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Background Journey mapping involves the creation of visual narrative timelines depicting the multidimensional relationship between a consumer and a service. The use of journey maps in medical research is a novel and innovative approach to understanding patient healthcare encounters. Objectives To determine possible applications of journey mapping in medical research and the clinical setting. Specialist palliative care services were selected as the model to evaluate this paradigm, as there are numerous evidence gaps and inconsistencies in the delivery of care that may be addressed using this tool. Methods A purposive convenience sample of specialist palliative care providers from the Supportive and Palliative Care unit of a major Australian tertiary health service were invited to evaluate journey maps illustrating the final year of life of inpatient palliative care patients. Sixteen maps were purposively selected from a sample of 104 consecutive patients. This study utilised a qualitative mixed-methods approach, incorporating a modified Delphi technique and thematic analysis in an online questionnaire. Results Our thematic and Delphi analyses were congruent, with consensus findings consistent with emerging themes. Journey maps provided a holistic patient-centred perspective of care that characterised healthcare interactions within a longitudinal trajectory. Through these journey maps, participants were able to identify barriers to effective palliative care and opportunities to improve care delivery by observing patterns of patient function and healthcare encounters over multiple settings. Conclusions This unique qualitative study noted many promising applications of the journey mapping suitable for extrapolation outside of the palliative care setting as a review and audit tool, or a mechanism for providing proactive patient-centred care. This is particularly significant as machine learning and big data is increasingly applied to healthcare.

Background Menopause is a natural phenomenon occurring as women approach middle-age. It is characterized by declining of ovarian function and onset of the last menstrual period and subsequent 12-month cessation of menstruation. Due to a growing aging population and longer life expectancies, sub-Saharan African women will spend a significant portion of their lives in postmenopause. Menopausal symptom research has been primarily conducted on Caucasian women from high-income countries. Understanding menopause symptom prevalence and perceptions among diverse women in Ethiopia will better inform reproductive health care. Methods We conducted a multi-stage, cross-sectional study on 226 perimenopausal and postmenopausal women aged 30-49 years in Gulele sub-city of Addis Ababa, Ethiopia. Data on socio-demographic characteristics, menopausal status and an 11-item Menopause Rating Scale (MRS) were collected using interviewer-administered questionnaire. Statistical analyses consisted of descriptive data and chi-squared analyses. Results Study participants were 40.4 ± 5.9 years, on average, with the majority married, educated at secondary school level, and comprised different ethnicities and wealth tertiles. The most prevalent types of menopausal symptoms reported from the MRS were from somatic subscale (65.9%) while psychological (46.0%) and urogenital subscale symptoms (30.5%) were also prevalent. The most commonly reported individual symptoms were: hot flushes (65.9% (95% CI: 59.4%–72.1%)), difficulty falling asleep (49.6% (95% CI: 42.9%-56.3%)), depressive mood (46.0% (95% CI: 39.4%-52.8%)), irritability (45.1% (95% CI: 38.5%-51.9%)), and anxiety (39.8% (95% CI: 33.4%-46.5%)). Each of the somatic, psychological, and urogenital MRS subscale scores were higher among postmenopausal women compared to perimenopausal women. Women self-reported differing severity levels of symptoms with high severity reported in 8.4% of total MRS, 1.3% of somatic, 10.6% of psychological, and 8.4% of urogenital scales. Conclusions Our study provides the first presentation of menopausal symptoms among perimenopausal and postmenopausal women in the Gulele sub-city of Addis Ababa, Ethiopia. We capture the prevalence of menopausal symptoms experienced as well as self-rated severity through the MRS. Our findings reflect menopausal symptoms in our specific study population and have been found to be consistent with previous international research.

Background and objectives: Hypernatremia can be community or hospital-acquired, and there may be specific factors unique to the hospital environment, such as intravenous fluid treatment, which contribute to hypernatremia. The aim of this study was to determine the factors associated with the progression from moderate to severe hospital-acquired hypernatremia among patients admitted under general medicine. Materials and Methods: In this retrospective, single-center cohort study (2012 to 2017), we used ICD-10 coding and medical records to identify adult patients who developed moderate hypernatremia and followed them for progression to severe hypernatremia. We profiled the serum biochemistry and the volume and composition of prescribed intravenous fluids. We applied logistic regression to determine the factors associated with the progression to severe hypernatremia, using the patients with moderate hypernatremia as reference. Results: Of the 180 medical inpatients (median age of 81 years) with moderate hospital-acquired hypernatremia, 9.4% progressed to severe hypernatremia. Normal saline comprised 76% of intravenous fluid volume administered prior to onset of moderate hypernatremia. After the onset, 38% of fluid volume prescribed remained normal saline. The factors independently associated with progression to severe hypernatremia included chronic kidney disease stage (odds ratio 2.38, 95% CI: 1.26–4.50, P = 0.008) and serum creatinine increase (per 10 µmol/L, OR 1.29, 95% CI: 1.07–1.57, P = 0.009). Conclusions: Patients with chronic kidney disease and acute kidney injury may have an increased risk of severe hospital-acquired hypernatremia.

Background and objectives: Linear growth stunting in children is considered a form of chronic malnutrition. However, nutritional interventions have modest effects on height. The World Health Organization (WHO) estimated that 171 million, or 23.8% of the world's children are stunted. Emerging research has implicated environmental exposures leading to poor intestinal health, which reduces nutrient absorption and growth hormone production. The condition is known as environmental enteric dysfunction (EED) and is onset by constant exposure to fecal pathogens with a possible link to mycotoxins created by mold species. A systematic review was conducted on EED and mycotoxins on stunting to understand current knowledge and novel areas for research expansion. Methods: Specific search terms were used to conduct a systematic review in WHO Library and PubMed public databases. Next, duplicates were removed and remaining full-text articles were screened for eligibility. The criteria for article inclusion included: primary research, publication between 2011-2016, translatability to humans, and focus on the main topics of research interest. Results: A total of 302 articles were found after the initial search, 191 articles remained after duplicates, and 23 articles met eligibility criteria. Among the final articles included in the review, 12 focused on EED and 11 on mycotoxins in stunting. EED etiology was confirmed in constant exposure to fecal pathogens in diverse underserved populations. EED interventions used micronutrient supplements, autoimmune treatments, and behavioral trials. None of the interventions significantly alleviated EED or stunting. Among mycotoxin-focused articles, studies found that aflatoxin affected linear growth and mycotoxin prevalence was established in new populations. Mycotoxin interventions tested absorbents for food and replaced contaminated maize in households with both studies showing promising results. Pathways linking mycotoxin exposure to EED was also articulated in recent articles. Conclusions: Primary research conducted in the last five years have yielded modest impacts on stunting resolution but have expanded knowledge. Novel pathways between EED and mycotoxins have been implicated in linear growth and highlight the unmet need for continued etiologic and interventional research. A majority of studies was conducted in low- and middle-income country settings, which highlights the lack of access to adequate sanitation infrastructure and implications on stunting.

This dissertation examines the ways in which four public school teachers in New Mexico demonstrate autonomy in key areas of classroom practice, including discipline, course offerings, assessments, content, and materials. Through a qualitative case study approach, this research explores how teachers describe their autonomy, what factors influence their decision-making, and how autonomy manifests in their instructional practices. The study is framed by Self Determination Theory, which highlights autonomy as a critical component of teacher motivation and professionalism. Findings suggest that while federal and state policies, such as No Child Left Behind (NCLB), Race to the Top (RTT), and the Every Student Succeeds Act (ESSA), have increasingly standardized education and limited teacher discretion, educators continue to exercise autonomy in their instructional methods and classroom management. The study concludes that enhancing teacher autonomy could contribute to improved job satisfaction, professional growth, and student learning outcomes. Recommendations include policy adjustments that balance accountability measures with greater flexibility for teachers to make pedagogical decisions in alignment with their students’ needs.

Child stunting, or linear growth faltering, affects 1 in 5 children under the age of five years. These 151 million stunted children predominantly live in low- and middle-income countries. For decades, clinicians and researchers considered stunting a form of chronic malnutrition but modest gains were made in eliminating stunting through nutritional interventions. This dissertation explored emerging areas in child stunting. Chapters 1 and 2 introduced stunting and provided backgrounds, respectively. The research was guided by the Social Ecological Model and Life Course Perspective in approaching stunting as embedded in macro structures at multiple levels over the life course of women and children. Chapter 3 described theoretical frameworks and an integrated model. The analyses focused on Madagascar and Zambia, which were ranked among countries with the highest proportions of child stunting. We used health data from the Demographic and Health Surveys (DHS) and armed conflict data from the Armed Conflict Location and Event Data Project (ACLED) database in Madagascar and Zambia. Chapter 4 detailed the methodology, including multivariate logistic and linear regression models assessing child stunting and height-for-age z-score (HAZ) outcomes. Chapter 5 examined maternal anthropometry and child gender factors. Results indicated that short stature or underweight in mothers were associated with increased stunting odds while higher maternal height and BMI scores were associated with higher child HAZ. Chapter 6 investigated household water and sanitation measures. We found that households without piped water and finished flooring were associated with increased stunting odds. Stunting was associated with lack of an advanced flush toilet in Zambia but not in Madagascar. Chapter 7 explored proximity of armed conflict events during critical developmental periods with child stunting and height. Conflict exposure during pregnancy was associated with increased stunting odds and lower HAZ in Madagascar but decreased odds and higher HAZ in Zambia. This dissertation framed stunting as occurring over the life course and embedded in multiple external structures. These studies were among the first to examine population-level environmental enteric dysfunction risk factors and apply disaggregated conflict data to stunting. We also contributed stunting context in Madagascar and Zambia, which have been understudied.

Autosomal recessive hypophosphatemic rickets type 2 (ARHR2) and generalized arterial calcification of infancy (GACI) occur secondary to biallelic ectonucleotide pyrophosphate/phosphodiesterase 1 (ENPP1) loss-of-function pathogenic variants. GACI is a life-threatening condition, often presenting in the neonatal period with heart failure and hypertension, caused by calcification of the media in large- and medium-sized arteries. ARHR2 typically manifests later in life. Children with ARHR2 commonly exhibit short stature, rachitic skeletal changes, progressive deformities of the lower limbs, skeletal fragility and bone/muscle pain. We present six cases of homozygous pathogenic variants in the ENPP1 gene causing ARHR2 and/or GACI. Case 1: Presented with lower limb deformities and pain with radiological evidence of rickets. Subsequent investigations displayed aortic and pulmonary arterial calcification. Case 2: Presented with lower limb deformities and knee pain. Confirmatory testing was undertaken following her brother’s (Case 1) diagnosis. Case 3: The diagnosis was made antenatally. Bisphosphonate treatment was instituted in both the pre- and post-natal periods due to the presence of extensive arterial calcifications. Rickets were noted by two years of age. Case 4: Presented with lower limb deformities and pain. There is neither any current evidence of arterial calcification nor hypertension. Case 5: Presented at 3 mo of age in cardiogenic shock with widespread calcification of large and medium-sized arteries. Bisphosphonate treatment was instituted. Case 6: Presented at 2 wk of age with right shoulder discomfort, with evidence of glenohumeral joint calcification. Further imaging revealed aortic, mediastinal, sternoclavicular joint and vertebral spinous process calcification. Case 1 and 2 were also found to have a heterozygous pathogenic ALPL variant consistent with hypophosphatasia. Clinical features, biochemistry, imaging and genetic analyses assist in the diagnosis of ARHR2 and GACI. Conventional therapy, oral phosphate and calcitriol for ARHR2 and bisphosphonates for GACI, have been utilized for many years. ENPP1 replacement treatment remains an exciting prospect for future management of ARHR2 and GACI secondary to loss of function of ENPP1.

[...]repowers have the potential to incorporate more local labor involvement. With proper training and facilities, authorized dealers and school bus operators can potentially perform a repower locally with a repower system (or kit) shipped to them. 4) The Repower Process and Supply Chain Mimic that of Brand-New Electric School Buses Brand new electric school buses are typically built by integrating an electric vehicle drive system with batteries and other high-voltage components into a chassis and then attaching the bus body. Because new and repowered buses use a comparable electric powertrain, both would face supply challenges for batteries, inverters, or electric motors. With this benefit, repowers can further increase the available annual production capacity for electric school buses. 6) More Companies are Offering Commercial Electric School Bus Repowering The electric school bus sector has both established repower companies and new, emerging businesses.

While several studies have investigated maternal exposures as risk factors for oral clefts, few have examined paternal factors. We conducted an international multi-centered case–control study to better understand paternal risk exposures for oral clefts (cases = 392 and controls = 234). Participants were recruited from local hospitals and oral cleft repair surgical missions in Vietnam, the Philippines, Honduras, and Morocco. Questionnaires were administered to fathers and mothers separately to elicit risk factor and family history data. Associations between paternal exposures and risk of clefts were assessed using logistic regression adjusting for potential confounders. A father’s personal/family history of clefts was associated with significantly increased risk (adjusted OR: 4.77; 95% CI: 2.41–9.45). No other significant associations were identified for other suspected risk factors, including education (none/primary school v. university adjusted OR: 1.29; 95% CI: 0.74–2.24), advanced paternal age (5-year adjusted OR: 0.98; 95% CI: 0.84–1.16), or pre-pregnancy tobacco use (adjusted OR: 0.96; 95% CI: 0.67–1.37). Although sample size was limited, significantly decreased risks were observed for fathers with selected occupations. Further research is needed to investigate paternal environmental exposures as cleft risk factors.

How We Analyzed EV Training Programs Our analysis focuses on post-secondary institutions with more than 500 students in Georgia, Michigan, Nevada, North Carolina and Tennessee from the National Center for Education Statistics College Navigator database, and builds on a previous assessment by the National Association of State Energy Officials, the American Association of State Highway and Transportation Officials and Duke University. To better understand the landscape for training opportunities, we looked at colleges and universities, and other technical schools in the states where the most private funds for electric vehicle and battery manufacturing facilities have been invested in the U.S. As of March 2024, data from the Environmental Defense Fund shows private auto manufacturers have committed the highest amount of investments — about $100 billion — in Georgia, Michigan, Nevada, North Carolina and Tennessee. Other examples in Michigan include Lansing Community College’s Advanced Electric Drive/Alternative Fuels certificate program, Kettering University’s Master of Engineering in Electric Vehicles Features and Objectives program and Wayne State University’s Electric-Drive Vehicle Engineering Institutions are also adding a specific class on EVs or alternate fuels to existing automative technology programs. While these programs already provide the knowledge base and occupational training suitable for various industries including the legacy auto industry, they offer more opportunities to introduce EV-specific curriculums as EV adoption increases. 3) Enrollment Requirements and Time Commitments Vary Significantly While many certificate programs do not specify enrollment prerequisites, a high school diploma or equivalent like the completion of a GED is a common prerequisite for associate degree programs in community and technical colleges or four-year institutions.