The Morality of Incentivising Organ Donations from Prisoners

Liver Transplantation in Malaysia: Needs, Obstacles, and Opportunities.

Think Globally, Act Locally: An Approach to Implementation of Clinical Practice Guidelines

South Africa has a rich organ-transplant history, and studies suggest that the SA public supports organ donation. In spite of this, persistently low donor numbers are a significant challenge. This may be due to a lack of contextually appropriate awareness and education, or to barriers to referring patients and families in clinical settings. It may also be due to ad hoc regulations that are not uniformly endorsed or implemented. In this article we present the findings of a study in Johannesburg that explored the attitudes and roles of nurses in end-of-life care and organ donation. A total of 273 nurses participated. Most were female and <50 years old. The majority expressed positive attitudes towards both end-of-life care and organ donation, but there was ambiguity as to whether referring patients and families for these services was within nursing scope of practice. The vast majority of participants noted that they would refer patients themselves if there was a mandatory, nationally endorsed referral policy. These findings have implications for clinical practice and policy, and suggest that the formulation and implementation of robust national guidelines should be a priority. Because nurses would follow such guidelines, this might lead to an increase in donor rates and circumvent some uncertainty regarding referral.

Introduction When potential brain dead donors are in line-up for organ retrieval, their loss would be such a disaster.[1] The aim of this study was to detect the occurrence of different disorders leading to pre-retrieval donor’s cardiac arrest and loss in order to prevent this energy and money wasting challenge. Methods Medical records of potential donors who were lost after transfer to organ procurement unit and before organ donation were reviewed and weigh of every responsible disorder was tested. Results In 14 years of experience in organ donation from 2003 to 2016, 46 (3.09%) out of 1485 potential donors were lost after their transfer to OPU with the aim of organ donation. Mean age of donors were not significantly different to actual donors. Similarly, the gender proportions were the same. (Male = 59% vs. 57.5% respectively) However, proportion of drug poisoning as the cause of brain death was more common in the lost donors. (19.5% versus 5.3%). Mean age of poisoned cases (actual donors and lost ones) was 26.7 ± 14.6 years. On the other hand, mean age of trauma-suffered cases was 29.4 ± 17.3 years. In contrast, CVA associated brain death victims had a mean age of 54.1 ± 8.6 years. 13 (28.2%) cases had a documented history of ischemic heart disease, which was not as common in actual donors. (4 cases, 8.6%) After excluding hypotension and Diabetes Insipidus which are two common stations in natural course of brain death [2], the leading disorders among lost cases were metabolic acidosis, hypocalcaemia hyperglycemia, Thrombocytopenia, different presentations of coagulopathy and severe anemia. 8 out 9 (88.85) poisoned lost cases had metabolic acidosis, which was higher than the other ones. (59.4%, p < 0.01) Clinical conditions of 22 (47.8%) cases were flared up by different severities of acute kidney injury and mean ALT levels were significantly higher than actual donors. (286.2 Versus 105.6, p < 0.001) All the above-mentioned disorders were significantly more common in lost donors than actual ones. Conclusion Drug toxicity, history of ischemic heart disease and occurrence of acute kidney injury and liver and lung dysfunction are associated with more potential donors’ loss before organ retrieval. Metabolic acidosis, Hyperglycemia, hypocalcaemia and coagulopathy are more common in unsuccessful organ donation effort. As a result, implementation of proper management especial guidelines for donors facing these abnormalities is recommended. Organ Procurement Unit (OPU) Study Group. NRITLD.

Background and Aims Overcoming gender disparity in access to kidney transplantation is a well-established universal challenge. The SRTR data showed a greater proportion of males than females for kidney transplant waitlists (61% vs 39%). Similarly, of 831 deceased donor kidney transplants (DDKT) conducted between 1997 and 2018 at IKDRC-ITS, 68% have been male and 32% female recipients while majority of donors in living donor kidney transplants (LDKT) were females. Prior to 2020, there duration on transplantation waitlist was the only criteria for deceased donor kidney allocation. In January 2020, SOTTO Gujarat was formed which implements a point system based deceased donor allocation policy including HLA mismatch, Panel Reactive Antibody, Donor Specific Antibody, age and duration on dialysis, amongst others. 2 additional points are allocated to female recipients in this allocation system. The aim is to study the impact of change in DDKT allocation policy on gender disparity. Method This is a retrospective, single-center, observational study. Number of male and female kidney transplant recipients was collected from the medical records held by the department of nephrology between January 2014 to December 2023. The data was categorized as before and after implementation of SOTTO Gujarat guidelines and analyzed. Results A total of 3182 kidney transplants were conducted at our centre over the study period, 2231 were LDKT while only 951 were DDKT. We found the percentage of female LDKT recipients to have remained disproportionately low as compared to male DDKT throughout the study period, while there was a gradually progressive increase in the percentage of female DDKT recipients with almost a doubling of female DDKT recipients from 27.57% in 2019 to 54.19% in 2023. This may be attributed to the compounding effect of allocating points to DSA, PRA, age of patient and gender as female patients tend to have higher PRA and DSA level after sensitization. Conclusion This study provides new insights into steps that can be taken to bridge the gender gap in DDKT. It shows that implementing a point based system for DDKT allocation policy with extra points for female recipients may increase the number of kidney transplants in them. Similar policy may be undertaken by other transplant centers as a bridge to achieve temporary solution till underlying factors leading to gender disparity are better understood and ways to overcome them are formed. Action should be taken to provide for equitable access to females at all stages, from diagnosis to treatment such as intensive and timely counselling. Policies for social empowerment of women must be formed including literacy, better maternal and child healthcare and financial independence. Raising awareness and education at a grassroot level must remain the key component to change public attitude regarding organ donation and ensure equitable access to transplantation for all.

Publication of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) marks 49 years since the first CPR guidelines were published in 1966 by an Ad Hoc Committee on Cardiopulmonary Resuscitation established by the National Academy of Sciences of the National Research Council.1 Since that time, periodic revisions to the Guidelines have been published by the AHA in 1974,2 1980,3 1986,4 1992,5 2000,6 2005,7 2010,8 and now 2015. The 2010 AHA Guidelines for CPR and ECC provided a comprehensive review of evidence-based recommendations for resuscitation, ECC, and first aid. The 2015 AHA Guidelines Update for CPR and ECC focuses on topics with significant new science or ongoing controversy, and so serves as an update to the 2010 AHA Guidelines for CPR and ECC rather than a complete revision of the Guidelines. The purpose of this Executive Summary is to provide an overview of the new or revised recommendations contained in the 2015 Guidelines Update. This document does not contain extensive reference citations; the reader is referred to Parts 3 through 9 for more detailed review of the scientific evidence and the recommendations on which they are based. There have been several changes to the organization of the 2015 Guidelines Update compared with 2010. “Part 4: Systems of Care and Continuous Quality Improvement” is an important new Part that focuses on the integrated structures and processes that are necessary to create systems of care for both in-hospital and out-of-hospital resuscitation capable of measuring and improving quality and patient outcomes. This Part replaces the “CPR Overview” Part of the 2010 Guidelines. Another new Part of the 2015 Guidelines Update is “Part 14: Education,” which focuses on evidence-based recommendations to facilitate widespread, consistent, efficient and effective implementation …

The scarcity of transplantable organs has led to the development of normothermic regional perfusion (NRP) to enhance organ viability and supply. While NRP offers promise to increase the quality and quantity of transplantable organs, its implementation raises significant ethical concerns regarding the Dead Donor Rule (DDR), consent/authorization, and physician participation. These concerns are further magnified in pediatric organ donation given such patients' increased vulnerability and lack of decision-making authority. While arguments continue to play out in the literature, several OPOs in the US perform NRP and are requesting institutions to implement this practice. As pediatric ethicists, our aim is to create guidelines for the ethical implementation of NRP in pediatric donors. We highlight the challenges regarding the DDR, discuss requirements for informed consent, outline a thoughtful approach for engaging with families during crises, and address conscientious objections for clinicians who are morally apprehensive about participating in NRP. We recommend collaboration with hospital/organizational leadership, transplant programs, organ procurement organizations, and clinical ethicists to collaboratively plan to address these ethical controversies at the institutional level. Use of a pre-NRP checklist may help ensure that all potential donor families and patients are treated with respect and fully informed about the process and that there is sufficient education of and support for clinicians who participate in NRP. If institutions and OPOs collaborate to implement these guidelines, they will ensure that they honor donors and their families without negatively impacting public trust in organ donation, increase organ supply and viability, and ultimately improve outcomes for transplant recipients.

Background New guidelines for assessing solid organ donors and recipients for Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) infection were published by the US Public Health Service (PHS) in 2020 and implemented into Organ Procurement and Transplantation Network (OPTN) policy on 3/1/21. Changes included a shorter risk criteria inclusionary timeframe and the removal of 4 risk criteria. Methods We analyzed OPTN deceased donor and transplant data 2 years pre-(3/1/19-2/28/21) and post-(3/1/21-3/1/23) implementation of the updated guidelines. For Kaplan-Meier survival analyses, the post- cohort included recipients transplanted before 1/1/23 to ensure recipients had at least 1 year follow-up plus a 3-month data lag. Utilization rates, defined as number of organs transplanted divided by number of available organs from donors with at least 1 organ recovered for the purpose of transplant, are shown for thoracic organs. Non-use rates, defined as number of organs recovered for the purpose of transplant but not transplanted divided by the total number of organs recovered for the purpose of transplant, are shown for abdominal organs. Results The proportion of donors considered to have PHS risk factors decreased by approximately 10% post-policy, both overall and by organ type (Fig. 1). There were no major differences pre- to post- in reported donor HIV, HCV or HBV NAT test results (Fig2. ). Post-policy, utilization rates for heart and lung for donors with risk factors were 34.9% and 17.5% respectively, compared to 34.3% and 20.0% pre-policy; while kidney and liver non-use rates for donors with risk factors were 20.3% and 8.2% respectively, compared to 17.2% and 7.9% pre-policy. There was no significant change in 1-year post-transplant patient survival for recipients who received organs from donors with PHS risk factors (Fig. 3). Conclusion Less restrictive PHS guidelines led to fewer donors being classified as having risk factors for disease transmission. Updated guidelines did not significantly affect donor infectious disease test results or post-transplant survival for recipients. Changes in donor organ utilization and non-use may be due to donor pool changes and/or overlapping policy implementations, and further investigation is warranted. Disclosures Lara A. Danziger-Isakov, MD, MPH, Aicuris: clinical research contract, paid to institutio|Ansun BioPharma: clinical research contract, paid to institution|Astellas: Advisor/Consultant|Astellas: clinical research contract, paid to institutio|Merck: clinical research contract, paid to institutio|Pfizer: Grant/Research Support|Takeda: clinical research contract, paid to institutio

Transplanted organs carry the risk of inadvertent donor cancer transmission. Some cancers in organ donors have been classified as being associated with a high or unacceptable risk, but the evidence for such recommendations is scanty. The risk of cancer transmission from donors characterized as high or unacceptable risk was studied by analysing transplant and cancer registry data. Donors and recipients from England (1990-2008) were identified from the UK Transplant Registry. Cancer details were obtained from cancer registries and classified using guidelines from the Council of Europe and Organ Procurement and Transplantation Network/United Network for Organ Sharing. Of 17,639 donors, 202 (1.1 per cent) had a history of cancer, including 61 donors with cancers classed as having an unacceptable/high risk of transmission. No cancer transmission was noted in 133 recipients of organs from these 61 donors. At 10 years after transplantation, the additional survival benefit gained by transplanting organs from donors with unacceptable/high-risk cancer was 944 (95 per cent confidence interval (c.i.) 851 to 1037) life-years, with a mean survival of 7.1 (95 per cent c.i. 6.4 to 7.8) years per recipient. Strict implementation of present guidelines is likely to result in overestimation of cancer transmission risk in some donors. Organs from some donors with cancers defined as unacceptable/high risk can be used safely.

Few aspects of clinical care are as controversial as pain management. Orthopaedic surgeons represent 2.5% of physicians in the United States, yet we write 7.7% of opioid prescriptions [9] and have the highest median number of prescriptions [8]. However, there is considerable uncertainty among our specialty on how much opioid medication we should be giving to patients in the peri-operative period. In the past two decades, we’ve heard from experts who told us that we were systematically undertreating chronic pain and should be prescribing opioids with substantially less concern [3]. We then heard from experts that long-acting opioids might not be as safe as advertised [16]. Most recently, we’ve heard that physician-prescribed opioids were the cause of an overdose epidemic [21]. And there is plenty of evidence that the experts were both completely correct and egregiously wrong in the treatment of patients affected by pain, in that patients with chronic pain suffer needlessly (true), but that the safety of aggressive management was assured (false). And these patients have been, to a large extent, ignored in the tumult over opioids. This month, we talk with Daniel B. C. Reid MD, MPH, lead author of an important article in this month’s Clinical Orthopaedics and Related Research®: “Statewide Prescription-Limiting Legislation and Postoperative Opioid Utilization Following Total Joint Arthroplasty” [19]. Interestingly, it turns out that clinical judgment, patient education, and a personalized approach to care seem to perform just fine when it comes to managing surgical pain. Although Dr. Reid’s group focused on arthroplasty, their findings are of interest to surgeons of any stripe. Management of peri-operative pain represents an ongoing challenge, and guidance on use of potentially lethal medication to combat that pain is valuable. The current controversy over opioids, covered in greater detail in a 2017 CORR® Editorial [11], began in the late 1990s, when the American Pain Society [2] brought attention to undertreatment of pain. And the data shows that prescriptions for opioids rose sharply, both in terms of numbers and dosage. Between 1991 and 2011, painkiller prescriptions in the United States tripled from 76 million to 219 million per year; as a consequence, deaths from opioid overdose rose as well. Age-adjusted opioid poisoning deaths quadrupled from 1999 to 2011 [7]. But by 2012, clinicians and the public were well aware of the issue. According to a recent study by Zhu and colleagues [24], the number of new opioid prescriptions dropped more than 50% from July 2012 to December 2017, and the number of prescribers dropped by 30%. At the same, it became clear that prescription opioids were no longer the predominant cause of death by overdose, and that the vast majority of opioid users were relying on illicit drugs such as heroin and fentanyl [5, 6, 14, 22]. Nonetheless, state legislators followed former White House Chief of Staff Rahm Emanuel’s advice that a good crisis should not be allowed to go to waste [15]. Currently, 35 states have operational Prescription Drug Monitoring Programs, and 11 additional states and one U.S. territory have passed legislation authorizing the development of a Prescription Drug Monitoring Programs. It’s not clear whether these programs work, though—some have shown reductions in opioid prescribing [1, 4], while others show changes which are modest at best [13, 20, 23]. However, the majority of available studies look at opioid use from the viewpoint of epidemiology, and provide little guidance for the orthopaedic practitioner. Hence, the need to look at specific patient groups, and to concentrate on patients undergoing surgery. Reid and his colleagues [19] have done just that with their study on patients undergoing total joint arthroplasty. The Rhode Island Uniform Controlled Substances Act was enacted in 2016, and went into effect the next year. The limitations on prescribing are substantial, and include daily dosing, total number of doses, and duration. Reid’s group compared opioid dosing in both opioid-naïve patients and those patients already using opioids, and looked whether prescribing patterns changed after implementation of state law. Opioid-naïve patients received less medication within the first 30 days compared to patients treated before implementation, but patients who were already on opioids prior to surgery continued to receive medication at unchanged levels. In short, an exaggerated political response to an iatrogenic crisis may actually have brought some measure of sanity to clinical care. Join me now for a Take 5 Interview with Daniel B. C. Reid MD, MPH, first author of “Statewide Prescription-Limiting Legislation and Postoperative Opioid Utilization Following Total Joint Arthroplasty.” Paul Manner MD, FRCSC:The Rhode Island Uniform Controlled Substances Act mandates a maximum of 30 morphine milligram equivalents per day for patients with acute pain who have not received opioids in the last 30 days. This works out to four 5 mg tablets of oxycodone per day. Unless Rhode Islanders are remarkably stoic, this seems like a low dose for a patient who’s just undergone major orthopaedic surgery. How do we balance overprescribing with the risk of undertreatment of pain? Daniel B. C. Reid MD, MPH: While Rhode Island is certainly home to wonderful citizens, I do not believe they are any more stoic then citizens of other states. It appears more likely that the patients and physicians in Rhode Island and the rest of the United States have grown accustomed to opioid overprescription during the last 2 to 3 decades. A number of factors, including aggressive marketing of prescription opioids by the pharmaceutical industry, national initiatives like “pain as the fifth vital sign”, and increasing pressure on physicians and hospitals to improve chronic and postoperative pain, appeared to have contributed to the dramatic rise in opioid utilization during this time period [10]. Usage of high doses of postoperative opioid pain medications appears to be less associated with the specific procedure, but rather the location in which it is performed. Patients in the United States routinely receive far higher doses of opioid pain medications than patients in many other countries. A 2009 study comparing the United States to the Netherlands found that 77% of patients undergoing surgery for hip fractures and 82% of those undergoing surgery for ankle fractures in the United States used outpatient opioid pain medications following surgery [12]. This compared to 0% and 6% of Dutch patients, respectively, in that same study. In our institution, immediately prior to implementation of the aforementioned legislation, even previously opioid-naïve patients were routinely receiving triple the currently allowable opioid dose after leaving the hospital. As surgeons, we were certainly concerned about the possibility for severe undertreatment of pain given such a dramatic shift in practice mandated by the state. We were anxious that our patients would be miserable following surgery, our office staff would be bombarded with calls about poorly controlled pain, our emergency departments would be filled with patients seeking prescription refills, and our patient satisfaction scores would suffer accordingly. In fact, my personal experience, and the experience of many of my colleagues, has been far different than we initially expected. The vast majority of patients have been surprisingly understanding, and they seem to agree with the new model. While calls to the office and the usage of early post-operative refills have increased slightly, this burden has been far lower than anticipated. Furthermore, we have not found any major increase in emergency department visits, unplanned hospital readmissions, or reoperations for pain when evaluating the effect of this legislation on related subspecialties including spine surgery [17, 18]. Based on our experience, once patient populations become accustomed to more conservative opioid pain regimens, they can accommodate surprisingly well to even rapid paradigm shifts. Certainly, balancing the risks of opioid overprescription with those of potential undertreatment of pain is challenging and will require further experience and objective data. Strict legislative restraints on prescribers of opioids appear to be becoming more and more common across the country. This pattern is unlikely to abate. In our experience, maintaining close communication with patients, determining which patients are at high-risk for poor post-operative pain control prior to surgery, and having the technological tools available to correct for undertreatment of pain remotely, including electronic prescribing of controlled substances, are important factors for easing this transition. Dr. Manner:It’s interesting that we see a reduction in use of opioids early and within the first 30 days, but not after the first 30 days. My clinical experience is that patients already exposed to opioids continue to need them long term; the opioid-naïve patients, by contrast, stop spontaneously. Was that the case here? And if so, is there a better way to manage the needs of these groups? Dr. Reid: Many studies have suggested that patients who have been previously exposed to opioids are much more likely to continue to use such medications long-term. When evaluating our data, after controlling for gender, preoperative benzodiazepine exposure, presence or absence of the legislation in question, and specific surgical procedure, pre-operative opioid use was the factor most strongly associated with prolonged opioid use. The fact that the regulations were associated with reduced opioid utilization only within the first 30 days suggests that such legislation is a more-effective determinant of prescriber behavior then patient behavior. Those patients who are high-risk for using opioids over the longer-term following surgery remain high-risk regardless of targeted legislation. This problem can be a real challenge to manage. Early identification of patients at risk for long-term usage is important. Patients already using opioid pain medications should be encouraged to decrease consumption prior to surgery. Additionally, surgeons should take the time to develop long-term pain control plans in the preoperative period. Establishing clear boundaries, maintaining surveillance for dual prescribing, and encouraging access to naloxone for overdose reversal, all are ways to improve quality of care. Dr. Manner:One of the concerns at the time of the introduction of bundled care was that surgeons would be less willing to operate on the “toughies”—those patients with multiple medical problems, or with less social support. Was there a change in clinician willingness to operate on opioid-tolerant patients after passage of the 2017 law? If so, what should we do about that? Dr. Reid: Providing care for patients with multiple or complex problems takes considerable time and energy. Not only are patients who present already habituated to opioid medications potentially more work for physicians and their staff who may already be overburdened, but the inherent risk of managing such patients may affect surgeon willingness to provide necessary care. The implementation of strict guidelines and close monitoring of prescription patterns by the state may further disincentivize the care of such patients. Counterintuitively, our experience has been that such regulations may strengthen the doctor-patient relationship. Our patients understand and appreciate the need for systemic solutions to the current opioid crisis. When appropriate preoperative expectations are set and pain-management plans are followed, most patients do surprisingly well with very small opioid doses. Even in difficult social situations, most physicians in our practice appreciate that they are no longer forced to be the “bad guy,” allowing the state to take on that role. Objectively, we did not see a substantial reduction in the proportion of patients previously habituated to narcotics who were treated with total joint arthroplasty following implementation of the law. While this suggests that cherry-picking of patients who were naïve to opioids prior to surgery in the post-legislation climate does not appear to be a major problem, further surveillance is certainly indicated. Dr. Manner:The legislation in question took effect in 2017. But there are good data to show that prescription of opioids was on a downward trend well before 2017, both in Rhode Island and across the country. If that is so, was this legislation effective? What’s the best approach for policy makers to provide timely and useful guidance? Dr. Reid: This is an important point. The legislation in question was passed in the midst of a growing recognition of the negative effects of opioids on patients, populations, and society as a whole. There is evidence that national opioid prescription rates peaked around 2010 to 2012 and have been slowly decreasing since then. It is certainly possible that national trends may have contributed in part to our findings. Nonetheless, it is unlikely that the magnitude of early prescription changes seen in the relatively short period between passage and implementation of the legislation can be explained by national trends or confounding variables alone. Personally, this legislation has affected my daily practice as well as that of my colleagues. We prescribe far less opioid medication than we did even a few years ago, and have achieved a much greater reduction than many of us initially thought possible. For small procedures, opioids are rarely prescribed. With appropriate preoperative discussion and setting of expectations, many patients do not even fill their opioid prescriptions after surgery. Regulations like those in place in Rhode Island are being enacted elsewhere; at least 36 states now have similar laws. There is an inherent conflict between the importance of using objective evidence to guide policymaking and the need for policymakers to address this important and wide-ranging crisis expeditiously. Early evidence as presented here appears to support the efficacy of such legislation in reducing early postoperative opioid utilization. Further rigorous study, including cross-state comparisons, monitoring of long-term effects, and surveillance for unintended consequences, is urgently needed. Dr. Manner:Presumably, one reason (if not the main one) to restrict opioid prescriptions is to reduce the chance of dying from an overdose. But what we see in Rhode Island is that the number of deaths by overdose is 232 in 2013, 240 in 2014, 290 in 2015, 336 in 2016, 324 in 2017, and 314 in 2018. It’s too early to tell what happens this year, but these figures indicate that the legislation has had little influence one way or the other. Is the legitimate prescription of opioids really the problem? Dr. Reid: While preventing overdose is certainly an important goal of prescribing restrictions, it is not the only goal. Even “safe” use of opioids has been associated with inferior patient outcomes, poorer patient satisfaction scores, chronic pain, and social/family problems. Furthermore, despite being associated with only a small proportion of opioid-related overdose deaths, prescription medications continue to be a primary source of opioids used for non-medical use through diversion. Over-prescription, in combination with poor patient education on proper disposal methods, likely contribute to this phenomenon. There does appear to be a slight trend toward decreasing overdose deaths in Rhode Island since 2016. This is especially interesting given the simultaneous increase in accidental overdose deaths nationally during this same period. Regardless, such comparisons are fraught with confounding, especially given the recent rise in overdose deaths secondary to synthetic opioids, such as fentanyl. Clearly, further surveillance and cross-state comparisons are needed.Daniel B. C. Reid MD, MPH

In response to an imminent surge in COVID-19 cases, the state of Massachusetts (MA) released its Crisis Standards of Care (CSC) guidelines in April 2020. A small group of Boston...

Background: Guidelines for the successful implementation of two-way dual language bilingual education (DLBE) programs foreground the role of program leadership, hiring and preparing culturally and linguistically competent teachers, family involvement, and the alignment between curriculum, assessments, and instruction in both languages. Absent in this framing for program implementation and success are the voices, lived experiences, and everyday contributions of immigrant children who take part in such programs. Focus: Grounded in a critical orientation to immigrant childhoods, this article explores how a group of 70 Brazilian immigrant children (ages 5–7) navigated a new two-way DLBE program (Portuguese–English) in the U.S. state of Massachusetts. By looking into how the children interacted and participated in class, we foreground how they contributed to the maintenance of the program as two-way DLBE implementers. Research Design: This article draws from a larger ethnographic research study conducted over three school calendar years (2018–2021). It leverages field notes from weekly classroom visits in the two-way DLBE program and semistructured interviews with 18 school staff members. Data sources were coded using thematic analysis, with attention to how immigrant children’s actions contributed to teachers’ instruction and how these contributions were perceived by educators and other staff members. Findings/Conclusions: Brazilian immigrant students in K–2 classrooms contributed daily to the implementation of their two-way DLBE program through language brokering across Portuguese- and English-medium classrooms, facilitating peer participation in class, and invoking transborder memories in ways that complexified the ongoing classroom discourse. However, two-way DLBE educators and other staff members characterized newcomer students from Brazil as bringing key linguistic assets to school while positioning the children born in Brazilian immigrant households in the United States as “caught in-between” languages and undermining the program implementation. These findings suggest the need for a holistic focus on immigrant childhoods in two-way DLBE programming.

Background/Objectives: The purpose of this article (a comparative analysis of state laws) is to thoroughly examine enacted state-level healthy universal school meals bills to summarize bill content and determine current practices for program implementation and long-term viability, with special attention to the Community Eligibility Provision (CEP). Methods: Bills enacted at the state level, as of 31 December 2025, were located electronically on state legislature websites and subsequently reviewed with rules, regulations, and implementation guidelines. Content analyses were conducted to identify patterns, themes, and key concepts pertaining to healthy universal school meals laws and program implementation guidelines to inform comparison policy analyses. Results: Nine states (California, Colorado, Maine, Massachusetts, Michigan, Minnesota, New Mexico, New York, and Vermont) have healthy universal school meals laws that include mandatory funding provisions for programming. Michigan is the only state that has a non-permanent law. Such laws eliminate requirements to certify individual students for free, reduced-price, or full-price meals based on their household income, and instead allow entire schools and/or school districts to offer all enrolled students no-cost meals. All states are funding healthy universal school meals programming by leveraging existing or new tax revenue to bridge the gap between the cost of school meals and federal meal reimbursements. Conclusions: State laws that leverage the Community Eligibility Provision (CEP) have become a key way to sustain universal school meal programs when federal funding falls short. States that direct resources to high-poverty schools, help districts determine the most accurate Identified Student Percentage, and reduce undercounting through strong direct-certification practices are better positioned to maintain universal meals over time. These strategies strengthen both child health and academic outcomes by ensuring stable access to no-cost, nutritious meals.

Moving pharmacy forward: Student pharmacists “embrace and advocate change in the profession”

Telehealth and Nutrition Support During the COVID-19 Pandemic