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Oncocytic adrenocortical neoplasms are a rare histopathological subtype of adrenal tumours which are usually benign and, if malignant, are less likely to metastasise. We report a case of a non-functioning oncocytic adrenocortical tumour, identified incidentally in a middle-aged woman. It was initially reported as a left-sided 3.5×3.4×5.6 cm adrenal adenoma. It however increased in size to 5.4×4.0×4.3 cm on follow-up scans. Subsequent review of the scans revealed an indeterminate lesion with a precontrast density of 30 Hounsfield units, an absolute washout of 42.6% and a relative washout of 28.6%. As a result, laparoscopic left adrenalectomy was performed. Histology confirmed oncocytic adrenocortical carcinoma when using the Lin-Weiss-Bisceglia system, though it was deemed benign when using the Helsinki scoring system. There has been no evidence of recurrence to date. This case highlights the potential pitfalls in the diagnosis of oncocytic neoplasms and the increased specificity of the Helsinki score in assessing metastatic potential.

Objectives. To quantify socioeconomic inequalities in COVID-19 mortality in Colombia and to assess the extent to which type of health insurance, comorbidity burden, area of residence, and ethnicity account for such inequalities. Methods. We analyzed data from a retrospective cohort of COVID-19 cases. We estimated the relative and slope indices of inequality (RII and SII) using survival models for all participants and stratified them by age and gender. We calculated the percentage reduction in RII and SII after adjustment for potentially relevant factors. Results. We identified significant inequalities for the whole cohort and by subgroups (age and gender). Inequalities were higher among younger adults and gradually decreased with age, going from RII of 5.65 (95% confidence interval [CI] = 3.25, 9.82) in participants younger than 25 years to RII of 1.49 (95% CI = 1.41, 1.58) in those aged 65 years and older. Type of health insurance was the most important factor, accounting for 20% and 59% of the relative and absolute inequalities, respectively. Conclusions. Significant socioeconomic inequalities exist in COVID-19 mortality in Colombia. Health insurance appears to be the main contributor to those inequalities, posing challenges for the design of public health strategies. (Am J Public Health. 2022;112(S6):S586–S590. https://doi.org/10.2105/AJPH.2021.306637 )

Traumatic experiences can have significant health effects, particularly when they are experienced during childhood. Structural determinants of health including environmental disasters and limited access to mental health services and affordable housing can contribute additional stress for parents with a personal history of childhood adversity. These factors can directly affect their children, contributing to intergenerational trauma. Pregnant people and families with young children are often referred to public health nursing maternal and child home visiting (HV) programs when there are concerns about historical or evolving childhood trauma. The strict eligibility and participation requirements of existing evidence-based maternal and child HV programs can exclude families that have experienced or are experiencing childhood trauma and its effects and can limit innovation by public health nurses, a hallmark of the field. Therefore, we advocate and describe the implementation of the Trauma Informed Approach in Public Health Nursing (TIA PHN) model, which incorporates a trauma-informed approach into a traditional maternal and child HV program in 3 California counties. TIA PHN, which began enrollment in March 2021, involves public health nurses and community health workers and integrates program evaluations in pursuit of evidence-based status. (Am J Public Health. 2022;112(S3):S298–S305. https://doi.org/10.2105/AJPH.2022.306737 )

There are few educational programs in the United States that have a primary focus on preparing nurses to engage in all levels of public health, health policy, and climate change. The United Nations sustainability development goals (SDG) and the Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (2021) report underscored the importance of key stakeholders, including nurses, engaging in advocacy and policy to promote health equity. We discuss the role of nursing at the intersection of public health, policy, climate change, and the SDG. We also discuss the history and merger of the University of California San Francisco (UCSF) School of Nursing public health and health policy specialties, a significant innovation in our effort to promote health equity. We provide a brief overview of the redesigning of our curriculum that meets the needs of today’s learners by including content on climate change, data analytics, and racial, social, and environmental justice. Finally, we emphasize the need to train the next cadre of nurses interested in careers in public health and health policy for us to meet the challenges facing our communities. (Am J Public Health. 2022;112(S3):S321–S327. https://doi.org/10.2105/AJPH.2022.306826 )

BackgroundMaternal depression and anxiety may increase the risk of offspring incontinence; however, current evidence is unable to draw causal inferences. This study aimed to examine prospective associations between maternal psychopathology and offspring incontinence/constipation and examine evidence for causal intra-uterine effects.MethodsThe study used data from 6,489 children from the Avon Longitudinal Study of Parents and Children. Mothers provided data on depression and anxiety (antenatal and postnatal) and their child’s incontinence (daytime wetting, bedwetting, soiling) and constipation at age 7. We used multivariable logistic regression to examine evidence for independent effects of maternal depression/anxiety on offspring incontinence/constipation and explore a critical/sensitive period of exposure. A negative control design was utilised to examine evidence causal intra-uterine effects.ResultsPostnatal maternal psychopathology was associated with an increased risk of offspring incontinence and constipation (e.g. postnatal anxiety and daytime wetting OR: 1.53; 95% CI: 1.21-1.94), and data were consistent with a critical period model. There was evidence for an independent effect of maternal anxiety. Antenatal maternal psychopathology was associated with constipation (e.g. antenatal anxiety OR: 1.57; 95% CI: 1.25-1.98), but there was no evidence for a causal intra-uterine effect.LimitationsAttrition and maternal reports without use of established diagnostic criteria for incontinence/constipation are potential limitations.ConclusionsChildren exposed to maternal postnatal psychopathology had a greater risk of incontinence/constipation, and maternal anxiety had stronger associations than depression.

Almost half of retroperitoneal (RP) sarcomas are liposarcomas (LPS). The large majority of RP LPS are either well-differentiated LPS (WDLPS) or dedifferentiated LPS (DDLPS), these latter further classified according to grading in G2 and G3 DDLPS. Surgery is the only potentially curative treatment to achieve local control and possibly cure in primary localized disease. Over the last decade, a better delineation of the different histology-specific patterns of failure and the development of nomograms predictors of outcome has led to a better management of these rare tumors, with a special focus on non-surgical treatments. Available evidences - although far from exhaustive - show that radiation therapy might have a role, if any, as neoadjuvant treatment in locally aggressive histologies (i.e. WDLPS and G2 DDLPS), while it does not seem beneficial for histologies with a higher metastatic risk (i.e. G3 DDLPS and leiomyosarcoma). Neoadjuvant chemotherapy, instead, can be considered to reduce the risk of distant metastasis while waiting for the results of an ongoing RCT (STRASS-2) evaluating its effect in these tumors. However, given the rarity of these diseases and the subsequent lack of strong evidences to guide treatment, outcome improvement in these patients remains a challenge. Patients' referral to a sarcoma center where a dedicated specialized multidisciplinary team tailor optimal treatment on a case-by-case basis is crucial to ensure these patients the best outcome. Refining available nomograms - e.g including molecular variables - and identifying predictors of response/toxicity to chemotherapy and immunotherapy might be significantly helpful in tailoring treatments to the patient's characteristics. Also, new systemic agents are eagerly awaited for improving the management further.

COVID-19 has had uneven impacts on health and well-being, with Indigenous communities in the Global South facing some of the highest risks. Focusing on the experience of Sri Lanka, this study identifies key policy responses to COVID-19, documents how they evolved over two years of the pandemic, and examines if and how government responses have addressed issues pertaining to Indigenous Peoples. Drawing upon an analysis of policy documents (n = 110) and interviews with policymakers (n = 20), we characterize seven key policy responses implemented by the Sri Lankan government: i) testing for and identifying COVID-19; ii) quarantine procedures; iii) provisional clinical treatments; iv) handling other diseases during COVID-19; v) movement; vi) guidelines to be adhered to by the general public; and vii) health and vaccination. The nature of these responses changed as the pandemic progressed. There is no evidence that policy development or implementation incorporated the voices and needs of Indigenous Peoples. © 2023

Patients undergoing cancer treatment experience global stress and cancer-specific stress. Both types of stress are associated with a higher symptom burden.In this cross-sectional study, we used a comprehensive set of demographic, clinical, and symptom characteristics to evaluate their relative contribution to the severity of global and cancer-specific stress.Patients (N = 941) completed study questionnaires before their second or third cycle of chemotherapy.Consistent with our a priori hypothesis, we found both common and distinct characteristics associated with higher levels of global stress and cancer-specific stress. A significant proportion of our patients had scores on the Impact of Event Scale-Revised suggestive of subsyndromal (29.4%) or probable (13.9%) posttraumatic stress disorder. Four of the 5 stepwise linear regression analyses for the various stress scales explained between 41.6% and 54.5% of the total variance. Compared with various demographic and clinical characteristics, many of the common symptoms associated with cancer and its treatments uniquely explained a higher percentage of the variance in the various stress scales. Symptoms of depression made the largest unique contribution to the percentage of total explained variance across all 5 scales.Clinicians need to assess for global stress, cancer-specific stress, and depression in patients receiving chemotherapy.Patients may benefit from integrative interventions (eg, mindfulness-based stress reduction, cognitive behavioral therapy, acupuncture) that simultaneously address stress and symptoms commonly associated with cancer and its treatments.

IntroductionHigh alcohol availability is related to increased alcohol consumption and harms. Existing quantitative research provides potential explanations for this relationship but there is little understanding of how people experience local alcohol availability. This is the first review to synthesise qualitative research exploring the relationship between alcohol availability and other factors in local alcohol environments.MethodsThe scoping review includes qualitative studies exploring community-level alcohol availability and other factors, facilitating the purchase and consumption of alcohol. We included studies focusing on children and adolescents as well as adults. Study findings were brought together using thematic analysis and the socio-environmental context model, which explains how certain environments may facilitate drinking.ResultsThe review includes 34 articles. The majority of studies were conducted since 2012. Most studies were conducted in the United Kingdom, Australia and South Africa. The physical availability of alcohol and proximity to local amenities and temporal aspects, like late night opening hours, may be linked to social factors, such as normalisation of drinking and permissive drinking environments. The review highlights the importance of social and cultural factors in shaping interactions with local alcohol environments.Discussion and ConclusionThis qualitative scoping review advances understanding of the pathways linking alcohol availability and alcohol harms by showing that availability, accessibility and visibility of alcohol may contribute towards permissive drinking environments. Further research is needed to better understand how people experience alcohol availability in their local environment and how this can inform alcohol control policies.

Funder: British Lung Foundation, Funder: National Institute for Health Research (NIHR), Lung-function impairment underlies chronic obstructive pulmonary disease (COPD) and predicts mortality. In the largest multi-ancestry genome-wide association meta-analysis of lung function to date, comprising 580,869 participants, we identified 1,020 independent association signals implicating 559 genes supported by ≥2 criteria from a systematic variant-to-gene mapping framework. These genes were enriched in 29 pathways. Individual variants showed heterogeneity across ancestries, age and smoking groups, and collectively as a genetic risk score showed strong association with COPD across ancestry groups. We undertook phenome-wide association studies for selected associated variants as well as trait and pathway-specific genetic risk scores to infer possible consequences of intervening in pathways underlying lung function. We highlight new putative causal variants, genes, proteins and pathways, including those targeted by existing drugs. These findings bring us closer to understanding the mechanisms underlying lung function and COPD, and should inform functional genomics experiments and potentially future COPD therapies.

Wastewater-based surveillance (WBS) of SARS-CoV-2 offers a complementary tool for clinical surveillance to detect and monitor Coronavirus Disease 2019 (COVID-19). Since both symptomatic and asymptomatic individuals infected with SARS-CoV-2 can shed the virus through the fecal route, WBS has the potential to measure community prevalence of COVID-19 without restrictions from healthcare-seeking behaviors and clinical testing capacity. During the Omicron wave, the limited capacity of clinical testing to identify COVID-19 cases in many jurisdictions highlighted the utility of WBS to estimate disease prevalence and inform public health strategies. However, there is a plethora of in-sewage, environmental and laboratory factors that can influence WBS outputs. The implementation of WBS therefore requires a comprehensive framework to outline an analysis pipeline that accounts for these complex and nuanced factors. This article reviews the framework of the national WBS conducted at the Public Health Agency of Canada to present WBS methods used in Canada to track and monitor SARS-CoV-2. In particular, we focus on five Canadian cities – Vancouver, Edmonton, Toronto, Montreal and Halifax – whose wastewater signals are analyzed by a mathematical model to provide case forecasts and reproduction number estimates. This work provides insights on approaches to implement WBS at the national scale in an accurate and efficient manner. Importantly, the national WBS system has implications beyond COVID-19, as a similar framework can be applied to monitor other infectious disease pathogens or antimicrobial resistance in the community.

As a result of the many efforts made in recent decades to implement bioclimatic criteria and passive house models in Mediterranean areas, traditional architectural typologies can play a role in the contemporary environmental architectural framework. The interactive and adaptive relationship between climate, site, and building is a fundamental rule in the climate-responsive approach to reducing environmental impacts. Lately, this idea has been extended to include protecting the cultural identities of places. Many cases in the Mediterranean Basin show that conventional courtyard houses can provide high adaptability, sustainability, and functionality. Mediterranean courtyard houses are founded on a set of adaptable and sustainable standards derived from a combination of active and passive design approaches. This paper presents a comparative study of courtyard houses in five Mediterranean countries: Spain, Türkiye, Greece, Libya, and Palestine, addressing four areas of interest: history, environment, society and geometry. Considering the bioclimatic approach as a critical component in reorienting the construction process, the study’s goal is to compare and evaluate the inner courtyards of these Mediterranean countries, analysing the most important constant factors and modification paths. The study concludes that the courtyard morphology is a shared human legacy with a past and future as it meets its inhabitants’ physical and sociocultural requirements. Furthermore, despite the differences in some aspects, courtyard houses were constructed throughout the Mediterranean with a common meaning of heaven on earth; this could imply that the courtyard garden is the world’s meaning.

Purpose: Babble Boot Camp (BBC) is a parent-implemented telepractice intervention for infants at risk for speech and language disorders. BBC uses a teach–model–coach–review approach, delivered through weekly 15-min virtual meetings with a speech-language pathologist. We discuss accommodations needed for successful virtual follow-up test administration and preliminary assessment outcomes for children with classic galactosemia (CG) and controls at age 2.5 years. Method: This clinical trial included 54 participants, 16 children with CG receiving BBC speech-language intervention from infancy, age 2 years, five children receiving sensorimotor intervention from infancy and changing to speech-language intervention at 15 months until 2 years of age, seven controls with CG, and 26 typically developing controls. The participants' language and articulation were assessed via telehealth at age 2.5 years. Results: The Preschool Language Scale–Fifth Edition (PLS-5) was successfully administered with specific parent instruction and manipulatives assembled from the child's home. The GFTA-3 was successfully administered to all but three children who did not complete this assessment due to limited expressive vocabularies. Referrals for continued speech therapy based on PLS-5 and GFTA-3 scores were made for 16% of children who received BBC intervention from infancy as compared to 40% and 57% of children who began BBC at 15 months of age or did not receive BBC intervention, respectively. Conclusions: With extended time and accommodations from the standardized administration guidelines, virtual assessment of speech and language was possible. However, given the inherent challenges of testing very young children virtually, in-person assessment is recommended, when possible, for outcome measurements.

Background: Poor sleep quality in school children can negatively impact their neurocognitive abilities and academic achievement. Increased screen time was shown to interfere with children’s sleep habits and disrupts their sleep pattern. This study aimed to understand the sleep patterns and sleep disorders in school children and the influence of screen time on sleep in children during the COVID-19 pandemic. Methods: This cross-sectional observational school-based study was done on 443 children aged 6-12 years. Data was collected through parent filled online questionnaire having a proforma and child sleep habit questionnaire (CSHQ), a validated questionnaire to assess sleep disorders in children Results: Out of 443 children studied, the average sleep duration of the study population was 9:06 hours ±42:18 min and, 34.3% of the children slept less than 9 hours per day. The prevalence of sleep disorders was found to be 76.52%. Significant screen time after 8 PM was observed in 65.9% and 62.2 % of children had a total screen time of more than 2 hours. Increased screen time after 8 PM, delayed bedtime and wake-up time in children and also contributed to sleep disorders. Bedtime resistance and daytime sleepiness were more commonly observed in children with increased screen time. Conclusions: Sleep disorders in children are more predominant than sleep deprivation. Increased screen time before bed was found to alter sleep patterns in children and increases bedtime resistance, daytime sleepiness, and sleep disorders.

Invasive pneumococcal disease (IPD) has a high clinical burden, particularly among children in developing countries. We presented 4 cases of IPD in children who were admitted to Pushpagiri institute of medical science and research centre, Kerala between 2021 and 2022. While our first 3 patients had milder course of disease, our fourth patient who presented with severe pneumonia with pleural effusion had poor outcome. The fact that three out of four of our patients have not received pneumococcal vaccination marks the necessity of this vaccine to prevent IPD in children.

Extraversion, of the Big Five personality traits, has been identified as the most socially relevant of the traits with respect to positive COVID-19 coping—yet relevant research is found conflicting. Studies assessing this discrepancy have not situated the influence of extraversion within a geographical and historical context. Thus, a likely contributor has been missed. Furthermore, extraversion is based on other-directed learning with respect to COVID-19 coping, and this has not been considered regarding its contrast to self-directed learning. To provide context, an examination of high-ranking Google Scholar results on extraversion and COVID-19 coping from different countries during the pandemic’s various waves is undertaken, including the introduction of vaccines as a factor in decreasing COVID-19’s perceived threat. These are then examined for relationships regarding public opinion. Following, extraversion is compared with other-directed learning and differentiated from self-directed learning. An understanding is thus presented for assessing when extraversion will be an effective personality trait for positive COVID-19 coping and when it will not. Extraversion’s effect is found inherently inconsistent for identifying positive COVID-19 coping because of its dependence on other-directed learning. The conclusion: stability in positive COVID-19 coping is contingent on personal values that guide self-directed learning rather than extraversion’s other-directed learning.

The Kosciuszko Bridge carries a 1.8 km long segment of the Brooklyn–Queens Expressway over Newtown Creek between Brooklyn and Queens in New York City, USA. The roadway is a vital link in the region's transportation network, carrying over 170 000 vehicles/day. Owing to structural and operational deficiencies, the existing structure was replaced. The new bridge consists of two parallel structures, one eastbound and one westbound, with main spans mirroring one another. Each structure consists of a single-tower cable-stayed main span over Newtown Creek with unbalanced main and back spans. This was the first cable-stayed bridge to be constructed in New York City, joining the ranks of the city's most iconic bridges. Here, two main span structures are discussed, with the focus primarily on the design and construction of the westbound, phase 2 bridge. Some key design aspects are outlined, including outboard cable anchorages, a concrete-filled counterweight and other details intended to facilitate construction, maintenance and inspection. The eastbound, phase 1 bridge was constructed under a design–build contract, and the westbound, phase 2 bridge as a design–bid–build. The paper also touches on some of the design aspects that were refined during the second phase.

PURPOSE Magrolimab is a monoclonal antibody that blocks cluster of differentiation 47, a don't-eat-me signal overexpressed on cancer cells. Cluster of differentiation 47 blockade by magrolimab promotes macrophage-mediated phagocytosis of tumor cells and is synergistic with azacitidine, which increases expression of eat-me signals. We report final phase Ib data in patients with untreated higher-risk myelodysplastic syndromes (MDS) treated with magrolimab and azacitidine (ClinicalTrials.gov identifier: NCT03248479 ). PATIENTS AND METHODS Patients with previously untreated Revised International Prognostic Scoring System intermediate-/high-/very high-risk MDS received magrolimab intravenously as a priming dose (1 mg/kg) followed by ramp-up to a 30 mg/kg once‐weekly or once‐every-2-week maintenance dose. Azacitidine 75 mg/m2 was administered intravenously/subcutaneously once daily on days 1-7 of each 28-day cycle. Primary end points were safety/tolerability and complete remission (CR) rate. RESULTS Ninety-five patients were treated. Revised International Prognostic Scoring System risk was intermediate/high/very high in 27%, 52%, and 21%, respectively. Fifty-nine (62%) had poor-risk cytogenetics and 25 (26%) had TP53 mutation. The most common treatment-emergent adverse effects included constipation (68%), thrombocytopenia (55%), and anemia (52%). Median hemoglobin change from baseline to first postdose assessment was −0.7 g/dL (range, −3.1 to +2.4). CR rate and overall response rate were 33% and 75%, respectively. Median time to response, duration of CR, duration of overall response, and progression-free survival were 1.9, 11.1, 9.8, and 11.6 months, respectively. Median overall survival (OS) was not reached with 17.1-month follow-up. In TP53-mutant patients, 40% achieved CR with median OS of 16.3 months. Thirty-four patients (36%) had allogeneic stem-cell transplant with 77% 2-year OS. CONCLUSION Magrolimab + azacitidine was well tolerated with promising efficacy in patients with untreated higher-risk MDS, including those with TP53 mutations. A phase III trial of magrolimab/placebo + azacitidine is ongoing (ClinicalTrials.gov identifier: NCT04313881 [ENHANCE]).

Alzheimer’s disease (AD) remains a global health challenge in the 21st century due to its increasing prevalence as the major cause of dementia. State-of-the-art artificial intelligence (AI)-based tests could potentially improve population-based strategies to detect and manage AD. Current retinal imaging demonstrates immense potential as a non-invasive screening measure for AD, by studying qualitative and quantitative changes in the neuronal and vascular structures of the retina that are often associated with degenerative changes in the brain. On the other hand, the tremendous success of AI, especially deep learning, in recent years has encouraged its incorporation with retinal imaging for predicting systemic diseases. Further development in deep reinforcement learning (DRL), defined as a subfield of machine learning that combines deep learning and reinforcement learning, also prompts the question of how it can work hand in hand with retinal imaging as a viable tool for automated prediction of AD. This review aims to discuss potential applications of DRL in using retinal imaging to study AD, and their synergistic application to unlock other possibilities, such as AD detection and prediction of AD progression. Challenges and future directions, such as the use of inverse DRL in defining reward function, lack of standardization in retinal imaging, and data availability, will also be addressed to bridge gaps for its transition into clinical use.

OBJETIVO: con el presente artículo se tratará de analizar los aspectos generales de los principios fundamentales que debe proteger el Estado, tales como la igualdad y la no segregación racial, cultural, religiosa y de genero a nivel internacional y nacional; considerados como una problemática que se ha luchado por su erradicación y protección a través de la historia MÉTODO: mediante la lectura e averiguación de diversos libros sobre militarización del Estado por qué se involucran y que efectos desarrolla en el ámbito político. RESULTADOS: es necesario establecer las causas de este fenómeno, los logros alcanzados y los desafíos que se deben someter los estados, siendo garantes de la población, para que estos tengan una mejor convivencia, en pro de los derechos humanos y fundamentales de cada individuo. CONCLUSIÓN: se necesita entablar las razones de este fenómeno, los logros alcanzados y los retos que se tienen que dominar los estados, siendo garante poblacional, para que dichos tengan una mejor convivencia, en pro de los derechos humanos y primordiales de cada persona.

Objectives Death literacy is a recent conceptualization representing both individual and community competence, for example, a set of knowledge and skills for engaging in end-of-life-related situations. Little is yet known about which factors are associated with death literacy. A cross-sectional survey using the Swedish version of the Death Literacy Index, the DLI-S, was therefore conducted to explore associations between death literacy and sociodemographic, health, and experience variables. Methods A quota sample of 503 adults (mean age 49.95 ± 17.92), recruited from an online Swedish survey panel, completed a survey comprising the DLI-S and background questions. Results A hierarchical regression model with 3 blocks explained 40.5% of the variance in death literacy, F(22, 477) = 14.75. The sociodemographic factors age, gender, education, widowhood, and religious/spiritual belief accounted for 13.7% of the variance. Adding professional care factors contributed to an additional 15.8% of variance, with working in health care being significantly associated with death literacy. Including experiential factors explained another 11.0% of the variance, of which experiences of caring for and supporting dying and grieving people, both in a work, volunteer, or personal context, were positively associated with death literacy. Significance of results This study contributes a tentative explanatory model of the influence of different factors on death literacy, outlining both direct and indirect associations. Our findings also support the hypothesized experiential basis for death literacy development in the Swedish context. The moderate degree of overall variance explained suggests there may be additional factors to consider to better understand the death literacy construct and how its development may be supported.

Although the secondary-tertiary transition has been investigated in mathematics education research with different focuses and theoretical approaches, it remains a major issue for students in the transition. With success in a science, technology, engineering, or mathematics (STEM) major at stake, we investigated a novel approach to support the transition from secondary precalculus or calculus to tertiary calculus. Using the Four Component Instructional Design (4C/ID) model and empirical data from the United States (US) nationally representative FICSMath project, we mapped instructional experiences of students in the transition to theoretical components of the 4C/ID model. From exploratory factor analysis (n=6,140), we found six factors that mapped to the 4C/ID model components and created the new Secondary Precalculus Calculus (SPC) 4C/ID model. In this model, the Learning Task Component represents tasks to engage learners in meaningful problem solving; the Support Component grounds instruction in reasoning and understanding; the Procedure Component integrates group work and graphing calculators to connect concepts to procedures; and the Part-Task Component represents instruction to develop automaticity. The SPC 4C/ID model presents a unique support for precalculus and calculus teachers in the quest of teaching for learning and transfer of learning across the transition.

Quaternary ammonium compounds (QACs), a large class of chemicals that includes high production volume substances, have been used for decades as antimicrobials, preservatives, and antistatic agents and for other functions in cleaning, disinfecting, personal care products, and durable consumer goods. QAC use has accelerated in response to the COVID-19 pandemic and the banning of 19 antimicrobials from several personal care products by the US Food and Drug Administration in 2016. Studies conducted before and after the onset of the pandemic indicate increased human exposure to QACs. Environmental releases of these chemicals have also increased. Emerging information on adverse environmental and human health impacts of QACs is motivating a reconsideration of the risks and benefits across the life cycle of their production, use, and disposal. This work presents a critical review of the literature and scientific perspective developed by a multidisciplinary, multi-institutional team of authors from academia, governmental, and nonprofit organizations. The review evaluates currently available information on the ecological and human health profile of QACs and identifies multiple areas of potential concern. Adverse ecological effects include acute and chronic toxicity to susceptible aquatic organisms, with concentrations of some QACs approaching levels of concern. Suspected or known adverse health outcomes include dermal and respiratory effects, developmental and reproductive toxicity, disruption of metabolic function such as lipid homeostasis, and impairment of mitochondrial function. QACs' role in antimicrobial resistance has also been demonstrated. In the US regulatory system, how a QAC is managed depends on how it is used, for example in pesticides or personal care products. This can result in the same QACs receiving different degrees of scrutiny depending on the use and the agency regulating it. Further, the US Environmental Protection Agency's current method of grouping QACs based on structure, first proposed in 1988, is insufficient to address the wide range of QAC chemistries, potential toxicities, and exposure scenarios. Consequently, exposures to common mixtures of QACs and from multiple sources remain largely unassessed. Some restrictions on the use of QACs have been implemented in the US and elsewhere, primarily focused on personal care products. Assessing the risks posed by QACs is hampered by their vast structural diversity and a lack of quantitative data on exposure and toxicity for the majority of these compounds. This review identifies important data gaps and provides research and policy recommendations for preserving the utility of QAC chemistries while also seeking to limit adverse environmental and human health effects.