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The number of pregnant women with opioid use disorder (OUD) has quadrupled from 1999 to 2014. Current first line treatment for OUD in pregnancy is methadone with increasing support for buprenorphine. Limited data exist on use of buprenorphine/naloxone for OUD in pregnancy despite it being standard therapy in the non-pregnant individuals. The aim of this study was to compare neonatal opioid withdrawal syndrome (NOWS) prevalence and characteristics among neonates born to women prescribed methadone and buprenorphine/naloxone.This is a retrospective cohort analysis of mother-neonate dyads treated with either methadone or buprenorphine/naloxone for OUD in pregnancy who received prenatal care in the substance abuse, treatment, education, and prevention program (STEPP) clinic and delivered at OSU. Primary neonatal outcomes included: neonates diagnosed and treated for NOWS, peak scores on Modified Finnegan Neonatal Abstinence Score (FNAS), number of scores ≥9 on FNAS, and duration of treatment for NOWS. Secondary outcomes included: fetal growth restriction, preterm birth (37 weeks), neonatal head circumference, birth weight, NICU admission, five-minute Apgar score, and length of hospitalization.From 2013 to 2017, we identified 588 mother-neonate dyads: 149 treated with methadone and 439 treated with buprenorphine/naloxone. Ninety-eight neonates (65.8%) in the methadone group were diagnosed with NOWS requiring pharmacological interventions compared with 170 (38.7%) in the buprenorphine/naloxone group (aOR 3.46, 95% confidence interval (CI) 2.31-5.20,Buprenorphine/naloxone treatment for OUD in pregnancy appears safe and has decreased NOWS and pharmacologic intervention for the neonate.

Background Weather can have both delayed and immediate impacts on animal populations, and species have evolved behavioral adaptions to respond to weather conditions. Weather has long been hypothesized to affect the timing and intensity of avian migration, and radar studies have demonstrated strong correlations between weather and broad-scale migration patterns. How weather affects individual decisions about the initiation of migratory flights, particularly at the beginning of migration, remains uncertain. Methods Here, we combine automated radio telemetry data from four species of songbirds collected at five breeding and wintering sites in North America with hourly weather data from a global weather model. We use these data to determine how wind profit, atmospheric pressure, precipitation, and cloud cover affect probability of departure from breeding and wintering sites. Results We found that the probability of departure was related to changes in atmospheric pressure, almost completely regardless of species, season, or location. Individuals were more likely to depart on nights when atmospheric pressure had been rising over the past 24 h, which is predictive of fair weather over the next several days. By contrast, wind profit, precipitation, and cloud cover were each only informative predictors of departure probability in a single species. Conclusions Our results suggest that individual birds actively use weather information to inform decision-making regarding the initiation of departure from the breeding and wintering grounds. We propose that birds likely choose which date to depart on migration in a hierarchical fashion with weather not influencing decision-making until after the departure window has already been narrowed down by other ultimate and proximate factors.

Background Each spring and fall billions of songbirds depart on nocturnal migrations across the globe. Theory suggests that songbirds should depart on migration shortly after sunset to maximize their potential for nightly flight duration or to time departure with the emergence of celestial cues needed for orientation and navigation. Although captive studies have found that songbirds depart during a narrow window of time after sunset, observational studies have found that wild birds depart later and more asynchronously relative to sunset than predicted. Methods We used coded radio tags and automated radio-telemetry to estimate the time that nearly 400 individuals from nine songbird species departed their breeding or wintering grounds across North America. We also assessed whether each species was most likely beginning long-distance migratory flights at departure or instead first making non-migratory regional flights. We then explored variation in nocturnal departure time by post-departure movement type, species, age, sex, and season. Results We found that 90% of individuals from species that were likely initiating long-distance migratory flights departed within 69 min of civil dusk, regardless of species, season, age, or sex. By contrast, species that likely first made non-migratory regional movements away from the migratory destination departed later and more asynchronously throughout the night. Regardless of post-departure movement type, 98% of individuals departed after civil dusk but otherwise showed no preference in relation to twilight phase. Conclusions Although the presence of celestial orientation cues at civil dusk may set a starting point for departure each night, the fact that species likely beginning long-distance migration departed earlier and more synchronously relative to civil dusk than those first making non-migratory regional movements is consistent with the hypothesis that departing promptly after civil dusk functions to maximize the potential for nightly flight duration and distance. By studying the onset of migration, our study provides baseline information about departure decisions that may enhance our understanding of departure timing throughout migration.

To evaluate demographic characteristics, care encounters, comorbidities, and clinical differences in Hmong and non-Hmong patients with gout.Using retrospective chart review, all inpatient encounters (Hmong versus non-Hmong) were reviewed from 2014 to 2017. Acute or chronic gout was the primary or secondary diagnosis for the encounter.Hmong gout patients were on average 11 years younger than non-Hmong patients, but after adjustment for age, sex, and type of encounter, they had similar rates of hypertension, diabetes mellitus, and heart disease. Hmong patients had significantly decreased renal function at the time of presentation; the odds ratio of chronic kidney disease for Hmong patients was 2.33 versus 1.48 for non-Hmong patients (P 0.05), the mean creatinine level was 3.3 mg/dl versus 2.0 mg/dl (β = 1.35, P 0.001), and the glomerular filtration rate was 44.8 ml/minute versus 49.3 ml/minute (β = -6.95, P 0.001). Hmong gout patients were more likely to use emergency care versus elective or urgent care, they were less likely to be using medications for the treatment of gout prior to admission (32.3% versus 58.2%), and the length of hospital stay was increased (8.8 versus 5.2 days; P 0.05).Hmong gout patients who had a tertiary care encounter were 11 years younger than non-Hmong patients with similar rates of comorbidities but had worse renal function despite the age differences. They were more likely to use emergency services, to be insured through Medicaid, and not to use preventive medications for gout prior to their encounter. Intensive efforts are needed in the Hmong population for culturally appropriate preventive care management of gout along with diabetes mellitus, hypertension, heart disease, and kidney disease.

BACKGROUND CONTEXT Excessive use of postoperative imaging after lumbar surgery has been documented, becoming a target for cutting costs. This must be balanced with the patient's need for information and allay their postoperative concerns. PURPOSE To determine the incidence and associated costs of patient interactions with the healthcare system, outside the standard follow up routine, in the first postoperative year. STUDY DESIGN Retrospective longitudinal cohort. PATIENT SAMPLE Consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 from a multi-surgeon single tertiary spine center. OUTCOME MEASURES All healthcare encounters: phone calls, office and emergency department visits, and additional testing METHODS A consecutive series of 200 patients who underwent lumbar fusions from 2018 to 2019 were identified. All non-routine healthcare encounters: phone calls, office and emergency department visits, and additional testing were collected. Direct costs for all healthcare services were determined using the Medicare Allowable rates. Indirect costs were determined using local, median income, length of office visits, and distance from the clinic to the patient's home. RESULTS Of 200 patients, 14 with thoracic fusion were excluded. The mean age of the 186 included patients was 58.26 years and 85 (46%) were male. Forty-seven percent (87/186) had only routine postoperative visits and 24 had revision surgery. Seventy-five patients made a total of 102 phone calls, 55 office visits, leading to 38 diagnostic studies none of which led to an additional intervention. Using Medicare Allowable rates, the mean direct cost was $776 per patient and the using a median income of $16/h the mean indirect cost was $124 per patient. There were no differences in the baseline characteristics among the patients who only had routine post-op encounters, had non-routine encounters or had a repeat surgery. CONCLUSIONS Forty percent of the patients undergoing lumbar surgery had a healthcare encounter outside their routine follow up that did not result in additional intervention after their index operation. These potentially unnecessary encounters create additional cost and inconvenience to both the patient and healthcare system. Providing patient reassurance is important and providers should identify ways to reduce associated costs through patient education, virtual visits, or new technologies to monitor patient's postoperative progress.

Seasonal migrations are used by diverse animal taxa, yet the costs and benefits of migrating have rarely been empirically examined. The aim of this study was to determine how migration influences two ecological currencies, energy expenditure and time allocated towards different behaviors, in a full annual cycle context. We compare these currencies among lesser black-backed gulls that range from short- ( 4500 km) migrants. Daily time-activity budgets were reconstructed from tri-axial acceleration and GPS, which, in conjunction with a bioenergetics model to estimate thermoregulatory costs, enabled us to estimate daily energy expenditure throughout the year. We found that migration strategy had no effect on annual energy expenditure, however, energy expenditure through time deviated more from the annual average as migration distance increased. Patterns in time-activity budgets were similar across strategies, suggesting migration strategy does not limit behavioral adjustments required for other annual cycle stages (breeding, molt, wintering). Variation among individuals using the same strategy was high, suggesting that daily behavioral decisions (e.g. foraging strategy) contribute more towards energy expenditure than an individual’s migration strategy. These findings provide unprecedented new understanding regarding the relative importance of fine versus broad-scale behavioral strategies towards annual energy expenditures.

Migrating animals show remarkable diversity in migration strategies, even between individuals from the same population. Migrating longer distances is usually expected to be costlier in terms of time, energy expenditure and risks with potential repercussions for subsequent stages within the annual cycle. Such costs are expected to be balanced by increased survival, for example due to higher quality wintering areas or lower energy expenditure at lower latitudes. We compared reproductive parameters and apparent survival of lesser black-backed gulls ( Larus fuscus ) breeding in The Netherlands, whose winter range extends from the UK to West Africa, resulting in one-way migration distances that differ by more than 4500 km. Individuals migrating furthest arrived later in the colony than shorter distance migrants, but still laid in synchrony with the colony and consequently had a shorter pre-laying period. This shorter pre-laying period affected neither egg volumes nor hatching success. We found no relationship between migration distance and apparent survival probability, corresponding with previous research showing that annual energy expenditure and distance travelled throughout the year is similar across migration strategies. Combined, our results indicate an equal fitness payoff across migration strategies, suggesting there is no strong selective pressure acting on migration strategy within this population.

Determining winter resighting range; median laying dates of lesser black-backed gulls in our study colony; accounting for nests of which the wintering location of two partners were known; mark-recapture survival analysis excluding GPS-tagged birds

STUDY DESIGN Retrospective single center propensity-matched observational cohort study that included patients who underwent 1- to 3-level lumbar fusion surgery for degenerative conditions. OBJECTIVE To compare 90-day complication rates between robotic-assisted and non-robotic-assisted lumbar spinal fusions in propensity-matched cohorts. SUMMARY OF BACKGROUND DATA A recent administrative database (PearlDiver) study reported increased 30-day complications with the utilization of robotic-assisted enabling technology. METHODS Of 146 robotic-assisted cases that met inclusion criteria, 114 were successfully propensity matched to 114 patients from 214 cases who had 1 to 3 level lumbar fusion without robotic assistance based on age, sex, body mass index, smoking status, American Society of Anesthesiologist grade, number of surgical levels, primary versus revision, and surgical approach (posterior-only or anterior-posterior). We excluded tumor, trauma, infection, or deformity cases. Outcomes included surgical and medical (major/minor) complications at intraoperative, immediately postoperative, 30- and 90-day postoperative intervals, including reoperations, and readmissions within 90 days. RESULTS All cause intraoperative complication rates were similar between non-robotic-assisted (5.3%) and robotic-assisted groups (10.5%, P = 0.366). Immediate postoperative medical complication rate was also similar between non-robotic-assisted (6.1%) and robotic-assisted groups (1.8%, P = 0.089). Thirty-day complication rates, 90-day complication rates, reoperation rates, and readmission rates showed no difference between non-robotic-assisted and robotic-assisted groups. There was no difference between return to OR for infection between the cohorts (non-robotic-assisted: 6 [5%] vs. robotic-assisted: 1 [0.8%], P = 0.119). There was however improved length of stay (LOS) in the robotic-assisted group compared with non-robotic-assisted group (2.5 vs. 3.17 days, P = 0.018). CONCLUSION In propensity-matched cohorts, patients undergoing 1- to 3-level robotic-assisted posterior lumbar fusion for degenerative conditions did not have increased 90-day complication rate, and had a shorter length of stay compared with non-robotic-assisted patients. There findings differ from a prior administrative database study as the robotic-assisted group in the current study had 0% return to OR for malpositioned screws and 0.8% return to OR for infection.Level of Evidence: 2.

Rates and drivers of natural forest regeneration are areas of uncertainty for policy, forest management and climate change mitigation. In this study, the rate of deforestation and the rate and drivers of natural regeneration are described for 56 million hectares of village land in Tanzania, a country undergoing rapid deforestation. To determine the regeneration and deforestation rates, remote sensing (RS) data for 500 randomly selected points were reviewed for a 34 year period from 1987 to 2021 using Google Earth Engine. Over this period, regeneration, involving a transition from forest to non-forest and back to forest was detected on 4.8% of village land (95% CI: 3.1%–7.1%), while 0.8% of land transitioned from non-forest to forest (95% CI: 0.2%–2.04%). 22% of village land was deforested (95% CI: 18.6%–26.1%), equivalent to a mean annual net loss of 0.35 million hectares of forest. Using a combination of RS data, field plots and structured interviews, the land cover change trajectories of 180 regenerating plots, in 10 sampling clusters, were assessed to identify regeneration drivers and assess biomass and tree species accumulation rates. Agricultural fallows are the regeneration driver in 47% of plots (95% CI: 39.8%–54.8%). Other common regeneration drivers include abandonment of cultivated areas for reasons apart from fallowing, conservation and post wood-extraction abandonment in 19% (95% CI: 13.9%–26%), 18.3% (95% CI: 13%–24.8%) and 12.8% (95% CI: 8.3%–18.6%) of plots, respectively. The mean carbon sequestration rate was 1.4 Mg C ha−1 y−1, equivalent to 4.3 Tg C y−1 (95% CI: 3.9–4.7 Tg C y−1) across the 3.15 million hectares of regenerating village land forest. The mean species accumulation rate was 1.08 species y−1 (95% CI: 1.0–1.2). Regeneration time, location and precipitation have the greatest influence on biomass and species richness. The study highlights the potential for natural regeneration to contribute to global and national climate and biodiversity goals and to sustainable, productive forest management. The importance of cooperation and policy-alignment between the forest, agriculture and land sectors are under-scored.

Rural communities bear a disproportionate share of the opioid and methamphetamine use disorder epidemics. Yet, rural people who use drugs (PWUD) are rarely included in trials testing new drug use prevention and treatment strategies. Numerous barriers impede rural PWUD trial engagement and advancing research methods to better retain rural PWUD in clinical trials is needed. This paper describes the Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-RThe PROUD-RThe protocol was approved by a central Institutional Review Board (University of Utah). Results of the study will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders.NCT03885024.

BACKGROUND: The opioid epidemic is at epic proportions currently in the United States. Exposure to opioids for surgery and subsequent postoperative pain management is a known risk factor for opioid dependence. In addition, opioids can have a negative impact on multiple aspects including clinical outcomes, length of hospital stay, and overall cost of care. Thus, the greatest effort to reduce perioperative opioid use is necessary and a multimodal pain control (MMPC) has been gaining popularity. However, its efficacy in spine surgery is not well known. We aimed to evaluate the efficacy of a MMPC protocol in patients undergoing lumbar single-level anterior lumbar interbody fusion (ALIF). METHODS: This is a retrospective comparative study. From a prospective, single-surgeon, surgical database, consecutive patients undergoing single-level ALIF with or without subsequent posterior fusion for degenerative lumbar conditions were identified before and after initiation of the MMPC protocol. The MMPC protocol consisted of a preoperative oral regimen of cyclobenzaprine (10 mg), gabapentin (600 mg), acetaminophen (1 g), and methadone (10 mg). Postoperatively they received a bilateral transverse abdominis plane block with 0.5% Ropivacaine prior to extubation. We compared in-hospital opioid consumption between the MMPC and non-MMPC cohorts as well as baseline demographic, the length of hospital stay, cost, and rate of postoperative ileus. Opioid consumption was calculated and normalized to the morphine milligram equivalents (MMEs). RESULTS: In total, 68 patients in the MMPC cohort and 39 in the non-MMPC cohort were identified. There was no difference in baseline demographics including sex, body mass index, smoking status, or preoperative opioid use between the two groups. Although there was no difference in the MMEs on the day of surgery (58.5 vs. 66.9, P=0.387), cumulative MMEs each day after surgery was significantly lower in the MMPC cohort, with final cumulative MMEs being reduced by 62% (120.2 vs. 314.8, P

OBJECTIVEUnexpected nonhome discharge causes additional costs in the current reimbursement models, especially to the payor. Nonhome discharge is also related to longer length of hospital stay and therefore higher healthcare costs to society. With increasing demand for spine surgery, it is important to minimize costs by streamlining discharges and reducing length of hospital stay. Identifying factors associated with nonhome discharge can be useful for early intervention for discharge planning. The authors aimed to identify the drivers of nonhome discharge in patients undergoing 1- or 2-level instrumented lumbar fusion.METHODSThe electronic medical records from a single-center hospital administrative database were analyzed for consecutive patients who underwent 1- to 2-level instrumented lumbar fusion for degenerative lumbar conditions during the period from 2016 to 2018. Discharge disposition was determined as home or nonhome. A logistic regression analysis was used to determine associations between nonhome discharge and age, sex, body mass index (BMI), race, American Society of Anesthesiologists grade, smoking status, marital status, insurance type, residence in an underserved zip code, and operative factors.RESULTSA total of 1502 patients were included. The majority (81%) were discharged home. Factors associated with a nonhome discharge were older age, higher BMI, living in an underserved zip code, not being married, being on government insurance, and having more levels fused. Patients discharged to a nonhome facility had longer lengths of hospital stay (5.6 vs 3.0 days, p < 0.001) and significantly increased hospital costs ($21,204 vs $17,518, p < 0.001).CONCLUSIONSIncreased age, greater BMI, residence in an underserved zip code, not being married, and government insurance are drivers for discharge to a nonhome facility after a 1- to 2-level instrumented lumbar fusion. Early identification and intervention for these patients, even before admission, may decrease the length of hospital stay and medical costs.

OBJECTIVEPosterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.METHODSA retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.RESULTSOf 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors’ first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.CONCLUSIONSDespite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors’ first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.

OBJECTIVEThe midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.METHODSFrom a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.RESULTSOf 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).CONCLUSIONSCompared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

ObjectivesTo determine women’s perception of the risk of food safety and how it relates to diet, health and decision making as part of formative research for a market-based intervention that aims to improve the safety of animal-source foods sold in informal markets.DesignQualitative study including in-depth personal interviews with 24 caregivers were conducted and complemented with a second follow-up PhotoVoice interview, which allowed the women to photograph their meals and perceptions of food safety and nutrition. Interview data were analysed using thematic analysis in MAXQDA. Participants were purposively sampled from a larger Safe Food, Fair Food for Cambodia study, conducted from May to August 2018.SettingUrban and periurban neighborhoods of Phnom Penh, Cambodia.Participants24 female caregivers (mothers and grandmothers) of children under age 5, each interviewed twice.FindingsA primary food safety concern expressed was that chemicals (pesticides and other agricultural additives) in animal-source foods, fruits and vegetables may impact the health of their families by causing diarrhoea and problems during pregnancy. This fear created a lack of trust in markets, which influenced their food purchasing behaviours and strategies for making the food safer for their families. These mitigation strategies, including food selection and cleaning, vary among the women but are perceived as important to be able to provide their families with what they define as safe meals.ConclusionsInterventions that wish to decrease rates of foodborne illness and increase animal source food consumption should also address the belief that the food system has been compromised by the addition of pesticides and agricultural additives.

Fat contributes most of the energy for migratory flight of birds, whereas lean body tissues (muscles and organs) contribute amino acids and water to maintain metabolic and osmotic homeostasis. During refueling at stopover sites, both fat and lean mass are recovered, but the dynamics of this recovery are poorly understood. We used non-invasive quantitative magnetic resonance (QMR) analysis to measure fat and lean mass of > 3,500 individuals of 25 songbird species during six spring and three autumn migration seasons between 2009 and 2019 at Long Point, ON, Canada. We used allometric scaling analysis and linear mixed-effects modeling of body composition data at both the population level (single capture) and the individual level (recapture). In the population-level analysis, lean mass scaled hypoallometrically with body mass, such that for every 20% increase in body mass, lean mass was predicted to increase by 12.1% in spring and 12.8% in autumn. Fat scaled hyperallometrically with body mass, such that for every 20% increase in body mass, fat mass was predicted to increase by 144% in spring and 136% in autumn. At the individual level, these allometric relationships were more extreme. As a result of this differential allometry, at low body masses, lean and fat mass contributes nearly equally to changes in mass, but at high body mass fat deposition becomes progressively more dominant. Spring migrants deposited relatively more fat than autumn migrants, and in autumn juvenile birds tended to have greater lean mass than adults. Our findings show that lean mass deposition during refueling by songbirds is substantial, and in line with the losses of protein expected in flight. The process of fat and lean mass deposition is characterized by non-linear dynamics which are influenced by the current body composition, season, and, to a lesser extent, age. The patterns suggest that the need for dietary protein to rebuild lean mass will be greater when body mass is low, during autumn migration, and in juvenile birds.

1. In animal ecology, energy expenditure is used for assessing the consequences of different behavioural strategies, life-history events or environments. Animals can also influence energy expenditure through instantaneous behavioural responses to their external environment. It is therefore of interest to measure energy expenditure of free-ranging animals across seasons and at high temporal resolutions. Heart rate has historically been used for this, but requires invasive surgery for long-term use. Dynamic body acceleration (DBA) is an alternative proxy for energy expenditure that is simpler to deploy, yet few studies have examined how it performs over extended time periods, or for species using different locomotory modes, especially passive modes like soaring flight.2. We measured DBA alongside heart rate in free-ranging lesser black-backed gulls, a seabird that moves using flapping flight, soaring and walking, and rests on both land and water. Our objectives were to compare the relative changes in DBA and heart rate among and within behaviours and to examine how accelerometers can be used to estimate daily energy expenditure by comparing DBA to time-energy budgets (TEBs).3. DBA and heart rate were sampled concurrently at 2.5- and 5-min intervals throughout the breeding season, though measurements were not exactly synchronised. Behaviour was identified from accelerometer measurements, and DBA and heart rate were averaged over bouts of consistent behaviour. Heart rate was converted to metabolic rate using an allometric calibration, after confirming its fit using metabolic measurements taken in captivity and values from existing literature. 4. Both proxies showed similar changes among behaviours, though DBA overestimated costs of floating, likely due to waves. However, relationships between DBA and heart rate were weak within a behaviour mode, possibly due to the lack of synchrony between proxy measurements.5. On daily scales, DBA and TEBs perform comparably for estimating daily energy expenditure. Accelerometery methods deviated from a 1:1 relationship with heart rate because acceleration could not measure variation in resting metabolic costs.6. We conclude DBA functions well for detecting energy expenditure arising from activity costs, including during soaring flight. We discuss scenarios where one method (DBA vs. TEBs) may be preferred over the other. Read the free Plain Language Summary for this article on the Journal blog.

University-utility partnerships (UUPs) are mutually beneficial collaborations that promote and accelerate innovation in the water sector. The Leaders Innovation Forum for Technology (LIFT) program worked with representatives from universities and utilities to define successful methods and strategies for establishing strong university-utility collaborative partnerships. Overall, partners in a successful university-utility collaboration need to be honest and realistic to match university capabilities and utility needs. In order to manage expectations at both organizations, utilities and universities must understand their respective points of view. Building and maintaining strong relationships should be a primary concern. Successful UUPs are built upon strong relationships between organizations rather than just strong research ideas. Different implementation structures should be considered for UUPs depending on what works best for both organizations. Common hurdles to overcome when implementing UUPs include working across distances and managing risks related to financing, intellectual property, and public outreach. PRACTITIONER POINTS: University-utility collaborative partnerships are mutually beneficial and promote innovation throughout the water sector as a whole Establishing successful partnerships can be challenging, but difficulties can be mitigated by following the described best practices Partnerships can be structured and implemented in a variety of ways depending on the specific needs of each organization involved.

Introduction The purpose of this study was to evaluate intraocular pressure (IOP) lowering and safety of XEN® stent in medically refractory, progressive, open-angle glaucoma (OAG). Methods Forty-seven eyes of 42 patients were treated with XEN® stent alone or combined with phacoemulsification. Results Mean IOP decreased from 22.34 ± 7.34 mmHg to 12.91 ± 4.21, 12.95 ± 4.36, 13.49 ± 3.91, and 13.36 ± 3.63 mmHg at 1, 3, 6, and 12 months (95% confidence interval [CI] [20.24, 24.44], [11.71, 14.12], [11.63, 14.27], [12.36, 14.62], and [12.10, 14.62]), respectively. Mean number of medications decreased from 2.96 ± 1.20 (95% CI [2.62, 3.30]) at baseline to 0.75 ± 1.27 (95% CI [0.31, 1.19]) at 1 year. At 1 year (n = 32), complete success was achieved in 68.8% (n = 22/32) (i.e., IOP reduction ≥ 20% and IOP

Occupational therapists promote meaningful engagement in occupations and associated role continuity, and encourage agency and citizenship. A lack of engagement can be understood as occupational dep...

BACKGROUND CONTEXT Health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” has been demonstrated to affect access to care and appropriate healthcare utilization. PURPOSE To determine the impact of health literacy in the evaluation and management of patients with chronic low back pain. STUDY DESIGN Cross sectional. PATIENT SAMPLE Patients seen at a multisurgeon spine specialty clinic. OUTCOME MEASURES Oswestry Disability Index, EQ-5D, and Numeric Rating Scales (0–10) for back and leg pain. METHODS The Newest Vital Sign (NVS) and Health Literacy Survey, Oswestry Disability Index, EQ-5D and pain scales were administered to patients undergoing evaluation and treatment for lumbar degenerative disease in the outpatient setting. Patients were surveyed regarding their use of medication, therapy, and pain management modalities. RESULTS Of 201 patients approached for participation, 186 completed the health literacy surveys. Thirty (17%) were assessed as having limited literacy, 52 (28%) as possibly having limited literacy and 104 (56%) having adequate literacy based on their NVS scores. The cohort with low NVS scores also had low Health Literacy Survey Scores. Patients with limited literacy had worse back and leg pain scores compared with patients with possibly limited literacy and adequate literacy. Patients with adequate health literacy were more likely to use medications (80% vs. 53%, p = .017) and were more likely to see a specialist (34% vs. 17%) compared with those with limited literacy. Patients with limited health literacy were not more likely to see a chiropractor (7% vs. 7%), but reported more visits (19 vs. 8). CONCLUSIONS Patients with lower health literacy reported worse back and leg pain scores, indicating either more severe disease or a fundamental difference in their responses to standard health-related quality of life measures. This study also suggests that patients with limited health literacy may underutilize some resources and overutilize other resources. Further study is needed to clarify these patterns, and to examine their impact on health status and clinical outcomes.

Study Design Prospective observational cohort. Objectives To examine the cost-effectiveness of IntraOperative ElectroMyeloGraphy (IO-EMG) by evaluating how often an abnormal IO-EMG signal changed the surgeon’s surgical plan, or replaced a pedicle screw either intra-operatively or as a second unplanned surgery. Methods Patients undergoing instrumented posterolateral lumbar fusion were monitored with intraoperative triggered EMG’s. Pedicle screws were placed freehand from L1 to S1 by attending physicians and fellows. Concern for pedicle breach was a screw stimulationResults There were 145 cases with a total of 725 pedicle screws placed. Mean age was 57.8 ± 14.2 yrs, OR time was 238 ± 95 minutes, EBL was 426.8 ± 354.3cc. Mean number of surgical levels fused was 2.7 ± 1.1. 686 (95%) screws stimulated at >10 mA and 39 (5%) screws stimulated at Conclusions Only 1% of the 725 lumbar pedicle screws placed in 8 of 145 cases required repositioning. Due to the infrequency of pedicle wall breaches and the cost of ION, the utility of this modality in straightforward lumbar fusions should be critically evaluated.