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BACKGROUND: Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS: This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS: Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS: Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Retinal ganglion cell (RGC) death in glaucoma and other optic neuropathies results in irreversible vision loss due to the mammalian central nervous systems limited regenerative capacity. RGC repopulation is a promising therapeutic approach to reverse vision loss from optic neuropathies if the newly introduced neurons can reestablish functional retinal and thalamic circuits. In theory, RGCs might be repopulated through the transplantation of stem cell-derived neurons or via the induction of endogenous transdifferentiation. The RGC Repopulation, Stem Cell Transplantation, and Optic Nerve Regeneration (RReSTORe) Consortium was established to address the challenges associated with the therapeutic repair of the visual pathway in optic neuropathy. In 2022, the RReSTORe Consortium initiated ongoing international collaborative discussions to advance the RGC repopulation field and has identified five critical areas of focus: (1) RGC development and differentiation, (2) Transplantation methods and models, (3) RGC survival, maturation, and host interactions, (4) Inner retinal wiring, and (5) Eye-to-brain connectivity. Here, we discuss the most pertinent questions and challenges that exist on the path to clinical translation and suggest experimental directions to propel this work going forward. Using these five subtopic discussion groups (SDGs) as a framework, we suggest multidisciplinary approaches to restore the diseased visual pathway by leveraging groundbreaking insights from developmental neuroscience, stem cell biology, molecular biology, optical imaging, animal models of optic neuropathy, immunology & immunotolerance, neuropathology & neuroprotection, materials science & biomedical engineering, and regenerative neuroscience. While significant hurdles remain, the RReSTORe Consortiums efforts provide a comprehensive roadmap for advancing the RGC repopulation field and hold potential for transformative progress in restoring vision in patients suffering from optic neuropathies.

Long-lived T-dependent B cell responses fail to develop during persistent infection of mice with Borrelia burgdorferi, the causative agent of Lyme disease, raising questions about the induction and/or functionality of anti-B. burgdorferi adaptive immune responses. Yet, a lack of reagents has limited investigations into B. burgdorferi-specific T and B cells. We attempted two approaches to track B. burgdorferi-induced CD4 T cells. First, a B. burgdorferi mutant was generated with an influenza hemagglutinin (HA) peptide, HA111-119, inserted into the B. burgdorferi arthritis-related protein (Arp) locus. Although this B. burgdorferi arp::HA strain remained infectious, peptide-specific TCR transgenic CD4 T cells in vitro, or adoptively transferred into B. burgdorferi arp::HA-infected BALB/c mice, did not clonally expand above those of recipients infected with the parental B. burgdorferi strain or a B. burgdorferi mutant containing an irrelevant peptide. Some expansion, however, occurred in B. burgdorferi arp::HA-infected BALB/c SCID mice. Second, a (to our knowledge) newly identified I-Ab-restricted CD4 T cell epitope, Arp152-166, was used to generate Arp MHC class II tetramers. Flow cytometry showed small numbers of Arp-specific CD4 T cells emerging in mice infected with B. burgdorferi but not with Arp-deficient Borrelia afzelii. Although up to 30% of Arp-specific CD4 T cells were ICOS+PD-1+CXCR5+BCL6+ T follicular helper cells, their numbers declined after day 12, before germinal centers (GCs) are prominent. Although some Arp-specific B cells, identified using fluorochrome-labeled rArp proteins, had the phenotype of GC B cells, their frequencies did not correlate with anti-Arp serum IgG. The data suggest a failure not in the induction, but in the maintenance of GC T follicular helper and/or B cells to B. burgdorferi.

OBJECTIVE: The objective of this qualitative study is to gauge physician sentiment about an emergency department (ED) clinical decision support (CDS) system implemented in multiple adult EDs within a university hospital system. This CDS system focuses on predicting patients likelihood of ED recidivism and/or adverse opioid-related events. METHODS: The study was conducted among adult emergency physicians working in three EDs of a single academic health system in Rhode Island. Qualitative, semistructured interviews were conducted with ED physicians. Interviews assessed physicians prior experience with predictive analytics, thoughts on the alerts placement, design, and content, the alerts overall impact, and potential areas for improvement. Responses were aggregated and common themes identified. RESULTS: Twenty-three interviews were conducted (11 preimplementation and 12 postimplementation). Themes were identified regarding each physician familiarity with predictive analytics, alert rollout, alert appearance and content, and on alert sentiments. Most physicians viewed these alerts as a neutral or positive EHR addition, with responses ranging from neutral to positive. The alert placement was noted to be largely intuitive and nonintrusive. The design of the alert was generally viewed positively. The alerts content was believed to be accurate, although the decision to respond to the alerts call-to-action was physician dependent. Those who tended to ignore the alert did so for a few reasons, including already knowing the information the alert contains, the alert offering information that is not relevant to this particular patient, and the alert not containing enough information to be useful. CONCLUSION: Ultimately, this alert appears to have a marginally positive effect on ED physician workflow. At its most beneficial, the alert reminded physicians to deeply consider the care provided to high-risk populations and to potentially adjust their care and referrals. At its least beneficial, the alert did not affect physician decision-making but was not intrusive to the point of negatively impacting workflow.

Through teaching and research, the authors have seen the magnificent ways that Black people use language to connect people, families, and communities across the Black diaspora. When students come to school using African American English, they know that many of their relatives, friends, and neighbors speak like them. They may also know that many of their educators do not use this variety of English. The message that African American students may internalize is that educators expect them to learn a new way of communicating--and that it may be at odds with their home language and culture. Parents and caregivers may need to advocate for their children by connecting with key educators and community members--including guidance counselors, learning specialists, administrators, teachers, and doctors. Through advocacy, students' needs can be met by working together to ensure that support and resources are fully available for all Black students. This article focuses on four key educational situations where advocacy may be particularly important: (1) building reading and literacy skills; (2) accessing speech, language, and hearing services; (3) developing individualized education plans; and (4) identifying support for gifted and talented students.

Background: South Africa has migrated the responsibility for early childhood development (ECD) centres from the Department of Social Services to the Department of Basic Education. This functional shift has ushered in consultations and discussions on how best to implement ECD, including opportunities the change may bring. Aim: By anchoring the understanding of ECD services in nurturing care, this study aimed to elucidate the provision of appropriate, inclusive services in early childhood development, including early childhood intervention, for children with disabilities in South Africa against the backdrop of the migration of services from one government ministry to another. Methods: This is an analytical article based on South African literature on ECD services, including interventions, with particular attention to children with disabilities, basing our understanding of these services in nurturing care. Results: We elucidate how the ideals of the Nurturing Care Framework can be achieved in the context of children with disabilities in South Africa using five themes: the need to localise services, developing tools and strategies for screening and early intervention, enhancing the efficacy of caregivers, supporting and training staff and collaborations. Conclusion: It is necessary to empower caregivers and professionals to address early childhood intervention and ECD needs of children with disabilities. Early childhood development centres are an important context for nurturing care, providing opportunities to promote and sustain health amongst a large number of children. Considering the function shift of ECD services in South Africa, these centres are well positioned to further nurturing care to children with disabilities through the provision of supportive environments that promote health and well-being.

BACKGROUND AND AIMS: Low outcome prevalence, often observed with opioid-related outcomes, poses an underappreciated challenge to accurate predictive modeling. Outcome class imbalance, where non-events (i.e. negative class observations) outnumber events (i.e. positive class observations) by a moderate to extreme degree, can distort measures of predictive accuracy in misleading ways, and make the overall predictive accuracy and the discriminatory ability of a predictive model appear spuriously high. We conducted a simulation study to measure the impact of outcome class imbalance on predictive performance of a simple SuperLearner ensemble model and suggest strategies for reducing that impact. DESIGN, SETTING, PARTICIPANTS: Using a Monte Carlo design with 250 repetitions, we trained and evaluated these models on four simulated data sets with 100 000 observations each: one with perfect balance between events and non-events, and three where non-events outnumbered events by an approximate factor of 10:1, 100:1, and 1000:1, respectively. MEASUREMENTS: We evaluated the performance of these models using a comprehensive suite of measures, including measures that are more appropriate for imbalanced data. FINDINGS: Increasing imbalance tended to spuriously improve overall accuracy (using a high threshold to classify events vs non-events, overall accuracy improved from 0.45 with perfect balance to 0.99 with the most severe outcome class imbalance), but diminished predictive performance was evident using other metrics (corresponding positive predictive value decreased from 0.99 to 0.14). CONCLUSION: Increasing reliance on algorithmic risk scores in consequential decision-making processes raises critical fairness and ethical concerns. This paper provides broad guidance for analytic strategies that clinical investigators can use to remedy the impacts of outcome class imbalance on risk prediction tools.

BACKGROUND: Little is known about specific obsessive-compulsive clinical features associated with lifetime history of suicide attempt in individuals with obsessive-compulsive disorder (OCD) and major depression. METHODS: The study sample included 515 adults with OCD and a history of major depression. In exploratory analyses, we compared the distributions of demographic characteristics and clinical features in those with and without a history of attempted suicide and used logistic regression to evaluate the association between specific obsessive-compulsive clinical features and lifetime suicide attempt. RESULTS: Sixty-four (12%) of the participants reported a lifetime history of suicide attempt. Those who had attempted suicide were more likely to report having experienced violent or horrific images (52% vs. 30%; p

Reading fluency (RF) involves the automaticity of many distinct reading skills (e.g., pacing, word recognition, phonological awareness) and allows cognitive resources to be allocated to higher-order reading skills (e.g., comprehension, synthesis). Early identification of students at-risk for RF deficits is critical, but many screeners require a level of basic proficiency with foundational reading skills. This review examines the longitudinal relationships between neurocognitive precursors of RF with special consideration of cognitive processing demands of measurement tasks. Eighteen articles yielded 80 unique correlations between 6 neurocognitive constructs (phonological processing, rapid automatic naming, working memory, nonverbal reasoning, orthographic processing, and visual-spatial processing) measured through 35 unique subtests/tasks and 2 primary RF outcomes (word RF and text RF) measured through 11 unique subtests/tasks. Phonological processing was the most frequently assessed neurocognitive predictor (41.3% of total correlations), followed by rapid automatic naming (32.5%). Nearly all correlation coefficients were significant (83.75%); 28.75% of correlations suggested a strong predictive relationship between a neurocognitive predictor and an RF outcome. The strength of correlation largely varied as a function of the task demands as evidenced through the supplemental process analyses, suggesting future consideration should be given to the specificity of task selection to improve ecologically valid conclusions. Evidence from this review supports the need to consider specific neurocognitive functions, specifically rapid automatic naming and orthographic processing, as critical components of dynamic and comprehensive assessments of reading to help identify students at-risk for future RF challenges.

Equity and advocacy are essential in deconstructing and challenging racism, but how do educators apply these concepts in preparation programs to promote sustainable change? This paper explores a qualitative study on educators' perceptions of racism in P-12 schools to examine how educator preparation can navigate complex terrain to better prepare candidates to employ equitable, and socially just practices informed by critical race theory and foster racial literacy. The researchers' findings support the works of others in the field who assert that educator preparation programs must explicitly address race-related issues to prepare both instructional and teacher leaders to confront critical concerns that impact students and communities.

OBJECTIVE: To evaluate the impact of a statewide treatment standards policy for post-overdose emergency department (ED) care on services provided and subsequent treatment engagement. METHODS: This pre-/post-study used electronic health record data and surveillance data from Rhode Island. Outcomes were compared for patients attending EDs for opioid overdose before (03/1/2015-02/28/2017) and after (04/01/2017-03/31/2021) policy release. RESULTS: Overall, 2,134 patients attended 2,891 ED visits for opioid overdose. Compared to pre-policy, visits post-policy more often included initiation of buprenorphine in or from the ED (

ObjectiveThe objective of this study was to estimate the association between receipt of specific post-overdose care services in the emergency department (ED) and subsequent engagement in treatment for opioid use disorder (OUD) after discharge.MethodsThis was a retrospective cohort study of Rhode Island residents treated at 1 of 4 EDs for opioid overdose who were not engaged in OUD treatment and were discharged home (May 2016-April 2021). Electronic health record data were used to identify ED services received, and state administrative data were used to define subsequent engagement in OUD treatment within 30 days. Multivariable conditional logistic regression was used to estimate the association between ED services received and subsequent treatment engagement.ResultsOverall, 1008 people not engaged in OUD treatment were treated at study EDs for opioid overdose and discharged home, of whom 146 (14%) subsequently engaged in OUD treatment within 30 days. Most patients were aged 25 to 44 years (59%) and non-Hispanic White (69%). Receipt of behavioral counseling in the ED (adjusted odds ratio [aOR] = 1.79, 95% confidence interval [CI] = 1.18-2.71) and initiation of buprenorphine treatment in/from the ED (aOR = 5.86, 95% CI = 2.70-12.71) were associated with treatment engagement. Receipt of a take-home naloxone kit or naloxone prescription and referral to treatment at discharge were not associated with treatment engagement. Overall, 49% of patients received behavioral counseling in the ED, and 3% initiated buprenorphine in/from the ED.ConclusionStrategies for increasing provision of behavioral counseling and initiation of buprenorphine in the ED may be useful for improving subsequent engagement in OUD treatment after discharge.

Authors explore recent education policies that ban the teaching of critical race theory, restrict teaching race-related topics, prohibit conversations about divisive concepts, and problematize their impact in further silencing (and potentially erasing) complex issues about race and racism and other forms of oppression in historical and sociocultural contexts. This article highlights legislative efforts and examines findings and implications from a study designed to explore perceptions of educators related to the anti-critical race theory bills.

Youth who report prosocial relationships with natural mentors show increased social and academic success and life satisfaction. However, little research investigates how mentors impact aspects of youth identity such as athleticism or religiosity. The present study applies a Bayesian Additive Regression Trees (BART) analysis model to data from a national longitudinal study (N = 15,701) to predict specific outcomes in educational, athletic, and religious domains. This analytic approach is uniquely well-suited for accurately drawing conclusions within highly collinear, high dimensional datasets. Analyses included demographic variables and childhood base rates of academic success, fitness, and religious beliefs as covariates. Findings indicate that the presence of an academic mentor during adolescence longitudinally predicts educational attainment, while athletic or religious mentors did not have significant impacts in terms of increasing athleticism or religiosity. These results suggest that academic mentors may have more longitudinal impacts on student success than other types of mentors.

Teacher-student interactions are at the core of formal learning experiences. Since these interactions can be affected by ways in which the teacher or student perceive themselves to be similar, we investigated the effects of racial/ethnic and gender similarities on the type and frequency of disciplinary incidents adolescents were involved in at one middle and one high school. Results indicated that the total number of times a student was disciplined in a given year was higher for students whose race or gender was different from that of their teacher.

Objective: Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency physician knowledge, confidence, and self-efficacy regarding buprenorphine prescribing and working with patients who use drugs after implementation of an ED buprenorphine quality improvement (QI) initiative.Methods: An anonymous, online survey was administered to emergency physicians staffing four EDs in New England in 2019 and 2020 before and after an ED QI initiative. Survey questions included novel and previously validated questions to assess confidence, knowledge, self-efficacy, and attitudes about buprenorphine and working with patients who use drugs. Confidence, self-efficacy, and attitude responses were assessed on a Likert scale. Participants received a gift card for survey completion. We analyzed pre- and post- survey responses descriptively and compared them using t-tests. Using logistic regression we evaluated the factors associated with buprenorphine prescribing.Results: Of 95 emergency physicians, 56 (58.9% response rate) completed the pre-intervention survey and 60 (63.2%) completed the post-survey. There was an increase in the number of X-waivered adult emergency physicians and ED buprenorphine prescribing after program implementation. Physician confidence increased from a mean of 3.4 (SD 0.8) to 3.9 (SD 0.7; scale 1–5, p < 0.01). Knowledge about buprenorphine increased from a mean score of 1.4 (SD 0.7) to 1.7 (SD 0.5, p < 0.01). Physician attitudes and self-efficacy did not change. Post-initiative, increased confidence was associated with higher odds of buprenorphine prescribing (odds ratio 4.4; 95% confidence interval 1.07–18.4).Conclusion: After an ED QI initiative, buprenorphine prescribing in the ED increased, as did both physician confidence in working with patients who use drugs and their knowledge of buprenorphine. Increased confidence was associated with higher odds of buprenorphine prescribing and should be a focus of future, buprenorphine implementation strategies in the ED.

Introduction: Black and Hispanic patients are frequently assigned lower acuity triage scores than White patients. This can lead to longer wait times, less aggressive care, and worse outcomes. In this study we aimed to determine whether these effects are more pronounced for patients with subjective complaints.Methods: We performed a retrospective analysis for all adult visits between 2016-2019 at an urban academic emergency department (ED) with acuity-based pods. We determined rates of initial high-acuity triage both across all patients and among the subset located in the high-acuity pod at time of disposition (either through initial assignment or subsequent up-triage). Analysis was performed for common chief complaints categorized as subjective (chest pain, dyspnea, any pain); observed (altered mental status); numeric (fever, hypotension); or protocolized (stroke, ST-elevation myocardial infarction). We constructed logistic regression models to control for age, race, gender, method of arrival, and final disposition.Results: We analyzed 297,355 adult ED visits. Black and Hispanic patients were less likely to be triaged to high-acuity beds (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.73-0.79 for Black, and aOR 0.87, 95% CI 0.84-0.90 for Hispanic patients). This effect was more pronounced for those with subjective chief complaints, including chest pain (aOR 0.76, 95% CI 0.73-0.79 for Black and 0.88, 95% CI 0.78-0.99 for Hispanic patients), dyspnea (aOR 0.79, 95% CI 0.68-0.92 and 0.8, 95% CI 0.72-0.99), and any pain (aOR 0.83, 95% CI 0.75-0.92 and 0.89, 95% CI 0.82-0.97, respectively). Among patients in the high-acuity pod at time of disposition, Black and Hispanic patients were disproportionately triaged to lower acuity pods on arrival (aOR 1.47, 95% CI 1.33-1.63 for Black and aOR 1.27, 95% CI 1.15-1.40 for Hispanic adults), with significant differences observed only for subjective chief complaints. No differences were observed for observed, objective, or protocolized complaints in either analysis.Conclusion: Black and Hispanic adults, including those who ultimately required high-acuity resources, were disproportionately triaged to lower acuity pods. This effect was more pronounced for patients with subjective chief complaints. Additional work is needed to identify and overcome potential bias in the assessment of patients with subjective chief complaints in ED triage.

ObjectiveTo examine the value of data obtained outside of regular healthcare visits (clinical communications) to detect problematic opioid use in electronic health records (EHRs).DesignA retrospective cohort study.ParticipantsChronic pain patient records in a large academic medical center.InterventionsWe compared evidence for problematic opioid use in (1) clinic notes, (2) clinical communications, and (3) full EHR data. We analyzed keyword counts and calculated concordance and Cohen's κ between data sources.Main outcome measureEvidence of problematic opioid use in EHR defined as none, some, or high.ResultsTwenty-six percent of records were discordant in determination of problematic opioid use between clinical communications and clinic notes. Of these, 54 percent detected more evidence in clinical communications, and 46 percent in clinic notes. Compared to full EHR review, clinic notes exhibited higher concordance (78 percent; κ = 0.619) than clinical communications (60 percent; κ = 0.290).ConclusionClinical communications are a valuable addition to opioid EHR research.

The COVID-19 pandemic has brought about collective experiences of grief; thus, counselors-in-training (CITs) and their doctoral student supervisors may encounter increases in grief-oriented clinical work. In considering how to support CITs' work with grieving clients, doctoral supervisors should be prepared to help CITs manage experiences of vicarious grief (VG). Given the ubiquity of loss and the limited amount of grief-specific coursework in counselor training, CITs could benefit from exploring their experiences of VG with their doctoral supervisors in clinical supervision--a core area of training for doctoral students enrolled in counselor education programs accredited by the Council for Accreditation of Counseling and Related Educational Programs. In this manuscript, we (a) provide an overview of the literature on VG, (b) discuss the potential impact of VG on CITs, (c) present a case study illustrating attention to VG in supervision, and (d) provide practical strategies doctoral supervisors can employ when addressing VG in supervision, drawing on Bernard and Goodyear's discrimination model.

Introduction: To address persistent gender inequities in academic medicine, women professional development groups (PDG) have been developed to support the advancement of women in medicine. While these programs have shown promising outcomes, long-term evaluative metrics do not currently exist. The objective of this study was to establish metrics to assess women’s PDGs.  Methods: This was a modified Delphi study that included an expert panel of current and past emergency department (ED) chairs and Academy for Women in Academic Emergency Medicine (AWAEM) presidents. The panel completed three iterative surveys to develop and rank metrics to assess women PDGs. Metrics established by the expert panel were also distributed for member-checking to women EM faculty.  Results: The expert panel ranked 11 metrics with high to moderate consensus ranking with three metrics receiving greater than 90% consensus: gender equity strategy and plan; recruitment; and compensation. Members ranked 12 metrics with high consensus with three metrics receiving greater than 90% consensus: gender equity strategy and plan; compensation; and gender equity in promotion rates among faculty. Participants emphasized that departments should be responsible for leading gender equity efforts with PDGs providing a supportive role.  Conclusion: In this study, we identified metrics that can be used to assess academic EDs’ gender equity initiatives and the advisory efforts of a departmental women’s PDG. These metrics can be tailored to individual departmental/institutional needs, as well as to a PDG’s mission. Importantly, PDGs can use metrics to develop and assess programming, acknowledging that many metrics are the responsibility of the department rather than the PDG.

Objectives: To describe the knowledge and attitudes of emergency nurses regarding caring for patients with opioid use disorder in the emergency department.Background: Many eligible patients with opioid use disorder do not receive available emergency department services for treatment and harm mitigation. While prior study examined contributing provider factors, little is known of nursing factors. This study describes knowledge and attitudes of emergency nurses regarding patients with opioid use disorder and their evidence-based treatment services in the emergency department setting.Methods: Anonymous email surveys with novel and previously validated questions based on The Theory of Planned Behavior Framework were distributed to emergency department nurses at a large, urban tertiary-care hospital. Chi-Square and independent samples t-tests were used in analyses.Results: More than one third of nurses completed the questionnaire (39%, 85/218). Most showed willingness and confidence screening for substance use disorder (95% and 88% respectively). Higher confidence providing buprenorphine and take-home naloxone was significantly associated with having worked fewer years (8.33 v. 15.62 , p=0.01 and 7.38 v. 12.03, p=0.03 respectively). Confidence administering buprenorphine was significantly associated with receiving in-service training (p=0.03). Staff with knowledge of take-home naloxone, positive attitudes toward syringe service programs, and a belief in a biopsychosocial basis of addiction were significantly younger and had worked significantly fewer years than those not indicating these beliefs. Specific educational gaps were identified.Conclusion: Emergency nurses display willingness to champion evidence-based care for patients with opioid use disorder. Younger age and having worked fewer years were significantly associated with positive attitudes towards recovery science, harm mitigation, and services knowledge. Having worked fewer years was significantly associated with greater confidence performing treatment and harm mitigation. In-service training was significantly associated with greater confidence administering buprenorphine. Further study should support generalizability and determine which staff development measures generate improved outcomes.

Giant congenital melanocytic nevi are NRAS-driven proliferations that may cover up to 80% of the body surface. Their most dangerous consequence is progression to melanoma. This risk often triggers preemptive extensive surgical excisions in childhood, producing severe lifelong challenges. We have presented preclinical models, including multiple genetically engineered mice and xenografted human lesions, which enabled testing locally applied pharmacologic agents to avoid surgery. The murine models permitted the identification of proliferative versus senescent nevus phases and treatments targeting both. These nevi recapitulated the histologic and molecular features of human giant congenital nevi, including the risk of melanoma transformation. Cutaneously delivered MEK, PI3K, and c-KIT inhibitors or proinflammatory squaric acid dibutylester (SADBE) achieved major regressions. SADBE triggered innate immunity that ablated detectable nevocytes, fully prevented melanoma, and regressed human giant nevus xenografts. These findings reveal nevus mechanistic vulnerabilities and suggest opportunities for topical interventions that may alter the therapeutic options for children with congenital giant nevi.