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Adegbenro Omotuyi John Fakoya,1,* Mariana Ndrio,2,* Kevin J McCarthy1 1Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, USA; 2University of Medicine and Health Sciences, Basseterre, St. Kitts and Nevis*These authors contributed equally to this workCorrespondence: Adegbenro Omotuyi John Fakoya, Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, 1501 Kings Highway, P.O.Box 33932, Shreveport, LA, 71130-3932, USA, Tel +1 318-469-3664, Fax +1 318-675-5889, Email adegbenro.fakoya@lsuhs.eduAbstract: The call for educational reform by the Carnegie Foundation for the Advancement of Teaching marked a pivotal juncture in the trajectory of medical education in the United States. The call underscored the imperative for educational restructuring to equip forthcoming physicians with the requisite skills to engage in lifelong learning. Among the several active teaching methods is the Peer Instruction (PI), a brainchild of Eric Mazur, empowering students to steer their own education and wield knowledge adeptly into real-world scenarios. In this review paper, we delve into the core elements of PI which involves the combination of four dynamic pedagogical approaches which are: Just-in-Time Teaching, ConcepTest, Audience Response System, and Think-Pair-Share technique. PIs effectiveness notwithstanding, it is not exempt from limitations such as its flexible implementation, lengthy time, the level of expertise required for instructional design, among others. While Peer Instruction has become increasingly popular among educators across other disciplines, with proven educational benefits with positive outcomes, PIs footprint in gradate and postgraduate medical education remains inchoate, evidenced by a paucity of scholarly references. This underscores a crucial gap - despite its proven potency in fueling engagement and learning, PI still lacks formal recognition and acknowledgement as a distinct instructional method in medical education. Within these boundaries, the promise of heightened education and amplified engagement beckons further exploration of PI as a medical educational model, warranting more consideration and research.Keywords: peer instruction, medical education, just-in-time teaching, ConcepTest, audience response system, think-pair-share

Objective: Post-9/11 veterans experienced more deployments, combat exposure, and disability than earlier military cohorts. Those in the military are also more likely to have experienced adverse childhood experiences. Despite these traumatic exposures, a substantial number of veterans report experiencing personal growth, development, and maturity from their military service., Method: This longitudinal survey study ( n = 5,245) examined the degree to which posttraumatic growth (PTG) was present among post-9/11 veterans. Several components of PTG were examined, including relating to others, seeing new possibilities, personal strength, spiritual growth, and appreciation for life., Results: Respondents rated their degree of personal growth and new appreciation of life most highly, while spiritual growth and appreciation of others were the least highly rated. Female veterans reported greater PTG. Veterans who experienced traumatic events (i.e., combat exposure, adverse childhood experiences), screened positive for posttraumatic stress disorder, and moral injury reported greater PTG than those who had not experienced those events or screened positive for posttraumatic stress disorder. Veterans reporting higher levels of social support and personal resilience were less likely to experience PTG. Veterans with other protective factors were more likely to experience PTG., Conclusions: Post-9/11 veterans report PTG in the face of various traumatic exposures. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Introduction: The impact of adverse childhood experiences (ACEs), warfare exposure, and mental health symptoms upon changes in body mass index (BMI) were examined in a large U.S. post-9/11 veteran sample to assess gender-specific changes in BMI within the first 2½ years after military service., Materials and Methods: Data were collected with institutional approval in 6 waves between 2016 and 2019 from veterans who (1) separated from active duty component service branches (i.e., Army, Navy, Air Force, and Marine Corps) or National Guard or Reserve or (2) deactivated from active duty status after serving in a National Guard or Reserve component. Veterans self-reported height and weight at separation/deactivation at wave 2, and weight was asked at each subsequent wave. Multilevel growth model analyses estimated the relationship between ACEs, warfare exposure, and mental health symptoms and BMI for males and females. Weighted wave 5 analyses were conducted to ensure the sample was calibrated for nonresponse based on wave 1 and the full sample (n = 48,965) for each cross-classification of the weighting variables of gender, rank, and branch., Results: Approximately one-third of the veterans reported a normal BMI at separation/deactivation in comparison to being overweight (51%) or obese (20%). Twenty-six percent of male veterans had a normal BMI in contrast to almost half of the female veterans. Male veterans who experienced 3-7 ACEs had a higher BMI (0.74) compared to male veterans without any ACEs, where a BMI increase of 0.08 per year was reported. Female veterans who experienced 1-2 ACEs had a higher BMI (0.89) compared to female veterans without ACEs. Male veterans who engaged in warfare (e.g., combat patrols and firing a weapon at enemy combatants) and experienced corollaries (i.e., consequences of combat) or who experienced corollaries alone (e.g., saw refugees who lost their homes/belongings) had higher BMIs (1.14 and 0.82, respectively) compared to male veterans without warfare exposure. Female veterans who experienced corollaries had a higher BMI (0.94) compared to female veterans with no warfare exposure. Female veterans who experienced warfare (i.e., corollaries and combat) had a higher BMI (0.71) compared to female veterans with no warfare exposure. Male veterans who screened positive for likely post-traumatic stress disorder (PTSD) or depressive symptoms had a higher BMI (1.01 and 0.52, respectively) compared to male veterans who did not screen positive. Male veterans who screened positive for likely PTSD increased their BMI by 0.10 per year. Male veterans who screened positive for both likely PTSD and depressive symptoms had a higher BMI (1.32) compared to male veterans who did not screen positive, and they increased their BMI by 0.21 per year. Female veterans who screened positive for likely PTSD and depressive symptoms had a higher BMI (0.78) and increased their BMI by 0.25 per year compared to female veterans who did not screen positive., Conclusions: Boosting veterans' and service members' mental and emotional healing from childhood and warfare adversities through sound health promotion policies and increased access to evidence-informed interventions is imperative for optimal body weight and physical health., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Importance: Subclinical hyperglycemia before pregnancy may be associated with the likelihood of maternal morbidity but is understudied among young people., Objective: To explore the association of preconception hemoglobin A1c (HbA1c) levels among adolescents and young adults with risk of gestational diabetes at first live birth., Design, Setting, and Participants: This retrospective cohort study used linked 2009 to 2017 birth registry, hospital discharge, and New York City Department of Health A1C Registry data for birthing individuals aged 10 to 24 years with no history of diabetes and at least 1 preconception HbA1c test in New York, New York. Statistical analysis was performed from August to November 2022., Exposure: Preconception HbA1c values categorized as no diabetes (HbA1c <5.7%) or prediabetes (HbA1c ≥5.7% to <6.5%)., Main Outcomes and Measures: The primary outcome was gestational diabetes at first birth. Secondary outcomes included hypertensive disorders of pregnancy, preterm birth, cesarean delivery, and macrosomia. Log binomial regression was used to estimate the relative risk (RR) of gestational diabetes at first birth by preconception HbA1c level, adjusting for prepregnancy characteristics. The optimal HbA1c threshold for gestational diabetes was examined using receiver operating curve regression., Results: A total of 14 302 individuals (mean [SD] age, 22.10 [1.55] years) met study eligibility criteria. Of these, 5896 (41.0%) were Hispanic, 4149 (29.0%) were Black, 2583 (18.1%) were White, 1516 (10.6%) were Asian, and 185 (1.3%) had other or unknown race and ethnicity. Most (11 407 individuals [79.7%]) had normoglycemia before pregnancy, and 2895 individuals (20.2%) had prediabetes. Adjusting for prepregnancy characteristics, those with preconception prediabetes had more than twice the risk of gestational diabetes vs those with normoglycemia (adjusted RR [aRR], 2.21; 95% CI, 1.91-2.56). Preconception prediabetes was associated with small increases in the likelihood of a hypertensive disorder of pregnancy (aRR, 1.18; 95% CI, 1.03-1.35) and preterm delivery (aRR, 1.18; 95% CI, 1.02-1.37). The aRRs for cesarean delivery (aRR, 1.09; 95% CI, 0.99-1.20) and macrosomia (aRR, 1.13; 95% CI, 0.93-1.37) were increased but not statistically significant. The optimal HbA1c threshold to identify gestational diabetes among adolescents and young adults was 5.6%. The threshold did not vary by obesity status but was slightly lower among Hispanic individuals (HbA1c of 5.5%)., Conclusions and Relevance: In this study of adolescents and young adults with at least 1 preconception HbA1c test, prediabetes was associated with increased likelihood of maternal cardiometabolic morbidity at first birth. Efforts to optimize cardiometabolic health before pregnancy may avert excess maternal risk.

Objective: We characterized the state-to-state transitions in postpartum A1c levels after gestational diabetes, including remaining in a state of normoglycemia or transitions between prediabetes or diabetes states of varying severity., Methods: We used data from the APPLE Cohort, a postpartum population-based cohort of individuals with gestational diabetes between 2009-2011and linked HbA1c data with up to 9 years follow-up (N=34,171). We examined maternal sociodemographic and perinatal characteristics as predictors of transitions in A1c progression using Markov multistate models., Results: In the first-year postpartum following gestational diabetes, 45.1% of people had no-diabetes, 43.1% had prediabetes, 4.6% had controlled diabetes and 7.2% had uncontrolled diabetes. Roughly two-thirds of individuals remained in same state in the next year. Black individuals were more likely to transition from pre-diabetes to uncontrolled diabetes (aHR: 2.32 95% CI: 1.21 ,4.47) than White persons. Perinatal risk factors were associated with disease progression and lower likelihood of improvement. For example, hypertensive disorders of pregnancy were associated with a stronger transition (aHR: 2.06 95% CI: 1.39, 3.05) from prediabetes to uncontrolled diabetes., Conclusions: We illustrate factors associated with adverse transitions in incremental A1c stages and describe patient profiles who may warrant enhanced postpartum monitoring., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In the United States, maternal health inequities disproportionately affect Global Majority (e.g., Asian, Black, and Hispanic) populations. Despite a substantial body of research underscoring the influence of racism on these inequities, little research has examined how experiences of gendered racial microaggressions during pregnancy and birth impact racially and ethnically diverse Global Majority pregnant and birthing people in obstetric hospital settings. We evaluated the psychometric properties of an adapted version of Lewis & Neville's Gendered Racial Microaggressions Scale, using data collected from 417 Global Majority birthing people. Findings from our study indicate that our adapted GRMS is a valid tool for assessing the experiences of gendered racial microaggressions in hospital-based obstetric care settings among Global Majority pregnant and birthing people whose preferred languages are English or Spanish. Item Response Theory (IRT) analysis demonstrated high construct validity of the adapted GRMS scale (Root Mean Square Error of Approximation = 0.1089 (95% CI 0.0921, 0.1263), Comparative Fit Index = 0.977, Standardized Root Mean Square Residual = 0.075, log-likelihood c2 = -85.6, df = 8). IRT analyses demonstrated that the unidimensional model was preferred to the bi-dimensional model as it was more interpretable, had lower AIC and BIC, and all items had large discrimination parameters onto a single factor (all discrimination parameters > 3.0). Given that we found similar response profiles among Black and Hispanic respondents, our Differential Item Functioning analyses support validity among Black, Hispanic, and Spanish-speaking birthing people. Inter-item correlations demonstrated adequate scale reliability, α = 0.97, and empirical reliability = 0.67. Pearsons correlations was used to assess the criterion validity of our adapted scale. Our scale's total score was significantly and positively related to postpartum depression and anxiety. Researchers and practitioners should seek to address instances of gendered racial microaggressions in obstetric settings, as they are manifestations of systemic and interpersonal racism, and impact postpartum health., (© 2024. The Author(s).)

The COVID-19 pandemic has led to economic turndowns, social restrictions, and family life alterations. The stress induced by the public health crisis and its consequences are beginning to be explored. This study examined stress experiences since the pandemic'sonset in work, financial, social, and health domainsamong a large sample of post-9/11, United States military veterans. The sample, who separated from active-duty service or deactivated from active status in a reserve component in 2016, completed an online survey (n = 3180) in 2020. Participants were 70% White non-Hispanic, 81% male, and had an average age of 38 years. Frequencies and descriptive statistics were calculated. Female veterans and veterans of colour reported significantly higher levels of stress across most life domains. The results suggest White, male, post-9/11 veterans may be somewhat protected from COVID-19 stress, but that the pandemic is exacerbatinghealth and social disparities experienced by post-9/11 veterans of colour and female veterans. Supports and comprehensive care, particularly targeted towardsat-risk populations, are likely needed to provide sufficient resources for resiliency during and after the pandemic., (© 2023 The Authors. Stress and Health published by John Wiley & Sons Ltd.)

Study Design: Case-control study., Objective: To introduce a classification system that will include the major types of degenerative changes and failures related to the proximal junction, and to determine the clinical course and characteristics for the different types of proximal junctional degeneration (PJD)., Summary of Background Data: Proximal junctional kyphosis (PJK) and failures are well recognized after adult spinal fusion, however, a standardized classification is lacking., Methods: The proposed system identified four different patterns of PJD: Type 1 (multi-level symmetrical collapse), Type 2 (Single adjacent level collapse), Type 3 (fracture) and Type 4 (spondylolisthesis). A single center database was reviewed from 2018 to 2021. Patients ≥18 years of age, who underwent posterior spinal fusion of ≥3 levels with an upper instrumented vertebral level between T8-L2, and a follow-up of ≥2 years were included. Radiographic measurements, revision surgery and time to revision were the primary outcomes., Results: 150 patients were included with a mean age of 65.1 (±9.8) years and a mean follow-up of 3.2 (±1) years. 69 patients (46%) developed significant degenerative changes in the proximal junction, and were classified accordingly. 20 (13%) were Type 1, 17 (11%) were Type 2, 22 (15%) were Type 3 and 10 (7%) were Type 4. Type 3 had a significantly shorter time to revision with a mean of 0.9 (±0.9) years. Types 3 and 4 had greater preoperative sagittal vertical axis, and Types 1 and 3 had greater final follow-up lumbar lordosis. Bone density measured by Hounsfield units showed lower measurements for Type 3. Types 1 and 4 had lower rates of developing PJK. Type 1 had the lowest revision rate with 40% (types 2, 3 and 4 were 77%, 73% and 80%, respectively, P=0.045)., Conclusion: This novel classification system defines different modes of degeneration and failures at the proximal junction, and future studies with larger sample sizes are needed for validation., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Drug-coated balloons (DCBs) are specialized coronary devices comprised of a semicompliant balloon catheter with an engineered coating that allows the delivery of antiproliferative agents locally to the vessel wall during percutaneous coronary intervention. Although DCBs were initially developed more than a decade ago, their potential in coronary interventions has recently sparked renewed interest, especially in the United States. Originally designed to overcome the limitations of conventional balloon angioplasty and stenting, they aim to match or even improve upon the outcomes of drug-eluting stents without leaving a permanent implant. Presently, in-stent restenosis is the condition with the most robust evidence supporting the use of DCBs. DCBs provide improved long-term vessel patency compared with conventional balloon angioplasty and may be comparable to drug-eluting stents without the need for an additional stent layer, supporting their use as a first-line therapy for in-stent restenosis. Beyond the treatment of in-stent restenosis, DCBs provide an additional tool for de novo lesions for a strategy that avoids a permanent metal scaffold, which may be especially useful for the management of technically challenging anatomies such as small vessels and bifurcations. DCBs might also be advantageous for patients with high bleeding risk due to the decreased necessity for extended antiplatelet therapy, and in patients with diabetes and patients with diffuse disease to minimize long-stented segments. Further studies are crucial to confirm these broader applications for DCBs and to further validate safety and efficacy., Competing Interests: Disclosures Dr Yeh has investigator-initiated research grants and is a consultant for Abbott Vascular, Boston Scientific and Medtronic, is a consultant for CathWorks, Elixir Medical, InfraRedx, Shockwave Medical, and Zoll Medical, and has investigator-initiated research grants with BD Bard, Cook and Philips Medical. Dr Cutlip has received research funding paid to institution from MedAlliance/Cordis. Dr Kirtane reports institutional funding to Columbia University and Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CathWorks, CSI, Philips, ReCor Medical, Neurotronic, Biotronik, Chiesi, Bolt Medical, Magenta Medical, Canon, SoniVie, and Shockwave Medical. In addition to research grants, institutional funding includes fees paid to Columbia University and Cardiovascular Research Foundation for consulting and speaking engagements in which Dr Kirtane controlled the content. Personal: travel expenses/meals from Amgen, Medtronic, Biotronik, Boston Scientific, Abbott Vascular, CathWorks, Concept Medical, Edwards, CSI, Novartis, Philips, Abiomed, ReCor Medical, Chiesi, Zoll, Shockwave, and Regeneron. Dr McEntegart reports research support paid to the institution from Boston Scientific and is a consultant for Shockwave, and part of the speakers bureau for Teleflex, Asahi, and Medtronic. The other authors report no conflicts.

In current-generation designs of total primary hip joint replacement, the prostheses are fabricated from alloys. The modulus of elasticity of the alloy is substantially higher than that of the surrounding bone. This discrepancy plays a role in a phenomenon known as stress shielding, in which the bone bears a reduced proportion of the applied load. Stress shielding has been implicated in aseptic loosening of the implant which, in turn, results in reduction in the in vivo life of the implant. Rigid implants shield surrounding bone from mechanical loading, and the reduction in skeletal stress necessary to maintain bone mass and density results in accelerated bone loss, the forerunner to implant loosening. Femoral stems of various geometries and surface modifications, materials and material distributions, and porous structures have been investigated to achieve mechanical properties of stems closer to those of bone to mitigate stress shielding. For improved load transfer from implant to femur, the proposed study investigated a strategic debulking effort to impart controlled flexibility while retaining sufficient strength and endurance properties. Using an iterative design process, debulked configurations based on an internal skeletal truss framework were evaluated using finite element analysis. The implant models analyzed were solid; hollow, with a proximal hollowed stem; FB-2A, with thin, curved trusses extending from the central spine; and FB-3B and FB-3C, with thick, flat trusses extending from the central spine in a balanced-truss and a hemi-truss configuration, respectively. As outlined in the International Organization for Standardization (ISO) 7206 standards, implants were offset in natural femur for evaluation of load distribution or potted in testing cylinders for fatigue testing. The commonality across all debulked designs was the minimization of proximal stress shielding compared to conventional solid implants. Stem topography can influence performance, and the truss implants with or without the calcar collar were evaluated. Load sharing was equally effective irrespective of the collar; however, the collar was critical to reducing the stresses in the implant. Whether bonded directly to bone or cemented in the femur, the truss stem was effective at limiting stress shielding. However, a localized increase in maximum principal stress at the proximal lateral junction could adversely affect cement integrity. The controlled accommodation of deformation of the implant wall contributes to the load sharing capability of the truss implant, and for a superior biomechanical performance, the collared stem should be implanted in interference fit. Considering the results of all implant designs, the truss implant model FB-3C was the best model.

Pharmaceutical managers have been encouraged to look to acquisitions and alliances for innovation. However, the literature warns that the capacity of a company to 'absorb' new knowledge is limited. Here, we introduce corporate divestitures as a tool for freeing up managerial attention. We build a sample of 349 companies, which announced 1784 divestitures and filed 63523 patents, over a 15-year period. We show that innovating companies that divest more produce more and improved patents, and those that divest to create corporate focus also produce more breakthroughs. In doing so, we introduce divestitures as an innovation tool, highlight the importance of the absorptive capacity of a company when discussing innovation, and add nuance to the discussion on external tools for innovation., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Responsive parenting serves an influential role in explaining the link between children's exposure to intimate partner violence (IPV) and children's mental health impairment, but how this occurs is not well elucidated. In some cases, researchers examine parenting as a mediator to explain how IPV leads to maladaptive outcomes (i.e., IPV negatively impacts one's capacity for responsive parenting, which in turn impacts children), whereas others examine moderation in which either the absence of responsive parenting exacerbates adverse outcomes or increased responsive parenting buffers risk. Mediation addresses theoretical questions about how or why IPV leads to maladaptive outcomes, whereas moderation addresses who might be most impacted. However, responsive parenting has rarely, if ever, been tested as both a mediator and moderator of the link between IPV and posttraumatic stress symptoms (PTSS) within the same sample. The current study examined the mediating and moderating role of responsive parenting on physical IPV exposure and child PTSS in a longitudinal sample of 391 children ages 3 to 5 years ( M  = 4.74, SD  = 0.89). Self-report measures of physical IPV exposure, parenting practices, and PTSS were completed by mothers. We found that responsive parenting significantly moderated and mediated the association between physical IPV exposure and child PTSS over time. Studies that include tests of both moderation and mediation are critical for advancing mechanistic insight into the role of parenting in the etiology of mental health impairment in children exposed to IPV., Competing Interests: Conflict of InterestThe authors do not have any conflicts of interests to report., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objective: Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women., Research Design and Methods: Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity., Results: The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control., Conclusions: Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities., (© 2023 by the American Diabetes Association.)

Background: Accurate data on the receipt of essential maternal and newborn health interventions is necessary to interpret and address gaps in effective coverage. Validation results of commonly used content and quality of care indicators routinely implemented in international survey programs vary across settings. We assessed how respondent and facility characteristics influenced the accuracy of women's recall of interventions received in the antenatal and postnatal periods., Methods: We synthesized reporting accuracy using data from a known sample of validation studies conducted in Sub-Saharan Africa and Southeast Asia, which assessed the validity of women's self-report of received antenatal care (ANC) (N = 3 studies, 3,169 participants) and postnatal care (PNC) (N = 5 studies, 2,462 participants) compared to direct observation. For each study, indicator sensitivity and specificity are presented with 95% confidence intervals. Univariate fixed effects and bivariate random effects models were used to examine whether respondent characteristics (e.g., age group, parity, education level), facility quality, or intervention coverage level influenced the accuracy of women's recall of whether interventions were received., Results: Intervention coverage was associated with reporting accuracy across studies for the majority (9 of 12) of PNC indicators. Increasing intervention coverage was associated with poorer specificity for 8 indicators and improved sensitivity for 6 indicators. Reporting accuracy for ANC or PNC indicators did not consistently differ by any other respondent or facility characteristic., Conclusions: High intervention coverage may contribute to higher false positive reporting (poorer specificity) among women who receive facility-based maternal and newborn care while low intervention coverage may contribute to false negative reporting (lower sensitivity). While replication in other country and facility settings is warranted, results suggest that monitoring efforts should consider the context of care when interpreting national estimates of intervention coverage., (© 2023. The Author(s).)

Military sexual trauma (MST) is a pervasive problem; this study examined the relationship of the precursory traumas of adverse childhood experiences (ACEs) and warfare exposure with MST. Post-9/11 veterans were surveyed at 3 months and at 24 to 30 months post-military separation. Female veterans who experienced at least 1 ACE but no warfare exposure were significantly more likely to receive unwanted sexual attention. Veterans (males and females) experiencing three or more ACEs but no warfare exposure were significantly more likely to receive unwanted sexual attention and contact. Experiencing only warfare exposure was not related to unwanted sexual attention or contact for females; however, a significant interaction was found between combined warfare exposure, ACEs, and MST for males and females. Veterans who reported warfare exposure and one to two or three or more ACEs were more likely to report unwanted sexual attention and/or contact. Exploration of individual ACEs revealed a significant relationship between childhood sexual abuse and unwanted sexual contact. For females, witnessing domestic violence predicted unwanted sexual contact. There was also a significant interaction between childhood sexual abuse and warfare exposure. Females who experienced both childhood sexual abuse and warfare exposure were significantly more likely to receive unwanted sexual attention and unwanted sexual contact. Albeit a small sample, males who experienced both were also significantly more likely to receive unwanted sexual attention. The findings reveal that precursory traumatic experiences in childhood and the interaction of ACEs and warfare exposure during military service can increase the likelihood of unwanted sexual attention and contact. This research further substantiates the need for screening efforts. It also demonstrates the importance of practitioners engaging in trauma-informed care principles and practices to address the residual effects of previous experiences during sexual trauma or mental health treatment efforts.

Although concurrent associations between parent and child posttraumatic stress symptoms (PTSS) have been well-documented, few longitudinal studies have examined bidirectional influences by modeling the effects of both parent and child PTSS simultaneously over time. The current study examines patterns of PTSS in children and their mothers beginning in preschool and continuing through elementary school age (ages 4-9 years) in a large, heterogeneous sample (N = 331 mother-child dyads). Mothers reported on their own and their child's posttraumatic stress symptoms. A random intercept cross-lagged panel model (RI-CLPM) was used to examine associations between symptoms across six time points. Results indicated that maternal and child symptoms were associated with each other at concurrent time points and tended to fluctuate in a synchronized manner relative to their overall mean symptom levels. Longitudinal cross-lagged paths were significant from mother to child, but non-significant from child to mother, suggesting that mothers' symptom fluctuation at one time point predicted significant fluctuation in children's symptoms at the subsequent time point. The concurrent co-variation of maternal and child symptoms and the predictive nature of maternal symptom flare-ups have important implications for both maternal and child mental health interventions and underscore the importance of attending to mothers' symptomatology early in treatment., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The fractional clearance of proteins as measured in healthy human subjects increases 10,000-100,000- fold when studied in nephrotic patients. This remarkable increase cannot be accounted for by extracellular biophysical mechanisms centered at the glomerular filtration barrier. Rather, it is the nephron and its combination of filtration and cellular uptake that can provide a plausible explanation of these fractional clearance changes. The nephron has two regions that critically determine the level proteinuria/albuminuria. Glomerular filtration of plasma proteins is primarily a size selective event that is basically unchanged in acquired and genetic kidney disease. The glomerular concepts of 'charge selectivity' and of 'large pores', previously used to explain proteinuria, are now recognized to be flawed and non-existent. Filtered proteins then encounter downstream two protein receptors of the Park and Maack type associated with the proximal tubular cell. The high capacity receptor is thought to retrieve the majority of filtered proteins and return them to the blood supply. Inhibition/saturation of this pathway in kidney disease may create the nephrotic condition and hypoproteinemia/hypoalbuminemia. Inhibitors of this pathway (possibly podocyte derived) are still to be identified. A relatively small proportion of the filtered protein is directed towards a high affinity, low capacity receptor that guides the protein to undergo lysosomal degradation. Proteinuria in normoproteinemic states is derived by inhibition of this pathway, such as in diabetes. The combination of glomerular sieving, and the degradation and retrieval pathways can quantitatively account for the changes in fractional clearance of proteins in the nephrotic condition. Finally, the general retrieval of filtered protein by the proximal tubular cell focuses on the teleological importance of this cell as this retrieval represents the third pillar of retrieval that this cell participates in (it also retrieves water and salt)., Competing Interests: WDC is employed by Salaqua Diagnostics Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Comper, Vuchkova and McCarthy.)

This study assessed the Moral Injury Symptoms Scale - Military Version - Short Form's (MISS-M-SF) factor structure and construct validity. Participants included 3650 combat-deployed U.S. veterans who answered all 10 MISS-M-SF items from the sixth wave of The Veterans Metric Initiative (TVMI). EFA results suggested a two-factor solution, based on item wording, fit best. CFA results indicated a bifactor model (one general factor and two method factors, based on item wording) fit best. Further investigation revealed that a one-factor model could be used despite the data's multidimensionality. Item-level analyses revealed four items represented the general factor exceptionally well, potentially simplifying assessment in research and clinical applications. Construct validity was also demonstrated through moderate to high correlations with conceptually related measures., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Recommendations on non-invasive imaging to assess pre-operative cardiac risk among liver transplant candidates vary amongst societal guidelines and individual institutional practices. In 2018, a standardized pre-transplant coronary evaluation protocol was established at Beth Israel Deaconess Medical Center, Boston MA, to ensure appropriate and consistent pre-operative testing was performed., Methods: All patients who underwent liver transplant evaluation between January 1st, 2016 and December 31st, 2019, were retrospectively analyzed and divided into three cohorts; before the introduction of the protocol (prior to 2018), initial protocol favoring invasive coronary angiography (ICA) (2018), and amended protocol favoring coronary computed tomography angiography (CCTA) (post-2018). We described clinical characteristics, candidacy for transplant, and cardiovascular complications during follow-up. As an unadjusted exploratory analysis, the Cochran-Armitage Exact Trend Test was used to examine univariate differences across time., Results: A total of 462 patients underwent liver transplant evaluation during the study period. Among these, 218 (47.2%) patients underwent stress test, 50 (10.8%) underwent CCTA, and 68 (14.8%) underwent ICA. Across the three time periods, there was an increase in the proportion of CCTAs performed (3%, 6.3%, and 26.3% respectively; p <0.001) and proportion of patients diagnosed with obstructive CAD using CCTA (0%, 30%, and 51.4% respectively; p = 0.04). There was no significant difference in post-transplant cardiac complications among patients evaluated before 2018, during 2018, and after 2018 (5.9% vs. 5.6 vs. 6.0%; p=1.0)., Conclusion: Our findings suggest it is reasonable to shift practice to a less invasive approach utilizing CCTA or nuclear stress testing when assessing liver transplant candidates at increased cardiovascular risk., Competing Interests: Conflicts of interest The authors declare no conflict of interest., (Copyright © 2021 Fundación Clínica Médica Sur, A.C. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: Studies on the effect of long-term use of combined oral contraceptives (COCs) on cervical dysplasia and/or cancer risk have been inconsistent. Less is known about the effects of other forms of hormonal contraception (HC). We examine whether HC use increases the risk of incident cervical intraepithelial neoplasia (CIN) 2, 3 and/or cancer after accounting for preexisting human papillomavirus (HPV) infection., Study Design: Systematic review of prospective studies on HC use as risk factor for cervical dysplasia with HPV infection documented prior to outcome assessment including PubMed and EMBASE records between January 2000 and February 2020 (Prospero #CRD42019130725)., Results: Among nine eligible studies, seven described recency and type of HC use and therefore comprise the primary analysis; two studies limit comparisons to ever versus never use and are summarized separately. All seven studies explored the relationship between oral contraceptive (OC) use and cervical dysplasia/cancer incidence: two found increased risk (adjusted odds ratio, aOR = 1.5-2.7), one found no association but decreased risk when restricted to women with persistent HPV (adjusted hazard ratio = 0.5), and four found no association. None of the seven studies differentiated between COC and progestin-only pills (POPs) by use recency or duration. The only study that included injectable progestin-only contraception (DMPA) found increased CIN3 incidence among current versus never users (aOR = 1.6). The one study that included Norplant found no association. Two studies included intrauterine device (IUD) use, but did not differentiate between hormonal and copper IUDs, and found no association., Conclusion: We found no consistent evidence that OC use is associated with increased risk for cervical dysplasia/cancer after controlling for HPV infection. There were too few studies of progestin-only injectables, implants or IUDs to assess their effect on cervical dysplasia/cancer risk., Implications: Use of single self-reported HC measures and insufficient distinction by hormonal constituent cloud our understanding of whether some HCs increase risk for cervical cancer. Methodologically rigorous studies with distinct HCs measured as time-varying exposures are needed to inform cervical cancer prevention efforts and improve our understanding of cervical cancer etiology., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This study assessed the effectiveness of employment programs components, which resulted in the identification of content and process components that increase employability. Employment program use was studied among 1172 United States of America military veterans to determine which content (i.e., interviewing skills) and process (i.e., working with a mentor/coach) components influence job attainment during a time of career and identity transition. Components were distilled utilizing a common components analysis approach (Morgan et al., 2018). Associations with finding employment up to 15 months after the military-to-civilian transition were explored. Veterans who engaged with employment programs were primarily accessing the following components: career planning, resume writing, and interviewing skills. However, only a few content components were significantly related to obtaining employment: interviewing (with mentor/coach), resume writing (online tools), translating military to civilian work (with mentor/coach), entrepreneurship (with mentor/coach), and virtual career fairs. Furthermore, not all processes or modes of instruction for content components were associated with success in the job market. Having a mentor/coach was one of the most effective delivery strategies. For example, veterans using programs delivered by a mentor/coach that translated military skills to civilian work were more likely to find a job at 6-9-months (84%) and 12-15-months (91%) post military separation. In addition, risks that predicted lower use of employment program components by veterans were identified such as junior enlisted rank, combat exposure, combat arms occupation, and physical health problems. With these findings, program developers, implementers, and funders can channel efforts towards the utilization of employment programs with effective components., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article., (© The Author(s), under exclusive licence to Springer Nature B.V. 2022.)

Background: Underemployment is a challenge for the civilian workforce and a particular risk for veterans as they transition from military service to civilian employment. Workers' economic and demographic characteristics factor into underemployment risk. Veterans may be at greater risk due to specific economic and demographic factors, transitional factors (e.g., geographic relocation), and characteristics of their military service (e.g., military skill alignment with civilian jobs)., Objectives: Describe underemployment experiences in employed post-9/11 veterans three years after their military transition to the civilian workforce., Methods: The current study uses self-reported underemployment experience data from a longitudinal study of transitioning veterans. This study compares average perceptions of veteran underemployment experiences by specific groups (e.g., by race, gender, and paygrade) using analysis of variance and logistic regression., Results: Veterans reported underemployment in their current jobs based on a perceived mismatch between the skills, education, and/or leadership experience they gained during military service., Conclusions: Veterans who were enlisted rank, identified as non-White, completed a bachelor's degree, and indicated PTSD symptoms reported higher pervasive underemployment. Intervention implications for the results, such as employer and veteran employment supports, are discussed.

Background: A substantial proportion of adolescent girls in Zambia lack the ability to decide their reproductive future. We examined the role of agency in early and unwanted adolescent childbearing., Methods: Using latent transition analysis, we characterized a multi-dimensional profile of adolescent agency annually over a four-year period. We investigated the influence of early life access to resources and time-varying predictors (school retention, violence, early marriage and unwanted/mistimed pregnancy and childbearing) on agency profile membership as well as transitions in agency status over time., Results: Four agency profiles were identified, with differences by age cohort (10-14 years vs. 15-19 years). Three profiles identified in both age cohorts were: Low-moderate agency , Self-assured gender conformers , and High agency . Unique to younger girls was the Gender conscious, low belief in abilities status, while among older girls was the Self-assured selective gender conscious status. While younger girls were likely to transition to the highest agency status over time, high agency membership declined among older girls. Early life resources were associated with augmented agency while exposure to negative events, particularly early marriage, were associated with detraction from high agency status. Girls who expressed high self-efficacy but gender-conforming values were most at risk of early marriage and unwanted/mistimed pregnancy while High agency girls were at comparatively low risk., Conclusions: Results show agency is dynamic but less mutable with increasing age. Early adolescent strategies which address inequitable gender norms and limit early marriage, may guard against losses to agency which contribute to unwanted fertility outcomes., (© 2022 The Authors. Published by Elsevier Ltd.)

Purpose: Childhood exposure to traumatic violence may shape how children respond to threatening faces and increase risk for psychopathology. Maltreated children may exhibit altered processing of threatening faces; however, the effects of witnessing intimate partner violence (IPV) on children's discrimination of facial expressions is under-studied. Emotional face processing differentially relates to psychopathology, with some evidence suggesting improved detection of angry faces in children with fear-related anxiety symptoms, whereas externalizing symptoms are associated with poorer detection of fearful faces and perhaps emotional faces broadly., Method: In this cross-sectional study, we examined discrimination of threatening emotional faces (angry, fearful) in relation to experiences of probable abuse and witnessing of physical IPV, as well as psychopathology. Children (N = 137, mean age = 5.01 years, SD = 0.81) completed a "face in the crowd task" designed to examine discrimination of angry and fearful faces. Children either searched for an angry face among fearful distractor faces or a fearful face among angry distractors. Probable child abuse, witnessed IPV, and symptoms were assessed in semi-structured maternal interviews., Results: Children who witnessed violence showed poorer accuracy when fearful faces were the target; however, effects for probable abuse were non-significant. Greater fear-related anxiety symptoms were associated with poorer accuracy for fearful faces. Externalizing symptoms were associated with poorer overall accuracy., Conclusions: Findings suggest that IPV and fear-related anxiety symptoms were associated with difficulty detecting fearful faces when angry distractors were present, consistent with prior research. Implications of violence- and symptom-associated deficits in emotional face processing are discussed., Competing Interests: Conflict of Interest: The authors declare that they have no conflict of interest.

Studies linking child maltreatment to abnormal neurophysiological responses to emotional stimuli and mental health impairment have not specifically explored these patterns in young children exposed to intimate partner violence (IPV). The present study examined two neurophysiological indicators, resting-state electroencephalography and an emotion event-related potential (ERP) in 21 IPV exposed and 30 nonexposed children ages 4-6 years recruited from the community and domestic violence shelters. Frontal alpha asymmetry (FAA) was assessed while at rest. FAA is often associated with avoidant/withdrawn behavior and increased risk of IPV-related mental health conditions (e.g., depression). Additionally, the late positive potential (LPP) ERP component, reflecting motivated attention, was acquired in the context of an age-appropriate affective oddball paradigm with low probability animal pictures as targets and human facial expressions (angry, happy, neutral) as distracters. Results demonstrated that IPV-exposed children, compared with nonexposed children, exhibited lower left FAA during resting state and reduced LPPs to oddball targets and affective faces relative to neutral faces in the oddball task. Together, these results suggest neural patterns associated with a blunted response to emotional stimuli and withdrawal tendencies, respectively, in young children exposed to IPV. Implications for emotional socialization in this vulnerable population are discussed., (© 2021 Wiley Periodicals LLC.)

Background: Children of parents with posttraumatic stress (PTS) face heightened risk for developing emotional and behavioral problems, regardless of whether they experience a traumatic event themselves. The current study investigates whether child FKBP5, a stress relevant gene shown to interact with child trauma exposure to increase risk for PTS, also moderates the well-established link between maternal PTS and child symptoms., Methods: Data are derived from a longitudinal lab-based study for which 205 dyads of trauma-exposed mothers and their preschool-age children from a sample enriched for violence exposure provided DNA samples and completed measures of maternal and child trauma-related symptoms. Hypotheses tested whether child FKBP5 rs1360780 SNP genotype interacts with child trauma exposure and maternal PTS to predict child trauma-related symptoms., Results: Hypotheses were partially supported, with maternal PTS predicting increased child symptoms for children carrying the minor T-allele (CT/TT), but not those homozygous for the major C-allele., Limitations: Study results may not generalize to lower-risk or non-clinical populations, did not assess between-group differences in race/ethnicity, and do not consider other genes that may interact with FKBP5 or contribute to genetic risk for trauma-related impairment., Conclusions: These findings provide the first evidence that the robust gene x environment interaction involving FKBP5 and child trauma exposure extends to other environmental perturbations, including maternal PTS. Our results highlight the importance of efforts to address trauma-related psychopathology in caregivers, which may disrupt intergenerational risk processes and improve outcomes for children., (Copyright © 2021. Published by Elsevier B.V.)

Population-based indicators of the coverage of key elements of high-quality family planning services are tracked via household surveys with female respondents, yet little work has been done to establish their validity. We take advantage of existing data sets from Cambodia and Kenya to compare women's responses at exit interviews following a health facility visit against the observations of a trained third-party observer during the visit. The results, which treat the observations as the reference standard, show that indicators that measure contraceptive methods received are accurately reported while indicators of whether the woman received her preferred method and whether information was "discussed" or "explained" during counseling are less reliably reported. Studies designed explicitly to assess the validity of family planning questions in household surveys, especially questions in large survey programs critical for monitoring demographic trends and programmatic coverage, are needed., (© 2021 The Authors. Studies in Family Planning published by Wiley Periodicals LLC on behalf of Population Council.)

Prosocial behaviors are a key component of young children's developing social competence. The current study examines the impact of two types of maternal socialization on young children's prosocial behaviors: emotional expressiveness (defined as maternal displayed positive and negative affect) and direct coaching of prosocial responses and explores the relationship of these socialization behaviors with mothers' own histories of psychosocial risk. An ethnically and socioeconomically diverse sample from the United States of 80 mother-child dyads at high risk for violence exposure was assessed when the children were preschool age. All of the maternal emotion socialization behaviors were evaluated by direct observation. The sample included 40 mothers with a history of childhood trauma and 40 mothers without such a history, matched on demographic characteristics. Results indicated that mothers with a history of childhood trauma experiences expressed more positive affect than those without childhood trauma, but the groups did not differ in expressed negative affect or prosocial coaching behaviors. For the full sample, even after controlling for relevant demographic and psychosocial risk factors, socialization behaviors were associated with preschool children's prosocial behavior. Findings reinforce the critical role of parental socialization behaviors in the development of young children's peer-directed prosocial behaviors and highlight the importance of helping parents to develop effective socialization skills., Competing Interests: Disclosure statement: The authors report no financial or other conflicts of interest in relation to the work described.

Electrophilic aldehyde (4-hydroxynonenal; 4-HNE), formed after lipid peroxidation, is a mediator of mitochondrial dysfunction and implicated in both the pathogenesis and the progression of cardiovascular disease. Manganese superoxide dismutase (MnSOD), a nuclear-encoded antioxidant enzyme, catalyzes the dismutation of superoxide radicals (O 2 •- ) in mitochondria. To study the role of MnSOD in the myocardium, we generated a cardiomyocyte-specific SOD2 (SOD2Δ) deficient mouse strain. Unlike global SOD2 knockout mice, SOD2Δ mice reached adolescence; however, they die at ~4 months of age due to heart failure. Ultrastructural analysis of SOD2Δ hearts revealed altered mitochondrial architecture, with prominent disruption of the cristae and vacuole formation. Noninvasive echocardiographic measurements in SOD2 Δ mice showed dilated cardiomyopathic features such as decreased ejection fraction and fractional shortening along with increased left ventricular internal diameter. An increased incidence of ventricular tachycardia was observed during electrophysiological studies of the heart in SOD2Δ mice. Oxidative phosphorylation (OXPHOS) measurement using a Seahorse XF analyzer in SOD2Δ neonatal cardiomyocytes and adult cardiac mitochondria displayed reduced O 2 consumption, particularly during basal conditions and after the addition of FCCP (H + ionophore/uncoupler), compared to that in SOD2fl hearts. Measurement of extracellular acidification (ECAR) to examine glycolysis in these cells showed a pattern precisely opposite that of the oxygen consumption rate (OCR) among SOD2Δ mice compared to their SOD2 fl littermates. Analysis of the activity of the electron transport chain complex identified a reduction in Complex I and Complex V activity in SOD2Δ compared to SOD2fl mice. We demonstrated that a deficiency of SOD2 increases reactive oxygen species (ROS), leading to subsequent overproduction of 4-HNE inside mitochondria. Mechanistically, proteins in the mitochondrial respiratory chain complex and TCA cycle (NDUFS2, SDHA, ATP5B, and DLD) were the target of 4-HNE adduction in SOD2Δ hearts. Our findings suggest that the SOD2 mediated 4-HNE signaling nexus may play an important role in cardiomyopathy., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Randomized trials inform the use of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death, yet management of patients considering ICD generator replacement procedures remains largely dependent on clinical judgment. Thus, we performed a systematic review of all studies evaluating outcomes associated with ICD generator replacement. We queried PubMed, Embase, Web of Science, and the Cochrane Database of Systematic Reviews for relevant studies with a prespecified search and adjudication strategy (PROSPERO registration number CRD42018100818) to evaluate outcomes including (1) survival; (2) clinical complications (eg, infection, hematoma); or (3) incidence of ICD therapy. From 1607 unique titles, 37 studies met inclusion criteria, describing outcomes for 238,949 patients. Procedural mortality was rare, but complications including reoperation (median 4.57%; range 0.38%-10.31%), infections (median 2.01%; range 0.03%-9.27%), and hematoma (median 1.22%, range 0.17%-2.53%) were observed in a small fraction of patients. Appropriate ICD therapy after generator replacement was common (median rate 23.03%; range 10.9%-31.4%), with an overall annualized event rate of 8.52% at median duration of follow-up of 32.4 months. Appropriate ICD therapy continued to occur at a significant annual rate even in patients who no longer met implantation criteria (5.27%) and in patients who never previously received ICD therapy (4.87%). This analysis of published observational data regarding ICD generator replacement procedures identifies relatively low risks of procedural complications and clinically meaningful rates of appropriate ICD therapies. These estimates may guide clinical decisions and inform the design of definitive trials., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Glycocalyces are the pericellular coat of glycoproteins, glycolipids, and proteoglycans. Yet the exploration of glycocalyx function is still ongoing because of the availability of investigative tools capable of discerning the function of one component without inflicting collateral changes in the organization/function of other constituents. The current report by Ramnath et al. explores the function of one family of molecules, the syndecans, as potential regulators of endothelial cell glycocalyx thickness in normal and diabetic glomeruli., (Copyright © 2020 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigates maternal responsive parenting behaviors as a theorized buffer to the detrimental impact of maternal PTSD symptoms on young children's depression and anxiety symptoms, disruptive behavior, and stress-related symptoms., Design: A multi-ethnic sample of 242 trauma-exposed mothers and their preschool-aged children was assessed. Maternal responsive parenting behaviors were observed during standardized parent-child interactions. Maternal and child mental health symptoms were reported by mothers., Results: Maternal PTSD symptoms were associated with their responsive parenting behaviors and predicted children's mental health symptoms. Responsive parenting was inversely associated with children's depression and stress-related symptoms. Moderation analyses revealed an interactive effect of maternal symptoms and responsive parenting on preschool children's disruptive behavior and stress-related symptoms., Conclusions: Responsive parenting behaviors can mitigate the ill effects of maternal PTSD symptoms. Nurturing relationships buffer the impact of maternal PTSD. Helping parents' to sensitively respond to their young children's distress can support positive outcomes in children., Competing Interests: Conflict of Interest Disclosures Each author signed a form for disclosure of potential conflicts of interest. No authors reported any financial or other conflicts of interest in relation to the work described.

Purpose: Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia., Methods: We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19 years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age., Results: Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable., Conclusions: Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Alternatives to the emergency department (ED) for expedient and high-value team-based cardiology care for patients with chest pain, volume overload, palpitations, and other urgent, but not life-threatening cardiac conditions are lacking. Here, we report on the development of the Cardiac Direct Access Unit (CDAc), an ambulatory cardiology unit with exam rooms, observation bays, and an advanced heart failure clinic., Methods: Patients referred to the CDAc are seen same-day by an attending cardiologist in a space independent from the ED. We performed a retrospective review of 1146 consecutive patients referred to the CDAc in its first year of operation. Among patients who were referred for urgent same-day evaluation, 60.1% were discharged home without observation., Results: Among the patients observed or directly discharged from CDAc, 2.4% were readmitted within 30 days for a related symptom. The highest rate of readmission (7.5%) was for heart failure, which compares favorably with guidelines for readmission benchmarks., Conclusion: Our first year of data suggests that a cardiology-directed observation unit may serve as a high-value alternative to the ED for appropriately selected patients.

Background : Young children may be adversely impacted by separation from and loss of caregivers and other loved ones. Such experiences often co-occur with interpersonal violence, unpredictability and other traumas. Whether separation/loss has unique effects independent of those other adversities is not known. Objective : This study aimed to establish whether separation/loss is associated with trauma-related symptoms, psychiatric disorders, and functional impairment in 18- to 48-month-old children independent of other adversities. Methods : Data from a cross-sectional community and clinical cohort were analyzed. Recruitment occurred in pediatric primary care, mental health, and developmental services sites. Children (33% female) were heterogeneous in ethnic background (55% minority) and family socioeconomic status (40% living in poverty). Results : Separation/loss was common (30.9% single type, 15.0% multiple types) and frequent amongst violence-exposed children (84.4% of violence-exposed children had experienced separation/loss from a loved one). However, violence exposure was uncommon amongst children with separation/loss experiences (only 23.9% were violence-exposed). Separation/loss was significantly associated with symptoms of posttraumatic stress and reactive attachment, as well as impairment and psychiatric disorders in models that controlled for sociodemographic and contextual risks, including other traumas. Psychiatric disorders were approximately 2.5 times more likely in children who had experienced multiple separations/losses, after accounting for interpersonal violence which was also significant. Conclusion : Professionals working with young children, policy-makers and caregivers should be aware that an accumulation of caregiver separations/losses, irrespective of violence and other traumatic exposure, may have detrimental effects on young children especially in the context of prior separations/losses or disruptions in their lives.

As fertility declines in low- and middle-income countries, the time women devote to childbearing and rearing may also be reduced. This shift has been described as one of the positive consequences of the demographic transition, as it opens opportunities for women to pursue educational and employment opportunities that were previously constrained by the demands of bearing and raising children. We estimate the numbers of children residing at home (with their mother) for women in 58 countries in Asia, Latin America, the Middle East and North Africa, and sub-Saharan Africa. We then examine the association between women's employment and having children at home. Finally, we assess trends over recent decades in the relationship between employment and childbearing, and differences in this relationship by mother's occupation. We find a negative association between women's employment and having children at home; this association varies substantially by world region, age of child, and mother's occupation.

Background: Evidence suggests that some forms of hormonal contraception (HC) increase women's risk of non-human immunodeficiency virus sexually transmitted infections (STIs), yet evidence has not been reviewed since 2008. We conducted an updated systematic review to incorporate studies published between January 2009 and June 2017 to examine the relationship between HCs and incident or recurrent STIs., Methods: We searched PubMed and EMBASE to identify prospective studies comparing risk of Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Trichomonas vaginalis, between women using HC versus nonhormonal methods or no methods. We summarize results by type of STI and HC and study quality using an adapted Newcastle-Ottawa Quality Assessment Scale., Results: Thirty articles met the inclusion criteria. Depo-medroxyprogesterone acetate (DMPA) reduces the risk of trichomoniasis (consistent evidence) and may increase the risk of HSV-2 (strong effect, few studies); inconclusive evidence exists for HPV, chlamydia, gonorrhea, and syphilis. Data on oral contraceptive pills (OCPs; generally not differentiated whether combined or progestin-only pills) suggest that use is associated with a reduced risk of trichomoniasis with inconclusive findings for HSV-2, HPV, chlamydia, gonorrhea, and syphilis. Very few studies included norethisterone enanthate (Net-En) injectable, implants or the levonorgestrel intrauterine device., Conclusions: Depo-medroxyprogesterone acetate and OCPs reduce the risk of trichomoniasis and DMPA may increase the risk of HSV-2. However, the potential for confounding cannot be ruled out. Future studies should specify the type of injectable or OCP used to increase understanding of biological pathways; more research is needed on implants and hormonal intrauterine devices.

Strategic alliances, in particular strategic alliances with universities, are widely thought to be beneficial to the drug discovery process. However, the discussion of alliances and their effect has tended to focus on single alliances and has ignored the fact that firms tend to participate in multiple alliances simultaneously. Here, we show the importance of adopting a portfolio perspective of strategic alliances. We build a model of the U.S. pharmaceutical industry, and show how 2298 alliances, announced over a 15-year period, impact the alliance portfolios of 324 pharmaceutical firms, and how that, in turn, impacts the breakthrough innovations that these firms produce. In doing so, we show the stengths and benifits of strategic alliances, but we also show the dangers of adopting a more the merrier approach to strategic alliance making., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Early childhood exposure to family violence predicts increased risk for psychopathology. However, violence between partners and towards children often co-occur. This complicates efforts to determine how experiences of family violence contribute to early mental health problems. Utilizing mother-report data on harsh parenting and intimate partner violence (IPV) from two large community-based, socioeconomically and ethnically diverse samples of 3-5-year-old children, we illustrate the value of a bifactor method for characterizing a family climate in which verbal and physical violence are more chronic and pervasive among family members. In our Calibration sample (N = 1,179), we demonstrate the fit of a bifactor model with a shared violence factor reflecting violence among partners and towards children and orthogonal factors for physically harsh parenting and IPV. Examination of item distributions along quartiles on the identified factors reveals that violent behaviors are most frequent/chronic in families with high scores on the shared violence factor. Next, we apply this model in Validation (N = 1,316) and lab-visit samples (N = 369). Children's symptoms and impairment showed relatively strong and consistent associations with the shared factor. Some unique associations with IPV and harsh parenting were also observed. Overall, patterns suggest particularly negative impact when verbal and physical violence are more chronic and pervasive among family members. Finally, evidence supporting the bifactor model's validity relative to multi-method data from coded interviews about child abuse and IPV and observed parenting is presented. Findings illustrate the value of a bifactor approach for the meaningful characterization of shared and specific features of family violence., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Harmful gender norms, views on the acceptability of violence against women, and power inequities in relationships have been explored as key drivers of male perpetration of intimate partner violence (IPV). Yet such antecedents have been inconsistently measured in the empirical literature. This systematic review aimed to identify which measures of gender inequitable norms, views, relations and practices are currently being used in the field, and which are most closely tied with male IPV perpetration., Methods: We searched five electronic databases to identify studies published between 2000 and 2015 that reported the association between such gender inequities and male perpetration of IPV. Identified scales were categorized by content area and level of generality, as well as other attributes, and we compared the consistency of scale performance across each category., Results: Twenty-three studies were identified, employing 64 measures. Scales were categorized into three main thematic areas: views on gender roles/norms, acceptance of violence against women, and gender-related inequities in relationship power and control. We also classified whether the scale was oriented to respondents' own views, or what they believed others do or think. While overall, measures were positively associated with IPV perpetration in 45% of cases, this finding varied by scale type. Measures inclusive of acceptance of violence against women or beliefs about men's sexual entitlement, followed by scales that measured respondents' views on gender roles/norms, were most consistently associated with IPV perpetration. Measures of relationship power showed less consistent associations. We found few scales that measured peer or community norms., Conclusion: Validated scales that encompass views on the acceptance of violence against women, and scales inclusive of beliefs about men's sexual entitlement, may be particularly promising for unpacking pathways to IPV perpetration, targeting interventions, and monitoring progress in IPV prevention efforts. A number of gaps in the literature are identified., Competing Interests: The authors have declared that no competing interests exist.

Impurity confinement in fusion plasmas is mainly determined by transport mechanisms in the core region. For the Wendelstein 7-X stellarator, its island divertor is expected to screen effectively external impurity sources in the scrape-off layer at higher densities. However, the unique feature of Tracer-Encapsulated Solid Pellet (TESPEL) injection, releasing impurities at a well-localized radial position directly in the core plasma, enables investigating such transport mechanisms. This paper reports on the detailed design of a completely new TESPEL injection system, which has been designed by the National Institute for Fusion Science, Toki, Japan, and is currently being installed at Max-Planck-Institut für Plasmaphysik, Greifswald, Germany, for the Wendelstein 7-X. This injector consists of a storage and injection unit, attached to a system of guiding tubes which run through 3 successive differential pumping stages. A light-gate system and an optical observation system are used to determine the location of the deposited tracers. Laboratory tests carried out by shooting TESPELs onto a sample foil showed good performance after careful realignment of the guiding tubes.

The paper reports on the optimization process of the soft X-ray pulse height analyzer installed on the Wendelstein 7-X (W7-X) stellarator. It is a 3-channel system that records X-ray spectra in the range from 0.6 to 19.6 keV. X-ray spectra, with a temporal and spatial resolution of 100 ms and 2.5 cm (depending on selected slit sizes), respectively, are line integrated along a line-of-sight that crosses near to the plasma center. In the second W7-X operation phase with a carbon test divertor unit, light impurities, e.g., carbon and oxygen, were observed as well as mid- to high-Z elements, e.g., sulfur, chlorine, chromium, manganese, iron, and nickel. In addition, X-ray lines from several tracer elements have been observed after the laser blow-off injection of different impurities, e.g., silicon, titanium, and iron, and during discharges with prefill or a gas puff of neon or argon. These measurements were achieved by optimizing light absorber-foil selection, which defines the detected energy range, and remotely controlled pinhole size, which defines photon flux. The identification of X-ray lines was confirmed by other spectroscopic diagnostics, e.g., by the High-Efficiency XUV Overview Spectrometer, HEXOS, and high-resolution X-ray imaging spectrometer, HR-XIS.

Increasing attention to adolescent girls has generated an abundance of programs and a growing body of research on adolescent girls in low- and middle-income countries. Despite this, questions remain about what implementation approaches in program design are most effective, hindering efficient resource allocation, program scale-up, and replication across settings. To address these questions, we conducted a systematic review to identify lessons learned and gaps in the evidence base. We searched four electronic databases to identify studies published between 1990 and 2014 that evaluated health, social, and/or economic development programs targeting adolescent girls in low- and middle-income countries. Seventy-seven (77) studies meeting specified criteria were identified, of which 19 presented results that allowed conclusions relevant to implementation science. Studies examining the following questions were assessed: To what extent, if any, do multicomponent interventions (as opposed to single-component interventions) improve outcomes for girls? What is the added value of involving actors in addition to the girl herself such as parents, guardians, husbands (i.e., multilevel interventions)? What is the threshold proportion of girls who need to participate in a program to bring about normative and behavior changes at the community level? Is a greater level of program exposure associated with greater programmatic benefit for girls? Can supplemental "booster" activities extend the benefits of a program after it ends? We found evidence to support associations between multicomponent (vs. single component) programs, and longer program exposure (vs. less program exposure), with more favorable outcomes for girls, although both conclusions include methodological limitations. Overall, few studies assessed boosters or program saturation, and evidence on multilevel versus single-level programs was inconclusive. Few studies assessed implementation science questions by design, exposing large gaps in the evidence base. We call for future research to explicitly test such implementation science questions to inform more effective use of resources and to improve outcomes for girls., (Copyright © 2017 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: Left ventricular (LV) thrombus is a complication of acute myocardial infarction (MI) and is associated with systemic thromboembolism. With randomized clinical trials investigating the optimal antithrombotic regimen in patients with MI who require concomitant chronic anticoagulation and with the emergence of the direct-acting oral anticoagulants, treatment options for post-MI LV thrombus have become more complicated. Herein, we review the epidemiology, pathogenesis, diagnosis, prevention, and treatment of LV thrombus after acute MI., Observations: Contemporary epidemiologic data suggest the incidence of LV thrombus, detected using optimal imaging modalities, may be as high as 15% in patients with ST-segment elevation MI and up to 25% in patients with anterior MI. While a standard transthoracic echocardiogram is commonly used for screening, it is limited by low sensitivity for LV thrombus detection, necessitating the addition of contrast (unless contraindicated) and/or use of cardiac magnetic resonance imaging when pretest probability is high. To our knowledge, there are no existing randomized clinical trials evaluating the safety and efficacy of anticoagulation in the prevention or treatment of LV thrombus after MI, and clinicians must rely on available epidemiologic and trial-generated data from related entities to guide treatment. Randomized clinical trials have confirmed that triple therapy increases bleeding rates compared with less potent antithrombotic regimens after MI, and observational data suggest that triple therapy regimens may not prevent LV thrombus formation. On the other hand, if an LV thrombus is detected, anticoagulation is essential to prevent systemic thromboembolism. We offer 1 approach to treatment, grounded in the best available data., Conclusions and Relevance: Uncertainties remain regarding the optimal screening pathway, frequency of follow-up imaging, candidate selection for thromboprophylaxis, and treatment strategies for post-MI LV thrombus. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to inform the optimal approach to treatment; however, more dedicated study of this clinical conundrum is also needed.

Background: The Children, Youth, and Families At-Risk (CYFAR) initiative provides funding and technical support for local community-based programs designed to promote positive outcomes among vulnerable populations. In 2013, CYFAR implemented significant changes in the way it provides technical assistance (TA) to grantees. These changes included introducing a new TA model in which trained coaches provide proactive support that is tailored to individual CYFAR projects. The purpose of this paper is to describe the evolution of this TA model and present preliminary findings from a formative evaluation., Methods: CYFAR Principal Investigators (PIs) were invited to respond to online surveys in 2015 and 2016. The surveys were designed to assess PI attitudes towards the nature and quality of support that they receive from their coaches., Results: CYFAR PIs reported that their coaches have incorporated a range of coaching skills and techniques into their work. PIs have generally positive attitudes towards their coaches, and these attitudes have become more positive over time., Conclusions: Results suggest that CYFAR PIs have been generally supportive of the new TA system. Factors that may have facilitated support include a strong emphasis on team-building and the provision of specific resources that support program design, implementation, and evaluation., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Lipid Phosphate phosphatase 3 (LPP3), encoded by the Plpp3 gene, is an enzyme that dephosphorylates the bioactive lipid mediator lysophosphatidic acid (LPA). To study the role of LPP3 in the myocardium, we generated a cardiac specific Plpp3 deficient mouse strain. Although these mice were viable at birth in contrast to global Plpp3 knockout mice, they showed increased mortality ~ 8 months. LPP3 deficient mice had enlarged hearts with reduced left ventricular performance as seen by echocardiography. Cardiac specific Plpp3 deficient mice had longer ventricular effective refractory periods compared to their Plpp3 littermates. We observed that lack of Lpp3 enhanced cardiomyocyte hypertrophy based on analysis of cell surface area. We found that lack of Lpp3 signaling was mediated through the activation of Rho and phospho-ERK pathways. There are increased levels of fetal genes Natriuretic Peptide A and B (Nppa and Nppb) expression indicating myocardial dysfunction. These mice also demonstrate mitochondrial dysfunction as evidenced by a significant decrease (P < 0.001) in the basal oxygen consumption rate, mitochondrial ATP production, and spare respiratory capacity as measured through mitochondrial bioenergetics. Histology and transmission electron microscopy of these hearts showed disrupted sarcomere organization and intercalated disc, with a prominent disruption of the cristae and vacuole formation in the mitochondria. Our findings suggest that LPA/LPP3-signaling nexus plays an important role in normal function of cardiomyocytes., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Young children are at significant risk of exposure to intimate partner violence (IPV), and vulnerable to exposure-related psychopathology, yet few studies investigate the effects of exposure to IPV on children under the age of 5 years. The current study investigated the role of maternal PTSD symptoms and parenting strategies in the relationship between mothers' IPV experiences and psychopathology in their young children, ages 3-6 years in a community-based cohort of 308 mother-child dyads at high risk for family violence. Data were collected from 2011 to 2014. IPV history and maternal PTSD symptoms were assessed by self-report questionnaires. Children's symptoms were assessed with a developmentally-sensitive psychiatric interview administered to mothers. Punitive/restrictive parenting was independently-coded from in-depth interviews with mothers about their disciplinary practices. Hypothesized direct and indirect pathways between physical and psychological IPV, maternal PTSD, maternal parenting style, and children's internalizing and externalizing symptoms were examined with mediation models. Results indicated that neither physical nor psychological IPV experienced by mothers was directly associated with children's symptoms. However, both types of victimization were associated with maternal PTSD symptoms. Examination of indirect pathways suggested that maternal PTSD symptoms mediated the relationship between mothers' psychological and physical IPV experiences and children's internalizing and externalizing symptoms and mothers' restrictive/punitive parenting mediated the relationship between mothers' psychological IPV and children's externalizing symptoms. In addition, there was a path from maternal physical IPV to child externalizing symptoms through both maternal PTSD symptoms and restrictive/punitive parenting. Findings highlight the importance of supporting parents in recovering from the sequelae of their own traumatic experiences, as their ensuing mental health symptoms and parenting behaviors may have a significant impact on their children's emotional health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to examine medical, social, and psychological factors associated with complications and reoperation after foot and ankle reconstruction., Methods: A retrospective chart review was conducted of 132 patients (135 feet; 139 operative cases) who had elective foot and ankle reconstruction. Medical, social, and psychological variables were documented. Primary outcomes included complications and reoperations., Results: The overall complication rate was 28% (39/139), and the reoperation rate was 17% (24/139). Alcohol use (P = .03) and preoperative narcotic use (P = .02) were risk factors for complications, with delayed wound healing more frequent in alcohol users (P = .03) and deep infection (P = .045) and nonunion (P = .046) more frequent preoperative narcotic use. Deep infection also was more frequent in tobacco users (P < .01). Older patients were less likely to undergo reoperation (risk of reoperation increased with age). Other variables were not associated with increased complications., Conclusion: Patients who consumed alcohol or had been prescribed any amount of narcotic within 3 months preoperatively were at increased risk for complications. Patients who smoked were more likely to have a wound infection. Surgeons should be aware of these factors and counsel patients before surgery., Levels of Evidence: Level III: Retrospective comparative study.