Prevalence of SARS-CoV-2 in newborns born to SARS-CoV-2-positive mothers at 2 weeks of life.

Introduction: Limited evidence exists on management recommendations for neonates born to SARS-CoV-2-positive mothers. This study looked at transmission risk of neonates presenting for primary care in a large regional health system within New York during the early months of the COVID-19 pandemic. Methods: This was a prospective, observational study of newborns born to SARS-CoV-2-positive mothers presenting at any of the 19 Northwell Health-Cohen Children's Medical Center primary care practices who underwent another oropharyngeal/nasopharyngeal swab for detection of SARS-CoV-2 by day of life (DOL) 14. Results: Among 293 newborns born to SARS-CoV-2-positive mothers who were negative at birth, 222 were retested at DOL 14, corresponding to times with different predominant strains. Of these, seven tested positive but had no symptoms. Conclusion: The overall low transmission rates and absence of symptomatic infection support the safety of direct breastfeeding after hospital discharge with appropriate hand and breast hygiene.

Despite mandated primary series, health care personnel still hesitant about COVID-19 vaccine and immunizing children.

IMPORTANCE: Healthcare personnel (HCP) are important messengers for promoting vaccines, for both adults and children. Our investigation describes perceptions of fully vaccinated HCP about COVID-19 vaccine for themselves and primary series for their children. OBJECTIVE: To determine associations between sociodemographic, employment characteristics and perceptions of COVID-19 vaccines among HCP overall and the subset of HCP with children, who were all mandated to receive a COVID-19 vaccine, in a large US metropolitan region. DESIGN: Cross-sectional survey of fully vaccinated HCP from a large integrated health system. SETTING: Participants were electronically enrolled within a multi-site NYS healthcare system from December 21, 2021, to January 21, 2022. PARTICIPANTS: Of 78,000 employees, approximately one-third accessed promotional emails; 6,537 employees started surveys and 4165 completed them. Immunocompromised HCP (self-reported) were excluded. EXPOSURE(S) (FOR OBSERVATIONAL STUDIES): We conducted a survey with measures including demographic variables, employment history, booster status, child vaccination status; vaccine recommendation, confidence, and knowledge. MAIN OUTCOME(S) AND MEASURES: The primary outcome was COVID-19 vaccine hesitancy for all dose types - primary series or booster doses - among HCP. RESULTS: Findings from 4,165 completed surveys indicated that almost 17.2 % of all HCP, including administrative and clinical staff, were hesitant or unsure about receiving a COVID-19 vaccine booster, despite the NYS recommendation to do so. Depending on age group, between 20 % and 40 % of HCP were hesitant about having their children vaccinated for COVID-19, regardless of clinical versus non-clinical duties. In multivariable regression analyses, lack of booster dose, unvaccinated children, females, income less than $50,000, and residence in Manhattan remained significantly associated with vaccine hesitancy. CONCLUSIONS AND RELEVANCE: Despite mandated COVID-19 vaccination, a substantial proportion of HCP remained vaccine hesitant towards adult booster doses and pediatric COVID-19 vaccination. While provider recommendation has been the mainstay of combatting COVID-19 vaccine hesitancy, a gap exists between HCP-despite clinical or administrative status-and the ability to communicate the need for vaccination in a healthcare setting. While previous studies describe the HCP vaccine mandate as a positive force to overcome vaccine hesitancy, we have found that despite a mandate, there is still substantial COVID-19 vaccine hesitancy, misinformation, and reluctance to vaccinate children.

Utilization and Patient-Reported Outcomes of Direct-to-Consumer Telemedicine During the First 6 Weeks of the COVID-19 Pandemic in the Largest Pediatric Ambulatory Network in New York State.

Objective: We aimed to (1) describe telemedicine utilization and usability during the first 6 weeks of the pandemic and (2) determine if usability varied by individual- or visit-level characteristics. Methods: We conducted a retrospective cohort study of ambulatory pediatric telemedicine visits occurring between March 10, 2020, and April 18, 2020, across a large academic health system. We performed manual chart review to assess individual- and visit-level characteristics and invited caregivers to respond to an adapted Telehealth Usability Questionnaire (TUQ). We used multiple logistic regression to determine predictors of high usability. Results: There were 3,197 ambulatory pediatric telemedicine visits, representing 2,967 unique patients. Patients were racially/ethnically diverse (42.5% non-Hispanic White) and primarily English-speaking (89.2%). Surveys were completed by 441 (17%) of those invited. Every item of the TUQ had agreement or strong agreement from the majority of respondents. Compared with non-Hispanic White, non-Hispanic Asian identity was associated with lower usability in three domains and overall, and non-Hispanic Black identity was associated with higher satisfaction and future use. As compared with caregivers of infants younger than 1 year, caregivers of older patients reported lower usability in the three domains. Conclusions: Telemedicine was successfully implemented across 18 ambulatory pediatric specialties in the largest health system in New York State at the onset of COVID-19, and caregivers found it usable and acceptable. Usability scores did not vary by visit-level characteristics but did vary by race/ethnicity and age. Further research is necessary to identify modifiable drivers of the patient experience, particularly in non-Hispanic Asian communities and older adolescents.

Sociodemographic Disparities in Ambulatory Pediatric Telemedicine Utilization During COVID-19.

Objective: Few studies have examined sociodemographic disparities in ambulatory pediatric telemedicine utilization during the coronavirus disease 2019 pandemic. We aimed to (1) assess disparities in telemedicine visit completion during the first 6 weeks of the pandemic in 2020 and (2) determine if these disparities were significantly different from those present in 2019, when all visits occurred in person. Methods: We compared sociodemographic characteristics of patients with successful versus unsuccessful telemedicine visits from March 10, 2020 to April 18, 2020, using generalized linear mixed models. We performed the same analysis for in-person visits from the same period in 2019. We tested for differences across years using interaction terms in a combined 2019-2020 model. Results: Of 3,639 telemedicine visits scheduled, 3,033 (83.3%) were successful. In 2020, Black/African American race was significantly associated with lower odds of telemedicine visit success (odds ratio 0.65 [95% confidence interval 0.49-0.87]) compared with White race, after adjusting for age, gender, ethnicity, insurance type, visit timing, visit specialty, social vulnerability index, and internet access. In 2019, racial identity other than White was significantly associated with lower odds of in-person visit success than White, as was public insurance compared with private. In the full 2019-2020 model, in-person visits (2019) had lower odds of success than telemedicine visits (2020), and neither race, insurance type, nor any other sociodemographic characteristic had significant interactions with year. Conclusions: Racial disparities were evident in telemedicine utilization early in the pandemic; however, these disparities were not significantly different from those seen in 2019, when all visits were in person. Furthermore, telemedicine may improve access to care overall, despite having no significant impact on inequity. Efforts to eliminate racial disparities in ambulatory pediatric health care utilization are necessary across visit modalities.

Quality of Web-Based Sickle Cell Disease Resources for Health Care Transition: Website Content Analysis.

Background: Adolescents and young adults with sickle cell disease (SCD) transitioning from pediatric to adult health care face a high-risk period associated with increased use of acute health care services and mortality. Although 59% of American citizens report using the internet for health care information, the quality of web-based, patient-facing resources regarding transition in SCD care has not been evaluated. Objective: This study aimed to evaluate the quality and readability of web-based health information on SCD, especially as it pertains to the transition to adulthood for inidividuals with SCD. The study also compared the readability and content scores of websites identified in 2018 to those from 2021 to assess any change in quality over time. Methods: Keywords representing phrases adolescents may use while searching for information on the internet regarding transition in SCD care, including "hydroxyurea" and "SCD transition," were identified. A web-based search using the keywords was conducted in July 2021 using Google, Yahoo, and Bing. The top 20 links from each search were collected. Duplicate websites, academic journals, and websites not related to SCD health care transition were excluded. Websites were categorized based on the source: health department, hospital or private clinician, professional society, and other websites. Websites were assessed using Health On the Net Foundation code of conduct (HONcode), Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FGL), Ensuring Quality Information for Patients (EQIP), and a novel SCD content checklist (SCDCC). EQIP and SCDCC scores range from 0- to 100. Each website was reviewed by 2 research assistants and assessed for interrater reliability. Descriptive statistics were calculated. Results: Of the 900 websites collected, 67 (7.4%) met the inclusion criteria: 13 health department, 7 hospital or private clinician, 33 professional society, and 14 other websites. A total of 15 (22%) out of 67 websites had HONcode certification. Websites with HONcode certification had higher FRE and EQIP scores and lower FGL scores than those without HONcode certification, reflecting greater readability. Websites without HONcode certification had higher SCDCC scores, reflecting greater clinical content. Only 7 (10%) websites met the National Institutes of Health recommendation of a seventh-grade or lower reading level. Based on EQIP scores, 6 (9%) websites were of high quality. The mean SCDCC score was 20.60 (SD 22.14) out of 100. The interrater reliability for EQIP and SCDCC ratings was good (intraclass correlation: 0.718 and 0.897, respectively). No source of website scored significantly higher mean EQIP, FRE, FGL, or SCDCC scores than the others (all P<.05). Conclusions: Although seeking health care information on the web is very common, the overall quality of information about transition in SCD care on the internet is poor. Changes to current web-based health care information regarding SCD care transitions would benefit transitioning youth by providing expectations, knowledge, skills, and tools to increase self-efficacy.

Caregiver support, burden, and long-term planning among caregivers of individuals with intellectual and developmental disabilities: A cross-sectional study.

BACKGROUND: Long-term care planning (LTCP) is critical for individuals with intellectual/developmental disabilities. Objectives of this study were to investigate progression through LTCP, and associations between social support and: (1) LTCP and (2) burden among family caregivers. METHODS: A cross-sectional survey was distributed to caregivers of individuals with intellectual/developmental disabilities in NY, OH, PA, and TX, exploring demographics, supports, burden, and LTCP behaviours. Bivariate and linear multiple regression analyses were used to investigate study objectives. RESULTS: Caregivers (n = 405) were predominantly parents, female, non-Hispanic, and in the 'learning to plan' stage of LTCP. Caregiver-identified social support was associated with further progression in LTCP (p = .020) and lower caregiver burden (p < .001). CONCLUSION: Social support was associated with further progression in LTCP, and associated with less burden, however fewer than 40% of caregivers reported having social support. Ongoing exploration of emotional/social needs of caregivers is necessary to better support these families.

Evidence for validity of the epidemic-pandemic impacts inventory (brief healthcare module): Internal structure and association with other variables.

The COVID-19 pandemic has subjected healthcare workers to enormous stress. Measuring the impact of this public health emergency is essential to developing strategies that can effectively promote resilience and wellness. The Epidemic-Pandemic Impacts Inventory Supplemental Healthcare Module-Brief Version (EPII-SHMb) was developed to measure impacts among occupational cohorts serving on the front lines of healthcare. While this instrument has been utilized in COVID-19 related studies, little is known about its psychometric properties. This study collects evidence for validity of the EPII-SHMb by evaluating its internal structure and how its scores associate with other variables. Physicians and nursing staff across a large New York health system were cross-sectionally surveyed using an online questionnaire between June and November 2020. Exploratory factor analysis resulted in a 3-factor solution, identifying factors Lack of Workplace Safety (7 items), Death/Dying of Patients (3 items), and Lack of Outside Support (2 items). Internal consistency was high overall and within physician/nursing and gender subgroups (Cronbach's alpha: 0.70 - 0.81). Median scores on Death/Dying of Patients were higher among those who directly cared for COVID-19 patients or worked in COVID-19 hospital units. These results are promising. Additional studies evaluating other dimensions of validity are necessary.

Physician challenges and supports during the first wave of the COVID-19 pandemic: A mixed methods study.

Introduction: During the COVID-19 pandemic, physicians encountered significant COVID-19-related negative experiences and psychological distress in both their personal and professional lives. To understand the factors that negatively impact physician well-being, a number of studies have pointed to multiple work system factors such as excessive workload and workflow interruptions. In addition, studies have shown that positive interpersonal relationships that provide social support may also serve as a buffering role against psychological distress. The aim of our study explores the challenges and sources of support for physicians relative to mental health symptoms. Methods: In this study, We used a cross-sectional study design with a convergent parallel mixed method approach combining both qualitative and quantitative data collected in parallel from a self-report questionnaire immediately following the first wave of COVID-19. The aim of our study explores the challenges and sources of support for physicians relative to mental health symptoms. Results: Of the 457 physicians in the study, the most frequently potential negative occupational experiences were, "Being at risk of contracting COVID-19 from patients/co-workers" (90.5%) and "Contact with distressed family members who cannot be with a loved one" (69.5%). We identified five common themes for main sources of social support (e.g. emotional support from family/friends) and six themes for challenges (e.g., work-related demands exacerbated by the pandemic). Discussion: Our study highlights COVID-19 and other pandemic-related challenges that negatively impacted the mental health of physicians. Interventions that provide targeted organizational supports (e.g. sufficient PPE and child support), as well as specific sources of support (e.g. family and emotional), can attenuate those challenges and stressors experienced during a pandemic.

The Effect of the COVID-19 Pandemic on Pediatric Physician Wellness: A Cross-Sectional Study.

The COVID-19 pandemic has provided challenges to all healthcare workers. While the brunt of treating COVID-19 patients fell upon adult providers, pediatricians also experienced significant stressors and disruptions. Academic pediatricians and trainees (fellows and residents) were redeployed to manage adult patients in hospitalist and intensive care settings and/or had major changes to their clinical schedules. In this study, we aimed to describe levels of self-reported depression, anxiety, and burnout in pediatric physicians following the initial wave of the pandemic at the largest integrated health system in New York State. A cross-sectional study was conducted among pediatric physicians who cared for patients during the COVID-19 pandemic within the Northwell Health System as part of the Northwell Wellbeing Registry, a longitudinal registry assessing the psychological impact of COVID-19 on healthcare providers. A total of 99 pediatric physician respondents were included in this study; 72% of whom were attendings, 28% of whom were trainees. Compared to attendings, trainees reported significantly higher proportions of burnout-emotional exhaustion (p = 0.0007) and burnout-depersonalization (p = 0.0011) on the Abbreviated Maslach Burnout Inventory. There was not a similar trend in probable depression or probable anxiety using the Patient Health Questionnaire. In a multivariable logistic regression model, being a trainee was significantly associated with increased odds of burnout-emotional exhaustion (OR 5.94, 95% Confidence Interval: 1.85-19.02). These findings suggest that fellows and residents were a vulnerable population during the COVID-19 pandemic. Training programs should pay special attention to their trainees during times of crisis, and future studies can help to identify protective factors to reduce the risk of burnout during these times.

Identifying key components of a web-based long term care planning intervention for family caregivers of individuals with intellectual/developmental disabilities.

BACKGROUND: Few family caregivers of individuals with intellectual or developmental disabilities develop long-term care (LTC) plans for their relative. Web-based interventions promoting LTC planning have potential for widespread adoption into clinical practice. METHODS: We conducted focus groups with 49 primary caregivers of individuals with intellectual or developmental disabilities in NY, PA, OH, DE, and TX to identify barriers and facilitators of LTC planning, review existing tools, and identify critical features for web-based LTC planning interventions. Participants also answered questions on demographic characteristics and functional status. RESULTS: NVivo qualitative analysis software was used to analyse focus groups using a grounded theory approach. Caregivers identified web tool accessibility and topics such as finances, housing, and government benefits as critical. Caregivers also described desired features for a LTC planning tool. CONCLUSIONS: This study identified desired characteristics of web-based LTC planning tools and ways in which existing web-based interventions might be adapted or enhanced.

Telehealth Utilization and Follow-Up Visits in Developmental-Behavioral Pediatrics During the COVID-19 Pandemic in 2020.

OBJECTIVE: The goal of this study was to understand the effect of transition to telehealth care on follow-up visit attendance in a developmental-behavioral pediatric (DBP) practice in 2020 versus in-person care in 2019. METHODS: This was a retrospective observational cohort study of follow-up visits occurring in a large DBP practice during a 6-week period in March/April of 2019 and 2020. The primary outcome was follow-up visit adherence, defined as completion of scheduled follow-up visit. The primary exposure was telehealth visit in 2020 versus in-person visit in 2019. Covariates included patient demographics and clinical characteristics. Data were analyzed using descriptive statistics and logistic regression. RESULTS: The cohort included 2142 visits for 1868 unique patients. The patient mean age was 9.2 ± 4.8 years, with 73.4% male, 56.5% non-Hispanic, 51.4% White, and 68.3% commercial insurance. There were 470 telehealth visits from March to April 2020 and 1672 in-person visits from March to April 2019. Compared with in-person visits, telehealth visits were more likely to be completed (75.3% vs 64.4%, p < 0.001). After adjusting for age, sex, race, ethnicity, insurance, and week of visit (weeks 1-3 vs 4-6), odds of having a complete follow-up visit were higher for telehealth visits than for in-person visits (odds ratio = 1.57; 95% confidence interval [1.23-2.00], p < 0.001). CONCLUSION: Follow-up visit attendance was higher for telehealth care in 2020 than in-person care in 2019. This association persisted after adjusting for insurance, age, race, and ethnicity, suggesting that telehealth is associated with increased follow-up visit attendance in DBP care. Further studies are needed to understand the impact of telehealth on DBP clinical outcomes in chronic disease management.

Caring for Children With Medical Complexity in the Early COVID-19 Pandemic in an Ambulatory Primary Care Setting.

BACKGROUND: Children with medical complexity (CMC) have multiple chronic conditions and require a high level of coordinated healthcare. The risk of COVID-19 among CMC is unclear. OBJECTIVES: We aim to identify and describe the prevalence and experience of COVID-19 among CMC and their caregivers during the initial weeks of the COVID-19 pandemic in the NY metropolitan area. METHODS: We performed a cross-sectional study of children enrolled in a structured clinical program for CMC at a large urban, academic general pediatrics practice in NY. RESULTS: In our patient population (n = 132), 16 patients had a known exposure with parents being the most common exposure in 37.5% (n = 6). Two patients were hospitalized for COVID-19 while the remainder of the confirmed or suspected COVID-19 cases were managed as an outpatient. CONCLUSIONS: Common sources of COVID-19 exposure were family members and home care providers. Almost all of our patients experienced interruption of medical care including missed therapies and visits.

The Impact of Physicians' COVID-19 Pandemic Occupational Experiences on Mental Health.

OBJECTIVE: To examine the association between a number of negative COVID-19 occupational experiences and probable anxiety, depression, and PTSD among physicians. METHODS: Cross-sectional examination of longitudinal registry data consisting of physician personal and occupational well-being. Multivariable logistic regressions were performed to determine the association between negative COVID-19 experiences and outcomes. RESULTS: Of the 620 eligible physicians, approximately half were female (49%), and 71% white with a mean age of 46.51 (SD = 13.28). A one-point increase in negative experience score was associated with a 23% increase in probable anxiety (OR = 1.23, 95% CI: 1.14-1.34), a 23% increase in probable depression (OR = 1.23, 95% CI: 1.13-1.33), and a 41% increase in probable PTSD (OR = 1.41, 95% CI: 1.30-1.52). CONCLUSIONS: Negative pandemic experiences were strongly associated with adverse mental health outcomes while greater resilience was protective.

Who Speaks First? Promoting Senior Resident Autonomy on Family-Centered Rounds: A QI Initiative.

BACKGROUND AND OBJECTIVES: Graduated autonomy is fundamental as trainees transition to independent practice. Family-centered rounds (FCR), the leading model of inpatient rounding in pediatrics, is an opportunity for trainees to demonstrate their competence in leading a health care team, which is an entrustable professional activity for all pediatric residents. At our institution, senior residents (SRs) at baseline performed at a novice level on the basis of the Senior Resident Empowerment Actions 21 (SREA-21), a validated tool that is used to assess SR autonomy during FCR. Our objective for this study was to increase the median percentage of SREA-21 domains in which SRs perform at a competent level from 38% to 75% within 6 months. METHODS: Researchers observed 4 FCR encounters weekly and calculated SREA-21 scores after 2 weeks on the basis of actions promoting SR autonomy performed by the SR-hospitalist dyad. The primary outcome measure was the percentage of SREA-21 domains in which the SR achieved a competent score on the SREA-21. We used the model for improvement to identify key drivers and test proposed interventions using serial plan-do-study-act cycles. Interventions included creation of unified inpatient SR expectations, introduction of a SR-hospitalist pre-FCR huddle, auditing of FCR interruptions, and direct feedback to the SR-hospitalist dyad after FCR. Run charts were used to track SR and hospitalist scores on the SREA-21. RESULTS: After multiple plan-do-study-act cycles, there was special cause improvement with a desirable shift upward in the centerline to 100%, which correlated with the project's interventions and surpassed our goal. CONCLUSIONS: Using quality improvement methodology, we improved SR autonomy during FCR, as measured by the SREA-21.

Increasing Pediatric to Adult Healthcare Transition Services Through Clinical Decision Supports.

PURPOSE: Despite American Academy of Pediatrics recommendations that adolescents receive healthcare transition (HCT) services starting at age 12, few do. Electronic health record-based clinical decision support (CDS) tools are effective at promoting healthcare provider adherence to clinical guidelines. This study's purpose was to increase provider HCT services engagement through implementation of a transition-specific CDS and participation in a transition-focused Learning Collaborative (LC). DESIGN AND METHODS: Three pediatric primary care sites of an urban, academic medical center implemented a transition CDS tool for ≥14-year-olds. Previously, one site had a version for ≥16-year-olds. Two sites participated in a LC with Plan-Do-Study-Act cycles targeting HCT services engagement, measured by CDS use and practice-level guideline implementation. RESULTS: From July 2018 through June 2019, providers at LC-participating sites engaged in HCT services at 8.0% (n = 480) and 5.3% (n = 145) of eligible patient visits compared to the control's 3.1% (n = 69). Engagement was highest for ≥18-year-olds at the LC-participating sites, 26.0% (n = 263) and 12.0% (n = 80), compared to the control's 7.2% (n = 31). After expanding from ≥16 to ≥14-year-olds, engagement decreased by 9.5% at ≥16-year-old visits. LC-participating sites reported increased HCT guideline adherence. CONCLUSIONS: Implementation of a transition-specific CDS with LC participation increased provider HCT services engagement and practice-level guideline implementation. Expansion to younger adolescents contributed to decreased engagement for older patients. Future research should assess opportunities to improve uptake and patient outcomes of transition CDS engagement. PRACTICE IMPLICATIONS: Quality improvement activities and transition clinical decision supports can improve provider engagement in recommended transition services for adolescents and young adults.

Developing a Hospital-Wide Transition Program for Young Adults With Medical Complexity.

PURPOSE: Transitional age adults (18-24 years) are the fastest growing cohort of patients in children's hospitals across the nation. The purpose of the study was to standardize pediatric to adult healthcare transfers of complex adult patients through a tiered and multimodal population-based intervention. METHODS: The Multidisciplinary Intervention Navigation Team (MINT) was developed to decrease variations in pediatric to adult medical transitions. System-level goals were to (1) increase provider and leadership engagement, (2) increase transition tools, (3) increase use of electronic medical record-based clinical decision supports, (4) improve transition practices through development of transition policies and clinical pathways; (5) increase transition education for patients and caregivers; (6) increase the adult provider referral network; and (7) implement an adult transition consult service for complex patients (MINT Consult). RESULTS: Between July 2015 and March 2017, MINT identified 11 transition champions, increased the number of divisions with drafted transition policies from 0 to 7, increased utilization of electronic medical record-based transition support tools from 0 to 7 divisions, held seven psychoeducational events, and developed a clinical pathway. MINT has received more than 70 patient referrals. Of patients referred, median age is 21 years (range, 17-43); 70% (n = 42) have an intellectual disability. Referring pediatric providers (n = 25) reported that MINT helped identify adult providers and coordinate care with other Children's Hospital of Philadelphia specialists (78%); and that MINT saved greater than 2 hours of time (48%). CONCLUSIONS: MINT improved the availability, knowledge, and use of transition-related resources; saved significant time among care team members; and increased provider comfort around transition-related conversations.

Domains of planning for future long-term care of adults with intellectual and developmental disabilities: Parent and sibling perspectives.

BACKGROUND: Research shows that adults with intellectual and developmental disabilities (IDD) increasingly outlive caregivers, who often struggle to plan for the future and have little support and knowledge surrounding long-term care planning. METHODS: The study team conducted interviews with parents and siblings of adults with IDD and performed qualitative coding using a modified grounded theory to explore domains of future planning and identify barriers and facilitators. RESULTS: Themes from the interviews revealed seven major domains of future planning that should be considered by caregivers of adults with IDD. These domains are housing, legal planning, identification of primary caregiver(s), financial planning, day-to-day care, medical management and transportation. Approaches to planning within each domain varied greatly. CONCLUSIONS: The study team dentified the domain of "identification of primary caregiver(s)" as potentially the most important step for caregivers when planning for the future, but also observed that the domains identified are significantly interrelated and should be considered together.