Changes associated with the COVID-19 pandemic on postpartum screening results in Ontario, Canada: The healthy babies healthy children screening tool.

BACKGROUND: Research on the impact of the COVID-19 pandemic on mothers/childbearing parents has mainly been cross-sectional and focused on psychological symptoms. This study examined the impact on function using ongoing, systematic screening of a representative Ontario sample. METHODS: An interrupted time series analysis of repeated cross-sectional data from a province-wide screening program using the Healthy Babies Healthy Children (HBHC) tool assessed changes associated with the pandemic at the time of postpartum discharge from hospital. Postal codes were used to link to neighborhood-level data. The ability to parent or care for the baby/child and other psychosocial and behavioral outcomes were assessed. RESULTS: The co-primary outcomes of inability to parent or care for the baby/child were infrequently observed in the pre-pandemic (March 9, 2019-March 15, 2020) and initial pandemic periods (March 16, 2020-March 23, 2021) (parent 209/63,006 (0.33%)-177/56,117 (0.32%), care 537/62,955 (0.85%)-324/56,086 (0.58%)). Changes after pandemic onset were not observed for either outcome although a significant (p = 0.02) increase in slope was observed for inability to parent (with questionable clinical significance). For secondary outcomes, worsening was only seen for reported complications during labor/delivery. Significant improvements were observed in the likelihood of being unable to identify a support person to assist with care, need of newcomer support, and concerns about money over time. CONCLUSIONS: There were no substantive changes in concerns about ability to parent or care for children. Adverse impacts of the pandemic may have been mitigated by accommodations for remote work and social safety net policies.

Mortality Following Childbirth in Ontario - A Twenty-Year Analysis of Temporal Trends and Causes.

OBJECTIVE: Maternal death during or after pregnancy is often preventable and accurate surveillance is key to prevention. We examined the number and causes of maternal death in Ontario over 20 years. METHODS: Retrospective cohort study including all hospital livebirths and stillbirths from 2002-2022 in the Canadian Institute for Health Information (CIHI) Discharge Abstracts (for hospitalizations) and National Ambulatory Care System (for emergency department encounters) linked to the Better Outcomes and Registry (BORN) births. Death was ascertained from childbirth to 365 days thereafter; all deaths were reviewed by at least 3 clinicians. RESULTS: There were 485 deaths among 2 764 214 live and stillbirths over 20 years-a maternal mortality ratio (MMR) of 17.5 per 100 000 (95% CI 16.0-19.2). There were 222 (45.8%) early deaths within 42 days of birth (MMR of 8.0 per 100 000; 95% CI 7.0-9.2), and 263 (54.2%) late deaths from 43 to 365 days after birth (MMR 9.5 per 100 000; 95% CI 8.4-10.7). Death was pregnancy-related in 169/485 cases (34.8%). Early death causes were predominantly hemorrhage, infection, preeclampsia, and pulmonary embolism. Top causes of 263 late deaths were cancer, injury, and cardiac arrest, or unknown. CONCLUSION: Most deaths within one-year of childbirth are not related to obstetrical factors; however, pregnancy complications factor in early deaths. Causes of early and late deaths differ, but examining late deaths is equally important to identify factors not regularly examined in maternal mortality. As death in early pregnancy or outside hospitals is not reported, mortality is likely higher.

Timing of cesarean delivery in women with ≥2 previous cesarean deliveries.

BACKGROUND: The rate of cesarean delivery is continuously increasing with the leading indication being a previous cesarean delivery. For women with 1 previous cesarean delivery, it is generally agreed that the optimal timing of delivery by elective cesarean delivery is during the 39th week of gestation, whereas for women with ≥2 previous cesarean deliveries, the optimal delivery time remains debatable. OBJECTIVE: To assess the maternal and neonatal risks associated with elective delivery at different gestational ages ranging from 37 0/7 to 39 6/7 weeks' gestation and to compare it with expectant management among women with at least 2 previous cesarean deliveries. STUDY DESIGN: This was a retrospective, population-based cohort study of all women with at least 2 previous cesarean deliveries who delivered after 36 6/7 weeks of gestation in Ontario, Canada, between April 2012 and March 2019. Women with multifetal pregnancies or major fetal anomalies were excluded. For each completed gestational week, outcomes of women who had an elective repeat cesarean delivery at that week solely because of 2 previous cesarean deliveries were compared with the outcomes of those who were managed expectantly and delivered at a later gestational age. The primary outcome was a composite of maternal outcomes including mortality and severe maternal morbidity. Secondary outcomes were adverse neonatal outcomes. RESULTS: A total of 26,522 women met the inclusion criteria. The maternal risk was similar for elective delivery at 37 0/7 to 38 6/7 weeks of gestation compared with expectant management. However, elective delivery at 39 0/7 to 39 6/7 weeks' gestation was associated with a decreased risk for adverse outcomes when compared with expectant management (adjusted risk ratio, 0.51; 95% confidence interval, 0.29-0.91). For the neonate, elective delivery during the 37th week of gestation significantly increased the incidence of the composite adverse outcome than in an ongoing pregnancy (adjusted risk ratio, 1.68; 95% confidence interval, 1.39-2.01), but was comparable for elective delivery at 38 0/7 to 39 6/7 weeks' gestation and expectant management. The risk for an unplanned cesarean delivery increased from 6.5% before 38 weeks' gestation to 21.7% before 39 weeks' gestation and to 32.6% before 40 weeks' gestation. CONCLUSION: For women with ≥2 cesarean deliveries, elective delivery at 38 0/7 to 38 6/7 weeks' gestation likely represents the optimal balance between neonatal and maternal risk while decreasing the likelihood of an unplanned cesarean delivery.

SARS-CoV-2 B.1.1.529 (Omicron) Variant Transmission Within Households - Four U.S. Jurisdictions, November 2021-February 2022.

The B.1.1.529 (Omicron) variant, first detected in November 2021, was responsible for a surge in U.S. infections with SARS-CoV-2, the virus that causes COVID-19, during December 2021-January 2022 (1). To investigate the effectiveness of prevention strategies in household settings, CDC partnered with four U.S. jurisdictions to describe Omicron household transmission during November 2021-February 2022. Persons with sequence-confirmed Omicron infection and their household contacts were interviewed. Omicron transmission occurred in 124 (67.8%) of 183 households. Among 431 household contacts, 227 were classified as having a case of COVID-19 (attack rate [AR] = 52.7%).† The ARs among household contacts of index patients who had received a COVID-19 booster dose, of fully vaccinated index patients who completed their COVID-19 primary series within the previous 5 months, and of unvaccinated index patients were 42.7% (47 of 110), 43.6% (17 of 39), and 63.9% (69 of 108), respectively. The AR was lower among household contacts of index patients who isolated (41.2%, 99 of 240) compared with those of index patients who did not isolate (67.5%, 112 of 166) (p-value <0.01). Similarly, the AR was lower among household contacts of index patients who ever wore a mask at home during their potentially infectious period (39.5%, 88 of 223) compared with those of index patients who never wore a mask at home (68.9%, 124 of 180) (p-value <0.01). Multicomponent COVID-19 prevention strategies, including up-to-date vaccination, isolation of infected persons, and mask use at home, are critical to reducing Omicron transmission in household settings.

Personality and psychopathology: In defense of a practical path toward integrating psychometric and biological approaches to advance a comprehensive model.

Personality and psychopathology each reflect patterns of internal experience and outward behavior that differ between people and affect functioning. Drawing strict distinctions between the two concepts is not only difficult, but it may prove unnecessary for advancing an integrated model of psychological experiences associated with mental illness. We argue that developing such a model will be critical for improving treatment outcomes, and we discuss a practical path forward. Proponents of psychometric approaches to developing models of psychological experience focus on observable phenotypes and utilize statistical methods to describe patterns of covariation among a broad range of symptoms and dispositions. Advocates of biologically based approaches emphasize neuroscientific tools for identifying abnormalities in brain function that give rise to an individual's experience. There is substantial evidence that measures of personality and measures of symptoms capture nonoverlapping, clinically important information for understanding how and for whom treatments for mental illness work. In this article, we highlight the importance of combining psychometric and neurobiological approaches in order to understand which features of an individual those measures reflect, which aspects of neurobiology generate and maintain those features, how they relate to each other, and critically, how best to alter them to reduce distress and dysfunction.

Maternal-Newborn Health System Changes and Outcomes in Ontario, Canada, During Wave 1 of the COVID-19 Pandemic-A Retrospective Study.

OBJECTIVE: To determine the population-level impact of COVID-19 pandemic-related obstetric practice changes on maternal and newborn outcomes. METHODS: Segmented regression analysis examined changes that occurred 240 weeks pre-pandemic through the first 32 weeks of the pandemic using data from Ontario's Better Outcomes Registry & Network. Outcomes included birth location, length of stay, labour analgesia, mode of delivery, preterm birth, and stillbirth. Immediate and gradual effects were modelled with terms representing changes in intercepts and slopes, corresponding to the start of the pandemic. RESULTS: There were 799 893 eligible pregnant individuals included in the analysis; 705 767 delivered in the pre-pandemic period and 94 126 during the pandemic wave 1 period. Significant immediate decreases were observed for hospital births (relative risk [RR] 0.99; 95% CI 0.98-0.99), length of stay (median change -3.29 h; 95% CI -3.81 to -2.77), use of nitrous oxide (RR 0.11; 95% CI 0.09-0.13) and general anesthesia (RR 0.69; 95% CI 0.58- 0.81), and trial of labour after cesarean (RR 0.89; 95% CI 0.83-0.96). Conversely, there were significant immediate increases in home births (RR 1.35; 95% CI 1.21-1.51), and use of epidural (RR 1.02; 95% CI 1.01-1.04) and regional anesthesia (RR 1.01; 95% CI 1.01-1.02). There were no significant immediate changes for any other outcomes, including preterm birth (RR 0.99; 95% CI 0.93-1.05) and stillbirth (RR 1.11; 95% CI 0.87-1.42). CONCLUSION: Provincial health system changes implemented at the start of the pandemic resulted in immediate clinical practice changes but not insignificant increases in adverse outcomes.

Maximizing Learning in the Operating Room: Residents' Perspectives.

BACKGROUND: Few studies examine how residents can optimize their educational experience in the OR on their terms. This study aimed to examine residents' perceptions of how learners can maximize their education in the OR. METHOD: Using constructivist grounded theory methodology, the authors conducted focus groups with general surgery residents, PGY1-5, followed by semi-structured interviews with attending surgeons from a single, academic medical center. Constant comparison was used to identify themes and explore their relationships. Theoretical sampling was used until saturation was achieved. RESULTS: Residents and attendings participated. Two phases of OR learning were identified, intra-operative and inter-operative. Characters that made optimized learning included control, struggling, and reflection. Residents who practiced self-reflection with their experiences, and were able to articulate this awareness to attendings, felt the OR was an ideal learning environment. Attendings echoed similar findings. CONCLUSIONS: Providing residents with a method of maximizing OR learning is critical to postgraduate clinical education. Currently, observation passively morphs into active learning and eventually independent operating in the OR. However, residents who practice self-regulated learning, and are able to discuss their educational goals with attendings, seem to find the OR a better learning environment and progress to independence more quickly. This was echoed by practicing attendings. Providing residents with a generalizable, self-regulated learning framework specific to operative educational experiences could maximize learning potential and expedite resident progression in the OR.

Perspectives of Canadian Health Care Providers on Fetal Alcohol Spectrum Disorder: Has Anything Changed in 15 years? A Brief Report.

Initiatives have been implemented to provide training to health care providers (HCPs) on the adverse health outcomes associated with alcohol use during pregnancy, including the risk of fetal alcohol spectrum disorder (FASD). The purpose of this exploratory study was to compare two cross-sectional data sets of HCP perspectives over 15 years. In 2002 and 2017, two samples of HCPs received a survey on FASD. The findings from these surveys may inform the development of ongoing educational initiatives to help HCPs with screening for alcohol use during pregnancy and early diagnosis and prevention of FASD.

Predictors of Limited Access to Dental Health Care Among NYC Taxi/FHV Drivers.

Taxi and for-hire vehicle (FHV) drivers are a largely immigrant, low-income occupational group at increased cardiovascular disease (CVD) risk. Poor dental health is a CVD risk factor, and dental care access is an unexamined taxi/FHV driver CVD risk factor. A cross-sectional survey was administered to 422 taxi/FHV drivers (2016-2017) to identify predictors of access to dental health care among drivers. One-third (n = 128, 30.3%) reported needing dental care/tests/treatment within the past six months, and nearly one-half (n = 61, 48%) were delayed/unable to obtain care. Only 57.6% (n = 241) had past-year dental cleanings. Not having enough money to cover household expenses was a significant predictor of being delayed/unable to obtain needed dental care/tests/treatment in the prior six months (0.5 OR; 95% CI, 0.28-0.89; p < .05). Lack of dental insurance coverage (2.72 OR; 95% CI, 1.60-4.63; p < .001) or lack of primary care provider (2.72 OR; 95% CI, 1.60-4.63; p < .001) were associated with lack of past-year dental cleaning. Seventeen percent of drivers with Medicaid were unaware of their dental coverage, which was associated with both inability to access needed dental care/tests/treatment in the past 6 months (p = .026) and no past-year dental cleaning (p < .001). Limited understanding of dental coverage was associated with both an inability to access needed dental care/tests/treatment in the past 6 months (p = .028) and lack of past-year dental cleaning (p = .014). Our findings can inform targeted intervention development to increase taxi/FHV driver dental care access/uptake, potentially improving their CVD risk.

Comparing outcomes of children and youth with fetal alcohol spectrum disorder (FASD) in the child welfare system to those in other living situations in Canada: Results from the Canadian National FASD Database.

AIMS: The current study aimed to explore differences in adverse outcomes between youth and adolescents with fetal alcohol spectrum disorder (FASD) living in child welfare care (i.e., foster care or group home) with those living with their biological parent(s) or with adoptive or other family member(s) in Canada. METHODS: Data gathered from the Canadian National FASD Database were used for analysis. A total of 665 youth and adolescents with a clinical diagnosis of FASD under the age of 18 living in child welfare care, with biological, adoptive or other family members, were included in the sample. Key areas examined included living situation, legal problems, experience of sexual or physical abuse, mental health (anxiety, conduct disorder, mood disorder and post-traumatic stress disorder) and suicidal ideation. Descriptive statistics and chi-square comparisons were utilized to explore these differences. RESULTS: Results revealed a significantly higher rate of reported sexual and physical abuse among individuals in child welfare care compared with those living with biological parents or with adoptive or other family member(s). Rates of difficulty with the law were also higher among those in child welfare care compared with adoptive/other family members. Conversely, the rate of mood disorders was significantly higher among those living with adoptive/other family members compared with child welfare care. Results highlight similar rates of reported suicidal ideation/attempts across all living situations, as well as mental health concerns. CONCLUSIONS: Results offer rare insight into the lives of youth and adolescents under age 18 with diagnosed FASD who reside in child welfare care in contrast to those living with biological parent(s) or with adoptive or other family members. These findings increase our awareness of the complexity of mental health concerns and suicide risk across all living environments. Results have further implications for policy, practice and clinical intervention.

Emotional Reactivity as a Vulnerability for Psychogenic Nonepileptic Seizures? Responses While Reliving Specific Emotions.

OBJECTIVE: Dysfunction in emotional processes is a hypothesized contributor to functional neurological disorders (FNDs), yet few studies have evoked real-time emotion during multimethod assessment incorporating subjective, behavioral, and psychophysiological indicators. This approach may reveal clinical and neurobiological vulnerability to FND and clarify how dysfunctional emotional processes serve as perpetuating factors. METHODS: Eleven participants with video-EEG-confirmed diagnoses of psychogenic nonepileptic seizures (PNES) were compared with 49 seizure-free trauma control subjects (TCs) with or without clinically elevated posttraumatic stress symptoms (25 clinically elevated [TC-clin], 24 not clinically elevated [TC-nonclin]). Participants recalled and described memories evoking anger, shame, happiness, and neutral feelings. RESULTS: Even though PNES patients and TCs reported similar amounts of emotional experience, PNES patients reported more difficulty reliving emotions and were less likely to complete the relived shame task. During and after reliving happiness, PNES and TC-clin groups showed respiratory sinus arrhythmia (RSA) decreases, indicating parasympathetic withdrawal, whereas the TC-nonclin group showed RSA increases. CONCLUSIONS: Findings from this pilot study are consistent with previous research and clinical observations that emotional engagement may be more effortful for PNES patients. Patterns of RSA change, which may also point to greater effortful engagement, were similar in PNES and TC-clin groups, suggesting that traumatic stress reactions may play a part. At the same time, experience of greater difficulty or avoidance may be even greater among PNES patients. Especially when regulatory resources are already limited, accumulated effort, coupled with self-threatening contexts such as shame, may be particularly problematic for those with PNES and perhaps other FNDs.

A framework for understanding the pathophysiology of functional neurological disorder.

The symptoms of functional neurological disorder (FND) are a product of its pathophysiology. The pathophysiology of FND is reflective of dysfunction within and across different brain circuits that, in turn, affects specific constructs. In this perspective article, we briefly review five constructs that are affected in FND: emotion processing (including salience), agency, attention, interoception, and predictive processing/inference. Examples of underlying neural circuits include salience, multimodal integration, and attention networks. The symptoms of each patient can be described as a combination of dysfunction in several of these networks and related processes. While we have gained a considerable understanding of FND, there is more work to be done, including determining how pathophysiological abnormalities arise as a consequence of etiologic biopsychosocial factors. To facilitate advances in this underserved and important area, we propose a pathophysiology-focused research agenda to engage government-sponsored funding agencies and foundations.

Screening and Intervention Practices for Alcohol Use by Pregnant Women and Women of Childbearing Age: Results of a Canadian Survey.

OBJECTIVE: To determine health care providers' familiarity with and use of the Society of Obstetricians and Gynaecologists of Canada's (SOGC's) 2010 Alcohol Use and Pregnancy Consensus Clinical Guidelines and to identify barriers and enablers that affected guideline uptake. METHODS: We conducted an online pan-Canadian survey of midwives, obstetricians, family physicians, and nurses. The survey was divided into five sections: knowledge, SOGC guidelines, screening and intervention practices, attitudes and beliefs, and demographic information. RESULTS: Just over half of the 588 respondents who provided care to pregnant women or to women of childbearing age were familiar with and used the guidelines. Most respondents screened for alcohol use by asking women about alcohol consumption, but relatively few used a screening questionnaire. Approximately two-thirds of respondents provided brief intervention and referral to harm reduction or treatment services. Enablers of guideline adherence included knowledge about the risks of alcohol in pregnancy, perceived responsibility to identify and address at-risk drinking, and a belief that women are motivated to reduce their alcohol consumption if pregnant or planning to become pregnant. Lack of confidence in ability to use screening questionnaires and to provide brief intervention, as well as a lack of belief in the effectiveness of both practices, were barriers to use. CONCLUSION: Strategies are needed to improve familiarity with and uptake of the Alcohol Use and Pregnancy Consensus Clinical Guidelines. Particular attention should be given to education and training regarding the use of validated screening questionnaires and brief intervention practices.

The educators' experience: Learning environments that support the master adaptive learner.

BACKGROUND: The Master Adaptive Learner (MAL) theoretical framework describes an integrated approach to learning that combines features of educational theory on self-regulated learning and aspects of quality improvement. In order to develop MAL students, it is important to pay attention to the learning environment. PURPOSE: To describe educators' perspectives about the learning environment needed to promote the development of master adaptive learners. METHODS: Thematic analysis of reports by medical educators who were workshop participants at a national presentation on creating effective learning environment to develop MAL in undergraduate medical education. RESULTS: Three themes educators considered important in the development of the Master Adaptive Learner were Adaptive Educator, Support for Learning, and Institutional Commitment. These findings suggest that in order to support the MAL, an educational setting should provide faculty who can be flexible and adapt to the developing MAL, learning experiences that support active learning, focused on groups as well as developing individual learners. Leaders in the educational setting should demonstrate a commitment to creating a culture to support learning and provide appropriate resources to that end. CONCLUSION: Learning environments to develop master adaptive learners need to have adaptive educators, teaching, learning, and institutional culture to support challenge and grow Master Adaptive Learners.

Comparison of pro- and anti-inflammatory responses in paired human primary airway epithelial cells and alveolar macrophages.

BACKGROUND: Airway epithelial cells and alveolar macrophages (AMs) are the first line of defense in the lung during infection. Toll-like receptor (TLR) agonists have been extensively used to define the regulation of inflammation in these cells. However, previous studies were performed in non-paired airway epithelial cells and AMs. The major goal of our study was to compare the pro- and anti-inflammatory responses of paired human primary airway epithelial cells and AMs to TLR3 and TLR4 agonists. METHODS: Tracheobronchial epithelial cells (TBEC) and AMs from four smokers and four non-smokers without lung disease were cultured with or without Poly(I:C) (PIC) (a TLR3 agonist) or LPS (a TLR4 agonist) for 4, 24 and 48 h. The immune responses of paired cells were compared. RESULTS: TBEC and AMs showed stronger pro-inflammatory cytokine (e.g., IL-8) responses to PIC and LPS, respectively. TLR3 and TLR4 mRNA levels were similar in non-stimulated TBEC and AMs. However, PIC stimulation in AMs led to sustained up-regulation of the immune negative regulators Tollip and A20, which may render AMs less sensitive to PIC stimulation than TBEC. Unlike AMs, TBEC did not increase NF-κB activation after LPS stimulation. Interestingly, smoking status was correlated with less TLR3 and IRAK-M expression in non-stimulated TBEC, but not in AMs. PIC-stimulated TBEC and LPS-stimulated AMs from smokers vs. non-smokers produced more IL-8. Finally, we show that expression of A20 and IRAK-M is strongly correlated in the two paired cell types. CONCLUSIONS: By using paired airway epithelial cells and AMs, this study reveals how these two critical types of lung cells respond to viral and bacterial pathogen associated molecular patterns, and provides rationale for modulating immune negative regulators to prevent excessive lung inflammation during respiratory infection.

Diagnostic utility of the Minnesota Multiphasic Personality Inventory-2 Restructured Form in the epilepsy monitoring unit: Considering sex differences.

Psychological assessment measures are frequently used to evaluate patients in epilepsy monitoring units. One goal of that assessment is to contribute information that may help with differential diagnosis between epilepsy and psychogenic nonepileptic seizures (PNES). The Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) is one such measure. Del Bene et al. (2017) recently published an analysis that was the first to compare MMPI-2-RF scale elevations between diagnostic groups stratified by sex. The purpose of the present study was to replicate that analysis in a larger sample. Similar to previous work, we found that both men and women with PNES were more likely than men and women with epilepsy to report high levels of somatic complaints (2 to 5 times greater odds of somatic symptom reporting) and a variety of types of complaints. Mood disturbance scales were not significantly elevated in our PNES sample. Results contribute to the small body of research on sex differences in patients with PNES and suggest that somatization is a key characterization across sexes.

Is brain response to food rewards related to overeating? A test of the reward surfeit model of overeating in children.

The reward surfeit model of overeating suggests that heightened brain response to rewards contributes to overeating and subsequent weight gain. However, previous studies have not tested whether brain response to reward is associated with food intake, particularly during childhood, a period of dynamic development in reward and inhibitory control neurocircuitry. We conducted functional magnetic resonance imaging (fMRI) with 7-11-year-old children (n = 59; healthy weight, n = 31; overweight, n = 28; 54% female) while they played a modified card-guessing paradigm to examine blood-oxygen-level-dependent (BOLD) response to anticipating and winning rewards (food, money, neutral). Food intake was assessed at three separate meals that measured different facets of eating behavior: 1) typical consumption (baseline), 2) overindulgence (palatable buffet), and 3) eating in the absence of hunger (EAH). A priori regions of interest included regions implicated in both reward processing and inhibitory control. Multiple stepwise regressions were conducted to examine the relationship between intake and BOLD response to rewards. Corrected results showed that a greater BOLD response in the medial prefrontal cortex for anticipating food compared to money positively correlated with how much children ate at the baseline and palatable buffet meals. BOLD response in the dorsolateral prefrontal cortex for winning food compared to money was positively correlated with intake at the palatable buffet meal and EAH. All aforementioned relationships were independent of child weight status. Findings support the reward surfeit model by showing that increased brain response to food compared to money rewards positively correlates with laboratory measures of food intake in children.

Discrimination and Health Among Taxi Drivers in New York and Toronto.

Immigrant taxi drivers in metropolitan cities are exposed to experiences of discrimination and occupation-based health risks. Given the structural differences in health care systems in the United States and Canada, we investigated the differences in reports of discrimination, health conditions and concern about health conditions between taxi drivers in New York City and Toronto, Ontario. Participants were recruited for a taxi driver Needs Assessment Survey as part of a Taxi Network needs assessment project using a street side convenience sampling technique in New York City and Toronto. The matched sample contained 33 drivers from Toronto and 33 drivers from NYC. All Toronto drivers in our sample reported having health insurance while over a quarter of NYC drivers did not have health insurance. Toronto drivers reported greater everyday and workplace discrimination. Drivers in both cities experienced higher rates than average, and reported concern about, major health conditions. We also found preliminary evidence suggesting a relationship between experiencing discrimination and reporting chronic pain. Our findings suggest the need for future research to more closely examine the associations between discrimination and health among the taxi driver population.

Learning to balance efficiency and innovation for optimal adaptive expertise.

It is critical for health professionals to continue to learn and this must be supported by health professions education (HPE). Adaptive expert clinicians are not only expert in their work but have the additional capacity to learn and improve in their practices. The authors review a selective aspect of learning to become an adaptive expert: the capacity to optimally balance routine approaches that maximize efficiency with innovative ones where energy and resources are used to customize actions for novel or difficult situations. Optimal transfer of learning, and hence the design of instruction, differs depending on whether the goal is efficient or innovative practice. However, the task is necessarily further complicated when the aspiration is an adaptive expert practitioner who can fluidly balance innovation with efficiency as the situation requires. Using HPE examples at both the individual and organizational level, the authors explore the instructional implications of learning to shift from efficient to innovative expert functioning, and back. They argue that the efficiency-innovation tension is likely to endure deep into the future and therefore warrants important consideration in HPE.

The Effects of Smoking Abstinence on Incentivized Spatial Working Memory.

BACKGROUND AND OBJECTIVE: Reward processing and working memory (WM) underlie value-based decision-making; consequently, joint examination of these systems may further our understanding of why smokers choose to smoke again following a quit attempt (relapse). While previous studies have demonstrated altered reward and WM function associated with nicotine exposure, little is known about the effects of abstinence on the joint function of these systems. The current study aims to address this gap. METHOD: Eighteen daily smokers were tested on a monetarily incentivized memory guided saccade (MGS) task on two separate, counterbalanced occasions, an abstinent and a non-abstinent session. The MGS task is a widely used metric of spatial working memory and enables precise quantification of the effects of rewards and nicotine exposure on behavior. RESULTS: During the non-abstinent session, participants showed increased accuracy of the initial saccade towards the remembered target location on reward vs. neutral trials. Participants also showed increased accuracy of the final saccade towards the target, across incentive types, only during the non-abstinent condition. DISCUSSION AND CONCLUSIONS: Our observation that rewards improve the accuracy of the initial memory guided saccade during the non-abstinent but not abstinent condition extends a growing literature indicating reduced motivation towards monetary rewards during abstinence. Further, differences in the accuracy of the final corrective saccade during the non-abstinent but not the abstinent condition suggests smoking abstinence-related effects on WM precision beyond those related to incentive motivation (e.g., sustained attention). SIGNIFICANCE: This work extends our fundamental understanding of smoking's effects on core affective and cognitive processes.