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Preseason functional tests have been previously associated with noncontact time-loss lower extremity injuries in a variety of athletic populations. This study aimed to determine the effectiveness of one or more functional tests to discriminate injury risk in a cohort of female collegiate volleyball players in the United States.Prospective cohort study.National Collegiate Athletic Association Division IIIII, National Association of Intercollegiate Athletics female volleyball players; PARTICIPANTS: 130 female volleyball players (mean age: 19.31 ± 1.1 years).Lower extremity functional test, single limb hop for distance, standing long jump, previous injury history, lower quarter Y-balance test, and limb symmetry index were measured prior to the season beginning. Noncontact time-loss lower quarter injuries were tracked during the season.Athletes with suboptimal scores on the single limb hop test (70% of height) and standing long jump (80% of height), combined with a previous history of injury, were three times more likely to sustain an injury during the season (OR = 3.0; 95% CI: 1.09 to 8.30). Individual functional tests did not discriminate injury risk.A battery of preseason functional tests and injury history discriminates injury risk in female collegiate volleyball players.

Background Magnetic sphincter augmentation (MSA) has gained popularity as a treatment for gastroesophageal reflux disease (GERD). The role of MSA in treating GERD in metabolic and bariatric surgery (MBS) patients at the time of primary MBS is unknown. Objective To determine the short-term outcomes of MSA placed at the time of MBS. Setting National database, United States. Methods We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for MSA performed at time of the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for the years 2017–2018. A propensity adjusted analysis was performed to assess 30-day outcomes of patients who had MSA placed versus those who did not. Results There were 319,580 patients who underwent MBS in the study period. Twenty-four patients had MSA at time of surgery. These patients did not have a higher reported rate of preoperative GERD (P = .93). Six patients (25%) with MSA had a RYGB; the other 18 patients (75%) patients had SG (P Conclusion MSA is safe in the short term in MBS. There is no difference in major morbidity or mortality and operative times are similar in MSA patients. The long-term efficacy of this practice is unknown.

The country fully entered into the Federal Structure of political governance through implementation of the Federal Constitution. The planning process also would have to redefine and readjust according to change in the country to keep the development spirit by setting national goals and objectives down to the lower tiers of the government. Therefore, it is pertinent to define the clear role and responsibilities of all stakeholders involved in the planning process of the country. This study has tried to address those issues by explaining frictional role, planning process and relationship among all planning units at each tier of government. National Planning Commission (NPC) has to interpret the goal into policy and program and send it to Provincial Government for further analysis and process as per the requirement of such Government. The Local Levels prepare their own plans and policies in line with the directives received from the NPC and send them both to the provincial planning entities and the NPC. A two-way algorithm of planning process both top-down and bottom-up will be in practice and they will be adjusted when necessary basis.

Objective: The US Dietary Guidelines for Americans recommends increased consumption of the dairy group to three daily servings for ages 9+ years to help achieve adequate intakes of prominent shortfall nutrients. Identifying affordable, consumer-acceptable foods to replace dairy’s shortfall nutrients is important especially for people who avoid dairy. Design: Linear programming identified food combinations to replace dairy’s protein and shortfall nutrients. We examined cost, energy and dietary implications of replacing dairy with food combinations optimised for lowest cost, fewest kJ or the smallest amount of food by weight. Setting: National Health and Nutrition Examination Survey (2011–2014). Participants: Nationally representative sample of US population; 2 years and older (n 15 830). Results: Phase 1 (only dairy foods excluded): when optimised for lowest cost or fewest kJ, all non-dairy food replacements required large amounts (2·5–10 cups) of bottled/tap water. Phase 2 (dairy and unreasonable non-dairy foods excluded (e.g. baby foods; tap/bottled water): when intake of non-dairy foods was constrained to Conclusions: Identifying affordable, consumer-acceptable foods that can replace dairy’s shortfall nutrients at both current and recommended dairy intakes remains a challenge.

ObjectiveTo determine trends in emergency admission rates requiring different levels of critical care in hospitals with and without a paediatric intensive care unit (PICU).DesignBirth cohort study created from Hospital Episode Statistics.SettingNational Health Service funded hospitals in England.Patients8 577 680 singleton children born between 1 May 2003 and 31 April 2017.Outcome measuresUsing procedure and diagnostic codes, we assigned indicators of high dependency care (eg, non-invasive ventilation) or intensive care (eg, invasive ventilation) to emergency admissions.InterventionsChildren were followed up until their fifth birthday to estimate high dependency and intensive care admission rates in hospitals with and without a PICU. We tested the yearly trend of high dependency and intensive care admissions to hospitals without a PICU using logistic regression models.ResultsEmergency admissions requiring high dependency care in hospitals without a PICU increased from 3.30 (95% CI 3.09 to 3.51) per 10 000 child-years in 2008/2009 to 7.58 (95% CI 7.28 to 7.89) in 2016/2017 and overtook hospitals with a PICU in 2015/2016. The odds of an admission requiring high dependency care to a hospital without a PICU compared with a hospital with a PICU increased by 9% per study year (OR 1.09, 95% CI 1.08 to 1.10). The same trend was not present for admissions requiring intensive care (OR 1.01, 95% CI 0.99 to 1.03).ConclusionsBetween 2008/2009 and 2016/2017, an increasing proportion of admissions with indicators of high dependency care took place in hospitals without a PICU.

Objective:Accurate and easy to use methods for dietary Na intake estimation in population level are lacking. We aimed at (i) estimating the mean Na intake in the group level using a variety of dietary methods (DM) and urinary methods (UM) and correlating them with 24-h urine collection (24UCol) and (ii) improving the accuracy of the existing DM.Design:The most common DM (three 24-h dietary recalls (24DR) and FFQ) and UM (24UCol and spot urine collection using common equations) were applied. To improve the existing: (i) 24DR, discretionary Na was quantified using salt-related questions or adding extra 15 % in total Na intake and (ii) FFQ, food items rich in Na and salt-related questions were added in the standard questionnaire (NaFFQ).Setting:National and Kapodistrian University of Athens, Greece.Participants:Totally, 122 high cardiovascular risk subjects (56·0 ± 12·6 years; 55·7 % males).Results:Mean 24 h Na excretion (24UNa) was 2810 ± 1304 mg/d. Spot urine methods overestimated the 24UNa (bias range: −1781 to −492 mg) and were moderately correlated to 24UCol (r = 0·469–0·596, P ≤ 0·01). DM underestimated the 24UNa (bias range: 877 to 1212 mg) and were weakly correlated with 24UCol. The improved DM underestimated the 24UNa (bias range: 877 to 923 mg). The NaFFQ presented the smallest bias (−290 ± 1336 mg) and the strongest correlation with 24UCol (r = 0·497, P ≤ 0·01), but wide limits of agreement in Bland–Altman plots (−2909 mg; 2329 mg), like all the other methods did.Conclusions:The existing methods exhibit poor accuracy. Further improvement of the newly developed NaFFQ could be promising for more accurate estimation of mean dietary Na intake in epidemiological studies. Additional validation studies are needed.

Objetivo: realizar uma análise descritiva e crítica sobre o desempenho deste sistema. Método: desenho do tipo retrospectivo com a utilização de dados primários (entrevistas com profissionais de saúde, gestores e usuários do programa), e secundários (dados do SI do PNSF e relatórios da Coordenação Geral de Alimentação e Nutrição, da gestão estadual e municipal, dentre outros documentos). Na análise da qualidade e pertinência da informação foram utilizadas as categorias: completude, confiabilidade, atualidade, acesso, fidedignidade, correção das metas, e coerência da informação com as metas e políticas vigentes. Resultados: apesar do SI dispor de dados de fácil acesso, os resultados apontaram erros no estabelecimento das metas e coberturas do programa e alimentação dos dados. A acessibilidade também foi prejudicada impedindo a utilização dos dados para tomada de decisão tanto no nível local, intermediário e nacional. Ademais, sérios problemas de planejamento decorrentes, pelo menos em parte, da cultura institucional que alicerça as práticas de saúde e mantém a informação como segredo ou recurso de poder político e burocrático, foram encontrados. Conclusão: Estudos e intervenções no sentido do aclaramento e resolução destas questões poderão contribuir para o aprimoramento dos sistemas de informação em saúde, de maneira a permitir o controle e redução da anemia por deficiência de ferro. AbstractObjectives: This article aimed to perform a descriptive and critique analysis of this system performance using as research outline the generation and use of data at the municipal level. Methods: The retrospective design used interviews with health professionals, managers and users of the program as the primary data, and, SI PNSF data and reports from the General Commission of Food and Nutrition, the state and municipal management, among other documents as a secondary material. The quality and relevance of the information was analyzed through the categories: completeness, reliability, timeliness, access, correction of goals and consistency of the information with the goals of health politics. Results: Despite the SI have easily accessible data, the results showed errors in setting national goals and program coverage, in addition to wrong data input by local coordinators. Accessibility was also affected, disallowing the use of data for decision making at the local, intermediate and national levels. Finally, there were serious planning problems arising, at least in part, the institutional culture that underpins health practices and maintains the information as secret or as political and bureaucratic power resource. Conclusion: Studies and interventions towards the clearing and settlement of these issues could contribute to the improvement of health information systems, and in particular the PNSF, so as to allow the control and reduction of iron deficiency anemia in children and pregnant Brazilian women.

BackgroundMany patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed.ObjectiveTo identify factors which influence speaking up, and to examine the impact of apology when problems occur.DesignRandomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied.SettingNational online survey.Participants1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate.Main outcomes and measuresAffective responses to care breakdowns, intent to speak up, willingness to recommend the hospital.ResultsTwice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((pConclusionsAsking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients’ willingness to recommend the hospital.

Objectives Provide normative values for cervical range of motion and describe trends in school age rugby union players. Design Cross-sectional study. Setting National 3 level club. Participants 59 school age rugby union players across under 8 (n = 8), under 9 (n = 9), under 10 (n = 15), under 13 (n = 13) and under 15 (n = 15) categories. Main outcome measures Cervical range of motion using a cervical range of motion device (CROM) to determine values for active range of motion. Results This study established mean ranges of motion for each age group. Pooled mean ranges with standard deviations for each direction were, flexion 66° (±11), extension 73° (±17), left rotation 69° (±9), right rotation 74° (±10), left lateral flexion 53° (±10) and right lateral flexion 49° (±12). No statistically significant differences were observed between the age groups, however, downward trends in lateral flexion were observed as age increased. School age rugby players had greater range of motion than senior playing counterparts. Conclusions No statistically significant differences in ranges of motion were observed between the age groups of under 8 through to under 15. However, downward trends in some ranges of motion highlight the need for age specific monitoring for potential adaptations to continued playing and comparison to age matched non-rugby players. Inclusion of other risk factors such as head re-positioning sense should also be evaluated to help guide injury risk reduction strategies.

Method of setting minimum wages has been a debatable issue across the world. Various countries have adopted various methods of minimum wage determination process primarily formulas, government rate setting, union bargained rates, and rate recommended by an expert body. International Labour Organization (ILO) puts forth that the process of setting-up minimum wages should be scientific and accommodative of the needs of the workers and their families. Although minimum wages remains an utmost prority as a redistributive tool, studies shows that its fixation are mostly driven by political interest of the incumbent government and the interest of the private sector. Nepal is not an exception to this. This paper attempts to propose a need based method of setting minimum wages for Nepal. In addition to the food and non-food information, unlike previous need based approaches, this study uses housing information from the nationally representative household survey to derive the minimum wages for Nepal. The minimum monthly salary/wages at 2019/20 prices per household is estimated at NRs. 21799 and daily wages is estimated at NRs. 838.43.This study is expected to guide policy makers in setting evidence-based minimum wages for Nepal.

ObjectiveTo estimate the incidence of laboratory-confirmed, invasive bacterial infections (IBIs) by week of age in infants over a 7-year period.DesignAnalysis of prospective national surveillance data for England.SettingNational Health Service hospitals in England.PatientsInfants aged Main outcome measuresIBI incidence by week of age, incidence rate ratio (IRR) at 8, 12 and 16 weeks compared with the first week of life, and the main pathogens responsible for IBI.ResultsThere were 22 075 IBI episodes between 2010/2011 and 2016/2017. The lowest annual cases were in 2011/2012 (n=2 799; incidence, 412/100 000 population), increasing year-on-year to 3 698 cases in 2016/2017 (incidence, 552/100 000 population). The incidence was highest in the first week of life and then declined rapidly. In 2016/2017, compared with the first week of life, weekly IBI incidence was 92% lower at 8 weeks (IRR 0.08; 95% CI 0.06 to 0.10) and 96% lower at 16 weeks of age (IRR 0.04; 95% CI 0.03 to 0.06). In 2016/2017, Escherichia coli was the most prevalent pathogen responsible for IBI (n=592, 16.0%), followed by group B Streptococci (n=493, 13.3%), Staphylococcus aureus (n=400, 10.8%) and Enterococci (n=304, 8.2%). The other pathogens were individually responsible for ConclusionIBI incidence declines rapidly after the first week of life, such that infants have a very low risk of IBI by the time they are eligible for their routine immunisations from 8 weeks of age.

The Bhutanese health system is committed to providing health services for all citizens and is interested in strengthening the country’s health research capacity. The objectives of this workshop were to understand the range of health research activities in Bhutan; to formulate a prioritized research agenda for the Ministry of Health (MoH); to share challenges, gaps and opportunities in health research; and to provide insights for future prioritization exercises. The MoH partnered with Khesar Gyalpo University of Medical University of Bhutan and USA-based facilitators to develop and pilot a methodology for health research priority setting. The Bhutan priority setting process was adapted from the Combined Approach Matrix and the Essential National Health Research methods. The methodology proved successful in the systematic creation of a list of health research priorities. Future priority setting processes will build on this workshop, continuing to refine and strengthen the priority setting process in Bhutan.

Objectives To increase access to hepatitis C virus (HCV) care and cure by deploying clinical pharmacy specialist (CPS) providers across the largest integrated health care system in the United States. Setting National integrated health care system. Practice description In late 2016, the Department of Veterans Affairs (VA) Pharmacy Benefits Management Clinical Pharmacy Practice Office (CPPO) partnered with the VA HIV, Hepatitis, and Related Conditions Program with the central priority of expanding veteran access to novel HCV treatments and timely cure to ultimately prevent morbidity and mortality associated with HCV disease progression. This successful collaboration resulted in clinical resource funding to bolster access to HCV treatment through the deployment of CPS providers. This enterprise-wide initiative to expand clinical pharmacy services for unmet health care needs in HCV treatment resulted in 52 VA facilities submitting full-time employment equivalent (FTEE) funding requests totaling more than $10 million dollars. Facilities may have requested funding for 1 or more FTEEs. Results Facilities hired 47 CPS providers and 5 clinical pharmacy technicians. CPS providers in this project recorded 24,888 patient care encounters providing care for 9593 unique patients and initiated new HCV treatment for 1191 treatment-naive patients. For an additional 8402 patients, the CPS provided HCV care activities such as evaluation and monitoring before, during, and after treatment. CPPO estimates that the same care delivered by nonpharmacist provider specialists (e.g., specialty physicians) cost an additional $936,535, or 48% more. Conclusion The deployment of HCV CPS resulted in a significant number of new HCV patients being screened and treated within the VA system.

Objective To assess whether robot-assisted reach training (RART) with an active assistant protocol can improve upper extremity function and kinematic performance in chronic stroke survivors. Design This study was conducted as a randomized controlled trial. Setting National rehabilitation center. Participants Chronic stroke survivors (N=38) were randomized into 2 groups: a robot-assisted reach training with assist-as-needed (RT-AAN) group and a robot-assisted reach training with guidance force (RT-G) group. Intervention The RT-AAN group received robot-assisted reach training with an assist-as-needed mode for 40 minutes per day, 3 times per week over a 6-week period, and the RT-G group participated in the RART with a guidance mode for 40 minutes per day, 3 times per week over a 6-week period. Main Outcome Measures Upper extremity functions were measured with Fugl–Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Box and Block Test. In addition, movement velocities were measured as an index for upper extremity kinematic performances in 6 directions. Results Both groups showed significant improvements in FMA, ARAT, and kinematics (movement velocity) in all directions (targets 1-6, P Conclusions RART with an active assistant protocol showed improvements of upper extremity function and kinematic performance in chronic stroke survivors. In particular, assist-as-needed robot control was effective for upper extremity rehabilitation. Therefore robot-assisted training may be suggested as an effective intervention to improve upper extremity function in chronic stroke survivors.

Background Carbohydrate quality influences major health outcomes; however, the best criteria to assess carbohydrate quality remain unknown. Objective The objectives were to: i) evaluate whether a diet that meets a carbohydrate ratio (simple, modified or dual ratio) is associated with higher nutrient intakes and diet quality, and ii) model the impact of substituting carbohydrate foods that meet the proposed ratios in place of foods that do not, on nutrient intakes. Design A secondary analysis of cross-sectional data from the 2011–12 Australian National Nutrition and Physical Activity Survey. Participants/Setting National data from participants aged 2 years and older (n = 12,153). Main outcome measures Ratios were defined as (i) simple ratio, 10:1 (10g carbohydrate:≥1g dietary fiber); (ii) modified ratio, 10:1:2 (10g carbohydrate:≥1g dietary fiber:≤2g free sugars); and (iii) dual ratio, 10:1 & 1:2 (10g carbohydrate:≥1g dietary fiber & ≤2g free sugars per 1g dietary fiber). Ratios were compared to nutrient intakes obtained via automated multiple-pass 24-hour dietary recall and diet quality calculated using the Australian Healthy Eating Index. Statistical analyses performed Substitution dietary modelling was performed. Data were analyzed using paired and independent sample t-tests. Results Ratio adherence was highest for simple (50.2% adults; 28.6% children), followed by dual (40.6% adults; 21.7% children), then modified (32.7% adults; 18.6% children) ratios. Participants who met any ratio reported higher nutrient intake and diet quality compared to those who failed to meet the respective ratio (P < .001 for all), with the greatest nutrient intakes found for those who met modified or dual ratios. Dietary modelling improved nutrient intakes for all ratios, with the greatest improvement found for the dual ratio. Conclusions All carbohydrate ratios were associated with higher diet quality, with a free sugars constraint in the dual ratio providing the greatest improvements.

OBJECTIVE. To create a larger, more representative community comparison sample of the Brief Test of Adult Cognition by Telephone (BTACT) data to facilitate assessment of cognitive function in research studies. SETTING. National U.S. community-based survey. PARTICIPANTS. 6,747 healthy adults aged 23 to 84 years (53% female; mean age = 55 years [SD = 13]). DESIGN. Secondary data analysis of BTACT data collected from the National Survey of Midlife Development in the United States (MIDUS) II and MIDUS Refresher cohorts. MAIN MEASURES. The Brief Test of Adult Cognition by Telephone, a brief (15–20 minute) measure of global cognitive function validated for telephone administration. RESULTS. This paper provides BTACT community comparison sample data based on age, sex, and education from a national sample. Similar to other cognitive measures, BTACT scores decreased with age and increased with education. CONCLUSIONS. The BTACT community comparison sample will facilitate investigation of cognitive functioning in large scale traumatic brain injury research studies, and will support secondary analysis of existing BTACT data gathered through the MIDUS study.

Objective:To identify the most cost-effective options/contributors of under-consumed food groups and nutrients in the USA.Design:Twenty-four-hour dietary recall data were used for the dietary sources of under-consumed food groups and nutrients. Costs were estimated using USDA National Food Price Database 2001–2004 after adjustments for inflation using Consumer Price Index.Setting:National Health and Nutrition Examination Survey, 2013–2016.Participants:A total of 10 112 adults aged 19+ years.Results:Top five cost-effective options for food groups were apple and citrus juice, bananas, apples, and melons for fruit; baked/boiled white potatoes, mixtures of mashed potatoes, lettuce, carrots and string beans for vegetables; oatmeal, popcorn, rice, yeast breads and pasta/noodles/cooked grains for whole grain; and reduced-fat, low-fat milk, flavoured milk and cheese for dairy. Top five cost-effective sources of under-consumed nutrients were rice, tortillas, pasta/noodles/cooked grains, rolls and buns, and peanut butter–jelly sandwiches for Mg; grits/cooked cereals, low- and high-sugar ready-to-eat (RTE) cereal, rolls and buns, and rice for Fe; low- and high-sugar RTE cereals, rice, protein and nutritional powders, and rolls and buns for Zn; carrots, margarine, other red and orange vegetables, liver and organ meats, butter and animal fats for vitamin A; and citrus juice, other fruit juice, vegetable juice, mustard and other condiments, and apple juice for vitamin C.Conclusions:Apple/citrus juice, white potatoes/carrots, oatmeal, RTE cereals and milk were the most cost-effective food sources of multiple under-consumed food groups and nutrients and can help promote healthy eating habits at minimal cost.

OBJECTIVE To describe demographics and to analyze temporal trends in the inpatient management of acute mastoiditis admissions. STUDY DESIGN Cross-sectional analysis. SETTING National Inpatient Sample, 2002-2014. PATIENTS 26,072 nonelective inpatient admissions with primary diagnosis of acute mastoiditis. INTERVENTION Myringotomy, mastoidectomy, or no procedure. MAIN OUTCOME MEASURES We described the patient- and hospital-level demographics of acute mastoiditis admissions and the frequency of complications. We evaluated the percentage of patients requiring surgical management. Binary logistic regression was performed to determine whether there was a significant increase in the percentage of patients treated at academic institutions. RESULTS The majority of patients were ≤40 years old (64.9%) and Elixhauser comorbidity index ≥4 (57.4%); 23.3% (SE 0.8%) presented with complications associated with acute mastoiditis, the most common of which was a subperiosteal abscess (11.5%, SE 0.7%). Among all admissions, 30.9% (SE 1.1%) underwent myringotomy, 13.8% (SE 0.8%) required both myringotomy and mastoidectomy. On multivariate analysis, there was a statistically significant increase in the percentage of mastoiditis admissions to teaching hospitals for all admissions (OR 1.55 [CI 1.22-1.97], p

ImportanceThirty-five years ago, the Heckler Report described health disparities among minority populations in the US. Since then, policies have been implemented to address these disparities. However, a recent evaluation of progress towards improving the health and health equity among US adults is lacking.ObjectivesTo evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades.DesignCross-sectional.SettingNational Health Interview Survey data, years 1999–2018.ParticipantsAdults aged 18–85 years.ExposureRace/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic).Main outcome and measuresProportion of adults reporting poor/fair health status, severe psychological distress, functional limitation, and insufficient sleep. We also estimated the gap between non-Hispanic White and the other subgroups for these four outcomes.ResultsWe included 596,355 adults (mean age 46 years, 51.8% women), of which 69.7%, 13.8%, 11.8% and 4.7% identified as non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic Asian, respectively. Between 1999 and 2018, Black individuals fared worse on most measures of health, with 18.7% (95% CI 17.1–20.4) and 41.1% (95% CI 38.7–43.5) reporting poor/fair health and insufficient sleep in 2018 compared with 11.1% (95% CI 10.5– 11.7) and 31.2% (95% CI 30.3–32.1) among White individuals. Notably, between 1999–2018, there was no significant decrease in the gap in poor/fair health status between White individuals and Black (−0.07% per year, 95% CI −0.16–0.01) and Hispanic (−0.03% per year, 95% CI −0.07– 0.02) individuals, and an increase in the gap in sleep between White individuals and Black (+0.2% per year, 95% CI 0.1–0.4) and Hispanic (+0.3% per year, 95% CI 0.1–0.4) individuals. Additionally, there was no significant decrease in adults reporting poor/fair health status and an increase in adults reporting severe psychological distress, functional limitation, and insufficient sleep.Conclusions and RelevanceThe marked racial/ethnic disparities in health of US adults have not improved over the last 20 years. Moreover, the self-perceived health of US adults worsened during this time. These findings highlight the need to re-examine the initiatives seeking to promote health equity and improve health.

The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.A retrospective study.National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.None.National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be80 years old (12.4% v 4.9%; p0.0001), female (36.1% v 34.3%; p0.0001), have American Society of Anesthesiologists physical statusIII (17.28% v 10.48%; p0.0001), and reside in urban areas (62.23% v 53.37%; p0.0001). They received care in the Northeast (17.6% v 10.1%; p0.0001) at low-volume centers (median 224 v 284 procedures; p0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical statusIII resulted in a 7% (p0.0001), 9% (p = 0.032), and 200% (p0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and0.5 [p0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

Background Due to the importance of water, the negative effects of water pollution on human health and the lack of proper knowledge of the state of research in this regard, the purpose of this study was to analyse scientific publications on water pollution in Iranian journals of environmental health. Methods This cross-sectional study was conducted using a scientometric method over a ten-year period (2008–2017) on articles published in five specialised environmental health journals emphasising the issue of water pollution. Data were collected through a researcher-based checklist using the International Committee of Medical Journal Editors (ICMJE) and the World Association of Medical Editors (WAME) recommendations. Data processing was done using descriptive statistics and VOSviewer software. Results A review of 1276 articles in specialised environmental health journals revealed that 33.7% of the articles were in the field of water. Physical and chemical factors in water were the main subjects of 21.4% of studies, and temperature and turbidity were the most important physical factors. Microbial agents in groundwater and surface water were the main subjects of 14.1% of the articles. The findings show that 55 of 430 articles related to water were written with contributions from 20 countries (including Iran), with the most contributions from researchers from Asia. Conclusions Good conditions do not exist to investigate the status of articles on water pollution in specialised environmental health journals in Iran over a ten-year period. Health policymakers should therefore provide mechanisms to encourage national researchers, especially environmental health professionals, by setting national research priorities on quality and water pollution to conduct studies in this regard.

The Care Act 2014 provides for ‘parity of esteem’ between people with social care needs and carers. This is achieved by extending the principles of prevention and wellbeing to carers; reinforcing carers’ right to an assessment; and setting national eligibility criteria for access to carer support services. This article reports on research that examined the impact of these changes on older co-resident carers of older people in four English local authorities. Findings are described in relation to four key themes: organisational arrangements and rationale; the aims of carer support and preventative services; design and delivery of carer assessment; and barriers to assessment and support. The findings of the research suggest that, despite the new statutory requirements, underlying contradictions and tensions in local authorities’ relationship with carers, and efforts to support them, remain unresolved.

BackgroundHearing loss is the most common sensory loss in humans and carries an enhanced risk of depression. No prior studies have attempted a contemporary machine learning approach to predict depression using subjective and objective hearing loss predictors.ObjectiveTo deploy supervised machine learning to predict scores on a validated depression scale using subjective and objective audiometric variables and other health determinant predictors.DesignWe used a large predictor set of health determinants to forecast individuals’ scores on a validated instrument to screen for the presence and severity of depression (PHQ-9). After model training, the relative influence of individual predictors on depression scores was stratified and analyzed.SettingNational Health and Nutrition Examination Survey (NHANES) 2015-2016 database.PatientsAdult survey participants.MeasurementsModel prediction error performance.ResultsThe test-set mean absolute error was 3.03 (CI 95%: 2.91-3.14) and 2.55 (CI 95%: 2.48-2.62) on datasets with audiology-only predictors and all predictors, respectively, on the PHQ-9’s 27-point scale. Participants’ self-reported frustration when talking to members of family or friends due to hearing loss was the fifth-most influential of all predictors. Of the top ten most influential audiometric predictors, five were related to social contexts, two for significant noise exposure, two objective audiometric parameters, and one presence of bothersome tinnitus.ConclusionsMachine learning algorithms can accurately predict PHQ-9 depression scale scores from NHANES data. The most influential audiometric predictors of higher scores on a validated depression scale were social dynamics of hearing loss and not objective Such models could be useful in predicting depression scale scores at the point-of-care in conjunction with a standard audiologic assessment.

ObjectiveTo evaluate the prevalence and temporal trends of presarcopenia and related body composition measurements.DesignCross-sectional study.SettingNational Health and Nutrition Examination Survey (NHANES) 1999–2006.MethodsPresarcopenia was defined according to the guidelines from the European Working Group on Sarcopenia. Logistic or linear regression models were used to evaluate the linear trend of the prevalence of presarcopenia, obesity and related body composition measurements.ParticipantsA total of 29 947 participants aged 18–90 years from five waves of the NHANES were included in the analysis.Outcome measuresPresarcopenia was sex-specifically defined as having a skeletal mass index ≤7.26 kg/m2 in men and ≤5.5 kg/m2 in women. Body composition measurements, including total body fat percentage, total body fat mass, total lean body mass, appendicular skeletal muscle mass and bone mineral density, were obtained by dual-energy X-ray absorptiometry.ResultsThe overall prevalence of presarcopenia ranged from 16.4% in 1999–2000 to 14.8% in 2005–2006 (p for trend=0.78). Presarcopenia was stable in both males (p for trend=0.36) and females (p for trend=0.20). The presarcopenia prevalence was significantly elevated among the age group of 18–39 years old (from 11.3% to 14.1%, p for trend=0.04) and among non-Hispanic blacks (p for trend ConclusionsThe prevalence of presarcopenia increased among young individuals over time. Non-Hispanic blacks also demonstrated an increasing trend in the prevalence over time.

The operative experience of today's general surgery (GS) residents are changing. The Surgical Council on Resident Education (SCORE) was founded to provide a standardized, competency-based curriculum. We set out to evaluate resident operative experience in core and advanced operations.Accreditation Council for Graduate Medical Education (ACGME) national operative log reports from 2010 to 2018 were reviewed. Operative volume data for 344 operations were extracted and analyzed. Operations were designated as core, advanced, or undefined as listed by SCORE, and stratified as GS or subspecialty.National analysis utilizing ACGME operative log reports.All graduating general surgery residents between 2010 and 2018.A total of 10,118 residents completed GS training with an average of 1121.5 ± 29.3 total cases. Core operations comprised 80.5% of total volume while advanced comprised only 8.0%. The total core experience increased (+7.0 cases/year), while total advanced experience decreased (-1.4 cases/year) (p0.01 each). Compositional analysis among core operations revealed an increase in 9/13 GS domains and a decrease in 8/10 subspecialty domains (all p0.05).There has been an increase in core operative experience with a concurrent decrease in advanced operative experience of graduating GS residents. These findings highlight the continued narrowing of the operative experience for trainees, with increasing focus on GS and less on subspecialty domains. Ongoing efforts to look beyond operative volume to ensure competency of graduates will prove beneficial.

Background/objectives Little is known about older adults who have intact capacity but do not have a desired surrogate to make decisions if their capacity becomes impaired. Design Cross-sectional study of a nationally representative sample. Setting National Social Life, Health, and Aging Project (NSHAP), 2005-2006. Participants Community-dwelling older adults without known cognitive impairment, aged 57 to 85, interviewed as part of NSHAP (n = 2,767). Measurements We examined demographic, medical, and social connectedness characteristics associated with answering "no" to this question: "Do you have someone who you would like to make medical decisions for you if you were unable, as for example if you were seriously injured or very sick?" Because many states permit nuclear family to make decisions for persons with no legally appointed health care agent, we used logistic regression to identify factors associated with individuals who were ill suited to this paradigm in the sense that they had nuclear family but did not have a desired surrogate. Results Among NSHAP respondents, 7.5% (95% confidence interval = 6.4-8.7) did not have a desired surrogate. Nearly 90% of respondents without desired surrogates had nuclear family. Compared with respondents with desired surrogates, those without desired surrogates had lower indicators of social connectedness. On average, however, they had four confidants, approximately 70% socialized at least monthly, and more than 90% could discuss their health with a confidant. Among respondents who had nuclear family, few characteristics distinguished those with and without desired surrogates. Conclusion Nearly 8% of older adults did not have a desired surrogate. Most had nuclear family and were not socially disconnected. Older adults should be asked explicitly about a desired surrogate, and strategies are needed to identify surrogates for those who do not have family or would not choose family to make decisions for them.

PURPOSE To compare the changes in axial length (AL) obtained after cataract surgery by partial coherence interferometry (PCI), swept-source optical coherence tomography with the composite method (SS-OCT/CM), and SS-OCT with the segmental method (SS-OCT/SM). SETTING National Hospital Organization, Tokyo Medical Center, Japan. DESIGN Retrospective case series. METHODS AL was measured preoperatively and 1 month postoperatively by PCI, SS-OCT/CM, and SS-OCT/SM. RESULTS Two hundred sixty-eight eyes in 139 patients who underwent cataract surgery were included. The mean ALs measured by PCI and SS-OCT/CM decreased significantly from 24.14 ± 1.58 to 24.05 ± 1.58 mm (P < .0001) and from 24.15 ± 1.58 to 24.05 ± 1.59 mm (P < .0001), respectively. The mean differences between the preoperative and postoperative AL were 0.083 ± 0.044 mm (PCI) and 0.096 ± 0.045 mm (SS-OCT/CM), respectively; Bland-Altman analysis revealed fixed bias between the preoperative and postoperative values. The mean preoperative and postoperative ALs measured by SS-OCT/SM were 24.12 ± 1.54 and 24.12 ± 1.54 mm, respectively (P = 0.97). The mean difference between the preoperative and postoperative ALs was 0.00 ± 0.03 mm on SS-OCT/SM; Bland-Altman analysis indicated good agreement between these values. CONCLUSIONS The difference between preoperative and postoperative ALs is less with SS-OCT/SM than with PCI or SS-OCT/CM. Assuming that AL is not altered by cataract surgery, AL measurement is more accurate by SS-OCT/SM than by PCI or SS-OCT/CM.

Objective To quantify the burden of traumatic spinal cord injury (SCI) as defined by nonfatal health loss and premature mortality among a large sample of participants over a 44-year period, and estimate the national burden of SCI in the United States for the year 2010. Design Longitudinal. Setting National SCI Model Systems and Shriners Hospitals. Participants Individuals (N=51,226) were categorized by neurologic level of injury as cervical (n=28,178) or thoracic and below (n=23,048). Main Outcome Measures The burden of SCI was calculated in years lost due to premature mortality (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY). Results For those with cervical level injuries, the overall YLLs and YLDs were 253,745 and 445,709, respectively, for an estimated total of 699,454 DALYs. For those with thoracic and below level injuries, the overall YLLs and YLDs were 153,885 and 213,160, respectively, for an estimated total of 367,045 DALYs. Proportionally adjusted DALYs attributable to SCI in 2010 were 445,911. Conclusions SCIs accounted for over 1 million years of healthy life lost in a national sample over a 44-year span. We estimated that 445,911 DALYs resulted from SCIs in the US in 2010 alone, placing the national burden of SCIs above other impactful conditions such as human immunodeficiency virus/acquired immune deficiency syndrome. Future investigations may employ DALYs to monitor trends in SCI burden in response to innovations in SCI care and identify subgroups of persons with SCIs for whom tailored interventions might improve DALYs.

Context The National Collegiate Athletic Association and US Department of Defense have called for educational programs to change the culture of concussion reporting, increase reporting behavior, and enhance the safety of players and service members. Objective To evaluate the effects of a novel peer concussion-education program (PCEP) in changing knowledge, attitudes, and norms about concussion reporting among collegiate student-athletes and assess program implementation. Design Randomized controlled trial and qualitative analysis of interviews. Setting National Collegiate Athletic Association athletic teams from randomly selected colleges or universities. Patients or Other Participants A total of 1614 male and female student-athletes from 60 teams at 10 colleges and universities and 8 athletic trainers. Intervention(s) The PCEP intervention trains 2 peer concussion educators to provide 2 education modules to their teammates. Knowledge, attitudes (oneself and teammates), and concussion occurrence or reporting were assessed at baseline, postintervention, and 1 month later. Eight athletic trainers were interviewed about program implementation. Results Compared with the control group, the intervention group showed greater increases occurred postintervention and at 1 month in concussion knowledge (F1,2648 = 51.3, P < .0001), intention to report (oneself, F2,2633 = 82.3, P < .0001; teammates, F2,2624 = 53.9, P < .0001), return-to-play protocol knowledge, (F2,2632 = 28.4, P < .0001), direct subjective norms (oneself, F2,2625 = 51.7, P < .0001; teammates, F2,2644 = 40.6, P < .0001), direct perceived behavioral control (oneself, F2,2628 = 53.7, P < .0001; teammates, F2,2615 = 68.2, P < .0001), and indirect attitudes (oneself, F2,2626 = 47.1, P < .001; teammates, F2,2623 = 40.9, P < .0001). Peer concussion-education program participants discussed concussion more often with a teammate (F1,1396 = 13.96, P < .0001) or athletic staff (F1,1396 = 6.62, P < .001). Qualitative program analysis revealed both positive aspects of the PCEP and areas for improvement. Conclusions The PCEP showed promise in increasing concussion knowledge, intention to report concussion, reporting a teammate's concussion, and facilitating attitudinal changes that support reporting among student-athletes.

ObjectiveThis paper aims to understand spatial and temporal trends in pregabalin prescribing and the relationship with deprivation across England at both general practice and clinical commissioning group (CCG) levels.DesignA set of 207 independent generalised additive models are employed to model the spatiotemporal trend of pregabalin prescribed and dispensed per 1000 population, adjusting for deprivation. The response variable is pregabalin prescribed in milligrams, with weighted Index of Multiple Deprivation (IMD), geographical location and time as predictors. The set of active prescribing facilities grouped within CCG is the unit of analysis.SettingNational Health Service open prescribing data; all general practices in England, UK between January 2015 and June 2017.PopulationAll patients registered to general practices in England, UK.ResultsAdjusting for deprivation, a North–South divide is shown in terms of prescribing trends, with the North of England showing increasing prescribing rates during the study period on average, while in the South of England rates are on average decreasing. Approximately 60% of general practices showed increasing prescribing rate, with the highest being 4.03 (1.75 for the most decreasing). There were no apparent spatial patterns in baseline prescription rates at the CCG level. Weighted IMD score proved to be statistically significant in 138 of 207 CCGs. Two-thirds of CCGs showed more pregabalin prescribed in areas of greater deprivation. Whether the prescribing rate is high due to high baseline prescription rate or increasing rates needs to be specifically looked at.ConclusionsThe spatial temporal modelling demonstrated that the North of England has a significantly higher chance to see increase in pregablin prescriptions compared with the South, adjusted for weighted IMD. Weighted IMD has shown positive impact on pregabalin prescriptions for 138 CCGs.

European Directive 2013/59/EURATOM requires the establishment and use of diagnostic reference levels (DRLs) for diagnostic and interventional procedures. The purpose of this study was to establish local DRLs for a major tertiary public hospital. As the hospital is the only such hospital in Malta, the same data collected for setting local DRLs can also be used for setting national DRLs, making local DRLs de facto national DRLs. A retrospective survey of cumulative kerma-area product (KAP) and fluoroscopy time data from the cardiac catheterisation laboratory and interventional radiology suites was carried out. The effect of system upgrades on cumulative KAP was also assessed. Local DRLs were set for common cardiology and interventional radiology procedures. All DRLs compare favourably with those in European literature. A Philips Allura Clarity upgrade to the cardiac catheterisation laboratories led to significant reductions in cumulative KAP (p ≪ 0.05) for most procedures.

ObjectiveTo delineate trends in types of protein in US adults from 1999 to 2010, we examined the mean intake of beef, pork, lamb or goat, chicken, turkey, fish, dairy, eggs, legumes, and nuts and seeds (grams per kilogram of body weight) among adults and according to subgroups, including chronic disease status.DesignSix cycles of the repeated cross-sectional surveys.SettingNational Health and Nutrition Examination Survey 1999 to 2010.ParticipantsUS adults aged ≥20 years (n 29 145, range: 4252–5762 per cycle).ResultsOverall, mean chicken (0·47 to 0·52 g/kg), turkey (0·09 to 0·13 g/kg), fish (0·21 to 0·27 g/kg) and legume (0·21 to 0·26 g/kg) intake increased, whereas dairy decreased (3·56 to 3·22 g/kg) in US adults (P ConclusionsDespite recommendations to reduce red meat, beef, lamb or goat intake did not change in adults, among those with a chronic disease or with lower socio-economic status.

Objectives To estimate the prevalence of diagnosed traumatic brain injury (TBI) in individuals hospitalized with hip fracture and examine its association with all‐cause mortality. Design Nested cohort study. Setting National sample of Medicare beneficiaries from 2006 to 2010. Participants Beneficiaries aged 65 and older hospitalized with hip fracture. Measurements TBI at the time of hip fracture was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The main outcome was all‐cause mortality during follow‐up. Results Prevalence of TBI in individuals with hip fracture was 2.7%. Absolute risk of mortality attributable to TBI in individuals with hip fracture was 15/100 person‐years. TBI was significantly associated with risk of death in multivariable analysis (hazard ratio=1.24, 95% confidence interval=1.14–1.35). Conclusion TBI was associated with greater risk of mortality in individuals with hip fracture. Practitioners should consider evaluating for presence of TBI in this vulnerable population. J Am Geriatr Soc 67:124–127, 2019.

OBJECTIVES To evaluate the Pittsburgh Fatigability Scale (PFS) as a predictor of performance and functional decline in mobility‐intact older adults. DESIGN Longitudinal analysis of Baltimore Longitudinal Study of Aging data. SETTING National Institute on Aging, Clinical Research Unit, Baltimore, Maryland. PARTICIPANTS Mobility‐intact men (46.8%) and women aged 60 to 89 with concurrent PFS administration and performance and functional assessment and follow‐up assessment within 1 to 4 years (N=579). MEASUREMENTS The PFS is a self‐administered, 1‐page assessment of expected physical and mental fatigue with a score ranging from 0 (no) to 5 (extreme) associated with performing 10 activities. Analyses examined associations between each dimension scored continuously (0–50), categorically (0–5), and dichotomously and change in and likelihood of clinically meaningful decline in usual and fast gait speed, chair stand pace, and reported walking ability. Covariates included age, age2, sex, race, visit status, baseline function, and follow‐up time. We defined meaningful decline as 0.05 m/s per year for usual gait speed, 0.07 m/s per year for fast gait speed, 0.02 chair stands/s per year and 1 point or more for walking ability index. RESULTS Over a mean 2.2 years, 20.5% to 37.7% of participants experienced meaningful decline across assessments. Independent of covariates, higher PFS physical and mental scores were most consistently associated with greater decline in usual gait speed, chair stand pace, and reported walking ability regardless of scoring approach. For example, higher physical fatigability was associated with twice the likelihood of meaningful decline in gait speed as lower physical fatigability (p=.001). PFS scores were superior to fatigue symptoms such as tiredness and energy level in predicting performance decline, which showed no association. CONCLUSION Routine self‐administered perceived fatigability assessment may help identify older persons vulnerable to accelerated mobility decline. J Am Geriatr Soc 66:2092–2096, 2018.

Objectives To examine prostate‐specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices. Design Observational study using serial cross‐sections, 2003 to 2013. Setting National fee‐for‐service Medicare. Participants Men aged 68 and older eligible for prostate cancer screening. Measurements National PSA screening practices in men aged 68 and older from 2003 to 2013 and change in regional screening rates in men aged 75 and older. Results The PSA screening rate in men aged 68 and older was 17.2% in 2003, 22.3% in 2008, and 18.6% in 2013 (p < .001 for all differences); rates ended slightly lower than rates in 2003 only in men 80 and older. Racial disparities in screening became less pronounced over this period. In men aged 75 and older, change in regional screening rates varied widely, with absolute rates growing by 15 per 100 enrollees in some areas and declining by the same amount in others. Areas with high social capital, a measure associated with diffusion of new ideas, were more likely to decline; malpractice intensity and managed care penetration had no effect. Conclusion Studying Medicare enrollees over time, we found little reduction in PSA screening and even increases according to race and in some regions. The heterogeneous changes across regions suggest that consistent reduction in the use of low‐value care may require change strategies that go beyond evidence and guidelines to include monitoring and feedback on performance. J Am Geriatr Soc 67:29–36, 2019.

Introduction In recent years there has been a trend towards centralisation of services for general paediatric surgery in the United Kingdom. Fewer District General Hospitals supply provision of paediatric surgery, placing a strain on Specialist Centres. The cause behind the decline is unclear but lack of interest from general surgical trainees may be a contributing factor. A survey was conducted across current higher surgical trainees to review this. Materials and methods A short online survey (Typeform) was sent nationally to higher general surgical trainees. The results were analysed using SPSS Version 21. Results 121 trainees responded to the survey. Only 29% trainees expressed an interest in pursuing general paediatric surgery as part of their future chosen specialty. The main concerns of trainees in regards to paediatric surgery was a limited training time, perception that a paediatric consultant would be unwilling to train a general surgical trainee, and a concern that ISCP requirements were unattainable in six months. There was no significant difference in opinion between those who had/not completed a paediatric surgical placement. Conclusion There is a growing disinterest of general surgical trainees to pursue paediatric surgery within their future chosen specialty. This is resulting in fewer consultants being qualified to provide the service within a District General Hospital. Trainees often have negative preconceived ideas about the specialty, which may be modified by a positive experience within the specialty.

Objectives To evaluate national trends in electrocardiogram (EKG) monitoring in Veterans Affairs (VA) beneficiaries prescribed high‐dose citalopram before and after the 2011–12 Food and Drug Administration (FDA) safety warnings. Design Interrupted time‐series analyses. Setting National VA healthcare system data linked to Medicare data for veterans dually eligible for VA and Medicare services. Participants Adult VA outpatients prescribed citalopram or sertraline from February 2010 to September 2013 (N=1,068,816). Measurements EKG monitoring for VA outpatients prescribed high‐dose citalopram (>40 mg/d aged ≤60, >20 mg/d aged >60) or sertraline. Results For individuals prescribed high‐dose citalopram, EKG monitoring increased from 9.0% before the start of the first FDA warning to a peak of 12.6% for individuals aged 18 to 60 and from 14.0% to 19.4% for individuals aged 61 to 100. However, following the second FDA warning in 2012, EKG monitoring declined, returning to prewarning levels in both age groups. EKG monitoring did not increase in individuals with a history of previous cardiac risk factors prescribed high‐dose citalopram in either age group. Conclusions EKG frequency did not significantly change in individuals with cardiac risk factors at greatest potential risk for QT prolongation. Lack of responsiveness to the FDA warnings may be due to many factors, including lack of clarity about which individuals should undergo EKG monitoring, provider substitution of alternative antidepressants for citalopram, conflicting evidence regarding risk for adverse cardiac events with high‐dose citalopram use, and lack of provider knowledge regarding the warnings.

Background Half of Americans experience mental illness during their lifetime. Significant opportunity exists for community pharmacists to deliver services to these patients; however, personal and practice-related barriers may prevent full engagement. Objective To assess the demographics, practice characteristics, service provision, stigma, attitudes and beliefs of a national sample of community pharmacists towards individuals with mental illness. Setting National random sample of 3008 community pharmacists in the USA. Method 101-item cross-sectional mailed survey questionnaire on: (1) demographics, (2) knowledge and practice characteristics, (3) provision of clinical pharmacy services, and (4) comparative opinions. Main outcome measure Scaled measures of service provision (comfort, confidence, willingness and interest) and comparative opinions (stigma, attitudes and beliefs) of mental illness, four linear regression models to predict service provision. Results A total of 239 responses were received (response rate 7.95%). Across pharmacy services, ratings for willingness/interest were higher than those for comfort/confidence. Pharmacists who reported providing medication therapy management (MTM) services for patients reported higher comfort (18.36 vs. 17.46, p

Objective To determine which factors (demographic, symptoms, comorbidities, and treatments) are associated with recovery of smell in patients with COVID-19 associated olfactory loss. Study design Prospective, longitudinal questionnaires. Setting National survey. Methods A longitudinal web-based nationwide survey of adults with COVID-19 associated smell and taste loss was launched April 10, 2020. After completing an initial entry survey, participants received detailed follow-up questionnaires 14 days, and 1, 3 and 6 months later. Results As of June 25, 2021, 798 participants met study inclusion criteria and completed 6-month questionnaires. Of demographic characteristics only age

Highlights • Lower-limb vibration detection is similar bilaterally post-transtibial amputation. • Lower-limb vibration detection is comparable to controls post-transtibial amputation. • Vibration detection is uniquely related to balance performance postamputation., Objectives To evaluate differences in vibration perception thresholds between adults with transtibial amputation and age-matched adults without amputation and to examine associations between vibration perception thresholds and balance performance. We hypothesized that adults with transtibial amputation would demonstrate lower thresholds compared with adults without amputation and that lower thresholds would be associated with better functional balance. Design Prospective cross-sectional study. Setting National conference, clinical practice, and university laboratory. Participants Adults (N=34) with a nondysvascular, unilateral, transtibial amputation and 43 age-matched controls without amputation. Interventions Participants’ vibration perception thresholds were evaluated bilaterally by applying a vibration stimulus to the midpatella and recording their verbal response to conscious perception of stimulus. Functional balance was assessed with the Berg Balance Scale and the Four Square Step Test. Main Outcome Measures Residual and sound limb (right and left for controls) vibration perception thresholds, Berg Balance Scale, and Four Square Step Test. Results For participants with transtibial amputation and controls, there were no significant between-group (P=.921) or interlimb (P=.540) differences in vibration perception thresholds. Overall, robust regression models explained 35.1% and 19.3% variance in Berg Balance Scale scores and Four Square Step Test times, respectively. Among adults with transtibial amputation, vibration perception thresholds were negatively associated with Berg Balance Scale scores (P=.009) and positively associated with Four Square Step Test times (P=.048). Among controls, average vibration perception thresholds were not significantly associated with functional balance (P>.050). Conclusions Adults with nondysvascular, transtibial-level amputation demonstrated similar vibration detection compared with adults with intact limbs, indicating that vibration detection is preserved in the amputated region postamputation. These findings suggest a unique relationship between vibration perception and functional balance post-transtibial amputation.

Background Understanding the burden of influenza‐associated severe acute respiratory infection (SARI) is important for setting national influenza surveillance and vaccine priorities. Estimating influenza‐associated SARI rates requires hospital‐based surveillance data and a population‐based denominator, which can be challenging to determine. Objectives We present an application of the World Health Organization's recently developed manual (WHO Manual) including hospital admission survey (HAS) methods for estimating the burden of influenza‐associated SARI, with lessons learned to help others calculate similar estimates. Methods Using an existing SARI surveillance platform in Cambodia, we counted influenza‐associated SARI cases during 2015 at one sentinel surveillance site in Svay Rieng Province. We applied WHO Manual‐derived methods to count respiratory hospitalizations at all hospitals within the catchment area, where 95% of the sentinel site case‐patients resided. We used HAS methods to adjust the district‐level population denominator for the sentinel site and calculated the incidence rate of influenza‐associated SARI by dividing the number of influenza‐positive SARI infections by the adjusted population denominator and multiplying by 100 000. We extrapolated the rate to the provincial population to derive a case count for 2015. We evaluated data sources, detailed steps of implementation, and identified lessons learned. Results We estimated an adjusted influenza‐associated 2015 SARI rate of 13.5/100 000 persons for the catchment area of Svay Rieng Hospital and 77 influenza‐associated SARI cases in Svay Rieng Province after extrapolation. Conclusions Methods detailed in the WHO Manual and operationalized successfully in Cambodia can be used in other settings to estimate rates of influenza‐associated SARI.

SETTING National Institute of Diseases of the Chest and Hospital, Dhaka; Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders, Dhaka; and Chittagong Chest Disease Hospital, Chittagong, Bangladesh. OBJECTIVE To present operational data and discuss the challenges of implementing FAST (Find cases Actively, Separate safely and Treat effectively) as a tuberculosis (TB) transmission control strategy. DESIGN FAST was implemented sequentially at three hospitals. RESULTS Using Xpert® MTB/RIF, 733/6028 (12.2%, 95%CI 11.4-13.0) patients were diagnosed with unsuspected TB. Patients with a history of TB who were admitted with other lung diseases had more than twice the odds of being diagnosed with unsuspected TB as those with no history of TB (OR 2.6, 95%CI 2.2-3.0, P < 0.001). Unsuspected multidrug-resistant TB (MDR-TB) was diagnosed in 89/1415 patients (6.3%, 95%CI 5.1-7.7). Patients with unsuspected TB had nearly five times the odds of being diagnosed with MDR-TB than those admitted with a known TB diagnosis (OR 4.9, 95%CI 3.1-7.6, P < 0.001). Implementation challenges include staff shortages, diagnostic failure, supply-chain issues and reliance on external funding. CONCLUSION FAST implementation revealed a high frequency of unsuspected TB in hospitalized patients in Bangladesh. Patients with a previous history of TB have an increased risk of being diagnosed with unsuspected TB. Ensuring financial resources, stakeholder engagement and laboratory capacity are important for sustainability and scalability.

OBJECTIVE: While some advocates have argued for marijuana as a treatment for tinnitus, the relationship between marijuana use and tinnitus is unknown. The objective of this study was to evaluate associations between marijuana use and the prevalence, severity, and rate of occurrence of tinnitus. STUDY DESIGN: Cross-sectional analysis of nationally representative data. SETTING: National Health and Nutrition Examination Survey 2011–2012. SUBJECTS AND METHODS: Statistical analysis was performed on data collected from 2705 non-institutionalized adults aged 20–69 who underwent audiometric testing and were administered questionnaires about hearing, drug use, current health status, and medical history. RESULTS: The use of marijuana at least once per month for the previous 12 months was significantly associated with experiencing tinnitus during that 12-month month (X(2)(1) = 19.41, p < 0.001). Subjects who used marijuana were more likely to experience tinnitus after accounting for covariables including age, gender, audiometric hearing loss, noise exposure history, depression, anxiety, smoking, salicylate use, cardiovascular disease, hypertension, and diabetes (OR = 1.75, 95% CI 1.02–3.01, p = 0.043). There were no associations between the severity or frequency of tinnitus occurrence and the quantity or frequency of marijuana use. Use of other substances such as alcohol, cocaine, methamphetamine, and heroin was not associated with tinnitus. CONCLUSION: Regular marijuana use is associated with prevalent tinnitus. However, no dose response between marijuana use and tinnitus was observed. The relationship between marijuana use and tinnitus is complex and is likely modulated by psychosocial factors.

BACKGROUND Alcohol use influences HIV disease severity through multiple mechanisms. Whether HIV disease severity is sensitive to changes in alcohol use among people with HIV (PWH) is understudied. SETTING National Veterans Health Administration. METHODS Pairs of AUDIT-C screens within 9-15 months (February 1, 2008-September 30, 2014) were identified among PWH from the Veterans Aging Cohort Study (VACS). Initial and follow-up VACS Index 2.0 pairs obtained 0-270 days after initial and follow-up AUDIT-Cs, respectively, determined change in VACS Index 2.0, a composite HIV severity measure. Change in VACS Index 2.0 was regressed on AUDIT-C change scores (-12 to +12) adjusted for demographics, initial VACS Index 2.0, and days between VACS Index measures. RESULTS Among 23,297 PWH (76,202 observations), most had no (51%) or low-level (38%) alcohol use initially. Most (54%) had no subsequent change; 21% increased and 24% decreased drinking. Initial VACS Index 2.0 scores ranged from 0 to 134, change scores ranged from -65 to +73, with average improvement of 0.76 points (SD 9.48). AUDIT-C change was associated with VACS Index 2.0 change (P < 0.001). Among those with stable alcohol use (AUDIT-C change ≤ │1│ point), VACS Index 2.0 improvements ranged 0.36-0.60 points. For those with maximum AUDIT-C increase (change from 0 to 12), VACS Index 2.0 worsened 3.74 points (95% CI: -4.71 to -2.78); for those with maximum AUDIT-C decrease (change from 12 to 0), VACS Index 2.0 changed minimally [-0.60 (95% CI: -1.43 to 0.23)]. CONCLUSIONS In this national sample, improvement in HIV severity was generally greatest among those with stable alcohol use (primarily those with no use).

Objectives To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures. Design Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions. Setting National databases of 70 million combined patients from 2007 to 2015. Patients/participants Humana and Medicare insured patients. Intervention Surgical treatment of tibial, femoral, and pilon fractures. Main outcome measurements Ninety-day readmission, 90-day complications, and all-time revision surgical intervention. Results The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all). Conclusions Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Childhood disability is on the rise and there is a national shortage of pediatric physiatrists in the United States. The 2009 Pediatric Rehabilitation Medicine Practice Survey identified concerns regarding inadequate geographic dispersion of providers, salary inequities, and limited academic competitiveness and external funding for research. Objective To describe the current state of the field of pediatric rehabilitation medicine. Design Survey of pediatric physiatrists in the United States in 2014 and 2017. Setting National. Participants Pediatric physiatrists INTERVENTIONS: Not applicable. Main outcome measurements Characteristics; clinical activities, responsibilities, and comfort; academic activities; and salaries and productivity. Results In both 2014 and 2017, the majority of pediatric physiatrists who responded were women (~63%) and worked at an academic teaching hospital (~68%). Pediatric physiatrists most commonly held the title of assistant professor and were overrepresented in the Midwest. Overall, 55.8% of providers felt that access was adequate in their area whereas only 3.7% felt access was adequate across the country. In 2017, 52.5% of pediatric physiatrists participated in research or other scholarly activities with 44.2% reporting having published original research at some point in their careers. The inflation adjusted mean salary in 2014 ($227 360) was not statistically different than in 2017 ($232 634, P = .422). In both years, full professors reported the highest academic full-time salaries. Individuals having at least one leadership title also reported significantly higher average full-time salaries than individuals with no titles. Conclusions Although gains have been made in terms of academic competitiveness and engagement in research in pediatric physiatry, there are areas of ongoing concern including large geographic practice variations with associated access to care problems, challenges with recruiting physicians to the field, and salary malalignment within the field of PM&R.

Context Optimal newborn screening thyroid-stimulating hormone (TSH) cut-offs are contentious. Analysis of demographic factors that impact screen TSH levels may help explain international variance and provide guidance to screening programmes. Objective To determine the influence of demographic factors on newborn screening TSH levels and screening performance parameters. Design and setting National, retrospective population study using blood spot TSH cards from the New Zealand newborn screening programme in 2010-2015. Patients 325 685 blood spot cards. Main outcome measures Likelihood of exceeding specific TSH thresholds (TSH ≥5, ≥10 and ≥15 mIU/L) and group-specific screening performance parameters. Results The likelihood of high TSH levels differed between ethnic groups. Pacific Island infants were more than twice as likely to have high-normal TSH levels (≥5 and ≥10 mIU/L) and nearly twice as likely to have a positive screen (≥15 mIU/L) as New Zealand Europeans. Māori or Chinese ethnicity, male sex, younger gestational age and greater socio-economic deprivation scores were also associated with high-normal TSH levels. At a TSH threshold ≥15 mIU/L, screening sensitivity was lowest (88.89% vs 95.83% overall) and PPV greatest (88.89% vs 62.84%) amongst Asian infants. Early samples were more than three times as likely to reach the screen-positive threshold and more likely to yield a false-positive result (PPV 20.00% vs 68.87%, P = 0.004). Conclusions Newborn TSH levels are impacted by a number of demographic variables, particularly ethnicity and age at sample collection. Screening performance may be improved through the use of targeted thresholds.

ObjectiveTo identify risk behaviour patterns for chronic non-communicable diseases (NCD) in the Brazilian population and to investigate associated socio-economic and demographic factors.DesignFactor analysis was used to identify patterns considering the following risk behaviours: consumption of soft drinks/artificial juice, sweet foods, red meat with apparent fat, chicken skin; inadequate consumption of fruits and vegetables; alcohol abuse; smoking; absence of physical activity during leisure time; and time spent watching television. The χ2 test was used to compare ratios. All analyses accounted for weighting factors and the study’s complex sampling design effect. The socio-economic and demographic variables evaluated were gender, age, schooling level and macro region of residence.SettingNational Health Survey, a household survey with national representation, conducted in 2013 in Brazil.ParticipantsIndividuals (n 60202) aged 18 years or over.ResultsFour risk behaviour patterns were identified: ‘Physical inactivity in leisure time and Inadequate consumption of fruits and vegetables’, ‘Saturated fat’, ‘Alcohol and Smoking’ and ‘Sedentary behaviour and Sugar’, explaining 52·01 % of the total variance. Overall, greater adherence to ‘Saturated fat’ and ‘Alcohol and Smoking’ patterns was observed among men and those with lower education level. The ‘Sedentary behaviour and Sugar’ and ‘Physical inactivity in leisure time and Inadequate consumption of fruits and vegetables’ patterns had greater adherence among younger individuals, and the first was associated with higher education whereas the second with less education among individuals residing in the North and Northeast regions.ConclusionsRisk behaviour patterns for NCD were heterogeneous, reflecting the socio-economic and demographic differences in Brazil.

Nigeria has made pledges at various international fora to mainstream renewable energy in its energy mix. In keeping with these pledges, the country's domain for alternative clean energy development is filled with multitudinous policy documents. This paper undertakes a systematic appraisal of the subsisting opportunities, pitfalls and dilemmas surrounding Nigeria's quest for alternative clean energy development. The data for this paper are generated from key informant interviews as well as formal policy documents and scholarly archival materials. The paper finds a huge gap between setting national energy transition targets and realizing same. It further finds that Nigeria is yet to begin its journey of energy transition from fossil fuels to renewable energy in real terms despite ambitious targets and projections. It links it to structural gaps, policy discordance, unconducive investment climate, questionable commitment of stakeholders to transit to renewable energy and inability to attract robust private investments. It recommends institutional overhaul to reposition the energy sector for real transition to green energy systems.