The coronavirus disease 19 (COVID-19) pandemic is broadly affecting the mental health and well-being of people around the world, and disproportionately affecting some groups with already pre-existing health inequities. Two groups at greater risk of physical and/or mental health detriments from COVID-19 and more profoundly impacted by the pandemic include frontline workers and American Indian/Alaska Native (AI/AN) communities. To provide support and prevent long-term mental health problems, we culturally adapted a psychological first aid guide specifically for COVID-19 frontline workers serving AI/AN communities. We engaged a diverse, collaborative work group to steer the adaptation content and process. We also held two focus group discussions with frontline workers in AI/AN communities to incorporate their perspectives into the adapted guide. Results from the group discussions and the collaborative work group were compiled, analyzed to extract themes and suggestions, and integrated into the adapted content of the guide. Main adaptations included updating language , framing the guide from a harm-reduction lens, incorporating cultural activities, values, and teachings common across diverse AI/AN communities , and validating feelings and experiences of frontline workers. The resulting adapted guide includes four modules and is available as a free online training. Our adaptation process may serve as a guiding framework for future adaptations of similar resources for specific groups. The adapted guide may stand as an enduring resource to support mental well-being, the prevention of mental health problems, and reduction of health inequities during the pandemic and beyond. Since the invasion and violent colonization of their ancestral homelands, American Indian and Alaska Native (AI/AN) communities have experienced devastating morbidity and mortality due to infectious diseases. The determinants that threaten AI/AN communities during infectious disease outbreaks today include concentrated poverty, multigenerational homes, lack of access to culturally appropriate health care, historical trauma, and food and water insecurity , tribal, and urban AI/AN health facilities reported staff shortages, including mental health providers, which limits access to mental health services for AI/AN people HHS, . Even whEarly evidence suggests the COVID-19 pandemic has had a significant and immediate impact on mental health globally  distinguished by the characteristic that the work they do cannot feasibly be performed remotely  created “Basic Psychosocial Skills–A Guide for COVID-19 Responders” to assist orientation and integration of psychosocial support for COVID-19 frontline workers across the globe in May 2020  of AI/AN experts to steer cultural revisions and adaptations of the original IASC guide. Additionally, we held two focus group discussions (FGDs) to gather input from frontline workers serving AI/AN communities to ensure the content of the guide was relevant and responsive to their needs, concerns, and experiences. After revising and refining the adapted content, we worked with an Indigenous-owned graphic design firm to create the adapted guide and online training with a culturally relevant, cohesive design. We use the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to specify and report adaptations and modifications to the PFA guide for frontline workers in AI/AN communities in a systematic way , a way of conducting research that considers inequities at the social, structural, physical, and environmental levels and includes actively involving community members and other important stakeholders in all phases of a project  with COVID-19 frontline workers in AI/AN communities. One focus group included seven frontline workers from the Southwest US, and the second included two frontline workers in urban AI/AN communities in the Northeast and Midwest US. Both focus group discussions took place virtually using Zoom with a facilitator and notetaker. Participants were asked to reflect on the collective experience of frontline workers responding to COVID-19 in their communities. The Institutional Review Board (IRB) at the Johns Hopkins Bloomberg School of Public Health (BSPH) determined this project to be non-human subjects research that did not require oversight by the IRB.FGDs were facilitated by a member of the research team who had no existing personal relationship with participants. FGD participants had not read the IASC PFA guide and were not affiliated with the CWG. The facilitator used a guide to ask questions about: (1) mental and behavioral health concerns, challenges, and stressors; (2) coping skills and existing supports/resources; and (3) resources needed or that could be improved. The first FGD took place in December 2020 and the second in January 2021.After each CWG meeting, the project team incorporated their feedback into draft adaptations of the guide and then presented it back to the CWG in subsequent meetings. This process allowed for checking the completeness and validity of incorporated suggestions and was used to iteratively revise and refine content. When CWG members were unable to attend meetings, they provided written feedback via email.Using notes and transcripts form the FGDs, the research team used a qualitative content analysis approach  General input and (2) Specific feedback on the original guide.At the outset, CWG members appreciated the original IASC guide’s note that first responders comprise a diverse group of people  and emphasized that frontline workers include more than just health care workers  and that taking into consideration this entire audience would be important for developing an effective resource. When asked about mental health concerns among frontline workers, CWG members described anxiety , feeling overburdened , difficulty balancing professional and personal responsibilities , social and cultural isolation , and feeling frustrated and confused by the rapid spread of COVID-19 misinformation.When asked what strategies and resources were already available and useful for frontline workers, CWG members mentioned tele-behavioral health services, engaging in cultural activities, and spending time outside. CWG members noted that some organizations were not adapting their policies quickly enough to align with the context of the pandemic and that policy updates were needed to increase flexibility and paid time off for frontline workers.CWG members generally agreed the guide was a helpful, relevant, and appropriate resource to adapt. The CWG recommended incorporating an overall theme of Indigenous relationality to highlight the importance of caring for all our relations, which includes maintaining balanced relationships among physical, spiritual, and mental health, as well as culture, family, and community. This also involves caring for AI/AN communities across diverse settings . Specific CWG recommendations included: 1) to take a strengths-based approach; (2) to validate that people may feel additional stress from historical trauma related to previous experiences with epidemics among AI/AN communities; (3) to promote a sense of relationality and connectedness to combat feelings of social and cultural isolation; and (4) to update and include relevant case examples to reflect AI/AN tribal and urban frontline worker experiences as helpful examples of how to apply the resources, skills, and knowledge contained in the guide. See Table  to take FGD participants shared many recommendations made by the CWG with some additions. Participants shared that challenges facing frontline workers in AI/AN communities included burnout, difficulty balancing pre-pandemic roles with new duties and responsibilities (including being unable to work remotely like others), increased workload, fear of contracting and spreading COVID-19 to family, compassion fatigue, anger and frustration (coupled with a lack of outlets to share these feelings with someone who would understand), and missing traditional cultural and spiritual practices. Many participants also touched on technical challenges of physical distancing and not being able to connect with family and friends who live far away, often related to challenges with using virtual meeting technology, primarily due to lack of access to broadband internet.When asked what resources or strategies could help frontline workers cope with these challenges, participants shared focusing on the positive successes of their work, harnessing community strengths, engaging in physical activity, spending time outside, connecting with religion/spirituality, finding safe ways to connect with family and friends, listening to music, and finding ways to safely engage in tribal and spiritual wellness practices. Participants also noted that the large amount of information from trusted sources was sometimes difficult to navigate and that more guidance around how to access and make use of this information is needed.When discussing resources needed to support frontline workers, participants shared that more resources to support self-care practices among frontline workers are needed, and that supervisors should model this behavior. Participants also shared that children, especially those related to frontline workers, could use more support in coping with stress related to virtual school and being unable to visit in person with friends and extended family.The final PFA for Frontline Workers in AI/AN Communities guide comprises four main modules see Fig. ; Table 2In line with CWG guidance, four case examples demonstrate how to apply resources and knowledge contained in the guide and represent experiences that may be familiar to frontline workers in AI/AN communities. The case examples in the guide include: (1) Caring for Elders: an applied example of how to stay connected while keeping Elders safe, as well as the importance and benefits of doing so; (2) Coping with stress and misinformation: an example that validates the stress frontline workers experience and offers practical solutions to cope; and (3) Stop-Reflect-Skoden: an example of how to apply the adapted problem solving tool from the guide. The annex includes a case example about supporting workers who are adapting to remote work environments.Motivated by two examples of the IASC guide turned into online trainings, we also created an online training to accompany this specific adaptation. The online training brings the guide’s content to life to teach skills and concepts. To enhance continuity across the guide and training, the same Indigenous-owned design firm developed videos for the training. Videos in the course include AI voice actors who deliver lectures and narrate case examples. Content is delivered in eight short videos including an introduction, four modules, and three case examples. The online training is hosted for free on CoursePlus, a learning platform at BSPH, and any interested person may register and complete the training and receive a certificate of completion. Table http://bit.ly/PsychFirstAid4COVID19. Instructions for how to access and navigate the free online training, along with information about this resource and how it was created, are also posted on this webpage. As the resource was created broadly to support frontline workers in AI/AN communities, it is widely available online for individuals to access and use, or for organizations to incorporate as part of their own training. In an effort to spur uptake of this resource by making it more worthwhile and beneficial, the training course was approved for AMA PRA Category 1 Credits™ between August 2021 and May 2022 so that health care and other professionals could obtain continuing education credit for completing the online training course.The final guide and annexes are publicly available and downloadable at While the final, adapted PFA resources are specifically intended to support frontline workers in AI/AN communities by providing them with the knowledge, skills, and attitudes to support mental well-being, ultimately, we hope and envision that they will have a wider impact. When frontline workers are equipped with the skills to support psychosocial well-being, those around them  may also experience positive effects. In the short-term, this may look like reduced levels of acute stress and increased coping behaviors, and in the long-term the intended impact is the prevention of mental health problems from developing or worsening as a result of the pandemic and related mental health stress. Additionally, for many Indigenous communities, well-being  of individuals and families is inherently connected to holistic community health Ullrich, . Within AI/AN communities are resilient and working diligently to address mental health concerns during the pandemic through culturally congruent approaches grounded in local values and Tribal sovereignty. COVID-19 has accelerated the expansion of telehealth services available through IHS, addressing critical gaps in mental health care IHS, . OrganizAs the COVID-19 pandemic evolves, this adapted resource and the process used to create it continue to be useful. The core competencies of PFA  remain relevant for many frontline workers, and this adaptation process could be used in the future to create PFA resources for new disaster events or other interventions. We report our process for adapting this guide with structure and transparency to (1) respond to calls to increase standardization of reporting adaptations of prevention interventions so as to better support implementation  whether frontline workers experience significant and lasting impacts on frontline worker mental health, knowledge, and competencies after completing the training course; and (2) whether the resource is generally perceived as useful and relevant. While PFA is widely disseminated, the evidence-base for this type of intervention is limited (Fox et al., Future work should also consider the mental and behavioral health impacts the pandemic has on children and families of frontline healthcare workers. Frontline healthcare workers do not experience the psychosocial stressors of the pandemic alone, and their children and families may need specific support during and after the pandemic (Souadka et al., It is difficult, if not impossible, to balance the breadth of cultural diversity across all Tribal Nations when creating a broad resource intended for use across these communities. Thus, the adapted guide may be missing important perspectives, and its cultural congruency may vary across tribal communities. However, we engaged a diverse CWG to steer the cultural adaptation, with specific attention to inclusivity of urban, rural, and reservation communities, and we hope these efforts have resulted in a resource that is widely applicable and useful in AI/AN communities. Another limitation of this adaptation process is that it is not culturally grounded (i.e., developed directly by and for a community and centering the sociocultural context of a specific target population; Okamoto et al., The COVID-19 pandemic has underscored existing health inequities around the world, including the pandemic’s disproportionate impact on AI/AN communities (Arrazola et al.,


Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue usually found complicating a wound, ulcer, or dermatosis. This article provides guidelines for the surveillance of cellulitis. The primary objectives of cellulitis surveillance are to (1) monitor trends in rates of infection, (2) describe the demographic and clinical characteristics of patients with cellulitis, (3) estimate the frequency of complications, and (4) describe the risk factors associated with primary and recurrent cellulitis. This article includes case definitions for clinical cellulitis and group A streptococcal cellulitis, based on clinical and laboratory evidence, and case classifications for an initial and recurrent case. It is expected that surveillance for cellulitis will be for all-cause cellulitis, rather than specifically for Strep A cellulitis. Considerations of the type of surveillance are also presented, including identification of data sources and surveillance type. Minimal surveillance necessary for cellulitis is facility-based, passive surveillance. Prospective, active, facility-based surveillance is recommended for estimates of pathogen-specific cellulitis burden. Participant eligibility, surveillance population, and additional surveillance considerations such as active follow-up of cases, the use of International Classification of Disease diagnosis codes, and microbiological sampling of cases are discussed. Finally, the core data elements to be collected on case report forms are presented. Streptococcus pyogenes (Strep A), Staphylococcus aureus, or other beta-hemolytic streptococci.Cellulitis is an acute bacterial infection of the skin and the subcutaneous tissue commonly affecting lower limbs. It is a diffuse, spreading infection characterized by redness (erythema), warmth (to touch), swelling or edema, and localized pain or tenderness . Fever, The Global Burden of Disease project estimated that almost 43 million cases of cellulitis occurred in 2019 (555 cases per 100 000 population), causing 18 069 deaths . AlthougClinical diagnosis of cellulitis is based on patient history and physical examination ; howeverWith antibiotic treatment, cellulitis usually has a good prognosis . RecurreAn effective surveillance system for cellulitis serves to: (1) monitor trends in age- and sex-specific incidence or prevalence of cellulitis among the population of a defined geographic area; (2) describe the demographic and clinical characteristics of people with confirmed Strep A cellulitis; and (3) provide estimates of disease burden of Strep A cellulitis.Potential additional objectives that may be incorporated include the following: (1) estimate the frequency of complications of cellulitis ; (2) describe the risk factors associated with primary and recurrent cellulitis; and (3) monitor the impact of prevention strategies and interventions on rates of hospitalization for primary and recurrent cellulitis and on the severity of episodes (possibly through proxy measures such as length of stay).emm types, presence of vaccine antigens, and antimicrobial susceptibility) to (1) measure strain-specific disease burden, (2) identify strain-specific outbreaks, (3) predict  the effectiveness of prospective (existing) vaccines, (4) monitor temporal trends in Strep A strains causing cellulitis, and (5) track antimicrobial resistance among Strep A isolates over time. These enhanced surveillance objectives are optional and not required in every surveillance system.Enhanced (nonroutine) surveillance programs, vaccine trials, or research projects may aim to describe selected genotypic or phenotypic features of Strep A isolates (strains) causing cellulitis .If cellulitis is accompanied by bacteremia or if Strep A is isolated from a deep tissue aspirate or specimen taken from a normally sterile body site, the illness should also be considered an invasive Strep A infection. A case would still be considered Strep A cellulitis if other bacteria are “also” present , and unusual predisposing factors, such as immersion injury, animal bites, neutropenia, and severe cell-mediated immunodeficiency . Note thAntibody detection tests can increase the diagnostic rate but are similarly not conducted as part of routine clinical assessment. For active surveillance within a clinical study, for example, antibody detection tests may be conducted to confirm a case of Strep A cellulitis by demonstrating a positive antibody response to recent Strep A infection. Currently, just 2 titers are used: antistreptolysin O (ASO) and anti-deoxyribonuclease B (ADB). It is recommended that ASO and ADB titers are interpreted by comparing acute and convalescent samples, demonstrating a rise in titer between these 2 time points. Acute serum should be collected as soon as possible after presentation, and convalescent samples should align with the peak antibody titers (ASO and ADB) to optimize sensitivity. Because the timing of the rise for ASO and ADB differ slightly at 3–5 weeks and 6–8 weeks, respectively , it is recommended that convalescent samples be conducted between 4 and 6 weeks to best capture the rise across both titers , primary care records , or health insurance databases. Considerations for using administrative health databases to identify cases are provided in International Classification of Diseases [ICD] diagnosis codes for cellulitis are not pathogen-specific).For each data source, surveillance staff should (1) know the purpose of the data source ; (2) identify any legal mandates governing the operations of the data source that may impact the accessibility or quality of the data from that source; (3) describe the representative population for the data; and (4) know the limitations of the data  may be used to identify probable cases for further investigation  for identification of the causative bacteria, physicians should be encouraged to collect specimens for bacterial cultures prior or close to initiation of antibiotic treatment where possible.The burden of cellulitis can be described in terms of incidence or prevalence. To enable comparison between different population sizes , the incidence rate of cellulitis should be calculated and reported. An incidence rate is the number of new episodes occurring per person per period of time at risk (person-time). To derive the incidence rate, the number of episodes is divided by the total number of person-time units  in which all the individuals in the group were under surveillance. The person-time is the total time a person had been observed as being disease-free. Incidence rate calculations should include all potential data sources that service the defined population, ensuring that infections are not counted more than once.Note that data from those with cellulitis at the start of the study would be considered prevalent cases and can only be included as an incidence case once they become disease-free, and they will be considered to have recurrent cellulitis at the time of their next episode. Given the frequency of cellulitis, it is recommended that incidence be expressed as episodes per 1000 population per year. It is useful to report incidence rates for initial and recurrent episodes as well as clinical and Strep A confirmed cellulitis separately where possible.Case report forms should be based on collecting only the information required to achieve the surveillance objectives. General surveillance variables include unique identifier, date and time of first enrollment or specimen collection, and site where participant is seen, such as setting, location, postcode, state/province/region, and country. Each encounter should also record a surveillance visit number/episode number if repeated episodes from the same person are included.Key demographic variables include date of birth or age (in days or months if <12 months and otherwise in years), sex, ethnicity/race, residential postcode, state/province/region, and country.Clinical and epidemiologic variables include information on anatomical site, clinical risk factors, severity of illness and disease outcome, presumed portal of Strep A entry , number and timing of previous episodes, epidemiologic risk factors, comorbidities, microbiological results and treatment, and length of stay, if hospitalized. Consideration should be given to capture information that will facilitate assessment of differential risk according to predisposing factors  or wider determinants of health.Depending on the purposes of surveillance it may be appropriate to document site of infection. This may include site categories such as lower limb, upper limb, facial, and dental or odontogenic.If the severity of cellulitis is measured, grading should be conducted using reproducible methods where possible. There are several stratification algorithms used in clinical practice, most of which grade the severity of cellulitis based on the presence or absence of defined systemic features and/or significant comorbidities. Examples include the Eron classification of cellulitis  and DundOpen Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.ofac267_Supplementary_DataClick here for additional data file.


A description is presented of the four-step process used by the Appalachian Regional Commission to develop a new Recovery to Work initiative. The Commission identified, defined, and described issues facing individuals who complete substance abuse disorder treatment and who seek reentry into the workforce. Key elements were identified for resources and supports to develop and maintain community-based substance abuse recovery ecosystems. The steps included conceptualization, data collection, analysis, and review to formulate recommendations for program and policy development. The full process of development was accomplished in twelve months. Appalachian Regional Commission (ARC) officials noted continuing evidence and received continuous testimony about the negative impacts of the high prevalence of substance abuse on the region’s workforce participation rates and its overall economy. While the primary types of substances abused have morphed over time, both qualitative and quantitative findings point to a disparity between national and Appalachian substance-abuse statistics.The Appalachian Regional Commission has taken a major role since 2000 in documenting substance-abuse disparities and drawing national attention and resources to the region through sponsoring conferences, supporting research studies, and funding small grant programs. An initial study in 2004 documented the nation’s first geographic region of disparities for health conditions and poor population-based outcomes.One aspect of the regional substance-abuse issue, elevated through pervasive stories, concerns difficulties faced by people who complete substance-abuse treatment and who seek meaningful employment. Feedback provided by local and state officials indicated there is a significant number of people completing substance-abuse disorder (SUD) treatment and encountering problems with continuing recovery, being prepared for work, and finding jobs. An internal review found limited references in government reports or other published sources about this subject.Appalachian Regional Commission Federal Co-Chair Tim Thomas identified interest among state economic development officials, regional businesses, and law enforcement in identifying how to assist people who had completed substance-abuse treatment through recovery to gain employment. In some communities and states, there seemed to be a large array of services, agreements, and structures in place that, if effectively organized, could form key elements of a recovery ecosystem. Other areas reported absence of services and providers. The Federal Co-Chair desired to engage state and local expertise to define challenges, identify promising approaches, and formulate the recommendations to inform future ARC actions in response to these issues.Viewpoints and contributions of multiple sectors were needed, including the voices of people in recovery, organizations providing treatment and recovery services, workforce development agencies, and employers. In 2019 ARC determined to engage a community-based participatory process for defining critical elements of recovery ecosystems, assessing priorities, and planning effective approaches for a unique regional recovery-to-work initiative proposed for 2020.The development of the recovery-to-work Initiative progressed over 12 months in four steps. In general these steps included (1) conceptualization of the recovery ecosystem model, (2) gathering ideas from the field that would help identify key elements of the model and existing related successful interventions, (3) review of ideas by a panel of experts leading to recommendations for action, and (4) the development of a range of ARC program interventions.The ARC staff conducted a planning meeting in October 2018 at which a graphic flow chart  was geneListening sessions were conducted at community colleges and a state park in the Appalachian regions of six states . ARC state liaisons and local development districts (LDDs) provided assistance in organizing meetings, supporting logistics, advertising, and recruiting speakers and participants. Single day sessions were organized with a 6-hour agenda. Listening sessions were conducted in the morning; public meetings were held in the afternoon. Five of six states followed this approach. One state conducted a single roundtable discussion. ARC identified a moderator to facilitate all meetings.11The invitational listening session included short presentations from ARC staff about the purpose of the meeting, from a state official about substance-abuse and workforce issues, and from a local person in recovery telling about their personal journey. Small groups of participants then rotated around three flip charts that contained questions about each element of the Recovery Ecosystem Model. Facilitated discussion among all participants clarified and expanded ideas recorded on the flip charts. Average listening session attendance was 25 people. The advertised afternoon public meeting opened with comments from ARC followed by a panel of state and regional speakers who described local issues. One speaker represented each of the three elements of the Recovery Ecosystem Model: recovery support services, job training programs, and employers. A facilitated discussion encouraged participation to gather additional perspectives. Average public meeting attendance was 75 people.Data were collected using three methods. Flip charts were used at listening sessions to record ideas. At the public meetings index cards were used to gather written responses to the statement, “The most important recommendation I would make to ARC regarding designing and planning initiatives to help adults with substance-abuse disorder secure meaningful employment following treatment is….” Field notes were taken throughout listening sessions and public meetings by ARC staff and the moderator. Separate reports were prepared for each state meeting based on the transcribed sources. Input from all six meetings was combined resulting in a large number of ideas and themes.Ideas were categorized using the Recovery Ecosystem Model elements. Themes and subthemes were generated. A second sort was conducted to assign ideas into steps of a traditional planning pyramid . The final report of the recovery-to-work regional meetings included tables summarizing themes and data using the Model and planning pyramid.The Appalachian Regional Commission created a Health Policy Advisory Council in 2000 with representatives drawn from each of the thirteen states with Appalachian counties. In 2019, this Council was reformed, renamed the ARC Substance Abuse Advisory Council, and appointed to focus on substance-abuse issues. Following consultation with ARC state liaisons, 24 people from the Appalachian regions of all 13 states received invitational letters of appointment in April 2019 from the ARC Federal Co-Chair. Membership was purposefully mixed. State and local governments, including LDD representatives, provided economic development viewpoints with updates on state policies and programming. Law enforcement contributed insights about legal and social issues. Community members, including recovery service and advocacy group representatives, brought the voices of those in recovery as well as their families and neighbors. Education and training organization representatives contributed experiences from outreach and operational adaptations that helped those in recovery obtain skills needed for employment. Employers reported on workforce trends and policies that facilitated or impinged on hiring and retaining those in recovery. Larger multicounty recovery service provider members shared programming experience. One-third of Council members attended one of the listening sessions.The Council convened in two multi-day meetings in 2019, on May 15–16 in Knoxville, Tennessee, and July 16–17 in Washington DC. The Council was tasked with developing recommendations, achievable within ARC’s mission, to help individuals in recovery get the support services and training they need to maintain recovery and successfully reenter the workforce. Council deliberations included review of input from the listening sessions. Recommendations were formulated to define, build, and strengthen recovery ecosystems across Appalachia. The Council’s recommendations were considered by ARC at its Annual Summit in Asheville, North Carolina, in September 2019.Appalachian Regional Commission staff provided background on the Recovery Ecosystem Model at the first meeting, described within the ARC mission of regional economic and workforce development. Council members who attended listening sessions shared insights about the tone and content from their state’s sessions. Several members with statewide substance-abuse responsibilities provided an overview of current federal programming and examples of state initiatives in recovery and workforce efforts.Council members were assigned to small groups to review data from listening sessions and public meetings. Each group reviewed one element of the Recovery Ecosystem Model and presented findings for full Council discussion. Council members then joined a work group, one group for each Model element, to organize preliminary recommendations. These were formatted using steps of a planning pyramid, including problem statements, goals for change, broad strategic approaches, and program activities. This ensured that each solution  was linked to one or more strategies that emerged from stated problems and associated goals for change. Each work group presented drafts of multiple recommendations for full Council discussion by the end of Meeting 1. Work group volunteers convened via conference calls to improve their recommendations based on Council questions and feedback prior to Meeting 2.At Meeting 2, work groups presented their redrafted recommendations for further Council discussion. Groups reconvened, finalized single-page recommendations on PowerPoint slides, and presented their products again for amendments and final wordsmithing. During this review, several gaps and overlaps were identified that led to new combinations and new recommendations. The full Council voted approval of a package of 14 recommendations with permissions given to members to submit final wording changes to the authoring work group.Following this discussion, the facilitator led Council members to develop a set of “We Believe” statements that summarized the Council’s beliefs about the ARC recovery ecosystem approach and expected outcomes. These declarative sentences were used as a preface in the Council recommendations report.The ARC Policy Group reviewed and approved the recommendations at its July meeting. Five of the 14 recommendations were suggested as priorities for initial action. The full Appalachian Regional Commission adopted the Policy Group’s report, including Council recommendations, at the September annual meeting and charged ARC staff with integrating the recommendations into action plans.While ARC had invested funds to address workforce participation and substance-abuse disorder (SUD) as separate challenges, no combined, comprehensive strategy had been established. Step 2, the listening sessions, and Step 3, the Advisory Council review, verified the importance of a local recovery ecosystem approach to address regional workforce reentry issues for people with SUD. ARC used the Council’s recommendations to inform future funding investments. A new $10 million federal budget appropriation was approved for Fiscal Year 2020 to support a recovery-to-work initiative in the Appalachian region. ARC also inserted a priority provision to strengthen substance-abuse responses in the large Partnerships for Opportunity and Workforce and Economic Revitalization (POWER) grant for communities and regions affected by job losses in coal mining, coal power plant operations, and coal-related supply chain industries. The involvement of states in the listening sessions and on the Council encouraged their engagement in and promotion of the new initiative. The new initiative fit into the historic ARC funding process, which relies on state development of packages of funding proposals for ARC review.12The four-step process demonstrated a proactive, regional approach for gathering and using community-level input to define problems, target programs, design appropriations, and form local partnerships to address the intersection of the region’s substance-abuse and economic development problems. Participants at state meetings and members of the Substance Abuse Advisory Council viewed the recovery-to-work focus as unique and badly needed. Seeking the “wisdom of the field” verified impacts of substance abuse on the region’s workforce and many local employment issues. Many state and local entities expressed support for the Recovery Ecosystem Model approach as a means to bring many interests together.The Recovery Ecosystem Model was a successful framework for gathering and organizing ideas through the listening sessions and public meetings. The ideas were then used by the Council to develop recommendations. The recommendations were adopted by ARC to offer regionally responsive and targeted funding opportunities to address recovery-to-work challenges.Almost 1000 ideas were generated through the six listening sessions and public meetings.The diversity of input assisted in clarifying problems. Personal stories of recovery journeys and deep-felt concerns of family and other community supporters described the impact of personal problems, service gaps, and community issues. Workforce trainers and recovery service providers added depth to themes of assessing and supporting personal readiness for recovery, job training, and finding work. Treatment and recovery service providers combined stories of individual cases and population-level statistics to identify success factors and systemic barriers. Some themes overlapped—lack of transportation, safe and available housing, and meeting social needs like childcare. Participants called for redesigning training systems to focus on the special needs of those in recovery. Employers acknowledged local workforce shortages and the economic need to reengage those in recovery into the job market. Attendees who experienced recovery emphasized that gaining and maintaining meaningful work was a prime facilitator during the recovery process. Ideas emerged for how to encourage greater cooperation between employers and recovery services, including continuity of important medication-assisted therapy services. Those in recovery, advocates, and law enforcement generated ways to overcome legal barriers and restrictive employment practices and regulations.The most challenging ideas emerged during facilitated discussions between participants focusing on different elements of the Recovery Ecosystem Model. Recovery services and workforce training programs discussed suggestions about how to better coordinate their services through colocation, shared personnel, and peer-to-peer case management. Traditional skills development programs were challenged by employers to include greater soft skills training for clients in recovery, such as time management, work readiness, social skills, and work–family balance. All sectors acknowledged real challenges in promoting community awareness of their own substance-abuse issues that could lead to broad support for individuals in recovery and appreciation of employers that accept perceived risks in hiring those in recovery.Sorting listening session and public meeting ideas using the planning pyramid format added breadth to data analysis. Long lists of problems were combined to produce rich themes that realistically intertwined individual and systems issues. While fewer in number, a list of goals provided clear statements of what participants felt needed to change. Many local strategies were synthesized into generic themes based on descriptions of similar field-tested practices and policies from different states. The Council’s multi-sector composition enabled full and rich discussions about both individual and systems problems. Important upstream causal and associated factors identified many different sectors as both part of the problem and potentially part of solutions. The vertical mix of local, regional, and state representatives aided lively debate to clarify perceptions of missions and to define optimal roles within an ecosystem. Representation from all thirteen states helped to define regional similarities and differences and generate a broad overview of characteristics of effective practices, programs, and policies.Over time ARC has deployed its attention and resources to address regional issues using four general strategies. The Council reviewed each recommendation, using a “Power of Four P’s” outline, to determine which strategies would be appropriate while also ensuring alignment with ARC’s mission. For example, recommendations designed for ARC to introduce the new recovery ecosystem framework including the workforce reentry goal, would gain national and state policy maker attention. This aligns with ARC’s Power of presence in both Washington DC and the thirteen state capitals. Developing new funding and redirecting existing funding to support recovery ecosystems fit ARC’s Power of the Purse. Recommendations that encouraged cooperative alliances with other national and state agencies reinforced ARC’s Power of Partnership strategy. Council recommendations encouraging news reports, web sites, and conferences to introduce and disseminate best practices and results of community interventions illustrate ARC’s Power of the Press. The Four P’s review helped members consider stepped approaches to implement final recommendations. This approach also reinforced ARC’s unique federal–state–local structure as a means to open avenues for true intergovernmental vertical collaboration, coupled with opportunities for multisector horizontal collaboration within communities.The Council generated a set of common beliefs about the recovery ecosystem. Six declarative sentences formed the rationale for their recommendations. These “We Believe” statements became the preface in the recommendations report:- Creation of recovery ecosystems is a sustainable solution to the regional substance-abuse epidemic that will benefit many sectors of communities.- A successful recovery ecosystem will improve workforce participation and significantly contribute to a more viable economy in the Appalachian region.- The combined understanding and energy of local leaders will lead to tested approaches that meet the unique needs of communities through structured recovery ecosystems that are adaptable across the region.- The infrastructure for a successful recovery ecosystem should be carefully crafted, deliberately implemented, and consistently evaluated. Lessons from the development of ecosystems should be shared as learning opportunities for all communities.- Long-term commitments by communities to support recovery to work and by employers to provide competitive compensation are critical.- Engaging the lived experience of people in recovery is critical to effect change, reduce fragmentation, and improve navigation of services.The Council’s fourteen recommendations can be found in The four-step process was successful in gaining the wisdom of the field by hearing voices of the recovery community, workforce programs, and employers as part of ARC’s response to the recovery-to-work issue. The entire process— including the listening sessions and public meetings, the Advisory Board deliberations, and full Commission review and approval—consumed less than 12 months. The process generated a credible justification for ARC to pursue investments in the niche of recovery-to-work initiatives. Extensive involvement of state and local interests in organizing meetings and recruiting participants and speakers was instrumental in quickly obtaining input that was integrated into the 2020 ARC grant offerings.The listening sessions were not conducted in all thirteen states of the region; therefore, the input may not represent ideas from across the entire Appalachian Region. However, this process confirms and expands similar findings from other ARC substance-abuse and labor workforce participation studies that encompass the entire region. Potential cultural biases of the findings were addressed through inclusion of a broad set of participants and sectors with diversified interests. The interpretation-of-findings process followed the principles of community-based participatory research throughout.16Agreement was found on fundamental principles. If Appalachia is not to be left behind in the national economic upswing experienced prior to the COVID-19 pandemic,


Reply to the Editor:Dr Gibney is a consultant for Intuitive Surgical, Inc. Dr Bostock reported no conflicts of interest.Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.The Atrioesophageal (AE) fistula, while rare, represents a diagnostic and therapeutic challenge to surgeons and unfortunately carries a high mortality.Prevention has traditionally centered on the tenets of (1) real-time esophageal location—either with echocardiography or esophagography, (2) limiting energy delivery time with minimal contact force, (3) intraluminal temperature monitoring, and (4) prophylactic use of postablation proton pump inhibitors,While the IMPACT study was not designed to detect a reduction in AE fistula formation, the endoscopic findings certainly support the notion that endoscopic cooling would be beneficial. To that end, we agree with Joseph and colleagues that active cooling should be part of the tenets of prevention and absolutely advocated for by both electrophysiologists and cardiothoracic surgeons alike.


Although combat has been found to be associated with adverse health outcomes, little is known about the impact of specific combat exposures, particularly among specialized personnel. This study examined the association of different types of combat exposures with behavioral health outcomes, and whether these associations differed by Army occupational specialization: General Purpose Forces infantrymen , Ranger Qualified infantrymen (n = 308), and Special Forces personnel (n = 593). Multivariable regression models estimated the association of combat severity, type of combat event , and type of killing with mental health disorders, trouble sleeping, and problem drinking. Combat severity, each type of combat event, and killing noncombatants were associated with adverse health outcomes after adjusting for covariates and other combat exposures. Except for trouble sleeping, these associations did not differ by occupational specialization, though the prevalence and odds of outcomes were generally lower for Special Forces personnel. Service members who deploy to active conflicts often experience combat, which has been consistently associated with subsequent adverse health outcomes, including mental health problems –5, sleepWhen combat exposure is examined in terms of specific event types, instead of broadly as described above, evidence suggests that certain exposures may drive associations between combat and adverse health outcomes. Specific combat events, such as fighting, killing, threat to oneself, and death/injury to others, have been associated with particular patterns of mental health outcomes, such as PTSD , 12–16, Among the specific types of combat events, one of the most complex is killing. The experience of killing in combat has been associated with PTSD , suicidaAnother limitation of the existing literature is that studies linking combat exposure and behavioral health mostly focused on conventional forces. While conventional forces represent the majority of military personnel in combat, personnel in the Special Operations Forces, such as those in the Army Special Forces (SF), are essential to enacting military strategy by undertaking sensitive missions with high stakes. These specialized units are assigned to high-priority, hostile, and politically sensitive missions and are the primary option for operations that include elements of time sensitivity, regional expertise, clandestinity, and/or high degrees of risk –33. Due Comparisons with other military personnel who volunteer for, are selected into, and complete intense and arduous training courses are potentially informative. One example of such personnel is Ranger Qualified (RQ) infantrymen who complete a 9-week premier leadership course  but continue to serve with conventional units and thus are not considered members of the Special Operations Forces. Despite high exposure to combat, these RQ infantrymen also report fewer mental and physical health problems compared with soldiers who complete standard training and serve in conventional units, such as General Purpose Forces (GPF) infantrymen . In ordeBuilding on the evidence documenting the link between specific categories of combat exposure and behavioral health outcomes, the present study was designed to (1) expand the scope of outcomes to include sleep problems, (2) examine the impact of type of killing on behavioral health outcomes, and (3) determine if these associations differ by occupational specialization. Leveraging data from a large military cohort, the first aim was to investigate the association of combat exposures  with mental health disorders, trouble sleeping, and problem drinking among soldiers serving in combat roles. The second aim was to investigate if these associations between types of combat exposures and behavioral health outcomes differed by type of occupational specialization . Results from this study can be used to inform targeted screening, prevention, and intervention efforts.The Millennium Cohort Study, the largest prospective cohort study of military personnel and veterans, was designed to investigate the effects of military service on health over time –39. SincThe sample for this study was restricted to U.S. Army personnel in one of three occupational specializations  who had completed at least one deployment in support of the conflicts in Iraq or Afghanistan . This study used definitions for these three Army occupational specializations that have been previously described . In summMental health disorders, trouble sleeping, and problem drinking were assessed using data from Millennium Cohort surveys, using the same approach as a previous study . ProbablCombat exposure was analyzed in three contexts: 1) combat severity, (2) four types of combat events , and (3) type of killing . These exposures were derived from 12 combat experience items on the survey , which are a core subset of the items assessed by the Walter Reed Army Institute Research Land Combat Study questionnaire  combat s. Combat Based on the cross-sectional design of the study and availability of the 12 combat items on surveys, one survey from either the 2007–2008 or 2011–2013 survey cycle was used as the assessment point for all analyses. These survey cycles were a baseline/enrollment survey or a follow-up survey, depending on the panel. The earlier survey was used as the assessment point unless one of the following exceptions was met, resulting in the second survey being used for assessment: the participant (1) was not in the specific occupational specialization  at time of earlier survey, (2) was missing combat data on the earlier survey (a non-responder or skipped combat items), or (3) did not endorse any combat items on the earlier survey but did endorse at least one combat item on the second survey. All variables  were measured at the assessment point.Covariates included demographics  and military service characteristics (service component and rank). Demographics and military characteristics were obtained from Department of Defense personnel records obtained from Defense Manpower Data Center, with the exception of marital status and education, which were obtained from the Millennium Cohort Study survey.Descriptive analyses were conducted to compare demographic and military characteristics, combat severity, type of combat event, type of killing, and outcomes by occupational specialization . Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression. Covariates  were selected a priori and remained in all multivariable models regardless of statistical significance to facilitate comparisons between groups. First, the association between occupational specialization and each outcome was investigated, adjusting for covariates. Next, the association of each combat exposure with each of the three outcomes was examined, using three types of models. Specifically, combat severity was the exposure of interest in Model 1. In Model 2, all types of combat events  were examined and mutually adjusted in a single model. In Model 3, type of killing  was the exposure of interest, with adjustment for fighting, threat to oneself, and death/injury of others.p < 0.05), the model was stratified by occupational specialization. A false discovery rate adjustment method was applied to account for multiple comparisons. When conducting multiple comparisons, false discovery rate adjustment procedures control the expected proportions of type I errors in null hypothesis testing, which are slightly less stringent than Bonferroni corrections but have greater power ).Consistent with previous studies, types of combat events  were associated with mental health disorders and problem drinking .(DOCX)Click here for additional data file.


Addressing nutrition disparities and preventing obesity require multi-level interventions, including policies that address the nutrition environment and other social determinants of health. The Nutrition and Obesity Policy Research Evaluation Network (NOPREN) was established in 2009 to conduct transdisciplinary research and accelerate the translation and implementation of science-based policy interventions. This study examined NOPREN’s collaborative practices and identified opportunities to improve network impact.n = 106) and in-depth, qualitative interviews (n = 18) to evaluate the experiences of NOPREN members and understand the extent to which NOPREN was achieving its goals.Using a mixed-methods approach, we combined quantitative survey data (Using the Consolidated Framework for Collaborative Research (CFCR), quantitative and qualitative results were organized into 11 themes. We find that NOPREN’s structure and standardized processes facilitate connections to individuals and resources, foster relationships, and support effective cross-sector collaborations. Areas of improvement include capacity building and a more intentional approach towards recruitment of a diverse membership.A collaborative research network can build synergy across sectors and accelerate knowledge transfer. These findings will be used to inform the network’s strategic priorities to maximize impact. Findings may also inform similar collaborative efforts for addressing complex public health problems.The online version contains supplementary material available at 10.1186/s12889-023-15148-2. Poor nutrition is a leading cause of mortality in the United States, contributing to more than 45% of cardiometabolic deaths due to obesity, type 2 diabetes, and other diet-sensitive chronic diseases . The onsNetworks, defined in this context as systems of interconnected people and organizations, can support policy research by facilitating cross-sector collaborations that harness decentralized resources to address complex problems, efficiently adapt to emerging challenges, and achieve a shared vision –10. For The Nutrition, Obesity, Policy, Research and Evaluation Network (NOPREN) was established in the United States in 2009 to foster understanding of the effectiveness of policies to prevent obesity through improved access to affordable, healthier foods and beverages in childcare, schools, worksites, and other community settings. Funded by the Centers for Disease Control and Prevention’s (CDC) Division of Nutrition, Physical Activity and Obesity (DNPAO), the NOPREN network serves as a conduit between academic researchers, public health practitioners, and federal agencies to advance the science and inform policies that impact communities –14. NOPRWork groups are a core part of the NOPREN structure and provide a platform for members to engage with others interested in similar topical areas. NOPREN houses nine work groups focused within nutrition and obesity policy research, including COVID-19 Food and Nutrition, Drinking Water, Early Childhood, Food Policy Councils, Food Security, Food Service Guidelines, Healthy Food Retail, Rural Food Access, and School Wellness. Several work groups are facilitated in collaboration with Healthy Eating Research, a national program of the Robert Wood Johnson Foundation. Members can participate in more than one work group. NOPREN supports regular work group meetings as well as monthly expert-led state-of-the-science webinars to disseminate current policy topics, research, methodologies, and interdisciplinary approaches.While academic productivity is an indicator of success among researchers, frameworks for cross-sector collaboration are emerging that enable a more comprehensive evaluation of coalition efficacy , 11. We We utilized a mixed methods approach to examine the performance of the network using both qualitative and quantitative data. Quantitative survey data provided an initial understanding of member engagement and perspectives. Semi-structured interviews, informed by results of the survey, were then conducted to explore the experiences of members in greater depth. The interviewer (TV) was a medical student at the time of the study, with no pre-existing relationship to NOPREN. The study was approved by the Committee for Human Subjects Research at UCSF .n = 633). The listserv allows members to have passive (receive newsletters) and active  involvement in the NOPREN network. The Coordinating Center at UCSF invited all members to participate in a survey and/or interview. Interview participants were not required to have participated in the initial survey. Both invitations were disseminated over email during a 1-month timeframe. The opportunity to participate in the interview was also shared during a network-wide meeting and several work group calls. Informed consent was obtained from participants using a standardized consent form. A total of 106 members completed the survey (17%) and 18 members participated in an interview (3%). Interviews were conducted until thematic saturation was achieved. Survey responses were collected between September–October 2020 and interviews were conducted between January–February of 2021.For the purposes of this study, NOPREN membership was defined as belonging to the NOPREN listserv  describes the formal and informal processes that NOPREN uses to support network communication, activities, and collaboration. Members found these resources to be useful or very useful, including the e-newsletter (96%), NOPREN products (81%), state-of-the-science webinars (78%), work group meetings (73%), and website (59%). Additional examples include the network’s administrative staff, leadership, and video-conference call platform. Participants value NOPREN’s coordination of monthly meetings and the communication and dissemination of timely information through its various platforms. Despite this, many newer members suggested additional efforts are needed to help members navigate the network and maximize its benefits by offering formal orientations and increasing accessibility of available resources.The theme broad representation (Theme 2) from multiple sectors. Survey respondents included members from academia (71%), non-profit organizations (12%) and the federal, state or local government (9%). Interview participants valued the diverse range of perspectives and skills that form the network, with varying depths of expertise including more senior, experienced members and early career professionals.NOPREN’s membership has breadth of active membership (Theme 3) and adopt strategies to ensure diverse participation, including those with backgrounds and experiences less commonly represented in academia. Participants supported the idea of conducting a focused assessment to identify gaps in representation and inclusion. Furthermore, participants recommended deliberate and strategic efforts to ensure the network is adequately addressing these gaps and elevating diverse voices, with greater focus on representation of historically marginalized populations. Although participants highlighted this as an important objective for the network, they also acknowledged that representation is a pervasive issue in the science, technology, engineering, and mathematics (STEM) fields, and upstream approaches are needed.Despite NOPREN’s ability to connect individuals from across disciplines, several members noted that the network could better support its collaboration climate (Theme 4) which facilitates partnerships and minimizes interpersonal conflict. Almost two-thirds (62%) of members surveyed report that these relationships have resulted in collaborative research opportunities. Further, survey results indicate that relationships developed through NOPREN resulted in a trusted colleague (59%) and tangible deliverables, including a conference presentation (47%), manuscript (44%), grant application (36%) and research project (33%). One example of how NOPREN achieves this is through its work groups, which provide members a forum to engage more deeply with specific topics of interest and collaborate on key priority areas. Participants expressed a desire for NOPREN to create more formal collaborative opportunities for those early in their career and/or new to the network. Interview participants had varying levels of experience and engagement with the network. For many, that engagement evolved and grew the longer they remained in the network, resulting in a more valuable experience. Ensuring that NOPREN has the infrastructure to facilitate engagement by members at all levels was noted to be important for creating a successful, collaborative network.Not only does NOPREN support cross-sector partnerships, but participants describe these relationships as collaborative and productive. Participants appreciate the network’s unique build relationships (Theme 5) that can sometimes result in collaborative and productive transdisciplinary policy research.The social capital domain describes how NOPREN connects its members to each other and resources, facilitates relationships, and promotes effective knowledge sharing. Respondents agree or strongly agree that NOPREN is effective at fostering connections to national experts (71%); diverse disciplines (64%); other networks, collaboratives or coalitions (58%); CDC representatives (48%); and governmental agencies (34%). In addition to facilitating connections, our analysis shows that NOPREN provides its members with space to formalize those connections and knowledge sharing (Theme 6), allowing members to draw upon the depth of expertise and transdisciplinary perspectives within the network to address large, complex public health issues that may not be as efficiently or effectively addressed in disciplinary silos. Furthermore, during the COVID-19 pandemic, participants described how pre-existing network infrastructure allowed for rapid information sharing, enabling members to respond swiftly to the emerging public health crisis.Participants also describe how NOPREN provides a forum for access to resources (Theme 7), including experts, small research grants, employment, and collaboration opportunities. Participants described benefitting from the timely dissemination of current public health research and practice. As a result, members gained perspective on how their own work aligns with broader, national efforts and CDC priorities, avoiding duplicative efforts and allowing for expansion upon the existing body of work. This is supported by results of the surveys, which indicate respondents agree or strongly agree that access to recent developments in the field (88%); a national perspective on the nutrition and obesity policy and research agenda (76%); and technical assistance, tools, and resources (47%) has positively impacted their career productivity.NOPREN also provides capacity building (Theme 8). This includes supporting the next generation of leaders in the field of nutrition and obesity through dedicated fellowship and training opportunities for students and early career professionals. However, survey results indicated that only 26% of participants agree or strongly agree that NOPREN has supported their career advancement, and 19% reported that their network relationships resulted in a mentor or mentee. Interview participants, especially those early in their career, articulated the need for NOPREN to invest in more formal and informal professional development opportunities. When asked directly, many participants supported the idea of developing a mentor–mentee program and/or work group for early career professionals to connect and learn from more senior researchers and practitioners. Despite the emphasis on early career professionals, several members also relayed the importance of extending these types of professional development opportunities to members at all career levels to facilitate greater knowledge sharing.In addition to facilitating cross-sector collaborations, NOPREN is committed to fostering the effectiveness of those collaborations through strategic thinking (Theme 9). While participants appreciated NOPREN’s recent focus on health equity, many emphasized the need for a more systematic and sustained approach that would inform network priorities into the future. In addition to a focus on a diverse membership, suggested strategies included formal integration of equity into the network’s mission. Further, when asked to rank a list of various research priorities, survey respondents prioritized greater topical focus on how the current food system contributes to health disparities and systemic racism.Another essential activity that influences the collaboration’s efforts is building external partnerships (Theme 10) was noted to be critical for effecting change. Interview participants noted the importance of engaging members who have established relationships with communities and organizations that are directly involved in providing public health programming and can inform the network’s work.Participants also acknowledged the importance of the external activities that enhance network impact. In particular, external communication (Theme 11) by disseminating information to diverse audiences outside of the network. Some participants described NOPREN’s unique capability to bridge the divide between research and practice , however participants more often expressed a desire for greater support with research dissemination and translation to improve the impact of NOPREN work.While NOPREN supports communication of information between members, the network also aims to engage in To illustrate our findings, we provide a case example demonstrating how the domains and themes described above intersect to form a successful network response. In March 2020, NOPREN members rapidly mobilized to form the COVID-19 School Nutrition Implications Work Group. Under the leadership of two academic investigators and one early-career fellow, the group initially focused on the nutrition implications of COVID-19-related school closures but later evolved to address the impacts of COVID-19 more broadly on food and nutrition security. By leveraging existing infrastructure and drawing upon long-standing partnerships and expertise within the NOPREN network, members were able to quickly and effectively create multi-disciplinary collaborations to conduct and disseminate policy-relevant research. Although initially started with existing NOPREN members, the group’s membership grew significantly as members brought in individuals and colleagues from their other professional networks. Within a year of launching, the COVID-19 Work Group grew to more than 500 members with representation from academic institutions, federal, state, and local practitioners, and advocacy and professional organizations. Broad, multi-sectoral representation was important for identifying opportunities and evaluating gaps as research and policies were translated into practice. The work group initially met on a bi-weekly basis, eventually shifting to a monthly meeting schedule. It also developed its own weekly digest to facilitate rapid information sharing across members. Numerous subgroups were formed and provided a platform for members to work on topics of mutual interest. In less than a year, the COVID-19 Work Group produced over 70 peer-reviewed research articles, perspectives, commentaries, issue briefs, fact sheets, op-eds, presentations, and tools. Products were either created through work group collaborations or the work group was credited with providing the infrastructure to support product development. These research publications and tools helped build the evidence base for how COVID-19 impacted the broader U.S. food system, including supply chain issues; farm and food sector worker health; and food venue and retail modifications. The multi-disciplinary workgroup also explored how existing social and ecological factors may have increased rates of food and nutrition insecurity among those at greatest risk for diet-related chronic disease. One academic researcher was able to leverage the infrastructure of the Work Group to secure a multi-million-dollar, multi-year grant to build on the work started in this group. Figure This mixed-methods network evaluation illustrates how NOPREN effectively addresses a multi-sector problem, uniting key players within a fragmented public health system to build the evidence base for effective nutrition and obesity policy. Uniting researchers with diverse areas of expertise can be an effective strategy for exploring the role of social and ecological factors that form the bedrock of social determinants of health and health disparities. The unique, collaborative forum NOPREN provides allows for innovation and a diversity of perspectives to inform research designs, with the ultimate goal of facilitating new ways of approaching long-standing challenges in the field of nutrition and obesity policy research. Researchers that leverage transdisciplinary expertise are better equipped to design studies that uncover how structural racism, policy, and environmental factors have historically contributed to unequal access to healthier foods and physical activity opportunities for specific populations.NOPREN serves as a potential model for other public health collaboratives seeking to address the root causes of disease through multi-sectoral research. Efforts to create synergy across sectors and institutions could benefit other complex public health challenges, including for example, substance abuse and adolescent mental health.While the evaluation highlighted many strengths of NOPREN’s approach, it also identified several areas that could be improved. NOPREN has expanded substantially in the last year to include a wealth of expertise and experiences, creating the imperative that it better orient new members to network processes to maximize its benefit for newcomers. Further, while respondents expressed deficits in skills necessary for effective research dissemination, many noted existing expertise within the network that could be called upon to help address this gap. Thus, facilitating connections and information sharing across individuals with differing areas of expertise can be further improved, a key function of a collaborative network. To accomplish this aim, the coordinating center can provide individuals with sufficient knowledge of the network to facilitate connections across areas of expertise, logistical support for multidisciplinary meetings, and collaborative tools to more readily disseminate information across work groups. Similarly, although the network is composed of a range of early to senior career professionals, strategies should be deployed to build capacity of early career members by facilitating meaningful relationships and fostering development of emerging leaders.Though this evaluation has identified existing resources within the network to address needs, for some gaps, part of the solution lies outside of the network. For example, support for a diverse membership requires inclusion of individuals less commonly represented within academia through strategic programming and recruitment. While networks unite members under a shared vision for change, healthy networks can evolve as collective understanding of the problem and agreed upon solutions and objectives change. As our understanding grows of the role workforce diversity plays in addressing health disparities, the network’s vision must evolve accordingly.Network evaluation is critical for network health. Engaging members in a network assessment can inform critical decisions to optimize strengths and address gaps, enabling long- term sustainability and impact . DespiteThis study explored how NOPREN’s collaborative practices unite academic researchers, public health practitioners, and federal agencies across the country to advance the field of nutrition and obesity policy research and identified opportunities to improve network impact. We find that NOPREN’s structure and standardized processes facilitate connections to individuals and resources, foster relationships, and support effective cross-sector collaborations. Opportunities for growth include capacity building and a continued, intentional focus on recruitment of a diverse membership.Additional file 1. Survey questions.Additional file 2. Interview guide.Additional file 3. Selected products developed by the healthy eating research NOPREN COVID-19 school nutrition implications work group, March 2020-February 2021.


In recent years, deep learning has emerged as a highly active research field, achieving great success in various machine learning areas, including image processing, speech recognition, and natural language processing, and now rapidly becoming a dominant tool in biomedicine . In partOne of the major challenges is that many approaches in deep learning and traditional machine learning are based on the assumption that the number of samples is huge in order to train models with a vast number of features. The situation in medicine is often reversed by necessity: the number of features desired to be analyzed is often one or two orders of magnitude greater than the number of samples. Researchers must contend with this fundamental issue, and in the end must be content with models that are consistent with the data.In this Special Issue entitled “Deep Learning and Machine Learning in Bioinformatics”, submissions address the application of deep learning and novel machine learning methods to diverse bioinformatic problems and provide practical guidance. These methods include useful approaches that may improve predictive performance and separately enhance our understanding of biological mechanisms of target diseases.Among the 55 submissions reviewed, 21 were accepted, including 17 research articles and 4 reviews, with 124 contributors. The contributions were global, for the accepted papers originating from 12 countries, including Australia (2), China, France, Italy (3), Japan (2), Poland, South Korea (2), Spain, Sweden, Taiwan, Thailand, and the United States (5). Ten research papers demonstrated the application of deep learning to various kinds of biological data. Le et al. proposed an ensemble neural network to identify essential genes via word embedding features from genomic sequences . PerssonHazra et al. employed generative adversarial networks (GAN) to create synthetic nucleic acid sequences of the cat genome .Seven research papers used traditional (non-deep learning) machine learning approaches to analyze biological data. Two computational methods were introduced, PUP-Fuse  and PredFour papers reviewed the use of deep learning or machine learning approaches to biological data analysis. Auslander et al. reviewed machine learning/deep learning approaches incorporated to establish bioinformatics and computational biology frameworks in the areas of molecular evolution, protein structure analysis, systems biology, and disease genomics . Del GiuIn summary, the articles in this Special Issue provide a range of reviews and updates to the use of deep learning and machine learning in bioinformatics.


Salivary gland cancers account approximately for 7% of all head and neck tumors ; these nRadical or partial resection based on tumor stage and histopathological diagnosis remains the gold standard, which can be followed by adjuvant radiotherapy (RT) treatment, depending on the presence of some prognostic factors.In the last decade, the introduction of new classifications in parotid surgery, such as the classification of branching pattern of facial nerve during parotidectomy proposed by Alomar and the European Salivary Gland Society’s classification of parotidectomies ,4, have In the era of precision medicine, the identification of molecular biomarkers for cancer detection is one of the greatest challenges for all clinicians, including ENT specialists, aiming to identify new prognostic factors of poorer and better outcomes.In this light, liquid biopsy is a new, safe, and minimally invasive diagnostic tool that individuates circulating tumor cells (CTCs) and circulating free DNA (cfDNA) to identify candidate therapeutic targets and to early detect tumor recurrence ,12. Metcalf et al. reported the first application of liquid biopsy to adenoid cystic carcinoma (ACC), showing some potential to detect clinically actionable mutations, to define the tumor profile, and to early detect tumor recurrence ; additioEmerging clinicopathological predictors of survival have been recently identified for acinic cell carcinoma (AciCC), mucoepidermoid carcinoma (MEC), small cell neuroendocrine carcinoma “Merkel type” (SNECM), salivary duct carcinoma (SDC), and other major salivary neoplasms ,21,22,23The aim of this Special Issue is to stimulate discussion about news in major salivary gland surgery, trying to provide evidence-based data focused on new prognostic factors in major salivary gland cancers, especially in parotid oncological surgery.


Neighbourhood accessibility influences health, social inclusion, and overall wellbeing of older adults. It is important to assess neighbourhood accessibility in relation to the diverse needs and challenges brought on by the intersection of aging and disability, particularly sensory and cognitive disabilities. Given the paucity of neighbourhood audit tools tailored for this population, The user-led Stakeholders’ Walkability/Wheelability Audit in Neighbourhoods (SWAN) tool was originally created for people with mobility disabilities and is now being adapted for seniors with sensory and cognitive disabilities to evaluate functionality, safety, appearance, supportive features, and social aspects in their neighbourhoods. In this paper, we present highlights and key takeaways from the process of adapting the SWAN tool for three user groups: people living with 1) Blindness or low vision, 2) Deafness and hearing loss, and 3) Dementia. Key steps in the iterative tool adaptation process include 1) identifying access needs/challenges for the three user groups based on a literature review, 2) online consultation with stakeholders with lived and/or professional experience (N = 4) to prioritize key access needs/challenges that will be captured through the SWAN tool and review draft versions of the tool, and 3) in-person pilot testing of tools with persons with lived experience (N = 2) in two urban/suburban neighbourhoods in British Columbia, Canada. Reflections of team members and input from stakeholders and pilot participants revealed issues that were addressed in tool development, namely 1) length of audit and participant fatigue, 2) legibility of tool, and 3) tailoring audit to participants’ context and needs.


Schema-therapy (ST) - one of the promising integrative models of psychotherapy, which shows its efficacy in many mental disorders. ST has main theoretical concepts: early maladaptive schemas (EMS), coping styles, modes and basic needs. EMS are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life. Existing literature shows the connection between EMS and behavioral problems, which could be more significant for patients with personality disorders. The prevalence of personality disorders is relatively low in the general population, but it’s highly overrepresented in the forensic population, especially in groups of sex offenders.The aim of this study is to examine if there is a prevalence of some EMS between sex offenders and their association with a diagnosed psychiatric disorder.Medical records and criminal case materials of 27 patients were reviewed, all of them were blamed for committing sex crimes and had to stay at the department for one month for forensic psychiatry examination. During their stay patients were examined several times and questioned with YSQ S3R.Most of the patients had psychiatric disorder: specific personality disorders (14), pedophilia (3), dependence syndrome (4), organic personality disorder (3). Some of them had several psychiatric diagnoses. The most prevalent EMS were abandonment, emotional deprivation, insufficient self-control and defectiveness.These findings show the prevalence of personality disorder and several EMS in sex offenders, which could be useful for the full understanding of the concept of PD and improve the organization of medical care for these individuals.No significant relationships.


Precision medicine is entering a new era of digital diagnostics; the availability of integrated digital pathology (DP) and structured clinical datasets has the potential to become a key catalyst for biomedical research, education and business development. In Europe, national programs for sharing of this data will be crucial for the development, testing, and validation of machine learning–enabled tools supporting clinical decision-making. Here, the Swiss Digital Pathology Consortium (SDiPath) discusses the creation of a Swiss Digital Pathology Infrastructure (SDPI), which aims to develop a unified national DP network bringing together the Swiss Personalized Health Network (SPHN) with Swiss university hospitals and subsequent inclusion of cantonal and private institutions. This effort builds on existing developments for the national implementation of structured pathology reporting. Opening this national infrastructure and data to international researchers in a sequential rollout phase can enable the large-scale integration of health data and pooling of resources for research purposes and clinical trials. Therefore, the concept of a SDPI directly synergizes with the priorities of the European Commission communication on the digital transformation of healthcare on an international level, and with the aims of the Swiss State Secretariat for Economic Affairs (SECO) for advancing research and innovation in the digitalization domain. SDPI directly addresses the needs of existing national and international research programs in neoplastic and non-neoplastic diseases by providing unprecedented access to well-curated clinicopathological datasets for the development and implementation of novel integrative methods for analysis of clinical outcomes and treatment response. In conclusion, a SDPI would facilitate and strengthen inter-institutional collaboration in technology, clinical development, business and research at a national and international scale, promoting improved patient care via precision medicine. Globally, despite significant advancements in medical technology, reaching a definitive diagnosis for many diseases still requires the microscopic evaluation of clinical tissue samples by surgical pathologists. In 2019, the European Union (EU) approved the usage of whole slide scans for such primary diagnoses, wherein routine glass histopathology slides are digitized and presented to pathologists for review on computer monitors. The potential of this digital pathology (DP) approach represents a major inflection point for both research and clinical workflows, since once slides are in a digital format, they become amenable to digital transfer and computational analysis.Research and development by industry and academic institutions have shown that these DP images can be analysed by sophisticated machine learning algorithms to enable (a) more precise characterization of the histological spectrum of disease, and (b) data mining of specific features for clinically relevant biomarkers , 2. By sIn Switzerland, and inclusive of a broader view in the European Union, there is an emerging opportunity to develop a unified national DP network consisting of both public and private institutions , 5. EachThis call for a national infrastructure is in concert with other recent national investments by the UK , GermanyFindability, Accessibility, Interoperability, Reusability (FAIR).A SDPI would promote digital diagnostic workflows on a national level by establishing five components: (a) data creation, (b) data storage, (c) data sharing, (d) data enhancement, and (e) data computing, all developed in line with the data principles of SDPI aims for a highly standardized environment for data creation, storage, and retrieval. This will enable improved cross-site data sharing and algorithm development, with linkage to national and international data sharing programs in a cost-efficient manner.Images will be stored on-site, in line with established hospital privacy, redundancy, and backup requirements. National guidelines which are currently being developed by a dedicated SDiPath Working Group are expected by mid 2022. Storage infrastructure would be designed in a scalable manner, such that as data is routinely created and additional storage is required, supplemental capacity can seamlessly be brought online.Approved users should be able to remotely query the SDPI in a privacy-preserving manner, enabling the estimation of cohort sizes for research projects and clinical trials. This information will be critical to obtain ethics approval for the release of coded data in accordance with established biobanking protocols and national regulations. Connection to the growing Swiss Personalized Health Network (SPHN) is envisaged to achieve multi-modal integration of health data for research purposes and integration in clinical trials . SynoptiAnnotations are needed for developing AI algorithms, biomarkers and tools. These annotations are often extremely time-consuming to collect, as only topic experts are able to create and validate their accuracy. The DP community has witnessed a significant reduction in experimental execution times via sharing of these annotations and associated tools , 15. BuiSDPI will provide high quality–coded, semantically structured and harmonized DP datasets for research purposes organized in the distributed BioMedIT data repository and made findable, accessible, interoperable and retrievable through a centralized registry with access control  Fig. 2)2). ThrouDetermination of minimal hardware, software, technical, and ethical requirements is crucial to enable smaller public and private hospitals with limited resources to contribute to the development of a SDPI. From the onset, a “plug and play” design must be considered, enabling new data producers to rapidly connect to the infrastructure in a standardized way, limiting costly re-development and one-off solutions.Switzerland has large vested interests in “Personalized Medicine” , and DP represents a highly synergistic and complementary approach to (a) genomic sequencing cores at university hospitals, (b) national networks to support data science established by the SPHN, (c) the Swiss Institute of Bioinformatics, and (d) the Swiss Biobanking Platform. On a European level, the ability to share resources  is seen as a key driver of greater research insights, impactful economic development opportunities and better patient care .DP affords the opportunity for significantly improved efficiency in terms of clinical care and disease research and in the technical development of diagnostic medical tools. These facets each require large quantities of data for both development and validation and yet no infrastructure in Switzerland exists to provide it. A SDPI would overcome this hurdle yielding benefits such as (a) decreased waiting times for pathological evaluation and improved (b) quality, (c) safety, (d) speed, and (e) specificity in medical assessments. Furthermore, a deployment infrastructure will enable sharing of clinically validated biomarkers, tools, and algorithms. This will thus ensure continual high-quality medical care for Swiss patients, while countering the anticipated shortage of pathologists during the next decade by increasing their efficiency.In that light, a number of university and public hospitals have already begun the digital transformation, in total having scanned well over a million slides, at an increasing rate of over 50k slides per year , 5. SDPIThe gold standard of clinical trial design requires large retrospective and prospective cohorts. Similar to other countries in Europe with limited populations, it is challenging for any isolated centre in Switzerland to recruit enough patients to conduct such trials. This places Switzerland at a disadvantage as compared to higher population countries, whose high-volume hospitals have been able to position themselves as lead innovators due to their access to large numbers of patients. A SDPI resolves this issue by allowing for the seamless merging of all patients across Switzerland into a virtual “single cohort”, enabling a competitive advantage that surpasses even those of large-single institute clinics. An attractive collaborative opportunity is thus created between Swiss Hospitals and Clinical Research Organisations which are both eager to conduct clinical trials, while at the same time are also limited in access to suitable patient populations. A more direct, cost-efficient collaboration between these two types of research entities, not only enables patients to be better matched to potentially life-saving treatment, but also facilitates the discovery of biomarkers to heavily reduce ineffective overtreatment and thus limit long-term potential toxic side effects of many therapies.Taken together, the high quality of care available in Switzerland, paired with its world-class precision medicine, cancer research and basic and translational science teams, creates an especially timely opportunity to genuinely improve patient care in the near term by the development of a highly synergistic nationwide Swiss Digital Pathology Infrastructure.