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The objective of this study was to ascertain how much U.S. medical students are taught about and know about military medical ethics, the Geneva Conventions, and the laws governing conscription of medical personnel. The authors developed an Internet-based questionnaire on these matters, and e-mail invitations to participate were sent to approximately 5,000 medical students at eight U.S. medical schools. Thirty-five percent of e-mail recipients participated in the survey. Of those, 94 percent had received less than one hour of instruction about military medical ethics and only 3.5 percent were aware of legislation already passed making a 'doctor's draft' possible; 37 percent knew the conditions under which the Geneva Conventions apply; 33.8 percent did not know that the Geneva Conventions state that physicians should 'treat the sickest first, regardless of nationality;' 37 percent did not know that the Geneva Conventions prohibit ever threatening or demeaning prisoners or depriving them of food or water; and 33.9 percent could not state when they would be required to disobey an unethical order. [ABSTRACT FROM AUTHOR]

Context: Studies of selected groups of persons with mental illness, such as those who are institutionalized or seen in mental health clinics, have reported rates of smoking to be higher than in persons without mental illness. However, recent population-based, nationally representative data are lacking.Objective: To assess rates of smoking and tobacco cessation in adults, with and without mental illness.Design, Setting, and Participants: Analysis of data on 4411 respondents aged 15 to 54 years from the National Comorbidity Survey, a nationally representative multistage probability survey conducted from 1991 to 1992.Main Outcome Measures: Rates of smoking and tobacco cessation according to the number and type of psychiatric diagnoses, assessed by a modified version of the Composite International Diagnostic Interview.Results: Current smoking rates for respondents with no mental illness, lifetime mental illness, and past-month mental illness were 22.5%, 34.8%, and 41.0%, respectively. Lifetime smoking rates were 39.1%, 55.3%, and 59.0%, respectively (P<.001 for all comparisons). Smokers with any history of mental illness had a self-reported quit rate of 37.1% (P =.04), and smokers with past-month mental illness had a self-reported quit rate of 30. 5% (P<.001) compared with smokers without mental illness (42.5%). Odds ratios for current and lifetime smoking in respondents with mental illness in the past month vs respondents without mental illness, adjusted for age, sex, and region of the country, were 2.7 (95% confidence interval [CI], 2.3-3.1) and 2.7 (95% CI, 2.4-3.2), respectively. Persons with a mental disorder in the past month consumed approximately 44.3% of cigarettes smoked by this nationally representative sample.Conclusions: Persons with mental illness are about twice as likely to smoke as other persons but have substantial quit rates. JAMA. 2000;284:2606-2610. [ABSTRACT FROM AUTHOR]

Objective: This study examined the impact of state medical licensure exemptions and telehealth registries on college students' access to psychiatric care., Methods: The authors attempted to contact 901 psychiatrists who advertised online on Psychology Today by using a simulated patient, described as a student attending college in a state with a medical licensure exemption or telehealth registry., Results: Contact was established with 282 (31%) psychiatrists across 10 states. Of the 143 contacted psychiatrists who were accepting new patients, seven (5%) were aware of state medical licensure exemptions, 43 (30%) were willing to establish care with students attending college in another state regardless of state laws, 42 (29%) were willing to learn about licensure exemptions, and 51 (36%) were unwilling to care for students in another state even when permitted by law., Conclusions: Given psychiatrists' lack of awareness of licensure exemptions and telehealth registries, interstate access to and continuity of care may be limited., Competing Interests: Dr. Conrad is a consultant to Physicians Realty Trust and to Mind and Match. Dr. Benson has volunteered for the EPIC Behavioral Healthcare specialty steering board and works for Headway, and her spouse has received equity from Cerevel Therapeutics and AbbVie through employment. The other authors report no financial relationships with commercial interests.

Objective: To document veterinary technicians' (VTs') experiences with medical futility and its subsequent impact on moral distress and attrition from the profession., Methods: A cross-sectional study using a 56-question web-based, confidential and anonymous survey was distributed through the National Association of Veterinary Technicians in America between January 19 and February 15, 2023., Results: There were 1,944 responses from approximately 8,500 members (22% response rate). Nearly all respondents (97.8%) reported having encountered futile treatments during their careers, with 94.7% having provided such treatments. Most respondents (83.7%) had been asked or directed to act against their conscience to provide futile treatments to terminally ill patients, with 80.8% having done so. Providing futile treatments resulted in moderate to severe stress in 76.9% of VTs surveyed; respondents reported experiencing negative emotional (96.6%) or physical responses (83.4%) associated with medically futile treatments. Nearly half (48.7%) have considered leaving their position due to moral distress associated with providing futile treatments, and 55.5% claimed to have firsthand knowledge of someone who has left the profession for the same reason., Conclusions: Encounters with medical futility were a common occurrence among respondents. Furthermore, futile medical treatments caused a significant increase in moral stress for the VTs polled, which may contribute to professional attrition., Clinical Relevance: Targeting ways to mitigate moral distress due to experiences with futility may increase retention and career satisfaction of VTs.

Objective: In this study, the authors sought to ascertain the availability of outpatient child psychiatric appointments in three U.S. cities., Methods: Using a simulated-patient methodology, investigators called 322 psychiatrists who were listed in a major insurer's database for three U.S. cities, and they attempted to make appointments for a child with three payment types: Blue Cross-Blue Shield, Medicaid, and self-pay., Results: Initial appointments were available 11% of the time, and it was most difficult to obtain an appointment under Medicaid coverage. Nineteen percent of phone numbers were wrong, and 25% of psychiatrists were not accepting new patients., Conclusions: These results are concerning given the current mental health crisis among youths and suggest the need for more psychiatrists, higher reimbursement rates for psychiatric services, and continued efforts to increase access to care. This study also highlights the need for insurance companies to maintain accurate information in their databases., Competing Interests: The authors report no financial relationships with commercial interests.

Perinatal mood and anxiety disorders, defined as mood and anxiety disorders during pregnancy and the year following birth, affect one in five pregnant and postpartum individuals in the United States and are associated with substantial morbidity and mortality for both pregnant individuals and their infants. Despite this tremendous prevalence and associated disease burden, the overwhelming majority of those affected do not receive treatment. Although prior research has identified several patient-level barriers to effective treatment, the contributions of system-level factors have been underappreciated. We present a pilot study using a simulated patient approach to describe the accessibility and affordability of mental health care through the 18 clinics affiliated with U.S. reproductive psychiatry fellowship programs. Based on our experience, a prospective patient seeking care from these 18 clinics without a prior referral would only have been successful half of the time-and even then may have to wait as long as 2 months for an initial appointment. These data underscore the need for clinicians, public health professionals, and institutions to address system-level barriers that undermine effective referrals for care, including implementing "warm-handoffs" to mental health providers and ending practices that restrict appointments to existing patients within a health care system. They also reinforce the importance of contemporary federal policy efforts to address maternal health, particularly among low-income and racially minoritized communities. Key policies include expanding postpartum insurance coverage, which plays a critical role in reducing insurance disruptions that can undermine the accessibility of mental health care and other vital health services.

New Findings: What is the central question of this study? Acute exposure to electronic cigarettes (Ecigs) triggers abnormal vascular responses in systemic arteries; however, effects on cerebral vessels are poorly understood and time for recovery is not known. We hypothesized that exposure to cigarettes or Ecigs would trigger rapid (<4 h) impairment of the middle cerebral artery (MCA) but that this would resolve by 24 h. What is the main finding and its importance? Cigarettes and Ecigs caused similar degree and duration of MCA impairment. We find it takes ~72 hours after exposure for MCA function to return to normal. This suggests that Ecig use is likely to produce similar adverse vascular health outcomes to those seen with cigarette smoke., Abstract: Temporal influences of electronic cigarettes (Ecigs) on blood vessels are poorly understood. In this study, we evaluated a single episode of cigarette versus Ecig exposure on middle cerebral artery (MCA) reactivity and determined how long after the exposure MCA responses took to return to normal. We hypothesized that cigarette and Ecig exposure would induce rapid (<4 h) reduction in MCA endothelial function and would resolve within 24 h. Sprague-Dawley rats (4 months old) were exposed to either air (n = 5), traditional cigarettes (20 puffs, n = 16) or Ecigs (20-puff group, n = 16; or 60-puff group, n = 12). Thereafter, the cigarette and Ecig groups were randomly assigned for postexposure vessel myography testing on day 0 (D0, 1-4 h postexposure), day 1 (D1, 24-28 h postexposure), day 2 (D2, 48-52 h postexposure) and day 3 (72-76 h postexposure). The greatest effect on endothelium-dependent dilatation was observed within 24 h of exposure (∼50% decline between D0 and D1) for both cigarette and Ecig groups, and impairment persisted with all groups for up to 3 days. Changes in endothelium-independent dilatation responses were less severe (∼27%) and shorter lived (recovering by D2) compared with endothelium-dependent dilatation responses. Vasoconstriction in response to serotonin (5-HT) was similar to endothelium-independent dilatation, with greatest impairment (∼45% for all exposure groups) at D0-D1, returning to normal by D2. These data show that exposure to cigarettes and Ecigs triggers a similar level/duration of cerebrovascular dysfunction after a single exposure. The finding that Ecig (without nicotine) and cigarette (with nicotine) exposure produce the same effects suggesting that nicotine is not likely to be triggering MCA dysfunction, and that vaping (with/without nicotine) has potential to produce the same vascular harm and/or disease as smoking., (© 2022 The Authors. Experimental Physiology © 2022 The Physiological Society.)

Objective: To document veterinarians' perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice., Sample: 477 veterinarians in small animal general and specialty veterinary practice., Procedures: A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations., Results: Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate., Clinical Relevance: The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

The rate of overdose deaths has increased dramatically over the past 2 decades. Recently, efforts have been made to expand access to medications for opioid use disorder, such as buprenorphine, by removing X-waiver training requirements. However, relieving such barriers has also raised concern about increasing diversion rates for buprenorphine use, defined as the use of buprenorphine for some purpose or by someone other than it was originally intended. Historically, diversion has been addressed through the criminalization of buprenorphine possession without a prescription. We argue that while buprenorphine diversion is not to be condoned, the benefits of such actions greatly outweigh the harms. Thus, criminalization of diverted buprenorphine represents a dangerous and wasteful response that threatens the progress made through expanded access to this lifesaving medication., Competing Interests: Conflict of interests: The authors do not hold any conflicting or competing interests., (© Copyright 2022 by the American Board of Family Medicine.)

Systemic cytokine concentrations have been extensively studied in implant-associated infections, providing sensitive diagnostic markers. However, less is known about the relationships of tissue-level cytokines surrounding the joint. The aim of this study was to define the cytokine profiles of tissues to investigate the use of these cytokines as markers of debridement in chronic joint infection. Using a rodent model, muscle samples were obtained from rats following Kirschner wire implantation and infection with Staphylococcus aureus to determine if: (1) differences exist in cytokine concentrations with proximity to infection, and (2) localized infection-specific markers can be identified on a tissue level to potentially serve as debridement markers in the future. Samples were collected from 4 distinct locations, and the concentrations of interleukin(IL)-1α, IL-1β, IL-4, IL-5, IL-6, IL-10, IL-12p70, IL-13, granulocyte-macrophage colony-stimulating factor, interferon-γ, and tumor necrosis factor-α were quantified in each sample, relative to the amount of tissue. Cytokine concentrations differed with proximity to the joint when implant or infection was present, and tissues at the operative knee joint showed the highest levels of most cytokines. Additionally, IL-1β, IL-4, and IL-6 showed promise, beyond diagnostics, as tissue-level indicators of infection response. Ultimately, this study illustrated that tissue-level evaluation provided insight into infection-specific response, and these markers may be useful for guiding the debridement of implant-associated infections., (© 2020 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Chlorpyrifos (CPF) is one of the most widely-used pesticides globally for agricultural purposes. Certain occupations (e.g., farmers, military) are at an increased risk for high-dose exposure to CPF, which can lead to seizures and irreversible brain injury. Workers with the highest risk of exposure typically experience increased circulating cortisol levels, which is related to physiological stress. To better represent this exposure scenario, a mouse model utilized exogenous administration of corticosterone (CORT; high physiologic stress mimic) in combination with chlorpyrifos oxon (CPO; oxon metabolite of CPF); this combination increases neuroinflammation post-exposure. In the present study adult male C57BL/6J mice were given CORT (200 μg/mL) in drinking water for seven days followed by a single intraperitoneal injection of CPO (8.0 mg/kg) on day eight, and euthanized 0.5, 2, and 24 h post-injection. Ten post-translationally modified proteins were measured in the frontal cortex and striatum to evaluate brain region-specific effects. The spatiotemporal response to CORT + CPO sequentially activated phosphoproteins (p-ERK1/2, p-MEK1/2, p-JNK) involved in mitogen-activated protein kinase (MAPK) signaling. Observed p-ZAP70 responses further integrated MAPK signaling and provided a spatiotemporal connection between protein phosphorylation and neuroinflammation. This study provides insight into the spatiotemporal cellular signaling cascade following CORT + CPO exposure that represent these vulnerable populations., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Aims: Veterans from the 1990-91 Gulf War were exposed to acetylcholinesterase inhibitors (AChEIs), and, following service, an estimated one-third began suffering from a medically unexplained, multi-symptom illness termed Gulf War Illness (GWI). Previous research has developed validated rodent models that include exposure to exogenous corticosterone (CORT) and AChEIs to simulate high stress and chemical exposures encountered in theater. This combination of exposures in mice resulted in a marked increase in neuroinflammation, which is a common symptom of veterans suffering from GWI. To further elucidate the mechanisms associated with these mouse models of GWI, an investigation into intracellular responses in the cortex were performed to characterize the early cellular signaling changes associated with this exposure-initiated neuroinflammation., Main Methods: Adult male C57BL/6J mice were exposed to CORT in the drinking water (200 μg/mL) for 7 days followed by a single intraperitoneal injection of diisopropyl fluorophosphate (DFP; 4.0 mg/kg) or chlorpyrifos oxon (CPO; 8.0 mg/kg), on day 8 and euthanized 0.5, 2, and 24 h post-injection. Eleven post-translationally modified protein targets were measured using a multiplexed ELISA., Key Findings: Phosphoprotein responses were found to be exposure specific following AChEI insult, with and without CORT. Specifically, CORT + CPO exposure was found to sequentially activate several phosphoproteins involved in mitogen activated protein kinase signaling (p-MEK1/2, p-ERK1/2, and p-JNK). DFP alone similarly increased proteins in this pathway (p-RPS6, and p-JNK), but the addition of CORT ameliorated these affects., Significance: The results of this study provide insight into differentially activated pathways depending on AChEI in these GWI models., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. Published by Elsevier Ltd.)

Events in 2020 have sparked a reimagination of how both individuals and institutions should consider race, power, health, and marginalization in society. In a response to these developments, we examine the current and past limitations of the ways in which bioethicists have considered race and, more generally, discourses of marginalization. We argue that the foundational principle of justice necessitates that bioethics, as an institution, maintain an active voice against systemic injustice. To carry out this charge, bioethics as a field should promote alternative narratives-"counter storytelling"-to the mainstream voices that have traditionally been heard and accepted, largely without opposition. Additionally, we engage with both Post-Colonial and Critical Race Theory, which we believe are important tools for bioethics in pursuit of equity. Ultimately, we advocate for a proactive form of bioethics that actively resists and denounces injustice and which considers a much wider variety of voices about justice than bioethics has historically considered.

Background: The study of localized immune-related factors has proven beneficial for a variety of conditions, and one area of interest in the field of orthopaedics is the impact of implants and localized infections on immune response. Several cytokines have shown increased systemic concentrations (in serum/plasma) in response to implants and infection, but tissue-level cytokines have not been investigated as thoroughly., Methods: This exploratory study investigated tissue-level cytokines in a cohort of patients (N = 17) in response to total knee arthroplasty and total knee revision to better understand the immune response to implants and localized infection (e.g., prosthetic joint infection). The overall goal of this study was to provide insight into the localized cytokine response of tissues and identify tissue-level markers specific to inflammation caused by implants vs. inflammation caused by infection. Tissues were collected across several anatomical locations and assayed with a panel of 20 human inflammatory cytokines to understand spatial differences in cytokine levels., Results: In this study, six cytokines were elevated in implanted joints, as compared to native joints: IL-10, IL-12p70, IL-13, IL-17A, IL-4, and TNF-α (p < 0.05). Seven cytokines showed infection-dependent increases in localized tissues: IL-1α, IL-1β, IL-6, IL-8, MCP-1, MIP-1α, and MIP-1β (p < 0.05)., Conclusions: This study demonstrated that differences exist in tissue-level cytokines in response to presence of implant, and some cytokines were specifically elevated for infection; these responses may be informative of overall tissue health. These results highlight the utility of investigating localized cytokine concentrations to offer novel insights for total knee arthroplasty and total knee revision procedures, as well as their complications. Ultimately, this information could provide additional, quantitative measurements of tissue to aid clinical decision making and patient treatment options.

The early cellular response to infection has been investigated extensively, generating valuable information regarding the mediators of acute infection response. Various cytokines have been highlighted for their critical roles, and the actions of these cytokines are related to intracellular phosphorylation changes to promote infection resolution. However, the development of chronic infections has not been thoroughly investigated. While it is known that wound healing processes are disrupted, the interactions of cytokines and phosphoproteins that contribute to this dysregulation are not well understood. To investigate these relationships, this study used a network centrality approach to assess the impact of individual cytokines and phosphoproteins during chronic inflammation and infection. Tissues were taken from patients undergoing total knee arthroplasty (TKA) and total knee revision (TKR) procedures across two tissue depths to understand which proteins are contributing most to the dysregulation observed at the joint. Notably, p-c-Jun, p-CREB, p-BAD, IL-10, IL-12p70, IL-13, and IFN-γ contributed highly to the network of proteins involved in aseptic inflammation caused by implants. Similarly, p-PTEN, IL-4, IL-10, IL-13, IFN-γ, and TNF-α appear to be central to signaling disruptions observed in septic joints. Ultimately, the network centrality approach provided insight into the altered tissue responses observed in chronic inflammation and infection.

Using salivary inflammatory markers as a noninvasive biomonitoring technique within natural social contexts has become increasingly important to link social and biological responses. Many studies have associated circulating cytokines to distinct aspects of physical activity and social/emotional behavior; however, they have not been linked to success and failure in a naturalistic setting for military personnel performing tasks. In this study, salivary cytokines were studied in a group of fifteen Air Force Reserve Officers' Training Corps (ROTC; 14 males, 1 female) subjects performing three mock hostage rescue missions, designed to prompt responses associated with baseline, success, and failure. Each subject completed the tasks of the mission individually and again in randomly assigned teams. Participants were outfitted via direct skin contact with comfortable external Zephyr™ sensors to monitor heart rate, breathing rate, and activity while completing each task. Saliva samples were collected before and after the completion of each mission, and cytokine levels were quantified using enzyme-labelled immunoassay (ELISA) beads. These biomarkers were used to describe the body's immune response to success and failure when performing a mock rescue mission individually and in a team. All measured cytokine levels increased following failed missions performed individually, compared to cytokine levels associated with successful missions. When completing the tasks as a team, there were no significant differences in cytokine response between success and failure; however, being in a team stimulated an increased pre-mission cytokine response, suggesting the concept of teamwork and performing with peers for the first time had a more significant impact than the notion of failing. Additionally, none of the cytokines tested for individual missions correlated to physical activity markers (heart rate, breathing rate, activity) measured during performance. These results indicate a potentially new noninvasive method of determining social stress levels under taxing conditions., Competing Interests: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. This study was funded by the 10.13039/100000185Defense Advanced Research Projects Agency (DARPA, United States, W911NF-12-0165) and 10.13039/100000002NIH (United States, P20GM103434) to the West Viginia Institutional Development Award (IDeA) Networks of Biomedical Research Excellence (INBRE)., (© 2020 The Authors.)

Toxicology is a broad field that requires the translation of biochemical responses to xenobiotic exposures into useable information to ensure the safety of the public. Modern techniques are improving rapidly, both quantitatively and qualitatively, to provide the tools necessary to expand available toxicological datasets and refine our ability to translate that data into relevant information via bioinformatics. These new techniques can, and do, impact many of the current critical roles in toxicology, including the environmental, forensic, preclinical/clinical, and regulatory realms. One area of rapid expansion is our understanding of bioenergetics, or the study of the transformation of energy in living organisms, and new mathematical approaches are needed to interpret these large datasets. As bioenergetics are intimately involved in the regulation of how and when a cell responds to xenobiotics, monitoring these changes (i.e., metabolic fluctuations) in cells/tissues post-exposure provides an approach to define the temporal scale of pharmacodynamic responses, which can be used to guide additional toxicological techniques (e.g., "omics"). This chapter will summarize important in vitro assays and in vivo imaging techniques to take real-time measurements. Using this information, our laboratory has utilized bioenergetics to identify significant time points of pharmacodynamic relevance as well as forecast the cell's eventual fate.

Objective: The objective of this study was to assess the accuracy of the Substance Abuse and Mental Health Services Administration (SAMHSA) database for patients who use it to seek buprenorphine treatment., Design and Measurements: Buprenorphine providers within a 25-mile radius of the county with the highest drug-related death rates within the 10 states with the highest drug-related death rates were identified and called to determine whether the provider worked there, prescribed buprenorphine, accepted insurance, had appointments, or charged for visits., Results: The number of providers listed in each county ranged from 1 to 166, with 5 counties having <10 providers. In 3 counties no appointments were obtained, and another 3 counties had ≤3 providers with availability. Of the 505 providers listed, 355 providers (70.3%) were reached, 310 (61.4%) of the 505 listings were correct numbers, and 195 (38.6%) of the 505 providers in the listings provided buprenorphine. Of the 173 clinics that provided buprenorphine and were asked about insurance, 131 (75.7%) accepted insurance. Of the 167 clinics that provided buprenorphine and were asked about Medicaid, 105 (62.9%) accepted it. Wait times for appointments ranged from 1 to 120 days, with an average of 16.8 days for those that had a waitlist. Among the 39 providers who reported out-of-pocket costs, the average cost was $231 (range: $90 to $600). One hundred forty of the 505 providers listed in the database had appointments available (27.7%). Three hundred sixty-five of the 505 providers did not have appointments available (72.3%) for various reasons, including the fact that 120 providers (32.9% of the 365 providers) could not be reached, and 137 of the numbers (37.5% of the 365 listed numbers) were wrong. Other reasons appointments could not be obtained included the fact that providers did not treat outpatients, were not accepting new patients, were out of office, or required a referral., Conclusion: Although the SAMHSA buprenorphine practitioner locator is used by patients and providers to locate treatment options, only a small portion of clinicians in the database ultimately offered initial appointments, implying that the database is only marginally useful for patients.

Objective: This study describes the experiences of adult psychiatry residents working in an established faculty-led asylum clinic within a community-based, academic residency program at the Cambridge Health Alliance., Methods: Eighteen psychiatry residents who participated in the asylum clinic were sent electronic surveys asking about their background and experience. Respondents' responses were collected anonymously., Results: Sixteen out of 18 (89%) trainees responded. Thirteen respondents had a personal history with immigration. Fifty-three percent of residents wanted to utilize their professional standing to advance moral good. Writing up affidavits was noted to be challenging by nine (60%) of 15 trainees. Ninety-four percent (15/16) of trainees noted that they would be willing to perform future evaluations. Most noted that performing evaluations had a significant impact on their clinical practice and their conceptualization of their own roles as psychiatrists., Conclusions: Participating in asylum evaluations impacts residents' sense of themselves as psychiatrists and expands their views about psychiatrists' roles.

Two thinkers have crafted visions of how they believe health-care resources ought to be allocated if there were universal health-care coverage in the United States. One is The Ends of Human Life (1994), in which Ezekiel Emanuel proposes to base resource allocation on community preferences. More recently, Charlene Galarneau has written Communities of Health Care Justice (2016), partly in response to Emanuel's earlier work. Both thinkers center their visions of just health care on communities, albeit differently structured from one another. This essay examines the similarities and differences in their proposals for resource allocation and addresses questions that arise from their proposals, such as: What are the advantages of their community-based approaches compared with more universal, nationalized options? What might prevent communities from excluding certain individuals from active participation? And finally, does positing active engagement in a community, all by itself, guarantee that justice and fairness will be served? The essay concludes that although community allocation of health services has some desirable elements, allocating resources in a centralized, national manner would be more efficient, practical, and more likely to prevent bias and discrimination against those at the margins of their communities.

Introduction: In the surgical setting, the most accepted technique for measuring tissue perfusion includes subjective identification, with visual and tactile inspections of the tissue, performed by a surgeon. Recently, fields such as ophthalmology, plastic surgery, and other surgical specialties, such as cardiac, vascular, and transplant surgery, have seen the emergence of laser-assisted fluorescent angiography (LAFA) to visualize real-time tissue perfusion during procedures., Case Report: The case of an 80-year-old woman, who presented with a wound over the left medial elbow following a subacute recurrent elbow dislocation, illustrates the use of this technology in the field of orthopedics. Initially, the patient was treated at an outside facility where the dislocation was reduced, and she was placed in a long arm splint. With concern of recurrent dislocation and wound development, she presented to the authors with a complex wound measuring about 9 cm x 5 cm with variable thickness ranging from 0 mm to 5 mm in depth. Her initial emergent irrigation and debridement and wound management was assisted by LAFA and the administration of indocyanine green to guide debridement and determine viable wound margins. After staging with external fixation and a negative pressure wound dressing, she later returned for skin grafting and healed uneventfully., Conclusions: In conjunction with plastic surgeons, the orthopaedic team utilized LAFA for debridement that led to both a successful wound repair and skin grafting procedure.

Background: Physician health program websites in 23 states provide many descriptions of possible physician impairment. This study sought to determine whether these descriptions are so broad that almost everyone might potentially be suspected of being impaired given these descriptions., Methods: The authors randomly selected 25 descriptions of impairment and then presented them anonymously online to members of the general population in full-time employment through Amazon's Mechanical Turk (N = 199). Half of the respondents randomly received a narrowly worded version, and half received a broadly worded version of the survey questions., Results: In the narrowly worded version of the survey, 70.9% of respondents endorsed at least one description of impairment, and 59.2% endorsed more than one. In the broadly phrased version, 96.9% endorsed at least one description, and 95.8% endorsed more than one. These respondents endorsed a median of 10 out of 25 (40%) descriptions., Conclusions: These findings call into question whether these descriptions really identify persons with poor performance or who pose a high risk of substantial, imminent harm to self or others in the workplace. They also demonstrate the extent to which these descriptions could potentially be misapplied and brand almost anyone as impaired.

Investigations of cellular responses involved in injury and repair processes have generated valuable information contributing to the advancement of wound healing and treatments. Intra- and extracellular regulators of healing mechanisms, such as cytokines, signaling proteins, and growth factors, have been described to possess significant roles in facilitating optimal recovery. This study explored a collection of 30 spatiotemporal responses comprised of cytokines (IL-1α, IL-1ß, IL-2, IL-6, TNF-α, MIP-1α), intracellular proteins (Akt, c-Jun, CREB, ERK1/2, JNK, MEK1, p38, p53, p90RSK), phosphorylated proteins (p-Akt, p-c-Jun, p-CREB, p-ERK1/2, p-GSK-3α/ß, p-HSP27, p-IκBα, p-JNK, p-MEK1, p-p38, p-p70S6K, p-p90RSK, p-STAT2, p-STAT3), and a protease (Caspase-3), measured in skeletal muscle tissue following a traumatic injury (rodent Gustilo IIIB fracture). To optimize the analysis of context-specific data sets, a network centrality parameter approach was used to assess the impact of each response in relation to all other measured responses. This approach identified proteins that were substantially amplified and potentially central in the wound healing network by evaluation of their corresponding centrality parameter, radiality. Network analysis allowed us to distinguish the progression of healing that occurred at certain time points and regions of injury. Notably, new tissue formation was proposed to occur by 168 h post-injury in severely injured tissue, while tissue 1-cm away from the site of injury that experienced relatively minor injury appeared to exhibit signs of new tissue formation as early as 24 h post-injury. In particular, hallmarks of inflammation, cytokines IL-1ß, IL-6, and IL-2, appear to have a pronounced impact at earlier time points (0-24 h post-injury), while intracellular proteins involved in cell proliferation, differentiation, or proteolysis (c-Jun, CREB, JNK, p38, p-c-Jun; p-MEK1, p-p38, p-STAT3) are more significant at later times (24-168 h). Overall, this study demonstrates the feasibility of a network analysis approach to extract significant information and also offers a spatiotemporal visualization of the intra- and extracellular signaling responses that regulate healing mechanisms., (Published by Elsevier Ltd.)

The websites of many physician health programs provide lists describing signs of impairment or indications to refer physician-employees for evaluation and possible treatment. This study aimed (1) to determine how many of these descriptions likely provide physicians' employers with sufficient evidence to legally request mental health examinations under the general regulations of the Americans with Disabilities Act (ADA); and (2) to find out who they described. The authors applied US Equal Employment Opportunity Commission guidance documents and sought expert legal advice to evaluate the descriptions for their consistency with the ADA. They used directed content analysis to review and code these descriptions into categories. Very few, if any, of the 571 descriptions appeared to provide sufficient evidence for employers to request an examination under the ADA. About 14%, however, could refer to physicians attempting to defend themselves, assert their ADA rights, or otherwise complain about the hospital; and 27% either described physicians who complain or else had discriminatory effects in one of several different ways. Leaders within the medical field should ensure that their policies and state laws pertaining to physician impairment comply with and incorporate the language of the ADA. They should also reevaluate the functions of these policies, laws, and physician health programs, and the implications for patient safety, physician wellness, suicide, and other important issues., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. Providers were less likely to have available appointments for children on Medicaid, which is public insurance for low-income people. The most common reason for being unable to make an appointment was that the listed phone number was incorrect. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Increasing the number of both types of providers may be necessary to increase access to mental health care for children.

Human activity has significantly increased the deposition of nitrogen (N) on terrestrial ecosystems over pre-industrial levels leading to a multitude of effects including losses of biodiversity, changes in ecosystem functioning, and impacts on human well-being. It is challenging to explicitly link the level of deposition on an ecosystem to the cascade of ecological effects triggered and ecosystem services affected, because of the multitude of possible pathways in the N cascade. To address this challenge, we report on the activities of an expert workshop to synthesize information on N-induced terrestrial eutrophication from the published literature and to link critical load exceedances with human beneficiaries by using the STressor-Ecological Production function-final ecosystem Services Framework and the Final Ecosystem Goods and Services Classification System (FEGS-CS). We found 21 N critical loads were triggered by N deposition (ranging from 2 to 39 kg N·ha -1 ·yr -1 ), which cascaded to distinct beneficiary types through 582 individual pathways in the five ecoregions examined (Eastern Temperate Forests, Marine West Coast Forests, North-western Forested Mountains, North American Deserts, Mediterranean California). These exceedances ultimately affected 66 FEGS across a range of final ecosystem service categories (21 categories, e.g., changes in timber production, fire regimes, and native plant and animal communities) and 198 regional human beneficiaries of different types. Several different biological indicators were triggered in different ecosystems, including grasses and/or forbs (33% of all pathways), mycorrhizal communities (22%), tree species (21%), and lichen biodiversity (11%). Ecoregions with higher deposition rates for longer periods tended to have more numerous and varied ecological impacts (e.g., Eastern Temperate Forests, eight biological indicators) as opposed to other ecoregions (e.g., North American Deserts and Marine West Coast Forests each with one biological indicator). Nonetheless, although ecoregions differed by ecological effects from terrestrial eutrophication, the number of FEGS and beneficiaries impacted was similar across ecoregions. We found that terrestrial eutrophication affected all ecosystems examined, demonstrating the widespread nature of terrestrial eutrophication nationally. These results highlight which people and ecosystems are most affected according to present knowledge, and identify key uncertainties and knowledge gaps to be filled by future research.

Purpose: Adolescents with substance use disorders are more likely to have a current psychiatric disorder. However, when compared with the adult literature, there is relatively limited information regarding the specific co-occurrence of certain mental health diagnoses and substance use disorders in adolescents. The objectives of this study were to build on the previous literature regarding mental health diagnoses and different types of substance use disorders in adolescents, as well as explore the differences, if any, between groupings of mental health diagnosis and type of substance used., Methods: Data were extracted from the clinical records of 483 individuals aged 11-24 years referred for an evaluation at the Adolescent Substance Abuse Program at Boston Children's Hospital. According to DSM-IV-Text Revision criteria, individuals received diagnoses of substance abuse or dependence and any additional psychiatric disorders. Problematic use was included within the sample for greater power analysis. A multivariable logistic regression model estimated the association between psychiatric diagnosis and substance use while adjusting for covariates including age and gender., Results: Multiple significant associations were found, including having any anxiety-related diagnosis and opioid use (odds ratio [OR] = 2.23, p < .001), generalized anxiety disorder and opioids (OR = 3.42, p = .008), cocaine and post-traumatic stress disorder (OR = 3.61, p = .01), and marijuana and externalizing behavior disorders (OR = 2.10, p = .024)., Conclusions: Our study found multiple significant associations between specific substances and certain co-occurring psychiatric disorders. The use of office screening systems to efficiently identify these youths should be a part of routine medical and psychiatric care., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Molecular mechanisms of wound healing have been extensively characterized, providing a better understanding of the processes involved in wound repair and offering advances in treatment methods. Both spatial and temporal investigations of injury biomarkers have helped to pinpoint significant time points and locations during the recovery process, which may be vital in managing the injury and making the appropriate diagnosis. This study addresses spatial and temporal differences of phosphoproteins found in skeletal muscle tissue following a traumatic femur fracture, which were further compared to co-localized cytokine responses. In particular, several proteins (Akt, ERK, c-Jun, CREB, JNK, MEK1, and p38) and post-translational phosphorylations (p-Akt, p-c-Jun, p-CREB, p-ERK1/2, p-MEK1, p-p38, p-GSK3α/β, p-HSP27, p-p70S6K, and p-STAT3) associated with inflammation, new tissue formation, and remodeling were found to exhibit significant spatial and temporal differences in response to the traumatic injury. Quadratic discriminant analysis of all measured responses, including cytokine concentrations from previously published findings, was used to classify temporal and spatial observations at high predictive rates, further confirming that distinct spatiotemporal distributions for total protein, phosphorylation signaling, and cytokine (IL-1α, IL-1ß, IL2, IL6, TNF-α, and MIP-1α) responses exist. Finally, phosphoprotein measurements were found to be significantly correlated to cytokine concentrations, suggesting coordinated intracellular and extracellular activity during crucial periods of repair. This study represents a first attempt to monitor and assess integrated changes in extracellular and intracellular signaling in response to a traumatic injury in muscle tissues, which may provide a framework for future research to improve both our understanding of wounds and their treatment options., (Copyright © 2015 Elsevier Ltd. All rights reserved.)