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Introduction:. The role of elective rotations in the orthopaedic residency selection process varies between programs. Our study aims to identify factors associated with residency programs that interview and match a greater proportion of applicants who have completed an elective rotation with their program. Methods:. Data were collected through the American Orthopaedic Association's Orthopaedic Residency Information Network database. Bivariate correlations and multivariate regression models were used to identify independent predictors of programs with a greater proportion of interviewees or residents who completed an elective rotation at the respective program. Results:. One hundred seventy-eight of the 218 existing residency programs were included in this study. Programs that offered fewer interviews and more away rotation positions per year were associated with a greater odds of its interviewees (OR = 0.36, p = 0.01; OR = 4.55, p < 0.001, respectively) and residents (OR = 0.44, p = 0.04; OR = 4.23, p < 0.001, respectively) having completed an elective rotation with the program. In addition, programs with fewer attendings (OR = 0.39, p = 0.03) and in-person interviews (OR = 3.04, p = 0.04) matched a greater proportion of their rotators. However, programs that interviewed applicants during the elective rotation were less likely to match their rotators (OR = 0.35, p = 0.04). Conclusion:. Certain program characteristics independently predict the likelihood of a program interviewing and matching their rotators. These findings may provide information for applicants and programs regarding the rotation process. Level of Evidence:. III.

Background: A shift toward performance, cost, outcomes, and patient satisfaction has occurred with healthcare reform promoting value-based programs. The purpose of this study was to evaluate the relationship between patient satisfaction and value with treatment in a cohort of patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods: Value was determined by the relationship of treatment outcome with episodic cost. Measurements included both clinical outcomes and patient-reported outcomes. Participating surgeons took part in the modified Delphi method resulting in an algorithm measuring patient value. Treatment outcome, cost, and resultant value (outcome/cost) of both TKA and THA were evaluated using binomial logistic regression by adjusting for age, gender, body mass index, Charlson comorbidity index, tobacco, education, and income with patient-reported satisfaction as the outcome. Results: This study had a total of 909 patients (TKA n = 438; THA n = 471), with an average age of 67 (TKA) and 65 (THA) years. Patient satisfaction shared a significant positive relationship with treatment outcome for TKA (odds ratio [OR] = 1.53, confidence interval [CI] = 1.35-1.73, P < .001) and THA (OR = 1.93, CI = 1.62-2.29, P < .001). Higher value was associated with a significantly higher odds of patient satisfaction for both TKA (OR = 1.39, CI = 1.25-1.54, P < .001) and THA (OR = 1.70, CI = 1.47-1.97, P < .001). Conclusions: This study showed a positive relationship between treatment outcome but not cost with subsequent value and patient satisfaction. This method provides a promising approach to comprehensively evaluate outcomes, cost, and value of total joint arthroplasty procedures. This approach can help predict the probability of value-driven patient satisfaction.

Category: Other Introduction/Purpose: Previous studies have reported conflicting data regarding 30-day readmission rates between patients of different races following orthopaedic surgery. Differences in specific reasons for 30-day readmission between races following orthopaedic surgery have yet to be explored. Methods: The ACS-NSQIP database was utilized to identify patients who underwent orthopaedic surgery and were readmitted within 30 days. Data was collected from 2015–2019, and patients were stratified into one of five race groups: American Indian/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, and White. Analysis of variance (ANOVA) with Bonferroni post-hoc analysis for multiple comparisons was used to compare differences in continuous variables between racial groups. Chi-square analysis with post-hoc analysis of adjusted standardized residuals was used to compare differences in categorical variables between racial groups. Results: In total, 975,857 patients from the ACS-NSQIP database were included in the study. All-cause readmission rate was significantly different across races. Asian and Native Hawaiian/Pacific Islander patients had significantly lower readmission rates (2.7% and 2.8%, respectively), whereas Black patients had significantly greater readmission rates (3.9%) (p < 0.01). Black patients had significantly greater readmission rates for deep incisional SSI, wound disruption, renal insufficiency, and pulmonary embolism, and a lower readmission rate for pneumonia compared to other races. Asian patients had a lower readmission rate for pulmonary embolism, wound disruption, superficial incisional SSI, and vein thrombosis requiring therapy. Conclusion: Specific causes of 30-day readmission were significantly different between races, with Black patients experiencing higher readmission rates and Asian and Hawaiian/Pacific Islander patients experiencing lower readmission rates overall. Our findings can inform which complications should be more carefully monitored in certain patient populations, and how peri- and post-operative management can be adjusted accordingly.

Background:. Greater faculty diversity within orthopaedic residency programs has been associated with an increased application rate from students of similarly diverse demographic backgrounds. It is unknown whether these underrepresented student populations have an equitable likelihood of being highly ranked and matching at these programs. Thus, we sought to evaluate the relationship between faculty and resident diversity, with a specific focus on sex, racial/ethnic groups that are underrepresented in medicine (URiM), and international medical graduates (IMGs). Methods:. The American Orthopaedic Association's Orthopaedic Residency Information Network database was used to collect demographic data on 172 US residency programs. Linear regression analyses were performed to determine the relationship between the proportion of female or URiM attendings at a program and the proportion of female, URiM, or IMG residents or top-ranked applicants (≥25 rank). URiM was defined as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” Results:. A mean of 13.55% of attendings were female and 14.14% were URiM. A larger fraction of female attendings was a positive predictor of female residents (p < 0.001). Similarly, a larger percentage of URiM attendings was a positive predictor of URiM residents (p < 0.001), as well as of URiM (p < 0.001) and IMG (p < 0.01) students being ranked highly. There was no significant association between URiM attendings and female residents/overall top-ranked applicants, or vice versa. Conclusions:. Residency programs with more female attendings were more likely to match female residents, and programs with more URiM attendings were more likely to highly rank URiM and IMG applicants as well as match URiM residents. Our findings indicate that orthopaedic surgery residencies may be more likely to rank and match female or URiM students at similar proportions to that of their faculty. This may reflect minority students preferentially applying to programs with more diverse faculty because they feel a better sense of fit and are likely to benefit from a stronger support system. Level of Evidence:. III.

Background:. Using the hand questionnaire (HAND-Q) patient-reported outcome measure, the effects of upper extremity surgery on patients’ perception of their sex life were explored. The hand is a uniquely sexual organ, and we hypothesized that self-reported measures of disease severity, quality of life, and emotional impact would correlate with sexual dissatisfaction among patients receiving treatment for hand/upper extremity conditions. Methods:. Patients were prospectively enrolled for hand questionnaire participation. Patients with valid responses to the following questions were included: functionality, hand appearance satisfaction, symptom severity, emotional dissatisfaction, sexual dissatisfaction, and treatment satisfaction. Composite scores were created and scored. Sexual dissatisfaction composite scores were compared through Spearman correlation coefficient analysis to quality of life, emotional dissatisfaction, hand appearance, symptom severity, and hand functionality. Results:. High levels of diminished quality of life correlated with sexual dissatisfaction (rs = 0.748, P < 0.001). Increased emotional dissatisfaction correlated with sexual dissatisfaction (rs = 0.827, P < 0.001). Increased satisfaction with hand appearance negatively correlated with sexual dissatisfaction (rs = –0.648, P = 0.001). Increased levels of dissatisfaction with hand functionality correlated with sexual dissatisfaction (rs = 0.526, P = 0.005). Conclusions:. The correlation between sex life and quality of life may allow surgeons to improve patient satisfaction when treating hand/upper extremity issues. The relationship between sex life and emotional dissatisfaction emphasizes the impact that sexual dissatisfaction has on patients’ lives. Evaluating the relationship between hand appearance and sexual dissatisfaction may indicate that patient self-perception of hand attractiveness plays a role in sex life.

Background: The direct anterior approach (DAA) for total hip arthroplasty (THA) has gained recent popularity, with 1 purported benefit being access to intraoperative fluoroscopy. However, there are limited data demonstrating improved component position with the use of intraoperative fluoroscopy. The aim of this study is to compare radiographic implant positioning on 2 consecutive cohorts of patients undergoing DAA THA performed by 1 surgeon either utilizing intraoperative fluoroscopy or not. We hypothesized that there would be no relevant radiographic differences between the cohorts. Methods: Forty-two consecutive patients underwent DAA THA utilizing fluoroscopy (IFC), and 42 consecutive patients then underwent DAA THA without fluoroscopy (NFC). Using preoperative pelvis radiographs and 6-week postoperative pelvis radiographs, acetabular anteversion, inclination, femoral offset, and templated component sizes vs final intraoperatively selected sizes were recorded and compared between cohorts. Results: Acetabular inclination was 45.0° for IFC and 45.6° for NFC (P = .629). Femoral offset difference preoperatively and postoperatively was 0.8 mm for IFC and 1.3 mm for NFC (P = .734). Number of hips within the so-called safe zone was 32 for IFC and 33 for NFC (P = .794). These all demonstrated no significant difference between the cohorts. However, acetabular anteversion was 13.7° for IFC and 11.2° for NFC (P = .02). Conclusions: In this limited series, the routine use of intraoperative fluoroscopy did not improve implant positioning or sizing. This may be surgeon-specific or due to the result of the use of acetabular landmarks to guide placement of the components without fluoroscopy. Keywords: Direct anterior approach, Total hip replacement, Fluoroscopy, Component positioning, Component safe zone

The following surgical technique describes a case of a 51-year-old man with severe juvenile rheumatoid arthritis that required a 2-stage revision of an infected revision total knee implant. The patient had previously been implanted with a revision rotating platform, constrained condylar device which gained excellent fixation through the use of diaphyseal-engaging stems, and a well-ingrown, fully porous-coated femoral metaphyseal sleeve. To avoid intraoperative complications while removing the femoral sleeve, a novel technique for femoral sleeve extraction was used. Using this technique, the femoral sleeve was successfully removed without intraoperative fracture or substantial bone loss.

We describe a unique, utilitarian reconstructive treatment option known as tibial “spackling” for chronic, localized medial joint line pain corresponding with progressive radiographic peripheral medial tibial bone loss beneath a well-fixed revision total knee arthroplasty tibial baseplate. It is believed that this localized pain is due to chronic irritation of the medial capsule and collateral ligament from the prominent medial edge of the tibial component. In the setting of failed nonoperative treatment, our experience with utilizing bone cement to reconstruct the medial tibial bone defect and create a smooth medial tibial surface has been successful in eliminating chronic medial soft tissue irritation.

Background: T wave oversensing (TWOS) is a major drawback of the subcutaneous implantable cardioverter defibrillator (S-ICD). Data on predictors of TWOS in S-ICD recipients are limited. We sought to investigate predictors of TWOS in a cohort of patients receiving an S-ICD at our institution. Methods: S-ICD recipients at our center were identified retrospectively and stratified based on the presence or absence of TWOS. Clinical and electrocardiographic parameters were collected and compared between the 2 groups. Results: Ninety-two patients underwent an S-ICD implantation at our institution between April 2010 and January 2015. Six (6.5%) patients had TWOS. These patients were younger (38.1±13.7 vs. 52.3±16.1 years, p=0.04) and had higher left ventricle ejection fractions (48.5±14.9% vs. 28.4±12.2%, p

A 44-year-old female presented with a chief complaint of left knee pain and dysfunction. The patient had a complex surgical history including patellar fracture repair, subsequent patellar ligament repair, and ultimately allograft reconstruction which was complicated by septic arthritis requiring graft resection. On presentation to our clinic, she was noted to have significant degenerative disease in addition to chronic extensor mechanism deficiency. She underwent primary total knee arthroplasty with concomitant tibial tubercle osteotomy and advancement. The patient has had an excellent result postoperatively including return of full range of motion without residual extensor lag.

Objective: To present tactics for optimizing outpatient vaginal hysterectomy and describe perioperative outcomes in a large consecutive case series.Methods: This is a descriptive study and review of clinical outcomes in 1,071 patients selected to undergo vaginal hysterectomy for benign indications from 2000 to 2010. The setting is a single-surgeon private practice in a community hospital. Outcome measures include length of hospital stay, estimated blood loss, operative time, uterine weight, and perioperative complications, including hospital readmissions and emergency room visits.Results: One thousand seventy-one of 1,162 cases (92%, 95% confidence interval [CI] 90.5-93.7) were total vaginal hysterectomies, of which 1,029 (96%, 95% CI 94.9-97.3) were discharged the same day after surgery. The median operative time was 34 minutes (range 17-210 minutes), and estimated blood loss was 45 mL (range 5-800 mL). The median patient age was 46 years (range 27-86 years), and median uterine weight was 160 g (range 25-1,380 g). One hundred ninety-three patients (18%, 95% CI 15.8-20.5) were nulliparous and 218 (20%, 95% CI 18-22.9) had prior pelvic surgery. Five patients (0.5%, 95% CI 0.2-1.1) required readmission or emergency room evaluation within the first 30 days.Conclusion: Vaginal hysterectomy can be successfully adopted as a same-day discharge procedure. In this population, regardless of previous pelvic surgery or nulliparity, good perioperative outcomes have been achieved. [ABSTRACT FROM AUTHOR]

Armed combat (also termed war or armed conflict) has profound direct and indirect impacts on the long-term physical and mental health of both military personnel and noncombatant civilians. Although most research has focused on immediate and short-term health consequences of war, an increasing number of studies have focused on the long-term health consequences for both veterans of military service and noncombatant civilians. However, these long-term studies focus almost entirely on posttraumatic stress disorder and other mental health problems; relatively few long-term studies have focused on physical injuries due to war and the impact of those injuries on relationships, work, and other aspects of life. This article reviews illustrative examples of the existing literature on these long-term health consequences of war, focusing not only on military veterans of several different armed conflicts but also on noncombatant civilian populations, including spouses and children of military veterans as well as refugees and internally displaced persons. Public health professionals can help address these problems. [ABSTRACT FROM AUTHOR]

Child prostitution is a significant global problem that has yet to receive appropriate medical and public health attention. Worldwide, an estimated 1 million children are forced into prostitution every year and the total number of prostituted children could be as high as 10 million. Inadequate data exist on the health problems faced by prostituted children, who are at high risk of infectious disease, pregnancy, mental illness, substance abuse, and violence. Child prostitution, like other forms of child sexual abuse, is not only a cause of death and high morbidity in millions of children, but also a gross violation of their rights and dignity. In this article we estimate morbidity and mortality among prostituted children, and propose research strategies and interventions to mitigate such health consequences. Our estimates underscore the need for health professionals to collaborate with individuals and organisations that provide direct services to prostituted children. Health professionals can help efforts to prevent child prostitution through identifying contributing factors, recording the magnitude and health effects of the problem, and assisting children who have escaped prostitution. They can also help governments, UN agencies, and non-governmental organisations (NGOs) to implement policies, laws, and programmes to prevent child prostitution and mitigate its effects on children's health. [ABSTRACT FROM AUTHOR]

University students frequently resort to psychostimulants to enhance their physical and mental performance and manage academic pressures. However, these substances can lead to dependence and other undesired symptoms, and little empirical data are available for relevant stakeholders, raising significant concerns in health care. Therefore, this study aims to characterize neurostimulant use among university students in Rio Grande do Sul, Brazil. We collected from 880 students' data using anonymous self-administration. The questionnaire included consumption patterns of caffeine, nicotine, ecstasy, methamphetamine, "merla" (coca base), methylphenidate, cocaine, crack, and ketamine. Additionally, participants shared information on demographic and socioeconomic factors. Use of at least one neurostimulant was reported by89.2% of the participants. Among nonusers, the most frequently cited reason was "previous information about harmful effects of these drugs." Caffeine, followed by nicotine, ecstasy, and methylphenidate were the most consumed substances, with main reasons being "improving academic performance" and "recreation." Women more often consumed caffeine (72.7%), while other psychostimulants were more consumed by men (42.2%) and individuals of other genders (0.5%). Students who consumed other substances had higher family incomes than that of families of caffeine users. In addition, 60.4% of caffeine users resided with family members, whereas 63.3% of users of other substances did not. Our findings can offer essential data on the reasons and symptoms associated with the use of neurostimulants among university students. This information could aid in raising awareness among students, universities, and health-care agencies about this often-neglected subject.

Background: Russia's invasion of Ukraine in February 2022 ignited the largest armed conflict in Europe since World War II. Ukrainian government agencies, civil society organizations, and international agencies have gathered an unprecedented amount of data about the impact of war on the environment, which is often the silent victim of war. We review these data and highlight the limitations of international governance for protection of the environment during time of war., Methods: We performed an integrative review of academic, institutional, and media information resources using the search terms "Ukraine", "Russia", "war", "environment", "health", "human rights", "international humanitarian law", "international human rights law", "ecocide", and "war crimes"., Main Text: Nearly 500,000 military personnel have been killed or wounded during the war, and more than 30,000 civilians have been killed or injured. Indirect health effects of the war have likely accounted for an even greater amount of civilian morbidity and mortality. The war has displaced more than 11 million people. Russia's military forces have caused extensive damage to civilian infrastructure. The war has devastated Ukraine's economy and reduced food and energy security in many countries. The war has caused more than $56.4 billion in damage to the environment. There has been widespread chemical contamination of air, water, and soil, and 30% of Ukraine has been contaminated with landmines and unexploded ordnance. Landscape destruction, shelling, wildfires, deforestation, and pollution have adversely affected 30% of Ukraine's protected areas. Russia's seizure of the Zaporizhzhia Nuclear Power Plant and destruction of the Nova Kakhovka Dam have posed risks of long-term environmental catastrophe. Most of these environmental impacts threaten human health., Conclusion: In addition to enormous human costs, Russia's war on Ukraine has had devastating impacts on the natural environment and the built environment. International law mandates that methods of warfare must be implemented with due regard to the protection and preservation of the natural environment. A just and lasting peace necessitates, among other requirements, rebuilding and restoration of Ukraine's natural environment and built environment. The environmental consequences of all wars need to be investigated and more effective measures need to be implemented to protect the environment during war., (© 2023. The Author(s).)

For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these 2 clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact quality of life-heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, and their often-insidious nature frequently leads to normalization. The effects on cognitive function and the related work and school absenteeism and presenteeism can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere., (Copyright © 2023 Elsevier Inc. All rights reserved.)

In policy and law, regulation of abortion is frequently treated differently from other health services. The safety of abortion is similar to that of other types of office- and clinic-based procedures, and facility requirements should be based on assuring high-quality, safe performance of all such procedures. False concerns for patient safety are being used as a justification for promoting regulations that specifically target abortion. The Project on Facility Guidelines for the Safe Performance of Primary Care and Gynecology Procedures in Offices and Clinics was undertaken by clinicians, consumers, and representatives from accrediting bodies to review the available evidence and guidelines that inform safe delivery of outpatient care. Our overall objective was to develop evidence-informed consensus guidelines to promote health care quality, safety, and accessibility. Our consensus determined that requiring facilities performing office-based procedures, including abortion, to meet standards beyond those currently in effect for all general medical offices and clinics is unjustified based on an analysis of available evidence. No safety concerns were identified.

Advancing the quality and safety of maternity care should be data-driven. Defining a standard set of clinical data elements, across electronic health record platforms and facilities, could accelerate performance measurement, benchmarking, and identification of better practices. In 2014, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists launched the Maternal Quality Improvement Program, a data-driven national clinical registry for maternity care. Having an agreed-on set of discrete data elements related to labor and delivery will set the stage for analysis of this care. Through the use of clinical performance measures and data quality metrics, the Maternal Quality Improvement Program will provide an opportunity for health care providers to better understand the overall quality and safety of the maternity care provided within their institution.

Climate change is causing increases in temperature, changes in precipitation and extreme weather events, sea-level rise, and other environmental impacts. It is also causing or contributing to heat-related disorders, respiratory and allergic disorders, infectious diseases, malnutrition due to food insecurity, and mental health disorders. In addition, increasing evidence indicates that climate change is causally associated with collective violence, generally in combination with other causal factors. Increased temperatures and extremes of precipitation with their associated consequences, including resultant scarcity of cropland and other key environmental resources, are major pathways by which climate change leads to collective violence. Public health professionals can help prevent collective violence due to climate change (a) by supporting mitigation measures to reduce greenhouse gas emissions, (b) by promoting adaptation measures to address the consequences of climate change and to improve community resilience, and, ((c) by addressing underlying risk factors for collective violence, such as poverty and socioeconomic disparities.)

Surgical site infections are the most common complication of surgery in the United states. Of surgeries in women of reproductive age, hysterectomy is one of the most frequently performed, second only to cesarean birth. Therefore, prevention of surgical site infections in women undergoing gynecologic surgery is an ideal topic for a patient safety bundle. The primary purpose of this safety bundle is to provide recommendations that can be implemented into any surgical environment in an effot to reduce the incidence of surgical site infection. This bundle was developed by a multidisciplinary team convened by the Council on Patient Safety in Women's Health Care. The bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. In addition to recommendations for practice, each of the domains stresses communication and teamwork between all members of the surgical team. Although the bundle components are designed to be adaptable to work in a variety of clinical settings, standardization within institutions is encouraged., (Copyright ©2016 American College of Obstetricians and Gynecologists.)

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

War and other forms of armed conflict have profound adverse effects on population health. It is important to document these effects to inform the general public and policy makers about the consequences of armed conflict, provide services to meet the needs of affected populations, protect human rights and document violations of international humanitarian law, and help to prevent future armed conflict. Documentation can be accomplished with surveillance, epidemiological surveys, and rapid assessment. Challenges include inadequate or absent data systems, social breakdown, forced migration, reporting biases, and the fog of war. The adverse effects of the Iraq War on population health demonstrate how the effects of armed conflict on population health can be documented. We recommend the establishment of an independent mechanism, operated by the United Nations or a multilateral organization, to investigate and document the effects of armed conflict on population health.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Healthcare costs in the United States are over 17% of GDP and climbing. Yet compared with other countries in the developed world, the US healthcare system has the worst record for quality of care in relation to cost. This poor performance and lack of improvement in cost versus quality has led to the development of the Triple Aim framework spearheaded by the Institute for Healthcare Improvement. The focus of the Triple Aim is to improve value of care by improving access to care, systems of care delivery, and quality of care while reducing the overall expenditure.

The environmental and health consequences of climate change, which disproportionately affect low-income countries and poor people in high-income countries, profoundly affect human rights and social justice. Environmental consequences include increased temperature, excess precipitation in some areas and droughts in others, extreme weather events, and increased sea level. These consequences adversely affect agricultural production, access to safe water, and worker productivity, and, by inundating land or making land uninhabitable and uncultivatable, will force many people to become environmental refugees. Adverse health effects caused by climate change include heat-related disorders, vector-borne diseases, foodborne and waterborne diseases, respiratory and allergic disorders, malnutrition, collective violence, and mental health problems. These environmental and health consequences threaten civil and political rights and economic, social, and cultural rights, including rights to life, access to safe food and water, health, security, shelter, and culture. On a national or local level, those people who are most vulnerable to the adverse environmental and health consequences of climate change include poor people, members of minority groups, women, children, older people, people with chronic diseases and disabilities, those residing in areas with a high prevalence of climate-related diseases, and workers exposed to extreme heat or increased weather variability. On a global level, there is much inequity, with low-income countries, which produce the least greenhouse gases (GHGs), being more adversely affected by climate change than high-income countries, which produce substantially higher amounts of GHGs yet are less immediately affected. In addition, low-income countries have far less capability to adapt to climate change than high-income countries. Adaptation and mitigation measures to address climate change needed to protect human society must also be planned to protect human rights, promote social justice, and avoid creating new problems or exacerbating existing problems for vulnerable populations., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

The 40th anniversary of the end of the Vietnam War is a useful time to review the adverse health consequences of that war and to identify and address serious problems related to armed conflict, such as the protection of noncombatant civilians. More than 58,000 U.S. servicemembers died during the war and more than 150,000 were wounded. Many suffered from posttraumatic stress disorders and other mental disorders and from the long-term consequences of physical injuries. However, morbidity and mortality, although difficult to determine precisely, was substantially higher among the Vietnamese people, with at least two million of them dying during the course of the war. In addition, more than one million Vietnamese were forced to migrate during the war and its aftermath, including many "boat people" who died at sea during attempts to flee. Wars continue to kill and injure large numbers of noncombatant civilians and continue to damage the health-supporting infrastructure of society, expose civilians to toxic chemicals, forcibly displace many people, and divert resources away from services to benefit noncombatant civilians. Health professionals can play important roles in promoting the protection of noncombatant civilians during war and helping to prevent war and create a culture of peace.

The weight of scientific evidence indicates that climate change is causally associated with collective violence. This evidence arises from individual studies over wide ranges of time and geographic location, and from two extensive meta-analyses. Complex pathways that underlie this association are not fully understood; however, increased ambient temperatures and extremes of rainfall, with their resultant adverse impacts on the environment and risk factors for violence, appear to play key roles. Collective violence due to climate change poses serious threats to health and human rights, including by causing morbidity and mortality directly and also indirectly by damage to the health-supporting infrastructure of society, forcing people to migrate from their homes and communities, damaging the environment, and diverting human and financial resources. This paper also briefly addresses issues for future research on the relationship between climate change and collective violence, the prevention of collective violence due to climate change, and States' obligations to protect human rights, to prevent collective violence, and to promote and support measures to mitigate and adapt to climate change., (Copyright © 2014 Levy and Sidel. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death and severe morbidity: obstetric hemorrhage, severe hypertension in pregnancy, and peripartum venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified: a structured approach for the recognition of early warning signs and symptoms, structured internal case reviews to identify systems improvement opportunities, and support tools for patients, families, and staff that experience an adverse outcome. This article details the formation of the National Partnership for Maternal Safety and introduces the initial priorities.

The adverse health consequences of the Iraq War (2003-11) were profound. We conclude that at least 116,903 Iraqi non-combatants and more than 4800 coalition military personnel died over the 8-year course. Many Iraqi civilians were injured or became ill because of damage to the health-supporting infrastructure of the country, and about 5 million were displaced. More than 31,000 US military personnel were injured and a substantial percentage of those deployed suffered post-traumatic stress disorder, traumatic brain injury, and other neuropsychological disorders and their concomitant psychosocial problems. Many family members of military personnel had psychological problems. Further review of the adverse health consequences of this war could help to minimise the adverse health consequences of, and help to prevent, future wars., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Because medical students and residents receive inadequate education and training in public health and preventive medicine, they will miss many opportunities, as they practice medicine, to improve the health of individual patients and populations. Although there is an ongoing need to expand the number and improve the specialist training of public health and preventive medicine residents, all medical students and residents should enter practice with substantive knowledge and practical skills in public health and preventive medicine. This knowledge and these skills will make them more effective in such areas as enabling patients to make lifestyle changes, identifying and reducing occupational and environmental risk factors, and empowering patients to manage their chronic health conditions. The authors propose a paradigm shift to establish public health and preventive medicine as the context for medical education and medical care.

In response to the attacks on Sept 11, 2001 (9/11), and the related security concerns, the USA and its coalition partners began a war in Afghanistan and subsequently invaded Iraq. The wars caused many deaths of non-combatant civilians, further damaged the health-supporting infrastructure and the environment (already adversely affected by previous wars), forced many people to migrate, led to violations of human rights, and diverted resources away from important health needs. After 9/11 and the anthrax outbreak shortly afterwards, the USA and other countries have improved emergency preparedness and response capabilities, but these actions have often diverted attention and resources from more urgent health issues. The documentation and dissemination of information about the adverse health effects of these wars and about the diversion of resources could help to mitigate these consequences and prevent their recurrence., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Competition for resources between or within nations is likely to become an increasingly common cause of armed conflict. Competition for petroleum is especially likely to trigger armed conflict because petroleum is a highly valuable resource whose supply is destined to contract. Wars fought over petroleum and other resources can create public health concerns by causing morbidity and mortality, damaging societal infrastructure, diverting resources, uprooting people, and violating human rights. Public health workers and the organizations with which they are affiliated can help prevent resource wars and minimize their consequences by (1) promoting renewable energy and conservation, (2) documenting the impact of past and potential future resource wars, (3) protecting the human rights of affected noncombatant civilian populations during armed conflict, and (4) developing and advocating for policies that promote peaceful dispute resolution.