Persistence to anti-CGRP monoclonal antibodies and onabotulinumtoxinA among patients with migraine: a retrospective cohort study.

BACKGROUND: To date, real-world evidence on persistence to anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies (mAbs) or onabotulinumtoxinA have excluded eptinezumab. This retrospective cohort study was performed to compare treatment persistency among patients with migraine on anti-CGRP mAbs (erenumab, fremanezumab, galcanezumab, or eptinezumab) or onabotulinumtoxinA. METHODS: This retrospective study used IQVIA PharmMetrics data. Adult patients with migraine treated with an anti-CGRP mAb or onabotulinumtoxinA who had 12 months of continuous insurance enrollment before starting treatment were included. A "most recent treatment episode" analysis was used in which the most recent episode was defined as the latest treatment period with the same drug (anti-CGRP mAb or onabotulinumtoxinA) without a ≥ 15-day gap in medication supply on/after June 25, 2020, to December 31, 2021. Patients were indexed at the start of their most recent episode. Patients were considered non-persistent and discontinued the therapy associated with their most recent episode if there was ≥ 15-day gap in medication supply. A Cox proportional-hazards model estimated the discontinuation hazard between treatments. The gap periods and cohort definition were varied in sensitivity analyses. RESULTS: The study included 66,576 patients (median age 46 years, 88.6% female). More eptinezumab-treated patients had chronic migraine (727/1074), ≥ 3 previous acute (323/1074) or preventive (333/1074) therapies, and more prior treatment episodes (3) than other treatment groups. Based on a 15-day treatment gap, patients on subcutaneous anti-CGRP mAbs had a 32% (95% CI: 1.19, 1.49; erenumab), 42% (95% CI: 1.27, 1.61; galcanezumab), and 58% (95% CI: 1.42, 1.80; fremanezumab) higher discontinuation hazard than those receiving eptinezumab, with this relationship attenuated, but still statistically significant based on 30-day and 60-day treatment gaps. There was no significant difference in the discontinuation hazard between eptinezumab and onabotulinumtoxinA. Based on a 15-day treatment gap among patients who newly initiated therapy, the discontinuation hazard of subcutaneous anti-CGRP mAbs remained significantly higher compared to eptinezumab and onabotulinumtoxinA. CONCLUSION: Patients treated with eptinezumab demonstrated persistency that was higher than subcutaneous anti-CGRP mAbs and similar to onabotulinumtoxinA.

Dose-response analysis of Bacillus thuringiensis HD-1 cry- spore reduction on surfaces using formaldehyde with pre-germination.

AIM: To establish a basis for rapid remediation of large areas contaminated with Bacillus anthracis spores. METHODS AND RESULTS: Representative surfaces of wood, steel and cement were coated by nebulization with B. thuringiensis HD-1 cry- (a simulant for B. anthracis) at 5.9 ± 0.2, 6.3 ± 0.2 and 5.8 ± 0.2 log10 CFU per cm2 , respectively. These were sprayed with formaldehyde, either with or without pre-germination. Low volume (equivalent to ≤2500 L ha-1 ) applications of formaldehyde at 30 g l-1 to steel or cement surfaces resulted in ≥4 or ≤2 log10 CFU per cm2 reductions respectively, after 2 h exposure. Pre-germinating spores (500 mmol l-1 l-alanine and 25 mmol l-1 inosine, pH 7) followed by formaldehyde application showed higher levels of spore inactivation than formaldehyde alone with gains of up to 3.4 log10 CFU per cm2 for a given dose. No loss in B. thuringiensis cry- viability was measured after the 2 h germination period, however, a pre-heat shock log10 reduction was seen for B. anthracis strains: LSU149 (1.7 log10), Vollum and LSU465 (both 0.9 log10), LSU442 (0.2 log10), Sterne (0.8 log10) and Ames (0.6 log10). CONCLUSIONS: A methodology was developed to produce representative spore contamination of surfaces along with a laboratory-based technique to measure the efficacy of decontamination. Dose-response analysis was used to optimize decontamination. Pre-germinating spores was found to increase effectiveness of decontamination but requires careful consideration of total volume used (germinant and decontaminant) by surface type. SIGNIFICANCE AND IMPACT OF THE STUDY: To be practically achievable, decontamination of a wide area contaminated with B. anthracis spores must be effective, timely and minimize the amount of materials required. This study uses systematic dose-response methodology to demonstrate that such an approach is feasible.

Transitions in Care: When Words Can Save Lives.

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

No longer waiting for an accident to happen: Simulation in emergency medicine.

The practice of emergency medicine (EM) requires proficient and expert skills in multiple high risk procedures. The emergency physician in-training needs a safe and realistic environment in which to practice and perfect the skills necessary to care for patients ranging from the critically ill to the patient with difficult intravenous access. Undergraduate medical, education overall has a need for training that enables students to develop the knowledge, skills and attitudes to practice in a variety of specialties. This article provides an overview of simulation in a three-year emergency medicine residency at Truman Medical Center, in a required final year clerkship for all medical students at the University of Missouri-Kansas City, and discusses national trends for the use of simulation in emergency medicine.

Evaluation and Management of Reduced Dietary Diversity in Children with Pediatric Feeding Disorder.

Pediatric Feeding Disorder, a common problem in children, is commoner in children with various developmental disorders. Children with pediatric feeding disorder can have food selectivity and lack dietary diversity (DD). In this paper, an understanding of DD in these children is provided along with a dietary diversity index that can be helpful in measuring and understanding the risks posed by this lack of DD. An overview of a management strategy to address decreased DD is proposed. In these children, improving DD can improve growth, micronutrient status, long-term metabolic health, and potentially quality of life.

Association of normal nailfold end row loop numbers with a shorter duration of untreated disease in children with juvenile dermatomyositis.

OBJECTIVE: To determine the association of normal numbers of end row loops (ERLs) in nailfold capillaries at the time of diagnosis of juvenile dermatomyositis (DM) with clinical findings in untreated children with the disease and to identify predictors of the development of decreased numbers of ERLs. METHODS: Clinical and laboratory data from 80 untreated children with juvenile DM were collected. ERL numbers were recorded at the time of diagnosis and at 24 months and 36 months thereafter. The 12 children who had normal ERLs at diagnosis were compared with the remaining 68 children. Outcomes included the duration of untreated disease, the duration of treatment with immunosuppressive medications, family medical history, Disease Activity Score (DAS) for juvenile DM, creatinine phosphokinase level, aldolase level, absolute number of CD3-CD56+/16+ natural killer cells, and von Willebrand factor antigen level. Cross-sectional and longitudinal analyses were performed. RESULTS: At diagnosis, children with normal ERLs had a shorter duration of untreated disease (P = 0.03) and a lower skin DAS (P = 0.045). Over time, an increased likelihood of having decreased numbers of ERLs was associated with a longer duration of untreated disease and with a higher skin DAS. CONCLUSION: The presence of a normal number of ERLs in juvenile DM appears to be associated with a shorter duration of symptoms and may be a useful indicator of disease chronicity in the newly diagnosed child. Normal ERLs is also associated with a lower skin DAS. The lack of association between normal ERLs and other variables indicates that normal findings on nailfold capillaroscopy should not be used as justification to delay immunosuppressive therapy in children with typical symptoms of juvenile DM.

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

OBJECTIVES: To determine whether the implementation of a standardized handover protocol could reduce the number of errors occurring during patient transitions from the operating room to the intensive care unit. DESIGN: Prospective, interventional study. SETTING: Pediatric cardiac intensive care unit. SUBJECTS: Seventy-nine patient handovers in patients transitioning from the operating room to the cardiac intensive care unit after congenital cardiac surgery. INTERVENTIONS: A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. A teamwork-driven handover process and protocol was developed using traditional and novel quality-improvement techniques. The postimplementation observational assessment of handovers was performed using the same preintervention assessment tool. Preintervention and postintervention data metrics were analyzed and compared. MEASUREMENTS AND MAIN RESULTS: Forty-one and 38 observations were performed in the preintervention and postintervention periods, respectively. Protocol implementation improved key areas of the handover process. Technical errors per handover were reduced from 6.24 to 1.52 (p < .0001), and critical verbal handoff information omissions were reduced from 6.33 to 2.38 (p < .0001) per handover. There was no change in duration of either the verbal handoff briefing or the overall handover process. Caregivers noted improvement in teamwork and handoff content received after the intervention. CONCLUSIONS: A formal, structured handover process for pediatric patients transitioning to the intensive care unit after cardiac surgery can reduce medical errors that occur during the admission process and improve teamwork among caregivers.

Sapropterin therapy increases stability of blood phenylalanine levels in patients with BH4-responsive phenylketonuria (PKU).

It has recently been demonstrated that variability in blood phenylalanine levels is inversely correlated with IQ and is a better predictor of IQ in early and continuously treated patients with phenylketonuria (PKU) than mean blood phenylalanine levels. This suggests that stability of blood phenylalanine should be a therapeutic goal in patients with PKU. The purpose of this study was to determine if treatment with sapropterin in patients with BH4-responsive PKU would increase the stability of blood phenylalanine levels. The records of all patients treated with sapropterin in the PKU Clinic at Children's Memorial Hospital in Chicago were examined retrospectively. Patients were included in the study if they were responsive to sapropterin during a 2- to 4-week challenge (reduction of blood phenylalanine level of at least 25% after 2weeks of therapy or, in the case of patients with well-controlled blood phenylalanine at the time of testing, increased dietary phenylalanine tolerance by 4weeks of treatment). A total of 37 subjects were eligible for inclusion (16male; 21 female); the mean age was 12.6years (range, 1.5-32.0). The total number of observations (phenylalanine levels) for all subjects was 1391 with a mean of 39 per subject (range, 13-96). Linear mixed modeling was utilized to estimate variances of the blood phenylalanine before (pre) and after (post) starting sapropterin. Likelihood ratio test was performed using SAS 9.1. Means and standard deviations for phenylalanine as estimated by the model were 6.67mg/dl (4.20) and post 5.16 (3.78). The mean level post-sapropterin was significantly lower (p=.0002). The within-subject variances (mean and SD) of phenylalanine were: pre 6.897 (2.62) and post 4.799 (2.19). These two variances are significantly different with a p=.0017. We conclude that sapropterin therapy results in increased stability of blood phenylalanine levels. This effect is likely to improve cognitive outcome in BH4-responsive patients with PKU.

Late sinus and atrial tachycardia after pediatric heart transplantation might predict poor outcome.

Our objective was to examine clinical/electrocardiogram (ECG) predictors and outcomes of arrhythmias beyond 1 year after pediatric heart transplantation (HTx). We performed a retrospective chart review of 94 1-year HTx survivors, 1988-2006. Clinical records identified patients with arrhythmias occurring >1 year after HTx requiring pharmacotherapy, excluding acute rejection. We reviewed preoperative diagnosis, gender, age at HTx, operative details, transplant coronary artery disease (TCAD), and mortality. We analyzed serial ECGs after HTx for HR, PR, QRS, QT, and QTc intervals. Our results found complete data in 58 patients, 14 (24%) with arrhythmia and 44 controls. Arrhythmias occurred 1.1-17.9 years after HTx (mean = 6.8): 11 focal atrial tachycardia, 1 atrial fibrillation/flutter, 1 atrioventricular node reentry tachycardia; only 1 patient had ventricular tachycardia (VT). Serial ECG intervals were similar between groups, as well as surgical technique, ischemic time, and rejection history. Seven patients (50%) with arrhythmias had death or graft death versus 11% of the controls (P = 0.006). Patients with arrhythmias were more likely to be diagnosed with TCAD (P = 0.007). The patient with VT had no TCAD. In conclusion, supraventricular arrhythmias were frequent (22%) in 1-year survivors of pediatric HTx. These patients were more likely to develop TCAD and/or graft loss/mortality.

Real-world droxidopa or midodrine treatment persistence in patients with neurogenic orthostatic hypotension or orthostatic hypotension.

BACKGROUND: Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension (OH) observed in the presence of neuropathy and is associated with increased risk of falling, impaired function, and poor quality of life. Droxidopa and midodrine are approved in the United States to treat symptomatic nOH and OH in adults, respectively. In this study, we compared the treatment persistence of droxidopa and midodrine. METHODS: A retrospective analysis of patients prescribed either droxidopa or midodrine was conducted using the Symphony Health Solutions database (Symphony Health Solutions, Phoenix, AZ, USA). Inclusion criteria were (1) a pharmacy insurance claim in at least 16 consecutive quarters from mid-2014 to 2018 and (2) an active prescription for droxidopa or midodrine of ≥30 days' duration during that period. Treatment persistence was defined as the time to the first break in drug coverage of ≥45 days and was capped at 365 days. RESULTS: Data from 2305 patients who received droxidopa and 117,243 patients who received midodrine were included in this analysis. Median (95% CI) treatment persistence was significantly longer in the droxidopa cohort versus the midodrine cohort (303 [274-325] vs 172 [169-176] days; P < 0.001). After adjustment for confounding factors, patients using droxidopa monotherapy (i.e., without any concomitant midodrine and/or fludrocortisone use) were 16% more likely to be persistent at any time point than patients using midodrine (P < 0.001). CONCLUSIONS: In this real-world data analysis, patients using droxidopa without concomitant medications for OH were more likely to remain on treatment than patients on midodrine.

A standardised bioassay method using a bench-top spray tower to evaluate entomopathogenic fungi for control of the greenhouse whitefly, Trialeurodes vaporariorum.

BACKGROUND: Bioassays evaluating entomopathogenic fungi (EPF) isolates for effective microbial control of whitefly are a fundamental part of the screening process for bioprotectants, but development of repeatable, robust bioassays is not straightforward. Currently, there is no readily available standardised method to test the efficacy of EPF on whitefly. Here, we describe the calibration and use of a spray tower to deliver a standardised protocol to assess EPF activity; the method was validated using 18 EPF from four genera in tests against greenhouse whitefly, Trialeurodes vaporariorum (Westwood). RESULTS: At 138 kPa, the sprayer delivered 0.062 mL mm-2 (620 L ha-1 ) and an even deposition of spray across the central 1590 mm2 of the spray area. Average conidial deposition for all EPF was 252 conidia mm-2 and equivalent to 2.5 × 1012 conidia ha-1 at an application concentration of 1 × 107 conidia mL-1 . Conidial deposition of a test Beauveria bassiana suspension increased with increasing application concentration. Egg laying by T. vaporariorum adults was restricted to 177 mm2 using clip cages specifically designed to ensure that third-instar T. vaporariorum received a uniform spray coverage. Nymphs occupied 373 ± 5 mm2 of the leaf after migrating during the first instar. Average T. vaporariorum mortality totaled 8-89% 14 days after application of 1 × 107 conidia mL-1 of each EPF isolate. CONCLUSION: Combining the calibrated sprayer and bioassay method provides a reliable, standardised approach to test the virulence of EPF against whitefly nymphs. This laboratory-based assay is affordable, replicable and allows the user to alter the dose of conidia applied to the target.

Athletic trainers' experience and comfort with evaluation and management of asthma: a pilot study.

BACKGROUND: Approximately 10% to 50% of competitive athletes experience asthma symptoms with exercise, due to either chronic asthma or exercise-induced bronchospasm. Early recognition and management of asthma symptoms may improve athletic performance and quality of life for athletes with asthma or exercise-induced bronchospasm. Athletic trainers may have frequent opportunities to identify asthma symptoms and assist athletes with management. OBJECTIVE: To survey athletic trainers about their experience and comfort with evaluation and management of asthma symptoms in athletes and identify athletic trainer characteristics associated with higher comfort levels. DESIGN AND SETTING: A 2005 cross-sectional survey of National Athletic Trainers' Association and Illinois Athletic Trainers Association members. PARTICIPANTS: A total of 304 athletic trainers. DATA COLLECTION AND ANALYSIS: Respondents completed a Web-based survey reporting years of experience, competitive level of athletes supervised, satisfaction with asthma education, experience evaluating asthma symptoms, and comfort managing asthma. RESULTS: Response rate was 13.9% (304 of 2,175). At least 23% of respondents evaluated asthma symptoms five or more times the previous year. Respondents working exclusively with junior high and/or high school athletes evaluated asthma symptoms more frequently than those working exclusively with college and/or professional athletes. Fifty-eight percent of respondents were unsatisfied with their asthma education. Only 25.3% were "very" comfortable managing asthma. Respondents with higher comfort levels evaluated asthma symptoms more frequently (p < 0.01, r = 0.18) and were more likely to be satisfied with their asthma education (p < 0.001). Over 95% of respondents endorsed more asthma education in athletic training curricula. CONCLUSIONS: Results of this pilot study indicate that athletic trainers have opportunities to help athletes manage asthma symptoms that can compromise athletic performance or limit sports participation. However, few athletic trainers are very comfortable managing asthma, and most are unsatisfied with their asthma education. Further study is needed to determine the effect of enhanced asthma education on athletic trainers' comfort and skills with asthma evaluation and management.

Development of a communication curriculum for emergency medicine residents.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires residency training programs to develop methods to teach and assess communication skills in residents to ensure competence as a practitioner. In response, we piloted a communication curriculum for emergency medicine residents. We describe the curriculum and suggest future directions for development based on the strengths and weaknesses of residents' performance and their reactions to the curriculum. DESCRIPTION: Twenty-six residents in a 3-year program at a university-affiliated county hospital participated. Curriculum components were an introductory session, a single standardized patient encounter using a locally written, unvalidated checklist assessing residents' communication skills, a videotape-facilitated self-assessment, and a private feedback session. EVALUATION: Residents demonstrated greatest strengths in basic interpersonal skills and efficient information gathering and greatest weakness in empathy. Residents rated the curriculum favorably. CONCLUSION: The curriculum as implemented offers an initial foundation for teaching and learning critical care communication. Instruction in empathy requires improvement.

High-risk adenovirus-infected pediatric allogeneic hematopoietic progenitor cell transplant recipients and preemptive cidofovir therapy.

ADV has emerged as an important pathogen in children undergoing allogeneic HPCT. A prospective study of the epidemiology of ADV infection and preemptive therapy of high risk ADV infections in children undergoing HPCT was undertaken. Cultures of throat, urine, and stool for viral pathogens and plasma for ADV PCR were obtained prior to transplantation, weekly for the first 100 days, and then monthly for one yr. Children developing high-risk ADV infections were treated preemptively with cidofovir 1 mg/kg/day given three times weekly for three wk. A case-controlled study was performed to identify risk factors for high-risk ADV infections. Seven (18%) of the 38 subjects developed high-risk ADV infections usually within 100 days of HPCT and were preemptively treated with i.v. cidofovir at a dose of 1 mg/kg/dose three times weekly for nine doses. High-risk ADV infections resolved in all seven patients without renal toxicity. CMV viremia occurred in two of seven patients during or shortly after therapy with cidofovir. A case-control study did not identify any risk factors that achieved statistical significance. Treatment with a modified dosing regimen of cidofovir was well-tolerated and high-risk ADV infections resolved in all patients.

Critical care recognition, management and communication skills during an emergency medicine clerkship.

BACKGROUND: Medical students need to learn how to recognize and manage critically ill patients; to communicate in critical situations with patients, families, and the healthcare team; and finally, to integrate technical knowledge with communication skills in caring for these patients. Meeting their needs will help prepare them to demonstrate, as physicians, the ability to synthesize information while simultaneously caring for patients, that the American Medical Association recently characterized as vital. AIMS: Responding to these needs, we developed and implemented a curriculum to enable students in a required emergency medicine clerkship to recognize, manage, and simultaneously communicate with critically ill patients. METHODS: The curriculum consisted of lectures and exercises on caring for the critically ill including: an introduction to the systematic approach; an interactive lecture on comprehensive communication; observation and discussion of real patients in the emergency department; participation in a single standardized patient encounter while peers and a faculty member observed them; assessment of students' own videotaped performance of the examination by using critical care and communication/interpersonal skills checklists; and receipt of private feedback based on the checklists from the faculty and the standardized patient. Students evaluated the curriculum at the end of the clerkship. RESULTS: Complete performance data for 46 students and curriculum evaluation data from 42 students were available. According to faculty assessment, students as a group performed 79.6% (SD 0.15) of the critical care and 70.9% (SD 11.5%) of the communication skills. Students most often demonstrated Basic Interpersonal Skills (97.9%, SD 0.056) and least often demonstrated Empathy skills (41.7%, SD 0.235). Students rated the curriculum positively. CONCLUSIONS: It is feasible to integrate the teaching of communication skills with the recognition and management of critically ill patients. The next step will be to revise the curriculum to address student deficiencies and to evaluate its effectiveness more rigorously.

Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial.

OBJECTIVES: We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts. METHODS: We evaluated IV insertion by pediatric emergency department physicians and nurses using the Veinlite (TransLite, Sugar Land, Tex). Patients who required nonemergent IV insertion were enrolled if younger than 3 years or aged 3 to 21 years with a history of difficult access. Participants were randomly assigned to transillumination or nontransillumination. Analyses were performed using a mixed-effects logistic regression model adjusting for provider effect. RESULTS: We evaluated 240 patients. After adjusting for significant covariates (safety catheter [P = 0.008], visibility [P = 0.01], and palpability [P = 0.03]) and controlling for provider effect, IV placement was more likely successful in first attempt in transilluminated patients (P = 0.03; odds ratio, 2.1 [95% confidence interval, 1.1-3.9]). After adjusting for significant covariates (safety catheter [P < 0.001], location [P = 0.005], and palpability [P = 0.05]) and controlling for provider effect, IV placement was more likely successful within 2 attempts in transilluminated patients (P = 0.01; odds ratio, 3.5 [95% confidence interval, 1.4-8.9]). Intracluster correlation for random effect of provider was 10% in first attempt and 16% within 2 attempts. CONCLUSIONS: After adjusting for multiple significant covariates and controlling for random effect of provider, our results indicated a benefit in the use of Veinlite transillumination for IV insertion in first attempt and within 2 attempts. This technique seemed to facilitate nonemergent IV placement in pediatric patients compared with standard practice.

The organizational impact of a new graduate pediatric nurse mentoring program.

Successful mentoring programs for new graduate nurses are designed to provide professional supports to ease the transition of these newcomers from student to practicing nurse. In the financially constrained health care environment, a resource-intensive program can be sustained only by leaders who see quantitative evidence of organizational impact over time. A descriptive study was undertaken at a pediatric academic medical center to compare the job satisfaction and retention rates of two cohorts of new graduate nurses: one before and one after the implementation of a Pediatric RN Internship Program. In this study overall job satisfaction was significantly higher in the post-internship group as compared to the pre-internship group. Improved job satisfaction was also reflected in a lower turnover rate (12% vs. 20% in the pre-internship group) that was sustained during the 2-year post-intervention study period. By lowering turnover rates, organizations avoid costs associated with recruitment, orientation, and temporary labor coverage for vacant RN positions.

A Free-Market Approach to the Match: A Proposal Whose Time Has Not Yet Come.

The authors respond to a proposal in this issue of Academic Medicine by Ray, Bishop, and Dow, who recommend adopting a free-market approach to the Match in which applicants and programs negotiate directly with each other to find and fill residency positions year-round. This Invited Commentary examines and responds to the reasons Ray and colleagues give for changing the Match and explores their proposal's implications and likelihood of success.The authors question Ray and colleagues' argument that assumptions underlying the National Resident Matching Program algorithm have been violated. The authors suggest there is insufficient evidence for the "July effect" and that the possibility for improvement in physician supply due to the year-round entry of graduates into the workforce ultimately faces the rate-limiting step of caps on residency positions allocated to programs. Most important, competency-based medical education, on which the free-market proposal depends, is not yet sufficiently developed.Nonetheless, the imbalanced ratio of applicants to positions in the Match is contributing to a rise in the numbers of student applications and program interviews. Although the proposed free-market approach might, as Ray and colleagues envision, curtail applications as well as reduce time and financial resources currently expended on the process, it would require significant changes on the part of applicants, residency programs, medical schools, and other stakeholders.Because the proposed free-market approach could reduce some negative effects of the imbalance of applicants and positions, it merits ongoing discussion along with other more immediate practical solutions to issues with the Match.