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Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, and Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n = 77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs Whites (27/37 [73%] vs 14/40 [35%], P < .001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately one-third of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences. [ABSTRACT FROM AUTHOR]

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Background and Objectives: Primary care residencies are undergoing dramatic changes because of changing health care systems and evolving demands for updated training models. We examined the relationships between residents' exposures to patient-centered medical home (PCMH) features in their assigned continuity clinics and their satisfaction with training.Methods: Longitudinal surveys were collected annually from residents evaluating satisfaction with training using a 5-point Likert-type scale (1=very unsatisfied to 5=very satisfied) from 2007 through 2011, and the presence or absence of PCMH features were collected from 24 continuity clinics during the same time period. Odds ratios on residents' overall satisfaction were compared according to whether they had no exposure to PCMH features, some exposure (1-2 years), or full exposure (all 3 or more years).Results: Fourteen programs and 690 unique residents provided data to this study. Resident satisfaction with training was highest with full exposure for integrated case management compared to no exposure, which occurred in 2010 (OR=2.85, 95% CI=1.40, 5.80). Resident satisfaction was consistently statistically lower with any or full exposure (versus none) to expanded clinic hours in 2007 and 2009 (eg, OR for some exposure in 2009 was 0.31 95% CI=0.19, 0.51, and OR for full exposure 0.28 95% CI=0.16, 0.49). Resident satisfaction for many electronic health record (EHR)-based features tended to be significantly lower with any exposure (some or full) versus no exposure over the study period. For example, the odds ratio for resident satisfaction was significantly lower with any exposure to electronic health records in continuity practice in 2008, 2009, and 2010 (OR for some exposure in 2008 was 0.36; 95% CI=0.19, 0.70, with comparable results in 2009, 2010).Conclusions: Resident satisfaction with training was inconsistently correlated with exposure to features of PCMH. No correlation between PCMH exposure and resident satisfaction was sustained over time. [ABSTRACT FROM AUTHOR]

This article explores the intersection between a trait of the commercial media and American criminal jurisprudence that existing legal scholarship has disregarded the systematic neglect of male victims in the publicity of human trafficking. Human trafficking, one of the world's three most profitable criminal activities and it affects U.S. also. The absence of publicity regarding boy sex trafficking makes it attractive to criminal networks, which specialize in getting young boys for sex and pornography.

Introduction: Stasilon® is a novel hemostatic woven textile composed of allergen-free fibers of continuous filament fiberglass and bamboo yarn. The development of this product resulted from controlled in vitro thrombogenic analysis of an array of potentially hemostatic textile materials and it has been cleared for both external and internal use by the United States Food and Drug Administration for the arrest of hemorrhage. The goal of the study was to assess the hemostatic and adhesive properties of Stasilon® in the setting of lifethreatening refractory hemorrhage. Case presentation: A 39-year-old Caucasian man presented with severe necrotic pancreatitis that failed multiple aggressive attempts to control associated bleeding with electrocautery, suture ligation, and sequential anatomic packing with cotton-based sponges. Subsequent retroperitoneal packing with Stasilon® produced a non-adherent wound-dressing interface and resulted in the achievement of persistent hemostasis in the operative field. Conclusion: In our patient, Stasilon® was demonstrated to be effective in the arrest of refractory hemorrhage. [ABSTRACT FROM AUTHOR]

The topics of youth language, computer-mediated communication (CMC) and hip-hop language are all established fields of contemporary linguistic research. Research into the nexus of all three fields is however far less prevalent. Whilst papers have been published that provide excellent introductions to the field, little or no study has been dedicated to analysing particular aspects of the online hip-hop world with reference to the relationship between youth identity and language. This paper exclusively documents and analyses the strategies employed by textbattlers, who interact online in the equivalent of the traditional MC contest or battle and spar for lyrical dominance. The analysis of the corpus suggests the potential for a culture of linguistic hypersensitivity and conscious linguistic performance to arise within this specific online hip-hop genre, the textbattle. It is in this sense that this genre has particular relevance to the question of how far individuals can be seen to manage consciously their identity through linguistic performance. [ABSTRACT FROM AUTHOR]

The article discusses the incoherence of the International Humanitarian Law (IHL) under the Protocol I of the Geneva Convention. It reflects on the attack of a U.S. pilot directed towards a group of insurgencies, which resulted to mass civilian casualties on June 15, 2003 in Fallujah, Iraq. It describes the relationship between contract theory and civilian immunity during armed conflict under the Protocol I.

Objectives: To profile trends of clinical AIDS-defining illness (ADI) among a cohort of human immunodeficiency virus (HIV)-infected women over a 12-year period. Methods: In a prospective evaluation of AIDS clinical presentation in the Women and Infants Transmission Study (WITS), 2255 subjects were enrolled and followed between December 1989 and June 2002 (total, 4993 person-years). Data on clinical AIDS presentation of 140 (6.2%) HIV-seropositive subjects were evaluated across three calendar periods corresponding to the use of different therapy regimens. Incidence rates (per 1000 woman-years) for AIDS and specific ADIs were compared between periods using Poisson regression methods. Results: Incidence rates of AIDS, Myco bacterium tuberculosis, recurrent bacterial pneumonia, herpes simplex disease, esophageal/bronchial candidiasis, wasting syndrome, and neurological diseases have showed significant downward trends. Among women with ADI, the frequency of either esophageal or bronchial candidiasis as initial ADI showed an increasing trend (Ptrend = 0.03), whereas a decrease in proportion of cases with nontuberculosis mycobacterial infection (Ptrend = 0.05) was observed over the same periods. In the multivariate analysis, both the CD4+ lymphocyte count and HIV-1 RNA at the time of diagnosis were independently associated with survival after AIDS. Highly active antiretroviral therapy (HAART) was associated with a 70% reduction in progression to death following AIDS. Conclusions: Temporal changes in the incidence and clinical presentations in HIV-positive women in our cohort reflect an increased use of HAART that may have a differential effect on reduction in the risk of ADIs. These illnesses, although considerably less frequent in recent years, are still important contributors to morbidity in HIV-positive women. [ABSTRACT FROM AUTHOR]

The article describes the result of the joint initiative between the American Board of Family Medicine and the Association of Family Medicine Residency Directors called "Preparing the Personal Physician for Practice." The extent of the response demonstrated a significant interest in the project and a readiness for change in the graduate medical education system. A summary of the responses received from the directors and remarks during a discussion forum at the 2006 PDW is presented.

Background: Diabetes mellitus (DM) is a major cause of illness and death in the United States, and diabetic patients are at increased risk for burn injury. We therefore sought to examine the impact of pre-existing DM on the risk of inpatient mortality and hospital acquired infections (HAI) among burn patients.Methods: Adult patients (≥18 years old) admitted from 2004 to 2013 were analyzed. Weighted Kaplan-Meier survival curves - adjusting for patient demographics, burn mechanism, presence of inhalation injury, total body surface area, additional comorbidities, and differential lengths of stay - were used to estimate the 30-day and 60-day risk of mortality and HAIs.Results: A total of 5539 adult patients were admitted and included in this study during the study period. 655 (11.8%) had a pre-existing DM. The crude incidence of HAIs and in-hospital mortality for the whole burn cohort was 8.5% (n=378) and 4.4% (n=243), respectively. Diabetic patients were more likely to be older, female, have additional comorbidities, inhalational injury, and contact burns. After adjusting for patient and burn characteristics, the 60-day risk of HAI among patients with DM was significantly higher, compared to non-diabetic patients (RR 2.07, 95% CI 1.28, 6.79). However, no significant difference was seen in the 60-day risk of mortality (RR 1.34, 95% CI 0.44, 3.10).Conclusions: Pre-existing DM significantly increases the risk of developing an HAI in patients following burn injury, but does not significantly impact the risk of inpatient mortality. Further understanding of the immune modulatory mechanism of burn injury and DM is imperative to better attenuate the acquisition of HAIs. [ABSTRACT FROM AUTHOR]

More than half of individuals experiencing major thermal burn injury (MThBI) receive an autologous skin graft (autograft), in which skin is removed from a healthy "donor" site and transplanted to the burn site. Persistent pain and itch at the graft site are major causes of suffering and disability in MThBI survivors. African Americans have a higher risk of MThBI, and in other clinical settings African Americans experience a greater burden of pain and itch relative to European Americans. However, to our knowledge, ethnic differences in skin graft site pain and itch outcomes after MThBI have not been assessed. We evaluated skin graft site pain and itch severity (0-10 Numeric Rating Scale [NRS]) over 1 year in a prospective multicenter cohort sample of African Americans and European Americans. In adjusted linear mixed models, African Americans experienced a slower rate of pain resolution in the acute phase of recovery (β = -0.05 vs -0.08 NRS points per day, P < 0.001), which resulted in a higher pain severity in the persistent phase of recovery (NRS mean difference = 1.21, 95% confidence interval [0.12-2.29]), although not statistically significant after correction for multiple comparisons. African Americans also experience greater itch severity in 6 weeks to 12 months after burn injury compared with European Americans (NRS mean difference = 1.86 [0.80-2.93]), which results from a faster rate of itch development in African Americans in the acute recovery phase after burn injury. Future studies may improve outcomes in African Americans and lead to new pathogenic insights that benefit all burn injury survivors. [ABSTRACT FROM AUTHOR]

To better understand trends in burn treatment patterns related to definitive closure, this study sought to benchmark real-world survey data with national data contained within the National Burn Repository version 8.0 (NBR v8.0) across key burn center practice patterns, resource utilization, and clinical outcomes. A survey, administered to a representative sample of U.S. burn surgeons, collected information across several domains: burn center characteristics, patient characteristics including number of patients and burn size and depth, aggregate number of procedures, resource use such as autograft procedure time and dressing changes, and costs. Survey findings were aggregated by key outcomes (number of procedures, costs) nationally and regionally. Aggregated burn center data were also compared to the NBR to identify trends relative to current treatment patterns. Benchmarking survey results against the NBR v8.0 demonstrated shifts in burn center patient mix, with more severe cases being seen in the inpatient setting and less severe burns moving to the outpatient setting. An overall reduction in the number of autograft procedures was observed compared to NBR v8.0, and time efficiencies improved as the intervention time per TBSA decreases as TBSA increases. Both nationally and regionally, an increase in costs was observed. The results suggest resource use estimates from NBR v8.0 may be higher than current practices, thus highlighting the importance of improved and timely NBR reporting and further research on burn center standard of care practices. This study demonstrates significant variations in burn center characteristics, practice patterns, and resource utilization, thus increasing our understanding of burn center operations and behavior., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Burn Association.)

We aimed to obtain reliable reference charts for sleep duration, estimate the prevalence of sleep complaints across the lifespan and identify risk indicators of poor sleep. Studies were identified through systematic literature search in Embase, Medline and Web of Science (9 August 2019) and through personal contacts. Eligible studies had to be published between 2000 and 2017 with data on sleep assessed with questionnaires including ≥100 participants from the general population. We assembled individual participant data from 200,358 people (aged 1-100 years, 55% female) from 36 studies from the Netherlands, 471,759 people (40-69 years, 55.5% female) from the United Kingdom and 409,617 people (≥18 years, 55.8% female) from the United States. One in four people slept less than age-specific recommendations, but only 5.8% slept outside of the 'acceptable' sleep duration. Among teenagers, 51.5% reported total sleep times (TST) of less than the recommended 8-10 h and 18% report daytime sleepiness. In adults (≥18 years), poor sleep quality (13.3%) and insomnia symptoms (9.6-19.4%) were more prevalent than short sleep duration (6.5% with TST < 6 h). Insomnia symptoms were most frequent in people spending ≥9 h in bed, whereas poor sleep quality was more frequent in those spending <6 h in bed. TST was similar across countries, but insomnia symptoms were 1.5-2.9 times higher in the United States. Women (≥41 years) reported sleeping shorter times or slightly less efficiently than men, whereas with actigraphy they were estimated to sleep longer and more efficiently than man. This study provides age- and sex-specific population reference charts for sleep duration and efficiency which can help guide personalized advice on sleep length and preventive practices.

During a pandemic, primary care is the first line of defense. It is able to reinforce public health messages, help patients manage at home, and identify those in need of hospital care. In response to the COVID-19 pandemic, primary care scrambled to rapidly transform itself and protect clinicians, staff, and patients while remaining connected to patients. Using the established public health framework for addressing a pandemic, we describe the actions primary care needs to take in a pandemic. Recommended actions are based on observed experiences of the authors' primary care practices and networks. Early in the COVID-19 pandemic, tasks focused on promoting physical distancing and encouraging patients with suspected illness or exposure to self-quarantine. Testing was not available and contract tracing was not possible. As the pandemic spread, in-person care was converted to virtual care using telehealth. Practices remained connected to patients using registries to reach out to those at risk for infection, with uncontrolled chronic conditions, or were socially vulnerable. Practices managed most patients with suspected COVID-19 at home. As the pandemic decelerates, practices are now preparing to address the direct and indirect consequences-complications from COVID-19 infections, missed treatment for acute problems, inadequate prevention, uncontrolled chronic disease, mental illness, and greater social needs. Throughout, practices bore tremendous financial burden, laying off staff or even closing at a time when most needed. Primary care must learn from this experience and be ready for the next pandemic. Policymakers and payers cannot fail primary care during their next time of need., (© 2020 Annals of Family Medicine, Inc.)

Approximately three quarters of major thermal burn injury (MThBI) survivors suffer from hypertrophic scarring (HTS) and over half experience chronic pain or itch. In survivors of MThBI, HTS and chronic pain or itch are considered one of the greatest unmet challenges of postburn injury care and psychosocial reintegration. Although scarring, itch, and pain have been clinically associated, there are no prospective, multisite studies examining tissue autograft site pain or itch and scar outcomes. The authors collected a representative cohort (n = 56) of MThBI survivors who received autografting within 14 days of injury and evaluated graft-site pain or itch severity (0-10 Numeric Rating Scale) and HTS using a validated scar photograph assessment scale 6 months following MThBI. Given that stress is known to influence wound healing, the authors also assessed the relationship between previous trauma exposure, peritraumatic stress, preburn overall health (SF-12), scarring, and chronic pain or itch severity using Spearman's correlation. Association between HTS and chronic pain or itch was significant in a linear regression model adjusted for age, sex, and ethnicity (β = 0.2, P = .033 for pain, β = 0.2, P = .019 for itch). Results indicate that prior trauma exposure is inversely correlated (r = -.363, P = .030) with scar severity, but not pain or itch severity 6 months after MThBI. Study results suggest that preburn chronic pain or itch is associated with pathological scarring 6 months following MThBI. Results also indicate that stress may improve scarring after MThBI. Further work to understand the mechanisms that underlie both HTS and chronic pain or itch and their relationship to chronic stress is critical to the development of novel therapies to assist burn survivors recover.

Ventilator-associated pneumonia (VAP) is a frequent complication of severe burn injury. Comparing the current ventilator-associated event-possible VAP definition to the pre-2013 VAP definition, we identified considerably fewer VAP cases in our burn ICU. The new definition does not capture many VAP cases that would have been reported using the pre-2013 definition. Infect Control Hosp Epidemiol 2017;38:867-869.

Background and Objectives: For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.

Background and Objectives: The Affordable Care Act has spurred significant change in the US health care system, including expansion of Medicaid and private insurance coverage to millions of Americans. As a result, the need for the medical education continuum to produce a family physician workforce that is sizable enough and highly skilled is significant. These two interdependent goals have emerged as top priorities for Family Medicine for America's Health, a new, 5-year, $21 million collaborative strategic effort of the eight US family medicine organizations to lead continued change in the US health care system. To achieve these important goals, reforms are needed across the entire educational continuum, including how we recruit, train, and help practicing family physicians refresh their skills. Such reforms must provide opportunities to acquire skills needed in new practice and payment environments, to incorporate new educational standards that reflect the public's expectations of family physicians, to collaborate with our primary care colleagues to develop effective interprofessional training, and to design educational programs that are socially accountable to the patients, families, and communities we serve. Through Family Medicine for America's Health, the discipline is well positioned to emerge as a leader in primary care workforce development and educational quality.

This study explores dynamic changes in network size and composition by examining patterns of older adults' social network change over time, that is: types of movements; the reason for the loss of network members; and the relation of movement and composition in concert. This study is a 6-year follow up of changes in the social networks of U.S.-Born Caucasian, African-American, and Caribbean older adults. One hundred and twenty-four community-dwelling older adults were interviewed during 2 data collection points over a 6-year period. Differences between Wave 1 and Wave 2 data were examined using paired sample t-tests confirmed with post-hoc tests and multivariate analyses. Results regarding types of movement showed that network changes were attributed to attrition--the "loss" of network members and a novel movement--the "addition" of network members not heretofore discussed. The results show an interaction between kinship status, ethnicity, and time--the attrition of non-kin members was underscored by ethnic differences. The type of network change was specific for type of network affiliation, such that children were more likely to be added to the networks of the young-old and kin were more likely to be lost in networks of the old-old. Older adults engage in social network interactions marked by compensatory processes beyond loss of network members such as social promotion and demotion. These social network processes are of emotional and functional significance for the older adult.

Maintenance of Certification for Family Physicians was created to enhance the quality of care delivered by family physicians but risked decreasing their engagement due to the increased burden of meeting additional requirements to remain board-certified. Participation by family physicians in Maintenance of Certification remains higher than predicted.

After two years of intensive study, in 2004 the Future of Family Medicine report concluded that the current U.S. health care system is inadequate and unsustainable, and called for changes within the specialty of family medicine to ensure the future health of the American public. With guidance and encouragement from many disciplines and health experts, a set of 10 recommendations was established to accomplish a transformative change in how family physicians serve their patients and how the essential function of primary care is achieved. From these recommendations came a period of innovation and experimentation in the training of family physicians, entitled Preparing the Personal Physician for Practice (P4). The P4 project is a carefully designed and evaluated initiative led by the American Board of Family Medicine and the Association of Family Medicine Residency Directors and administered by TransforMED, a practice redesign initiative of the American Academy of Family Physicians. Fourteen family medicine programs were chosen to participate and will put their innovations into practice from 2007 to 2012, during which time regular evaluation will be conducted. The purpose of P4 is to learn how to improve the graduate medical education of family physicians such that they are prepared to be outstanding personal physicians and to work in the new models of practice now emerging. The innovations tested by P4 residencies are expected to inspire substantial changes in the content, structure, and locations of training of family physicians and to guide future revisions in accreditation and certification requirements.

Background: Carotid body tumors (CBT) are rare, infrequently malignant vascular neoplasms that are near the carotid bifurcation. Surgical excision is the treatment of choice, but individual surgeons or an institution cannot accumulate sufficient expertise to evaluate their outcomes with confidence. Our purpose was to report outcomes of surgical procedures for CBT from a nationwide dataset., Study Design: Data were retrieved from the Nationwide Inpatient Sample from nonfederal hospital discharge abstracts. Data were queried for ICD-9-CM code 39.8, operations on the carotid body and vascular bodies, and code 38.2, carotid endarterectomy. Outcomes analyzed were length of stay, charges, and in-hospital mortality., Results: An estmated 4,601 operations were identified, 3,746 for CBT surgical procedures only, and in 855 a carotid endarterectomy was also performed. Overall morbidity was 3.3%. Mortality with CBT alone was 2.0% but was 8.8% if carotid endarterectomy was also performed. CBT surgical procedures are most commonly performed in western states where higher elevations are found. Women constituted 59% of the population; mortality for women was higher than for men (12.4% versus 7.9%). Mortality in urban teaching hospitals was 2.1% and in nonteaching hospitals 4.9%., Conclusions: CBT surgical procedures are rare but are performed across a broad age spectrum. Mortality rate is low for patients having CBT alone but rises when CE is added. Women are more commonly affected and fare less well. Addition of CE to CBT surgical procedures and the resulting poor outcomes have not been previously described. Consideration should be given to referral of CBT patients to hospitals where mortality rates are low.