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Retrogressive thaw slumps (RTS) are thermokarst features in ice-rich hillslope permafrost terrain and can cause dynamic changes to the landscape. Their occurrence in the Arctic has become increasingly frequent. RTS can significantly impact permafrost stability and generate substantial carbon emissions. Understanding the spatial distribution of RTS is critical to understanding and modelling global warming factors from permafrost thaw. Mapping RTS using conventional Earth observation approaches is challenging due to the highly dynamic nature and often small scale of RTS in the Arctic. In this study, we trained deep neural network models to map RTS across several landscapes in Siberia and Canada. Convolutional neural networks were trained with 965 RTS features, where 509 were from the Yamal and Gydan peninsulas in Siberia, and 456 from six other pan-Arctic regions including Canada and Northeastern Siberia. We used 4-m Maxar commercial imagery as the base map, 10-m NDVI derived from Sentinel-2 as the vegetation feature and 2-m ArcticDEM as the elevation feature. The best-performing model reached a validation Intersection over Union (IoU) score of 0.74 and a test IoU score of 0.71. Compared to past efforts to map RTS features, this represents one of the best-performing models and generalises well for mapping RTS in different permafrost regions, representing a critical step towards pan-Arctic deployment. Our experiments shed light on the impact of within-class and between-class variances of RTS in different regions on the model performance and provided critical implications for our follow-up study. We propose this method as an effective, accurate and computationally undemanding approach for RTS mapping.

The ability to sense and respond to proteotoxic insults declines with age, leaving cells vulnerable to chronic and acute stressors. Reproductive cues modulate this decline in cellular proteostasis to influence organismal stress resilience inC. elegans. We previously uncovered a pathway that links the integrity of developing embryos to somatic health in reproductive adults. Here, we show that the nuclear receptor NHR-49, a functional homolog of mammalian peroxisome proliferator-activated receptor alpha (PPARα), regulates stress resilience and proteostasis downstream of embryo integrity and other pathways that influence lipid homeostasis, and upstream of HSF-1. Disruption of the vitelline layer of the embryo envelope, which activates a proteostasis-enhancing inter-tissue pathway in somatic tissues, also triggers changes in lipid catabolism gene expression that are accompanied by an increase in fat stores. NHR-49 together with its co-activator MDT-15 contributes to this remodeling of lipid metabolism and is also important for the elevated stress resilience mediated by inhibition of the embryonic vitelline layer as well as by other pathways known to change lipid homeostasis, including reduced insulin-like signaling and fasting. Further, we show that increased NHR-49 activity is sufficient to suppress polyglutamine aggregation and improve stress resilience in an HSF-1-dependent manner. Together, our results establish NHR-49 as a key regulator that links lipid homeostasis and cellular resilience to proteotoxic stress.

Deaths due to prescription opioid overdoses are at record high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy, but little is known about how much is needed to adequately treat acutely painful conditions for outpatients. The purpose of this study was to quantify the usage of opioids prescribed from the pediatric emergency departments of a Midwestern tertiary care children's hospital system.This was a prospective descriptive study in which patients aged 0 to 17 years seen in 2 pediatric emergency departments who received a prescription for an outpatient opioid were enrolled. The main outcome was opioid doses used at home, which was obtained via phone follow-up. Additional information, including patient demographics, location, prescriber specialty, diagnosis, and opioid name and amount prescribed, was obtained via chart review.A total of 295 patients were enrolled, with 281 completing the study (95%). The median numbers of opioid doses prescribed and used were 12 and 2 doses, respectively, with 9 doses in excess. Patients with lower extremity fractures used more opioids than other diagnoses, with a median of 8 doses. The majority of families reported keeping extra doses at home.Prescribed opioid doses exceeded used doses by a factor of 6. Lower extremity fractures required more doses than other acutely painful conditions. We should consider limiting doses prescribed to decrease excess opioids available for misuse and abuse.

Unprecedented change is occurring in the Northern high latitude regions as a result of climate change. With related degradation of large carbon stocks sequestered in Arctic permafrost, it is essential that the carbon cycle, and its changes over time, is properly monitored. Greenhouse gas (GHG) fluxes can directly be monitored through the eddy covariance (EC) method and flux chambers. However, harsh weather conditions and remoteness make it difficult to establish and keep such monitoring sites running in the Arctic, and accordingly the past and current data coverage is comparatively sparse.In this study, we aim to evaluate the coverage of the existing network of high latitude GHG flux monitoring sites, and quantify uncertainties in our understanding of regional-scale vertical carbon exchange processes. Our intent is to outline the limits of this network both spatially and temporally. We investigate how changes over time in flux observations affect the networks extrapolation potential, and how gaps in the network extent could best be filled. For this purpose, we applied and extended the network representativeness metric used for the FLUXCOM project. First we calculate an extrapolation index, which indicates the relative error when predicting fluxes at increasing dissimilarity in environmental conditions from the existing sites in the network. Here we train a model to predict fluxes based on the top 10 predictor variables from FLUXCOM of the nearest locations in variable space to reference flux data. We then correlate prediction errors to distance in variable space, which allows us to quantify prediction errors for each location and time step in our domain.This analysis uses an extended version of our database of high latitude GHG flux monitoring sites produced in previous studies. This information is also available as an online mapping tool, which facilitates a variety of science applications. Although coverage is improved over past epochs, large gaps still remain in Russia and Canada, and across the Arctic wintertime. The most consistent year-round coverage of GHG fluxes occurs in Alaska and Europe. Our study prioritizes locations for network extension in Russia, Canada, and select locations in Alaska, and highlights where upgrades in instrumentation and battery capacity (e.g., extend monitoring into shoulder seasons and winter) would be most efficient.

Although education has been delivered remotely for over a century, technological advances provide the opportunity to access quality education through online study. Our experience delivering a postgraduate health economics program at Deakin University, Australia, illustrates the opportunities and challenges associated with online education. Online delivery improves the viability of postgraduate health economics, where the number of on-campus students may not be large enough to sustain a course. Online delivery can be designed to provide an equivalent learning experience for students compared to on-campus delivery, but this requires significant infrastructure and resourcing, including extensive staff time to prepare and update learning resources as well as ongoing student contact time essential to building successful learning communities. It also requires strong technical, academic, financial and political support at an organization level. Blended delivery, combining online and in-person components, are popular with students due to flexibility and in-person social interaction.

Background The Board of the Association of Pediatric Program Directors (APPD) partnered with the APPD Global Health Learning Community (GHLC) to establish the APPD Global Pediatric Educator Scholarship. This award seeks to recognize pediatric educators who demonstrate leadership in improving pediatric education in low- and middle-income countries, and provide them with career development opportunities by attending the APPD Spring meeting. Two educators per year have been awarded the scholarship since 2017. Award Evaluation The authors sent survey questions via email and obtained responses from 6 (100%) of the scholarship awardees, 8 (75%) APPD GHLC leadership individuals, and 4 (67%) APPD Board members. Three authors analyzed the responses with consensus achieved on themes. Results Awardees noted learning about educational strategies, academic opportunities through networking, and context for stronger bilateral exchange with partners. APPD leaders noted an expansion of the organization's mission to include global presence. Challenges included program visibility, sustainable funding, and logistics. Suggestions included better incorporation of awardees into APPD membership, longitudinal mentorship, targeted conference navigation, and visits to local academic institutions. Conclusions The APPD Global Educator Scholarship is a replicable model of organizational global outreach that expands the concept of bidirectional exchange to include career sponsorship for global partners.

The Arctic-boreal zone (ABZ) is experiencing amplified warming, actively changing biogeochemical cycling of vegetation and soils. The land-to-atmosphere fluxes of CO2 in the ABZ have the potential to increase in magnitude and feedback to the climate causing additional large scale warming. The ability to model and predict this vulnerability is critical to preparation for a warming world, but Earth system models have biases that may hinder understanding the rapidly changing ABZ carbon fluxes. Here we investigate circumpolar carbon cycling represented by the Community Land Model 5 (CLM5.0) with a focus on seasonal gross primary productivity (GPP) in plant functional types (PFTs). We benchmark model results using data from satellite remote sensing products and eddy covariance towers. We find consistent biases in CLM5.0 relative to observational constraints: (1) the onset of deciduous plant productivity to be late, (2) the offset of productivity to lag and remain abnormally high for all PFTs in fall, (3) a high bias of grass, shrub, and needleleaf evergreen tree productivity, and (4) an underestimation of productivity of deciduous trees. Based on these biases, we focus model development of alternate phenology, photosynthesis schemes, and carbon allocation parameters at eddy covariance tower sites. Although our improvements are focused on productivity, our final Model Recommendation results in other component CO2 fluxes, e.g. Net Ecosystem Exchange (NEE) and Terrestrial Ecosystem Respiration (TER), that are more consistent with observations. Results suggest that algorithms developed for lower latitudes and more temperate environments can be inaccurate when extrapolated to the ABZ, and that many land surface models may not accurately represent carbon cycling and its recent rapid changes in high latitude ecosystems, especially when analyzed by individual PFTs.

Habitat selection by animals is conventionally linked with nature selection pressures. However, niche construction as a potent evolutionary agent palys a crucial role for many types of evolutionary habitat selection by species and this modifies nature selection pressures. We used data obtained from an 11-year period to observe the evolutionary habitat selection by the plateau pika (Ochotona curzoniae) in relation to the niche construction of livestock management. We hypothesized that the niche construction of local nomads affects the evolutionary habitat selection of the plateau pika, and furthermore that the plateau pika does not fit niche conservatism in the Kobresia ecosystem of the Qinghai Tibetan Plateau (QTP). In order to verify the above hypotheses, we used the distance to the nearest yak-bedding areas and dung management as the variables that most strongly explain variation in pika occupancy (probability) and detection probability based on free-ranging livestock. Both pika occupancy and detection probability decrease sharply with increasing distance to the nearest yak-bedding area, suggesting that pika population densities are highest closest to yak-bedding areas. There is a strong correlation between dung cover and occupancy of the plateau pika; the more dung drying on the ground, the more plateau pikas occupy the area. Consequently, the plateau pika is frequently detected in damaged grass. Rangeland dominated by Kobresia sedges on the QTP is modified by livestock grazing and management, especially by dung management. This is the first research suggesting that local nomads may cause expansion of the habitat of the plateau pika. In sum, the habitat of the plateau pika is expanding and there is strong evidence that it retains its biodiversity on the Qinghai-Tibetan Plateau in spite of exposure to poison as control measure. Still, the current control management of the plateau pika may result in diminished diversity of both fauna and flora species and a collapse of the food web on the QTP.

BACKGROUND: Interest in global health (GH) among pediatric residents continues to grow. GH opportunities in pediatric fellowship programs in the United States are poorly described. We aimed to evaluate GH offerings among accredited general and subspecialty pediatric fellowship programs and identify implementation barriers. METHODS: This was a cross-sectional study by pediatric GH educators from the Association of Pediatric Program Directors Global Health Learning Community and the American Board of Pediatrics Global Health Task Force. Fellowship program directors and GH educators at accredited US pediatric fellowship programs were surveyed. Data were analyzed by using descriptive and comparative statistics. RESULTS: Data were obtained from 473 of 819 (57.8%) fellowship programs, representing 111 institutions. Nearly half (47.4%) offered GH opportunities as GH electives only (44.2%) or GH tracks and/or fellowships (3.2%) (GHT/Fs). Pretravel preparation and supervision were variable. Programs offering GH opportunities, compared to those without, were more likely to report that GH training improves fellow education (81.9% vs 38.3%; P < .001) and recruitment (76.8% vs 35.9%; P < .001). Since 2005, 10 programs with GHT/Fs have graduated 46 fellows, most of whom are working in GH. Of those with GHT/Fs, 71% believe national accreditation of GH fellowships would define minimum programmatic standards; 64% believe it would improve recruitment and legitimize GH as a subspecialty. CONCLUSIONS: GH experiences are prevalent in accredited US pediatric fellowship programs, and programs offering GH perceive that these opportunities improve fellow education and recruitment. Responses suggest that standards for GH opportunities during fellowship would be useful, particularly regarding pretravel preparation and mentorship for trainees.

OBJECTIVE Eating disorders are associated with multiple medical complications. We report contemporary medical data, for newly admitted adult inpatient and residential level of care patients. METHOD Medical records of a transdiagnostic sample of 1,026 patients, with eating disorders, were retrospectively reviewed for the presence of a broad array of medical complications at time of admission. The prevalence of physiologically relevant medical complications was assessed across major eating disorder categories. RESULTS Of the patients, 93.6% were female, and they had an average age of 28.1 (SD = 10.1, range 17-69). The average admission body mass index was 16.1 (SD = 2.3). The prevalence of abnormal laboratory values varied by eating disorder subtype. In patients with anorexia nervosa-restricting subtype, 51.4% had low prealbumin, 36.1% were leukopenic, 34.3% had osteoporosis, 30.0% vitamin D deficiency, 16.8% metabolic alkalosis, 16.0% had hyponatremia, 14.2% hypokalemia, and 7.1% hypoglycemia. These patients had normal average QTc intervals. In patients with anorexia nervosa-binge purging subtype, 42.4% had hypokalemia, 33.3% metabolic alkalosis, osteoporosis in 21.1%, and they had longer QTc intervals (433.9 ms, p

Objective Research on health initiatives for rural batey communities in the Dominican Republic is needed. Design and Sample This study utilized a pretest-posttest design to examine the feasibility and acceptability of a nutritional intervention targeting rural migrant sugarcane families. Participants (N = 310) were primarily female (61%) and ranged in age from 13 to 64 years (M = 25.9; SD = 10.4). A convenience sample was recruited from six rural bateyes in the southern region of the Dominican Republic. Intervention The intervention was developed for the target population in partnership with a grass-roots organization. The intervention consisted of a short video in the participant's preferred language (Spanish or Creole) describing the importance of consuming a diverse diet. Participants then completed an interactive meal-planning activity to enhance skills learned in the video. The main outcome variable was knowledge and a secondary outcome was participants’ performance on the interactive activity. Results Results showed that the intervention was well received by the target population and participants demonstrated a significant increase in nutrition knowledge (p

* Abbreviations: AAP — : American Academy of Pediatrics ABP — : American Board of Pediatrics APPD — : Association of Pediatric Program Directors ETC — : Education and Training Committee GH — : global health GHLC — : Global Health Learning Community GHTF — : Global Health Task Force LMIC — : low- and middle-income country SOICH — : Section on International Child Health Pediatric trainees are increasingly seeking global health (GH) educational opportunities, with ∼1 in 4 participating in a GH elective during residency.1,2 Training programs have responded to this demand: surveys suggest that ∼58% of residency and 47% of fellowship training programs offer GH electives.3,4 In accordance with best practices pertaining to short-term GH electives, many programs are attempting to build GH training opportunities beyond electives, including longitudinal GH curricula at their respective institutions, predeparture preparation training, postreturn debriefing, and global training partnerships.1,2,4–11 Concomitantly, educators are recognizing that all trainees, not just those planning to work abroad, need to learn about GH-related topics. The “local global health” framework12 highlights that diseases do not respect borders, resource limitation is not unique to low- and middle-income countries (LMICs), and core skills are necessary for all trainees caring for patients and families from (and going to) diverse settings. These skills include using interpreters effectively, caring for immigrants and travelers, employing … Address correspondence to Nicole E. St Clair, MD, Department of Pediatrics, University of Wisconsin–Madison School of Medicine and Public Health, H4/477 Mailcode 4108, 600 Highland Ave, Madison, WI 53792-4108. E-mail: nstclair{at}wisc.edu

In mice, pluripotent cells are thought to derive from cells buried inside the embryo around the 16-cell stage. Sox2 is the only pluripotency gene known to be expressed specifically within inside cells at this stage. To understand how pluripotency is established, we therefore investigated the mechanisms regulating the initial activation of Sox2 expression. Surprisingly, Sox2 expression initiated normally in the absence of both Nanog and Oct4 (Pou5f1), highlighting differences between embryo and stem cell models of pluripotency. However, we observed precocious ectopic expression of Sox2 prior to the 16-cell stage in the absence of Yap1, Wwtr1 and Tead4. Interestingly, the repression of premature Sox2 expression was sensitive to LATS kinase activity, even though LATS proteins normally do not limit activity of TEAD4, YAP1 and WWTR1 during these early stages. Finally, we present evidence for direct transcriptional repression of Sox2 by YAP1, WWTR1 and TEAD4. Taken together, our observations reveal that, while embryos are initially competent to express Sox2 as early as the four-cell stage, transcriptional repression prevents the premature expression of Sox2, thereby restricting the pluripotency program to the stage when inside cells are first created., Highlighted Article: The pluripotency marker SOX2 is not initially regulated by OCT4 and NANOG, but by HIPPO pathway members during the first 2 days of mouse embryogenesis.

In the mouse embryo, pluripotent cells arise inside the embryo around the 16-cell stage. During these early stages, Sox2 is the only gene whose expression is known to be induced specifically within inside cells as they are established. To understand how pluripotent cells are created, we investigated the mechanisms regulating the initial activation of Sox2 expression. Surprisingly, Sox2 expression initiated normally in the absence of both Nanog and Oct4, highlighting differences between embryo and stem cell models of pluripotency. However, we observed precocious, ectopic expression of Sox2 prior to the 16-cell stage in the absence of Yap1, Wwtr1, and Tead4. Interestingly, the repression of premature Sox2 expression was sensitive to LATS1/2 activity, even though it normally does not limit TEAD4/YAP1/WWTR1 activity during these early stages. Finally, we present evidence for direct transcriptional repression of Sox2 by YAP1/WWTR1/TEAD4. Taken together, our observations reveal that, while embryos are initially competent to express Sox2 as early as the 4-cell stage, transcriptional repression prevents the premature expression of Sox2, thereby restricting the pluripotency program to the stage when inside cells are first created.

BACKGROUND: Global health (GH) offerings by pediatric residency programs have increased significantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of these programs, there is currently no widely accepted definition for what comprises a GH track in residency. METHODS: A panel of 12 pediatric GH education experts was assembled to use the Delphi method to work toward a consensus definition of a GH track and determine essential educational offerings, institutional supports, and outcomes to evaluate. The panelists completed 3 rounds of iterative surveys that were amended after each round on the basis of qualitative results. RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH track was achieved during the second round of surveys. Consensus was achieved that at minimum, GH track educational offerings should include a longitudinal global child health curriculum, a GH rotation with international or domestic underserved experiences, predeparture preparation, preceptorship during GH electives, postreturn debrief, and scholarly output. Institutional supports should include resident salary support; malpractice, evacuation, and health insurance during GH electives; and a dedicated GH track director with protected time and financial and administrative support for program development and establishing partnerships. Key outcomes for evaluation of a GH track were agreed on. CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports and educational offerings, is instrumental in ensuring consistency in quality GH education among pediatric trainees. Consensus on outcomes for evaluation will help to create quality resident and program assessment tools.

BACKGROUND On May 22, 2011, an F5 tornado ripped through the city of Joplin, Mo, resulting in over 150 fatalities and over 750 injuries. Pediatric trauma centers in the region needed to be prepared to receive patients. Little data exist on the types of patients who are received at pediatric trauma centers after disasters such as tornados. OBJECTIVE The purpose of this study is to describe the patients received at the nearest level 1 pediatric trauma center after the tornado. METHODS Cases were identified through the trauma registry. Data regarding patient demographics, past medical history, characteristics of injury, treatment received, and outcomes were obtained retrospectively from medical records. RESULTS A total of 10 patients were received at the pediatric trauma center. Traumatic brain injury was the most common diagnosis followed by orthopedic and maxillofacial injuries. Seven patients required surgical procedures in the operating room, but only 1 patient required surgery within the first 24 hours of arrival. Eight patients were intubated and were in the pediatric intensive care unit. The average length of stay in the hospital was 19.4 days with a range of 14 hours to 94 days. CONCLUSIONS Immediately after a significant tornado in the referral region, pediatric trauma centers need to prepare to receive patients. Head injuries will likely be common, and pediatric trauma centers will likely receive multiple intubated patients. Knowledge of injuries received and resources needed can better prepare these trauma centers for future devastating tornadoes.

Osteoporosis and osteopenia are increasingly prevalent conditions among older adults. Not only do the fractures associated with poor bone health have significant health consequences for the individual, but also their economic impact is placing increasing financial burden on governments and society. This study aimed to determine the direct economic cost of osteoporosis, osteopenia, and fractures among Australians aged 50 years and older in 2017. This study uses previous Australian data on the incidence and prevalence of osteoporosis and osteopenia together with recent Australian data on health service utilization after fracture to provide an estimate of the economic burden of osteoporosis. A bottom-up costing approach was used to determine the average direct health care and non-health care total costs of a fracture, as well as the average community health service costs of managing individuals with osteoporosis or osteopenia. The total direct cost of osteoporosis in Australia in 2017 was estimated to be $3.44 billion (AUD 2017, USD 2.77 billion). Treatment of fractures accounted for 68% of total direct costs, and non-fracture management of osteoporosis accounted for 32%. Hip fractures accounted for the highest proportion (43%) of the total direct cost of fractures, although fractures at "other" sites accounted for 38.5%. Fractures among individuals aged 70 years and older accounted for 74% of the direct costs (55% and 19% in women and men, respectively). Fracture costs in those with osteopenia accounted for 50% of direct fracture treatment costs. This up-to-date cost analysis estimated that costs in 2017 were three times higher than in 2007. These estimates will aid clinicians, policy makers, researchers, and health care organizations to acknowledge the economic importance of reducing osteoporosis-related fractures and associated costs. This provides a strong public health case to promote bone health that will assist in reducing future fracture-related costs. © 2018 American Society for Bone and Mineral Research.

We present a case series of clinically definite acute stroke with negative diffusion-weighted imaging (DWI). This study retrospectively examined a large population of stroke patients with the aim of identifying which stroke syndromes were more likely to be negative on MRI. Patient records and images were reviewed in order to confirm clinically definite stroke and DWI negativity. A total of 701 patients had MRI during the study period. A total of 16 patients with DWI-negative MRI and clinically definite stroke as diagnosed by experienced stroke consultants were identified. A total of 15 of the 16 cases were classified as either posterior circulation or lacunar strokes, and the most common syndromes were ataxic hemiparesis and isolated internuclear ophthalmoplegia.

Cells of the early embryo are totipotent because they will differentiate to produce the fetus and its surrounding extraembryonic tissues. By contrast, embryonic stem (ES) cells are considered to be merely pluripotent because they lack the ability to efficiently produce extraembryonic cell types. The relatively limited developmental potential of ES cells can be explained by the observation that ES cells are derived from the embryo after its cells have already begun to specialize and lose totipotency. Meanwhile, at the time that pluripotent ES cell progenitors are specified, so are the multipotent progenitors of two extraembryonic stem cell types: trophoblast stem (TS) cells and extraembryonic endoderm stem (XEN) cells. Notably, all three embryo-derived stem cell types are capable of either self-renewing or differentiating in a lineage-appropriate manner. These three types of embryo-derived stem cell serve as paradigms for defining the genes and pathways that define and maintain unique stem cell identities. Remarkably, some of the mechanisms that maintain the specific developmental potential of each stem cell line do so by preventing conversion to another stem cell fate. This chapter highlights noteworthy studies that have identified the genes and pathways that normally limit the interconversion of stem cell identities.

Background The demand for Global Health (GH) experiences in pediatric residencies has grown dramatically. These experiences do not need to be limited to international settings. Through the required advocacy training in residency, many residents have experiences with underserved populations similar to populations in GH settings. In addition, there are various GH experiences within the local communities. Two separate institutions (Children’s Mercy Hospital, Kansas City, and Cincinnati Children’s Hospital Medical …

Background In the past decade, interest in global health (GH) among graduating pediatric residents has grown. The availability of these opportunities can influence their ranking of fellowship programs. Current GH opportunities in pediatric fellowship programs in the United States (US) are not well described. Methods This was a cross-sectional study by pediatric GH educators including representatives from the Association of Pediatric Program Directors (APPD) GH Learning Community and the American Board of Pediatrics. Program directors and GH educators at US pediatric fellowship programs were surveyed using REDCap®. Data were analyzed using standard descriptive statistics. Results Data were collected from 473 of 819 (58%) eligible US pediatric fellowship programs representing 111 institutions across all APPD regions and ABP subspecialties. 47% offered GH training opportunities as either GH electives (n=209, 44%) or formal GH fellowships (n=15, 3%). There was variable pretravel preparation (Table 1) and supervision for research projects, with almost 20% of programs indicating a lack of GH faculty on fellows' scholarship oversight committees. Programs offering any GH opportunities, compared to those without, were more likely to report that available GH training improves fellow education (82% vs. 38%, p Conclusions GH experiences are an integral part of many US fellowship programs, and programs offering GH perceive that these opportunities improve the education and recruitment of fellows. Data suggest that standards for GH opportunities during fellowship training would be useful, particularly pertaining to pre-travel preparation, supervision, and mentorship for trainees.

Objective The number of pediatric Global Health (GH) tracks has more than doubled in less than 10 years. The goal of this study was to describe the characteristics of the pediatric GH tracks to identify commonalities and differences in track structure, funding, and education. In addition, we also identified demographic, institutional, and residency-related factors that were significantly associated with educational offerings and logistical challenges. Methods A cross-sectional survey was electronically administered to pediatric residency programs with GH tracks. Statistical analyses included frequencies to describe GH track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. Results Leaders of 32 pediatric GH tracks (67%) completed the survey. The majority of GH tracks were completed within the 3 years of residency (94%) and identified a GH track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. Conclusions Despite the presence of multiple similarities among pediatric GH tracks, there are large variations in track structure, education, and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH track, which may provide a framework for quality, consistency, and comparison of GH tracks.

We compared performance characteristics of 7 weight estimation methods examining predictive performance and human factors errors.This was a prospective study of 80 emergency care providers (raters) and 80 children aged 2 months to 16 years. Raters estimated weights in 5 children with the following 7 strategies: visual estimation, Advanced Pediatric Life Support, Luscombe and Owens, Broselow tape, devised weight estimation method, 2D Mercy TAPE (2DT), and 3D Mercy TAPE (3DT). Quantitative errors were determined by checking rater values against values returned with optimal method use.Four hundred rater-child pairings generated 2800 weight estimates. For all methods, rater-estimated weights were less accurate than weights derived by optimal application. Skill-based, perception, and judgment/decision error were observed. For visual estimation, weights were underestimated in most children. For Advanced Pediatric Life Support/Luscombe and Owens, order of operations markedly impacted errors with 23% of calculations requiring addition first performed incorrectly versus 9% of calculations requiring multiplication first. For Broselow tape, only 63% of cases were eligible for estimation with this device, yet raters assigned a weight in 96% of cases. For Devised Weight Estimation Method, 96% of overweight and 48% of obese children were classified as slim or average. For 2DT/3DT, the 2DT was prone to more errors most commonly use of the wrong side of the device (24%). The impact of rater characteristics on error was most pronounced for methods requiring calculation.Skill-based, perception, or judgment errors were observed in more than 1 of 20 cases. No singular strategy was used with 100% accuracy.

OBJECTIVES Deaths due to prescription opioid overdoses are at record-high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy. The purpose of this study was to describe the opioid prescribing practices in the emergency departments and urgent care sites of a Midwestern tertiary care children's hospital system. METHODS This retrospective medical record review examined the visits from the 2 pediatric emergency departments and 2 pediatric urgent care sites in the system from June 1, 2012, to May 31, 2013, during which an outpatient opioid prescription was written. The primary outcome was number of days of opioid prescribed. Other data collected included patient demographics, diagnosis, and prescriber information; factors associated with prescriptions written for more than 5 days were identified. RESULTS A total of 4075 opioid prescriptions were included in the 1-year study period, and 3991 of these had complete data for analysis. The median amount prescribed was 3.3 days with an interquartile range of 2.5 days. Odds of receiving a prescription of more than 5 days' duration were higher for children younger than 1 year (odds ratio [OR], 12.3; 95% confidence interval [CI], 7.3-21.0), 1 to 4 years of age (OR, 7.7; 95% CI, 5.5-10.8), and 5 to 9 years of age (OR, 2.4; 95% CI, 1.7-3.4); for children with noninjury diagnoses (OR, 1.4; 95% CI, 1.2-1.7); or if prescribed by a resident physician (OR, 1.4; 95% CI, 1.1-1.8) or from the urgent care (OR, 1.4; 95% CI, 1.1-1.7). CONCLUSIONS Opioid prescriptions of more than 5 days were more frequently prescribed for younger patients, noninjury diagnoses, or if prescribed by a resident physician or from the urgent care. We need to focus on medical student, resident, and provider education as well as further opioid research in order to decrease unnecessary prescribing.

Business service companies generate revenue by delivering high-quality services to their clients. Such business services could be customer support, transaction processing, information technology, etc. Given the large service volume, meeting strict service level agreements while maintaining a reasonable profit margin can be challenging. Naturally, the worker crowd is trained by the enterprise using carefully designed standard operations and workflows aimed at maximizing its performance and thus the output. Service delivering workflows are never perfect, continuous effort must be invested into improving and optimizing the workflows. However, such effort is usually difficult to sustain. Despite considerable advances in the workflow optimization technologies, a business analyst may still spend countless hours studying the workflow in order to identify the opportunities for improvement. This issue motivated us to develop a novel crowd-based framework to utilize the worker crowd for workflow optimization. In this paper, we illustrate our approach to effectively leverage the internal worker crowd to improve the workflows for the enterprise. A modeling is provided to elaborate the different stages in the framework. And a reference implementation is detailed to demonstrate the practical use of the framework.

Although there has been rapid growth in global health educational experiences over the last two decades, the flow of learners remains overwhelmingly one directional; providers from high-resourced settings travel to limited-resourced environments to participate in clinical care, education, and/or research. Increasingly, there has been a call to promote parity in partnerships, including the development of bidirectional exchanges, where trainees from each institution travel to the partner's setting to learn from and teach each other. As global health educators and steering committee members of the Association of Pediatric Program Directors Global Health Pediatric Education Group, we endorse the belief that we must move away from merely sending learners to international partner sites and instead become true global health partners offering equitable educational experiences. In this article, we summarize the benefits, review common challenges, and highlight solutions to hosting and providing meaningful global health experiences for learners from limited-resourced partner institutions to academic health centers in the United States.

We present a man with clinically stable systemic myasthenia gravis (MG) which flared with a low dose of peripherally injected botulinum toxin type A (BTX-A). Botulinum toxin drugs generally have an excellent safety profile, however, they are contentious in patients with neuromuscular disorders. Despite this, there remain limited reports on the systemic effects of botulinum therapy in patients with MG. This man is one of less than 10 reported patients worldwide in whom MG was exacerbated by a peripheral BTX-A injection. This is an important reminder to Australian clinicians of the potential risks of this common place medication in patients with neuromuscular disorders, even those with stable disease.

This paper describes the results of a multi-year ethnographic study of how knowledge workers integrate new technology into their work practices. We studied mobile and remote workers who use smartphones, tablets, cloud computing, and social networking to support their work. Study findings describe the characteristics of mobile work, the coordination of multiple devices and sources of information, how new technology functioned as a social resource and issues that arose when participants used personal mobile devices to support work. We will also discuss how we are working with corporate teams to renew our research projects, and the solutions and services the company offers to support the changing nature of work.

Nesoryzomys swarthi, the most endangered of the three surviving, endemic Galapagos "rice rats," was only discovered in the early 20th Century and was considered extinct until its rediscovery in 1997 at a north-central coastal location on Isla Santiago. Potential threats to the entire genus include invasive rodent species, feral cats, new diseases, and climate change. These threats have been the basis for conservation breeding recommendations (as yet unmet) by several observers during the last several decades. This paper considers likely dietary requirements of N. swarthi in light of recent studies on the ecology of this species plus new data on the nutrient composition of Opuntia galapageia (a "resource refuge" for this species) and circulating vitamin values of animals sampled on Isla Santiago. It is concluded that, despite some unusually high mineral values for O. galapageia, a diet for N. swarthi under human care should be the same as it is for most other rodents, noting some caution in regard to possible needs for mineral and/or protein adjustment.

When developing a successor of an existing product, it is relatively easy to involve consumers in the early stages of the process – one could for example observe them using the current products, and discuss with them what could be improved. However, when creating products from ‘scratch’, consumers might find it difficult to articulate future needs, to appreciate the potential and limitations of new technologies, or think about possible applications. So, consumer “co-creation” in the early creative phase will require alternative approaches towards user requirements definition, concept development, and concept feedback. A range of different approaches to include the consumer perspective early in the development process will be presented. Furthermore, implications from a Human Factors perspective will be discussed.

Background: Interest in global health (GH) among residents has had an unprecedented surge of attention and growth. Long-term international electives are currently regarded as gold standard for residents to gain exposure to GH, enhance their medical knowledge, increase their exposure to multicultural populations, and consider cost-effect care in low-resource settings. However, for reasons including few funding options, in-house call requirements, and lack of formal GH tracks or faculty, few residents are able to travel abroad …