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In 2015, the Office of Diversion and Reentry Division (ODR), an internal department of the Los Angeles County Department of Health Services, was created to redirect individuals with serious mental illness from the criminal justice system. Part of ODR's mission is to identify individuals currently incarcerated in a Los Angeles County jail who are experiencing a serious mental health disorder and, to the extent practical, provide them with appropriate community-based care with the goals of reducing recidivism and improving health outcomes. Such redirection from the traditional criminal justice process is often characterized as diversion. To better build and scale efforts to support this work, in 2018, the Los Angeles County's Board of Supervisors asked for a study of the existing county jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors. Researchers found that an estimated 61 percent of the jail mental health population were likely appropriate candidates for diversion; 7 percent were potentially appropriate; and 32 percent were likely not appropriate candidates for diversion. These findings will help the county determine how it would need to scale community-based treatment programs to accommodate these individuals. The authors also provide recommendations for future programming and research. This study will be of interest to state and county governments as well as other organizations serving criminal justice–involved populations with serious mental illness.

Initiation of antiretroviral therapy (ART) in early compared with chronic human immunodeficiency virus (HIV) infection is associated with a smaller HIV reservoir. This longitudinal analysis of 60 individuals who began ART during primary HIV infection (PHI) investigates which pre- and posttherapy factors best predict HIV DNA levels (a correlate of reservoir size) after treatment initiation during PHI. The best predictor of HIV DNA at 1 year was pre-ART HIV DNA, which was in turn significantly associated with CD8 memory T-cell differentiation (effector memory, naive, and T-bet−Eomes− subsets), CD8 T-cell activation (CD38 expression) and T-cell immunoglobulin and mucin-domain containing-3 (Tim-3) expression on memory T cells. No associations were found for any immunological variables after 1 year of ART. Levels of HIV DNA are determined around the time of ART initiation in individuals treated during PHI. CD8 T-cell activation and memory expansion are linked to HIV DNA levels, suggesting the importance of the initial host-viral interplay in eventual reservoir size., Human immunodeficiency virus (HIV) DNA persists within the viral reservoir despite therapy. A longitudinal analysis of 60 individuals treated during early HIV infection showed that HIV DNA levels are “set” early in infection and predicted by an activated immune response.

OBJECTIVE: To evaluate the association Hurricane Harvey landfall with maternal and neonatal morbidity. METHODS: Using an institutional perinatal database from two hospitals in Houston, Texas, women with non-anomalous singletons delivering after 24 weeks of gestation between August 2011 and June 2018 were included. To evaluate the possible association of hurricane landfall with pregnancy outcomes, Gravid women delivering within 280 days (40 weeks) on or after August 25(th), 2017 (the day of hurricane landfall) were categorized as exposed, and women delivered prior to August 25(th), 2017, were the reference group. Composite maternal morbidity included any of the following: hypertensive disorders of pregnancy, chorioamnionitis, endometritis, blood transfusion, peripartum hysterectomy, maternal critical care admission, pulmonary edema or maternal death. Composite neonatal morbidity included any of the following: 5-minute Apgar score ≤ 3, respiratory distress syndrome, use of ventilator or continuous positive airway pressure, suspected newborn sepsis, seizure, stillbirth, or neonatal death. Adjusted odds ratios (aOR) were calculated after correcting for possible confounders identified on univariate analysis. Disruption in outcome trends were measured in time series analyses. RESULTS: Of 40,502 deliveries in our database, 29,179 (72%) met the inclusion criteria, with 3,842 (13.2%) delivering within 280 days of Hurricane Harvey landfall. Women delivering after Hurricane Harvey were on average less likely to be obese and more likely to be older, Caucasian, married, have a household income over $75,000, a high school education, and private insurance. However, compared to the cohort of gravid patients who delivered prior to Hurricane Harvey, composite maternal morbidity increased by 27% (11.5% compared to 14.7%, aOR 1.27 95% CI 1.14–1.42) after the storm. Composite neonatal morbidity increased by 50% (7.8% compared to 11.9%, aOR 1.52 95% CI 1.34–1.71). In time series analyses, we observed a significant shift in composite maternal morbidity specific to women of low socioeconomic status (estimate 2.87, p=0.028). CONCLUSION: Despite having fewer at-risk baseline characteristics, gravid patients delivering after landfall by Hurricane Harvey had a significantly higher likelihood of adverse outcomes as did their neonates.

The study aimed to evaluate change in practitioners’ knowledge and attitudes following a one-day training course focused on best practice when working with trauma and psychosis. The primary aim was to evaluate whether psychological perspectives and understanding of trauma and psychosis changed post-training.

• Background:Antiretroviral therapy (ART) has led to dramatic improvements in survival for people living with HIV, but is unable to cure infection, or induce viral control off therapy. Designing intervention trials with novel agents with the potential to confer a period of HIV remission without ART, remains a key scientific and community goal. We detail the rationale, design, and outcomes of a randomised, placebo-controlled trial of two HIV-specific long-acting broadly neutralising antibodies (bNAbs); 3BNC117-LS and 10-1074-LS, which target CD4 binding site and V3 loop respectively, on post-treatment viral control.• Methods:RIO is a randomised, placebo-controlled, double-blinded prospective phase II study. Eligible individuals will have started ART within 3 months of primary HIV infection and have viral sequences that appear to be sensitive to both bNAbs. It will randomise 72 eligible participants 1:1 to the following arms via a two-stage design. In stage 1, arm A participants are given dual long-acting (LS-variants) bNAbs infusions, followed by intensively monitored Analytical Treatment Interruption (ATI) (n=36); in arm B, participants receive placebo infusions followed by ATI. The primary endpoint will be time to viral rebound within 36 weeks after ATI. Upon viral rebound, the participant and researcher are unblinded. Participants in arm A recommence ART and complete the study. Participants in arm B are invited to restart ART and enroll into stage 2 where they will receive open-label LS bNAbs, followed by a second ATI 24 weeks after. Secondary and exploratory endpoints include adverse events, time to undetectable viraemia after re-starting ART, immunological markers, HIV proviral DNA, serum bNAb concentrations in blood, bNAb resistance at viral rebound, and quality of life measures.• Discussion:The two-stage design was determined in collaboration with community involvement. This design allows all participants the option to receive bNAbs. It also tests the hypothesis that bNAbs may drive sustained HIV-control beyond the duration of detectable bNAb concentrations. Community representatives were involved at all stages. This included the two-stage design, discussion on the criteria to restart ART, frequency of monitoring visits off ART and reducing the risk of onward transmission to HIV-negative partners. It also included responding to the challenges of COVID-19.Trial registration: The protocol is registered on Clinical.trials.gov and EudraCT and has approval from UK Ethics and MHRA.

Many animals, including insects, need to solve the problem of self-righting if inverted and substrate is one understudied factor that could affect righting ability. In this study we ask the questions, how does Halyomorpha halys self-right and does variation in substrate affect self-righting? To address our questions we used four substrates with different features and filmed H. halys righting response on each substrate (n = 22 individuals). We also used two synced cameras to film the most common righting method and quantified its kinematics. Self-righting metrics did vary depending on substrate in terms of diversity of righting methods used, duration of the successful righting event, number of fails per attempt, and stance width. We also determined that the symmetrical forward flip is the most common method used by H. halys. In the forward flip H. halys creates a tripod of support using the hindlegs and the tip of the abdomen to elevate the anterior portion of the body off the substrate and pitch forward onto its feet. In addition to demonstrating that substrate can impact self-righting and quantifying the symmetrical forward flip, we also provide a foundation for future explorations of sensory feedback and adaptive motor control using H. halys.

Previously published data from our group and others demonstrate that human milk oligosaccharide (HMOs), as well as milk and infant fecal microbial profiles, vary by geography. However, little is known about the geographical variation of other milk-borne factors, such as lactose and protein, as well as the associations among these factors and microbial community structures in milk and infant feces. Here, we characterized and contrasted concentrations of milk-borne lactose, protein, and HMOs, and examined their associations with milk and infant fecal microbiomes in samples collected in 11 geographically diverse sites. Although geographical site was strongly associated with milk and infant fecal microbiomes, both sample types assorted into a smaller number of community state types based on shared microbial profiles. Similar to HMOs, concentrations of lactose and protein also varied by geography. Concentrations of HMOs, lactose, and protein were associated with differences in the microbial community structures of milk and infant feces and in the abundance of specific taxa. Taken together, these data suggest that the composition of human milk, even when produced by relatively healthy women, differs based on geographical boundaries and that concentrations of HMOs, lactose, and protein in milk are related to variation in milk and infant fecal microbial communities, This research was funded by the National Science Foundation IOS-BIO 1344288; the Ministry of Economy and Competitiveness, Spain (AGL2013-4190-P); the European Commission (624773-FP-7-PEOPLE-2013-IEF, to LR); and in part by National Institutes of Health NICHD R01-HD092297 and COBRE Phase III grant P30GM103324. Sterile, single-use milk collection kits were provided by Medela Inc.

Rapid expansions of bioinformatics and computational biology have broadened the collection and use of -omics data including genomic, transcriptomic, methylomic and a myriad of other health data types, in the clinic and the laboratory. Both clinical and research uses of such data require co-analysis with large datasets, for which participant privacy and the need for data custodian controls must remain paramount. This is particularly challenging in multi-jurisdictional settings, such as Canada, where health privacy and security requirements are often heterogeneous. Data federation presents a solution to this, allowing for integration and analysis of large datasets from various sites while abiding by local policies.The Canadian Distributed Infrastructure for Genomics platform (CanDIG) enables federated querying and analysis of -omics and health data while keeping that data local and under local control. It builds upon existing infrastructures to connect five health and research institutions across Canada, relies heavily on standards and tooling brought together by the Global Alliance for Genomics and Health (GA4GH), implements a clear division of responsibilities among its participants and adheres to international data sharing standards. Participating researchers and clinicians can therefore contribute to and quickly access a critical mass of -omics data across a national network in a manner that takes into account the multi-jurisdictional nature of our privacy and security policies. Through this, CanDIG gives medical and research communities the tools needed to use and analyze the ever-growing amount of -omics data available to them in order to improve our understanding and treatment of various conditions and diseases. CanDIG is being used to make genomic and phenotypic data available for querying across Canada as part of data sharing for five leading pan-Canadian projects including the Terry Fox Comprehensive Cancer Care Centre Consortium Network (TF4CN) and Terry Fox PRecision Oncology For Young peopLE (PROFYLE), and making data from provincial projects such as POG (Personalized Onco- Genomics) more widely available.

Cauda equina syndrome (CES) is a rare neurological emergency that requires prompt diagnosis and immediate surgical intervention for the best potential patient outcome. CES results from the compression of spinal roots along the lower spine usually at the level of L2 or below. It typically presents with severe low back pain, pain radiating to lower extremities, motor weakness, sensory loss, saddle anesthesia, bladder and bowel dysfunction. It is most commonly caused by a large central intervertebral disc herniation or central canal spinal stenosis but can also occur on occasion from abscesses, neoplasms, and inflammatory conditions. If the patient's symptoms are overlooked and surgical intervention is delayed there is a risk for long-term damage to neurological function. Here, we will present a case of a 46-year-old female with a long-standing history of back pain that presented to her primary care office with worsening back pain symptoms as well as a new presentation of urinary incontinence. A prompt MRI confirmed CES and the patient was advised to report to the nearest ED. At the hospital, neurosurgeons performed a laminectomy and found a mass along L3 that was compressing the cauda equina and associated nerve roots. The pathology of the mass revealed an extramedullary plasmacytoma (EMP) that was later determined to originate from the right psoas muscle. The case provides insight into the patient's presentation of CES and the key differentiating factors that led the medical care team to order the appropriate work up and prevent the long-term complications associated with an untreated CES.

Whaling has decimated North Atlantic right whales Eubalaena glacialis (NARW) since the 11th century and southern right whales E. australis (SRW) since the 19th century. Today, NARWs are Critically Endangered and decreasing, whereas SRWs are recovering. We review NARW health assessment literature, NARW Consortium databases, and efforts and limitations to monitor individual and species health, survival, and fecundity. Photographs are used to track individual movement and external signs of health such as evidence of vessel and entanglement trauma. Post-mortem examinations establish cause of death and determine organ pathology. Photogrammetry is used to assess growth rates and body condition. Samples of blow, skin, blubber, baleen and feces quantify hormones that provide information on stress, reproduction, and nutrition, identify microbiome changes, and assess evidence of infection. We also discuss models of the population consequences of multiple stressors, including the connection between human activities (e.g. entanglement) and health. Lethal and sublethal vessel and entanglement trauma have been identified as major threats to the species. There is a clear and immediate need for expanding trauma reduction measures. Beyond these major concerns, further study is needed to evaluate the impact of other stressors, such as pathogens, microbiome changes, and algal and industrial toxins, on NARW reproductive success and health. Current and new health assessment tools should be developed and used to monitor the effectiveness of management measures and will help determine whether they are sufficient for a substantive species recovery.

Evaluations of the conservation status of the endangered North Atlantic right whale as well as many other wildlife species often rely extensively on counts and cause‐of‐death determinations of carcasses found accidentally or during dedicated surveys. Even when survey effort dedicated to a population is extensive, many deaths may go unseen. We used an abundance estimation model to derive estimates of cryptic mortality for North Atlantic right whales and found that observed carcasses accounted for only 36% of all estimated death during 1990–2017. We found strong evidence that total mortality varied over time, and that observed carcass counts were poor predictors of estimated annual numbers of whales dying. Importantly, there were substantial differences between fractions of deaths determined to be entanglement related during necropsy (49%) and the fraction of cryptic deaths suffering serious injuries related to entanglement (87%). Although we concluded that a single year's observations produced poor estimates of carcass detection rates due to the volatility of ratios of small counts, ratio estimates of data pooled over periods of consistent survey may offer better information on detection rates. Additionally, it appears unwise to consider cause of death determinations from detected carcasses as representative of cause‐specific mortality rates in right whales given the large number of seriously injured whales from entanglement that are likely part of the unseen mortality.

Health care workers (HCWs) are at higher risk for SARS-CoV-2 infection and may play a role in transmitting the infection to vulnerable patients and members of the community. This is particularly worrisome in the context of asymptomatic infection. We performed a cross-sectional study looking at asymptomatic SARS-CoV-2 infection in HCWs. We screened asymptomatic HCWs for SARS-CoV-2 via PCR. Complementary viral genome sequencing was performed on positive swab specimens. A seroprevalence analysis was also performed using multiple assays. Asymptomatic health care worker cohorts had a combined swab positivity rate of 29/5776 (0.50%, 95%CI 0.32–0.75) relative to a comparative cohort of symptomatic HCWs, where 54/1597 (3.4%) tested positive for SARS-CoV-2 (ratio of symptomatic to asymptomatic 6.8:1). SARS-CoV-2 seroprevalence among 996 asymptomatic HCWs with no prior known exposure to SARS-CoV-2 was 1.4–3.4%, depending on assay. A novel in-house Coronavirus protein microarray showed differing SARS-CoV-2 protein reactivities and helped define likely true positives vs. suspected false positives. Our study demonstrates the utility of routine screening of asymptomatic HCWs, which may help to identify a significant proportion of infections.

This report describes a study of pardon petition evaluations that were performed by the Office of the Pardon Attorney (OPA), a unit in the U.S. Department of Justice that processes thousands of requests for executive clemency each year. A statistical examination was conducted on how OPA screens incoming petitions for technical compliance, investigates the facts underlying each petitioner’s request for clemency, and applies substantive standards for evaluating the merits of such petitions when crafting recommendations to the U.S. President to grant or deny relief. Data were analyzed for any patterns in OPA decisions that indicated statistically significant evidence of racial or ethnic bias.

Two mass mortality events in 2016 and 2019 affecting the eastern oyster in the Mississippi Sound permitted an investigation of population dynamics during the collapse and recovery from systemic stressors capable of producing local extinction. In this study, metrics were reported as true population metrics with values included in proportion to the size class representation in the population. The approach was critical as trends in Dermo prevalence and weighted prevalence varied substantially between size classes, and this permitted elucidation of recovery trajectories not obvious from the population as a whole. The division of the population into larger and smaller size classes revealed a consistent differential in the time series for Dermo prevalence and weighted prevalence; these metrics did not return to levels observed before the 2016 mortality event in the 2-y interim between the 2016 and 2019 mortality events, and prevalence, in particular, remained low in the smaller size class. The time delay in the return of Dermo infection due to a substantial change in the size frequency of the population toward smaller initially uninfected animals is consistent with the differential in Dermo and young oyster cell doubling times and the required time delay, albeit relatively short, for transmission to occur. Gonadal thickness generally tracked with condition index and followed the expected seasonal cycle; any impact resulting from the 2016 mortality event on these metrics appeared to be inconsequential. The relationship between the adductor muscle diameter and shell height varied little over the time series and was much more stable than between the adductor muscle diameter and shell weight, suggesting a change in the oyster shell shape post-2016. By inference, shell weight is more variable among the three metrics in estimation of the condition index and standardization of other health indices. The ability to establish health metrics for both specific size classes and the population as a whole is essential to understanding the temporal impacts of a severe stressor or mortality event on oyster populations.

Stock–recruitment relationships (SRR) are used by many resource managers as a metric to evaluate stock reproductive potential and rebuilding capacity when harvested. This relationship is more evident in traditional finfish stock assessment models where larvae are frequently limited by the abundance of spawning adults, whereas invertebrate resources are much more confounding and often do not express a clear spawning SRR. Oysters in particular appear to be limited more strongly by post-settlement mortality as larvae are regularly demonstrated to be present in high abundance in response to timely shell plants; yet unexpectedly, a brood SRR appears to be present. Because of the unique life history of oysters which provide their own habitat through reef accretion, a posit is that the quantity and quality of such habitat are crucial determinants of recruitment to the stock, and habitat quality acts as a surrogate for brood stock in the stock–recruit relationship. An extensive dataset from Delaware Bay with a 65-y time series was analyzed to assess the relationship between available Crassostrea virginica natural reef materials and subsequent spat (

Human milk is the optimal nutrition source for infants, and oligosaccharides represent the third most abundant component in milk after lactose and fat. Human milk oligosaccharides (HMO) are favorable macromolecules which are, interestingly, indigestible by the infant but serve as substrates for bacteria. Hypothesizing that the maternal diet itself might influence HMO composition, we sought to directly determine the effect maternal diet on HMO and the milk bacteria. Employing a human cross-over study design, we demonstrate that distinct maternal dietary carbohydrate and energy sources preferentially alter milk concentrations of HMO, including fucosylated species. We find significant associations between the concentration of HMO-bound fucose and the abundance of fucosidase (a bacterial gene that digests fucose moieties) harbored by milk bacteria. These studies reveal a successive mechanism by which the maternal diet during lactation alters milk HMO composition, which in turn shapes the functional milk microbiome prior to infant ingestion.

Although certain individuals with HIV infection can stop antiretroviral therapy (ART) without evidence of viral load rebound, the mechanisms under-pinning ‘post-treatment control’ remain unclear. Twelve individuals who had received 12 months of ART from primary HIV infection and then undertook a TI were sampled at the time of stopping therapy. Using RNA-Seq we explored gene expression in CD4 T cells to look for evidence of a mechanism that might underpin virological rebound and lead to discovery of an associated biomarker. Using independent analysis tools, genes associated with the type I interferon response were strongly associated with a delayed time to viral rebound following TI. These are the first data we are aware of that link transcriptomic signatures associated with innate immunity with control following TI. While these results need to be confirmed in larger trials, they could help define a strategy for new therapies and identify new biomarkers for remission.

The North Atlantic right whale (Eubalaena glacialis) remains one of the most endangered large whales in the world. Over the past two decades, there has been increasing interest in addressing the problems hampering the recovery of North Atlantic right whales by using innovative research techniques, new technologies, analyses of existing databases, and enhanced conservation and education strategies. This increased interest demanded better coordination and collaboration among all stakeholders to ensure that there was improved access to data, research efforts were not duplicative, and that findings were shared with all interested parties. The North Atlantic Right Whale Consortium, initially formed in 1986 by five research institutions to share data among themselves, was expanded in 1997 to address these greater needs. Currently, the Consortium membership is comprised of representatives from more than 100 entities including: research, academic, and conservation organizations; shipping and fishing industries; whale watching companies; technical experts; United States (U.S.) and Canadian Government agencies; and state authorities. North Atlantic Right Whale Consortium members agreed in 2004 that an annual “report card” on the status of right whales would be useful. This report card includes updates on the status of the cataloged population, mortalities and injury events, and a summary of management and research efforts that have occurred over the previous 12 months. The Board’s goal is to make public a summary of current research and management activities, as well as provide detailed recommendations for future activities. The Board views this report as a valuable asset in assessing the effects of research and management over time.

The nonlinear nature of dual active bridge (DAB) converters arises from switching between linear dynamics at controlled intervals. In this paper, we model DAB as a hybrid dynamical system consisting of a finite number of modes with linear dynamics and switching surfaces specifying the transition between the modes. In the conventional phase shift modulation (PSM) strategy, the phase shift φ governs the mode transitions and can be used to control DAB output voltage and power. We incorporate φ as a system state and calculate a linearization about a nominal trajectory with so-called saltation matrices that capture the first-order effects of perturbing the states between mode transitions. We demonstrate this linearization provides an accurate discrete-time small-signal model of the DAB.

A major issue in identification of protective T cell responses against SARS-CoV-2 lies in distinguishing people infected with SARS-CoV-2 from those with cross-reactive immunity generated by exposure to other coronaviruses. We characterised SARS-CoV-2 T cell immune responses in 168 PCR-confirmed SARS-CoV-2 infected subjects and 118 seronegative subjects without known SARS-CoV-2 exposure using a range of T cell assays that differentially capture immune cell function. Strong ex vivo ELISpot and proliferation responses to multiple antigens (including M, NP and ORF3) were found in those who had been infected by SARS-CoV-2 but were rare in pre-pandemic and unexposed seronegative subjects. However, seronegative doctors with high occupational exposure and recent COVID-19 compatible illness showed patterns of T cell responses characteristic of infection, indicating that these readouts are highly sensitive. By contrast, over 90% of convalescent or unexposed people showed proliferation and cellular lactate responses to spike subunits S1/S2, indicating pre-existing cross-reactive T cell populations. The detection of T cell responses to SARS-CoV-2 is therefore critically dependent on the choice of assay and antigen. Memory responses to specific non-spike proteins provides a method to distinguish recent infection from pre-existing immunity in exposed populations.

BackgroundIt is not known whether SARS-CoV-2 can be transmitted from mother to infant during breastfeeding, and if so whether the benefits of breastfeeding outweigh this risk. This study was designed to evaluate 1) if SARS-CoV-2 RNA can be detected in milk and on the breast of infected women, 2) concentrations of milk-borne anti-SARS-CoV-2 antibodies, and 3) the capacity of milk to neutralize SARS-CoV-2 infectivity.MethodsWe collected 37 milk samples and 70 breast swabs (before and after breast washing) from 18 women recently diagnosed with COVID-19. Samples were analyzed for SARS-CoV-2 RNA using RT-qPCR. Milk was also analyzed for IgA and IgG specific for the nucleocapsid protein, receptor binding domain (RBD), S2 subunit of the spike protein of SARS-CoV-2, as well as 2 seasonal coronaviruses using ELISA; and for its ability to neutralize SARS-CoV-2.ResultsWe did not detect SARS-CoV-2 RNA in any milk sample. In contrast, SARS-CoV-2 RNA was detected on several breast swabs, although only one was considered conclusive. All milk contained SARS-CoV-2-specific IgA and IgG, and levels of anti-RBD IgA correlated with SARS-CoV-2 neutralization. Strong correlations between levels of IgA and IgG to SARS-CoV-2 and seasonal coronaviruses were noted.ConclusionsOur data do not support maternal-to-child transmission of SARS-CoV-2 via milk; however, risk of transmission via breast skin should be further evaluated. Importantly, milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.

The cover image is based on the Review Article SARS‐CoV‐2 and human milk: What is the evidence? by Kimberly A. Lackey et al., https://doi.org/10.1111/mcn.13032. [Image: see text]

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed—and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

The Boiling Water Reactor (BWR) Mark I (Mk I) Containment Program was implemented by the Owner’s Group circa 1970 to mitigate the effects of small, intermediate and design bases, Loss of Coolant Accident (LOCA), pipe break accidents on the torus, supports, internal structures and attached piping [1 & 2]. One of the significant mitigation attributes implemented during the Mk I Program is Normal Operation (NO) with a drywell-to-wetwell Differential Pressure (dP) maintained by the plant Nitrogen Make-up System used to inert the Primary Containment (PC) [3]. The differential pressure served to reduce the downcomer water leg in the vent system resulting in significantly reduced vent system thrust and pool swell loads. The vent system is designed to transport the mixture of drywell atmosphere, steam, and water forced from the drywell by the increasing pressure post-accident, quenching it in the pool of water maintained in the suppression chamber (torus). Based on plant experience, to sustain PC dP requires frequent venting of the Torus or nitrogen make-up to the drywell requiring Standby Gas System operation and cycling of PC vent and purge valves which places additional burden on the charcoal filters. The venting also places burden on Control Room Operators to perform the required actions and maintain Technical Specification (TS) limits. Elimination of the dP benefits plant operation by minimizing cycling of PC Isolation Valves, reduction of burden on Control Room operators due to the wider pressure control envelop, reduction in Standby Gas System cycles extending charcoal filter life and a reduction of the nitrogen make-up [4]. Overall, the Utility estimates that elimination of the dP will provide an estimated cost savings of $0.5 M per year.

We screened three separate cohorts of healthcare workers for SARS-CoV-2 via nasopharyngeal swab PCR. A seroprevalence analysis using multiple assays was performed in a subgroup. The asymptomatic health care worker cohorts had a combined swap positivity rate of 29/5776 (0.50%, 95%CI 0.32-0.75) compared to the symptomatic cohort rate of 54/1597 (3.4%) (ratio of symptomatic to asymptomatic 6.8:1). Sequencing demonstrated several variants. The seroprevalence (n=996) was 1.4-3.4% depending on assay. Protein microarray analysis showed differing SARS-CoV-2 protein reactivities and helped define likely true positives vs. suspected false positives. Routine screening of asymptomatic health care workers helps identify a significant proportion of infections.

The novel coronavirus SARS-CoV-2 has emerged as one of the most compelling and concerning public health challenges of our time. To address the myriad issues generated by this pandemic, an interdisciplinary breadth of research, clinical, and public health communities has rapidly engaged to collectively find answers and solutions. One area of active inquiry is understanding the mode(s) of SARS-CoV-2 transmission. While respiratory droplets are a known mechanism of transmission, other mechanisms are likely. Of particular importance to global health is the possibility of vertical transmission from infected mothers to infants through breastfeeding or consumption of human milk. However, there is limited published literature related to vertical transmission of any human coronaviruses (including SARS-CoV-2) via human milk and/or breastfeeding. Results of the literature search reported here (finalized on April 17, 2020) revealed a single study providing some evidence of vertical transmission of human coronavirus 229E; a single study evaluating presence of SARS-CoV in human milk (it was negative); and no published data on MERS-CoV and human milk. We identified 12 studies reporting human milk tested for SARS-CoV-2; one study detected the virus in one milk sample, and another study detected SARS-CoV-2 specific IgG in milk. Importantly, none of the studies on coronaviruses and human milk report validation of their collection and analytical methods for use in human milk. These reports are evaluated here, and their implications related to the possibility of vertical transmission of coronaviruses (in particular, SARS-CoV-2) during breastfeeding are discussed.

OBJECTIVES: Profiles of human milk oligosaccharides (HMO) and milk/infant fecal microbiota vary globally. However, associations between and among HMO, other milk-borne factors (e.g., lactose, protein), and milk/infant fecal microbiomes have not been well-investigated. Here we tested the hypothesis that variations in milk lactose, protein, and HMO concentrations are associated with variations in the structure of milk and infant fecal microbial communities. METHODS: Milk/infant fecal samples from 357 maternal-infant dyads collected as part of the INSPIRE study from 11 geographically/culturally diverse sites located in eight countries (Ethiopia, The Gambia, Ghana, Kenya, Peru, Spain, Sweden, and USA) were analyzed. DNA was extracted and bacterial 16S rRNA V1V3 hypervariable region amplified/sequenced for microbiome analysis. HMO, lactose, and protein profiles were generated from HPLC and spectrophotometric assays. RESULTS: Milk and infant feces share many of the same abundant bacterial genera, while also containing unique bacterial communities. Community states type (CST) analyses indicate both sample types group into a relatively small number of discrete communities characterized by enrichment of specific taxa (e.g., Streptococcus, Bifidobacterium). Concentrations of milk lactose and protein varied by population/CST. Additionally, variation in the microbial community structure of milk and infant feces was associated with concentrations of total/individual HMO, lactose, and protein. CONCLUSIONS: Similar to HMO concentrations, milk lactose and protein vary globally. Variations in milk and infant fecal microbial communities are associated with those of milk lactose, protein, and HMO concentrations. Given these results, as well as prior data on the influence of other environmental variables (e.g., pumped vs. direct breastfeeding), additional longitudinal studies are needed to better understand this complex network of maternal-infant-microbe interactions with respect to environmental factors and how differences impact postnatal maternal-infant health. FUNDING SOURCES: National Science Foundation (award 1,344,288), National Institutes of Health (R01 HD092297), and USDA.

Background:The London patient (participant 36 in the IciStem cohort) underwent allogeneic stem-cell transplantation with cells that did not express CCR5 (CCR5Δ32/Δ32); remission was reported at 18 months after analytical treatment interruption (ATI). Here, we present longer term data for this patient (up to 30 months after ATI), including sampling from diverse HIV-1 reservoir sites. Methods:We used ultrasensitive viral load assays of plasma, semen, and cerebrospinal fluid (CSF) samples to detect HIV-1 RNA. In gut biopsy samples and lymph-node tissue, cell-copy number and total HIV-1 DNA levels were quantified in multiple replicates, using droplet digital PCR (ddPCR) and quantitative real-time PCR. We also analysed the presence of intact proviral DNA using multiplex ddPCR targeting the packaging signal (ψ) and envelope (env). We did intracellular cytokine staining to measure HIV-1-specific T-cell responses. We used low-sensitive and low-avidity antibody assays to measure the humoral response to HIV-1. We predicted the probability of rebound using a mathematical model and inference approach. Findings:HIV-1 viral load in plasma remained undetectable in the London patient up to 30 months (last tested on March 4, 2020), using an assay with a detection limit of 1 copy per mL. The patient's CD4 count was 430 cells per μL (23·5% of total T cells) at 28 months. A very low-level positive signal for HIV-1 DNA was recorded in peripheral CD4 memory cells at 28 months. The viral load in semen was undetectable in both plasma (lower limit of detection [LLD] 6cells) at 21 months. CSF was within normal parameters at 25 months, with HIV-1 RNA below the detection limit (LLD 1 copy per mL). HIV-1 DNA by ddPCR was negative in rectum, caecum, and sigmoid colon and terminal ileum tissue samples at 22 months. Lymph-node tissue from axilla was positive for the long-terminal repeat (33 copies per 106cells) andenv(26·1 copies per 106cells), negative for ψ and integrase, and negative by the intact proviral DNA assay, at 27 months. HIV-1-specific CD4 and CD8 T-cell responses have remained absent at 27 months. Low-avidity Env antibodies have continued to decline. Mathematical modelling suggests that the probability of remission for life (cure) is 98% in the context of 80% donor chimerism in total HIV target cells and greater than 99% probability of remission for life with 90% donor chimerism. Interpretation:The London patient has been in HIV-1 remission for 30 months with no detectable replication-competent virus in blood, CSF, intestinal tissue, or lymphoid tissue. Donor chimerism has been maintained at 99% in peripheral T cells. We propose that these findings represent HIV-1 cure.

Endodontic rotary files are cutting instruments used to perform root canal procedures within a tooth interior. Focusing on quantitative fractographic analysis increases necessary, clinical performance understanding of file separation failure. This research employed controlled, dynamic testing to failure of commercial rotary files, analyzing the fractographic, forensic characteristics in relation to Weibull reliability determination, considering: (1) design analysis; (2) stress concentrations; (3) times to failure; (4) number of cycles to failure (NCF). Ex vivo testing included three file designs, each having constant tip size (0.035 mm), taper (0.06 mm/mm), and length (25 mm). Files were individually tested using an electric, torque-controlled handpiece, rotating within a standardized, simulated canal until fracture separation occurred. Fractographic analysis, including critical measurements, was conducted using the scanning electron microscope (SEM) (PhenomProX, PhenomWorld, NL). Weibull statistical analysis established reliability factors per design group. Fractographic analysis identified separation fractures, processing inclusions, flexural-fatigue striations, and stress concentrations at flute pitches. Calculated NCF median values (1277—EE; 899—VB; 713—PI) demonstrated significant statistical differences among groups (p

In 2015, the Office of Diversion and Reentry Division (ODR), an internal department of the Los Angeles County Department of Health Services, was created to redirect individuals with serious mental illness from the criminal justice system. Part of ODR's mission is to identify individuals currently incarcerated in a Los Angeles County jail who are experiencing a serious mental health disorder and, to the extent practical, provide them with appropriate community-based care with the goals of reducing recidivism and improving health outcomes. Such redirection from the traditional criminal justice process is often characterized as diversion. To better build and scale efforts to support this work, in 2018, the Los Angeles County's Board of Supervisors asked for a study of the existing county jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors. Researchers found that an estimated 61 percent of the jail mental health population were likely appropriate candidates for diversion; 7 percent were potentially appropriate; and 32 percent were likely not appropriate candidates for diversion. These findings will help the county determine how it would need to scale community-based treatment programs to accommodate these individuals. The authors also provide recommendations for future programming and research. This study will be of interest to state and county governments as well as other organizations serving criminal justice-involved populations with serious mental illness.

Summarizes findings of a report in which researchers estimated the percentage of individuals with mental health disorders in Los Angeles County jails who could be diverted from traditional criminal justice processing to community-based care.

Objective The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

Introduction We present an unusual case of sequential right ventricular outflow tract obstruction (RVOTO) caused by pulmonary and subpulmonary stenosis, with formation of aortopulmonary collaterals. Case presentation We report a case of a 47 year old Senegalese man who presented with a three year history of shortness of breath on exertion which worsened over the past week. Cardiovascular examination revealed a parasternal heave, a systolic murmur loudest in the pulmonary area and no evidence of fluid overload. A transthoracic echocardiogram revealed leftward septal deviation during systole due to right ventricular pressure overload, severe right ventricular hypertrophy (RV free wall end-diastolic thickness of 8mm) and normal systolic function (FAC 47%), a dilated right atrium and moderate tricuspid regurgitation with estimated maximum pressures of 112mmHg. On continuous-wave doppler of the right ventricular outflow tract (RVOT), there was a late peaking systolic flow with maximum velocity of 3.8m/s. A cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) was performed which showed sequential stenoses of the RVOT; one at subvalvular level by an infundibular muscular ridge with an area of 0.7 cm2 in mid-systole and one at the level of a dome-shaped pulmonary valve with planimetered valve area of 0.5cm2, severe RV hypertrophy and normal RV ejection fraction. Aortopulmonary collaterals from proximal thoracic descending aorta were seen. The main pulmonary artery was shown to be dilated with no evidence of pulmonary artery branch stenosis. See image: In-plane phase contrast velocity flow mapping of the RVOT using a VENC of 80cm/s, showing aliasing at the level of the pulmonary valve (red arrow) and at the level of the infundibulum (white arrow). Conclusion Congenital pulmonary stenosis (PS) occurs in 8% of congenital heart defects. 80% of pulmonary valve stenosis is typically dome-shaped with commissural fusion whilst the remainder is of the dysplastic type. Congenital PS can be associated with RVOTO at the infundibular level secondary to reactive muscular hypertrophy. In our case, there is a discrete, circumferential muscular ridge at the level of the infundibulum resulting in sequential outflow tract obstruction. PS with intact ventricular septum occurs in conjunction with varying degrees of right ventricular hypertrophy and elevated right ventricular systolic pressures. A dilated pulmonary artery is common in dome-shaped subtype of PS. Survival into adulthood of severe PS is primarily dependent on the adequacy of pulmonary blood flow from systemic-to-pulmonary collateral arteries, which serve as an additive, or the only source of blood supply to the pulmonary arterial vasculature. These collaterals are usually seen in association with cyanotic congenital heart disease such as pulmonary atresia and tetralogy of fallot. Abstract P1691 Figure. Sequential RVOTO

The authors examine liability and compensation issues relating to the future distribution and administration of a COVID-19 vaccine. They provide a brief history of how liability and compensation concerns have been addressed in previous public health threats, discuss how the global pandemic might complicate matters of legal immunity, and suggest consideration of appropriate compensation for adverse effects to encourage vaccinations.

The microbiome is thought to play a role in the maintenance of a healthy pregnancy and thus may either contribute to or protect from preterm birth. Study of the human microbiome has been aided by metagenomic sequencing approaches, providing greater insight into the commensal bacteria that coexist in and on our bodies. The vaginal microbiome has been the most widely studied, though there have been recent efforts to explore the gut, cervical-vaginal, placental and oral microbiomes in the further search of etiologies of preterm birth. To date, a specific microbiome community or microorganism has yet to be reliably associated with preterm birth. This is partly due to the fact that the ‘normal’ constituents' microbiome can vary widely between healthy individuals. Before our knowledge of the microbiome can be utilized and applied in clinical practice, a greater understanding of the ‘healthy’ microbiome must be achieved. In particular, we must first appreciate how our microbes influence our biology to promote a healthy pregnancy or alternately render preterm birth.

This paper outlines the experience of an integrated psychological therapies service in applying for accreditation from the Accreditation Programme for Psychological Therapies Services (APPTS). Reflections on the challenges and benefits of the APPTS process are considered.

Ocean quahogs [ Arctica islandica (Linnaeus, 1769)] are the longest-lived, non-colonial animal known today, with a maximum life span exceeding 500 years. Ocean quahogs are a commercially important bivalve, inhabiting the continental shelf of the North Atlantic basin. We examined growth rates of ocean quahogs that were fully recruited to the commercial fishery (>80-mm shell length) from four sites covering the range of the stock along the east coast of the U.S. through analysis of annual growth lines in the hinge plate. Both geographic and temporal differences (on a scale of decadal or longer) in growth rates exist throughout the range of the stock. The age at which animals reached 60, 80, and 90 mm decreased significantly, and average growth rates to 60, 80, and 90 mm increased significantly with birth year at a New Jersey and a Long Island site, both located in the southwestern portion of the stock, since the late 1700s/early 1800s, likely in response to increasing bottom water temperatures. That is, growth rates vary temporally with birth date at the southwestern sites, with younger animals growing at a much faster rate in recent decades than those born many decades previously, whereas at the northern sites off southern New England and on Georges Bank, changes in growth rates through time are limited to older adult animals or absent altogether. Thus, at the southern portion of the range, variation in growth rate over time exists in all phases of ocean quahog life, whereas on Georges Bank, little evidence exists for any differential in growth rate over the last ~200 years. The fact that ocean quahogs record the rise in ocean temperatures after the Little Ice Age in the Mid-Atlantic Bight southeast of southern New England, yet demonstrate little evidence of such a rise in the southern New England and Georges Bank region, would suggest a differential response of ocean circulation and its control of bottom water temperature between the northern and southern portions of the Mid-Atlantic Bight over the last 200+ years.

This brief paper explores the feasibility and therapeutic impact of a community based short-term compassion focused therapy (CFT) group within an adult mental health community treatment team.

We present the Canadian Distributed Infrastructure for Genomics (CanDIG) platform, which enables federated querying and analysis of human genomics and linked biomedical data. CanDIG leverages the standards and frameworks of the Global Alliance for Genomics and Health (GA4GH) and currently hosts data for five pan-Canadian projects. We describe CanDIG’s key design decisions and features as a guide for other federated data systems.