Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States.

BACKGROUND: While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US). METHODS: This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance. RESULTS: A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH. CONCLUSION: Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure.

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Diversity, seasonal abundance, and environmental drivers of chaetognath populations in North Inlet Estuary, South Carolina, USA.

Chaetognaths (Phylum: Chaetognatha) are one of the most abundant phyla of zooplankton worldwide and play an important role in marine trophic interactions. Although the role of chaetognaths in global ecosystems is well understood, the spatial variation and environmental drivers of estuarine chaetognath populations is poorly understood. To provide the first known record of chaetognath species composition in a coastal estuary in the south-eastern USA, chaetognaths were identified and quantified from zooplankton samples collected on a monthly basis in 2019 and 2020 from North Inlet Estuary in South Carolina. Parasagitta tenuis was the most abundant species of the five found, making up 33% of total abundance. The egg presence of these chaetognaths was further analyzed to gauge reproductive cycles. Abundance and egg presence were compared with surface and bottom measurements of temperature, salinity, and dissolved oxygen levels to determine the driving abiotic factors behind chaetognath's seasonal variability and reproductive cycles. Temperature, salinity, and dissolved oxygen all had low (r < ±.29), non-significant correlations with abundance. Chaetognath egg production was most significantly associated with dissolved oxygen (p < .001) and seasonal changes in temperature (p < .001). Our initial findings indicate the continued abundance of chaetognath in a local estuary are dependent on abiotic factors that are strongly influenced by a changing climate.

The Effects of Nickel and Copper on Tropical Marine and Freshwater Microalgae Using Single and Multispecies Tests.

Microalgae are key components of aquatic food chains and are known to be sensitive to a range of contaminants. Much of the available data on metal toxicity to microalgae have been derived from temperate single-species tests with temperate data used to supplement tropical toxicity data sets to derive guideline values. In the present study, we used single-species and multispecies tests to investigate the toxicity of nickel and copper to tropical freshwater and marine microalgae, including the free-swimming stage of Symbiodinium sp., a worldwide coral endosymbiont. Based on the 10% effect concentration (EC10) for growth rate, copper was two to four times more toxic than nickel to all species tested. The temperate strain of Ceratoneis closterium was eight to 10 times more sensitive to nickel than the two tropical strains. Freshwater Monoraphidium arcuatum was less sensitive to copper and nickel in the multispecies tests compared with the single-species tests (EC10 values increasing from 0.45 to 1.4 µg Cu/L and from 62 to 330 µg Ni/L). The Symbiodinium sp. was sensitive to copper (EC10 of 3.1 µg Cu/L) and less sensitive to nickel (EC50 >1600 µg Ni/L). This is an important contribution of data on the chronic toxicity of nickel to Symbiodinium sp. A key result from the present study was that three microalgal species had EC10 values below the current copper water quality guideline value for 95% species protection in slightly to moderately disturbed systems in Australia and New Zealand, indicating that they may not be adequately protected by the current copper guideline value. By contrast, toxicity of nickel to microalgae is unlikely to occur at exposure concentrations typically found in fresh and marine waters. Environ Toxicol Chem 2023;42:901-913. © 2023 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

COVID-19 and Psychosocial Well-Being: Did COVID-19 Worsen U.S. Frontline Healthcare Workers' Burnout, Anxiety, and Depression?

Healthcare workers are highly regarded for their compassion, dedication, and composure. However, COVID-19 created unprecedented demands that rendered healthcare workers vulnerable to increased burnout, anxiety, and depression. This cross-sectional study assessed the psychosocial impact of COVID-19 on U.S. healthcare frontliners using a 38-item online survey administered by Reaction Data between September and December 2020. The survey included five validated scales to assess self-reported burnout (Maslach Summative Burnout Scale), anxiety (GAD-7), depression (PHQ-2), resilience (Brief Resilience Coping Scale), and self-efficacy (New Self-Efficacy Scale-8). We used regression to assess the relationships between demographic variables and the psychosocial scales index scores and found that COVID-19 amplified preexisting burnout (54.8%), anxiety (138.5%), and depression (166.7%), and reduced resilience (5.70%) and self-efficacy (6.5%) among 557 respondents (52.6% male, 47.5% female). High patient volume, extended work hours, staff shortages, and lack of personal protective equipment (PPE) and resources fueled burnout, anxiety, and depression. Respondents were anxious about the indefinite duration of the pandemic/uncertain return to normal (54.8%), were anxious of infecting family (48.3%), and felt conflicted about protecting themselves versus fulfilling their duty to patients (44.3%). Respondents derived strength from their capacity to perform well in tough times (74.15%), emotional support from family/friends (67.2%), and time off work (62.8%). Strategies to promote emotional well-being and job satisfaction can focus on multilevel resilience, safety, and social connectedness.

Stressful Life Events, Postpartum Depressive Symptoms, and Partner and Social Support Among Pregnant People with Disabilities.

INTRODUCTION: As an increasing number of people with disabilities become pregnant and give birth, understanding their vulnerabilities for poor mental health and life stress can help to improve their health and well-being. We examined whether people with disabilities are more likely to experience stressful life events 12 months before childbirth, postpartum depressive symptoms (PDS), and lack of postpartum partner and social support, and compared these associations by race/ethnicity. METHODS: Using the Massachusetts Pregnancy Risk Assessment Monitoring System 2016-2020 data (n = 6,483), we used univariate and multivariable logistic regression models to estimate the associations of disability with stressful life events, PDS, and postpartum partner and social support, and calculated risk ratio (RR), adjusted RR, and 95% confidence interval (CI). We also conducted stratified analyses by race/ethnicity. RESULTS: The prevalence of disability was 10.7% overall, and 8.8% among White non-Hispanic people, 14.3% among Black non-Hispanic people, 15.5% among Hispanic people, and 8.3% among Asian non-Hispanic people. Compared with people without disabilities, those with disabilities were more likely to report emotional stress (RR, 1.54; 95% CI, 1.36-1.74), partner-related stress (RR, 2.55; 95% CI, 2.23-2.91), financial stress (RR, 1.55; 95% CI, 1.44-1.68), traumatic stress (RR, 2.27; 95% CI, 1.85-2.79), and PDS (RR, 3.77; 95% CI, 3.13-4.53). People with disabilities were also more likely to lack a partner's emotional support (RR, 2.57; 95% CI, 2.21-2.97), financial support from the newborn's father (RR, 2.89; 95% CI, 2.39-3.51), and social support while feeling tired or frustrated (RR, 2.05; 95% CI, 1.68-2.52). These associations remained statistically significant after adjustment for maternal factors and newborn's birth year. Strong associations of disability with stressful life events (including emotional stress and partner-related stress), PDS, lacking partner's emotional support, and social support existed across racial/ethnic groups. CONCLUSIONS: Pregnant people with disabilities may benefit from additional screening for stressful life events and depression during pregnancy and postpartum. Multidisciplinary efforts that combine mental health screening and treatment, peer support groups, increased health care provider training about caring for people with disabilities during pregnancy, and better access to care for pregnant people with disabilities are needed to improve their health and support their desire to become parents.

A Descriptive Analysis of Redemption Patterns by Vendor Type Among: WIC Participants in Massachusetts.

BACKGROUND: The retail environment is an important determinant of food package redemption in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The objectives of this study were to describe where Massachusetts WIC households redeemed their food benefits each month and monthly variations in benefit redemption depending on a household's most frequently used vendor type each month. DESIGN: These were cross-sectional and longitudinal analyses of administrative data provided by Massachusetts WIC. PARTICIPANTS/SETTING: Monthly redemption data for 209,973 households shopping at approximately 1,000 unique vendors between January 2015 and August 2019 were analyzed. MAIN OUTCOME MEASURES: Outcomes were mean monthly percentage of households that relied on each vendor type when redeeming benefits and mean monthly percent redemption for each benefit category. STATISTICAL ANALYSES PERFORMED: For each month, households were classified as using 1 of 8 vendor types. The monthly percentage of households redeeming at each vendor type was calculated, as well as the monthly percent redemption for each benefit category by vendor type. The averages of these monthly percentages were computed for 2015 and 2019. Data from months when households did not redeem any benefits were excluded from primary analyses because it was not possible to determine their vendor type for that month. RESULTS: On average across months in 2019, the majority of Massachusetts WIC households (63%) relied on large vendors only (ie, superstores, supermarkets, and large grocery stores) when redeeming benefits, and 5% relied on small grocery or convenience stores only. Between 2015 and 2019, mean monthly reliance on small grocery and convenience stores decreased by 3.1 and 0.7 percentage points, respectively. Compared with other vendor types, households that redeemed benefits at superstores only had, in an average month, lower redemption levels for most benefit categories. For example, in the 2019 mean across months, percent redemption of breakfast cereal was 53% among households redeeming at superstores only compared with 74% for those redeeming at small grocery stores only. By contrast, households that relied on small grocery stores only had, in an average month, lower redemption levels for yogurt and cash value benefit compared with other vendor types; for example, in the 2019 mean across months, percent redemption of yogurt was 34% among households redeeming at small grocery stores only compared with 62% among those redeeming at supermarkets only. CONCLUSIONS: Results suggest that retail-based efforts to increase redemption should consider vendor-type reliance. Strategies to increase redemption may be especially important for WIC shoppers relying on superstores.

Impact of SARS-CoV-2 lockdown on expansion of HIV transmission clusters among key populations: A retrospective phylogenetic analysis.

Background: Public health measures designed to reduce SARS-CoV-2 transmission led to reduced access to care and prevention services for people living with or at risk of acquiring HIV, particularly during the initial introduction of extensive restrictions. This reduction in access may have contributed to increases in HIV transmission not outweighed by decreases in transmission occurring as a result of reduced contact rates promoted by the same public health measures. Methods: We synthesize available province-wide HIV data in British Columbia, Canada, together with public mobility data to phylogenetically investigate the early impacts of SARS-CoV-2 on HIV transmission. Cluster growth, coalescent branching events and lineage-level diversification rates were assessed in "pre-lockdown" (January 22-March 21, 2020), "lockdown" (March 22-May 20, 2020) and "post-lockdown" (May 21-July 19, 2020) to facilitate comparison of transmission trends across key populations. Findings: Results reveal increased HIV transmission in a limited number of clusters in association with reduced access to health services during the initial introduction of SARS-CoV-2-related restrictions. In particular, clusters associated with people who inject drugs (PWID) show rapid growth, extensive branching events in phylogenetic trees during and following the lockdown period, and elevated median change in individuals' viral diversification rates during lockdown compared to clusters associated with men who have sex with men (MSM), consistent with increased transmission rates between PWID. Interpretation: Increased vigilance and innovative targeted solutions are critical to offset potential negative impacts of SARS-CoV-2 or future pandemic-related restrictions on HIV epidemic dynamics. Funding: Funding sources include Genome Canada and Genome BC, the Public Health Agency of Canada, the BC Centre for Excellence in HIV/AIDS, and the Canadian Institutes of Health Research Coronavirus Rapid Response Programme. Student funding includes a NSERC CREATE scholarship and a Canadian Institutes of Health Research graduate fellowship.

Risk Factors, Screening, Diagnosis, and Treatment of Osteoporosis in HIV-Infected Adults in an HIV Primary Care Clinic.

Background: The population of people living with HIV is aging, and with aging come emergent comorbidities, including osteoporosis, for which screening and treatment are becoming increasingly important. Osteoporosis prevalence among those living with HIV is 3 times greater than among HIV-uninfected controls. Objective: To assess and describe osteoporosis risk factors, screening, diagnosis, and treatment for people 50 years of age or older living with HIV and receiving care at a multidisciplinary HIV primary care clinic. Methods: A retrospective chart review of people 50 years of age or older living with HIV was conducted at the John Ruedy Clinic in Vancouver, British Columbia, between June 1, 2016, and June 1, 2019. Patients who had had fewer than 2 yearly follow-up appointments were excluded. Results: A total of 146 patients were included in the analysis; most were male (n = 134, 92%), and the median age was 55 years. Patients had a median of 3 osteoporosis risk factors (in addition to age and HIV infection), and 145 patients had at least 1 risk factor. All screening for osteoporosis was conducted by dual-energy X-ray absorptiometry (DXA). Thirty-nine (27%) of the patients were screened with DXA, 92 (63%) were not screened, and 15 (10%) already had a diagnosis of osteoporosis. The DXA screening identified osteoporosis in an additional 10 patients and osteopenia in 22 patients. Treatments for patients with osteoporosis included bisphosphonates (n = 15, 60%) and vitamin D or calcium (or both), without any other medications (n = 4, 16%). In the overall study population, 32 (22%) of the patients were taking calcium and 46 (32%) were taking vitamin D. Conclusions: Many patients aged 50 years or older and receiving HIV care at the John Ruedy Clinic had or were at risk for osteoporosis. An opportunity exists to increase screening and treatment of these individuals. A multidisciplinary team may be crucial in achieving this goal.

Contexte: La population des personnes vivant avec le VIH vieillit et, avec le vieillissement, des comorbidités émergent, dont l'ostéoporose, pour laquelle le dépistage et le traitement sont de plus en plus importants. La prévalence de l'ostéoporose chez les personnes vivant avec le VIH est 3 fois plus élevée que chez les témoins non infectés. Objectif: Évaluer et décrire les facteurs de risque, le dépistage, le diagnostic et le traitement de l'ostéoporose chez les personnes d'au moins 50 ans vivant avec le VIH et qui reçoivent des soins dans une clinique pluridisciplinaire de soins primaires pour le VIH. Méthodes: Un examen rétrospectif des dossiers des personnes d'au moins 50 ans vivant avec le VIH a été effectué à la clinique John Ruedy à Vancouver (Colombie-Britannique) entre le 1er juin 2016 et le 1er juin 2019. Les patients qui avaient eu moins de 2 rendez-vous de suivi annuels ont été exclus de l'étude. Résultats: Au total, 146 patients ont été inclus dans l'analyse; la plupart étaient des hommes (n = 134, 92 %) et l'âge médian était de 55 ans. Les patients avaient une médiane de 3 facteurs de risque d'ostéoporose (en plus de l'âge et de l'infection par le VIH), et 145 patients avaient au moins 1 facteur de risque. Tous les dépistages de l'ostéoporose ont été réalisés par absorption biphotonique à rayons X (DXA). Trente-neuf patients (27 %) ont été dépistés par DXA, 92 (63 %) ne l'ont pas été et 15 (10 %) avaient déjà un diagnostic d'ostéoporose. Le dépistage par DXA a permis d'identifier l'ostéoporose chez 10 patients supplémentaires et l'ostéopénie chez 22 patients. Le traitement des patients atteints d'ostéoporose comprenait des bisphosphonates (n = 15, 60 %) et de la vitamine D ou du calcium (ou les deux) sans autre médicament (n = 4, 16 %). Dans la population générale de l'étude, 32 patients (22 %) prenaient du calcium et 46 (32 %) prenaient de la vitamine D. Conclusions: De nombreux patients d'au moins 50 ans recevant des soins pour le VIH à la clinique John Ruedy présentaient un risque d'ostéoporose ou l'avaient déjà développée. Il est possible d'accroître leur dépistage et leur traitement, et une équipe multidisciplinaire peut être cruciale pour atteindre cet objectif.

Clinical, electrophysiological, and imaging findings in childhood brachial plexus injury.

AIM: To assess the prognostic capabilities of various diagnostic modalities for childhood brachial plexus injuries (BPIs) and brachial plexus birth injury (BPBI) and postneonatal BPI. METHOD: In this single-center retrospective cross-sectional study, we examined children with BPIs diagnosed or confirmed by electrodiagnostic studies between 2013 and 2020, and compared the prognostic value of various components of the electrophysiologic findings, magnetic resonance imaging (MRI) data, and the Active Movement Scale (AMS). We developed scoring systems for electrodiagnostic studies and MRI findings, including various components of nerve conduction studies and electromyography (EMG) for electrodiagnostic studies. RESULTS: We identified 21 children (10 females and 11 males) aged 8 days to 21 years (mean 8y 6.95mo) who had a total of 30 electrodiagnostic studies, 14 brachial plexus MRI studies, and 10 surgical procedures. Among the diagnostic modalities assessed, brachial plexus MRI scores, EMG denervation scores, and mean total EMG scores were the most valuable in predicting surgical versus non-surgical outcomes. Correspondingly, a combined MRI/mean total EMG score provided prognostic value. INTERPRETATION: Brachial plexus MRI scores and specific electrodiagnostic scores provide the most accurate prognostic information for children with BPI. Our grading scales can assist a multidisciplinary team in quantifying results of these studies and determining prognosis in this setting. WHAT THIS PAPER ADDS: A new scoring system to quantify results of electrodiagnostic and magnetic resonance imaging (MRI) studies is presented. Severity of denervation has good prognostic value for childhood brachial plexus injuries (BPIs). Composite electromyography scores have good prognostic value for childhood BPIs. Brachial plexus MRI has good prognostic value for childhood BPIs.

Exposure duration and composition are important variables to predict short-term toxicity of effluents to a tropical copepod, Acartia sinjiensis.

Predicting the toxicity of effluent exposures, which vary in duration, composition, and concentration, poses a challenge for ecological risk assessments. Effluent discharges may frequently result in the exposure of aquatic organisms to high concentrations of mixed contaminants for short durations. In the receiving environment effluents will undergo dilution and physical or chemical processes that further reduce contaminant concentrations at varying rates. To date, most studies comparing toxicity risks of continuous and pulsed contaminant exposures have focused on individual contaminants. In this study, the toxicity to the tropical euryhaline copepod Acartia sinjiensis of two complex effluents was assessed, comparing 6- and 18-h pulses and 78-h continuous exposures. Observations of larval development success and population size were completed after a 78-h incubation period, to observe for latent effects after pulse exposures. The chemical compositions of the effluents were assessed over time and different contaminants (i.e., metals, ammonia or organics) declined at differing rates. These were characterized as either a minimal, steady, or rapid decline. Nauplii development and population after 78 h were more impacted by effluent exposures following an 18-h pulse, compared to a 6-h pulse. Based on pulse-exposure concentrations, the 50% effect concentrations (EC50) were similar for continuous and 18-h exposures but up to 3-fold greater (lower toxicity) for the shorter 6-h exposures. Time-weighted average concentrations did not accurately predict toxicity from pulse exposures of the effluents. Concentration-addition toxicity modelling using toxicity data from pulse exposures of single contaminants was useful for predicting the toxicity of chemical mixtures exposed for varying durations. Recommendations for modified approaches to assessing risks of short-term effluent discharges are discussed.

Caregiver Perspectives on Underutilization of WIC: A Qualitative Study.

OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC. METHODS: In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research. RESULTS: Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others. CONCLUSIONS: Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

A Prediction Model for Positive Infant Meconium and Urine Drug Tests.

OBJECTIVE: This study aimed to determine the factors associated with positive infant drug screen and create a shortened screen and a prediction model. STUDY DESIGN: This is a retrospective cohort study of all infants who were tested for drugs of abuse from May 2012 through May 2014. The primary outcome was positive infant urine or meconium drug test. Multivariable logistic regression was used to identify independent risk factors. A combined screen was created, and test characteristics were analyzed. RESULTS: Among the 3,861 live births, a total of 804 infants underwent drug tests. Variables associated with having a positive infant test were (1) positive maternal urine test, (2) substance use during pregnancy, (3) ≤ one prenatal visit, and (4) remote substance abuse; each p-value was less than 0.0001. A model with an indicator for having at least one of these four predictors had a sensitivity of 94% and a specificity of 69%. Application of this screen to our population would have decreased drug testing by 57%. No infants had a positive urine drug test when their mother's urine drug test was negative. CONCLUSION: This simplified screen can guide clinical decision making for determining which infants should undergo drug testing. Infant urine drug tests may not be needed when a maternal drug test result is negative. KEY POINTS: · Many common drug screening criteria are not predictive.. · Four criteria predicted positive infant drug tests.. · No infant urine drug test is needed if the mother tests negative..

The Massachusetts Racial Equity Data Road Map: Data as a Tool Toward Ending Structural Racism.

BACKGROUND: In 2015, the Massachusetts Department of Public Health (MDPH) adopted a Title V maternal and child health priority to "promote health and racial equity by addressing racial justice and reducing disparities." A survey assessing staff capacity to support this priority identified data collection and use as opportunities for improvement. In response, MDPH initiated a quality improvement project to improve use of data for action to promote racial equity. METHODS: MDPH conducted value stream mapping to understand existing processes for using data to inform racial equity work. Key informant interviews and a survey of program directors identified challenges to using data to promote racial equity. MDPH used a cause-and-effect diagram to identify and organize challenges to using data to inform racial equity work and better understand opportunities for improvement and potential solutions. RESULTS: Key informants highlighted the need to consider structural factors and historical and community contexts when interpreting data. Program directors noted limited staff time, lack of performance metrics, competing priorities, low data quality, and unclear expectations as challenges. To address the identified challenges, the team identified potential solutions and prioritized development and piloting of the MDPH Racial Equity Data Road Map (Road Map). CONCLUSIONS: The Road Map framework provides strategies for data collection and use that support the direction of actionable data-driven resources to racial inequities. The Road Map is a resource to support programs to authentically engage communities; frame data in the broader contexts that impact health; and design solutions that address root causes. With this starting point, public health systems can work toward creating data-driven programs and policies to improve racial equity.

Pulse-Exposure Toxicity of Ammonia and Propoxur to the Tropical Copepod Acartia sinjiensis.

Toxicity risk assessments of short-term discharges of contaminated waters to the aquatic environment have shown that receptor organisms can tolerate higher pulse-exposure than continuous-exposure concentrations of some contaminants. However, these observations are influenced by the mode of toxicity of the contaminants present and the concentration-time profile of the exposure. For common metal contaminants, the time-weighted average concentration (TAC) of the exposure has been useful for predicting risk of toxicity to multiple species, including the tropical, euryhaline copepod Acartia sinjiensis. To increase our understanding of the application and limitations of the TAC approach, the present study examined how varied pulse-exposure durations affect the toxicity of fast-acting contaminants, ammonia, and the common pesticide propoxur to this copepod species. Copepod larvae were exposed under continuous-exposure conditions (all life stages from eggs to nauplii to copepodites exposed) and as 6- and 18-h pulse exposures applied during the most sensitive life stage only (24-h-old nauplii) within 78-h tests. Larval development ratio and population size were assessed as test endpoints. Generally, increased exposure duration resulted in increased toxicity. Trends observed for ammonia and propoxur were slightly different for larval development and population size. Larvae tolerated greater concentrations of contaminants in a 6-h pulse (higher 10% effect concentration) than in an 18-h pulse, or a continuous 78-h exposure, whereas toxicity responses converged for the 18- and 78-h exposures. Continuous toxicity thresholds were always protective of pulse exposures, providing a conservative toxicity threshold for all durations of pulse exposures. Although generalizations for predictions of risk based on TACs are frequently effective for common metal contaminants, the TAC approach was not effective for ammonia and propoxur. Environ Toxicol Chem 2022;41:208-218. © 2021 SETAC.

Breastfeeding Advocacy: A Look into the Gap Between Breastfeeding Support Guidelines and Personal Breastfeeding Experiences of Faculty Physicians.

Objectives: Despite increased lactation support for mothers over the past few decades, physician mothers still face considerable challenges to achieving their breastfeeding goals. Disparities in breastfeeding exist between physician and nonphysician mothers in the United States. To formulate an effective advocacy agenda for this population, we surveyed faculty physician mothers about their breastfeeding experiences. We hypothesized that identifying frequent, modifiable barriers to breastfeeding could generate ideas for improved lactation support for female physicians. Study Design: A deidentified breastfeeding survey was sent to female faculty physicians at an academic children's hospital in 2020. Inclusion criteria included female faculty physicians who had given birth within the past 5 years. The responses of those who selected "yes" when asked if they had breastfed were analyzed. Results: Fifteen percent of respondents stated that they did not meet their breastfeeding goals. The most prevalent theme for both positive and negative factors in the qualitative analysis was pumping breast milk. Physician mothers provided key insight into (1) the impact of their role as physicians on their breastfeeding experience, (2) impact of their return to work on breastfeeding, and (3) ideas for improved lactation support. Conclusion: This study highlights the need to improve maternal and infant health by advocating for faculty physicians who are providing breast milk for their children. Advocacy efforts should focus on improving conditions for breast milk pumping and for effective policies around return to work after delivery. Further development and study of individualized breastfeeding support plans for physician mothers is needed.

The effects of pulse exposures of metal toxicants on different life stages of the tropical copepod Acartia sinjiensis.

Effluent discharges can potentially result in high concentrations of metals entering aquatic environments for short durations, ranging from a few hours to days. The environmental risks of such exposures are challenging to accurately assess. Risk assessment tools for effluent discharges include comparison of toxicant concentrations with guideline values and the use of direct toxicity assessments, both of which were designed to assess continuous, rather than pulse, contaminant exposures. In this study, a chronic pulse-exposure toxicity test was developed using the tropical euryhaline calanoid copepod Acartia sinjiensis. This copepod has a rapid life cycle and is highly sensitive to metal contaminants, with 50% effect concentrations (chronic EC50) for larval development of 1.7, 8.6 and 0.7 µg L-1 for copper, nickel and zinc, respectively. The toxicities of copper and nickel were assessed as a continuous exposure (78 h) and as pulses (3, 6 and 18 h) initiated at varying life stages, from egg to copepodite, and measured larval development over 78 h. Generally, 24-h old nauplii were more sensitive or of similar sensitivity to copper and nickel pulses than 48-h old nauplii. The 78-h test duration enabled observations of chronic effects following pulse exposures, which frequently occurred in the absence of acute effects. The EC50 values for pulse exposures were higher than those of continuous exposure by up to approximately 16-fold and 15-fold for copper and nickel, respectively. When metal-pulse exposure concentrations were expressed using the time-weighted averaged concentration (TAC), resultant concentration response curves were similar to those in continuous exposures to the same metal, suggesting that thresholds based on continuous exposures were also protective for pulse exposures to these metals. This research improves our understanding of the toxicity of pulse contaminant exposures and assists with developing improved approaches to for the risk assessment and regulation of short-term contaminant discharges.

Rapid Blood Transfusion: The Importance of Hemodilution and Needleless Connectors.

INTRODUCTION:  Large-bore cannulas are critical to administering IV fluids and blood products during resuscitation and treatment of hemorrhage. Although catheter flow rates for crystalloid solutions are well defined, rapid administration of blood products is poorly characterized. In this in vitro study, we examined the effects of hemodilution and needleless connectors on red blood cell (RBC) flow rates. METHODS:  To determine RBC flow rates through large-bore cannulae, a crystalloid solution (Normosol®, Hospira, Lake Forest, IL) or RBC units were warmed and delivered under pressure (360 mmHg) using a Level 1 H-1200 Fast Flow Fluid Warmer (Smiths Medical, St. Paul, MN). Flow rates for crystalloid, packed RBCs and diluted RBCs were determined using a stopwatch. Additionally, the effect of the MaxPlus® clear needleless connector (CareFusion, San Diego, CA) was measured in all three infusion groups. RESULTS:  Flow rates for undiluted RBC units were 53% slower than crystalloid solution (220 mL/min vs. 463 mL/min; p=0.0003), however, when RBC units were diluted to a hematocrit of ~30% flow rate improved to 369 mL/min (p=0.005). The addition of the MaxPlus® needleless connector reduced flow of crystalloid solution by 47% (245 mL/min; p=0.0001), undiluted RBCs by 64% (78 mL/min; p=0.01), and diluted RBCs by 51% (180 mL/min; p=0.00003). Compared to undiluted RBC units, hemodilution increased RBC delivery rate through a MaxPlus® connector by 130% (p=0.004) and by 68% (p=0.02) when the catheter was directly connected to the Level 1 tubing (MaxPlus® excluded). CONCLUSION:  In settings requiring rapid transfusion of RBC units, needleless connectors should not be used and hemodilution should be considered in order to decrease the time required to deliver an equivalent red cell mass.

Management of brain tumors presenting in pregnancy: a case series and systematic review.

Patients who present with brain tumors during pregnancy require unique imaging and neurosurgical, obstetrical, and anesthetic considerations. Here, we review the literature and discuss the management of patients who present with brain tumors during pregnancy. Between 2009 and 2019, 9 patients were diagnosed at our institution with brain tumors during pregnancy. Clinical information was extracted from the electronic medical records. The median age at presentation was 29 years (range, 25-38 years). The most common symptoms at presentation included headache (n=5), visual changes (n=4), hemiparesis (n=3), and seizures (n=3). The median gestational age at presentation was 20.5 weeks (range, 11-37 weeks). Of note, 8 patients (89%) delivered healthy newborns, and 1 patient terminated her pregnancy. In addition, 5 patients (56%) required neurosurgical procedures during pregnancy (gestational ages, 14-37 weeks) because of disease progression (n=2) or neurologic instability (n=3). There was 1 episode of postneurosurgery morbidity (pulmonary embolism [PE]) and no surgical maternal mortality. The median length of follow-up was 15 months (range, 6-45 months). In cases demonstrating unstable or progressive neurosurgical status past the point of fetal viability, neurosurgical intervention should be considered. The physiological and pharmacodynamic changes of pregnancy substantially affect anesthetic management. Pregnancy termination should be discussed and offered to the patient when aggressive disease necessitates immediate treatment and the fetal gestational age remains previable, although neurologically stable patients may be able to continue the pregnancy to term. Ultimately, pregnant patients with brain tumors require an individualized approach to their care under the guidance of a multidisciplinary team.

Moyamoya disease in children and its anesthetic implications: A review.

Moyamoya disease is a rare, progressive cerebral vasculopathy which most commonly presents in the first and fourth decades of life. The mainstay of treatment is surgical revascularization; without treatment, most patients experience ischemic or hemorrhagic strokes. This report reviews moyamoya disease, its associated conditions, surgical treatment techniques, and anesthetic management of patients with moyamoya disease.