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Background: We aimed to better understand the impact of statewide legislation removing personal belief exemptions (PBEs) for the measles, mumps, and rubella (MMR) school immunization requirement and factors associated with resulting health-seeking behaviors. Methods: We used chi-squared tests and logistic regression models to determine individual- and school-level characteristics associated with holding a MMR PBE and with post-law MMR immunization status among students linked to the Washington State Immunization Information System. Results: Of students with a MMR PBE pre-law change, 43.0% completed the MMR vaccine series and 40.4% sought another exemption type. Religious exemptions made up most new MMR exemptions signed (71.8%), followed by medical exemptions (18.5%), and religious membership exemptions (9.7%). Students were more likely to complete the vaccine series post-law change if they attended a school with a low school-level MMR exemption rate, a public school, or held a lower number of school-required immunization exemptions. Conclusions: This study confirms previous concerns that parents might replace their PBE with another exemption type; however, nearly half the students in the cohort completed the MMR vaccine series. Our findings suggest that targeted immunization policies can increase MMR coverage 1-year post-law change but must account for a replacement effect when exemption categories are eliminated.

This article describes the need for health professions educators to consider their and others' epistemologies in their work. It introduces four categories of epistemic beliefs and discusses common topics and their relationships to epistemological traditions, including how they can conflict with one another. It also suggests a mechanism for surfacing and managing epistemological tensions.

Autistic people's perceptions of their interactions with criminal justice professionals are predominantly negative; however, little is known about the state of interactions on a global scale. To further understanding, a comprehensive stakeholder questionnaire was created. Aspects of reliability and validity including evidence for test content and internal structure were gathered using expert reviews, cognitive interviewing, pilot data collection, and a larger data collection effort (N = 1618). Data was gathered from the autism community through perspectives of parents/caregivers as well as from self-reported autistic adults. Criminal justice professionals included law enforcement officers, corrections professionals, probation and parole officers, forensic psychologists and legal professionals. The scale development process was detailed in order to sufficiently document the initial psychometric evidence and share the steps taken to gain diverse stakeholder input. This study is a critical first step in generating further information to facilitate policy and program development with wide applicability.

Abstract There are 11 species of triatomines in the USA, with seven reported in the American Southwest. These species are capable of transmitting Trypanosoma cruzi, the etiological agent of Chagas disease, but are generally sylvatic and rarely infect humans in the USA. iNaturalist is one of the most popular citizen science data portals, where users record encounters with any individual organism. As of November 2023, iNaturalist reported 722 confirmed triatomine observations in the American Southwest. Maximum entropy ecological niche modelling and bioclimatic environmental variables were used to predict zones of highest human-triatomine interaction. Models fit well for Triatoma protracta (0.85), T. rubida (0.94), and T. recurva (0.96). Precipitation in the warmest quarter was most predictive of T. protracta presence, while precipitation in the driest quarter was most predictive of T. rubida and T. recurva. Locations identified in the American Southwest with highest potential for human-triatomine interaction, and potential T. cruzi transmission, were coastal California, the Sierra Nevada foothills, southern Arizona and border areas of northern Mexico. Study findings can be used for targeted surveillance efforts to address the paucity of contemporary information regarding triatomine species diversity and geographical and ecological associations in the American Southwest.

Abstract Aims Many European healthcare providers struggle to adopt multidisciplinary, integrated care pathways for people with heart failure (HF) as recommended by the European Society of Cardiology. PRO‐HF (Program to Optimize Heart Failure Patient Pathways) was developed to help clinicians identify strengths, gaps, and shortcomings in their HF pathways and support tailored interventions to optimize pathways and enhance patient care. We report initial findings from baseline assessments of HF pathway characteristics and challenges from 10 hospitals in six European countries (France, Ireland, Portugal, Spain, The Netherlands, and United Kingdom). Methods and results Baseline assessments were holistic appraisals of full HF services to calibrate current status and development needs and assist management teams in prioritizing improvement projects. Assessments were performed using a comprehensive checklist of measures covering the HF patient journey from diagnosis to ongoing follow‐up. These included a digital survey sent to full HF care teams and one‐to‐one interviews. The digital survey focused on four key areas (HF outpatient clinic; remote patient management; efficient device implantation and inpatient pathways; and network maximization) and 16 dimensions of excellence. Priority areas and themes for action identified in baseline assessments were (i) provision of HF specialist care; (ii) data capture and analysis; (iii) institutional care protocols; (iv) hospital‐wide strategies; and (v) multidisciplinary teams (MDTs). Suboptimal specialist care of emergency inpatients was an issue at all hospitals and prioritized at 8/10. Availability and accessibility of data on patients, activities, and outcomes was an issue at all hospitals and prioritized by 4/10. A lack of clear protocols, templates, and tools for some HF activities created variability in patient care (e.g., HF specialist consultations, diagnostic testing, follow‐up appointments, medications, and device eligibility) and inefficient use of clinician time. This made it difficult to initiate new technologies (e.g., remote patient monitoring) due to the risk of overburdening staff. MDTs were frequently understaffed. Multiple interventions were identified to address gaps and shortcomings that could be tailored to specific needs of individual hospitals (e.g., inpatient pathway optimization, creation/optimization of HF outpatient clinics, development of an HF performance dashboard, enhancement of protocol adherence, streamlining cardiac resynchronisation therapy pathways, and MDT coordination). Conclusions PRO‐HF provides a valuable opportunity to identify gaps and significant shortcomings in HF pathways in European hospitals. Preliminary findings from hospitals that have initiated suggested changes to address these challenges are encouraging, though longer‐term follow‐up from more hospitals is needed to confirm the impact of PRO‐HF on HF pathway optimization and patient care.

Improving the lubrication condition of oil-starved rolling bearings is a proven method to improve their reliability and service life. In this study, a composite surface texture was designed inspired by the microscopic structure of cactus spine, pitcher plant and blood clam. Superhydrophobic surface coating technology was also employed. An oil self-transportation biomimetic composite surface was developed on the guiding surface of a thrust ball bearing. Experimental results show that the biomimetic composite surface effectively drives oil for high-speed directional transport. The biomimetic composite guiding surface bearing demonstrated excellent best vibration and friction torque performance. Compared to conventional bearing, it has an overall vibration performance improvement of 37.4 %, as well as a significant reduction in friction torque of 43.3 % and wear of 72.2 %. We conclude that oil self-transportation biomimetic composite surfaces on rolling bearings can significantly improve the lubrication condition.

Abstract Background Hypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity in the U.S., with rates highest among birthing people who are Black, rural residents, and/or have low-income. Severe hypertension, in particular, increases risk of stroke and other serious pregnancy complications. To promote early detection and treatment of severe hypertension, the Alliance for Innovation on Maternal Health developed the Severe Hypertension During Pregnancy and Postpartum Period Safety Bundle (HTN Bundle). Multiple studies have demonstrated the HTN Bundle’s effectiveness in the inpatient setting. With funding from the National Heart, Lung, and Blood Institute, we engaged community partners to adapt the HTN Bundle for the outpatient setting (i.e., O-HTN Bundle) and planned for its implementation. In this paper, we describe the protocol for a study evaluating O-HTN Bundle implementation in 20 outpatient clinics serving Black, rural, and/or low-income populations. Methods This study is a hybrid type 3 effectiveness-implementation trial with a multiple baseline design. We will implement the O-HTN Bundle in three successive cohorts of clinics using a multicomponent implementation strategy to engage community partners (coalition, patient workgroup) and support clinics (training, facilitation, education materials, and simulations of severe hypertension events). To test the strategy, we will compare clinic fidelity to evidence-based guidelines for (a) patient education on hypertension and (b) blood pressure measurement technique, with repeated measures occurring before and after strategy receipt. We will also observe strategy effects on community- and clinic-level intermediate outcomes (community engagement, organizational readiness), implementation outcomes (reach, adoption, fidelity, maintenance), and effectiveness outcomes (receipt of guideline concordant care). Analyses will address whether outcomes are equitable across Black, rural, and/or low-income subgroups. Guided by the Consolidated Framework for Implementation Research 2.0, we will use mixed methods to identify adaptations and other determinants of implementation success. Discussion This study integrates community engagement and implementation science to promote equitable and timely response to severe HTN in the outpatient setting during pregnancy and postpartum. This is one of the first studies to implement an outpatient HTN Bundle and to use simulation as a strategy to reinforce team-based delivery of guideline concordant care. Trial registration This study was registered with ClinicalTrials.gov as “Testing Implementation Strategies to Support Clinic Fidelity to an Outpatient Hypertension Bundle (AC3HIEVE).” Registration number NCT06002165, August 21, 2023: https://clinicaltrials.gov/study/NCT06002165 .

Relative rank models of risky decision-making suggest that human preferences are informed by sampled (and not absolute) values and their relative ranks. According to this proposal, an attribute's absolute value (e.g., money or probability), retrieved from memory or/and available in the context, has a relative rank within the sampled attribute values. Moreover, decision-makers use the relative ranks of sampled absolute values when they choose or evaluate an option. In contrast, we present evidence from studies with more than 1100 UK adults, that human preferences are indeed informed by an attribute's absolute value. In particular, when making a choice between two economic gambles (a safe gamble or a risky gamble), we found that the likelihood of choosing the risky gamble increased when it was with a desirable monetary prize (a larger amount of money – £150), regardless of the distribution and relative ranks of sampled monetary values. However, when both the safe and risky gambles were with non-desirable monetary prizes (£0.50 or £1.50), participants' preferences were influenced by the distribution and relative ranks of sampled monetary values. Accordingly, we propose that decision-making desirability triggers participants' willingness to use absolute values in their choice; the switch between participants making relative and absolute judgment is predicted by Edwards et al. (2012).

The level structure of Er158 has been studied using the Gammasphere spectrometer via the Cd114(Ca48,4n) reaction at 215 MeV with both thin (self-supporting) and thick (backed) targets. The level scheme has been considerably extended with more than 200 new transitions and six new rotational structures, including two strongly coupled high-K bands. Configuration assignments for the new structures are based on their observed alignments, B(M1)/B(E2) ratios of reduced transition probabilities, excitation energies, and comparisons with neighboring nuclei and theoretical calculations. With increasing angular momentum, this nucleus exhibits Coriolis-induced alignments of both neutrons and protons before it then undergoes a rotation-induced transition from near-prolate collective rotation to a noncollective oblate configuration. This transition occurs via the mechanism of band termination around spin 45ħ in three rotational structures. Two distinct lifetime branches, consistent with the crossing of a collective "fast"rotational structure by an energetically favored "slow"terminating sequence, are confirmed for the positive-parity states, and similar behavior is established in the negative-parity states. Weak-intensity, high-energy transitions are observed to feed into the terminating states. At the highest spins, three collective bands with high dynamic moments of inertia and large quadrupole moments were identified. These bands are interpreted as triaxial strongly deformed structures and mark a return to collectivity at ultrahigh spin.

People are generally able to selectively attend and remember high-value over low-value information. Here, we investigated whether young and older adults would display typical value-based memory selectivity effects for to-be-learned item-value associations when goal-directed information about the meaning of associated values was presented before and after encoding. In two experiments, both young and older adults were presented with one (Experiment 1) or multiple (Experiment 2) lists of words that were arbitrarily paired with different numerical values (e.g., door-8) or font colors (e.g., door presented in red), which indicated each words value. In Experiment 1, participants were told that the numerical value indicated the relative importance of each item either before they studied the list (preencoding), after they studied it (postencoding), or not at all (no value control instructions). Older adults were significantly more selective in the preencoding condition relative to the other conditions, whereas younger adults were not selective in any condition on this single-list (numerical) value task of Experiment 1. In Experiment 2, young and older adults were tested on four additional lists of both pre- and postencoding trials each after studying and recalling four lists of words without any value instructions. Results from Experiment 2 revealed that both young and older adults selectively prioritized high-value words on the preencoding trials, but not on postencoding trials, on this color-based categorical (low-medium-high) value task. The present study highlights a critical role of goal-directed knowledge of value-based instructions prior to encoding to facilitate typically observed value-directed memory selectivity for important information. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Previous studies that suggest a shorter time from cervical ripening balloon placement to delivery with shorter total balloon placement time have excluded patients with prior cesarean deliveries. Objective: To evaluate, in patients with a prior history of cesarean delivery undergoing cervical ripening with a double-balloon catheter, whether planned removal of device after 6 vs 12 hours would result in shorter time to vaginal delivery. Study Design: A before-and-after study was performed after a practice change occurred November 2020, shortening the planned time of double-balloon catheter placement for cervical ripening from 12 to 6 hours. Data were collected via retrospective electronic chart review. Primary outcome was time from balloon placement to vaginal delivery. Secondary outcomes included rates of cesarean delivery, maternal intraamniotic infection, and uterine rupture. Kaplan–Meier curves compared median times to delivery between the groups. A Cox proportional-hazards model was used to adjust for time of balloon placement, number of previous vaginal deliveries, and co-medications used. Results: From November 2018 to November 2022, 189 analyzable patients with a prior history of cesarean delivery received a double-balloon catheter for cervical ripening during their trial of labor. Patients were separated into pre- and postpolicy change groups (n=91 and 98, respectively). The median time to vaginal delivery for the pregroup was 28 hours (95% CI: 26, 35) and 25 hours (95% CI: 23, 29) for those in the postgroup (P value .052). After adjusting for dilation at time of balloon placement, number of previous vaginal deliveries, and co-medication, the estimated hazard ratio for successful vaginal delivery postpolicy change was 1.89 (95% CI: 1.27, 2.81). There were no differences in rates of secondary outcomes. Conclusion: In patients with prior cesarean delivery undergoing mechanical cervical ripening with a double-balloon catheter, planned removal at 6 hours compared to 12 hours may result in higher chances of successful vaginal delivery and possibly a shorter time to delivery, without increasing rates of cesarean delivery and intraamniotic infection.

Symbionts dominate planetary diversity and three primary symbiont diversification processes have been proposed: co-speciation with hosts, speciation by host-switching, and within-host speciation. The last mechanism is prevalent among members of an extraordinary marine symbiosis in the Indian River Lagoon, Florida, composed of a host mantis shrimp, Lysiosquilla scabricauda, and seven host-specific commensal vasconielline “yoyo” clams (Galeommatoidea) that collectively occupy two distinct niches: burrow-wall-attached, and host-attached/ectocommensal. This within-host symbiont radiation provides a natural experiment to test how symbiont coexistence patterns are regulated in a common ancestral habitat. The competitive exclusion principle predicts that sister taxa produced by adaptive speciation (with distinct morphologies and within-burrow niches) are most likely to coexist whereas the neutral theory predicts no difference among adaptive and non-adaptive sister taxa co-occurrence. To test these predictions, we engaged in (1) field-censusing commensal species assemblages; (2) trophic niche analyses; (3) laboratory behavioral observations. Although predicted by both models, the field census found no mixed-niche commensal assemblages: multi-species burrows were exclusively composed of burrow-wall commensals. Their co-occurrence matched random assembly process expectations, but presence of the single ectocommensal species had a highly significant negative effect on recruitment of all burrow-wall commensal species (P

Background: The National Healthcare Safety Network (NHSN) provides detailed surveillance case definitions for healthcare-associated infections (HAI), including central line-associated bloodstream infections (CLABSI). CLABSI data are used for several purposes, including improving patient safety, value-based purchasing, and comparing hospitals’ performance. Our Infection Prevention (IP) team conducts house-wide HAI surveillance. To ensure that our hospital CLABSI reporting is accurate and that staff are implementing case definitions consistently and systematically, we conducted an internal validation of CLABSI. This undertaking allowed us to identify educational opportunities for IPs and improve surveillance data consistency. Methods: At UNC Hospitals, data on all positive blood cultures collected in the inpatient setting from July 2022 – June 2023 were obtained from electronic medical records. A random number generator was used to select 16 records per quarter. Each record was then randomly assigned to two different IPs (out of 8 total inpatient IPs) for review. Concordance of CLABSI classification was summarized across the two reviews and compared to the initial review. Discordant cases were then reviewed by the Associate IP Director (a certified IP with 15 years of experience) for final adjudication. A summary of findings and discordant cases details were discussed at regular IP educational meetings. Results: From July 2022-June 2023, there were 1658 positive blood cultures collected in the inpatient setting. Of the 64 randomly selected blood cultures, total concordance amongst all reviewers occurred 65.6% of the time. Concordance improved in the 2nd half of FY23 compared to the 1st half (72% vs, 59%, p>0.05). Amongst the 33% of blood culture results with reviewer discrepancy, the most common reasons were related to distinction of a bloodstream infection secondary to another infection site (32%) and application of the repeat infection timeframe (18%). Importantly, there was only one instance where a blood culture result was categorized by all 3 reviewers as present on admission, but upon Associate Director review, actually represented a CLABSI (i.e., false negative). Conclusions: Standardized case definitions remain open to interpretation. At our hospital, we experienced discordance in approximately one-third of instances during review of blood culture data amongst trained infection preventionists. Reviewing all blood culture data is key for validation so that both false positives and false negative CLABSIs can be identified. Identifying the most common reasons for discordance and using specific examples when case disagreement occurred for educational purposes may lead to improved reliability and accuracy of application of the NHSN surveillance defintions.

While the coronavirus crisis altered all facets of life across the globe, its impact on American higher education posed immediate challenges to students and faculty alike. Disruptions in normal, in-person instruction affected all students' abilities to connect and create, but first-year students and their professors were particularly restricted in areas relating to classroom engagement, interpersonal exchange, and academic support. This pilot study presents first-year experiences of honors students during this time. Using reflective writing exercises, authors examine and assess a range of student responses (n = 98) to this extraordinary circumstance. Qualitative content analyses and coding reveal eight major themes: (1) shift in perspective resulting in personal growth; (2) changes in family dynamics and interpersonal connections; (3) focus on economic concerns; (4) focus on mental health and coping strategies; (5) changes in impressions of others and society; (6) understanding a "new normal"; (7) lack of trust; and (8) increase in social isolation. Results indicate that COVID's multifaceted effect on honors students range in consequence from health to professional outlook. Authors suggest that understanding the nature of the first-year experience during this time can facilitate multi-level approaches and inclusive strategies for honors practitioners to help students effectively move forward on their educational path.

This pilot study describes a nascent first-year honors colloquia series using human-centered design (HCD). An interdisciplinary team of instructors redesigned the course with the intention of engaging the whole student in transformative learning and creating a curriculum that addresses problems and opportunities focused on the needs, contexts, emotions, and behaviors of all students, faculty, administrators, and community involved in the series. Authors describe the HCD process, observing the challenges faced by faculty in realizing its design principles, and student (n = 98) reflections on a two-part prototype involving innovation and entrepreneurship emphasizing "wicked" problems and resolutions. Students were asked to reflect on their honors college experience, in general, and then specifically focus on the course, assignments, events, and activities in which they engaged throughout the program. Authors consider the benefits of research through the immersion and observation of participants, arguing that such continuing research engagement (thought and action) informs iterations of the curriculum that are then evaluated in a continuing cycle of HCD. Qualitative analyses indicate that students' lived experience align with curricular objectives and design. Authors conclude that HCD offers promising and innovative strategies that honors practitioners can use to engage students and manage potential pitfalls and pivots in honors curricula and programs after COVID.

Abstract Radiogenic isotopic compositions of arc magmas are a key tool for studying active margin evolution. They have two isotopic end-members: melts formed mostly from juvenile asthenosphere and melts sourced from evolved continental crust/continental lithospheric mantle. Cordilleran-margins are typically more isotopically juvenile near the trench, and conversely, increasingly evolved landward. However, this model has not been tested on the ~1,500 km long Mesozoic-Cenozoic arc of the Antarctic Peninsula. Here we show that while geochemical compositions remain largely constant, radiogenic isotopes become increasingly juvenile with time. Unlike other continental arcs, there is no association between isotopic composition and spatial distribution. This is attributed to: (i) slow subduction of young oceanic lithosphere, resulting in narrowing of the arc and reduced capacity to incorporate continental crust into melts, and (ii) the Cenozoic decrease in convergence rate, which reduced the friction in the slab-overriding plate interface, allowing the arc melts to increasingly source from young juvenile asthenosphere.