Scaling of buccal mass growth and muscle activation determine the duration of feeding behaviours in the marine mollusc Aplysia californica.

The mechanical forces experienced during movement and the time constants of muscle activation are important determinants of the durations of behaviours, which may both be affected by size-dependent scaling. The mechanics of slow movements in small animals are dominated by elastic forces and are thus quasistatic (i.e. always near mechanical equilibrium). Muscular forces producing movement and elastic forces resisting movement should scale identically (proportional to mass2/3), leaving the scaling of the time constant of muscle activation to play a critical role in determining behavioural duration. We tested this hypothesis by measuring the duration of feeding behaviours in the marine mollusc Aplysia californica whose body sizes spanned three orders of magnitude. The duration of muscle activation was determined by measuring the time it took for muscles to produce maximum force as A. californica attempted to feed on tethered inedible seaweed, which provided an in vivo approximation of an isometric contraction. The timing of muscle activation scaled with mass0.3. The total duration of biting behaviours scaled identically, with mass0.3, indicating a lack of additional mechanical effects. The duration of swallowing behaviour, however, exhibited a shallower scaling of mass0.17. We suggest that this was due to the allometric growth of the anterior retractor muscle during development, as measured by micro-computed tomography (micro-CT) scans of buccal masses. Consequently, larger A. californica did not need to activate their muscles as fully to produce equivalent forces. These results indicate that muscle activation may be an important determinant of the scaling of behavioural durations in quasistatic systems.

Understanding China's shifting priorities and priority-setting processes in development assistance for health.

Over the past two decades, China has become a distinctive and increasingly important donor of development assistance for health (DAH). However, little is known about what factors influence China's priority-setting for DAH. In this study, we provide an updated analysis of trends in the priorities of Chinese DAH and compare them to comparable trends among OECD Development Assistance Committee (DAC) donors using data from the AidData's Global Chinese Development Finance Dataset (2000-2017, version 2.0) and the Creditor Reporting System (CRS) database (2000-2017). We also analyse Chinese medical aid exports before and after the start of the COVID-19 pandemic using a Chinese Aid Exports Database. We further explore the potential factors influencing China's shifting priority-setting processes by reviewing Chinese official documents following Walt and Gilson's policy analysis framework (context-actors-process-content) and by testing our conjectures empirically. We find that China has become an important DAH donor to most regions if measured using project value, including but not limited to Africa. China has prioritized aid to African and Asian countries as well as to CRS subsectors that are not prioritized by DAC donors, such as medical services and basic health infrastructure. Chinese quarterly medical aid exports almost quintupled after the start of the COVID-19 pandemic. Noticeably, China has allocated more attention to Asia, eye diseases and infectious disease outbreaks over time. In contrast, the priority given to malaria has declined over the same period. Regarding factors affecting priority shifts, the outbreaks of SARS and Ebola, the launch of the Belt and Road Initiative and the COVID-19 pandemic appear to be important milestones in the timeline of Chinese DAH. Unlike stereotypes of China as a 'lone wolf' donor, our analysis suggests multilateral processes are influential in informing and setting Chinese DAH priorities.

International Partnerships to Develop Evidence-informed Priority Setting Institutions: Ten Years of Experience from the International Decision Support Initiative (iDSI).

All health systems must set priorities. Evidence-informed priority-setting (EIPS) is a specific form of systematic priority-setting which involves explicit consideration of evidence to determine the healthcare interventions to be provided. The international Decision Support Initiative (iDSI) was established in 2013 as a collaborative platform to catalyze faster progress on EIPS, particularly in low- and middle-income countries. This article summarizes the successes, challenges, and lessons learned from ten years of iDSI partnering with countries to develop EIPS institutions and processes. This is a thematic documentary analysis, structured by iDSI's theory of change, extracting successes, challenges, and lessons from three external evaluations and 19 internal reports to funders. We identified three phases of iDSI's work-inception (2013-15), scale-up (2016-2019), and focus on Africa (2019-2023). iDSI has established a global platform for coordinating EIPS, advanced the field, and supported regional networks in Asia and Africa. It has facilitated progress in securing high-level commitment to EIPS, strengthened EIPS institutions, and developed capacity for health technology assessments. This has resulted in improved decisions on service provision, procurement, and clinical care. Major lessons learned include the importance of sustained political will to develop EIPS; a clear EIPS mandate; inclusive governance structures appropriate to health financing context; politically sensitive and country-led support to EIPS, taking advantage of policy windows for EIPS reforms; regional networks for peer support and long-term sustainability; utilization of context appropriate methods such as adaptive HTA; and crucially, donor-funded global health initiatives supporting and integrating with national EIPS systems, not undermining them.

Organizational Formation for Priority Setting: Historical Perspectives and Thematic Analysis of India's Health Technology Assessment Agency.

Countries pursuing universal health coverage must set priorities to determine which benefits to add to a national health program, but the roles that organizations play are less understood. This article investigates the case of the formation of an organization with a mandate for choice of technology for public health interventions and priorities, the Health Technology Assessment India. First, we narrate a chronology of agenda setting and adoption of national policy for organizational formation drawing on historical documentation, publicly available literature, and lived experiences from coauthors. Next, we conduct a thematic analysis that examines windows of opportunity, enabling factors, barriers and conditions, roles of stakeholders, messaging and framing, and specific administrative and bureaucratic tools that facilitated organization formation. This case study shows that organizational formation relied on the identification of multiple champions with sufficient seniority and political authority across a wide group of organizations, forming a coalition of broad base support, who were keen to advance health technology assessment policy development and organizational placement or formation. The champions in turn could use their roles for policy decisions that used private and public events to raise priority and commitment to the decisions, carefully considered organizational placement and formation, and developed the network of organizations for the generation of technical evidence and capacity building for health technology assessment, strengthened by international networks and organizations with financing, expertise, and policymaker relationships.

Focal electrical stimulation of human retinal ganglion cells for vision restoration.

Objective. Vision restoration with retinal implants is limited by indiscriminate simultaneous activation of many cells and cell types, which is incompatible with reproducing the neural code of the retina. Recent work has shown that primate retinal ganglion cells (RGCs), which transmit visual information to the brain, can be directly electrically activated with single-cell, single-spike, cell-type precision - however, this possibility has never been tested in the human retina. In this study we aim to characterize, for the first time, direct in situ extracellular electrical stimulation of individual human RGCs.Approach. Extracellular electrical stimulation of individual human RGCs was conducted in three human retinas ex vivo using a custom large-scale, multi-electrode array capable of simultaneous recording and stimulation. Measured activation properties were compared directly to extensive results from macaque.Main results. Precise activation was in many cases possible without activating overlying axon bundles, at low stimulation current levels similar to those used in macaque. The major RGC types could be identified and targeted based on their distinctive electrical signatures. The measured electrical activation properties of RGCs, combined with a dynamic stimulation algorithm, was sufficient to produce an evoked visual signal that was nearly optimal given the constraints of the interface.Significance. These results suggest the possibility of high-fidelity vision restoration in humans using bi-directional epiretinal implants.

Sexual Violence and Substance Use Diagnosed in Emergency Department Discharges in Hawaii, 2005-2014.

BACKGROUND: Substance use (SU) and sexual violence (SV) present unique challenges when contextualizing their relationship due to underreporting of SU and SV. Both are significant public health concerns with a large magnitude and expense to the overall U.S. and to the state of Hawaii, which is identified as a high-intensity drug-trafficking area. Since substance users have a higher risk for sexual violence than the general public, this study aims to analyze the proportion and demographics of emergency department (ED) visit individuals reporting sexual violence with or without substance use disorder and examine how the number of ED visits of individuals diagnosed with SV and SU disorder compare to all individuals. METHODS: Data from the Healthcare Cost and Utilization Project was used to examine the relationship between SV and SU. The database contained 3.5 million observations for 24 Hawaii hospitals from 2005-2014. The data was summarized in descriptive statistics and Chi-square tests were run to assess statistical significance for variables of interest. RESULTS: A greater proportion of individuals reporting sexual violence also reported substance use disorders compared to the general population of individuals. While 8% of all ED visits were related to SU, 17% of ED visits involving SV were also related to SU, demonstrating a statistically significant association between SV and SU. CONCLUSIONS: There is a greater need to further understand the complexity of the relationship between substance use and sexual violence. Sexual violence and substance use disorders share a complex relationship; survivors of sexual abuse may develop a substance use disorder, and those who use drugs and alcohol may be at an increased risk for sexual violence. Results from this study demonstrate visits for individuals reporting sexual violence have a greater proportion of substance use disorder than visits for the general population.

Linking Public Health and Public Safety Data on Co-occurring Disorders Among Adults in Hawaii's Criminal Justice System.

To better understand the behavioral health treatment needs of adults involved in the criminal justice system and to improve the continuum of services provided to this vulnerable population, Hawaii initiated a data linkage project that connects substance use and mental health data from the state Department of Public Safety with behavioral health treatment data from the state Department of Health for the State of Hawaii. Specifically, this linkage project begins to examine behavioral health treatment levels recommended by the criminal justice system and Hawaii State Hospital inpatient psychiatric admissions. We provide a preliminary summary on individuals who were both involved in the criminal justice system and received court-ordered inpatient psychiatric treatment and outline data governance procedures, future directions, and practice recommendations.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China.

BACKGROUND: China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health. METHODS: A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models. RESULTS: The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25). CONCLUSION: More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

Planning and Implementation of COVID-19 Isolation and Quarantine Facilities in Hawaii: A Public Health Case Report.

In response to the second surge of COVID-19 cases in Hawaii in the fall of 2020, the Hawaii State Department of Health Behavioral Health Administration led and contracted a coalition of agencies to plan and implement an isolation and quarantine facility placement service that included food, testing, and transportation assistance for a state capitol and major urban center. The goal of the program was to provide safe isolation and quarantine options for individual residents at risk of not being able to comply with isolation and quarantine mandates. Drawing upon historical lived experiences in planning and implementing the system for isolation and quarantine facilities, this qualitative public health case study report applies the plan-do-study-act (PDSA) improvement model and framework to review and summarize the implementation of this system. This case study also offers lessons for a unique opportunity for collaboration led by a public behavioral health leadership that expands upon traditionally narrow infectious disease control, by developing a continuum of care that not only addresses immediate COVID-19 concerns but also longer-term supports and services including housing, access to mental health services, and other social services. This case study highlights the role of a state agency in building a coalition of agencies, including a public university, to respond to the pandemic. The case study also discusses how continuous learning was executed to improve delivery of care.

Mitigation Planning and Policies Informed by COVID-19 Modeling: A Framework and Case Study of the State of Hawaii.

In the face of great uncertainty and a global crisis from COVID-19, mathematical and epidemiologic COVID-19 models proliferated during the pandemic. Yet, many models were not created with the explicit audience of policymakers, the intention of informing specific scenarios, or explicit communication of assumptions, limitations, and complexities. This study presents a case study of the roles, uses, and approaches to COVID-19 modeling and forecasting in one state jurisdiction in the United States. Based on an account of the historical real-world events through lived experiences, we first examine the specific modeling considerations used to inform policy decisions. Then, we review the real-world policy use cases and key decisions that were informed by modeling during the pandemic including the role of modeling in informing planning for hospital capacity, isolation and quarantine facilities, and broad public communication. Key lessons are examined through the real-world application of modeling, noting the importance of locally tailored models, the role of a scientific and technical advisory group, and the challenges of communicating technical considerations to a public audience.

Automatic Identification of Axon Bundle Activation for Epiretinal Prosthesis.

OBJECTIVE: Retinal prostheses must be able to activate cells in a selective way in order to restore high-fidelity vision. However, inadvertent activation of far-away retinal ganglion cells (RGCs) through electrical stimulation of axon bundles can produce irregular and poorly controlled percepts, limiting artificial vision. In this work, we aim to provide an algorithmic solution to the problem of detecting axon bundle activation with a bi-directional epiretinal prostheses. METHODS: The algorithm utilizes electrical recordings to determine the stimulation current amplitudes above which axon bundle activation occurs. Bundle activation is defined as the axonal stimulation of RGCs with unknown soma and receptive field locations, typically beyond the electrode array. The method exploits spatiotemporal characteristics of electrically-evoked spikes to overcome the challenge of detecting small axonal spikes. RESULTS: The algorithm was validated using large-scale, single-electrode and short pulse, ex vivo stimulation and recording experiments in macaque retina, by comparing algorithmically and manually identified bundle activation thresholds. For 88% of the electrodes analyzed, the threshold identified by the algorithm was within ±10% of the manually identified threshold, with a correlation coefficient of 0.95. CONCLUSION: This works presents a simple, accurate and efficient algorithm to detect axon bundle activation in epiretinal prostheses. SIGNIFICANCE: The algorithm could be used in a closed-loop manner by a future epiretinal prosthesis to reduce poorly controlled visual percepts associated with bundle activation. Activation of distant cells via axonal stimulation will likely occur in other types of retinal implants and cortical implants, and the method may therefore be broadly applicable.

Characterization of an Electronic Corneal Prosthesis System.

PURPOSE: Corneal opacity is a leading cause of reversible blindness worldwide. An electronic corneal prosthesis, or intraocular projector, could potentially restore high-quality vision without need for corneal clarity. MATERIALS AND METHODS: Four intraocular projection systems were constructed from commercially available electronic components and encased in biocompatible plastic housing. They were tested for optical properties, biocompatibility, heat dissipation, waterproofing, and accelerated wear. A surgical implantation technique was developed. RESULTS: Intraocular projectors were produced of a size that can fit within the eye. Their optics produce better than 20/200 equivalent visual acuity. MTT assay demonstrated no cytotoxicity of devices in vitro. Temperature testing demonstrated less than 2°C increase in temperature after 1 h. Three devices lasted over 12 weeks under accelerated wear conditions. Implantation surgery was demonstrated via corneal trephination insertion in a cadaver eye. CONCLUSION: This is the first study to demonstrate and characterize fully functional intraocular projection systems. This technology has the potential to be an important new tool in the treatment of intractable corneal blindness.

Comparison of RN licensure examination: China and the United States.

Having the two largest nursing workforces across the globe, both China and the United States have implemented licensure examinations to standardize the qualifications of registered nurse. China established the National Nursing Licensure Examination (NNLE) in 1995. Like the National Council Licensure Examination for Registered Nurses (NCLEX-RN) in the United States, the NNLE has become an important link in the nurse registration process and contributed a lot in quality assurance and development of nursing profession. It may be necessary for the NNLE to learn from NCLEX-RN in several aspects, including increasing the frequency of exam, providing examinees with individualized services, and continuing reforming exam content and format. By better aligning the content and format of the examination with the current nursing paradigm and clinical requirements, nurses may enter the healthcare field better prepared to care for patients. Considering the magnitude of their nursing workforce, both China and the United States have great potential to serve as a role model for other developing countries as they look towards establishing national nursing education programs. As new policies around standardized nurse education in China take form, we urge that the NNLE be included alongside curricular reforms. As these reforms are implemented, continued research will be needed to evaluate the effectiveness of curriculum and licensure exam regulations upon nurse preparedness and quality of nursing care in China.

Living Alone and Homelessness as Predictors of 30-Day Potentially Preventable Hospital Readmission.

INTRODUCTION: The effect of social factors on health care outcomes is widely recognized. Health care systems are encouraged to add social and behavioral measures to electronic health records (EHRs), but limited research demonstrates how to leverage this information. We assessed 2 social factors collected from EHRs - social isolation and homelessness - in predicting 30-day potentially preventable readmissions (PPRs) to hospital. METHODS: EHR data were collected from May 2015 through April 2017 from inpatients at 2 urban hospitals on O'ahu, Hawai'i (N = 21,274). We performed multivariable logistic regression models predicting 30-day PPR by living alone versus living with others and by documented homelessness versus no documented homelessness, controlling for relevant factors, including age group, race/ethnicity, sex, and comorbid conditions. RESULTS: Among the 21,274 index hospitalizations, 16.5% (3,504) were people living alone and 11.2% (2,385) were homeless; 4.2% (899) hospitalizations had a 30-day PPR. In bivariate analysis, living alone did not significantly affect likelihood of a 30-day PPR (16.6% [3,376 hospitalizations] without PPR vs 14.4% [128 hospitalizations] with PPR; P = .09). However, documented homelessness did show a significant effect on the likelihood of 30-day PPR in the bivariate analysis (11.1% [2,259 hospitalizations] without PPR vs 14.1% [126 hospitalizations] with PPR; P = .006). In multivariable models, neither living alone nor homelessness was significantly associated with PPR. Factors that were significantly associated with PPR were comorbid conditions, discharge disposition, and use of an assistive device. CONCLUSION: Homelessness predicted PPR in descriptive analyses. Neither living alone nor homelessness predicted PPR once other factors were controlled. Instead, indicators of physical frailty (ie, use of an assistive device) and medical complexity (eg, hospitalizations that required assistive care post-discharge, people with a high number of comorbid conditions) were significant. Future research should focus on refining, collecting, and applying social factor data obtained through acute care EHRs.

Epiretinal stimulation with local returns enhances selectivity at cellular resolution.

OBJECTIVE: Epiretinal prostheses are designed to restore vision in people blinded by photoreceptor degenerative diseases, by directly activating retinal ganglion cells (RGCs) using an electrode array implanted on the retina. In present-day clinical devices, current spread from the stimulating electrode to a distant return electrode often results in the activation of many cells, potentially limiting the quality of artificial vision. In the laboratory, epiretinal activation of RGCs with cellular resolution has been demonstrated with small electrodes, but distant returns may still cause undesirable current spread. Here, the ability of local return stimulation to improve the selective activation of RGCs at cellular resolution was evaluated. APPROACH: A custom multi-electrode array (512 electrodes, 10 µm diameter, 60 µm pitch) was used to simultaneously stimulate and record from RGCs in isolated primate retina. Stimulation near the RGC soma with a single electrode and a distant return was compared to stimulation in which the return was provided by six neighboring electrodes. MAIN RESULTS: Local return stimulation enhanced the capability to activate cells near the central electrode (<30 µm) while avoiding cells farther away (>30 µm). This resulted in an improved ability to selectively activate ON and OFF cells, including cells encoding immediately adjacent regions in the visual field. SIGNIFICANCE: These results suggest that a device that restricts the electric field through local returns could optimize activation of neurons at cellular resolution, improving the quality of artificial vision.