Influenza A viral burst size from thousands of infected single cells using droplet quantitative PCR (dqPCR).

An important aspect of how viruses spread and infect is the viral burst size, or the number of new viruses produced by each infected cell. Surprisingly, this value remains poorly characterized for influenza A virus (IAV), commonly known as the flu. In this study, we screened tens of thousands of cells using a microfluidic method called droplet quantitative PCR (dqPCR). The high-throughput capability of dqPCR enabled the measurement of a large population of infected cells producing progeny virus. By measuring the fully assembled and successfully released viruses from these infected cells, we discover that the viral burst sizes for both the seasonal H3N2 and the 2009 pandemic H1N1 strains vary significantly, with H3N2 ranging from 101 to 104 viruses per cell, and H1N1 ranging from 101 to 103 viruses per cell. Some infected cells produce average numbers of new viruses, while others generate extensive number of viruses. In fact, we find that only 10% of the single-cell infections are responsible for creating a significant portion of all the viruses. This small fraction produced approximately 60% of new viruses for H3N2 and 40% for H1N1. On average, each infected cell of the H3N2 flu strain produced 709 new viruses, whereas for H1N1, each infected cell produced 358 viruses. This novel method reveals insights into the flu virus and can lead to improved strategies for managing and preventing the spread of viruses.

Novel Skin Prep Technique Reduces OR Preparation Times in a Randomized Trial for Podiatric and Orthopedic Procedures.

The primary objectives of any high-volume surgery department should be patient safety, block time utilization and operating room efficiency. Reducing preparation time in the OR prior to actual surgery can improve operating room efficiency and utilization, but only if patient safety can be maintained. With this goal, this study evaluated a novel skin preparation technique using a device named ULTRAPREP™, a sterile, medical-grade plastic bag that is applied to the upper or lower extremity in the pre-operative holding area which allows for skin disinfection outside the OR (referred to as "disinfection bag"). The study compared preparation times required in the OR and antiseptic efficiency (through Colony Forming Units (CFU) counts) for traditional methods versus using the disinfection bag on a total of 115 patients undergoing podiatric or orthopedic surgeries (upper and lower extremities) in one hospital. The disinfection bag reduced skin preparation time in the OR from 16.8±3.5min to 10.9±2.7min, which was a 35.2% reduction, and was statistically significant (p<0.01). Skin antisepsis met safety standards of <15 CFUs for all cases regardless of preparation type at 48h and 72h. There was no statistical difference in CFU levels between the traditional and disinfection bag methods at 48h or 72h (p>0.11). Therefore, ULTRAPREP™ has shown the ability to decrease operating room time while keeping surgical site infection rates to a minimum. Minimizing activities in the OR optimizes use of this costly resource and brings overall savings to the surgery department.

Nitrogen pollution interacts with heat stress to increase coral bleaching across the seascape.

Climate change is increasing the frequency and magnitude of temperature anomalies that cause coral bleaching, leading to widespread mortality of stony corals that can fundamentally alter reef structure and function. However, bleaching often is spatially variable for a given heat stress event, and drivers of this heterogeneity are not well resolved. While small-scale experiments have shown that excess nitrogen can increase the susceptibility of a coral colony to bleaching, we lack evidence that heterogeneity in nitrogen pollution can shape spatial patterns of coral bleaching across a seascape. Using island-wide surveys of coral bleaching and nitrogen availability within a Bayesian hierarchical modeling framework, we tested the hypothesis that excess nitrogen interacts with temperature anomalies to alter coral bleaching for the two dominant genera of branching corals in Moorea, French Polynesia. For both coral genera, Pocillopora and Acropora, heat stress primarily drove bleaching prevalence (i.e., the proportion of colonies on a reef that bleached). In contrast, the severity of bleaching (i.e., the proportion of an individual colony that bleached) was positively associated with both heat stress and nitrogen availability for both genera. Importantly, nitrogen interacted with heat stress to increase bleaching severity up to twofold when nitrogen was high and heat stress was relatively low. Our finding that excess nitrogen can trigger severe bleaching even under relatively low heat stress implies that mitigating nutrient pollution may enhance the resilience of coral communities in the face of mounting stresses from global climate change.

A Quantitative Method to Measure the Kinetics of Elemental Mercury Emissions From Black Shale (Nova Scotia, Canada).

A controlled chamber method using continuous gold trap atomic fluorescence spectroscopy (AFS) (Tekran 2537X) for the analysis of Hg(0) emissions from moderate mass rock samples was developed and tested. A series of black shale and other bedrock samples from Nova Scotia, Canada, were used to test the method and its reproducibility. Hg(0) emissions at 170°C were measured to quantify both free surficial Hg(0) and Hg(0) that had penetrated the rock structure. High volumes of chamber air (45 L) were sampled using 30 min collection times to achieve detectable elemental mercury (Hg(0)) emissions. We found higher percentage masses of Hg(0) were released (1.1%-4.1% of total Hg mass present) in black shale samples as compared to granite and basalt samples from the same region (0.0%-0.3% released) over 350 h of continuous analysis time. The pseudo first order emission rate constants ranged from 0.015-0.245 h-1 (mean 0.063 h-1, standard deviation (SD) 0.102) for the black shale samples analyzed and was 0.004 h-1 for the granite sample. The 24-h zero-order emission rate constants ranged between 0.41 and 3.54 ng h-1 (mean 1.4 ng h-1, SD 1.3) for the black shale samples analyzed and were ~ 0.01 ng h-1 for the granite and basalt samples. This technique has useful implications for examining rock properties and Hg(0) emission rates.

Sea ice extent and phenology influence breeding of high-Arctic seabirds: 4 decades of monitoring in Nunavut, Canada.

Seabirds breeding in the high Arctic contend with variable annual sea ice conditions, with important consequences depending on a species' unique reproductive and foraging ecology. We assessed the influence of sea ice extent and phenology on seabird breeding biology using monitoring data collected for northern fulmar (Fulmarus glacialis), glaucous gull (Larus hyperboreus), black-legged kittiwake (Rissa tridactyla), and thick-billed murre (Uria lomvia) breeding at Prince Leopold Island, Nunavut, Canada over 4 decades. We expected that years of later sea ice break-up and greater ice cover around the colony would create greater challenges to foraging and could result in delayed nest initiation, decreased colony attendance, and lower nesting success, but with distinct responses from each species. We also tested for time-lagged effects of ice conditions, where sea ice in a given year could impact food availability or juvenile recruitment in later years. Ice conditions around the colony exhibited no significant overall temporal trends or changepoints over the past 50 years (1970-2021), while counts of kittiwakes and murres increased over the study period 1975-2013. No trends were evident in counts of fulmars or gulls or in egg-laying dates or nest success for any species. However, three species (all but glaucous gulls) exhibited unique responses between breeding metrics and sea ice, highlighting how breeding decisions and outcomes may differ among species under the same environmental conditions in a given year. Time-lagged effects were only detected for kittiwake nest counts, where the date of spring ice break-up around the colony was negatively associated with counts at a 5-year lag. Greater distances to open water were associated with lower colony attendance by fulmars and later nest initiation by kittiwakes and murres. Our analyses provide additional insights to effects of sea ice on high-Arctic seabird breeding ecology, which will be useful in predicting and planning for the complex effects of a changing climate and changing human pressures on this high-latitude ecosystem and for the management of high-Arctic marine-protected areas.

Open set classification strategies for long-term environmental field recordings for bird species recognition.

Deep learning is one established tool for carrying out classification tasks on complex, multi-dimensional data. Since audio recordings contain a frequency and temporal component, long-term monitoring of bioacoustics recordings is made more feasible with these computational frameworks. Unfortunately, these neural networks are rarely designed for the task of open set classification in which examples belonging to the training classes must not only be correctly classified but also crucially separated from any spurious or unknown classes. To combat this reliance on closed set classifiers which are singularly inappropriate for monitoring applications in which many non-relevant sounds are likely to be encountered, the performance of several open set classification frameworks is compared on environmental audio datasets recorded and published within this work, containing both biological and anthropogenic sounds. The inference-based open set classification techniques include prediction score thresholding, distance-based thresholding, and OpenMax. Each open set classification technique is evaluated under multi-, single-, and cross-corpus scenarios for two different types of unknown data, configured to highlight common challenges inherent to real-world classification tasks. The performance of each method is highly dependent upon the degree of similarity between the training, testing, and unknown domain.

Using teledermatology to prevent and diagnose skin cancer in the rural United States.

ABSTRACT: In the United States, skin cancer is a prevalent and sometimes preventable form of cancer that causes a significant disease burden in rural and urban communities. Studies have shown, however, that rural residents are less likely to engage in primary prevention behaviors against skin cancer, and rural populations have higher skin cancer incidence and mortality than urban residents. Teledermatology can be used to address disparities in both skin cancer diagnosis and health education to improve dermatology outcomes in rural communities. This article reviews teledermatology formats, barriers, and benefits to encourage integration of teledermatology modalities into clinical practice.

Evidence of vasculature and chondrocyte to osteoblast transdifferentiation in craniofacial synovial joints: Implications for osteoarthritis diagnosis and therapy.

Temporomandibular joint osteoarthritis (TMJ OA) leads to permanent cartilage destruction, jaw dysfunction, and compromises the quality of life. However, the pathological mechanisms governing TMJ OA are poorly understood. Unlike appendicular articular cartilage, the TMJ has two distinct functions as the synovial joint of the craniofacial complex and also as the site for endochondral jaw bone growth. The established dogma of endochondral bone ossification is that hypertrophic chondrocytes undergo apoptosis, while invading vasculature with osteoprogenitors replace cartilage with bone. However, contemporary murine genetic studies support the direct differentiation of chondrocytes into osteoblasts and osteocytes in the TMJ. Here we sought to characterize putative vasculature and cartilage to bone transdifferentiation using healthy and diseased TMJ tissues from miniature pigs and humans. During endochondral ossification, the presence of fully formed vasculature expressing CD31+ endothelial cells and α-SMA+ vascular smooth muscle cells were detected within all cellular zones in growing miniature pigs. Arterial, endothelial, venous, angiogenic, and mural cell markers were significantly upregulated in miniature pig TMJ tissues relative to donor matched knee meniscus fibrocartilage tissue. Upon surgically creating TMJ OA in miniature pigs, we discovered increased vasculature and putative chondrocyte to osteoblast transformation dually marked by COL2 and BSP or RUNX2 within the vascular bundles. Pathological human TMJ tissues also exhibited increased vasculature, while isolated diseased human TMJ cells exhibited marked increased in vasculature markers relative to control 293T cells. Our study provides evidence to suggest that the TMJ in higher order species are in fact vascularized. There have been no reports of cartilage to bone transdifferentiation or vasculature in human-relevant TMJ OA large animal models or in human TMJ tissues and cells. Therefore, these findings may potentially alter the clinical management of TMJ OA by defining new drugs that target angiogenesis or block the cartilage to bone transformation.

Total mercury, methylmercury, phosphate, and sulfate inputs to a bog ecosystem from herring gull (Larus smithsoniansus) guano.

Avian biovector transport is an important mechanism for the movement of contaminants and nutrients to remote locations, usually bird colonies, through excretion, molting and decomposition of carcasses. Methylmercury (MeHg) is a bioaccumulative neurotoxin and endocrine disruptor which is present in many remote ecosystems. We collected guano samples biweekly from a herring gull (Larus smithsoniansus) colony over two summers and analyzed MeHg, total mercury (THg), water-extractable phosphate (PO43-) and sulfate (SO42-). Concentrations of THg in guano declined through the summer months while %MeHg significantly increased (ranging from 12% to 100% of THg), suggesting a switch in diet as gull nutritional needs or food availability changed through the summer. The percentage of PO43- in dry guano increased throughout the summer (ranging from 2.8% to 4.4% of dry weight) and SO42- varied throughout the season (ranging from 0.1% to 0.8% of dry weight). These data indicate that gulls are transporting considerable amounts of MeHg, PO43-, and likely other contaminants to Big Meadow Bog, Nova Scotia.

Classifying the emotional speech content of participants in group meetings using convolutional long short-term memory network.

Emotion is a central component of verbal communication between humans. Due to advances in machine learning and the development of affective computing, automatic emotion recognition is increasingly possible and sought after. To examine the connection between emotional speech and significant group dynamics perceptions, such as leadership and contribution, a new dataset (14 group meetings, 45 participants) is collected for analyzing collaborative group work based on the lunar survival task. To establish a training database, each participant's audio is manually annotated both categorically and along a three-dimensional scale with axes of activation, dominance, and valence and then converted to spectrograms. The performance of several neural network architectures for predicting speech emotion are compared for two tasks: categorical emotion classification and 3D emotion regression using multitask learning. Pretraining each neural network architecture on the well-known IEMOCAP (Interactive Emotional Dyadic Motion Capture) corpus improves the performance on this new group dynamics dataset. For both tasks, the two-dimensional convolutional long short-term memory network achieves the highest overall performance. By regressing the annotated emotions against post-task questionnaire variables for each participant, it is shown that the emotional speech content of a meeting can predict 71% of perceived group leaders and 86% of major contributors.

Rumen fluid metabolomics of beef steers differing in feed efficiency.

INTRODUCTION: Beef is the most consumed red meat in the United States, and the US is the largest producer and consumer of beef cattle globally. Feed is one of the largest input costs for the beef cattle industry, accounting for 40-60% of the total input costs. Identifying methods for improving feed efficiency in beef cattle herds could result in decreased cost to both producers and consumers, as well as increased animal protein available for global consumption. METHODS: In this study, rumen fluid was collected from low- (n = 14) and high-RFI (n = 15) steers. Rumen fluid was filtered through a 0.22 µM syringe filter, extracted using 0.1% formic acid in acetonitrile:water:methanol (2:2:1) and injected into the Dionex UltiMate 3000 UHPLC system with an Exactive Plus Orbitrap MS. Peaks were identified using MAVEN and analyzed using MetaboAnalyst 4.0 and SAS. Significance was determined using an α ≤ 0.05. RESULTS: Eight metabolites were greater in low-RFI steers compared to high-RFI steers, including 3,4-dihydroxyphenylacetate, 4-pyridoxate, citraconate, hypoxanthine, succinate/methylmalonate, thymine, uracil, and xylose (P ≤ 0.05). These metabolites were predominantly involved in amino acid and lipid metabolism. CONCLUSIONS: Rumen fluid metabolomes differ in steers of varying feed efficiencies. These metabolites may be used as biomarkers of feed efficiency, and may provide insight as to factors contributing to differences in feed efficiency that may be exploited to improve feed efficiency in beef cattle herds.

Anti-parasite treatment results in decreased estimated survival with increasing lead (Pb) levels in the common eider Somateria mollissima.

Field experiments where parasites are removed through treatment and contaminant levels in host tissues are recorded can provide insight into the combined effects of parasitism and contaminants in wild populations. In 2013 and 2014, we treated northern common eider ducks (Somateria mollissima) arriving at a breeding colony with either a broad-spectrum antihelminthic (PANACUR®) or distilled water, and measured their blood lead (Pb) levels. Breeding propensity and clutch sizes were inversely related to Pb in both treatment groups. In comparison, a negative effect of Pb on resight probability the following year was observed only in the anti-parasitic treatment (APT) group. These contrasting patterns suggest a long-term benefit to survival of intestinal parasitism in eiders experiencing Pb exposure. The arrival date of hens explained some, but not all, of the effects of Pb. We weigh the merits of different hypotheses in explaining our results, including protective bioaccumulation of Pb by parasites, condition-linked thresholds to costly reproduction and the direct effects of APT on eider health. We conclude that variation in helminth parasitism influences survival in this migratory bird in counterintuitive ways.

Experimental and Computational Studies of Unimolecular 1,1-HX (X = F, Cl) Elimination Reactions of C2D5CHFCl: Role of Carbene:HF and HCl Adducts in the Exit Channel of RCHFCl and RCHCl2 Reactions.

The gas-phase unimolecular reactions of C2D5CHFCl molecules with 94 kcal mol-1 of vibrational energy have been studied by the chemical-activation experimental technique and by electronic-structure computations. Products from the reaction of C2D5CHFCl molecules, formed by the recombination of C2D5 and CHFCl radicals in a room temperature bath gas, were measured by gas chromatography-mass spectrometry. The 2,1-DCl (81%) and 1,1-HCl (17%) elimination reactions are the principal processes, but 2,1-DF and 1,1-HF elimination reactions also are observed. Comparison of experimental rate constants to calculated statistical rate constants provides threshold energies. The potential surfaces associated with C2D5(F)C: + HCl and C2D5(Cl)C: + HF reactions are of special interest because hydrogen-bonded adducts with HCl and HF with dissociation energies of 6.4 and 9.3 kcal mol-1, respectively, are predicted by calculations. The relationship between the geometries and threshold energies of transition states for 1,1-HCl elimination and carbene:HCl adducts is complex, and previous studies of related molecules, such as CD3CHFCl, CD2ClCHFCl, C2D5CHCl2, and halogenated methanes are included in the computational analysis. Extensive calculations for CH3CHFCl as a model for 1,1-HCl reactions illustrate properties of the exit-channel potential energy surface. Since the 1,1-HCl transition state is submerged relative to dissociation of the adduct, inner and outer transition states should be considered for analysis of rate constants describing 1,1-HCl elimination and addition reactions of carbenes to HCl.

Unimolecular HBr and HF Elimination Reactions of Vibrationally Excited C2H5CH2Br and C2D5CHFBr: Identification of the 1,1-HBr Elimination Reaction from C2D5CHFBr and Search for the C2D5(F)C:HBr Adduct.

Chemical activation experiments and computational methods have been used to study the unimolecular reactions of C2H5CH2Br and C2D5CHFBr with 90 and 93 kcal mol-1 of vibrational energy, respectively. The four-centered elimination reactions of HBr and DBr are the dominant reactions; however, 2,1-DF, 1,1-HBr, and 1,1-HF reactions are also observed from C2D5CHFBr. The main focus was to search for the role of the C2D5(F)C:HBr adduct in the 1,1-HBr elimination for comparison with carbene adducts in 1,1-HX(Y) elimination from RCHXY (X,Y = Cl and F) molecules. Models of transition states and molecules from electronic structure calculations were used in statistical calculations of the rate constants to assign threshold energies for each reaction based on the experimental rate constants. The threshold energy for 2,1-HBr elimination from 1-bromopropane is 50 kcal mol-1, which is in basic agreement with thermal activation experiments. Comparison of the 2,1-DBr and 2,1-HBr rate constants permits discussion of the kinetic isotope effects and the effect of F atom substitution on the threshold energy for 2,1-HBr elimination. Although CD3CD═CDF from 1,1-HBr elimination of C2D5CHFBr followed by D atom migration is an experimentally observed product, dissociation of the C2D5(F)C:HBr adduct may be the rate-limiting step rather than crossing the barrier associated with the transition state for 1,1-HBr elimination. The calculated dissociation energies of C2H5(X)C:HF adducts are 9.9, 9.3, and 9.0 kcal mol-1 for X = F, Cl, and Br, and the values for C2H5(F)C:HX are 9.9, 6.4, and ∼4.9 kcal mol-1.

Effects of short-term Rhodiola Rosea (Golden Root Extract) supplementation on anaerobic exercise performance.

The purpose of this study was to examine the effects of short-term Rhodiola Rosea (Golden Root Extract (GRE)) supplementation on repeated Wingate performance. Eleven physically active college aged females were recruited for this study. In a within groups counterbalanced study design, participants were supplemented with either 1,500 mg/day of GRE or placebo (gluten-free cornstarch) for 3 days. Participants also took an additional 500 mg dose of corresponding treatment 30 minutes prior to testing of each trial. During each exercise trial, participants completed 3 × 15-second Wingate Anaerobic Tests (WAnTs) separated by 2-minute active recovery periods. Each exercise trial was separated by a 7 day washout period. Over the 3 × 15-second WAnTs, mean watts (p = 0.017, ES = 0.55), mean anaerobic capacity (p = 0.025, ES = 0.96), mean anaerobic power (p = 0.03, ES = 1.07), mean peak watts (p = 0.029,ES = 0.46), and mean total work (p = 0.017, ES = 0.49) were higher in the GRE treatment trial versus placebo. However, mean fatigue index (p = 0.094, ES = 0.39) was unaffected regardless of treatment. Our results show that GRE supplementation enhanced anaerobic exercise performance as measured through repeated WAnTs. GRE may possess ergogenic benefits and findings hold important implications for boosting anaerobic performance in repeated anaerobic bouts of exercise.

Biventricular support with HeartWare ventricular assist device in a pediatric patient.

Use of ventricular assist devices is increasing in the pediatric population. This has included the extended use of adult continuous-flow devices in the pediatric population. In a minority of cases, biventricular support may be needed. In these situations, biventricular support with continuous-flow devices can be surgically challenging, and therefore, only few cases have been reported. Here, we present a case of implantation of two HeartWare HVAD devices for biventricular support for a decompensating patient with acute myocarditis as well as present an alternative implantation surgical strategy.

Are ingested plastics a vector of PCB contamination in northern fulmars from coastal Newfoundland and Labrador?

While marine animals are exposed to environmental contaminants via their prey, because plastic pollution in the aquatic environment can concentrate some chemicals, ingested plastics are thought to increase the exposure of biota to contaminants. Currently, in the literature there are contradictory results relating to how higher levels of ingested plastics by birds may lead to higher levels of polychlorinated biphenyl (PCBs). To date none of these have incorporated known Toxic Equivalency Factors (TEFs) for non-ortho and mono-ortho congeners of PCB which is critical to assessing the potential effects from PCBs. We examined northern fulmars (Fulmarus glacialis) from the Labrador Sea region Canada, and the ingested plastics from these same birds for comparative PCB concentrations. We found no significant correlations between the PCB concentrations in the birds and the mass or number of retained ingested plastic pieces in the stomach, this held true when PCBs were considered by a number of different ways, including ∑4PCB, ∑PCB, lower-chlorinated, high-chlorinated, non-ortho PCB, and mono-ortho congeners. PCB concentrations were lower in plastics as compared with livers. We found significant differences in congener profiles between the ingested plastics and seabird livers suggesting that while plastics do not contribute to the PCB concentrations, there may be some interactions between plastics and the chemicals that the birds are exposed to via ingested plastics.

Human IL-32 expression protects mice against a hypervirulent strain of Mycobacterium tuberculosis.

Silencing of interleukin-32 (IL-32) in a differentiated human promonocytic cell line impairs killing of Mycobacterium tuberculosis (MTB) but the role of IL-32 in vivo against MTB remains unknown. To study the effects of IL-32 in vivo, a transgenic mouse was generated in which the human IL-32γ gene is expressed using the surfactant protein C promoter (SPC-IL-32γTg). Wild-type and SPC-IL-32γTg mice were infected with a low-dose aerosol of a hypervirulent strain of MTB (W-Beijing HN878). At 30 and 60 d after infection, the transgenic mice had 66% and 85% fewer MTB in the lungs and 49% and 68% fewer MTB in the spleens, respectively; the transgenic mice also exhibited greater survival. Increased numbers of host-protective innate and adaptive immune cells were present in SPC-IL-32γTg mice, including tumor necrosis factor-alpha (TNFα) positive lung macrophages and dendritic cells, and IFN-gamma (IFNγ) and TNFα positive CD4(+) and CD8(+) T cells in the lungs and mediastinal lymph nodes. Alveolar macrophages from transgenic mice infected with MTB ex vivo had reduced bacterial burden and increased colocalization of green fluorescent protein-labeled MTB with lysosomes. Furthermore, mouse macrophages made to express IL-32γ but not the splice variant IL-32ß were better able to limit MTB growth than macrophages capable of producing both. The lungs of patients with tuberculosis showed increased IL-32 expression, particularly in macrophages of granulomas and airway epithelial cells but also B cells and T cells. We conclude that IL-32γ enhances host immunity to MTB.

Plastic and Non-plastic Debris Ingestion in Three Gull Species Feeding in an Urban Landfill Environment.

Plastic debris is recognized as a widespread, common and problematic environmental pollutant. An important consequence of this pollution is the ingestion of plastic debris by wildlife. Assessing the degree to which different species ingest plastics, and the potential effects of these plastics on their health are important research needs for understanding the impacts of plastic pollution. We examined debris (plastic and other types) ingestion in three sympatric overwintering gull species (Herring gulls Larus smithsonianus, Great Black-backed Gulls Larus marinus, and Iceland Gulls Larus glaucoides) to understand how debris ingestion differs among species, age classes and sexes in gulls. We also assessed how plastic burdens were associated with body condition to investigate how gulls may be affected by debris ingestion. There were no differences among the species, age classes or sexes in the incidence of debris ingestion (plastic or otherwise), the mass or number of debris pieces ingested. We found no correlation between ingested plastics burdens and individual condition. Gulls ingested plastic debris, but also showed high levels of other debris types as well, including metal, glass and building materials, including a metal piece of debris found within an abscess in the stomach. Thus, when the health effects of debris ingestion on gulls, and other species that ingest debris, is of interest, either from a physical or chemical perspective, it may be necessary to consider all debris types and not just plastic burdens as is often currently done for seabirds.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State.

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.