An estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources  and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.The aim of this study is to compare the ways in which Veterans Affairs’ (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.This cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.This study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.The factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.DERR1-10.2196/14039 The Donnected ,6. For eAs the cost of living with an SCI can be insurmountable, the monthly financial compensation provided to service-connected veterans living with SCI through the VBA can be used to offset the loss of wages. In addition, veterans who are service connected specifically for their spinal cord condition  may also qualify for additional grants funded through the VBA. These grants promote functional independence by providing resources for the aid and attendance required to maintain the veteran in the least restrictive setting; for example, a VA automobile allowance or specially adapted housing grant where the goal is to help veterans participate in their home life, employment, and social activities that might otherwise be inaccessible and maintain positive quality of life ,8-10.Despite VA’s efforts to reduce the financial burden associated with successful rehabilitation, independent living, and community integration through disability benefits, a portion of veterans living with SCI have nonservice-connected disabilities because their disabilities were not incurred or aggravated by their military service ,6. On thThe Department of Veterans Affairs (VA) estimates approximately 450 newly injured veterans and active-duty members receive rehabilitation at VA’s SCI centers annually ,11,12.Rehub and spoke system. The VA SCI/D System of Care includes 25 regional SCI/D Centers (known as hubs) that provide comprehensive range of care including, inpatient and outpatient rehabilitation, specialty care, and coordinated lifelong continuum of care delivered by interdisciplinary teams [The primary goal of VA SCI and Disorders (SCI/D) services is to restore functioning, reduce secondary complications, and promote the health and sustainability of functional independence to maximize QOL after injury . The VA ry teams . After rry teams . Thus, iry teams ,17.National Institute on Disability, Independent Living, and Rehabilitation Research, Administration for Community Living, US Department of Health and Human Services, supports innovative projects and research in the delivery; demonstration; and evaluation of medical, rehabilitation, vocational, and other services to meet the needs of individuals with SCI. The Northern New Jersey Spinal Cord Injury System (NNJSCIS) was established as a SCIMS in 1990. The NNJSCIS provides a comprehensive continuum of state-of-the-art care for persons with spinal cord injury and their families from the time of injury through rehabilitation and return to the community.The SCI Model Systems (SCIMS) are specialized programs of care in SCI that gather information and conduct research with the goal of improving long-term functional, vocational, cognitive, and QOL outcomes for individuals with SCI. SCIMS, sponsored by the service connected [average impairment in earning capacity [scheduler ratings), with a higher percentage of rating equaling a greater functional impairment and amount of disability compensation awarded. Typically, a VA disability rating is derived from an algorithm that combines the individual scheduler ratings of each compensated disability [VA provides monthly disability compensation benefits to veterans who develop medical conditions and disabilities related to military service; that is, who are deemed onnected ,18-19,20onnected  followincapacity -23,18-19sability ,6. Theresability ,6. The asability ,6. Unliksability -23,18-19invisible wounds) and external factors  [Little is known about the differential impact of service-connected status on the health status, functional outcomes, QOL, and health care utilization patterns of veterans living with SCI. Interestingly, veterans service-connected for PTSD have been found to report high rates of medical impairment, psychiatric symptomatology, and utilization of medical and mental health services ,23,18. Fenefits) . These fThe proposed study intends to address this gap in the literature using qualitative research methods to explore the perspectives of service-connected and nonservice-connected veterans living with SCI, family caregivers as well as SCI clinicians about factors that contribute to these veterans’ health status, functional outcomes, and health care utilization. On the basis of the aforementioned literature, individual/personal factors, socioeconomic, family, and health system factors will be explored. Individual factors such as demographic characteristics , cultural beliefs, socioeconomic status , and health risk behaviors  have been found to the impact on health status, functional outcomes, and health care utilization in veterans living with SCI . Family This investigation will be guided by the framework of the International Classification of Functioning, Disability, and Health (ICF) ,26 to exThe proposed project will use qualitative methods to examine the factors associated with outcomes for service-connected and nonservice-connected SCI. Qualitative methods have the advantage of allowing us to address these aims in a manner that is meaningful to individuals who are actively involved in SCI veteran rehabilitation: veterans living with SCI, family caregivers, and SCI clinicians. We propose the following aims:To describe veterans living with SCIs’ reasons for seeking versus not seeking service-connected disability compensation and the factors that influence their choice.To explore the impact of service-connected disability compensation on health status, functional outcomes, QOL, and medical decision making .To explore the impact of service-connected disability compensation on the family caregivers and households of veterans living with SCI.To explore SCI clinicians’ perspectives on the impact of service-connected disability compensation status on the provision of adequate long-term health care and rehabilitation for veterans living with SCI.To develop a set of practice and policy recommendations about the impact of service-connection status of veterans living with SCI on clinical and policy guidelines, family interventions, caregiver training, and patient education programs.The proposed work is significant because it will provide new knowledge about veterans living with SCI with and without service connected disability compensation in the realm of family caregiver support, access to community resources, personal factors, and health behaviors, including patient-provider relationships and their impact on health status, functional outcomes, and QOL. The findings will describe areas of care considered priorities for veterans living with SCI and families that must be clearly integrated into clinical care to support the successful maintenance of health status, functional outcomes, and QOL.The study protocol, research team and data collection instruments were reviewed and approved by the institutional review board (IRB) at each study site as well as US Army Medical Research and Materiel Command`s Office of Research Protections, Human Research Protection Office.experts to explore the health status, functional outcomes, and QOL of veterans living with SCI with different types of disability benefits and who decide to receive their health care from VA centers and non-VA.This cross-sectional qualitative study will use a community-based participatory approach to examine the reasons for seeking disability compensation benefits, factors associated with outcomes, and choice of health care facility among veterans living with SCI with and without service-connected disability benefits. Community-Based Participatory Research represents a collaborative process between researchers and community partners; builds on the unique strengths, knowledge, and resources within a given community by employing local knowledge in the understanding of health problems and their potential solutions; and facilitates collaboration throughout all phases of the research .We will hub and spoke system of care, private care sector of SCI care, caregiving, and SCI research.To achieve these aims, we assembled a highly productive and interdisciplinary team of SCI/D researchers and community advisors with expertise in qualitative research methods, VA SCI The study will collect data from 3 groups of participants involved in sustaining the health status, functional independence, and QOL of veterans living with SCI who are impacted by the type of disability benefits and health care utilization patterns:An equal number of veterans living with SCI receiving clinical services or who have previously participated in research at the East Orange Campus of the VA New Jersey Health Care System (VANJHCS) or Northern New Jersey SCI Model System (comprised the Kessler Foundation and Kessler Institute for Rehabilitation) will participate in phase 1 (n=15 per site) and 2 (n=30 per site) of the study (described below).Inclusion criteria are being male, veterans (or served on active duty service in the US Armed Forces), at least 18 years of age, SCI that occurred at least 1 year ago, and receiving health care/rehabilitation at the participating VANJHCS and/or a participating Spinal Cord Injury Model System site or Spinal Cord Injury Model System (SCIMS).Exclusion criteria are inability to communicate because of neurological impairment ; identifying as a female. We limited the scope of the study to patients to male veterans living with SCI because there are not likely to be sufficient numbers of female veterans living with SCI to be able to recruit a meaningful sample of them, given a larger proportion of people with SCI and veterans are males and thus beyond the scope of this project.primary caregivers. Family caregivers who may be eligible to participate in the focus groups or interviews will be identified by clinical staff  or an SCI veteran who participated in a semistructured interview. A member of the research team will contact the family caregiver to inform them about the study and determine if they meet the eligibility criteria to provide additional information and make arrangements to obtain informed consent before the start of focus group or interview data collection.SCI often results in physical limitations such that receiving assistance from others is critical to maintaining health and facilitating full societal integration. The help received ranges from assistance with basic daily activities such as bowel and bladder management and dressing, as well as instrumental activities of daily living, including managing household finances, shopping, or transportation. In the United States, most home care is provided through informal mechanisms by family members , and almClinicians’ perceptions are important because they may affect patient-provider relationships, the course, and the outcome of treatment. Clinicians have knowledge of the medical and functional consequences of SCI and experience providing training to veterans living with SCI and their family caregivers to plan for adjusting to home life and community reintegration. SCI clinicians at each participating center will be informed of the study through written (flyers and emails) and oral communications with local study leaders and/or supervisory staff. We will recruit a sample of 10 clinicians at both sites that includes staff members who have experience providing direct care or services to veterans living with SCI at each of the research sites. The SCI clinical staff will include physiatrists, nurses, social workers, physical, recreation, and occupational therapists who have at least 2 years of experience providing care to SCI. Clinicians who are interested in participating and wish to be contacted by the research team will receive additional information and, if interested, give informed consent before the start of focus group data collection.Each group of participants has real-world experiences and clinical knowledge that will inform the content of the key practice recommendations that can be readily integrated into clinical guidelines, family interventions, caregiver training, and patient education programs.Two study sites that serve veterans living with SCI in New Jersey will conduct the proposed study: VANJHCS and Northern New Jersey Spinal Cord Injury System. A description of each research site is provided in After obtaining approval from the IRB at the study sites, purposeful sampling strategies will be used to identify and recruit potential study participants. A research coordinator (RC) will recruit potential participants using advertisements, brochures, and referrals from SCI registries at each collaborative site. If we do not get an adequate recruitment response, we will implement the snowball recruitment technique that involves asking participants to inform and encourage friends, colleagues, and other peers to participate .In recent years, data saturation has become the gold standard by which purposive sample sizes are determined in qualitative research . TheoretOnce each participant completes oral and written informed consent and is scheduled for interview or focus group session, he/she will receive a telephone reminder 2 weeks before the interview or focus group as well as a written letter 1 week beforehand. The day before the event, the consultant will make 1 last round of confirmatory phone calls. Participants will be compensated for their time. In addition, to maintain enrollment and participation, we will provide transportation cost for a portion of veterans living with SCI and family caregiver on an as-needed basis.independently interpret the reasons and impact of the disability benefits on veterans living with SCIs’ . Results from each phase will be analyzed separately and then merged to inform the content of the subsequent phases as well as the set of practice recommendations that can be readily integrated into clinical guidelines and family interventions. Three methods of qualitative data will be collected: chart review, semistructured interviews, and focus groups. These 3 qualitative data collection methods will be implemented over 4 phases of sequential qualitative data collection outlined in comprehensive annual history/physical exam with specialty assessments, offering an annual evaluation is mandated for patients with SCI in the Veterans Health Administration (VHA) [The RC will be trained to use a standardized chart abstraction instrument to gather demographic, clinical, and disability benefits data. The chart review will be designed to help prepare and supplement data gathered in subsequent phases by providing data that will (1) inform the development of discussion questions for the participant interviews and focus groups; (2) confirm the veterans living with SCI disability status and rating; and (3) documentation of health status, functional information, and patient/family education logs gathered during the most recent annual evaluation of 30 veterans living with SCI (15 per site). An annual evaluation was defined as a on (VHA) .Semistructured interviews will be aimed at capturing service-connected and nonservice-connected veterans living with SCI perspectives on ways in which their financial compensation (or lack thereof) impacts their health status, functional independence during community reintegration, QOL, and their utilization of health care. The sample will be equally split between study sites (n=30) veterans. We will modify items from the benefits coverage inventory, a measure that has been used in previous research to assess rehabilitation/independent living benefits received after discharge in 5 areas: housing, personal care assistant, transportation; outpatient therapies , and equipment (durable and nondurable). The measure asks about who pays for these items . We will work with the CAB to develop semistructured interview questions that relate to service-connected disability benefits. The semistructured interview will discuss veterans living with SCIs’ likes and dislikes of the being service-connected or nonservice-connected—their perceptions about whether disability benefits may be viewed as a barrier to independence, and difficulties with bureaucracy for some veterans living with SCI. The interview will ask veterans living with SCI to express their experiences about unexpected barriers associated with seeking service-connected financial compensation. Key questions will focus on their health status, maintenance of their functional independence during community reintegration, health care, and rehabilitation experiences. The individual semistructured interview allows for rapport and confidence building at a sensitive time after injury so that more honest opinions and attitudes may be revealed more readily than in a group setting. The interviewer can answer respondent questions, probe for additional answers, and observe visual cues. To facilitate access to veterans living with SCI who are unable to come to the research site for an interview, we will use the VA’s real-time video health tool—Clinical Video Telehealth that is a technology that is frequently used in the VA to promote video communication between patients and providers  clinical factors of veterans living with SCI who seek different types of disability compensation benefits ; (2) describe their perception about the relationship between disability benefits and health status, functional outcomes and health care utilization among veterans living with SCI; (3) identify VA and private-sector health care system issues related to disability compensation benefits, which are obstacles for veterans living with an SCI; and (4) identify solutions to address these concerns.To design a useful set of practice recommendations, we will analyze results from phases I to IV separately and then merge them to prepare the content materials for phase V. The chart review, interview, and focus group data will be prepared for analysis by converting the raw data  into partially processed data , which will then be coded and subjected to an analytic theme. The analysis will focus on the key research questions and include the following steps:Read each transcript in an editing style to augment an initial codebook template developed from the ICF guidelines and interview guide.Read and reread highlighted portions to develop keywords .Divide the themes, patterns, and categories into groups by the research questions.Examine the convergence/divergence by completing the following steps:Convergence will be examined by determining what themes fit together to develop the internal homogeneity and external heterogeneity.Internal homogeneity will be determined by analyzing the themes to see which are more similar, and external heterogeneity was determined by analyzing the themes to see which ones are distinctly different from each other .These processes will enhance the credibility of the research. Divergence will reveal some of the patterns within the categories and helps to make connections among the themes for categorical saturation .Qualitative data collected in phases I to IV will generate its own findings to add additional information to our understanding about the reasons veterans living with SCI seek different types of disability benefits and how these factors that are associated with health status, functional outcomes, and QOL. Triangulation is methodological approach that contributes to the validity and reliability of qualitative data collection when multiple method and sources are employed . Triangugroup-to-group validation [Using the themes generated from the qualitative analyses, we will work with the CAB to summarize to identify the most frequently cited factors  that impact veterans living with SCIs’ decision to seek service-connected disability benefits  and across samples of participants—a process that is known as lidation .There are a number of steps outlined in the literature used to develop targeted recommendations for clinical guidelines, developing recommendations for patient and family educational resources, and policy-level interventions. First, the research team will generate a summary of the most frequently cited factors identified from the data as recommendations to the CAB. Examples of potential interventions include revisions to existing patient and family education material related to programs and services available from the VA for veterans with SCI; educational interventions for SCI clinicians to make them more aware of resources available from the VA that are correlated with positive clinical practice outcomes for veterans with SCI veteran, and their families, caregivers, and other clinicians; procedures to help clinicians identify veterans living with SCI at civilian hospitals and connecting these veterans and their families with knowledgeable VA advocates  and VA disability compensation and health care resources.targets of change. After identifying the factors that are both important and modifiable, the CAB and research team will decide which factors will be targeted for recommendations for interventions. Finally, the CAB and research team will select promising strategies or key recommendations to develop an intervention action-point document. The intervention action-point document will be a road map toward the operationalization of an educational intervention for SCI, families, SCI clinicians, and policy recommendations for the VBA.Second, the CAB and research team will have monthly consensus meetings, which will be used to evaluate aspects of the most frequently cited individual, family, SCI clinician, and systemic factors generated from the data: importance to veterans living with SCI and modifiability. Determination of importance can be obtained in several ways, such as the CAB rating on the degree of importance, and assessing socially significant implications of the qualitative findings. The CAB and research team will collaboratively rate the modifiability of the individual, family, SCI clinician, and systemic factors from the qualitative data by asking the question, “Can this problem easily be addressed?” or “Can this solution be implemented pragmatically?” The collaborative will rate these individual, family, SCI clinician, and systemic factors as (1) factors that can be completely changed, (2) factors that may be modified, but we are unable to change them completely, and (3) factors that are nonmodifiable. Third, the CAB and research team will select Content of the intervention action-point document will be evaluated assessed for their appeal, clarity, and appropriateness for the target users. We will recruit veterans living with SCI and family caregivers who participated in phases I to III. We will recruit approximately 5 veterans living with SCI and 5 family caregivers. Veterans living with SCI and family caregivers will be asked if they are willing to participate in future groups or interviews. Members of the research team will recruit those who agreed using personal phone calls. If we do not get an adequate response from the previously identified participants, advertisements, brochures, word of mouth, and the aforementioned snowball technique will be used. An honorarium will be offered to compensate participants for their time and transportation.The project was funded in July 2015, and recruitment was completed in October 2018.A total of 69 male veterans living with an SCI participated in medical chart review and interview phases of the study. The mean age of the sample was 59.5 years . Most of the veterans self-identified as non-Hispanic white , married , had some college education , and unemployed . In terms of military experience, approximately one-third served in the army  and primarily in the Vietnam era . The majority of veterans sustained their injury after military service , and were living with paraplegia  for an average of mean 15.0 years  of the veterans self-identified as nonservice connected and 36% (25/69) were service connected for SCI or another disability . A total of 18 caregivers participated in focus groups and interviews at the 2 sites. All of the caregivers were females, the mean age of caregivers was 64.8 years (SD 10.8) and reported caregiving for their loved one for approximately, 15.9 years (SD 11.4). A total of 9 SCI clinicians participated in a focus group at Veterans Administration New Jersey Healthcare System and 10 at the SCIMS site. Comparable clinical professions  were represented in each focus group and average of 11.5 years (SD 8.8) working in their current positions.Preliminary content review of narrative data suggests that veterans living with an SCI and caregiver participants varied in their reasons why they did not apply for VA disability compensation, including a lack of knowledge and misinterpretations about the VA disability compensation eligibility and health care coverage from the VBA and VHA, respectively.independently interpret the reasons and impact of service-connected compensation (or lack thereof) on the health status, functional outcomes, QOL, and health care utilization of veterans living with SCI. Preliminary findings suggest a small proportion of participants receive VA service-connected disability compensation benefits. Participants’ responses indicate that veterans living with an SCI and their caregivers may not be fully aware of their eligibility for VA disability compensation, making it more difficult to make an informed decision about pursuing VA disability compensation benefits. To make an informed decision about eligibility for VA disability compensation benefits, veterans living with SCI should be connected with an experienced veterans benefits advocate (ie veterans service officer). Study findings will be used to generate a set of practice recommendations to the clinical guidelines, family interventions, caregiver training, and patient education programs that can be tested in a future large-scale multisite quantitative study to devise targeted community-based interventions.This qualitative study will use a community-based approach to derive information from veterans living with SCI, family caregivers, and SCI clinicians about their day-to-day experiences with being service connected or nonservice connected status. Of particular interest is how these groups


A growing number of formal postgraduate training programs have been established to provide emergency medicine physician assistants (EMPA) with the unique skills and knowledge to work in the emergency department (ED). The objective of this study was to provide an overview of the current state of EMPA postgraduate training and to describe program characteristics and curriculum components.We conducted a cross-sectional study of EMPA postgraduate training programs using data from websites and contacting individual programs to provide program characteristics and curriculum components. Variables collected included length of program, curriculum , size of program/number of trainees, affiliation with emergency medicine (EM) residency, geographic location, and salary.We identified 29 EMPA postgraduate training programs in 17 states, with at least one additional program in development. The mean length of EMPA training programs is 15 months (range 12–24 months). The most common non-ED/elective rotations are orthopedics, ultrasound, anesthesiology, and trauma. The mean number of trainees per class is 3.46 ; 27 of 29 (93%) programs were in institutions that also had an EM residency program. The mean annual salary is $58,566 .EMPA postgraduate training programs have common characteristics and curriculum components despite a lack of a specialty-specific accrediting organization or certifying examination. The overall growth and current number of these programs merits further research focusing on whether standardized curricula, formal recognition, and accreditation should be developed. Physician assistants (PAs) have been integrated into clinical practice in emergency departments (ED) since the early 1970s,2There are currently more than 225 Accreditation Council for Graduate Medical Education-accredited EM residencies,14Unlike EPs, EMPAs are not required to complete formal postgraduate training programs in EM, and currently there are no EM-specific standards, competencies, or continuing education requirements for EMPAs. Almost 80% of EMPAs cite “on-the-job training” as the method by which they receive EM training.16EMPA postgraduate training programs offer an opportunity to formalize training in EM for PAs and to provide a foundation for lifelong learning and practice improvement. Completion of specialty-specific postgraduate training by PAs has been identified as an alternative to on-the-job training, and might enhance competitiveness in the job market and decrease onboarding time for newly hired PAs.18Postgraduate training programs for PAs have existed in multiple specialties since the early 1970s, and since at least the 1980s for EMPAs.We performed a cross-sectional study to identify EMPA postgraduate training programs and to describe their characteristics and curriculum components. The study received exempt status approval from the University of Missouri-Columbia School of Medicine Institutional Review Board. Between October 2016 and January 2017, we collected data by searching individual program websites, the SEMPA website, and the Association of Postgraduate PA Programs website. Where incomplete, and to verify information, these public data were supplemented by contacting EMPA programs by telephone and/or email for additional information.All three authors extracted data using a data form based on an initial review of common program features using a standardized electronic data form see . VariablWe identified a total of 29 EMPA postgraduate training programs, with at least one additional program in development. EMPA programs are found in 17 states . The meaThe mean annual salary is $58,566 . The mean number of trainees per class is 3.46 . All programs require a formal application process that includes letters of recommendation and an interview. Programs uniformly require certification by the National Commission on Certification of Physician Assistants (NCCPA) prior to beginning the postgraduate EMPA training.EMPAs are now an important part of the EM workforce and will continue to be in the coming decades. Postgraduate EMPA training programs focused on EM knowledge, skills, and abilities can play a significant role in creating this workforce. EM is a unique practice environment for PAs, featuring a vast knowledge base and procedural competency in a high-risk environment.There is an opportunity for the development of standardized curricula, training programs, and a certification process for EMPAs that could be like EP training, with a focus on the unique and collaborative practice needs of EMPAs. This formalized training in EM knowledge and skills would prepare PAs to work in a variety of ED settings. Postgraduate EMPA training programs, when partnered with an EM residency training program, might enhance the understanding of all members of the EM team about the key role of EMPAs in providing emergency care. Further standardization of basic curricula, with the ability to tailor specific program and institutional needs and resources, could accelerate the growth of EMPA training programs by encouraging existing EM residencies to develop co-existing EMPA postgraduate training programs. In 2007, there were five postgraduate EMPA training programs.23Our study identified 29 programs, an increase of 24 programs in a decade. The rapid growth of these programs suggests a need for specialized EM training and is analogous to the increased number of EM residency programs over the past decade. When EM residencies were first developed and board certification adopted as the standard for EPs, the American College of Emergency Physicians (ACEP) played a significant role. Similarly, SEMPA has been at the forefront of education and advocacy for EMPAs, and as a close partner of other EM organizations, including ACEP, could be a catalyst for formalizing EMPA education and certification.Our study shows curricular similarities among EMPA postgraduate training programs. The curricular similarities that already exist provide a foundation for standardizing EMPA postgraduate training and for the future development of board certification or another similar recognition for EMPAs who have completed these training programs. This formal recognition, whether via board certification or another mechanism would underscore the unique role and commitment of EMPAs to patient care in the ED. Accreditation and certification processes would need to be developed and implemented. One existing example is the availability of voluntary accreditation through the Accreditation Review Commission on the Education for the Physician Assistant (ARC-PA).24Finally, the geographic distribution of EMPA postgraduate programs and EM residency programs are similar, consistent with the affiliation of most EMPA programs in departments and/or institutions with existing EM residencies. EMPA programs are likely found in these settings because of the educational infrastructure and ED volume and acuity that provide the necessary training environment for both EMPA and EM residency training programs. The co-existence of EMPA and emergency physician training programs in the same institution offers an opportunity for interdisciplinary learning and is critical to developing a workforce of EMPAs and EPs who will work collaboratively to provide high quality, patient-centered emergency care.Our study does not evaluate potential barriers to EMPA training programs or explore outcome measures related to the training. For example, we did not evaluate whether EMPAs who completed postgraduate training provided higher quality, higher value emergency care, or are more desirable as job applicants compared to those who did not have these experiences. We also did not evaluate the potential funding barriers to EMPA programs, especially at a time when government and institutional funding for graduate medical education and postgraduate training is limited, and entering a training program means deferred income for a PA. Future research should explore the cost-effectiveness of EMPA postgraduate training programs in recruiting, training, and retaining EMPAs. Additionally, future investigation into outcomes associated with EMPA postgraduate training is merited.Our methodology relied primarily on publicly available data and on responses by individual programs to requests for information. It is possible that the data about existing programs are incomplete or missing. Not all postgraduate EMPA programs have websites or other easily accessible information. Because there is no single accreditation body or database for EMPA programs, there might be programs for which data were not included in our study. Our results might underestimate the number of training programs and under-report some of the characteristics of the programs identified. However, the data that are readily available and included in our study suggest similarities among EMPA postgraduate programs from which broad inferences might be drawn about the overall state of EMPA training.Our results provide a foundation for further investigation of curricular best practices and standardized curricula for EMPA postgraduate training. EMPA postgraduate training programs have common characteristics and curriculum components despite a lack of a specialty-specific accrediting organization or certifying examination. The overall growth and current number of these programs merits further research focusing on whether standardized curricula, formal recognition, and accreditation should be developed specifically for EMPA training programs. Additionally, best practices for program components and educational methods should be evaluated and disseminated among existing programs. EMPA postgraduate training programs can provide an important foundation for expanding the PA workforce in emergency medicine.


Big data trends in biomedical and health research enable large-scale and multi-dimensional aggregation and analysis of heterogeneous data sources, which could ultimately result in preventive, diagnostic and therapeutic benefit. The methodological novelty and computational complexity of big data health research raises novel challenges for ethics review. In this study, we conducted a scoping review of the literature using five databases to identify and map the major challenges of health-related big data for Ethics Review Committees (ERCs) or analogous institutional review boards. A total of 1093 publications were initially identified, 263 of which were included in the final synthesis after abstract and full-text screening performed independently by two researchers. Both a descriptive numerical summary and a thematic analysis were performed on the full-texts of all articles included in the synthesis. Our findings suggest that while big data trends in biomedicine hold the potential for advancing clinical research, improving prevention and optimizing healthcare delivery, yet several epistemic, scientific and normative challenges need careful consideration. These challenges have relevance for both the composition of ERCs and the evaluation criteria that should be employed by ERC members when assessing the methodological and ethical viability of health-related big data studies. Based on this analysis, we provide some preliminary recommendations on how ERCs could adaptively respond to those challenges. This exploration is designed to synthesize useful information for researchers, ERCs and relevant institutional bodies involved in the conduction and/or assessment of health-related big data research. The generation of digital data has drastically increased in the last years due to the ubiquitous deployment of digital technology as well as advanced computational analytics techniques , 2. The Big data trends characterize various sectors including basic science , 4, busiThe availability of health-related big data holds the promise of exerting a positive impact on biomedical research. For example, tailoring diagnostics to automated analyses of high resolution images has become a standard procedure in cancer research . In paraWhile opening the prospect of clinical benefit, the use of health-related big data raises important challenges. In light of their methodological novelty, potentially far-reaching impacts, and computational complexity, big data approaches to human health have been claimed to raise ethical, legal and social implications . EthicalThe ethical, legal and social implications of health-related big data raise novel challenges also for Ethics Review Committees (ERCs). ERCs and institutional review boards are increasingly requested to evaluate an ever-growing number of research projects and associated activities involving big data , whose risks and benefits often appear hard to assess. Some authors have called for the development of comprehensive regulatory policies for healthcare entities and new computing safeguards that can address public concerns, such as the protection of individually identifiable information . Howevernecessary to address the concerns associated with the use of anonymized data for research [The nature of big data studies also challenges the current mandate and purview of ERCs. For example, studies involving publicly available and anonymized data have traditionally been perceived to be outside of the purview of ERCs. This would include data from Twitter (which are public by default), Facebook or other online platforms. Furthermore, ethical safeguards for human subjects research “are often written with definitions that exclude Internet research”. This isresearch . In contresearch , expertsresearch .In the present study, we aim to identify the promises and challenges of health-related big data research that have relevance for ERCs. Furthermore, we use these findings to suggest how ERCs could adaptively respond to this methodological transformation. This exploration is designed to synthesize useful information for researchers, ERCs and relevant institutional bodies involved in the conduction and/or assessment of health-related big data research.thof September 2018 we conducted a scoping review of the scientific literature and searched five databases  to retrieve eligible publications. We searched title, abstract, and keywords for the terms:  AND  AND (“policy” OR “ethics” OR “governance” OR "ethics committee" OR “IRB” OR "review board" OR “assessment”). Query logic was modified to adapt to the language used by each engine or database. Screening identified 1093 entries. All entries were imported into the Endnote literature manager software. Three phases of filtering were performed independently by two researchers to minimize subjective bias.On the 18http://prisma-statement.org/) as a guide  focused on the assessment of big data trends in the biomedical/healthcare context. Reviews, letters to the editors, business reports and dissertations were not included. A total of 263 studies were included in the final synthesis and imported manually into Microsoft Excel 15.40 format based on a shared data-charting form. Following the recommendations to enhance scoping study methodology delineated by Levac et al. [Second, eligibility assessment was performed independently by two of the co-authors on the remaining 867 articles through title-abstract screening and, subsequently, full text screening. Diverging inclusion choices between the two reviewers were discussed with the research group with documented reasons. Studies included in the synthesis had the following features: (i) original articles, book chapters or conference proceedings; (ii) written in English, Italian, French or German (languages spoken by the researchers); (iii) published before September 18c et al. , the datThird, based on the same recommendations, we performed both a descriptive numerical summary and a thematic analysis. In the former analysis, both relative and cumulative frequencies were extracted and graphically represented using bar charts. Following Arksey and O'Malley , our desOur results reveal a large, diverse and rapidly growing body of literature on the impact of big data in the biomedical domain. Data show that the overall number of articles published in the time period 2012–2017 is 131 times higher compared to the period 2001–2005 as represented in Data breakdown by medical speciality and field of medical application indicates that big data approaches have been discussed and evaluated in relation to several branches of medicine including neurology and psychiatry (n = 31), oncology (n = 17), cardiology (n = 8), medical genetics (n = 8), immunology and infectious diseases (n = 8), as well as nuclear medicine and radiology (n = 6). Crossfield evaluations of health-related big data appeared highly prevalent (n = 155).Thematic analysis identified a number of potential opportunities and challenges associated with health-related big data approaches, many of which have relevance for ethics review. Opportunities could be grouped into four main themes: biomedical research, prevention, healthcare delivery and healthcare management. Potential benefits in the research domain include the possibility of collecting real-world data, accelerating the development of new medical technology and facilitating translational research. Big data was also associated with the improvement of preventive measures at both the individual and population level. In relation to care delivery, the following benefits were envisioned: precision and personalized medicine, earlier and more accurate diagnostics, enhanced clinical decision-making, ubiquitous health monitoring, improved patient safety and better therapy. Subsequent numeric analysis of thematic clusters is presented in Envisioned challenges appeared of seven major types: technical (n = 125), ethical (n = 81), methodological (n = 66), regulatory (n = 39), social (n = 16), infrastructural (n = 11) and financial (n = 10). Technical challenges relate to issues inherent in the data ecosystem. These include data security, data quality, data storage, data linkage, and tools for data reuse. Methodological challenges relate to the system of methods used in the study and include issues of standardizing data and metadata, integrating and processing data, monitoring resource utilisation and compensating for incomplete data. Regulatory challenges relate to rules or directives such as those regulating data ownership and the accountability of actors in relation to the potential risks associated with using and managing data. Social challenges are those that have relevance for human society and its members. These include, among others, secondary uses of data in relation to participants consent, sociocultural and ethnic bias and subsequent risk of discrimination, power asymmetries between data subjects and data controllers. Finally, financial and infrastructural issues included the financial viability of data storage sites and to the level of preparedness of existing infrastructures respectively.Ethical challenges are those related to moral principles. Our analysis revealed privacy and confidentiality to be by far the dominant concern (n = 146) in the ethical domain, followed by informed consent (n = 49), fairness and justice (n = 34), trust (n = 23), data ownership (n = 18) and others. While the analysis revealed a number of implications with relevance for ethics review, only 13% of reviewed studies provided specific normative recommendations for ERCs or other institutional review boards. Data breakdown by study methodology revealed that only a small portion of those recommendations  was informed by empirical methods.A subsequent analysis of thematic co-occurrences shows a strong mutual relationship between different thematic families, especially between technical and ethical issues, as shown in This study presents four main limitations. First, a selection bias might be present since the search retrieved only articles written in languages known by the researchers , excluding articles written in other languages. A similar limitation affects database selection as searching other databases may have possibly identified additional relevant studies. While this risk of selection bias applies to any review since the number of databases that can be feasibly searched is always finite, we attempted to minimize selection bias by exploring both domain-general and domain-specific databases, including the major databases in biomedical research and computer science, which represent the primary interdisciplinary intersection when it comes to biomedical big data. Second, as it was often observed in relation to scoping reviews, the explorative nature and broad focus of our search methodology makes it ‘unrealistic to retrieve and screen all the relevant literature’ . HoweverThe drastic increase over the past 5 years in the number of studies discussing the implications of health-related big data confirms the research community’s increasing attention to the applicability of big data approaches into the healthcare domain. As the application of big data in healthcare  and the The large prevalence of cross-field evaluations of health-related big data is an indicator of the potential of big data approaches to aggregate data from multiple medical data sources (e.g. combining data about gene expression and brain function in neurogenic studies) and multiple levels of clinical intervention (e.g. linking prevention and diagnostics to therapy and care delivery). In addition, analyses show that clinical outcomes can be produced from novel and non-strictly medical data sources. These include using Twitter to track and even forecast disease activity , exploitThe high frequency of technical challenges addressed when assessing health-related big data highlights the persistence of a number of technical weaknesses and limitations, most of which are likely dependent on the historical novelty of such sociotechnical trend. These include problems of data quality, integrity, and security. Developing robust technical solutions that can guarantee the quality, integrity and security of the data, and allow their secure transmission, linkage and storage, was often presented as a priority for any successful deployment of big data for human health. This might require the development of better security-protecting infrastructures, data wrangling and scripting (e.g. batch processing) tools for data cleansing in order to guarantee the quality of data -for example, through automatic detection and removal of corrupt or inaccurate records- as well as techniques that can preserve the integrity of data through the entire data cycle, prevent corruption and enable interoperability. Furthermore, distributed ledger technology, distributed storage and incremental analytics are also believed to hold promises in the health domain , 60. FroThe relative frequency of methodological issues, however, highlights that fixing technical problems alone might not be sufficient to use big data for good. ERCs are usually required to evaluate the methodological soundness of a study if this has ethical consequences. For example, if a RCT is designed without giving participants an equal chance of being assigned to any group, ERCs are entitled to assess the methodological soundness of the study to preserve the principle of fairness. For the same reason, in the context of big data research, ERCs might be entitled to assess the soundness of studies whose methods may result in algorithmic discrimination or breaches of personal privacy. For example, they may examine whether the researchers have implemented all necessary safeguards to prevent algorithmic bias and comply with data security standards.Examining the methodological soundness of health-related big data studies will likely require the adoption of different assessment criteria compared to traditional biomedical research. For example, it may require a rethinking of what counts as “public” data and what counts as “harm” in data-driven research. In addition, big data research is usually not based on the formulation and testing of specific research hypotheses, but on the identification of patterns from large volumes of data. This hypothesis-free nature of (some) big data research makes it harder to apply conventional epistemological mechanisms for scientific demarcation and quality control like falsifiability and refutability . This poEthical challenges also constitute an important area of consideration for ERCs. Data breakdown by class of ethical consideration reveals that the current ethical debate is being largely monopolized by issues of privacy and data protection . It was These technical, methodological and ethical challenges should not be seen as sealed rooms. Thematic analysis reveals an intimate interconnection between the three thematic families. For example, the technical problem of data security appears strictly connected to the ethical notion of privacy and the regulatory principle of data protection. Similarly, methodological errors like dataset bias might have detrimental ethical consequences such as racial and gender discrimination. This intimate link between technical and ethical issues highlights the importance of cooperative approaches to study design in big data research through strategies like ethical design of data-collecting technologies, proactive ethical assessment of big data studies and ethical requirement analyses for data-sharing platforms, data storage sites and other digital infrastructures. ERCs should be sensitized to this interconnection and examine how weaknesses in one domain affect other domains of evaluation. Similarly, the interdependence of epistemological and ethical issues, which was already highlighted by Mittelstad and Floridi , requireOverall, these findings have three main and direct implications for ERCs. First, the significance and complexity of technical and methodological challenges suggests that members of ERCs should need to acquire stronger technical and methodological expertise to adequately review and evaluate health-related big data studies. This might require specific educational courses or other training activities aimed at strengthening ERC-members’ ability to identify technical/methodological problems or inaccuracies, especially those that can result in harms to data subjects or society like data security breaches, database corruption and biased algorithm training. Specialized training modules in data science, bioinformatics and cybersecurity might serve this purpose. In parallel, as emerging from the normative suggestions, ERCs need to consider including experts from the afore listed disciplines within the review board. Since health-related big data is here to stay, new expert profiles are needed during the review process. Data scientists, security experts, bioinformaticians should complement the expertise of clinicians, ethicists and other traditional ERC members. ERC members will need to be equipped with the necessary tools to inspect how the data will be collected, in conformity with which security standards they will be stored and shared, what classification systems will be employed, how uncertainty will be quantified, what cluster models will be adopted during exploratory data mining etc.In spite of these important challenges, ERCs might still be faced with uncertainty when reviewing health-related big data studies. Review results indicate that only a tiny fraction of studies (13%) provided specific normative recommendations for ERCs. These are suggestions or proposals for ERCs as to the best course of action. Further thematic analysis reveals a general disagreement and a lack of consensus on what codes of conduct should be prioritized, with some authors  favourinIn the debate on what ERCs should do in relation to health-related big data, the opinion of ERC members is missing. Future empirical research is highly required to explore the needs, views and attitudes of ERC members about health-related big data. Empirical research in this domain could methodologically build upon previous studies involving ethics advisors working in big-data-related areas of research such as genomics governance . CombiniFinally, it is legitimate to raise the question of whether ERCs should be the only governance body responsible for the evaluation of biomedical big data research. Given their traditional mandate, which is deeply rooted in the pre-digital era of biomedical research, it might be reasonably argued that ERCs are ill-suited to exercise exclusive ethical oversight on health-related big data research. Research regulators should consider whether complementary governance mechanisms such as data boards, data security committees or allied bodies are necessary to expand the bandwidth and sensitivity of ethical oversight.S1 File(DOCX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.S3 File(ENLX)Click here for additional data file.


In the wake of the West African Ebola virus disease (EVD) outbreak of 2014–2016, thousands of EVD survivors began to manifest a constellation of systemic and ophthalmic sequelae. Besides systemic arthralgias, myalgias, and abdominal pain, patients were developing uveitis, a spectrum of inflammatory eye disease leading to eye pain, redness, and vision loss. To investigate this emerging eye disease, resources and equipment were needed to promptly evaluate this sight-threatening condition, particularly given our identification of Ebola virus in the ocular fluid of an EVD survivor during disease convalescence.A collaborative effort involving ophthalmologists, infectious disease specialists, eye care nurses, and physician leadership at Eternal Love Winning Africa (ELWA) Hospital in Liberia led to the development of a unique screening eye clinic for EVD survivors to screen, treat, and refer patients for more definitive care. Medications, resources, and equipment were procured from a variety of sources including discount websites, donations, purchasing with humanitarian discounts, and limited retail to develop a screening eye clinic and rapidly perform detailed ophthalmologic exams. Findings were documented in 96 EVD survivors to inform public health officials and eye care providers of the emerging disease process. Personal protective equipment was tailored to the environment and implications of EBOV persistence within intraocular fluid.A screening eye clinic was feasible and effective for the rapid screening, care, and referral of EVD survivors with uveitis and retinal disease. Patients were screened promptly for an initial assessment of the disease process, which has informed other efforts within West Africa related to immediate patient care needs and our collective understanding of EVD sequelae. Further attention is needed to understand the pathogensis and treatment of ophthalmic sequelae given recent EVD outbreaks in West Africa and ongoing outbreak within Democratic Republic of Congo. The West African Ebola virus disease (EVD) outbreak from 2014–2016 resulted in thousands of EVD survivors at-risk for uveitis, an inflammatory eye condition with the potential for vision impairment or blindness if not promptly diagnosed and treated. Given the equipment and resource limitations within West Africa, particularly for subspecialty eye care, a screening eye clinic was developed at ELWA Hospital in Liberia to promptly screen, treat, and refer patients with eye disease. The implementation of a screening eye clinic in collaboration with leadership at ELWA Hospital was of immediate relevance given our limited understanding of this eye disease prior to the recent EVD outbreak. Resourceful procurement of medications and equipment, as well as the development of modular systems within an eye clinic setting, facilitated patient examination, teaching, and documentation of this spectrum of ophthalmic illness. Development of a screening eye clinic and its rapid implementation were needed to improve our collective undersanding of the spectrum of uveitis as a disease sequelae of EVD, relevant for recent and future outbreaks. The West African Ebola virus disease (EVD) outbreak from 2014–2016 was of historic magnitude with over 28,600 cases and 11,300 deaths predominantly within the highest transmission countries of Liberia, Sierra Leone and Guinea., the cliSpecifically, after our team cared for a repatriated United States health care worker (HCW) with aggressive, sight-threatening panuveitis associated with heterochromia, scleritis, and refractory hypotony following recovery from life-threatening, critical illness due to EVD, there were concerns for ophthalmic sequelae with potentially vision-threatening consequences throughout West Africa.,6 Anothe8 are described for the screening of survivors in the EVD outbreak setting. Given the recent and ongoing outbreaks in the Democratic Republic of Congo (DRC), there likely will be an ongoing need to understand the resources, equipment, expertise and systems needed for EVD survivor care beyond the critical importance of acute EVD care in resource limited settings.In this report, we describe the detailed personnel requirements, ophthalmic equipment and supply procurement strategy, screening eye clinic design and flow that could be utilized in the screening setting, and a modular design of the clinic for clinical evaluation and teaching of basic components of the eye exam to in-country staff. In addition, infection control precautions and personal protective equipment guided by our initial assessment of EBOV by RT-PCR in both intra- and extraocular fluidEternal Love Winning Africa Hospital is a health facility founded by Serving in Mission (SIM) in 1965 located in Paynesville City, Monrovia, Liberia. Faith-based organizations (Samaritan’s Purse and SIM) developed and operated the ELWA (ELWA-1 and 2) Ebola Treatment Units (ETUs) from June to August 2014 with the support of Medecins sans Frontieres-Belgium (MSF-B).[In-country Liberian personnel requirements required at ELWA Hospital during development of the eye clinic included registration , interpreters/ medical assistants (4), and primary care physicians (2) involved in direct EVD patient care in an Ebola Treatment Unit (ETU) setting. Emory University and United States HCWs included three ophthalmologists and one infectious disease provider familiar with EVD survivor sequelae and EVD patient care in an ETU setting. In addition, engagement with the Ministry of Health and Sanitation Liberia was important for ongoing discussion of the patient findings, determination of resources needed for clinical ophthalmic care, and temporary Liberian medical licensure for physicians involved in EVD survivor ophthalmic care.EVD survivors who were receiving ongoing care at ELWA Hospital Survivor Clinic were offered an ophthalmic evaluation during the screening program period at the time of their general medical care evaluation. In addition, EVD survivor associations were engaged by ELWA clinicians regarding the screening effort prior to the eye care program so that they could receive an evaluation, care, or referral as needed. The presence of an eye clinic for screening, treatment, and referral was also directly communicated with existing EVD survivor clinics in Monrovia (e.g. Médecins Sans Frontières) for patient evaluation.A supply list for the ophthalmic clinic was generated to include all clinical equipment required for the eye exam , slit lamp examination, and dilated fundus exam . StandarA conference room with a large table and two separate patient examination rooms were utilized and partitioned into task-specific stations including 1) history-taking 2) pupillary evaluation, ocular motility, visual field testing, intraocular pressure, and dilation 3) slit lamp examination, indirect ophthalmoscopy, photography, and counseling including description of medication regimens, referral to other providers, and follow-up visit .Patients checked in at a registration desk with HCWs wearing PPE that included a face shield, fluid impervious gown and gloves. EVD survivor certificates were verified at the registration desk. Forehead temperature with an infrared thermometer was measured. Patients with temperatures less than 38 degrees Celsius (100.4 degrees Farenheit) were evaluated. Ophthalmic examination was deferred in patients with a fever or any systemic signs of EVD  until complete medical evaluation could be performed. HCWs in the screening eye care facility wore fluid-impervious gowns and gloves. Strict handwashing precautions were performed with 0.05% chlorine and all equipment  was disinfected with alcohol between patients. At the time the clinic was conducted, limited information was available on the kinetics of EBOV in the tear film, specifically whether the tear film was fully clear of EBOV. EBOV persistence in tear film has been documented at 33 days post acute infection.[During the West African EVD outbreak, there was heightened travel regulatory approval to ensure safety of the HCWs and the public in the rare event of EBOV infection. Emory University physicians underwent several tiers of university regulatory approval including Department Chair, Dean, Chief Executive Officer of The Emory Clinic, and the Emory University Executive Travel Safety Committee . After rWith thorough supply lists designed for ophthalmic examination in a resource-limited setting, multiple sources were utilized for procurement and judicious resource use, as summarized in The estimated value of medications, equipment, and supplies for the screening eye clinic was $94,800 and all materials were procured for $11,895, a discount of approximately 87% of the total value of goods utilizing multiple methods of procurement, donations through the generosity of various entities , as well as humanitarian discount pricing when possible.Components of the clinic design included modular stations for 1) history, review of systems, and general physical examination 2) visual acuity measurement 3) pupil, motility, visual fields, intraocular pressure measurement and dilation 4) slit lamp and indirect ophthalmoscopy, photography, and counseling. These clinical stations provided opportunities for both clinical care and instruction of the basic eye exam for in-country HCWs and were recorded on standardized case report forms for documentation and follow-up (Appendix). In particular, patients were evaluated for findings suggestive of uveitis. Specific complications of uveitis assessed included posterior synechiae, band keratopathy, and cataract. The use of indirect ophthalmoscopy and hands-on experience with in-country eye care provider allowed the evaluation of patients for retinal and optic nerve disease. Following the clinic setup and operations in April 2015, the ophthalmic clinic, equipment and medications remained available for ELWA hospital physicians and staff for patient follow-up examination and treatment. In addition, EVD survivors who were not specifically assessed during clinic operations could be evaluated thereafter.Based on this setup, 96 EVD survivors were successfully examined, treated or referred when appropriate. To ensurBased on these initial experiences in Liberia and developing a screening eye clinic in partnership with ELWA Hospital, the portability, structure, and equipment of the ophthalmologic exam and consultation setup was discussed with the World Health Organization, Ministry of Health and Sanitation Sierra Leone National Eye Program and partnering non-governmental organizations including Partners in Health, and Médecins sans Frontières. Over 2,700 EVD survivors in Sierra Leone have been screened through the National Eye Program with clinical form development, treatment protocols and guidance on uveitis prevalence and disease burden.As a consequence of the West African EVD outbreak from 2014–2016, thousands of EVD survivors remain at-risk for systemic and ocular sequelae mandating equipment and resources for ongoing health care needs.–15 GivenThe urgent development of a screening eye clinic during the EVD outbreak setting was mandated because of initial experiences with United States HCWs who developed sight-threatening disease and extrMeetings with local eye care providers in West Africa have been subsequently continued to discuss the vision-threatening complications that are currently being studied by investigators in Sierra Leone, Liberia, and Guinea. Within Sierra Leone, the Ebola Virus Persistence in Ocular Tissues and Fluids (EVICT) Study is ongoing to evaluate the prevalence of Ebola virus in ocular fluids of EVD survivors anticipating cataract surgery. Recent results have describing the safety and feasibility of vision-restorative cataract surgery in EVD survivors with a sequential assessment of aqueous humor fluid for EBOV by RT-PCR and subsequent cataract surgery. The National Institutes of Health PREVAIL Study and Eye Sub-study is a prospective, controlled, natural history evaluation of EVD survivors and asymptomatic close contacts with patients receiving ongoing care with local Ministry of Health eye care providers and surgeons. The PostBesides the development of a screening clinic to carry out detailed screening with standardized reporting of uveitis complications in the cohort of EVD survivors, our setup also included consideration of the environment and safety concepts including PPE tailored to the potential risk of EBOV exposure health care providers involved in the clinic. Our knowledge at the time of the screening clinic design included the following: 1) Ebola virus may be harbored in ocular fluid at least 100 days post acute EVD diagnosis ; 2) our The development of screening clinics in resource-limited settings has been reported in India, sub-Saharan Africa and rural parts of Asia., 23 Pred10 through the implementation of this screening clinic, has been consistent with other studies estimating a prevalence of uveitis between 18% and 34% of EVD survivors.[The goals of the screening clinic that were accomplished included identification of EVD survivors requiring immediate eye care, referral to eye care providers, and informing implementing partners and public health organizations regarding technical needs of equipment for ophthalmic care needs. Patients with eye disease were referred to MOHS providers for ongoing care and lessons learned were utilized to inform EVD screening in Sierra Leone given the urgency of uveitis care with the potential for severe vision loss if left untreated. Moreover, our findings in addition to recent findings by other organizations, have been informative for educational symposia conducted in Sierra Leone related to eye disease in Ebola survivors and the design of management protocols for distribution to health care workers in West Africa. In addition, our report of the ophthalmic complications with a 22% rate of uveitis and impact on visionurvivors.,13,15,21Importantly, no symptoms of EVD developed in the HCWs who participated in ophthalmic assessments of EVD survivors and underwent 21-day symptom and temperature monitoring following re-entry in the United States. While the exposure of HCWs to EVD survivors with uveitis was short-term in this evaluation of EVD survivors in Monrovia, Liberia, there remain no known risks of EBOV transmission through casual contact including the ophthalmic examination of EVD survivors, underscoring the importance of safety of ophthalmic examination with appropriate PPE. However, the potential risk of EBOV persistence in ocular fluids immediately following acute EVD and during early disease convalescence less than 3 month remains unknown. Despite these uncertainties, efforts are ongoing to better understand and reduce stigma associated with EVD, which is an ongoing concern amongst EVD survivors. Further In summary, through a collaboration with United States-based ophthalmologists and leadership of ELWA Hospital, in conjunction with eye care specialists from the Ministry of Health, Liberia we were able to develop and rapidly implement a screening eye clinic for EVD survivors. The procurement of equipment through a variety of sources, modular clinic design, and attention to PPE appropriate for the ophthalmic examination setting were necessary to provide efficient care, referral, and safety for patients and health care providers. Lessons learned from this clinic were communicated to other countries with thousands of EVD survivors and underscore the importance of ongoing understanding of eye disease in EVD survivors, particularly given the ongoing outbreak in eastern DRC.


Approximately four in ten family caregivers experience high intensity care, based on the number of caregiving hours, activities of daily living (ADLs) and instrumental ADLs supported for the care recipient. Using the 2015 Caregiving in the U.S. Survey, we examined outcomes associated with high (compared to low or medium) intensity of care. High intensity was positively associated with emotional stress ; financial strain ; physical strain ; and declines in caregiver health . High intensity was also associated with greater difficulty coordinating recipient care , higher odds of performing complex medical/nursing tasks  and, among task performers, greater difficulty performing tasks . High intensity of care impacts caregiver health and the caregiving role in multiple domains; new clinical and policy approaches are needed to mitigate risks and ensure adequate support.


The Adirondack Park in New York State contains a unique and limited distribution of boreal ecosystem types, providing habitat for a number of birds at the southern edge of their range. Species are projected to shift poleward in a warming climate, and the limited boreal forest of the Adirondacks is expected to undergo significant change in response to rising temperatures and changing precipitation patterns. Here we expand upon a previous analysis to examine changes in occupancy patterns for eight species of boreal birds over a decade (2007–2016), and we assess the relative contribution of climate and non-climate drivers in determining colonization and extinction rates. Our analysis identifies patterns of declining occupancy for six of eight species, including some declines which appear to have become more pronounced since a prior analysis. Although non-climate drivers such as wetland area, connectivity, and human footprint continue to influence colonization and extinction rates, we find that for most species, occupancy patterns are best described by climate drivers. We modeled both average and annual temperature and precipitation characteristics and find stronger support for species’ responses to average climate conditions, rather than interannual climate variability. In general, boreal birds appear most likely to colonize sites that have lower levels of precipitation and a high degree of connectivity, and they tend to persist in sites that are warmer in the breeding season and have low and less variable precipitation in the winter. It is likely that these responses reflect interactions between broader habitat conditions and temperature and precipitation variables. Indirect climate influences as mediated through altered species interactions may also be important in this context. Given climate change predictions for both temperature and precipitation, it is likely that habitat structural changes over the long term may alter these relationships in the future. The Adirondack Park in New York State is in the southern edge of the range for several species of boreal forest birds within eastern North America. The network of public and private lands that constitutes The Adirondack Park represents critical boreal habitat for both resident and migratory birds, including large patches of lowland boreal habitats which are otherwise rare in the northeastern United States. The habitats of these boreal specialists—cool, wet, sphagnum-draped bogs and forested northern swamps—are thought to be particularly vulnerable to climate change ,2. EffecNon-climate stressors, including changing land use patterns, altered wetland size and connectivity, and exurban residential development, are also significant drivers of change in this region. Distinguishing climate-driven changes from other drivers is particularly challenging in this context, but is a critical component of identifying the underlying reasons for declines in a number of boreal species. Species interactions are believed to be more influential at southern ends of species ranges, whereas climate is expected to play a greater role at northern edges ,10. As sThis analysis uses a decade of occupancy data (2007–2017) to identify the primary drivers of dynamic occupancy rates (colonization and extinction) for eight species associated with lowland boreal habitats in the Adirondack Park. We explore the relative contributions of climate and landscape characteristics on boreal bird occupancy patterns. A previous analysis revealed declining occupancy patterns for 4 of these species, and only one of them demonstrating a pattern of increase . We prevThe present analysis builds upon the previous 5-year analysis  by usingPicoides dorsalis), boreal chickadee , Canada jay , Lincoln’s sparrow , palm warbler , olive-sided flycatcher , rusty blackbird , and yellow-bellied flycatcher . These species were selected because they best represent the lowland boreal habitats of the Adirondacks and are also well-sampled with point-count methods.Our non-invasive sample method required no specific research permits. Nearly all sites were located on public land; permission for access was obtained on the small number of private land sites. Our study site, target species, site selection, and monitoring methods are fully described in . Our ana2 located in the northern part of New York State in the US . The boreal habitats that are the subject of this study consist of bogs, fens, wooded wetlands, and open river corridors in the Adirondack Park. Boreal habitats are distributed in small patches throughout the Adirondacks but are most concentrated in a band running from the north-central part of the park to the southwestern edge (Picea mariana) and tamarack (Larix laricina), ericaceous shrubs such as leatherleaf  and Labrador tea (Ledum groenlandicum), herbaceous plants such as pitcher plant (Sarracenia purpurea) and sedges  and Sphagnum mosses.Our study was conducted in the Adirondack Park, an area of 19,700 kmern edge . These hWe conducted unlimited distance point counts to assess presence/absence of our 8 target species along transects of 5 points spaced at least 250m apart within boreal wetland habitats . We emplI value for boreal wetland polygons with a fixed distance band of 5 km; these values were then used as an index of habitat connectivity for boreal wetland habitats. Area and connectivity of study wetlands were calculated previously as described in [GIS datasets used previously for investigating non-climate drivers of boreal bird dynamics were employed in the current study to examine the influence of wetland size (area), connectivity, human footprint, latitude, and elevation on colonization and extinction rates. These datasets have been previously described  and are ribed in . Similarribed in  scores aribed in . Althougribed in  was creaTemperature and precipitation data were obtained from the Parameter-elevation Relationships on Independent Slopes model  at 800mAs per the prior 5-year analysis, to investigate dynamics of boreal birds in the Adirondacks, we used the multi-season model implemented in program Presence  to calcuWe repeated a model set tested previously  to examiWe used a second model set to explore the influence of temperature and precipitation on dynamic rates. We used PRISM data (800m) to explore the influence of means, variability, and extremes of breeding and wintering season temperature and precipitation on colonization and extinction rates for 8 boreal bird species. Specific variables included: mean winter  and breeding season  temperature, variability in winter (Var Winter Temp) and breeding season (Var Breeding Temp) temperature, mean winter (Winter Ppt) and breeding season (Breeding Ppt) precipitation, variability in winter (Var Winter Ppt) and breeding season (Var Breeding Ppt) precipitation, mean temperature of the hottest (Temp Hottest Month) and coldest (Temp Coldest Month) months, and mean precipitation during the wettest (Ppt Wettest Month) and driest (Ppt Driest Month) months. As per the initial analysis, we held one of the dynamic rates constant and varied the other within the model set. We found that means and extremes were correlated in terms of temperature during the time period of our study, but not in terms of precipitation. Given that each of our models contained only one predictor variable, we chose to maintain both aspects of temperature information in the model set. In contrast to the landscape context variables, climate drivers are expected to display comparatively high interannual variability. We therefore modeled each of 12 climate variables in two ways; one in which these variables changed annually and were related to dynamic rates for each individual year, and one in which conditions were averaged across the 10-year study period and dynamic rates were related to long-term average conditions. This combination of 12 climate variables modeled on each of 2 dynamic rates and as both seasonal and average effects resulted in a total of 48 total models conducted for each species . Though We ran a full set of models for each species combining model sets from Parts 1 and 2 of our analysis to examine non-climate drivers  in combination with temperature and precipitation characteristics in order to assess the relative contribution of both to long-term boreal bird dynamics in the Adirondack Park. Because results from Part 2 of this analysis (Results) indicated that dynamic rates were influenced by average rather than yearly temperature and precipitation characteristics, in this final model set we included the effect of average rather than annual temperature and precipitation conditions on colonization and extinction across the 10-year study period.Both the prior 5-year  and the In general, results of the 10-year analysis agreed with and confirmed prior findings from the analysis of the 5-year dataset. Wetland area, connectivity, and human footprint remained the most consistent drivers across species in terms of the direction of influence, with the majority of species more likely to persist in large, well connected sites with low human footprint . In contWe calculated occupancy trends over the 10-year study period in order to determine whether trends identified in the prior 5-year analysis had continued. We had previously identified patterns of declining occupancy for black-backed woodpecker, boreal chickadee, and olive-sided flycatcher, as well as a decline, though small, for Canada jay. Lincoln’s sparrow and rusty blackbird showed little change in occupancy rates over the prior 5-year analysis period, while palm warbler was the sole species with a demonstrable increase in occupancy . We did We found no support for models with year-to-year variation, suggesting that annual extinction and colonization rates may not track interannual variability in temperature and precipitation. Our subsequent results and discussion therefore refer only to the responses of species to average climate conditions over the course of the study, and thus relate to spatial patterns of temperature and precipitation and their influence on occupancy patterns. Factor weights  revealed a number of patterns in the responses of birds to temperature and precipitation . ColonizResponses to temperature and precipitation among individual species were highly variable. Five species were best described by 1 or 2 models , but for 3 species  a total of 4 to 7 models could be considered equally good representatives of dynamic rates (ΔAIC < 2.0). Among top models , precipiAmong variables occurring in top models, direction of influence on individual species’ colonization rates was highly variable . BreedinResponses to temperature and precipitation were more consistent across species with respect to influence on extinction rates . Mean brThe last part of our analysis combined models from Parts 1 and 2 to determine the degree to which climate influences extinction and colonization patterns relative to previously identified drivers. We found that for 6 of 8 target species, top models were climate driven . Top modResponses were variable across species, but with respect to colonization, breeding season precipitation had higher cumulative model weight across all species than did non climate factors and its influence was generally negative. Second most important to colonization rates was winter season precipitation, which was also generally a negative influence, followed by wetland connectivity. Similarly, with respect to extinction drivers, breeding season temperature and winter precipitation were more influential in controlling extinction rates than previously considered non-climate variables. Higher breeding season temperatures tended to decrease extinction probability while higher winter precipitation enhanced it. Consideration of all factors together demonstrates that boreal birds appear most likely to colonize sites that have generally lower levels of precipitation, and a high degree of connectivity, while they tend to persist in sites that are warmer in the breeding season and have low and less variable precipitation in the winter .The Adirondack Park lies at the transition between the temperate and boreal biomes and provides habitat for a number of specialized and rare northern birds. As species at the southern edge of their range, they are expected to be vulnerable to climate change and potential indicators of the influence of climate change on wildlife in a high latitude system ,26,27. OWe previously highlighted the importance of several non-climate factors in driving occupancy patterns, including latitude and elevation. Responses to latitude and elevation may reflect possible northward or upslope movements influenced by climate change as temperatures warm. Our prior analysis identified mixed responses, with most species more likely to persist at low elevation and high latitude, which only partially supports the expectation of northward and upward movement in response to climate change. However, our study focused solely on low elevation boreal community types and, among them, increasing latitude is associated with lower elevation. The current analysis demonstrates the degree to which temperature and precipitation may offer a better means of exploring the influence of climate than latitude and elevation, as temperature and precipitation patterns appear to be more closely related to extinction and colonization dynamics for most species.Though responses were highly species specific, we found that, in general, extinction and colonization processes were both important in controlling long-term dynamic occupancy patterns for boreal birds and that extinction was related most closely to temperature patterns, whereas colonization appears to be more closely related to precipitation. Across all factors and all species, persistence appears most likely at sites characterized by warmer average temperatures and low precipitation , combined with large wetland size, high connectedness, and low human footprint. These characteristics are found most often among our study sites in the northwest “boreal core” of the Adirondacks . The larOngoing and projected climate change patterns in the northeastern US indicate a future that is decidedly warmer, especially in the winter months ,32. IncrPredictions about future precipitation in the northeast are less certain but generally indicate an increase in winter precipitation, with a greater proportion occurring as rain rather than snow, and increased variability in precipitation patterns overall ,32. We fThere is uncertainty as to the degree to which wildlife populations respond to average conditions with respect to climate, or whether variability and/or extremes of climate are more critical ,40. ThouThough observed patterns of decline among boreal birds at the range margin are consistent with expectations based on climate change , direct The future of large open peatlands in a warmer and wetter world is uncertain , and obsOur findings suggest that, currently, the large and well-connected peatland complexes in the northwest region of the Adirondacks may serve as source habitats for metapopulations of boreal birds. Metapopulations, however, rely on the exchange of individuals between the sources and the sinks . Most weS1 File(XLSX)Click here for additional data file.S2 File(PDF)Click here for additional data file.


Silicon nanoparticles (SiNPs) are the promising materials in the various applications due to their unique properties like large surface area, biocompatibility, stability, excellent optical and electrical properties. Surface, optical and electrical properties are highly dependent on particle size, doping of different materials and so on. Porous structures in silicon nanomaterials not only improve the specific surface area, adsorption, and photoluminescence efficiency but also provide numbers of voids as well as the high surface to volume ratio and enhance the adsorption ability. In this review, we focus on the significance of porous silicon/mesoporous silicon nanoparticles (pSiNPs/mSiNPs) in the applications of energy storage, sensors and bioscience. Silicon as anode material in the lithium-ion batteries (LIBs) faces a huge change in volume during charging/discharging which leads to cracking, electrical contact loss and unstable solid electrolyte interphase. To overcome challenges of Si anode in the LIBs, mSiNPs are the promising candidates with different structures and coating of different materials to enhance electrochemical properties. On the basis of optical properties with tunable wavelength, pSiNPs are catching good results in biosensors and gas sensors. The mSiNPs with different structures and modified surfaces are playing an important role in the detection of biomarkers, drug delivery and diagnosis of cancer and tumors. Silicon nanoparticles (SiNPs) have been remained a material of great interest with versatile and promising applications compared to the bulk material due to their physical and chemical properties , mesoporous (pore diameter 2–50 nm) and macro porous (pore diameter >50 nm). Because of alternation in the structure of silicon, a tremendous variation happen in optical properties of SiNPs which can attribute to the reduction in refractive index and enhancement in PL efficiency as compare to silicon at room temperature  and lithium diffusivity of Si also limits its electrochemical performance. It has been noted that micro and nanostructure of silicon have good electrochemical performance as compare to bulk silicon as anode material  . Exterior carbon coating prevented the direct contact electrolyte with silicon particles and interior voids provided extra space to silicon particles during volume expansion as in Figure −1 at current rate 2 A g−1 after 2,000 and 4,000 cycles in Figure Continuous charging/discharging solid electrolyte interphase film by direct interaction between electrolyte and silicon particles is developed on silicon particles in the anode. SEI film on silicon particles acts as a barrier to further diffusion of lithium-ion and directly affects cycle life of Si anode  via a two-step sol-gel process. Si@C@TiO2 composite as anode material handled conductivity, volume change during lithiation/delithiation and unstable SEI film. In Si@C@TiO2 composite carbon enhanced electrical conductivity by providing an electronic path to electron during the electrochemical process, TiO stabilized structure integrity of anode by providing mechanical properties and controlled the SEI film by stopping the direct contact of electrolyte to silicon as shown in Figure Furthermore, electrochemical properties of silicon anode material enhanced by the modified structure of SiNPs and by using double coating of different materials   , intercalated and electrical properties but after some cycles of charging/discharging volume of silicon changes. Continuous volume changes in silicon anode lead to fractures and affect the electrochemical properties. Solid electrolyte interphase developed on the particle by an electrolyte which leads to electrical contact loss. These challenges pulverization, electrical loss and stable SEI film by mesoporous silicon have been elaborated. It is observed that SiNPs play an important role to control volume changes in Si-anode as compare to silicon bulk. To control pulverization in Si anode further structure of silicon particles has been modified to mesoporous, 3D and hollow spheres. By structural modification of SiNPs, a significant enhancement of electrochemical properties have been noted. Furthermore, to control volume change and improve electrical contact loss and stabilization of SEI film, SiNPs were coated with different materials . Coating of different materials on SiNPs has significantly improved electrochemical properties and stabilize SEI films on particles. It is noted that the double coating of different material on particles enhanced electronic conductivity, capacity and control SEI film by stopping direct contact of electrolyte to particles. For future work, silicon anode material for commercial use still needs to be improved in volume change, stabilization of SEI film, high capacity, long cycle life, initial Coulombic efficiency and rate capability.In this review, we focus on the importance of pSiNPs with different structures in various fields. Silicon has much attractive material as an anode in LIBs due to their theoretical capacity  varies after adsorption of different molecules on the surface of porous silicon. This variation in properties are used to detect different materials. Further pSiNPs can be used to detect different compounds and biomarkers of different diseases which are still undetected.2 g−1), tunable optical properties and void spaces which act as good drug carriers. MSiNPs have been used as drug carriers, for therapy and detection of cancer cells due to their unique properties optical, non-toxicity, biocompatibility and surface properties. Detection and treatment of cancer tissues, tumors, and some biomarkers have been observed successfully by use of pSiNPs.Mesoporous structure of silicon provides a large surface area (200–800 mAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.