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Objective: To develop natural language processing (NLP) solutions for identifying patients’ unmet social needs to enable timely intervention. Patients and Methods: Design: A retrospective cohort study with review and annotation of clinical notes to identify unmet social needs, followed by using the annotations to develop and evaluate NLP solutions. Participants: A total of 1103 primary care patients seen at a large academic medical center from June 1, 2019, to May 31, 2021 and referred to a community health worker (CHW) program. Clinical notes and portal messages of 200 age and sex-stratified patients were sampled for annotation of unmet social needs. Systems: Two NLP solutions were developed and compared. The first solution employed similarity-based classification on top of sentences represented as semantic embedding vectors. The second solution involved designing of terms and patterns for identifying each domain of unmet social needs in the clinical text. Measures: Precision, recall, and f1-score of the NLP solutions. Results: A total of 5675 clinical notes and 475 portal messages were annotated, with an inter-annotator agreement of 0.938. The best NLP solution achieved an f1-score of 0.95 and was applied to the entire CHW-referred cohort (n=1103), of whom >80% had at least 1 unmet social need within the 6 months before the first CHW referral. Financial strain and health literacy were the top 2 domains of unmet social needs across most of the sex and age strata. Conclusion: Clinical text contains rich information about patients’ unmet social needs. The NLP can achieve good performance in identifying those needs for CHW referral and facilitate data-driven research on social determinants of health.

Abstract This study explores the geochemical reactions that can cause permeability loss in hydraulically fractured reservoirs. The experiments involved the reaction of powdered-rock samples with produced brines in batch reactor system at temperature of 95 °C and atmospheric pressure for 7-days and 30-days respectively. Results show changes in mineralogy and chemistry of rock and fluid samples respectively, therefore confirming chemical reactions between the two during the experiments. The mineralogical changes of the rock included decreases of pyrite and feldspar content, whilst carbonate and illite content showed an initial stability and increase respectively before decreasing. Results from analyses of post-reaction fluids generally corroborate the results obtained from mineralogical analyses. Integrating the results obtained from both rocks and fluids reveal a complex trend of reactions between rock and fluid samples which is summarized as follows. Dissolution of pyrite by oxygenated fluid causes transient and localized acidity which triggers the dissolution of feldspar, carbonates, and other minerals susceptible to dissolution under acidic conditions. The dissolution of minerals releases high concentrations of ions, some of which subsequently precipitate secondary minerals. On the field scale, the formation of secondary minerals in the pores and flow paths of hydrocarbons can cause significant reduction in the permeability of the reservoir, which will culminate in rapid productivity decline. This study provides an understanding of the geochemical rock–fluid reactions that impact long term permeability of shale reservoirs.

Abstract Background Echocardiography is widely used to evaluate left ventricular (LV) diastolic function in patients suspected of heart failure. For patients in sinus rhythm, a combination of several echocardiographic parameters can differentiate between normal and elevated LV filling pressure with good accuracy. However, there is no established echocardiographic approach for the evaluation of LV filling pressure in patients with atrial fibrillation. The objective of the present study was to determine if a combination of several echocardiographic and clinical parameters may be used to evaluate LV filling pressure in patients with atrial fibrillation. Results In a multicentre study of 148 atrial fibrillation patients, several echocardiographic parameters were tested against invasively measured LV filling pressure as the reference method. No single parameter had sufficiently strong association with LV filling pressure to be recommended for clinical use. Based on univariate regression analysis in the present study, and evidence from existing literature, we developed a two-step algorithm for differentiation between normal and elevated LV filling pressure, defining values ≥ 15 mmHg as elevated. The parameters in the first step included the ratio between mitral early flow velocity and septal mitral annular velocity (septal E/e’), mitral E velocity, deceleration time of E, and peak tricuspid regurgitation velocity. Patients who could not be classified in the first step were tested in a second step by applying supplementary parameters, which included left atrial reservoir strain, pulmonary venous systolic/diastolic velocity ratio, and body mass index. This two-step algorithm classified patients as having either normal or elevated LV filling pressure with 75% accuracy and with 85% feasibility. Accuracy in EF ≥ 50% and EF

Abstract Background Quality smoking data is crucial for assessing smoking-related health risk and eligibility for interventions related to that risk. Smoking information collected in primary care practices (PCPs) is a major data source; however, little is known about the PCP smoking data quality. This project compared PCP smoking data to that collected in the Māori and Pacific Abdominal Aortic Aneurysm (AAA) screening programme. Methods A two stage review was conducted. In Stage 1, data quality was assessed by comparing the PCP smoking data recorded close to AAA screening episodes with the data collected from participants at the AAA screening session. Inter-rater reliability was analysed using Cohen’s kappa scores. In Stage 2, an audit of longitudinal smoking status was conducted, of a subset of participants potentially misclassified in Stage 1. Data were compared in three groups: current smoker (smoke at least monthly), ex-smoker (stopped > 1 month ago) and never smoker (smoked

Background Kidney disease is common in heart failure with preserved ejection fraction (HFpEF). However, the biologic correlates and prognostic significance of kidney injury (KI), in HFpEF, beyond the estimated glomerular filtration rate (eGFR), are unclear. Methods and Results Using baseline plasma samples from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial, we measured the following KI biomarkers: cystatin‐C, fatty acid‐binding protein‐3, Beta‐2 microglobulin, neutrophil gelatinase‐associated lipocalin, and kidney‐injury molecule‐1. Factor analysis was used to extract the common variability underlying these biomarkers. We assessed the relationship between the KI‐factor score and the risk of death or HF‐related hospital admission in models adjusted for the Meta‐Analysis Global Group in Chronic Heart Failure risk score and eGFR. We also assessed the relationship between the KI factor score and ~5000 plasma proteins, followed by pathway analysis. We validated our findings among HFpEF participants in the Penn Heart Failure Study. KI was associated with the risk of death or HF‐related hospital admission independent of the Meta‐Analysis Global Group in Chronic Heart Failure risk score and eGFR. Both the risk score and eGFR were no longer associated with death or HF‐related hospital admission after adjusting for the KI factor score. KI was predominantly associated with proteins and biologic pathways related to complement activation, inflammation, fibrosis, and cholesterol homeostasis. KI was associated with 140 proteins, which reproduced across cohorts. Findings regarding biologic associations and the prognostic significance of KI were also reproduced in the validation cohort. Conclusions KI is associated with adverse outcomes in HFpEF independent of baseline eGFR. Patients with HFpEF and KI exhibit a plasma proteomic signature indicative of complement activation, inflammation, fibrosis, and impaired cholesterol homeostasis.

Abstract Interest continues to grow in Arctic megafaunal ecological engineering, but, since the mass extinction of megafauna ~ 12–15 ka, key physiographic variables and available forage continue to change. Here we sought to assess the extent to which contemporary Arctic ecosystems are conducive to the rewilding of megaherbivores, using a woolly mammoth (M. primigenius) proxy as a model species. We first perform a literature review on woolly mammoth dietary habits. We then leverage Oak Ridge National Laboratories Distributive Active Archive Center Global Aboveground and Belowground Biomass Carbon Density Maps to generate aboveground biomass carbon density estimates in plant functional types consumed by the woolly mammoth at 300 m resolution on Alaska’s North Slope. We supplement these analyses with a NASA Arctic Boreal Vulnerability Experiment dataset to downgrade overall biomass estimates to digestible levels. We further downgrade available forage by using a conversion factor representing the relationship between total biomass and net primary productivity (NPP) for arctic vegetation types. Integrating these estimates with the forage needs of woolly mammoths, we conservatively estimate Alaska’s North Slope could support densities of 0.0–0.38 woolly mammoth km−2 (mean 0.13) across a variety of habitats. These results may inform innovative rewilding strategies.

Abstract Excessive STAT3 signalling via gp130, the shared receptor subunit for IL-6 and IL-11, contributes to disease progression and poor survival outcomes in patients with colorectal cancer. Here, we provide evidence that bazedoxifene inhibits tumour growth via direct interaction with the gp130 receptor to suppress IL-6 and IL-11-mediated STAT3 signalling. Additionally, bazedoxifene combined with chemotherapy synergistically reduced cell proliferation and induced apoptosis in patient-derived colon cancer organoids. We elucidated that the primary mechanism of anti-tumour activity conferred by bazedoxifene treatment occurs via pro-apoptotic responses in tumour cells. Co-treatment with bazedoxifene and the SMAC-mimetics, LCL161 or Birinapant, that target the IAP family of proteins, demonstrated increased apoptosis and reduced proliferation in colorectal cancer cells. Our findings provide evidence that bazedoxifene treatment could be combined with SMAC-mimetics and chemotherapy to enhance tumour cell apoptosis in colorectal cancer, where gp130 receptor signalling promotes tumour growth and progression.

IntroductionPatient and Public Involvement (PPI) can have a positive impact on research. PPI can make research more meaningful and appropriate as well as preventing research waste. For decades, patient advocates with HIV have played a key part in public health and research. This article presents the PPI activity undertaken during a doctoral study. The aim of this article is to demonstrate how PPI was embedded into a doctoral study that explored the feasibility of HIV testing in dental settings.MethodsPatients and the public were invited to be involved with the feasibility study through various organisations and charities. A comprehensive PPI activity strategy was devised, and appropriate funding was obtained. Patients and the public were predominantly consulted or collaboratively involved with several aspects of the study.FindingsPatients and the public positively contributed to the intervention development and the resources supporting its implementation. As a result, the study resources (i.e., questionnaire and information leaflets) were easier to read, and the intervention was more appropriate to the needs of patients. Furthermore, the training and focus groups conducted with dental patients and people with HIV benefitted from input of people with lived experience.ConclusionsPPI can be embedded within doctoral studies provided there is sufficient funding, flexibility, and supervisory support. However, PPI activity may be impacted by limited resource and a priori research protocol and funding agreements.

Abstract Fires were historically rare in tropical forests of West and Central Africa, where dense vegetation, rapid decomposition, and high moisture limit available fuels. However, increasing heat and drought combined with forest degradation and fragmentation are making these areas more susceptible to wildfires. We evaluated historical patterns of Moderate Resolution Imaging Spectroradiometer active fires in African tropical forests from 2003 to 2021. Trends were mostly positive, particularly in the northeastern and southern Congo Basin, and were concentrated in areas with high deforestation. Year‐to‐year variation of fires was synchronized with increasing temperature and vapor pressure deficit. There was anomalously high fire activity across the region during the 2015–2016 El Niño. These results contrast with the drier African woodlands and savannas, where fire has been decreasing. Further attention to fires in African tropical forests is needed to understand their global impacts on carbon dynamics and their local implications for biodiversity and human livelihoods.

Background The relationship of serial NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) measurements with changes in cardiac features and outcomes in heart failure (HF) remains incompletely understood. We determined whether common clinical covariates impact these relationships. Methods and Results In 2 nationwide observational populations with HF, the relationship of serial NT‐proBNP measurements with serial echocardiographic parameters and outcomes was analyzed, further stratified by HF with reduced versus preserved left ventricular ejection fraction, inpatient versus outpatient enrollment, age, obesity, chronic kidney disease, atrial fibrillation, and attainment of ≥50% guideline‐recommended doses of renin‐angiotensin system inhibitors and β‐blockers. Among 1911 patients (mean±SD age, 65.1±13.4 years; 26.6% women; 62% inpatient and 38% outpatient), NT‐proBNP declined overall, with more rapid declines among inpatients, those with obesity, those with atrial fibrillation, and those attaining ≥50% guideline‐recommended doses. Each doubling of NT‐proBNP was associated with increases in left ventricular volume (by 6.1 mL), E/e′ (transmitral to mitral annular early diastolic velocity ratio) (by 1.4 points), left atrial volume (by 3.6 mL), and reduced left ventricular ejection fraction (by −2.1%). The effect sizes of these associations were lower among patients with HF with preserved ejection fraction, atrial fibrillation, or advanced age (Pinteraction

Background Although several studies have addressed plasma proteomics in heart failure with preserved ejection fraction, limited data are available on the prognostic value of urinary proteomics. The objective of our study was to identify urinary proteins/peptides associated with death and heart failure admission in patients with heart failure with preserved ejection fraction. Methods and Results The study population included participants enrolled in TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial). The relationship between urine protein levels and the risk of death or heart failure admission was assessed using Cox regression, in both nonadjusted analyses and adjusting for urine creatinine levels, and the MAGGIC (Meta‐Analysis Global Group in Chronic Heart Failure) score. A total of 426 (12.4%) TOPCAT participants had urinary protein data and were included. There were 40 urinary proteins/peptides significantly associated with death or heart failure admission in nonadjusted analyses, 21 of which were also significant adjusted analyses. Top proteins in the adjusted analysis included ANGPTL2 (angiopoietin‐like protein 2) (hazard ratio [HR], 0.5731 [95% CI, 0.47–0.7]; P=3.13E‐05), AMY2A (α amylase 2A) (HR, 0.5496 [95% CI, 0.44–0.69]; P=0.0001), and DNASE1 (deoxyribonuclease‐1) (HR, 0.5704 [95% CI, 0.46–0.71]; P=0.0002). Higher urinary levels of proteins involved in fibrosis (collagen VI α‐1, collagen XV α‐1), metabolism (pancreatic α‐amylase 2A/B, mannosidase α class 1A member 1), and inflammation (heat shock protein family D member 1, inducible T cell costimulatory ligand) were associated with a lower risk of death or heart failure admission. Conclusions Our study identifies several novel associations between urinary proteins/peptides and outcomes in heart failure with preserved ejection fraction. Many of these associations are independent of clinical risk scores and may aid in risk stratification in this patient population.

Olivia T. Ngadjui (she/her), PhD, NCC, LPC (ID) is an Assistant Professor of Counselor Education and Counseling Psychology at Western Michigan University. Her research interests include (a) expanding culturally responsive practice for teaching, counseling, supervising, research/scholarship, and leadership/advocacy in counselor education (b) culturally responsive strategies for informing the work of teachers and practitioners working with students of color in P-12 school environments and (c) preventative wellness practices in counselor education for budding counselors. Elizabeth A. Doughty Horn (she/her), PhD, LCPC (ID) is a Department Associate Chair and Professor of Counseling at Idaho State University. Her research interests include (a) grief and loss (b) mental health counseling and (c) supporting doctoral students’ research agendas.

Many forest cover maps have been generated by using optical and/or microwave images, but these forest cover maps have large area and spatial discrepancies. To date, few studies have assessed forest cover maps in terms of two biophysical parameters used in forest definition: canopy height and canopy coverage. We generated annual forest cover maps from 2007 to 2010 and evergreen forest cover maps from 2000 to 2021 in the Brazilian Amazon using the images from the Phased Array type L-band Synthetic Aperture Radar and the time series images from the Moderate Resolution Imaging Spectroradiometer, using the forest definition of the Food and Agriculture Organization of the United Nations (>5 m tree height and >10 % canopy coverage) as the reference. We used the canopy height and canopy coverage datasets from the Geoscience Laser Altimeter System during 2003–2007 to assess annual forest cover maps from 2007 to 2010 and annual evergreen forest cover maps from 2003 to 2007, and the results show high accuracy of these forest cover and evergreen forest cover maps. These annual forest cover maps and annual evergreen forest cover maps provide data support for the analyses of the causes, processes, and consequences of forest cover changes in the Brazilian Amazon (https://doi.org/10.6084/m9.figshare.21445626; Qin and Xiao, 2022a; https://doi.org/10.6084/m9.figshare.21445590; Qin and Xiao, 2022b).

Abstract Carbapenem-resistant Escherichia coli (CREC) ST410 has recently emerged as a major global health problem. Here, we report a shift in CREC prevalence in Chinese hospitals between 2017 and 2021 with ST410 becoming the most commonly isolated sequence type. Genomic analysis identifies a hypervirulent CREC ST410 clone, B5/H24RxC, which caused two separate outbreaks in a children’s hospital. It may have emerged from the previously characterised B4/H24RxC in 2006 and has been isolated in ten other countries from 2015 to 2021. Compared with B4/H24RxC, B5/H24RxC lacks the bla OXA-181-bearing X3 plasmid, but carries a F-type plasmid containing bla NDM-5. Most of B5/H24RxC also carry a high pathogenicity island and a novel O-antigen gene cluster. We find that B5/H24RxC grew faster in vitro and is more virulent in vivo. The identification of this newly emerged but already globally disseminated hypervirulent CREC clone, highlights the ongoing evolution of ST410 towards increased resistance and virulence.

Abstract Interleukin (IL-)11, an IL-6 family cytokine, has pivotal roles in autoimmune diseases, fibrotic complications, and solid cancers. Despite intense therapeutic targeting efforts, structural understanding of IL-11 signalling and mechanistic insights into current inhibitors are lacking. Here we present cryo-EM and crystal structures of the human IL-11 signalling complex, including the complex containing the complete extracellular domains of the shared IL-6 family β-receptor, gp130. We show that complex formation requires conformational reorganisation of IL-11 and that the membrane-proximal domains of gp130 are dynamic. We demonstrate that the cytokine mutant, IL-11 Mutein, competitively inhibits signalling in human cell lines. Structural shifts in IL-11 Mutein underlie inhibition by altering cytokine binding interactions at all three receptor-engaging sites and abrogating the final gp130 binding step. Our results reveal the structural basis of IL-11 signalling, define the molecular mechanisms of an inhibitor, and advance understanding of gp130-containing receptor complexes, with potential applications in therapeutic development.

HIV point of care testing (POCT) is a common approach to expanding testing into non-specialised settings. Dental services have untapped potential to screen for health conditions including HIV. However, the perspectives of UK dental patients, dental professionals, and people with HIV are unknown. Ten focus groups were undertaken with dental patients, professionals, and people with HIV. The Framework method was used to analyse the qualitative data. Six themes were generated from the focus group data. The themes explored perceptions of HIV, the purpose, appropriateness, and acceptability of HIV testing in dental settings, and new processes that would need to be established in order to successfully implement point of care HIV testing in UK dental settings. Training needs were identified including communication skills and updates to current knowledge about HIV. HIV testing in dental settings is generally acceptable to dental patients, dental professionals, and PWH. However, of concern were logistical challenges and the risk of patients surprised at being offered an HIV test during a visit to the dentist. Nonetheless, the public health benefits of the intervention were well understood, i.e., early detection of HIV and initiation of treatment to improve health outcomes. Dental teams were able to generate novel solutions that could help to overcome contextual and logistical challenges to implementing HIV testing in dental settings.

This article concerns the problematic connection between Marxism and Andragogy. The former is generally regarded as an unpopular, discredited and, in some political circles, a dangerously revolutionary political doctrine, mainly of historical interest. The latter is a conventional, contemporary, and pragmatic approach to adult education that distinguishes between teaching methods appropriate for children and adults. What follows in a discussion of whether the two can be connected and, if so, for what purpose?

Despite the importance that international educators place on the health and safety of students, not enough attention is given to the wellness of professionals during crises. This narrative study explored how the response to COVID-19 affected the wellness of six international educators. We found that the changes to professional social relationships, new challenges faced throughout a long-term pandemic, and uncertainty about the future affected the wellness of the participants in myriad ways.

Counselors are frequently called upon to be advocates for their clients and, more broadly, to advocate for the counseling profession. However, many new counselors struggle with integrating advocacy work in their counseling practice. This article provides an overview of service learning and identifies ways counselor educators may foster advocacy skills among counselors-in-training through the use of planned service learning experiences in the counselor education curriculum. The authors then provide examples of service learning activities for use within the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2016 core curricular areas, including professional orientation and ethical practice, social and cultural diversity, career development, helping relationships, and group work.

Aligning job descriptions at Duke University Schools of Medicine and Nursing with the Joint Task Force for Clinical Trial Competencies (JTFCTC) spurred additional related activities--namely, establishing professional pathways and career ladders for clinical research professional (CRP) positions. CRPs leave Academic Medical Centers for many reasons, but lack of career advancement opportunities is one of the top observations. Duke developed a competency-based tiering system for CRP job classifications. This process of Tier Advancement allows CRPs to advance their tier through demonstration of knowledge, skills, and abilities in a variety of clinical research competencies. Tier Advancement is point-based and permits CRPs to advance within a single job classification, removing the need for onerous reclassification. The point-based nature of the system allows flexibility, in that CRPs can advance by demonstrating a limited set of in-depth specialized competencies or a breadth of responsibilities across a wide array of competencies. Tier Advancement has provided benefit to individual employees by offering an opportunity for self-driven career development. It has also benefited the institution by increasing CRP retention rates and allowed Duke to better understand current competency levels of its workforce.

COVID-19 largely brought U.S. education abroad to a halt. As universities and education abroad organizations bolstered risk management policies, students slowly returned to study abroad programs. Our phenomenological study explored the meaning that students who studied abroad during the pandemic gave to their experiences. We found that the essence of the phenomenon was an amplified version of the meaning that students gave to pre-pandemic study abroad experiences.

Abstract The future of coastal wetlands will depend on the combined effects of climate change and human impacts from urbanization and coastal management. Disentangling the effects of these factors is difficult, but satellite imagery archives provide a way to track biological and physical changes in wetlands over recent decades to reveal how coastal wetlands have been changing in response to climate and human drivers. In this study, we used Landsat to monitor the conditions of 32 coastal wetlands in southern California from 1984 to 2019 and identify environmental and human drivers of these trends. Wetland conditions were characterized by vegetation greenness, using the normalized difference vegetation index (NDVI), and by habitat composition, derived from areal estimates of wetland and subtidal habitats. Overall, wetlands displayed three types of long‐term response: greening and gaining wetland (10), greening and losing wetland (16), and browning and losing wetland (6). Regional environmental drivers with overall positive effects on wetland NDVI were sea level, wave height, and precipitation, whereas stream discharge, vapor pressure deficit, and air temperature had negative or nonlinear effects. Wetland area change was primarily correlated with sea level, but response was highly contextual among sites. Negative trends in wetland NDVI and area were more common in larger sites with low elevations and in sites with open inlets. Restoration had mixed effects, with only half of the restored sites showing positive changes in NDVI and wetland area post‐restoration. The important work of managing and restoring urban coastal wetlands is complicated by variability and context and requires us to account for the influence of humans and climate as we build a regional understanding of historic, present, and future wetland health.

Abstract Background The term ‘care‐experienced’ refers to anyone who is currently in care or has been in care at any stage in their life. A complex interplay of factors leads to care‐experienced children and young people (CECYP) experiencing poorer oral health and access to dental care than their peers. A rapid review of the co‐production of health and social care research with vulnerable children and young people (CYP) was carried out to inform the development of a co‐produced research project exploring the oral health behaviours and access to dental services of CECYP. Here, ‘co‐production’ refers to the involvement of CYP in the planning or conduct of research with explicit roles in which they generate ideas, evidence and research outputs. Aim To learn how to meaningfully involve vulnerable CYP in the co‐production of health and social science research. Objectives To identify: Different approaches to facilitating the engagement of vulnerable CYP in co‐production of health and social science research; different activities carried out in such approaches, challenges to engaging vulnerable CYP in co‐production of health and social science research and ways to overcome them and areas of best practice in relation to research co‐production with vulnerable CYP. Search Strategy A rapid review of peer‐reviewed articles was conducted in six databases (MEDLINE, Embase, SocINDEX, CINAHL, PsycINFO and Web of Science) and grey literature to identify studies that engaged vulnerable CYP in co‐approaches to health and social research. Main Results Of 1394 documents identified in the search, 40 were included and analysed. A number of different approaches to co‐production were used in the studies. The CYP was involved in a range of activities, chiefly the development of data collection tools, data collection and dissemination. Individual challenges for CYP and researchers, practical and institutional factors and ethical considerations impacted the success of co‐production. Discussion and Conclusion Co‐production of health and social science with vulnerable CYP presents challenges to researchers and CYP calling for all to demonstrate reflexivity and awareness of biases, strengths and limitations. Used appropriately and well, co‐production offers benefits to researchers and CYP and can contribute to research that reflects the needs of vulnerable CYP. Adherence to the key principles of inclusion, safeguarding, respect and well‐being facilitates this approach. Patient and Public Contribution Members of our patient and public involvement and stakeholder groups contributed to the interpretation of the review findings. This manuscript was written together with a young care leaver, Skye Boswell, who is one of the authors. She contributed to the preparation of the manuscript, reviewing the findings and their interpretation.

People experiencing severe and multiple disadvantage (SMD) have disproportionately high levels of dental disease and tooth loss but have limited access to dental care. This paper presents an evidence-based case study of co-designing, implementing, evaluating and refining a community dental clinic for people experiencing SMD in the Southwest of England. It shares challenges, lessons, and solutions. Tailored interventions that coordinate flexible and responsive care are important for facilitating dental access for individuals experiencing SMD. Participatory approaches can deliver a range of impacts both on research and service development. No single fixed model of co-design can be applied in service development, and the choice will vary depending on local context, available resources and joint decision making. Through co-design, vulnerable populations such as those with SMD can shape dental services that are more acceptable, appropriate and responsive to their needs. This approach can also ensure long-term sustainability by bridging treatment pathway development and commissioning.

Introduction Pediatric trauma resuscitations are low-frequency, high-stakes events that require skilled multidisciplinary teams with strong medical knowledge and communication skills. Methods This pediatric trauma simulation training session included two cases and formats. The first case was designed in a traditional format and featured a 12-month-old child with inflicted blunt head and abdominal trauma. The second case was organized in successive rounds utilizing the rapid cycle deliberate practice (RCDP) model and featured an 18-month-old with gunshot wounds to the abdomen and chest. Educational objectives included effective communication in a multidisciplinary team, timely completion of primary and secondary surveys, awareness of systems and processes related to trauma care, and increasing competency with low-frequency pediatric trauma skills. Necessary equipment included high-fidelity toddler-sized mannequins, chest tube task trainer or applicable mannequin and equipment, intubation equipment and supplies, intraosseous access, and blood products with rapid delivery infusers. This training session was designed for learners in a multidisciplinary team including physician trainees, nurses, and advanced practice providers; adjustments could be made to the team members as desired. Results Quantitative and qualitative evaluations demonstrated high learner satisfaction and engagement, particularly in the RCDP style of learning. Discussion Multidisciplinary team practice of pediatric trauma scenarios, particularly utilizing the RCDP simulation model, provides the opportunity to improve teamwork and communication, practice procedural skills, and deepen team members' understanding of and comfort with trauma resuscitations.

Background Identifying novel molecular drivers of disease progression in heart failure (HF) is a high‐priority goal that may provide new therapeutic targets to improve patient outcomes. The authors investigated the relationship between plasma proteins and adverse outcomes in HF and their putative causal role using Mendelian randomization. Methods and Results The authors measured 4776 plasma proteins among 1964 participants with HF with a reduced left ventricular ejection fraction enrolled in PHFS (Penn Heart Failure Study). Assessed were the observational relationship between plasma proteins and (1) all‐cause death or (2) death or HF‐related hospital admission (DHFA). The authors replicated nominally significant associations in the Washington University HF registry (N=1080). Proteins significantly associated with outcomes were the subject of 2‐sample Mendelian randomization and colocalization analyses. After correction for multiple testing, 243 and 126 proteins were found to be significantly associated with death and DHFA, respectively. These included small ubiquitin–like modifier 2 (standardized hazard ratio [sHR], 1.56; P

The existence of coastal ecosystems depends on their ability to gain sediment and keep pace with sea level rise. Similar to other coastal areas, Northeast Florida (United States) is experiencing rapid population growth, climate change, and shifting wetland communities. Rising seas and more severe storms, coupled with the intensification of human activities, can modify the biophysical environment, thereby increasing coastal exposure to storm-induced erosion and inundation. Using the Guana Tolomato Matanzas National Estuarine Research Reserve as a case study, we analyzed the distribution of coastal protection services–expressly, wave attenuation and sediment control–provided by estuarine habitats inside a dynamic Intracoastal waterway. We explored six coastal variables that contribute to coastal flooding and erosion–(a) relief, (b) geomorphology, (c) estuarine habitats, (d) wind exposure, (e) boat wake energy, and (f) storm surge potential–to assess physical exposure to coastal hazards. The highest levels of coastal exposure were found in the north and south sections of the Reserve (9% and 14%, respectively) compared to only 4% in the central, with exposure in the south driven by low wetland elevation, high surge potential, and shorelines composed of less stable sandy and muddy substrate. The most vulnerable areas of the central Reserve and main channel of the Intracoastal waterway were exposed to boat wakes from larger vessels frequently traveling at medium speeds (10–20 knots) and had shoreline segments oriented towards the prevailing winds (north-northeast). To guide management for the recently expanded Reserve into vulnerable areas near the City of Saint Augustine, we evaluated six sites of concern where the current distribution of estuarine habitats (mangroves, salt marshes, and oyster beds) likely play the greatest role in natural protection. Spatially explicit outputs also identified potential elevation maintenance strategies such as living shorelines, landform modification, and mangrove establishment for providing coastal risk-reduction and other ecosystem-service co-benefits. Salt marshes and mangroves in two sites of the central section (N-312 and S-312) were found to protect more than a one-quarter of their cross-shore length (27% and 73%, respectively) from transitioning to the highest exposure category. Proposed interventions for mangrove establishment and living shorelines could help maintain elevation in these sites of concern. This work sets the stage for additional research, education, and outreach about where mangroves, salt marshes, and oyster beds are most likely to reduce risk to wetland communities in the region.