 28–53 years; 70% male). Median burn size was 16% TBSA (IQR 6–30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r2 0.01–0.12). Conclusion Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005–2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008–2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.

Background Successful medication management for bipolar disorder requires clinicians to monitor and adjust regimens as needed, to achieve maximum effectiveness and patient adherence. This study aims to measure the prevalence of indications for medication adjustment at visits for bipolar disorder treatment; the frequency with which physicians recommend medication adjustments; and how strongly the indications predict the adjustments. Methods Data included 3,094 visits for 457 patients in Bipolar CHOICE, a comparative effectiveness study that compared treatment with lithium versus quetiapine. A set of indications for adjustment was matched to reports of whether the physician recommended a medication adjustment at that visit, and what type. Associations between indication and adjustment were examined using bivariate tests and hierarchical logistic mixed effects models. Results Medication adjustment was recommended at 63% of the visits where one of the indications was present, and at 53% of all visits. In multivariable analyses, adjustment was more likely to be recommended if there was an indication of non-response or side effects, for patients who started on quetiapine rather than lithium, or for patients who were female, married, employed or more educated. Limitations The study's cross-sectional design implies that observed associations could result from confounding variables. Also, the CHOICE trial placed certain restrictions on physicians’ medication choices, although this is not likely to have resulted in major alterations of prescribing patterns. Conclusions Clinical inertia may help explain the lack of any adjustment recommendation at 37% of the visits where one of the indications was present. Other explanations could also apply, such as watchful waiting.

Public parks provide places for urban residents to obtain physical activity (PA), which is associated with numerous health benefits. Adding facilities to existing parks could be a cost-effective approach to increase the duration of PA that occurs during park visits. Using objectively measured PA and comprehensively measured park visit data among an urban community-dwelling sample of adults, we tested the association between the variety of park facilities that directly support PA and the duration of PA during park visits where any PA occurred. Cross-classified multilevel models were used to account for the clustering of park visits (n = 1553) within individuals (n = 372) and parks (n = 233). Each additional different PA facility at a park was independently associated with a 6.8% longer duration of PA bouts that included light-intensity activity, and an 8.7% longer duration of moderate to vigorous PA time. Findings from this study are consistent with the hypothesis that more PA facilities increase the amount of PA that visitors obtain while already active at a park. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11524-018-0311-1) contains supplementary material, which is available to authorized users.

OBJECTIVE: To evaluate the operation rate in Ghana and characterize it by types of procedures and hospital level. BACKGROUND: The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations/100,000 people as a benchmark at which low- and middle-income countries could achieve most of the population-wide benefits of surgery, but did not define procedure-type benchmarks. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district-level (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 o f 5 tertiary hospitals, and scaled-up to nationwide estimates. Operations were categorized into those deemed as essential procedures (most cost-effective, highest population impact) by the World Bank’s Disease Control Priorities Project versus other. RESULTS: An estimated 232,776 [95% uncertainty interval (95% UI) 178,004 to 287,549] operations were performed nationally. The annual rate of oper ations was 869 of 100,000 (95% UI 664 to 1073). The rate fell well short of the benchmark. 77% of the estimated annual national surgical output was in the essential procedure category. Most operations (62%) were performed at district-level hospitals. Most district-level hospitals (54%) did not have fully trained surgeons, but nonetheless performed 36% of district-level hospital operations. CONCLUSION: The operation rate was short of the Lancet Commission bench mark, indicating large unmet need, although most operations were in the essential procedure category. Future global surgery benchmarking should consider both total numbers and priority levels. Most surgical care was delivered at district-level hospitals, many without fully trained surgeons. Benchmarking to improve surgical care needs to address both access defi ciencies and hospital and provider level.

Introduction Road traffic injuries (RTI) are a leading cause of morbidity and mortality around the world. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using nationally representative survey data. Methods The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, and disability from injury was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate. Results A total of 13,765 respondents from 7115 households in the four countries were surveyed. RTIs occurred in 2.2% (2.0–2.5%) of the population and accounted for 12.9% (11.5–14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years); 74% were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (requiring anesthesia). Major disability resulting in limitations of work or daily activity occurred in 38.5% (33.0–43.9%). Conclusion RTIs account for a significant proportion of disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, improved access to timely emergency, trauma and surgical care may help alleviate the burden due to RTI in LMICs.

Objectives The objective of this study was to report the effectiveness of trazodone for treatment of bruxism in dementia. Methods A single case study of a 66-year-old man with severe vascular dementia and awake bruxism was performed. Results The patient's bruxism responded robustly to titration of trazodone. He tolerated the medication with no untoward sedation or other adverse effects. Conclusions Bruxism is occasionally encountered in patients with advanced dementia and raises concerns about nutritional compromise and about potential need for poorly tolerated dental treatment. Trazodone may potentially be effective for bruxism in some patients.

Introduction Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. Methods Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010–April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N = 5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. Results The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. Conclusions Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.

Disorders of swallowing are poorly characterized but quite common in schizophrenia. They are a source of considerable morbidity and mortality in this population, generally as a result of either acute asphyxia from airway obstruction or more insidious aspiration and pneumonia. The death rate from acute asphyxia may be as high as one hundred times that of the general population. Most swallowing disorders in schizophrenia seem to fall into one of two categories, changes in eating and swallowing due to the illness itself and changes related to psychotropic medications. Behavioral changes related to the illness are poorly understood and often involve eating too quickly or taking inappropriately large boluses of food. Iatrogenic problems are mostly related to drug-induced extrapyramidal side effects, including drug-induced parkinsonism, dystonia, and tardive dyskinesia, but may also include xerostomia, sialorrhea, and changes related to sedation. This paper will provide an overview of common swallowing problems encountered in patients with schizophrenia, their pathophysiology, and management. While there is a scarcity of quality evidence in the literature, a thorough history and examination will generally elucidate the predominant problem or problems, often leading to effective management strategies.

Recent work has revealed links between memory, imagination, and problem solving, and suggests that increasing access to detailed memories can lead to improved imagination and problem-solving performance. Depression is often associated with overgeneral memory and imagination, along with problem-solving deficits. In this study, we tested the hypothesis that an interview designed to elicit detailed recollections would enhance imagination and problem solving among both depressed and nondepressed participants. In a within-subjects design, participants completed a control interview or an episodic specificity induction prior to completing memory, imagination, and problem-solving tasks. Results revealed that compared to the control interview, the episodic specificity induction fostered increased detail generation in memory and imagination and more relevant steps on the problem-solving task among depressed and nondepressed participants. This study builds on previous work by demonstrating that a brief interview can enhance problem solving among individuals with depression and supports the notion that episodic memory plays a key role in problem solving. It should be noted, however, that the results of the interview are relatively short-lived.

Objectives To examine the effectiveness of low-dose lithium carbonate for managing carbamazepine-induced hyponatremia. Methods Single case study in an 88 year old man with bipolar illness and vascular dementia who had failed to respond to other mood stabilizers. Results The patient had developed hyponatremia on two separate occasions when treated with carbamazepine. Introduction of low-dose lithium resulted in prompt normalization of serum sodium levels, which was maintained for the subsequent 8 weeks. Conclusions Carbamazepine may sometimes be the best or only viable treatment option for patients with bipolar illness or other conditions. When its use is complicated by syndrome of inappropriate ADH, dose reduction and fluid restriction are the simplest options but, if ineffective, addition of lithium may be a feasible, albeit somewhat complicated, alternative.

International audience; in animals, strictly maternal inheritance (SMi) of mitochondria is the rule, but one exception (doubly uniparental inheritance or DUI), marked by the transmission of sex-specific mitogenomes, has been reported in bivalves. Associated with DUI is a frequent modification of the mitochondrial cox2 gene, as well as additional sex-specific mitochondrial genes not involved in oxidative phosphorylation. With the exception of freshwater mussels (for 3 families of the order Unionida), these DUI-associated features have only been shown in few species [within Mytilidae (order Mytilida) and Veneridae (order Venerida)] because of the few complete sex-specific mitogenomes published for these orders. Here, we present the complete sex-specific mtDNAs of two recently-discovered DUI species in two families of the order Venerida, Scrobicularia plana (Semelidae) and Limecola balthica (tellinidae). these species display the largest differences in genome size between sex-specific mitotypes in DUI species (>10 kb), as well as the highest mtDNA divergences (sometimes reaching >50%). An important in-frame insertion (>3.5 kb) in the male cox2 gene is partly responsible for the differences in genome size. The S. plana cox2 gene is the largest reported so far in the Kingdom Animalia. The mitogenomes may be carrying sex-specific genes, indicating that general mitochondrial features are shared among DUI species. Animal mitochondrial DNA (mtDNA) is typically depicted as a strictly maternally inherited (SMI) circular DNA molecule that is relatively small (~16 kb) and genomically streamlined with almost invariant gene content (13 protein-coding genes and 24 structural RNAs) 1,2. However, important deviations do occur in the mtD-NAs of bivalve molluscs, which not only display dramatic variation in size (67 kb) 3,4 and gene arrangement 5 , but also the presence of additional protein-coding genes not associated with oxidative phospho-rylation 6-9. An even more extreme departure from the norm in bivalve mitochondrial genomes is their mode of doubly uniparental inheritance (DUI)-both egg and sperm mitochondria are transmitted from generation to generation in several bivalve species, but only male offspring retain paternally-transmitted mitochondria (with male or M mtDNA) in their gametes 10-12. Adult females of DUI-exhibiting species usually possess only the female-transmitted mtDNA (F mtDNA) in their soma and gametes whereas males possess F mtDNA in their soma and M mtDNA in their gametes 10-13. The DNA divergence between F and M mtDNAs usually vary from about 8% to 40% depending on the species 12,14. Genetic analyses suggested that both F and M mtDNAs in DUI bivalves evolve at a faster rate than typical metazoan mtDNA, and that M mtDNA evolves faster than F mtDNA 15-17. One factor explaining this observation may be that the M genome is subject to weaker selective pressures than the F genome due to an unequal "division of labor" in the DUI system 16. Typical animal mtDNA functions in gonads and somatic tissues of both sexes whereas under DUI, F mtDNA functions in female gonads and the soma of both sexes, while M mtDNAs functions primarily in spermatozoa of male gonads and only partially in the male soma 13,16,18. As opposed to SMI that promotes homoplasmy, a state in which all mtDNA copies are typically genetically identical in each cell, thus preventing potentially harmful genomic conflicts, DUI is a naturally heter-oplasmic system in which two highly divergent mitochondrial lineages coexist in the same nuclear background, enabling the analysis of the consequences of tissue heteroplamy 13 .

IntroductionInhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury.MethodsData collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics.ResultsData from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (pConclusionsBurn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

To understand the cost burden of medical care it is essential to partition medical spending into conditions. Two broad strategies have been used to measure disease-specific spending. The first attributes each medical claim to the condition that physicians list as its cause. The second decomposes total spending for a person over a year to their cumulative set of health conditions. Traditionally, this has been done through regression analysis. This paper has two contributions. First, we develop a new cost attribution method to attribute spending to conditions using a more flexible attribution approach, based on propensity score analysis. Second, we compare the propensity score approach to the claims-based approach and the regression approach in a common set of beneficiaries age 65 and older in the 2009 Medicare Current Beneficiary Survey. Our estimates show that the three methods have important differences in spending allocation and that the propensity score model likely offers the best theoretical and empirical combination.

The etiology of late-onset Alzheimer's disease is unknown. Recent epidemiological studies suggest that exposure to high levels of ozone (O3) may be a risk factor for late-onset Alzheimer's disease. Nonetheless, whether and how O3 exposure contributes to AD development remains to be determined. In this study, we tested the hypothesis that O3 exposure synergizes with the genetic risk factor APOE e4 and aging leading to AD, using male apolipoprotein E (apoE)4 and apoE3 targeted replacement mice as men have increased risk exposure to high levels of O3 via working environments and few studies have addressed APOE e4 effects on males. Surprisingly, our results show that O3 exposure impairs memory in old apoE3, but not old apoE4 or young apoE3 and apoE4, male mice. Further studies show that old apoE4 mice have increased hippocampal activities or expression of some enzymes involved in antioxidant defense, diminished protein oxidative modification, and neuroinflammation following O3 exposure compared with old apoE3 mice. These novel findings highlight the complexity of interactions between APOE genotype, age, and environmental exposure in AD development.

Delusional disorder is a relatively rare psychotic illness characterized by delusions with contents that are theoretically possible but highly unlikely, and an absence of the disorganized thought and negative symptoms characteristic of schizophrenia. The illness is rarely studied systematically and most guidance with regard to the treatment derives from case reports and small case series. Antipsychotic medications are the mainstay of treatment, but it is not clear whether any particular agent is more effective than others. We report the case of a patient with delusional disorder who had failed to respond to risperidone but improved markedly with aripiprazole. Aripiprazole may show promise as a treatment for delusional disorder, possibly as a result of its effects on both dopaminergic and serotonergic receptors.

To measure self-valuation, involving constructive prioritization of personal well-being and a growth mindset perspective that seeks to learn and improve as the primary response to errors, in physicians and evaluate its relationship with burnout and sleep-related impairment.We analyzed cross-sectional survey data collected between July 1, 2016, and October 31, 2017, from 5 academic medical centers in the United States. All faculty and medical-staff physicians at participating organizations were invited to participate. The self-valuation scale included 4 items measured on a 5-point (0-4) Likert scale (summative score range, 0-16). The self-valuation scale was developed and pilot tested in a sample of 250 physicians before inclusion in the multisite wellness survey, which also included validated measures of burnout and sleep-related impairment.Of the 6189 physicians invited to participate, 3899 responded (response rate, 63.0%). Each 1-point score increase in self-valuation was associated with -1.10 point lower burnout score (95% CI, -1.16 to -1.05; standardized β=-0.53; P.001) and 0.81 point lower sleep-related impairment score (95% CI, -0.85 to -0.76; standardized β=-0.47; P.001), adjusting for sex and medical specialty. Women had lower self-valuation (Cohen d=0.30) and higher burnout (Cohen d=0.22) than men. Lower self-valuation scores in women accounted for most of the sex difference in burnout.Low self-valuation among physicians is associated with burnout and sleep-related impairment. Further research is warranted to develop and test interventions that increase self-valuation as a mechanism to improve physician well-being.

Divided attention may be more important than ever to comprehend, given ubiquitous distractors in modern living. In humans, concern has been expressed about the negative impact of distraction in education, the home, and the workplace. While acetylcholine supports divided attention, in part via muscarinic receptors, little is known about the specific muscarinic subtypes that may contribute. We designed a novel, high-response rate test of auditory sustained attention, in which rats complete variable-ratio runs on one of two levers, rather than emitting a single response. By doing this, we can present a secondary visual distractor task during some trials, for which a correct nosepoke response is reinforced with a more palatable food pellet. The nonspecific muscarinic antagonist scopolamine impaired performance, and slowed and reduced lever press activity. We then explored antagonists that preferentially block the M1 and M4 subtypes, because these receptors are potential therapeutic targets for cognitive enhancers. Telenzepine, an M1-preferring antagonist, impaired divided attention performance, but not performance of the attention task without distraction. Telenzepine also had fewer nonspecific effects than scopolamine. In contrast, the M4-preferring antagonist tropicamide had no effects. Analysis of overall behavior also indicated that accuracy in the main attention task decreased as a function of engagement with the distractor task. These results implicate the M1 receptor in divided attention.

The Kampala Trauma Score (KTS) has been proposed as a triage tool for use in low- and middle-income countries (LMICs). This study aimed to examine the diagnostic accuracy of KTS in predicting emergency department outcomes using timely injury estimation with Abbreviated Injury Scale (AIS) score and physician opinion to calculate KTS scores.This was a diagnostic accuracy study of KTS among injured patients presenting to Komfo Anokye Teaching Hospital AE, Ghana. South African Triage Scale (SATS); KTS component variables, including AIS scores and physician opinion for serious injury quantification; and ED disposition were collected. Agreement between estimated AIS score and physician opinion were analyzed with normal, linear weighted, and maximum kappa. Receiver operating characteristic (ROC) analysis of KTS-AIS and KTS-physician opinion was performed to evaluate each measure's ability to predict AE mortality and need for hospital admission to the ward or theatre.A total of 1053 patients were sampled. There was moderate agreement between AIS criteria and physician opinion by normal (κ=0.41), weighted (κKTS predicted mortality and need for admission from the ED well when early estimation of the number of serious injuries was used, regardless of method (i.e. AIS criteria or physician opinion). This study provides evidence for KTS to be used as a practical and valid triage tool to predict patient prognosis, ED outcomes and inform referral decision-making from first- or second-level hospitals in LMICs.

The unmet need for cleft lip and/or palate (CL/P) care in India is significant. However, estimates required for CL/P care program planning are lacking.To estimate the unmet need for CL/P surgery in India at the state level.To determine the proportion of individuals with CL/P who presented for care in India, data were used from patients who received care at Operation Smile programs in 12 low- and middle-income countries from June 1, 2013, to May 31, 2014. The resulting model describes the prevalent unmet need for cleft surgery in India by state and includes patients older than the surgery target ages of 1 and 2 years for cleft lip and cleft palate repair, respectively. Next, the total number of unrepaired CL/P cases in each state was estimated using state-level economic and health system indicators.Prevalent unmet need for CL/P repair.In the 28 states with available data, an estimated 72 637 cases of unrepaired CL/P (uncertainty interval, 58 644-97 870 cases) were detected. The percentage of individuals with unrepaired CL/P who were older than the respective target ages ranged from 37.0% (95% CI, 30.6%-43.8%) in Goa to 65.8% (95% CI, 60.3%-70.9%) in Bihar (median, 57.9%; interquartile range, 52.6%-63.4%). The rate of unrepaired CL/Ps ranged from less than 3.5 per 100 000 population in Kerala and Goa to 10.9 per 100 000 population in Bihar (median rate, 5.9 [interquartile range, 4.6-7.3] per 100 000 population).An estimated 72 000 cases of unrepaired CL/P are found in India. Poor states with less health care infrastructure have exceptionally high rates (eg, Bihar). These estimates are useful for informing international and national CL/P care strategies, allocating resources, and advocating for individuals and families affected by CL/P more broadly.NA.

Sixty million people were displaced from their homes due to conflict, persecution, or human rights violations at the end of 2014. This vulnerable population bears a disproportionate burden of disease, much of which is surgically treatable. We sought to estimate the surgical needs for forcibly displaced persons globally to inform humanitarian assistance initiatives. Data regarding forcibly displaced persons, including refugees, internally displaced persons (IDPs), and asylum seekers were extracted from United Nations databases. Using the minimum proposed surgical rate of 4669 procedures per 100,000 persons annually, global, regional, and country-specific estimates were calculated. The prevalence of pregnancy and obstetric complications were used to estimate obstetric surgical needs. At least 2.78 million surgical procedures (IQR 2.58–3.15 million) were needed for 59.5 million displaced persons. Of these, 1.06 million procedures were required in North Africa and the Middle East, representing an increase of 50 % from current unmet surgical need in the region. Host countries with the highest surgical burden for the displaced included Syria (388,000 procedures), Colombia (282,000 procedures), and Iraq (187,000). Between 4 and 10 % of required procedures were obstetric surgical procedures. Children aged

Received December 18, 2015; revised January 11, 2016; accepted January 11, 2016. From Department of Psychiatry, University of South Florida College of Medicine, Tampa, FL (WLW, GAS); Departments of Psychiatry and Geriatric Medicine, University of South Florida College of Medicine, Tampa, FL (JTS). Send correspondence and reprint requests to Jonathan T. Stewart, M.D., D.F.A.P.A., A.G.S.F., Mental Health and Behavioral Sciences Service (116A), James A Haley VA Hospital, 13000 Bruce B Downs BLVD, Tampa FL 33612; e-mail: jonathan.stewart1@va.gov Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine. Introduction

Purpose Civilians living amid conflict are at high-risk of burns. However, the epidemiology of burns among this vulnerable group is poorly understood, yet vital for health policy and relief planning. To address this gap, we aimed to determine the death and disability, healthcare needs and household financial consequences of burns in post-invasion Baghdad. Methods A two-stage, cluster randomized, community-based household survey was performed in May 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about cause of household member death, households were interviewed regarding burn specifics, healthcare required, disability, relationship to conflict and resultant financial hardship. Results Nine-hundred households, totaling 5148 individuals, were interviewed. There were 55 burns, which were 10% of all injuries reported. There were an estimated 2340 serious burns (39 per 100,000 persons) in Baghdad in 2003. The frequency of serious burns generally increased post-invasion to 8780 burns in 2013 (117 per 100,000 persons). Eight burns (15%) were the direct result of conflict. Individuals aged over 45 years had more than twice the odds of burn than children aged less than 13 years (aOR 2.42; 95%CI 1.08–5.44). Nineteen burns (35%) involved ≥20% body surface area. Death (16% of burns), disability (40%), household financial hardship (48%) and food insecurity (50%) were common after burn. Conclusion Civilian burn in Baghdad is epidemic, increasing in frequency and associated with household financial hardship. Challenges of healthcare provision during prolonged conflict were evidenced by a high mortality rate and likelihood of disability after burn. Ongoing conflict will directly and indirectly generates more burns, which mandates planning for burn prevention and care within local capacity development initiatives, as well as humanitarian assistance.

Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error.To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.Sleep-related impairment.Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P .001), work exhaustion (r = 0.58; P .001), and overall burnout (r = 0.59; P .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.

Background Doubly uniparental inheritance (DUI) of mitochondrial DNA in bivalves is a fascinating exception to strictly maternal inheritance as practiced by all other animals. Recent work on DUI suggests that there may be unique regions of the mitochondrial genomes that play a role in sex determination and/or sexual development in freshwater mussels (order Unionoida). In this study, one complete mitochondrial genome of the hermaphroditic swan mussel, Anodonta cygnea, is sequenced and compared to the complete mitochondrial genome of the gonochoric duck mussel, Anodonta anatina. An in silico assessment of novel proteins found within freshwater bivalve species (known as F-, H-, and M-open reading frames or ORFs) is conducted, with special attention to putative transmembrane domains (TMs), signal peptides (SPs), signal cleavage sites (SCS), subcellular localization, and potential control regions. Characteristics of TMs are also examined across freshwater mussel lineages. Results In silico analyses suggests the presence of SPs and SCSs and provides some insight into possible function(s) of these novel ORFs. The assessed confidence in these structures and functions was highly variable, possibly due to the novelty of these proteins. The number and topology of putative TMs appear to be maintained among both F- and H-ORFs, however, this is not the case for M-ORFs. There does not appear to be a typical control region in H-type mitochondrial DNA, especially given the loss of tandem repeats in unassigned regions when compared to F-type mtDNA. Conclusion In silico analyses provides a useful tool to discover patterns in DUI and to navigate further in situ analyses related to DUI in freshwater mussels. In situ analysis will be necessary to further explore the intracellular localizations and possible role of these open reading frames in the process of sex determination in freshwater mussel. Electronic supplementary material The online version of this article (10.1186/s12864-018-4583-3) contains supplementary material, which is available to authorized users.

A 65-year-old man with a lifelong history of paranoid schizophrenia had been treated with 50 mg of risperidone microspheres every 2 weeks for the past 10 years and had tolerated this therapy well. Approximately 1 year ago some drooling and a modest resting tremor developed, but there were no other

Background Transcatheter aortic valve implantation (TAVI) is an alternative and effective contemporary intervention to surgical aortic valve replacement (SAVR) for patients with severe aortic valve disease at increased surgical risk. Guidelines recommend a multidisciplinary “Heart Team” (MHT) review of patients considered for a TAVI procedure, but this has been little studied. We reviewed the characteristics, treatments and outcomes of such patients reviewed by the MHT at our centre. Methods Data on consecutive patients with severe aortic valve stenosis discussed by the Auckland City Hospital MHT from June 2011 to August 2016 were obtained from clinical records. Patient characteristics, treatment and outcomes were analysed using standard statistical methods. Results Over the 5-year period 243 patients (mean age 80.2 ± 8.0 years, 60% male) were presented at the MHT meeting. TAVI was recommended for 200, SAVR for 26 and medical therapy for 17 patients, with no significant difference in mean age (80.2 ± 8.3, 80.4 ± 6.1, 80.4 ± 7.3 years, respectively) or EuroSCORE II (6.5 ± 4.7%, 5.3 ± 3.6%, 6.7 ± 4.3%, respectively). Over time, there was an increase in the number of patients discussed and treated, with no change in their mean age, but the mean EuroSCORE II significantly decreased (TAVI p = 0.026, SAVR p = 0.004). Survival after TAVI and SAVR was similar to that of the age-matched general population, but superior to medical therapy p = 0.002 (93% (n = 162), 84% (n = 21) and 73% (n = 18) at one year and 85% (n = 149), 84% (n = 21) and 54% (n = 13) at 2 years, respectively). Conclusions An increasing number of patients were discussed at the MHT meeting with the majority undergoing TAVI, with a similar age and EuroSCORE II to those allocated SAVR or medical therapy. Survival following TAVI and SAVR was superior to medical therapy and similar to the age-matched general population. These findings suggest that the MHT process is robust, consistent and appropriately allocating a limited treatment resource.

Humanitarian organizations care for burns during crisis and while supporting healthcare facilities in low-income and middle-income countries. This study aimed to define the epidemiology of burn-related procedures to aid humanitarian response. In addition, operational data collected from humanitarian organizations are useful for describing surgical need otherwise unmet by national health systems. Procedures performed in operating theatres run by Médecins Sans Frontières-Operations Centre Brussels (MSF-OCB) from July 2008 through June 2014 were reviewed. Surgical specialist missions were excluded. Burn procedures were quantified, related to demographics and reason for humanitarian response, and described. A total of 96,239 operations were performed at 27 MSF-OCB projects in 15 countries between 2008 and 2014. Of the 33,947 general surgical operations, 4,280 (11%) were for burns. This proportion steadily increased from 3% in 2008 to 24% in 2014. People receiving surgical care from conflict relief missions had nearly twice the odds of having a burn operation compared with people requiring surgery in communities affected by natural disaster (adjusted odds ratio, 1.94; 95% confidence interval, 1.46-2.58). Nearly 70% of burn procedures were planned serial visits to the theatre. A diverse skill set was required. Unmet humanitarian assistance needs increased US$400 million dollars in 2013 in the face of an increasing number of individuals affected by crisis and a growing surgical burden. Given the high volume of burn procedures performed at MSF-OCB projects and the resource intensive nature of burn management, requisite planning and reliable funding are necessary to ensure quality for burn care in humanitarian settings.

Mitochondrial DNA (mtDNA) is predominantly maternally inherited in eukaryotes. Diverse molecular mechanisms underlying the phenomenon of strict maternal inheritance (SMI) of mtDNA have been described, but the evolutionary forces responsible for its predominance in eukaryotes remain to be elucidated. Exceptions to SMI have been reported in diverse eukaryotic taxa, leading to the prediction that several distinct molecular mechanisms controlling mtDNA transmission are present among the eukaryotes. We propose that these mechanisms will be better understood by studying the deviations from the predominating pattern of SMI. This minireview summarizes studies on eukaryote species with unusual or rare mitochondrial inheritance patterns, i.e., other than the predominant SMI pattern, such as maternal inheritance of stable heteroplasmy, paternal leakage of mtDNA, biparental and strictly paternal inheritance, and doubly uniparental inheritance of mtDNA. The potential genes and mechanisms involved in controlling mitochondrial inheritance in these organisms are discussed. The linkage between mitochondrial inheritance and sex determination is also discussed, given that the atypical systems of mtDNA inheritance examined in this minireview are frequently found in organisms with uncommon sexual systems such as gynodioecy, monoecy, or andromonoecy. The potential of deviations from SMI for facilitating a better understanding of a number of fundamental questions in biology, such as the evolution of mtDNA inheritance, the coevolution of nuclear and mitochondrial genomes, and, perhaps, the role of mitochondria in sex determination, is considerable.

Beyond resource deficiencies, other barriers to care prevent patients from receiving surgery in low- and middle-income countries (LMICs). This study aimed to develop and pilot a comprehensive, generalizable tool for assessing the barriers to surgical care. Sociodemographic, clinical and 38 questions regarding potential barriers to surgical care were asked during a surgical outreach to two district and one regional hospital in Upper East Region, Ghana. Sites were selected to capture individuals with prolonged unmet surgical needs and represent geographic, socioeconomic, and healthcare development differences. Results were indexed into three dimensions of barriers to care (i.e., ‘acceptability,’ ‘affordability,’ and ‘accessibility’) so that communities could be compared and targeted interventions developed. The tool was administered to 148 participants (98 % response rate): Bolgatanga 54 (37 %); Amiah 16 (11 %); and Sandema 78 (52 %). Amiah had the fewest barriers to surgical care (median index 8.3; IQR 7.6–9.3), followed by Sandema (8.2; IQR 5.3–9.2) and Bolgatanga (6.7; IQR 3.9–9.5). Individual dimension scores (i.e., acceptability, affordability, accessibility) ranged from 10.8 to 18 out of 18 possible points. Main factors contributing to low dimension scores were different between communities: Bolgatanga—cost and healthcare navigation; Amiah—social marginalization and poor medical understanding; Sandema—distance to surgically capable facility. This study identified a number of significant barriers, as well as successes for patients’ ability and willingness to access surgical care that differed between communities. The tool itself was well accepted, easy to administer and provided valuable data from which targeted interventions can be developed.