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Background: Dietary interventions have potential to improve symptoms and outcomes in patients with heart failure (HF), but there are barriers to eating nutrient-dense diets. One strategy to address challenges is to provide medically tailored meals (MTMs), fully prepared meals that align with an individual's nutritional needs. In this systematic review, we examined clinical outcomes of studies that provided MTMs to patients with HF., Methods and Results: We searched CINAH, EBSCO/MEDLINE, EMBASE, PUBMED and the Cochrane Central Register of Controlled Trials to identify MTM interventions published between 2013 and 2023. We included six studies. Five studies involved sodium restriction. Four of these were randomized control trials and one was a matched cohort study. Sample sizes ranged from 31 to 641. Patient populations included individuals who had heart failure, acute decompensated heart failure and heart failure with preserved ejection fraction. One study involved energy restriction in patients with heart failure with preserved ejection fraction and obesity. This was a randomized controlled study with a sample size of 100. Sodium-restriction interventions, when aligned with Dietary Approaches to Stop Hypertension goals, reduced 90-day HF readmissions in one study and trended towards improving 30-day and 12-week HF readmissions in another. The energy-restriction intervention reduced diastolic blood pressure, weight, and inflammatory biomarkers, and improved quality of life (QoL) and cardiorespiratory fitness. Neither intervention had an impact on mortality., Conclusions: Provision of sodium-restricted MTMs to patients with HF may reduce the risk of rehospitalization. Provision of energy-restricted MTMs to patients with HF and obesity can improve symptoms, weight loss, QoL, and cardiorespiratory fitness. Adequately powered randomized controlled trials are needed to confirm these effects and investigate underlying mechanisms., (Published by Elsevier Inc.)

Public health practitioners rely on timely surveillance data for planning and decision-making; however, surveillance data are often subject to delays. Epidemic trend categories, based on time-varying effective reproductive number (R t ) estimates that use nowcasting methods, can mitigate reporting lags in surveillance data and detect changes in community transmission before reporting is completed. CDC analyzed the performance of epidemic trend categories for COVID-19 during summer 2024 in the United States and at the state level in New Mexico. COVID-19 epidemic trend categories were estimated and released in real time based on preliminary data, then retrospectively compared with final emergency department (ED) visit data to determine their ability to detect or confirm real-time changes in subsequent ED visits. Across the United States and in New Mexico, epidemic trend categories were an early indicator of increases in COVID-19 community transmission, signifying increases in COVID-19 community transmission in May, and a confirmatory indicator that decreasing COVID-19 ED visits reflected actual decreases in COVID-19 community transmission in September, rather than incomplete reporting. Public health decision-makers can use epidemic trend categories, in combination with other surveillance indicators, to understand whether COVID-19 community transmission and subsequent ED visits are increasing, decreasing, or not changing; this information can guide communications decisions., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Juliet Pulliam reports institutional support from the Bill and Melinda Gates Foundation, the Wellcome Trust, and the South Africa Department of Science and Innovation; consulting fees from the National Institute for Public Health and the Environment, the Netherlands; and membership on the Strategic Advisory Board for the Medical Research Council’s Centre for Global Infectious Disease Analysis, Imperial College, London. No other potential conflicts of interest were disclosed.

Unrepresented patients who lack decision-making capacity can remain in hospitals for weeks awaiting guardianship and subsequent discharge, resulting in medically unnecessary and costly extended stays. The guardianship process is complicated and requires collaboration between the medical and legal systems. The Rocky Mountain Regional Veteran Affairs Medical Center created a guardianship social worker position to improve the guardianship process by developing subject matter expertise, infrastructure, and standardized procedures. In this brief report, we provide preliminary data on the impact of a guardianship social worker. Time to guardianship completion, mean lengths of stay (LOS), counts of completed guardianships, and cost estimates were compared before and after the guardianship social worker position was created. The mean time to complete guardianships decreased from 121.9 to 69.8 days ( p  = .13), the mean LOS for patients awaiting guardianship decreased from 129.8 to 117.2 days ( p  = .39), and the yearly counts of completed guardianships increased from 2 to 9 ( p  = .002). Estimated inpatient cost savings per patient was $56,244. While promising, these preliminary data are limited by small case numbers and the unknown impact of the COVID-19 pandemic on long-term placement. Creating guardianship-focused social work positions has the potential to create efficiencies in the guardianship process.

Aims: This study aimed to describe nurses' experiences caring for patients who use medicinal cannabis. For the purpose of this study, the term 'medicinal cannabis' is used to describe cannabis-based products that are sourced legally or illegally., Design: Qualitative study using thematic analysis., Methods: Eleven registered nurses explored their experiences caring for patients using medicinal cannabis in the Australian healthcare sector. Semistructured interviews were via telephone, Zoom or face to face. Transcribed interview data were analysed using the six phases of thematic analysis., Results: The nurses' experiences of caring for patients who use medicinal cannabis were described in three themes; 'Searching for predictable processes of regulation, access and use of medicinal cannabis', 'One conundrum after another' and 'There is a lot to learn'. Overall, nurses described feeling underprepared to care for patients who use or want to use medicinal cannabis in the Australian healthcare sector., Conclusion: The results indicate that nurses want to have meaningful discussions with patients about the use of medicinal cannabis, yet do not always have the confidence to do so. Nurses sought their own education on how to better support patients. All participants echoed the need for education. The nurse's role in caring for and supporting patients using medicinal cannabis could improve the patient experience., Implications for the Profession And/or Patient Care: Nurses play an essential role in improving the patient's experience and advocating for those using or wanting to discuss medicinal cannabis as a part of holistic care. Defining the nurse's role in effectively caring for patients can begin by providing evidence-based education to nurses. Including nurses in policy development and beginning to understand the legal and regulatory implications for nurses are important., Impact: This is the first study presenting current issues for nurses who care for patients using medicinal cannabis in Australian healthcare systems., Reporting Method: COREQ guidelines were adhered to for this study., No Patient or Public Contribution: For this research project on the experiences of registered nurses caring for patients using medicinal cannabis, we did not engage members of the patient population or the general public., (© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.)

Side-chain engineering in molecular semiconductors provides a versatile toolbox for precisely manipulating the material's processability, crystallographic properties, as well as electronic and optoelectronic characteristics. This study explores the impact of integrating hydrophilic side chains, specifically oligoethylene glycol (OEG) units, into the molecular structure of the small molecule semiconductor, 2,7-bis(2(2-methoxy ethoxy)ethoxy) benzo[ b ]benzo[4,5] thieno[2,3- d ] thiophene (OEG-BTBT). The investigation includes a comprehensive analysis of thin film morphology and crystallographic properties, along with the optimization of deposition parameters for improving the device performance. Despite the anticipated benefits, such as enhanced processability, our investigation into OEG-BTBT-based organic field-effect transistors (OFETs) reveals suboptimal performance marked by a low effective charge carrier mobility, a low on/off ratio, and a high threshold voltage. The study unveils bias stress effects and device degradation attributed to the high ionization energy of OEG-BTBT alongside the hydrophilic nature of the ethylene-glycol moieties, which lead to charge trapping at the dielectric interface. Our findings underscore the need for a meticulous balance between electronic properties and chemical functionalities in molecular semiconductors to achieve stable and efficient performance in organic electronic devices., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Since the first applications of nanohoops in organic electronics appear promising, the time has come to go deeper into their rational design in order to reach high-efficiency materials. To do so, systematic studies dealing with the incorporation of electron-rich and/or electron-poor functional units on nanohoops have to be performed. Herein, the synthesis, the electrochemical, photophysical, thermal, and structural properties of two [4]cyclo-2,7-carbazoles, [4]C-Py-Cbz, and [4]C-Pm-Cbz, possessing electron-withdrawing units on their nitrogen atoms (pyridine or pyrimidine) are reported. The synthesis of these nanohoops is first optimized and a high yield above 50% is reached. Through a structure-properties relationship study, it is shown that the substituent has a significant impact on some physicochemical properties (eg HOMO/LUMO levels) while others are kept unchanged (eg fluorescence). Incorporation in electronic devices shows that the most electrically efficient Organic Field-Effect transistors are obtained with [4]C-Py-Cbz although this compound does not present the best-organized semiconductor layer. These experimental data are finally confronted with the electronic couplings between the nanohoops determined at the DFT level and have highlighted the origin in the difference of charge transport properties. [4]C-Py-Cbz has the advantage of a more 2D-like transport character than [4]C-Pm-Cbz, which alleviates the impact of defects and structural organization., (© 2024 The Authors. Advanced Science published by Wiley‐VCH GmbH.)

This work provides a comprehensive illustration of a crystalline melt memory effect recorded for three solvates of the 2,7-bis(2-(2-methoxyethoxy)ethoxy)benzo[ b ]benzo[4,5] thieno[2,3- d ]thiophene (OEG-BTBT) molecule with dichloromethane (DCM) molecules. Combined optical microscopy and X-ray diffraction measurements at different temperatures are used to get an overview of the structural and morphological properties like melting points, isotropic transition temperatures, induction times, and crystallization kinetics of the three forms. An outstanding observation is made upon annealing the three polymorphs at temperatures well above their respective melting points as well as above the optical clearance temperature. After cooling back to room temperature, recrystallization results in the formation of the initial phase present before the annealing process. This melt memory effect is observed for all three solvates. These observations can be correlated to the strong interaction between the DCM molecules and the oligoethylene glycol side chains, even in the molten state. This conclusion rationalizes the experimental observation made upon solvent vapor annealing of the crystalline sample with DCM, which unambiguously transformed the system into a disordered state., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

The discovery of new polymorphs opens up unique applications for molecular materials since their physical properties are predominantly influenced by the crystal structure type. The deposition of molecules at surfaces offers great potential in the variation of the crystallization conditions, thereby allowing access to unknown polymorphs. With our surface crystallization approach, four new phases are found for an oligoethylene glycol-benzothienobenzothiophene molecule, and none of these phases could be identified via classical polymorph screening. The corresponding crystal lattices of three of the new phases were obtained via X-ray diffraction (XRD). Based on the volumetric considerations together with X-ray fluorescence and Raman spectroscopy data, the phases are identified as solvates containing one, two or three solvent molecules per molecule. The strong interaction of dichloromethane with the oligoethylene glycol side chains of the molecules may be responsible for the formation of the solvates. Temperature-dependent XRD reveals the low thermal stability of the new phases, contrary to the thermodynamically stable bulk form. Nevertheless, the four solvates are stable under ambient conditions for at least two years. This work illustrates that defined crystallization at surfaces enables access to multiple solvates of a given material through precise and controlled variations in the crystallization kinetics.

Chiral molecules are known to behave as spin filters due to the chiral induced spin selectivity (CISS) effect. Chirality can be implemented in molecular semiconductors in order to study the role of the CISS effect in charge transport and to find new materials for spintronic applications. In this study, the design and synthesis of a new class of enantiopure chiral organic semiconductors based on the well-known dinaphtho[2,3-b:2,3-f]thieno[3,2-b]thiophene (DNTT) core functionalized with chiral alkyl side chains is presented. When introduced in an organic field-effect transistor (OFET) with magnetic contacts, the two enantiomers, (R)-DNTT and (S)-DNTT, show an opposite behavior with respect to the relative direction of the magnetization of the contacts, oriented by an external magnetic field. Each enantiomer displays an unexpectedly high magnetoresistance over one preferred orientation of the spin current injected from the magnetic contacts. The result is the first reported OFET in which the current can be switched on and off upon inversion of the direction of the applied external magnetic field. This work contributes to the general understanding of the CISS effect and opens new avenues for the introduction of organic materials in spintronic devices., (© 2023 The Authors. Advanced Science published by Wiley-VCH GmbH.)

Aims: To identify how social participation facilitates pre-registration student nurses learning and professional development using social media., Design: A social survey using thematic analysis to explore Caribbean student nurses' views of social media usage from an open-ended question in a survey., Methods: A qualitative analysis of student nurses from Jamaica and Trinidad and Tobago, who completed an open-ended question in a survey. Data were analysed using thematic analysis., Results/findings: The three themes identified were: (1) Social media and communication; (2) Social media and self-care; and (3) Social media and learning., Conclusion: This paper used qualitative evidence to identify and report a new way of viewing SoMe in nursing education as a student-centred educational learning tool. SoMe can improve the effectiveness of student nurses learning, while developing fundamental skills (open-mindedness, critical thinking, professionalism and decision-making) for nursing practice. Social participation and connectivism theory are embedded in student nurses' learning journey. However, it has been used by student nurses outside the traditional university teaching and their capacity to own their personal learning. To meet the new generation of student nurses' learning needs, it is important that higher education institutions develop guidance, support and use of social media for learning to support student nurses in their education as students and also future professionals., Impact: This study addresses how social participation is used in social media to contribute to Caribbean student nurses' education. The main finding is the introduction of a new learning theory supporting learning using social media. This study has an impact on using social media for learning., Patient or Public Contribution: No patient or public contribution., (© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

In the field of π-conjugated nanohoops, the size of the macrocycle has a strong impact on its structural characteristics, which in turn affect its electronic properties. In this work, we report the first experimental investigations linking the size of a nanohoop to its charge transport properties, a key property in organic electronics. We describe the synthesis and study of the first example of a cyclocarbazole possessing five constituting building units, namely [5]-cyclo-N-butyl-2,7-carbazole, [5]C-Bu-Cbz. By comparison with a shorter analogue, [4]-cyclo-N-butyl-2,7-carbazole, [4]C-Bu-Cbz, we detail the photophysical, electrochemical, morphological and charge transport properties, highlighting the key role played by the hoop size. In particular, we show that the saturated field effect mobility of [5]C-Bu-Cbz is four times higher than that of its smaller analogue [4]C-Bu-Cbz (4.22×10 -5 vs 1.04×10 -5  cm 2  V -1  s -1 ). However, the study of the other organic field-effect transistor characteristics (threshold voltage V TH and subthreshold slope SS) suggest that a small nanohoop is beneficial for good organization of the molecules in thin films, whereas a large one increases the density of structural defects, and hence of traps for the charge carriers. The present findings are of interest for the further development of nanohoops in electronics., (© 2023 The Authors. Chemistry - A European Journal published by Wiley-VCH GmbH.)

This study set out to examine pre-analytical factors affecting the frequency of positive results in newborn screening for biotinidase deficiency. This investigation was prompted by an increase in the annual screen positive rate for biotinidase deficiency in Ontario from 2.65x10 -4 in 2016 to 6.57x10 -4 in 2017. Season and trend decomposition was used to separate seasonality from an underlying trend in the time series of biotindase activity measurements for the period 2014-01-12 to 2019-07-27 (n = 798,770). This analysis revealed a marked seasonal effect (winter = median + ⩽ 17 MRU, summer = mean - ⩽20 MRU) and a non-linear negative trend. Seasonal temperature was correlated with biotinidase results (Pearson's r = 0.79) but not with the observed negative trend (Pearson's r = 0.0025). Time series analysis of biotinidase results grouped by print lot of filter paper revealed that recently printed filter paper cards inhibit biotinidase and that this inhibition resolved over time. This study demonstrates that biotindase activity is inhibited by both increased seasonal temperature and collection on newly printed filter cards., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: To study the association between the collection and use of clinician performance information in physician practices and patient experience in primary care., Study Design: Patient experience scores are calculated from the 2018-2019 Massachusetts Statewide Survey of Adult Patient Experience of Primary Care. Physicians were attributed to physician practices using the Massachusetts Healthcare Quality Provider database. Scores were matched to information on the collection or use of clinician performance information from the National Survey of Healthcare Organizations and Systems using practice name and location., Methods: We conducted observational multivariant generalized linear regression at the patient level where the dependent variables were 1 of 9 patient experience scores and the independent variables were 1 of 5 domains in the collection or use of performance information of the practice. Patient-level controls included self-reported general health, self-reported mental health, age, sex, education, and race/ethnicity. Practice-level controls include the size of the practice and the availability of weekend and evening hours., Results: Nearly 90% of practices in our sample collect or use clinician performance information. High patient experience scores were associated with whether any information was collected and used, especially with whether the practice shared this information internally to compare. Among practices that used clinician performance information, patient experience was not associated with whether the information was used in more aspects of care., Conclusions: The collection and use of clinician performance information were associated with better primary care patient experience among physician practices. Deliberate efforts to use clinician performance information in ways that cultivate clinicians' intrinsic motivation may be especially effective for quality improvement.

To date, all efficient host materials reported for phosphorescent OLEDs (PhOLEDs) are constructed with heteroatoms, which have a crucial role in the device performance. However, it has been shown in recent years that the heteroatoms not only increase the design complexity but can also be involved in the instability of the PhOLED, which is nowadays the most important obstacle to overcome. Herein, we design pure aromatic hydrocarbon materials (PHC) as very efficient hosts in high-performance white and blue PhOLEDs. With EQE of 27.7 %, the PHC-based white PhOLEDs display similar efficiency as the best reported with heteroatom-based hosts. Incorporated as a host in a blue PhOLED, which are still the weakest links of the technology, a very high EQE of 25.6 % is reached, surpassing, for the first time, the barrier of 25 % for a PHC and FIrpic blue emitter. This performance shows that the PHC strategy represents an effective alternative for the future development of the OLED industry., (© 2022 The Authors. Angewandte Chemie International Edition published by Wiley-VCH GmbH.)

The charge transport of crystalline organic semiconductors is limited by dynamic disorder that tends to localize charges. It is the main hurdle to overcome in order to significantly increase charge carrier mobility. An innovative design that combines a chemical structure based on sulfur-rich thienoacene with a solid-state herringbone (HB) packing is proposed and the synthesis, physicochemical characterization, and charge transport properties of two new thienoacenes bearing a central tetrathienyl core fused with two external naphthyl rings: naphtho[2,3-b]thieno-[2''',3''':4'',5'']thieno[2″,3″:4',5']thieno[3',2'-b]naphtho[2,3-b]thiophene (DN4T) and naphtho[1,2-b]thieno-[2''',3''':4'',5'']thieno[2'',3'':4',5']thieno[3',2'-b]naphtho[1,2-b]thiophene are presented. Both compounds crystallize with a HB pattern structure and present transfer integrals ranging from 33 to 99 meV (for the former) within the HB plane of charge transport. Molecular dynamics simulations point toward an efficient resilience of the transfer integrals to the intermolecular sliding motion commonly responsible for strong variations of the electronic coupling in the crystal. Best device performances are reached with DN4T with hole mobility up to μ = 2.1 cm 2 V -1 s -1 in polycrystalline organic field effect transistors, showing the effectiveness of the electronic coupling enabled by the new aromatic core. These promising results pave the way to the design of high-performing materials based on this new thienoacene, notably through the introduction of alkyl side-chains., (© 2022 The Authors. Advanced Science published by Wiley-VCH GmbH.)

Background: Pulmonary artery sling (PAS) is usually associated with long-segment congenital tracheal stenosis (LSCTS). This combination of abnormalities can also be associated with lung hypoplasia abnormalities (hypoplasia, aplasia, or agenesis). This study analyzed the association of lung hypoplasia abnormalities with combined PAS and LSCTS and its influence on its surgical outcomes., Methods: All patients (0 to 18 years) who underwent surgical procedures for both PAS and LSCTS from 1995 to 2019 were analyzed retrospectively for mortality, ventilation days, and intensive care unit days by dividing them into those with normal lungs (group 1) and hypoplastic lungs (group 2)., Results: Included were 75 patients (30 girls [40%]), who were a median age of 5.7 months (interquartile range [IQR], 2.9-13.3 months), median weight of 5.5 kg (IQR, 4.1-7.9 kg), and had a median follow-up of 99.8 months (IQR, 54.5-152.0 months); of these, 8 patients (10.7%) had hypoplastic right lung, comprising hypoplasia in 7 (87.5%), aplasia in 1 (12.5%), and agenesis in 0 (0%). There was a significant difference in mortality (group 1, 9.0%; group 2, 50%; P = .007) but no significant difference in median ventilation days (group 1, 9.0; group 2, 9.0; P = .89) or in median intensive care unit days (group 1, 14.0; group 2, 11.5; P = .44)., Conclusions: Lung hypoplasia associated with PAS and LSCTS is usually right-sided. As a result of severe airway obstruction and single-lung physiology, there is a high requirement of preoperative cardiorespiratory support and a significant association with adverse surgical outcomes., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Macrocycles possessing radially oriented π-orbitals have experienced a fantastic development. However, their incorporation in organic electronic devices remains very scarce. In this work, we aim at bridging the gap between organic electronics and nanorings by reporting the first detailed structure-properties-device performance relationship study of organic functional materials based on a nanoring system. Three [4]cyclo- N -alkyl-2,7-carbazoles bearing different alkyl chains on their nitrogen atoms have been synthesized and characterized by combined experimental and theoretical approaches. This study includes electrochemical, photophysical, thermal, and structural solid-state measurements and charge transport properties investigations. An optimized protocol of the Pt approach has been developed to synthesize the [4]cyclocarbazoles in high yield (52-64%), of great interest for further development of nanorings, especially in materials science. The charge transport properties of [4]cyclocarbazoles and model compound [8]cycloparaphenylene ( [8]CPP ) have been studied. Although no field effect (FE) mobility was recorded for the benchmark [8]CPP , FE mobility values of ca. 10 -5 cm 2 ·V -1 ·s -1 were recorded for the [4]cyclocarbazoles. The characteristics (threshold voltage V TH , subthreshold swing SS, trapping energy Δ E ) recorded for the three [4]cyclocarbazoles appear to be modulated by the alkyl chain length borne by the nitrogen atoms. Remarkably, the space-charge-limited current mobilities measured for the [4]cyclocarbazoles are about 3 orders of magnitude higher than that of [8]CPP (1.37/2.78 × 10 -4 cm 2 ·V -1 ·s -1 for the [4]cyclocarbazoles vs 1.21 × 10 -7 cm 2 ·V -1 ·s -1 for [8]CPP ), highlighting the strong effect of nitrogen bridges on the charge transport properties. The whole study opens the way to the use of nanorings in electronics, which is now the next step of their development.

Purpose: The Bureau of Communicable Disease (BCD) at the New York City Department of Health and Mental Hygiene developed and implemented a multi-level intervention to: 1) establish bureau-wide race consciousness; 2) provide opportunities to examine the contemporary manifestations of racism impacting institutions and communities; 3) develop praxis applying a racial equity and social justice lens to communicable disease surveillance; and 4) center the experiences of Black, Indigenous, People of Color (BIPOC) staff., Methods: A staff committee designed and implemented a multipronged initiative grounded in Public Health Critical Race (PHCR) praxis. The findings from a qualitative report focused on the experiences of POC staff formed the basis of the initiative., Results: Three major themes were identified in the report (Microaggressions Report) as factors that resulted in institutional inequities within the workplace: race-based biases in promotion of staff; lack of opportunity sharing for professional growth; and dominant power relations silencing the voices of POC staff. Based on findings from the Microaggressions Report, BCD designed and implemented seven interventions including: 1) Racial Identity Caucusing; 2) Multimedia Learning; 3) All-staff Workshops; 4) Social Breakout Committee; 5) Surveillance and Data Equity; 6) Core Values Development; and 7) Committee for Hiring, Retention and Promotion., Conclusion: We describe the rationale, design, and implementation of a multipronged intervention at a local health department as a strategy to address institutional racism. The creation of a Microaggressions Report and the PHCR methodology framed our ongoing effort to improve workplace culture and promote equitable opportunities for POC staff., Competing Interests: Competing Interests: None declared., (Copyright © 2021, Ethnicity & Disease, Inc.)

Purpose of Review: The goal of the paper is to review the epidemiology, pathogenesis, diagnosis, and manifestations of perioperative anaphylaxis (POA). We seek to review the most common culprits of POA and different diagnostic modalities for evaluation., Recent Findings: Specific IgE testing has a limited role in POA evaluation due to lack of widespread availability and low sensitivity. Basophil activation testing is complementary to skin tests and can assist NMBA sensitivity diagnosis in complex cases. In the past years, there has been an exponential increase in suspected teicoplanin allergic reactions in the European Union. Chlorhexidine is also being increasingly implicated as a culprit in POA. Multiple classes of perioperative medications cause POA. Diagnostic modalities available include skin testing with nonirritating concentrations, basophil activation tests, specific IgE, and drug provocation testing. An accurate record and critical analysis of perioperative events is more important than isolated test results. Future studies evaluating the pathophysiology of these reactions and other therapeutic strategies, such as targeting the MRGPRX2 receptor, are needed.

New York City (NYC) was an epicenter of the coronavirus disease 2019 (COVID-19) outbreak in the United States during spring 2020 (1). During March-May 2020, approximately 203,000 laboratory-confirmed COVID-19 cases were reported to the NYC Department of Health and Mental Hygiene (DOHMH). To obtain more complete data, DOHMH used supplementary information sources and relied on direct data importation and matching of patient identifiers for data on hospitalization status, the occurrence of death, race/ethnicity, and presence of underlying medical conditions. The highest rates of cases, hospitalizations, and deaths were concentrated in communities of color, high-poverty areas, and among persons aged ≥75 years or with underlying conditions. The crude fatality rate was 9.2% overall and 32.1% among hospitalized patients. Using these data to prevent additional infections among NYC residents during subsequent waves of the pandemic, particularly among those at highest risk for hospitalization and death, is critical. Mitigating COVID-19 transmission among vulnerable groups at high risk for hospitalization and death is an urgent priority. Similar to NYC, other jurisdictions might find the use of supplementary information sources valuable in their efforts to prevent COVID-19 infections., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED). † These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Background: Comorbid long segment congenital tracheal stenosis and congenital cardiovascular abnormalities in children pose significant challenges with regard to repairing these abnormalities simultaneously or in stages. The aim of this study was to explore whether this combination of abnormalities needs a staged approach for surgical repairs., Methods: All children who underwent both tracheal and cardiac surgical procedures at a tertiary hospital from 1995 to 2018 were analyzed retrospectively for mortality, ventilation days, postoperative intensive care unit days, mediastinitis, and unplanned reoperation by dividing them into simultaneous repairs (group 1), staged repairs within the same admission (group 2), and staged repairs during different admissions (group 3)., Results: Of 110 patients included in the study (group 1, 74; group 2. 10; and group 3, 26 patients), there was no significant difference in mortality (P = .85), median ventilation days (P = .99), median intensive care unit days (P = .23), unplanned airway reoperation (P = .36), and unplanned cardiac reoperation (P = .77). There was a significant difference in the rate of mediastinitis (group 1, 3%; group 2, 10%; and group 3, 19%; P = .02). There was no significant difference in 5-year survival (group 1, 86.2%; group 2, 77.8%; and group 3, 85.1%; P = .86). A higher STAT category was identified to be a risk factor for mortality in multivariate Cox regression analysis (relative risk, 5.45)., Conclusions: Combined tracheal and cardiac abnormalities need a stratified approach to facilitate better clinical outcomes. Although the trajectory of care is often based on the clinical presentation, establishing a management protocol will be helpful, for which setting an international database will be useful., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Dieulafoy's disease is a rare vascular lesion characterized by presence of large aberrant arteries within the submucosa of gastrointestinal tract or respiratory tract with a potential to cause life-threatening hemorrhage. Treatment includes bronchoscopy ablation, angiographic embolization or surgery. We report management of 7-year old girl with Dieulafoy's disease in the airway who presented with recurrent hemoptysis. Bronchial angiography revealed multiple feeding vessels to the lesion. Considering the potential risk of recurrence with embolization, sleeve resection of bronchus offered complete resolution. This case demonstrates the usefulness of bronchial angiography as part of multi-faceted approach before surgery in the management of Dieulafoy's disease., (Copyright © 2020 Yeh, Ramaswamy, Shin, McIntyre, McIntosh, Racicot, Chippington, Stuart and Muthialu.)

Background: Multiple comorbidities thought to be associated with poor coordination due to the need for shared treatment plans and active involvement of patients, among other factors. Cardiovascular and mental health comorbidities present potential coordination challenges relative to diabetes., Objective: To determine how cardiovascular and mental health comorbidities relate to patient-centered coordinated care in the Department of Veterans Affairs., Design: This observational study used a 2 × 2 factorial design to determine how cardiovascular and mental health comorbidities are associated with patient perceptions of coordinated care among patients with type 2 diabetes mellitus as a focal condition., Participants: Five thousand eight hundred six patients attributed to 262 primary care providers, from a national sample of 29 medical centers, who had completed an online survey of patient-centered coordinated care in the Department of Veterans Affairs (VA)., Main Measures: Eight dimensions from the Patient Perceptions of Integrated Care (PPIC) survey, a state-of-the-art measure of patients' perspective on coordinated and patient-centered care., Key Results: Mental health conditions were associated with significantly lower patient experiences of coordinated care. Hypotheses for disease severity were not supported, with associations in the hypothesized direction for only one dimension., Conclusions: Results suggest that VA may be adequately addressing coordination needs related to cardiovascular conditions, but more attention could be placed on coordination for mental health conditions. While specialized programs for more severe conditions (e.g., heart failure and serious mental illness) are important, coordination is also needed for more common, less severe conditions (e.g., hypertension, depression, anxiety). Strengthening coordination for common, less severe conditions is particularly important as VA develops alternative models (e.g., community care) that may negatively impact the degree to which care is coordinated.

Background: Delivering care to patients with complex healthcare needs benefits from coordination among healthcare providers. Greater levels of care coordination have been associated with more favorable patient experiences, cost management, and lower utilization of services. Organizational approaches consider how systems, practices, and relationships influence coordination and associated outcomes., Objective: Examine measures of organizational coordination and their association with patient experiences of care coordination involving specialists., Design: Cross-sectional surveys of patients and primary care providers (PCPs)., Participants: Final sample included 3183 patients matched to 233 PCPs from the Veterans Health Administration. All patients had a diagnosis of type 2 diabetes mellitus and one of four other conditions: hypertension; congestive heart failure; depression/anxiety; or severe mental illness/posttraumatic stress disorder., Main Measures: Patients completed a survey assessing perceptions of coordinated care. We examined ratings on three domains: specialist knowledge management; knowledge integration across settings and time; and knowledge fragmentation across settings and time. We created care coordination measures involving the PCP and three specialty provider types. PCPs provided ratings on relational coordination for specialists, feedback coordination, and team coordination. We aligned patient's specialty services used with corresponding PCP ratings of that specialty., Key Results: Patient ratings were significantly lower on specialist knowledge management and knowledge integration when either PCPs did not use feedback coordination (b = - .20; b = - .17, respectively) or rated feedback coordination lower (b = - .08 for both). Teamwork was significantly related to specialist knowledge management (b = .06), knowledge integration (b = .04); and knowledge fragmentation (b = - .04). Relational coordination was related to coordination between the primary care provider and (i) diabetes specialist (b = .09) and (ii) mental health provider (b = .12)., Conclusions: Practices to improve provider coordination within and across primary care and specialty care services may improve patient experiences of care coordination. Improvements in these areas may improve care efficiency and effectiveness.

Cystic fibrosis (CF) is a complex multiorgan disorder that is among the most common fatal genetic diseases benefiting from therapeutic interventions early in life. Newborn screening (NBS) for presymptomatic detection of CF currently relies on a two-stage immunoreactive trypsinogen (IRT) and cystic fibrosis transmembrane conductance regulator (CFTR) mutation panel algorithm that is sensitive but not specific for identifying affected neonates with a low positive predictive value. For the first time, we report the discovery of a panel of CF-specific metabolites from a single 3.2 mm diameter dried blood spot (DBS) punch when using multisegment injection-capillary electrophoresis-mass spectrometry (MS) as a high-throughput platform for nontargeted metabolite profiling from volume-restricted/biobanked specimens with quality control. This retrospective case-control study design identified 32 metabolites, including a series of N-glycated amino acids, oxidized glutathione disulfide, and nicotinamide that were differentially expressed in normal birth weight CF neonates without meconium ileus ( n = 36) as compared to gestational age/sex-matched screen-negative controls ( n = 44) after a false discovery rate adjustment ( q < 0.05). Also, 16 metabolites from DBS extracts allowed for discrimination of true CF cases from presumptive screen-positive carriers with one identified CFTR mutation and transient neonatal hypertrypsinogenemic neonates ( n = 72), who were later confirmed as unaffected due to a low sweat chloride (<29 mM) test result. Importantly, six CF-specific biomarker candidates satisfying a Bonferroni adjustment ( p < 7.25 × 10 -5 ) from three independent batches of DBS specimens included several amino acids depleted in circulation (Tyr, Ser, Thr, Pro, Gly) likely reflecting protein maldigestion/malabsorption. Additionally, CF neonates had lower ophthalmic acid as an indicator of oxidative stress due to impaired glutathione efflux from exocrine/epithelial tissue and elevation of an unknown trivalent peptide that was directly correlated with IRT (ρ = 0.332, p = 4.55 × 10 -4 ). Structural elucidation of unknown metabolites was performed by high-resolution MS/MS, whereas biomarker validation was realized when comparing a subset of metabolites from matching neonatal DBS specimens independently analyzed by direct infusion-MS/MS at an accredited NBS facility. This work sheds new light into the metabolic phenotype of CF early in life, which is required for better functional understanding of CFTR mutations of unknown clinical consequence and the development of more accurate yet cost-effective strategies for CF screening.

Objectives: Several procedures have been described to correct pectus excavatum and carinatum. We have used a modified Ravitch procedure (STRATOS titanium bars) for patients who were unsuitable for the minimally invasive Nuss procedure. The operation produced excellent cosmetic results, but we have noted several fractures and displacements of the STRATOS bars., Methods: We reviewed all our STRATOS patients since first use in 2009 until 2014. We collated the following data of each patient: diagnosis, severity of pectus deformity, comorbidity, previous operations for pectus, age at bar implantation, the number of bars implanted and duration of implantation. Patients with severe comorbidity were excluded., Results: Between 2009 and 2014, 39 patients were treated for pectus deformities using the STRATOS bars. Twelve of 39 patients (31%) were identified as having bar(s) broken before removal. There were no significant differences between patients with fractured bars and those without, except for the number of bars implanted (P = 0.016)., Conclusions: This incidence of bar fracture is unexpectedly high, although the literature on this topic is sparse. The high fracture rate is alarming, because of its unpredictability and lack of clear aetiological factors. The operation is done (largely) for psychosocial and cosmetic reasons, and therefore, we must have complete confidence in the quality of the bars used in teenage pectus patients. We raise the issue to warn other units and encourage them to report bar fracture rates.

Objective: Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers., Data Sources: Veterans Health Administration's Corporate Data Warehouse., Study Design: Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n = 744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n = 256,690) and reviewing charts for cases at high and moderate probability of an AE., Principal Findings: Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n = 405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent., Conclusions: The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: To examine factors associated with 0- to 7-day admission after outpatient surgery in high-volume specialties: general surgery, orthopedics, urology, ear/nose/throat, and podiatry., Study Design: We calculated rates and assessed diagnosis codes for 0- to 7-day admission after outpatient surgery for Centers for Medicare and Medicaid Services (CMS) and Veterans Health Administration (VA) dually enrolled patients age 65 and older. We also estimated separate multilevel logistic regression models to compare patient, procedure, and facility characteristics associated with postoperative admission., Data Collection: 2011-2013 surgical encounter data from the VA Corporate Data Warehouse; geographic data from the Area Health Resources File; CMS enrollment and hospital admission data., Principal Findings: Among 63,585 outpatient surgeries in 124 facilities, 0- to 7-day admission rates ranged from 5 percent (podiatry) to 28 percent (urology); nearly 66 percent of the admissions occurred on the day of surgery. Only 97 admissions were detected in the CMS data (1 percent). Surgical complications were diagnosed in 4 percent of admissions. Procedure complexity, measured by relative value units or anesthesia risk score, was associated with admission across all specialties., Conclusion: As many as 20 percent of VA outpatient surgeries result in an admission. Complex procedures are more likely to be followed by admission, but more evidence is required to determine how many of these reflect potential safety or quality problems., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: To assess satisfaction with maternity waiting home built spaces and features in women who are at risk for underutilizing maternity waiting homes (i.e. residential facilities that temporarily house near-term pregnant mothers close to healthcare facilities that provide obstetrical care). Specifically we wanted to answer the questions: (1) Are built spaces and features associated with maternity waiting home user satisfaction? (2) Can built spaces and features designed to improve hygiene, comfort, privacy and function improve maternity waiting home user satisfaction? And (3) Which built spaces and features are most important for maternity waiting home user satisfaction?, Design: A cross-sectional study comparing satisfaction with standard and non-standard maternity waiting home designs. Between December 2016 and February 2017 we surveyed expectant mothers at two maternity waiting homes that differed in their design of built spaces and features. We used bivariate analyses to assess if built spaces and features were associated with satisfaction. We compared ratings of built spaces and features between the two maternity waiting homes using chi-squares and t-tests to assess if design features to improve hygiene, comfort, privacy and function were associated with higher satisfaction. We used exploratory robust regression analysis to examine the relationship between built spaces and features and maternity waiting home satisfaction., Setting: Two maternity waiting homes in Malawi, one that incorporated non-standardized design features to improve hygiene, comfort, privacy, and function (Kasungu maternity waiting home) and the other that had a standard maternity waiting home design (Dowa maternity waiting home)., Participants: 322 expectant mothers at risk for underutilizing maternity waiting homes (i.e. first-time mothers and those with no pregnancy risk factors) who had stayed at the Kasungu or Dowa maternity waiting homes., Findings: There were significant differences in ratings of built spaces and features between the two differently designed maternity waiting homes, with the non-standard design having higher ratings for: adequacy of toilets, and ratings of heating/cooling, air and water quality, sanitation, toilets/showers and kitchen facilities, building maintenance, sleep area, private storage space, comfort level, outdoor spaces and overall satisfaction (p = <.0001 for all). The final regression model showed that built spaces and features that are most important for maternity waiting home user satisfaction are toilets/showers, guardian spaces, safety, building maintenance, sleep area and private storage space (R 2  = 0.28)., Key Conclusions and Implications for Practice: The design of maternity waiting home built spaces and features is associated with user satisfaction in women at risk for underutilizing maternity waiting homes, especially related to toilets/showers, guardian spaces, safety, building maintenance, sleep area and private storage space. Improving maternity waiting home built spaces and features may offer a promising area for improving maternity waiting home satisfaction and reducing barriers to maternity waiting home use., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Newborn screening programs have expanded to include molecular-based assays as first-tier tests and the success of these assays depends on the quality and yield of DNA extracted from neonatal dried blood spots (DBS). To meet high throughput and rapid turnaround time requirements, newborn screening laboratories adopted rapid DNA extraction methods that produce crude extracts. Quantification of DNA in neonatal DBS is not routinely performed due to technical challenges; however, this may enhance the performance of assays that are sensitive to amounts of input DNA. In this study, we developed a novel high throughput method to quantify total DNA in DBS. It is based on specific acid-catalyzed depurination of DNA followed by mass spectrometric quantification of adenine. The amount of adenine was used to calculate DNA quantity per 3.2 mm DBS. Reference intervals were established using archived, neonatal DBS (n = 501) and a median of 130.6 ng of DNA per DBS was obtained, which is in agreement with literature values. The intra- and interday variations were <15%. The limits of detection and quantification were 12.5 and 37.8 nmol/L adenine, respectively. We demonstrated that DNA from neonatal DBS can be successfully quantified in high throughput settings using instruments currently deployed in NBS laboratories.

The CDC recommended active monitoring of travelers potentially exposed to Ebola virus during the 2014 West African Ebola virus disease outbreak, which involved daily contact between travelers and health authorities to ascertain the presence of fever or symptoms for 21 days after the travelers' last potential Ebola virus exposure. From October 25, 2014, to December 29, 2015, the New York City Department of Health and Mental Hygiene (DOHMH) monitored 5,359 persons for Ebola virus disease, corresponding to 5,793 active monitoring events. Most active monitoring events were in travelers classified as low (but not zero) risk (n = 5,778; 99%). There were no gaps in contact with DOHMH of ≥2 days during 95% of active monitoring events. Instances of not making any contact with travelers decreased after CDC began distributing mobile telephones at the airport. Ebola virus disease-like symptoms or a temperature ≥100.0°F were reported in 122 (2%) active monitoring events. In the final month of active monitoring, an optional health insurance enrollment referral was offered for interested travelers, through which 8 travelers are known to have received coverage. Because it is possible that active monitoring will be used again for an infectious threat, the experience we describe might help to inform future such efforts.

Glutaric aciduria type 3 (GA3) is associated with decreased conversion of free glutaric acid to glutaryl-coA, reflecting deficiency of succinate-hydroxymethylglutarate coA-transferase, caused by variants in the SUGCT (C7orf10) gene. GA3 remains less well known, characterised and understood than glutaric aciduria types 1 and 2. It is generally considered a likely "non-disease," but this is based on limited supporting information, with only nine individuals with GA3 described in the literature. Clinicians encountering a patient with GA3 therefore still face a dilemma of whether or not this should be dismissed as irrelevant.We have identified three unrelated Canadian patients with GA3. Two came to clinical attention because of symptoms, while the third was identified by a population urine-based newborn screening programme and has so far remained asymptomatic. We describe the clinical histories, biochemical characterisation and genotypes of these individuals. Examination of allele frequencies underlines the fact that GA3 is underdiagnosed. While one probable factor is that some GA3 patients remain asymptomatic, we highlight other plausible reasons whereby this diagnosis might be overlooked.Gastrointestinal disturbances were previously reported in some GA3 patients. In one of our patients, severe episodes of cyclic vomiting were the major problem. A trial of antibiotic treatment, to minimise bacterial GA production, was followed by significant clinical improvement.At present, there is insufficient evidence to define any specific clinical phenotype as attributable to GA3. However, we consider that it would be premature to assume that this condition is completely benign in all individuals at all times.

The incidence of Legionnaires' disease in the United States has been increasing since 2000. Outbreaks and clusters are associated with decorative, recreational, domestic, and industrial water systems, with the largest outbreaks being caused by cooling towers. Since 2006, 6 community-associated Legionnaires' disease outbreaks have occurred in New York City, resulting in 213 cases and 18 deaths. Three outbreaks occurred in 2015, including the largest on record (138 cases). Three outbreaks were linked to cooling towers by molecular comparison of human and environmental Legionella isolates, and the sources for the other 3 outbreaks were undetermined. The evolution of investigation methods and lessons learned from these outbreaks prompted enactment of a new comprehensive law governing the operation and maintenance of New York City cooling towers. Ongoing surveillance and program evaluation will determine if enforcement of the new cooling tower law reduces Legionnaires' disease incidence in New York City.

Introduction: Despite strong incentives to use cardiac rehabilitation (CR), patient participation is low in the Veterans Health Administration (VHA). This is paradoxical given that VHA is an integrated health care system that offers a range of CR programs which should logically reduce barriers to access to CR participation. The purpose of this study was to better understand the contextual factors that influence patient participation in CR and how patients consider factors together when making decisions about CR participation., Materials and Methods: Using a qualitative study design we examined patient and provider perceptions of CR across six VHA medical centers with high- and low-enrollment rates between December 2014 and October 2015. We conducted semistructured interviews with CR eligible patients who had both enrolled and not enrolled in CR (n = 16), cardiology providers who could refer patients to CR and CR staff who provided CR services (n = 15). Data were analyzed using grounded thematic techniques., Results: We identified program and patient-specific factors related to CR participation. The four program factors were: program responsiveness to patient needs, CR schedule, specialized CR program equipment, and the CR program social environment. Program factors were primarily discussed by individuals associated with sites that had high CR enrollment rates. The patient-specific factor that promoted participation was patient perceptions of CR benefits. Disincentives to participation included competing conditions or obligations, logistical/cost challenges, convenience, and fear of exercise. CR participation entailed a complex process in which patients balanced factors that reinforced patient perceptions that CR was beneficial against factors that acted as disincentives to participation., Conclusions: CR participation was influenced by both program and patient factors. Patients weighed factors that fostered perceptions that CR was beneficial against factors that served as disincentives to CR participation when considering CR participation. High-enrollment sites may be better at countering disincentives to participate and/or improve patient perceptions of CR. Actionable ways to improve CR participation include encouraging providers to strongly and frequently endorse CR, educating patients about the importance and benefits of CR, emphasizing how exercises are individualized, supervised and monitored, educating patients about how CR is safe and effective, how CR offers peer support, and structuring CR programs to be responsive to patient needs in terms of duration, frequency, schedule, and location., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Background: Improving patient care quality in intensive care units is increasingly important as intensive care unit services account for a growing proportion of hospital services. Organizational factors associated with quality of patient care in such units have been identified; however, most were examined in isolation, making it difficult to assess the relative importance of each. Furthermore, though most intensive care units now use a closed model, little research has been done in this specific context., Objectives: To examine the relative importance of organizational factors associated with patient care quality in closed intensive care units., Method: In a national exploratory, cross-sectional study focused on intensive care units at US Veterans Health Administration acute care hospitals, unit directors were surveyed about nurse and physician staffing, work resources and training, patient care coordination, rounding, and perceptions of patient care quality. Administrative records yielded data on patient volume and facility teaching status. Descriptive statistics, bivariate analyses, and regression modeling were used for data analysis., Results: Sixty-nine completed surveys from directors of closed intensive care units were returned. Regression model results showed that better patient care coordination (β = 0.43; P = .01) and having adequate work resources (β = 0.26; P = .02) were significantly associated with higher levels of patient care quality in such units ( R 2 = 0.22)., Conclusions: Augmenting work resources and/or focusing limited hospital resources on improving patient care coordination may be the most productive ways to improve patient care quality in closed intensive care units., (©2017 American Association of Critical-Care Nurses.)

Mass spectrometry (MS)-based metabolomic initiatives that use conventional separation techniques are limited by low sample throughput and complicated data processing that contribute to false discoveries. Herein, we introduce a new strategy for unambiguous identification and accurate quantification of biomarkers for inborn errors of metabolism (IEM) from dried blood spots (DBS) with quality assurance. A multiplexed separation platform based on multisegment injection-capillary electrophoresis-mass spectrometry (MSI-CE-MS) was developed to provide comparable sample throughput to flow injection analysis-tandem MS (FIA-MS/MS) but with greater selectivity as required for confirmatory testing and discovery-based metabolite profiling of volume-restricted biospecimens. Mass spectral information is encoded temporally within a separation by serial injection of three or more sample pairs, each having a unique dilution pattern, alongside a quality control (QC) that serves as a reference in every run to facilitate between-sample comparisons and/or batch correction due to system drift. Optimization of whole blood extraction conditions on DBS filter paper cut-outs was first achieved to maximize recovery of a wide range of polar metabolites from DBS extracts. An interlaboratory comparison study was also conducted using a proficiency test and retrospective neonatal DBS that demonstrated good agreement between MSI-CE-MS and validated FIA-MS/MS methods within an accredited facility. Our work demonstrated accurate identification of various IEM based on reliable measurement of a panel of primary or secondary biomarkers above an upper cutoff concentration limit for presumptive screen-positive cases without stable isotope-labeled reagents. Additionally, nontargeted metabolite profiling by MSI-CE-MS with temporal signal pattern recognition revealed new biomarkers for early detection of galactosemia, such as N-galactated amino acids, that are a novel class of pathognomonic marker due to galactose stress in affected neonates.

Background Newborn screening for propionic acidemia and methylmalonic acidurias using the marker propionylcarnitine (C3) is neither sensitive nor specific. Using C3 to acetylcarnitine (C3/C2) ratio, together with conservative C3 cut-offs, can improve screening sensitivity, but the false positive rate remains high. Incorporating the marker 2-methylcitric acid has been suggested, to improve the positive predictive value for these disorders without compromising the sensitivity. Methods Between July 2011 and December 2012 at the Newborn Screening Ontario laboratory, all neonatal dried blood spot samples that were reported as screen positive for propionic acidemia or methylmalonic acidurias based on elevated C3 and C3/C2 ratio were analyzed for 2-methylcitric acid, using liquid chromatography tandem mass spectrometry. Results Of 222,420 samples screened, 103 were positive for methylmalonic acidurias or propionic acidemia using C3 and C3/C2 ratio as markers. There were nine true positives: propionic acidemia (n = 3), Cobalamin (Cbl) A (n=1), and Cbl C (n = 5). Among false positives there were 72 neonates not affected, 20 with maternal B 12 deficiency, and two incidental finding (transcobalamin II and unclassified Cbl defect). 2-Methylcitric acid was analyzed in all 103 samples and ranged between 0.1 and 89.4 µmol/l (reference range 0.04-0.36). Only 14 samples exceeded the set 2-methylcitric acid cut-off of 1.0 µmol/l, including the samples from all nine true positives. Conclusion By including 2-methylcitric acid in the screening algorithm, the positive predictive value of our primary and secondary screening targets improved from 8.7 to 64.3%. This would have eliminated 89 unnecessary referrals while maintaining 100% sensitivity.

Introduction: Health care sector corruption diverts resources that could otherwise be used to improve access to health services. Use of private-sector practices such as a public-private partnership (PPP) model for hospital governance and management may reduce corruption. In 2011, a government-run hospital in Lesotho was replaced by a PPP hospital, offering an opportunity to compare hospital systems and practices., Objective: To assess whether a PPP model in a hospital can help curb corruption., Methods: We conducted 36 semistructured interviews with key informants between February 2013 and April 2013. We asked about hospital operations and practices at the government-run and PPP hospitals. We performed content analysis of interview data using a priori codes derived from the Corruption in the Health Sector framework and compared themes related with corruption between the hospitals., Results: Corrupt practices that were described at the government-run hospital (theft, absenteeism, and shirking) were absent in the PPP hospital. In the PPP hospital, anticorruption mechanisms (controls on discretion, transparency, accountability, and detection and enforcement) were described in four management subsystems: human resources, facility and equipment management, drug supply, and security., Conclusion: The PPP hospital appeared to reduce corruption by controlling discretion and increasing accountability, transparency, and detection and enforcement. Changes imposed new norms that supported personal responsibility and minimized opportunities, incentives, and pressures to engage in corrupt practices. By implementing private-sector management practices, a PPP model for hospital governance and management may curb corruption. To assess the feasibility of a PPP, administrators should account for cost savings resulting from reduced corruption.

Objectives: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning., Methods: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results., Results: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success., Conclusions: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

Health care public-private partnerships (PPPs) between a government and the private sector are based on a business model that aims to leverage private-sector expertise to improve clinical performance in hospitals and other health facilities. Although the financial implications of such partnerships have been analyzed, few studies have examined the partnerships' impact on clinical performance outcomes. Using quantitative measures that reflected capacity, utilization, clinical quality, and patient outcomes, we compared a government-managed hospital network in Lesotho, Africa, and the new PPP-managed hospital network that replaced it. In addition, we used key informant interviews to help explain differences in performance. We found that the PPP-managed network delivered more and higher-quality services and achieved significant gains in clinical outcomes, compared to the government-managed network. We conclude that health care public-private partnerships may improve hospital performance in developing countries and that changes in management and leadership practices might account for differences in clinical outcomes., (Project HOPE—The People-to-People Health Foundation, Inc.)

Intrauterine growth restriction (IUGR) is associated with an increased risk of developing obesity, insulin resistance and cardiovascular disease. However, its effect on energetics in heart remains unknown. In the present study, we examined respiration in cardiac muscle and liver from adult mice that were undernourished in utero. We report that in utero undernutrition is associated with impaired cardiac muscle energetics, including decreased fatty acid oxidative capacity, decreased maximum oxidative phosphorylation rate and decreased proton leak respiration. No differences in oxidative characteristics were detected in liver. We also measured plasma acylcarnitine levels and found that short-chain acylcarnitines are increased with in utero undernutrition. Results reveal the negative impact of suboptimal maternal nutrition on adult offspring cardiac energy metabolism, which may have life-long implications for cardiovascular function and disease risk., (© 2015 Authors.)

My decision to be a research student arose from my desire to add something new to the body of knowledge about the experiences of older people from black and minority ethnic (BME) backgrounds in hospital.

Abstract -Public-private partnerships (PPPs) seek to expand access to quality health services in ways that best leverage the capacities and resources of both sectors. There are few examples of PPPs in the hospital sector in developing countries, and little is known about how the involvement of the private sector transforms the delivery of health services in this context. In 2006, the government of Lesotho adopted a PPP approach for the health sector, contracting out to design, build, and operate a hospital network in its capital district. This case study examines differences between a government-run hospital and the PPP-run hospital that replaced it, using in-depth interviews with key informants, observation of management systems, and document review. Key informants emphasized changes in infrastructure, communication, human resource management, and organizational culture that improved quality and demand for services. Important drivers of improved performance included better defined policies and procedures, empowerment and training of managers and staff, and increased accountability. Well-functioning support systems kept the hospital clean and equipment functioning, reduced stock-outs, and allowed staff to do the jobs they were trained to do. The Lesotho PPP model provides insight into the mechanisms by which public-private partnerships may increase access and quality of care.