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Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.

Elevated depressive symptoms are a risk factor for diabetes. Although depressive symptoms can remit or emerge over time, little work has considered if courses of depressive symptoms are associated with incident diabetes. The purpose of this study was to explore associations between courses of depressive symptoms and incident diabetes. Data came from the English Longitudinal Study of Ageing ( n  = 4,978), which is an ongoing, cohort study of adults aged 50 years and older residing in private households in England. Depressive symptoms were measured biennially from 2002 to 2008. Participants were categorized into one of six groups: no depressive symptoms, remitted depressive symptoms, incident depressive symptoms with remission, incident depressive symptoms without remission, chronic depressive symptoms, and variable course. Diabetes status was self-reported biennially from 2010 to 2018. After adjusting for covariates, remitted depressive symptoms ( HR  = 1.52, 95% CI [1.06, 2.22]) and variable course depressive symptoms ( HR  = 1.83, 95% CI [1.19, 2.81]) remained associated with incident diabetes. In sensitivity analyses, which lowered the cut-off score for depressive symptoms, variable course depressive symptoms ( HR  = 1.61, 95% CI [1.11, 2.33]) remained associated with incident diabetes. Specific courses of depressive symptoms, including variable course depressive symptoms, were associated with diabetes incidence. Continuing to examine the link between patterns of depressive symptoms over time and incident diabetes may lead to the development of more targeted interventions.

Globally, a growing number of children and adolescents are left behind when parents migrate. We investigated the effect of parental migration on the health of left behind-children and adolescents in low-income and middle-income countries (LMICs). For this systematic review and meta-analysis we searched MEDLINE, Embase, CINAHL, the Cochrane Library, Web of Science, PsychINFO, Global Index Medicus, Scopus, and Popline from inception to April 27, 2017, without language restrictions, for observational studies investigating the effects of parental migration on nutrition, mental health, unintentional injuries, infectious disease, substance use, unprotected sex, early pregnancy, and abuse in left-behind children (aged 0–19 years) in LMICs. We excluded studies in which less than 50% of participants were aged 0–19 years, the mean or median age of participants was more than 19 years, fewer than 50% of parents had migrated for more than 6 months, or the mean or median duration of migration was less than 6 months. We screened studies using systematic review software and extracted summary estimates from published reports independently. The main outcomes were risk and prevalence of health outcomes, including nutrition (stunting, wasting, underweight, overweight and obesity, low birthweight, and anaemia), mental health (depressive disorder, anxiety disorder, conduct disorders, self-harm, and suicide), unintentional injuries, substance use, abuse, and infectious disease. We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs) using random-effects models. This study is registered with PROSPERO, number CRD42017064871. Our search identified 10 284 records, of which 111 studies were included for analysis, including a total of 264 967 children (n=106 167 left-behind children and adolescents; n=158 800 children and adolescents of non-migrant parents). 91 studies were done in China and focused on effects of internal labour migration. Compared with children of non-migrants, left-behind children had increased risk of depression and higher depression scores (RR 1·52 [95% CI 1·27–1·82]; SMD 0·16 [0·10–0·21]), anxiety (RR 1·85 [1·36–2·53]; SMD 0·18 [0·11–0·26]), suicidal ideation (RR 1·70 [1·28–2·26]), conduct disorder (SMD 0·16 [0·04–0·28]), substance use (RR 1·24 [1·00–1·52]), wasting (RR 1·13 [1·02–1·24]) and stunting (RR 1·12 [1·00–1·26]). No differences were identified between left-behind children and children of non-migrants for other nutrition outcomes, unintentional injury, abuse, or diarrhoea. No studies reported outcomes for other infectious diseases, self-harm, unprotected sex, or early pregnancy. Study quality varied across the included studies, with 43% of studies at high or unclear risk of bias across five or more domains. Parental migration is detrimental to the health of left-behind children and adolescents, with no evidence of any benefit. Policy makers and health-care professionals need to take action to improve the health of these young people. Wellcome Trust.

Depression and diabetes are independent risk factors for one another, and both are associated with increased risk of cognitive decline. Diabetes patients with lower cognitive function are more likely to suffer poorer health outcomes. However, the role of depression in cognitive decline among people with diabetes is not well understood. This systematic review assessed whether adults with comorbid diabetes and depression or depressive symptoms exhibit greater cognitive decline relative to individuals with diabetes alone. Searches were run in CINAHL, the Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, and PubMed (MEDLINE) with no time or language restrictions. Studies were eligible for inclusion if they were of any quantitative study design, included participants aged 18 years or older with diabetes mellitus of which some must have presented with current depression, and measured cognition as an outcome. The Cochrane Collaboration's Risk Of Bias In Non-randomized Studies-of Interventions tool was used for quality assessment of each study and its collected outcome. Fifteen articles were included in the final analysis. The high degree of heterogeneity in exposures, outcomes, and participant characteristics precluded a meta-analysis of any of the studies, and the risk of bias observed in these studies limits the strength of the evidence. Nonetheless, this review found the presence of comorbid depression was associated with poorer cognitive outcomes than for persons with diabetes alone. While large-scale preventive efforts must address epidemic levels of diabetes and its comorbidities, on the patient level healthcare professionals must be cognizant of the added difficulties that depression poses to patients and the extra support required to management diabetes in these cases. This systematic review is registered with the University of York Centre for Reviews and Dissemination under registration number 2015:CRD42015025122.

258 million people reside outside their country of birth; however, to date no global systematic reviews or meta-analyses of mortality data for these international migrants have been done. We aimed to review and synthesise available mortality data on international migrants. In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, and Google Scholar databases for observational studies, systematic reviews, and randomised controlled trials published between Jan 1, 2001, and March 31, 2017, without language restrictions. We included studies reporting mortality outcomes for international migrants of any age residing outside their country of birth. Studies that recruited participants exclusively from intensive care or high dependency hospital units, with an existing health condition or status, or a particular health exposure were excluded. We also excluded studies limited to maternal or perinatal outcomes. We screened studies using systematic review software and extracted data from published reports. The main outcomes were all-cause and International Classification of Diseases, tenth revision (ICD-10) cause-specific standardised mortality ratios (SMRs) and absolute mortality rates. We calculated summary estimates using random-effects models. This study is registered with PROSPERO, number CRD42017073608. Of the 12 480 articles identified by our search, 96 studies were eligible for inclusion. The studies were geographically diverse and included data from all global regions and for 92 countries. 5464 mortality estimates for more than 15·2 million migrants were included, of which 5327 (97%) were from high-income countries, 115 (2%) were from middle-income countries, and 22 (<1%) were from low-income countries. Few studies included mortality estimates for refugees (110 estimates), asylum seekers (144 estimates), or labour migrants (six estimates). The summary estimate of all-cause SMR for international migrants was lower than one when compared with the general population in destination countries (0·70 [95% CI 0·65–0·76]; I2=99·8%). All-cause SMR was lower in both male migrants (0·72 [0·63–0·81]; I2=99·8%) and female migrants (0·75 [0·67–0·84]; I2=99·8%) compared with the general population. A mortality advantage was evident for refugees (SMR 0·50 [0·46–0·54]; I2=89·8%), but not for asylum seekers (1·05 [0·89–1·24]; I2=54·4%), although limited data was available on these groups. SMRs for all causes of death were lower in migrants compared with the general populations in the destination country across all 13 ICD-10 categories analysed, with the exception of infectious diseases and external causes. Heterogeneity was high across the majority of analyses. Point estimates of all-cause age-standardised mortality in migrants ranged from 420 to 874 per 100 000 population. Our study showed that international migrants have a mortality advantage compared with general populations, and that this advantage persisted across the majority of ICD-10 disease categories. The mortality advantage identified will be representative of international migrants in high-income countries who are studying, working, or have joined family members in these countries. However, our results might not reflect the health outcomes of more marginalised groups in low-income and middle-income countries because little data were available for these groups, highlighting an important gap in existing research. Our results present an opportunity to reframe the public discourse on international migration and health in high-income countries. Wellcome Trust, National Institute for Health Research, Medical Research Council, Alliance for Health Policy and Systems Research, Department for International Development, Fogarty International Center, Grand Challenges Canada, International Development Research Centre Canada, Inter-American Institute for Global Change Research, National Cancer Institute, National Heart, Lung and Blood Institute, National Institute of Mental Health, Swiss National Science Foundation, World Diabetes Foundation, UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, and European Society for Clinical Microbiology and Infectious Diseases (ESCMID) Study Group Research Funding for the ESCMID Study Group for Infections in Travellers and Migrants.

The ruined-city motif in the Old English poem The Wanderer (lines 73–87) has long been read as a reflex of traditional Germanic diction, and as a symbol of material transience. In line with more recent biblical readings of the poem, this paper identifies a number of analogues and possible sources for both the excidio urbis image and other images of transience, in the biblical Book of Ezekiel. Among these correspondences between The Wanderer and the prophetic biblical narrative are references to scavenging animals, traditionally read as Germanic ‘beasts of battle’ when encountered in the Old English elegies. Reading this passage alongside Gregory the Great’s Homilies on Ezekiel further illuminates how the poem’s structure and changing use of tense corresponds with contemporary thought on the revelatory processes of prophecy. It is here proposed that the Old English poet has chosen to use images and devices which resonate with both biblical and traditional vernacular poetic diction.

The rat lungworm, Angiostrongylus cantonensis, is an emerging veterinary and public health concern. We describe A. cantonensis infections in a zoo-housed parma wallaby and free-ranging Virginia opossums and roof rats in San Diego, California, USA. Angiostrongyliasis should be considered in central nervous system disease in humans and animals in this region.

This study presents the first full history of Old English poetic mise-en-page, drawing its approach from the fields of literary criticism, art history, metrics, palaeography, and the history of the book. Paying special attention to lineation, this book surveys the layout of poetry from the earliest Latin writings in England, to modern editions of the twentieth and twenty-first centuries. It argues that the vernacular verse page is not, as has often been assumed, merely constrained by linguistic status. Rather, the layout of Old English poetry is shown to be the result of engaged scribal and editorial choices, and one of a set of tools used to meet readers' needs and to express identities. Old English verse is not laid out \"like prose,\" but like Old English verse.

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver program's impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.