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The past two decades has seen a substantial rise in the use of opioids for chronic pain, along with opioid-related mortality and adverse effects. A contributor to opioid-associated mortality is the high prevalence of moderate/severe sleep-disordered breathing, including central sleep apnea and obstructive sleep apnea, in patients with chronic pain. Although evidence-based treatments are available for sleep-disordered breathing, patients are not frequently assessed for sleep-disordered breathing in pain clinics. To aid healthcare providers in this area of clinical uncertainty, we present evidence on the interaction between opioids and sleep-disordered breathing, and the prevalence and predictive factors for sleep-disordered breathing in patients on opioids for chronic pain. We provide recommendations on how to evaluate patients on opioids for risk of moderate/severe sleep-disordered breathing in clinical care, which could lead to earlier use of therapeutic interventions for opioid-associated sleep-disordered breathing, such as opioid cessation or positive airway pressure therapy. This would improve quality of life and well-being of patients with chronic pain., Competing Interests: Competing interests: JW reports grants from the Ontario Ministry of Health and Long-Term Care, Anesthesia Patient Safety Foundation, and University of Toronto Merit Research Award. FC reports research support from the Ontario Ministry of Health and Long-Term Care, University Health Network Foundation, and UpToDate royalties. STOP-Bang questionnaire: proprietary to University Health Network., (© American Society of Regional Anesthesia & Pain Medicine 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Inhalation 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., Methods: Data 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., Results: Data 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 (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses., Conclusions: Burn 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., Competing Interests: The authors have declared that no competing interests exist.

Background: The concurrent use of sedating centrally acting drugs and opioids by chronic pain patients occurs routinely despite concerns of negative impacts on respiration during sleep. The effects of centrally acting drugs and opioids on sleep apnoea have not been well characterised. The objective of this study was to assess the effect of concomitant centrally acting drugs and opioids on the prevalence and severity of sleep apnoea in chronic pain patients., Methods: We conducted a prospective cohort study at five chronic pain clinics. Each participant underwent an in-laboratory polysomnography and daily morphine milligram equivalents were calculated. Participants were grouped into centrally acting drugs and opioid users versus sole opioid users., Results: Of the 332 consented participants, 204 underwent polysomnography and 120 (58.8%) had sleep apnoea (72% obstructive, 20% central, and 8% indeterminate sleep apnoea). Overall, 35% (71 of 204) were taking opioids alone, and 65% (133 of 204) were taking centrally acting drugs and opioids. There was a 69% decrease in the odds of having sleep apnoea (apnoea-hypopnoea index ≥5 events·h -1 ) in participants taking benzodiazepine/opioids versus sole opioid users (OR 0.31, 95% CI:0.12-0.80, p=0.015). Additionally, concomitant benzodiazepine/opioids versus sole opioid use was associated with a decrease in respiratory arousal index scores (p=0.03). Mean overnight S pO 2 was approximately 1% lower in the concomitant benzodiazepine/opioids group versus sole opioid users (93.1±2.5 versus 94.4±2.1%, p=0.01)., Conclusion: In chronic pain patients on opioids, administration of certain benzodiazepine sedatives induced a mild respiratory depression but paradoxically reduced sleep apnoea risk and severity by increasing the respiratory arousal threshold., Competing Interests: Conflict of interest: S. Mir has nothing to disclose. Conflict of interest: J. Wong reports grants from Ontario Ministry of Health and Long-Term Care for this work; grants to their institution from the Anesthesia Patient Safety Foundation and Merck Canada outside the submitted work; and a University of Toronto Merit Research Award. Conflict of interest: C.M. Ryan was funded by the Ontario Ministry of Health and Long-Term Care Innovation Fund, the University Health Network Foundation, and the Dept of Anesthesia and Pain Medicine, University Health Network–Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada, during the conduct of the study; and reports grants from Physician's Service Incorporated, the Ontario Thoracic Society and the Canadian Institute of Health Research, and an investigator trial management fee from Breso-Tec, all outside the submitted work. Conflict of interest: G. Bellingham has nothing to disclose. Conflict of interest: M. Singh reports grants from the Canadian Anesthesiologists’ Society, the Society of Anesthesiology and Sleep Medicine (Milwaukee, Wisconsin), the Ontario Ministry of Health and Long-Term Care and The Lung Association (Toronto, Canada; supported by the Ontario Thoracic Society); Career Scientist Award from the Canadian Anesthesiologists’ Society; and a Merit Award from the Dept of Anesthesiology and Pain Medicine, University of Toronto (Toronto, Canada), all outside the submitted work; and serves on the Medical Advisory Board of the Hypersomnia Foundation (Atlanta, GA) on a voluntary basis. Conflict of interest: R. Waseem has nothing to disclose. Conflict of interest: D.J. Eckert was funded by a National Health and Medical Research Council of Australia Senior Research Fellowship (1116942) during the conduct of the study. He reports research grants and personal fees for consultancy from Bayer; research grants, and personal fees for consultancy and an advisory board from Apnimed; and a Collaborative Research Centre Consortium Grant between the Australian Government, academia and industry (industry partner: Oventus Medical), all outside the submitted work. Conflict of interest: F. Chung reports grants from the Ontario Ministry of Health and Long-Term Care, and the University Health Network Foundation, for this work; and Up-to-Date royalties and nonfinancial support from STOP-Bang (proprietary to University Health Network) outside the submitted work., (Copyright ©ERS 2020.)

Purpose: This work compares posterior retinotomy vs perfluorocarbon liquid (PFCL) for subretinal fluid (SRF) drainage during pars plana vitrectomy for primary rhegmatogenous retinal detachment (RRD)., Methods: In this large, multicenter, retrospective comparative study, 2620 patients underwent pars plana vitrectomy (with or without scleral buckle) for uncomplicated RRD. Patients for whom SRF was drained via the primary break without retinotomy or PFCL were excluded; those who required both retinotomy and PFCL were similarly excluded. Remaining patients were separated into "retinotomy" and "PFCL" cohorts. Subgroup analysis was conducted for macula-on and macula-off subgroups. Postoperative outcomes were analyzed and compared., Results: A total of 760 eyes (82.7%) had retinotomy and 159 eyes (17.3%) had PFCL for drainage of SRF, and baseline characteristics between the 2 groups were similar. Postoperative analysis showed similar outcomes between the retinotomy and PFCL cohorts, including final visual acuity ( P  = .19), redetachment rate ( P  = .30), anatomic success ( P  = .28), presence of postoperative epiretinal membrane ( P  = .75), and other macular pathologies ( P > .99). Subgroup analysis yielded similar outcomes for macula-on and macula-off subgroups. Postoperative presence of retained PFCL was 2.4%, possibly a factor in the slightly higher number of subsequent surgical procedures ( P  = .03) in the PFCL cohort., Conclusions: Postoperative outcomes for retinotomy vs PFCL during RRD repair are comparable, aside from slightly greater number of subsequent surgical procedures needed in the PFCL cohort. Our analysis suggests both techniques are reasonable tools in the repair of macula-on or macula-off RRD., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: There is limited and conflicting data on whether sleep-disordered breathing (SDB) is associated with postoperative major cardiovascular and cerebrovascular events (MACCE), and mortality., Objectives: To determine whether SDB is associated with increased risks of MACCE, mortality and length of hospital stay., Design: Retrospective cohort analysis from the Nationwide Inpatient Sample., Setting: Adults who underwent elective abdominal, orthopaedic, prostatic, gynaecological, thoracic, transplant, vascular or cardiac surgery in the United States of America between 2011 and 2014., Patients: The study cohort included 1813 974 surgical patients, of whom 185 615 (10.2%) had SDB. Emergency or urgent surgical procedures were excluded., Main Outcome Measures: The incidences of MACCE, respiratory and vascular complications, in-hospital mortality and mean length of hospital stay were stratified by SDB. Linear and logistic regression models were constructed to determine the independent association between SDB and outcomes of interest., Results: The incidences of MACCE [25.3 vs. 19.8%, odds ratio (OR) 1.20, P < 0.001] and respiratory complications (11.75 vs. 8.0%, OR 1.43, P < 0.001) were significantly higher in patients with SDB than in those without SDB. SDB was associated with higher rates of atrial fibrillation (14.7 vs. 10.8%, P < 0.001), other arrhythmias (6.0 vs. 5.4%, P < 0.001) and congestive heart failure (9.8 vs. 7.1%, P < 0.001). SDB patients had a lower rate of myocardial infarction (3.1 vs. 3.4%, OR 0.69, P < 0.001), lower mortality (0.6 vs. 1.3%, P < 0.001) and shorter length of hospital stay (4.8 vs. 5.2 days, P < 0.001)., Conclusion: SDB was associated with increased risks of MACCE, and respiratory and vascular complications, but had a lower incidence of in-hospital mortality and shorter length of hospital stay.

Purpose: Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes., Design: Multicenter, retrospective, interventional cohort study., Participants: Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed., Methods: A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age <40 years (bias toward SB) was excluded. Comparable cases of moderately complex RRD were then chosen naive to surgeon, surgery, and outcome for subgroup analysis., Main Outcome Measures: Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson's chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision., Results: Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P < 0.001)., Conclusions: For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to prospectively evaluate sleep patterns and the presence of sleep-disordered breathing in children with myasthenia gravis. We further aimed to examine the relationship between sleep and daytime respiratory function using spirometry tests including upright and supine forced vital capacity, sniff nasal inspiratory pressure, and maximal inspiratory pressure., Methods: Eleven children between 3 and 18 years old with confirmed myasthenia gravis were recruited from The Hospital for Sick Children Neuromuscular Clinic in this prospective observational study. After informed consent was obtained, patients underwent a comprehensive clinical assessment with collection of anthropometric data. Following this, all subjects performed pulmonary function tests, overnight polysomnography and completed the Epworth Sleepiness Scale questionnaire., Results: Two of eleven children who reported no symptoms of sleep disordered breathing were diagnosed with mild to moderate obstructive sleep apnea. Pulmonary function tests showed abnormal maximal inspiratory pressure in 6 of 11 patients, whereas seated forced vital capacity as well as seated to supine forced vital capacity ratios were normal in the entire group., Conclusions: In our small group of pediatric myasthenia gravis subjects, there was an unexpected finding of obstructive sleep apnea in 2 of the 11 patients studied. Maximal inspiratory pressure appears to be a more sensitive method of detecting abnormalities compared to upright or seated forced vital capacity. A larger multicenter study is needed to validate our findings and to determine the impact of obstructive sleep apnea in the pediatric myasthenia gravis population as well as risk factors associated with sleep disordered breathing.

Purpose: To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes., Design: This study used an RCS method., Participants: All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database., Methods: To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis., Main Outcome Measures: Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS)., Results: Inter-rater reliability showed significant agreement among raters (P < 0.001). Of 2620 patients, 2335 had >90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB., Conclusions: We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Burn care remains among the most complex of the time-sensitive treatment interventions in medicine today. An enormous quantity of specialized resources are required to support the critical and complex modalities needed to meet the conventional standard of care for each patient with a critical burn injury. Because of these dependencies, a sudden surge of patients with critical burn injuries requiring immediate and prolonged care following a burn mass casualty incident (BMCI) will place immense stress on healthcare system assets, including supplies, space, and an experienced workforce (staff). Therefore, careful planning to maximize the efficient mobilization and rational use of burn care resources is essential to limit morbidity and mortality following a BMCI. The U.S. burn care profession is represented by the American Burn Association (ABA). This paper has been written by clinical experts and led by the ABA to provide further clarity regarding the capacity of the American healthcare system to absorb a surge of burn-injured patients. Furthermore, this paper intends to offer responders and clinicians evidence-based tools to guide their response and care efforts to maximize burn care capabilities based on realistic assumptions when confronted with a BMCI. This effort also aims to align recommendations in part with those of the Committee on Crisis Standards of Care for the Institute of Medicine, National Academies of Sciences. Their publication guided the work in this report, identified here as "conventional, contingency, and crisis standards of care." This paper also includes an update to the burn Triage Tables- Seriously Resource-Strained Situations (v.2)., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Study Objectives: Opioids have been reported to increase the risk for sleep-disordered breathing (SDB) in patients with noncancer chronic pain on opioid therapy. This study aims to determine the pooled prevalence of SDB in opioid users with chronic pain and compare it with patients with pain:no opioids and no pain:no opioids., Methods: A literature search of PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials was conducted. We included all observational studies that reported the prevalence of SDB in patients with chronic pain on long-term opioid therapy (≥3 months). The primary outcome was the pooled prevalence of SDB in opioid users with chronic pain (pain:opioids group) and a comparison with pain:no opioids and no pain:no opioids groups. The meta-analysis was performed using a random-effects model., Results: After screening 1,404 studies, 9 studies with 3,791 patients were included in the meta-analysis (pain:opioids group, n = 3181 [84%]; pain:no opioids group, n = 359 [9.4%]; no pain:no opioids group, n = 251 [6.6%]). The pooled prevalence of SDB in the pain:opioids, pain:no opioids, and no pain:no opioids groups were 91%, 83%, and 72% in sleep clinics and 63%, 10%, and 75% in pain clinics, respectively. Furthermore, in the pain: opioids group, central sleep apnea prevalence in sleep and pain clinics was 33% and 20%, respectively., Conclusions: The pooled prevalence of SDB in patients with chronic pain on opioid therapy is not significantly different compared with pain:no opioids and no pain:no opioids groups and varies considerably depending on the site of patient recruitment (ie, sleep vs pain clinics). The prevalence of central sleep apnea is high in sleep and pain clinics in the pain:opioids group. Clinical Trial Registration: Registry: PROSPERO: International prospective register of systematic reviews; Name: Prevalence of sleep disordered breathing, hypoxemia and hypercapnia in patients on oral opioid therapy for chronic pain management; URL: https://www.crd.york.ac.uk/prospero/display&#95;record.php?ID=CRD42018103298; Identifier: CRD42018103298., (© 2020 American Academy of Sleep Medicine.)

Background: Geography is an important yet underexplored factor that may influence the care and outcomes of burn survivors. This study aims to examine the impact of geography on physical and psychosocial function after burn injury., Methods: Data from the Burn Model Systems National Database (1997-2015) were analyzed. Individuals 18 years and older who were alive at discharge were included. Physical and psychosocial functions were assessed at 6, 12, and 24 months postinjury using the following patient-reported outcome measures: Community Integration Questionnaire, Physical Composite Scale and Mental Composite Scale of the 12-Item Short Form Health Survey, Satisfaction with Appearance Scale, and Satisfaction with Life Scale. Descriptive statistics were generated for demographic and medical data, and mixed regression models were used to assess the impact of geography on long-term outcomes., Results: The study included 469 burn survivors from the Centers for Medicare and Medicaid Services regions 10, 31 from region 8, 477 from region 6, 267 from region 3, and 41 from region 1. Participants differed significantly by region in terms of race/ethnicity, burn size, burn etiology, and acute care length of stay (P < 0.001). In adjusted mixed model regression analyses, scores of all 5 evaluated outcome measures were found to differ significantly by region (P < 0.05)., Conclusions: Several long-term physical and psychosocial outcomes of burn survivors vary significantly by region. This variation is not completely explained by differences in population characteristics. Understanding these geographical differences may improve care for burn survivors and inform future policy and resource allocation.

The objective of this review was to systematically evaluate the available literature addressing the use of orthoses (splints and casts) with adult and pediatric burn survivors and determine whether practice guidelines could be proposed. This review provides evidence-based recommendations specifically for rehabilitation professionals who are responsible for burn survivor rehabilitation. A summary recommendation was made after the literature was retrieved using a systematic review and critical appraisal by multiple authors. The level of evidence of the literature was determined in accordance with the Oxford Centre for Evidence-based Medicine criteria. Due to the low level of evidence in the available literature, only one practice guideline could be recommended: orthotic use should be considered as a treatment choice for improving range of motion or reducing contracture in adults who have sustained a burn injury. To address the rehabilitation-specific gaps found in the literature regarding orthotic use in burn rehabilitation and provide guidance to clinicians, a formal expert consensus exercise was conducted as a final step to the project. The resultant manuscript provides a summary of the literature regarding orthotic use with burn patients, one practice guideline, proposed orthotic terminology and additional practice recommendations based on expert opinion. The limitations in the current literature are also discussed, and suggestions are made for future studies in the area of orthotic use after burn injury., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The Young Adult Burn Outcome Questionnaire (YABOQ) is a validated, English-language patient-reported outcome assessment of young adults' recovery from burn injury across 15 scale domains. We evaluated the cross-cultural validity of a newly developed Spanish version of the YABOQ. Secondary data from English- and Spanish-speaking burn survivors (17 to 30 years of age) were obtained from the Multicenter Benchmarking Study. We conducted classic psychometric analyses and evaluated the measurement equivalence of the English and Spanish YABOQs in logistic and ordinal logistic regression differential item functioning analyses. All multi-item scales in the Spanish YABOQ demonstrated adequate reliability except the Pain and Itch scales. One item in the Perceived Appearance scale showed differential item functioning across English- and Spanish-speaking burn survivors, but the observed differential item functioning had no clinically significant impact on scale-level Perceived Appearance scores. Our findings support the cross-cultural validity of the YABOQ Physical Function, Perceived Appearance, Sexual Function, Emotion, Family Function, Family Concern, Satisfaction with Symptom Relief, Satisfaction with Role, Work Reintegration and Religion scales among English- and Spanish-speaking young adult burn survivors. This work supports the use of these English and Spanish YABOQ scales to assess the effect of therapeutic interventions on young adults' burn outcomes in pooled analyses and to assess disparities in young adults' burn outcomes across language groups., (© American Burn Association 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries., Methods: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years., Results: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010)., Conclusion: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Despite many advances in burn care, the development of extremity contracture remains a common and vexing problem. Extremity contractures have been documented in up to one third of severely burned patients at discharge. However, little is known about the long-term impact of these contractures. The purpose of this study was to examine the association of extremity contractures with employment after burn injury., Methods: We obtained data from the Burn Model System database from 1994 to 2003. We included in the study cohort all adult patients who were working prior to injury and identified those discharged with and without a contracture in one of the major extremity joints (shoulder, elbow, wrist, hip, knee and ankle). We classified contracture severity according to mild, moderate and severe categories. We performed descriptive analyses and predictive modeling to identify injury and patient factors associated with return to work (RTW) at 6, 12, and 24 months., Results: A total of 1,203 participant records met criteria for study inclusion. Of these, 415 (35%) had developed a contracture at discharge; 9% mild, 12% moderate, and 14% severe. Among 801 (67%) participants who had complete data at 6 months after discharge, 70% of patients without contracture had returned to work compared to 45% of patients with contractures (p < 0.001). RTW increased at each subsequent follow-up time point for the contracture group, however, it remained significantly lower than in no-contracture group (both p < 0.01). In multivariable analyses, female sex, non-Caucasian ethnicity, larger burn size, alcohol abuse, number of in-hospital operations, amputation, and in-hospital complications were associated with a lower likelihood of employment. In adjusted analyses, discharge contracture was associated with a lower probability of RTW at all 3 time points, although its impact significantly diminished at 24 months., Conclusions: This study indicates an association between discharge contracture and reduced employment 6, 12 and 24 months after burn injury. Among many other identified patient, injury, and hospitalization related factors that are barriers to RTW, the presence of a contracture at discharge adds a significant reintegration burden for working-age burn patients., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Background/objectives: To investigate potential mechanisms underlying the well-established relationship of diabetes and obesity with cognitive decline, among older adults participating in a population-based study., Design/setting: Ten-year population-based cohort study., Participants: A total of 478 individuals aged 65 years and older., Measurements: We assayed fasting blood for markers of glycemia (glucose and hemoglobin A1c [HbA1c]), insulin resistance (IR) (insulin and homeostatic model assessment of IR), obesity (resistin, adiponectin, and glucagon-like peptide-1), and inflammation (C-reactive protein). We modeled these indices as predictors of the slope of decline in global cognition, adjusting for age, sex, education, APOE*4 genotype, depressive symptoms, waist-hip ratio (WHR), and systolic blood pressure, in multivariable regression analyses of the entire sample and stratified by sex-specific median WHR. We then conducted WHR-stratified machine-learning (Classification and Regression Tree [CART]) analyses of the same variables., Results: In multivariable regression analyses, in the entire sample, HbA1c was significantly associated with cognitive decline. After stratifying by median WHR, HbA1c remained associated with cognitive decline in those with higher WHR. No metabolic indices were associated with cognitive decline in those with lower WHR. Cross-validated WHR-stratified CART analyses selected no predictors in participants older than 87 to 88 years. Faster cognitive decline was associated, in lower WHR participants younger than 87 years, with adiponectin of 11 or greater; and in higher WHR participants younger than 88 years, with HbA1c of 6.2% or greater., Conclusions: Our population-based data suggest that, in individuals younger than 88 years with central obesity, even modest degrees of hyperglycemia might independently predispose to faster cognitive decline. In contrast, among those younger than 87 years without central obesity, adiponectin may be a novel independent risk factor for cognitive decline. J Am Geriatr Soc 68:991-998, 2020., (© 2020 The American Geriatrics Society.)

Background: Obstructive sleep apnea (OSA) is associated with long-term cardiovascular morbidity and is highly prevalent in patients with cardiovascular disease (CVD). The objectives of this scoping review were to determine the prevalence of OSA inpatients hospitalized for CVD and to map the range of in-hospital outcomes associated with OSA., Methods: We searched MEDLINE(R), Embase, and Cochrane Databases for articles published from 1946-2018. We included studies involving non-surgical adults with OSA or at high risk of OSA who were hospitalized for CVD. The outcomes were considered as in-hospital if they were collected from admission up to 30 days post-discharge from hospital., Results: After the screening of 4642 articles, 26 studies were included for qualitative synthesis. Eligible studies included patients presenting with acute coronary syndromes (n = 19), congestive heart failure (n = 6), or any cardiovascular disease (n = 1). The pooled prevalence of OSA in cardiac inpatients was 48% (95% CI: 42-53). The in-hospital outcomes reported were mortality (n = 4), length of stay (n = 8), left ventricular ejection fraction (n = 8), peak troponin (n = 7), peak B-type natriuretic peptide (n = 4), and composite cardiovascular complications (n = 2)., Conclusions: OSA is highly prevalent in the cardiac inpatient population. The outcomes reported included mortality, cardiac function, cardiac biomarkers, and resource utilization. There are significant knowledge gaps regarding the effect of treatment and OSA severity on these outcomes. The findings from this review serve to inform further areas of research on the management of OSA among patients with CVD., Competing Interests: The authors declare no conflict of interest.

Digging animals may alter many characteristics of their environment as they disrupt and modify the ground's surface by creating foraging pits or burrows. Extensive disturbance to the soil and litter layer changes litter distribution and availability, potentially altering fuel loads. In many landscapes, including peri-urban areas, fire management to reduce fuel loads is complex and challenging. The reintroduction of previously common digging animals, many of which are now threatened, may have the added benefit of reducing fuel loads. We experimentally examined how the reintroduction of a marsupial bandicoot, quenda (Isoodon fusciventer), altered surface fuel loads in an urban bush reserve in Perth, Western Australia. Foraging activities of quenda (where they dig for subterranean food) were substantial throughout the reserve, creating a visibly patchy distribution in surface litter. Further, in open plots where quenda had access, compared to fenced plots where quenda were excluded, quenda foraging significantly reduced litter cover and litter depth. Similarly, estimated surface fuel loads were nearly halved in open plots where quenda foraged compared to fenced plots where quenda were absent (3.6 cf. 6.4 Mg/ha). Fire behavior modeling, using the estimated surface fuel loads, indicated the predicted rate of spread of fire were significantly lower for open plots where quenda foraged compared to fenced plots under both low (29.2 cf. 51.4 m/h; total fuels) and high (74.3 cf. 130.4 m/h; total fuels) fire conditions. Although many environments require fire, including the bushland where this study occurred, fire management can be a considerable challenge in many landscapes, including urban bushland reserves, which are usually small and close to human infrastructure. The reintroduction of previously common digging species may have potential value as a complimentary tool for reducing fuel loads, and potentially, fire risk., (© 2019 by the Ecological Society of America.)

Introduction: Electrical injuries exhibit significant acute and long-term sequelae. Amputation and neurological deficits are common in electrical injury survivors. There is a paucity of information on the long-term outcomes of this population. Therefore, this study examines the long-term outcomes of electrical injuries by comparing them to fire/flame injuries., Methods: Data from the Burn Model System National Database collected between 1996 and 2015 was examined. Demographic and clinical characteristics for adult burn survivors with electrical and fire/flame injuries were compared. Satisfaction With Life Scale (SWLS), Short Form-12 Physical Composite Score (SF-12 PCS), Short Form-12 Mental Composite Score (SF-12 MCS), and employment status were examined at 24 months post-injury. Linear and logistic regression models were used to assess differences in outcome measures between groups, controlling for demographic and clinical variables., Results: A total of 1147 adult burn survivors (111 with electrical injuries; 1036 with fire/flame injuries) were included in this study. Persons with electrical injuries were more likely to be male and injured at work (p<0.001). SF-12 PCS scores were significantly worse for survivors with electrical injuries at 24 months post-injury than survivors with fire/flame injuries (p<0.01). Those with electrical injuries were nearly half as likely to be employed at 24 months post-injury than those with fire/flame injuries (p=0.002). There were no significant differences in SWLS and SF-12 MCS between groups., Conclusions: Adult survivors with electrical injuries reported worse physical health and were less likely to be employed at 24 months post-injury compared to survivors with fire/flame injuries. A more detailed understanding of return to work barriers and work accommodations is merited for the electrical injury population. Furthermore, the results of this study should inform future resource allocation for the physical health and employment needs of this population., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Mild to moderate cognitive decrements are a well-known phenomenon associated with diabetes mellitus. In this review, we provide an overview of the cognitive consequences of type 1 and type 2 diabetes based on hallmark studies that follow patients over an extended period of time. In patients with type 1 diabetes, cognitive dysfunction appears soon after diagnosis and can be found in individuals of any age. The magnitude of these effects is generally modest, although their severity is especially pronounced in those with early onset type 1 diabetes (diagnosis before 7 years of age) or those who have developed microvascular disease, such as proliferative retinopathy. Rates of type 2 diabetes have increased dramatically over the past 20 years, in part driven by the world-wide epidemic of obesity, and this form of diabetes is appearing at a progressively younger age. Again, cognition may be disrupted, particularly in those who are in poorer glycemic control, and there is some evidence to suggest that with increasing diabetes duration, the rate of cognitive decline is accelerated and the risk of dementia is increased significantly., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0-5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1-5 years). We developed a working conceptual framework based on the BOQ0-5, the National Research Council and Institute of Medicine's Model of Child Health, and the World Health Organization's International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents' perceptions of their child's pain, skin-related discomfort, and fatigue. The functioning domain describes children's physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To investigate the effect of patient and injury characteristics on employment for working-age, adult survivors of burn injury using the multicenter Burn Model System national database., Design: Longitudinal survey., Setting: Multicenter regional burn centers., Participants: Adult burn survivors (N=967) age≥18 years with known employment status prior to injury were included in the analysis at 12 months after injury., Interventions: Not applicable., Main Outcome Measures: Employment status at 12 months after injury., Results: The analyses determined that those employed preinjury had higher odds of being employed (odds ratio [OR]=8.1; 95% confidence interval [CI], 4.9-13.1). White, non-Hispanic individuals were also more likely to be employed (OR=1.49; 95% CI, 1.0-2.1). Older individuals, females, those with longer hospitalizations, amputation during the acute hospitalization, and those with high pain interference at hospital discharge had lower odds of working after injury. Preinjury living situation, preinjury alcohol and drug misuse, number of acute operations and burn size (total body surface area, %) were not significant predictors of employment status at 12 months after burn injury., Conclusion: Preinjury employment remains the most significant predictor for postburn employment. Although past reports have focused on predictors for postburn employment, we believe that we need to seek greater understanding of modifiable risk factors for unemployment and examine issues related to work retention, performance, accommodations, and career trajectories for the working-age survivor of burn injury., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to determine the impact of weekend versus weekday admission to an inpatient rehabilitation facility on the risk of acute care transfer in patients with stroke., Design: This was a retrospective analysis using the Uniform Data System for Medical Rehabilitation, a national database comprising data from 70% of US inpatient rehabilitation facilities. A total of 1,051,436 adult (age ≥18 yrs) stroke cases were identified between 2002 and 2014 that met inclusion criteria. Logistic regression models were developed to test for associations between weekend (Friday-Sunday) versus weekday (Monday-Thursday) inpatient rehabilitation facility admission and transfer to acute care (primary outcome) and inpatient rehabilitation facility length of stay (secondary outcome), adjusting for relevant patient, medical, and facility variables. A secondary analysis examined acute care transfer from 2002 to 2009 before passage of the Affordable Care Act (ACA), 2010 to 2012 post-Affordable Care Act, and 2013 to 2014 after implementation of the Hospital Readmissions Reduction Program., Results: Weekend inpatient rehabilitation facility admission was associated with increased odds of acute care transfer (odds ratio = 1.06, 95% confidence interval = 1.04-1.08) and slightly shorter inpatient rehabilitation facility length of stay (P < 0.001). Overall, the risk of acute care transfer decreased after the ACA and Hospital Readmissions Reduction Program., Conclusions: Weekend admission to inpatient rehabilitation facility may pose a modest increase in the risk of transfer to acute care in patients with stroke., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand disparities in obesity rates among adolescents with mobility disabilities; (2) Describe limitations of current clinical screening methods of obesity in children with mobility disabilities; and (3) Identify potential alternatives for obesity screening in children with mobility disabilities., Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Objective: To examine differences in long-term social reintegration outcomes for burn survivors with and without peer support attendance., Design: Cross-sectional survey., Setting: Community-dwelling burn survivors., Participants: Burn survivors (N=601) aged ≥18 years with injuries to ≥5% total body surface area (TBSA) or burns to critical areas (hands, feet, face, or genitals)., Interventions: Not applicable., Main Outcome Measures: The Life Impact Burn Recovery Evaluation Profile was used to examine the following previously validated 6 scale scores of social participation: Family and Friends, Social Interactions, Social Activities, Work and Employment, Romantic Relationships, and Sexual Relationships., Results: Burn support group attendance was reported by 330 (55%) of 596 respondents who responded to this item. Attendees had larger burn size (43.4%±23.6% vs 36.8%±23.4% TBSA burned, P<.01) and were more likely to be >10 years from injury (50% vs 42.5%, P<.01). Survivors who attended at least 1 support group scored significantly higher on 3 of the scales: Social Interactions (P=.01), Social Activities (P=.04), and Work and Employment (P=.05). In adjusted analyses, peer support attendance was associated with increased scores on the Social Interactions scale, increasing scores by 17% of an SD (95% confidence interval, 1%-33%; P=.04)., Conclusions: Burn survivors who reported peer support attendance had better social interaction scores than those who did not. This is the first reported association between peer support group attendance and improvements in community reintegration in burn survivors. This cross-sectional study prompts further exploration into the potential benefits of peer support groups on burn recovery with future intervention studies., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The impact of simple snoring on sleep structure and sleepiness has not been well described. In several studies, self-reported snoring was associated with increased daytime sleepiness. However, most studies did not distinguish patients with simple snoring from those with coexisting obstructive sleep apnea (OSA) using objective measures. We therefore evaluated the relationship between objectively measured snoring and both sleep structure and daytime sleepiness in patients with no or mild OSA., Methods: Subjects referred for suspected sleep disorders underwent polysomnography (PSG) during which breath sounds were recorded by a microphone. Those with an apnea-hypopnea index (AHI) <15/h were analyzed. Individual snores were identified by a computer algorithm, from which the snore index (SI) was calculated as the number of snores/h of sleep. Sleep stages and arousals were quantified. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale (ESS) score., Results: 74 (35 males) subjects were included (age, mean ± SD: 46.4 ± 15.3 years and body mass index: 29.8 ± 7.0 kg/m 2 ). The mean SI was 266 ± 243 snores/h. Subjects were categorized according to their SI into 3 tertiles: SI < 100, between 100-350, and >350. No sleep structure indeces, arousals, or ESS score differed among SI tertiles (p > 0.13). There was no correlation between SI and any of these variables (p > 0.29). In contrast, the AHI was significantly related to frequency of arousals (r = 0.23, p = 0.048)., Conclusions: These findings suggest that simple snoring assessed objectively is not related to indices of sleep structure or subjective sleepiness., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To examine differences in long-term social reintegration outcomes for burn survivors with and without work-related injuries., Design: Cross-sectional survey., Setting: Community-dwelling burn survivors., Participants: Burn survivors (N=601) aged ≥18 years with injuries to ≥5% total body surface area or burns to critical areas (hands, feet, face, or genitals)., Interventions: Not applicable., Main Outcome Measures: The Life Impact Burn Recovery Evaluation Profile was used to examine the following previously validated 6 scale scores of social participation: Family and Friends, Social Interactions, Social Activities, Work and Employment, Romantic Relationships, and Sexual Relationships., Results: Older participants, those who were married, and men were more likely to be burned at work (P<.01). Burn survivors who were injured at work scored significantly lower on the Work and Employment scale score after adjusting for demographic and clinical characteristics (P=.01). All other domain scale scores demonstrated no significant differences between groups. Individuals with work-related injuries scored significantly worse on 6 of the 19 items within the Work and Employment scale (P<.05). These individuals were more likely to report that they were afraid to go to work and felt limited in their ability to perform at work., Conclusions: Burn survivors with work-related injuries report worse work reintegration outcomes than those without work-related injuries. Identification of those at higher risk for work reintegration challenges after burn injury may enable survivors, providers, employers, and insurers to better use appropriate resources to promote and target optimal employment outcomes., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The risk of death is elevated in patients taking opioids for chronic non-cancer pain. Respiratory depression is the main cause of death due to opioids and sleep apnoea is an important associated risk factor., Methods: In chronic pain clinics, we assessed the STOP-Bang questionnaire (a screening tool for sleep apnoea; S noring, T iredness, O bserved apnoea, high blood P ressure, B ody mass index, age, neck circumference and male gender), Epworth Sleepiness Scale, thyromental distance, Mallampati classification, daytime oxyhaemoglobin saturation (SpO 2 ) and calculated daily morphine milligram equivalent (MME) approximations for each participant, and performed an inlaboratory polysomnogram. The primary objective was to determine the predictive factors for sleep apnoea in patients on chronic opioid therapy using multivariable logistic regression models., Results: Of 332 consented participants, 204 underwent polysomnography, and 120 (58.8%) had sleep apnoea (AHI ≥5) (72% obstructive, 20% central and 8% indeterminate sleep apnoea), with a high prevalence of moderate (23.3%) and severe (30.8%) sleep apnoea. The STOP-Bang questionnaire and SpO 2 are predictive factors for sleep apnoea (AHI ≥15) in patients on opioids for chronic pain. For each one-unit increase in the STOP-Bang score, the odds of moderate-to-severe sleep apnoea (AHI ≥15) increased by 70%, and for each 1% SpO 2 decrease the odds increased by 33%. For each 10 mg MME increase, the odds of Central Apnoea Index ≥5 increased by 3%, and for each 1% SpO 2 decrease the odds increased by 45%., Conclusion: In patients on opioids for chronic pain, the STOP-Bang questionnaire and daytime SpO 2 are predictive factors for sleep apnoea, and MME and daytime SpO 2 are predictive factors for Central Apnoea Index ≥5., Trial Registration Number: NCT02513836., Competing Interests: Competing interests: FC reports research support from the Ontario Ministry of Health and Long-Term Care and the University Health Network Foundation; and UpToDate royalties and STOP-Bang proprietary to the University Health Network. JW reports grants from the Ontario Ministry of Health and Long-Term Care, Anesthesia Patient Safety Foundation and the University of Toronto Merit Research Award. MMM: reports support from Novo Nordisk, Allergan and Amgen. DNJ reports personal fees from universities, colleges and professional medical associations. He is an unpaid member of the Physicians for Responsible Opioid Prescribing (PROP), which is sometimes cast as an 'anti-opioid' group, but in actuality is invested in prescribing that is safer and more evidence-based. He is also a member of the American College of Medical Toxicology. Both groups have publicly available positions on this issue. Other coauthors have no conflict of interest reported., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include risk factors, such as obesity, male sex, and aging. More recently, there has been a precipitous increase in the prevalence of obstructive sleep apnea in youth. Drivers of this phenomenon include both increasing obesity and the survival of children with complex medical conditions into adulthood. Appropriate treatment and long-term management of obstructive sleep apnea is critical to ensure that these youth maintain well-being unfettered by secondary comorbidities. To this end, patient engagement and seamless transition of care from pediatric to adult health care systems is of paramount importance. To date, this is an unacknowledged and unmet need in most sleep programs. This article highlights the need for guideline-driven sleep disorder transition processes and illustrates the authors' experience with the development of a program for sleep apnea., Competing Interests: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Overnight extracellular rostral fluid shifts have been shown to be of importance in patients with fluid-retaining states and are associated with a higher prevalence of sleep apnea. Pulmonary hypertension is frequently associated with right ventricular dysfunction and progressive right ventricular failure, and an increased prevalence of sleep apnea has been described. In light of the importance of fluid shifts in the pathophysiology of sleep apnea, we aimed to explore temporal fluid shifts in patients with pulmonary hypertension with and without sleep apnea. Patients with pulmonary hypertension (WHO Group 1 or 4) had overnight extracellular rostral fluid shift assessment before and a minimum of 3 months after initiation of pulmonary hypertension-specific therapy. Fluid shift measurements of extracellular leg, abdominal, thoracic and neck fluid volumes were performed simultaneously. Twenty-nine patients with pulmonary hypertension (age 55 ± 16 years, 69% female) participated. Sleep apnea was diagnosed in 15 subjects (apnea-hypopnea index 14 [8-27] per hr). There were no significant differences in baseline or overnight leg extracellular rostral fluid, abdominal extracellular rostral fluid, thoracic extracellular rostral fluid or neck extracellular rostral fluid between those with and without sleep apnea. There was a significant inverse correlation between the sleep apnea severity and the overnight change in leg extracellular rostral fluid (r = -0.375, p = 0.049). There were no significant differences detected in overnight extracellular rostral fluid shifts from baseline to follow-up. Treatment-naïve patients with pulmonary hypertension both with and without sleep apnea demonstrate overnight extracellular rostral fluid shifts from the legs into the thorax and neck. Pulmonary hypertension-specific treatment, while significantly improving cardiac haemodynamics, had little impact on nocturnal extracellular rostral fluid shifts or the presence of sleep apnea., (© 2019 European Sleep Research Society.)

To determine the association between potential risk factors and multiple organ failure (MOF) in severe burn adult patients, we performed a secondary analysis of data from the "Inflammation and the Host Response to Injury" database, which included patients from six burn centers in the United States between 2003 and 2009. Three hundred twenty-two adult patients (aged ≥16 years) with severe burns (≥20.0% total body surface area [TBSA]) were included. MOF was defined according to the Denver score. Potential risk factors were analyzed for their association with MOF. Models were built using multivariable logistic regression analysis. Eighty-eight patients (27.3%) developed MOF during the study period. We found that TBSA, age, and inhalation injury were significant risk factors for MOF. This predictive model showed good performance, with the total area under the receiver operating characteristic curve being 0.823. Moreover, among patients who developed MOF, inhalation injury was significantly associated with the development of MOF in the acute phase (within three days of injury) (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.3). TBSA, age, lactate, and Denver score within 24h were associated with the late phase development of MOF. Thus, we have identified key risk factors for the onset of MOF after severe burn injury. Our findings contribute to the understanding of individualized treatment and will potentially allow for efficient allocation of resources and a lower threshold for admission to an intensive care unit, which can prevent the development of MOF and eventually reduce mortality., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: Obstructive sleep apnea (OSA) is highly prevalent in post-stroke patients and observational evidence suggests that untreated it is a harbinger of poorer outcomes in this population. Clinical trials on the impact of treatment of OSA with continuous positive airway pressure (CPAP) have countered difficulties with patient engagement and adherence to CPAP therapy. Real-world data on continuous positive airway pressure initiation and usage in the post-stroke population with obstructive sleep apnea is limited., Methods: We performed a clinical retrospective study between January 2006 and June 2015 to describe the short- and long-term CPAP usage in the post-stroke population with OSA, and to assess which patient, disease, and treatment-related factors were associated with CPAP purchase, initiation, and usage in this population., Results: Of 191 post-stroke patients' recommended CPAP therapy, post-prescription usage at 3, 6, 12, 24, and 60 months was 58%, 53%, 48%, 45%, and 39% respectively. OSA severity-related factors, such as AHI or degree of nocturnal hypoxemia, were not significantly associated with CPAP usage. Predictors of CPAP usage at all time points were younger age, male sex, never smokers, and no history of hypertension. There were some differences in predictors of CPAP usage between early and later time periods., Conclusions: We demonstrated that the long-term usage of CPAP therapy is possible with most of the attrition occurring in the first 3 months. Upfront healthcare resource allocation to CPAP initiation and usage in this population may improve longer-term usage.

Objective: To examine differences in long-term employment outcomes in the postacute care setting., Design: Retrospective review of the prospectively collected Burn Model System National Database., Setting and Participants: A total of 695 adult survivors of burn injury enrolled between May 1994 and June 2016 who required postacute care at a Burn Model System center following acute care discharge were included. Participants were divided into 2 groups based on acute care discharge disposition. Those who received postacute care at an inpatient rehabilitation facility (IRF) following acute care were included in the IRF group (N=447), and those who were treated at a skilled nursing facility, long-term care hospital, or other extended-care facility following acute care were included in the Other Rehab group (N=248)., Interventions: Not applicable., Main Outcome Measures: Employment status at 12 months postinjury. Propensity score matching and logistic regression were utilized to determine the effect of postacute care setting on employment status., Results: Individuals in the IRF group had larger burns and were more likely to have an inhalation injury and to undergo amputation. At 12 months postinjury, the IRF group had over 9 times increased odds of being employed compared to the Other Rehab group, using propensity score matching (P=.046)., Conclusions: While admitting patients with more severe injuries, IRFs provided a long-term benefit for survivors of burn injury in terms of regaining employment. Given the current lack of evidence-based guidelines on postacute care decisions, the results of this study shed light on the potential benefits of the intensive services provided at IRFs in this population., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Long-term trials are key to understanding chronic symptoms such as pain and itch. However, challenges such as high attrition rates and poor recruitment are common when conducting research. The aim of this work was to explore these issues within a long-term randomized control trial using transcranial direct current stimulation to treat pain and itch. This parallel double blinded, placebo-controlled randomized trial was comprised of 15 transcranial direct current stimulation visits and 7 follow-up visits. Participants were over the age of 18, had a burn injury that occurred at least 3 weeks before enrollment, and reported having pain and/or itch that was moderate to severe in intensity. A total of 31 subjects were randomized into either an active or sham transcranial direct current stimulation groups. There were no significant differences between the groups in terms of age, race, education, baseline depression, or anxiety. The median dropout time was at visit 19 (visit 16 [SE = 1.98] for the sham group and visit 19 [SE = 1.98] for the active group). Analysis showed no differences in the dropout rate between groups [χ2(1) = 0.003, P = .954]. The dropout rate was 46.7% for the sham group and 43.8% for the active group. Overall, 45.2% of the subjects dropped out of the trial. Long-term clinical trials are an essential part of evaluating interventions for symptoms such as chronic pain and itch. However, as seen in this trial, long-term studies in the burn population often face recruitment and adherence challenges., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The Burn Outcomes Questionnaire for children ages 5-18 years (BOQ5-18) is a widely used, reliable, and valid parent-reported outcome measure designed to assess children's recovery from burn injuries in 12 physical and psychosocial domains. This study evaluated the feasibility, acceptability, and usefulness of a feedback system that delivered BOQ and Pediatric Symptom Checklist (PSC-17; a widely used measure of psychosocial functioning) results to burn care clinicians prior to an outpatient appointment or a postoperative surgical encounter. The BOQ and the PSC-17 were administered to the parents of 147 children receiving outpatient or surgical care in two pediatric burn hospitals. Clinician and parent perceptions of the feedback system were evaluated using debriefing questionnaires. Over half of all patients were at-risk on at least one BOQ subscale, and risk on three or more BOQ domains was significantly associated with a higher likelihood of poor psychological scores on the PSC-17 (P < .001). Significant differences in BOQ scores were found between the two hospital sites on four BOQ subscales, three related to physical ability and one to psychosocial well-being. Parent ratings of the feedback system were positive, with 90% of parents in both settings agreeing that the BOQ tablet experience was easy and helpful. Clinician attitudes differed across the two settings with more positive clinician ratings of the system in the outpatient setting (P < .001). Clinician interviews revealed that the data was especially useful in bringing to light psychosocial aspects of functioning relevant to long-term recovery from burn injuries., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Previous studies have shown that obstructive sleep apnea (OSA) is associated with a higher risk of cognitive impairment or dementia in the elderly, leading to deleterious health effects and decreasing quality of life. This systematic review aims to determine the prevalence of OSA in patients with mild cognitive impairment (MCI) and examine whether an association between OSA and MCI exists., Methods: We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsychINFO, Scopus, the Web of Science, ClinicalTrials.gov and the International Clinical Trials Registry Platform for published and unpublished studies. We included studies in adults with a diagnosis of MCI that reported on the prevalence of OSA. Two independent reviewers performed the abstract and full-text screening, data extraction and the study quality critical appraisal., Results: Five studies were included in the systematic review. Overall, OSA prevalence rates in patients with MCI varied between 11 and 71% and were influenced by OSA diagnostic methods and patient recruitment locations (community or clinic based). Among studies using the following OSA diagnostic measures- self-report, Home Sleep Apnea Testing, Berlin Questionnaire and polysomnography- the OSA prevalence rates in MCI were 11, 27, 59 and 71%, respectively. In a community-based sample, the prevalence of OSA in patients with and without MCI was 27 and 26%, respectively., Conclusions: Based on limited evidence, the prevalence of OSA in patients with MCI is 27% and varies based upon OSA diagnostic methods and patient recruitment locations. Our findings provide an important framework for future studies to prospectively investigate the association between OSA and MCI among larger community-based cohorts and implement a standardized approach to diagnose OSA in memory clinics., Prospero Registration: CRD42018096577.

Social and emotional recovery from burn injury is a complex process impacted by both clinical and social factors. Because level of education (LOE) has been correlated to overall health, health outcomes, and life expectancy, we questioned whether LOE might be associated with successful social recovery after burn injury. The Life Impact Burn Recovery Evaluation (LIBRE) data set served as a novel tool to explore this question. The LIBRE project is a collaborative effort designed to provide a clinical yardstick for social reintegration among burn survivors. After institutional review board approval, 601 burn survivor respondents, aged 18 or over with >5% TBSA burn were surveyed and a six-scale, 126-item LIBRE Profile was derived from their responses. LOE was collapsed into four categories ranging from less than high school equivalency certificate to graduate degree. Impact of burn injury on subsequent LOE was examined by splitting the sample into those burned at age 30 years or less and those burned at greater than 30 years of age. Regression models were run to estimate associations between education and scale scores with adjustment for age at injury, sex, marital status, work status, TBSA, and time since burn. Regression models were run on the entire cohort and then stratified by age at burn injury (≤30 vs >30). Among all subjects, we found an association between LOE and social recovery as measured by LIBRE scale scores. This association was contributed entirely from the cohort burned at age 30 or less: for those burned at greater than age 30, there was no association between LOE and social recovery. Of particular interest, the distribution of LOE among those burned at ≤ 30 was very similar to LOE distribution in both millennials and in the U.S. population at large. LOE appears to be associated with social recovery for those burned at younger ages but not for those burned at over age 30. More importantly, burn injury during schooling may have no impact on a survivor's educational trajectory since distribution of LOE in our ≤30 cohort mirrors that of the general population. LOE and age at burn injury may provide a quick screen for survivors at risk of difficult social reintegration, allowing providers to target those at risk with additional peer support and counseling., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Work integration and retention after burn injury is a key outcome. Little is known about how burn survivors reintegrate into the workplace. This article compares scores on the Life Impact Burn Recovery Evaluation (LIBRE) Profile, a burn-specific measure of social participation, between burn survivors and general population samples, focusing on the Work and Employment domain., Methods: Convenience samples of burn survivors and the U.S. population were obtained. Differences in demographic and clinical characteristics and LIBRE Profile scores were assessed. To examine work and employment, we compared family and friends, social activities, and social interactions scores among working vs nonworking burn survivors., Results: Six hundred and one burn survivors (320 employed) and 2000 U.S. residents (1101 employed) were surveyed. The mean age (P = .06), distributions of sex (P = .35), and Hispanic ethnicity (P = .07) did not differ significantly. Distributions of race (P < .01) and education (P = .01) differed significantly. The burn survivor sample had higher scores, demonstrating higher participation, for work and employment (mean = 49.5, SD = 9.42) than the general sample (mean = 46.94, SD = 8.94; P < .0001), which persisted after adjusting for demographic characteristics. Scores on the three domains administered to all respondents were higher (P < .001) for working than nonworking burn survivors., Conclusion: Distributions indicated higher social participation in the burn survivor sample than the general sample. Possible explanations include sample bias; resilience, posttraumatic growth, or response-shift of survivors; and limitations of using items in the general sample. Working burn survivors scored higher than those not working. Future work can explore factors that mediate higher scores and develop interventions., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: There is limited understanding of how burn injuries at different ages are associated with normal growth and development as well as the burn recovery process. This study provides new useful insights by comparing social participation outcomes among burn survivors injured in childhood compared with injuries sustained in middle age, and older adulthood., Methods: Items from the development of the LIBRE profile were administered to 601 adult burn survivors with ≥5% TBSA burned or burns to critical areas (hands, feet, face, or genitals). Each item was answered on a 5-point Likert scale with higher scores denoting better outcomes. Mean scores for the 6 LIBRE profile scales (sexual relationships, family and friends, social interactions, social activities, work and employment, and romantic relationships) were compared between those burned as children (<18years) and those burned as adults (≥18years). Regression analyses were used to assess differences between groups with adjustment for demographic and clinical characteristics., Results: Of the 597 burn survivors having complete data on age at injury, 165 (27.6%) sustained burn injuries as a child. Those burned as children were more frequently female than those burned as adults (57% vs 47%) and were also more frequently white non-Hispanic (89% vs 77%). Marital status and education level were similar in the two groups. Those who were burned as children had slightly higher scores on the social activities, work and employment and romantic relationships scales. However, these differences did not persist in adjusted regression analyses., Conclusions: Burn survivors who sustained injuries as a child fared at least as well as those burned as adults in a broad range of long-term social participation outcomes. The impact on long-term social participation outcomes of burn survivors was not significantly different between individuals with burns sustained during important developmental stages at young ages and those injured later in life., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

Oro-facial fibrosis in systemic sclerosis (Scleroderma;SSc) has a major impact on mouth function, facial appearance, and patient quality of life. Lipotransfer is a method of reconstruction that can be used in the treatment of oro-facial fibrosis. The effect of this treatment not only restores oro-facial volume but has also been found to reverse the effects of oro-facial fibrosis. Adipose derived stem cells (ADSCs) within the engrafted adipose tissue have been shown to be anti-fibrotic in SSc and are proposed as the mechanism of the anti-fibrotic effect of lipotransfer. A cohort of 62 SSc patients with oro-facial fibrosis were assessed before and after stem cell enriched lipotransfer treatment. Clinical evaluation included assessment of mouth function using a validated assessment tool (Mouth Handicap in Systemic Sclerosis Scale-MHISS), validated psychological measurements and pre and post-operative volumetric assessment. In addition, to understand the mechanism by which the anti-fibrotic effect of ADSCs occur, SSc derived fibroblasts and ADSCs from this cohort of patients were co-cultured in direct and indirect culture systems and compared to monoculture controls. Cell viability, DNA content, protein secretion of known fibrotic mediators including growth factor- β1 (TGF β-1) and connective tissue growth factor (CTGF) using ELISA analysis and fibrosis gene expression using a fibrosis pathway specific qPCR array were evaluated. Mouth function (MHISS) was significantly improved (6.85±5.07) (p<0.0001) after treatment. All psychological measures were significantly improved: DAS 24 (12.1±9.5) (p<0.0001); HADS-anxiety (2.8±3.2) (p<0.0001), HADS-depression (2.0±3.1) (p<0.0001); BFNE (2.9 ± 4.3) (p<0.0001); VAS (3.56±4.1) (p<0.0001). Multiple treatments further improved mouth function (p<0.05), DAS (p<0.0001) and VAS (p = 0.01) scores. SSc fibroblast viability and proliferation was significantly reduced in co-culture compared to monoculture via a paracrine effect over 14 days (p < 0.0001). Protein secretion of transforming growth factor (TGF-β1) and connective tissue growth factor (CTGF) was significantly reduced in co-culture compared to monoculture (p < 0.0001). Multiple fibrosis associated genes were down regulated in SSc co-culture compared to monoculture after 14 days including Matrix metalloproteinase-8 (MMMP-8), Platelet derived growth factor-β (PDGF-β) and Integrin Subunit Beta 6 (ITG-β6). Autologous stem cell enriched lipotransfer significantly improved the effects of oro-facial fibrosis in SSc in this open cohort study. Lipotransfer may reduce dermal fibrosis through the suppression of fibroblast proliferation and key regulators of fibrogenesis including TG-β1 and CTGF. Our findings warrant further investigation in a randomised controlled trial., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Our aims were to evaluate HRV in pulmonary hypertension (WHO Group 1 and 4) compared to control subjects, and to assess whether the presence of sleep apnea in those with pulmonary hypertension would be deleterious and cause greater impairment in HRV., Methods: This retrospective case-control study analyzed electrocardiogram segments obtained from diagnostic polysomnography., Results: Forty-one pulmonary hypertension patients were compared to 41 age, sex and apnea-hypopnea index matched healthy controls. The pulmonary hypertension group had decreased high frequency, very low frequency, low frequency, and percentage of normal R-R intervals that differ by > 50 ms compared to control subjects. Moderate to severe right ventricle dysfunction on echocardiography was a predictor of lower high frequency in pulmonary hypertension patients., Conclusions: There were no differences in any HRV measures in pulmonary hypertension patients with or without sleep apnea. Impaired HRV was demonstrated in pulmonary hypertension patients however, the presence of sleep apnea did not appear to further reduce vagal modulation.

Background and Rational: Obstructive Sleep Apnea (OSA) is a common disorder, affecting almost 10% of adults, but very underdiagnosed. This is largely due to limited access to overnight sleep testing using polysomnography (PSG). Our goal was to distinguish OSA from healthy individual using a simple maneuver during wakefulness in combination with machine learning methods. Methods: Participants have undergone an overnight PSG to determine their ground truth OSA severity. Separately, they were asked to breathe through a nasal mask or a mouth piece through which negative pressure (NP) was applied, during wakefulness. Airflow waveforms were acquired and several features were extracted and used to train various classifiers to predict OSA. Results and Discussion: The performance of each classifier and experimental setup was calculated. The best results were obtained using Random Forest classifier for distinguishing OSA from healthy individuals with a very good area under the curve of 0.80. To the best of our knowledge, this is the first study to deploy machine learning and NP with promising path to diagnose OSA during wakefulness.

Oxandrolone, a testosterone analog, is used to counteract the catabolic effects of burn injury. Recent animal studies suggest a possible hormonal association with heterotopic ossification (HO) development postburn. This work examines oxandrolone administration and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. Additionally, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn/trauma-related HO. Acutely burned adults admitted between 2000 and 2014, survived through discharge, and had a HO risk factor of 7 or higher were selected for analysis from a single burn center. Oxandrolone administration, clinical and demographic data, and elbow HO were recorded and were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse model. Mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO and were analyzed by Student's t test. Subjects who received oxandrolone had a higher incidence of elbow HO than those that did not receive oxandrolone. However, when controlling for oxandrolone administration, oxandrolone duration, postburn day oxandrolone initiation, HO risk score category, age, sex, race, burn size, and year of injury, there was no significant difference between rates of elbow HO between the two populations. In agreement with the review, in the mouse model, while there was a trend toward the oxandrolone group developing a greater volume of HO, this did not reach statistical significance., (© American Burn Association 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The objective of this study was to determine the effects of feeding synthetic zeolite A for 3 wk before expected calving on peripartal serum mineral concentrations, hypocalcemia, oxidant status, and performance. Holstein cows (n = 55) entering their second or greater lactations were assigned randomly to 1 of 2 dietary treatments starting 21 d before expected calving: control (CON: 40% corn silage, 33% wheat straw, and 27% concentrate; n = 29) or experimental [EXP: CON plus zeolite A (X-Zelit, Protekta Inc., Lucknow, ON, Canada/Vilofoss, Graasten, Denmark; n = 26) at an inclusion rate of 3.3% of dry matter, targeting 500 g/d as-fed]. Cows were fed the same postpartum diet and housed in individual tiestalls through 28 d in milk. Cows fed EXP had higher serum Ca concentrations as parturition approached and during the immediate postpartum period. Serum P concentrations were lower for the EXP-fed cows during the prepartum period and the first 2 d of lactation, whereas serum Mg concentrations were lower than those of the CON-fed cows only during the immediate periparturient period. Cows fed EXP had decreased prevalence of subclinical hypocalcemia (SCH) from d -1 through 3 relative to day of parturition, with the largest difference occurring within the first day postpartum. Prepartum dry matter intake tended to be decreased and rumination was decreased in cows fed EXP; however; postpartum dry matter intake, rumination, milk yield, milk component yield, and colostrum measurements did not differ between treatments. Cows fed EXP tended to have increased hazard of pregnancy by 150 d in milk when controlling for parity compared with CON-fed cows; potential reproductive benefits merit further study. This study demonstrated that zeolite A supplementation during the prepartum period results in markedly improved serum Ca concentrations around parturition and similar postpartum performance compared with controls and is effective at decreasing hypocalcemia in multiparous Holstein cows., (Copyright © 2019 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Essential AA are critical for multiple physiological processes. Branched-chain AA (BCAA) supplementation has beneficial effects on body weight, lipogenesis, and insulin resistance in several species. The BCAA are used for milk and body protein synthesis as well as being oxidized by the tricarboxylic acid cycle to produce ATP during catabolic states. The objective was to evaluate the effect of rumen-protected BCAA (375 g of 27% l-Leu, 85 g of 48% l-Ile, and 91 g of 67% l-Val) with or without propylene glycol (PG) oral administration on milk production, dry matter intake, nonesterified fatty acids, β-hydroxybutyrate, and plasma urea nitrogen during the first 35 d in milk (DIM) in dairy cattle. Multiparous Holstein cows were enrolled in blocks of three 28 d before expected calving and assigned randomly to either the control or 1 of 2 treatments. The control (n = 26) received 200 g/d of dry molasses, the BCAA treatment (n = 23) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM, and the BCAA plus PG (BCAAPG) treatment (n = 25) received BCAA mixed with 200 g/d of dry molasses from calving until 35 DIM plus 300 mL of PG once daily from calving until 7 DIM. Postpartum, dry matter intake least squares means (LSM; 95% confidence interval) were 20.7 (19.9, 21.7), 21.3 (20.4, 22.3), and 21.9 (20.9, 22.8) kg for control, BCAA, and BCAAPG, respectively. Milk yield (1-35 DIM) LSM were 41.7 (39.4, 44.0), 42.7 (40.3, 45.0), and 43.7 (41.4, 46.0) kg for control, BCAA, and BCAAPG, respectively. Energy-corrected milk LSM were 50.3 (46.8, 53.7), 52.4 (48.9, 55.8), and 52.9 (49.5, 56.4) kg for control, BCAA, and BCAAPG, respectively. Milk urea nitrogen LSM in milk for control, BCAA, and BCAAPG were 8.60 (8.02, 9.22), 9.70 (9.01, 10.45), and 9.75 (9.08, 10.47) mg/dL. Plasma urea nitrogen concentrations LSM for control, BCAA, and BCAAPG were 8.3 (7.7, 8.9), 10.1 (9.4, 10.9), and 9.6 (9.4, 10.3) mg/dL, respectively. The numbers of plasma samples classified as hyperketonemia were 77, 44, and 57 in control, BCAA, and BCAAPG, respectively. The BCAA supplementation increased plasma urea nitrogen and milk urea nitrogen, free valine concentration in plasma, and decreased hyperketonemia events during the postpartum period., (Copyright © 2019 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues., (Copyright © 2019 Elsevier Ltd. All rights reserved.)