The Chief Wellness Officer: A long overdue catalyst for systemic change in Emergency Medicine.

GOALS: The American healthcare system is amid a burnout epidemic, worsened by COVID, that must be addressed expeditiously and with high priority. The burden Emergency Physicians encountered before and during the pandemic is well known, with countless healthcare workers exiting the work force. A Chief Wellness Officer (CWO) is a senior leader who works primarily to cultivate organisational wellness and to foster and promote a culture of well-being throughout an institution. Specifically, the CWO assists the health system leadership promote clinician engagement and address clinician burnout. This paper explores the status of existing CWOs, and cites the benefits, impacts, and barriers to implementation of a CWO, with focus on the field of Emergency Medicine (EM). METHODS: A steering committee of wellness experts was formed from a national EM organisation. A purposive search and literature review using search terms relating to CWOs was completed. Publications were examined for relevance and recency. The committee created an online questionnaire surveying current US CWOs, conducted personal interviews, and met through regular focused meetings. A framework delineating the role of a CWO as an organisation evolves from instituting novice wellness interventions to expert organisational innovations was created. PRINCIPLE FINDINGS: Despite their title, CWOs are not regularly included in c-suite decisions. Barriers to instituting a CWO include perceived financial cost, the medical system itself, and physician resistance. Defining and measuring objective return on investment may be a solution to overcoming barriers. CWOs who create comprehensive institutional wellness innovations bring organisations to the highest proficient and expert levels of wellness practices, positively affecting physician engagement and deflecting burnout. CWOs instituting novice and beginner levels of wellness interventions, especially in EM, only modestly impact individual wellness practices. PRACTICAL APPLICATIONS: A CWO and team with an organisational voice and a C-suite stakeholder's seat are essential to centralising and leading effective wellness efforts and innovations in EM and other specialities. This team will improve the work environment and culture and begin to fix our broken healthcare system and providers.

Racial and Ethnic Inequities in Development of Type 2 Diabetes After Gestational Diabetes Mellitus.

OBJECTIVE: To estimate racial and ethnic disparities in type 2 diabetes mellitus after gestational diabetes mellitus (GDM) and to investigate baseline pregnancy clinical and social or structural characteristics as mediators. METHODS: We conducted a retrospective cohort of individuals with GDM using linked 2009-2011 New York City birth and hospital data and 2009-2017 New York City A1c Registry data. We ascertained GDM and pregnancy characteristics from birth and hospital records. We classified type 2 diabetes as two hemoglobin A 1c test results of 6.5% or higher. We grouped pregnancy characteristics into clinical (body mass index [BMI], chronic hypertension, gestational hypertension, preeclampsia, preterm delivery, caesarean, breastfeeding, macrosomia, shoulder dystocia) and social or structural (education, Medicaid insurance, prenatal care, and WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] participation). We used Cox proportional hazards models to estimate associations between race and ethnicity and 8-year type 2 diabetes incidence, and we tested mediation of pregnancy characteristics, additionally adjusting for age and nativity (U.S.-born vs foreign-born). RESULTS: The analytic data set included 22,338 patients with GDM. The 8-year type 2 diabetes incidence was 11.7% overall and 18.5% in Black, 16.8% in South and Southeast Asian, 14.6% in Hispanic, 5.5% in East and Central Asian, and 5.4% in White individuals with adjusted hazard ratios of 4.0 (95% CI 2.4-3.9), 2.9 (95% CI 2.4-3.3), 3.3 (95% CI 2.7-4.2), and 1.0 (95% CI 0.9-1.4) for each group compared with White individuals. Clinical and social or structural pregnancy characteristics explained 9.3% and 23.8% of Black, 31.2% and 24.7% of Hispanic, and 7.6% and 16.3% of South and Southeast Asian compared with White disparities. Associations between education, Medicaid insurance, WIC participation, and BMI and type 2 diabetes incidence were more pronounced among White than Black, Hispanic, and South and Southeast Asian individuals. CONCLUSION: Population-based racial and ethnic inequities are substantial in type 2 diabetes after GDM. Characteristics at the time of delivery partially explain disparities, creating an opportunity to intervene on life-course cardiometabolic inequities, whereas weak associations of common social or structural measures and BMI in Black, Hispanic and South and Southeast Asian individuals demonstrate the need for greater understanding of how structural racism influences postpartum cardiometabolic risk in these groups.

Severe outcomes following pediatric cannabis intoxication: a prospective cohort study of an international toxicology surveillance registry.

INTRODUCTION: An increasing number of jurisdictions have legalized recreational cannabis for adult use. The subsequent availability and marketing of recreational cannabis has led to a parallel increase in rates and severity of pediatric cannabis intoxications. We explored predictors of severe outcomes in pediatric patients who presented to the emergency department with cannabis intoxication. METHODS: In this prospective cohort study, we collected data on all pediatric patients (<18 years) who presented with cannabis intoxication from August 2017 through June 2020 to participating sites in the Toxicology Investigators Consortium. In cases that involved polysubstance exposure, patients were included if cannabis was a significant contributing agent. The primary outcome was a composite severe outcome endpoint, defined as an intensive care unit admission or in-hospital death. Covariates included relevant sociodemographic and exposure characteristics. RESULTS: One hundred and thirty-eight pediatric patients (54% males, median age 14.0 years, interquartile range 3.7-16.0) presented to a participating emergency department with cannabis intoxication. Fifty-two patients (38%) were admitted to an intensive care unit, including one patient who died. In the multivariable logistic regression analysis, polysubstance ingestion (adjusted odds ratio = 16.3; 95% confidence interval: 4.6-58.3; P < 0.001)) and cannabis edibles ingestion (adjusted odds ratio = 5.5; 95% confidence interval: 1.9-15.9; P = 0.001) were strong independent predictors of severe outcome. In an age-stratified regression analysis, in children older than >10 years, only polysubstance abuse remained an independent predictor for the severe outcome (adjusted odds ratio 37.1; 95% confidence interval: 6.2-221.2; P < 0.001). As all children 10 years and younger ingested edibles, a dedicated multivariable analysis could not be performed (unadjusted odds ratio 3.3; 95% confidence interval: 1.6-6.7). CONCLUSIONS: Severe outcomes occurred for different reasons and were largely associated with the patient's age. Young children, all of whom were exposed to edibles, were at higher risk of severe outcomes. Teenagers with severe outcomes were frequently involved in polysubstance exposure, while psychosocial factors may have played a role.

Predictors and Trends in First-Trimester Hemoglobin A1c Screening in New York City, 2009 to 2017.

Glycated hemoglobin is an adjunct tool in early pregnancy to assess glycemic control. We examined trends and maternal predictors for those who had A1c screening in early pregnancy using hospital discharge and vital registry data between 2009 and 2017 linked with the New York City A1C Registry (N = 798,312). First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017. The likelihood of screening became less targeted to high-risk patients over time, with a decrease in mean A1c values from 5.8% (95% confidence interval [CI]: 5.8, 5.9) to 5.3 (95% CI: 5.3, 5.4). The prevalence of gestational diabetes mellitus increased while testing became less discriminate for those with high-risk factors, including pregestational type 2 diabetes, chronic hypertension, obesity, age over 40 years, as well as Asian or Black non-Hispanic race/ethnicity. KEY POINTS: · First-trimester A1c screening increased from 2.3% in 2009 to 7.7% in 2017 in New York City.. · The likelihood of screening became less targeted to high-risk patients over time.. · The prevalence of gestational diabetes mellitus increased, while testing became less discriminate..

Succimer Mitigates the Perioperative Risk for an Increase in Blood Lead Levels During Bulletectomy: A Case Report.

CASE: A 38-year-old man with a tibial plateau fracture required treatment for elevated blood lead level (BLL) from retained bullet fragments in the same knee from a gunshot wound 21 years earlier. Oral succimer presurgery and postsurgery decreased the BLL from 58 to 15 µg/dL. CONCLUSION: Parenteral chelation has been previously recommended to mitigate an increase in BLLs during surgical intervention to remove bullet fragments. Oral succimer was an effective and well-tolerated alternative to intravenous chelation. Further research is needed to determine the optimal route, timing, and duration of chelation in patients with elevated BLL in need of bulletectomy.

Influence of Gestational Diabetes Mellitus on Diabetes Risk and Glycemic Control in a Retrospective Population-Based Cohort.

OBJECTIVE: Racial/ethnic-specific estimates of the influence of gestational diabetes mellitus (GDM) on type 2 diabetes remain underexplored in large population-based cohorts. We estimated racial/ethnic differences in the influence of GDM on diabetes risk and glycemic control in a multiethnic, population-based cohort of postpartum women. RESEARCH DESIGN AND METHODS: Hospital discharge and vital registry data for New York City (NYC) births between 2009 and 2011 were linked with NYC A1C Registry data between 2009 and 2017. Women with baseline diabetes (n = 2,810) were excluded for a final birth cohort of 336,276. GDM on time to diabetes onset (two A1C tests of ≥6.5% from 12 weeks postpartum onward) or glucose control (first test of A1C <7.0% following diagnosis) was assessed using Cox regression with a time-varying exposure. Models were adjusted for sociodemographic and clinical factors and stratified by race/ethnicity. RESULTS: The cumulative incidence for diabetes was 11.8% and 0.6% among women with and without GDM, respectively. The adjusted hazard ratio (aHR) of GDM status on diabetes risk was 11.5 (95% CI 10.8, 12.3) overall, with slight differences by race/ethnicity. GDM was associated with a lower likelihood of glycemic control (aHR 0.85; 95% CI 0.79, 0.92), with the largest negative influence among Black (aHR 0.77; 95% CI 0.68, 0.88) and Hispanic (aHR 0.84; 95% CI 0.74, 0.95) women. Adjustment for screening bias and loss to follow-up modestly attenuated racial/ethnic differences in diabetes risk but had little influence on glycemic control. CONCLUSIONS: Understanding racial/ethnic differences in the influence of GDM on diabetes progression is critical to disrupt life course cardiometabolic disparities.

Macromolecular Engineering and Additive Manufacturing of Polyisobutylene-Based Thermoplastic Elastomers. II. The Poly(styrene-b-isobutylene-b-styrene)/Poly(phenylene oxide) System.

This series of publications describes research rendering soft polyisobutylene (PIB)-based thermoplastic elastomers 3D printable by blending with rigid chemically compatible thermoplastics. The molecular structure, morphology, physical properties, and 3D printability of such blends have been systematically investigated. The authors' first report was concerned with the rendering of soft poly(styrene-b-isobutylene-b-styrene) (SIBS) 3D printable by blending with rigid polystyrene (PS). Here they report the macromolecular engineering of SIBS/polyphenylene oxide (PPO) blends for 3D printing. PPO, a rigid high-performance thermoplastic, is compatible with the hard PS block in SIBS; however, neither PPO nor SIBS can be directly 3D printed. The microphase-separated structures and physical properties of SIBS/PPO blends are systematically tuned by controlling blending ratios and molecular weights. Suitable composition ranges and desirable properties of SIBS/PPO blends for 3D printing are optimized. The morphology and properties of SIBS/PPO blends are characterized by an ensemble of techniques, including atomic force microscopy, small-angle X-ray scattering, and thermal and mechanical properties testing. The elucidation of processing-structure-property relationship of SIBS/PPO blends is essential for 3D printing and advanced manufacturing of high-performance polymer systems.

Synthesis of High-Molecular-Weight and Strength Polyisobutylene-Based Polyurethane and Its Use for the Development of a Synthetic Heart Valve.

Under optimized synthesis conditions, for the first time, polyisobutylene-based polyurethane (PIB-PU) is prepared with 70% PIB soft segment (i.e., a bioinert and calcification-resistant PU) with Mn > 100 000 Da, 32 MPa ultimate strength, and 630% elongation. The key parameters for this achievement are a) the precise stoichiometry of the polyurethane forming reaction, specifically the use of highly purified di-isocyanate (4,4'-methylene-bis (phenyl isocyanate), MDI), and b) the increased solid content of the synthesis solution to the limit beyond which increased viscosity prevents stirring. The shape of the stress-strain trace of PIB-PU indicates a two-step failure starting with a reversible elastic (Hookean) region up to ≈50% yield, followed by a slower linearly increasing high-modulus-deformation region suggesting the strengthening of PIB soft segments by entanglement/catenation, and the hard segments by progressively ordering urethane domains. This PIB-PU is a candidate for a fully synthetic bioprosthetic heart valve since preliminary studies show that PIB-PU has impressive fatigue life.

A Review of Cancer Immunotherapy Toxicity II: Adoptive Cellular Therapies, Kinase Inhibitors, Monoclonal Antibodies, and Oncolytic Viruses.

Immunotherapy for cancer has undergone a rapid expansion in classes, agents, and indications. By utilizing aspects of the body's innate immune system, immunotherapy has improved life expectancy and quality of life for patients with several types of cancer. Adoptive cellular therapies, including chimeric antigen receptor T (CAR T) cell therapy, involve the genetic engineering of patient T cells to allow for targeting of neoplastic cells. Monitoring of patients during the lymphodepletion prior to therapy and following CAR T cell infusion is necessary to detect toxicity of therapy. Specific toxicities include cytokine release syndrome and neurologic toxicity, both of which may be life-threatening. Tocilizumab and/or corticosteroids should be considered for moderate to severe toxicity. Kinase inhibitor toxicity can occur as "on target" effects or "off target" effects to multiple organ systems due to shared protein epitopes. Treatments are organ-specific. Infusion reactions are common during treatment with monoclonal antibodies and treatment is largely supportive. Clinical experience with oncolytic viruses is limited, but local reactions including cellulitis as well as systemic influenza-like syndromes have been seen but are typically mild. Although clinical experience with adverse effects due to newer immunotherapy agents is growing, an up-to-date understanding of their mechanisms and potential toxicities is critical.

Excess Deaths in Mexico City and New York City During the COVID-19 Pandemic, March to August 2020.

Objectives. To estimate all-cause excess deaths in Mexico City (MXC) and New York City (NYC) during the COVID-19 pandemic. Methods. We estimated expected deaths among residents of both cities between March 1 and August 29, 2020, using log-linked negative binomial regression and compared these deaths with observed deaths during the same period. We calculated total and age-specific excess deaths and 95% prediction intervals (PIs). Results. There were 259 excess deaths per 100 000 (95% PI = 249, 269) in MXC and 311 (95% PI = 305, 318) in NYC during the study period. The number of excess deaths among individuals 25 to 44 years old was much higher in MXC (77 per 100 000; 95% PI = 69, 80) than in NYC (34 per 100 000; 95% PI = 30, 38). Corresponding estimates among adults 65 years or older were 1263 (95% PI = 1199, 1317) per 100 000 in MXC and 1581 (95% PI = 1549, 1621) per 100 000 in NYC. Conclusions. Overall, excess mortality was higher in NYC than in MXC; however, the excess mortality rate among young adults was higher in MXC. Public Health Implications. Excess all-cause mortality comparisons across populations and age groups may represent a more complete measure of pandemic effects and provide information on mitigation strategies and susceptibility factors. (Am J Public Health. 2021;111(10): 1847-1850. https://doi.org/10.2105/AJPH.2021.306430).

Glucocorticoid-Mediated Changes in Male Green Treefrog Vocalizations Alter Attractiveness to Females.

Adrenal glucocorticoids (GCs) are increasingly recognized as important modulators of male courtship signals, suggesting that circulating levels of these steroids can play a central role in sexual selection. However, few studies have examined whether GC-mediated effects on male sexual signals actually impact mate choice by females. Here, we examine how corticosterone (CORT)-mediated changes in the vocalizations of male green treefrogs, Dryophytes cinereus, influence attractiveness to females. In this species, agonistic acoustic signaling between rival males competing for mates increases circulating CORT levels in contest losers. Acute elevations in CORT, in turn, decrease the duration of male advertisement calls and increase the latency between successive calls, resulting in a net reduction in vocal effort (the amount of signaling per unit time) that occurs independently of changes in circulating androgens. Based on known preferences for acoustic features in D. cinereus, and other anuran species, the direction of CORT-mediated effects on temporal call characteristics is expected to compromise attractiveness to females, but whether they are of sufficient magnitude to impact female mate choice decisions is unclear. To examine whether CORT-mediated effects on male advertisement calls reduce attractiveness to females, we broadcast vocalizations in dual speaker playback experiments approximating the mean and 1 SD above and below the mean call duration and vocal effort values (the two primary vocal features impacted by elevated CORT) of males with low and high CORT levels. Results revealed strong preferences by females for the calls characteristic of males with low CORT in tests using the approximate mean and 1 SD above the mean call duration and vocal effort values, but females did not show a preference for calls of males with low CORT in trials using call values approximating 1 SD below the mean. Overall, females preferred males with signal traits predictive of low CORT, however this effect was nonlinear with attenuated preferences when signal alternatives differed only marginally indicating a possible thresholding effect. Specifically, females appeared to discriminate between males with low versus high CORT based primarily on differences in call rates associated with CORT-mediated changes in call duration and vocal effort. Our results highlight that changes in circulating CORT during male-male vocal interactions can decrease attractiveness to females, suggesting that circulating levels of CORT can play a critical role in both intra- and intersexual selection.

Paternal Jail Incarceration and Birth Outcomes: Evidence from New York City, 2010-2016.

OBJECTIVES: To examine population-level associations between paternal jail incarceration during pregnancy and infant birth outcomes using objective measures of health and incarceration. METHODS: We use multivariate logistic regression models and linked records on all births and jail incarcerations in New York City between 2010 and 2016. RESULTS: 0.8% of live births were exposed to paternal incarceration during pregnancy or at the time of birth. After accounting for parental sociodemographic characteristics, maternal health behaviors, and maternal health care access, paternal incarceration during pregnancy remains associated with late preterm birth (OR = 1.34, 95% CI = 1.21, 1.48), low birthweight (OR = 1.39, 95% CI = 1.27, 1.53), small size for gestational age (OR = 1.35, 95% CI = 1.17, 1.57), and NICU admission (OR = 1.14, 95% CI = 1.05, 1.24). CONCLUSIONS: We found strong positive baseline associations (p < 0.001) between paternal jail incarceration during pregnancy with probabilities of all adverse outcomes examined. These associations did not appear to be driven purely by duration or frequency of paternal incarceration. These associations were partially explained by parental characteristics, maternal health behavior, and health care. These results indicate the need to consider paternal incarceration as a potential stressor and source of trauma for pregnant women and infants.

A Review of Cancer Immunotherapy Toxicity: Immune Checkpoint Inhibitors.

Cancer immunotherapy, which leverages features of the immune system to target neoplastic cells, has revolutionized the treatment of cancer. The use of these therapies has rapidly expanded in the past two decades. Immune checkpoint inhibitors represent one drug class within immunotherapy with its first agent FDA-approved in 2011. Immune checkpoint inhibitors act by disrupting inhibitory signals from neoplastic cells to immune effector cells, allowing activated T-cells to target these neoplastic cells. Unique adverse effects associated with immune checkpoint inhibitors are termed immune-related adverse effects (irAEs) and are usually immunostimulatory in nature. Almost all organ systems may be affected by irAEs including the dermatologic, gastrointestinal, pulmonary, endocrine, and cardiovascular systems. These effects range from mild to life-threatening, and their onset can be delayed several weeks or months. For mild irAEs, symptomatic care is usually sufficient. For higher grade irAEs, discontinuation of therapy and initiation of immunosuppressive therapy may be necessary. The management of patients with irAEs involves multidisciplinary care coordination with respect to the long-term goals the individual patient. Clinicians must be aware of the unique and sometimes fatal toxicologic profiles associated with immunotherapies to ensure prompt diagnosis and appropriate management.

Adapting urban best management practices for resilience to long-term environmental changes.

Stormwater best management practices (BMPs) help mitigate the adverse effects of urban development on stream hydrology and water quality, and are widely specified in development requirements and watershed management plans. However, design of stormwater BMPs largely relies on experience with historic climate, which may not be a reliable guide to the future. To inform BMP design that is robust to future conditions, it is important to examine how potential changes in precipitation, temperature, and potential evapotranspiration will affect the performance of BMPs. We use continuous simulation modeling to examine BMP performance under current and potential future climatic conditions and determine the changes needed in site configuration to address future impacts. We perform modeling for five development types in five different regions of the United States and explore both conventional ("gray") and green infrastructure (GI) stormwater management approaches. If stormwater designs are adapted to address potential future climate conditions, this study suggests that the most cost-effective approaches may use both gray and green BMPs. If the magnitude of extreme weather events increases dramatically, then gray practices that provide detention storage may have better cost-effectiveness. Incorporating risk of future climate impacts into stormwater design may help communities become more resilient. PRACTITIONER POINTS: There is a risk that projected changes in meteorological forcing will negatively affect stormwater BMP performance. Under projected future climate conditions, this study suggests the most cost-effective approaches may use both gray and green BMPs. If the magnitude of extreme weather events increases dramatically, gray practices that provide detention storage may have better cost-effectiveness. Flexibility is beneficial in adaptation and resilience planning due to uncertainty in projected precipitation volume and intensity changes.

Sequential Multimaterial Additive Manufacturing of Functionally Graded Biopolymer Composites.

Cellulose, chitin, and pectin are three of the most abundant natural materials on Earth. Despite this, large-scale additive manufacturing with these biopolymers is used only in limited applications and frequently relies on extensive refinement processes or plastic additives. We present novel developments in a digital fabrication and design approach for multimaterial three-dimensional printing of biopolymers. Specifically, our computational and digital fabrication workflow-sequential multimaterial additive manufacturing-enables the construction of biopolymer composites with continuously graded transitional zones using only a single extruder. We apply this method to fabricate structures on length scales ranging from millimeters to meters. Transitional regions between materials created using these methods demonstrated comparable mechanical properties with homogenous mixtures of the same composition. We present a computational workflow and physical system support a novel and flexible form of multimaterial additive manufacturing with a diverse array of potential applications.

A comparison between telehealth and face-to-face delivery of a brief alcohol intervention for college students.

BACKGROUND: Problematic alcohol use is a common occurrence among college students. While empirically supported interventions exist, their access is typically limited to those with greater resources. There has been an expansion of services provided via telehealth to increase client access to treatment in the health care field. However, the evidence is mixed regarding the effectiveness of face-to-face versus telehealth interventions and there is a gap in the literature regarding brief alcohol interventions delivered via telehealth. As such, the purpose of this study was to test the effectiveness of a well-validated brief alcohol screening and intervention for college students (BASICS) when conducted face-to-face or through a videoconferencing system. Method: Participants included 51 college students who engaged in heavy episodic drinking (5+ drinks for males and 4+ drinks for females over a two hour period) over the last two weeks. They were randomly assigned to receive the face-to-face or telehealth intervention and completed a variety of questionnaires throughout. Follow up data on the participant's alcohol use and alcohol-related problems was collected at 1-, 2-, and 3-months. Multilevel modeling in SAS was utilized for analyses, which included the modeling of treatment outcome trajectories and the influence of predictors on the trajectory of change for each outcome. Results: Results indicated that the intervention significantly reduced alcohol consumption and related problems regardless of condition. Both conditions saw an increase in treatment satisfaction and therapeutic alliance between the two sessions. Increased therapeutic alliance resulted in greater decreases in alcohol use and related harm across both conditions. Additionally, those with a mental health diagnosis showed greater improvement related to risk reduction for both treatment modalities. Conclusion: In sum, the results of this study suggest that telehealth services should be further implemented and the BASICS intervention can be effectively delivered via telehealth for college students.