Federal Facility Research Articles

Multiomics Profiling Distinguishes Sebaceous Carcinoma from Benign Sebaceous Neoplasms and Provides Insight into the Genetic Evolution of Sebaceous Carcinogenesis.

Sebaceous carcinoma is the third most common nonkeratinocyte skin cancer in the United States with 1,000 cases per year. The clinicopathologic features of sebaceous carcinoma and benign sebaceous neoplasms (adenomas, sebaceomas) can overlap, highlighting the need for molecular biomarkers to improve classification. This study describes the genomic and transcriptomic landscape of sebaceous neoplasms in order to understand tumor etiology and biomarkers relevant for diagnosis and treatment. We performed whole-genome sequencing (WGS) and whole-transcriptome sequencing (WTS) of sebaceous neoplasms from six academic and two federal healthcare facilities in the United States diagnosed between January 1, 1999, and December 31, 2021. We evaluated 98 sebaceous neoplasms: 64 tumors (32 adenomas, 2 sebaceomas, 5 atypical sebaceous neoplasms, 25 carcinomas) had sufficient material for WGS, 96 tumors (42 adenomas, 11 sebaceomas, 8 atypical sebaceous neoplasms, 35 carcinomas) had sufficient material for WTS, and 62 tumors (31 adenomas, 2 sebaceomas, 5 atypical sebaceous neoplasms, 24 carcinomas) had sufficient material for combined WGS and WTS. Overall, we found decreased cholesterol biosynthesis and increased TP53 mutations, copy number gains (chromosome 6, 8q, and/or 18), and tumor mutation burden-high (>10 mutations/MB) in carcinomas compared to adenomas. Although diminished compared to adenomas, most carcinomas still had higher cholesterol biosynthesis than nonmalignant skin. Multiomics profiling also supported a precancerous model of tumor evolution with sebaceomas and atypical sebaceous neoplasms being likely intermediate lesions. The study findings highlight key diagnostic biomarkers for sebaceous carcinoma and suggest that immunotherapy and modulation of cholesterol biosynthesis could be effective treatment strategies.

Weight gain and social support networks in Canadian federal correctional facilities

Weight gain and social support networks in Canadian federal correctional facilities

The Adoption of Electronic Procurement and Readiness Assessment in Central Ethiopia Regional State

Electronic procurement is a digitalized means of procurement processes. This study aims to assess its applicability in the central Ethiopia regional state by studying the hindrance factors and the opportunity that can come for the construction sector of the region. A descriptive and explorative study approach has been performed. Qualitative data from public procurement administrators, IT professionals, and construction stakeholders were collected through interviews. -P nor eGP has not been introduced to the region yet. Also to use it factors such as the knowledge gap, lack of infrastructure provisions, and collaboration works with fear of losing competitiveness were probable hindrances. On the other hand, resource-saving, increasing transparency, and accuracy of bid evaluation were found as main probable opportunities. Incorporating practitioners, and combining system development with an adaptability test can provide useful input for further. Timely support from the federal government, capacity-building programs, facility and infrastructure development, and government enforcing mechanisms were found as necessary matters to implement the e-P system for the construction sector. This research is the first study in the area with this topic and also it is a very new topic as a country in general. Hence, in a way, it introduced the system for the pubic construction procurement of the region and stakeholders. The findings contribute as a source to the public body for the launch of the eGP Ethiopia in the region, and a lead for private developers. Additionally, it implements the very nature of the research which is multidisciplinary by incorporating IT professionals.

Associations between toxicity-weighted concentrations and dementia risk: Results from the Cardiovascular Health Cognition Study

BackgroundAir pollution is a modifiable risk factor for dementia. Yet, studies on specific sources of air pollution (i.e., toxic chemical emissions from industrial facilities) and dementia risk are scarce. We examined associations between toxicity-weighted concentrations of industrial pollution and dementia outcomes among a large, multi-site cohort of older adults. MethodsParticipants (n = 2770) were ≥ 65 years old (Mean = 75.3, SD = 5.1 years) from the Cardiovascular Health Cognition Study (1992–1999). Toxicity-weighted concentrations were estimated using the Risk Screening Environmental Indicator (RSEI) model which incorporates total reported chemical emissions with toxicity, fate, and transport models. Estimates were aggregated to participants' baseline census tract, averaged across 1988–1992, and log2-transformed. Dementia status was clinically adjudicated in 1998–1999 and categorized by subtype (Alzheimer's, vascular, mixed). We assessed whether RSEI-estimated toxicity-weighted concentrations were associated with 1) odds of prevalent dementia and 2) incident dementia risk by subtype. ResultsAfter adjusting for individual and census-tract level covariates, a doubling in toxicity-weighted concentrations was associated with 9 % higher odds of prevalent dementia (OR = 1.09, 95 % CI: 1.00, 1.19). In discrete-time survival models, each doubling in toxicity-weighted concentrations was associated with a 16 % greater hazard of vascular dementia (HR = 1.16, 95 % CI: 1.01, 1.34) but was not significantly associated with all-cause, Alzheimer's disease, or mixed dementia (p's > 0.05). DiscussionLiving in regions with higher toxicity-weighted concentrations was associated with higher odds of prevalent dementia and a higher risk of incident vascular dementia in this large, community-based cohort of older adults. These findings support the need for additional studies to examine whether toxic chemical emissions from industrial and federal facilities may be a modifiable target for dementia prevention.

The effect of substance use Certificate‐of‐Need laws on access to substance use disorder treatment facilities

AbstractWe investigate how substance use Certificate‐of‐Need (CON) laws influence access to substance use disorder treatment facilities in the United States. We use the National Directory of Drug and Alcohol Abuse Treatment Facilities data set, which lists all federal, state, and local government facilities and private facilities that provide substance use treatment services in 2020. Based on the locations of these facilities, we develop a novel access index to substance use disorder treatment facilities that accounts for driving distance and duration to measure the ease of reaching these facilities for individuals living at the population‐weighted county centroids. We find that counties in states with CON laws that border counties without such laws have nearly 10% less spatial accessibility to substance use disorder treatment facilities at a 5% level of significance.

Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients.

There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers. A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument. Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10). This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.

Intellectual and developmental disabilities in Ontario's criminal justice and forensic mental health systems: Using data to tell the story.

International studies show that adults with intellectual and developmental disabilities (IDD) are disproportionately represented in the criminal justice and forensic mental health systems; however, it is difficult to capture their involvement across systems in any one jurisdiction. The current study aimed to estimate the prevalence of IDD across different parts of the criminal justice and forensic mental health systems in Ontario and to describe the demographic and clinical profiles of these individuals relative to their counterparts without IDD. This project utilised administrative data to identify and describe the demographic and clinical characteristics of adults with IDD and criminal justice or forensic involvement across four sectors: federal correctional facilities, provincial correctional facilities, forensic inpatient mental health care and community mental health programmes. Questions were driven by and results were contextualised by a project advisory group and people with lived experience from the different sectors studied, resulting in a series of recommendations. Adults with IDD were over-represented in each of the four settings, ranging from 2.1% in federal corrections to 16.7% in forensic inpatient care. Between 20% (forensic inpatient) and 38.4% (provincial corrections) were under the age of 25 and between 34.5% (forensic inpatient) and 41.8% (provincial corrections) resided in the lowest income neighbourhoods. Medical complexity and rates of co-occurring mental health conditions were higher for people with IDD than those without IDD in federal and provincial corrections. Establishing a population-based understanding of people with IDD within these sectors is an essential first step towards understanding and addressing service and care needs. Building on the perspectives of people who work in and use these systems, this paper concludes with intervention recommendations before, during and after justice involvement.

Important issues of professional burnout among hematologists and hematology department nursing staff during the COVID-19 pandemic

Background. Professional burnout (PB) among medical staff, namely hematologists, is of major importance, especially given the current shortage of personnel. It is of extreme value during the COVID-19 pandemic.Aim. To determine the degree of PB development among hematologists and nursing staff of hematological departments of federal and regional medical institutions in the context of the COVID-19 pandemic and to identify the associated factors.Materials and methods. The study was conducted in the period from July 2022 to September 2022 in the form of a onetime online survey of hematologists and nursing staff of hematology departments of federal and regional medical institutions in different cities of the Russian Federation. To interview specialists, a special checklist based on an Internet resource (Google forms) was used. It included burnout questionnaire Maslach Burnout Inventory (MBI) and questions related to factors that may be associated with the formation of PB. Statistical analysis included pairwise and multiple comparisons, as well as χ2 test, correlation and logistic regression analysis.Results. A total of 162 specialists took part in the online survey. More than half of the specialists (52 %) had high degree of emotional exhaustion, high level of depersonalization was detected in 39.5 % of specialists, and low level of personal accomplishment – in one third of specialists (32.1 %). It was shown that physicians, compared with nurses, had significantly higher indicators of PB. The level of problems for all PB components was significantly lower among specialists working in federal health facilities than among specialists working in regional clinics. The specialists who worked in the “red zone” showed a greater degree of emotional exhaustion and depersonalization than the specialists who did not work in the “red zone” during the pandemic. The formed PB syndrome was observed in 16 % of specialists, and its signs – in 42 %. The risk of PB was significantly greater in hematologists than in nurses, as well as among specialists with increased levels of depression and anxiety and dissatisfaction with the level of personal protective measures.Conclusion. The high importance of PB and the need for preventive measures among specialists of hematological centers and hematology departments in the Russian Federation is shown.

Package Performance Study: A Historical Perspective and Planning for a Path Forward

The topic of spent nuclear fuel (SNF) transportation often draws public attention and concerns regarding safety, and with large-scale shipping campaigns expected in the future, public interest is anticipated to substantially increase. In 1999, the U.S. Nuclear Regulatory Commission (NRC) began an initiative called the Package Performance Study (PPS) that initially focused on SNF transportation cask responses to severe transportation accidents. A public participation approach was to be used to help guide the scope and parameters of the study, which was also to consider using full-scale physical testing of a SNF transportation cask, where appropriate. In 2010, the NRC decided not to go forward with physical testing as proposed. In 2006, the National Academy of Sciences (NAS) conducted a study on SNF and high-level radioactive waste transportation in the United States. The NAS study recommended that full-scale cask testing, as well as other accepted methodologies, continue to be used as part of the package performance evaluation. In 2012, the Blue Ribbon Commission on America’s Nuclear Future (BRC) recommended conducting the PPS with a full-scale rail transportation cask for the purpose of building public trust and confidence in the safety of SNF transport. In 2021, the U.S. Department of Energy (DOE) restarted a consent-based siting process, focusing on how to site federal facilities for the interim consolidated storage of SNF using a consent-based approach. Large-scale SNF transportation would be necessary for any such interim storage facility. As the planning activities begin for future large-scale shipping campaigns, the DOE is considering options for conducting a DOE-led PPS to help build public trust and confidence in the transportation of SNF. Therefore, the DOE is gathering information related to the previous NRC-led PPS efforts, as well as applicable international experience with the testing of SNF packages. This paper discusses previous NRC efforts, as well as the current status of a DOE-led PPS, which is in the early planning stages.

A step towards the final frontier: Lessons learned from acceptance testing of the first HPE/Cray EX 3000 system at ORNL

SummaryIn this article, we summarize the deployment of the Air Force Weather (AFW) HPC11 system at Oak Ridge National Laboratory (ORNL) including the process followed to successfully complete acceptance testing of the system. HPC11 is the first HPE/Cray EX 3000 system that has been successfully released to its user community in a federal facility. HPC11 consists of two identical 800‐node supercomputers, Fawbush and Miller, with access to two independent and identical lustre parallel file systems. HPC11 is equipped with Slingshot 10 interconnect technology and relies on the HPE Performance Cluster Manager software for system configuration. ORNL has a clearly defined acceptance testing process used to ensure that every new system deployed can provide the necessary capabilities to support user workloads. We worked closely with HPE and AFW to develop a set of tests that used the United Kingdom's Meteorological Office's Unified Model and 4‐dimensional variational data assimilation. We also included benchmarks and applications from the Oak Ridge Leadership Computing Facility portfolio to fully exercise the HPE/Cray programming environment and evaluate the functionality and performance of the system. Acceptance testing of HPC11 required parallel execution of each element on Fawbush and Miller. In addition, careful coordination was needed to ensure successful acceptance of the newly deployed lustre file systems alongside the compute resources. In this work, we present test results from specific system components and provide an overview of the issues identified, challenges encountered, and the lessons learned along the way.

Acceptance of Insurance by Psychiatrists and Other Physicians, 2007-2016.

The authors aimed to analyze psychiatrists' and other physicians' acceptance of insurance and the associations between insurance acceptance and specific physician- and practice-level characteristics. Using the restricted version of the National Ambulatory Medical Care Survey, January 2007-December 2016, the authors analyzed acceptance of private insurance, public insurance, and any insurance among psychiatrists compared with nonpsychiatrist physicians. Because data were considered restricted, all analyses were conducted at federal Research Data Center facilities. The unweighted sample included an average of 4,725 physicians per 2-year time grouping between 2007 and 2016, with an average of 7% being psychiatrists. Nonpsychiatrists participated in all insurance networks at higher rates than did psychiatrists, and the acceptance gap was wider for public (Medicare and Medicaid) than private (noncapitated and capitated) insurance. Among psychiatrists, those practicing in metropolitan statistical areas and those in solo practices were significantly less likely than their peers in other locations and treatment settings to accept private, public, or any insurance. These findings were also observed among nonpsychiatrists, although to a lesser extent. In addition to general policy interventions to improve insurance network adequacy for psychiatric care, additional measures or incentives to promote insurance network participation should be considered for psychiatrists in solo practices and those in metropolitan areas.

Poster 396: Barriers and facilitators to national licensure for US medical professionals: what Covid has taught us and using sports medicine as a launch pad

Objectives: GLOBAL AIM: Increase license portability across state lines for all US medical professionals. SPECIFIC AIM: Increase the ability to provide medical care nationwide for all US sports medicine physicians (who have a CAQ for their specialty) across state lines and set a precedent for other licensed healthcare professionals by 2026. The aim is to extend the portability of medical licensure across state lines to all sports medicine professionals (not just those who care for professional teams) and use this as a precedent eventually for all types of healthcare workers. Currently sports medicine physicians for professional teams are allowed to provide care across state lines which is legislated by “The Sports Medicine Licensure Clarity Act” (SMLCA) in 2018. As July 22, 2022, licensure is allowed for at least telemedicine across state lines for 23 states and has been extended by the HHS as part of Covid healthcare measures that were implemented in 2020. Methods: Review of current policies, barriers and facilitators has been performed using various search strategies and qualitative techniques. Current state and national laws were reviewed and will be presented. California has a large population where there is no reciprocity for other medical professionals, therefore meetings have been set with the Business Professions Committee with a plan to submit a bill sponsored by a state assemblyman to expand access to licensure across state lines in 2023. Results: One barrier is the loss of states’ autonomy as well as the individual authority and stature a medical professional may gain from being on a licensing board. Most US states have no reciprocity and not all have the licensure process standardized. Some states have a non-transparent process and others do not wish to participate in regional compacts such as California. Even more concerning, some states are found to more-likely censure doctors of color and perform sham peer review. This is an example of bias in medical credentialing that can impede diversity and inclusion efforts. The European Union allows medical licensure across national borders. Doctors need to pass a language proficiency test for the country they wish to practice in, regardless of which European country they received their medical training. Given that English is the only language of instruction in the US, proficiency can be easily evaluated. Language should not be a barrier to license portability, especially if one is already licensed in one US state even for foreign medical graduates. The Covid pandemic showed licensure is obtainable in a relatively rapid fashion across state lines. In addition, federal health care facilities such as the VA system already allow practitioners licensed in one state to practice in another without a license to that specific state. Portability across state-lines aids practitioners who practice on state borders in both rural and urban areas, such as the NH and VT border(rural), and NY and DC metro areas (urban) as well as telehealth for both an immobile and mobile populations, enhancing equitable healthcare access. This also removes financial barriers of cost for licensing fees for practitioners and staff resources to process licenses. Conclusions: The US has one of the most restrictive medical licensures of all developed countries, making mobilization of healthcare workers extremely difficult. Removing this barrier will be beneficial when medical staff is needed across state lines for pandemics, natural disasters, intake of refugees/immigrants, and global sporting events held in the US such as the World Cup in 2026, and Olympics in 2028. This could also extend access for the general US population to healthcare providers via “tele-medicine” (virtual/video visits), to essentially all populations (socio-economically disadvantaged, immigrants, those with mobility and transportation barriers, rural locations etc). This will ensure higher quality care, better follow-up along with more timely and equitable healthcare, which are all currently limited by restricting portability and requiring licenses for each individual state.

Analysis of cranioplasty procedures performed in Novosibirsk from 2016 to 2022

Background: Studies on reconstructive neurosurgical interventions are always relevant due to the persistence of cranial defects, mainly caused by traumatic brain injuries (TBI). To provide medical care to the patients with cranial defects more efficiently, it is necessary to assess a large number of surgical interventions in studies.Objective: To analyze data on reconstructive neurosurgical interventions performed at Novosibirsk hospitals.Methods: We performed a multicenter observational retrospective non-randomized study of the total cranioplasty surgical interventions from 2016 to 2022. The study involved five neurosurgical departments in Novosibirsk hospitals. In 450 of 673 cases the inclusion criteria were met.Results: The majority of patients (n = 361; 80.2%) underwent surgical interventions in federal health facilities. Urban residents prevailed (n = 260) among the patients who met the inclusion criteria. Craniectomies were mainly indicated for the consequences of TBI (n = 319; 70.9%). Time to cranioplasty ranged from 0.1 to 320 months (mean: 23.9 ± 39.2; median: 11.6 months). There were non-clinically significant differences in terms of primary and reconstructive operations between the defects caused by TBI and other conditions. In 51.1% of cases, we found two features describing the size and complexity of the skull defect. In 19.3% of cases, patients were diagnosed with a skull defect (affected anatomical areas were specified).Conclusions: Over seven years, 450 Novosibirsk residents underwent cranioplasty in five neurosurgical Novosibirsk hospitals (mean: 64.3 surgical interventions a year). Comparing the recent results with previous studies data in terms of performed craniectomies, we found that reconstructive interventions are lacking 99.7 cases per year. To reduce the time to cranioplasty, it is necessary to make a registry of patients with skull defects.

Between and Across Institutions: Multiple Removals, Settler Colonialism, and Histories of the West

In the early 2000s, Faith O’Neil (Sisseton-Wahpeton Oyate) sought answers about what had happened to her family members incarcerated at the Canton Asylum for Insane Indians—a federal facility opened in South Dakota in1902 and overseen by the Bureau of Indian Affairs (BIA). Around the same time, I sought answers in the National Archives, trying to understand lived histories in Canton’s locked wards. As I researched and started writing a book about people on the inside of Canton and their kin outside of it, I collaborated with tribal historians and activists. When I began contacting descendants to offer digital copies of archived sources about their kin, Faith O’Neil answered my letter. O’Neil’s decision to share her own historical sources and family memories with me, and our joint research efforts while I completed my book project, set in motion a different approach to interpreting institutions and Western history.1 (1) According to Faith O’Neil, her mother Cora Winona Faribault was born on September 28, 1926, at the Canton Asylum. Faith’s grandmother, Elizabeth Alexis Faribault (Sisseton-Wahpeton Dakota), had been detained at the Indian Asylum since 1915. For years she was forced to work in asylum superintendent Harry Hummer’s bungalow—right up until she gave birth to Cora Winona. Shortly after delivering the child, Dr. Hummer informed concerned administrators at the Bureau of Indian Affairs that Faribault’s inherent defectiveness caused the unexpected pregnancy. Hummer—the same person who exploited Faribault’s coerced work—assured the BIA that Faribault was well cared for at the institution. He further argued that it was in her best interest to remain there. The commissioner concurred. Mother and child would be kept together in locked wards for several more years.2 (2)

Guidelines in Practice: Patient Information Management.

Patient information management can involve paper and electronic documentation. Because the patient's health care record (HCR) is a legal document, it must provide an accurate representation of care. The record contains protected health information and must be secure. In addition, the documentation must adhere to local, state, and federal regulations and facility policies; it also may incorporate recommendations from national professional guidelines. The AORN "Guideline for patient information management" was recently updated and provides evidence-based best practices for comprehensive perioperative documentation that aligns with the nursing workflow. This article includes an overview of patient information management and discusses recommendations for health information technology, the patient HCR, perioperative record design, documentation and nursing workflow, informed consent documentation, order documentation, modifying patient HCRs, education, policies and procedures, and quality. Perioperative nurses should review the guideline in its entirety and apply the recommendations for patient information management as applicable to their individual roles.

Midterm Durability and Structural Valve Degeneration of Transcatheter Aortic Valve Replacement in a Federal Facility.

Transcatheter aortic valve replacement (TAVR), previously reserved for patients of intermediate to prohibitive surgical risk, has now been expanded to patients of any surgical risk with severe aortic stenosis. Bioprostheses are prone to structural valve degeneration (SVD), a progressive and multifactorial process that limits valve durability. As the population undergoing TAVR shifts toward a lower-risk and younger profile, long-term durability is a crucial determinant for patient outcomes. Our objective was to determine the incidence and risk factors of SVD at midterm follow-up in a veteran TAVR population. Patients undergoing TAVR at our federal facility were retrospectively evaluated for SVD and other endpoints with standardized consensus criteria. Multivariable Cox proportional hazards analysis was performed to evaluate risk factors for mortality and SVD. From 2013 to 2020, 344 patients (median age, 78 years) underwent TAVR. Survival from all-cause mortality was 91.3% at 1 year, 75.1% at 3 years, and 61.7% at 5 years. Cumulative freedom from SVD was 98.2% at 1 year, 96.5% at 3 years, and 93.7% at 5 years. All 13 patients with SVD met hemodynamic criteria, and 1 required intervention. Median time to hemodynamic SVD was 1.04 years. Independent risk factors for SVD included age (hazard ratio [HR] = 0.92, 95% confidence interval [CI]: 0.86 to 0.99) and valve size (HR = 0.19, 95% CI: 0.04 to 0.89). SVD was evident at a low but detectable rate at 5-year follow-up. Further understanding of TAVR biomechanics as well as continued longer-term follow-up will be essential for informing patient-specific risk of SVD.

From Procurement to Consumption: A Model to Understand Nutrition Policy Implementation in Permanent Supportive Housing

Background: Food insecurity has become an increasingly complex public health issue across the United States, particularly among various people battling with current or previous homelessness. This project sought to understand the food system in permanent supportive housing sites (PSH) that serve formerly homeless individuals and to explore the use of nutrition standards, specifically the Food Service Guidelines for Federal Facilities (FSGFFs), in this context. Methods: Participants were members of the administrative staff involved in the food procurement process, food preparation, administrative tasks, and daily operations in a small-intensive program managed by a local nonprofit agency that serves 12 adults over the age of 18 who experience chronic homelessness and persistent mental illness, or substance use disorders, and a second PSH site that helps 41 low-income adults with health conditions experiencing homelessness. The PSH Inquiry Tool (PSH-IT) was developed to better understand the business operations at each site, and the PSH Audit (PSH-A) was created to assess the applicability of FSGFF at each site. Results: Findings suggest that funding mechanisms, staff training, staff capacity, and access to nutrition education were critical barriers to the successful development and implementation of nutrition standards in PSH sites. Furthermore, findings suggest that adaptations to FSGFFs are required before implementation at PSH sites. Conclusion: This report advocates for increased involvement of community stakeholders to support nutrition policy development and implementation, a nutrition policy that impacts all levels of the food system from procurement to consumption, and local, state, or federal policy changes to support improved nutrition in PSH.

Dual-Energy, Dual-Exposure PA and Lateral Chest Radiograph: Not Your Father's Chest X-Ray.

In the last two decades, our military and federal health care facilities have transitioned from traditional X-rays exposing film screen systems, developed much like photographic film, to an entirely digital detection system that affords computer processing of images and digital image and report distribution. While health care providers are well aware of the practicality of these advancements, they may not be aware of the improved diagnostic capabilities afforded by these new methods. In this report, we outline how application of physical principles of X-rays, with digital detectors and computer data manipulation, can present images demonstrating chest and heart diseases that were previously not readily visible by traditional film screen systems. More recently, dual-energy, dual-exposure systems have been implemented. This commentary is to educate the medical community so that they may better understand not only the written report but the information on the images being provided, along with potential pitfalls to avoid. Specifically, we demonstrate improved detection of pulmonary nodules and coronary atherosclerosis with the dual-energy technique.

Machine Learning Forecasts to Reduce Risk of Entrainment Loss of Endangered Salmonids at Large-Scale Water Diversions in the Sacramento–San Joaquin Delta, California

Incidental entrainment of fishes at large-scale state and federal water diversion facilities in the Sacramento-San Joaquin Delta, California, can trigger protective management actions when limits imposed by environmental regulations are approached or exceeded. These actions can result in substantial economic costs, and likewise they can affect the status of vulnerable species. Here, we examine data relevant to water management actions during January–June; the period when juvenile salmonids are present in the Delta. We use a quantile regression forest approach to create a risk forecasting tool, which can inform adjustments of diversions based on near real-time predictions. Models were trained using historical entrainment data (Water Years 1999–2019) for Sacramento River winter-run Chinook Salmon or Central Valley Steelhead and a suite of environmental and water operations metrics. A range of models was developed; their performance was evaluated by comparison of a quantile loss metric. The models were validated through examination of partial dependence plots, cross-validation procedures, and further evaluated through WY 2019 pilot testing, which integrated real-world uncertainty in environmental parameters into model predictions. For both species, the strongest predictor of loss was the previous week’s entrainment loss. In addition, risk increased with higher water exports and more negative Old and Middle Rivers (OMR) flows. Point estimates of loss were modestly correlated with observations (R2 0.4 to 0.6), but the use of a quantile regression approach provided reliable prediction intervals. For both species, the predicted 75th quantile appears to be a robust and conservative estimator of entrainment risk, with overprediction occurring in fewer than 20% of cases. This quantile balances the magnitude of over- and under-prediction and results in a low probability (< 5% of predictions) of unexpected high-take events. These models, and the web-based application through which they are made accessible to non-technical users, can provide a useful and complementary approach to the current system of managing entrainment risk.

Differences in obstetric practices and outcomes of postpartum hemorrhage across Nigerian health facilities.

ObjectiveTo explore differences in obstetric practices and clinical outcomes of postpartum hemorrhage (PPH) in Nigerian facilities.MethodsA descriptive cross‐sectional study of public health facilities providing maternal healthcare services in Nigeria. Surveys were conducted across 38 purposively sampled facilities (January 2020–March 2021) to collect information on obstetric practices related to the management of the third stage of labor, treatment of postpartum hemorrhage, and clinical outcomes related to postpartum hemorrhage in the preceding 12 months.ResultsThe median number of annual births per facility was 2230 (IQR, 1952–3283). The cesarean section rate was 21.6% (range 2.1%–52.6%). There was large variability in PPH rate (median 3%, range 0.4%–16.8%) and blood transfusions for PPH (median 2.8%, range 0.4%–48.6%) after vaginal birth. There was less variability for laparotomies (median 0.25%, range 0%–2.8%) and maternal deaths (median 0.11%, range 0%–0.64%) due to PPH after vaginal birth. The number of maternal deaths from all causes varied (median 0.27%, range 0%–3.5%). The rates of PPH and adverse maternal outcomes did not vary substantially between state or federal facilities, region, type of facility, and the number of clinical staff.ConclusionAcross the Nigerian facilities surveyed there was large variation in PPH rates and adverse maternal outcomes due to PPH. This variability remains largely unexplained and requires further insights and detailed data to gain a deeper understanding of the root causes and challenges to implement customized solutions to improve maternal outcomes.