Engineering strategies and challenges of endolysin as an antibacterial agent against Gram-negative bacteria.

Bacteriophage endolysin is a novel antibacterial agent that has attracted much attention in the prevention and control of drug-resistant bacteria due to its unique mechanism of hydrolysing peptidoglycans. Although endolysin exhibits excellent bactericidal effects on Gram-positive bacteria, the presence of the outer membrane of Gram-negative bacteria makes it difficult to lyse them extracellularly, thus limiting their application field. To enhance the extracellular activity of endolysin and facilitate its crossing through the outer membrane of Gram-negative bacteria, researchers have adopted physical, chemical, and molecular methods. This review summarizes the characterization of endolysin targeting Gram-negative bacteria, strategies for endolysin modification, and the challenges and future of engineering endolysin against Gram-negative bacteria in clinical applications, to promote the application of endolysin in the prevention and control of Gram-negative bacteria.

Comparison of B-Scan ultrasonography, ultra-widefield fundus imaging, and indirect ophthalmoscopy in detecting retinal breaks in cataractous eyes.

BACKGROUND/OBJECTIVES: To evaluate the diagnostic performance of B-scan kinetic ultrasonography (USG), standard ultra-widefield (UWF) imaging, and indirect ophthalmoscopy (IDO) in retinal break detection in cataractous eyes. SUBJECTS/METHODS: We consecutively enrolled 126 cataract patients (including 246 eyes) with no comorbidities that could decrease best corrected visual acuity (BCVA). Three index tests (USG, nonmydriatic UWF, and mydriatic IDO) were performed preoperatively to screen for retinal breaks. One week after cataract extraction, a dilated IDO examination was repeated for the definitive diagnosis of retinal break as the reference standard. The sensitivity, specificity, Youden index (YI), and predictive values of each index test were calculated according to postoperative ophthalmoscopic findings. A deep-learning nomogram was developed to quantify the risk of retinal break presence using patients' baseline data and findings reported from preoperative ophthalmic tests. RESULTS: Fifty-two eyes (21%) were excluded from appropriate preoperative UWF imaging because of massive lens opacity. The BCVA cutoff point with maximum YI indicating UWF applicability was 0.6 logMAR (YI = 0.3; area under curve [AUC] = 0.7). Among all 246 eyes, preoperative IDO, USG, and UWF showed fair interobserver agreement (all κ > 0.2). According to postoperative IDO findings, the index tests with the highest sensitivity and specificity were USG (100%) and preoperative IDO (99%), respectively. CONCLUSIONS: For cataractous eyes without vision-impairing comorbidities, a BCVA better than 0.6 logMAR (Snellen acuity, 20/80) allows for appropriate nonmydriatic standard UWF imaging. In a high-volume clinic equipped with skilled ophthalmic examiners, screening with USG followed by directed IDO allows the efficient identification of retinal breaks in cataractous eyes.

Novel compound heterozygous variants in LTBP2 associated with relative anterior microphthalmos.

PURPOSE: Relative anterior microphthalmos (RAM) is a rare congenital defect associated with severe vision impairment that is primarily caused by genetic alterations. The purpose of this study was to identify the causative genetic variants in two Chinese families with RAM with an autosomal recessive inheritance pattern. METHODS: DNA samples were obtained from two probands and their family members. Targeted next-generation sequencing (NGS) was used to screen 425 genes associated with inherited eye diseases to identify possible disease-causing variants in the two patients. Sanger sequencing was subsequently used to validate the results in both families. RESULTS: The targeted NGS panel identified potentially causative novel variants of the latent transforming growth factor beta binding protein 2 (LTBP2) gene in the two RAM families: a missense variant (c.2771C > T; p.Ala924Val) and an intronic variant (c.4582 + 9A > G) in Family A and a different missense variant (c.5239C > A; p.Arg1747Ser) and a synonymous variant (c.951G > A; p.Pro317Pro) in Family B. These four novel variants all cosegregated with the disease phenotype. CONCLUSION: To our knowledge, this is the first study to report novel LTBP2 gene variants related to RAM. Considering the importance of LTBP2 in ocular development, we provide initial insights into the potential pathogenic mechanisms of LTBP2 in RAM.

[Application of electrical impedance tomography imaging technology combined with generative adversarial network in pulmonary ventilation monitoring].

Electrical impedance tomography (EIT) plays a crucial role in the monitoring of pulmonary ventilation and regional pulmonary function test. However, the inherent ill-posed nature of EIT algorithms results in significant deviations in the reconstructed conductivity obtained from voltage data contaminated with noise, making it challenging to obtain accurate distribution images of conductivity change as well as clear boundary contours. In order to enhance the image quality of EIT in lung ventilation monitoring, a novel approach integrating the EIT with deep learning algorithm was proposed. Firstly, an optimized operator was introduced to enhance the Kalman filter algorithm, and Tikhonov regularization was incorporated into the state-space expression of the algorithm to obtain the initial lung image reconstructed. Following that, the imaging outcomes were fed into a generative adversarial network model in order to reconstruct accurate lung contours. The simulation experiment results indicate that the proposed method produces pulmonary images with clear boundaries, demonstrating increased robustness against noise interference. This methodology effectively achieves a satisfactory level of visualization and holds potential significance as a reference for the diagnostic purposes of imaging modalities such as computed tomography.

Association Between Endothelial Cell Density and Corneal Thickness in Medium, Short, and Long Eyes of Han Chinese Cataract Patients.

PURPOSE: To evaluate the association between the endothelial cell density (ECD) and central corneal thickness (CCT) in medium, short, and long eyes of preoperative Han Chinese cataract patients. DESIGN: Retrospective cross-sectional study. METHODS: We consecutively enrolled 410 eyes, namely, 50 short eyes (axial length [AL]<22.0 mm), 150 medium eyes (22.0≤AL<24.0 mm), 120 medium-long eyes (24.0≤AL<26.0 mm), and 90 long eyes (AL≥26.0 mm), of 410 adult patients scheduled for cataract surgery. The ECD and CCT were determined preoperatively with a noncontact specular microscope. The association between the CCT and ECD was identified by using a multivariable regression analysis. A thin cornea was defined as having a CCT less than 500 µm. RESULTS: After adjusting for age, the presence of arterial hypertension, the presence of diabetes mellitus, intraocular pressure, and AL, a positive association between the CCT and ECD was identified in short eyes (linear regression coefficient [B]=3.40; standardized B [ß]=0.52; P = .03), medium eyes (B = 2.33; ß=0.28; P = .002), medium-long eyes (B = 1.84; ß=0.25; P = .02), and long eyes (B = 2.69; ß=0.41; P = .04). In the total group, the multivariable logistic analysis showed a significant link between the presence of a thin cornea and a lower ECD (odds ratio [OR]=0.80 per 100 cells/mm2 increase; P = .001). CONCLUSIONS: For cataract patients of Han ethnicity, a significant association between a thin CCT and a lower ECD was shown across the AL spectrum and was most prominent in short eyes. Eyes with a thin cornea are more likely to have a lower ECD.

Rosavin extends lifespan via the insulin/IGF-1 signaling pathway in Caenorhabditis elegans.

Rosavin, a phenylpropanoid glycoside, is the specific index component and one of the main active components of Rhodiola rosea. Currently, there are few studies describing the antiaging effect of rosavin, and most of them are mainly based on in vitro antioxidant research. Our study aimed to investigate the antiaging activities and mechanisms of rosavin in Caenorhabditis elegans. Using Caenorhabditis elegans as the model, the lifespan of Caenorhabditis elegans under various stressors (heat and juglone) and normal conditions was studied, and the antioxidant activities of rosavin were discussed. To discover the underlying mechanisms, we analyzed daf-16 nuclear localization, the expression of the sod-3p::GFP fusion protein, mRNA levels, and loss-of-function mutants of IIS-associated genes. The results showed that rosavin significantly improved the lifespan of Caenorhabditis elegans under stress and normal conditions. Rosavin can increase the expression and activity of antioxidant enzymes and suppress the generation of malondialdehyde and ROS in nematodes. Additionally, it promotes the nuclear localization of daf-16 and improves the expression of the sod-3 gene in Caenorhabditis elegans. The data revealed that rosavin activated the insulin/IGF-1 signaling pathway by downregulating the upstream components daf-2 and age-1. In summary, these results verify that rosavin could increase the lifespan of Caenorhabditis elegans through the insulin/IGF-1 signaling pathway.

Single Cobalt Ion-Immobilized Covalent Organic Framework for Lithium-Sulfur Batteries with Enhanced Rate Capabilities.

Covalent organic frameworks (COFs) are notable for their remarkable structure, function designability, and tailorability, as well as stability, and the introduction of "open metal sites" ensures the efficient binding of small molecules and activation of substrates for heterogeneous catalysis and energy storage. Herein, we use the postsynthetic metal sites to catalyze polysulfide conversion and to boost the binding affinity to active matter for lithium-sulfur batteries (LSBs). A dual-pore COF, USTB-27, with hxl topology has been successfully assembled from the imine chemical reaction between 2,3,8,9,14,15-hexa(4-formylphenyl)diquinoxalino [2,3-a:2',3'-c]phenazine and [2,2'-bipyridine]-5,5'-diamine. The chelating nitrogen sites of both modules are able to postsynthetically functionalize with single cobalt sites to generate USTB-27-Co. The discharge capacity of the sulfur-loaded S@USTB-27-Co composite in a LSB is 1063, 945, 836, 765, 696, and 644 mA h g-1 at current densities of 0.1, 0.2, 0.5, 1.0, 2.0, and 5.0 C, respectively, much superior to that of non-cobalt-functionalized species S@USTB-27. Following the increased current densities, the rate performance of S@USTB-27-Co is much better than that of S@USTB-27. In particular, the capacity retention at 5.0 C has a magnificent increase from 19% for the latter species to 61% for the former one. Moreover, S@USTB-27-Co exhibits a higher specific capacity of 543 mA h g-1 than that of S@USTB-27 (402 mA h g-1) at a current density of 1.0 C after electrochemical cycling for 500 runs. This work illustrates the "open metal sites" strategy to engineer the active chemical component conversion in COF channels as well as their binding strength for specific applications.

Influence of Ocular Biometry Parameters on the Predictive Accuracy of IOL Power Formulas in Patients with High Myopia.

INTRODUCTION: The aim of this study was to investigate the influence of ocular biometry parameters on the predictive accuracy of 10 intraocular lens (IOL) power formulas in patients with high myopia (HM). METHODS: We analyzed 202 eyes of 202 patients. The ocular biometry was determined preoperatively using an IOLMaster 700. The associations between the biometry parameters and the prediction error (PE) 1 month postoperatively were assessed. HM was defined as an axial length exceeding 26.50 mm. RESULTS: In patients with HM (n = 108), the K6, Emmetropia Verifying Optical (EVO), Olsen, and Barrett Universal II (BUII) formulas had the lowest absolute PEs among the 10 formulas. The ocular biometry parameters were not associated with the PE of K6, EVO, Olsen, or BUII. A longer axial length in HM eyes was associated with myopic outcomes by Kane, Hoffer QST, and VRF and hyperopic outcomes by Holladay 2 and T2. Steeper keratometry, a deeper anterior chamber, and a thicker lens were associated with a hyperopic shift in HM eyes when using VRF, Kane, and Hoffer QST, respectively. In patients without HM (n = 94), there was no difference between the formulas in absolute PE. The significant associations between the biometry parameters and PE in patients with HM were not present in patients without HM. CONCLUSIONS: K6, EVO, Olsen, and BUII displayed high accuracy in HM eyes and were not influenced by preoperative biometry parameters. For the remaining formulas, the preoperative keratometry, anterior chamber depth, lens thickness, and axial length were possible error sources underlying an inaccurate IOL power prediction in patients with HM.

Clinical value of serum MMP-3 in chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is defined as the progressive deterioration of renal parenchyma and decline in renal unit function. In the early stages of CKD(G1 + G2), symptoms are usually not obvious and cannot be effectively recognized on the basis of available clinical markers. Progression to the middle and late stages of CKD results in severe kidney damage with multiple complications causing adverse outcomes, including death. Therefore, the early diagnosis and monitoring of CKD is critical. Matrix metalloproteinase-3 (MMP-3), an extracellular matrix-degrading enzyme, plays an important role in kidney diseases. However, the clinical significance of serum MMP-3 levels in CKD has rarely been reported. METHODS: We quantified the serum MMP-3 levels of 237 patients with CKD and 96 healthy individuals by using a highly sensitive time-resolved fluorescence immunoassay and analyzed differences in MMP-3 levels among the stages of CKD and the correlations of these changes with clinical indicators. RESULTS: The serum MMP-3 concentrations of patients with CKD (171.76 ± 165.22 ng/mL) were significantly higher than those of healthy controls (34.05 ± 22.93 ng/mL; P < 0.0001). In CKD, serum MMP-3 levels were significantly correlated with estimated glomerular filtration rate (eGFR) (r =  - 0.5804, P < 0.0001), serum creatinine (CREA) (r = 0.5823, P < 0.0001), blood urea nitrogen (BUN) (r = 0.6106, P < 0.0001), and protein-to-creatinine ratio (r = 0.4992, P < 0.0001). Randomized forest analysis finds CREA, BUN, and MMP-3 most significant influences on CKD disease severity. The critical value of MMP-3 concentration of 40.39 ng/mL combined with eGFR was effective in diagnosing positive patients in the early (G1 + G2) stage of CKD and showed a positivity rate of 73.45 %. Moreover, in the early stages of CKD, patients with CKD who had serum MMP-3 concentration > 100 ng/mL had more severe renal impairment and inflammation than those with CKD who have lower serum MMP-3 concentrations. CONCLUSION: Elevated serum MMP-3 levels are correlated with decreased kidney function in CKD progression, and patients with concomitant inflammation may express high levels of serum MMP-3. Serum MMP-3 may assist eGFR in improving the diagnosis of patients with early CKD.

Identification of large yellow croakers (Larimichthys crocea) scavenger receptor genes: Involvement in immune response to Pseudomonas plecoglossicida infection and hypoxia-exposure experiments.

Scavenger receptors (SRs) are pattern recognition receptors involved in the innate immune defense against pathogen infection in fish. However, there has not been much research done on teleosts. In this study, 18 members of the SR gene family were found in large yellow croaker. The identification of the SR gene family showed that the protein length of SR members in large yellow croaker were quite different, and most SR genes were distributed in nuclear and endoplasmic. The evolutionary relationship, exon/intron structure and motif analysis revealed that members of the SR gene family were highly conserved. The results of the expression profiles after Pseudomonas plecoglossicida infection and hypoxia-exposure demonstrated that SR members were involved in inflammatory reactions. Especially, COLEC12 and SCARF1 exhibited substantial changes in response to both P. plecoglossicida and hypoxia stress, indicating their possible immunological functions. The result of this study revealed that SR genes played a vital part in the innate immune response of large yellow croaker, and would give important details for a deeper comprehension of the SR gene family's regulation mechanism under various conditions in large yellow croaker.

Discrete Miktoarm Star Block Copolymers with Tailored Molecular Architecture.

Molecular architecture is a critical factor in regulating phase behaviors of the block copolymer and prompting the formation of unconventional nanostructures. This work meticulously designed a library of isomeric miktoarm star polymers with an architectural evolution from the linear-branched block copolymer to the miktoarm star block copolymer and to the star-like block copolymer (i.e., 3AB → 3(AB1)B2 → 3(AB)). All of the polymers have precise chemical composition and uniform chain length, eliminating inherent molecular uncertainties such as chain length distribution or architectural defects. The self-assembly behaviors were systematically studied and compared. Gradually increasing the relative length of the branched B1 block regulates the ratio between the bridge and loop configuration and effectively releases packing frustration in the formation of the spherical or cylindrical structures, leading to a substantial deflection of phase boundaries. Complex structures, such as Frank-Kasper phases, were captured at a surprisingly higher volume fraction. Rationally regulating the molecular architecture offers rich possibilities to tune the packing symmetry of block copolymers.

Deep Learning-Based 6-DoF Object Pose Estimation Considering Synthetic Dataset.

Due to the difficulty in generating a 6-Degree-of-Freedom (6-DoF) object pose estimation dataset, and the existence of domain gaps between synthetic and real data, existing pose estimation methods face challenges in improving accuracy and generalization. This paper proposes a methodology that employs higher quality datasets and deep learning-based methods to reduce the problem of domain gaps between synthetic and real data and enhance the accuracy of pose estimation. The high-quality dataset is obtained from Blenderproc and it is innovatively processed using bilateral filtering to reduce the gap. A novel attention-based mask region-based convolutional neural network (R-CNN) is proposed to reduce the computation cost and improve the model detection accuracy. Meanwhile, an improved feature pyramidal network (iFPN) is achieved by adding a layer of bottom-up paths to extract the internalization of features of the underlying layer. Consequently, a novel convolutional block attention module-convolutional denoising autoencoder (CBAM-CDAE) network is proposed by presenting channel attention and spatial attention mechanisms to improve the ability of AE to extract images' features. Finally, an accurate 6-DoF object pose is obtained through pose refinement. The proposed approach is compared to other models using the T-LESS and LineMOD datasets. Comparison results demonstrate the proposed approach outperforms the other estimation models.

Nanostructurally Engineering Covalent Organic Frameworks for Boosting CO2 Photoreduction.

Herein, a series of imine-linked covalent organic frameworks (COFs) are developed with advanced ordered mesoporous hollow spherical nanomorphology and ultra-large mesopores (4.6 nm in size), named OMHS-COF-M (M = H, Co, and Ni). The ordered mesoporous hollow spherical nanomorphology is revealed to be formed via an Ostwald ripening mechanism based on a one-step self-templated strategy. Encouraged by its unique structural features and outstanding photoelectrical property, the OMHS-COF-Co material is applied as the photocatalyst for CO2 -to-CO reduction. Remarkably, it delivers an impressive CO production rate as high as 15 874 µmol g-1 h-1 , a large selectivity of 92.4%, and a preeminent cycling stability. From in/ex situ experiments and density functional theory (DFT) calculations, the excellent CO2 photoreduction performance is ascribed to the desirable cooperation of unique ordered mesoporous hollow spherical host and abundant isolated Co active sites, enhancing CO2 activation, and improving electron transfer kinetics as well as reducing the energy barriers for intermediates *COOH generation and CO desorption.

Choosing Veterans Affairs: Determinants of post-9/11 Veterans' enrollment in Veterans Affairs health care.

Following recent policy changes, younger Veterans have particularly increased options for where to receive their health care. Although existing research provides some understanding of non-modifiable individual (e.g., age) and external community (e.g., non-VA provider supply) factors that influence VA enrollment, this study focused on modifiable facility access and quality factors that could influence Veterans' decisions to enroll in VA. In this cohort study, we examined enrollment in and use of VA services in the year following military separation as the binary outcome using mixed-effects logistic regressions, stratified by Active and Reserve Components. This study included 260,777 Active and 101,572 Reserve Component post-9/11 Veterans separated from the military in fiscal years 2016 to 2017. Independent variables included 4 access measures for timeliness of VA care and 3 VA quality measures, which are included in VA Medical Centers' performance plans. Eligible Veterans were more likely to enroll in VA when the closest VA had higher quality scores. After accounting for timeliness of VA care and non-modifiable characteristics, rating of primary care (PC) providers was associated with higher VA enrollment for Active Component (odds ratio [OR] = 1.014, 95% confidence interval [CI]: 1.007-1.020). Higher mental health (MH) continuity (OR = 1.039, 95% CI: 1.000-1.078) and rating of PC providers (OR = 1.009, 95% CI: 1.000-1.017) were associated with higher VA enrollment for Reserve Component. Improving facility-specific quality of care may be a way to increase VA enrollment. In a changing policy environment, study results will help VA leadership target changes they can make to manage enrollment of Veterans in VA and deliver needed foundational services.

Effects of Chinese herbal diet on hematopoiesis, immunity, and intestines of mice exposed to different doses of radiation.

Radiotherapy causes a series of side effects in patients with malignant tumors. Polygonati Rhizoma, Achyranthis Bidentatae Radix, and Epimedii Folium are all traditional Chinese herbs with varieties of functions such as anti-radiation and immune regulation. In this study, the above three herbs were used as a herbal diet to study their effects on the hematopoietic, immune, and intestinal systems of mice exposed to three doses of radiation. Our study showed that the diet had no radiation-protective effect on the hematopoietic and immune systems. However, at the radiation dose of 4 Gy and 8 Gy, the diet showed an obvious radiation-protective effect on intestinal crypts. At the dose of 8 Gy, we also found that the Chinese herbal diet had an anti-radiation effect on reducing the loss of the inhibitory nNOS+ neurons in the intestine. That provides a new diet for relieving the symptoms of hyperperistalsis and diarrhea in patients after radiotherapy.

Optimal Timing of Repositioning Surgery for a Plate-Haptic Toric Intraocular Lens: A Multicenter Retrospective Study.

PURPOSE: To evaluate risk factors for significant rotation and determine optimal timing for repositioning surgery following a plate-haptic toric intraocular lens (IOL) implantation. METHODS: This retrospective study enrolled patients who underwent the plate-haptic toric IOL implantation at seven hospitals in Shanghai. IOL rotation and residual astigmatism were compared before and after repositioning surgery. Risk factors for significant IOL rotation after cataract surgery were identified by stepwise multiple linear regression analysis. Spearman's and linear regression analyses were performed to identify factors associated with IOL rotation after repositioning. The receiver operator characteristic (ROC) curve was used to analyze the optimal timing for repositioning surgery. RESULTS: Among 2,745 eyes implanted with the toric IOL, 46 eyes (1.68%) of 45 patients underwent repositioning surgery. Axial length and lens thickness were significantly associated with IOL rotation before repositioning. After repositioning surgery, IOL rotation and residual astigmatism were significantly reduced (all P < .001). IOL rotation after repositioning was negatively associated with the timing of repositioning surgery (all P < .001). The ROC curve showed that the optimal cut-off for the timing of repositioning surgery was 15 days or greater. CONCLUSIONS: The prevalence of repositioning surgery after the plate-haptic toric IOL implantation was 1.68%, and the optimal timing for repositioning surgery was recommended to be 2 to 3 weeks after cataract surgery. [J Refract Surg. 2023;39(2):120-126.].

A Comparative Study on the Accuracy of IOL Calculation Formulas in Nanophthalmos and Relative Anterior Microphthalmos.

PURPOSE: We sought to compare the prediction accuracy of 6 intraocular lens (IOL) formulas, namely, the Haigis, Hoffer Q, Holladay I, SRK/T, Barrett Universal II and Hoffer QST formulas, in microphthalmic eyes, including those with nanophthalmos and relative anterior microphthalmos (RAM). DESIGN: Retrospective case series. METHODS: Twenty-six eyes with nanophthalmos (axial length [AL] 16.84 ± 1.36 mm, range 15.25 mm-19.82 mm) and 12 eyes with RAM (corneal diameter 8.41 ± 0.92 mm, range 7.00 mm-9.50 mm) receiving cataract surgery were included. The IOL Master 500 was used for biometry; thus, lens thickness (LT) was omitted in the IOL power calculation. The mean and median arithmetic and absolute prediction errors (PEs) of the 6 original calculation formulas, the absolute PEs of the 6 formulas after optimization, and the proportion of PEs within ±0.25 diopters (D), ±0.5 D, ±1 D, and ±2 D with each formula were compared. The factors influencing PE were analyzed by multivariate regression. RESULTS: In the nanophthalmos group, the overall prediction results were shifted to myopia. The original Haigis formula had the smallest median absolute PE (1.61 D, P < 0.001), and the optimized Haigis formula had the highest proportion of PEs within ±0.25 D, ±0.5 D, and ±1 D. In the RAM group, the overall prediction results were not significantly different from 0 (P > .05). No significant difference was found among the formulas before optimization (P = .146) and after optimization (P = .161), but the optimized Barrett Universal II formula had the highest proportion of PEs within ±1 D and ±2 D. CONCLUSIONS: When omitting the LT parameter in the calculation, the Haigis formula was the most accurate in cataract patients with nanophthalmos (AL <20 mm) among the 6 IOL calculation formulas, and the Barrett Universal II formula had the highest accuracy in cataract patients with RAM (corneal diameter ≤9.5 mm).

Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics.

OBJECTIVE: Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors. METHODS: This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care. RESULTS: Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06). CONCLUSIONS: With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.