Peer-reviewed Literature Research Articles

Current limitations and future research needs for predicting soil precompression stress: A synthesis of available data

Precompression stress, compression index, and swelling index are used for characterizing the compressive behavior of soils, and are essential soil properties for establishing decision support tools to reduce the risk of soil compaction. Because measurements are time-consuming, soil compressive properties are often derived through pedotransfer functions. This study aimed to develop a comprehensive database of soil compressive properties with additional information on basic soil properties, site characteristics, and methodological aspects sourced from peer-reviewed literature, and to develop random forest models for predicting precompression stress using various subsets of the database. Our analysis illustrates that soil compressive properties data primarily originate from a limited number of countries. There is a predominance of precompression stress data, while little data on compression index or recompression index are available. Most precompression stress data were derived from the topsoils of conventionally tilled arable fields, which is not compatible with knowledge that subsoil compaction is a serious problem. The data compilation unveiled considerable variations in soil compression test procedures and methods for calculating precompression stress across different studies, and a concentration of data at soil moisture conditions at or above field capacity. The random forest models exhibited unsatisfactory predictive performance although they performed better than previously developed models. Models showed slight improvement in predictive power when the underlying data were restricted to a specific precompression stress calculation method. Although our database offers broader coverage of precompression stress data than previous studies, the lack of standardization in methodological procedures complicates the development of predictive models based on combined datasets. Methodological standardization and/or functions to translate results between methodologies are needed to ensure consistency and enable data comparison, to develop robust models for precompression stress predictions. Moreover, data across a wider range of soil moisture conditions are needed to characterize soil mechanical properties as a function of soil moisture, similar to soil hydraulic functions, and to develop models to predict the parameters of such soil mechanical functions.

The central neck in 3 dimensions: a digital model derived from radiology, peer-reviewed literature, and medical illustration

This project aims to create a 3-dimensional (3D) digital model of central neck anatomy, including muscles, neurovasculature, and viscera. The neck was segmented from a CT angiogram of a healthy 29-year-old female, and then transferred into 3D illustration software after removing imaging artifact. To enhance anatomical accuracy, details not captured by imaging or unclear from the study were added and refined with relevant peer-reviewed literature. These structures were later incorporated into the head and neck model. Following segmentation, the 3D models was refined in 3D CAD software. Structures not identified by segmentation were designed by a medical illustrator and all structures were refined from peer-reviewed anatomic literature. Where discrepancies were found in the literature, the size, source, and methodology of the studies were considered to determine the most common variants of each structure. Finally, the 3D model was uploaded to MedReality for online viewing. Technological progress in illustration software, patient specific anatomic modeling, and precise 3D CAD modeling has allowed the most accurate 3D surgical anatomy model to be created when combined with existing literature. The associated 3D model and manuscript will serve as a helpful tool for medical professionals regardless of academic level. To our knowledge, this literature-based model of the central neck combined with 3D anatomic modeling from real patient data is unprecedented and should aid in surgical anatomy education.

The lateral neck in 3 dimensions: A digital model derived from radiology, peer-reviewed literature, and medical illustration

ObjectivesTo develop an anatomically accurate 3-dimensional (3D) digital model of the lateral neck anatomy, including musculature, neurovasculature, and other associated structures such as lymphatics Materials and MethodsLateral neck anatomy, emphasizing level 1-4 structures, were segmented from a CT angiogram of a healthy 29-year-old female which was later transferred into a 3D illustration software after removal of imaging artifacts. To enhance anatomical accuracy, details not captured by imaging or unclear from the study were refined with relevant peer-reviewed literature. These structures were incorporated into the head and neck model. ResultsFollowing segmentation, the 3D models was refined in 3D CAD software. Structures not identified by segmentation, including vagus and phrenic nerves and lymphatics beyond the scan resolution, were designed by a medical illustrator and all structures were refined from peer-reviewed anatomic literature. Where discrepancies were found in the literature, the sample size, source, and methodology of the studies were considered to determine the most common variant of each structure. Finally, the 3D model was uploaded to MedReality® for online viewing. ConclusionThis study demonstrates the critical anatomic structures, landmarks, and surgical relationships relevant to the lateral neck. The associated 3D model and manuscript will serve as a helpful tool for a broad range of clinicians and trainees in search of a detailed 3D anatomic description of the lateral neck. This literature-based model of the central neck combined with 3D anatomic modeling from real patient data should aid in surgical anatomy education.

Current state and future perspectives in the diagnosis of eyelid margin disease: clinical review.

The eyelid margin is vital to ocular surface integrity. Much peer-reviewed literature has been established in eyelid margin inflammation, better known as blepharitis. The purpose was to review and understand the impact of eyelid margin disease. Anterior blepharitis causes inflammation at the eyelash base, ciliary follicles, and the palpebral skin. Posterior blepharitis occurs when there is inflammation with the posterior eyelid margin disease. In common usage, the term "blepharitis" used alone almost always refers to anterior blepharitis. Classification of eyelid margin disease should be based on etiopathogenesis, location, primary vs secondary, and chronicity. Blepharitis has several etiopathologies (infectious, inflammatory, and squamous). Meibomian gland dysfunction (MGD) can refer to the functional and/or structural problems with the meibomian gland. Meibomitis (or meibomianitis) occurs when there is inflammation associated with the MGD. The presence of blepharitis and/or MGD (with or without inflammation) can affect the ocular surface and thereby affect anterior segment and cataract surgeries. This review article evaluates the differential diagnoses of eyelid margin disease, including various forms of blepharitis, MGD, and meibomitis.

The pterygopalatine fossa in three dimensions: a digital anatomical model derived from radiographic imaging, refined with peer-reviewed literature, and optimized with medical illustration

The pterygopalatine fossa in three dimensions: a digital anatomical model derived from radiographic imaging, refined with peer-reviewed literature, and optimized with medical illustration

Public Engagement in Health Policy-Making for Older Adults: A Systematic Search and Scoping Review.

As the world's population ages, there has been increasing attention to developing health policies to support older adults. Engaging older adults in policy-making is one way to ensure that policy decisions align with their needs and priorities. However, ageist stereotypes often underestimate older adults' ability to participate in such initiatives. This scoping review aims to describe the characteristics and impacts of public engagement initiatives designed to help inform health policy-making for older adults. A systematic search of peer-reviewed and grey literature (English only) describing public engagement initiatives in health policy-making for older adults was conducted using six electronic databases, Google and the Participedia website. No geographical, methodological or time restrictions were applied to the search. Eligibility criteria were purposefully broad to capture a wide array of relevant engagement initiatives. The outcomes of interest included participants, engagement methods and reported impacts. This review included 38 papers. The majority of public engagement initiatives were funded or initiated by governments or government agencies as a formal activity to address policy issues, compared to initiatives without a clear link to a specific policy-making process (e.g., research projects). While most initiatives engaged older adults as target participants, there was limited reporting on efforts to achieve participant diversity. Consultation-type engagement activities were most prevalent, compared to deliberative and collaborative approaches. Impacts of public engagement were frequently reported without formal evaluations. Notably, a few articles reported negative impacts of such initiatives. This review describes how public engagement practices have been conducted to help inform health policy-making for older adults and the documented impacts. The findings can assist policymakers, government staff, researchers and seniors' advocates in supporting the design and execution of public engagement initiatives in this policy sector. Older adult partners from the McMaster University Collaborative for Health and Aging provided strategic advice throughout the key phases of this review, including developing a review protocol, data charting and synthesis and interpreting and presenting the review findings. This collaborative partnership was an essential aspect of this review, enhancing its relevance and meaningfulness for older adults.

Improving Health Equity for Children Who Are Multiply Marginalized: A Narrative Review of Intersectional Interventions

Abstract Date Presented 03/22/24 This scoping review, spanning peer-reviewed and gray literature, summarizes interventions for health equity in children with disabilities and additional marginalized identities. Results from 31 articles inform approaches for promoting health parity. Primary Author and Speaker: Christie Cyktor Contributing Authors: Amy Houtrow, Jessica Jarvis, Ateh Fonteh, Helina Mengesha

Occupational post-exposure prophylaxis among healthcare workers: a scoping review of factors affecting optimal utilization.

Post-exposure prophylaxis (PEP) is an efficacious prevention method when initiated promptly after an HIV exposure. Yet, PEP has been underutilized, even among healthcare workers (HCWs) with occupational exposure in sites with PEP policies and procedures and access to PEP medications. It is important to understand the dynamics of uneven PEP use in what appears to be an optimal context to better protect the health and wellbeing of HCWs. We conducted a scoping review to elucidate factors influencing HCWs' use of PEP after occupational exposure. We searched PubMed, PsychInfo and Google Scholar for peer-reviewed literature published in English from 2014 to 2022 using the terms HIV, postexposure/post-exposure prophylaxis, acceptability, healthcare workers, and values and preferences. An inductive narrative review of the resulting 53 studies identified core themes. Nearly all studies (96%) with various HCW types and settings occurred in low- and middle-income countries (LMICs) in Africa and Asia. Identified themes arrayed along a trajectory of PEP use experience: awareness/knowledge; acceptability; availability/access; uptake/use; adherence/completion. Across studies, awareness of PEP for HIV prevention was high, knowledge about drug regimens and healthcare facility policies was moderate to low; acceptability of PEP was moderate to high; PEP's perceived accessibility/availability was inconsistent and varied by geographic location and setting; HCWs' uptake of PEP was low, affected by not knowing how to report an exposure and being unaware of PEP availability; and adherence/completion of PEP regimens was moderate to low, impeded by side effects and a belief that completing regimens was unnecessary to avert seroconversion. HCWs consistently expressed concern about HIV stigma. Findings are limited by the inconsistent use of constructs across studies and a lack of clarity about reporting exposure events. Multi-level approaches are needed to address the interplay of individual, social and structural barriers that diminish HCWs' PEP use. Improved training, incident reporting, 24-hour access to non-stigmatizing PEP services and monitoring of adherence/completion are essential to optimizing HCWs' PEP use. Lessons from HCWs' experience in LMICs may inform understanding of PEP under-use among people in these settings with non-occupational exposures.

A New Process Model for Relationship-Centred Shared Decision-Making in Physical Medicine and Rehabilitation Settings.

We present a relationship-centred shared-decision-making (RCSDM)process model to explicate factors that shape decision-making processes during physical medicine and rehabilitation (PMR) encounters among patients, their care partnersand practitioners. Existing shared decision-making (SDM) models fall short in addressing the everyday decisions routinely made regarding persons with chronic disabilities who require high levels of support, their care partnersand rehabilitation practitioners. In PMR, these everyday decisions are small scale, immediateand in service to a larger therapeutic goal. They can be thought of as micro-decisionsand involve multiple practitioners, care partnersand patients. How micro-decisions are made in this context is contingent on multiple roles and relationships among these relevant parties. Our model centres on micro-decisions among patients, their care partnersand practitioners based on our disorders of consciousness (DoC) research. To develop our model, we examined peer-reviewed literature in SDM in PMR, chronic disabilityand person-centeredness; formed collaborations and co-created our constructs with rehabilitation practitioners and with care partners who have lived experience of caring for persons with DoC; analysed emerging empirical dataand vetted early versions with expert scientific and clinical audiences. Our model builds from the core tenets of relational autonomy,and scholarship and activism of disability advocates. Our model conceptualizes four non-hierarchical levels of analysis to understand the process of micro-decision-making in chronic disability and medical rehabilitation: social forces (historical and sociological); roles and relationships (multiple and intersecting); relational dimensions (interactional and contextual)and micro-decision moments (initiation, responseand closure). Relationships among patients, their care partnersand practitioners are the intersubjective milieu within which decisions are made. Our conceptual model explicates the process of micro-decision-making in PMR. Care partners (or caregivers) and rehabilitation practitioners are active members of our team. We work together to develop research projects, collect, analyseand disseminate data. The conceptual model we present in this manuscript was co-created-input from care partners and practitioners on previously collected data became the impetus to develop the RCSDM process model and share co-authorship in this manuscript.

Contouring With Neuromodulators.

Botulinum toxins, originally used for facial rejuvenation, have emerged as a promising tool for sculpting and refining contours for both the face and body. The peer-reviewed literature on neuromodulator contouring treatments was analyzed, with a particular emphasis on studies and case reports involving the use of botulinum toxin type A. Modification of face, neck, shoulder, arm, and calf contour has been reported. Treatment and dosing protocols vary with the strength and depth of the target muscle. Regional effects of neuromodulator treatment begin to appear approximately 2 weeks after injection and are often most prominent at the 70- to 90-day time point. Although treatments are generally well tolerated, short-term muscle weakness and other side effects may occur. The use of neuromodulators to enhance facial and body contours has demonstrated efficacy, but further research is needed to validate their use and explore the full potential of this intervention through larger randomized controlled trials. The application of neuromodulators as a minimally invasive tool to address the rising demand for nonsurgical body sculpting represents a promising frontier in aesthetics.

Systematic review of bovine and zoonotic tuberculosis in the Western Pacific and the Southeast Asia regions of the World Health Organization.

Tuberculosis (TB) remains a leading cause of mortality worldwide. We conducted this systematic review to understand the distribution of bovine and zoonotic tuberculosis in the World Health Organization (WHO)'s Southeast Asia Region (SEAR) and Western Pacific Region (WPR) to inform our understanding of the risk posed by this disease. A two-pronged strategy was used by evaluating data from peer-reviewed literature and official reports. A systematic search was conducted using a structured query in four databases (Web of Science, Scopus, Medline, and PubMed) to identify any reports of the occurrence of zoonotic TB. No language and time constraints were used during the search, but non-English language articles were later excluded. The official data were sourced from the World Organization for Animal Health's (WOAH) World Animal Health Information System (WAHIS) and WHO's global TB database. The retrieved records from SEAR and WPR (n = 113) were screened for eligibility, and data about disease occurrence were extracted and tabulated. In SEAR, all of the five studies that conducted Mycobacterium speciation (5/6) in humans were from India, and the reported Mycobacterium species included M. tuberculosis, M. bovis, M. scrofulacium, M. kansasii, M. phlei, M. smegmatis and M. orygis. In WPR, Mycobacterium speciation investigations in humans were conducted in Australia (8), China (2), Japan (2), NewZealand (2) and Malaysia (1), and the reported Mycobacterium species included M. bovis, M. africanum and M. tuberculosis. Seven countries in WHO's SEAR have officially reported the occurrence of Mycobacterium bovis in their animals: Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. In WPR, the WAHIS information system includes reports of the identification of M. bovis from 11 countries - China, Fiji, Japan, Malaysia, Mongolia, New Zealand, the Philippines, the Republic of Korea, Singapore, Tonga and Viet Nam. In contrast, human zoonotic TB cases in the WHO database were only listed from Australia, Brunei Darussalam and Palau countries. The available data suggests under-reporting of zoonotic TB in the regions. Efforts are required to strengthen zoonotic TB surveillance systems from both animal and human health sides to better understand the impact of zoonotic TB in order to take appropriate action to achieve the goal of ending the TB epidemic.

Veterans in Care Homes: An International Scoping Review to Inform UK Policy and Practice

Context: In contrast to the mental and physical health needs of veterans, veterans’ social care needs remain relatively neglected by policymakers and researchers. Objective: To inform UK veterans policy and practice by drawing together the expectedly limited international research base on veterans in care homes. Method: An international scoping review of peer-reviewed and grey research literature was conducted, informed by Levac et al.’s (2010) six-stage process. Findings: Thirty-three papers were found to meet the inclusion/exclusion criteria. The papers’ contents typically fell into one or more of the following themes: social connection, care preferences and autonomy, and military-related physical and mental health needs. Limitations: Very little (n = 1) UK-situated research was found, with the majority of retrieved papers (n = 24) being US-based, impeding transferability and relevancy of the findings to a UK context. Implications: Veterans’ social care needs were found to be a largely underexplored area of research, especially in the UK. There is a pressing need for UK veterans’ policymakers to redress existing imbalances in the focus of policy and research by raising the status and importance of the social care needs of UK veterans, as has been achieved on the mental and physical health fronts.

Nurses' experiences and perceptions of running nurse-led clinics: A scoping review.

To explore what is known about nurses' experiences and perceptions of running nurse-led clinics. Nurse-led clinics were established to address health care needs. In collaboration with medical practitioners, advanced practice nurses may take a selected group of patients and manage their ongoing healthcare independently. Their experiences in running nurse-led clinics directly impact patient satisfaction and clinical outcomes. Scoping review of the peer-reviewed literature. Systematic search through CINAHL, Medline, PsycINFO and Web of Science databases from January 2010 to September 2023. This scoping review is guided by the updated methodological guidance for the conduct of scoping review from Joanna Briggs Institute. Of 2747 retrieved articles, 15 were included in this review. Synthesis of the findings revealed that nurses believed implementing nurse-led clinics was beneficial to themselves, patients, and healthcare systems. However, they faced challenges in running nurse-led clinics, including insufficient support, teamwork obstacles and lack of role recognition. Nurses need to be proactive in promoting their clinics and overcoming challenges. Healthcare organizations are responsible for creating a positive culture to support nurse-led services. Future research should focus on ways to increase global awareness of nurse-led clinics.

Tolerance to and postoperative outcomes with early oral feeding following elective bowel surgery: a systematic review with meta-analysis

Advancements in gastrointestinal surgery have directed attention toward optimizing recovery, including through the use of feeding methods that reduce prolonged postoperative hospital stays, complications, and mortality, among other undesirable outcomes. This study's primary goals were to identify current peer-reviewed literature reporting the postoperative outcomes of elective bowel surgery and to evaluate the clinical evidence of patients' tolerance to oral feeding following elective bowel surgery. An exhaustive literature search was conducted via PubMed and Scopus. The search results were screened for potential articles, and articles were assessed for eligibility based on prespecified eligibility criteria. The data were synthesized, and the results were reported and discussed thematically. The database search yielded 1,667 articles, from which 18 randomized controlled trials were chosen for inclusion in this study. This study included 874 early oral feeding (EOF) patients, 865 traditional oral feeding patients, and 91 patients whose postoperative care was unspecified. Data synthesis was done, and meta-analyses were conducted. The results showed that EOF patients required a significantly shorter time to tolerate a solid diet and had shorter hospital stays. In addition, bowel function was restored earlier in EOF groups. The results show good tolerance to EOF, shorter hospitalizations, and faster restoration of bowel function, suggesting that EOF after elective bowel surgery is relatively safe. However, further studies with similar baseline conditions should be conducted to verify these results.

Prevalence and determinants of risky behaviors: a comprehensive review of substance use and sexual risk behaviors among adolescents in the United States

Adolescents are often the most vulnerable to risky behaviors due to their quest for independence, experimentation, and identity development, resulting in deep-rooted patterns that affect health across the life course. This review examines the prevalence and determinants of substance use and sexual risk behaviors among adolescents in the United States. A systematic search of peer-reviewed literature published between 1980-2023 was conducted using multiple databases. Studies focusing on U.S. adolescents aged 12-19 and reporting on prevalence or associated factors of substance use (alcohol, tobacco, marijuana, or any illicit drugs) or sexual risk behaviors (early sexual initiation, multiple partners, or inconsistent condom use) were included. The review synthesized data from 40 studies meeting inclusion criteria. Results indicate concerning rates of substance use and sexual risk-taking, with variations by demographic factors. Alcohol and marijuana use were most prevalent, reported by 30-40% of adolescents. Nearly half of high school students reported having sexual intercourse, with 40% not using condoms consistently. Prevalence was generally higher among older adolescents, sexual minorities, and some racial minority groups. Key determinants of risk behaviors were reviewed based on socioecological models including individual, interpersonal, community and societal factors. The review highlights the multilevel nature of influences on adolescent risk behaviors. Findings underscore the need for tailored interventions addressing multiple determinants. Particular attention to vulnerable groups such as African American Adolescents and social determinants of health inequities is warranted. More research on risk and protective factors and effective interventions is needed. This synthesis can inform the development of evidence-based policies and programs to reduce substance use and sexual risk behaviors among U.S. adolescents.

Humanitarian health education and training state-of-the-art: a scoping review.

In the past decade, humanitarian emergencies have been increasing, leading to an higher demand for humanitarian health professionalization. Education and training are critical for preparing these workers to provide effective care during crises. Understanding the current state-of-the-art in humanitarian health education is essential to inform research and development of future educational programs. This review surveys the peer-reviewed literature to provide insights into the current thinking in the field. A review was conducted in March 2023 and updated in May 2024 using PubMed, Web of Science, Scopus, and Education Resources Information Center databases for English-language peer-reviewed articles published since January 2013. The review followed the Joanna Briggs Institute methodology for scoping reviews and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data were analyzed using qualitative content analysis and presented as a narrative descriptive summary. After screening, 32 articles met the inclusion criteria. The themes of the selected articles focus on education and training frameworks, mapping, and programs. Despite the growing opportunities, most education and training programs are based in the Global North. The gaps identified include a lack of standardized curriculum or competency frameworks and evaluation frameworks to guide the development and evaluation of further standardized training programs. Interdisciplinary and collaborative partnerships, iterative design, and mixed teaching methods and modalities, including e-learning, facilitated successful training. However, logistical and technical constraints and the lack of standardized training frameworks were barriers to developing, implementing, and evaluating such training programs. This review provides an overview of the humanitarian health education trends over the last decade and identifies key areas for future educational development and research. The findings emphasize the importance of adapting interdisciplinary and collaborative partnerships and prioritizing the training of local staff through regional centers, local leadership, and accessible e-learning, including e-simulation. The review also highlights the need for continued research and evaluation of humanitarian health education and training programs with standardized metrics to evaluate training programs and identify areas for improvement. These steps will help ensure that humanitarian health professionals receive adequate training to provide effective healthcare in crisis situations.

Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: A Review of Current Evidence.

The aim of this review is to summarize information published in the recent peer-reviewed literature on reverse shoulder arthroplasty (RSA) for proximal humerus fractures. Although there is still some debate regarding which may be the best treatment for proximal humerus fractures in certain age ranges, RSA seems to offer more predictable results than other surgical treatments for elderly patients. Successful tuberosity healing seems to correlate with better outcomes. Recent trends indicate interest in cementless fixation, fracture-specific stems and a 135-degree polyethylene opening angle. RSA provides a successful surgical solution for selected proximal humerus fractures. Indications, design features, and surgical execution have continued to evolve over the last few years.

A Quantitative Systematic Literature Review of Combination Punishment Literature: Progress Over the Last Decade.

This review evaluated single-case experimental design research that examined challenging behavior interventions utilizing punishment elements. Thirty articles published between 2013 and 2022 met study inclusion criteria. Study quality was also assessed. Through multiple levels of analysis (e.g., descriptive statistics, non-parametric statistics), we examined (a) participant and study trends, (b) differential outcomes related to temporal reinforcement approaches (antecedent, consequent, or combined reinforcement) applied alongside punishment element(s), (c) differential outcomes related to the punishment type (negative, positive) applied alongside reinforcement, and (d) effect sizes associated with study rigor across peer-reviewed and gray literature. Our results may tentatively suggest that, for certain situations, concurrently applying punishment with antecedent reinforcement approaches may coincide with significantly larger effect sizes compared to combined temporal reinforcement approaches, while positive punishment applied concurrently with reinforcement may coincide with larger but non-significant intervention effects. Most featured articles met rigor criteria, but larger effects were seen in peer-reviewed literature.

Women’s experiences of needing abortion care whilst incarcerated: a systematic review of the international literature

Incarcerated women are confined in institutions designed to punish. These sites often ignore the complex mental and physical health needs of people who are incarcerated. Despite the World Health Organization stressing the need for access to reproductive healthcare in carceral institutions, stigma surrounding abortion care and health inequalities create contextually specific issues for incarcerated people seeking to access these services. There is also a dearth of research conducted directly with incarcerated women, trans men and non-binary people to examine their experiences of abortion. A systematic review of international peer-reviewed and grey literature was completed to summarise existing evidence from research conducted on the experiences of needing abortion care whilst incarcerated. Various experiences were identified including: conditions of confinement shaping abortion decisions; bureaucratic obstacles to accessing abortion services; incarcerated women, carceral staff and carceral healthcare staff’s lack of understanding of abortion rights and procedures; and a scarcity of support and empathy, including experiences of stigmatisation and lack of confidentiality. There exists a significant gap in research examining the experiences of incarcerated people who may need an abortion, emphasising the need for international collaboration and advocacy to address systemic issues that extend beyond local contexts.

What Do We Mean by Sharing of Patient Data? DaSH - A Data Sharing Hierarchy of Privacy and Ethical Challenges.

Sharing of clinical data is common and necessary for patient care, research, public health, and innovation. The term "data sharing," however, is often ambiguous in its many facets and complexities-each of which involves ethical, legal, and social issues. To our knowledge there is no extant hierarchy of data sharing that assesses these issues. Develop a hierarchy explicating the risks and ethical complexities of data sharing with particular focus on patient data privacy. We surveyed the available peer-reviewed and gray literature, and with our combined extensive experience in bioethics and medical informatics, created this hierarchy. We present six ways data are shared and provide a tiered Data Sharing Hierarchy (DaSH) of risks, showing increasing threats to patients' privacy and to clinicians and organizations as one progresses up the hierarchy from data sharing for direct patient care, public health and safety, scientific research, commercial purposes, complex combinations of the preceding efforts, and among networked third parties. We offer recommendations to enhance benefits of data sharing while mitigating risks and protecting patients' interests by: improving consenting; developing better policies and procedures; clarifying, simplifying, and updating regulation to include all health-related data regardless of source; expanding the scope of bioethics for information technology; and increasing ongoing monitoring and research. Data sharing, while essential for patient care, is increasingly complex, opaque, and perhaps perilous for patients, clinicians and healthcare institutions. Risks increase with advances in technology and with more encompassing patient data from wearables and artificial intelligence database mining. Data sharing places responsibilities on all parties: patients, clinicians, researchers, educators, risk managers, attorneys, informaticists, bioethicists, institutions, and policy makers.