Health Affairs

The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing , WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is "deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction," and he called on countries to take action now to contain the virus. "We should double down," he said. "We should be more aggressive." [...].

The worldwide burden of kidney disease is rising, but public awareness remains limited, underscoring the need for more effective communication by stakeholders in the kidney health community. Despite this need for clarity, the nomenclature for describing kidney function and disease lacks uniformity. In June 2019, Kidney Disease: Improving Global Outcomes (KDIGO) convened a Consensus Conference with the goal of standardizing and refining the nomenclature used in the English language to describe kidney function and disease, and of developing a glossary that could be used in scientific publications. Guiding principles of the conference were that the revised nomenclature should be patient-centered, precise, and consistent with nomenclature used in the KDIGO guidelines. Conference attendees reached general consensus on the following recommendations: (i) to use "kidney" rather than "renal" or "nephro-" when referring to kidney disease and kidney function; (ii) to use "kidney failure" with appropriate descriptions of presence or absence of symptoms, signs, and treatment, rather than "end-stage kidney disease"; (iii) to use the KDIGO definition and classification of acute kidney diseases and disorders (AKD) and acute kidney injury (AKI), rather than alternative descriptions, to define and classify severity of AKD and AKI; (iv) to use the KDIGO definition and classification of chronic kidney disease (CKD) rather than alternative descriptions to define and classify severity of CKD; and (v) to use specific kidney measures, such as albuminuria or decreased glomerular filtration rate (GFR), rather than "abnormal" or "reduced" kidney function to describe alterations in kidney structure and function. A proposed 5-part glossary contains specific items for which there was general agreement. Conference attendees acknowledged limitations of the recommendations and glossary, but they considered standardization of scientific nomenclature to be essential for improving communication.

American Journal of Physical Medicine & Rehabilitation 91(7):p 549, July 2012. | DOI: 10.1097/PHM.0b013e318255982e

Team-based learning™ (TBL) is an instructional strategy developed in the business school environment in the early 1990s by Dr Michaelsen who wanted the benefits of small group learning within large classes. In 2001, a US federal granting agency awarded funds for educators in the health sciences to learn about and implement the strategy in their educational programs; TBL was put forward as one such strategy and as a result it is used in over 60 US and international health science professional schools. TBL is very different from problem-based learning (PBL) and other small group approaches in that there is no need for multiple faculty or rooms, students must come prepared to sessions, and individual and small groups of students (teams) are highly accountable for their contributions to team productivity. The instructor must be a content-expert, but need not have any experience or expertise in group process to conduct a successful TBL session. Students do not need any specific instruction in teamwork since they learn how to be collaborative and productive in the process. TBL can replace or complement a lecture-based course or curriculum.

INTRODUCTION: Discussions about sexual health are uncommon in clinical encounters, despite the sexual dysfunction associated with many common health conditions. Understanding of the importance of sexual health and sexual satisfaction in U.S. adults is limited. AIM: To provide epidemiologic data on the importance of sexual health for quality of life and people's satisfaction with their sex lives and to examine how each is associated with demographic and health factors. METHODS: Data are from a cross-sectional self-report questionnaire from a sample of 3,515 English-speaking U.S. adults recruited from an online panel that uses address-based probability sampling. MAIN OUTCOME MEASURES: We report ratings of importance of sexual health to quality of life (single item with five-point response) and the Patient-Reported Outcomes Measurement Information System Satisfaction With Sex Life score (five items, each with five-point responses, scores centered on the U.S. mean). RESULTS: High importance of sexual health to quality of life was reported by 62.2% of men (95% CI = 59.4-65.0) and 42.8% of women (95% CI = 39.6-46.1, P < .001). Importance of sexual health varied by sex, age, sexual activity status, and general self-rated health. For the 55% of men and 45% of women who reported sexual activity in the previous 30 days, satisfaction with sex life differed by sex, age, race-ethnicity (among men only), and health. Men and women in excellent health had significantly higher satisfaction than participants in fair or poor health. Women with hypertension reported significantly lower satisfaction (especially younger women), as did men with depression or anxiety (especially younger men). CONCLUSION: In this large study of U.S. adults' ratings of the importance of sexual health and satisfaction with sex life, sexual health was a highly important aspect of quality of life for many participants, including participants in poor health. Moreover, participants in poorer health reported lower sexual satisfaction. Accordingly, sexual health should be a routine part of clinicians' assessments of their patients. Health care systems that state a commitment to improving patients' overall health must have resources in place to address sexual concerns. These resources should be available for all patients across the lifespan.

The historical evolution of infant feeding includes wet nursing, the feeding bottle, and formula use. Before the invention of bottles and formula, wet nursing was the safest and most common alternative to the natural mother's breastmilk. Society's negative view of wet nursing, combined with improvements of the feeding bottle, the availability of animal's milk, and advances in formula development, gradually led to the substitution of artificial feeding for wet nursing. In addition, the advertising and safety of formula products increased their popularity and use among society. Currently, infant formula-feeding is widely practiced in the United States and appears to contribute to the development of several common childhood illnesses, including atopy, diabetes mellitus, and childhood obesity.

OBJECTIVE: The authors present an accurate and comprehensive snapshot of appendicitis and the practice of appendectomy in the 1990s. METHODS: Appendectomies were performed on 4950 patients in 147 Department of Defense hospitals worldwide over a 12-month period ending January 31, 1993. RESULTS: The median age was 23 years (range, 6 months to 82 years) with 64% males and 36% females. The patients were assigned a diagnosis of normal appendix in 632 (13%) cases, acute appendicitis in 3286 (66%) cases, and perforated appendicitis in 1032 (21%) cases. There were no differences in perforation and normal appendix rates between those operations performed in teaching hospitals versus community hospitals or between high-volume hospitals (> or = 100 appendectomies/year) versus low-volume hospitals. Both a preoperative temperature > or = 100.5 and a preoperative leukocyte count > or = 10,000 were incapable of discriminating between patients with appendicitis and those with a normal appendix. Multivariate analysis showed a significantly increased risk of perforation associated with age younger than or equal to 8 years (38% vs. 18%) and age older than or equal to 45 years (49% vs. 18%). Females had a significantly higher rate of normal appendices (19% vs. 9%) and a lower rate of perforation (18% vs. 23%). The complication rates to include reoperation and intraabdominal sepsis were markedly increased in those patients with perforation. There were four deaths in this series (0.08%). CONCLUSIONS: Despite a marked decline in associated mortality over the past 50 years, rates of perforation and negative appendectomy remain unchanged because they are influenced strongly by factors untouched by the intervening technologic advances.

Women oxidize more lipid and less carbohydrate and protein compared with men during endurance exercise. The increase in fat oxidation is associated with higher intramyocellular lipid content and use as well as greater adipocyte lipolysis. Glucose rates of appearance and disappearance are lower for women than for men, with no change in basal muscle glycogen, and some evidence for muscle glycogen sparing during endurance exercise. Women oxidize less protein compared with men and show lower leucine oxidation during exercise. The consistent and robust finding of higher mRNA abundance for most components of fat-oxidation pathways in women compared with men is directionally consistent with the substrate-oxidation data. A lack of directional consistency between mRNA species involved in carbohydrate and protein metabolism and the known sex differences during exercise implies that fat oxidation is regulated and that carbohydrate and protein oxidation follow by metabolic demand. Administration of 17-beta-estradiol to men recapitulates most of the described sex differences in metabolism and mRNA content. The greater fat oxidation for women during submaximal endurance exercise compared with men seems to occur partly through a sex hormone-mediated enhancement of lipid-oxidation pathways.

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) share phenotypic and pathologic overlap. Recently, an expansion of GGGGCC repeats in the first intron of C9orf72 was found to be a common cause of both illnesses; however, the molecular pathogenesis of this expanded repeat is unknown. Here we developed both Drosophila and mammalian models of this expanded hexanucleotide repeat and showed that expression of the expanded GGGGCC repeat RNA (rGGGGCC) is sufficient to cause neurodegeneration. We further identified Pur α as the RNA-binding protein of rGGGGCC repeats and discovered that Pur α and rGGGGCC repeats interact in vitro and in vivo in a sequence-specific fashion that is conserved between mammals and Drosophila. Furthermore, overexpression of Pur α in mouse neuronal cells and Drosophila mitigates rGGGGCC repeat-mediated neurodegeneration, and Pur α forms inclusions in the fly eye expressing expanded rGGGGCC repeats, as well as in cerebellum of human carriers of expanded GGGGCC repeats. These data suggest that expanded rGGGGCC repeats could sequester specific RNA-binding protein from their normal functions, ultimately leading to cell death. Taken together, these findings suggest that the expanded rGGGGCC repeats could cause neurodegeneration, and that Pur α may play a role in the pathogenesis of amyotrophic lateral sclerosis and frontotemporal dementia.

The authors analyze the challenges to using academic measures (MCAT scores and GPAs) as thresholds for admissions and, for applicants exceeding the threshold, using personal qualities for admission decisions; review the literature on using the medical school interview and other admission data to assess personal qualities of applicants; identify challenges of developing better methods of assessing personal qualities; and propose a unified system for assessment. The authors discuss three challenges to using the threshold approach: institutional self-interest, inertia, and philosophical and historical factors. Institutional self-interest arises from the potential for admitting students with lower academic credentials, which could negatively influence indicators used to rank medical schools. Inertia can make introducing a new system complex. Philosophical and historical factors are those that tend to value maximizing academic measures. The literature identifies up to 87 different personal qualities relevant to the practice of medicine, and selecting the most salient of these that can be practically measured is a challenging task. The challenges to developing better personal quality measures include selecting and operationally defining the most important qualities, measuring the qualities in a cost-effective manner, and overcoming "cunning" adversaries who, with the incentive and resourcefulness, can potentially invalidate such measures. The authors discuss potential methods of measuring personal qualities and propose a unified system of assessment that would pool resources from certification and recertification efforts to develop competencies across the continuum with a dynamic, integrated approach to assessment.

Ethnography is a type of qualitative research that gathers observations, interviews and documentary data to produce detailed and comprehensive accounts of different social phenomena. The use of ethnographic research in medical education has produced a number of insightful accounts into its role, functions and difficulties in the preparation of medical students for clinical practice. This AMEE Guide offers an introduction to ethnography - its history, its differing forms, its role in medical education and its practical application. Specifically, the Guide initially outlines the main characteristics of ethnography: describing its origins, outlining its varying forms and discussing its use of theory. It also explores the role, contribution and limitations of ethnographic work undertaken in a medical education context. In addition, the Guide goes on to offer a range of ideas, methods, tools and techniques needed to undertake an ethnographic study. In doing so it discusses its conceptual, methodological, ethical and practice challenges (e.g. demands of recording the complexity of social action, the unpredictability of data collection activities). Finally, the Guide provides a series of final thoughts and ideas for future engagement with ethnography in medical education. This Guide is aimed for those interested in understanding ethnography to develop their evaluative skills when reading such work. It is also aimed at those interested in considering the use of ethnographic methods in their own research work.

Teamwork is integral to a working environment conducive to patient safety and care. Team training is one methodology designed to equip team members with the competencies necessary for optimizing teamwork. There is evidence of team training's effectiveness in highly complex and dynamic work environments, such as aviation and health care. However, most quantitative evaluations of training do not offer any insight into the actual reasons why, how, and when team training is effective. To address this gap in understanding, and to provide guidance for members of the health care community interested in implementing team training programs, this article presents both quantitative results and a specific qualitative review and content analysis of team training implemented in health care. Based on this review, we offer eight evidence-based principles for effective planning, implementation, and evaluation of team training programs specific to health care.

BACKGROUND: New psychoactive substances constitute a growing and dynamic class of abused drugs in the United States. On July 12, 2016, a synthetic cannabinoid caused mass intoxication of 33 persons in one New York City neighborhood, in an event described in the popular press as a "zombie" outbreak because of the appearance of the intoxicated persons. METHODS: We obtained and tested serum, whole blood, and urine samples from 8 patients among the 18 who were transported to local hospitals; we also tested a sample of the herbal "incense" product "AK-47 24 Karat Gold," which was implicated in the outbreak. Samples were analyzed by means of liquid chromatography-quadrupole time-of-flight mass spectrometry. RESULTS: The synthetic cannabinoid methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate (AMB-FUBINACA, also known as MMB-FUBINACA or FUB-AMB) was identified in AK-47 24 Karat Gold at a mean (±SD) concentration of 16.0±3.9 mg per gram. The de-esterified acid metabolite was found in the serum or whole blood of all eight patients, with concentrations ranging from 77 to 636 ng per milliliter. CONCLUSIONS: The potency of the synthetic cannabinoid identified in these analyses is consistent with strong depressant effects that account for the "zombielike" behavior reported in this mass intoxication. AMB-FUBINACA is an example of the emerging class of "ultrapotent" synthetic cannabinoids and poses a public health concern. Collaboration among clinical laboratory staff, health professionals, and law enforcement agencies facilitated the timely identification of the compound and allowed health authorities to take appropriate action.

Orthopaedic surgeons, like all physicians, must make clinical decisions based on the best available evidence. This evidence comes from individual clinical experience and external sources1. Although clinical experience is left to the physician, the medical and surgical literature provides the best external evidence. To facilitate the process of determining the best evidence to answer a clinical question, The Journal of Bone & Joint Surgery assigns level of evidence (LOE) ratings to all clinical articles. Since 20032, The Journal has used a hierarchical rating system based on the recommendations of the Centre for Evidence-Based Medicine (CEBM) in Oxford, United Kingdom, to rank articles according to the study design used to answer the primary research question3. In 2011, the CEBM updated its recommendations. After robust internal and external discussion, The Journal has decided to keep pace with the CEBM and has updated our LOE table. The new LOE table emphasizes the clinical applications of research findings and encourages a more holistic assessment of study design and execution. Those familiar with the original table will notice that this update retains many features of its predecessor4. Nonclinical articles (such as cadaveric and animal studies) are still excluded from the ranking system, studies are still divided by type (therapeutic, prognostic, diagnostic, or economic analysis), and much of the ranking criteria remains the same. Although the new table borrows from the original, it also represents an important departure. The most apparent change is structural. The rows and columns have been transposed, and there is an additional column for clinical questions. This new design reflects the order and the types of questions that arise in the process of clinical care. In this way, the table continues to provide a hierarchy of evidence, but it also assumes a new role, guiding busy clinicians to the best available evidence in real time. Whereas interaction with the original table was limited to authors and editors, the new table will engage readers more directly. Readers are encouraged to formulate their clinical question and to consult the table to determine how to conduct their search. For example, if a clinician asks, “does this intervention help?” the table will direct the reader to seek Therapeutic Level-I (randomized controlled trial) studies first, followed sequentially by Levels II (prospective cohort), III (retrospective cohort), and IV (case series). For clinicians who already perform literature searches in this fashion, the table’s increased accessibility will provide transparency to The Journal’s process of assigning LOEs. Another important update is the table footnote that allows authors and editors to grade Level-I through IV studies upward due to “dramatic effect” or downward on the basis of “study quality, imprecision, or indirectness or because the absolute effect size is very small.” The criteria in the table still guide the process, but this increased flexibility allows for more appropriate LOE assignments when the decision is not obvious. It is also important to note that, although this table is based on CEBM recommendations, we chose not to follow CEBM’s policy of reserving the Level-I designation for systematic reviews. Systematic reviews are important, but we believe that high-quality original research merits an equally high LOE5. Additionally, The Journal recently published guidelines for the submission of systematic reviews and meta-analyses6. Lastly, the section on “Economic and Decision Analyses” was eliminated from the CEBM table, but we have elected to include these studies, now referred to as “Economic” in our table, as they are very important in orthopaedic surgery. These research methodologies are performed with use of preexisting data. The quality of these data and the type of analysis affect the LOE7,8. In probabilistic sensitivity analysis, each realization of a parameter is drawn from a prespecified distribution. In stochastic sensitivity analysis, the parameter values are selected from plausible ranges, for example, within the 95% confidence interval of the point estimate. We view the LOE system as a guide to help determine the robustness of research quality but caution that a higher LOE does not necessarily reflect the clinical importance of a given study. The reader is still responsible for examining each article critically and deciding what constitutes the best external evidence for his or her specific clinical question. The Journal publishes studies based on quality of evidence and clinical importance and will continue to take both into account. - Levels of Evidence for Primary Research Question1,2 Study Type Question Level I Level II Level III Level IV Level V Diagnostic—Investigating a diagnostic test Is this (early detection) test worthwhile? • Randomized controlled trial • Prospective3 cohort4 study • Retrospective5 cohort4 study• Case-control6 study • Case series • Mechanism-based reasoning Is this diagnostic or monitoring test accurate? • Testing of previously developed diagnostic criteria (consecutive patients with consistently applied reference standard and blinding) • Development of diagnostic criteria (consecutive patients with consistently applied reference standard and blinding) • Nonconsecutive patients• No consistently applied reference standard • Poor or nonindependent reference standard • Mechanism-based reasoning Prognostic—Investigating the effect of a patient characteristic on the outcome of a disease What is the natural history of the condition? • Inception3 cohort study (all patients enrolled at an early, uniform point in the course of their disease) • Prospective3 cohort4 study (patients enrolled at different points in their disease)• Control arm of randomized trial • Retrospective5 cohort4 study• Case-control6 study • Case series • Mechanism-based reasoning Therapeutic—Investigating the results of a treatment Does this treatment help? What are the harms?7 • Randomized controlled trial • Prospective3 cohort4 study• Observational study with dramatic effect • Retrospective5 cohort4 study• Case-control6 study • Case series• Historically controlled study • Mechanism-based reasoning Economic Does the intervention offer good value for dollars spent? Computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level-I studies, lifetime time duration, outcomes expressed in dollars per quality-adjusted life years (QALYs) and uncertainty examined using probabilistic sensitivity analyses Computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level-II studies, lifetime time duration, outcomes expressed in dollars per QALYs and uncertainty examined using probabilistic sensitivity analyses Computer simulation model (Markov model) with inputs derived from Level-II studies, relevant time horizon, less than lifetime, outcomes expressed in dollars per QALYs and stochastic multilevel sensitivity analyses Decision tree over the short time horizon with input data from original Level-II and III studies and uncertainty is examined by univariate sensitivity analyses Decision tree over the short time horizon with input data informed by prior economic evaluation and uncertainty is examined by univariate sensitivity analyses 1.This chart was adapted from OCEBM Levels of Evidence Working Group, “The Oxford 2011 Levels of Evidence,” Oxford Centre for Evidence-Based Medicine, http://www.cebm.net/ocebm-levels-of-evidence/. A glossary of terms can be found here: http://www.cebm.net/glossary/.2.Level-I through IV studies may be graded downward on the basis of study quality, imprecision, indirectness, or inconsistency between studies or because the effect size is very small; these studies may be graded upward if there is a dramatic effect size. For example, a high-quality randomized controlled trial (RCT) should have ≥80% follow-up, blinding, and proper randomization. The Level of Evidence assigned to systematic reviews reflects the ranking of studies included in the review (i.e., a systematic review of Level-II studies is Level II). A complete assessment of the quality of individual studies requires critical appraisal of all aspects of study design.3.Investigators formulated the study question before the first patient was enrolled.4.In these studies, “cohort” refers to a nonrandomized comparative study. For therapeutic studies, patients treated one way (e.g., cemented hip prosthesis) are compared with those treated differently (e.g., cementless hip prosthesis).5.Investigators formulated the study question after the first patient was enrolled.6.Patients identified for the study on the basis of their outcome (e.g., failed total hip arthroplasty), called “cases,” are compared with those who did not have the outcome (e.g., successful total hip arthroplasty), called “controls.”7.Sufficient numbers are required to rule out a common harm (affects >20% of participants). For long-term harms, follow-up duration must be sufficient.

Each year, the American Cancer Society (ACS) publishes a summary of its recommendations for early cancer detection, including guideline updates, emerging issues that are relevant to screening for cancer, and a summary of the most current data on cancer screening rates for US adults. In 2006, there were no updates to ACS guidelines for early cancer detection. In this issue of the journal, we describe criteria for successful screening, discuss recent evidence and policy changes that have implications for cancer screening, summarize the ACS guidelines and describe guidelines reviews that are underway, and provide an update of the most recent data pertaining to participation rates in cancer screening from the Centers for Disease Control and Prevention's (CDC's) Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (NHIS).

In previous articles, I have developed two inter-linked lines of argument. The first has been that the complexity of public services delivery in the twenty-first century has moved beyond a situatio...

Science advances on a foundation of trusted discoveries. Reproducing an experiment is one important approach that scientists use to gain confidence in their conclusions. Recently, the scientific community was shaken by reports that a troubling proportion of peer-reviewed preclinical studies are not reproducible. Because confidence in results is of paramount importance to the broad scientific community, we are announcing new initiatives to increase confidence in the studies published in Science . For preclinical studies (one of the targets of recent concern), we will be adopting recommendations of the U.S. National Institute of Neurological Disorders and Stroke (NINDS) for increasing transparency. * Authors will indicate whether there was a pre-experimental plan for data handling (such as how to deal with outliers), whether they conducted a sample size estimation to ensure a sufficient signal-to-noise ratio, whether samples were treated randomly, and whether the experimenter was blind to the conduct of the experiment. These criteria will be included in our author guidelines.

OBJECTIVE: Examine substance use and mental health issues among U.S. military personnel. METHODS: Data were from the 2008 (and before) population-based Department of Defense Health Related Behavior Surveys. The sample size for the 2008 survey was 28,546 (70.6% response rate). RESULTS: Analyses examined substance use, stress, depression, post-traumatic stress disorder (PTSD), suicidal ideation and attempts, deployment, and job satisfaction. Trends show reductions in tobacco use and illicit drug use, but increases in prescription drug misuse, heavy alcohol use, stress, PTSD, and suicidal attempts. Deployment exacerbated some of these behavior changes. Despite the demanding lifestyle, job satisfaction was high. CONCLUSIONS: The military has shown progress in decreasing cigarette smoking and illicit drug use. Additional emphasis should be placed on understanding increases in prescription drug misuse, heavy alcohol use, PTSD, and suicide attempts, and on planning additional effective interventions and prevention programs. Challenges remain in understanding and addressing military mental health needs.

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Anticipating the future under the influence of climate change is one of the most important challenges of our time, and the topic of the special section in this issue of Science (see p. 472). The natural systems that provide oxygen, clean water, food, storm and erosion protection, natural products, and the potential for future resources, such as new genetic stocks for cultivation, must be protected, not just because it is part of good stewardship but also so that they can take care of us. But even the first step of modeling the effects of greenhouse gas sources and sinks on future temperatures requires input from atmospheric scientists, oceanographers, ecologists, economists, policy analysts, and others. The problem is even more difficult because the very factors that influence temperature changes, such as ocean circulation and terrestrial ecosystem responses, will themselves be altered as the climate changes.With so many potential climate-sensitive factors to consider, scientists need ways to narrow down the range of possible environmental outcomes so that they know what specific problems to tackle.