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Abstract Background Depression in children presents a significant health burden to society and often co-exists with chronic illnesses, such as human immunodeficiency virus (HIV). Research has demonstrated that 10–37% of children and adolescents living with HIV also suffer from depression. Low-and-middle income countries (LMICs) shoulder a disproportionate burden of HIV among other health challenges, but reliable estimates of co-morbid depression are lacking in these settings. Prior studies in Rwanda, a LMIC of 12 million people in East Africa, found that 25% of children living with HIV met criteria for depression. Though depression may negatively affect adherence to HIV treatment among children and adolescents, most LMICs fail to routinely screen children for mental health problems due to a shortage of trained health care providers. While some screening tools exist, they can be costly to implement in resource-constrained settings and are often lacking a contextual appropriateness. Methods Relying on international guidelines for diagnosing depression, Rwandan health experts developed a freely available, open-access Child Depression Screening Tool (CDST). To validate this tool in Rwanda, a sample of 296 children with a known diagnosis of HIV between ages 7–14 years were recruited as study participants. In addition to completing the CDST, all participants were evaluated by a mental health professional using a structured clinical interview. The validity of the CDST was assessed in terms of sensitivity, specificity, and a receiver operating characteristic (ROC) curve. Results This analysis found that depression continues to be a co-morbid condition among children living with HIV in Rwanda. For identifying these at-risk children, the CDST had a sensitivity of 88.1% and specificity of 96.5% in identifying risk for depression among children living with HIV at a cutoff score of 6 points. This corresponded with an area under the ROC curve of 92.3%. Conclusions This study provides evidence that the CDST is a valid tool for screening depression among children affected by HIV in a resource-constrained setting. As an open-access and freely available tool in LMICs, the CDST can allow any health practitioner to identify children at risk of depression and refer them in a timely manner to more specialized mental health services. Future work can show if and how this tool has the potential to be useful in screening depression in children suffering from other chronic illnesses.

Abstract Background Rwanda has made substantial economic progress over the past two decades. However, evidence suggests that malnutrition among children remains high in spite of this progress. This study aims to examine trends and potential risk factors associated with childhood stunting from 2000 to 2015 in Rwanda. Methods Data for this study come from the 2000 to 2015 Rwanda’s Demographic and Health Surveys (DHS), a cross-sectional, population-based survey that is conducted every 5 years. Following prior work, we define stunting based on age and weight as reported in the DHS. We assess the overall prevalence of stunting among children under the age of 5 in Rwanda and then conduct bivariate analyses across a range of policy-relevant demographic, socioeconomic, and health variables. We then incorporate key variables in a multivariable analysis to identify those factors that are independently associated with stunting. Results The prevalence of stunting among children under the age of 5 in Rwanda declined from 2000 (47.4%) to 2015 (38.3%), though rates were relatively stagnant between 2000 and 2010. Factors associated with higher rates of stunting included living in the lowest wealth quintile, having a mother with limited education, having a mother that smoked, being of the male sex, and being of low-birth weight. Conclusions Though overall stunting rates have improved nationally, these gains have been uneven. Furthering ongoing national policies to address these disparities while also working to reduce the overall risk of malnutrition will be necessary for Rwanda to reach its overall economic and health equity goals.

The Covid-19 pandemic has exposed critical inequities in global healthcare supply chains and the need for these systems to be analyzed and reoriented with an equity lens. Implementation research methodology can guide the use of evidence-based interventions to re-orient health supply chains towards equity and optimize health outcomes. Using this approach, private and public sector entities can adapt their strategies to focus not just on efficiency and cost savings but ensuring that vulnerable populations have access to essential medications, vaccines, and supplies. Findings can inform regulations that address supply chain inequities at the global level, strengthen existing systems to fill structural gaps at the national level, and address contextual challenges at the subnational level. This methodology can help account for historical practices from prior health initiatives, identify contemporary barriers and facilitators for positive change, and have applicability to the Covid-19 pandemic and ongoing vaccine distribution efforts. An implementation research approach is critical in equipping health supply chains with a path for more resilient and equitable distribution of necessary supplies, vaccines, and delivery of care.

Background Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study’s objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time. Methods and findings This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20–44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%). Conclusions Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs.

Produced water is a problem. This brackish byproduct of oil and gas production contains salts, dissolved solids, organic compounds, and naturally occurring radioactive materials. And that is putting it nicely. Produced water is seen as a liability to oil and gas producers and is generally disposed of via reinjection or open pits. The disposal is costly and creates future environmental hazards. However, through emerging technology and minor alterations to the New Mexico Statutes, this liability can be converted to an asset for all New Mexicans. In 2009, the New Mexico Legislature bifurcated the appropriation method for produced water by the intended future use of the water. Appropriations for certain industrial and agricultural uses are allowed under a truncated appropriation process; while any other use must follow the costlier traditional appropriation method. Under the new rules, oil and gas producers need only file a form with the State to 'appropriate' the water for reinjection or disposal via certain industrial uses. However, if the producer desires to use the produced water in any non-enumerated purpose, including making the water potable, the producer must follow the costly and time consuming traditional appropriation route. By removing this bifurcation, the New Mexico Legislature would encourage producers to actively seek additional uses of what was once deemed a liability. This would reduce environmental concerns and lower overall oil and gas production costs while 'creating' more water resources in an arid state., I. INTRODUCTIONIn 2015, New Mexico oil and gas production generated almost 900 million barrels (1) of briny water that is produced along with oil and gas. This briny water is [...]

We present a collection of analogies that are intended to help students better understand the foreign and often nuanced vocabulary of the genetics curriculum. Why is it called the "wild type"? What is the difference between a locus, a gene, and an allele? What is the functional (versus a rule-based) distinction between dominant and recessive alleles? It is our hope that by using these analogies, teachers at all levels of the K-16 curriculum can appeal to the common experience and common sense of their students, to lay a solid foundation for mastery of genetics and, thereby, to enhance understanding of evolutionary principles.

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.

As the world has transitioned from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs), we have been pleased to observe thoughtful and constructive dialogue among policy-makers, academics, stakeholders, activists, and many others regarding these global policies aimed at improving the health and well-being of the world now and in the future

Research has been conducted on the putative auxin efflux carriers Arabidopsis PIN4. Results indicate that AtPIN4 generates a sink for auxin the quiescent center of the root meristem essential for auxin distribution and patterning.

A cryptic promoter, Palpha, situated between PR and PRM, induces genetic transcription within the OR domain of bacteriophage lambda. The increase in preincubation time reduces the strength of Palpha since many open complexes are formed at PR and PRm as a result of the separation of RNA polymerase from Palpha. Transcription is induced by the open complexes formed at Palpha at any one of the two A residues 46 and 48 bp upstream from PRM. Open complex formation at Palpha is stopped by the up mutations in PRM, and the open complexes developed at Palpha are not stable.

Research has been conducted on microbial population densities of apple leaves. The authors have monitored the changes in these densities via the use of semidestructive approach, and report that the use of this technique to track Aureobasidium pullulans densities on leaves has revealed that the rank order of A. pullulans densities remains the same.

Produced water is a problem. This brackish byproduct of oil and gas production contains salts, dissolved solids, organic compounds, and naturally occurring radioactive materials. And that is putting it nicely. Produced water is seen as a liability to oil and gas producers and is generally disposed of via reinjection or open pits. The disposal is costly and creates future environmental hazards. However, through emerging technology and minor alterations to the New Mexico Statutes, this liability can be converted to an asset for all New Mexicans. In 2009, the New Mexico Legislature bifurcated the appropriation method for produced water by the intended future use of the water. Appropriations for certain industrial and agricultural uses are allowed under a truncated appropriation process; while any other use must follow the costlier traditional appropriation method. Under the new rules, oil and gas producers need only file a form with the State to 'appropriate' the water for reinjection or disposal via certain industrial uses. However, if the producer desires to use the produced water in any nonenumerated purpose' including making the water potable, the producer must follow the costly and time consuming traditional appropriation route. By removing this bifurcation, the New Mexico Legislature would encourage producers to actively seek additional uses of what was once deemed a liability. This would reduce environmental concerns and lower overall oil and gas production costs while 'creating' more water resources in an arid state. [ABSTRACT FROM AUTHOR]

Trauma activation fees are intended to help trauma centers cover the costs of providing lifesaving care at all times, but they have fallen under greater scrutiny because of a lack of regulation and wide variability in charges. We leveraged the federal Hospital Price Transparency rule to systematically describe trauma activation fees as captured in the Turquoise Health database for all Level I-III trauma centers nationally and across payer types. As of April 18, 2023, a total of 38 percent of US trauma centers published trauma activation fees. These fees varied widely by payer type. The minimum fee charged was $40 (for a Medicaid contract); the maximum fees charged were $28,356 (self-pay) and $28,893 (commercial payers). Trauma centers that were larger, metropolitan, located in the West, and associated with proprietary (investor-owned, for-profit) hospitals had higher trauma activation fees. Proprietary hospitals posted fees that were 60 percent higher than those published by public, nonfederal hospitals. Unmerited variation in trauma activation fees may suggest that the current funding strategy is equitable neither for trauma centers nor for the severely injured patients who rely on them for lifesaving care.

Objectives: Recent studies fail to find a consistent relationship between adoption of electronic health records (EHRs) and improved hospital performance. We sought to examine whether the quality of hospital management modifies the association between EHR adoption and outcomes related to cost and quality., Study Design: Retrospective study of a random sample of US acute care hospitals., Methods: Management quality was assessed via phone interviews with clinical managers predominantly from cardiac units in a random sample of 325 hospitals using a validated scale of management practices in 4 areas: operations, performance monitoring, target setting, and talent management. American Hospital Association InformationTechnology Supplement data captured whether or not these hospitals had at least a basic EHR. Acute myocardial infarction (AMI) outcomes included risk-adjusted 30-day mortality, average length-of-stay, and average payment per discharge measured using MedPAR data. Ordinary least squares regressions assessed whether management quality modifies the relationship between EHR adoption and AMI outcomes., Results: While we found no association between EHR adoption and our outcomes, management quality modified the relationship in the predicted direction. For length of stay, the coefficient on the interaction between EHR and management was -1.48 (P = .05) and for payment, it was -7786.74 (P = .014). We did not find strong evidence of effect modification for mortality (coefficient = -0.05; P = .37)., Conclusions: Coupled with ongoing policy efforts to achieve nationwide EHR adoption is a growing unease that our national investment may not result in better, more efficient care. Our study is among the first to offer empirical evidence that management quality may help explain why some hospitals see substantial gains from EHR adoption while others do not.

We describe a novel phenotype in Arabidopsis embryos homozygous for the temperature-sensitive topless-1 mutation. This mutation causes the transformation of the shoot pole into a root. Developing topless embryos fail to express markers for the shoot apical meristem (SHOOT MERISTEMLESS and UNUSUAL FLORAL ORGANS) and the hypocotyl (KNAT1). By contrast, the pattern of expression of root markers is either duplicated (LENNY, J1092) or expanded (SCARECROW). Shifts of developing topless embryos between permissive and restrictive temperatures show that apical fates (cotyledons plus shoot apical meristem) can be transformed to basal fates (root) as late as transition stage. As the apical pole of transition stage embryos shows both morphological and molecular characteristics of shoot development, this demonstrates that the topless 1 mutation is capable of causing structures specified as shoot to be respecified as root. Finally, our experiments fail to show a clear link between auxin signal transduction and topless-1 mutant activity: the development of the apical root in topless mutant individuals is not dependent on the activity of the predicted auxin response factor MONOPTEROS nor is the expression of DR5, a proposed 'auxin maximum reporter', expanded in the apical domain of topless embryos.