A US perspective on closing the carbon cycle to defossilize difficult-to-electrify segments of our economy.

Electrification to reduce or eliminate greenhouse gas emissions is essential to mitigate climate change. However, a substantial portion of our manufacturing and transportation infrastructure will be difficult to electrify and/or will continue to use carbon as a key component, including areas in aviation, heavy-duty and marine transportation, and the chemical industry. In this Roadmap, we explore how multidisciplinary approaches will enable us to close the carbon cycle and create a circular economy by defossilizing these difficult-to-electrify areas and those that will continue to need carbon. We discuss two approaches for this: developing carbon alternatives and improving our ability to reuse carbon, enabled by separations. Furthermore, we posit that co-design and use-driven fundamental science are essential to reach aggressive greenhouse gas reduction targets.

Methods for health workforce projection model: systematic review and recommended good practice reporting guideline.

BACKGROUND: Health workforce projection models are integral components of a robust healthcare system. This research aims to review recent advancements in methodology and approaches for health workforce projection models and proposes a set of good practice reporting guidelines. METHODS: We conducted a systematic review by searching medical and social science databases, including PubMed, EMBASE, Scopus, and EconLit, covering the period from 2010 to 2023. The inclusion criteria encompassed studies projecting the demand for and supply of the health workforce. PROSPERO registration: CRD 42023407858. RESULTS: Our review identified 40 relevant studies, including 39 single countries analysis (in Australia, Canada, Germany, Ghana, Guinea, Ireland, Jamaica, Japan, Kazakhstan, Korea, Lesotho, Malawi, New Zealand, Portugal, Saudi Arabia, Serbia, Singapore, Spain, Thailand, UK, United States), and one multiple country analysis (in 32 OECD countries). Recent studies have increasingly embraced a complex systems approach in health workforce modelling, incorporating demand, supply, and demand-supply gap analyses. The review identified at least eight distinct types of health workforce projection models commonly used in recent literature: population-to-provider ratio models (n = 7), utilization models (n = 10), needs-based models (n = 25), skill-mixed models (n = 5), stock-and-flow models (n = 40), agent-based simulation models (n = 3), system dynamic models (n = 7), and budgetary models (n = 5). Each model has unique assumptions, strengths, and limitations, with practitioners often combining these models. Furthermore, we found seven statistical approaches used in health workforce projection models: arithmetic calculation, optimization, time-series analysis, econometrics regression modelling, microsimulation, cohort-based simulation, and feedback causal loop analysis. Workforce projection often relies on imperfect data with limited granularity at the local level. Existing studies lack standardization in reporting their methods. In response, we propose a good practice reporting guideline for health workforce projection models designed to accommodate various model types, emerging methodologies, and increased utilization of advanced statistical techniques to address uncertainties and data requirements. CONCLUSIONS: This study underscores the significance of dynamic, multi-professional, team-based, refined demand, supply, and budget impact analyses supported by robust health workforce data intelligence. The suggested best-practice reporting guidelines aim to assist researchers who publish health workforce studies in peer-reviewed journals. Nevertheless, it is expected that these reporting standards will prove valuable for analysts when designing their own analysis, encouraging a more comprehensive and transparent approach to health workforce projection modelling.

Immunohistochemistry and immunofluorescence utilization audit by subspecialty in an academic setting: A step toward stewardship.

There are immunohistochemistry (IHC) and immunofluorescence (IF) panels described in the literature and established by personal and institutional experiences that are in common use by pathologists in their daily practice. Stewardship is a difficult discussion because IHC utilization is influenced by many factors including the pathologist's experience, background, practice setting, personal bias, and medicolegal culture. We developed the methodology to audit the IHC/IF utilization in our academic subspecialty practice. We aim to share this methodology and to provide our data that can be used for consideration by other subspecialized academic practices. This analysis included a total of 63,157 specimens that were accessioned during 2022, representing 38,612 cases. The likelihood of ordering IHC/IF ranged from 1 % (in genitourinary pathology) to 59 % (in renal pathology). The average percentage of specimens with IHC/IF was 21 % for the entire practice. In cases where IHC/IF was ordered, the number of stained slides averaged 4.9 per specimen for the entire practice. The number of IHC/IF slides per specimen ranged from 1.9 (in gastrointestinal pathology) to 12.2 (in renal pathology). The highest number of antibodies ordered for a single specimen by subspecialty ranged from 11 (in cardiac pathology) to 63 (in dermatopathology). Renal pathology was the only subspecialty that had an average number of IHC/IF slides that was statistically significantly different from all other subspecialties. We described the various patterns of utilization by subspecialty and rationalized their subtle differences. We also analyzed the types of cases that exceeded the reimbursement limits set by the Centers for Medicare and Medicaid Services (CMS).

Assessment of bladder filling during prostate cancer radiation therapy with ultrasound and cone-beam CT.

Prostate cancer patients undergoing external beam radiation therapy (EBRT) benefit from a full bladder to decrease bowel and bladder toxicity. Ultrasound may offer a proxy metric for evaluation, sparing CBCT dosing. Patients were prospectively enrolled pre-simulation from January 2017 to February 2018. Bladder volume was evaluated prior to RT using US daily and CBCT for three daily treatments and then weekly unless otherwise indicated. 29 patients completed median 40 days of RT, resulting in 478 CBCT and 1,099 US bladder volumes. 21 patients were treated to intact glands and 8 to the post-prostatectomy bed. Median patient age was 70 years. Bladder volume on CBCT and US positively correlated (r = 0.85), with average bladder volume for all patients of 162 mL versus 149 mL, respectively. Bladder volume during treatment was consistently lower than the volume at CT simulation (153 mL vs 194 mL, p<0.01) and progressively declined during treatment. Patients older than 70 years presented with lower average bladder volumes than those < 70 years (122 mL vs 208 mL, respectively, p<0.01). Patients with the highest agreement between CBCT and US (<10% variability) had higher average bladder volumes (192 mL vs 120 mL, p=0.01). US was found to be an accurate measure of bladder volume and may be used to monitor daily bladder volumes in patients being treated with radiation for prostate cancer.

Impact of the monetary value of housing assistance on adult health outcomes.

OBJECTIVE: To assess the impact of the dollar value of federal low-income housing assistance on adult health outcomes and whether this impact varies across housing assistance programs. DATA SOURCES: We use the National Health Interview Survey (NHIS) from 1999 to 2016 linked with administrative records from the Department of Housing and Urban Development (HUD) tracking receipt of low-income housing assistance from 1999 to 2017. DESIGN: We use two approaches to assess the impact of the value of housing assistance among HUD housing assistance recipients on outcomes capturing overall health and mental health, chronic and acute health conditions, health care hardship, and food insecurity. First, we use multivariable regression models that adjust for a wide array of possible confounders. Second, we use an instrumental variable approach in which the county-level supply of HUD housing serves as an instrument for the value of housing assistance. DATA COLLECTION/EXTRACTION METHODS: Our sample includes all 12,031 adult HUD linkage-eligible NHIS respondents who were currently in HUD housing at the time of their NHIS interview. PRINCIPAL FINDINGS: We find the most consistent associations between the value of housing assistance and measures of health care hardship, a relationship that is most robust for Housing Choice Voucher recipients, where we find a $100 increase in the value of housing assistance is associated with a 6.2 percentage point decrease in probability of needing but not being able to afford medical care. We find little evidence that the value of housing assistance impacts overall health or chronic health outcomes. CONCLUSIONS: The relationship between the value of housing assistance and health likely operates via an income effect, wherein receipt of a more valuable benefit frees up resources to spend on needed care. Policy changes to increase the value of housing assistance may have tangible health benefits for tenants receiving housing assistance.

The 2016 Presidential Election, the Public Charge Rule, and Food and Nutrition Assistance Among Immigrant Households.

Objectives. To investigate whether the 2016 US presidential election and the subsequent leak of a proposed change to the public charge rule reduced immigrant families' participation in food and nutrition assistance programs. Methods. We used nationally representative data on n = 57 808 households in the United States from the 2015-2018 Current Population Survey-Food Security Supplement. We implemented difference-in-difference-in-difference analyses to investigate whether the election and proposed rule change produced decreases in immigrant families' participation in food and nutrition assistance programs and whether such decreases varied according to state policy generosity toward immigrants. Results. Findings indicate significant and large decreases in Supplemental Nutrition Assistance Program, School Breakfast Program, and National School Lunch Program participation among immigrants in moderately generous states but no changes to receipt of food assistance from nongovernmental sources or to household food insecurity. Conclusions. Both anti-immigrant rhetoric and the perceived threat of policy enactment can be enough to produce chilling effects that have potentially serious implications for the health of immigrant households and thus the health of the nation. (Am J Public Health. 2022;112(12):1738-1746. https://doi.org/10.2105/AJPH.2022.307011).

Risk Assessment of Human Papillomavirus-Positive Cytology-Negative Cervical Cancer Screening in Black and White Women.

OBJECTIVES: As we move toward human papillomavirus (HPV) only as the preferred cervical cancer screening method, we performed a retrospective analysis of Black and White women with negative cytology (Papanicolaou negative [PAPneg]) and positive high-risk HPV (hrHPV) (HPVpos) results and determined follow-up. METHODS: We searched our pathology data system for patients with PAPneg/HPVpos results (2017-2019). Follow-up data were reviewed (39 months), and a comparison among race was performed. RESULTS: In total, 1,728 patients were identified (Black, 53%; White, 47%). Twenty-nine percent of the patients had no follow-up with no difference among the races. HPV 16 was more common among Whites (P < .01), while non-16/18 hrHPV was more common among Black patients (P = .01). A total of 30 (3.3%) Black and 26 (3.2%) White patients were diagnosed with cervical intraepithelial neoplasia grade 2/3 (CIN 2/3). More White women were diagnosed on biopsy alone (negative endocervical curettage) compared with Black women (20 vs 9, P < .01). Meanwhile, there were 21 Black and 6 White women with CIN 2/3 on endocervical curettage (P = .01). CONCLUSIONS: Follow-up of women with PAPneg/HPVpos remains a challenge. There was no disparity in follow-up when cohorts were compared. However, Black women had higher numbers of high-grade intraepithelial lesions on endocervical curettage.

SNAP participation and the health and health care utilisation of low-income adults and children.

OBJECTIVE: This article examined whether participation in the Supplemental Nutrition Assistance Program (SNAP) produced changes to adult and child health and health care utilisation during a period of economic recession. DESIGN: Instrumental variables analysis relying on variation in state SNAP policies to isolate exogenous variation in household SNAP participation. SETTING: Nationally representative data on child and adult health from the 2008 to 2013 National Health Interview Survey. PARTICIPANTS: Participants were 92 237 adults and 45 469 children who were either eligible for SNAP based on household income and state eligibility rules or were low income but not eligible for SNAP benefits. RESULTS: For adults, SNAP participation increased the probability of reporting very good or excellent health, and for both adults and children, reduced needing but having to go without dental care or eyeglasses. The size of these benefits was especially pronounced for children. However, SNAP participation increased the probability of needing but not being able to afford prescription medicine, and increased psychological distress for adults and behavioural problems for children under age 10. CONCLUSIONS: SNAP's benefits for adult health and improved access to dental and vision care for adults and children suggest benefits from the program's expansions during the current COVID-induced crisis. Predicted negative effects of SNAP participation suggest the need for attention to program and benefit structure to avoid harm and the need for continued research to explore the causal effects of program participation.

The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study.

STUDY OBJECTIVE: Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care. METHODS: This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt. RESULTS: Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED. CONCLUSION: ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.

The impacts of agroforestry interventions on agricultural productivity, ecosystem services, and human well-being in low- and middle-income countries: A systematic review.

Background: Agroforestry, the intentional integration of trees or other woody perennials with crops or livestock in production systems, is being widely promoted as a conservation and development tool to help meet the 2030 UN Sustainable Development Goals. Donors, governments, and nongovernmental organizations have invested significant time and resources into developing and promoting agroforestry policies and programs in low- and middle-income countries (LMICs) worldwide. While a large body of literature on the impacts of agroforestry practices in LMICs is available, the social-ecological impacts of agroforestry interventions is less well-studied. This knowledge gap on the effectiveness of agroforestry interventions constrains possibilities for evidence-based policy and investment decisions to advance sustainable development objectives. Objectives: The primary objective of this Campbell systematic review was to synthesize the available evidence on the impacts of agroforestry interventions in LMICs on agricultural productivity, ecosystem services, and human well-being. The secondary objectives were to identify key pathways through which agroforestry interventions lead to various outcomes and how the interventions affect different sub-groups of the population. Search Methods: This review is based on a previously created evidence and gap map (EGM) of studies evaluating the impacts of agroforestry practices and interventions on agricultural productivity, ecosystem services, and human well-being. We included published and unpublished literature in the English language covering the period between 2000 and October 20, 2017. We searched six academic databases and 19 organization websites to identify potentially relevant studies. The search was conducted for our EGM in mid-2017, and we did not conduct an additional search for this systematic review. Selection Criteria: We included randomized control trials (RCTs) and quasi-experimental studies assessing the effect of an agroforestry intervention on at least one outcome measure of agricultural productivity, ecosystem services, or human well-being for farmers and their farmland in LMICs. Agroforestry interventions include any program or policy designed to promote and support the adoption or maintenance of agroforestry practices, which include trees on farms, silvopasture, shade-grown crops, and homegardens with trees, among others. Moreover, the studies needed to include a nonagroforestry comparator, such as conventional agriculture or forestry systems or a before-after comparison. Data Collection and Analysis: We used a standardized data extraction spreadsheet to extract details about each included study. We also used a standardized form to assess risk of bias for each of the included studies in this SR. Meta-analysis techniques were used to combine and synthesize effect size estimates for the outcomes measures that had sufficient data. We used a random effects models for the meta-analyses and use Hedge's g (difference in means divided by the pooled standard deviation) to report effect size estimates. The outcomes without enough evidence for meta-analysis were discussed narratively. Main Results: We identified 11 studies across nine countries, all of which used quasi-experimental methods. Overall, the quality of the evidence base was assessed as being low. Studies were rated as having high or critical risk of bias if they failed to convincingly address more than one of the main potential sources of bias, namely selection bias, group equivalence, and spillover effects. Given the low number of studies and the high risk of bias of the evidence base, the results of this SR are limited and should be considered a baseline for future work. The results of the meta-analysis for impacts on yields indicated that agroforestry interventions overall may lead to a large, positive impact on yield (Hedge's g = 1.16 [-0.35, 2.67] (p = .13)), though there was high heterogeneity in the results (I 2 = 98.99%, τ 2 = 2.94, Q(df = 4) = 370.7). There were positive yield impacts for soil fertility replenishment practices, including incorporating trees in agricultural fields and improved fallow practices in fields where there are severe soil fertility issues. In other cases, incorporating trees into the production system reduced productivity and took land out of production for conservation benefits. These systems generally used an incentive provision scheme to economically offset the reductions in yields. The result of the meta-analysis on income suggests that agroforestry interventions overall may lead to a small, positive impact on income (Hedge's g = 0.12 [-0.06, 0.30] (p = .20)), with moderately high heterogeneity in the results (I 2 = 75.29%, τ 2 = 0.04, Q(df = 6) = 19.16). In cases where improvement yields were reported, there were generally attendant improvements in income. In the cases where payments were provided to offset the potential loss in yields, incomes also generally improved, though there were mixed results for the certification programs and the tenure security permitting scheme. One program, which study authors suggested may have been poorly targeted, had negative yield impacts. There was not enough comparable evidence to quantitatively synthesize the impacts of agroforestry interventions on nutrition and food security outcomes, though the results indicted positive or neutral impacts on dietary diversity and food intake were likely. Surprisingly, there was little evidence on the impacts of agroforestry interventions on environmental outcomes, and there was no consistency of environmental indicator variables used. However, what has been studied indicates that the environmental benefits are being achieved to at least some extent, consistent with the broader literature on agroforestry practices. The evidence base was insufficient to evaluate the interaction between environmental and social impacts. Several studies explicitly considered variable impacts across different population sub-groups, including differential impacts on small-holders versus large-holders, on woman-headed households versus male-headed households, and on richer groups versus poorer groups. Small-holder farmers typically experienced the most positive effect sizes due to the agroforestry interventions. Women and poorer groups had mixed outcomes relative to men and richer households, highlighting the importance of considering these groups in intervention design. Authors' Conclusions: There is limited evidence of the impacts of agroforestry interventions, restricting our ability to draw conclusions on the effect sizes of different intervention types. The existing evidence forms a baseline for future research and highlights the importance of considering equity and socio-economic factors in determining suitable intervention design. Some key implications for practice and policy include investing in programs that include pilot programs, funding for project evaluation, and that address key equity issues, such as targeting to smallholders, women, poor, and marginalized groups. Funding should also be given to implementing RCTs and more rigorous quasi-experimental impact evaluations of agroforestry interventions over longer time-periods to collect robust evidence of the effectiveness of various schemes promoting agroforestry practices.

Canadian Internal Medicine Ultrasound (CIMUS) Expert Consensus Statement on the Use of Lung Ultrasound for the Assessment of Medical Inpatients With Known or Suspected Coronavirus Disease 2019.

OBJECTIVES: To develop a consensus statement on the use of lung ultrasound (LUS) in the assessment of symptomatic general medical inpatients with known or suspected coronavirus disease 2019 (COVID-19). METHODS: Our LUS expert panel consisted of 14 multidisciplinary international experts. Experts voted in 3 rounds on the strength of 26 recommendations as "strong," "weak," or "do not recommend." For recommendations that reached consensus for do not recommend, a fourth round was conducted to determine the strength of those recommendations, with 2 additional recommendations considered. RESULTS: Of the 26 recommendations, experts reached consensus on 6 in the first round, 13 in the second, and 7 in the third. Four recommendations were removed because of redundancy. In the fourth round, experts considered 4 recommendations that reached consensus for do not recommend and 2 additional scenarios; consensus was reached for 4 of these. Our final recommendations consist of 24 consensus statements; for 2 of these, the strength of the recommendations did not reach consensus. CONCLUSIONS: In symptomatic medical inpatients with known or suspected COVID-19, we recommend the use of LUS to: (1) support the diagnosis of pneumonitis but not diagnose COVID-19, (2) rule out concerning ultrasound features, (3) monitor patients with a change in the clinical status, and (4) avoid unnecessary additional imaging for patients whose pretest probability of an alternative or superimposed diagnosis is low. We do not recommend the use of LUS to guide admission and discharge decisions. We do not recommend routine serial LUS in patients without a change in their clinical condition.

Policies to reduce food insecurity: An ethical imperative.

A quarter of U.S. households receive food assistance, yet more than 11% still experience food insecurity annually. We argue that an expansion-oriented approach to food and nutrition assistance policy is an ethical imperative. Drawing on values from the Capability Approach and Social Empathy Model and supported by empirical evidence, we propose an ethical framework characterized by four principles that can be used to assess and inform the development of just food policies. We argue that policies should (1) embrace compassion, (2) create opportunity, (3) consider essential needs, and (4) promote knowledge and empathy. In an applied case, we evaluate current SNAP policy in terms of those principles and offer recommendations to promote justice in the design and implementation of SNAP and other food policies.

Ensuring a Post-COVID Economic Agenda Tackles Global Biodiversity Loss.

The COVID-19 pandemic has caused dramatic and unprecedented impacts on both global health and economies. Many governments are now proposing recovery packages to get back to normal, but the 2019 Intergovernmental Science-Policy Platform for Biodiversity and Ecosystem Services Global Assessment indicated that business as usual has created widespread ecosystem degradation. Therefore, a post-COVID world needs to tackle the economic drivers that create ecological disruptions. In this perspective, we discuss a number of tools across a range of actors for both short-term stimulus measures and longer-term revamping of global, national, and local economies that take biodiversity into account. These include measures to shift away from activities that damage biodiversity and toward those supporting ecosystem resilience, including through incentives, regulations, fiscal policy, and employment programs. By treating the crisis as an opportunity to reset the global economy, we have a chance to reverse decades of biodiversity and ecosystem losses.

Supplemental Nutrition Assistance Program Participation Improves Children's Health Care Use: An Analysis of the American Recovery and Reinvestment Act's Natural Experiment.

OBJECTIVE: To examine the impact of increased Supplemental Nutrition Assistance Program (SNAP) benefit levels as provided by the American Recovery and Reinvestment Act (ARRA) beginning in April 2009 on the health care use and health care needs of participating children. METHODS: Difference-in-differences analysis compared changes in health care use and needs between children in SNAP-eligible households and those in low-income but SNAP-ineligible households before and after ARRA's implementation, using data from the nationally representative National Health Interview Survey (NHIS). Survey respondents reported on children's health care use and outstanding health care needs. Our sample included approximately 38,500 children in low-income households who completed the core NHIS, and a subsample of 15,000 sample children who reported additional information. RESULTS: Approximately 6% of low-income children had delayed care due to cost. Three percent and 4% of children in low-income households and low-income single-parent households, respectively, reported needing health care but not being able to afford it. The increase in SNAP benefits was associated with a 65% reduction in outstanding medication needs due to affordability among SNAP-eligible children, relative to low-income, ineligible children. There was also a reduction in the likelihood that children had seen a general doctor in the last year. Among children in single-parent households, SNAP benefit expansion was associated with a 3.2 percentage point decrease in needing but not being able to afford health care. CONCLUSIONS: Findings suggest that even a small increase in household resources leads to reductions in outstanding health care needs due to affordability, particularly among children.

Needlestick and sharps injuries in orthopedic surgery residents and fellows.

OBJECTIVE: Needlestick and sharps injury (NSSI) is a common occupational hazard of orthopedic surgery training. The purpose of this study was to examine the incidence and surrounding circumstances of intraoperative NSSI in orthopedic surgery residents and fellows and to examine postexposure reporting. DESIGN: A 35-question cross-sectional survey. SETTING: The study was conducted by orthopedic surgery residents and faculty at a nonprofit regional hospital. PARTICIPANTS: The questionnaire was distributed to US allopathic orthopedic surgery residency and fellowship programs; 300 orthopedic surgery trainees participated in the survey. RESULTS: Of 223 trainees who had completed at least 1 year of residency, 172 (77.1%) sustained an NSSI during residency, and 57 of 63 trainees (90.5%) who had completed at least 4 years sustained an NSSI during residency. The most common causes of NSSI were solid needles, followed by solid pins or wires. The surgical activity most associated with NSSI was wound closure, followed by fracture fixation. The type of surgery most frequently associated with NSSI was orthopedic trauma, followed by hip and knee arthroplasty. Of 177 trainees who had sustained a prior NSSI, 99 (55.9%) failed to report all events to their institution's occupational health department. CONCLUSIONS: The incidence of NSSI during residency training is high, with >90% of trainees in their fifth year or later of training having received an injury during their training, with a mean of >4 separate events. Most trainees with an NSSI did not report all of their events, which implies that changes are needed in the incident reporting process universally.

Food Insecurity and Child Health.

OBJECTIVES: Food insecurity is an important public health problem facing children in the United States. Although a number of previous studies suggest that food insecurity has negative impacts on health, these studies have not dealt thoroughly with issues of selection bias. We use propensity scoring techniques to approximate the causal effects of food insecurity on children's health and health care use outcomes. METHODS: We use nationally representative data from the 2013-2016 waves of the National Health Interview Study (N = 29 341). Using inverse probability of treatment weighting, a propensity scoring method, we examine a broad range of child health outcomes and account for a comprehensive set of controls, focusing on a sample of children 2 to 17 years old. RESULTS: Household food insecurity was related to significantly worse general health, some acute and chronic health problems, and worse health care access, including forgone care and heightened emergency department use, for children. Compared to rates had they not been food insecure, children in food-insecure household had rates of lifetime asthma diagnosis and depressive symptoms that were 19.1% and 27.9% higher, rates of foregone medical care that were 179.8% higher, and rates of emergency department use that were 25.9% higher. No significant differences emerged for most communicable diseases, such as ear infections or chicken pox, or conditions that may develop more gradually, including anemia and diabetes. CONCLUSIONS: Policies used to reduce household food insecurity among children may also reduce children's chronic and acute health problems and health care needs.

Technical Note: Assessment of scatter originating from the x-ray tube collimator assembly of modern angiography systems.

PURPOSE: While scatter from the patient is assumed to be the primary source of occupational radiation dose associated with fluoroscopically guided interventional procedures, the potential contribution of scatter from the x-ray collimator assembly is unknown. The purpose of this work was to survey clinical x-ray angiography systems to assess the potential contribution of collimator assembly scatter on occupational radiation dose. METHODS: Experimental methods were designed to measure the relative contributions of scatter originating from within the collimator assembly of the x-ray tube to total scatter, which included scatter from a patient-simulating phantom. Measurements were acquired as a function of lateral distance from the x-ray beam center using a posterior anterior (PA) projection and at a fixed location for variable right anterior oblique to left anterior oblique projections in the range -90º to 90º. For one system, the collimator assembly was partially disassembled to assess the scatter contribution of individual components. For two systems, 0.5 mm Pb was added to the inner surface of the collimator assembly cover and tested for efficacy to block collimator assembly scatter. RESULTS: Considering all x-ray systems and only the PA projection, collimator assembly scatter contributed 20-50% to total scatter. For x-ray projection angles of -90º to 90º, the relative contribution of collimator assembly to total scatter was dependent on projection angle and ranged from 5% to 56%. X-ray systems with kerma-area product meters demonstrated higher collimator assembly scatter than those without. Considering all projection angles, the addition of 0.5 mm Pb to the inside of the collimator assembly cover reduced collimator assembly scatter from 28% to 16% of total scatter for both systems. CONCLUSION: Findings from this work suggest that contemporary radiation safety practices and guidelines should be revised to account for scatter originating from the collimator assembly of angiographic x-ray tubes.

Explaining long-term outcome trajectories in social-ecological systems.

Improved knowledge of long-term social and environmental trends and their drivers in coupled human and natural systems is needed to guide nature and society along a more sustainable trajectory. Here we combine common property theory and experimental impact evaluation methods to develop an approach for analyzing long-term outcome trajectories in social-ecological systems (SESs). We constructed robust counterfactual scenarios for observed vegetation outcome trajectories in the Indian Himalaya using synthetic control matching. This approach enabled us to quantify the contribution of a set of biophysical and socioeconomic factors in shaping observed outcomes. Results show the relative importance of baseline vegetation condition, governance, and demographic change in predicting long-term ecological outcomes. More generally, the findings suggest the broad potential utility of our approach to analyze long-term outcome trajectories, target new policy interventions, and assess the impacts of policies on sustainability goals in SESs across the globe.

Emergency department charges may be associated with mortality in patients with severe sepsis and septic shock: a cohort study.

BACKGROUND: Sepsis severity of illness is challenging to measure using claims, which makes sepsis difficult to study using administrative data. We hypothesized that emergency department (ED) charges may be associated with hospital mortality, and could be a surrogate marker of severity of illness for research purposes. The objective of this study was to measure concordance between ED charges and mortality in admitted patients with severe sepsis or septic shock. METHODS: Cohort study of all adult patients presenting to a 60,000-visit Midwestern academic ED with severe sepsis or septic shock (by ICD-9 codes) between July 1, 2008 and June 30, 2010. Data on demographics, admission APACHE-II score, and disposition was extracted from the medical record, and comorbidities were identified from diagnosis codes using the Elixhauser methodology. Summary statistics were reported and bivariate concordance was tested using Pearson correlation. Logistic regression models for 28-day mortality were developed to measure the independent association with mortality. RESULTS: We included a total of 294 patients in the analysis. We found that ED charges were inversely related to mortality (adjusted OR 0.829 per $1000 increase in total ED charges, 95%CI 0.702-0.980). ED charges were also independently associated with 28-day hospital-free and ICU-free days (0.74 days increase per $1000 additional ED charges, 95%CI 0.06-1.41 and 0.81 days increase per $1000 additional ED charges, 95%CI 0.05-1.56, respectively). ED charges were also associated with APACHE-II score ($34 total ED charges per point increase in APACHE-II score, 95%CI $6-62). CONCLUSIONS: ED charges in administrative data sets are associated with in-hospital mortality and health care utilization, likely related to both illness severity and intensity of early sepsis resuscitation. ED charges may have a role in risk adjustment models using administrative data for acute care research.