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To determine whether neurodevelopmental biomarkers at 2 years of age are already present in the newborns' EEG at birth.Low-risk term newborns were enrolled and studied utilizing EEG prior to discharge from the birth hospital. A 14-channel EEG montage (scalp-level) and source signals were calculated using the EEG. Their spectral power was calculated for each of the five frequency bands. Cognitive, language and motor skills were assessed using the Bayley Scales of Infant Development-III at age 2 years. The relationship between the spectral power in each frequency band and neurodevelopmental scores were quantified using the Spearman's r. The role of gender, gestational age (GA) and delivery mode, if found significant (P 0.05), were controlled by analyzing partial correlation.We studied 47 newborns and found a significant association between gender, and delivery mode with EEG power. Scalp- and source-level spectral powers were positively associated with cognitive and language scores. At the source level, significant associations were identified in the parietal and occipital regions.Electrophysiological biomarkers of neurodevelopment at age 2 years are already present at birth in low-risk term infants.Low-risk newborns' EEG utility as a screening tool to optimize neurodevelopmental outcome warrants further evaluation.

Introduction: Arrhythmias in the neonatal period are common and can be classified as bradyarhythmias and tachyarrhythmias and as benign or non-benign. Neonatal arrhythmias are further differentiated between those with abnormalities in generation (non-sinus) and those with abnormalities in propagation. Because the neonatal myocardium is immature and operates at the peak of the Starling curve, significant changes in heart rate can result in a decline in cardiac output and compromise end-organ perfusion. This is especially true for premature neonates, those critically ill, or those with concomitant congenital heart disease. While sustained arrhythmias are frequently witnessed and recorded in tertiary neonatal intensive care units (NICU) very little data exists on the observance of non-sustained brady or tachyarrhythmias in this cohort. No prospective study has been performed on all neonates admitted to a large tertiary NICU throughout their entire stay. The purpose of this study was to prospectively evaluate the prevalence and type of arrhythmias in a large NICU population from admission to discharge. Methods: All neonates admitted to the NICU at Inova Children’s Hospital at Inova Fairfax Medical Campus between January 1, 2021 and April 1, 2021 were prospectively evaluated from admission to hospital discharge via continuous bedside monitoring reviewed every 24 hours. Concerning telemetry strips were reviewed by two team members as well as the senior electrophysiologist. Results: Two-hundred and one neonates (mean gestational age = 344/7 weeks’) were enrolled in the study. Admission length ranged from 1 to 195 days (total of 5624 patient days, median 16 days). Overall, 68% (N = 137) of admissions had one or more arrhythmias, the most common of which was sinus tachycardia (65%, N = 130), followed by sinus bradycardia (30%, N = 60). Clinically relevant arrhythmias were diagnosed in 6.5% of neonates. During the study period there were four deaths, none of which were directly attributable to a primary arrhythmia. Conclusion: Approximately 68% of neonates exhibited at least one arrhythmia. Although the vast majority of these arrhythmias were benign, clinically relevant arrhythmias were observed in 6.5%. Patients admitted to the NICU appear to have a relatively high burden of benign arrhythmias, but a relatively low burden of pathologic arrhythmias.

Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities.To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses.From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022.Use of methamphetamine alone, opioids alone, or both.Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses.Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P .001). Only 66 participants (17%) using methamphetamine alone had naloxone.These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

BACKGROUND Previous studies have described an association between preterm birth and maturation of the autonomic nervous system (ANS); however, this may be impacted by multiple factors, including prematurity-related complications. Our aim was to evaluate for the effect of prematurity-related morbidity on ANS development in preterm infants in the NICU. METHODS We compared time and frequency domains of heart rate variability (HRV) as a measure of ANS tone in 56 preterm infants from 2 NICUs (28 from each). One cohort was from a high-morbidity regional referral NICU, the other from a community-based inborn NICU with low prematurity-related morbidity. Propensity score matching was used to balance the groups by a 1:1 nearest neighbor design. ANS tone was analyzed. RESULTS The two cohorts showed parallel maturational trajectory of the alpha 1 time-domain metric, with the cohort from the high-morbidity NICU having lower autonomic tone. The maturational trajectories between the two cohorts differed in all other time-domain metrics (alpha 2, RMS1, RMS2). There was no difference between groups by frequency-domain metrics. CONCLUSIONS Prematurity-associated morbidities correlate with autonomic development in premature infants and may have a greater impact on the extrauterine maturation of this system than birth gestational age. IMPACT Autonomic nervous system development measured by time-domain metrics of heart rate variability correlate with morbidities associated with premature birth. This study builds upon our previously published work that showed that development of autonomic tone was not impacted by gestational age at birth. This study adds to our understanding of autonomic nervous system development in a preterm extrauterine environment. Our study suggests that gestational age at birth may have less impact on autonomic nervous system development than previously thought.

In this ground-breaking study, Robin Baker investigates the contribution ancient Mesopotamian theology made to the origins of Christianity. Drawing on a formidable range of primary sources, Baker's conclusions challenge the widely held opinion that the theological imprint of Babylonia and Assyria on the New Testament is minimal, and what Mesopotamian legacy it contains was mediated by the Hebrew Bible and ancient Jewish sources. After evaluating and substantially supplementing previous research on this mediation, Baker demonstrates significant direct Mesopotamian influence on the New Testament presentation of Jesus and particularly the character of his kingship. He also identifies likely channels of transmission. Baker documents substantial differences among New Testament authors in borrowing Mesopotamian conceptions to formulate their Christology. This monograph is an essential resource for specialists and students of the New Testament as well as for scholars interested in religious transmission in the ancient Near East and the afterlife of Mesopotamian culture.

Background Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl’s dramatic increase in the recreational drug supply over the past decade. Methods We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes. Results PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers. Conclusion PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Background The CHOICES study randomized participants with HIV and opioid use disorder (OUD) to HIV clinic-based extended-release naltrexone (XR-NTX), which requires complete cessation of opioid use, versus treatment-as-usual (i.e., buprenorphine, methadone). Study participants randomized to XR-NTX were interviewed to assess their experiences with successful and unsuccessful XR-NTX induction. Methods Semi-structured qualitative interviews were completed with a convenience sample of study participants with HIV and OUD (n = 37) randomized to XR-NTX in five HIV clinics between 2018 and 2019. All participants approached agreed to be interviewed. Interviews were digitally recorded, professionally transcribed, and analyzed using thematic analysis. Results Participants included women (43%), African Americans (62%) and Hispanics (16%), between 27 to 69 years of age. Individuals who completed XR-NTX induction (n = 20) reported experiencing (1) readiness for change, (2) a supportive environment during withdrawal including comfort medications, and (3) caring interactions with staff. Four contrasting themes emerged among participants (n = 17) who did not complete induction: (1) concern and anxiety about withdrawal including past negative experiences, (2) ambivalence about or reluctance to stop opioids, (3) concerns about XR-NTX effects, and (4) preferences for other medications. Conclusions The results highlight opportunities to improve initiation of XR-NTX in high-need groups. Addressing expectations regarding induction may enhance XR-NTX initiation rates. Trial Registration ClinicalTrials.gov: NCT03275350. Registered September 7, 2017. https://clinicaltrials.gov/ct2/show/NCT03275350?term=extended+release+naltrexone&cond=Opioid+Use.

Background Residential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment. Methods A retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes. Results Of 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73–2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80–1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23–0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32–2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56–2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46–1.29; interaction p = 0.001). Conclusions Relative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

Purpose To compare early changes in autonomic nervous system (ANS) tone between newborns with complex congenital heart disease (CHD) and newborns without CHD. Methods We performed a case–control study of heart rate variability (HRV) in newborns with complex CHD [transposition of the great arteries (TGA) or hypoplastic left heart syndrome (HLHS)] and low-risk control newborns without CHD. Cases with CHD were admitted following birth to a pediatric cardiac intensive care unit and had archived continuous ECG data. Control infants were prospectively enrolled at birth. ECG data in cases and controls were analyzed for HRV in the time and frequency domains at 24 h of age. We analyzed the following HRV metrics: alpha short (αs), alpha long (αL), root mean square short and long (RMSs and RMSL), low-frequency (LF) power, normalized LF (nLF), high-frequency (HF) power, and normalized HF (nHF). We used ANOVA to compare HRV metrics between groups and to control for medication exposures. Results HRV data from 57 infants with CHD (TGA, n = 33 and HLHS, n = 24) and from 29 controls were analyzed. The HRV metrics αS, RMSL, LF, and nLF were significantly lower in infants with CHD than in the controls. Due to the effect of normalization, nHF was higher in CHD infants (P

PURPOSE: The mature central autonomic network includes connectivity between autonomic nervous system brainstem centers and the cerebral cortex. The study objective was to evaluate the regional connectivity between the cerebral cortex and brainstem autonomic centers in term newborns by measuring coherence between high-density electroencephalography and heart rate variability as measured by electrocardiography. METHODS: Low-risk term newborns with birth gestational age 39–40 weeks were prospectively enrolled and studied using time-synced electroencephalography and electrocardiography for up to 60 minutes before discharge from the birth hospital. The cortico-autonomic nervous system association was analyzed using coherence between electroencephalography-delta power and heart rate variability. Heart rate variability measured parasympathetic tone (root mean square of successive differences of heart rate) and sympathetic tone (standard deviation of heart rate). RESULTS: One hundred and twenty-nine low-risk term infants were included. High coherence delta(-)root mean square of successive differences was found in central, bi-temporal, and occipital brain regions with less robust coherence delta-standard deviation in the central region and bi-temporal areas. CONCLUSIONS: Our findings describe a topography of cortico-autonomic connectivity present at term in low-risk newborns, which was more robust to parasympathetic than sympathetic brainstem centers and was independent of newborn state.

The empirical study of the role of sperm competition in the evolution of sexual traits has historically been problematic through the inability either to measure sperm competition levels directly in the present or to reconstruct changes in the evolutionary past. Here, we develop and test a procedure based on paternity data that potentially permits both. For our pilot study, we use the rate of change of the seminal protein gene SEMG2 for catarrhine primates published by Dorus et al. (Nat Genet 36:1326–1329, 2004). From their data, Dorus et al. proposed a two-part hypothesis: (1) sperm competition plays a role in the evolution of the SEMG2 gene and (2) higher levels of sperm competition generate more positive selection for change in SEMG2 than lower levels. Dorus et al. were limited, however, by being able to use only proxy measures of sperm competition and only seven “recent” segments of catarrhine primate phylogeny. Here, we develop a “timeline procedure” that permits the Dorus hypothesis to be tested using data from across the whole of catarrhine phylogeny. Our analysis supports part (1) of the Dorus hypothesis but questions part (2), suggesting instead that changes in level of sperm competition have a more powerful influence on the rate of evolution of traits than the level of sperm competition itself. We conclude that the timeline procedure developed here could be a valuable investigative tool in the role of sperm competition in the evolution of sexual traits measured over evolutionary time such as SEMG2. The empirical study of the role of sperm competition in the evolution of sexual traits has historically been problematic through the inability to measure sperm competition levels directly in the present and to reconstruct changes in the evolutionary past. Here, we test a “timeline procedure” based on paternity data that potentially permits both. For our pilot study, we use the rate of change of the seminal protein gene SEMG2 for catarrhine primates published by Dorus et al. (Nat Genet 36:1326–1329, 2004). Whereas Dorus et al. were limited to using proxy measures for only “recent” segments of catarrhine primate phylogeny, our method permits direct measures of sperm competition to be applied across the whole of Catarrhine phylogeny. We conclude that this new procedure could be valuable for investigation of the role of sperm competition in the evolution of a wide range of sexual traits.

OBJECTIVES: The objective of this study was to investigate methamphetamine use among people who use opioids in rural Oregon communities to explore reasons for use and perceptions of methamphetamine consequences. METHODS: We conducted interviews and surveys with participants who inject drugs or misuse prescription opioids in 2 rural Oregon counties with high opioid overdose rates. Survey participants were identified through participant-driven sampling initiated in syringe service programs and field outreach (n = 144). Semi-structured interviews with participants were recruited from the same locations (n = 52). RESULTS: Of 144 surveys completed, 112 reported using opioids in the past 30 days; 96% of the 112 also report methamphetamine use. Among the 124 reporting injection drug use, 50% indicated they injected both methamphetamine and heroin in the past 30 days. Interview participants reported early exposure to methamphetamine and indicated that methamphetamine was more widely available, less expensive, and less stigmatized compared to heroin. Participants reported using methamphetamine to improve work-life functioning and because they enjoy the high produced from simultaneous use. Several participants reported a conscious effort to shift to methamphetamine from heroin as a harm reduction strategy. Some participants reported being involuntarily discharged from treatment for opioid use disorder due to methamphetamine use. Several participants perceived methamphetamine as conveying overdose prevention or reversal benefits, while fentanyl contamination in methamphetamine was reported or suspected. CONCLUSION: As rural communities respond to evolving drug supply and demand, there is increasing need for public health efforts to address the emerging issue of concurrent methamphetamine and opioid use.

In premature infants, we investigated whether the duration of extrauterine development influenced autonomic nervous system (ANS) maturation.We performed a longitudinal cohort study of ANS maturation in preterm infants. Eligibility included birth gestational age (GA) 37 weeks, NICU admission, and expected survival. The cohort was divided into three birth GA groups: Group 1 (≤29 weeks), Group 2 (30-33 weeks), and Group 3 (≥34 weeks). ECG data were recorded weekly and analyzed for sympathetic and parasympathetic tone using heart rate variability (HRV). Quantile regression modeled the slope of ANS maturation among the groups by postnatal age to term-equivalent age (TEA) (≥37 weeks).One hundred infants, median (Q1-Q3) birth GA of 31.9 (28.7-33.9) weeks, were enrolled: Group 1 (n = 35); Group 2 (n = 40); and Group 3 (n = 25). Earlier birth GA was associated with lower sympathetic and parasympathetic tone. However, the rate of autonomic maturation was similar, and at TEA there was no difference in HRV metrics across the three groups. The majority of infants (91%) did not experience significant neonatal morbidities.Premature infants with low prematurity-related systemic morbidity have maturational trajectories of ANS development that are comparable across a wide range of ex-utero durations regardless of birth GA.Heart rate variability can evaluate the maturation of the autonomic nervous system. Metrics of both the sympathetic and parasympathetic nervous system show maturation in the premature extrauterine milieu. The autonomic nervous system in preterm infants shows comparable maturation across a wide range of birth gestational ages. Preterm newborns with low medical morbidity have maturation of their autonomic nervous system while in the NICU. Modern NICU advances appear to support autonomic development in the preterm infant.

The study examines impacts of delivery system reforms and Medicaid expansion on treatment for alcohol use disorders within the Oregon Health Plan (Medicaid). Diagnoses, services and pharmacy claims related to alcohol use disorders were extracted from Medicaid encounter data. Logistic regression and interrupted time series analyses assessed the percent with alcohol use disorder entering care and the percent receiving pharmacotherapy before (January 2010 – June 2012) and after (January 2013 – June 2015) the initiation of Oregon’s Coordinated Care Organization (CCO) model (July 2012 – December 2012). Analyses also examined changes in access following Medicaid expansion (January 2014). Treatment entry rates increased from 35% in 2010 to 41% in 2015 following the introduction of CCOs and Medicaid expansion. The number of Medicaid enrollees with a diagnosed alcohol use disorder increased about 150% from 10,360 (2013) to 25, 454 (2014) following Medicaid expansion. Individuals with an alcohol use disorder who were prescribed a medication to support recovery increased from 2.3% (2010) to 3.8% (2015). In Oregon, Medicaid expansion and health care reforms enhanced access and improved treatment initiation for alcohol use disorders.

Commentators have long been divided in appraising Gideon. Some consider him an outstanding champion of Yahweh’s cause. Others judge him as, at best, flawed, at worst a vainglorious manipulator who corrupted Israel’s relationship with Yahweh and weakened her hold on the Promised Land. Despite abundant commentary on Gideon, the Midianite’s dream has attracted little specific exegetical attention beyond recognition that, on hearing its interpretation, Gideon was transformed. Yet it must surely rank as one of the most remarkable episodes in Judges. This study considers the dream’s hermeneutical function in illuminating Gideon’s character and changing relationship with Yahweh. It examines the dream’s place in the Gideon narrative and explores the meaning of its symbolism for the writer’s time and readership. It demonstrates that the narrative’s structure, and the dream’s place within it, were carefully planned and crucial to its interpretation. Finally, it analyses heuristic literary devices used in the narrative.

The Judges 10:6 list of the gods of the surrounding nations to which Israel adhered in preference to Yahweh is unprecedented in its detail. Moreover, it forms the literal center of the book of Judges according to the Masoretic verse count. In the composition’s rhetorical plan, similarly, it constitutes the fulcrum in the account of the relations between Yahweh and his people. The worship of these deities and the syncretistic application of aspects of their cults to normative Yahwism provoke the response from Israel’s god that he will deliver them no more and that they should “appeal to the gods you have chosen” for deliverance. This rupture in the relationship sets the scene for Jephthah’s rise. The Gileadites, in extremis, take the initiative to engineer a human solution to a divine problem by approaching Jephthah, a social outcast with proven leadership and combat skills. The article analyses the place and role of Jephthah in Judges, the repercussions of his brief ascendancy, his relationship with the minor judges, as well as with Ehud and Abimelech, and the meaning of the shibboleth incident. The conclusions challenge the widely held scholarly view, originally proposed by Martin Noth, that Jephthah is the common denominator between the judge-deliverer figures and the minor judges. In addition, it advances a new interpretation of the significance of the choice of the noun shibboleth as the password at the Jordan fords.

The Song of Deborah’s unusual language and style, and the potency of its imagery combine to make it one of the most analysed and debated texts in the Hebrew Bible. Although many aspects of the Song have remained opaque, there is scholarly consensus that it was composed in approximately the form we have it in the period of the Judges. This consensus is largely founded on linguistic analysis of the text. This article approaches the Song from a different direction. It considers the cultural markers found in Judges 5:28-30 and analyses what they reveal about the Sitz im Leben of these verses.

Objective To examine the influence of Oregon's coordinated care organizations (CCOs) and pay-for-performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services. Data Sources/Study Setting Secondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs. Study Design Longitudinal mixed-methods design with simultaneous data collection with equal importance. Data Collection/Extraction Methods Qualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6-month transition period, and 30 months following CCO implementation. Data were aggregated by half-year with analyses restricted to Medicaid recipients 18–64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion. Principal Findings Quantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI. Conclusions Results provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment.

Objective:Title 42 of the Code of Federal Regulations Part 2 (42 CFR Part 2) controls the release of patient information about treatment for substance use disorders. In 2016, the Substance Abuse and Mental Health Services Administration (SAMHSA) released a proposed rule to update the regulations, reduce provider burdens, and facilitate information exchange. Oregon’s Medicaid program (Oregon Health Plan) altered the financing and structure of medical, dental, and behavioral care to promote greater integration and coordination. A qualitative analysis examined the perceived impact of 42 CFR Part 2 on care coordination and integration.Methods:Interviews with 76 stakeholders (114 interviews) conducted in 2012–2015 probed the processes of integrating behavioral health into primary care settings in Oregon and assessed issues associated with adherence to 42 CFR Part 2.Results:Respondents expressed concerns that the regulations caused legal confusion, inhibited communication and information sharing, and required u...

Background The CTN-0067 CHOICES trial tests implementation of extended-release naltrexone (XR-NTX) versus treatment-as-usual (TAU) for opioid use disorders (OUD) in HIV clinics to improve HIV viral suppression. The study team investigated recruitment strategies to elucidate the barriers and facilitators to recruitment and enrollment in the study. Main text Methods: Semi-structured, in-depth, digitally recorded interviews were completed with study recruitment-related staff and medical providers (n = 26) from six participating HIV clinics in the fall of 2018. Interviews probed 1) factors that might prevent prospective participants from engaging in study recruitment and enrollment procedures and 2) strategies used by study staff that encourage eligible patient participation. Interviews were transcribed and thematically analyzed using a content analysis approach. Results: All respondents reported that barriers to recruitment and enrollment included challenging patient social and structural factors (e.g., homelessness or living environments with high substance use, criminal justice involvement), difficulty locating patients with unsuppressed HIV viral load and OUD within the HIV clinic, time-consuming study enrollment processes, and stigma around HIV and OUD which inhibited treatment seeking. Some respondents observed that distrust of research and researchers impeded recruitment activities in the community. A specific medication-related barrier was patient fear of opioid abstinence required prior to XR-NTX induction. Facilitators of recruitment included use of trusted peer outreach/recruitment workers in the community, hospitalizations that offered windows of opportunities for screening and XR-NTX induction, providing participant transportation, and partnerships with harm reduction organizations for referrals. Conclusions Though study personnel encountered barriers to recruitment in the CHOICES study, persons with untreated HIV and OUD can be enrolled in multisite clinical trials by using enhanced recruitment strategies that extend outside of the HIV clinic. Employing peer outreach workers and collaborating with syringe service programs may be especially helpful in facilitating recruitment and merit inclusion in similar study protocols.

Objective To establish whether fetal cerebral vasoreactivity (CVRO2 ), following maternal hyperoxia, is predicted by fetal cerebral and uteroplacental Doppler pulsatility indices (PI) at baseline, fetal pulmonary vasoreactivity to oxygen (PVRO2 ), gestational age (GA), or sex. Methods Pulsatility index of middle (MCA), anterior (ACA), posterior cerebral (PCA), umbilical (UA), uterine (UtA), and branch of the pulmonary arteries (PA) were obtained, by ultrasound, before (baseline), during (hyperoxia) and after 15 minutes of maternal administration of 8 L/min of 100% oxygen, through a non-rebreathing face mask, in normal singleton pregnancies within 20 to 38 weeks' gestation. CVRO2 was defined as changes greater than zero in z score of PI of the cerebral arteries from baseline to hyperoxia. Logistic modeling was applied to identify CVRO2 predictors. Results A total of 97 pregnancies were eligible. In the overall population, median z scores of PI of MCA, ACA, and PCA did not differ between study phases. Based on the logistic model, baseline z scores for cerebral PI and GA were the best predictors of CVRO2 . Conclusions In low-risk pregnancies, fetal CVRO2 to hyperoxia does not occur uniformly but depends on cerebral PI and GA at baseline. These findings may provide useful reference points when oxygen is administered in high-risk pregnancies.

Multiple myeloma (MM) is a slow-growing malignancy characterized by a low proliferation rate of plasma cells and a relatively rare incidence of tumour lysis syndrome (TLS). Three myeloma patients developed TLS following cytotoxic therapy (two after radiation treatment) that was associated with an abrupt increase of serum free light chains (FLC). All three patients demonstrated extramedullary plasmacytomas that exhibited aggressive features compared to the original myeloma. The findings suggested that an abrupt liberation (rather than slow secretion) of FLC from myeloma cells may trigger a fulminant cast nephropathy and present an unrecognized risk factor and potentially aggravating component of TLS.

Significance Preterm birth (PTB) complications are the leading cause of long-term morbidity and mortality in children. The genetic and molecular characteristics of PTB and related disorders remain unclear. In this study, a family-based cohort of 791 family trios, including 270 PTB and 521 control families, was investigated by using whole-genome sequencing, RNA sequencing, and DNA methylation data. Integrative analysis identified 160 genomic variants associated with PTB-related phenotypes and led to the discovery of 72 candidate biomarker genes for very early PTB (VEPTB). The genes associated with VEPTB involve growth signaling and inflammation- and immunity-related pathways. With these data, and by stratifying PTB by subphenotype, we have identified PTB genes and pathways that can be used as a starting point in further clinical studies., Preterm birth (PTB) complications are the leading cause of long-term morbidity and mortality in children. By using whole blood samples, we integrated whole-genome sequencing (WGS), RNA sequencing (RNA-seq), and DNA methylation data for 270 PTB and 521 control families. We analyzed this combined dataset to identify genomic variants associated with PTB and secondary analyses to identify variants associated with very early PTB (VEPTB) as well as other subcategories of disease that may contribute to PTB. We identified differentially expressed genes (DEGs) and methylated genomic loci and performed expression and methylation quantitative trait loci analyses to link genomic variants to these expression and methylation changes. We performed enrichment tests to identify overlaps between new and known PTB candidate gene systems. We identified 160 significant genomic variants associated with PTB-related phenotypes. The most significant variants, DEGs, and differentially methylated loci were associated with VEPTB. Integration of all data types identified a set of 72 candidate biomarker genes for VEPTB, encompassing genes and those previously associated with PTB. Notably, PTB-associated genes RAB31 and RBPJ were identified by all three data types (WGS, RNA-seq, and methylation). Pathways associated with VEPTB include EGFR and prolactin signaling pathways, inflammation- and immunity-related pathways, chemokine signaling, IFN-γ signaling, and Notch1 signaling. Progress in identifying molecular components of a complex disease is aided by integrated analyses of multiple molecular data types and clinical data. With these data, and by stratifying PTB by subphenotype, we have identified associations between VEPTB and the underlying biology.

Background It is important to understand patterns and predictors of initiation and engagement in treatment for Medicaid-covered individuals with substance use disorders because Medicaid is a major source of payment for addiction treatment in the United States. Our analysis examined similarities and differences in predictors between adults and adolescents. Methods An analysis of Oregon Medicaid claims data for the time period January 2010 through June 2015 assessed rates of substance use and of treatment initiation and engagement using the Healthcare Effectiveness Data and Information Set (HEDIS) definitions. The analysis included individuals aged 13–64 with a new alcohol and other drug dependence diagnosis who met the HEDIS enrollment criteria and did not have cancer. We created 4 logistic regression models to assess treatment initiation and engagement, separately for adults (ages 18–64) and adolescents (ages 13–17). Independent predictors included age, gender, race, the interaction of gender and race, urban/rural residence, presence of any chronic disease, a psychiatric diagnosis, or a pain diagnosis. Results Among adults, odds of initiation were lower in white males than in nonwhite males, white females, and nonwhite females. Conversely, among adolescents, odds of initiation were higher in white males than in the other gender/race groups. Predictors of initiation also went in opposite directions for presence of a psychiatric diagnosis (negative in adults, positive in adolescents) and urban residence (positive in adults, negative in adolescents). We found similar patterns in models of engagement, although for engagement those with a psychiatric diagnosis had lower odds of engagement in both adults and adolescents. Conclusions Predictors of treatment initiation and engagement for alcohol and drug use disorders differed between adults and adolescents on Medicaid. A better understanding of these differences will enable development of targeted treatment programs that are effective within age groups.

Background Multi-stakeholder partnerships play a critical role in dissemination and implementation in health and safety. To better document and understand construction partnerships that have successfully scaled up effective interventions to protect workers, this case study focused on the collaborative processes of the Asphalt Paving Partnership. In the 1990s, this partnership developed, evaluated, disseminated, and achieved near universal, voluntary adoption of paver engineering controls to reduce exposure to asphalt fumes. Methods We used in-depth interviews (n = 15) and document review in the case study. Results We describe contextual factors that both facilitated and challenged the formation of the collaboration, central themes and group processes, and research to practice (r2p) outcomes. Conclusions The Asphalt Paving Partnership offers insight into how multi-stakeholder partnerships in construction can draw upon the strengths of diverse members to improve the dissemination and adoption of health and safety innovations and build a collaborative infrastructure to sustain momentum over time. Am. J. Ind. Med. 58:824–837, 2015. © 2015 Wiley Periodicals, Inc.

BACKGROUND: Research translation too often relies on passive methods that fail to reach those who can impact the workplace. The need for better research to practice (r2p) approaches is especially pressing in construction, where a disproportionate number of workers suffer serious injury illness. METHODS: A triage process was designed and used to systematically review completed research, assess r2p readiness, establish priorities, and launch dissemination follow-up efforts. A mixed quantitative and qualitative approach was used. RESULTS: The process proved effective in ensuring that significant findings and evidence-based solutions are disseminated actively. Key factors emerged in the selection of follow-up priorities, including availability of partners able to reach end users, windows of opportunity, and cross-cutting approaches that can benefit multiple dissemination efforts. CONCLUSIONS: Use of a systematic triage process may have an important role to play in building r2p capacity in construction safety and health. Language: en

BACKGROUND: Falls are the leading cause of fatalities in construction. The Safety Pays, Falls Cost campaign aims to prevent falls in residential construction. A critical component of our social marketing approach was to involve 70 partners in reaching target audiences. METHODS: We assessed partner engagement April 2012-August 2013 through: (1) baseline partnership quality interviews (eight partners); (2) pre-/post-partner "market" readiness in-depth interviews (three partners); (3) a pre-/post- (29/31 partners) online partner engagement survey; and (4) standardized metrics to measure partner activity. RESULTS: We found a high level of interest and engagement that increased with the addition of prompting to action through regular communication and new resources from organizers and formation of local partnerships that were able to tailor their activities to their own communities or regions. CONCLUSION: It is feasible to leverage government-labor-management partnerships that enjoy trust among target audiences to widely disseminate campaign materials and messages. Am. J. Ind. Med. © 2015 Wiley Periodicals, Inc. Language: en

Objective Health system reform is largely dependent upon the transformation of primary care in addition to the alignment of incentives that mediate the allocation of resources. The Patient-Centered Medical Home (PCMH) is a model of enhanced primary care that encourages coordination, patient-centered care, integration of public health services, and innovative methods for improving population health-all critical elements of health system reform. Because it changes the way primary care is organized and delivered, the PCMH model has been adopted as a foundational component of Oregon's health system transformation. This article presents insights drawn from an evaluation of the implementation of Oregon's Patient-Centered Primary Care Home (PCPCH) program and the adoption of the model by primary care providers. Design We used a mixed-methods approach consisting of 2 surveys of recognized PCPCH practices, qualitative document analysis, and key informant interviews. Evaluation research findings were triangulated with findings from PCPCH clinic site visits conducted as part of a regulatory verification process. Results Survey results describe a broad range of strategies and practices adopted by recognized PCPCH clinics within 6 defined core attributes: (1) access to care; (2) accountability; (3) comprehensive whole-person care; (4) continuity; (5) coordination and integration; and (6) person- and family-centered care. We also identify 4 key factors that influenced the conceptualization, development, and implementation of the PCPCH program: (1) support and motivations; (2) administrative barriers and resource constraints; (3) alignment of short- and long-term financial incentives; and (4) leadership and interpersonal relationships. Conclusions This evaluation provides insights into the factors that influence implementation of a primary care home program as public policy; the strategies and challenges associated with implementation of the model; and the implications of both for other states that are engaged in-or considering-similar system reform efforts.

D-Bifunctional protein deficiency, caused by recessive mutations in HSD17B4, is a severe disorder of peroxisomal fatty acid oxidation. Nonspecific clinical features may contribute to diagnostic challenges. We describe a newborn female with infantile-onset seizures and nonspecific mild dysmorphisms who underwent extensive genetic workup that resulted in the detection of a novel homozygous mutation (c.302+1_4delGTGA) in the HSD17B4 gene, consistent with a diagnosis of D-bifunctional protein deficiency. By comparing the standard clinical workup to diagnostic analysis performed through research-based whole-genome sequencing (WGS), which independently identified the causative mutation, we demonstrated the ability of genomic sequencing to serve as a timely and cost-effective diagnostic tool for the molecular diagnosis of apparent and occult newborn diseases. As genomic sequencing becomes more available and affordable, we anticipate that WGS and related omics technologies will eventually replace the traditional tiered approach to newborn diagnostic workup.

Objectives The phrase “level of sperm competition” is used only vaguely in the primate literature. There is also little distinction between the important elements of frequency and intensity of sperm competition, largely because the two current forms of measurement (socio-sexual system and relative testes size) are both proxies which allow neither precision nor fine distinctions. Both measures have critics, socio-sexual system in particular being branded subjective, misleading, and changeable. Testes size is considered the more reliable despite its validation resting on correlations with the other, less reliable, proxy. Recently, genetic paternity studies have been mooted to provide a potentially superior third measure of sperm competition but so far lack a formal interpretive framework. Here we use the published and relatively comprehensive genetic field studies of the Hominoidea to develop such a framework. Materials and methods Formulae are derived to convert paternity data into a direct measure of the frequency, intensity, and overall level of sperm competition. We then compare these measures with relative testes size at the study, species, and phylogenetic levels. Results A significant correlation between level of sperm competition and relative testes size was obtained at each level. These correlations provide independent support for the continuing use of testes size as a proxy measure when such a measure is sufficient. However, they also suggest that paternity data and our formulae yield a viable alternative measure. Discussion This alternative measure based on paternity data has a number of advantages. Not only is it a potentially direct measure of the level of sperm competition but it also allows the roles of frequency and intensity to be studied separately when of interest.

OBJECTIVE To examine whether a one-factor executive function (EF) model fit data for three groups of children differing in birth criteria (extremely low birth weight [ELBW], late preterm [LPT], and Term) at each of two chronological ages, 3 and 6 years, and whether the latent mean amount of EF differed. METHODS A retrospective observational cohort study of 1,079 participants; 668 aged 3 years born 2000-2009 (93 ELBW, 398 LPT, and 177 Term) and 411 aged 6 years born 1998-2006 (126 ELBW, 102 LPT, and 183 Term). Latent means analysis was conducted using five indicators for EF: noun fluency, action-verb fluency, similarities reasoning, matrices reasoning, and working memory. RESULTS A one-factor model had acceptable fit for all groups (RMSEA 0.95, SRMR

Recent NIH policy stipulates that multi-site studies must use a single or IRB (Institutional Review Board) in order to streamline the review process while maintaining standards for human subjects protection. The Western States Node of the Clinical Trials Network (CTN) used a single IRB for protocol CTN-0067, a clinical trial testing the use of an opioid antagonist (extended-release naltrexone) versus opioid agonists (buprenorphine or methadone) for opioid use disorders among individuals living with HIV. This case study discusses the processes and challenges associated with use of a single IRB. These lessons are also informed by other single IRB experiences within the CTN. The intention of the NIH single IRB policy is to facilitate efficient IRB processes. Advanced planning and transparent communication, however, are critical to avoid stalling IRB approval and protocol implementation. Research teams need to account for local IRB willingness to cede to a single IRB and understand the variations in interpretations of abbreviated reviews. In order to facilitate the effective use of single IRBs, recommendations include assigning staff at each study site for IRB submission coordination and interaction with the lead site IRB staff, training investigators and key regulatory staff on expectations for working with single IRBs, dedicating a regulatory specialist at the lead site to manage the process, developing a communication plan, and supporting the development of strong working relationships with local regulatory staff and the single IRB. The CTN experiences with single IRBs may provide insights for other investigators. Keywords: Institutional Review Boards, Single IRB, Clinical trial regulations, NIH IRB regulations

Community-based participatory research (CBPR) is increasingly being used to better understand and improve the health of diverse communities. A key strength of this research orientation is its adaptability to community contexts and characteristics. To date, however, few studies explicitly discuss adaptations made to CBPR principles and processes in response to community context and partners' needs. Using data from our CBPR study, the San Francisco Chinatown Restaurant Worker Health and Safety Project, and drawing from literature on immigrant political incorporation, we examine the links between the contexts of the Chinese immigrant worker community, adaptations made by our collaborative, and study outcomes. In particular, we explore the concepts of contexts of reception and participatory starting points, which may be especially relevant for partnerships with immigrant communities whose members have historically had lower rates of civic and political participation in the US. We discuss contextual findings such as worker partner accounts of language barriers, economic and social marginalization, and civic skills and participation, as well as subsequent adaptations made by the partnership. We also describe the relative effectiveness of these adaptations in yielding equitable participation and building partners' capacity. We conclude by sharing lessons learned and their implications for CBPR and partnerships with immigrant communities more broadly.

In Hollow Men, Robin Baker provides a reappraisal of the Book of Judges account of Israel's Settlement of Canaan. Written under Assyrian suzerainty in Manasseh’s reign, Judges is a theological commentary on the Settlement and an esoteric work of prophecy.

In Hollow Men, Robin Baker provides a reappraisal of the Book of Judges account of Israel's Settlement of Canaan. Written under Assyrian suzerainty in Manasseh’s reign, Judges is a theological commentary on the Settlement and an esoteric work of prophecy.

In Hollow Men, Robin Baker provides a reappraisal of the Book of Judges account of Israel's Settlement of Canaan. Written under Assyrian suzerainty in Manasseh’s reign, Judges is a theological commentary on the Settlement and an esoteric work of prophecy.