Promoting Sustainability Practices in the Outpatient Pediatric Setting.

Healthcare systems intend to address health needs of a community, but unfortunately may also inadvertently exacerbate the climate crisis through increased greenhouse gas (GHG) emissions. Clinical medicine has not evolved to promote sustainability practices. New attention to the enormous impact of healthcare systems on GHG emissions and an escalating climate crisis has resulted in some institutions taking proactive measures to mitigate these negative effects. Some healthcare systems have made large-scale changes to conserve energy and materials, resulting in significant monetary savings. In this paper, we share our experience with developing an interdisciplinary work "green" team within our outpatient general pediatrics practice to implement changes, albeit small, to reduce our workplace carbon footprint. We share our experience with reducing paper usage by consolidating vaccine information sheets into a single use information sheet with quick response (QR) codes. We also share ideas for all workplaces to raise awareness of sustainability practices and to foster new ideas to address the climate crisis in both our professional and personal realms. These can help promote hope for the future and shift the collective mindset about climate action.

Transdisciplinary Approach Practicum for Speech-Language Pathology and Special Education Graduate Students.

Speech-language pathology and special education graduate student teams participated in an intensive summer practicum for social communication skills with children with autism spectrum disorders, utilizing a transdisciplinary approach that aligned to the frameworks utilized for implementation science. Questionnaires measuring transdisciplinary approach knowledge and comfort level were administered pre/post-practicum. Results of the questionnaires, written daily team reflections, course evaluations, and a focus group interview indicated an increase in all measures, including an increased knowledge of TA, increased understanding and comfort level with the other discipline, and a higher level of confidence and openness in working collaboratively utilizing a transdisciplinary approach.

College Access, Success and Equity for Students on the Autism Spectrum.

College may be considered a gateway to success, yet access to college is limited for young adults with autism. Given the research recommendations to elicit student experiences and to communicate among universities to improve college access, success, and equity, the present study examined the questions: What factors are perceived as pathways to success or barriers to success by college students on the autism spectrum? What university provided accommodations and/or support services do they prefer? Participants from four universities completed surveys and semi-structured interviews. Findings from the multi-university study suggest the need to provide transition planning and systematic non-academic social and emotional supports from the start of the college experience as well as specific training for faculty, staff, and peers.

Centro SOL: A Community-Academic Partnership to Care for Undocumented Immigrants in an Emerging Latino Area.

PROBLEM: From 2000 to 2014, the Latino population in Baltimore city, an emerging Latino settlement area, experienced rapid growth. Many of these individuals are undocumented and not eligible for coverage. Academic medical centers often lead the way in addressing the health needs of undocumented immigrants; however, examples from emerging immigrant areas are limited. APPROACH: In October 2013, Johns Hopkins Medicine clinicians established the Center for Salud/Health and Opportunities for Latinos (Centro SOL) to better address the health needs of Baltimore's growing Latino community. Centro SOL's mission focuses on four core activities: clinical services; advocacy and community engagement efforts; pipeline/education opportunities; and research consultations. Progress is measured through a scorecard reviewed annually by Centro SOL leadership. OUTCOMES: Centro SOL's program has expanded health care access for undocumented immigrants, patient safety and quality of service/care programs for patients with limited English proficiency, and pipeline opportunities for Latino youth. In 2017, 2,763 uninsured patients received primary or specialty care and 290 people received group therapy to address stress-related conditions. In addition, 49 Latino students (ranging from high school to postgraduate students) received mentorship at Centro SOL. NEXT STEPS: In the next five years, Centro SOL plans to expand the pipeline for Latinos interested in health professions fields and to further improve access to health services for Latino families through both advocacy efforts and enhanced clinical services.

The Influence of Human Demography on Land Cover Change in the Great Lakes States, USA.

The Great Lakes region contains productive agricultural and forest lands, but it is also highly urbanized, with 32 of its 52 million residents living in nine large metropolitan areas. Urbanization of undeveloped areas may adversely affect the productivity of agricultural and forest lands, and the provision of ecosystem services. We combine demographic and remote sensing data to evaluate land cover change in the region using a two-phase statistical modeling approach that predicts the incidence and extent of land cover change for each of the region's 10,579 county subdivisions. Observed patterns are spatially uneven, and the probability of land cover change is influenced by current land use, human habitation, industry, and demographic change. Pseudo R2 values varied from 0.053 to 0.338 for the first-phase logistic models predicting the presence of land cover change; second-stage beta models predicting the rate of change were more reliable, with pseudo R2 ranging from 0.225 to 0.675. Overall, changes from agriculture or greenspace to development were much more predictable than changes from agriculture to greenspace or vice versa, and demographic variables were much more important in models predicting change to development. Although models successfully predicted the general location of land cover change, and models from before the Great Recession were useful for predicting the location but not the amount of change during the recession, fine-grained prediction remained challenging. Understanding where future changes are most probable can inform planning and policy-making, which may reduce the impact of development on resource production, environmental health, and ecosystem services.

Testimonios, A Mental Health Support Group for Latino Immigrants in an Emergent Latino Community.

Latino immigrants face many stressors before, during, and after migration to the U.S., but there are few mental health services available to help them cope with this transition. We established free group sessions moderated by bilingual therapists to address the unmet mental health needs of Latino immigrants.

A Familiarization Protocol Facilitates the Participation of Children with ASD in Electrophysiological Research.

This paper includes a detailed description of a familiarization protocol, which is used as an integral component of a larger research protocol to collect electroencephalography (EEG) data and Event-Related Potentials (ERPs). At present, the systems available for the collection of high-quality EEG/ERP data make significant demands on children with developmental disabilities, such as those with an Autism Spectrum Disorder (ASD). Children with ASD may have difficulty adapting to novel situations, tolerating uncomfortable sensory stimuli, and sitting quietly. This familiarization protocol uses Evidence-Based Practices (EBPs) to increase research participants' knowledge and understanding of the specific activities and steps of the research protocol. The tools in this familiarization protocol are a social narrative, a visual schedule, the Premack principle, role-playing, and modeling. The goal of this familiarization protocol is to increase understanding and agency and to potentially reduce anxiety for child participants, resulting in a greater likelihood of the successful completion of the research protocol for the collection of EEG/ERP data.

Electrophysiological Indices of Audiovisual Speech Perception in the Broader Autism Phenotype.

When a speaker talks, the consequences of this can both be heard (audio) and seen (visual). A novel visual phonemic restoration task was used to assess behavioral discrimination and neural signatures (event-related potentials, or ERP) of audiovisual processing in typically developing children with a range of social and communicative skills assessed using the social responsiveness scale, a measure of traits associated with autism. An auditory oddball design presented two types of stimuli to the listener, a clear exemplar of an auditory consonant-vowel syllable /ba/ (the more frequently occurring standard stimulus), and a syllable in which the auditory cues for the consonant were substantially weakened, creating a stimulus which is more like /a/ (the infrequently presented deviant stimulus). All speech tokens were paired with a face producing /ba/ or a face with a pixelated mouth containing motion but no visual speech. In this paradigm, the visual /ba/ should cause the auditory /a/ to be perceived as /ba/, creating an attenuated oddball response; in contrast, a pixelated video (without articulatory information) should not have this effect. Behaviorally, participants showed visual phonemic restoration (reduced accuracy in detecting deviant /a/) in the presence of a speaking face. In addition, ERPs were observed in both an early time window (N100) and a later time window (P300) that were sensitive to speech context (/ba/ or /a/) and modulated by face context (speaking face with visible articulation or with pixelated mouth). Specifically, the oddball responses for the N100 and P300 were attenuated in the presence of a face producing /ba/ relative to a pixelated face, representing a possible neural correlate of the phonemic restoration effect. Notably, those individuals with more traits associated with autism (yet still in the non-clinical range) had smaller P300 responses overall, regardless of face context, suggesting generally reduced phonemic discrimination.

Coverage isn't enough: building primary care capacity in the setting of health reform.

The Access Partnership is a program linking uninsured patients with primary and specialty care. Expansion of primary care access resulted in an influx of patients with multiple chronic conditions, causing the primary care practice to reach capacity after seven months. Our program may provide lessons in ensuring primary care access as the Affordable Care Act is implemented.

Identifying patient, community and program specific barriers to free specialty care utilization by uninsured patients in East Baltimore.

Uninsured individuals face multiple barriers to accessing specialty care. The Access Partnership (TAP) offers free specialty care and care coordination to qualified uninsured patients at an urban academic medical center for a small program entry fee (waived for financial hardship). In the program's first year, 104 eligible patients (31%) did not enroll. To understand why, we investigated demographic, referral, personal, and program-specific factors. After adjusting for age, gender, and ZIP code, diagnostic and therapeutic referrals were more likely to be completed than ancillary referrals (OR=8.56, p=.001; OR 3.53, p=.03). There was no difference between pain related and ancillary referrals (OR=2.80, p=.139). Eighteen patients were surveyed and reported program and patient-specific barriers. While removing costs is necessary to improve access to specialty care for underserved patients, it is insufficient. Improving communication from program coordinators and enrollment strategies may help to improve utilization of free care programs by the uninsured.

Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings.

UNLABELLED: Chronic wounds are a major healthcare problem costing the United States billions of dollars a year. The American Academy of Dermatology has underscored the significance of wound care in dermatological practice. It is critical for all dermatologists to understand the elements of diagnosis and therapy. We emphasize major aspects of diagnosis and present a simple classification of wound dressings with guidelines for usage and relative cost data. LEARNING OBJECTIVE: After completing this learning activity, participants should be able to diagnose common types of chronic wounds, formulate a therapeutic plan, and describe the major classes of topical therapies and dressings for the chronic wound.

Morphological and molecular effects of 20-hydroxyecdysone and its agonist tebufenozide on CF-203, a midgut-derived cell line from the spruce budworm, Choristoneura fumiferana.

The morphological and molecular responses of a midgut-derived cell line of the spruce budworm, Choristoneura fumiferana, to 20-hydroxyecdysone (20E) and the nonsteroidal ecdysone agonist, tebufenozide (RH-5992), were investigated. The cells responded to these compounds by clumping, generating filamentous extensions, increased mortality and expression of the transcription factor, Choristoneura hormone receptor 3 (CHR3). This cell line can be used as a model system to study the mode of action of ecdysone and its agonists. With subsequent passaging in ecdysteroid-containing medium, the degree of clumping increased and the clumping could not be reversed by subculturing in ecdysteroid-free medium. Cell numbers of the adapted cell lines in 20E and RH-5992 containing media were not significantly decreased, compared to the control, but both cell lines accumulated less (14)C-labeled RH-5992 and lost the capability of expressing CHR3 in response to these compounds. Taken together, the cell lines appeared to develop a mechanism to adapt to the toxic effects of these compounds. Arch. Insect Biochem. Physiol. 55:68-78, 2004.

Pathogenicity of Choristoneura fumiferana nucleopolyhedrovirus propagated in vitro at different incubation temperatures.

To optimize the in vitro production of Choristoneura fumiferana nucleopolyhedrovirus (CfMNPV) as a potential microbial pest control agent, the pathogenicity of occlusion bodies (OBs) produced in two cell lines at three incubation temperatures was determined by bioassay. A plaque-purified isolate of CfMNPV was amplified in permissive C. fumiferana cell lines, FPMI-CF-203 and FPMI-CF-2C1, and incubated at 22, 24, and 28 degrees C. Occlusion bodies propagated in FPMI-CF-203 cells at 28 degrees C were significantly larger (17.5 microm(3)) and more pathogenic (LD(50) = 27; LD(95) = 185, where LD(50) and LD(95) are doses required to kill 50 and 95% of the test larvae, respectively) than those produced in either of the cell lines at any of the incubation temperatures tested. Increased temperatures yielded larger OBs from both cell lines. The pathogenicity of OBs propagated in the FPMI-CF-203 cell line increased with incubation temperature, whereas that of OBs produced in FPMI-CF-2C1 cells decreased. Comparison of the pathogenicity of OBs, whether naturally occurring or genetically modified, should be standardized by cell line and incubation temperature used for propagation. Production efficiency decreased with increasing incubation temperature for each cell line. Lower incubation temperatures used for propagation, and standardization of the titer of viral inoculum, should be further investigated to determine the economic feasibility of the in vitro production of CfMNPV as a microbial pest control agent.

A model for managed behavioral health care in an academic department of psychiatry.

In response to the effects of the managed care environment on patient flow and care, the department of psychiatry and behavioral sciences of the Johns Hopkins School of Medicine developed and has been managing a capitated behavioral health care program. The program is responsible for providing mental health and substance abuse services for 22,000 members of the TRICARE Uniformed Services Family Health Plan (USFHP), directed by the U.S. Department of Defense. The integration of primary care and behavioral health care is a major feature of the USFHP/TRICARE program. The authors describe the transition from a carve-out for-profit managed care organization to the integrated program managed by the department. During the first two years of the program, access to services increased and use of inpatient services decreased without the need to deny service use. To supplement previous reports of the involvement of academic psychiatry departments in behavioral health care, the authors supply utilization and financial data that may serve as benchmarks for similar efforts by other departments.