Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

STUDY AIM: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach. BACKGROUND: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described. METHODS: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements. RESULTS: We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC. CONCLUSION: This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study. APPLICATION: We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Use of personal care products during pregnancy and birth outcomes - A pilot study.

Prenatal exposure to endocrine disrupting chemicals (EDCs) from personal care products may be associated with birth outcomes including preterm birth and low birth weight. There is limited research examining the role of personal care product use during pregnancy on birth outcomes. Our pilot study consisted of 164 participants in the Environmental Reproductive and Glucose Outcomes (ERGO) study (Boston, MA), with data on self-reported personal care product use at four study visits throughout pregnancy (product use in the 48 h before a study visit and hair product use in the month before a study visit). We used covariate-adjusted linear regression models to estimate differences in mean gestational age at delivery, birth length, and sex-specific birth weight-for-gestational age (BW-for-GA) Z-score based on personal care product use. Hair product use in the past month prior to certain study visits was associated with decreased mean sex-specific BW-for-GA Z-scores. Notably, hair oil use in the month prior to study visit 1 was associated with a lower mean BW-for-GA Z-score (V1: -0.71, 95% confidence interval: -1.12, -0.29) compared to non-use. Across all study visits (V1-V4), increased mean birth length was observed among nail polish users vs. non-users. In comparison, decreased mean birth length was observed among shave cream users vs. non-users. Liquid soap, shampoo, and conditioner use at certain study visits were significantly associated with higher mean birth length. Suggestive associations were observed across study visits for other products including hair gel/spray with BW-for-GA Z-score and liquid/bar soap with gestational age. Overall, use of a variety of personal care products throughout pregnancy was observed to be associated with our birth outcomes of interest, notably hair oil use during early pregnancy. These findings may help inform future interventions/clinical recommendations to reduce exposures linked to adverse pregnancy outcomes.

Risk-Factor Based Lead Screening and Correlation with Blood Lead Levels in Pregnancy.

OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 µg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.

Bereaved College Students: Social Support, Coping Style, Continuing Bonds, and Social Media Use as Predictors of Complicated Grief and Posttraumatic Growth.

Many college students experience the death of someone close to them and could be at risk for complicated grieving. Their primary sources of support may be unavailable as family members may live far away and their peers may be unprepared to respond to their grief. In addition, college students are exposed to a variety of stressors that could result in maladaptive coping. Furthermore, although most college-aged students use social media, little is known about its impact on grieving. The purpose of this study was to examine the degree to which social support, coping, continuing bonds, and social media use predicted complicated grief and posttraumatic growth in a sample of college students who had experienced an interpersonal loss. Participants (N = 258; 77.5% female, M age = 19.98, SD = 1.41) completed an online survey assessing the aforementioned constructs using Likert-type scales. Findings from two hierarchical regressions indicated that coping variables accounted for the greatest percentage of variance in grieving outcomes with avoidant-emotional coping being the most robust predictor of complicated grief and problem-focused coping accounting for considerable variance in posttraumatic growth (both were associated positively with the outcomes). As hypothesized, continuing bonds explained variance in both grieving outcomes with externalized continuing bonds and maintaining continuing bonds on social media predicting complicated grief and internalized continuing bonds contributing to posttraumatic growth (also all positively associated). Social support from family also was predictive of posttraumatic growth in the positive direction. Future research directions and implications for practice are discussed with the hope that this research might inform the development of interventions to assist college students who are grieving.

Endocrine disrupting chemical-associated hair product use during pregnancy and gestational age at delivery: a pilot study.

BACKGROUND: Prenatal endocrine disrupting chemical (EDC) exposure has been associated with increased risk of preterm birth. Non-Hispanic Black women have higher incidence of preterm birth compared to other racial/ethnic groups and may be disproportionately exposed to EDCs through EDC-containing hair products. However, research on the use of EDC-associated hair products during pregnancy and risk of preterm birth is lacking. Therefore, the objective of this pilot study was to estimate associations of prenatal hair product use with gestational age at delivery in a Boston, Massachusetts area pregnancy cohort. METHODS: The study population consisted of a subset of participants enrolled in the Environmental Reproductive and Glucose Outcomes (ERGO) Study between 2018 and 2020. We collected self-reported data on demographics and hair product use using a previously validated questionnaire at four prenatal visits (median: 12, 19, 26, 36 weeks' gestation) and abstracted gestational age at delivery from medical records. We compared gestational age and hair product use by race/ethnicity and used linear regression to estimate covariate-adjusted associations of product use and frequency of use at each study visit with gestational age at delivery. Primary models were adjusted for maternal age at enrollment and delivery method. RESULTS: Of the 154 study participants, 7% delivered preterm. Non-Hispanic Black participants had lower mean gestational age at delivery compared to non-Hispanic White participants (38.2 vs. 39.2 weeks) and were more likely to report ever and more frequent use of hair products. In regression models, participants reporting daily use of hair oils at visit 4 had lower mean gestational age at delivery compared to non-users (ß: -8.3 days; 95% confidence interval: -14.9, -1.6). We did not find evidence of associations at earlier visits or with other products. CONCLUSIONS: Frequent use of hair oils during late pregnancy may be associated with shorter gestational duration. As hair oils are more commonly used by non-Hispanic Black women and represent potentially modifiable EDC exposure sources, this may have important implications for the known racial disparity in preterm birth.

Ambient PM gross ß-activity and glucose levels during pregnancy.

BACKGROUND: Exposure to ionizing radiation has been associated with insulin resistance and type 2 diabetes. In light of recent work showing an association between ambient particulate matter (PM) gross ß-activity and gestational diabetes mellitus (GDM) among pregnant women, we examined pregnancy glucose levels in relation to PM gross ß-activity to better understand this pathway. METHODS: Our study included 103 participants receiving prenatal care at Beth Israel Deaconess Medical Center in Boston, MA. PM gross ß-activity was obtained from US Environmental Protection Agency's RadNet program monitors, and blood glucose levels were obtained from the non-fasting glucose challenge test performed clinically as the first step of the 2-step GDM screening test. For each exposure window we examined (i.e., moving average same-day, one-week, first-trimester, and second-trimester PM gross ß-activity), we fitted generalized additive models and adjusted for clinical characteristics, socio-demographic factors, temporal variables, and PM with an aerodynamic diameter ≤ 2.5 µm (PM2.5). Subgroup analyses by maternal age and by body mass index were also conducted. RESULTS: An interquartile range increase in average PM gross ß-activity during the second trimester of pregnancy was associated with an increase of 17.5 (95% CI: 0.8, 34.3) mg/dL in glucose concentration. Associations were stronger among younger and overweight/obese participants. Our findings also suggest that the highest compared to the lowest quartile of one-week exposure was associated with 17.0 (95% CI: - 4.0, 38.0) mg/dL higher glucose levels. No associations of glucose were observed with PM gross ß-activity during same-day and first-trimester exposure windows. PM2.5 was not associated with glucose levels during any exposure window in our data. CONCLUSIONS: Exposure to higher levels of ambient PM gross ß-activity was associated with higher blood glucose levels in pregnant patients, with implications for how this novel environmental factor could impact pregnancy health.

Assessing women's career barriers across racial/ethnic groups: The Perception of Barriers Scale.

The purpose of the study was to examine the factor structure, measurement invariance, and psychometric properties of a commonly used measure of perceived career barriers (The Perception of Barriers Scale; Luzzo & McWhirter, 2001) with racially diverse college women. The results supported a 9-factor structure for the Perception of Barriers Scale; configural, metric, and scalar invariance for the 9-factors were found with Asian, African American, Latina, and White college women. All groups of women of color reported higher career barriers due to racism and higher educational barriers due to racial discrimination than White women. The results also demonstrated potential differences in salient barriers for women of color (educational barriers due to lack of confidence/skills for Asian women, career barriers due to sexism and racism for African American women, and educational barriers due to financial concerns for Latina women). The reliability estimates of the subscales were satisfactory and support for criterion validity was demonstrated. The results highlighted the importance of measuring and identifying salient barriers for college women of color. Future research and practice implications for assessing and ameliorating salient barriers for college women are discussed. (PsycINFO Database Record

Racial identity invalidation with multiracial individuals: An instrument development study.

OBJECTIVES: Racial identity invalidation, others' denial of an individual's racial identity, is a salient racial stressor with harmful effects on the mental health and well-being of Multiracial individuals. The purpose of this study was to create a psychometrically sound measure to assess racial identity invalidation for use with Multiracial individuals (N = 497). METHOD: The present sample was mostly female (75%) with a mean age of 26.52 years (SD = 9.60). The most common racial backgrounds represented were Asian/White (33.4%) and Black/White (23.7%). Participants completed several online measures via Qualtrics. RESULTS: Exploratory factor analyses revealed 3 racial identity invalidation factors: behavior invalidation, phenotype invalidation, and identity incongruent discrimination. A confirmatory factor analysis provided support for the initial factor structure. Alternative model testing indicated that the bifactor model was superior to the 3-factor model. Thus, a total score and/or 3 subscale scores can be used when administering this instrument. Support was found for the reliability and validity of the total scale and subscales. In line with the minority stress theory, challenges with racial identity mediated relationships between racial identity invalidation and mental health and well-being outcomes. CONCLUSIONS: The findings highlight the different dimensions of racial identity invalidation and indicate their negative associations with connectedness and psychological well-being. (PsycINFO Database Record

Cost Analysis of Following Up Incomplete Low-Risk Fetal Anatomy Ultrasounds.

OBJECTIVES: To examine the clinical utility and cost of follow-up ultrasounds performed as a result of suboptimal views at the time of initial second-trimester ultrasound in a cohort of low-risk pregnant women. METHODS: We conducted a retrospective cohort study of women at low risk for fetal structural anomalies who had second-trimester ultrasounds at 16 to less than 24 weeks of gestation from 2011 to 2013. We determined the probability of women having follow-up ultrasounds as a result of suboptimal views at the time of the initial second-trimester ultrasound, and calculated the probability of detecting an anomaly on follow-up ultrasound. These probabilities were used to estimate the national cost of our current ultrasound practice, and the cost to identify one fetal anomaly on follow-up ultrasound. RESULTS: During the study period, 1,752 women met inclusion criteria. Four fetuses (0.23% [95% CI 0.06-0.58]) were found to have anomalies at the initial ultrasound. Because of suboptimal views, 205 women (11.7%) returned for a follow-up ultrasound, and one (0.49% [95% CI 0.01-2.7]) anomaly was detected. Two women (0.11%) still had suboptimal views and returned for an additional follow-up ultrasound, with no anomalies detected. When the incidence of incomplete ultrasounds was applied to a similar low-risk national cohort, the annual cost of these follow-up scans was estimated at $85,457,160. In our cohort, the cost to detect an anomaly on follow-up ultrasound was approximately $55,000. CONCLUSIONS: The clinical yield of performing follow-up ultrasounds because of suboptimal views on low-risk second-trimester ultrasounds is low. Since so few fetal abnormalities were identified on follow-up scans, this added cost and patient burden may not be warranted.

Cerclage in twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospective cohort study.

BACKGROUND: Cervical dilation in the second trimester is associated with a greater than 90% rate of spontaneous preterm birth and a poor perinatal prognosis. OBJECTIVE: To compare the perinatal outcomes of twin pregnancies with dilated cervix in women who underwent either cerclage or expectant management. STUDY DESIGN: Retrospective cohort study of asymptomatic twin pregnancies identified with cervical dilation of ≥1 cm at 16-24 weeks (1997-2014) at 7 institutions. Exclusion criteria were genetic or major fetal anomaly, multifetal reduction at >14 weeks, prior cerclage placement, monochorionic-monoamniotic placentation, active vaginal bleeding, labor, chorioamnionitis, elective termination of pregnancy, or medically indicated preterm birth. The primary outcome was incidence of spontaneous preterm birth at <34 weeks. Secondary outcomes were incidence of spontaneous preterm birth at <32 weeks, <28 weeks, and <24 weeks; perinatal mortality; and composite adverse neonatal outcome (respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and sepsis). RESULTS: A total of 76 women with twin pregnancy with dilated cervix of 1.0-4.5 cm were managed with either cerclage (n = 38) or expectant management (n = 38). Demographic characteristics were not significantly different. Analysis was adjusted for amniocentesis and vaginal progesterone use. In the cerclage group, 29 women (76%) received prophylactic indomethacin and 36 (94%) received prophylactic antibiotics, whereas the expectant management group did not. Interval from time at diagnosis of open cervix to delivery in the cerclage group was 10.46 ± 5.6 weeks vs 3.7 ± 3.2 weeks in the expectant management group, with a mean difference of 6.76 weeks (95% confidence interval [CI], 4.71-8.81). There were significant decreases in spontaneous preterm birth at <34 weeks (52.6% vs 94.7%; adjusted odds ratio [aOR], 0.06; 95% CI, 0.03-0.34), at <32 weeks (44.7% vs 89.4%; aOR, 0.08; 95% CI, 0.03-0.34); at <28 weeks (31.6% vs 89.4%; aOR, 0.05; 95% CI, 0.01-0.2); and at <24 weeks (13.1% vs 47.3%; aOR, 0.17; 95% CI, 0.05-0.54). There were also significant reductions in perinatal mortality (27.6% vs 59.2%; aOR, 0.24; 95% CI, 0.11-0.5), neonatal intensive care unit admission (75.9% vs 97.6%; aOR, 0.07; 95% CI, 0.01-0.66), and composite adverse neonatal outcome (33.9% vs 90.5%; aOR, 0.05; 95% CI, 0.01-0.21). CONCLUSION: Cerclage, indomethacin, and antibiotics in twin pregnancies with dilated cervix ≥1 cm before 24 weeks were associated with significant longer latency period from diagnosis to delivery (6.7 weeks), decreased incidence of spontaneous preterm birth at any given gestational age, and improved perinatal outcome when compared with expectant management.

An Evaluation of the Feasibility and Safety of a Home-Based Telemental Health Treatment for Posttraumatic Stress in the U.S. Military.

BACKGROUND: Although home-based telemental health options have the potential to greatly expand the range of services available to U.S. military service members, there remains a need to demonstrate that home-based care is technically feasible, safe, and effective and meets the military health system's standards of care before widespread implementation can be achieved. The purpose of this preliminary study was to evaluate the feasibility and safety of providing U.S. military service members with a behavioral health treatment delivered directly to the home using videoconferencing. MATERIALS AND METHODS: Ten previously deployed soldiers volunteered to complete eight sessions of a novel behavioral activation treatment for posttraumatic stress disorder. The primary clinical outcomes assessed included symptoms of posttraumatic stress and depression. Patient safety data and attitudes about seeking mental health services, treatment satisfaction, treatment adherence, and treatment compliance were also assessed. RESULTS: Clinically significant reductions in posttraumatic stress symptom severity and depression symptoms were observed. Soldiers indicated high levels of satisfaction with the treatment, and there were no adverse events requiring activation of emergency safety procedures. Technical problems associated with the network were observed but successfully mitigated. CONCLUSIONS: The results provide initial support for the feasibility and safety of telemental health treatments delivered by videoconferencing to the homes of soldiers. The optimal technical infrastructure needs to be determined to support expansion of synchronous videoconferencing capabilities to the home. The findings provide preliminary evidence of the feasibility, safety, and high user satisfaction with home-based telemental health in the military setting.

Work, family, support, and depression: employed mothers in Israel, Korea, and the United States.

Our research revealed differences in work-family constructs for employed mothers in 3 countries, Israel (N = 105), Korea (N = 298), and the United States (N = 305). Although levels of work-family conflict were comparable, the Korean women had the lowest levels of work-family enrichment compared with the Israeli and American mothers. Moreover, Korean women reported the most depression and the least support from both spouses and employers. Spousal support mediated the relationship between work-family conflict and depression for employed mothers in Israel, Korea, and the United States. As hypothesized by conservation of resources theory (Hobfoll, 1989, 1998, 2001), threat of resource loss (operationalized as work-family conflict) was related to depression more strongly than was resource gain (i.e., work-family enrichment).

Cohort profile: the Environmental Reproductive and Glucose Outcomes (ERGO) Study (Boston, Massachusetts, USA) - a prospective pregnancy cohort study of the impacts of environmental exposures on parental cardiometabolic health.

PURPOSE: Pregnancy and the postpartum period are increasingly recognised as sensitive windows for cardiometabolic disease risk. Growing evidence suggests environmental exposures, including endocrine-disrupting chemicals (EDCs), are associated with an increased risk of pregnancy complications that are associated with long-term cardiometabolic risk. However, the impact of perinatal EDC exposure on subsequent cardiometabolic risk post-pregnancy is less understood. The Environmental Reproductive and Glucose Outcomes (ERGO) Study was established to investigate the associations of environmental exposures during the perinatal period with post-pregnancy parental cardiometabolic health. PARTICIPANTS: Pregnant individuals aged ≥18 years without pre-existing diabetes were recruited at <15 weeks of gestation from Boston, Massachusetts area hospitals. Participants completed ≤4 prenatal study visits (median: 12, 19, 26, 36 weeks of gestation) and 1 postpartum visit (median: 9 weeks), during which we collected biospecimens, health histories, demographic and behavioural data, and vitals and anthropometric measurements. Participants completed a postpartum fasting 2-hour 75 g oral glucose tolerance test. Clinical data were abstracted from electronic medical records. Ongoing (as of 2024) extended post-pregnancy follow-up visits occur annually following similar data collection protocols. FINDINGS TO DATE: We enrolled 653 unique pregnancies and retained 633 through delivery. Participants had a mean age of 33 years, 10% (n=61) developed gestational diabetes and 8% (n=50) developed pre-eclampsia. Participant pregnancy and postpartum urinary phthalate metabolite concentrations and postpartum glycaemic biomarkers were quantified. To date, studies within ERGO found higher exposure to phthalates and phthalate mixtures, and separately, higher exposure to radioactive ambient particulate matter, were associated with adverse gestational glycaemic outcomes. Additionally, certain personal care products used in pregnancy, notably hair oils, were associated with higher urinary phthalate metabolite concentrations, earlier gestational age at delivery and lower birth weight. FUTURE PLANS: Future work will leverage the longitudinal data collected on pregnancy and cardiometabolic outcomes, environmental exposures, questionnaires, banked biospecimens and paediatric data within the ERGO Study.

CARM1 is required for proper control of proliferation and differentiation of pulmonary epithelial cells.

Coactivator-associated arginine methyltransferase I (CARM1; PRMT4) regulates gene expression by multiple mechanisms including methylation of histones and coactivation of steroid receptor transcription. Mice lacking CARM1 are small, fail to breathe and die shortly after birth, demonstrating the crucial role of CARM1 in development. In adults, CARM1 is overexpressed in human grade-III breast tumors and prostate adenocarcinomas, and knockdown of CARM1 inhibits proliferation of breast and prostate cancer cell lines. Based on these observations, we hypothesized that loss of CARM1 in mouse embryos would inhibit pulmonary cell proliferation, resulting in respiratory distress. By contrast, we report here that loss of CARM1 results in hyperproliferation of pulmonary epithelial cells during embryonic development. The lungs of newborn mice lacking CARM1 have substantially reduced airspace compared with their wild-type littermates. In the absence of CARM1, alveolar type II cells show increased proliferation. Electron microscopic analyses demonstrate that lungs from mice lacking CARM1 have immature alveolar type II cells and an absence of alveolar type I cells. Gene expression analysis reveals a dysregulation of cell cycle genes and markers of differentiation in the Carm1 knockout lung. Furthermore, there is an overlap in gene expression in the Carm1 knockout and the glucocorticoid receptor knockout lung, suggesting that hyperproliferation and lack of maturation of the alveolar cells are at least in part caused by attenuation of glucocorticoid-mediated signaling. These results demonstrate for the first time that CARM1 inhibits pulmonary cell proliferation and is required for proper differentiation of alveolar cells.

Synchronous telehealth technologies in psychotherapy for depression: a meta-analysis.

BACKGROUND: Many patients suffering from depression lack immediate access to care. The use of synchronous telehealth modalities to deliver psychotherapy is one solution to this problem. This meta-analysis examined differences in treatment efficacy for psychotherapy administered via synchronous telehealth as compared to standard nontelehealth approaches. METHOD: We located 14 articles that met inclusion criteria of the use of a synchronous telehealth modality for treatment compared to a standard nontelehealth modality comparison group. RESULTS: Overall, a statistically significant systematic difference between modes of delivery was not identified (g = 0.14, SE = 0.08, 95% CI = [-0.03, 0.30], P = .098, I(2) = 49.74%). Stratification methods and metaregression were used to analyze the contributions of type of comparison group, intervention modality, and targeted mental health outcome to moderation of effect size (ES) estimates and heterogeneity. Type of comparison group (face-to-face versus care-as-usual) had the strongest influence on observed heterogeneity and moderated the summary ES. The only detectable difference in efficacy was restricted to studies that used care-as-usual as the comparison group (g = 0.29, SE = 0.06, 95% CI = [0.16, 0.41], P < .001, I(2) = 5.14%). CONCLUSIONS: Overall, we found no evidence to suggest that the delivery of psychotherapy via synchronous telehealth modalities is less effective than nontelehealth means in reducing depression symptoms.

Work-family enrichment among dual-earner couples: can work improve our family life?

The extent to which resources generated at work and positive affect were associated with enrichment in the family domain among 107 dual-earner couples was investigated. Grounded in work-family enrichment theory (Greenhaus & Powell, 2006), this study examined the indirect effect of workplace organizational support on family satisfaction through positive affect at work. Organizational support for work-family management was associated with positive affect at work for both women and men, and positive affect at work was related to family satisfaction for women. One interpersonal effect emerged: women's positive affect at work was associated with family satisfaction for men. Implications for theory, practice, research, and workplace policy are discussed.

"Leaving before she leaves": considering future family when making career plans.

An instrument was developed to measure the extent to which people consider future children and romantic partners when planning for a career (i.e., the PLAN scale). Two independent factor-analytic studies of a total of 726 college women were conducted to assess the factor structure and psychometric properties of this measure. Results suggested that the PLAN represents a general Considering Future Family When Making Career Plans factor and 2 domain-specific factors: Considering Children and Prioritizing and Compromising for Partner. Suggestions for future research and practice using the PLAN scale are provided.

Fractal approaches to scaling transformations to sustainability.

Responses to sustainability challenges are not delivering results at the scale and speed called for by science, international agreements, and concerned citizens. Yet there is a tendency to underestimate the large-scale impacts of small-scale, local, and contextualized actions, and particularly the role of individuals in scaling transformations. Here, we explore a fractal approach to scaling sustainability transformations based on "universal values." Universal values are proposed as intrinsic characteristics that connect humans and nature in a coherent, acausal way. Drawing on the Three Spheres of Transformation framework, we consider how enacting universal values can generate fractal-like patterns of sustainability that repeat recursively across scales. Fractal approaches shift the focus from scaling through "things" (e.g., technologies, behaviors, projects) to scaling through a quality of agency based on values that apply to all. We discuss practical steps involved in fractal approaches to scaling transformations to sustainability, provide examples, and conclude with questions for future research.

Serum creatine kinase after exercise: drawing the line between physiological response and exertional rhabdomyolysis.

INTRODUCTION: In this investigation we assessed the spectrum of creatine kinase (CK) responses in military recruits undergoing basic training. METHODS: Musculoskeletal examination data, questionnaire findings, and CK levels were obtained from 499 recruits at days 0, 3, 7, and 14 of training. Correlations of CK with ethnicity, age, body mass index, exercise, muscle pain, and climate were obtained. RESULTS: None of the subjects developed clinical exertional rhabdomyolysis (ER). The mean/median serum CK values were 223/157, 734/478, 1226/567, and 667/486 IU/L at days 0, 3, 7, and 14, respectively, with a wide overall range (34-35,056 IU/L). African-American subjects had higher mean CK levels. CONCLUSIONS: CK elevations and muscle pain are common during basic training. Widely accepted laboratory diagnostic values for ER are routinely exceeded in this military recruits, suggesting that CK levels >50 times the upper limit of normal are more specific. The findings support using CK as a marker for ER. Normal laboratory reference ranges for CK should be published by ethnicity.

Home-based telemental healthcare safety planning: what you need to know.

Telemental health (TMH) care provided directly to the home is an emerging area of care delivery. TMH care involves awareness of safety issues and adequate safety planning, although detailed practical recommendations for home-based TMH safety planning are absent in the literature. With this article we aim to increase awareness of safety issues associated with home-based synchronous TMH treatment and to discuss recommendations for consistent safety planning that can inform the development of standard operating procedures, emergency protocols, and overall good TMH practice. Specific areas discussed include consideration of state and local requirements, appropriateness of TMH care, technology and infrastructure, and emergency management and monitoring procedures. The topic of safety, as it relates to TMH policy, as well as the need for additional TMH research are also discussed.