Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care.

To examine the association between scope-of-practice (SoP) regulations and racial disparities in pediatric mental health services. We used the National Survey of Children's Health (2016-2020; n = 33,790) to examine racial disparities in unmet mental health care needs and receipt of mental health medication between states with and without SoP expansions for psychologists and nurse practitioners (NP). Our primary outcomes were (1) unmet mental health care needs and (2) receipt of mental health medication. We examined heterogeneous treatment effects of SoP expansion on the outcomes using logistic regression with interaction terms between SoP expansion and race/ethnicity. We estimated population-level racial disparities for both outcomes stratified by SoP expansion to identify differences in racial disparities. The psychologist SoP expansion-associated reduction in unmet need was 15.8 percentage-points (CI= -25.3, -6.2) larger for Other-race children than for White children. The psychologist SoP expansion-associated increase in medication was 5.1%-points (CI=. 0.8, 9.4) larger for Black children and 5.6%-points (CI = 0.5, 10.8) for Other-race children. No differences were found for NP SoP expansion. Racial disparities in both outcomes were lower in psychologist SoP expansion states but varied in NP SoP states. Expanded SoP was generally associated with lower racial disparities in pediatric mental health care access.

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care settings in Australia: A qualitative descriptive study.

PROBLEM: There is little documented evidence regarding the practice of midwives providing care for women with acute concerns in early pregnancy (< 20 weeks) in Australia. BACKGROUND: Women can experience unexpected complications at any gestation of pregnancy and may seek acute care in an emergency or gynaecology service, usually staffed by registered nurses (RNs). They may not receive care from specialised pregnancy clinicians, including midwives. The role and scope of practice of midwives working in acute early pregnancy settings in Australia has not been previously reported. This study provides an opportunity to document practice in an area of pregnancy care not often visible within maternity services in Australia. RESEARCH AIM: To describe midwives' and RNs perceptions, perspectives and experiences of role and scope of practice in acute early pregnancy care provision in Australia. METHODS: A qualitative descriptive approach was adopted. Midwives and RNs with acute early pregnancy knowledge and experience were recruited. Semi-structured interviews were conducted, and data analysed using inductive thematic analysis. FINDINGS: Fifteen participants were interviewed. Three themes were constructed from interview data: Personal and Professional Influences; Being There for Women; The Impact of Setting. DISCUSSION: Findings reinforce the lack of clarity around how midwives' scope is enabled in traditional acute early pregnancy care. Setting of care has influenced practice and seen a barrier for midwives who don't hold nursing registration from fulfilling professional scope. Results provide novel benchmarking evidence regarding a largely hidden area of midwifery, signposting areas for reform within education, policy and health service sectors.

How do dental practices respond to changes in scope of practice regulations?

Regulations that restrict the tasks that credentialed workers are allowed to perform may affect a firm's input choices, output, and which part of the market the firm serves. Using dental practice survey data from 1989 to 2014 and a stacked difference-in-differences design, this paper examines the effects of state-level scope of practice regulations on the behavior of dental practices. Results suggest that scope of practice deregulation in regards to dental hygienists' ability to administer nitrous oxide or local anesthesia is associated with fewer dentist visits per week in the short-term, lower patient wait times, and an increased likelihood of treating lower revenue generating publicly insured patients. There is weak evidence that scope of practice deregulation alters a practice's labor inputs.

Nutrition and Physical Activity Interventions for Adults in the General Population: A Position Paper from the Academy of Nutrition and Dietetics and the American Council on Exercise.

It is the position of the Academy of Nutrition and Dietetics and the American Council on Exercise that nutrition and physical activity interventions delivered by qualified nutrition and exercise practitioners, within their scopes of practice, can improve lifestyle behaviors and cardiometabolic risk factors for adults in the general population. Effective interventions require client-centered, evidence-based care provided by skilled practitioners using inclusive, dynamic methods, and collaboration with an interprofessional team, as appropriate. Increased access to evidence-based nutrition and physical activity interventions is necessary to improve public health and should be a target for policymakers, healthcare systems, and practitioners. Adults who attain a nutritious diet and adequate physical activity have improved overall health compared to their counterparts. However, most adults do not meet population recommendations. Qualified nutrition and exercise practitioners can collaborate with clients and interprofessional teams to provide nutrition and physical activity interventions and improve outcomes. However, recent guidelines have identified a need for guidance on best practices for delivering behavioral lifestyle counseling, referring to other practitioners, and improving access to disease prevention services. This position paper aims to address common barriers for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults in the general population, and best practices for overcoming these barriers. Collective action from interprofessional practitioners and implementation partners can increase access to high-quality, individualized services to prevent disease and improve health and well-being on a population level. This position was approved in July 2024 and will remain in effect until December 31, 2031.

MACCoM: A multiple attention and convolutional cross-mixer framework for detailed 2D biomedical image segmentation.

The UNet architecture, which is widely used for biomedical image segmentation, has limitations like blurred feature maps and over- or under-segmented regions. To overcome these limitations, we propose a novel network architecture called MACCoM (Multiple Attention and Convolutional Cross-Mixer) - an end-to-end depthwise encoder-decoder fully convolutional network designed for binary and multi-class biomedical image segmentation built upon deeperUNet. We proposed a multi-scope attention module (MSAM) that allows the model to attend to diverse scale features, preserving fine details and high-level semantic information thus useful at the encoder-decoder connection. As the depth increases, our proposed spatial multi-head attention (SMA) is added to facilitate inter-layer communication and information exchange, enabling the network to effectively capture long-range dependencies and global context. MACCoM is also equipped with a convolutional cross-mixer we proposed to enhance the feature extraction capability of the model. By incorporating these modules, we effectively combine semantically similar features and reduce artifacts during the early stages of training. Experimental results on 4 biomedical datasets crafted from 3 datasets of varying modalities consistently demonstrate that MACCoM outperforms or matches state-of-the-art baselines in the segmentation tasks. With Breast Ultrasound Image (BUSI), MACCoM recorded 99.06 % Jaccard, 77.58 % Dice, and 93.92 % Accuracy, while recording 99.50 %, 98.44 %, and 99.29 % respectively for Jaccard, Dice, and Accuracy on the Chest X-ray (CXR) images used. The Jaccard, Dice, and Accuracy for the High-Resolution Fundus (HRF) images are 95.77 %, 74.35 %, and 95.95 % respectively. The findings here highlight MACCoM's effectiveness in improving segmentation performance and its valuable potential in image analysis.

Unlocking potential: a qualitative exploration guiding the implementation and evaluation of professional role substitution models in healthcare.

BACKGROUND: As role substitution models gain prominence in healthcare, understanding the factors shaping their effectiveness is paramount. This study aimed to investigate factors that impact the implementation and performance evaluation of professional role substitution models in healthcare, with a focus on understanding the variables that determine their success or failure in adoption, execution, continuity, and outcomes. METHODS: The exploratory qualitative study used semi-structured interviews with key opinion leaders, decision makers, facilitators, recipients, and frontline implementers, who had influence and involvement in the implementation of professional role substitution models. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Between November 2022 and April 2023, 39 stakeholders were interviewed. Factors influencing implementation and evaluation of allied health professional role substitution models of care aligned with the five core CFIR domains (innovation, outer setting, inner setting, individuals, implementation process) and outcome domain incorporating implementation and innovation outcomes. The six themes identified within these CFIR domains were, respectively; i) Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages; ii) Navigating the complex landscape of external factors that influence implementation and evaluation; iii) Impact of internal structural, political, and cultural contexts; iv) The roles and contributions of individuals in the process; v) Essential phases and strategies for effective implementation; and vi) The assessment of outcomes derived from allied health professional role substitution models. CONCLUSIONS: The study highlights the complex interplay of contextual and individual factors that influence the implementation and performance evaluation of professional role substitution models. It emphasises the need for collaboration among diverse stakeholders to navigate the challenges and leverage the opportunities presented by expanded healthcare roles. Understanding these multifaceted factors can contribute to the development of an empowered workforce and a healthcare system that is more efficient, effective, safe, and sustainable, ultimately benefiting patients.

Economies of scope in the Norwegian public hospital sector.

This study investigates the potential economies of scope in the Norwegian public hospital sector after a major structural and organizational reform. Economies of scope refers to potential cost savings occurring from the scope of production rather than the scale. We use a data driven approach to distinguish between relatively specialized and differentiated hospitals. Using registry data spanning the period 2013-2019, we use non-parametric data envelopment analysis with bootstrapping procedures to investigate the potential presence of economies of scope. This is done separately for three different dimensions of which hospital production can be either specialized or differentiated. The findings suggest that economies of scope are present in the Norwegian hospital sector, meaning that there are cost savings related to the optimal differentiation of the activity. It is difficult to conclude on how these findings relate to the reform.

Thermal tolerance of giant salmonfly nymphs (Pteronarcys californica) varies across populations in a regulated river.

Warming of aquatic ecosystems is transforming the distribution, phenology and growth of the organisms dependent upon these ecosystems. Aquatic insects such as stoneflies are especially vulnerable to warming because the aquatic nymph stage of their life cycle depends on cool, well-oxygenated, flowing water habitat. We tracked thermal effects on available aerobic capacity of the aquatic nymph stage of an iconic and vulnerable stonefly species, the giant salmonfly (Pteronarcys californica), to compare habitat thermal regime measurements for two salmonfly populations from habitats separated by a gradient in summer weekly maximum temperatures. Contrary to expectations, the thermal optima range of the warmer habitat population was cooler than for the cooler habitat population. We posit that this unexpected interpopulation variation in thermal response is more strongly driven by diel and seasonal thermal variability than by the highest summer temperatures experienced within respective habitats. Additionally, we show that summer daily maximum temperatures could result in periodic limits in available aerobic capacity to support work of the warmer habitat nymphs and may be the mechanism underlying reduced abundance relative to the upstream cooler habitat population. Our findings provide insight into potential thermal and metabolic mechanisms that could regulate the success of ecological and culturally important aquatic insect species experiencing global change. We conclude that thermal regimes and thermal variation, not just mean and maximum temperatures, are critical drivers of aquatic insect responses to water temperatures.

Pharmacists' current and potential prescribing roles in primary care in the Netherlands: a case study.

In some countries, pharmacists have obtained prescribing rights to improve quality and accessibility of care and reduce physician workload. This case study explored pharmacists' current roles in and potential for prescribing in primary care in the Netherlands, where prescribing rights for pharmacists do not exist. Participatory observations of pharmacists working in either general practice or community pharmacy were conducted, as were semi-structured interviews about current and potential practice. The latter were extended to patients and other healthcare professionals, mainly general practitioners, resulting in 34 interviews in total. Thematic analyses revealed that pharmacists, in all cases, wrote prescriptions that were then authorized by a physician before dispensing. General practice-based pharmacists often prescribed medications during patient consultations. Community pharmacists mainly influenced prescribing through (a) medication reviews where the physician and/or practice nurse often were consulted to make treatment decisions, and (b) collaborative agreements with physicians to start or substitute medications in specific situations. These findings imply that the pharmacists' current roles in prescribing in the Netherlands resemble collaborative prescribing practices in other countries. We also identified several issues that should be addressed before formally introducing pharmacist prescribing, such as definitions of tasks and responsibilities and prescribing-specific training for pharmacists.

Interventions to Expand Community Pharmacists' Scope of Practice.

BACKGROUND: The role of community pharmacists has evolved beyond the dispensing of medicines. The aim of this scoping review was to describe the interventions that expand the pharmacist's scope of practice within a community pharmacy setting and assess their effectiveness. METHODS: We performed a scoping review to identify randomised controlled trials (RCTs), published worldwide from 2013 to 2024, which focused on interventions designed to expand pharmacists' scope of practice in the community. The review was undertaken in accordance with the Joanna Briggs Institute methodology for scoping reviews. To address the aim of this scoping review, the included RCTs were mapped to themes influenced by the Professional Practice Standards 2023 as developed by the Pharmaceutical Society of Australia: medication management, collaborative care and medication adherence. RESULTS: Twelve studies demonstrated the potential to expand community pharmacists' scope of practice. Two RCTs resulted in no effect of the intervention. One RCT (conducted in Italy) led to an actual change to community pharmacists' scope of practice, with a statistically significant improvement in the proportion of patients with controlled asthma. CONCLUSIONS: On the whole, this scoping review synthesised the findings of peer-reviewed RCT studies that revealed expanding community pharmacists' scope of practice may result in improved patient outcomes, a reduced burden for the healthcare system, and greater productivity.

Scope of Negation, Gestures, and Prosody: The English Negative Quantifier as a Case in Point.

The present paper examines how English native speakers produce scopally ambiguous sentences and how they make use of gestures and prosody for disambiguation. As a case in point, the participants in the present study produced the English negative quantifiers. They appear in two different positions as (1) The election of no candidate was a surprise (a: 'for those elected, none of them was a surprise'; b: 'no candidate was elected, and that was a surprise') and (2) no candidate's election was a surprise (a: 'for those elected, none of them was a surprise'; b: # 'no candidate was elected, and that was a surprise.' We were able to investigate the gesture production and the prosodic patterns of the positional effects (i.e., a-interpretation is available at two different positions in 1 and 2) and the interpretation effects (i.e., two different interpretations are available in the same position in 1). We discovered that the participants tended to launch more head shakes in the (a) interpretation despites the different positions, but more head nod/beat in the (b) interpretation. While there is not a difference in prosody of no in (a) and (b) interpretation in (1), there are pitch and durational differences between (a) interpretations in (1) and (2). This study points out the abstract similarities across languages such as Catalan and Spanish (Prieto et al. in Lingua 131:136-150, 2013. 10.1016/j.lingua.2013.02.008; Tubau et al. in Linguist Rev 32(1):115-142, 2015. 10.1515/tlr-2014-0016) in the gestural movements, and the meaning is crucial for gesture patterns. We emphasize that gesture patterns disambiguate ambiguous interpretation when prosody cannot do so.

An Actuated Variable-View Rigid Scope System to Assist Visualization in Diagnostic Procedures.

OBJECTIVE: Variable-view rigid scopes offer advantages compared to traditional angled laparoscopes for examining a diagnostic site. However, altering the scope's view requires a high level of dexterity and understanding of spatial orientation. This requires an intuitive mechanism to allow an operator to easily understand the anatomical surroundings and smoothly adjust the scope's focus during diagnosis. To address this challenge, the objective of this work is to develop a mechanized arm that assists in visualization using variable-view rigid scopes during diagnostic procedures. METHODS: A system with a mechanized arm to maneuver a variable-view rigid scope (EndoCAMeleon - Karl Storz) was developed. A user study was conducted to assess the ability of the proposed mechanized arm for diagnosis in a preclinical navigation task and a simulated cystoscopy procedure. RESULTS: The mechanized arm performed significantly better than direct maneuvering of the rigid scope. In the preclinical navigation task, it reduced the percentage of time the scope's focus shifted outside a predefined track. Similarly, for simulated cystoscopy procedure, it reduced the duration and the perceived workload. CONCLUSION: The proposed mechanized arm enhances the operator's ability to accurately maneuver a variable-view rigid scope and reduces the effort in performing diagnostic procedures.Clinical and Translational Impact Statement: The preclinical research introduces a mechanized arm to intuitively maneuver a variable-view rigid scope during diagnostic procedures, while minimizing the mental and physical workload to the operator.

Thermal performance curves for aerobic scope and specific dynamic action in a sexually dimorphic piscivore: implications for a warming climate.

Digestion can make up a substantial proportion of animal energy budgets, yet our understanding of how it varies with sex, body mass, and ration size is limited. A warming climate may have consequences on animal growth and feeding dynamics that will differentially impact individuals in their ability to efficiently acquire and assimilate meals. Many species, such as walleye (Sander vitreus), exhibit sexual size dimorphism (SSD), whereby one sex is larger than the other, suggesting sex-differences in energy acquisition and/or expenditure. Here we present the first thorough estimates of specific dynamic action (SDA) in adult walleye using intermittent-flow respirometry. We fed male (n=14) and female (n=9) walleye two ration sizes; 2% and 4% of individual body weight, over a range of temperatures from 2 - 20°C. SDA was shorter in duration and reached higher peak rates of oxygen consumption with increasing temperatures. Peak SDA increased with ration size and decreased with body mass. The proportion of digestible energy lost to SDA (i.e., the SDA coefficient) was consistent at 6% and was unrelated to temperature, body mass, sex, or ration size. Our findings suggest that sex has a negligible role in shaping SDA, nor is SDA a contributor to SSD for this species. Standard and maximum metabolic rates were similar between sexes but maximum metabolic rate decreased drastically with body mass. Large fish, which are important for population growth due to reproductive hyperallometry, may therefore face a bioenergetic disadvantage and struggle most to perform optimally in future, warmer waters.

Assessing metabolic rates in zebrafish using a 3D-printed intermittent-flow respirometer and swim tunnel system.

Zebrafish have become a widely used vertebrate model in physiology and reliable measures of their metabolic rate are needed. We have developed a 3D-printed respirometer and swim tunnel system and used it for obtaining accurate measurement of standard metabolic rate (SMR) and maximal, aerobic metabolic rate (MMR) in zebrafish under rest and maximal exercise, respectively. We compared a slow (stepwise) protocol to a fast (continuous) protocol for determining MMR. The fast protocol yielded slightly (but not significantly) higher oxygen consumption rates than the slow protocol and the data, in contrast to the slow protocol, followed a normal distribution. These findings point to the fast protocol as a fast and reliable method for obtaining accurate values of MMR in zebrafish. We make the 3D drawings for printing the system available to researchers, to help streamline the field of metabolic research in zebrafish and other smaller fish species.

Coronary circulation enhances the aerobic performance of wild Pacific salmon.

Female Pacific salmon often experience higher mortality than males during their once-in-a-lifetime up-river spawning migration, particularly when exposed to secondary stressors (e.g. high temperatures). However, the underlying mechanisms remain unknown. One hypothesis is that female Pacific salmon hearts are more oxygen-limited than those of males and are less able to supply oxygen to the body's tissues during this demanding migration. Notably, female hearts have higher coronary blood flow, which could indicate a greater reliance on this oxygen source. Oxygen limitations can develop from naturally occurring coronary blockages (i.e. coronary arteriosclerosis) found in mature salmon hearts. If female hearts rely more heavily on coronary blood flow but experience similar arteriosclerosis levels as males, they will have disproportionately impaired aerobic performance. To test this hypothesis, we measured resting (RMR) and maximum metabolic rate (MMR), aerobic scope (AS) and acute upper thermal tolerance in coho salmon (Oncorhynchus kisutch) with an intact or artificially blocked coronary oxygen supply. We also assessed venous blood oxygen and chemistry (cortisol, ions and metabolite concentrations) at different time intervals during recovery from exhaustive exercise. We found that coronary blockage impaired MMR, AS and the partial pressure of oxygen in venous blood (PvO2) during exercise recovery but did not differ between sexes. Coronary ligation lowered acute upper thermal tolerance by 1.1°C. Although we did not find evidence of enhanced female reliance on coronary supply, our findings highlight the importance of coronary blood supply for mature wild salmon, where migration success may be linked to cardiac performance, particularly during warm water conditions.

Mechanisms of enhanced cardiorespiratory performance under hyperoxia differ with exposure duration in yellowtail kingfish.

Hyperoxia has been shown to expand the aerobic capacity of some fishes, although there have been very few studies examining the underlying mechanisms and how they vary across different exposure durations. Here, we investigated the cardiorespiratory function of yellowtail kingfish (Seriola lalandi) acutely (~20 h) and chronically (3-5 weeks) acclimated to hyperoxia (~200% air saturation). Our results show that the aerobic performance of kingfish is limited in normoxia and increases with environmental hyperoxia. The aerobic scope was elevated in both hyperoxia treatments driven by a ~33% increase in maximum O2 uptake (MO2max), although the mechanisms differed across treatments. Fish acutely transferred to hyperoxia primarily elevated tissue O2 extraction, while increased stroke volume-mediated maximum cardiac output was the main driving factor in chronically acclimated fish. Still, an improved O2 delivery to the heart in chronic hyperoxia was not the only explanatory factor as such. Here, maximum cardiac output only increased in chronic hyperoxia compared with normoxia when plastic ventricular growth occurred, as increased stroke volume was partly enabled by an ~8%-12% larger relative ventricular mass. Our findings suggest that hyperoxia may be used long term to boost cardiorespiratory function potentially rendering fish more resilient to metabolically challenging events and stages in their life cycle.

Retrospective study of 189 cases of acute perforated peptic ulcer: safety and efficacy of over-the-scope-clip based endoscopic closure.

BACKGROUND: To compare the clinical outcomes in patients with acute perforated peptic ulcer (PPU) treated with over-the-scope clip (OTSC), non-surgical, and surgical interventions, and to explore the effectiveness and safety of OTSC closure. METHODS: Hospital stay, antibiotic use, diet resumption time, and mortality rate were analyzed retrospectively. Binary Logistic regression analysis was used to identify the risk factors influencing PPU complicated with sepsis. RESULTS: Patients were divided into three treatment groups: OTSC (n = 62), non-surgical (n = 72), and surgical (n = 55) groups. The median time (IQR) from symptom onset to admission was 9.0 (4-23) h. 88.71% (55/62) of the patients in In the OTSC group underwent OTSC closure within 24 h (median [IQR] time: 14.5 [7.00-30.25] h). The perforation diameters in the OTSC and surgical groups were 9.87 mm ± 5.97 mm and 8.55 mm ± 6.17 mm, respectively. The median (IQR) hospital stays in the OTSC (9.50 [7.00-12.25] days) and non-surgical group (9.00[7.00-13.00]days) were similar (p > 0.05), but shorter than that in surgical group (12.00[10.00-16.00]days), (p < 0.05). The median duration of antibiotic use was shorter in the OTSC group (7.00[3.00-10.00]) than in the non-surgical group (9.00[7.00-11.00]) and surgical group (11.00[9.00-13.00]) ( p < 0.05); and the time to resume oral feeding was shorter in the OTSC group (4.00[2.00-5.25]) than in the non-surgical group (7.00[6.13-9.00]) and surgical group (8.00[6.53-10.00]), respectively ( p < 0.05). No mortality difference among groups (p = 0.109) was found. Lower albumin level at admission, older age, and elevated creatinine levels were associated with increased sepsis risk, with OR(95%CI) of 0.826 (0.687-0.993), 1.077 (1.005-1.154), and 1.025 (1.006-1.043), respectively (all p < 0.05). CONCLUSION: OTSC closure improves clinical outcomes of acute PPU patients without sepsis. Age, hypoalbuminemia, and baseline renal dysfunction increase the risk of sepsis, while mortality was associated with sepsis and multiorgan dysfunction.