Preterm and low birth weight (LBW) infants are at risk for cardiorespiratory instability in the semi-upright car seat position. Other “at-risk” infants include those with critical congenital heart disease (CCHD), though there are no formal recommendations for screening in this population. The objectives of this study were (1) to assess car seat tolerance screening (CSTS) practices in patients with CCHD at our institution and (2) to understand the epidemiology of this population, including incidence and risk factors for CSTS failure. We performed a retrospective medical record review of neonates with CCHD admitted between 2013 and 2020. Descriptive statistics and bivariate analyses were used to characterize CSTS performance and failure risks in this patient population. We identified 211 patients as having CCHD, of whom 171 infants underwent CSTS (81

Introduction: Tetrahydrocannabinol (THC), the major psychoactive marijuana cannabinoid, can be transferred to neonates via maternal breast milk (MBM) feeds, but available literature on the safety of concomitant breastfeeding and THC use is inconsistent. This study aimed to assess neonatal intensive care unit (NICU) policies related to toxicology screening and provision of MBM from THC-positive mothers. We hypothesized variation in policies exists across the nation and may be associated with state legalization status. Methods: Cross-sectional survey of U.S. NICU policies related to: (1) toxicology screening of mother-baby dyads and (2) MBM feeding limitations based on THC screening status. We assessed the impact of THC legalization status on the various MBM limitations. Results: Of 187 NICUs surveyed, 79% performed selective toxicology screening based on risk factors, clinical concerns, or provider discretion. Of those that specifically addressed THC exposure and MBM feeding policies, 60% had at least one limitation to MBM feeds, ranging from preventing any MBM feeding during NICU admission to limiting MBM until mother tested negative for THC. We found no significant association between state legalization status and MBM limitations. NICU and nursery policies differed in 33% of institutions. Conclusions: Substantial variation exists in NICU policies regarding toxicology screening and MBM limitations related to THC. These inconsistent policies are based not on THC legalization status but rather on the location of delivery. More research is needed on the effect of THC exposure on neonates, but we could limit inconsistent care by following current national medical organization guidelines of education and shared decision-making with mothers.

Objective To assess implicit bias by administrating the Modified Finnegan Score (MFS) for quantifying neonatal opioid withdrawal and to evaluate risk of decreased opioid treatment of Black versus White infants. Study Design Study participants were nurses recruited from a large tertiary care center who received three clinical vignettes portraying withdrawing infants and were randomized to receive an accompanying photo of either a Black or White infant. MFS results were compared for identical vignettes based on race of infant photo. Results Out of 275 nurses, 70 completed the survey. In vignette 2, nurses aged ≤35 years scored Black infants lower than White infants (MFS=8.3 ± 2 vs. 9.5 ± 1.2, p =0.012). Nurses with <5 years of experience and ≤10 years of experience also scored Black infants lower for the same vignette (8.2 ± 2.3 vs. 9.6 ± 1.2, p =0.032 and 8.3 ± 2 vs. 9.5 ± 1.2, p =0.0083). Conclusion Implicit bias may contribute to the difference in opioid treatment.

BACKGROUND AND AIM Gender (male or female) designated at birth is referred to as secondary sex ratio (SSR); the WHO quotes SSR for natural conception as 103 -110 males per 100 female births.Assisted reproduction has been reported to impact SSR in relation to blastocyst transfer, IVF insemination, morphology and more recently morphokinetic events.Algorithm scores (1-10), predictive of live birth (LB), were retrospectively analysed from 3009 live births, to determine the impact in relation to SSR. METHODS IVF and ICSI embryos were time-lapse monitored (EmbryoScope, Vitrolife) and transferred at the blastocyst stage after morphokinetic algorithm selection.The established in-house morphokinetic algorithm utilises variables t3,t4,t5,t8,tSB,tB, and trophectoderm grade to give a LB prediction score from 1 to 10. (10 indicating the highest chance of LB). Scores were grouped as A (1-5) and B (6-10) and were analysed from 3009 LB, with gender recorded at birth, from 12 networked fertility clinics (2011-2022). The relationships between score group and insemination method were considered in respect to SSR. RESULTS The overall SSR was 105.0 (95% CI: 104.3-105.0) which is comparable to SSR for natural conception. The proportions of births per score group were group A 11% (n=330) and group B 89% (n=2679). Group B favored males with 107 per 100 female births (95% CI: 106.6-107.4) compared with group A with 88 males (95% CI: 82.6-92.3, p=0.0906). A similar trend was observed for insemination type, with IVF favoring males: SSR 113 (95% CI: 110.1-117.0) vs ICSI SSR 99 (95% CI: 99.7-100.1, p =0.0937) Combining IVF insemination and score group A produced the highest incidence of male births, SSR 116 (95% CI:112.2-120.3) with ICSI and group A with the lowest, SSR 83 (95% CI: 76.1-90.0, p=0.0309). CONCLUSIONS Our data is in line with reported SSR for natural conception. Both IVF and higher algorithm scores were related to increased numbers of male births per 100 females. When these variables were combined, the highest number of male births were achieved per 100 females. This review requires follow-up to confirm the findings due to relatively small number of embryos in the group deemed to have a lower propensity for live birth, by morphokinetic algorithm.

Arctic Indigenous food systems are typified by diverse social interactions that maintain food security. Given the numerous challenges Arctic Indigenous communities face, it is important to understand diversity in these systems and how they are impacted by change. This study adopts a mixed methods approach that combines participatory methods with network analysis to assess the diversity of food-related interactions between different actor types in the mixed food system on St. Paul Island, Alaska. We conducted 36 interviews with local food system actors to identify current food security challenges and food-related interactions in the local food system. We used network analysis to investigate the diversity of interactions in the food system quantitatively. We simulated the effects of two key food security challenges (out-migration and knowledge loss) on food system diversity and explored interventions to increase diversity. Qualitative data from the same interviews were used to embed our results in the lived realities of the St. Paul Island community. Our approach reveals diverse interactions in the local food system, reflecting both subsistence and market-based elements of the St. Paul Island mixed economy. While both challenges threaten the system's diversity, out-migration presents a more immediate risk to food system diversity than knowledge loss. We advocate for targeting a combination of food system interventions at the community level to enhance food system diversity effectively. Our research contributes to understanding the importance of diversity for Arctic Indigenous food security and emphasizes the need to recognize the complex interactions between food system interventions and their implications for Arctic Indigenous communities.

Understanding the drivers of dietary decisions is crucial for encouraging and facilitating environmentally sustainable consumption patterns. Previous work has focused on the utility that consumers place on factors such as price, quality, and ethics when making dietary decisions, or on the effects of personal values and peer influence on consumption of individual products. However, less attention has been paid to the interacting roles of values, perceptions, and social networks in dietary decision-making, and how these relate to mismatches between values and diet choice. Here, we develop an agent-based model of individual consumers making choices between five possible diets: omnivore, flexitarian, pescatarian, vegetarian, or vegan. Each consumer makes decisions based on personal constraints and values, and their perceptions of how well each diet matches with those values. Consumers can also be influenced by each other's perceptions via interaction across three social networks: household members, friends, and acquaintances. We show that consumers primarily make decisions based on cost and taste, even when they value ethics and health, and illustrate three potential causes of the 'attitude-behavior gap' between ethical motivations and diet choice. This highlights the potential for both policy-driven changes to pricing structures, and increased awareness around sustainability and health attributes of different diets, in overcoming constraints and misperceptions to facilitate transitions to sustainable diets.

Racial minorities report lower perceived quality of care received compared to non-Hispanic White Americans, resulting in racial disparities in patient satisfaction. Medical mistrust, defined as a lack of confidence in the medical establishment and the intentions of medical personnel, is more prevalent among racial minority groups and is associated with poorer health outcomes. This study examines the prevalence and racial differences of patient/caregiver medical mistrust and its relationship to patient satisfaction among the pediatric patient population at a large urban academic medical center. A cross-sectional anonymous survey was conducted for caregivers of pediatric families seen at an urban tertiary care facility, including demographic information, the Patient Satisfaction Questionnaire (PSQ), and the Group-Based Medical Mistrust Scale (GBMMS). Linear regressions and mediation analyses were performed, examining race-based medical mistrust and associations with patient satisfaction. Sixty-seven surveys (67

Within research on societal transitions, 'post-normal' scientific approaches such as transdisciplinary research are increasingly prominent. The difficulties of interdisciplinary and transdisciplinary research are well-established, but less attention has been paid to the underlying causes of these difficulties. In this essay, we argue that the political natures of both 'transdisciplinarity' and 'transitions' themselves underlie the more visible research challenges. While recent work has outlined how transitions research, embedded as it is in the sociopolitical milieu, can reproduce or challenge existing regimes, here we discuss more specifically the politics of projects themselves, which necessarily affect how they inform societal transitions. Using literature and examples from our own work, we outline three politically contested areas in projects - stakeholder inclusion, understanding of transitions, and research questions that are considered - and identify two broad orientations that research can follow to address these: incremental or fundamental. The interconnectedness of the political aspects of transdisciplinary transitions research requires explicit attention, we argue, if such work is to effectively address complex and 'wicked' societal challenges.

BACKGROUND AND AIM We have previously shown that full or partial compaction of human embryos is highly predictive of live birth outcomes, where embryos that fully compact with no excluded cells are significantly more likely to produce a live birth than those that exclude some cells from the process (Montgomery et. al., 2018). The mechanism for this is poorly understood, but it may be an indication of oocyte quality and as such, may be related to the age of the oocyte. METHODS In order to investigate whether the occurrence of partial versus complete compaction is related to the age of the oocyte we conducted a retrospective data analysis across 11 clinics using data from 01.08.2019 to 09.11.2022 which included 29,634 embryos that were cultured in time-lapse incubation and also underwent compaction. Of these, a morula grade of either M1(complete compaction) or M2 (partial compaction) was recorded by the embryologist just prior to the first sign of blastulation for 20,003 embryos (67.4%). The incidence of M1 and M2 morula's was analysed in the following age groups: ≤ 35 and ≥ 36 according to the age of the oocyte, as well as the proportion of missing data in each group, using a chi squared test. RESULTS There was no significant difference in the incidence of omitted morula grade between the two age groups with 4268/13058 (32.6%) in the ≤ 35 group and 5363/16576 (32.3%) in the≥ 36 group (p=0.365). There was a significant difference in the number of partial and fully compacted morula's in the two age groups with 4,651/8790 (52.9%) being graded as M1 in the ≤ 35 group, compared to 7, 738/16,384 (45.03%) in the ≥ 35 group (p=0.0013). CONCLUSIONS This large data set suggests that the ability of an embryo to undergo complete compaction is related to the age of the oocyte and therefore potentially to ploidy status, but this is yet to be determined. Further data relating to the duration of the compaction process and the percentage of excluded cells according to age will also be presented in order to gain an overall picture of how oocyte age affects this process.

OBJECTIVES:Routine gastric aspirate (RGA) monitoring is a common yet controversial practice intended for early identification of gastrointestinal pathology in infants receiving gavage feeds. Our objectives were to evaluate the association of ceasing RGA monitoring on the incidence of necrotizing enterocolitis (NEC) as well as nutritional outcomes in a large population of very low birth weight (VLBW) and very preterm neonates.METHODS:Retrospective record review of neonates born ≤32 weeks and/or VLBW from 2 cohorts: (1) during pre-feed RGA monitoring (September 2015 to June 2018) and (2) after cessation of RGA ("non-RGA") monitoring (July 2018 to December 2020). We compared incidence of NEC, time-to-full enteral feeds, central line duration, and duration of parenteral nutrition (PN) in bivariate and multivariable models accounting for changes in feeding protocols over time.RESULTS:We identified 617 subjects, 53% in the RGA monitoring cohort (n = 327) and 47% in non-RGA cohort (n = 290). The non-RGA cohort had feeds initiated earlier ( P < 0.0001), achieved full enteral feeds more rapidly ( P < 0.0001), received a shorter duration of PN ( P = 0.0003), and had shorter central access duration ( P < 0.0001) without increasing NEC risk. In fact, the non-RGA cohort had a lower incidence of NEC ( P = 0.0345) compared to the RGA cohort. Even after adjusting for changes in feeding protocols over time in a multivariable model, the RGA cohort had significantly higher odds of NEC.CONCLUSIONS:Pre-feed RGA monitoring in the absence of concerning clinical exam findings is not indicated for neonates receiving gavage feeds as it does not improve NEC incidence but instead may delay important nutritional outcomes such as feed initiation and central line removal.

Objective To develop predictive models of Ureaplasma spp lower airway tract infection in preterm infants. Methods A dataset was assembled from five cohorts of infants born <33 weeks gestational age (GA) enrolled over 17 years (1999–2016) with culture and/or PCR-confirmed tracheal aspirate Ureaplasma status in the first week of life (n=415). Seventeen demographic, obstetric and neonatal factors were analysed including admission white blood cell (WBC) counts. Best subset regression was used to develop three risk scores for lower airway Ureaplasma infection: (1) including admission laboratory values, (2) excluding admission laboratory values and (3) using only data known prenatally. Results GA and rupture of membranes >72 hours were significant predictors in all 3 models. When all variables including admission laboratory values were included in the regression, WBC count was also predictive in the resulting model. When laboratory values were excluded, delivery route was found to be an additional predictive factor. The area under the curve for the receiver operating characteristic indicated high predictive ability of each model to identify infants with lower airway Ureaplasma infection (range 0.73–0.77). Conclusion We developed predictive models based on clinical and limited laboratory information available in the perinatal period that can distinguish between low risk (<10%) and high risk (>40%) of lower airway Ureaplasma infection. These may be useful in the design of phase III trials of therapeutic interventions to prevent Ureaplasma -mediated lung disease in preterm infants and in clinical management of at-risk infants.

Abstract Study question How does a livebirth (LB) prediction algorithm, built in-house on data from 6228 known outcomes from all ages, perform when categorised by female age? Summary answer The algorithm scored and ranked embryos accurately for clinical outcome (FH) regardless of female age; with proportions of poor prognosis embryos highest in older patients. What is known already Time-lapse incubation enables development of predictive algorithms using key morphokinetic variables to score embryos according to potential for clinical outcomes. Maternal age is associated with embryo quality and implantation. Understanding whether kinetic events are influenced by increasing age may benefit embryo selection and patient information provision. There is little evidence of a correlation between advancing maternal age and morphokinetics, although incidence of abnormal cleavage is linked to aneuploidy and reduced blastulation. Predictive algorithms are generally applied to embryos irrespective of oocyte age but are they effective in selecting the optimum embryo for transfer comparatively across differing maternal age groups? Study design, size, duration A retrospective, comparative analysis of 10034 transferred embryos from 2011 to 2022 in 11 sister fertility clinics. Embryos were cultured for 4 - 6 days in time-lapse incubation before transfer (Embryoscope, Vitrolife). A score was derived using a prospectively validated in-house statistical algorithm, assessing 6 manually annotated morphokinetic variables (t3,t4,t5,t8,tSB,and tB) and trophectoderm grade. Embryos were scored 1 to10 for increasing live birth (LB) potential. Participants/materials, setting, methods All transferred embryos were assessed for age of the patient or donor at treatment, traceable to an algorithm score (1-10) with known implantation, defined by presence of fetal heart (KID-FH). Embryos were assigned to two age groups, < 38 years (n6948) or > = 38 years (n3086) and compared according to the distribution of algorithm scores. Comparative significance of the two groups, against each other and the whole cohort, was assessed for significance using chi-squared. Main results and the role of chance Comparison of the KID-FH per score, for age groups revealed increasing implantation rates and effective ranking per score in each age group, <38 KID-FH scores 1 to10; 9.6%,17.8%, 25.7%, 24.3%, 28.3%, 38.2%, 41.4%, 48.4%, 54.6% and 57.8% and for > = 38 score 1-10; 2.0%, 3.8%, 5.9%, 9.9%, 10.8%, 17.9%, 22.2%, 22.0% 31.6% and 36.8%. KID-FH increased incrementally with increasing score in both maternal age groups, demonstrating that the algorithm is predictive irrespective of maternal age. The percentage incidence of scores were compared, <38 years, score 1 to 10; 3.8%, 4.6%, 4.5%, 5.0%, 6.2%, 7.5%, 9.3%, 12.4%, 16.8%, 29.8% versus > = 38 years 1 to 10; 8.0%, 9.4%, 7.1%, 9.2%, 8.7%, 9.4%,10.5%,11.0%, 11.2%,15.4%. There were significantly higher numbers of embryos with lower scores (p = 0.01) in the > = 38 age group (scores 1-6) than the <38 age group. The younger ages conversely, had significantly greater high scoring embryos 9-10, (p = 0.01), score 7 to 8 were comparable across the age groups. The algorithm score is effective in determining implantation potential irrespective of maternal age. Embryos with poorer implantation potential are present in significantly greater numbers in the older age group and this age group attains significantly fewer high potential embryos when compare to younger patient embryos. Limitations, reasons for caution The data for this analysis was determined from multiple clinics within a fertility group operating under uniform practices. The derived algorithm variables and outcomes may not be transferable to another clinic setting. Follow up is required for known live birth outcomes to confirm comparative prediction to KID-FH per age group. Wider implications of the findings The algorithm score infers embryo competence irrespective of age with differences existing only in the prevalence of low and high scores. This algorithm differentiation promises to inform clinicians and patients regarding their chance of success, when utilised to assess embryos. Morphology alone does not have this breadth or predictive capability Trial registration number N/A

BACKGROUND:Intern preparation courses are often broad in scope; there are few published specialty-specific programs outside of General Surgery and Obstetrics. We designed an internal medicine (IM) residency preparatory course at the University of Maryland School of Medicine, which aimed to prepare graduating medical students for the rigours of IM residency training, mapped to Entrustable Professional Activities (EPAs). METHODS:Fourteen fourth-year medical students who were matriculating into IM residency programs enrolled in a 4-week long residency preparation course. The course was designed to teach skills using case-based learning modules, specialty topic seminars, simulation laboratories, procedure laboratories and clinical practice. Participants were surveyed before and after the course on their perceived knowledge and ability with the skills tested. RESULTS:With the exception of 'giving signout to a colleague', there was a significant difference in the participant's perceived ability for each skill taught within the course (P < 0.03 for each), with mean pre-course scores of 1.4-3.7 (SD = 0.5-1.2) and mean post-course scores of 3.2-4.2 (SD = 0.5-1.3). A second survey on course evaluation and perceived impact, completed 3 months after starting intern year, resulted in all respondents reporting that the information learned during the course had directly affected their care of patients on a daily or weekly basis. The modified Ottawa scale was the primary assessment means for the EPAs, with participants approaching entrustment at the conclusion of the course. CONCLUSIONS:Implementation of an IM-specific residency preparation course is a useful adjunct in the fourth year of medical school.