Characterizing the impacts of public health control measures on domestic violence services: qualitative interviews with domestic violence coalition leaders.

BACKGROUND: Prior to the availability of pharmaceutical control measures, non-pharmaceutical control measures, including travel restrictions, physical distancing, isolation and quarantine, closure of schools and workplaces, and the use of personal protective equipment were the only tools available to public health authorities to control the spread of COVID-19. The implementation of these non-pharmaceutical control measures had unintended impacts on the ability of state and territorial domestic violence coalitions to provide services to victims. METHODS: A semi-structured interview guide to assess how the COVID-19 pandemic impacted service provision and advocacy generally, and how COVID-19 control measures specifically, created barriers to services and advocacy, was developed, pilot tested, and revised based on feedback. Interviews with state and territorial domestic violence coalition executive directors were conducted between November 2021 and March 2022. Transcripts were inductively and deductively coded using both hand-coding and qualitative software. RESULTS: Forty-five percent (25 of 56) of state and territorial domestic violence coalition executive directors representing all 8 National Network to End Domestic Violence (NNEDV) regions were interviewed. Five themes related to the use of non-pharmaceutical pandemic control measures with impacts on the provision of services and advocacy were identified. CONCLUSIONS: The use of non-pharmaceutical control measures early in the COVID-19 pandemic had negative impacts on the health and safety of some vulnerable groups, including domestic violence victims. Organizations that provide services and advocacy to victims faced many unique challenges in carrying out their missions while adhering to required public health control measures. Policy and preparedness plan changes are needed to prevent unintended consequences of control measure implementation among vulnerable groups as well as to identify lessons learned that should be applied in future disasters and emergencies.

Standardized Tracheostomy Education Across the Enterprise.

PURPOSE: The purpose of this quality improvement project was to create a Tracheostomy Subject Matter Expert (Trach SME) Committee to standardize tracheostomy care, education, and the discharge process across Boston Children's Hospital. DESIGN AND METHODS: Boston Children's Hospital (BCH) is a free-standing urban tertiary pediatric hospital with 15 inpatient units. The newly formed Trach SME Committee evaluated the discharge process across the enterprise including hospital satellites and intra-hospital practice. Education materials were centralized, and policies were reviewed, revised and standardized to reflect current best practice. The Trach SME provided education to Trach Champions from each area that became resources for their respective units. The Trach SME also developed measurement outcomes to assess the effectiveness of the education process. RESULTS: In the implementation year of 2104, our 7-day unplanned readmission rate for tracheostomy patients was 18.18%. This rate decreased to 6.67% in 2015 and to 0% in 2016. In 2015, we began to monitor 30-day unplanned readmissions and the rate was 6.67% in 2015 and decreased to 0% in 2016. CONCLUSIONS AND PRACTICE IMPLICATIONS: Standardization of policies, procedures and caregiver educational materials for the management of patients with a tracheostomy tube improved tracheostomy care across the enterprise and reduced tracheostomy readmission rates.

Nursing-led Home Visits Post-hospitalization for Children with Medical Complexity.

PURPOSE: Hospital discharge for children with medical complexity (CMC) can be challenging for families. Home visits could potentially benefit CMC and their families after leaving the hospital. We assessed the utility of post-discharge home visits to identify and address health problems for recently hospitalized CMC. DESIGN AND METHODS: A prospective study of 36 CMC admitted to a children's hospital from 4/15/2015 to 4/14/2016 identified with a possible high risk of hospital readmission and offered a post-discharge home visit within 72h of discharge. The visit was staffed by a hospital nurse familiar with the child's admission. The home visit goals were to reinforce education of the discharge plan, assess the child's home environment, and identify and address any problems or issues that emerged post-discharge. RESULTS: The children's median age was 6years [interquartile range (IQR) 2-18]. The median distance from hospital to their home was 38miles (IQR 8-78). All (n=36) children had multiple chronic conditions; 89% (n=32) were assisted with medical technology. The nurse identified and helped with a post-discharge problem during every (n=36) visit. Of the 147 problems identified, 26.5% (n=39) pertained to social/family issues (e.g., financial instability), 23.8% (n=35) medications (e.g., wrong dose), 20.4% (n=30) durable medical equipment (e.g., insufficient supply or faulty function), 20.4% (n=30) child's home environment (e.g., unsafe sleeping arrangement), and 8.8% (n=13) child's health (e.g., unresolved health problem). CONCLUSIONS: Home visits helped identify and address post-discharge issues that occurred for discharged CMC. PRACTICAL IMPLICATIONS: Hospitals should consider home visits when optimizing discharge care for CMC.

Piecing together female extra-pair mate choice: females really do prefer more ornamented males.

Evolutionary biologists have long been fascinated by extravagant male traits that abound across the animal kingdom and yet convey no apparent benefits to survival. From isopods to elephants, from armaments to ornaments, researchers have spent decades studying male-male competition and female mate choice in an effort to understand the significance of these secondary sexual characteristics. Among socially monogamous species, a frequently proposed explanation for the existence of male ornaments is that they are indicators of male genetic quality subject to female extra-pair mate choice. However, despite over two decades of extensive research into extra-pair paternity (EPP), the evidence that females actually choose more ornamented extra-pair sires is surprisingly scant. Consequently, whether EPP and female choice have contributed to the evolution of male ornaments in socially monogamous species, and what fitness benefits (if any) they signal to females, remains unclear. Progress in this field has been hampered by the challenge of dissociating clear female choice for ornamentation from confounding factors. In this issue of Molecular Ecology, Whittingham & Dunn (2016) use an experimental approach in a bird species with very high rates of EPP to tease apart these correlative effects. In doing so, they demonstrate clearly that male ornamentation is subject to female extra-pair mate choice. Their findings further suggest that EPP can be adaptive for females, and represent an important step forward in validating the role of EPP as an evolutionary driver of ornamental elaboration in socially monogamous species.

Pregnancy-induced remodeling of heart valves.

Recent studies have demonstrated remodeling of aortic and mitral valves leaflets under the volume loading and cardiac expansion of pregnancy. Those valves' leaflets enlarge with altered collagen fiber architecture, content, and cross-linking and biphasic changes (decreases, then increases) in extensibility during gestation. This study extends our analyses to right-sided valves, with additional compositional measurements for all valves. Valve leaflets were harvested from nonpregnant heifers and pregnant cows. Leaflet structure was characterized by leaflet dimensions, and ECM composition was determined using standard biochemical assays. Histological studies assessed changes in cellular and ECM components. Leaflet mechanical properties were assessed using equibiaxial mechanical testing. Collagen thermal stability and cross-linking were assessed using denaturation and hydrothermal isometric tension tests. Pulmonary and tricuspid leaflet areas increased during pregnancy by 35 and 55%, respectively. Leaflet thickness increased by 20% only in the pulmonary valve and largely in the fibrosa (30% thickening). Collagen crimp length was reduced in both the tricuspid (61%) and pulmonary (42%) valves, with loss of crimped area in the pulmonary valve. Thermomechanics showed decreased collagen thermal stability with surprisingly maintained cross-link maturity. The pulmonary leaflet exhibited the biphasic change in extensibility seen in left side valves, whereas the tricuspid leaflet mechanics remained largely unchanged throughout pregnancy. The tricuspid valve exhibits a remodeling response during pregnancy that is significantly diminished from the other three valves. All valves of the heart remodel in pregnancy in a manner distinct from cardiac pathology, with much similarity valve to valve, but with interesting valve-specific responses in the aortic and tricuspid valves.

Conditions for a Rh(I)-catalyzed [2 + 2 + 1] cycloaddition reaction with methyl substituted allenes and alkynes.

The direct installation of the C4 and C10 methyl groups present in the 6,12-guaianolide framework using a Rh(I)-catalyzed cyclocarbonylation reaction of methyl subsituted allenes and alkynes is described. High yields of bicyclo[5.3.0]decanes are afforded when low reaction concentrations involving syringe pump addition of the allene-yne to the catalyst are used.

Maternal exercise before and during pregnancy does not impact offspring exercise or body composition in mice.

BACKGROUND: The genome, the environment, and their interactions simultaneously regulate complex traits such as body composition and voluntary exercise levels. One such environmental influence is the maternal milieu (i.e., in utero environment or maternal care). Variability in the maternal environment may directly impact the mother, and simultaneously has the potential to influence the physiology and/or behavior of offspring in utero, post birth, and into adulthood. Here, we utilized a murine model to examine the effects of the maternal environment in regard to voluntary exercise (absence of wheel running, wheel running prior to gestation, and wheel running prior to and throughout gestation) on offspring weight and body composition (% fat tissue and % lean tissue) throughout development (~3 to ~9 weeks of age). Additionally, we examined the effects of ~6 weeks of maternal exercise (prior to and during gestation) on offspring exercise levels at ~9 weeks of age. RESULTS: We observed no substantial effects of maternal exercise on subsequent male or female offspring body composition throughout development, or on the propensity of offspring to engage in voluntary wheel running. At the level of the individual, correlational analyses revealed some statistically significant relationships between maternal and offspring exercise levels, likely reflecting previously known heritability estimates for such traits. CONCLUSIONS: The current results conflict with previous findings in human and mouse models demonstrating that maternal exercise has the potential to alter offspring phenotypes. We discuss our negative findings in the context of the timing of the maternal exercise and the level of biological organization of the examined phenotypes within the offspring.

A Comparison of Antibiotic Serum Concentrations Drawn Simultaneously from Peripherally Inserted Central Catheters and Peripheral Veins in Children with Respiratory Infection.

The purpose of the study was to evaluate serum concentration of antibiotics drawn from a peripherally inserted central catheter (PICC) compared with a peripheral venipuncture. This prospective comparative study included patients with ages 1month to 21years admitted with a respiratory infection requiring IV vancomycin or IV tobramycin via a newly placed PICC. The difference between the antibiotic levels from the venipuncture and PICC samples was statistically significant for both the peak and trough levels. However, the difference in values was not enough to impact antibiotic dosing and therefore was not clinically significant.

Differential Development of the Chordae Tendineae and Anterior Leaflet of the Bovine Mitral Valve.

There is increasing evidence that some adult mitral valve pathologies may have developmental origins involving errors in cell signaling and protein deposition during valvulogenesis. While early and late gestational stages are well-documented in zebrafish, chicks, and small mammalian models, longitudinal studies in large mammals with a similar gestational period to humans are lacking. Further, the mechanism of chordae tendineae formation and multiplication remains unclear. The current study presents a comprehensive examination of mitral anterior leaflet and chordae tendineae development in a bovine model (a large mammal with the same gestational period as humans). Remarkably distinct from small mammals, bovine development displayed early branched chordae, with increasing attachments only until birth, while the anterior leaflet grew both during gestation and postnatally. Chordae also exhibited accelerated collagen deposition, maturation, and crimp development during gestation. These findings suggest that the bovine anterior leaflet and chordae tendineae possess unique processes of development despite being a continuous collagenous structure and could provide greater insight into human valve development.

Impact of dance interventions on the symptoms of dementia: A mixed-methods systematic review.

OBJECTIVES: This mixed-methods systematic review determined the impact of dance interventions on symptoms of Alzheimer's disease and related dementias (ADRD) among persons living in residential care. METHODS: Seven databases (Medline, EMBASE, CINAHL, PsycINFO, Web of Science, Ageline, and AMED) were searched. Studies published before June 2022 that investigated the impact of dance interventions on symptoms of ADRD were eligible for inclusion. Risk of bias was assessed using CASP, ROBINS-I, and ROB-2. Quantitative and qualitative objectives provided a convergent segregate narrative synthesis for the review. The review protocol was registered on PROSPERO (CRD42021220535). RESULTS: Two quantitative and two qualitative studies met the inclusion criteria. Dance interventions decreased levels of agitation and aggression, and improved behavioural and psychological symptoms. CONCLUSIONS: Studies suggest that dance interventions reduce the symptoms of dementia through increased expression, emotions, and improved relationships for persons with ADRD. However, the small number of included studies limits these conclusions.

Impacts of the COVID-19 Response on the Domestic Violence Workforce.

Many frontline and essential workers faced increased levels of stress, anxiety, depression, and even suicide ideation during the pandemic response. These and other factors led to burnout, shifts into non-patient or client-facing roles, or leaving an occupation altogether. Domestic violence advocates experienced increases in many types of stressors as they continued to provide essential services to victims and survivors during the pandemic. However, in most cases they did so without protections offered to essential workers, like priority access to personal protective equipment (PPE) or vaccines. Executive directors of U.S. State and Territorial Domestic Violence Coalitions were identified using the National Network to End Domestic Violence website and contacted via email to schedule key informant interviews. Interviews were conducted, recorded, and transcribed using Zoom. Themes were identified using both inductive and deductive coding. Twenty-five of 56 (45%) coalition executive directors completed an interview. Three main themes related to workforce were identified, including an accelerated rate of job turnover among both leadership and staff; a lack of essential worker status for domestic violence advocates; and unsustainable levels of stress, fear, and exhaustion. While familiar challenges drove these outcomes for this predominantly female, low-wage workforce, such as a lack of access to childcare, other factors, including the lack of access to PPE, training, and hazard pay for those working in person, highlighted inequities facing the domestic violence workforce. The factors identified as impacting the domestic violence workforce-turnover, low status, and high levels of stress, fear, and exhaustion-made the already challenging provision of advocacy and services more difficult. Domestic violence advocates are essential first responders and must be supported in ways that increase the resilience of empowerment-based services for victims and survivors.

On the sand and among the crowds: a new species of Woodworthia gecko (Reptilia: Diplodactylidae) from Auckland, Aotearoa/ New Zealand.

Woodworthia is a diverse genus of diplodactylid geckos found in Aotearoa/ New Zealand, with 17 likely species. Despite this diversity, only two species have been formally described: Woodworthia maculata (Gray, 1845) and W. chrysosiretica (Robb, 1980). In this paper, we use an integrated taxonomic approach to describe a new species of Woodworthia gecko, Woodworthia korowai sp. nov., found along the western coastline of the Auckland Region, New Zealand. Although this species occurs in duneland habitat behind a popular beach near New Zealands most populated city, it was only recognised as a distinct taxon in 2016. We describe W. korowai sp. nov. based on a suite of morphological character states and substantial genetic divergence, based on the mitochondrial NADH dehydrogenase subunit 2 (ND2) gene, that distinguish it from W. maculata sensu stricto and all other known species of Woodworthia. Phylogenetic reconstruction and molecular dating place it sister to the W. maculata group, with an estimated time of divergence in the mid to late Pliocene. This gecko is one of the most geographically restricted of all Woodworthia geckos, occupying an area of less than 500 km2 within the Auckland Region. Its narrow range and coastal association make it susceptible to environmental and genetic stochasticity. Furthermore, the popularity and recreational usage of the dune system threaten its habitat. Therefore, we hope that this description will bring attention to the value of coastal environments and the unique and sensitive duneland of Te Korowai-o-Te-Tonga/ South Kaipara Peninsula and Te Oneone Rangatira/ Muriwai Beach in particular and encourage conservation efforts to protect this newly described species and its habitat.

Lessons Learned From the COVID-19 Pandemic in the United States by Domestic Violence Coalition Leaders.

This U.S. study explores lessons learned about domestic violence service delivery during the COVID-19 pandemic identified by state, territory, and tribal coalition leadership to advance preparedness and guide structural improvements for future disasters. Semi-structured interviews with 25 Coalition leaders identified public health control measures and victim-centered strategies used to mitigate the pandemic's impacts on services and advocacy. Three main themes emerged: workforce innovations, system empowerment, and the simultaneous pandemic of racial injustice. The COVID-19 pandemic inspired Coalitions to respond creatively and highlighted resources needed to support survivors and the domestic violence (DV) workforce going forward, including reassessing the current state of the DV movement.

Internal Transcribed Spacer and 16S Amplicon Sequencing Identifies Microbial Species Associated with Asbestos in New Zealand.

Inhalation of asbestos fibres can cause lung inflammation and the later development of asbestosis, lung cancer, and mesothelioma, and the use of asbestos is banned in many countries. In most countries, large amounts of asbestos exists within building stock, buried in landfills, and in contaminated soil. Mechanical, thermal, and chemical treatment options do exist, but these are expensive, and they are not effective for contaminated soil, where only small numbers of asbestos fibres may be present in a large volume of soil. Research has been underway for the last 20 years into the potential use of microbial action to remove iron and other metal cations from the surface of asbestos fibres to reduce their toxicity. To access sufficient iron for metabolism, many bacteria and fungi produce organic acids, or iron-chelating siderophores, and in a growing number of experiments these have been found to degrade asbestos fibres in vitro. This paper uses the internal transcribed spacer (ITS) and 16S amplicon sequencing to investigate the fungal and bacterial diversity found on naturally-occurring asbestos minerals, asbestos-containing building materials, and asbestos-contaminated soils with a view to later selectively culturing promising species, screening them for siderophore production, and testing them with asbestos fibres in vitro. After filtering, 895 ITS and 1265 16S amplicon sequencing variants (ASVs) were detected across the 38 samples, corresponding to a range of fungal, bacteria, cyanobacterial, and lichenized fungal species. Samples from Auckland (North Island, New Zealand) asbestos cement, Auckland asbestos-contaminated soils, and raw asbestos rocks from Kahurangi National Park (South Island, New Zealand) were comprised of very different microbial communities. Five of the fungal species detected in this study are known to produce siderophores.

Categorization of a Universal Coding System to Distinguish Use of Durable Medical Equipment and Supplies in Pediatric Patients.

Importance: Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES. Objective: To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid. Design, Setting, and Participants: This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023. Exposure: DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems). Main Outcomes and Measures: The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC). Results: Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs. Conclusions and Relevance: In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity.

OBJECTIVES: Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention. METHODS: We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits. RESULTS: There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32). CONCLUSIONS: A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

Physiological remodeling of the mitral valve during pregnancy.

There is growing evidence that heart valves are not passive structures but can remodel with left ventricular dysfunction. To determine if these tissues remodel under nonpathological conditions, we examined the mirtal valve anterior leaflet during the volume loading and cardiac expansion of pregnancy using a bovine model. We measured leaflet dimensions, chordal attachments, and biaxial mechanical properties of leaflets collected from never-pregnant heifers and pregnant cows (pregnancy duration estimated from fetal length). Hydrothermal isometric tension (HIT) tests were performed to assess the denaturation temperature (T(d)) associated with collagen molecular stability and the load decay half-time (t(1//2)) associated with intermolecular cross-linking. Histological changes were examined using Verhoeff-van Gieson and picrosirius red staining with polarized light. We observed striking changes to the structure and material properties of the mitral anterior leaflet during pregnancy. Leaflet area was increased 33%, with a surprising increase (nearly 25%) in chordae tendinae attachments. There was a biphasic change in leaflet extensibility: it rapidly decreased by 30% and then reversed to prepregnant values by late pregnancy. The 2°C decrease in T(d) in pregnancy was indicative of collagen remodeling, whereas the 70% increase in HIT t(1/2) indicated an increase in collagen cross-linking. Finally, histological results suggested transient increases in leaflet thickness and transient decreases in collagen crimp. This remodeling may compensate for the increased loading conditions associated with pregnancy by normalizing leaflet stress and maintaining coaptation. Understanding the mechanisms of mitral valve physiological remodeling in pregnancy could contribute to alternative treatments of pathological remodeling associated with left ventricular dysfunction.

A protective antiarrhythmic role of ursodeoxycholic acid in an in vitro rat model of the cholestatic fetal heart.

UNLABELLED: Intrahepatic cholestasis of pregnancy may be complicated by fetal arrhythmia, fetal hypoxia, preterm labor, and, in severe cases, intrauterine death. The precise etiology of fetal death is not known. However, taurocholate has been demonstrated to cause arrhythmia and abnormal calcium dynamics in cardiomyocytes. To identify the underlying reason for increased susceptibility of fetal cardiomyocytes to arrhythmia, we studied myofibroblasts (MFBs), which appear during structural remodeling of the adult diseased heart. In vitro, they depolarize rat cardiomyocytes via heterocellular gap junctional coupling. Recently, it has been hypothesized that ventricular MFBs might appear in the developing human heart, triggered by physiological fetal hypoxia. However, their presence in the fetal heart (FH) and their proarrhythmogenic effects have not been systematically characterized. Immunohistochemistry demonstrated that ventricular MFBs transiently appear in the human FH during gestation. We established two in vitro models of the maternal heart (MH) and FH, both exposed to increasing doses of taurocholate. The MH model consisted of confluent strands of rat cardiomyocytes, whereas for the FH model, we added cardiac MFBs on top of cardiomyocytes. Taurocholate in the FH model, but not in the MH model, slowed conduction velocity from 19 to 9 cm/s, induced early after depolarizations, and resulted in sustained re-entrant arrhythmias. These arrhythmic events were prevented by ursodeoxycholic acid, which hyperpolarized MFB membrane potential by modulating potassium conductance. CONCLUSION: These results illustrate that the appearance of MFBs in the FH may contribute to arrhythmias. The above-described mechanism represents a new therapeutic approach for cardiac arrhythmias at the level of MFB.

Rape aggression defense and workplace violence prevention.

An R.A.D. Basic Physical Defense program for women employees, launched by a health system's corporate security department, has proven to be a popular low cost method of workplace violence prevention, according to the author, one of the program's instructors. The initial investment in equipment and certification is negligible compared to the benefits and potential benefits it brings, she reports.