Transgender and gender-independent individuals (TGI) encounter myriad barriers to accessing affirming healthcare. Healthcare discrimination and erasure exposure among TGI individuals is vital to understanding healthcare accessibility, utilization behaviors, and health disparities in this population. Exposure to gender identity-related healthcare discrimination and erasure in childhood may contribute to TGI adults’ healthcare utilization behaviors. The commonality of childhood exposure to gender identity-related healthcare discrimination and its relationship to healthcare avoidance during the early months of the COVID-19 pandemic among TGI adults were explored. TGI adults aged 18 to 59 (N = 342) in the United States were recruited online during the summer of 2020. Among individuals who reported childhood exposure to gender identity-related healthcare discrimination, 51% reported experiencing two or more distinct forms of discrimination. Hierarchical logistic regression indicated that exposure to healthcare discrimination in childhood significantly increased the odds of healthcare avoidance during the early months of the COVID-19 pandemic, after accounting for demographic factors and self-reported COVID-19 symptoms . These findings suggest that childhood exposure to gender identity-related healthcare discrimination is a prominent barrier to the utilization of healthcare for TGI adults, even during a global pandemic. Gender identity-related stigmatization, discrimination, and erasure in healthcare settings serve as central barriers to the accessibility and utilization of healthcare for individuals who embody transgender and gender independent (TGI) identities ,2. TGI iTerminology. The term transgender and gender nonconforming (TGNC) is umbrella terminology used to refer to individuals whose gender identities, gender roles, and gender expressions do not align with or conform to the gender norms associated with their sex assigned at birth , significantly predicted healthcare avoidance during the early months of the COVID-19 pandemic over and above the covariates. For each one-point increase in the childhood healthcare discrimination measure, respondents were 30% more likely to have avoided needed healthcare in the early months of the COVID-19 pandemic due to anticipation of gender identity-related discrimination.A hierarchical logistic regression analysis  was condThis study expands the literature about TGI individuals’ healthcare experiences and utilization behaviors ,10,12,18Independent of an individual’s age, race/ethnicity, income level, disability/neurodivergent identity, and health insurance coverage status, lifetime exposure to healthcare discrimination predicted avoiding needed healthcare in the past year when they anticipated encountering gender identity-based discrimination, even despite this past year including pandemic conditions. Findings indicate that higher levels of lifetime exposure to varied forms of healthcare discrimination significantly increase the likelihood that TGI individuals will avoid needed healthcare due to anticipation of gender identity-based discrimination in healthcare settings. These findings demonstrate the considerable toll that healthcare discrimination has on TGI individuals in instances when they must consider the potential risks of seeking or avoiding healthcare beyond gender-affirming care  when it is needed. These findings demonstrate the considerable toll that healthcare discrimination has on TGI individuals in instances when they must consider the potential risks of seeking or avoiding healthcare beyond gender-affirming care  when it is needed. The postponement and avoidance of healthcare have been found to have detrimental outcomes ,24. As oHealthcare institutions and providers can work to ensure that these barriers of cisgenderism  and cisnormativity  are replaced with affirmation and a conceptualization of gender as a more expansive, nonbinary construct . It is iInclusive forms and records would also support TGI individuals in conveying the manner in which their gender identity intersects with their bodies to healthcare providers. TGI individuals may conceal their gender identities to avoid discrimination in healthcare settings which has healthcare accessibility  and outcome  implications . The useTGI individuals, particularly youth, their families, and their doctors, are being increasingly targeted by legislation and executive orders issued by governors that restrict the accessibility of gender-affirming care in states across the U.S. . DespiteCausal inferences could not be made in this study due to its cross-sectional design. Longitudinal cohort studies should be employed to expand knowledge regarding TGI identity development and healthcare accessibility barriers. This study used an online and non-probability sampling method, thereby lessening its representativeness of the diversity that exists among the TGI population. Despite the geographical representativeness of the U.S, the most marginalized tier  of this population were unable to be accessed; as such, these results cannot be generalized to all TGI individuals. Future studies should strive to utilize probability sampling. While this study captured the reported prevalence of healthcare discrimination and healthcare avoidance behaviors associated with the discrimination faced in healthcare settings by this population, it did not investigate exposure to discrimination in specific healthcare settings . Future studies should assess exposure to erasure and discrimination within specific healthcare specialties. This study garnered information about respondents’ disabilities/neurodivergence but did not inquire about participants’ diagnoses of specific chronic health conditions.Notwithstanding these limitations, this study provides information that is critical to understanding the health behaviors and subsequent health implications for the TGI population. This study provides evidence of the persistence of myriad institutional, structural, and ideological barriers to transgender and gender-independent individuals’ abilities to access healthcare, with associations of deleterious health behaviors  generally, amidst a global pandemic, and has articulated numerous clinical and policy implications for future consideration.


Background: Autosomal-dominant facioscapulohumeral muscular dystrophy (FSHD) is a muscular dystrophy with associated retinal abnormalities such as retinal vessel tortuosity, focal retinal pigment epithelium defect and large telangiectasia vessels. Methods: Case report of an FSHD 16-year-old female referred for blurred vision in both eyes (20/40), evening fever and shoulder muscle weakness over the past month preceding assessment. A multimodal assessment including visual acuity (VA), microperimetry (MP), multifocal electroretinogram (mfERG), optical coherence tomography (OCT), fluorescein angiography (FA) and fundus autofluorescence (FAF) was performed. Results: OCT showed pseudocyst macular abnormalities and disruption of the photoreceptor layer with no signs of macular ischemia/exudation. Macular function showed foveal impairment recorded by mfERG and MP as a reduction of the response amplitude density and retinal sensitivity, respectively. No medical treatment was prescribed. After three years, patient’s VA slightly improved to 20/32. OCT showed resolution of bilateral pseudocyst macular changes and persistence of photoreceptor disruption. By contrast, mfERG recordings remained abnormal for impaired foveal function and microperimetry mean sensitivity was reduced as well. Conclusions: This multimodal assessment showed persistent VA impairment at three years follow-up associated to abnormal foveal function and reduced retinal sensitivity, with spontaneous resolution of morphological macular changes, suggesting a retinal neurodegenerative process on the basis of the disease. After three years, the patient’s visual acuity slightly improved to 20/32 in both eyes. The repeated SD-OCT scans showed spontaneous resolution of bilateral pseudocyst macular changes and persistence of photoreceptor disruption , morphological  and functional (mfERG and microperimetry) assessment for studying the macular area.This multimodal assessment allowed for the finding of a persistent visual acuity impairment at three years follow-up that is associated to abnormal foveal function and reduced retinal sensitivity, with resolution of morphological macular changes, thus suggesting that visual acuity changes can be associated to foveal outer layers of retinal neurodegeneration, similarly to that found by our group in several neurodegenerative diseases .Bilateral visual impairment in a case of FSHD followed for three years was secondary to macular degeneration trait and not associated to vascular retinal barrier damage. The self-resolved macular abnormalities lead us to think that the pseudocyst changes could be an epiphenomenon of FSHD disease, possibly due to retinal vacuolization, whose pathogenic mechanisms need to be clarified by larger studies correlating signs of supposed vasculopathy and macular dystrophy appearance.


Severe childhood malnutrition impairs growth and development short-term, but current understanding of long-term outcomes is limited. We aimed to identify studies assessing neurodevelopmental, cognitive, behavioural and mental health outcomes following childhood malnutrition.We systematically searched MEDLINE, EMBASE, Global Health and PsycINFO for studies assessing these outcomes in those exposed to childhood malnutrition in low-income and middle-income settings. We included studies assessing undernutrition measured by low mid-upper arm circumference, weight-for-height, weight-for-age or nutritional oedema. We used guidelines for synthesis of results without meta-analysis to analyse three outcome areas: neurodevelopment, cognition/academic achievement, behaviour/mental health.We identified 30 studies, including some long-term cohorts reporting outcomes through to adulthood. There is strong evidence that malnutrition in childhood negatively impacts neurodevelopment based on high-quality studies using validated neurodevelopmental assessment tools. There is also strong evidence that malnutrition impairs academic achievement with agreement across seven studies investigating this outcome. Eight of 11 studies showed an association between childhood malnutrition and impaired cognition. This moderate evidence is limited by some studies failing to measure important confounders such as socioeconomic status. Five of 7 studies found a difference in behavioural assessment scores in those exposed to childhood malnutrition compared with controls but this moderate evidence is similarly limited by unmeasured confounders. Mental health impacts were difficult to ascertain due to few studies with mixed results.Childhood malnutrition is associated with impaired neurodevelopment, academic achievement, cognition and behavioural problems but evidence regarding possible mental health impacts is inconclusive. Future research should explore the interplay of childhood and later-life adversities on these outcomes. While evidence on improving nutritional and clinical therapies to reduce long-term risks is also needed, preventing and eliminating child malnutrition is likely to be the best way of preventing long-term neurocognitive harms.CRD42021260498. High mortality risk and impaired growth are well-recognised short-term risks of childhood malnutrition.While there is increasing appreciation of longer-term risks for survivors, notably adult cardiometabolic non-communicable disease, other longer-term risks have been poorly described.There is strong evidence that malnutrition impairs neurodevelopment and academic achievement in childhood which has significant implications for future well-being and prospects of those affected.Childhood malnutrition is associated with impaired cognition and behavioural problems with evidence of effects through to adolescence and adulthood but the effect of nutritional treatment and interplay with childhood adversity, coexisting illness such as HIV and environmental factors in influencing these outcomes is unclear.Study findings imply that there are likely to be long-term effects of childhood malnutrition on cognition and well-being lasting through adolescence and adulthood.Long-term needs of malnutrition survivors need to be carefully considered in treatment programmes. Further research is needed on the effects of nutritional therapy, adversity and environmental factors to tailor future interventions, particularly with regard to mental health which has been little researched.Severe childhood malnutrition is widespread and has a high disease burden concentrated in low-income and middle-income settings.5Understanding long-term outcomes following child malnutrition is especially important because improved treatment has thankfully resulted in more children with malnutrition surviving into adolescence and adulthood.Causal pathways linking malnutrition with neurodevelopment, cognition, behaviour and mental health are complex. Previous studies have found children admitted to hospital with severe malnutrition often have severe developmental delays with significant implications for ongoing development, well-being and potential future capital.10A 1995 review found school-age children who suffered from early childhood malnutrition generally had poorer IQ levels, cognitive function, school achievement and greater behavioural problems than matched controls and, to a lesser extent, siblings.We searched MEDLINE, EMBASE, Global Health and PsycINFO for studies published between 1 January 1995 and 6 January 2022 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.10.1136/bmjgh-2022-009330.supp1Supplementary dataWe included studies from low-income and middle-income countries reporting neurodevelopmental, cognitive, school/academic achievement, mental health or behavioural outcomes in children under five exposed to malnutrition compared with children without malnutrition . We defined childhood malnutrition as undernutrition using standard definitions (definitions which are commonly measured in research and often related to severe adverse outcomes)14 15We included cross-sectional, cohort, case-control and controlled trial study designs which had a comparator group not exposed to childhood malnutrition. We excluded conference papers and reviews which did not include original data. We excluded studies which failed to define how malnutrition, child neurodevelopment, cognition, school/academic achievement, mental health or behaviour were measured. We also excluded studies looking at specific sub-populations of children . No language restrictions were placed on studies.Titles and abstracts were screened by two independent reviewers . The full texts of titles and abstracts chosen by any reviewer were then independently reviewed by two reviewers  against our selection criteria. We also screened reference lists of included studies. Data extraction of included studies was done by one of AK or MGo into a standard template . Data extraction was subsequently checked by a second separate reviewer . Disagreements regarding inclusion of full texts and data extraction were resolved through mutual discussion.We assessed study quality using the National Institute for Health and Care Excellence (NICE) quality appraisal checklist.We grouped studies into three outcome areas: neurodevelopmental, cognition/academic achievement and mental health/behavioural outcomes (with some studies reporting outcomes from more than one category). We differentiated tools which measured general neurodevelopmental outcomes  from those which specifically measured only cognition or academic language tests. We undertook a narrative synthesis of results within each of these areas as diverse outcomes and measurement tools precluded meta-analysis. We followed the Synthesis without meta-analysis (SWiM) reporting guidelines for analysing and reporting results.17For neurodevelopmental studies we grouped studies and compared results by neurodevelopmental assessment tool used. For studies investigating cognition/academic achievement, we grouped those that measured IQ or executive function and those that measured either school or language performance/assessment results. For mental health/behaviour studies, we grouped studies that used behavioural assessment tools and then into groups by mental health condition or domain assessed.For each study outcome where available, we recorded the unadjusted and adjusted results in cases and controls, reported effect sizes, and results from any statistical significance tests. When synthesising results by the groupings described above, we used vote counting by direction of effect to assess the number of studies which recorded differences between cases and controls. We summarised results in tables showing the number of studies with an effect on each outcome area. We also recorded the age group  at which outcomes were measured to compare results between studies. Using SWiM guidelines we used vote counting in conjunction with study quality scores  to summarise the strength of conclusions.Thirty studies met our selection criteria .18–47 FuStudy quality scoring is included in We identified nine studies assessing neurodevelopmental outcomes of malnutrition . A summaWe identified 12 studies (three from BNS) assessing cognitive outcomes of malnutrition . A summaEleven studies investigated cognition using several tools assessing intelligence and executive function . Eight oWe identified 14 studies (8 from BNS) assessing mental health and behavioural outcomes of malnutrition . A summaSeven studies (five from BNS) investigated different mental health outcomes .19 26 39Our review finds strong evidence that exposure to malnutrition in childhood impairs neurodevelopment and academic achievement. There is moderate evidence that childhood malnutrition is associated with impaired cognition and is associated with more behavioural problems throughout childhood and adolescence. However, there is uncertainty around the relative contributions of malnutrition and other associated factors  to these outcomes. Research investigating mental health outcomes in children with malnutrition is inconclusive and there are few studies investigating specific mental health domains such as depression. These results have implications for policy-makers surrounding the long-term care needs of those treated for childhood malnutrition and there is a need for research exploring how nutritional therapies and social interventions affect these outcomes.Due to study heterogeneity, we were unable to perform a meta-analysis of any results. We therefore, used published guidelines to synthesise results and determine the strength of evidence for each outcome area. Despite this, there are still limitations given potential publication bias of positive associations between malnutrition and the outcomes investigated. Our review, however, builds on previously published evidence which has suggested links between malnutrition and poorer IQ levels, cognitive function, school achievement and greater behavioural problems.48Impaired neurodevelopment in childhood is likely linked to subsequently poorer academic achievement in childhood and adolescence and may also be linked to increased behavioural problems seen in some studies.While there is still uncertainty around the relative contributions of associated medical and social factors, there is increasing evidence from this review that the early impacts of malnutrition are related to worse academic, cognitive and behavioural outcomes compared with well-nourished peers. Preventing and decreasing childhood malnutrition is therefore of key importance to prevent serious long-term neurocognitive issues in affected children, particularly given the ongoing high malnutrition prevalence in many low-income and middle-income settings. Further research is needed on how to optimise treatment and to best support ongoing care for survivors to improve outcomes in the long term.


Monoclonal Gammopathy of Undetermined Significance (MGUS) is an understudied precursor of multiple myeloma (MM), the second most prevalent hematologic malignancy in the US. MGUS is incidentally diagnosed, and its significance is unclear as only 1% per year transition to MM. MGUS is highly prevalent among adults aged ≥ 50 years. In this presentation, we will review mixed-method approaches. Using healthcare claims and electronic health records from patients in central Massachusetts, we applied group-based trajectory modeling and conditional Poisson regression. These analyses were complemented by a qualitative analysis of in-depth interviews with providers and MGUS patients. Together, these methodologies provided a comprehensive evaluation of the impact of MGUS on healthcare utilization in older adults. The qualitative analysis provided a better understanding of the patient and provider factors influencing healthcare utilization after an MGUS diagnosis. The presentation will highlight how the use of these methodologies provide different perspectives among understudied premalignant conditions.


Urban residency benefits cognition in later life. In China, the household registration system (hukou) creates another place-based advantage/disadvantage for cognitive aging. We exam the interplay of rural/urban residence and hukou across the life-course in creating cumulative advantage/disadvantage in cognitive aging trajectories using longitudinal data from the 2011-2018 China Health and Retirement Longitudinal Study and its Life History Survey. Results from linear mixed effect models show that always urban dwellers with urban hukou exhibited the highest level of cognitive function and the slowest decline, and the always rural dwellers with rural hukou had the worst cognitive function and experienced a faster decline. Rural-to-urban shifts had better cognitive health than always rural dwellers, but the advantages depend on urban hukou attainment and specific mechanisms. This research suggests cumulative advantage/disadvantage in cognitive aging by residence and hukou throughout life and demonstrates that institutional discrimination and exclusionary policy may create inequality in aging processes.


The current study addresses how cancer and aging influence older adults' health trajectories differently. The unique cross-sequential design allowed the study to compare the health changes between long-term (5 years +) older cancer survivors  and demographic-matched older adults without a history of cancer in the same geographic area within the same period by merging two longitudinal studies. The study also captured comprehensive information on health disparities over time. General linear models were employed. The findings showed that neither previous cancer experience nor aging affects health trajectories in later life. Conversely, comorbidities, being African American, female, having less than a college degree, and living alone significantly decreased the health trajectory in later life for all older adults. Moreover, when compared to other groups, older African American cancer survivors reported low scores in self-reported health after controlling for other conditions.


Pure cutaneous recurrence after breast-conserving surgery is rare and presents a unique challenge to clinicians. Some carefully selected patients may be amenable to further breast-conserving therapy. We present the case of a 45-year-old female with a cutaneous recurrence of previously treated right breast cancer along the operative scar in the upper outer quadrant. The patient underwent a further wide local excision with lateral intercostal artery perforator flap with a skin paddle reconstruction. We achieved volume replacement with this technique, disease control, and a pleasing cosmetic result. Breast-conserving surgery (BCS) is a well-established treatment modality for patients with early breast cancer and offers good cosmesis, low rates of recurrence, and survival outcomes comparable to mastectomy ,2. In paA 45-year-old female was diagnosed with a cutaneous breast cancer recurrence in the upper outer quadrant of her right breast approximately 10 years after a lumpectomy for early breast cancer Figures . At the BCS with adjuvant treatment achieves survival rates equivalent to those seen in patients treated with a mastectomy, while also achieving favorable cosmetic outcomes and low rates of locoregional recurrence . The risA completion mastectomy is usually the treatment modality of choice for ipsilateral breast cancer recurrence. More recently, further BCS has emerged as a feasible option in select patients. Alpert et al. published outcomes of completion mastectomy versus further BCS in 146 patients with ipsilateral breast cancer recurrence . After aOncoplastic techniques have continued to develop and offer patients good oncological outcomes with excellent cosmesis. In 1979, anatomical studies by Kerrigan and Daniel provided a sound understanding of intercostal vessels and skin flaps in the surgical repair of large trunk defects . FocusinHamdi et al. elaborated on the utility of intercostal perforator (ICAP) flaps in breast reconstructive surgery in 2006 . The conThe modified LICAP flap with a skin paddle is a novel way to replace volume and associated cutaneous defects in the breast tissue. Examples include cutaneous recurrence of breast cancer, as described, in patients who have had previous scar retraction or even skin necrosis where skin and volume replacement is required. It is not limited to just cutaneous recurrences, which are rare in themselves. The procedure offers both excellent oncological margins and cosmetic results and is suitable in carefully selected patients who participate in multidisciplinary treatment planning.


The purpose of this study was to identify the association between physical/mental health problems and depressive symptoms among older Black Americans (age ≥ 65) using the 2018 Health and Retirement Study (N = 812). People with multiple medical conditions face substantial emotional difficulties including depressive symptomatology. The study of depressive symptoms among older Black Americans is an emerging area of research. Several existing studies reported a higher prevalence of depressive symptoms among this population. They also experience a disproportionate burden of multimorbidity, both physically and mentally. For statistical analysis, depressive symptoms were measured with the eight-item CES-D scale . Physical multimorbidity was measured by asking whether respondents had ever been diagnosed with seven diseases . Mental multimorbidity was measured by asking whether they had ever been diagnosed with three diseases . Covariates included gender, marital status, and income (logged). A negative binomial regression showed that (a) higher numbers of physical health problems were associated with higher depressive symptoms ; (b) higher number of mental health problems were also related to higher depressive symptoms among older Black Americans . These findings underscore the importance of identifying and managing depressive symptoms among older Black Americans, who present with greater physical/mental health multimorbidity.


Personal networks are a key component in the provision of social support for older adults. Such support is particularly critical during the COVID-19 pandemic, when traditional avenues of social engagement or assistance are disrupted. Here, we use nationally representative data from the National Social Life, Health, and Aging Project that assesses older adults’ pre-pandemic personal networks and receiving instrumental help and emotional support during the pandemic. We find that larger pre-pandemic confidant networks predict higher odds of receiving needed help and support, higher odds of receiving help and support more often than before the pandemic, and lower odds of being unable to get help. Denser pre-pandemic networks also predict higher odds of receiving instrumental help and support during the pandemic, while having a greater proportion of kin in pre-pandemic networks predicts higher odds of receiving pandemic help for non-white older adults only. Together, results suggest that features of older adults’ pre-pandemic confidant network structure and composition can provide underlying conditions for receiving social support during the pandemic.


Pulmonary Langerhans cell histiocytosis (PLCH) is an uncommon diffuse cystic lung disease that occurs almost exclusively in young adult smokers. High-resolution computed tomography of the chest allows a confident diagnosis of PLCH in typical presentation, when nodules, cavitating nodules, and cysts coexist and show a predominance for the upper and middle lung. Atypical presentations require histology for diagnosis. Histologic diagnosis rests on the demonstration of increased numbers of Langerhans cells and/or specific histological changes. PLCH is one of the few diseases in which bronchoalveolar lavage (BAL) has a high diagnostic value and can in some circumstances replace lung biopsy. We present a case of PLCH in an elderly non-smoker. Chest imaging revealed the presence of advanced interstitial lung disease with a fibrocystic pattern. BAL cellular analyses disclosed a macrophage pattern with CD1a phenotype that strongly supports the PLCH diagnosis, even in the setting of atypical clinical presentation and a lack of smoking exposure. PLCH is extremely rare in non-smokers and could represent a distinct phenotype. BRAF-V600E mutation on the BAL cytology specimen and/or whole blood NGS for mutations and fusions in genes of the MAPK-ERK and related pathways provide supplementary diagnostic evidence, especially for atypical PLCH, and could stratify different pathological phenotypes [PLCH is a rare disorder (<5% of ILD cases) of unknown etiology that occurs predominantly in young smokers (>90% of patients) . PLHC beenotypes . The limenotypes . Unfortu


Conventional structural neuroimaging methods can identify changes in cortical thickness but cannot relate these changes to specific cortical layers due to a lack of sensitivity. However, several indirect measures sensitive to changes specifically occurring in supragranular cortical layers were developed recently .The aim was to assess the ability of these novel measures to detect cortical layers thickness characteristics potentially associated with risk or resilience to developing schizophrenia.43 first-episode schizophrenia (FES) male patients, 29 non-converted individuals at ultra-high risk of psychosis , and 43 matched healthy controls (HC) underwent structural MRI at 3T Philips scanner. Images were processed via FreeSurfer and MATLAB to derive two markers specific to supragranular thickness change: gyral-sulcal thickness differences (GSTD) and gyral-sulcal intrinsic curvature differences on pial surface (GSCD).GSCD measures were increased in temporal, parietal and occipital cortices, whereas both GSTD and GSCD were increased in the right frontal cortex in FES compared to HC. No GSTD or GSCD were changed in ncUHR compared to HC, and GSCD was decreased in the frontal cortex compared to FES.Our findings from the indirect measures indicate a potential predominance of supragranular thinning in FES and suggest that a supragranular thinning in the right frontal lobe might be associated with precipitating risk and/or illness effects of schizophrenia. At the same time, no clear supragranular markers directly associated with resilience or risk mechanisms were identified. The work was supported by RFBR grant 20-013-00748.


Our first objective is to investigate how between subject differences in the likelihood of record linkage consent and record linkability determine the composition of and so risks of biases in estimates from linkable business datasets. The utility of datasets linking information from multiple sources is compromised by such non-linkage biases, but both components of the linkage process have rarely been considered. Our second objective is to introduce methods for evaluating non-linkage bias risks in datasets. Such evaluations can inform linkage method choice and assessment of the validity of linked dataset findings. Previous work, often lacking non-linked subject information on non-sample dataset covariates, tends to utilise overall linkage rates as quality measures, but in the related area of survey non-response correlations between analogous response rates and non-response biases are weak.We utilise the UK 2010 Small Business Survey (SBS) dataset. If a survey subject consents to record linkage, an attempt is made to append their Inter-Departmental Business Register (IDBR) identifier (if one exists), enabling linkage to other surveys etc. Given this, we evaluate bias risks arising from variation in subject linkage consent and identifier appendability, as well as its product, overall linkability, utilising representativeness indicators developed to evaluate survey non-response bias risks. These measure risks in terms of sample-subset similarity (representativeness) given an attribute covariate set obtained from the sample dataset, based on variation in subject inclusion propensities estimated by logistic regression, and are decomposable to assess correlates of inclusion propensity variation. Specifically, we use the CV (the standard deviation of inclusion propensities divided their mean), computed given nine attribute covariates describing business demography and perceived performance.We give full details in our presentation. Briefly, overall CVs suggest the linkable dataset exhibits substantial non-representativeness and non-linkage bias risk. Decompositions suggest main impacts on the linkable dataset are under-representation of very small businesses , due to being both less likely to consent and less likely to have an identifier appended, and under-representation of businesses unable / refusing to respond to survey items, due to being less likely to consent.Our analyses provide evidence of non-linkage bias risks in linked SBS datasets caused by under-representation of several sample subgroups. Each is explicable given known IDBR under-coverage or knowledge of business response processes. We also conclude that representativeness indicators are an easily applied method by which such risks can be evaluated.


Driven by the aim of realizing functional robotic systems at the milli- and submillimetre scale for biomedical applications, the area of magnetically driven soft devices has received significant recent attention. This has resulted in a new generation of magnetically controlled soft robots with patterns of embedded, programmable domains throughout their structures. This type of programmable magnetic profiling equips magnetic soft robots with shape programmable memory and can be achieved through the distribution of discrete domains (voxels) with variable magnetic densities and magnetization directions. This approach has produced highly compliant, and often bio-inspired structures that are well suited to biomedical applications at small scales, including microfluidic transport and shape-forming surgical catheters. However, to unlock the full potential of magnetic soft robots with improved designs and control, significant challenges remain in their compositional optimization and fabrication. This review considers recent advances and challenges in the interlinked optimization and fabrication aspects of programmable domains within magnetic soft robots. Through a combination of improvements in the computational capacity of novel optimization methods with advances in the resolution, material selection and automation of existing and novel fabrication methods, significant further developments in programmable magnetic soft robots may be realized. Variation of the material distribution and magnetic profile has enabled MSRs to demonstrate shape-forming and navigational abilities far beyond those of current soft robots (Programmable magnetic soft robots (MSRs) are typically formed through the combination of magnetic particles with soft elastomeric materials, and are controlled wirelessly t robots . Their pt robots  presentst robots , shape-ft robots  and origt robots .An idealized approach to the development of programmable MSRs is illustrated in This review aims to highlight the most significant developments and challenges specific to the optimization and fabrication of programmable domains for biomedical MSR applications. Following a review of programmable MSRs presented in the literature, we first consider specifically recent developments in optimization procedures, including physics-based modelling, deep learning and genetic algorithm protocols. This is followed by examination of novel fabrication methods across lithographic patterning, direct ink writing and direct laser writing that both support fabrication of optimal designs and limit optimization flexibility. We conclude the review with a discussion focused on the main current challenges and future directions of optimization and fabrication methods for the advancement of programmable MSRs.Many MSR designs rely on magnetic profiling approaches, as depicted in via UV curing, which fixed characteristic magnetization properties to individual target domains. Early research into MSR profiling was largely limited to non-programmable  materials with heterogeneous magnetic distributions, typically restricting shape-forming and navigational abilities to planar deformations . More rein vivo environments such as the endometrium . Another key challenge remains in capturing the MSR’s underlying physics at high fidelity and across a range of voxel scales. This includes interpreting viscous and frictional forces and self-interaction between magnetic regions at submillimetre scales. It is therefore pertinent to investigate methods with reduced computational burden and integration with realtime predictive model data, such that programmable MSR behaviours may be optimized with ever-increasing accuracy and reliability .Deep learning optimization integrates statistical modelling with iterative neural network computation to derive voxel configurations for desired deformation. The integration of deep learning algorithms with MSR fabrication has potential to significantly improve the selectivity and computational reach of MSR optimization, in turn paving the way for a new generation of optimized programmable MSRs.via experiment, which is arduous, or via simulation, which reintroduces the aforementioned errors in modelling assumptions. This presents a significant challenge to adoption in deep learning-based optimization of programmable magnetic domains  to impart varied magnetic properties between cured layers. LP realizes exceptional applicability for single and multidirectional voxel magnetization, ranging from binary magnetization patterning in 1D to arbitrary multi-layer encoding in 3D programmable materials. It has therefore played an integral role, alongside studies into magnetic, complex 3D shape configurations, for biomedical MSR prototypes (In terms of programmable MSR fabrication, LP comprises a family of additive methods which involve embedding magnetic particles within curable substrates, followed by selective magnetization and composite curing (ototypes .via selective curing of a UV resin. Embedded particles were first magnetized with an external magnetic field. A template was then utilized to expose particular composite regions to UV light, locking in the embedded particle magnetizations. This automated process was used to fabricate 2D elastomeric MSRs with programmable magnetic anisotropies and facilitated the development of a bio-inspired undulatory swimming robot which utilized encoded travelling wave motion along its length to achieve flagellar motion, commonly observed in spermatozoa and bacterial cells. This may hold promising applications for minimally invasive navigation throughout complex vasculature or cerebral spinal fluid (A digital light processing lithographic method was developed by al fluid .In contrast, A lithographic approach was also taken by in vivo application (Current challenges for LP voxel-encoding lie in the limited availability of biocompatible materials . Future lication .DIW couples digitally-driven methods of fused deposition modelling with programmable magnetization to produce voxelated structures with readily encoded magnetic anisotropies . DIW incA similar method was developed by At present, DIW suffers from deteriorating print quality at submillimetre scales, largely as the scale of embedded magnetic particles is approached. Additionally, shorter voxel lengths at the submillimetre scale induces weaker magnetic densities between adjacent voxels. Both of these issues reduce the MSR’s overall sensitivity to external magnetic actuation, as well as its ability to achieve deformations of greater complexity . Future via optical additive manufacturing. A magnetic field programs anisotropies throughout each printed voxel layer, whilst a laser scans across target regions for localized encoding of magnetic anisotropies. The application of heat by laser scanning prevents thermal diffusion of magnetic particles to non-target regions, whilst rapid cooling fixes the selected magnetization patterns before consecutive layers are printed. The integration of DLW with pre-existing fabrication methods presents promising opportunities for the rapid, automated fabrication of programmable domains at micrometre scales (Direct laser writing couples digitally-driven laser curing with programmable magnetization to selectively encode magnetic anisotropies at submillimetre scales. Similar to previous methods, DLW involves embedding magnetic particles within curable elastomeric matrices, often e scales .via global laser heating and individual voxel-programming at resolutions of 30 µm. The method was used to encode various magnetization profiles on a flower-inspired six-arm gripper robot (er robot . The sixCurrently, limitations in laser penetration depth remain a significant challenge in DLW, in turn limiting the method’s expansion to rapid 3D fabrication and programming . Future in vivo drug delivery. To support flexible, rapid fabrication of MSRs, Other fabrication methods, including injection molding and magnetic spraying, have also played an essential role in the development of programmable MSRs for biomedical applications. Low-pressure injection molding methods for soft continuum MSR fabrication have recently been presented . Lloyd eIt is evident that, even within a short period, significant developments in the optimization and fabrication of programmable domains have played an integral role in miniaturizing and improving the functionality of bio-inspired MSRs. As indicated in via the integration of reliable and computationally efficient optimization procedures with flexible fabrication methods. To maximize this potential, it is therefore pertinent to address the resolution, material, computational and automation challenges that affect the presented optimization and fabrication methods.As outlined, the field holds exceptional potential via experimental data integration due to difficulty of reliable data collection at such scales. At present, optimization via genetic algorithms remains the most promising method, largely due to its operation with model-free experimental arrangements, capability of unlimited search space sizes and potential for increased adoption across various digitally-driven programmable MSR fabrication methods.The computational capacity of physics-based modelling remains a significant hurdle in determining optimal voxel behaviours at submillimetre scales and across the full spectrum of underlying physical interactions which influence programmable MSR actuation. With the identified need for improved models to capture the dynamics, material properties and interaction forces, the required current and potential computational burden of physics-based modelling is significant. The integration of real data to tune adaptive models may be pursued to reduce the computational burden of future physics-based model methods. In deep learning methods, the trade-off between experimental data and simulation data use remains a significant challenge to widespread adoption. Efforts to reduce modelling assumption errors, particularly within underlying FEM models, may be applied for improved reliability of simulation-driven deep learning methods. The choice to utilise experimental data within future optimization procedures may depend on the voxel scale and resolutions applied throughout MSR geometry, with submillimetre scales less likely to be optimized Additionally, significant challenges in the resolution, material selection and automation of current fabrication techniques must also be addressed. The limited availability of biocompatible materials remains a significant hurdle for current LP methods, however, additional research into the use of gelatin and hydrogel-based materials may improve the method’s potential as a widely adopted programmable MSR fabrication procedure. Furthermore, several LP and other fabrication techniques comprise a series of manual steps, reducing the efficiency of the overall MSR fabrication process and hence limiting both its reproducibility and scalability for high-volume fabrication. These manual processes, however, bring greater flexibility for precise domain assembly, as observed in It is widely anticipated that improvements in the capacity of both statistical and physics-based optimization coupled with further improvements to the resolution, material selection and automation of existing and novel fabrication methods will pave the way for further novel programmable MSRs. If an appropriate voxel resolution can be achieved across both optimization and fabrication aspects of MSR development, extended shape-forming abilities and improved biocompatibility hold the potential to unlock novel applications at the milli- and submillimetre scales.


Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalitiesA mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health , shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.Public health strategy development can address health inequalities through community-informed consultative exercises involving seldom heard members of vulnerable communities.Community consultations seeking to reach typically underrepresented groups require gatekeepers acting as gateways, and meeting participants where they are comfortably located at community venues.


End-stage renal disease (ESRD) causes age-accelerating disease and disproportionally affects older and minority patients; the preferred treatment is kidney transplantation (KT). Rates of KT have risen 5-fold for older adults since 1990 but there is great heterogeneity in KT outcomes by frailty and waitlist status. The person-environment fit theory posits that improving a person’s lived environment will facilitate optimal individual functioning. We recruited a balanced sample of 20 participants  with respect to their frail/ pre-frail and inactive/ active waitlist status to explore personal experience and the lived environment through the use of photovoice, gaining insight into the person-environment fit of those older adults awaiting KT. We will discuss IRB issues, recruitment and logistical tips with using Photovoice. This work will help to inform what vulnerable and marginalized older adults awaiting KT must be prepared for psychologically and physically, including modifications needed to their lived environments.


Metabolic acidosis, a common complication in patients with chronic kidney disease (CKD), results in a multitude of deleterious effects. Though the restoration of kidney function following transplantation is generally accompanied by a correction of metabolic acidosis, a subset of transplant recipients remains afflicted by this ailment and its subsequent morbidities. The vulnerability of kidney allografts to metabolic acidosis can be attributed to reasons similar to pathogenesis of acidosis in non-transplant CKD, and to transplant specific causes, including donor related, recipient related, immune mediated factors, and immunosuppressive medications. Correction of metabolic acidosis in kidney transplantation either with alkali therapy or through dietary manipulations may have potential benefits and the results of such clinical trials are eagerly awaited. This review summarizes the published evidence on the pathogenesis and clinical consequences of chronic metabolic acidosis in kidney transplant recipients. CalcineRejection can cause tubulitis and ischemic tubular dysfunction, affecting H + ATPase activity and anion exchanger leading to RTA . HoweverLastly, hyperkalemia, a common occurrence post kidney transplantation  also contributes to development of acidosis. Hyperkalemia decreases ammonia generation and transport in proximal tubule and collecting duct respectively, leading to impaired ammonia excretion and subsequent metabolic acidosis . Of the 2 level less than 22 mmol/L at three months post-transplant was associated with increased risk of graft loss and death censored graft failure , metabolic acidosis defined as the serum total CO failure . Similar failure ; however failure . This poPost transplantation anemia is common in kidney transplant patients with prevalence being reported around 30–50% of the patients . The pat2 vitamin D3 by proximal tubule, increasing calcium excretion and serum PTH levels, thus promoting bone resorption sorption . In vitreoclasts . Additioeoclasts , therefoeoclasts .Individuals with advanced kidney disease often have reduced muscle mass and exercise tolerance . PhysicaMetabolic acidosis has been shown to be an independent risk factor for all-cause mortality in CKD . These fThere is a paucity of evidence attesting to the benefits of metabolic acidosis correction in kidney transplant recipients. In fact, in a large retrospective study of 4741 kidney transplant recipients sodium bicarbonate therapy was associated with higher risk of graft failure . HoweverIn a small randomized controlled trial aimed to investigate the effect of sodium bicarbonate therapy on vascular endothelial function in 20 kidney transplant recipients , the sodData on dietary fruits and vegetable consumption as a measure of metabolic acidosis correction in kidney transplant recipients is even scarcer. In CKD, a diet rich in fruits and vegetables favorably affects acid-base metabolism, neutralizes diet-induced acid, and has been shown to be cardio-protective . In a prMetabolic acidosis is an understudied, highly prevalent complication in kidney transplant recipients. In addition to mechanisms described in metabolic acidosis of CKD, calcineurin inhibitors play a central role in its development and maintenance, through dysregulation of tubular transport proteins involved in acid load handling. Additional research aimed to unfold the mechanisms and consequences of metabolic acidosis present post kidney transplantation will help inform future large intervention trials designed to correct it, in an attempt to prevent allograft loss and improve overall survival in kidney transplant recipients.


Do physician group practices participating in bundled payments among Medicare beneficiaries exhibit similar or different changes in episode outcomes compared with participating hospitals?This cohort study with a difference-in-differences analysis found that physician group practices participating in bundled payments had associated savings with surgical but not medical episodes, whereas participating hospitals had savings associated with both episode types.The findings of this cohort study suggest that policy makers should consider the comparative performance of participant type when designing and evaluating future bundled payment models. Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown.To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals.This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022.Hospitalization for any of the 10 highest-volume episodes  included in the BPCI initiative for Medicare patients of participating PGPs and hospitals.The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality.The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710  received care through 379 BPCI-participating hospitals and 1441 propensity-matched non−BPCI-participating hospitals, and 592 071  received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non−BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical  but not for medical episodes . Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical  and medical  episodes.This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models. This cohort study evaluates the association between bundled payments and episode outcomes per medical and surgical episodes for physician groups compared with hospitals participating in the Medicare bundled payments initiative. Along with hospitals, PGPs participated in model 2 of Medicare’s Bundled Payments for Care Improvement (BPCI) initiative,10 assuming accountability for the quality and costs of medical and surgical episodes spanning hospital admission and up to 90 days of postacute care. Although PGP participation in BPCI was associated with reduced Medicare payments and improved quality for joint replacement episodes,11 data are lacking for the hundreds of groups participating in other medical and surgical episodes.Although hospital participation in bundled-payment programs has been well studied,12 We addressed this knowledge gap by evaluating the association between PGPs and hospitals participating in BPCI model 2 on episode outcomes and comparing PGP vs hospital performance.To coordinate participation in future payment models, policy makers must understand the dynamics of PGP vs hospital performance, particularly given the evidence from other payment models indicating that physician groups may perform differently than hospitals in managing quality and costs.STROBE) reporting guideline.13This study was approved by the University of Pennsylvania Institutional Review Board and informed consent was waived because only historical data with minimal risk of harm were used. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology  and a subsequent intervention period . The study sample included Medicare fee-for-service beneficiaries receiving care through BPCI PGPs and hospitals for 1 of 10 episodes, each defined by a set of Medicare Severity-Diagnosis Related Group codes: the top 5 highest-volume medical episodes  and the top 5 highest-volume surgical episodes . We excluded beneficiaries with end-stage kidney disease or insurance coverage through Medicare Advantage, as well as beneficiaries who had any non-Inpatient Prospective Payment System claims, lacked continuous primary Medicare fee-for-service coverage during or in the 12 months preceding the episode, or died during the index hospital admission.3 We excluded episodes between January 1, 2013, and September 30, 2013, to account for the transitional period during which PGPs and hospitals may have implemented care process changes in anticipation of BPCI.We constructed episodes beginning with hospital admission and spanning 90 days after hospital discharge, capturing episodes beginning on or before September 30, 2017. To avoid bias arising from Medicare precedence rules for overlapping episodes between participating PGPs and hospitals, we followed prior methods and constructed naturally occurring episodes by assigning overlapping ones to the earlier hospitalization.12 and those with any BPCI PGPs or BPCI hospitals were defined as BPCI Markets. We categorized patients based on hospitalization for 1 of 10 episodes of interest through BPCI PGPs, non-BPCI PGPs, BPCI hospitals, or non-BPCI hospitals. Patients receiving care through BPCI PGPs and hospitals were categorized as “BPCI-both.”We used Medicare claims data (2011-2018) to identify BPCI PGPs and BPCI hospitals. Groups and hospitals that never participated in any of the 48 episodes in BPCI were categorized as non-BPCI PGPs and non-BPCI hospitals. We used propensity scores to match BPCI with non-BPCI PGPs and BPCI with non-BPCI hospitals , and other responses were classified in the “other” category.The study exposures were dichotomous indicators of PGP participation and hospital participation in BPCI. To reflect participant entry into BPCI at different times, participation indicators were time-varying and specific to each PGP or hospital. Groups and hospitals were considered as participants after enrolling in BPCI, regardless of subsequently dropping out. Covariates were chosen based on prior studies and included patient demographic and clinical variables, such as age, sex, and disease severity (defined using Elixhauser comorbidities), as well time-varying market variables, such as Medicare population size and Medicare Advantage penetration.The study’s primary outcome was 90-day total episode spending . Secondary outcomes were 90-day readmissions and 90-day mortality. We also evaluated a number of exploratory spending and utilization outcomes (eMethods 2 in 18 We used a difference-in-differences (DID) method to mimic a 2 × 2 factorial experiment comparing BPCI participation among hospitals and PGPs. Per the factorial design, we classified the treatment groups to reflect patient exposure to BPCI hospitals, BPCI PGPs, both (BPCI-both), and neither (non-BPCI). This approach enabled the comparison of episode performance for BPCI PGPs (vs non-BPCI) and BPCI hospitals (vs non-BPCI), as well as between BPCI PGPs and BPCI hospitals).Characteristics between the propensity-matched BPCI and non-BPCI PGPs and BPCI and non-BPCI hospitals were compared using standardized differences of means and proportions.19 Nonparticipating PGPs and hospitals were assigned the same treatment indicators as their propensity matched organizations. We evaluated medical and surgical episodes separately because they involve different care processes that may have different associations with outcomes.19In adjusted analyses, DID models included PGP- and hospital-specific indicators of BPCI participation as treatment to reflect the time-varying nature of BPCI participation—that is, the fact that PGPs and hospitals could start participating at different times. This approach contrasted with traditional DID models, in which the baseline and treatment periods are fixed regardless of timing of actual contract initiation.We used generalized linear models with identity links and normal distributions for all outcomes. All models included episode (Medicare Severity-Diagnosis Related Group code) and market  fixed effects to generate within-episode type, within-market estimates that addressed time-invariant episode type, and geographic differences. Models also included time  fixed-effects to account for secular trends. Robust standard errors were clustered at the hospital level.20 we assessed the relationship between the primary outcome and potentially time-varying market-level covariates and how those covariates changed over time across the 4 study groups .Final model specifications for the primary outcome included only covariates deemed as potential confounders according to this process  as being in the BPCI PGP group. Finally, we repeated analyses for the mortality outcome by including individuals who died during index hospitalization.In response to an association observed between BPCI participation and differential changes in mortality that, to our knowledge, has not been previously described in the literature, we conducted post hoc analyses to explore robustness. First, we described selection based on observable and unobservable patient characteristics. Second, we tested approaches to mitigate bias from unobserved clinical severity of patients. Third, we repeated analyses using our modeling approach, but using data from that earlier time period, to assess the ability to replicate those mortality results.The total study sample comprised 2011 to 2018 Medicare claims data for 1 288 781 beneficiaries, of whom 696 710 patients  received care through 379 BPCI hospitals and 1441 propensity-matched non-BPCI hospitals; and 592 071 patients  received care from 6405 physicians in BPCI PGPs and 24 758 propensity-matched physicians in non-BPCI PGPs.Compared with non−BPCI-participating hospitals, participating hospitals tended to be larger, nonprofit, teaching hospitals located in urban areas and markets with larger populations and smaller proportions of low-income individuals . In contrast, there were no differential changes in spending between BPCI PGP and non-BPCI groups  or between BPCI-both and non-BPCI groups . The BPCI hospitals had differentially greater reductions in total episode spending compared with BPCI PGPs .In adjusted analysis of medical episodes , but not between BPCI PGP and non-BPCI groups . Compared with the non-BPCI group, there were differential decreases in mortality for BPCI PGPs  and BPCI hospitals . The BPCI hospitals and BPCI PGPs did not exhibit comparatively differential changes in mortality or readmissions. The BPCI hospitals differed from nonparticipants with respect to exploratory outcomes for medical episodes , BPCI PGP group , and BPCI-both  compared with the non-BPCI group. The magnitude of spending changes did not differ between BPCI hospitals and PGPs .In adjusted analysis . In contrast, there were no differential changes in readmissions for the BPCI hospital or BPCI-both groups compared with the non-BPCI group .Compared with patients in the non-BPCI group, those in the BPCI PGP group had differentially greater changes in 90-day readmissions  and BPCI hospitals  compared with patients in the non-BPCI group. The magnitude of these changes was not different for BPCI hospitals vs BPCI PGPs . Compared with nonparticipants, BPCI hospitals and PGPs differed in exploratory surgical episode outcomes (eTable 10 in Mortality changed differentially for patients cared for through BPCI PGPs (difference, –0.5 pp; 95% CI, –0.8 to –0.2 pp; 3 that found no association between BPCI hospital participation and differential mortality changes.Compared with the main study analyses, results of sensitivity analyses were qualitatively similar (eFigures 7-12 in In this cohort study with DID analysis, participation of PGPs and hospitals in BPCI was associated with cost savings for surgical episodes; however, only hospital participation was associated with cost savings for medical episodes. Hospital and PGP participation were associated with different patterns of changes in postacute utilization and mortality. For example, for medical episodes, hospital participation in BPCI was significantly associated with reductions in length of stay at skilled nursing facilities, whereas PGP participation was not. For surgical episodes, PGP participation in BPCI was associated with reductions in home health use, whereas hospital participation was not. These findings pose 3 implications.11 Although it is only one aspect of a payment model’s success, spending reductions are critical because policy makers increasingly judge the viability of bundled payment programs by their cost savings.22First, these findings underscore the benefit of engaging PGPs in episode-based payment models. This analysis adds to prior work by describing the association of PGP participation in BPCI with cost savings for multiple surgical episodes, extending beyond hip and knee replacements.12 demonstrating that PGPs may be more successful than hospitals at reducing spending in population-based payment models, such as acute care organizations. Future work should elucidate drivers underlying this distinction. For example, hospitals may be better positioned to coordinate with postacute care organizations such as skilled nursing facilities given their high volume of shared patients. These strategies may be particularly important for medical conditions where the episode cost savings come from reductions in postacute care facility length of stay rather than reductions in the proportion of individuals discharged.3 Policy makers may consider these facets of performance when considering participant types in future alternative payment models.Second, these study findings affirm the suitability of hospitals to bundled payment models, specifically highlighting their relative advantage over PGPs in achieving cost and potential quality outcomes for medical conditions. These findings contrast with prior researchThird, these study findings emphasize the need for future research on the drivers of cost savings and quality improvements under bundled payments. Our results regarding BPCI-participating PGPs point to the importance of changes in readmissions and postacute care utilization in determining episode savings. Yet as observed from BPCI-participating hospitals, different patterns of utilization changes may drive savings for different episode types. Specifically, in these findings medical episode savings were associated with reductions in length of stay within skilled nursing facilities, whereas surgical episode cost savings came from fewer discharges to skilled nursing facilities.Additional work is also needed to assess the relationship between bundled payments and quality improvements. Although differential mortality reductions were observed by this study, there was also evidence of observable and unobservable favorable patient selection under bundled payments. This makes definitive conclusions regarding changes in health care quality challenging. Clarity on whether apparent quality changes represent true improvements, patient selection, or measures of both is highly relevant to policy and should be the focus of future studies.This study had some limitations worth noting. Findings may have been subject to residual confounding; however, we mitigated concerns by using a DID design that accounted for unobserved heterogeneity and patient and hospital characteristics. We evaluated the highest-volume episodes under a single program; however, BPCI model 2 was the direct basis for ongoing PGP and hospital participation in BPCI Advanced. Also, we did not include more recent data from BPCI Advanced because physician group participation files were not available. Moreover, we were unable to match physicians or identify episodes using tax identification number-level information owing to a lack of data availability. However, our approach using all episodes per National Provider Identification number and any participation in BPCI was conservatively biased toward the null hypothesis. Furthermore, to our knowledge, mortality reductions have not been previously described, and although we tested the robustness of the findings using a range of sensitivity and post hoc analyses, the analyses suggested the presence of unobservable patient selection that precluded definitive conclusions regarding any changes in health care quality. Despite conducting sensitivity analyses using alternative modeling approaches for episode spending as the primary outcome, future work should assess the use of modeling approaches beyond ordinary least-squares for other outcomes.This cohort study with DID analysis found that PGP participation in BPCI was associated with cost savings for surgical episodes but not for medical episodes, whereas hospital participation in BPCI was associated with savings for both episode types. Policy makers should consider the comparative performance of participant type when designing and evaluating future bundled payment models.


Bronchopulmonary sequestration (BPS) and hybrid lesion of congenital pulmonary airway malformation (CPAM) are congenital lung lesions typically presenting with systemic vascular connection. We describe and categorize this atypical systemic vascular anatomy in congenital lung lesions.In a medical chart review from 2005 to 2020 patients with systemic vascular connection of congenital lung lesions were identified. Clinical and radiological data were collected and compared. Two experienced pediatric radiologists reviewed postnatal thoracic contrast-enhanced computed tomography scans to describe and categorize atypical vascular anatomy. We completed our findings with a review on vascular anatomy in congenital lung lesions.A total of 21 patients with congenital lung lesions  had systemic arterial supply; with seven of these additionally having systemic venous drainage. Origin of the feeding arteries from the aorta or aortic main branches was described as supra-diaphragmatic (descending thoracic aorta) in nine and infra-diaphragmatic in ten patients . In two patients with hybrid lesions both supra- and infra-diaphragmatic arterial feeders were found. Additional systemic venous connection of supra-diaphragmatic type drains into the azygos-hemiazygos system (4/21) while the infra-diaphragmatic type (3/21) drains into caval vein, portal or splenic vein.Various variants of systemic arterial and venous connection of congenital lung lesions can be found. Classification of systemic arterial connection as well as venous drainage of congenital lung lesions as supra-diaphragmatic and infra-diaphragmatic types is intuitive, simple and may be important for the surgeon to avoid unanticipated situations and to perform safe resections. Congenital pulmonary lesions are occasionally detected in prenatal ultrasound examinations. The most common lesions are congenital pulmonary airway malformation (CPAM) and bronchopulmonary sequestration (BPS). Atypical systemic blood supply is a characteristic feature of BPS, but there is also a number of CPAMs presenting with systemic vascular connection referred to as hybrid lesions . PrenataThis is a retrospective chart review performed in a tertiary perinatal center in a large Austrian city. After institutional review board approval, all patients with BPS and CPAM were identified in prenatal, neonatal and surgical database from 2005 to 2020. Only patients with systemic vascular connection  of congenital lung lesion were included. Medical records were reviewed for pre- and postnatal clinical data; complications and outcome of treatment were assessed. Two experienced pediatric radiologists reviewed postnatal CECTs (iodixanol) to precisely describe the atypical anatomy of both arterial and venous systemic connection of congenital pulmonary lesions. We focus on description and categorization of vascular anatomy of these congenital lung lesions. A literature review on vascular characteristics in congenital lung lesions completes our data.From 2005 to 2020, 48 patients  with either BPS or CPAM were treated at our department of pediatric surgery in a tertiary university hospital. In 39 cases these congenital lung lesions were identified in prenatal ultrasound examination. Postnatal CECT scan did not depict systemic vascular supply in 25 of 48 patients with congenital lung lesions—these were “classical” CPAM. In two patients, prenatally diagnosed congenital lung lesion was not confirmed postnatally: one child had a normal CECT scan and the other showed small vascular connections between the thoracic aorta and the pulmonary artery in the absence of a lung lesion.In 21 cases postnatal CECT depicted systemic vascular connection of congenital lung lesions: nine extralobar bronchopulmonary sequestrations (EBPS), five intralobar bronchopulmonary sequestrations (IBPS) and seven hybrid lesions. CECT scans were performed with general anaesthesia at a median age of 95 days (range 1–218 days) in all patients. In seven of these 21 patients, systemic vascular supply had been identified prenatally .n = 4) and the abdominal aorta (n = 6). Further possible supra- and infra-diaphragmatic types of arterial feeders in congenital lung lesions are presented in n = 2) or infra-diaphragmatic types (n = 1). Maximum diameter of the arterial systemic branches ranged from 1.0 to 5.0 mm (median = 2.3 mm).Arterial blood supply of the congenital lung lesion was categorized as supra-diaphragmatic and infra-diaphragmatic, depending on the origin of the arterial branch . Supra-dSeven of twenty-one cases of congenital lung lesions with systemic arterial supply additionally had atypical systemic venous drainage . Supra-dOpen surgical resection of BPS and hybrid lesion was performed in all 21 patients with congenital lung lesion and systemic vascular supply. Postoperative complications were found in three patients (3/21). In two patients pneumothorax urged chest tube insertion in the postoperative phase. One patient had postoperative hemothorax due to blood oozing from injured intercostal vessels necessitating revision surgery within 8 h. No bleeding occurred from the ligated atypical systemic arteries or veins. At follow up 6 months after surgery all patients presented without any complaints.In congenital lung lesions, systemic vascular connection of the lesion is a frequent and characteristic finding. Atypical arterial and venous vessels play an important role in diagnosis and classification of these lesions. BPS may be diagnosed prenatally by depiction of a lung mass with systemic arterial connection. It is well-known that intralobar and extralobar bronchopulmonary sequestration  may be distinguished by venous return of the lesion: IBPS drains via pulmonary veins while EBPS drains systemically. An overlap between BPS and CPAM has been found and this congenital lung lesion has been described as hybrid lesion—a CPAM with systemic vascular connection . It is nSystemic arterial supply in congenital lung lesions seems to frequently originate from the thoracic or abdominal aorta . NeverthIn our series five patients had more than one systemic artery. As described in the sparse literature on this subject, this may not be a rare finding  and evenThe most distal systemic arterial feeder in our series originated from the celiac trunk; but even arterial supply coming from a renal artery has been described . In thisAtypical systemic venous drainage occurs less frequently than atypical arterial supply in congenital lung lesions, as the majority of intralobar BPS show normal venous drainage via pulmonary veins. Nevertheless, systemic venous drainage may also be found in IBPS . Supra-dIn congenital lung lesions, atypical systemic vascular connection is a major cause of morbidity: high output cardiac failure, congestive heart failure or hemoptysis may occur . AlthougThe high degree of variability of systemic vascular anatomy necessitates clear and intuitive classification of this systemic arterial and venous connection in congenital lung lesions. Based on the origin of systemic arteries and veins we differentiate supra-diaphragmatic and infra-diaphragmatic vascular types of congenital lung lesions. This differentiation has practical-surgical relevance: as the diaphragm separates abdominal and thoracic cavity, vascular injury during surgery in congenital lung lesion with infra-diaphragmatic arterial supply may cause fatal intraabdominal bleeding. Therefore, our classification may contribute to correct preoperative evaluation to avoid unanticipated vascular complications.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.SK: study conception and design. FS, MS, and JK: data collection. SK, FS, MS, and JK: analysis and interpretation of results and draft manuscript preparation. All authors reviewed the results and approved the final version of the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Medial prefrontal cortex (mPFC) interacts with distributed networks that give rise to goal-directed behavior through afferent and efferent connections with multiple thalamic nuclei and recurrent basal ganglia-thalamocortical circuits. Recent studies have revealed individual roles for different thalamic nuclei: mediodorsal (MD) regulation of signaling properties in mPFC neurons, intralaminar control of cortico-basal ganglia networks, ventral medial facilitation of integrative motor function, and hippocampal functions supported by ventral midline and anterior nuclei. Large scale mapping studies have identified functionally distinct cortico-basal ganglia-thalamocortical subnetworks that provide a structural basis for understanding information processing and functional heterogeneity within the basal ganglia. Behavioral analyses comparing functional deficits produced by lesions or inactivation of specific thalamic nuclei or subregions of mPFC or the basal ganglia have elucidated the interdependent roles of these areas in adaptive goal-directed behavior. Electrophysiological recordings of mPFC neurons in rats performing delayed non-matching-to position (DNMTP) and other complex decision making tasks have revealed populations of neurons with activity related to actions and outcomes that underlie these behaviors. These include responses related to motor preparation, instrumental actions, movement, anticipation and delivery of action outcomes, memory delay, and spatial context. Comparison of results for mPFC, MD, and ventral pallidum (VP) suggest critical roles for mPFC in prospective processes that precede actions, MD for reinforcing task-relevant responses in mPFC, and VP for providing feedback about action outcomes. Synthesis of electrophysiological and behavioral results indicates that different networks connecting mPFC with thalamus and the basal ganglia are organized to support distinct functions that allow organisms to act efficiently to obtain intended outcomes. The ability to act based on the current incentive value of action outcomes is a defining feature of purposive or goal-directed behavior, one that distinguishes goal-directed responses from stimulus-elicited habits that are unaffected by changing outcome values . Goal-diWe focus on behavioral and electrophysiological studies that allow direct comparisons between mPFC, the basal ganglia, and thalamus. Rodent mPFC corresponds to regions of primate cingulate cortex . It is aGoal-directed responses are guided by the incentive value of anticipated action outcomes . Much ofAlthough questions remain about their precise roles it seems clear that PL, IL, and MO are important for anticipating the incentive value of potential action outcomes. Neurophysiological recordings of brain activity have confirmed that neurons in these areas fire in anticipation of action outcomes and provided evidence that this information is also represented in other areas that give rise to goal-directed behavior. Human functional magnetic resonance imaging (fMRI) studies show that anticipation of monetary awards is associated with cortical activation in midcingulate/supplementary motor and insular areas distinct from areas of anterior and posterior cingulate cortices activated during award delivery . Electron = 50) in rats performing a dynamic DNMTP task (n = 63) exhibited increased activity within 0.2 s after reward delivery began and lasted until 1 s after it ended. They did not respond following unrewarded incorrect choices. It is unclear from timing data whether these responses are related to consummatory activity or reward delivery. Other studies have provided evidence that neurons in orbitofrontal cortex and mPFC encode information about the identity and subjective value of rewards  analyses have revealed two levels of organization in learned action sequences: actions initiating learned sequences or chunks of learned sequences have elevated RTs reflecting the cost of planning an organized sequence ahead of time while actions later in sequences (or chunks) exhibit reduced RTs reflecting the benefits of performing a practiced sequence . Bailey While fMRI analyses have revealed preparatory activity in multiple brain regions, including motor, somatosensory, and parietal regions, only signals originating in contralateral supplementary motor and premotor regions consistently predict the type of sequential finger movement executed . AC cortAdaptive responding requires constant updating of sensory information to guide ongoing actions in dynamic environments. M2 plays a critical role in flexibly mapping sensory signals to motor actions, consistent with its prominent connections to sensory and association cortices and motor control areas . EarlierConvergent evidence indicates that cingulate areas of mPFC monitor current actions and outcomes, provide error feedback and information about reward value and manage conflict when there is competition between potential actions or strategies . ContingLesions or inactivation of mPFC affect the ability of organisms to adapt when contingencies between stimuli, actions, and outcomes are changed during extinction learning . ElectroTo respond adaptively in dynamic contexts organisms must constantly update information about environmental conditions and action-outcome contingencies across short and long timescales. mPFC is interconnected with important memory systems and has functional properties that seem well suited for this purpose see . mPFC isLonger-term memories promote adaptive responding by gradually integrating information across time, a function that allows organisms to adjust to lasting changes in the external environment or response contingencies. All areas of mPFC receive projections from the hippocampal-entorhinal cortex network and the BLA , importaAll areas of mPFC have afferent and efferent connections with multiple nuclei in central thalamus . These aThe central lateral (CL), paracentral (PC), and central medial (CM) rostral intralaminar nuclei project to distinct areas of mPFC and striatum that are connected by corticostriatal projections. These appear organized to control cortical-basal ganglia networks and thus the selection of goals, actions, and sensory signals . The venLesion and inactivation studies have confirmed the dependence of mPFC function on distinct contributions of different thalamic nuclei see . MD lesiLesions damaging the rostral intralaminar nuclei  have effects comparable to mPFC lesions on DMTP and DNMTP: producing delay-independent deficits for egocentric DMTP and DNMTP that affect both speed and accuracy of choice responses with more limited effects on allocentric radial maze DNMTP . IntralaThe anterior thalamic AM and IAM nuclei are important nodes in pathways linking the hippocampal system with PL and AC areas of mPFC . AM and Striatum, the input side of the basal ganglia, receives projections from virtually all areas of cerebral cortex and the limbic system . These cLesion studies have demonstrated functional specialization at the level of the broad channels of information flow in dorsolateral, dorsomedial, and ventral striatum. Dorsolateral and dorsomedial striatum have also been dissociated for tasks used to distinguish goal-directed and habitual action control. Treatments disrupting dorsolateral striatum increase sensitivity to outcome devaluation and contingency degradation, interfere with execution of species-specific and learned sequential actions, and bias animals toward spatial rather than response-related cues in navigation while disruption of dorsomedial striatum blocks sensitivity to outcome devaluation and contingency degradation, decreases dependence on spatial navigation cues and increases reliance on habit learning . These fThe multiple striatal subnetworks revealed by large-scale mapping studies indicate that striatal specialization extends beyond the broad division into dorsomedial, dorsolateral, and ventral domains. Ventral striatum is considered an important link between limbic systems encoding reward and aversion and motor circuits . It receLesions or inactivation of ventral pallidum produce delay-dependent impairment of RT and accuracy of DMTP, comparable to effects of mPFC, central thalamic, and ventral striatal lesions . Cross-iMedial prefrontal cortex is organized as a hub for multiple large-scale neural networks that give rise to prospective, concurrent, and retrospective processes that support adaptive goal-directed behavior . ElectroAnatomical evidence indicates that mPFC is organized along a dorsal to ventral gradient, with more dorsal areas closely linked to sensory and motor cortices and ventral areas of mPFC receive more prominent connections with amygdala and limbic areas of cortex, including hippocampal and parahippocampal areas . Lesion Medial prefrontal cortex has reciprocal connections with multiple central thalamic nuclei that have distinct effects on adaptive goal-directed responding . This inMediodorsal is the main source of focal thalamic projections to middle layers of mPFC and accordingly is often emphasized in treatments analyzing the role of thalamus in mPFC function. Recent studies have elucidated a role for MD regulating signal processing properties of mPFC neurons and stressed its importance for rapid trial-by-trial learning and complex decision making . LesionsDorsal and ventral areas of striatum are comprised of distinct subdomains defined by open loop projections from functionally specific areas of cerebral cortex and the limbic system, closed loop projections from subregions of prefrontal cortex, and thalamostriatal projections primarily from midline and intralaminar nuclei. Both electrophysiological and behavioral findings (reviewed above) are consistent with the hypothesized distinction between ventral striatum processing reward signals and facilitating the motivational control of performance and dorsal striatum forming associations between sensory, motor, and limbic inputs to guide action selection and support the acquisition of goal-directed actions . Large-sThalamus serves as an important integrative center for cortico-basal ganglia networks as nodes connecting basal ganglia to cortex and as the source of thalamostriatal projections that terminate on medium spiny neurons in striatum . MD is a(1)Medial prefrontal cortex (mPFC) interacts with the basal ganglia and thalamus to support functions that allow organisms to control actions intended to obtain desired outcomes . These include prospective anticipation of potential action outcomes, selection and maintenance of motor goals, and motor preparation; concurrent control and monitoring of ongoing actions; and retrospective updating of information and strategies to guide future behavior.(2)Medial prefrontal cortex is organized with dorsal regions prominently connected with sensory and motor cortices controlling motor planning, prospective decision making, motor response memory, and flexible responding based on trial-specific sensory cues. Ventral areas have more prominent connections with hippocampus, amygdala, and limbic areas of cortex and are important for anticipating action outcomes, fear learning and extinction, and systems memory consolidation.(3)Electrophysiological recordings during DNMTP reveal neurons with responses related to actions and outcomes distributed throughout mPFC. Although there is no sudden transition apparent when electrodes are driven ventrally through mPFC, there are significant trends for neurons with responses related to motor preparation, lever press actions, and movements between levers to be distributed in dorsal mPFC and neurons with responses related to reward anticipation, movements toward reinforcement, and memory delay to be more frequent in ventral mPFC. Inactivation of central thalamus affects the expression of action- and outcome-related responses in mPFC. The inclusion of choice responses during DNMTP trials engages mPFC neurons to respond to task-relevant information.(4)Lesion studies indicate that dorsal striatum is important for associative and sensorimotor control and ventral striatum for reward and motivational control of goal-directed behaviors. Deficits produced by striatal lesions parallel the effects of lesions damaging anatomically related areas of mPFC. Large scale mapping studies have described extensive reconfiguration and integration of corticostriatal projections into striatal subnetworks that provide a structural basis for information processing and functional heterogeneity within striatum.(5)Multiple thalamic nuclei have afferent and efferent connections with mPFC that appear organized to control different aspects of goal-directed responding. The mediodorsal nucleus (MD) is the main source of focal thalamic input to middle layers of mPFC. Recent evidence indicates that MD amplifies and sustains activity in mPFC neurons that encodes information about actions and outcomes important for rapid trial-by-trial learning, complex decision making, and working memory. The intralaminar nuclei have thalamostriatal and thalamocortical projections that control transmission of information in cortico-basal ganglia networks. Behavioral studies have confirmed that intralaminar lesions have broad effects on functions that depend on mPFC and striatum. The ventral medial nucleus has prominent connections with dorsal regions of mPFC and adjacent sensorimotor cortex that support integrative motor responses. The ventral midline reuniens and rhomboid nuclei provide a critical link between mPFC and hippocampus and play a critical role in spatial and contextual memories and systems memory consolidation. The interoanteromedial (IAM) and anterior medial (AM) nuclei are nodes in pathways linking mPFC with hippocampus important for allocentric spatial learning and memory. While lesion studies indicate that mPFC lesions do not impair allocentric spatial memory, reciprocal connections with AM and IAM provide a link between mPFC and hippocampal-related systems that mediates this function.(6)Comparisons of neuronal activity in mPFC, MD thalamus, and ventral pallidum (VP) reveal important similarities and differences for information represented in these areas in rats performing a dynamic DNMTP task. Neurons in mPFC exhibit responses related to motor preparation, reward anticipation, and prospective memory delays not observed in VP. Responses related to motor preparation and prospective memory delays are also not observed in MD. Although reward anticipation responses are observed in MD, these are delayed and less robust. This suggests that mPFC exerts top-down control of prospective processes anticipating action outcomes, selecting motor goals, and preparing to execute action sequences. VP, by contrast, is dominated by neurons with responses related to reward delivery and reward-related actions consistent with evidence that VP provides feedback about action outcomes and affects the vigor of outcome-related responses.RM was primarily responsible for writing the article. MF, EK, and BG contributed to the writing and discussion. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Population aging in Singapore has encouraged the development of ambient smart communities to support healthy aging. Poor understanding of the living activities that address both clinical and biological concerns may plague efficient aging service designs and community health programs. We have designed a new computational workflow to identify important living activities for older adults in Singapore. We investigated innovatively three pillars of human life aspects: activities, clinical health, and biological health to identify living activities that are significantly associated with both clinical health and biological health. Cross-sectional data analyses were performed on 1356 community-living Chinese older adults of 65–80 years old in the Singapore Longitudinal Aging Study II (SLASII) cohort. 7 out of 29 living activities were found significantly associated with clinically healthy aging and showed improved prediction accuracy towards health status in machining learning schemes. Furthermore, biological age has been computed by screening and modeling 66 biomarkers. 15 out of the 29 living activities were found significantly associated with biologically healthy aging. Checking the overlapping living activities, we have found that physical exercise and cognitive-simulating activities are the most important activities for healthy aging: such as jogging regularly and reading, writing, and doing puzzles often. We regroup participants into active and non-active groups according to these two activities. The Keplan-Meier survival analysis showed statistically significant differences in survival time between the active and non-active groups (p < 0.001) in an 8-year longitudinal study. The workflow, results and biomarkers may provide references for future health program design improvement.


Disparities in vaccination uptake among migrant populations are well documented. WHO and ECDC have sought renewed focus on participatory research that engages migrants in co-producing tailored initiatives to address vaccination inequities and increase coverage.This community-based participatory research study aims to engage Congolese migrants in co-developing a tailored approach to increase vaccine uptake. Phase 1 used poster walls and in-depth interviews with Congolese migrants (n = 32) to explore COVID-19 vaccination beliefs, experiences, and preferred information sources and communication methods, analysed iteratively and thematically in NVivo.Institutional distrust has shaped this population’s interpretation of the pandemic response and enabled vaccine misinformation and conspiracy theories to take hold. We found complex information networks and preference for Francophone, African and social media. Limited English proficiency and preference for the oral tradition restricted engagement with official public health messaging. Suspicion of government motives, low knowledge, and culturally specific perceptions about vaccination contributed to belief that breakthrough infections and need for COVID-19 boosters imply the vaccine is not effective. The population felt coerced by vaccination reminders and mandates, and were resultantly more hesitant to accept COVID-19 vaccination.The population’s specific characteristics suggest that existing and trusted interpersonal networks and oral communication in first languages should be harnessed to spread credible information and encourage vaccine uptake, and mandate policies are unlikely to be effective. Training local role models to facilitate vaccination dialogues and myth-bust may be effective at changing behaviour. The next phases will gather more information from key stakeholders and engage migrants in workshops to co-design insight-driven, tailored interventions.• Global policy-setting organisations have called urgently for participatory research that engages migrants in the co-production of tailored initiatives to address vaccination inequalities.• Populations with strong interpersonal networks and low trust in public institutions may be receptive to tailored, community-centred dialogue approaches using local messengers and role models.