Using the Points of Distribution Site Model for Timely and Safe Administration of COVID-19 Vaccinations During the Pandemic.

The Georgia Department of Public Health-East Central District and its local partners implemented an open, drive-through point of distribution site to administer the COVID-19 vaccine to eligible populations. The site was in Augusta, Georgia, from mid-December 2020 through mid-May 2021. The target population for this intervention was individuals eligible for the COVID-19 vaccine to prevent and slow transmission of severe acute respiratory syndrome coronavirus 2 infection. The point of distribution site successfully provided 42 342 vaccines. (Am J Public Health. 2022;112(S3):S279-S283. https://doi.org/10.2105/AJPH.2022.306820).

Examining the Impact of a Nursing Course Redesign on Student Outcomes, Faculty Workload, and Costs.

ABSTRACT: This study examined the impact of a nursing course redesign from traditional face-to-face to a hybrid format on student outcomes, workload allocation, and associated costs. In this quasi-experimental study, baccalaureate students received either traditional (n = 47) or hybrid delivery (n = 46); each group had equal degree-type representation. Average exam scores were analyzed using an independent t-test, with no significant differences found between groups. Faculty workload decreased by one third, and there was a 16.6 percent reduction in overall costs to implement the course. Course redesign can be effective for reducing faculty workload and costs while achieving course outcomes.

Construction of Femoral Vessel Nomograms for Planning Cardiac Interventional Procedures in Children 0-4 Years Old.

The objectives of this study were to construct femoral artery (FA) and femoral vein (FV) nomograms in children aged 0-4 years and to construct probability curves for the occurrence of arterial access complications based on the size of the FA. The FV and FA are commonly accessed during cardiac catheterizations in children with congenital heart diseases (CHD). However, nomograms for vessel dimensions based on child's age or size are not available. This knowledge may be helpful for interventional planning. A prospective study was performed on 400 children (age 0-4 years) with CHD undergoing cardiac catheterizations over a 3-year period. Ultrasound evaluation of the right and left FA and FV was performed under anesthesia prior to vascular access. Regression modeling was applied to derive nomograms based on quantile polynomial regression, which yielded good fit to the data judged by R-squared. GAMLSS transformation method was used to formulate smoothed percentiles. A separate prospective evaluation of FA to determine the size below which loss of pulse (LOP) are likely to occur was performed. Nomograms for FA and FV diameter and cross-sectional area against age and body surface area and probability curves for FA LOP were constructed. It is now possible to examine ultrasound-based normal sizes of femoral vein and artery in children 0-4 years of age. Femoral vessel nomograms and LOP probability curves may help with interventional planning. Future studies with larger sample size, including children of other ages may be useful.

Role of Transcatheter patent ductus arteriosus closure in extremely low birth weight infants.

BACKGROUND: Patent ductus arteriosus (PDA) is common in extremely low birth weight (ELBW) infants. The objectives of this study were to describe our early clinical experience of transcatheter PDA closure (TCPC) in ELBW infants, compare outcomes with surgical ligation of PDA (SLP), and identify risk factors for prolonged respiratory support. METHODS: A retrospective review was performed comparing infants born <27 weeks, weighing <1 kg at birth and < 2 kg during TCPC with 2:1 propensity-score matched group of infants that underwent SLP. Change in respiratory severity scores (RSS) immediately post-procedure and the time taken for return to pre-procedure RSS for TCPC versus SLP was compared. Factors contributing to prolonged elevation of RSS were identified. RESULTS: Eighty ELBW infants (median procedure weight: 1060 [range 640-2000] grams) that underwent successful TCPC were compared with 40 infants that underwent SLP (procedure weight 650-1760 g). There was greater increase in RSS following SLP compared to TCPC (76% vs. 18%; P < 0.01). It took longer for RSS to return to pre-procedural scores post-SLP compared to post-TCPC (28 vs. 8.4 hr; P < 0.01). Elevated pulmonary artery pressure (PAP) and TCPC at >8 weeks of age were associated with prolonged (>30-days) elevation of RSS ≥ 1 (OR = 5.4, 95%CI: 2.2-9.4, P < 0.01 and OR = 2.86, 95%CI: 1.5-4.2, P = 0.05 respectively). Overall complication rate for TCPC was 3.7%. CONCLUSIONS: TCPC is feasible in infants as small as 640-2000 g and can be performed safely in the majority. TCPC may offer faster weaning of respiratory support compared to SLP when performed earlier in life, and before the onset of elevated PAP.

Utility of the Medtronic microvascular plug™ as a transcatheter implantable and explantable pulmonary artery flow restrictor in a swine model.

BACKGROUND: A surgical pulmonary artery band (PAB) is used to control excessive pulmonary blood flow for certain congenital heart diseases. Previous attempts have been made to develop a transcatheter, implantable pulmonary flow restrictor (PFR) without great success. We modified a microvascular plug (MVP) to be used as a PFR. The objectives of this study were to demonstrate feasibility of transcatheter implantation and retrieval of the modified MVP as a PFR, and compare PA growth while using the PFR versus PAB. METHODS AND RESULTS: The PFR was implanted in eight newborn piglets in bilateral branch pulmonary arteries (PAs). Immediately post-PFR implantation, the right ventricular systolic pressure increased from a median of 20-51 mmHg. Transcatheter retrieval of PFR was 100% successful at 3, 6, and 9 weeks and 50% at 12-weeks post-implant. A left PAB was placed via thoracotomy in four other newborn piglets. Debanding was performed 6-weeks later via balloon angioplasty. On follow-up, the proximal left PA diameters in the PFR and the PAB groups were similar (median 8 vs. 7.1 mm; p = 0.11); albeit the surgical band sites required repeat balloon angioplasty secondary to recurrent stenosis. By histopathology, there was grade II vessel injury in two pigs immediately post-retrieval of PFR that healed by 12 weeks. CONCLUSIONS: Transcatheter implantation and retrieval of the MVP as a PFR is feasible. PA growth is comparable to surgical PAB, which is likely to require reinterventions. The use of the MVP as a PFR in humans has to be trialed before recommending its routine use.

Influence of Clothing on Thermoregulation and Comfort During Exercise in the Heat.

Davis, JK, Laurent, CM, Allen, KE, Zhang, Y, Stolworthy, NI, Welch, TR, and Nevett, ME. Influence of clothing on thermoregulation and comfort during exercise in the heat. J Strength Cond Res 31(12): 3435-3443, 2017-Sport textiles of synthetic fiber have been proposed to have superior properties for keeping wearers cooler, drier, and more comfortable compared with natural fibers. The impact of various fiber content and fabric construction on thermoregulation and perceptual responses are not well understood. Eight male collegiate athletes performed 3 counterbalanced trials of 45-minute treadmill run at 60% of maximal oxygen uptake in an environmental chamber (32° C). Three different fibers, consisting of 100% cotton, a blend of natural fibers (50/50% cotton/soybean), and a synthetic fiber (100% polyester) with mesh loops to facilitate ventilation through the clothing, were tested. Heat strain indices, microenvironment temperature, ratings of perceived exertion (RPE), and clothing comfort were measured. Session RPE (S-RPE) and session thermal sensation (S-TS) were recorded 20 minutes after each trial. There was no effect of clothing on rectal, skin, and body temperatures, heart rate, RPE, or comfort measures (p ≥ 0.05). A significant effect was observed for synthetic fiber compared with cotton on S-RPE (p = 0.03), S-TS (p = 0.04), and the microenvironment temperature at the chest (p = 0.02). No significant difference was shown for any other fibers on S-RPE, S-TS, or other microenvironment areas (p ≥ 0.05). These results show that clothing fiber content and fabric construction had no effect on thermoregulation, RPE, or clothing comfort during moderate-intensity exercise in the heat; whereas synthetic fabric construction indeed effectively reduced regional microenvironment temperature and attenuated global exertion and TS, which may have important implications for exercise tolerance in the heat.

Pubertal timing and sexual risk behaviors among rural African American male youth: testing a model based on life history theory.

Life History Theory (LHT), a branch of evolutionary biology, describes how organisms maximize their reproductive success in response to environmental conditions. This theory suggests that challenging environmental conditions will lead to early pubertal maturation, which in turn predicts heightened risky sexual behavior. Although largely confirmed among female adolescents, results with male youth are inconsistent. We tested a set of predictions based on LHT with a sample of 375 African American male youth assessed three times from age 11 to age 16. Harsh, unpredictable community environments and harsh, inconsistent, or unregulated parenting at age 11 were hypothesized to predict pubertal maturation at age 13; pubertal maturation was hypothesized to forecast risky sexual behavior, including early onset of intercourse, substance use during sexual activity, and lifetime numbers of sexual partners. Results were consistent with our hypotheses. Among African American male youth, community environments were a modest but significant predictor of pubertal timing. Among those youth with high negative emotionality, both parenting and community factors predicted pubertal timing. Pubertal timing at age 13 forecast risky sexual behavior at age 16. Results of analyses conducted to determine whether environmental effects on sexual risk behavior were mediated by pubertal timing were not significant. This suggests that, although evolutionary mechanisms may affect pubertal development via contextual influences for sensitive youth, the factors that predict sexual risk behavior depend less on pubertal maturation than LHT suggests.

Mutation of A677 in histone methyltransferase EZH2 in human B-cell lymphoma promotes hypertrimethylation of histone H3 on lysine 27 (H3K27).

Trimethylation of histone H3 on lysine 27 (H3K27me3) is a repressive posttranslational modification mediated by the histone methyltransferase EZH2. EZH2 is a component of the polycomb repressive complex 2 and is overexpressed in many cancers. In B-cell lymphomas, its substrate preference is frequently altered through somatic mutation of the EZH2 Y641 residue. Herein, we identify mutation of EZH2 A677 to a glycine (A677G) among lymphoma cell lines and primary tumor specimens. Similar to Y641 mutant cell lines, an A677G mutant cell line revealed aberrantly elevated H3K27me3 and decreased monomethylated H3K27 (H3K27me1) and dimethylated H3K27 (H3K27me2). A677G EZH2 possessed catalytic activity with a substrate specificity that was distinct from those of both WT EZH2 and Y641 mutants. Whereas WT EZH2 displayed a preference for substrates with less methylation [unmethylated H3K27 (H3K27me0):me1:me2 k(cat)/K(m) ratio = 9:6:1] and Y641 mutants preferred substrates with greater methylation (H3K27me0:me1:me2 k(cat)/K(m) ratio = 1:2:13), the A677G EZH2 demonstrated nearly equal efficiency for all three substrates (H3K27me0:me1:me2 k(cat)/K(m) ratio = 1.1:0.6:1). When transiently expressed in cells, A677G EZH2, but not WT EZH2, increased global H3K27me3 and decreased H3K27me2. Structural modeling of WT and mutant EZH2 suggested that the A677G mutation acquires the ability to methylate H3K27me2 through enlargement of the lysine tunnel while preserving activity with H3K27me0/me1 substrates through retention of the Y641 residue that is crucial for orientation of these smaller substrates. This mutation highlights the interplay between Y641 and A677 residues in the substrate specificity of EZH2 and identifies another lymphoma patient population that harbors an activating mutation of EZH2.

Is Prenatal Lead Exposure a Concern in Infancy? What Is the Evidence?

BACKGROUND: Exposure to unhealthy and unsafe environments cause 1 in 4 deaths in childhood each year. Early exposure to lead beginning prenatally and continuing throughout childhood is one of the mechanisms associated with unhealthy and unsafe environments, particularly in industrial countries and urban communities. Lead is a known heavy metal that crosses the placenta and blood-brain barrier depositing in fetal tissues. PURPOSE: The purpose of this integrative review was to determine which maternal-fetal dyads were at high risk for elevated umbilical cord lead (Pb) levels and to examine the consequences associated with elevated umbilical cord Pb levels. SEARCH STRATEGY: PubMed was searched to obtain English language publications from 2005 to March 2015 for studies examining the effects of prenatal lead exposure on infant outcomes using key terms "lead" combined with "infant." A total of 17 articles were retained for analysis. FINDINGS: Infants with elevated umbilical cord blood lead levels were associated with maternal demographic factors and country of origin. Maternal-specific exposure to lead products prior to or during pregnancy was associated with elevated umbilical cord blood lead levels. The consequences of prenatal lead exposure to the infant at birth anthropometrically were mixed. The evidence on neurological consequences of prenatal exposure to lead appears to reflect changes in cognitive impairment; however, it needs further study. IMPLICATIONS FOR PRACTICE: The major recommendation is primary prevention of lead exposure across the life span. Implementation of policies that reduce the availability of leaded products to reduce leaded products, especially ones aimed at children and women of childbearing age. IMPLICATIONS FOR RESEARCH: Research needs to be focused in 2 directions: (1) prevention of lead exposure during pregnancy and (2) prevention of lead leaching from bones for all women of childbearing age.

Influence of Dehydration on Intermittent Sprint Performance.

This study examined the effects of dehydration on intermittent sprint performance and perceptual responses. Eight male collegiate baseball players completed intermittent sprints either dehydrated (DEHY) by 3% body mass or euhydrated (EU). Body mass was reduced through exercise in the heat with controlled fluid restriction occurring 1 day before the trial. Participants completed twenty-four 30-m sprints divided into 3 bouts of 8 sprints with 45 seconds of rest between each sprint and 3 minutes between each bout. Perceived recovery status (PRS) scale was recorded before the start of each trial. Heart rate (HR), ratings of perceived exertion (RPE) (0-10 OMNI scale), and perceived readiness (PR) scale were recorded after every sprint, and session RPE (SRPE) was recorded 20 minutes after completing the entire session. A 2 (condition) × 3 (bout of sprints) repeated-measures ANOVA revealed a significant main effect of condition on mean sprint time (p = 0.03), HR (p < 0.01), RPE (p = 0.01), and PR (p = 0.02). Post hoc tests showed significantly faster mean sprint times for EU vs. DEHY during the second (4.87 ± 0.29 vs. 5.03 ± 0.33 seconds; p = 0.01) and third bouts of sprints (4.91 ± 0.29 vs. 5.12 ± 0.44 seconds; p = 0.02). Heart rate was also significantly lower (p ≤ 0.05) for EU during the second and third bouts. Post hoc measures also showed significantly impaired (p ≤ 0.05) feelings of recovery (PRS) before exercise and increased (p ≤ 0.05) perceptual strain before each bout (PR) during the second and third bouts of repeated sprint work (i.e., RPE and PR) and after the total session (SRPE) in the DEHY condition. Dehydration impaired sprint performance, negatively altered perception of recovery status before exercise, and increased RPE and HR response.

Design of a Medical Triage Evidence-Based Clinical Management Protocol and Implementation of Medical Triage On-Line Training for Use by Mission of Mercy Volunteers.

Evidence-based protocols in safety net settings can help standardize care practices, increase organizational workflow, and enhance quality outcomes for those receiving services. The purpose of this quality improvement project is two-fold: to design an evidence-based medical triage clinical management protocol, and, to influence adherence to that protocol by safety net medical triage volunteers through an on-line volunteer orientation. Leadership skills were required to help translate evidence-based practice recommendations into useful tools to assist in directing practice. Project outcomes included successful multidisciplinary practice change, significantly improved volunteer knowledge surrounding medical triage protocol parameters, increased organizational workflow, and enhanced quality client outcomes.

Racial microstressors, racial self-concept, and depressive symptoms among male African Americans during the transition to adulthood.

Racial discrimination is a pervasive stressor that can undermine mental health among African American youth and young adults. Several studies identify links between racial discrimination and depressive symptoms; however, this research base does not focus on male African American youth who experience significant racism-related stress during the transition to young adulthood. Moreover, few prospective studies consider significant confounding variables that affect exposure to and perception of discriminatory treatment. In response to this need, we examined the effect of exposure to racial discrimination from ages 16 to 18 on depressive symptoms among male African Americans at age 20. Racial self-concept, one's sense of positivity about one's race, was examined as a mediator and self-control as a moderator. Hypotheses were tested with 222 participants, age 16 at baseline and age 20 at the endpoint. Participants provided self-report data at five time points. Exposure to racial discrimination from ages 16 to 18 predicted depressive symptoms at age 20, net of confounding influences. Racial self-concept mediated this effect. Self-control moderated the influence of discrimination on racial self-concept. This study underscores the salience of racial discrimination in the development of depressive symptoms among African American male youth and the clinical utility of interventions targeting racial pride and self-control.

Pathways from Racial Discrimination to Multiple Sexual Partners Among Male African American Adolescents.

African American male adolescents' involvement with multiple sexual partners has important implications for public health as well as for their development of ideas regarding masculinity and sexuality. The purpose of this study was to test hypotheses regarding the pathways through which racial discrimination affects African American adolescents' involvement with multiple sexual partners. We hypothesized that racial discrimination would engender psychological distress, which would promote attitudes and peer affiliations conducive to multiple sexual partnerships. The study also examined the protective influence of parenting practices in buffering the influence of contextual stressors. Participants were 221 African American male youth who provided data at ages 16 and 18; their parents provided data on family socioeconomic disadvantages. Of these young men, 18.5% reported having 3 or more sexual partners during the past 3 months. Structural equation models indicated that racial discrimination contributed to sexual activity with multiple partners by inducing psychological distress, which in turn affected attitudes and peer affiliations conducive to multiple partners. The experience of protective parenting, which included racial socialization, closeness and harmony in parent-child relationships, and parental monitoring, buffered the influence of racial discrimination on psychological distress. These findings suggest targets for prevention programming and underscore the importance of efforts to reduce young men's experience with racial discrimination.

Mutations flanking the carbohydrate binding site of surfactant protein D confer antiviral activity for pandemic influenza A viruses.

We recently reported that a trimeric neck and carbohydrate recognition domain (NCRD) fragment of human surfactant protein D (SP-D), a host defense lectin, with combinatorial substitutions at the 325 and 343 positions (D325A+R343V) exhibits markedly increased antiviral activity for seasonal strains of influenza A virus (IAV). The NCRD binds to glycan-rich viral envelope proteins including hemagglutinin (HA). We now show that replacement of D325 with serine to create D325S+R343V provided equal or increased neutralizing activity compared with D325A+R343V. The activity of the double mutants was significantly greater than that of either single mutant (D325A/S or R343V). D325A+R343V and D325S+R343V also strongly inhibited HA activity, and markedly aggregated, the 1968 pandemic H3N2 strain, Aichi68. D325S+R343V significantly reduced viral loads and mortality of mice infected with Aichi68, whereas wild-type SP-D NCRD did not. The pandemic H1N1 strains of 1918 and 2009 have only one N-linked glycan side on the head region of the HA and are fully resistant to inhibition by native SP-D. Importantly, we now show that D325A+R343V and D325S+R343V inhibited Cal09 H1N1 and related strains, and reduced uptake of Cal09 by epithelial cells. Inhibition of Cal09 was mediated by the lectin activity of the NCRDs. All known human pandemic strains have at least one glycan attachment on the top or side of the HA head, and our results indicate that they may be susceptible to inhibition by modified host defense lectins.

The neonatal nurse's role in preventing abusive head trauma.

Abusive head trauma in infants occurs in 24.6 to 39.8 per 100,000 infants in developed countries. Abusive head trauma refers to any type of intentional head trauma an infant sustains, as a result of an injury to the skull or intracranial contents from a blunt force and/or violent shaking. The clinical question was: what evidence-based interventions have been implemented by neonatal nurses to prevent abusive head trauma in infants? PubMed was searched to obtain English language publications from 2005 to May 2014 for interventions focused on preventing abusive head trauma using the key term "shaken baby syndrome." A total of 10 studies were identified that met the inclusion criteria. All of the interventions targeted prevention of abusive head trauma with information about abusive head trauma/shaken baby syndrome and the "normal" infant crying behaviors. Interventions taught parents why infants cried, how to calm the infants, ways to cope with inconsolable infants, and how to develop a plan for what to do if they could not cope anymore. Parents who participated in the interventions were consistently able to explain the information and tell others about the dangers of shaking infants compared to the control parents. Only 2 studies calculated the preintervention abusive head trauma rate and the postintervention frequency of abusive head trauma. Each found significant differences in abusive head trauma.

Molecular mechanisms of inhibition of influenza by surfactant protein D revealed by large-scale molecular dynamics simulation.

Surfactant protein D (SP-D), a mammalian C-type lectin, is the primary innate inhibitor of influenza A virus (IAV) in the lung. Interactions of SP-D with highly branched viral N-linked glycans on hemagglutinin (HA), an abundant IAV envelope protein and critical virulence factor, promote viral aggregation and neutralization through as yet unknown molecular mechanisms. Two truncated human SP-D forms, wild-type (WT) and double mutant D325A+R343V, representing neck and carbohydrate recognition domains are compared in this study. Whereas both WT and D325A+R343V bind to isolated glycosylated HA, WT does not inhibit IAV in neutralization assays; in contrast, D325A+R343V neutralization compares well with that of full-length native SP-D. To elucidate the mechanism for these biochemical observations, we have determined crystal structures of D325A+R343V in the presence and absence of a viral nonamannoside (Man9). On the basis of the D325A+R343V-Man9 structure and other crystallographic data, models of complexes between HA and WT or D325A+R343V were produced and subjected to molecular dynamics. Simulations reveal that whereas WT and D325A+R343V both block the sialic acid receptor site of HA, the D325A+R343V complex is more stable, with stronger binding caused by additional hydrogen bonds and hydrophobic interactions with HA residues. Furthermore, the blocking mechanism of HA differs for WT and D325A+R343V because of alternate glycan binding modes. The combined results suggest a mechanism through which the mode of SP-D-HA interaction could significantly influence viral aggregation and neutralization. These studies provide the first atomic-level molecular view of an innate host defense lectin inhibiting its viral glycoprotein target.

The development of conventional sexual partner trajectories among african american male adolescents.

African American male youth disproportionately report involvement with multiple sexual partners, which increases their risk for sexually transmitted infections and initiation of unplanned pregnancies. Little is known about the developmental precursors of sexual partner trajectories among African American male youth. Moreover, few studies focus on the many African American youth who evince highly conventional sexual partner trajectories, i.e., youth who have only one partner or abstain from sexual activity across time. Using four waves of data from a longitudinal study, we hypothesized that an accumulation of social and economic disadvantages in early adolescence would negatively influence youths' conventional sexual partner trajectories in late adolescence. We expected these disadvantages to affect youths' receipt of protective family processes and their reports of a set of intrapersonal processes (self-regulation, hope, and low levels of anger) linked to generally conventional behavior. Hypotheses were tested with data from 315 African American male youth from 11 to 18.5 years of age and their primary caregivers. Our results supported the hypotheses. Socioeconomic disadvantages during preadolescence predicted less involvement in conventional sexual partner trajectories from ages 16 to 18.5 years. This association was mediated by protective family processes and a set of interrelated intrapersonal protective processes. Preventive interventions designed to promote protective parenting and intrapersonal processes can be expected to promote sexual behavior trajectories characterized by abstinence or relations with very few partners.

Mutagenesis of surfactant protein D informed by evolution and x-ray crystallography enhances defenses against influenza A virus in vivo.

The recognition of influenza A virus (IAV) by surfactant protein D (SP-D) is mediated by interactions between the SP-D carbohydrate recognition domains (CRD) and glycans displayed on envelope glycoproteins. Although native human SP-D shows potent antiviral and aggregating activity, trimeric recombinant neck+CRDs (NCRDs) show little or no capacity to influence IAV infection. A mutant trimeric NCRD, D325A/R343V, showed marked hemagglutination inhibition and viral neutralization, with viral aggregation and aggregation-dependent viral uptake by neutrophils. D325A/R343V exhibited glucose-sensitive binding to Phil82 hemagglutinin trimer (HA) by surface plasmon resonance. By contrast, there was very low binding to the HA trimer from another virus (PR8) that lacks glycans on the HA head. Mass spectrometry demonstrated the presence of high mannose glycans on the Phil82 HA at positions known to contribute to IAV binding. Molecular modeling predicted an enhanced capacity for bridging interactions between HA glycans and D325A/R343V. Finally, the trimeric D325A/R343V NCRD decreased morbidity and increased viral clearance in a murine model of IAV infection using a reassortant A/WSN/33 virus with a more heavily glycosylated HA. The combined data support a model in which altered binding by a truncated mutant SP-D to IAV HA glycans facilitates viral aggregation, leading to significant viral neutralization in vitro and in vivo. These studies demonstrate the potential utility of homology modeling and protein structure analysis for engineering effective collectin antivirals as in vivo therapeutics.

Hypoxic Ischemic Encephalopathy: Pathophysiology and Experimental Treatments.

Hypoxic ischemic encephalopathy (HIE) is a serious birth complication affecting full term infants: 40-60% of affected infants die by 2 years of age or have severe disabilities. The majority of the underlying pathologic events of HIE are a result of impaired cerebral blood flow and oxygen delivery to the brain with resulting primary and secondary energy failure. In the past, treatment options were limited to supportive medical therapy. Currently, several experimental treatments are being explored in neonates and animal models to ameliorate the effects of secondary energy failure. This review discusses the underlying pathophysiologic effects of a hypoxic-ischemic event and experimental treatment modalities being explored to manage infants with HIE. Further research is needed to better understand if the long-term impact of the experimental treatments and whether the combinations of experimental treatments can improve outcomes in infants with HIE.

Integrating Stakeholder Engagement With Claims-Based Research on Health Insurance Design and Bipolar Disorder.

Researchers increasingly recognize that stakeholder involvement enhances research relevance and validity. However, reports of patient engagement in research that relies on administrative records data are rare. The authors' collaborative project combined quantitative and qualitative studies of costs and access to care among U.S. adults with employer-sponsored insurance. The authors analyzed insurance claims to estimate the impacts on enrollee costs and utilization after patients with bipolar disorder were switched from traditional coverage to high-deductible health plans. In parallel, in-depth interviews explored people's experiences accessing treatment for bipolar disorder. Academic investigators on the research team partnered with the Depression and Bipolar Support Alliance (DBSA), a national advocacy organization for people with mood disorders. Detailed personal stories from DBSA-recruited volunteers informed and complemented the claims analyses. Several DBSA audience forums and a stakeholder advisor panel contributed regular feedback on study issues. These multiple engagement modes drew inputs of varying intensity from diverse community segments. Efforts to include new voices must acknowledge individuals' distinct interests and barriers to research participation. Strong engagement leadership roles ensure productive communication between researchers and stakeholders. The involvement of people with direct experience of care is especially necessary in research that uses secondary data. Longitudinal, adaptable partnerships enable colearning and higher-quality research that captures the manifold dimensions of patient experiences.