Rewilding soil and litter invertebrates and fungi increases decomposition rates and alters detritivore communities.

Habitat degradation and associated reductions in ecosystem functions can be reversed by reintroducing or 'rewilding' keystone species. Rewilding projects have historically targeted restoration of processes such as grazing regimes or top-down predation effects. Few projects focus on restoring decomposition efficiency, despite the pivotal role decomposition plays in global carbon sequestration and nutrient cycling. Here, we tested whether rewilding entire communities of detritivorous invertebrates and fungi can improve litter decomposition efficiency and restore detritivore communities during ecological restoration. Rewilding was conducted by transplanting leaf litter and soil, including associated invertebrate and fungal communities from species-rich remnant sites into species-poor, and geographically isolated, revegetated farmland sites in a temperate woodland region of southeastern Australia. We compared communities in sites under the following treatments: remnant (conservation area and source of litter transplant), rewilded revegetation (revegetated farmland site with litter transplant) and control revegetation (revegetated site, no transplant). In one 'before' and three 'after' sampling periods, we measured litter decomposition and the abundance and diversity of detritivorous invertebrates and fungi. We quantified the effect of detritivores on the rate of litter decomposition using piecewise Structural Equation Modelling. Decomposition was significantly faster in rewilding sites than in both control and remnant areas and was largely driven by a greater abundance of invertebrate detritivores. Similarly, the abundance of invertebrate detritivores in rewilding revegetation sites exceeded the level of remnant communities, whereas there was little difference between control and remnant sites. In contrast, rewilding did not increase saprotrophic fungi relative abundance/diversity and there was no strong relationship between decomposition and fungal diversity. Our findings suggest the relatively simple act of transplanting leaf litter and soil can increase functional efficiency during restoration and alter community composition. Our methods may prove important across a range of contexts where other restoration methods have failed to restore ecosystem processes to pre-degradation levels.

Abcg2a is the functional homolog of human ABCG2 expressed at the zebrafish blood-brain barrier.

BACKGROUND: A principal protective component of the mammalian blood-brain barrier (BBB) is the high expression of the multidrug efflux transporters P-glycoprotein (P-gp, encoded by ABCB1) and ABCG2 (encoded by ABCG2) on the lumenal surface of endothelial cells. The zebrafish P-gp homolog Abcb4 is expressed at the BBB and phenocopies human P-gp. Comparatively little is known about the four zebrafish homologs of the human ABCG2 gene: abcg2a, abcg2b, abcg2c, and abcg2d. Here we report the functional characterization and brain tissue distribution of zebrafish ABCG2 homologs. METHODS: To determine substrates of the transporters, we stably expressed each in HEK-293 cells and performed cytotoxicity and fluorescent efflux assays with known ABCG2 substrates. To assess the expression of transporter homologs, we used a combination of RNAscope in situ hybridization probes and immunohistochemistry to stain paraffin-embedded sections of adult and larval zebrafish. RESULTS: We found Abcg2a had the greatest substrate overlap with ABCG2, and Abcg2d appeared to be the least functionally similar. We identified abcg2a as the only homolog expressed at the adult and larval zebrafish BBB, based on its localization to claudin-5 positive brain vasculature. CONCLUSIONS: These results demonstrate the conserved function of zebrafish Abcg2a and suggest that zebrafish may be an appropriate model organism for studying the role of ABCG2 at the BBB.

Abcg2a is the functional homolog of human ABCG2 expressed at the zebrafish blood-brain barrier.

Background: A principal protective component of the mammalian blood-brain barrier (BBB) is the high expression of the multidrug efflux transporters P-glycoprotein (P-gp, encoded by ABCB1) and ABCG2 (encoded by ABCG2) on the lumenal surface of endothelial cells. The zebrafish P-gp homolog Abcb4 is expressed at the BBB and phenocopies human P-gp. Comparatively little is known about the four zebrafish homologs of the human ABCG2 gene: abcg2a, abcg2b, abcg2c, and abcg2d. Here we report the functional characterization and brain tissue distribution of zebrafish ABCG2 homologs. Methods: To determine substrates of the transporters, we stably expressed each in HEK-293 cells and performed cytotoxicity and fluorescent efflux assays with known ABCG2 substrates. To assess the expression of transporter homologs, we used a combination of RNAscope in situ hybridization probes and immunohistochemistry to stain paraffin-embedded sections of adult and larval zebrafish. Results: We found Abcg2a had the greatest substrate overlap with ABCG2, and Abcg2d appeared to be the least functionally similar. We identified abcg2a as the only homolog expressed at the adult and larval zebrafish BBB, based on its localization to claudin-5 positive brain vasculature. Conclusions: These results demonstrate the conserved function of zebrafish Abcg2a and suggest that zebrafish may be an appropriate model organism for the studying the role of ABCG2 at the BBB.

Tools to guide clinical discussions on physical activity, sedentary behaviour, and/or sleep for health promotion between primary care providers and adults accessing care: a scoping review.

BACKGROUND: Health care providers have reported low knowledge, skill, and confidence for discussing movement behaviours (i.e., physical activity, sedentary behaviour, and sleep), which may be improved with the use of tools to guide movement behaviour discussions in their practice. Past reviews have examined the psychometric properties, scoring, and behavioural outcomes of physical activity discussion tools. However, the features, perceptions, and effectiveness of discussion tools for physical activity, sedentary behaviour, and/or sleep have not yet been synthesized. The aim of this review was to report and appraise tools for movement behaviour discussions between health care providers and adults 18 + years in a primary care context within Canada or analogous countries. METHODS: An integrated knowledge translation approach guided this review, whereby a working group of experts in medicine, knowledge translation, communications, kinesiology, and health promotion was engaged from research question formation to interpretation of findings. Three search approaches were used (i.e., peer-reviewed, grey literature, and forward searches) to identify studies reporting on perceptions and/or effectiveness of tools for physical activity, sedentary behaviour, and/or sleep. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. RESULTS: In total, 135 studies reporting on 61 tools (i.e., 51 on physical activity, one on sleep, and nine combining two movement behaviours) met inclusion criteria. Included tools served the purposes of assessment (n = 57), counselling (n = 50), prescription (n = 18), and/or referral (n = 12) of one or more movement behaviour. Most tools were used or intended for use by physicians, followed by nurses/nurse practitioners (n = 11), and adults accessing care (n = 10). Most tools were also used or intended to be used with adults without chronic conditions aged 18-64 years (n = 34), followed by adults with chronic conditions (n = 18). The quality of the 116 studies that evaluated tool effectiveness varied. CONCLUSIONS: Many tools were positively perceived and were deemed effective at enhancing knowledge of, confidence for, ability in, and frequency of movement behaviour discussions. Future tools should guide discussions of all movement behaviours in an integrated manner in line with the 24-Hour Movement Guidelines. Practically, this review offers seven evidence-based recommendations that may guide future tool development and implementation.

Developing and testing the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide for primary care providers using think-aloud, near-live, and interview procedures.

BACKGROUND: Canada's 24-Hour Movement Guidelines for Adults have shifted the focus from considering movement behaviours (i.e., physical activity, sedentary behaviour, and sleep) separately to a 24-h paradigm, which considers how they are integrated. Accordingly, primary care providers (PCPs) have the opportunity to improve their practice to promote all movement behaviours cohesively. However, PCPs have faced barriers to discussing physical activity alone (e.g., time, competing priorities, inadequate training), leading to low frequency of physical activity discussions. Consequently, discussing three movement behaviours may seem challenging. Tools to facilitate primary care discussions about physical activity have been developed and used; however, few have undergone usability testing and none have integrated all movement behaviours. Following a synthesis of physical activity, sedentary behaviour, and sleep tools for PCPs, we developed the Whole Day Matters Tool and User Guide that incorporate all movement behaviours. The present study aimed to explore PCPs' perceptions on the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide to improve their relevancy among PCPs. METHODS: Twenty-six PCPs were observed and audio-video recorded while using the Tool and User Guide in a think-aloud procedure, then in a near-live encounter with a mock service-user. A debriefing interview using a guide informed by Normalization Process Theory followed. Recordings were transcribed verbatim and analysed using content analysis and a critical friend to enhance rigour. RESULTS: PCPs valued aspects of the Tool and User Guide including their structure, user-friendliness, visual appeal, and multi-behaviour focus and suggested modifications to improve usability and acceptability. Findings are further discussed in the context of Normalization Process Theory and previous literature. CONCLUSIONS: The Tool and User Guide were revised, including adding plain language, reordering and renaming sections, reducing text, and clarifying instructions. Results also informed the addition of a Preamble and a Handout for adults accessing care (i.e., patients/clients/service-users) to explain the evidence underpinning the 24-Hour Movement Guidelines for Adults and support a person-centered approach. These four resources (i.e., Tool, User Guide, Preamble, Handout) have since undergone a consensus building process to arrive at their final versions before being disseminated into primary care practice.

Moving toward co-production: five ways to get a grip on collaborative implementation of Movement Behaviour curricula in undergraduate medical education.

Several "calls to action" have imposed upon medical schools to include physical activity content in their overextended curricula. These efforts have often neither considered medical education stakeholders' views nor the full complexity of medical education, such as competency-based learning and educational inflation. With this external pressure for change, few medical schools have implemented physical activity curricula. Moreover, Canada's new 24-Hour Movement Guidelines focus on the continuum of movement behaviours (physical activity, sedentary behaviour, and sleep). Thus, a more integrated process to overcome the "black ice" of targeting all movement behaviours, medical education stakeholder engagement, and the overextended curriculum is needed. We argue for co-production in curriculum change and offer five strategies to integrate movement behaviour curricula that acknowledge the complexity of the medical education context, helping to overcome our "black ice." Our objectives were to investigate 24-Hour Movement Guideline content in the medical curriculum and develop an integrated process for competency-based curriculum renewal. Stakeholders were equal collaborators in a two-phased environmental scan of 24-Hour Movement Guideline content in the Queen's University School of Medicine. Findings and a working curriculum map highlight how new, competency-based content may be embedded in an effort to guide more relevant and feasible curriculum changes.

À plusieurs reprises, les facultés de médecine ont été invitées à inclure du contenu en matière d'activité physique dans leurs cursus déjà chargés. Ces appels à l'action ont souvent omis de prendre en compte les points de vue des parties prenantes de l'éducation médicale ainsi que toute la complexité de cette dernière, y compris l'approche par compétence et les contenus de cursus qui ne cessent de croître. Malgré la pression externe, peu de facultés de médecine ont mis en place des programmes d'activité physique. De plus, les nouvelles directives canadiennes en matière de mouvement sur 24 heures sont axées sur le continuum des comportements de mouvement (activité physique, comportement sédentaire et sommeil). Une approche intégrée est de mise pour négocier le terrain glissant que constitue la nécessité de cibler tous les comportements de mouvement, de solliciter les parties prenantes de l'éducation médicale et de prendre en considération le cursus chargé. Nous prônons la collaboration pour effectuer ces modifications dans les programmes d'études par le biais de cinq stratégies d'intégration de contenu sur les comportements de mouvement qui reconnaissent la complexité du contexte de l'éducation médicale. Nos objectifs étaient d'étudier le contenu des directives en matière de mouvement sur 24 heures et de créer un processus intégré pour la révision du cursus basé sur les compétences. Les parties prenantes ont collaboré sur un pied d'égalité à une analyse environnementale en deux phases du contenu des directives en matière de mouvement sur 24 heures à la Faculté de médecine de l'Université Queen's. Les résultats et le projet de programme élaboré illustrent la manière d'intégrer du contenu nouveau basé sur les compétences et d'opérer ainsi des changements pertinents et réalisables dans le cursus.

Five ways to counter ableist messaging in medical education in the context of promoting healthy movement behaviours.

One in five Canadians have a disability and there are well-documented gaps in care for this equity-deserving group that have roots in medical education. In this paper, we highlight the unintended consequences of ableist messaging for persons living with disabilities, particularly in the context of promoting healthy movement behaviours. With its broad reach and public trust, the medical community has a responsibility to acknowledge the reality of ableism and take meaningful action. We propose five strategies to counter ableist messaging in medical education: (1) increase knowledge and confidence among physicians and trainees to optimize movement behaviours in persons living with disabilities, (2) perform personal and institutional language audits to ensure terminology related to disability is inclusive and avoids causing unintended harm, (3) challenge ableist messages effectively, (4) address the unmet healthcare needs of persons living with disabilities, and (5) engage in efforts to reform medical curricula so that persons living with disabilities are represented and treated equitably. Physicians and trainees are well-positioned to deliver competent and inclusive care, making medical education an opportune setting to address health inequities related to disability.

Un Canadien sur cinq souffre d'un handicap. Cette population subit des inégalités bien documentées sur le plan des soins de santé, une situation qui une situation qui découle en partie de l'éducation médicale. Dans cet article, nous mettons en évidence les conséquences involontaires du discours capacitiste véhiculé dans le contexte de la promotion de l'activité physique pour les personnes vivant avec un handicap. Compte tenu de l'influence de la communauté médicale et la confiance que lui témoigne le public, elle se doit de reconnaître. Nous proposons cinq stratégies pour contrer les discours capacitistes en éducation médicale : (1) renforcer les connaissances et la confiance des médecins et des stagiaires pour leur permettre d'optimiser les comportements kinésiques chez les personnes vivant avec un handicap, (2) effectuer des vérifications linguistiques pour garantir que la terminologie liée au handicap qu'emploient les personnes et les établissements est inclusive et n'entraîne pas de préjudices involontaires, (3) contrer efficacement le discours capacitiste, (4) répondre aux besoins de santé non satisfaits des personnes vivant avec un handicap, et (5) participer aux efforts de réforme des programmes d'études médicales afin que les personnes vivant avec un handicap soient représentées et traitées équitablement. Les médecins et les stagiaires occupent une position privilégiée pour offrir des soins compétents et inclusifs, ce qui fait de l'éducation médicale un cadre opportun pour combattre les inégalités en matière de soins liées au handicap.

Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review.

Background: There is currently a paucity of data on urethral-related outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) with urethral lengthening (UL)and vaginectomy. Methods: A systematic review was performed utilizing MEDLINE, Web of Science, Cochrane Library, Europe PMC, OSF Preprints, and EMBASE. Methodologic quality was scored using Methodological Index for Non-Randomized Studies (MINORS) criteria. Four independent reviewers performed the article evaluation, data extraction, and methodologic quality assessment. Primary outcomes included standing to urinate/pee (STP), penile length, glanular meatus, urethral stricture, fistula, and flap necrosis. Results were summarized qualitatively with descriptive statistics. Results: A total of 2,881 articles of which 11 retrospective reviews of 13 cohorts met criteria; 4.3/16 average (avg) MINORS score. Six metoidioplasty cohorts had an average penile length of 6 cm, 74% reported successful STP, and a quarter developed stricture or fistula. Phalloplasty cohorts included radial forearm flap (RF) and Anterolateral Thigh flap (ALT). Of the 4 RF studies nearly a third developed a stricture or fistula and only one study reported 99% STP with a glanular meatus. Three ALT studies reported no length but had 80-90% STP with a glanular meatus and a quarter with stricture or fistula. Conclusions: Urethral complications in MaPGAS-UL in a cohort with prior vaginectomy are common and variably reported. Patient centered outcome measures as well as clearly defined outcome metrics created in partnership with community members are needed.

Self-Compassion, Adaptive Reactions and Health Behaviours Among Adults With Prediabetes and Type 1, Type 2 and Gestational Diabetes: A Scoping Review.

Engaging in health-promoting behaviours has health benefits for people with prediabetes or diabetes. People experience negative affect after diagnoses, which can impede self-regulation of health behaviours. Self-compassion, extending care to oneself in difficult times, can mitigate negative affect and promote self-regulation. This scoping review explored the relationship between self-compassion and adaptive affect, self-regulation and engagement in health-promoting/management behaviours among people with prediabetes or diabetes. We conducted a scoping literature search from 6 databases for studies and conference abstracts. Randomized controlled trials and cross-sectional, longitudinal, observational and qualitative designs focused on self-compassion were included. Eligible studies included adults with diabetes (prediabetes, type 1, type 2 and gestational), measured self-compassion using a validated Self-Compassion Scale (quantitative) or included the 3 components (qualitative) and investigated: negative affect, health promoting/management behaviours and/or self-regulation. After deduplication, 5,338 quantitative and 953 qualitative abstracts, and 18 conference proceedings were screened leaving 35 articles. Full-text screening retained 11 eligible studies (6 cross-sectional studies, 2 randomized controlled trials, 2 longitudinal studies and 1 qualitative study). Higher self-compassion was associated with decreased negative affect in 9 studies and was positively associated with well-being in 1 cross-sectional study. Self-compassion led to decreased negative affect and improved blood glucose in 2 interventions. Five studies found positive associations between self-compassion and health-promoting/management behaviours. One qualitative study found self-compassion to benefit affective reactions, health-promoting behaviours and self-regulation. This review shows that self-compassion is linked to adaptive behavioural and affective responding among people with prediabetes and diabetes, and the need for more research on self-compassion and self-regulation in these populations.

Patterns of Opioid Use in the 12 Months Following Geriatric Fragility Fractures: A Population-Based Cohort Study.

OBJECTIVES: Fractures of the hip, distal radius, and proximal humerus are common in the Medicare population. This study's objective was to characterize patterns and duration of opioid use, including regional variations in use, after both surgical and nonoperative management. DESIGN: Population-based cohort study. SETTING AND PARTICIPANTS: A cohort of opioid-naïve community-dwelling US Medicare beneficiaries who survived a hip, distal radius, or proximal humerus fracture between January 1, 2007 and December 31, 2010. Cohort members were required to be opioid-naïve for 4 months prior to fracture. MEASURES: We analyzed the proportion of patients with an active opioid prescription in each month following the index fracture, and report continued fills at 12 months postfracture. We also compared opioid prescription use in fractures treated surgically and nonsurgically and characterized state-level variation in opioid prescription use at 3 months postfracture. RESULTS: There were 91,749 patients included in the cohort. Hip fracture patients had the highest rate of opioid use at 12 months (6.4%), followed by proximal humerus (5.7%), and distal radius (3.7%). Patients who underwent surgical fixation of proximal humerus and wrist fractures had higher rates of opioid use in each of the first 12 postoperative months compared with those managed nonoperatively. There was significant variation of opioid use at the state level, ranging from 7.6% to 18.2% of fracture patients filling opioid prescriptions 3 months after the index fracture. CONCLUSIONS/IMPLICATIONS: Opioid-naïve patients sustaining fragility fractures of the hip, proximal humerus, or distal radius are at risk to remain on opioid medications 12 months after their index injury, and surgical management of proximal humerus and distal radius fractures increases opioid use in the 12 months after the index fracture. There is significant state-level variation in opiate consumption after index fracture in nonvertebral geriatric fragility fractures. Opportunity exists for targeted quality improvement efforts to reduce the variation in opioid use following common geriatric fragility fractures.

Patient Profiling Can Identify Spondylolisthesis Patients at Risk for Conversion from Nonoperative to Operative Treatment.

BACKGROUND: Factors that are relevant to the decision regarding the use of surgical treatment for degenerative spondylolisthesis include disease-state severity and patient quality-of-life expectations. Some factors may not be easily appraised by the surgeon. In prospective trials involving patients undergoing nonoperative and operative treatment, there are instances of crossover in which patients from the nonoperative group undergo surgery. Identifying and understanding patient characteristics that may influence crossover from nonoperative to operative treatment will aid understanding of what motivates patients toward pursuing surgery. METHODS: Patients with degenerative spondylolisthesis who were randomized to nonoperative care in a prospective, multicenter study were evaluated over 8 years of enrollment. Two cohorts were defined: (1) the surgery cohort (patients who underwent surgery at any point) and (2) the nonoperative cohort (patients who did not undergo surgery). A Cox proportional hazards model, modeling time to surgery, was used to explore demographic data, clinical diagnoses, and patient expectations and attitudes after adjusting for other variables. A subanalysis was performed on surgery within 6 months after enrollment and surgery >6 months after enrollment. RESULTS: One hundred and forty-five patients who had been randomized to nonoperative treatment, 80 of whom crossed over to surgery, were included. In analyzing baseline differences between the 2 cohorts, patients who underwent surgery were younger; however, there were no significant difference between the cohorts in terms of race, sex, or comorbidities. Treatment preference, greater Oswestry Disability Index score, marital status, and no joint problems were predictors of crossover to surgery. Clinical factors, including stenosis, neurological deficits, and listhesis levels, did not show a significant relationship with crossover. At the time of long-term follow-up, the surgery cohort showed significantly greater long-term improvement in health-related quality of life (p < 0.001). The difference was maintained throughout follow-up. CONCLUSIONS: Neurological symptoms and diagnoses, including listhesis and stenosis severity, did not predict crossover from nonoperative care to surgery. Attitudes toward surgery, greater Oswestry Disability Index score, marital status, and no joint problems were independent predictors of crossover from nonoperative to operative care. Certain demographic characteristics were associated with higher rates of crossover, although they were connected to patient attitudes toward surgery. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Results of Surgery Compared With Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Randomized trial with a concurrent observational cohort study. OBJECTIVE: To compare 8-year outcomes between surgery and nonoperative care and among different fusion techniques for symptomatic lumbar degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA: Surgical treatment of DS has been shown to be more effective than nonoperative treatment out to 4 years. This study sought to further determine the long-term (8-year) outcomes. METHODS: Surgical candidates with DS from 13 centers with at least 12 weeks of symptoms and confirmatory imaging were offered enrollment in a randomized controlled trial (RCT) or observational cohort study (OBS). Treatment consisted of standard decompressive laminectomy (with or without fusion) versus standard nonoperative care. Primary outcome measures were the Short Form-36 (SF-36) bodily pain and physical function scores and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and yearly up to 8 years. RESULTS: Data were obtained for 69% of the randomized cohort and 57% of the observational cohort at the 8-year follow up. Intent-to-treat analyses of the randomized group were limited by high levels of nonadherence to the randomized treatment. As-treated analyses in the randomized and observational groups showed significantly greater improvement in the surgery group on all primary outcome measures at all time points through 8 years. Outcomes were similar among patients treated with uninstrumented posterolateral fusion, instrumented posterolateral fusion, and 360° fusion. CONCLUSION: For patients with symptomatic DS, patients who received surgery had significantly greater improvements in pain and function compared with nonoperative treatment through 8 years of follow-up. Fusion technique did not affect outcomes. LEVEL OF EVIDENCE: 1.

A Person-Centered, Registry-Based Learning Health System for Palliative Care: A Path to Coproducing Better Outcomes, Experience, Value, and Science.

BACKGROUND: Palliative care offers an approach to the care of people with serious illness that focuses on quality of life and aligning care with individual and family goals, and values in the context of what is medically achievable. OBJECTIVE: Measurement of the impact of palliative care is critical for determining what works for which patients in what settings, to learn, improve care, and ensure access to high value care for people with serious illness. METHODS: A learning health system that includes patients and families partnering with clinicians and care teams, is directly linked to a registry to support networks for improvement and research, and offers an ideal framework for measuring what matters to a range of stakeholders interested in improving care for this population. MEASUREMENTS: Measurement focuses on the individual patient and family experience as the fundamental outcome of interest around which all care delivery is organized. RESULTS: We describe an approach to codesigning and implementing a palliative care registry that functions as a learning health system, by combining patient and family inputs and clinical data to support person-centered care, quality improvement, accountability, transparency, and scientific research. DISCUSSION: The potential for a palliative care learning health system that, by design, brings together enriched information environments to support coproduction of healthcare and facilitated peer networks to support patients and families, collaborative clinician networks to support palliative care program improvement, and collaboratories to support research and the application of research to benefit individual patients is immense.

Local emergency medical response after a terrorist attack in Norway: a qualitative study.

INTRODUCTION: On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare. METHODS: We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS' success. Two independent teams of professional experts classified and validated the identified determinants. RESULTS: Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation. CONCLUSION: The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

Risk Factors for Reoperation in Patients Treated Surgically for Degenerative Spondylolisthesis: A Subanalysis of the 8-year Data From the SPORT Trial.

STUDY DESIGN: Retrospective analysis of prospective data from the degenerative spondylolisthesis (DS) arm of the Spine Patient Outcomes Research Trial. OBJECTIVE: The aim of this study was to identify risk factors for reoperation in patients treated surgically for DS and compare outcomes between patients who underwent reoperation with nonreoperative patients. SUMMARY OF BACKGROUND DATA: Several studies have examined outcomes following surgery for DS, but few have identified risk factors for reoperation. METHODS: Analysis included patients with neurogenic claudication (>12 weeks), clinical neurological signs, spinal stenosis, and DS on standing lateral x-rays. Univariate and multivariate analyses were used to investigate patient characteristics and risk factors. Treatment effects (TEs) were calculated and compared between study groups. RESULTS: Of 406 patients, 72% underwent instrumented fusion, 21% noninstrumented fusion, and 7% decompression alone. At 8 years, the reoperation rate was 22%, of which 28% occurred within 1 year, 54% within 2 years, 70% within 4 years, and 86% within 6 years. The reasons for reoperation included recurrent stenosis or progressive spondylolisthesis (45%), complications such as hematoma, dehiscence, or infection (36%), or new condition (14%). Reoperative patients were younger (62.2 vs. 65.3, P = 0.008). Significant risk factors were use of antidepressants (P = 0.008, hazard ratio [HR] 2.08) or having no neurogenic claudication upon enrollment (P = 0.02, HR 1.82). Patients who were smokers, diabetics, obese, or on workman's compensation were not at greater risk for reoperation. At 8-year follow-up, scores for SF-36 bodily pain (BP), Oswestry Disability Index, American Academy of Orthopaedic Surgeons/Modems version (ODI), and stenosis frequency index were better in nonreoperative patients. TE favored nonreoperative patients for SF-36 BP, physical function, ODI, Stenosis Bothersomeness Index, and satisfaction with symptoms (P < 0.001). CONCLUSION: The incidence of reoperation for patients with DS was 22% 8 years following surgery. Patients with a history of no neurogenic claudication and patients taking antidepressants were more likely to undergo reoperation. Outcome scores and TE were more favorable in nonreoperative patients. LEVEL OF EVIDENCE: 2.

Evidence on the Validity of a Comprehensive Health Risk Index and Implications for Ambulatory Care and Population Health Management.

A novel, comprehensive health risk index for adults has been validated and is now ready for use to improve the health of individuals and populations. This health risk index provides an estimate of the avoidable risk of death for adults 30 years or older. It includes 12 evidence-based clinical and behavioral risk factors and was validated on discrimination and calibration using the NHANES (National Health and Nutrition Examination Survey) and Framingham Heart Study cohorts. The results from both cohorts were consistent and similar. Discrimination was good, and calibration was acceptable but tended to overpredict mortality risk for females in the higher-risk deciles.

Pain Recurrence After Discectomy for Symptomatic Lumbar Disc Herniation.

STUDY DESIGN: Secondary analysis of data from a concurrent randomized trial and cohort study. OBJECTIVE: The aim of this study was to determine risks and predictors of recurrent pain following standard open discectomy for subacute/chronic symptomatic lumbar disc herniation (SLDH). SUMMARY OF BACKGROUND DATA: Most previous studies of recurrence after discectomy do not explicitly define pain resolution and recurrence, and do not account for variable durations of time at risk for recurrence. METHODS: We used survival analysis methods to examine predictors of leg pain recurrence. For individuals with initial resolution of leg pain, we defined recurrent leg pain as having leg pain, receiving lumbar epidural steroid injections, or undergoing lumbar surgery subsequent to initial leg pain resolution. We calculated cumulative risks of leg pain recurrence using Kaplan-Meier survival curves, and examined predictors of recurrence using Cox proportional hazards models. We used similar methods to examine LBP recurrence. RESULTS: One- and three-year cumulative risks of leg pain recurrence were 20% and 45%, respectively. One- and three- year leg pain recurrence risks were substantially lower in participants with complete initial resolution of leg pain (17% and 41%, respectively) than in those without (27% and 54%, respectively). In multivariate analyses, complete leg pain resolution (adjusted hazard ratio [aHR] 0.69; 95% confidence interval [CI] 0.52-0.90), smoking (aHR 1.68 [95% CI 1.22-2.33]), and depression (aHR 1.74 [95% CI 1.18-2.56]) predicted leg pain recurrence. The 1- and 3-year risk of LBP recurrence was 29% and 65%, respectively. LBP recurrence risk at 3 years was substantially lower in participants with complete initial resolution of LBP than in those without, but not at 1 year. CONCLUSION: Recurrence of leg pain and LBP is common after discectomy for SLDH. Cumulative risks of both leg pain and LBP recurrence were generally lower in participants achieving complete initial resolution of pain post-discectomy. LEVEL OF EVIDENCE: 2.

Synergistic Biomineralization Phenomena Created by a Combinatorial Nacre Protein Model System.

In the nacre or aragonite layer of the mollusk shell, proteomes that regulate both the early stages of nucleation and nano-to-mesoscale assembly of nacre tablets from mineral nanoparticle precursors exist. Several approaches have been developed to understand protein-associated mechanisms of nacre formation, yet we still lack insight into how protein ensembles or proteomes manage nucleation and crystal growth. To provide additional insights, we have created a proportionally defined combinatorial model consisting of two nacre-associated proteins, C-RING AP7 (shell nacre, Haliotis rufescens) and pseudo-EF hand PFMG1 (oyster pearl nacre, Pinctada fucata), whose individual in vitro mineralization functionalities are well-documented and distinct from one another. Using scanning electron microscopy, flow cell scanning transmission electron microscopy, atomic force microscopy, Ca(II) potentiometric titrations, and quartz crystal microbalance with dissipation monitoring quantitative analyses, we find that both nacre proteins are functionally active within the same mineralization environments and, at 1:1 molar ratios, synergistically create calcium carbonate mesoscale structures with ordered intracrystalline nanoporosities, extensively prolong nucleation times, and introduce an additional nucleation event. Further, these two proteins jointly create nanoscale protein aggregates or phases that under mineralization conditions further assemble into protein-mineral polymer-induced liquid precursor-like phases with enhanced ACC stabilization capabilities, and there is evidence of intermolecular interactions between AP7 and PFMG1 under these conditions. Thus, a combinatorial model system consisting of more than one defined biomineralization protein dramatically changes the outcome of the in vitro biomineralization process.