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We constructed a database of cross-tropopause convection in the Asian monsoon region for the months of May through October of 2017 using overshooting tops (OTs), deep convective features that penetrate the local cirrus anvil layer and the local tropopause, with Meteosat-8 geostationary satellite detections. The database of 40 918 OTs represents a hemispheric record of convection covering the study domain from 10∘ S to 55∘ N and from 40 to 115∘ E. With this database, we analyzed the geographic, monthly, and altitude distribution of this convection and compared it to the convective distributions represented by satellite observations of outgoing longwave radiation (OLR) and precipitation. We find that cross-tropopause convection is most active during the months of May through August (with daily averages of these months above 300 OTs per day) and declines through September and October. Most of this convection occurs within Northern India and Southern India, the Bay of Bengal, and the Indian Ocean regions, which together account for 75.1 % of all OTs. We further identify distinct, differing seasonal trends within the study subregions. For the Northern India, Southern India, and Bay of Bengal regions, the distribution of OTs follows the development of the Asian monsoon, with its north–south movement across the study period. This work demonstrates that when evaluating the effects of convection on lower stratospheric composition over the Asian monsoon region, it is important to consider the impact of cross-tropopause convection specifically, as well as the contributions from both land-based and oceanic regions due to the significant geographic and monthly variation in convective activity.

The health outcomes of very low birthweight (VLBW) infants in neonatal intensive care units (NICUs) may be jeopardized when required nursing care is missed. This correlational study is the first to look at the association between missed nursing care and mortality, morbidity, and length of stay (LOS) for VLBW infants in a U.S. NICU sample. We used 2016 hospital administrative discharge abstracts for VLBW newborns ( n = 7,595) and NICU registered nurse survey responses ( n = 6,963) from the National Database of Nursing Quality Indicators. The 190 sample hospitals were from 19 states in all regions. Missed clinical nursing care was significantly associated with higher odds of bloodstream infection and longer LOS, but not mortality or severe intraventricular hemorrhage. With further research, these results may motivate the development of interventions to reduce missed clinical nursing care in the NICU.

Anti-programmed cell death protein 1 (PD1) antibodies, pembrolizumab and nivolumab, alone or in combination with ipilimumab, have become standard treatment for melanoma and multiple other malignancies. Neurological adverse effects are rare and have not been well characterized to date. Patients who developed neurological adverse effects while being treated with PD1, alone or in combination with ipilimumab, were retrospectively identified from 10 cancer centers. Fifty-eight patients were included, and the median time from treatment initiation to development of neurological adverse effects was 7 weeks (range, 1-86.5 weeks). Thirty-seven (64%) toxicities affected the peripheral nervous system. Fifty (86%) patients were treated with corticosteroids, with 22 (37%) patients requiring further immunomodulation including intravenous immunoglobulin (16), plasmapheresis (7), mycophenolate mofetil (4), cyclophosphamide (1), and rituximab (1). Twenty-seven (46%) had a complete resolution of their neurological symptoms, and two (4%) patients died secondary to complications from their neurological adverse effects. The response rate of the cancer to immunotherapy was 78%, and the median progression free survival was not reached. Neurological adverse effects can occur with PD1 treatment, do not appear to impact treatment response, but may be irreversible or worsen in some patients. Management may require immunomodulation beyond corticosteroids.

Postgraduate training programmes rely on faculty to meet core educational needs, including simulation. Time is arguably the most valuable resource for academic physicians, which presents a challenge for recruiting faculty to provide extra-clinical teaching. To increase faculty engagement in simulation-based education (SBE), we first identified barriers to participation. Next, we sought to overcome barriers using a self-determination theory (SDT) framework to increase motivation using strategies that addressed faculty autonomy, competence and relatedness.Faculty from a single department of emergency medicine were surveyed about factors influencing participation in SBE. Responses were grouped into themes and used to develop the intervention-a faculty support bundle-to overcome common barriers and promote participation. Supports focused on course materials, organisational consistency and peer recognition. Faculty participation in SBE pre- and post-implementation of the support bundle was analysed via chi-squared analysis. Faculty who delivered SBE were resurveyed after the implementation phase to explore how the support bundle affected their experience.Initial survey response was 41%. Reported barriers to participation in SBE included scheduling issues, preparation time, competing responsibilities, lack of confidence with simulation and lack of interest. Twenty-four faculty participated in SBE during the pre-implementation phase, compared to 39 post implementation (p = 0.03).The faculty support bundle increases faculty participation in SBE. Strategies focused on internal motivators identified using an SDT framework. In contrast to traditional external motivators, these were no cost interventions. Those seeking to increase faculty participation in SBE should consider implementing similar strategies.

Although incivility in nursing education is linked with negative physical and psychological effects on students, it is unclear how resilience and stress interact and relate to student incivility. The purpose was to understand the role of resilience and stress with peer incivility in a sample of prelicensure nursing students during coronavirus disease 2019. The study design was cross-sectional and correlational. Data were from an online survey administered to undergraduate nursing students of one college of nursing in a southwestern US state during September-October 2020. In a sample of 490 students, ordinal regression model results supported that including a stress and resilience interaction term resulted in a nonsignificant effect of stress and resilience, as the main effect correlates on low-level uncivil student behavior. More research is needed to understand the prevalence of stress and resilience at different points in prelicensure nursing education so that targeted interventions can be developed and deployed to assist students.

In the era of data-driven medicine, rapid access and accurate interpretation of medical images are becoming increasingly important. The DICOM Image ANalysis and Archive (DIANA) system is an open-source, lightweight, and scalable Python interface that enables users to interact with hospital Picture Archiving and Communications Systems (PACS) to access such data. In this work, DIANA functionality was detailed and evaluated in the context of retrospective PACS data retrieval and two prospective clinical artificial intelligence (AI) pipelines: bone age (BA) estimation and intra-cranial hemorrhage (ICH) detection. DIANA orchestrates activity beginning with post-acquisition study discovery and ending with online notifications of findings. For AI applications, system latency (exam completion to system report time) was quantified and compared to that of clinicians (exam completion to initial report creation time). Mean DIANA latency was 9.04 ± 3.83 and 20.17 ± 10.16 min compared to clinician latency of 51.52 ± 58.9 and 65.62 ± 110.39 min for BA and ICH, respectively, with DIANA latencies being significantly lower (p

Environmental remediation of polluted sites in developing communities often faces difficulties due to the misalignment of project objectives with the needs and interests of local communities, establishment of unrealistic expectations for the outcome of the project, and failure to account for the available resources in the community itself. Remediation decisions favor technical data and technical solutions as the main means of determining remediation options, requiring significant investment and local capacity that are often not found in developing communities. Often these systems fail to account for the social aspects in environmental management and remediation. In contrast, new approaches in local knowledge-based solutions focus on pre-existing environmental management initiatives to establish objectives that are meaningful to the community itself. “Positive deviance” – or the idea that there are solutions already in communities that are successful at addressing challenges despite the barriers that a community faces – are often overlooked during project design and implementation. Identifying examples of positive deviance and working with community members who are well versed in local challenges, available resources, and local capacity presents opportunities for community members to establish project objectives and provides the foundation for future environmental management projects in the area. We present a case study of artisanal and small-scale gold mining (ASGM) in the Andes municipality, Antioquia, Colombia and local initiatives to overcome community-identified environmental pollutants. Through a series of semi-structured interviews, surveys, and site visits, we identified community perception of environmental pollutants, management techniques for mining waste, and grassroots initiatives that were locally developed to address them. Through key communication and interaction between innovators with identified positive deviance projects, technical experts, and other miners facing similar challenges, innovative projects that account for the social, political, and economic realities of a developing community can become widespread, leading to improved environmental and social conditions.

Ultrasound screening for thyroid cancer is recommended in familial adenomatous polyposis (FAP). This study investigated the prevalence of thyroid neoplasia in children with FAP.Cross-sectional study of children with FAP at an academic hospital. Clinical and ultrasound data were analyzed for the prevalence of thyroid nodules and cancer.Of 37 children with FAP, 8 (22%) had thyroid nodules and 2 (5%) had thyroid cancer. Nodules (30%) and cancer (9%) were more common among female subjects and rare among male subjects.Thyroid ultrasound screening in adolescence may benefit female subjects with FAP but has limited utility in male subjects.

The aim of this study was to evaluate the effect on bleeding risk when fluconazole is administered concomitantly with direct oral anticoagulants (DOACs).This was a retrospective cohort study including hospitalized adult patients prescribed a DOAC with or without fluconazole.The Ohio State University Wexner Medical Center, a tertiary care academic medical center with more than 1800 beds.Hospitalized patients ages 18-89 years who received apixaban or rivaroxaban with or without fluconazole from October 1, 2016, to September 30, 2021, were included. The minimum duration of DOAC or DOAC with fluconazole therapy was 48 h. Patients were excluded if they received fluconazole400 mg daily or a DOAC at doses outside those recommended for atrial fibrillation or venous thromboembolism treatment or prophylaxis. Patients were matched based on DOAC received.Patients who received a DOAC with fluconazole were compared with those receiving a DOAC alone. The primary outcome was a composite of major, clinically relevant nonmajor, and minor bleeding events at 30 days.There were 216 patients included, 108 in the DOAC with fluconazole group and 108 in the DOAC alone group. More patients in the DOAC with fluconazole group experienced bleeding at 30 days compared with the DOAC alone group [35/108 (32%) vs. 21/108 (19%), respectively; p = 0.03]; however, after adjusting for proven confounding variables (hemoglobin and concomitant carvedilol) this was found not to be statistically significant [adjusted odds ratio 1.71, 95% confidence interval 0.85-3.40].Patients receiving a DOAC with fluconazole were not at significantly increased risk for bleeding at 30 days compared with those receiving a DOAC alone after controlling for confounding variables. As an increasing number of patients are prescribed DOACs, the results of this study may inform clinical decision-making on the safety of concomitant DOAC and fluconazole use.

In metrology, the certification of potassium hydrogen phthalate (KHP) as a reference material is made using the potential primary method of coulometric titration. Usually, this titration is performed in three steps at constant current, where two endpoint (EP) times are determined from the nonlinear regression that fits the empirical W-function (eWf) to the experimental data. As an alternative, we propose the implementation of the theoretical coulometric titration curve (TC). The TC allowed us to compute the KHP amount of substance, the influence of CO

OBJECTIVEInhibition of platelet aggregation is universally used to prevent thromboembolic complications related to stent placement in endovascular neurosurgery, but excessive inhibition potentiates hemorrhagic complications. Previously, the authors demonstrated that two different commercially available measures of adenosine diphosphate (ADP)–dependent platelet inhibition—the VerifyNow P2Y12 clopidogrel assay (measured in platelet reactivity units [PRU]) and maximal amplitude (MA) attributable to ADP activity (MA-ADP) derived from thromboelastography (TEG) with platelet mapping (PM)—yielded wildly different results. This study sought to analyze observed complications to quantify the ideal therapeutic windows for both tests.METHODSNinety-one patients with simultaneous or near-simultaneous PRU and TEG-PM results who underwent craniocervical endovascular stenting at the authors’ institution between September 2015 and November 2017 were identified and retrospectively enrolled. From November 2017 until June 2019, 109 additional patients were prospectively enrolled. For this study, in-hospital thrombotic and hemorrhagic complications (both CNS and non-CNS) were tabulated, and receiver operating characteristic (ROC) curve analysis was used to identify threshold values of the PRU and MA-ADP for predicting each type of complication.RESULTSOf the 200 patients enrolled, 7 were excluded because of anemia or thrombocytopenia outside of the test manufacturer’s specified ranges and 1 was excluded because they did not have a TEG-PM result. Including complications of all severities, there were a total of 15 CNS thrombotic complications, 1 access-site thrombotic complication, 3 CNS hemorrhages, 8 access-site hemorrhagic complications, and 3 hemorrhagic complications not affecting either the CNS or the access site. ROC curve analysis yielded therapeutic threshold values of 118–144 PRU. The results demonstrated PRU has a significant dose-dependent effect on the rates of thrombosis and hemorrhage. Logistic regression models did not demonstrate statistically significant relationships between the MA-ADP and either thrombosis or hemorrhage. ROC analysis based on these models is of little value and did not identify significant threshold values for MA-ADP.CONCLUSIONSThere continues to be poor correlation between the results of TEG-PM and PRU. PRU accurately predicted complications, with a relatively narrow ideal value range of 118–144. The MA-ADP alone does not appear able to accurately predict either hemorrhagic or thrombotic complications in this group.

The health benefits of breast milk feeding have been well-established, yet disparities exist, with African American mothers having the lowest breast milk feeding rates in the United States. This prospective, longitudinal study examined infant feeding (breast milk and/or infant formula) from birth to age 16 weeks, predictors of any breast milk feeding by age 1 week, and predictors of cessation of any breast milk feeding by ages 3, 8, and 16 weeks among primiparous African American mothers. This secondary analysis included 185 mother–infant dyads from the Sleep SAAF (Strong African American Families) study, a randomized clinical trial testing a responsive parenting vs. child safety control intervention. Mothers reported sociodemographic and psychosocial characteristics at age 1 week and infant feeding practices at ages 1, 3, 8, and 16 weeks. Rates of any breast milk feeding decreased from 66.5% at 1 week to 23.3% at 16 weeks. Bivariate logistic regression models showed that prepregnancy BMI (OR = 1.09), working prepregnancy (OR = 2.25), and food insecurity (OR = 2.49) significantly increased the odds of mothers feeding any breast milk by 1 week, whereas Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation (OR = 0.21) significantly decreased the odds. Bivariate logistic regression models showed that Supplemental Nutrition Assistance Program (SNAP) participation (OR = 2.86) and racial discrimination (OR = 2.14) significantly increased the odds of cessation of any breast milk feeding by 3 weeks. SNAP (OR = 2.33) and WIC (OR = 2.38) participation significantly increased the odds of cessation of any breast milk feeding by 8 weeks, whereas higher prepregnancy BMI (OR = 0.95) decreased the odds. Higher mother’s age (OR = 0.92) significantly decreased the odds of cessation of any breast milk feeding by 16 weeks. The findings can be used to inform targeted interventions to promote mothers feeding any breast milk and help reduce breast milk feeding disparities among African American mothers.

BackgroundPeople with upper extremity (UE) amputations report receiving insufficient information about treatment options. Furthermore, patients commonly report not knowing what questions to ask providers. A question prompt sheet (QPS), or list of questions, can support patient-centered care by empowering patients to ask questions important to them, promoting patient-provider communication, and increasing patient knowledge. This study assessed information needs among people with UE amputations about UE vascularized composite allotransplantation (VCA) and developed a UE VCA-QPS.MethodsThis multi-site, cross-sectional, mixed-methods study involved in-depth and semi-structured interviews with people with UE amputations to assess information needs and develop a UE VCA-QPS. Qualitative data were analyzed by thematic analysis; quantitative data were analyzed by descriptive statistics. The initial UE VCA-QPS included 130 items across 18 topics.ResultsEighty-nine people with UE amputations participated. Most were male (73%), had a mean age of 46 years, and had a unilateral (84%) and below-elbow amputation (56%). Participants desired information about UE VCA eligibility, evaluation process, surgery, risks, rehabilitation, and functional outcomes. After refinement, the final UE VCA-QPS included 35 items, across 9 topics. All items were written at a ≤ 6th grade reading level. Most semi-structured interview participants (86%) reported being ‘completely’ or ‘very’ likely to use a UE VCA-QPS.ConclusionPeople with UE amputations have extensive information needs about UE VCA. The UE VCA-QPS aims to address patients’ information needs and foster patient-centered care. Future research should assess whether the UE VCA-QPS facilitates patient-provider discussion and informed decision-making for UE VCA.

There is little evidence on the role of diet in childhood/adolescence and multiple sclerosis (MS) in adulthood. The MS Sunshine Study recruited adults with recent-onset MS ( n = 602) and matched controls ( n = 653). Of these, 84% provided dietary recall for specific ages between childhood and young adulthood (6–10, 11–15 and 16–20 years). We used logistic regression to test associations between age-specific diet and case-control status. Consumption of fruit (all ages), yoghurt (all ages) and legumes (11–15 years) was associated with lower probability of adult-onset MS (all p

While health care for people with an intellectual disability in Australia has transitioned from institutional specialisation to a mainstream primary care model, access and quality of health care in...

To identify evidence related to association between the nurse work environment and severe maternal morbidity in high-income countries.Quantitative Systematic review.Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PubMed/Medline, and Scopus were systematically searched for studies published in English from January 1990-December 2019. Studies were selected based on a priori eligibility criteria.Two independent reviewers used a two-phase screening process. First, the reviewers assessed the eligibility of studies based on titles and abstracts; followed by assessing the full text of all remaining studies based on the eligibility criteria. An adapted version of the Joanna Briggs Institute data extraction tool was created to extract relevant information from studies reviewed during the second screening phase.Of the 535 de-duplicated articles examined by two independent reviewers, there were no eligible empirical studies that assessed the association between nurse work environment and severe maternal morbidity.There is a critical gap in knowledge regarding how characteristics of the nurse work environment may influence severe maternal morbidity in high-income countries. Future directions for nursing research include using available maternal health surveillance hospital-level data, conducting high-quality studies, and using evidence-based frameworks to guide future studies. Future directions for nursing practice include leveraging professional learning communities for nursing education and training and leveraging quality improvement initiatives.As the first known systematic review of its kind, this 'empty review' provides evidence of a lacking body of literature on the association between nurse work environment, as a modifiable organizational characteristic and preventable severe maternal morbidity in high-income countries. This article provides a call to action in the form of five recommendations for future nursing research and practice, which could serve to elucidate research, practice, and policy opportunities to reduce preventable severe maternal morbidity in high-income countries.目的: 确定高收入国家护士工作环境与严重孕产妇发病率之间关系的相关证据。 设计: 定量系统评估。 数据来源: 对护理学及医疗相关文献累计索引、Cochrane系统评估数据库、PubMed/Medline和Scopus中1990年1月至2019年12月期间以英文形式发表的研究进行了系统检索。根据先验的资格标准进行研究选择。 评估方法: 两名独立评估员采用了二阶段筛选过程。首先, 评估员根据标题和摘要评估研究的资格条件; 然后根据资格标准评估所有剩余研究的全文内容。创建了Joanna Briggs Institute数据提取工具的改编版, 以便从第二个筛选阶段审查的研究中提取相关信息。 结果: 在两名独立评估员审查的535篇去重文章中, 没有符合条件的实证研究评估护士工作环境与严重孕产妇发病率之间的关系。 结论: 在高收入国家, 关于护士工作环境的特点如何影响严重孕产妇发病率的问题, 目前存在关键知识空白。护理研究的未来方向包括利用现有的孕产妇健康监测医院层面的数据, 开展高质量的研究, 并利用循证框架来指导未来的研究。护理实践的未来方向包括利用专业学习社区进行护理教育和培训, 以及利用质量改进举措。 影响: 作为第一项已知的系统性评估,这种‘空洞的评估’提供了证据, 证明在高收入国家, 作为一种可改变的组织特征的护士工作环境与可预防的严重孕产妇发病率之间缺乏文献参考。本文以对未来护理研究和实践提出五项建议的形式发出行动呼吁, 这些建议可有助于阐明研究、实践和政策机会, 以降低高收入国家可预防的严重孕产妇发病率。.

Highlights • Targeted anti-cytokine agents, tocilizumab and anakinra, used to treat COVID-19 related cytokine storm yield mixed results. • Early identification of cytokine storm using laboratory abnormalities can detect patients prior to mechanical ventilation. • Early identification and treatment of cytokine storm with anakinra and corticosteroids led to improved outcomes compared to initiating tocilizumab shortly after mechanical ventilation. • Early identification and treatment of cytokine storm may be more important than which anti-inflammatory treatment is chosen. • Our results provide additional support for the use of corticosteroid treatment of COVID19 cytokine storm., Objective To examine outcomes among patients who were treated with the targeted anti-cytokine agents, anakinra or tocilizumab, for COVID-19 -related cytokine storm (COVID19-CS). Methods We conducted a retrospective cohort study of all SARS-coV2-RNA-positive patients treated with tocilizumab or anakinra in Kaiser Permanente Southern California. Local experts developed and implemented criteria to define COVID19-CS. All variables were extracted from the electronic health record. Results At tocilizumab initiation (n = 52), 50 (96.2%) were intubated, and only 7 (13.5%) received concomitant corticosteroids. At anakinra initiation (n = 41), 23 (56.1%) were intubated, and all received concomitant corticosteroids. Fewer anakinra-treated patients died (n = 9, 22%) and more were extubated/never intubated (n = 26, 63.4%) compared to tocilizumab-treated patients (n = 24, 46.2% dead, n = 22, 42.3% extubated/never intubated). Patients who died had more severe sepsis and respiratory failure and met COVID-CS laboratory criteria longer (median = 3 days) compared to those extubated/never intubated (median = 1 day). After accounting for differences in disease severity at treatment initiation, this apparent superiority of anakinra over tocilizumab was no longer statistically significant (propensity score-adjusted hazards ratio 0.46, 95% confidence interval 0.18–1.20). Conclusions Prompt identification and treatment of COVID19-CS prior to intubation may be more important than the specific type of anti-inflammatory treatment. Randomized controlled trials of targeted anti-cytokine treatments and corticosteroids should report duration of cytokine storm in addition to clinical severity at randomization.

Recently, states have enacted teacher-carry laws. While controversial, little scholarship has tapped public attitudes toward such reforms. Because public opinion shapes policy, the public is an imp...

Corporal punishment, defined as the application of physical pain (e.g., spanking, slapping, or grabbing) to decrease a child’s undesirable behavior, is associated with negative mental health outcomes. Clients may present to mental health counselors with concerns that stem from their experience of corporal punishment. Mental health counselors work to prevent deleterious consequences of corporal punishment through the provision of psychoeducation on effective parenting strategies. Given that young adults are the largest group of prospective parents in the United States, the present investigators examined attitudes about the utility of corporal punishment as a disciplinary strategy among young adults who do not have children. Results revealed differences in the rates of endorsement of corporal punishment as a disciplinary strategy by gender and ethnicity. Higher rates were found among young adults who identified as male and those who identified as White relative to those who identified as female and those who identified as Latinx, respectively. These findings have a number of implications for challenging stereotypes (e.g., that Latinx clients endorse corporal punishment at higher rates than clients who identify as White) and enhancing mental health counselors’ prevention efforts (e.g., targeting attitudes about corporal punishment among those likely to become parents).

Studies of racial disparities in juvenile justice are primarily organized around four theoretical frameworks: focal concerns, racial threat, symbolic threat, and attribution theory. Moreover, juvenile justice research sometimes neglects to pay close attention to the front-end outcome of pre-adjudication detention. Therefore, the present study contends that status characteristics theory may broaden our understanding of how and why disparities in pre-adjudication detention arise. Moreover, the present study seeks to find how juvenile justice disparities in pre-adjudication detention emerge across races, among other social, legal, and community factors. Therefore, the present study focuses on the pre-adjudication detention decisions of judges and probation officers, utilizing quantitative data from the Virginia Department of Juvenile Justice and merged with American Community Survey data.

This study examines the role of source identification in the emotional response to everyday sounds. Although it is widely acknowledged that sound identification modulates the unpleasantness of sounds, this assumption is based on sparse evidence on a select few sounds. We gathered more robust evidence by having listeners judge the causal properties of sounds, such as actions, materials, and causal agents. Participants also identified and rated the pleasantness of the sounds. We included sounds from a variety of emotional categories, such as Neutral, Misophonic, Unpleasant, and Pleasant. The Misophonic category consists of everyday sounds that are uniquely distressing to a subset of listeners who suffer from Misophonia. Sounds from different emotional categories were paired together based on similar causal properties. This enabled us to test the prediction that a sound’s pleasantness should increase or decrease if it is misheard as being in a more or less pleasant emotional category, respectively. Furthermore, we were able to induce more misidentifications by imposing spectral degradation in the form of envelope vocoding. Several instances of misidentification were obtained, all of which showed pleasantness changes that agreed with our predictions.

This study was undertaken to evaluate a multicomponent health system intervention designed to reduce escalating disease-modifying treatment (DMT) expenditures and improve multiple sclerosis (MS) outcomes by increasing use of preferred formulary and highly effective DMTs (HETs).We conducted a trend study of treatment utilization and expenditure outcomes prior to (2009-2011) and during (2012-2018) MS Treatment Optimization Program (MSTOP) implementation in Kaiser Permanente Southern California (KPSC) compared to a Kaiser Permanente region of similar size. Annual relapse rates (ARRs) were obtained from KPSC's electronic health records.Adherence to preferred formulary DMTs increased from 25.4% in 2011 to 72.2% in 2017 following MSTOP implementation in KPSC and 22.1% to 43.8%, respectively, in the comparator. KPSC's annual DMT expenditures in 2018 were less than in 2011 despite an 11.3% increase in DMT-treated members. The decline in average per patient per year of treatment expenditures from a peak of $43.1 K in 2014 to $26.3 K in 2018 in KPSC was greater than the comparator, which peaked at $52.1 K and declined to $40.0 K in 2018. Over the 7 years following initiation of MSTOP, cumulative MS DMT expenditures were $161.6 million less than the comparator. HET use increased to 62.5% of per patient treatment-years versus 32.4% in the comparator. This corresponded to a 69% decline in adjusted ARR (95% confidence interval = 64.1-73.2%; p 0.0001) among DMT-treated patients in KPSC.A novel, expert-led health system intervention reduced MS DMT expenditures despite rising prices while simultaneously reducing MS relapse rates. Our focus on health system progress toward meaningful, measurable targets could serve as a model to improve quality and affordability of MS care in other settings. ANN NEUROL 2022;92:164-172.