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As Catholic high schools continue to experience success in interscholastic athletic leagues, state associations have repeatedly contemplated ways to thwart the perceived Catholic school advantage. In a number of states, the athletic associations have responded to the success of private schools in interscholastic competition by applying a multiplier to the private school's enrollment. The multiplier artificially inflates private school enrollment so that when schools are divided into separate classifications based on enrollment, private schools are grouped with public schools that have larger enrollments and presumably better teams. The underlying assumption is that private schools have an unfair advantage that requires such an adjustment. This article will take a case-study methodological approach, examining those states that have considered enacting a multiplier. The case study approach will inform a critical analysis regarding the multiplier and the rationale for its use.

This article outlines the significant legal decisions regarding collective bargaining in Catholic schools, identifies the governance structures employed in Catholic schools and the methods of translating these governance structures into documents required by civil law, and concludes with the citation of two recent court decisions that demonstrate the method of incorporation and the day-to-day governance practices utilized in Catholic schools that are of great importance to educational leaders.

The pre‐sidedress soil nitrate test (PSNT) was developed over 30 years ago to determine sidedress nitrogen (N) fertilizer recommendations for corn (Zea mays L.). Since the original PSNT calibrations were developed, changes in production practices such as no‐till and cover cropping and increases in corn yields and N use efficiency could affect the accuracy of PSNT recommendations. To update the PSNT recommendations in Pennsylvania and demonstrate the test's efficacy, we compiled a dataset of 32 calibration sites and 13 demonstration sites where the PSNT was conducted, and the economically optimum N rate (EONR) for corn was determined from an N fertilizer yield response curve. We recalibrated the PSNT recommendation algorithm and compared its accuracy to the original calibration. The new calibration resulted in a single long‐term manure history factor that interacted with the PSNT result to adjust the sidedress N recommendation (−5.7 kg N ha−1 [mg NO3‐N kg−1]−1). The new calibration also included a term for a mixed species cover crop, which increased the sidedress N recommendation 56.2 kg N ha−1. Finally, the coefficient that scales the N fertilizer recommendation based on yield goal decreased by 29% from the original calibration to 12.9 kg N Mg−1 grain. The new algorithm for predicting EONR reduced the error of the sidedress N recommendation by one‐half compared to the original calibration. The new PSNT calibration will allow users to accurately determine sidedress N recommendations in sites with a long‐term manure history and underscores the importance of updating soil fertility recommendation algorithms with modern data. Core Ideas: Recalibrating the pre‐sidedress soil nitrate test (PSNT) for modern corn production systems may be necessary.A single long‐term manure history factor interacted with the PSNT result to adjust sidedress N recommendations.The new PSNT calibration reduced the error of sidedress N recommendations by half compared to the original.With a new calibration, the PSNT is a reliable tool to predict sidedress N rates for corn with a manure history. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to systematically develop and validate an instrument to assess parental perceptions toward adapted physical education (APE) teachers, who work with children with autism. Methods: Participants included two expert panels and parents of children and youth with autism. The survey used a Likert-scale design where parents rated their level of satisfaction regarding communication with, qualifications of, and rapport with the APE teachers. Results: Based on a coefficients for each of the three subscales, it was concluded that the survey had high internal validity. Split-half reliability determined by the Spearman Brown Prophecy coefficient indicated high reliability. Conclusion: Preliminary evidence demonstrated that the survey may be a useful tool in assessing parental perceptions of their child's APE teacher.

Illustrates how networking standards are critical to the connectivity success of public education. Highlights the partnership of one district in Pennsylvania's statewide Link-to-Learn Project with a computer solutions firm. Discusses obstacles and prescription for the network upgrade. Includes suggestions for school districts contemplating computerization. (AEF)

From the ongoing crisis at the Pennsylvania State University, trustees everywhere are learning that they really are responsible for what goes on in athletics, and that good governance has come to be more demanding--on trustees; on administrators, faculty, and staff; and, perhaps, on external constituents--more vulnerable to internal and external pressures, and more intrusive or even invasive than anyone had cause to imagine in the past. Good governance seems suddenly to be something that everyone knows on sight and that no one had imagined before. This article presents two starkly visible cases that trustees everywhere would like to understand.

Background: In recent years, there has been increasing recognition of the importance of early maternal‐newborn contact for the health and well‐being of the newborn and promotion of breastfeeding. However, little research has investigated the association between early maternal‐newborn contact and the mother's birth experience. Methods: As part of a large‐scale prospective, cohort study (the First Baby Study [FBS]), nearly 3000 women who delivered in Pennsylvania (2009‐2011) reported how soon after delivery they first saw, held, and fed their newborns. Birth experience was measured via telephone interview 1 month postpartum, using the FBS Birth Experience Scale, a 16‐item scale which addresses women's feelings about the delivery. General linear models were used to measure associations between time to first maternal‐newborn contact and birth experience, controlling for relevant confounders, including maternal age, race/ethnicity, insurance coverage, delivery mode, gestational age, and pregnancy and delivery complications. Results: The sooner that new mothers first saw, held, and fed their newborns after delivery the more positive their childbirth experiences (all P‐values < 0.001). Women who delivered by cesarean were less likely to see, hold and feed their newborns shortly after delivery than those who delivered vaginally (all P‐values < 0.001), and reported less positive birth experiences (P < 0.001). However, if they first saw, held, and fed their newborns shortly after delivery, they reported more positive birth experiences than those who delivered vaginally (P = 0.010). Discussion: Early maternal‐newborn contact after delivery was associated with positive birth experiences for new mothers, particularly those who delivered by cesarean. [ABSTRACT FROM AUTHOR]

Background Mode of delivery at first childbirth largely determines mode of delivery at subsequent births, so it is particularly important to understand risk factors for cesarean delivery at first childbirth. In this study, we investigated risk factors for cesarean delivery among nulliparous women, with focus on the association between labor induction and cesarean delivery. Methods A prospective cohort study of 2851 nulliparous women with singleton pregnancies who attempted vaginal delivery at hospitals in Pennsylvania, 2009-2011, was conducted. We used nested logistic regression models and multiple mediational analyses to investigate the role of three groups of variables in explaining the association between labor induction and unplanned cesarean delivery-the confounders of maternal characteristics and indications for induction, and the mediating (intrapartum) factors-including cervical dilatation, labor augmentation, epidural analgesia, dysfunctional labor, dystocia, fetal intolerance of labor, and maternal request of cesarean during labor. Results More than a third of the women were induced (34.3%) and 24.8% underwent cesarean delivery. Induced women were more likely to deliver by cesarean (35.9%) than women in spontaneous labor (18.9%), unadjusted OR 2.35 (95% CI 1.97-2.79). The intrapartum factors significantly mediated the association between labor induction and cesarean delivery (explaining 76.7% of this association), particularly cervical dilatation <3 cm at hospital admission, fetal intolerance of labor, and dystocia. The indications for labor induction only explained 6.2%. Conclusions Increased risk of cesarean delivery after labor induction among nulliparous women is attributable mainly to lower cervical dilatation at hospital admission and higher rates of labor complications. [ABSTRACT FROM AUTHOR]

Objectives To determine whether slow gait speed increases the risk of costly long-term nursing home residence when accounting for death as a competing risk remains unknown. Design Longitudinal cohort study using proportional hazards models to predict long-term nursing home residence and subdistribution models with death as a competing risk. Setting Community-based prospective cohort study. Participants Older women (mean age 76.3) participating in the Study of Osteoporotic Fractures who were also enrolled in Medicare fee-for-service plans (N = 3,755). Measurements Gait speed was measured on a straight 6-m course and averaged over two trials. Long-term nursing home residence was defined using a validated algorithm based on Medicare Part B claims for nursing home-related care. Results Participants were followed until long-term nursing home residence, disenrollment from Medicare plan, death, or December 31, 2010. Over the follow-up period (median 11 years), 881 participants (23%) experienced long-term nursing home residence, and 1,013 (27%) died before experiencing this outcome. Slow walkers (55% of participants with gait speed <1 m/s) were significantly more likely than fast walkers to reside in a nursing home long-term (adjusted hazards ratio ( aHR) = 1.79, 95% confidence interval ( CI) = 1.54-2.09). Associations were attenuated in subdistribution models ( aHR = 1.52, 95% CI = 1.30-1.77) but remained statistically significant. Conclusion Older community-dwelling women with slow gait speed are more likely to experience long-term nursing home residence, as well as mortality without long-term residence. Ignoring the competing mortality risk may overestimate long-term care needs and costs. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate feasibility and impact of evidence-based medicine (EBM) educational prescriptions (EPs) in medical student clerkships. Methods: Students answered clinical questions during clerkships using EPs, which guide learners through the “four As” of EBM. Epidemiology fellows graded EPs using a rubric. Feasibility was assessed using descriptive statistics and student and fellow end-of-study questionnaires, which also measured impact. In addition, for each EP, students reported patient impact. Impact on EBM skills was assessed by change in EP scores over time and scores on an EBM objective structured clinical exam (OSCE) that were compared to controls from the prior year. Results: 117 students completed 402 EPs evaluated by 24 fellows. Average score was 7.34/9.00 (SD 1.58). 69 students (59%) and 21 fellows (88%) completed questionnaires. Most students thought EPs improved “Acquiring” and “Appraising”. Almost half thought EPs improved “Asking” and “Applying”. Fellows did not value grading EPs. For 18% of EPs, students reported a “change” or “potential change” in treatment. 56% “confirmed” treatment. EP scores increased by 1.27 (95% CI: 0.81–1.72). There were no differences in OSCE scores between cohorts. Conclusions: Integrating EPs into clerkships is feasible and has impact, yet OSCEs were unchanged, and research fellows had limitations as evaluators. [ABSTRACT FROM PUBLISHER]

The early childhood professionals recognize the limitations of conventional testing with young children. This recognition has given rise to Authentic Assessment, now recognized officially as best practice by the major professional organizations. However, no national studies have been conducted to document the comparative qualities of either authentic or conventional approaches—according to meaningful external standards. Based on a national Internet survey of professionals, we report details of a social validity study of common measurement methods on eight operationally defined standards for developmentally appropriate assessment linked to professionally sanctioned practice standards and indicators. Approximately 1,500 professional responses reveal higher quality appraisals for authentic assessment over conventional testing methods for early childhood intervention purposes. Based on these results, we offer recommendations to advance valid, sensible, and contextually appropriate assessment for early childhood intervention. [ABSTRACT FROM PUBLISHER]

Objective To assess defects in expression of critical cell cycle checkpoint genes and proteins in patients with rheumatoid arthritis (RA) relative to presence or absence of methotrexate (MTX) treatment, and to investigate the role of JNK in induction of these genes by MTX. Methods Flow cytometric analysis was used to quantify changes in levels of intracellular proteins, measure reactive oxygen species (ROS), and determine apoptosis in different lymphoid populations. Quantitative reverse transcription-polymerase chain reaction was used to identify changes in cell cycle checkpoint target genes. Results RA patients expressed reduced baseline levels of MAPK9, TP53, CDKN1A, CDKN1B, CHEK2, and RANGAP1 messenger RNA (mRNA) and JNK total protein. The reduction in expression of mRNA for MAPK9, TP53, CDKN1A, and CDKN1B was greater in patients not receiving MTX than in those receiving low-dose MTX, with no difference in expression levels of CHEK2 and RANGAP1 mRNA between MTX-treated and non-MTX-treated patients. Further, JNK levels were inversely correlated with C-reactive protein levels in RA patients. In tissue culture, MTX induced expression of both p53 and p21 by JNK-2- and JNK-1-dependent mechanisms, respectively, while CHEK2 and RANGAP1 were not induced by MTX. MTX also induced ROS production, JNK activation, and sensitivity to apoptosis in activated T cells. Supplementation with tetrahydrobiopterin blocked these MTX-mediated effects. Conclusion Our findings support the notion that MTX restores some, but not all, of the proteins contributing to cell cycle checkpoint deficiencies in RA T cells, via a JNK-dependent pathway. [ABSTRACT FROM AUTHOR]

Purpose: Many healthcare facilities require staff nurses to complete annual competency assessments on central line care. However, the question arises, could simulation provide a better assessment of competency and possibly help nurses retain competence longer? Review of Relevant Literature: A thorough review of the literature revealed that limited investigation has been done regarding the perception or effectiveness of simulation as a tool for competency evaluation. Multiple authors have identified simulation as an advantageous method for training health care providers in central line care. Several studies have linked simulation based training with decreased central line associated bacteremia rates. There is also evidence in the literature that simulation has great potential as a competency validation technique. Discussion: A sample of staff nurses participated in one of four central line care scenarios in a simulation environment. The participants were asked to complete a demographics survey as well as a self-assessment on central line competency prior to the simulation experience. Debriefing followed the simulation, offering the participant feedback on performance and verification of correct and incorrect actions. The self-assessment was then repeated to measure participant perception post-simulation. Implications for Clinical Practice: No significant difference of performance in the simulation was inferred from baccalaureate-prepared nurses versus diploma or associate-prepared nurses. Almost all participants rated their competence in caring for a central line as either "competent" or "highly competent." However upon demonstration of central line skills in the simulation, all but two participants omitted a critical step. Omitting these steps places the patient at risk for infection or other complications. [ABSTRACT FROM AUTHOR]

The article focuses on Pennsylvania's commonwealth court regarding the issues related to regarding the issues related to the legislations concerning worker wages. It offers information on the role of commonwealth court in the development of the Pennsylvania Prevailing Wage Act (PWA) jurisprudence. It also explores the court's decisional law regarding enforcement of the PWA.

Examines municipal managers' attitudes regarding the performance and leadership styles of police chiefs in Pennsylvania. Assessment of the performance and leadership attributes of police chiefs by municipal managers; Performance traits and leadership qualities; Differences in education levels of police chiefs.

Investigates among- and within-year community-level patterns in the phenology of wood-warblers in old field/deciduous forest habitat in Pennsylvania. Site description and sampling methods; Statistical model; General patterns; Detrended correspondence analysis; Results and discussion.

Presents a case study about the success and the problems facing the Pittsburgh Partnership for Neighborhood Development (PPND) as a community development corporations. Determinant factor for the success of community development corporations; Mechanics and systems of operation of the organization; Political and economic problems that affects the organization.

Melanic white-tailed deer are distinguished from normal white-tailed deer by having uniform black hairs on the back with subdued black hairs on the belly, a completely dark face and ears, a distinctive mid-dorsal stripe extending from the head to tile apex of the tail and a tail with black dorsally and white ventrally. We report records for two melanistic white-tailed deer in Pennsylvania. A male fawn was captured in Valley Forge National Historical Park in 1999 and an adult male was harvested in Bucks County in 2002. Since at least one melanistic deer was produced in this region, there is a possibility another melanic deer will be produced in the future. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines.Methods: This is a before-after retrospective cohort study at a single academic center. This center adopted guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery. Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses were included. For the primary outcome of cesarean delivery rate among induced or augmented patients, 200 consecutive women managed before guideline adoption were compared with 200 similar patients afterward. Secondary outcomes of overall cesarean delivery rate, maternal morbidity, neonatal outcomes, and labor management practices were analyzed with inclusion of intervening spontaneously laboring women.Results: Between September 13, 2013, and September 28, 2014, 275 women preguideline and 292 postguideline were identified to include 200 deliveries after induction or augmentation each. Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.Conclusion: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm. [ABSTRACT FROM AUTHOR]

Purpose: To determine the incidence of dose-limiting (DL) chemotherapy-induced peripheral neuropathy (CIPN) events in clinical practice. Patients and Methods: This retrospective cohort study included 488 women who received docetaxel or paclitaxel. The primary outcome was a DL event (dose delay, dose reduction, or treatment discontinuation) attributed to CIPN (DL CIPN). The paired t test was used to test the difference in received cumulative dose and planned cumulative dose by dose reduction and treatment discontinuation status. Results: A total of 150 unique DL events occurred in 120 women (24.6%). More than one third (37.3%; n = 56) of the events were attributed to CIPN. The 56 DL CIPN events occurred in 50 women (10.2%). DL CIPN incidence differed significantly by agent (docetaxel, 2.4%; n = five of 209; paclitaxel, 16.1%; n = 45 of 279; P < .001). DL CIPN occurred in 24.5% and 14.4% of women who received paclitaxel 80 mg/m2 weekly for 12 cycles and 175 mg/m2 biweekly for four cycles, respectively (adjusted odds ratio, 2.11; 95% CI, 0.97 to 4.60; P = .06). The cumulative dose actually received was significantly lower than the planned cumulative dose among women who had a dose reduction or treatment termination attributed to CIPN (9.4% less; P < .001 and 28.4% less; P < .001, respectively). Conclusion: Oncologists limited the dosing of chemotherapy because of CIPN in a significant proportion of paclitaxel recipients, most frequently in those who received a weekly regimen. Patients who had their dose reduced or discontinued received significantly less cumulative chemotherapy than planned. The implications of these DL CIPN events on treatment outcomes must be investigated. [ABSTRACT FROM AUTHOR]

Abstract: Background: Single-photon emission computed tomography (SPECT) has been employed in the study of altered regional cerebral blood flow (CBF) in experimental and chronic pain. CBF patterns have not been evaluated in patients with acute postoperative pain. Objective: The purpose of this pilot study was to employ SPECT to measure CBF distribution associated with postoperative dental pain and to compare these CBF patterns to subsequent images in the same patients who were experiencing pain relief versus continued or worsening pain who had received active or placebo analgesic interventions. The primary outcome measure was the percentage change in blood flow in various regions of interest. Methods: Twenty-two healthy individuals (10 males and 12 females, age range 20–29 years) who underwent the removal of ≥1 partial or full bony impacted mandibular third molars were evaluated for pain intensity as the local anesthesia dissipated, employing a 0 to10 numeric rating scale (0 = no pain; 10 = worst imaginable). When the subjects'' pain level reached ≥4/10, they were injected intravenously with 260 MBq of technetium Tc 99m bicisate (ethyl cysteinate dimer). Under double-blind conditions and 10 minutes before being placed in the SPECT scanner, the first 10 subjects were randomized to receive intravenous ketorolac 15 mg or saline while the remaining 12 subjects were randomized to receive by mouth either ibuprofen 400 mg, ibuprofen 200 mg, acetaminophen 1000 mg, or placebo. One hour after drug administration, subjects were reevaluated for pain, injected with 925 MBq of technetium Tc 99m bicisate, given rescue medication if required, and then rescanned. CBF ratios were obtained for regions of interest and by normalizing to average whole brain activity. Results: Subjects generally had a moderate degree (mean [SD], 7.3% [4.0%]) of thalamic asymmetry on initial scans with pain; after treatment, subjects reporting worsening pain regardless of the intervention had higher thalamic asymmetry (8.1% vs 2.8%) than those reporting relief of pain. Subjects who reported reduced pain after the intervention had significantly different (P < 0.05) mean CBF changes compared with those reporting worsening pain in the left prefrontal cortex, left sensorimotor area, right anterior cingulate, and right caudate. Conclusions: Acute postoperative dental pain was associated with moderate thalamic asymmetry that improved following successful pain management. Sustained or worsening pain was associated with increased CBF in brain regions associated with pain pathways, whereas pain relief was associated with decreased activity in the same areas. [Copyright &y& Elsevier]

Currently, no consensus has been reached regarding the management of hyperlipidemia in patients who develop statin-associated myalgia (SAM). Many statin-intolerant patients use alternative lipid-lowering therapies, including red yeast rice. The present trial evaluated the tolerability of red yeast rice versus pravastatin in patients unable to tolerate other statins because of myalgia. The study was conducted in a community-based setting in Philadelphia, Pennsylvania. A total of 43 adults with dyslipidemia and a history of statin discontinuation because of myalgia were randomly assigned to red yeast rice 2,400 mg twice daily or pravastatin 20 mg twice daily for 12 weeks. All subjects were concomitantly enrolled in a 12-week therapeutic lifestyle change program. The primary outcomes included the incidence of treatment discontinuation because of myalgia and a daily pain severity score. The secondary outcomes were muscle strength and plasma lipids. The incidence of withdrawal from medication owing to myalgia was 5% (1 of 21) in the red yeast rice group and 9% (2 of 22) in the pravastatin group (p = 0.99). The mean pain severity did not differ significantly between the 2 groups. No difference was found in muscle strength between the 2 groups at week 4 (p = 0.61), week 8 (p = 0.81), or week 12 (p = 0.82). The low-density lipoprotein cholesterol level decreased 30% in the red yeast rice group and 27% in the pravastatin group. In conclusion, red yeast rice was tolerated as well as pravastatin and achieved a comparable reduction of low-density lipoprotein cholesterol in a population previously intolerant to statins. [Copyright &y& Elsevier]

One strategy to limiting eutrophication in waterways is to reduce the concentration of water-extractable P (WEP) in land-applied manure. In this study, we investigated the feasibility of using mine drainage residuals (MDR), waste solids produced in large quantities from coal mine drainage treatment, to reduce WEP in dairy manure. Twenty MDRs from treatment systems in Pennsylvania were collected and analyzed to determine concentrations of pollutants that may limit land application. Laboratory dose-response tests were conducted using the selected MDRs to determine the effectiveness and kinetics of WEP reduction, and three field-scale MDR application tests were conducted to demonstrate the process of using MDR to decrease manure WEP. The MDR-manure mixtures investigated in this study do not exceed biosolid land application concentration limits set by the USEPA. Amendment rates of 5-10 g MDR L -1 of manure provided significant reductions in WEP. Iron-rich MDR, produced from passive and oxidant treatment of mine drainage, required 1-4 d to reduce WEP to an equilibrium concentration, while Ca-rich materials, produced from lime treatment, required 4-7 d. Three field studies at operating dairy farms confirmed the reduction in WEP when manure was amended with MDR. Unit costs calculated for a 1,900-m 3 manure tank treated with 4.4 g L -1 MDR were US$2.16 per 1,000 L of manure and $30 kg -1 WEP removed. These findings indicate that the WEP of dairy manure is not a fixed chemical parameter and can be modified with amendments such as MDR., (© 2020 The Authors. Journal of Environmental Quality © 2020 American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America.)

We aimed to evaluate the association between pulmonary hypertension (PH) hemodynamic classification and all-cause mortality in patients with symptomatic severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). PH is common and associated with post-TAVI outcomes in patients with severe AS. Although PH in these patients is primarily driven by elevated left-sided pressures (postcapillary PH), some patients develop increased pulmonary vascular resistance (PVR) configuring the combined pre- and postcapillary PH (CpcPH). We analyzed severe AS patients with mean pulmonary artery pressure (mPAP) measured by right heart catheterization (RHC) before TAVI between 2011 and 2017. PH hemodynamic classification was defined as: No PH (mPAP < 25 mm Hg); precapillary PH (mPAP ≥ 25 mm Hg, pulmonary capillary wedge pressure (PCWP) ≤15 mm Hg); isolated postcapillary PH (IpcPH; mPAP ≥ 25 mm Hg, PCWP > 15 mm Hg, PVR ≤ 3 Wood units (WU); CpcPH (mPAP ≥ 25 mm Hg, PCWP > 15 mm Hg, PVR > 3 WU). Kaplan-Meier and Cox regression analyses were used to test the association of PH hemodynamic classification with post-TAVI all-cause mortality. We examined 561 patients (mean age 82 ± 8 years, 51% men, mean LVEF 54 ± 14%). The prevalence of no PH was 201 (36%); precapillary PH, 59 (10%); IpcPH, 189 (34%); and CpcPH, 112 (20%). During a median follow-up of 30 months, 240 all-cause deaths occurred. Patients with CpcPH had higher mortality than those with no-PH even after adjustment for baseline characteristics (Hazard ratio 1.56, 95% confidence interval 1.06 to 2.29, p = 0.025). There was no survival difference among patients with non-PH, precapillary PH and IpcPH. In conclusion, for patients with symptomatic severe AS treated with TAVI, CcpPH is independently associated with long-term all-cause mortality despite successful TAVI., Competing Interests: Disclosures Dr. Schindler has served on the advisory board of Boston Scientific; and on the speakers’ bureau for Edwards Lifesciences; Dr. Gleason has received research funding from Medtronic and Boston Scientific; and has been a consultant for Abbott; Dr. Cavalcante has received research funding and consultant fees from Medtronic Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Deep sternal wound infections (DSWI) often require flap reconstruction to obliterate dead space and provide healthy soft tissue coverage. A better understanding of risk factors for complications after DSWI flap reconstruction may improve operative management., Methods: A retrospective study (2007-2018) was conducted of all patients with DSWI after cardiothoracic procedure referred to a single reconstructive surgeon for flap reconstruction. Patient and operative factors were reviewed, including procedure types and outcomes. Predictors of morbidity and mortality rates were analyzed., Results: A total of 119 patients requiring flap reconstruction for DSWI met inclusion criteria. Unilateral (49.6%) or bilateral (40.3%) pectoralis muscle flaps were performed most frequently, followed by vertical rectus abdominis myocutaneous (VRAM) (4.2%), omental (4.2%), and omental/pectoralis flap combination (1.7%). Superficial surgical site infection (SSI) was the predominant postoperative complication (17.6%). Débridement/revisional procedures were required in 19 patients (16%), and flap failure occurred in 5 (4.2%). Overall 30-day mortality was 15.1%. End-stage renal disease (P = .002), congestive heart failure (P = .049), low albumin (P = .004), cardiopulmonary bypass time (P = .0001), need for open chest (P = .020), and high American Society of Anesthesiologists Physical Status Classification (P = .003) were associated with higher mortality. By multivariate analysis, multidrug resistance was predictive of any postoperative complication (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.3-23.2; P = .018), VRAM was predictive of SSI (OR, 9.6; 95% CI, 1.4-66.4; P = .022), and end-stage renal disease (OR, 8.57; 95% CI, 1.06-69.1; P = .044) was predictive of higher mortality., Conclusions: Pectoralis muscle flaps are the workhorse for complex sternal wound coverage, but complications after flap reconstruction for DSWIs remain high. In particular, end-stage renal disease, VRAM reconstruction, and multidrug-resistant infection may predict a complicated postoperative course in these patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Nearly a third of women in the United States deliver by cesarean at first childbirth. The extent to which women's prenatal mode of delivery preference contributes to the cesarean decision is not clear. Little research has measured pregnant nulliparous women's prelabor mode of delivery preference in relation to actual mode of delivery in the United States. Materials and Methods: A total of 3006 pregnant nulliparous women were asked about mode of delivery preference during pregnancy as part of the First Baby Study, a prospective study of women delivering in Pennsylvania hospitals, 2009-2011. Multivariable regression models were used to assess the association between women's preference for cesarean delivery and two decision stages: (1) the decision to have planned prelabor cesarean and (2) the intrapartum decision to have unplanned cesarean among those attempting vaginal delivery, adjusting for confounders. Results: Overall, 3.1% preferred cesarean delivery, 3.0% had no preference, and 93.9% preferred vaginal. Among those who preferred vaginal delivery, 4% had a planned cesarean; among those with no preference, 13.3% did; and among those who preferred cesarean, 33.7% did. In adjusted models, preference for cesarean was strongly associated with having planned prelabor cesarean (adjusted odds ratio [aOR] = 6.02; 95% confidence interval [CI] = 3.26-11.12), but was not significantly associated with unplanned cesarean among those who attempted vaginal delivery (aOR = 1.35; 95% CI = 0.77-2.38). Conclusions: Although preference for cesarean delivery among nulliparous women was uncommon, women who preferred cesarean were more likely to have planned prelabor cesarean delivery than those who preferred vaginal delivery.

Importance: Women are underrepresented at higher ranks in academic medicine. However, the factors contributing to this disparity have not been fully elucidated. Implicit bias and unconscious mental attitudes toward a person or group may be factors. Although academic medical centers use physician trainee evaluations of faculty to inform promotion decisions, little is known about gender bias in these evaluations. To date, no studies have examined narrative evaluations of medical faculty by physician trainees for differences based on gender., Objective: To characterize gender-associated linguistic differences in narrative evaluations of medical faculty written by physician trainees., Design, Setting, and Participants: This retrospective cohort study included all faculty teaching evaluations completed for the department of medicine faculty by medical students, residents, and fellows at a large academic center in Pennsylvania from July 1, 2015, through June 30, 2016. Data analysis was performed from June 1, 2018, through July 31, 2018., Main Outcomes and Measures: Word use in faculty evaluations was quantified using automated text mining by converting free-text comments into unique 1- and 2-word phrases. Mixed-effects logistic regression analysis was performed to assess associations of faculty gender with frequencies of specific words and phrases present in a physician trainee evaluation., Results: A total of 7326 unique evaluations were collected for 521 faculty (325 men [62.4%] and 196 women [37.6%]). The individual words art (odds ratio [OR], 7.78; 95% CI, 1.01-59.89), trials (OR, 4.43; 95% CI, 1.34-14.69), master (OR, 4.24; 95% CI, 1.69-10.63), and humor (OR, 2.32; 95% CI, 1.44-3.73) were significantly associated with evaluations of male faculty, whereas the words empathetic (OR, 4.34; 95% CI, 1.56-12.07), delight (OR, 4.26; 95% CI, 1.35-13.40), and warm (OR, 3.45; 95% CI, 1.83-6.49) were significantly associated with evaluations of female faculty. Two-word phrases associated with male faculty evaluations included run rounds (OR, 7.78; 95% CI, 1.01-59.84), big picture (OR, 7.15; 95% CI, 1.68-30.42), and master clinician (OR, 4.02; 95% CI, 1.21-13.36), whereas evaluations of female faculty were more likely to be associated with model physician (OR, 7.75; 95% CI, 1.70-35.39), just right (OR, 6.97; 95% CI, 1.51-32.30), and attention (to) detail (OR, 4.26; 95% CI, 1.36-13.40)., Conclusions and Relevance: The data showed quantifiable linguistic differences between free-text comments about male and female faculty in physician trainee evaluations. Further evaluation of these differences, particularly in association with ongoing gender disparities in faculty promotion and retention, may be warranted.

Background: In recent years, there has been increasing recognition of the importance of early maternal-newborn contact for the health and well-being of the newborn and promotion of breastfeeding. However, little research has investigated the association between early maternal-newborn contact and the mother's birth experience., Methods: As part of a large-scale prospective, cohort study (the First Baby Study [FBS]), nearly 3000 women who delivered in Pennsylvania (2009-2011) reported how soon after delivery they first saw, held, and fed their newborns. Birth experience was measured via telephone interview 1 month postpartum, using the FBS Birth Experience Scale, a 16-item scale which addresses women's feelings about the delivery. General linear models were used to measure associations between time to first maternal-newborn contact and birth experience, controlling for relevant confounders, including maternal age, race/ethnicity, insurance coverage, delivery mode, gestational age, and pregnancy and delivery complications., Results: The sooner that new mothers first saw, held, and fed their newborns after delivery the more positive their childbirth experiences (all P-values < 0.001). Women who delivered by cesarean were less likely to see, hold and feed their newborns shortly after delivery than those who delivered vaginally (all P-values < 0.001), and reported less positive birth experiences (P < 0.001). However, if they first saw, held, and fed their newborns shortly after delivery, they reported more positive birth experiences than those who delivered vaginally (P = 0.010)., Discussion: Early maternal-newborn contact after delivery was associated with positive birth experiences for new mothers, particularly those who delivered by cesarean., (© 2018 Wiley Periodicals, Inc.)

Among students with influenza-like illness at a Pennsylvania college student health center during 2016-2017, 44 (15%) of 288 with respiratory specimens tested positive for human adenovirus (HAdV). HAdV-3, -7, and -4 predominated, and types clustered temporally. HAdV infection should be considered among college students with acute respiratory illness.

Background: Single-level open lumbar microdiscectomy surgery is one of the most straightforward and effective spinal surgeries performed by spinal surgeons today to treat disk herniation. Although a common operation, little in the literature is reported on the exact overall time, cost, and effort associated with the performance of this surgery. The consistency of this operation across institutions and disciplines makes it a good starting point to accurately track the total time and effort of all phases of the surgical intervention., Methods: Eighteen patients undergoing elective single-level open lumbar microdiscectomy surgery were prospectively enrolled in this study. The time spent interacting with each patient by every member of the surgical team was tracked and recorded along will every phone call and e-mail. All perioperative times associated with the surgery were tracked and analyzed. Each patient was followed from their first interaction through surgery and for the first 3 months postoperatively., Results: The advanced practice providers spent the most time with the patient both pre- and postoperatively followed by the surgeon and resident. A total of 2.98 hours was spent with the patient preoperatively in clinic and 1.69 hours postoperatively. The total time commitment of an institution treating this condition was 12.56 hours., Conclusions: Comparing our results with the Centers for Medicare and Medicaid Services data, a significant discrepancy and underestimation was observed. As such, we hope our results enable health care providers to more accurately allocate resources for the provision of high-quality medical care to patients with this increasingly common condition., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of this paper was to explore disparities associated with the route of hysterectomy in the University of Pittsburgh Medical Center (UPMC) health system and to evaluate whether the hysterectomy clinical pathway implementation impacted disparities in the utilization of minimally invasive hysterectomy (MIH)., Methods: We performed a retrospective medical record review of all the patients who have undergone hysterectomy for benign indications at UPMC-affiliated hospitals between fiscal years (FY) 2012 and 2014., Results: A total number of 6373 hysterectomy patient cases were included in this study: 88.7% (5653) were European American (EA), 11.02% (702) were African American (AA), and the remaining 0.28% (18) were of other ethnicities. We found that non-EA, women aged 45-60, traditional Medicaid, and traditional Medicare enrollees were more likely to have a total abdominal hysterectomy (TAH). Residence in higher median income zip code (> $61,000) was associated with 60% lower odds of undergoing TAH. Both FY 2013 and 2014 were associated with significantly lower odds of TAH. Logistic regression results from the model for non-EA patients for FY 2012 and FY 2014 demonstrated that FY and zip code income group were not significant predictors of surgery type in this subgroup. Pathway implementation did not reduce racial disparity in MIH utilization., Conclusion: This study demonstrated that there is a significant disparity in MIH utilization, where non-EA and Medicaid/Medicare recipients had higher odds of undergoing TAH. Further research is needed to investigate how care standardization may alleviate healthcare disparities.

Purpose: Image-based brachytherapy is increasingly used for gynecologic malignancies. We report early outcomes of magnetic resonance imaging (MRI)-guided brachytherapy., Methods and Materials: Consecutive patient cases with FIGO stage IB1 to IVA cervical cancer treated at a single institution were retrospectively reviewed. All patients received concurrent cisplatin with external beam radiation therapy along with interdigitated high-dose-rate intracavitary brachytherapy. Computed tomography or MRI was completed after each application, the latter acquired for at least 1 fraction. High-risk clinical target volume (HRCTV) and organs at risk were identified by Groupe Européen de Curiethérapie and European SocieTy for Radiotherapy and Oncology guidelines. Doses were converted to equivalent 2-Gy doses (EQD2) with planned HRCTV doses of 75 to 85 Gy., Results: From 2007 to 2013, 128 patients, median 52 years of age, were treated. Predominant characteristics included stage IIB disease (58.6%) with a median tumor size of 5 cm, squamous histology (82.8%), and no radiographic nodal involvement (53.1%). Most patients (67.2%) received intensity modulated radiation therapy (IMRT) at a median dose of 45 Gy, followed by a median brachytherapy dose of 27.5 Gy (range, 25-30 Gy) in 5 fractions. At a median follow up of 24.4 months (range, 2.1-77.2 months), estimated 2-year local control, disease-free survival, and cancer-specific survival rates were 91.6%, 81.8%, and 87.6%, respectively. Predictors of local failure included adenocarcinoma histology (P<.01) and clinical response at 3 months (P<.01). Among the adenocarcinoma subset, receiving HRCTV D90 EQD2 ≥84 Gy was associated with improved local control (2-year local control rate 100% vs 54.5%, P=.03). Grade 3 or greater gastrointestinal or genitourinary late toxicity occurred at a 2-year actuarial rate of 0.9%., Conclusions: This study constitutes one of the largest reported series of MRI-guided brachytherapy in North America, demonstrating excellent local control with acceptable morbidity. Dose escalation may be warranted when feasible for adenocarcinomas to offset the risk of local failure., (Copyright © 2015 Elsevier Inc. All rights reserved.)

To explore the feasible treatment alternatives for organic contaminant, especially organic arsenic species in the landfill gas (LFG) condensate, a variety of treatment approaches were examined and evaluated in this study. Biological degradation, conventional and advanced oxidation, and physical absorption showed limited effectiveness to convert the methylated arsenic to inorganic arsenic. Reverse osmosis (RO) was found to be able to remove the organic arsenic and meet the discharge limits. Maximum removal efficiency and cost level were summarized for all treatment approaches tested, which can be a reference for the organic arsenic treatment method selection under different circumstances., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: More than a dozen studies have reported a reduced rate of childbearing after caesarean delivery (CD). It has been hypothesised that this is because women who deliver by CD are less likely to intend to have subsequent children than women who deliver vaginally - either before childbirth or as a consequence of CD. Little research has addressed either of these hypotheses., Methods: As part of an ongoing prospective study, we interviewed 3006 women in their third trimester and 1 month after first childbirth to assess subsequent childbearing intentions., Results: Women who delivered by CD were similar to those who delivered vaginally in intent to have at least one additional child, both before childbirth (90.1% vaginal, 89.9% CD; P = 0.97) and after (87.8% vaginal, 87.1% CD; P = 0.87); however, women who had CD were less likely to intend two or more additional children, both before childbirth (34.7% vaginal, 29.2% CD; P = 0.03) and after (32.2% vaginal, 26.1% CD; P = 0.01). Among women who intended to have at least one additional child before childbirth, 5.0% reported intending to have no additional children 1 month after delivery (5.1% vaginal, 4.6% CD; P = 0.52)., Conclusions: Women whose first delivery is by CD are less likely to intend a relatively large family of three or more children than those who deliver vaginally, but delivery by CD does not decrease women's intentions to have at least one more child any more than does vaginal delivery, at least in the short term., (© 2012 Blackwell Publishing Ltd.)

An innovative training program to provide clinical research training for clinicians was created in 1979 at the University of Pennsylvania School of Medicine, now the Perelman School of Medicine. The program's principal and continuing aim is to provide trainees mentored experiences and the training needed to become skilled independent investigators able to conduct clinical research and develop academic careers as independent clinical investigators.The authors identify the vision that led to the creation of the master of science in clinical epidemiology (MSCE) degree program and describe today's training program, including administration, oversight, participating faculty, and trainees. They also describe the program's core curriculum, elective options, seminars on ongoing research, training in the responsible conduct of research, professional development activities, and the development and completion of a closely mentored clinical research project.Approximately 35 new trainees enter the two- to three-year program annually. Funding is provided primarily by National Institutes of Health-funded training programs and supplemented by private industry, private foundations, and employee-based benefits. More than 500 individuals have received or are currently receiving training through the MSCE program. A large percentage of former trainees maintain full-time positions in academic medicine today.The authors identify some challenges that have been met and insights regarding funding, faculty, trainees, and curriculum. Ongoing challenges include recruiting trainees from some selected highly paid, procedure-oriented specialties, maintaining sufficient mentors for the continually increasing numbers of trainees, and distinguishing applicants who truly desire a primary research career from others.

Successful aging (SA) is a multidimensional phenotype involving preservation of cognitive ability, physical function, and social engagement throughout life. Multiple components of SA are heritable, supporting a genetic component. The Amish are genetically and socially isolated with homogeneous lifestyles, making them a suitable population for studying the genetics of SA. DNA and measures of SA were collected on 214 cognitively intact Amish individuals over age 80. Individuals were grouped into a 13-generation pedigree using the Anabaptist Genealogy Database. A linkage screen of 5944 single nucleotide polymorphisms (SNPs) was performed using 12 informative subpedigrees with an affected-only 2-point and multipoint linkage analysis. Eleven SNPs produced 2-point LOD scores >2, suggestive of linkage. Multipoint linkage analyses, allowing for heterogeneity, detected significant LOD scores on chromosomes 6 (HLOD = 4.50), 7 (LOD*= 3.11), and 14 (HLOD = 4.17), suggesting multiple new loci underlying SA., (© 2011 The Authors Annals of Human Genetics © 2011 Blackwell Publishing Ltd/University College London.)

Context: Real-world adherence to bisphosphonate therapy is poor. Consistent data support a relation between medication adherence and fracture reduction, but relatively little attention has been paid to the effect of the method used to measure adherence on this relation or on the relation between adherence and specific fracture types., Objective: Our objective was to assess the relation between bisphosphonate adherence and the risk of hip, vertebral, distal forearm, and any fracture using different measures of adherence., Design: We conducted a cohort study using administrative claims data. Adherence was assessed in sequential 60-d periods. In models incorporating time-varying measures of adherence, the adjusted relation between adherence and fracture was examined using several methods for calculating the proportion of days covered (PDC)., Patients: Patients included community-dwelling elderly enrolled in a Pennsylvania pharmaceutical assistance program and Medicare initiating an oral bisphosphonate for osteoporosis., Main Outcome Measures: Risk of hip, vertebral, distal forearm, and any osteoporotic fracture was assessed., Results: Fractures occurred at a rate of 43 per 1000 person-years among the 19,987 patients meeting study eligibility criteria. There was an inverse relation between adherence and fracture rate for all adherence measures and fracture types, excluding distal forearm fractures. High (80-100%) cumulative PDC was associated with a 22% reduction in overall fracture rate, a 23% reduction in hip fracture rate, and 26% reduction in vertebral fracture rate., Conclusions: We found a consistent relation between adherence with osteoporosis treatment and fracture reduction, regardless of method for measuring PDC. The similarity in results across adherence measures is likely due to the high correlation between them.

New particle formation and growth events have been observed in several urban areas and are of concern due to their potential negative effects on human health. The main purpose of this study was to investigate the chemistry of ultrafine particles during the growth phase of the frequently observed nucleation events in Pittsburgh (approximately 100 events per year) and therefore infer the mechanisms of new particle growth in the urban troposphere. An Aerodyne aerosol mass spectrometer (AMS) and two SMPS systems were deployed at the U.S. EPA Pittsburgh Supersite during September 2002. Significant nucleation events were observed in 3 out of the 16 days of this deployment, including one of the 10 strongest nucleation events observed in Pittsburgh over a period of 15 months. These events appear to be representative of the climatology of new particle formation and growth in the Pittsburgh region. Distinctive growth of sulfate, ammonium, organics, and nitrate in the ultrafine mode (33-60 nm in a vacuum aerodynamic diameter or approximately 18-33 nm in physical diameter) was observed during each of these three events, with sulfate always being the first (and the fastest) species to increase. Ultrafine ammonium usually increased 10-40 min later than sulfate, causing the ultrafine mode particles to be more acidic during the initial stages of the nucleation events. Significant increase of ultrafine organics often happened after 11:00 a.m., when photochemistry is more intense. This observation coupled with a parallel increase of ultrafine m/z 44, a mass fragment generally representative of oxygenated organic compounds, indicates that secondary organic species contribute significantly to the growth of particles at a relatively later time of the event. Among all these four species, nitrate was always a minor component of the ultrafine particles and contributed the least to the new particle growth.

Objective: Little is known about risk factors that increase the risk of development of opioid side effects. Our objective was to evaluate the effect of the type of opioid, age, gender, and race on the incidence of side effects from short-term opioid use., Methods: A secondary analysis of a retrospective cohort study in 35 community-based and tertiary hospitals was done. There were 8855 black or white subjects aged 16 years and older. Patients received meperidine (INN, pethidine), morphine, or fentanyl as part of their treatment. Measurements were made to assess the presence of nausea and vomiting and respiratory depression., Results: Of the patients, 26% had nausea and vomiting and 1.5% had respiratory depression after opioid administration. After adjustment for opioid dose, route of administration, age, gender, and race, meperidine produced less nausea and vomiting (odds ratio [OR] = 0.7; 95% confidence interval [CI], 0.5-0.8) and less respiratory depression (OR = 0.6; 95% CI, 0.2-0.9) than morphine. The risk of respiratory depression increased with age. Compared with patients aged between 16 and 45 years, those aged between 61 and 70 years had 2.8 times the risk of development of respiratory depression (95% CI, 1.2-6.6); those aged between 71 and 80 years had 5.4 times the risk (95% CI, 2.4-11.8); and those aged older than 80 years had 8.7 times the risk (95% CI, 3.8-20.0). Men had less nausea and vomiting than women (OR = 0.5; 95% CI, 0.4-0.6). White subjects had more nausea and vomiting than black subjects (OR = 1.4; 95% CI, 1.1-1.7)., Conclusions: Meperidine produced fewer side effects than morphine during short-term use. The risk of respiratory depression increases substantially after 60 years of age. Women have nausea and vomiting more often than men. The effect of race deserves further investigation.