Hypothyroxinemia and weight velocity in preterm infants.

OBJECTIVES: Hypothyroxinemia of prematurity (HOP) is characterized by low free thyroxine (FT4) associated with low or normal thyroid stimulating hormone (TSH). The objective of this study is to define FT4 and TSH values in very preterm infants (<32 weeks postmenstrual age, PMA) and correlate hypothyroxinemia and levothyroxine treatment with growth velocity at 28 days and 36 weeks PMA. METHODS: Preterm neonates <32 weeks PMA admitted to the regional neonatal intensive care unit (NICU) at the Children's Hospital of Georgia (USA) between January 2010 and July 2022 were routinely screened for hypothyroxinemia. FT4 and TSH values were obtained on 589 eligible neonates between day of life (DOL) 4 and 14. Growth velocity (g/kg/day) from DOL 14 to DOL 28 and 36-weeks PMA were calculated for each neonate and potential explanatory variables (PMA, sex, and race) were incorporated into multivariate regression models to identify associations between HOP and growth velocity. RESULTS: In 589 preterm infants, PMA at birth was strongly associated inversely with FT4 (R=0.5845) and modestly with TSH (R=0.2740). Both FT4 and gestational age, but not TSH or levothyroxine treatment, were associated with growth velocity at 28 days of life and at 36 weeks PMA. CONCLUSIONS: We provide a large data set for identifying FT4 and TSH measurements and identify hypothyroxinemia of prematurity as a potential mediator of slow postnatal growth in very preterm infants.

Primary or Delayed Repair for Complete Atrioventricular Septal Defect, Tetralogy of Fallot, and Ventricular Septal Defect: Relationship to Country Economic Status.

OBJECTIVE: Primary repair in the first six months of life is routine for tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect in high-income countries. The objective of this analysis was to understand the utilization and outcomes of palliative and reparative procedures in high versus middle-income countries. METHODS: The World Database of Pediatric and Congenital Heart Surgery identified patients who underwent surgery for: tetralogy of Fallot, complete atrioventricular septal defect, and ventricular septal defect. Patients were categorized as undergoing primary repair, repair after prior palliation, or palliation only. Country economic status was categorized as lower middle, upper middle, and high, defined by the World Bank. Multiple logistic regression models were utilized to identify independent predictors of hospital mortality. RESULTS: Economic categories included high (n = 571, 5.3%), upper middle (n = 5,342, 50%), and lower middle (n = 4,793, 49.7%). The proportion of patients and median age with primary repair were: tetralogy of Fallot, 88.6%, 17.7 months; complete atrioventricular septal defect, 83.4%, 7.7 months; and ventricular septal defect, 97.1%, ten months. Age at repair was younger in high income countries (P < .0001). Overall mortality after repair was lowest in high income countries. Risk factors for hospital mortality included prematurity, genetic syndromes, and urgent or emergent operations (all P < .05). CONCLUSIONS: Primary repair was selected in >90% of patients, but definitive repair was delayed in lower and upper middle income countries compared with high-income countries. Repair after prior palliation versus primary repair was not a risk factor for hospital mortality. Initial palliation continues to have a small but important role in the management of these three specific congenital heart defects.

Small-angle strabismus detection by telemedicine in an experimental model.

PURPOSE: To evaluate the ability of observers to accurately detect strabismus using an alternate cover testing approach via telemedicine and to assess the effect of various factors related to video conditions on the accuracy rate. METHODS: Videos were made by the authors in which different angles of strabismus, up to 12Δ, were induced by prism and recorded using alternate cover testing. The videos were made under a variety of conditions that incorporated various head postures, lighting, fixation target position and motion, and viewing angle. The videos were shown to observers of varying levels of expertise. The accuracy of detecting the deviation was assessed and analyzed for statistical significance. RESULTS: The overall rate of detection was significantly affected by the angle of deviation, with 12Δ being correctly detected with 94% accuracy, 8Δ with 72% accuracy, and 4Δ with <50% accuracy. Esotropia and hypertropia were more accurately detected than exotropia for all angles tested. The level of training of the observer did not correlate with detection accuracy. However, accuracy was negatively affected by backlighting and movement of the fixation target during cover testing. CONCLUSIONS: Our data demonstrate that detection of even relatively small angles of strabismus can be accomplished with a high level of accuracy using telemedicine and an alternate cover testing strategy. For optimal results, it is important to consider conditions related to the fixation target and lighting.

Galectin-3 Mediates Vascular Dysfunction in Obesity by Regulating NADPH Oxidase 1.

BACKGROUND: Obesity is associated with increased risk of cardiovascular disease, but underlying mechanisms remain elusive. Metabolic dysfunction, especially hyperglycemia, is thought to be a major contributor, but how glucose impacts vascular function is unclear. GAL3 (galectin-3) is a sugar-binding lectin upregulated by hyperglycemia, but its role as a causative mechanism of cardiovascular disease remains poorly understood. Therefore, the objective of this study was to determine the role of GAL3 in regulating microvascular endothelial vasodilation in obesity. METHODS: GAL3 was measured and found to be markedly increased in the plasma of overweight and obese patients, as well as in the microvascular endothelium of diabetic patients. To investigate causative mechanisms in cardiovascular disease, mice deficient in GAL3 were bred with obese db/db mice to generate lean, lean GAL3 knockout, obese, and obese GAL3 knockout genotypes. Endothelial cell-specific GAL3 knockout mice with novel AAV-induced obesity recapitulated whole-body knockout studies to confirm cell specificity. RESULTS: Deletion of GAL3 did not alter body mass, adiposity, or plasma indices of glycemia and lipidemia, but levels of plasma reactive oxygen species as assessed by plasma thiobarbituric acid reactive substances were normalized in obese GAL3 knockout mice. Obese mice exhibited profound endothelial dysfunction and hypertension, both of which were rescued by GAL3 deletion. Isolated microvascular endothelial cells from obese mice had increased expression of NOX1 (nicotinamide adenine dinucleotide phosphate oxidase 1), which we have previously shown to contribute to increased oxidative stress and endothelial dysfunction, which was normalized in microvascular endothelium from mice lacking GAL3. Cell-specific deletion confirmed that endothelial GAL3 regulates obesity-induced NOX1 overexpression and subsequent microvascular function. Furthermore, improvement of metabolic syndrome by increasing muscle mass, improving insulin signaling, or treating with metformin decreased microvascular GAL3, and thereby NOX1, expression levels. CONCLUSIONS: Deletion of GAL3 normalizes microvascular endothelial function in obese db/db mice, likely through a NOX1-mediated mechanism. Pathological levels of GAL3, and in turn NOX1, are amenable to improvements in metabolic status, presenting a potential therapeutic target to ameliorate pathological cardiovascular consequences of obesity.

Hyperthermic intrathoracic extracorporeal chemotherapy for secondary malignant pleural disease.

OBJECTIVES: Pleural metastasis has extremely poor prognosis. Resection of pleural implants with infusion of intrathoracic hyperthermic chemotherapy may offer a survival advantage in selected patients. We evaluated the safety and efficacy of hyperthermic intrathoracic extracorporeal chemotherapy (HITEC) in patients who underwent pleurectomy/decortication (P/D) for secondary malignant pleural disease (SPD). METHODS: A total of 101 patients were evaluated over 72 months, with 35 patients electing to proceed with P/D and 60 minutes of HITEC with cisplatin at 42°C. Inclusion criteria were adults 18-79 years with unilateral pleural dissemination. Exclusion criteria were patients without control of primary site, extrathoracic metastatic disease, significant comorbidities, and a history of adverse reaction to cisplatin. RESULTS: Median age was 56 years (36-73); 60% were women. SPD was thymoma in 13, breast cancer in 9, lung cancer in 6, colon cancer in 2, renal cell in 2, and esophageal, anal, and thymic cancers in one each. There was no operative mortality. Postoperative complications occurred in 18 patients (51%). No patient developed renal failure. Median follow-up was 24 months (4-60). The overall survival rate was 61%; 17 patients (49%) developed recurrent disease at a median of 12 months (6-36). There were no recurrences after 36 months Eleven patients (31%) died of metastatic disease at a median of 17 months (7-25). CONCLUSIONS: Surgical cytoreduction of SPD followed by HITEC with cisplatin was well tolerated. No patient developed cisplatin-related toxicities. Long-term follow-up is warranted to determine survival advantage and refinement of inclusion criteria.

Mapping Health Disparities in 11 High-Income Nations.

Importance: Health care delivery faces a myriad of challenges globally with well-documented health inequities based on geographic location. Yet, researchers and policy makers have a limited understanding of the frequency of geographic health disparities. Objective: To describe geographic health disparities in 11 high-income countries. Design, Setting, and Participants: In this survey study, we analyzed results from the 2020 Commonwealth Fund International Health Policy (IHP) Survey-a nationally representative, self-reported, and cross-sectional survey of adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK, and the US. Eligible adults older than age 18 years were included by random sampling. Survey data were compared for the association of area type (rural or urban) with 10 health indicators across 3 domains: health status and socioeconomic risk factors, affordability of care, and access to care. Logistic regression was used to determine the associations between countries with area type for each factor, controlling for individuals' age and sex. Main Outcomes and Measures: The main outcomes were geographic health disparities as measured by differences in respondents living in urban and rural settings in 10 health indicators across 3 domains. Results: There were 22 402 survey respondents (12 804 female [57.2%]), with a 14% to 49% response rate depending on the country. Across the 11 countries and 10 health indicators and 3 domains (health status and socioeconomic risk factors, affordability of care, access to care), there were 21 occurrences of geographic health disparities; 13 of those in which rural residence was a protective factor and 8 of those where rural residence was a risk factor. The mean (SD) number of geographic health disparities in the countries was 1.9 (1.7). The US had statistically significant geographic health disparities in 5 of 10 indicators, the most of any country, while Canada, Norway, and the Netherlands had no statistically significant geographic health disparities. The indicators with the most occurrences of geographic health disparities were in the access to care domain. Conclusions and Relevance: In this survey study of 11 high-income nations, health disparities across 10 indicators were identified. Differences in number of disparities reported by country suggest that health policy and decision makers in the US should look to Canada, Norway, and the Netherlands to improve geographic-based health equity.

Hospital Mortality and Adverse Events Following Repair of Congenital Heart Defects in Developing Countries.

BACKGROUND: Mortality associated with the correction of congenital heart disease has decreased to approximately 2% in developed countries and major adverse events are uncommon. Outcomes in developing countries are less well defined. The World Database for Pediatric and Congenital Heart Surgery was utilized to compare mortality and adverse events in developed and developing countries. METHODS: A total of 16,040 primary procedures were identified over a two-year period. Centers that submitted procedures were dichotomized to low/middle income (LMI) and high income (HI) by the Gross National Income per capita categorization. Mortality was defined as any death following the primary procedure to discharge or 90 days inpatient. Multiple logistic regression models were utilized to identify independent predictors of mortality. RESULTS: Of the total number of procedures analyzed, 83% (n = 13,294) were from LMI centers. Among all centers, the mean age at operation was 2.2 years, with 36% (n = 5,743) less than six months; 85% (n = 11,307) of procedures were STAT I/II for LMI centers compared with 77% (n = 2127) for HI centers (P < .0001). Overall mortality across the cohort was 2.27%. There was a statistical difference in mortality between HI centers (0.55%) versus LMI centers (2.64%) (P < .0001). After adjustment for other risk factors, the risk of death remained significantly higher in LMI centers (odds ratio: 2.36, 95% confidence interval: 1.707-3.27). CONCLUSION: Although surgical expertise has increased across the globe, there remains a disparity with some outcomes associated with the correction of congenital heart disease between developing and developed countries. Further studies are needed to identify specific opportunities for improvement.

The effects of strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED): Study protocol for a pilot randomized controlled trial.

BACKGROUND: Exercise may improve executive function among people living with all-cause dementia (PWD), but more evidence is needed. The aim of this pilot randomized controlled trial (RCT) is to examine whether exercise plus usual care improves the primary outcome of executive function, and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes compared to usual care alone among PWD. METHODS AND STUDY DESIGN: The strEngth aNd BaLance exercise on Executive function in people living with Dementia (ENABLED) protocol is a pilot parallel, 6-month assessor-blinded RCT (1:1) in residential care facilities, including n = 21 receiving exercise plus usual care and n = 21 usual care alone [NCT05488951]. We will collect primary (Color-Word Stroop Test) and secondary physiological (inflammation, metabolic aging, epigenetics) and behavioral (cognition, psychological health, physical function, and falls) outcomes at baseline and 6 months. We will obtain falls monthly from medical charts. We will collect physical activity, sedentary behavior, and sleep via wrist-worn accelerometers over 7 days at baseline and 6 months. The physical therapist-led adapted Otago Exercise Program will involve 1-h of strength, balance and walking 3×/week for 6 months in groups of 5-7. We will use generalized linear mixed models to examine differences over time in primary and secondary outcomes between groups and examine potential interactions with sex and race. DISCUSSION: This pilot RCT will examine the direct effects and potential underlying physiological mechanisms of exercise on executive function and other behavioral outcomes in PWD, which may have implications for clinical care management.

Galectin-3 Mediates Vascular Dysfunction in Obesity by Regulating NADPH Oxidase 1.

Rationale: Obesity increases the risk of cardiovascular disease (CVD) through mechanisms that remain incompletely defined. Metabolic dysfunction, especially hyperglycemia, is thought to be a major contributor but how glucose impacts vascular function is unclear. Galectin-3 (GAL3) is a sugar binding lectin upregulated by hyperglycemia but its role as a causative mechanism of CVD remains poorly understood. Objective: To determine the role of GAL3 in regulating microvascular endothelial vasodilation in obesity. Methods and Results: GAL3 was markedly increased in the plasma of overweight and obese patients, as well as in the microvascular endothelium of diabetic patients. To investigate a role for GAL3 in CVD, mice deficient in GAL3 were bred with obese db/db mice to generate lean, lean GAL3 knockout (KO), obese, and obese GAL3 KO genotypes. GAL3 KO did not alter body mass, adiposity, glycemia or lipidemia, but normalized elevated markers of reactive oxygen species (TBARS) in plasma. Obese mice exhibited profound endothelial dysfunction and hypertension, both of which were rescued by GAL3 deletion. Isolated microvascular endothelial cells (EC) from obese mice had increased NOX1 expression, which we have previously shown to contribute to increased oxidative stress and endothelial dysfunction, and NOX1 levels were normalized in EC from obese mice lacking GAL3. EC-specific GAL3 knockout mice made obese using a novel AAV-approach recapitulated whole-body knockout studies, confirming that endothelial GAL3 drives obesity-induced NOX1 overexpression and endothelial dysfunction. Improved metabolism through increased muscle mass, enhanced insulin signaling, or metformin treatment, decreased microvascular GAL3 and NOX1. GAL3 increased NOX1 promoter activity and this was dependent on GAL3 oligomerization. Conclusions: Deletion of GAL3 normalizes microvascular endothelial function in obese db/db mice, likely through a NOX1-mediated mechanism. Pathological levels of GAL3 and in turn, NOX1, are amenable to improvements in metabolic status, presenting a potential therapeutic target to ameliorate pathological cardiovascular consequences of obesity.

Continued Increase in Cost of Care Despite Decrease in Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

INTRODUCTION: Previous studies have demonstrated decreased hospital length of stay (LOS) for children undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). METHODS: Hospitalization event data from the Kids Inpatient Database were queried for all PSF events for AIS performed in 2009, 2012, and 2016 using diagnosis and surgical codes. Data were subdivided into two groups: pre-enhanced recovery after surgery (ERAS) (2009 and 2012) and post-ERAS (2016). The primary outcome variables were LOS and total treatment charge (adjusted for 2020 inflation). Univariate and multivariate analysis were performed to identify differences in outcome variables. RESULTS: A total of 12,010 unique hospitalization events were identified, 74% female, mean 14.3 years. There was a decrease in LOS (pre-ERAS: 5.4 ± 4.0 versus 4.3 ± 3.2 days, P < 0.0001) with an increase in adjusted total treatment charge (pre-ERAS $193,544.4 ± $108,116.1 versus $200,469.1 ± $110,112.6; P = 0.0013). Pre-ERAS, male sex, smaller hospital, and non-Medicaid insurance were predictive of longer LOS, whereas pre-ERAS, older age, non-White race, male sex, hospital outside the Northeast, and non-Medicaid insurance were predictive of higher treatment costs. DISCUSSION: There continues to be a significant decrease in LOS for PSF hospitalization events for AIS; however, total treatment charges continue to rise. Future research should investigate potential factors influencing total treatment charges after PSF for AIS.

Overlay Analysis of Cone-Beam Computed Tomography Volumes Acquired before and after Horizontal Alveolar Ridge Augmentation.

OBJECTIVE: The objective of this study was to illustrate the efficacy of a novel imaging analysis technology to capture horizontal and vertical dimensional changes following horizontal alveolar ridge augmentation (HRA). METHODS: Cone-beam computed tomography (CBCT) volumes from 65 HRA sites in 57 patients were available for evaluation, employing a three-dimensional analysis software to overlay preoperative and post-augmentation CBCT volumes. Horizontal and vertical alveolar ridge dimensional (HRD/VRD) changes were recorded considering a panel of patient-, site-, and procedure-related explanatory variables. RESULTS: VRD changes ranged from -2.9 to 3.0 mm, more than half anterior sites losing alveolar ridge height. Mean HRD increase at the 3- and 5-mm levels apical to the alveolar crest amounted to 2.3±1.6 and 2.4±1.3 mm, respectively, membrane fixation and non-resorbable membrane use associated with significantly greater gains. CONCLUSIONS: To date, studies reporting dimensional changes following HRA predominantly rely on serial in situ orofacial caliper recordings omitting vertical alterations. The protocol employed in this study allows simultaneous HRD and VRD evaluations and assures baseline and post-augmentation recordings are made at the same alveolar ridge position. Compared with in situ recording, CBCT overlay analysis may achieve a more complete characterization of dimensional changes following HRA.

Time- and Species-Dependent Bacterial Adhesion to Titanium over Short Exposure Periods: An In Vitro Study.

A considerable percentage of dental implant patients experience biofilm-mediated peri-implant disease following transmucosal abutment application. Bacterial adhesion is an early step in biofilm development. Our purpose was to assess adhesion of specific bacterial species to titanium over short exposure periods. Eight bacterial species were selected for this analysis: Streptococcus oralis, Streptococcus mitis, Gemella haemolysans, Streptococcus gordonii, Streptococcus sanguinis, Neisseria flavescens, Streptococcus salivarius, and Pseudomonas aeruginosa. We cultured each species with appropriate media and exposed titanium foil discs to the bacteria for 60, 15, 5, 1, or 0.25 minutes. Optical density at 600-nm wavelength (OD600) was assessed for the baseline inoculum and each species/exposure combination. The proportion of bacteria adherent to titanium was determined for each experimental condition. Striking titanium adhesion was noted for all evaluated species even when exposure time was limited to 15 seconds. Strategies to limit bacterial adhesion at dental implant surfaces may offer potential for improved treatment outcomes and preservation of peri-implant health.

Are We Ready to Integrate Artificial Intelligence Literacy into Medical School Curriculum: Students and Faculty Survey.

BACKGROUND: The effects of Artificial Intelligence (AI) technology applications are already felt in healthcare in general and in the practice of medicine in the disciplines of radiology, pathology, ophthalmology, and oncology. The expanding interface between digital data science, emerging AI technologies and healthcare is creating a demand for AI technology literacy in health professions. OBJECTIVE: To assess medical student and faculty attitudes toward AI, in preparation for teaching AI foundations and data science applications in clinical practice in an integrated medical education curriculum. METHODS: An online 15-question semi-structured survey was distributed among medical students and faculty. The questionnaire consisted of 3 parts: participant's background, AI awareness, and attitudes toward AI applications in medicine. RESULTS: A total of 121 medical students and 52 clinical faculty completed the survey. Only 30% of students and 50% of faculty responded that they were aware of AI topics in medicine. The majority of students (72%) and faculty (59%) learned about AI from the media. Faculty were more likely to report that they did not have a basic understanding of AI technologies (χ2, P = .031). Students were more interested in AI in patient care training, while faculty were more interested in AI in teaching training (χ2, P = .001). Additionally, students and faculty reported comparable attitudes toward AI, limited AI literacy and time constraints in the curriculum. There is interest in broad and deep AI topics. Our findings in medical learners and teaching faculty parallel other published professional groups' AI survey results. CONCLUSIONS: The survey conclusively proved interest among medical students and faculty in AI technology in general, and in its applications in healthcare and medicine. The study was conducted at a single institution. This survey serves as a foundation for other medical schools interested in developing a collaborative programming approach to address AI literacy in medical education.

Assessing medical students' knowledge in differentiating the diagnosis and treatment of unipolar vs bipolar depression.

BACKGROUND: Depression is one of the leading causes of premature death and disability. However, both unipolar and bipolar depression are underdiagnosed and undertreated. The aims of this study were to assess medical students' level of confidence in and knowledge of diagnosing and treating depression before and after completing a psychiatry clerkship, and their knowledge of differentiating unipolar vs bipolar depression. METHODS: Third-year medical students at Augusta University (Georgia, USA) completed an online questionnaire to assess confidence in and knowledge of diagnosing and treating unipolar and bipolar depression. RESULTS: Students who completed a psychiatry clerkship were statistically significantly more comfortable/confident with diagnosing (P < .0001) and treating (P < .0001) unipolar depression. Regarding bipolar depression, 73% of students who completed a psychiatry clerkship correctly diagnosed bipolar disorder, vs 59% of students who did not complete a psychiatry clerkship. This difference was not statistically significant (P = .181). CONCLUSIONS: Students who completed a psychiatry clerkship were more confident in diagnosing and treating unipolar depression compared with those who did not complete a psychiatry clerkship. However, there was no statistically significant difference between students who had completed a psychiatry clerkship and those who had not completed a psychiatry clerkship in making the correct diagnosis of bipolar depression. Neither group had a very high rate of correct diagnosis.

Effects of Race, Cardiac Mass, and Cardiac Load on Myocardial Function Trajectories from Childhood to Young Adulthood: The Augusta Heart Study.

Background The overall goal of this longitudinal study was to determine if the Black population has decreased myocardial function, which has the potential to lead to the early development of congestive heart failure, compared with the White population. Methods and Results A total of 673 subjects were evaluated over a period of 30 years including similar percentages of Black and White participants. Left ventricular systolic function was probed using the midwall fractional shortening (MFS). A longitudinal analysis of the MFS using a mixed effect growth curve model was performed. Black participants had greater body mass index, higher blood pressure readings, and greater left ventricular mass compared with White participants (all P<0.01). Black participants had a 0.54% decrease of MFS compared with White participants. As age increased by 1 year, MFS increased by 0.05%. As left ventricular mass increased by 1 g, MFS decreased by 0.01%. As circumferential end systolic stress increased by 1 unit, MFS decreased by 0.04%. The MFS trajectories for race differed from early age to young adulthood. Conclusions Changes in myocardial function mirror the race-dependent variations in blood pressure, afterload, and cardiac mass, suggesting that myocardial function depression occurs early in childhood in populations at high cardiovascular risk such as Black participants.

Association of Self-Reported Burnout and Protective Factors in Single Institution Resident Physicians.

BACKGROUND: Studies examining mitigating factors associated with residents' experience of burnout have found mixed results; thus the most effective approaches for programs to prevent resident burnout are unclear. OBJECTIVE: We used mixed methods to explore the association of 4 psychological constructs thought to be important protective factors for burnout-grit, resiliency, social support, and psychological flexibility-across a wide variety of residency programs at 1 institution. METHODS: The explanatory sequential study design included an online survey of previously published scales measuring burnout, grit, resiliency, social support, and psychological flexibility. The survey was sent to 20 residency programs in a single institution during the 2017-2018 academic year. Data were analyzed using descriptive statistics and ordinal logistic regressions to determine the association of protective factors and demographic variables. Interviews with 13 residents were conducted and analyzed deductively and inductively to identify when and how residents employed the protective factors. RESULTS: Among the 268 responders (51% response rate), grit, resiliency, social support, and psychological flexibility were individually inversely associated with burnout level. However, resiliency and relationship status were no longer associated with burnout when all 4 factors were included in the model. Interviews revealed that grit both protects from and contributes to burnout, residents prefer peer support, and they cognitively "step back" when stress is high. CONCLUSIONS: Although many programs and institutions focus on resiliency in wellness programs, there may be other factors to consider, such as grit and equipping students with tools to disengage psychologically when feeling stressed or overwhelmed.

Differences in Medical Students' Academic Performance between a Pass/Fail and Tiered Grading System.

OBJECTIVES: Medical school implementation of a pass/fail grading system offers the opportunity for a reduction in student stress and anxiety and the creation of a less competitive environment, leading to an improvement in overall well-being. Some critics of a pass/fail system have raised concerns of a decrement in academic performance. The purpose of this research project was to determine whether medical students at the Medical College of Georgia experienced a significant change in academic performance when graded using a pass/fail grading system rather than a tiered grading system in the year 1 curriculum. METHODS: This retrospective cohort study included a convenience sample of two cohorts of students: the first had tiered grading in the first year of medical school (classes of 2015 and 2016; n = 389) and the second cohort had pass/fail grading in the first year of medical school (classes of 2017 and 2018; n=385). Students' undergraduate grade point average and Medical College Admission Test scores in the two cohorts were compared. The first- and second-year averages and comprehensive finals, and the US Medical Licensing Examination step 1 scores were compared. Mann-Whitney U tests were calculated to compare the cohorts' grades. RESULTS: Overall, both cohorts performed similarly in the first and second year of medical school and on US Medical Licensing Examination step 1; however, there were a few unimportant but statistically significant differences of 1 to 2 points on a 100-point scale. In a few instances, the pass/fail cohort performed slightly better and in others, slightly worse. CONCLUSIONS: Overall academic performance was similar. The potential for an enhanced learning environment associated with pass/fail grading does not create an important decrement in academic performance.

Conditions and Dynamics That Impact Maternal Health Literacy among High Risk Prenatal-Interconceptional Women.

The purpose of the study was to describe conditions and dynamics in the lives of high-risk, low-income, Southern United States prenatal-interconceptional women (n = 37) in a home visiting program that promoted maternal health literacy progression. In the Life Course Health Development (LCHD) Model, conditions were risk and protective factors that impacted health. Dynamics drove the complex, epigenetic relationships between risk and protective factors. Maternal health literacy promotion helped participants address conditions and dynamics to create positive life changes. This research was a retrospective, mixed methods study of women's service records documenting care from prenatal admission to 24 months post-delivery. The Life Skills Progression Instrument (LSP) was scored to measure maternal health literacy progression. Ethnographic content analysis of visit notes triangulated with quantitative data enabled specificity of critical data elements. Subsequently, a complementary focus group was conducted with the Registered Nurse Case Managers (RNCM). Severe social conditions included devastating poverty, low educational achievement, transient housing, unstable relationships, incarceration, lack of continuous health insurance, and shortage of health care providers. Dynamics included severe psycho-social stressors, domestic violence, lack of employment, low income, low self-esteem and self-expectations, and social/family restraints upon women's intended positive changes. An important protective factor was the consistent, stable, evidence-informed relationship with the RNCM. Findings from the focus group discussion supported content analysis results.

Perinatal program evaluations: methods, impacts, and future goals.

The objective of this methodology note is to examine perinatal program evaluation methods as they relate to the life course health development model (LCHD) and risk reduction for poor birth outcomes. We searched PubMed, CDC, ERIC, and a list from the Association of Maternal and Child Health Programs (AMCHP) to identify sources. We included reports from theory, methodology, program reports, and instruments, as well as reviews of Healthy Start Programs and home visiting. Because our review focused upon evaluation methods we did not include reports that described the Healthy Start Program. The LCHD model demonstrates the non-linear relationships among epigenetic factors and environmental interactions, intentionality or worldview within a values framework, health practices, and observed outcomes in a lifelong developmental health trajectory. The maternal epigenetic and social environment during fetal development sets the stage for the infant's lifelong developmental arc. The LCHD model provides a framework to study challenging maternal child health problems. Research that tracks the long term maternal-infant health developmental trajectory is facilitated by multiple, linked public record systems. Two instruments, the life skills progression instrument and the prenatal risk overview are theoretically consistent with the LCHD and can be adapted for local or population-based use. A figure is included to demonstrate a method of reducing interaction among variables by sample definition. Both in-place local programs and tests of best practices in community-based research are needed to reduce unacceptably high infant mortality. Studies that follow published reporting standards strengthen evidence.