Temporal organization of narrative recall is present but attenuated in adults with hippocampal amnesia.

Studies of the impact of brain injury on memory processes often focus on the quantity and episodic richness of those recollections. Here, we argue that the organization of one's recollections offers critical insights into the impact of brain injury on functional memory. It is well-established in studies of word list memory that free recall of unrelated words exhibits a clear temporal organization. This temporal contiguity effect refers to the fact that the order in which word lists are recalled reflects the original presentation order. Little is known, however, about the organization of recall for semantically rich materials, nor how recall organization is impacted by hippocampal damage and memory impairment. The present research is the first study, to our knowledge, of temporal organization in semantically rich narratives in three groups: (1) Adults with bilateral hippocampal damage and severe declarative memory impairment, (2) adults with bilateral ventromedial prefrontal cortex (vmPFC) damage and no memory impairment, and (3) demographically matched non-brain-injured comparison participants. We find that although the narrative recall of adults with bilateral hippocampal damage reflected the temporal order in which those narratives were experienced above chance levels, their temporal contiguity effect was significantly attenuated relative to comparison groups. In contrast, individuals with vmPFC damage did not differ from non-brain-injured comparison participants in temporal contiguity. This pattern of group differences yields insights into the cognitive and neural systems that support the use of temporal organization in recall. These data provide evidence that the retrieval of temporal context in narrative recall is hippocampal-dependent, whereas damage to the vmPFC does not impair the temporal organization of narrative recall. This evidence of limited but demonstrable organization of memory in participants with hippocampal damage and amnesia speaks to the power of narrative structures in supporting meaningfully organized recall despite memory impairment.

Multilevel Barriers to Long-Acting Reversible Contraceptive Uptake: A Narrative Review.

Unintended pregnancies, which occur in almost half (45%) of all pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives (LARCs), namely intrauterine devices and implants. Although LARCs are highly acceptable to women at risk of unintended pregnancies, barriers to accessing LARCs hinder its uptake. These barriers are greater among racial and socioeconomic lines and persist within and across the intrapersonal, interpersonal, institutional, and policy levels. A synthesis of these barriers is unavailable in the current literature but would be beneficial to health care providers of reproductive-aged women, clinical managers, and policymakers seeking to provide equitable reproductive health care services. The aim of this narrative review was to aggregate these complex and overlapping barriers into a concise document that examines: (a) patient, provider, clinic, and policy factors associated with LARC access among populations at risk of unintended pregnancy and (b) the clinical implications of mitigating these barriers to provide equitable reproductive health care services. This review outlines numerous barriers to LARC uptake across multiple levels and demonstrates that LARC uptake is possible when the woman is informed of her contraceptive choices and when financial and clinical barriers are minimized. Equitable reproductive health care services entail unbiased counseling, a full range of contraceptive options, and patient autonomy in contraceptive choice.

Are two occupational therapists better than one? Occupational therapists' perspectives of intra-disciplinary practice within community health.

INTRODUCTION: Intra-disciplinary practice is rarely discussed in occupational therapy and the broader health-care literature. Community-based occupational therapists often work autonomously in clients' homes and consequently have limited access to routine intra-disciplinary practices. Additionally, the community-based role covers a large scope of practice requiring comprehensive expertise. This study aimed to describe occupational therapists' perspectives on intra-disciplinary practice within community health settings. METHODS: This study utilised an online cross-sectional survey design, collecting quantitative and qualitative data to explore perspectives of occupational therapists working within Australian community health services. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis. Both forms of data were compared and contrasted. RESULTS/FINDINGS: Eighty occupational therapists completed the survey. Seventy-eight participants (97%) previously used or currently use intra-disciplinary practice in their workplace. Participants predominantly consult their peers when client needs are perceived as complex. Participants indicated that intra-disciplinary practice can benefit the client, therapist, and workplace. Enablers and barriers to the use of intra-disciplinary practice had overlapping themes, including access to therapists, attitudes towards intra-disciplinary practice, management support, and funding influences. Most participants expressed a desire to utilise intra-disciplinary practices (n = 70, 87%) and were also likely or extremely likely to incorporate it into their clinical work (n = 73, 91%). Participants who did not want to utilise intra-disciplinary practices or who were unsure provided reasons related to cost, practice inefficiencies, and being uncertain of the benefit. CONCLUSIONS: Occupational therapists perceive intra-disciplinary practice as beneficial for problem-solving and an opportunity for knowledge sharing that supports therapist confidence with clinical reasoning. Conversely, some therapists believe its use may lead to client confusion, a greater need for communication and coordination among therapists, and that power differentials between therapists may discourage equal collaboration. Greater understanding of intra-disciplinary practice will help guide how it is used and supported in community health settings.

Racial Differences in the Risk of Prenatal Depression Among Women Experiencing Childhood and Adult Stressors.

INTRODUCTION: Stress exposure during a woman's own childhood and adulthood likely elevate risk of prenatal depression (PND). However, most PND screening tools fail to assess for events prior to conception. This study examined the differential effects of adverse childhood experiences (ACE) and adult life stressors on PND. METHODS: This cross-sectional study was conducted among 199 racially diverse pregnant women, ages 18 to 43, recruited from clinics and ongoing university-based studies between 2012 and 2018. The ACE Scale assessed maternal childhood trauma exposure. Validated scales examining subjective stressors assessed for chronic adult stressors. PND was assessed with the Edinburgh Depression Scale, with the Rini Pregnancy-Related Anxiety Scale as a covariate. Associations were measured using multivariable linear regression modeling. Results were stratified by self-identified Black or white race. RESULTS: Among 199 participants, mean age was 26.8 years and 67.8% were Black. Controlling for age, race, education, and prenatal anxiety, all participants reporting both childhood trauma and adult stressors were at increased risk for PND (p < 0.0001). PND risk was increased among Black women with childhood stressors (p < 0.01) or three or more adult stressors (p < 0.0001) and among White women following any number of adult stressors (p < 0.001). DISCUSSION: These findings highlight the importance of cumulative exposure to stress and trauma across the life span as indicators of risk for PND. Black and white participants had differential development of risk, depending on timing and number of exposures. Prenatal depression risk screening during routine prenatal care should include an assessment of current and historical trauma and stressors.

Delivering Health Information to Parents via a Theory-Informed SMS-Based Intervention: Development and Results from a Pilot Study.

INTRODUCTION: Short message service (SMS), or text-based, health interventions offer a promising opportunity to deliver health education and have been shown to improve diet and exercise. However, few are theory-based or target low-income parents. This pilot study, informed by the Theory of Planned Behavior (TPB), primarily sought to determine if health education delivered via SMS was feasible and acceptable to low-income parents of young children. METHODS: Using a one-group, pre- to post-test study design to assess a 12-week SMS-based health education program, parents enrolled in a health-related program at an early childhood development center for low-income families were sent three text messages per week that corresponded to a weekly diet or physical activity-related theme. Surveys assessed pre-post changes in TPB constructs and collected program feedback. RESULTS: Among the 119 eligible parents invited to participate, 109 were sent all text messages for the duration of the study. Participants were mostly Black (98.9%), 25-39 years old (83.9%), female (93.8%), and in single-parent households (63.8%). More than half (n = 59) completed the pre-survey, answered a bi-directional program text, or completed the post-survey. Twelve participants completed both the pre- and post-survey and at least one bi-directional text. Post-survey results revealed that most participants liked the program design and enjoyed their experience with the program. CONCLUSIONS: SMS-based interventions can simplify delivery of health information to low-income parents of young children. Although engagement was low, retention was high, and feedback was largely positive.

State Abortion Policies and Maternal Death in the United States, 2015‒2018.

Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level generalized linear Poisson regression models with robust standard errors to estimate 4-year TMM, MM, and LMM rate ratios and 95% confidence intervals (CIs) associated with a 1-unit increase in the abortion index, adjusting for state-level covariates. Results. States with the higher score of abortion policy composite index had a 7% increase in TMM (adjusted rate ratio [ARR] = 1.07; 95% CI = 1.02, 1.12) compared with states with lower abortion policy composite index, after we adjusted for state-level covariates. Among individual abortion policies, states with a licensed physician requirement had a 51% higher TMM (ARR = 1.51; 95% CI = 1.15, 1.99) and a 35% higher MM (ARR = 1.35; 95% CI = 1.09, 1.67), and states with restrictions on Medicaid coverage of abortion care had a 29% higher TMM (ARR = 1.29; 95% CI = 1.03, 1.61). Conclusions. Restricting access to abortion care at the state level may increase the risk for TMM.

Influences of club connectedness among young adults in Western Australian community-based sports clubs.

BACKGROUND: Along with physical benefits, community-based sport provides opportunities to enhance connectedness, an important protective factor of social and emotional health. However, young Australians participating in sport have been found to drink alcohol at higher levels than their non-sporting peers, and many clubs serve unhealthy food and beverages. This study explored the association between the dependent variable, level of alcohol consumption (AUDIT-C) and connectedness to club and other health behaviours among young people aged 18-30 years who play club sport in Western Australia. METHODS: An online cross sectional survey measured levels of alcohol consumption (AUDIT-C), alcohol-related harm, connectedness (including volunteering and team cohesion), mental wellbeing, healthy food options and club sponsorship among young adults aged 18-30 years involved in sports clubs in Western Australia (n = 242). Relationships and association between the dependent variable (AUDIT-C) and independent variables were assessed. RESULTS: Male sportspeople were more likely to drink alcohol at high-risk levels than females (p < .001), and respondents belonging to a club that received alcohol-related sponsorship were more likely to drink at high-risk levels (p = .019). Females were significantly more likely to want healthy food and beverage options provided at their clubs (p = 0.011). When all factors were considered team cohesion (p = 0.02), alcohol expectations (p = < .001), occurrences of experienced alcohol-related harm (p = <.001) and length of club membership (p = 0.18) were significant predictors of high-risk AUDIT-C (R2 = .34, adjusted R2 = .33, F (4, 156) = 20.43, p = <.001). High-risk AUDIT-C and club connectedness predicted strong team cohesion (R2 = .39, adjusted R2 = .39, F (2, 166) = 53.74, p = <.001). CONCLUSIONS: Findings from this study may inform policy and practice to enhance healthy behaviours among young adults participating in community sports clubs in Australia and other countries.

Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana.

BACKGROUND: Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. OBJECTIVE: To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. MATERIALS AND METHODS: This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses. RESULTS: After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). CONCLUSION: Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.

Safety and utility of surveillance biopsies in pediatric kidney transplant patients.

There is currently no way to diagnose a rejection before a change in serum creatinine. This had led some to start doing SB, but little data exist on the utility and safety of SB in pediatric patients. There is also little known on practice patterns of pediatric nephrologists. A retrospective review of pediatric kidney transplant SB between January 2013 and January 2017 at a single center was performed. A survey went to the PedNeph email list. There were 47 SB; 15 at 6 months, 12 at 1 year, 13 at 2 years, and 7 at 3 years. There were 3 minor (1 gross hematuria and 2 hematomas) and no major complications. On 6-month SB, 1 had SC 1A ACR (6.7%) with no BR ACR. On the 12-month SB, there were 5 with SCBR ACR (41.7%) and 1 with SC AMR (8.3%). On the 2-year SB, there were 4 that had SCBR ACR (30.8%), and 1 with SC AMR (7.7%). On the 3-year SB, 1 had chronic transplant glomerulitis (14.3%). The survey showed that 34.3% of pediatric nephrologists perform SB. SB can be performed safely. By early identification of histological lesions, SB gives us an opportunity for individualized immunosuppressive regimens that may prevent chronic allograft dysfunction and improve long-term graft outcome.

Practice Change From Intermittent Medication Boluses to Bolusing From a Continuous Infusion in Pediatric Critical Care: A Quality Improvement Project.

OBJECTIVES: To determine whether implementing a guideline to bolus medications from continuous infusions in PICUs affects nursing satisfaction, patient safety, central line entries, medication utilization, or cost. DESIGN: This is a pre- and postimplementation quality improvement study. SETTING: An 11-bed ICU and 14-bed cardiac ICU in a university-affiliated children's hospital. PATIENTS: Patients less than 18 years old admitted to the PICU or pediatric cardiac ICU receiving a continuous infusion of dexmedetomidine, midazolam, fentanyl, morphine, vecuronium, or cisatracurium from May 2015 to May 2016, excluding November 2015 (washout period), were eligible for inclusion. INTERVENTIONS: Change in practice from administering bolus doses from an automated dispensing machine to administering bolus medications from continuous infusion in PICUs. MEASUREMENTS AND MAIN RESULTS: Timing studies were conducted pre- and post implementation in 29 and 26 occurrences, respectively. The median time from the decision to give a bolus until it began infusing decreased by 169 seconds (p < 0.01). Nursing satisfaction increased from 19.3% pre- to 100% post implementation. Safety was assessed via barcode scanning compliance, which decreased by 1.4% for patients and 1% for medications, and smart pump limit overrides. The percentage of infusion pump bolus overrides increased as expected, with the majority (99%) of these exceeding soft maximum limits by less than two-fold. Central line entries were unaffected post implementation. To assess medication utilization, a total of 50 patients in each intervention group were selected for retrospective chart review. Daily fentanyl boluses increased from one to three (p = 0.021). However, midazolam infusion dose and fentanyl infusion duration decreased (p = 0.026 and p = 0.005, respectively). Medication utilization was otherwise unchanged post implementation (p > 0.05). Annualized cost avoidance was $124,160. CONCLUSIONS: Implementation of bolus medications from continuous infusion in PICUs significantly decreased time to begin a bolus dose and increased nursing satisfaction. The practice change also improved medication utilization without negatively impacting patient safety.

Alteplase infusion versus dwell for clearance of partially occluded central venous catheters in critically ill pediatric patients.

OBJECTIVE: To evaluate the efficacy and safety of alteplase infusions and alteplase local instillations (dwells) to clear partially occluded central venous catheters in critically ill children. DESIGN: Retrospective study. SETTING: PICU in a single, tertiary care, academic children's hospital. PATIENTS: Retrospective review of the medical records of all critically ill pediatric patients less than 18 years old who received an alteplase infusion or dwell as the treatment for a partial central venous catheter occlusion. The typical infusion regimen was to administer 0.1 mg/kg of body weight (maximum, 2 mg/dose) of alteplase in 25 mL of 0.9% sodium chloride over 3 hours. The standard dwell was to administer and aspirate alteplase in a 1 mg/mL concentration as a fixed dose as ordered by the prescriber (maximum, 2 mg/dose). Efficacy was defined as documentation of positive blood return from the catheter. Radiology reports, nursing and physician documentation, and laboratory values were reviewed to assess for bleeding events. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred fifty occlusion events were included for analysis. Overall, 72 of 84 alteplase infusions (86%) and 53 of 66 alteplase dwells (80%) resulted in resolution of the lumen occlusion event as documented by positive blood return from the catheter after a maximum of two doses (p = 0.39). One major bleeding event occurred in each arm; both were deemed unlikely related to alteplase. CONCLUSIONS: Alteplase infusions to clear partially occluded central venous catheters appear to be as efficacious as alteplase dwells in critically ill children. In occlusions treated with an infusion, more occlusions resolved in older and larger patients and in patients with catheters in place less than 7 days. In occlusions treated with a dwell, more occlusions resolved in smaller catheters. The safety profile for both infusions and dwells was acceptable for the pediatric critically ill population.

Maternity Care Deserts in Louisiana and Breastfeeding Initiation.

BACKGROUND: Breastfeeding provides physical, psychological, and immunological benefits to both the mother and infant, but breastfeeding rates are suboptimal. The purpose of this study was to examine whether residing in a maternity care desert (a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with lower breastfeeding rates among birthing people in Louisiana from 2019 to 2020. METHODS: Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all live births provided by the Louisiana Office of Vital Records (n = 112,151), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory geospatial analysis to examine the association between place of residence and breastfeeding initiation and racial disparities in initiation. We conducted a secondary within-group analysis by fitting the fully adjusted model stratified by race/ethnicity for non-Hispanic white and non-Hispanic Black birthing people. RESULTS: We found that residing in a parish with limited (odds ratio [OR] = 0.87; 95% confidence interval [CI] [0.77, 0.99]) to no access (OR = 0.88; 95% CI [0.80, 0.97]) was significantly associated with lower breastfeeding initiation rates. The within-group analysis determined that both non-Hispanic Black and non-Hispanic white birthing people residing in a parish with limited or no maternity care access had lower breastfeeding initiation rates. CONCLUSION: Reducing rural and racial inequities in breastfeeding may require structural changes and investments in infrastructure to deliver pregnancy care.

A review of trauma laparotomy at Christchurch Hospital.

AIM: Trauma is one of the leading causes for years of life lost in New Zealand. Its costs to acute care services alone amount to hundreds of millions per year, and it is the main contributor to years of life lost in patients under 40. Since 2016, the Canterbury Trauma Registry has been actively collecting data on all major traumas presenting to Christchurch hospital. This study will aim to define the demographics of trauma laparotomy patients presenting to Christchurch Hospital, and to assess the relationship between missed injuries (MI) on computed tomography (CT) imaging and time to theatre. METHODS: A retrospective study of trauma patient from June 2016 to February 2019. Data for major trauma patients were supplied from the Canterbury Trauma Registry. Data for minor trauma patients were individually selected from the online operative procedures registry. Non-parametric analysis was undertaken with an independent sample Kruskal-Wallis test alongside pairwise comparisons. RESULTS: Sixty trauma laparotomies were performed over 36 months, predominantly male gender (43/60) and under 40 years of age (39/60). Motor vehicle accident (31/60) and knife injuries (10/60) were the most common mechanisms. Fourty-three out of sixty patients received pre-operative CT scans. Fourty out of sixty patients received a CT scan within 2 hours. Large bowel injuries (four cases) and small bowel (three cases) were the most common missed injuries on pre-operative CT. Small bowel injuries are the predominate injury in blunt trauma while diaphragm and liver injuries predominated in penetrating trauma. Four patients did not undergo laparotomy within 24 hours. There is a statistically significant difference (p<0.001) in time to operating theatre between patients with no pre-operative CT and patients with no MI on CT and patients with MI on CT. There is no statistically significant difference (p<0.231) in time to operating theatre in patients with no MI on CT and patients with MI on CT. CONCLUSION: There is no statistically significant difference in time to operation between trauma laparotomy patients with no MI on pre-operative CT to patients with MI on pre-operative CT. There are recognisable injury patterns in trauma patients. There are delays in trauma patients receiving prompt CT imaging. CT imaging can miss life-threatening injury, close patient observation and further examination, and imaging or operative therapy may be required even if initial imaging is reassuring.

MEMCONS: How Contemporaneous Note-Taking Shapes Memory for Conversation.

Written memoranda of conversations, or memcons, provide a near-contemporaneous record of what was said in conversation, and offer important insights into the activities of high-profile individuals. We assess the impact of writing a memcon on memory for conversation. Pairs of participants engaged in conversation and were asked to recall the contents of that conversation 1 week later. One participant in each pair memorialized the content of the interaction in a memcon shortly after the conversation. Participants who generated memcons recalled more details of the conversations than participants who did not, but the content of recall was equally and largely accurate for both participants. Remarkably, only 4.7% of the details of the conversation were recalled by both of the partners after a week delay. Contemporaneous note-taking appears to enhance memory for conversation by increasing the amount of information remembered but not the accuracy of that information. These findings have implications for evaluating the testimony of participants on conversations with major political or legal ramifications.

The COVID-19 pandemic's impact on all-cause mortality disparities in Medicare: By race, income, chronic health, mental/behavioral health, disability.

BACKGROUND: The Medicare-enrolled population is heterogeneous across race, ethnicity, age, dual eligibility, and a breadth of chronic health, mental and behavioral health, and disability-related conditions, which may be differentially impacted by the COVID-19 pandemic. OBJECTIVE: To quantify changes in all-cause mortality prior-to and in the first year of the COVID-19 pandemic across Medicare's different sociodemographic and health-condition subpopulations. METHODS: This observational, population-based study used stratified bivariate regression to investigate Medicare fee-for-service subpopulation differences in pre-pandemic (i.e., 2019 versus 2016) and pandemic-related (2020 versus 2019) changes in all-cause mortality. RESULTS: All-cause mortality in the combined Medicare-Advantage (i.e., managed care) and fee-for-service beneficiary population improved by a relative 1% in the ten years that preceded the COVID-19 pandemic, but then escalated by a relative 15.9% in 2020, the pandemic's first year. However, a closer look at Medicare's fee-for-service subpopulations reveals critical differences. All-cause mortality had actually been worsening prior to the pandemic among most psychiatric and disability-related condition groups, all race and ethnicity groups except White Non-Hispanic, and Medicare-Medicaid dual-eligible (i.e., low-income) beneficiaries. Many of these groups then experienced all-cause mortality spikes in 2020 that were over twice that of the overall Medicare fee-for-service population. Of all 61 chronic health conditions studied, beneficiaries with schizophrenia were the most adversely affected, with all-cause mortality increasing 38.4% between 2019 and 2020. CONCLUSION: This analysis reveals subpopulation differences in all-cause mortality trends, both prior to and in year-one of the COVID-19 pandemic, indicating that the events of 2020 exacerbated preexisting health-related inequities.

A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19.

BACKGROUND: Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES: To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19. METHODS: A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values. RESULTS: At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked. CONCLUSIONS: Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.

Mate choice for major histocompatibility complex genetic divergence as a bet-hedging strategy in the Atlantic salmon (Salmo salar).

Major histocompatibility complex (MHC)-dependent mating preferences have been observed across vertebrate taxa and these preferences are expected to promote offspring disease resistance and ultimately, viability. However, little empirical evidence linking MHC-dependent mate choice and fitness is available, particularly in wild populations. Here, we explore the adaptive potential of previously observed patterns of MHC-dependent mate choice in a wild population of Atlantic salmon (Salmo salar) in Québec, Canada, by examining the relationship between MHC genetic variation and adult reproductive success and offspring survival over 3 years of study. While Atlantic salmon choose their mates in order to increase MHC diversity in offspring, adult reproductive success was in fact maximized between pairs exhibiting an intermediate level of MHC dissimilarity. Moreover, patterns of offspring survival between years 0+ and 1+, and 1+ and 2+ and population genetic structure at the MHC locus relative to microsatellite loci indicate that strong temporal variation in selection is likely to be operating on the MHC. We interpret MHC-dependent mate choice for diversity as a likely bet-hedging strategy that maximizes parental fitness in the face of temporally variable and unpredictable natural selection pressures.

Parallelism in the oxygen transport system of the lake whitefish: the role of physiological divergence in ecological speciation.

In North America, populations of lake whitefish (Coregonus clupeaformis) have evolved sympatric 'dwarf' and 'normal' ecotypes that are associated with distinct trophic niches within lakes. Trophic specialization should place diverging physiological demands on individuals, and thus, genes and phenotypes associated with energy production represent ideal candidates for studies of adaptation. Here, we test for the parallel divergence of traits involved in oxygen transport in dwarf and normal lake whitefish from Québec, Canada and Maine, USA. We observed significant differences in red blood cell morphology between the ecotypes. Specifically, dwarfs exhibited larger nuclei and a higher nucleus area/total cell area than normal whitefish in all of the lakes examined. In addition, isoelectric focusing gels revealed variation in the haemoglobin protein components found in whitefish. Dwarf and normal whitefish exhibited a similar number of protein components, but the composition of these components differed, with dwarf whitefish bearing a greater proportion of cathodic components compared to the normals. Furthermore, dwarf whitefish showed significant haemoglobin gene upregulation in the brain compared with the levels shown in normals. Together, our results indicate that metabolic traits involved in oxygen transport differ between the whitefish ecotypes and the strong parallel patterns of divergence observed across lakes implicates ecologically driven selection pressures. We discuss the function of these traits in relation to the differing trophic niches occupied by the whitefish and the potential contributions of trait plasticity and genetic divergence to energetic adaptation.

Inter-rater agreement when linking stroke interventions to the extended international classification of functioning, disability and health core set for stroke.

PURPOSE: To uncover the factors that influence inter-rater agreement when extracting stroke interventions from patient records and linking them to the relevant categories in the Extended International Classification of Functioning, Disability and Health Core Set for Stroke. METHOD: Using 10 patient files, two linkers independently extracted interventions and linked the target of the intervention to relevant functions in the ICF. The percentage agreement of extracted interventions and the ICF codes was calculated. Non-matching interventions and codes were further analysed to determine the reasons for poor agreement. RESULTS: A total of 518 interventions were extracted, with 44.01% agreement between the two linkers. Of the non-agree codes and interventions, 43.79% were due to mismatched ICF codes and 56.20% were due to mismatched interventions. Differences were due to linkers (a) extracting interventions from different parts of the patient note (b) differences in interpreting the target of the intervention, and (c) choosing a different code with similar meaning. CONCLUSION: Greater reliability when linking interventions to ICF codes can be achieved by; health services using a consistent progress note that uses ICF language, recording the intervention aim, linkers knowing the aims of each discipline's interventions and using multiple reliability checks and analysis to inform the linking method.Implications for rehabilitationLinking intervention targets to the ICF and to the ICHI is an emerging research field.Development of trustworthy inter-rater reliability methods is needed to achieve its potential to demonstrate the equity, quality and effectiveness of interventions.Independent linking of patient notes to the ICF can identify factors that impact inter-rater reliability.When writing patient notes, health professionals should use a consistent format that identifies the functional target of the intervention using ICF terms.

Keto-Bezoar: Adverse Event Related to Initiation of Ketogenic Diet in an Infant.

The ketogenic diet is frequently used as part of the treatment regimen for pediatric patients with refractory epilepsy. This diet is generally well tolerated, with constipation being the most described side effect. This case highlights a previously undocumented severe complication of a "keto-bezoar" formation related to the initiation of the ketogenic diet in a young infant.