Martin Luther King, Jr. Community Hospital

Microplastics have been documented in drinking water, but their effects on human health from ingestion, or the concentrations at which those effects begin to manifest, are not established. Here, we report on the outcome of a virtual expert workshop conducted between October 2020 and October 2021 in which a comprehensive review of mammalian hazard studies was conducted. A key objective of this assessment was to evaluate the feasibility and confidence in deriving a human health-based threshold value to inform development of the State of California's monitoring and management strategy for microplastics in drinking water. A tiered approach was adopted to evaluate the quality and reliability of studies identified from a review of the peer-reviewed scientific literature. A total of 41 in vitro and 31 in vivo studies using mammals were identified and subjected to a Tier 1 screening and prioritization exercise, which was based on an evaluation of how each of the studies addressed various quality criteria. Prioritized studies were identified largely based on their application and reporting of dose-response relationships. Given that methods for extrapolating between in vitro and in vivo systems are currently lacking, only oral exposure in vivo studies were identified as fit-for-purpose within the context of this workshop. Twelve mammalian toxicity studies were prioritized and subjected to a Tier 2 qualitative evaluation by external experts. Of the 12 studies, 7 report adverse effects on male and female reproductive systems, while 5 reported effects on various other physiological endpoints. It is notable that the majority of studies (83%) subjected to Tier 2 evaluation report results from exposure to a single polymer type (polystyrene spheres), representing a size range of 0.040 to 20 µm. No single study met all desired quality criteria, but collectively toxicological effects with respect to biomarkers of inflammation and oxidative stress represented a consistent trend. While it was possible to derive a conservative screening level to inform monitoring activities, it was not possible to extrapolate a human-health-based threshold value for microplastics, which is largely due to concerns regarding the relative quality and reliability of current data, but also due to the inability to extrapolate data from studies using monodisperse plastic particles, such as polystyrene spheres to an environmentally relevant exposure of microplastics. Nevertheless, a conservative screening level value was used to estimate a volume of drinking water (1000 L) that could be used to support monitoring activities and improve our overall understanding of exposure in California's drinking water. In order to increase confidence in our ability to derive a human-health-based threshold value in the future, several research recommendations are provided, with an emphasis towards strengthening how toxicity studies should be conducted in the future and an improved understanding of human exposure to microplastics, insights critically important to better inform future risk assessments. Supplementary Information: The online version contains supplementary material available at 10.1186/s43591-022-00030-6.

Questions of resource allocation can pose practical and ethical dilemmas for clinicians. In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. Even using these criteria, it can be difficult to reconcile completing claims to determine which patients should be given priority. To what extent the physician's fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. Although the courts have been reluctant to become involved in allocation decisions in health care, they expect physicians to show allegiance to their patients regardless of budgetary concerns. The allocation of resources on the basis of clinically irrelevant factors such as religion or sexual orientation is prohibited. Clear, fair and publicly acceptable institutional and professional policies can help to ensure that resource allocation decisions are transparent and defensible.

BACKGROUND: In the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States. METHODS: A comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Three randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis. CONCLUSIONS: These guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.).

In this paper we present the results of a full-scale study of a beam scraping system that is designed to guarantee reliable operation of the SSC throughout the whole cycle and for minimum background for experiments at the interaction regions. The machine aperture limits and beam loss formation are analyzed. Simulation programs and a calculational model are described. The physics of beam scraping is explored, and measures to increase significantly the system efficiency are determined. A tolerable scraping rate, taking into account scraper material integrity, quench limits in downstream superconducting magnets, radiation shielding requirements, and minimal beam halo levels at the IPs are also determined. Finally, a complete multi-component scraper system in the SSC East Cluster is proposed. Throughout the paper we define a scraper as a primary absorber consisting of precise movable jaws that have a flat inner edge along the circulation beam and which may be forced to touch the beam halo in horizontal or vertical planes. Secondary absorbers -- collimators -- are destined to intercept outscattered protons and other particles produced in scraper material. All these are surrounded with a radiation shielding. 15 refs., 50 figs., 13 tabs.

INTRODUCTION: Real-world evidence has demonstrated the effectiveness of secukinumab in the treatment of psoriasis; however, limited data are available on patient profiles of US secukinumab initiators over time and clinical outcomes in biologic-naive patients. This study describes clinical characteristics of secukinumab initiators by year, and the clinical outcomes in patients after 6- and/or 12-month follow-up visits, stratified by prior biologic use. METHODS: This observational study included patients enrolled in the CorEvitas (formerly Corrona) Psoriasis Registry. Analyses were conducted in two patient cohorts: (1) all secukinumab initiators, stratified by year, and (2) those who initiated and maintained secukinumab through a 6- and/or 12-month follow-up visit. For all secukinumab initiators, patient characteristics at initiation were described per calendar year; in initiators with follow-up visits, mean (SD) differences in percentage affected body surface area (BSA), five-point Investigator's Global Assessment (IGA), and Psoriasis Area and Severity Index (PASI) scores between baseline and follow-up visits were calculated. Analyses were conducted separately for biologic-naive and biologic-experienced patients. RESULTS: Between 2015 and 2020, the proportion of secukinumab initiators in the registry who were biologic-naive increased each year from 12.5% to 49.7%. Overall, 1518 patients initiated secukinumab at or after enrollment; 980 (64.6%) were biologic experienced, and 538 (35.4%) were biologic naive. At 6 months, biologic-experienced and biologic-naive patients reported mean (SD) decreases in BSA (-9.3 [14.5] versus -11.7 [16.6]), IGA (-1.4 [1.3] versus -1.7 [1.4]), and PASI (-5.2 [6.6] versus -6.7 [7.8]). The proportion of patients with an IGA score of clear/almost clear (0/1) increased over fivefold, irrespective of biologic experience. At 12 months, similar improvements were seen. CONCLUSIONS: The proportion of biologic-naive secukinumab initiators increased over time. Biologic-naive patients demonstrated similar improvements in clinical outcomes compared with biologic-experienced patients, suggesting that secukinumab may be considered as a first-line therapy for psoriasis.

The physician's role in a neighborhood health center is varied and, at times, frustrating. In addition to primary health care, his activities may include teaching, administration, community relations, social advocacy and research. Current training programs do not equip physicians for primary medical care or interdisciplinary team practice, essential aspects of functioning well in health centers.

Health care in the United States is among the most technologically advanced in the world, but it is largely failing to meet the needs of the nation. The US can claim international excellence in important areas of care, such as cancer treatment, and it leads the world in biomedical innovation and building a well-prepared and dedicated clinical workforce. The Affordable Care Act was a major step forward in expanding access to health care in the US. However, Americans are faced with staggering health costs, inadequate access to care, pervasive health inequities, and lagging life expectancy compared with other developed nations. In this article, part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2025 initiative, we present a partial road map for transforming the US health care system. We propose bold national goals: affordable and equitable care for all, an additional decade of healthy birthdays after retirement, elimination of racial and ethnic disparities in health, substantial reduction in health care expenditures, and, most important, improved health outcomes. To achieve these goals, we recommend changes to ensure coverage for all, invest in primary care and social determinants of health, create financing to incentivize population health, and improve transparency and accountability. Major systemic transformation of the US health care system is not just required; it is a moral and economic imperative.

PURPOSE: The purpose of this paper is to describe the partnerships and activities of the Washington State Asian and Pacific Islander Task Force on Hepatitis B Immunization to: 1) increase hepatitis B vaccination of older Asian American and Pacific Islander (AAPI) children and 2) prevent hepatitis B virus (HBV) infection in Washington State. METHODS: Multiple strategies were used to increase hepatitis B vaccination rates among AAPI children, including developing a Task Force consisting of members from public and private organizations. Specific strategies included: 1) developing and distributing culturally specific hepatitis B educational materials, 2) supporting a household cluster survey to assess hepatitis B vaccination coverage rates of AAPI children, 3) conducting hepatitis B immunization and blood testing clinics at local Chinese language schools, and 4) conducting outreach through media sources. PRINCIPAL FINDINGS: Hepatitis B vaccination data from two clinics with large numbers of AAPI clients were evaluated for children aged 0 to 19 years. The results suggest that the average number of hepatitis B vaccinations given per month has been increasing between 1995 through March 2001. Although no causal association between vaccination rates and activities of the Task Force can be made, these data suggest that our efforts may have had a positive impact. CONCLUSIONS: Hepatitis B prevention efforts in a high-risk community can be accomplished in partnership with the AAPI community and organizations working with these communities. Collaborations require persistence, patience, flexibility, and creativity to achieve community and public health goals.

The hispid pocket mouse (Chaetodipus hispidus) occurs throughout the Great Plains, mainly west of the Missouri River. In Nebraska, this species likely occurs throughout the state, but records of occurrence were lacking for east-central and northeastern counties. During a survey in 2008 for the plains pocket mouse (Perognathus flavescens) in eastern Nebraska, we documented C. hispidus in 10 new counties, including a modest range expansion into northeastern Nebraska. Many individuals were captured on moderately compact soils consisting of silt, but some also were captured on sandy and other friable soils. Most individuals were captured in areas containing some exposed ground, but this may reflect our trap placement for P. flavescens. Individuals from northeastern and east-central Nebraska best resembled C. h. spilotus from southeastern Nebraska, with black coloration suffused on the dorsum, head, and dorsal side of the tail; however, our individuals generally lacked the characteristic bright ochraceous coloration along lateral lines and on the dorsum. Limited evidence supports a recent expansion in distribution within the region.

Although geographic variation in health care services is well established, relatively less is known about ambulatory surgical procedures in California. Thus, we sought to describe statewide trends according to geographic and institutional factors. Using the California Office of State Health Planning and Development Ambulatory Surgery and Hospital Utilization datasets, overall and per-capita procedure rates by county and institution were calculated and compared across 2012 to 2014. There was substantial variation in services provided at the county level (Range: 49-382,142 cases/county). Among the 10 largest counties, there was a more than 2-fold difference in case volume per capita; across all counties, a 50-fold variation was observed. Changes in county population size and surgical case volume were correlated only if Los Angeles, the most populous and highest-volume county in the state, was excluded as an outlier. In the first year of California's full Medicaid expansion, Medicaid ambulatory surgery cases increased 29 per cent and self-pay cases decreased 16 per cent. The top 10 facilities by volume experienced substantial volatility in case volume over two years, ranging from -19.6 to +11.5 per cent. Geographic differences in rates of ambulatory surgery may be related to population shifts, but this was not uniformly true. The factors driving this variation and its impact on patient care warrant further investigation.

Precision medicine promises significant health benefits but faces challenges such as complex data management and analytics, interdisciplinary collaboration, and education of researchers, healthcare professionals, and participants. Addressing these needs requires the integration of computational experts, engineers, designers, and healthcare professionals to develop user-friendly systems and shared terminologies. The widespread adoption of large language models (LLMs) such as Generative Pretrained Transformer (GPT) and Claude highlights the importance of making complex data accessible to non-specialists. We evaluated the Stanford Data Ocean (SDO) precision medicine training program’s learning outcomes, AI Tutor performance, and learner satisfaction by assessing self-rated competency on key learning objectives through pre- and post-learning surveys, along with formative and summative assessment completion rates. We also analyzed AI Tutor accuracy and learners’ self-reported satisfaction, and post-program academic and career impacts. Additionally, we demonstrated the capabilities of the AI Data Visualization tool. SDO demonstrates the ability to improve learning outcomes for learners from broad educational and socioeconomic backgrounds with the support of the AI Tutor. The AI Data Visualization tool enables learners to interpret multi-omics and wearable data and replicate research findings. SDO strives to mitigate challenges in precision medicine through a scalable, cloud-based platform that supports data management for various data types, advanced research, and personalized learning. SDO provides AI Tutors and AI-powered data visualization tools to enhance educational and research outcomes and make data analysis accessible to users from broad educational backgrounds. By extending engagement and cutting-edge research capabilities globally, SDO particularly benefits economically disadvantaged and historically marginalized communities, fostering interdisciplinary biomedical research and bridging the gap between education and practical application in the biomedical field. Bahmani, Cha, Alavi, Dixit et al. evaluate an AI-facilitated precision medicine learning platform they built, Stanford Data Ocean. The platform, which provided 3594 costfree certification accesses across 93 countries, demonstrates positive training outcomes across bioinformatics topics for low and middle income learners. Precision medicine is the use of various types of health data specific to an individual to improve disease prevention, diagnosis, or treatment. We used artificial intelligence to build a precision medicine learning platform for clinicians and researchers in training. Students in 93 countries accessed the platform and found it helpful. It could be particularly helpful for training students in low- and middle-income countries.

Advance care planning (ACP) is a discussion between an incurably ill patient, a healthcare professional and if possible, a relative about preferences for end-of-life care, and ACP may improve the communication in this situation. However, in the Danish healthcare system there is no formalized and systematically used standard procedure for discussions with patients about their knowledge of their treatment options, values and preferences. In this article we review the concept of ACP, including definition, experiences from abroad and the status of ACP in Denmark.

What provides the school administrator with a feel ing of achievement? What kind of recognition does he seek? What, in brief, motivates the school admin istrator ? Some answers are suggested below.

AIMS: This study aimed to partner with patients, advocates, and physicians to better understand the barriers that exist for Black and African Americans to enroll in prostate cancer (PCa) clinical trials. PATIENTS & METHODS: Through moderated discussions with patients, advocates, and physicians, we identified potential opportunities to increase the enrollment of underrepresented patients in PCa clinical trials. RESULTS: We identified key barriers to Black and African American enrollment in PCa clinical trials that were shared by all groups but also identified group-specific barriers. We developed recommendations based on key themes that have the potential to increase the enrollment of Black and African Americans in PCa clinical trials. CONCLUSIONS: While racial diversity in PCa clinical trials remains an unsolved problem, there are significant opportunities to better address this unmet need. Through a multi-perspective approach to identify key barriers that limit Black and African American enrollment in PCa clinical trials, we developed recommendations for both sponsors and clinical trial sites to increase diverse patient enrollment in PCa clinical trials, with a focus on employing practical strategies.

Background In-house night call systems for ICUs are frequently implemented to enable hands-on patient care and provide direct supervision of resident physicians at night. Previous studies have highlighted the benefits of an in-house night float (NF) such as minimized time to intervention but failed to consistently demonstrate an improvement in patient outcomes. This study aimed to evaluate the impact of an in-house critical care fellow at night on the resident experience and assess for impact on patient morbidity and mortality. Methods An in-house overnight critical care fellow shift was implemented at West Virginia University Hospital in 2018. Resident physicians rotating overnight in the medical ICU (MICU) for six-month periods before and after the intervention were anonymously surveyed. A retrospective chart review of 300 patients admitted overnight to the MICU was performed. Multiple patient outcomes from the pre (2017) and post (2018) intervention periods were collected and compared using a two-sample t-test. Results In the post-intervention survey, nearly every element of resident experience improved (availability of support, comfort in performing invasive procedures, and input in treatment plans), and far fewer residents felt overwhelmed relative to the pre-intervention survey. The resident experience markedly improved with the addition of an in-house critical care fellow. For the retrospective chart review, both groups had similar severity of illness and there was no change in ICU or hospital length of stay. No difference in mortality was found, though the study was underpowered for this outcome. For secondary measures, there was no difference in mechanical ventilation or use days, though more procedures performed were overnight compared to the former staffing model. Conclusions Implementation of an in-house overnight critical care fellow shift in the MICU positively impacted resident experience without worsening patient outcomes. The intervention did not worsen measures of morbidity or mortality but did lead to an increased number of procedures performed overnight. The model of in-house NF coverage continues to be preferred by clinicians.

e23152 Background: California’s San Joaquin Valley has the worst air quality in the U.S., exacerbated by hazards, such as wildfires. Wildfire smoke is associated with increased risks of lung and other cancers. Outdoor workers, children, older adults, and those with pre-existing health conditions are most at-risk, compounded by inequitable access to healthcare and preventive services, such as lung cancer screening. This qualitative and expert panel methods study aimed to (1) examine impacts of wildfire smoke on at-risk populations, particularly regarding cancer risks, and (2) identify and prioritize solutions to reduce health impacts. The overall objective is to identify modifiable solutions that can be implemented, tested, and advocated for by community members for local policy change. Methods: We collaborated with a Community Advisory Board (CAB) comprised of multi-level interested groups to conduct semi-structured interviews in English and Spanish with 48 community members, outdoor workers, employers, clinicians, payers, and policymakers. Interviews explored health impacts and solutions to poor air quality in the region exacerbated by seasonal wildfire smoke. We used thematic analysis to identify key challenges and solutions. Using RAND Expert Panel Modified Delphi Methods, with our CAB, we rated effectiveness, feasibility, and implementation costs of proposed solutions on a 10-point scale (0 being least effective, feasible, and most costly and 10 being most effective, feasible, and least costly). After initial ratings, the panel refined their ratings through group discussion to achieve consensus. Results: We identified the following themes 1) concerns about impacts on youth; 2) limited awareness of health impacts; and 3) local healthcare shortages and lack of affordable care. Solution themes included: 1) adaptable work schedules for outdoor workers; 2) stricter regulation of pesticide use and industrial emissions; 3) targeted education on air quality risks and 4) expanded access to affordable lung cancer screening. Solutions agreed upon by the expert panel as most effective included: 1) training Community Health Workers to bridge care gaps (mean ± SD, 8.9 ± 1.4); 2) development of comfortable, heat-feasible protective equipment (8.9 ± 1.1); 3) provision of air purifiers (8.7 ± 1.3); 4) utility discounts for households with air filter use (8.7 ± 1.0), and, 5) training for outdoor workers on risks and protective equipment use (8.6 ± 1.0). Conclusions: Community-driven strategies that are identified and agreed upon across multi-level interested groups are urgently needed to address cancer risks posed by poor air quality due to wildfires.

We developed an innovative one-week community clerkship for all fifth-year medical students at Utrecht UMC. Students follow this clerkship in a variety of community care and welfare organizations (eg social community teams or organizations that support psychiatric patients or migrants). Learning goals: students get acquainted with organizations and professionals within the social domain, students experience the social context of healthcare, and they reflect on the meaning of these experiences for their work as a physician. The reflection papers show that students gain insight in social determinants of health. Learning about clients in their everyday live is appreciated by students, as well as getting insight in the social domain. However students find it difficult to relate these experiences with the medical context. Participating social organizations value the clerkship because they feel the need to train future doctors in the social domain.

Organisms of the order Chlamydiales comprise a group of obligate intracellular pathogens of ever-growing importance and number. Over the past six years, comparative analyses of complete chlamydial genome sequences have provided an explosive amount of data that have led to important new hypotheses regarding the molecular origins of Chlamydiales. It was surprising that Chlamydiales had many proteins that were similar to plant proteins targeted to the chloroplast. Protease-like activating factor (CPAF) is unique to Chlamydiales and likely critical to host adaptive immunity. Many of the gene differences identified are clustered into discrete regions including the replication termination region terminus or the plasticity zone (PZ), the two clusters plus PmpD of polymorphic membrane proteins (Pmp), the transmembrane head (TMH)/Inc protein cluster, and the biotin biosynthetic operon. Some of the most interesting data on Inc proteins has come from Chlamydiales genomic comparisons, where 20 open reading frames were identified for the genus Chlamydia. Studying the genetic variability of multiple genes encoded by chlamydial genomes has resulted in insights into the molecular evolution of this organism. Researchers have focused on the comparative genetics of genes with sufficient genetic variation or those with specialized structural or housekeeping functions. From these studies, a number of findings are revealing the mechanisms by which Chlamydiales diverge.

Nutrition has been recognized as a foundation for good oral health and general health, with a bidirectional relationship having been established between nutrition and oral and overall health.1 Various specific macro- and micronutrients from the intake of food serve as fuel for a person's body to grow and function.1 The oral cavity plays the unique role of gatekeeper, providing the pathway of nutrition to the body. Because of the rapid cell turnover of oral mucosa, the oral cavity also may manifest early signs of nutrient deficiencies as well as other indicators of systemic disease.2 As a result, problems in the oral cavity can profoundly affect one's appetite, desire and ability to eat, and, consequently, nutritional status and overall health.1.

Glomus tumors are benign subepithelial mesenchymal neoplasms generally found in the fingers. It is rare to find a glomus tumor in the gastrointestinal tract. This is a case of a gastric glomus tumor (GGT). It is important to understand the difference betwen a glomus tumor and a gastrointestinal stromal tumor (GIST), which is far more common. The patient is a 26 year old Caucasian female who, for the past one year, had been visiting the gastroenterology clinic with complaints of epigastric abdominal pain, constipation, diarrhea, and heartburn. She was a moderately built individual with no abnormal vitals or notable findings on physical examination. We decided to do an EGD, and a mass in the body of the stomach was discovered. CT abdomen revealed a high density nodular lesion. EUS showed a 2.5cm x 2.2cm submucosal mass with mixed echogenicity and cystic spaces, arising from the muscularis propria of the stomach wall. The biopsy was consistent with a neuroendocrine lesion. Neuroendocrine markers were negative. However, smooth muscle actin and vimentin were strongly immunoreactive. Serotonin levels were normal, and octreotide scan revealed a faint glow in the tumor. Surgery was consulted and laparoscopic partial gastrectomy was performed. Pathology of the wedge resection revealed a gastric glomus tumor 1.8cm in diameter with well-defined margins and no evidence of malignancy. Subepithelial tumors of the gastrointestinal tract include carcinoid tumors, lymphomas, glomus tumors, and GIST. GIST, being the most common, are thought to arise from the interstitial cells of Cajal of the autonomic nervous system of the intestine. Glomus tumors arise from the glomus body in the intramuscular layer, typically in the antrum of the stomach. Both appear on CT as well-circumscribed homogenous masses, and on EUS as hypoechoic masses. However, GGT can be distinguished from GIST based on immunohistochemisty. GIST is typically positive for c-kit (CD117), whereas GGT may test positive for smooth muscle actin, laminin, collagen type IV, desmin, and vimentin.2680_A Figure 1. MR Abdomen, showing a 2.2cm homogenously-enhancing subepithelial gastric antral wall mass.2680_B Figure 2. Microscopic examination, showing multiple blood vessels surrounded by round glomus cells.Even though EUS-FNA differentiates GTs from more aggressive gastric tumors with a 95.6% accuracy, surgery is still preferred. According to the National Comprehensive Cancer Network, if the GIST is >2cm it should be surgically resected. Even if there were any doubt between a GT or GIST, wedge resection is the therapeutic management of choice. This rare case taught us how to diagnose and treat a gastrointestinal glomus tumor.