University of Maryland Charles Regional Medical Center

This study was designed to assess the utility and impact on perinatal mortality of a model traditional birth attendant (TBA) training program in rural Mozambique by comparing birth attendance and outcomes in similar communities with and without trained TBAs. Birth attendants and pregnancy outcomes were compared in 1) communities with good access to trained TBAs, 2) randomly selected, comparable communities with no access to trained TBAs, and 3) communities with good access to functioning maternities. Information was collected by interviews with women in randomly selected households. A total of 4,169 women were interviewed who reported on 3,616 completed pregnancies, which resulted in a birth or fetal death. Among women with good access to trained TBAs, 33% reported giving birth attended by a trained TBA, 43% reported giving birth at a health facility, and 24% reported giving birth attended by an untrained person. Among women without access to trained TBAs, 58% reported giving birth at health facilities, and 42% reported attendance by untrained persons. Among women with access to functioning maternity centers, 77% reported giving birth at a health facility and 22% said their birth was attended by an untrained person. There was no significant difference in perinatal or infant mortality among the groups. This study demonstrated a preference for health facility deliveries among rural Mozambican women with good access to trained TBAs. It also failed to demonstrate a reduction in perinatal or infant mortality associated with TBA training. Women said they preferred to deliver in health facilities because conditions were considered better and interventions could be performed if needed. The preference for health facility birth over home birth with a TBA may have been related to difficulties with TBA neighbors and their families or fear of potential witchcraft. Efforts to promote TBA training should be balanced with support for birthing services based in health facilities.

Abstract Despite its basic and translational importance, the neural circuitry supporting the perception of emotional faces remains incompletely understood. Functional imaging studies and chronic lesion studies indicate distinct roles of the amygdala and insula in recognition of fear and disgust in facial expressions, whereas intracranial encephalography studies, which are not encumbered by variations in human anatomy, indicate a somewhat different role of these structures. In this article, we leveraged lesion-mapping techniques in individuals with acute right hemisphere stroke to investigate lesions associated with impaired recognition of prototypic emotional faces before significant neural reorganization can occur during recovery from stroke. Right hemisphere stroke patients were significantly less accurate than controls on a test of emotional facial recognition for both positive and negative emotions. Patients with right amygdala or anterior insula lesions had significantly lower scores than other right hemisphere stroke patients on recognition of angry and happy faces. Lesion volume within several regions, including the right amygdala and anterior insula, each independently contributed to the error rate in recognition of individual emotions. Results provide additional support for a necessary role of the right amygdala and anterior insula within a network of regions underlying recognition of facial expressions, particularly those that have biological importance or motivational relevance and have implications for clinical practice.

Secondary hyperparathyroidism is commonly seen in patients with chronic kidney disease (CKD) due to hypocalcemia, hyperphosphatemia and low vitamin D levels and is associated with high-turnover bone disease. In contrast, some patients with advanced CKD, including those requiring dialysis (end-stage renal disease [ESRD]), develop adynamic bone disease with features of low-turnover bone disease. Low serum parathyroid hormone (PTH) has been used as a biochemical marker of adynamic bone disease. Low PTH levels may not necessarily be due to adynamic bone disease but could be a manifestation of the malnutrition inflammation complex syndrome (MICS). The optimal management of hypoparathyroidism associated with MICS is not well known. Currently, there is insufficient evidence to suggest if there is any role in improving nutritional and inflammatory status among patients with CKD and MICS. Furthermore, it also remains unclear whether these changes will help address low PTH levels seen in these patients. We report three patients with advanced CKD who had very low PTH levels possibly attributed to MICS. In addition, we briefly discuss other characteristics and pathophysiology of MICS.

OBJECTIVE: Continuous fetal heart rate (FHR) monitoring is considered by some as necessary to the expectant management of patients with preterm premature rupture of membranes (PPROM). No data exist to support this premise, and liability may be incurred if such an order cannot be practically carried out. The purpose of our study is to evaluate the performance of prolonged FHR monitoring in terms of the completeness of recorded tracings. METHODS: A retrospective cohort study was performed between 2004 and 2006 in a tertiary care hospital on patients being expectantly managed with PPROM at 24-34 weeks of gestation. Forty-seven singleton gravidas with a physician order of continuous external FHR monitoring were included. Exclusion criteria were evidence of labour, chorioamnionitis or FHR abnormalities that prompted delivery. FHR tracings during the prolonged monitoring period were reviewed. RESULTS: The study cohort was monitored for a duration of 321-2272 min (mean 970 min). In total, 28.3% (95% confidence interval 23.8-33%) of the tracing did not show a legible recording. Gestational age is negatively correlated with the proportion of absent tracing, whereas body mass index is positively correlated. There is no significant difference in the absent signal proportion between the first half of the monitoring period and the second half or between day and night. CONCLUSIONS: In patients with PPROM being expectantly managed, a significant proportion (28.3%) of the FHR tracing was not recorded as ordered. This suggests that 'continuous' prolonged external fetal monitoring may not be practically feasible and alternative monitoring approaches should be considered.

In reaching their conclusion that ‘a live sheep model appears to be a better training tool than a manikin model for all forms of cricothyroidotomy training’, Moran et al. [1] appear to have considerably lowered the bar for the animal model. They have compared the use of live sheep to a rudimentary task trainer, rather than a human cadaver or one of the validated high-fidelity manikins, the latter of which have repeatedly been shown to be superior to the use of animals for teaching this vital skill. A study published in the Journal of the American College of Surgeons compared the use of dogs and human cadavers for cricothyroidotomy training. This study found that participants misplaced 30.2% of cricothyroidotomies, when performing the procedure on live animals, compared with only 3.6% when using human cadavers [2]. Another study compared the use of the Simulab’s Trauma Man® simulator (Simulab, Seattle, WA, USA) with the use of live animals for the American College of Surgeons’ Advanced Trauma Life Support (ATLS) course, which includes cricothyroidotomy training. This study found that the simulator ‘to be superior to the animal model in teaching surgical airways’ [3]. Subsequent studies comparing the Simulab Trauma Man to animal use have found similar results [4]. Even studies examining the efficacy of low fidelity task trainers have found that ‘practice on mannequins leads to reduction in cricothyroidotomy times and improvement in success rates’ [5]. Based in part on the data presented in the Block et al. study cited above, since 2001 the American College of Surgeons has endorsed the Simulab Trauma Man (and now approves additional simulators) as a complete replacement for animal use in ATLS training. Approximately 95% of facilities offering the course in the USA use exclusively non-animal training methods. The pedagogical virtues of the anatomical specificity present in cadavers and the most well-designed simulators, the benefits of repeatability, objective feedback and skills assessment capabilities offered by modern simulators, and the ethical advantages of using non-animal training methods, all weigh heavily in favour of moving away from animal models for difficult airway training once and for all. In light of the above, endorsing the use of animals based on one study, which uses an impoverished manikin model, may be biased and also not scientific. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Introduction Leptospirosis is endemic to Puerto Rico, affecting people through seasonal increases and outbreaks. This report describes the diagnostic approach and clinical characteristics of leptospirosis cases identified through active undifferentiated acute febrile illness (UAFI) surveillance in Puerto Rico. Materials and Methods From 2019-2021, active surveillance was conducted in four emergency departments (ED), with standardized recruitment of patients aged ≥5 years, presenting with fever or a history of fever of unknown origin within the past two weeks. Additional cases were recruited from referrals of patients with positive leptospirosis diagnostic tests routinely ordered by clinicians. All enrolled patients were subject to a standardized diagnostic algorithm using PCR and serology to identify probable and confirmed leptospirosis cases. Patient data was collected from electronic medical records and interviews. Results Leptospirosis was diagnosed in 4% of 406 ED-enrolled UAFI patients, eight confirmed and eight probable cases. Referrals resulted in identification of 12 routinely detected cases (five confirmed and seven probable). Of the 28 cases, 71% were ≤7 days-post-onset, 71% were male, average age was 43 years old, and the most common presentations included lower back pain (82%), headache (75%), fatigue (71%), vomiting (71%), myalgia (71%), and calf pain (64%). Common clinical laboratory findings were elevated AST (78%), hyperglycemia (74%), thrombocytopenia (48%), proteinuria (62%), and hematuria (62%). Classification of four isolates identified L. interrogans serovar Icterohaemorrhagiae/Copenhageni (n=2), L. borgpetersenii serovar Ballum/Guangdong, and L. kirschneri (no serovar match). All but one of the leptospirosis cases met the current Council of State and Territorial Epidemiologists’ definition for clinical compatibility with leptospirosis. Hemorrhagic symptoms and acute kidney injury with jaundice were associated with being a leptospirosis case. Conclusions These findings underscore the role of leptospirosis among febrile illness in Puerto Rico, the need for increased awareness to optimize diagnosis and treatment, and further research to improve prevention and intervention strategies.

Il est bien connu que la Seconde sophistique prend pour modèle le passé de la Grèce. Il semble moins connu qu’elle utilise des monuments et des objets pour réévaluer les modèles du passé et en proposer de nouveaux. Dans la Vie d’Apollonios de Tyane de Philostrate, le narrateur présente une série de monuments et d’objets, grecs et barbares, qui invitent à réinterpréter les figures exemplaires du passé, aussi bien mythologiques qu’historiques. Il apparaît alors que la culture grecque a perdu de son prestige, concurrencée par le passé d’autres cultures, mais qu’elle coexiste avec celles-ci en préservant son identité. D’ailleurs, monuments et objets sont souvent à interpréter comme des symboles de résistance.

This paper aims to point the strategies of manipulation that exist in the delivery apps discourse, which try to seduce motorized two-wheeler delivery drivers with the proposal of autonomy and flexible work, disguised by an unreal ideology of entrepreneurship.The selected corpus of this paper are part of contents reach in the online media and also on the iFood's and Uber's institutional websites, and this analysis is based on the principles proposed by the discursive semiotics of Greimas.This research allowed us to conclude that the companies adopt dynamics such the gamefication to keep workers connected to the app for longer time, and also that they are extensively supervised by apps the whole time they're connected to it.

Introduction: Earlier studies have suggested that disparities in stroke care exist for racial and gender groups. Our objective was to examine compliance with defect free care for these groups in a stroke clinical network. Defect free care gauges compliance with the delivery of selected core metrics reflecting best practices. The stroke clinical network providers and stakeholders have been meeting for over 5 years to share best practices and perform improvement projects. The Stroke Clinical Network consists of nine stroke centers located in rural, suburban and urban geographical regions. Methods: Stroke coordinators at nine stroke centers (8 PSCs and 1 CSC) used the GWTG registry to obtain Defect-Free reports using the filters: male, female, African American and white. Populations included patients with a diagnosis of stroke, ICH and SAH. Data was collected for Jan 2016-December 2019. The proportion of defect free compliance was calculated for these subgroups: African American, white, male and female. Results: There was not a difference in defect free care compliance between African American and white stroke populations (AA defect free 90% 2355/2583; white defect free 89% 4176/4685). The range for defect free compliance for AA was 70-98%. The lowest score of 70% was in an urban hospital. The range for defect free compliance for whites was 82-97%. There was not a difference in defect free care between male and female patients (female defect free 92% 5311/5771; male defect free 90% 4646/5211). The range for defect free compliance for females was 78-98%. The range for defect free compliance for males was 70-98%. For all patients in the stroke clinical network defect free care compliance was 91% (9957/10982). Conclusions: In a geographically diverse Stroke Clinical Network there were no disparities in defect care compliance due to gender or race. Future plans include performing a deep dive of the individual care measures to identify opportunities for improvement. The results indicate having an effective Stroke Clinical Network in which best practices and standardization of care are achieved provides an effective strategy to improve defect-care compliance across a network of hospitals.

Objective To describe the access, effectiveness, survival, and adverse events (AEs) of secukinumab (SEC) in patients with axial spondyloarthritis (axSpA) and axial psoriatic arthritis (axPsA). Methods In a multicenter, observational, retrospective cohort study, patients ≥ 18 years with axSpA or axPsA who had received ≥ 1 dose of SEC were included. The number of days between the request for the drug and the first application was calculated. Effectiveness was defined as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) < 4 at 6 months. Drug survival was analyzed using Kaplan-Meier curves and Cox regression analysis. Results One hundred seventeen patients were included: 72 (61.5%) with axPsA and 45 (38.5%) with axSpA. Those having public health insurance presented a longer delay in receiving SEC (median 90 days [IQR 60-150]) vs those using the social security system ( P = 0.01) and those with private health coverage ( P = 0.009). Effectiveness of SEC after 6 months was achieved in 72/117 patients (61.5%): 44/72 patients with axial PsA (61.5%) and 28/45 patients with axSpA (62.2%; P = 0.91). The median SEC survival was 48 months (95% CI 32-63). The only factor associated with reduced survival was SEC as third-line treatment or higher (hazard ratio 3.43, 95% CI 1.11-11.10; P = 0.04). The incidence of AEs was 7.9 events/100 patients/year (95% CI 5-12). Conclusion The delay in receiving SEC was longer in patients with public health insurance. Patients using SEC as third-line or higher therapy had 3.4 times less survival. AEs were mild and no AEs of interest were observed.

Comment un romancier originaire d’Émèse représente-t-il, à travers deux personnages, l’un égyptien, l’autre éthiopien, le sanctuaire emblématique de l’hellénisme, le « nombril » du monde ? La représentation relève-t-elle de la fiction ou de la réalité ? Est-elle construite sur l’intertextualité ou correspond-elle à une chose vue ? Il est difficile de trancher, d’autant plus que la datation de l’œuvre est incertaine. La description, sous la forme de l’ekphrasis, privilégie les cérémonies religieuses où prend naissance l’amour des protagonistes. Delphes et Apollon jouent un rôle central dans l’intrigue, même si, hors de Grèce, leur renommée et leur primauté sont remises en question, voire ignorées. Commencée dans le sanctuaire delphique, l’histoire d’amour trouve sa consécration en Éthiopie, à Méroé, où Hélios supplante Apollon.

Background Healing success for fifth metatarsal fracture nonunions is challenging and hindered by risk factors for nonunion. Pulsed electromagnetic field stimulation (PEMF) promotes bone healing and can help overcome biological deficiencies in patients at risk. Objective The current study assessed the impact of PEMF treatment to promote successful bone healing in metatarsal nonunion. Methods A multi-center, retrospective study was conducted to evaluate PEMF treatment for fifth metatarsal fracture nonunion. Subjects undergoing treatment and eligible for treatment with PEMF (PhysioStim™ device) were enrolled. Subjects were followed for up to 12 months to determine bone healing status determined by radiographic assessment. Subjects were assessed for healing status and impact of risk factors for nonunion. Results Fifty-six (n=56) subjects were included in the analysis. Subjects were 89.3% female with a mean age of 59.7 years. Of the risk factors studied, 75.0% of subjects had at least 1 risk factor associated with compromised bone healing. PEMF treatment started shortly after the nonunion diagnosis, and the average time from nonunion diagnosis until successful healing was 154.7 days. Approximately 62.5% of subjects showed successful healing of their 5th metatarsal fracture by 4 months; 75.0% of subjects healed by 6 months; 91.1% of subjects healed by 12-months. The number of risk factors (up to 5 total per subject) was associated with longer heal times (p<0.02). Of the risk factors studied, only nicotine use was associated with longer healing times (p<0.03). Conclusion Metatarsal nonunion subjects treated with PEMF achieved favorable time to healing despite having risk factors for compromised healing.

Abstract For the first time in the history of the National Alliance for Caregiving and AARP’s Caregiving in the US survey, the survey sample size was increased radically to oversample caregivers at the state level. The purpose of these oversamples was to obtain the prevalence of caregivers in each state and to provide more detailed information about caregivers and their experiences at the state level. Information shared during this session will include the sample plan and weighting strategy as well as the prevalence of caregivers at the state level. In addition, summary information will be provided about caregivers and their experiences at the state level.

Three Brazilian chalcidoids (Hymenoptera) , egg-parasitoids of Jones, 1908 (Lepidoptera; Attacidae) Iri this paper 4 z8t2 -r/s De Santis, 1982 (Eupelmidae) and a'iï'ií2 and J. i/as rhrtcoiJe new spe cies of Encyrtidae are studied.

Introduction: Atrial fibrillation (Afib) is a well-known and significant risk factor for acute ischemic stroke (AIS). Various factors are considered when determining if AIS patient with Afib should be discharged on anticoagulation (AC). Not all are appropriate for AC due to various potential contraindications. At a large geographically diverse Stroke Clinical Network (SCN), composed of one large academic certified comprehensive stroke center (CSC), and seven primary stroke centers (PSCs), a retrospective analysis was conducted to evaluate if there were differences in prescribing AC amongst varying demographics. Methods: The Get With the Guidelines® database was queried for stroke patients discharged from the SCN between 2023-2024 to evaluate AC prescription practices for patients with known Afib. Patients were excluded if they had a hemorrhagic stroke, died during hospitalization, discharged to hospice, left against medical advice, or did not have a documented history or new finding of Afib. Additional data elements collected included age, sex, race, mRS at discharge, NIHSS at presentation, disposition, and if discharging facility was a PSC or a CSC. Categorical variables were compared using chi-squared tests to examine relationships between demographic and medical variables and AC prescribing at discharge. Results: A total of 671 AIS patients met the inclusion criteria. Mean age was 75.1 (SD ± 12.2), 53% were male (353/671), and 64.1% were white (430/671). Of the 671, a total of 83.7% (562/671) were discharged on AC, 13.6% (91/671) were discharged without AC but with a documented contraindication, and overall only 2.7% (18/671) were discharged without AC and no documented contraindication. There was a relationship between being discharged without AC and no documented reason from the PSC compared to those discharged from the CSC (3.8% vs. 0.4%; p < 0.01). There were no other statistically significant differences in patient demographics between the two groups. Conclusions: In conclusion, this large SCN demonstrated high rates of appropriate anticoagulation prescribing, with 83.7% of stroke patients with Afib discharged on AC for secondary stroke prevention. Areas of opportunity remain for patients being discharged from the primary stroke centers. Future studies should focus on identifying barriers to appropriate AC prescribing and those patients’ candidacy for left atrial appendage closure

Le diagnostic de plus en plus fréquent de kyste rénal implique de savoir identifier et prendre en charge de manière adéquate les lésions ayant un potentiel de malignité. Le but de cet article de revue est de réaliser une mise au point sur les caractéristiques morphologiques, histologiques et thérapeutiques des tumeurs kystiques du rein.Une revue systématique de la littérature sur PubMed et ScienceDirect a été effectuée. Les études prospectives et rétrospectives chez l'adulte, ainsi que les revues de la littérature ont été examinées.La classification de Bosniak, utilisée à travers le monde, permet un langage commun aux radiologues et urologues pour décrire les kystes rénaux selon leur potentiel de malignité. La probabilité de néoplasie est de 0, 15, 50 et 95 % pour les kystes de catégorie I, II, III et IV, respectivement. Il s'agit de carcinome de bas grade le plus souvent. Les kystes IIF (F pour follow-up) sont malins dans 25 % des cas et nécessitent une surveillance par imagerie à 6 mois puis régulièrement pendant 5 ans. Elle peut se faire par TDM, IRM ou échographie de contraste. La biopsie rénale, longtemps non recommandée dans les tumeurs kystiques, pourrait permettre de prévenir 40 % de chirurgies non nécessaires. Les kystes Bosniak I et II symptomatiques peuvent être traités par sclérothérapie ou résection du dôme saillant. Les catégories III et IV doivent bénéficier d'un traitement selon les règles d'exérèse carcinologique.La catégorie IIF constitue la principale difficulté diagnostique et thérapeutique des tumeurs kystiques du rein. La biopsie permet un diagnostic fiable, sans risque carcinologique.The expansion of renal cysts diagnosis in the population entails to learn how to properly identify and treat potentially malignant lesions. The aim of this review article is to discuss anatomical and pathological characteristics as well as treatment of cystic renal tumors.A literature review of Medline publications on renal cysts and cystic tumors was conducted. Prospective and retrospective studies in adults, and previous reviews were analyzed.Bosniak classification of renal cysts is used worldwide among urologists and radiologists to categorize cystic lesions according to their potential malignancy. There is a 0, 15, 50 and 95 % chance of cancerous cells in Bosniak I, II, III, and IV, respectively. The most frequent pathology is renal cell carcinoma, usually low grade and low stage. Category IIF cysts (F for follow-up) have a 25 % chance of malignancy and require surveillance at 6 months and regularly for 5 years. The follow-up can be done with CT imaging, MRI or contrast enhanced ultrasonography. Cyst biopsy, which was not recommended for a long time, could prevent 40 % of unnecessary surgeries for benign lesions. Bosniak category I and II cysts can be treated if symptomatic, by sclerotherapy or laparoscopic deroofing of the cyst. Category III and IV lesions must be treated as malignant tumors with security margins.Diagnosis and treatment of Bosniak category IIF renal cysts remain the primary challenge for physicians in cystic renal tumor management. Biopsies of renal cysts seem reliable, with no risk of malignant cell dissemination.

Objectives: Ultrasound-accelerated thrombolysis (UAT) has become an alternative to catheter-directed thrombolysis (CDT) for the treatment of acute limb ischemia. The purpose of this study was to compare outcomes and hospital costs for these two treatments.

Introduction: Statins are recommended in national guidelines for secondary prevention following acute ischemic stroke (AIS). Studies have reported patients not taking statins after AIS have increased mortality. The purpose of this retrospective quality improvement initiative was to determine if there is a difference in prescription of statin medications at discharge for patients with AIS within a Stroke Clinical Network (SCN), consisting of one comprehensive stroke center (CSC) and eight primary stroke centers (PSC). Methods: The Get with The Guidelines registry was queried for AIS patients admitted to the SCN between 2017-2022 to evaluate discharge practices for statins. Information was collected to include age, gender, race, history of CAD, DM, HTN, and if discharging facility was a PSC or a CSC. Patients were excluded if they died, discharged to hospice, or if a reason for no statin at discharge was documented. A Chi-square and a multivariable regression were performed to examine the relationships between demographic and medical variables and if a statin was prescribed at discharge. Results: A total of 15,606 AIS patients were identified. Mean age was 68 years (SD +/- 14.2), 50% male (7798/15606), and 38.8% Black (6061/15606). Of the 15,606, a total of 13,319 (85.3%) were prescribed a statin at discharge. Compared to patients with the following risk factors, there was a significant difference in the odds of being discharged without a statin for patients who did not have HTN (OR 1.52, 95% CI [1.36-1.69]), DM (OR 1.65, 95% CI [1.48-1.83]) or CAD (OR 1.34, 95% [1.18-1.53]). Patients who are < 70, white, female, and discharged from a PSC are also at higher risk for non-statin use. Conclusions: In a large SCN, those without well-known vascular risk factors, those under the age of 70, white patients and women were at higher risk of not being prescribed statins at discharge. Further studies should be done to address these disparities and to optimize secondary stroke prevention.

Les recherches sur la rception de l'Antiquit (Classical Reception Studies) sont particulirement actives en Grande-Bretagne et, plus largement, dans les pays de langue anglaise. Depuis peu, les diffrents projets de recherche qui se consacrent aux problmatiques de rception ont fait le choix de s'unir dans un rseau. Le Classical Reception Studies Network (http://www2.open.ac.uk/ ClassicalStudies/GreekPlays/crsn/ index.shtml) est un site internet regroupant toutes les annonces de manifestations relatives la rception de l'Antiquit en Grande-Bretagne et au-del, ainsi que des liens vers les diffrents centres de recherche qui s'y consacrent. Parmi eux, deux s'intressent plus prcisment la rception du thtre antique : le Reception of the texts and images of ancient Greece research project , dirig par Lorna Hardwick, travaille sur la rception des textes et images de la Grce ancienne dans le thtre et la posie anglophone de la fin du XX e sicle, et l'APGRD d'Oxford, qui a pour domaine de recherche les mises en scne du thtre antique. C'est de ce dernier que je compte ici parler.

This timely and informative article studies the extent to which leadership development programs are present in hospitals and what factors influence them. Using a national data set for hospitals, the authors use regression analyses to make such determinations and attempt to predict the implications of the relative presence of such programs on hospitals. Over the course of my career, I have witnessed a significant increase in the number and types of leadership development programs in hospitals. I believe that other seasoned hospital executives would agree. As Kim and Thompson point out, such programs can offer healthcare organizations strategic advantages that exhibit themselves in a variety of ways, including (1) aiding in executive and mid-level management recruitment and retention, (2) strategically building high-performing organizations through enhanced leadership, and (3) ensuring that the leadership team is reflective of the community it serves and desires to serve. The study raises some interesting questions about the presence of leadership development in healthcare organizations that merit further consideration. In our nation's rural and critical access hospitals, where effective leadership is essential to keep these important community resources operational, there is less likelihood that leadership development programs exist. This is understandable on one hand, as resources for such programs are often scarce. In more urban areas, it appears that cultural diversity programs are not prevalent to the extent the authors expected, and the unresolved question is why that remains the case. As the growing national trend among hospitals is to become formally associated with larger systems, it is gratifying to hear from the authors that leadership development programs are more prevalent in systems, and especially so in not-for-profit organizations. The authors raise the issue of whether there is a predictive linkage between the presence of leadership development programs and organizational profitability. As a practicing healthcare executive, I would be surprised to learn that there is a direct causal relationship between the two. I believe rather that further research will find that the presence of greater discretionary organizational resources allows for the continued expansion of leadership development programs. The findings of this study certainly add to the available evidence on the offering of leadership development programs in hospitals and raise important questions regarding those hospitals providing such programs and those that do not. Hospital leaders' perceptions concerning such programs' value and the availability of discretionary resources to support them are two important factors that likely drive the decision to offer programs. Due to the expected retirements of many senior executives and mid-level managers in hospitals and health systems in the near future, leadership development will become even more important as our healthcare environment becomes increasingly complex and the pressures on hospitals grow. Going forward, hospital executives' desire to learn more about the attributes and benefits of successful leadership development programs will be instrumental in their decisions regarding these initiatives and should spur additional research into this important topic.