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Background Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m 2 . To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m 2 . Methods We searched MEDLINE ® , the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another. Results Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications. Conclusions The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

Visitation to parks and protected areas (PPAs) has become increasingly widespread in the United States. This increased visitation is especially concerning within congressionally designated wilderness areas where federal agencies are tasked with the dual mandate of preserving wilderness character while simultaneously providing high-quality outdoor recreation experiences. This study investigated the influence of social, situational, and ecological factors on outdoor recreation visitor behaviors and decision making within the Lye Brook Congressionally Designated Wilderness (LBW) area in Vermont, USA. An on-site intercept survey (n = 576) was employed to collect data from LBW visitors in the summer of 2021. Descriptive and multi-variate statistics (e.g., binary logistic regression, structural equation modeling) indicated that visitor behaviors (e.g., coping, substitution) and decision-making (e.g., intention-to-return) were significantly influenced by social (e.g., conflict), situational (e.g., litter, access), and ecological (e.g., trail conditions, weather) impacts. Moreover, the presence of various weather conditions was found to significantly influence the severity of perceived social, situational, and ecological impacts. Study results indicated that outdoor recreation experiences are multifaceted, necessitating a suite of social, situational, and ecological considerations, especially when examining the relationship between visitor coping behaviors and intention-to-return. This research advances the coping framework, provides empirical support for future examination of social–ecological system (SES) theory, and emphasizes the utility of employing an adaptive systems approach for sustainable PPA management.

Environmental noise knows no boundaries, affecting even protected areas. Noise pollution, originating from both external and internal sources, imposes costs on these areas. It is associated with adverse health effects, while natural sounds contribute to cognitive and emotional improvements as ecosystem services. When it comes to parks, individual visitors hold unique perceptions of soundscapes, which can be shaped by various factors such as their motivations for visiting, personal norms, attitudes towards specific sounds, and expectations. In this study, we utilized linear models and geospatial data to evaluate how visitors' personal norms and attitudes, the park's acoustic environment, visitor counts, and the acoustic environment of visitors' neighborhoods influenced their perception of soundscapes at Muir Woods National Monument. Our findings indicate that visitors' subjective experiences had a greater impact on their perception of the park's soundscape compared to purely acoustic factors like sound level of the park itself. Specifically, we found that motivations to hear natural sounds, interference caused by noise, sensitivity to noise, and the sound levels of visitors' home neighborhoods influenced visitors' perception of the park's soundscape. Understanding how personal factors shape visitors' soundscape perception can assist urban and non-urban park planners in effectively managing visitor experiences and expectations.

Continuum surface methods, including the Sendova–Walton theory, offer a novel approach to fracture modeling in which boundary mechanics are used to augment the classical linear elastic fracture mechanics model for improved prediction of material behavior near fracture surfaces. These methods would be extremely useful in design simulations, but would require numerical implementation which to date has not been available. This has not been previously addressed due to the higher-order tangential derivatives appearing in the fracture surface boundary conditions which make standard implementation techniques, such as the finite element method, a challenge to implement. We propose a method for this implementation which involves reformulating the fracture boundary conditions to remove these higher-order derivatives in the case of mode-III fracture. We also present the initial results of our finite element implementation, which verify the improved stress and displacement field predictions near fracture surfaces.

Burgeoning urbanization, development and human activities have led to reduced opportunities for nature experience in quiet acoustic environments. Increasing noise affects both humans and wildlife alike. We experimentally altered human‐caused sound levels in a paired study using informational signs that encouraged quiet behaviours in week‐on, week‐off blocks on the trail system of Muir Woods National Monument, California, USA to test if the soundscape influences both wildlife and human experiences. Using continuous measurements from acoustic recording units (n = 13) spatially distributed within the park, we found signs significantly lowered sound levels by approximately 1.2 decibels (A‐weighted), thereby increasing listening area by 24% and bird availability by approximately 5.8% for every 1 decibel decrease. Visitor‐intercept surveys (n = 537) revealed that our mitigation increased the number of birds perceived by visitors, rankings of soundscape pleasantness, and importantly, preferences for soundscape management. By lowering human‐caused sound levels, we created an acoustic environment equivalent to a ~21% reduction in visitors. The positive feedback cycle we describe may lead to increased conservation support in a time when the extinction of nature experience looms. A free Plain Language Summary can be found within the Supporting Information of this article. A free Plain Language Summary can be found within the Supporting Information of this article.

ABSTRACTParks and protected areas (PPAs) are crucial for providing society with essential ecosystem services, encompassing both tangible and intangible benefits derived from healthy ecosystems. While previous research has predominantly focused on material-based ecosystem services, limited attention has been devoted to the impact of non-material cultural ecosystem services (CES), such as recreation and cultural-historic aspects, on visitor loyalty. Visitor loyalty refers to an individual’s commitment and willingness to repeatedly visit a PPA. CES can significantly shape these attitudes, as many visitors are drawn to specific PPAs due to their cultural significance or scenic beauty. This study investigated how CES influences visitor loyalty attitudes and intention-to-return at the Great Bay National Estuarine Research Reserve (GBE). In the summer of 2022, data were collected from 645 GBE visitors using a population sampling approach. Structural equation modeling analyses revealed a robust link between various CES factors, visitor loyalty attitudes, and intention-to-return. For instance, findings suggest that education and the sense of place exert a strong and consistent influence on visitor attitudes regarding referrals, financial support, volunteerism, and advocacy. Additionally, positive visitor attitudes toward referrals strongly and independently predicted their overall intent to revisit the GBE. This research contributes to the advancement of both CES and visitor loyalty frameworks, offering empirical insights for natural resource managers. By acknowledging the significance and trade-offs associated with CES elements, like education and the sense of place, resource managers can enhance visitor loyalty and secure the long-term sustainability of natural resources worldwide.

Continued racial/ethnic health disparities were recently described as \"the most serious and shameful health care issue of our time.\" Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types. To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA. Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities. We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review). Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group. From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength). Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.

Objective This study aims to conduct an evidence review of the effectiveness, harms, and cost-effectiveness of pharmacogenomics-guided antidepressant treatment for major depressive disorder. Methods We searched MEDLINE®, the Cochrane Central Registry of Controlled Trials, and PsycINFO through February 2017. We used prespecified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO number CRD42016036358). Results We included two randomized trials (RCT), five controlled cohort studies, and six modeling studies of mostly women in their mid-40s with few comorbidities. CNSDose (ABCB1, ABCC1, CYP2C19, CYP2D6, UGT1A1) is the only pharmacogenomics test that significantly improved remission (one additional remitting patient in 12 weeks per three genotyped, 95% CI 1.7 to 3.5) and reduced intolerability in an RCT. ABCB1 genotyping leads to one additional remitting patient in 5 weeks per three genotyped (95% CI 3 to 20), but tolerability was not reported. In an RCT, GeneSight (CYP2D6, CYPC19, CYP1A2, SLC6A4, HTR2A) did not statistically significantly improve remission, and evidence is inconclusive about its tolerability. Evidence is generally low strength because RCTs were few and underpowered. Cost-effectiveness is unclear due to lack of directly observed cost-effectiveness outcomes. We found no studies that evaluated whether pharmacogenomics shortens time to optimal treatment, whether improvements were due to switches to genetically congruent medication, or whether effectiveness varies based on test and patient characteristics. Conclusions Certain pharmacogenomics tools show promise of improving short-term remission rates in women in their mid-40s with few comorbidities. But, important evidence limitations preclude recommending their widespread use and indicate a need for further research.

To provide evidence synthesis for faster-paced healthcare decision-making, rapid reviews have emerged as a streamlined alternative to standard systematic reviews. In 2012, the Veterans Affairs Evidence-based Synthesis Program (VA ESP) added rapid reviews to support Veterans Health Administration (VHA) operational partners' more urgent decision-making needs. VHA operational partners play a substantial role in dissemination of ESP rapid reviews through a variety of routes, including posting on the VA ESP's public website ( http://www.hsrd. va.gov/publications/esp/ ). As demand for rapid reviews rises, much progress has been made in characterizing methods and practices. However, evidence synthesis organizations still seek to better understand how and when rapid reviews are being used. The VA ESP administered an online survey to rapid review operational partners. The survey assessed the nature of decision-making needs, overall perception of review content, resulting actions, and implementation timeframe. We use descriptive statistics and narrative methods to summarize findings. Between October 2011 and April 2015, we completed 12 rapid reviews for 35 operational partners. Operational partners were primarily non-academic subject matter experts with VA operations' decision-making authority. The most common topic categories reviewed were policy or system (50 %) or process of care (42 %) initiatives. Median report completion time was 14.5 weeks. Survey response rate was 46 %, with at least one operational partner responding for 92 % of reports. Reviews served multiple purposes including policy directive or regulation (72 %), supporting program development and evaluation (55 %), identifying future research needs (45 %), and determining implementation strategy (45 %). Overall, operational partners' perception of report content was positive. A majority of rapid reviews were used immediately and informed actions ranking high on the Institute of Medicine's Degrees of Impact framework: 45.4 % effected change, 18.2 % inspired action, 18.2 % informed the field, 9.1 % received recognition, and 9.1 % spread a message. VA ESP rapid reviews have increased the VHA's uptake of evidence to inform time-sensitive system-level decision-making. Key areas of interest for future evaluation include assessing user perception of our streamlined methods and the quality of our efforts to inform users of these methods, as well as comparing the usability and impact of our rapid and standard systematic reviews.

Three patients ranging from 49 to 61 years-old presented to our pain clinic after failing multiple treatment attempts for debilitating, chronic post-traumatic headaches, neck pain and involuntary muscle spasm following gunshot wounds to the head, neck and face. Concurrent cervical dystonia was noted in each patient on presentation. All patients were treated with onabotulinumtoxin A (ONA) injections in the head and neck. Each patient reported between 70% and 100% improvement of their headache pain, neck pain and spasm with a significant reduction in the frequency, duration and intensity of their headaches. This level of improvement has been successfully maintained in all three patients with regular ONA injections at 90-day intervals. Two patients experienced a single relapse in symptoms when scheduling conflicts caused them to miss their regularly scheduled ONA injections by several weeks. These symptoms resolved when their ONA injections resumed, suggesting that ONA is the causative agent alleviating their symptoms.