To meet the specific education needs of ethics committee members (primarily full-time healthcare professionals), the Regional Ethics Department of Kaiser Permanente Northern California (KPNCAL) and Washington State University’s Elson Floyd School of Medicine have partnered to create a one-academic year Medical Ethics Certificate Program. The mission-driven nature of the KPNCAL-WSU’s Certificate Program was designed to be a low-cost, high-quality option for busy full-time practitioners who may not otherwise opt to pursue additional education.

This article discusses the specific competency-focused methodologies and pedagogies adopted, as well as how the Certificate Program made permanent changes in response to the global pandemic. This article also discusses in detail one of the Program’s signature features, its Practicum—an extensive simulated clinical ethics consultation placing students in the role of ethics consultant, facilitating a conflict between family members played by paid professional actors. This article concludes with survey data responses from Program alumni gathered as part of a quality study.

The literature on emotion and risk-taking is large and heterogeneous. Whereas some studies have found that positive emotions increase risk-taking and negative emotions increase risk aversion, others have found just the opposite. In this study, we investigated this question in the context of a risky decision-making task with embedded high-resolution sampling of participants’ subjective emotional valence. Across two large-scale experiments (N = 329 and 524), we consistently found evidence for a negative association between self-reported emotional valence and risk-taking behaviors. That is, more negative subjective affect was associated with increased risk-seeking, and more positive subjective affect was associated with increased risk aversion. This effect was evident both when we compared participants with different levels of mean emotional valence as well as when we considered within-participant emotional fluctuations over the course of the task. Prospect-theoretic computational modeling analyses suggested that both between- and within-participant effects were driven by an effect of emotional valence on the curvature of the subjective utility function (i.e., increased risk tolerance in more negative emotional states), as well as by an effect of within-person emotion fluctuations on loss aversion. We interpret findings in terms of a tendency for participants in negative emotional states to choose high-risk, high-reward options in an attempt to improve their emotional state.

The One Health High-Level Expert Panel’s definition of One Health includes optimizing the health of people, animals (wild and domestic) and ecosystems. For many One Health practitioners, wildlife that can spread zoonoses are the focus, particularly if they can come in contact with people. However, ecosystem health is often best-indicated by less-encountered species, for instance, amphibians and reptiles. This review highlights how these taxa can benefit human health and well-being, including cultural significance, as well as their impact on plant, animal and environmental health. We highlight current challenges to the health of these species and the need to include them in the One Health Joint Action Plan. We conclude with a call to action for inclusion of amphibians and reptiles in a One Health approach.

Studies indicate a high burden of mental health disorders among female sex workers (FSWs) in low- and middle-income countries (LMICs). Despite available data on suicidal ideation and suicide attempts among FSWs, little is known about suicide deaths in this hard-to-reach population. This study aims to examine the extent to which suicide is a cause of maternal mortality among FSWs, the contexts in which suicides occur, and the methods used. From January to October 2019, the Community Knowledge Approach method for identifying cause-specific deaths in communities was employed across eight LMICs (Angola, Brazil, the Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa). A total of one thousand two hundred eighty FSWs provided detailed reports on two thousand one hundred twelve FSW deaths in the preceding 5 years, including 288 (13.6%) suicides, 178 (61.8%) of which were maternal. Of these maternal suicides, 57.9% occurred during pregnancy (antepartum), 20.2% within two months of delivery (puerperium), and 21.9% in the 2–12 months following delivery (postpartum). The highest proportion of suicides occurred in Nigeria, Kenya, and DRC in sub-Saharan Africa. A total of 504 children lost their mothers to suicide. Further research is needed to identify interventions for suicide risk among FSW mothers.

This paper examines the population of corporate directors of Britain at the turn of the twentieth century. Over the period 1881-1911 the corporate form became the most common mode of business organisation for large businesses. As their number increased, the population of directors expanded and reflected an increasingly diversified corporate landscape. Based on a large-scale dataset, this paper analyses the characteristics and networks of this wider population of directors. The study goes beyond previous work, which has mainly focused on elite directors or prominent companies, and shows three key findings. First, the population of directors was very connected into a large network, complete isolation from this network was rare. Second, over 1881-1911 director interlocks with banks became less important for most sectors, while interlocks with other financial institutions such as trusts became increasingly important. Insurance companies stood out as the most connected sector spanning smaller local companies and larger international ones. Third, during the period studied there was a shift from director clusters that were mainly based on proximity, to those that were connected through industries.

Arrays of heaving buoy type wave energy converters (WECs) are a promising contender to harness the renewable power of ocean waves on a commercial scale but require strategies to achieve efficient capture of wave energy over broad frequency bands for economic viability. A WEC-array design is proposed for absorption over a target frequency range in the two-dimensional water wave context by spatially grading the resonant properties of WECs via linear spring–damper power take-off mechanisms. The design is based on theories for rainbow reflection and rainbow absorption, which incorporate analyses based on Bloch wave modes and pole–zero pairs in complex frequency space. In contrast to previous applications of these theories, the influence of a higher-order passband and associated pole–zero pairs are shown to influence absorption at the high-frequency end of the target interval. The theories are used to inform initialisations for optimisation algorithms, and an optimised array of only five WECs is shown to give near-perfect absorption ($\geq$99 %) over the target interval. Broadband absorption is demonstrated when surge and pitch motions are released, for irregular sea states, and for incident wave packets in the time domain, where the time-domain responses are decomposed into Bloch modes to connect with the underlying theory.

In an era marked by growing conflicts, prolonged humanitarian needs and less donor funding, collaboration between the humanitarian and peacebuilding sectors is essential for more effective responses. This paper examines the complexities of fostering such collaboration, emphasizing the importance of integrated multisectoral approaches capable of addressing both immediate necessities and long-term peace and development objectives. While recent initiatives such as the humanitarian–development–peace nexus framework and the United Nations Secretary-General's Agenda for Humanity reflect progress toward integrated approaches, substantial collaborative challenges persist. This paper identifies three key entry points for mutual learning between humanitarian and peace actors. Firstly, it discusses a “peace-responsive” approach to humanitarian activities that proactively contributes to “peace-positive” outcomes. Secondly, it emphasizes the need for the peace sector to learn from humanitarian efforts regarding accountability to affected communities. Thirdly, it underscores the need to understand the normative foundations of each sector and their implications for joint action. Drawing on these insights, the paper offers recommendations for policy-makers and practitioners to help them advance joint approaches to humanitarian assistance and peacebuilding in conflict-affected contexts.

Since 2010, the UK government has transformed social security administration using digital technology and automated instruments to create and deliver a single working-age benefit known as Universal Credit (UC). Social policy scholars have given much attention to the key policy tenets of UC but engaged less with leading aspects of automated and digital delivery and their relationship to different forms of administrative burdens for UC recipients. This article addresses this empirical and conceptual gap by drawing on administrative burdens literature to analyse empirical data from forty-four interviews with UC recipients. We conclude by highlighting three costs: temporal, financial, and emotional. These costs illustrate the political dimensions of technical features of UC, as they affect accountability procedures and paths to legal entitlements that have bearings on certain claimants’ rights.

Background: Automated sepsis alerts have become a widely implemented screening tool aimed at early detection of clinically unstable patients. Prior research has shown mixed results depending on the type of screening tools used and the patient population studied. This study aimed to evaluate the predictive value of an alert system created for identifying patients with sepsis to determine utility in clinical practice prior to implementation. Additionally, clinical management of those with and without sepsis was compared to measure potential added benefit of this system in clinical decision making. Methods: A TheraDoc® software sepsis alert was generated for non-ICU patients meeting >2 SIRS criteria within a 24-hour time period (temperature >38°C or 90, respiratory rate >20 or partial pressure CO2 12,000 or 10% bands/immature cells) during March 2023. Alerts were excluded if they were duplicates (using identical criteria or a second alert within 24 hours), triggered by labs collected >48 hours prior, or death or discharge occurred before the time of alert. The primary outcome was positive predictive value (PPV) of sepsis identification, confirmed by ICD-10 codes and diagnostic studies (cultures, imaging). Secondary outcomes included clinical management (antibiotic utilization [AU] and choice, infectious disease [ID] consultations and culture collection). Antibiotics were categorized as broad-spectrum using National Healthcare Safety Network (NSHN) criteria. Secondary outcomes were compared between sepsis and SIRS without infection groups (SIRS) by chi-square analysis. Results: After applying exclusion criteria, 116 of 166 alerts were analyzed; 55 of 116 alerts had confirmed sepsis (PPV 47.4%). Patients with sepsis were more likely to have an ID consult (16% [9/55] vs 7% [4/61]) and cultures collected (70.9% [39/55] vs 39.3% [24/61]) compared to SIRS patients, however these differences were not statistically significant. AU was higher with confirmed infections compared to SIRS patients (94.5% [52/55] vs 32.8% [20/61], p < 0 .05) along with use of broad-spectrum antibiotics (73% [38/52] vs 40% [ 8/20] p < 0 .05). Conclusions: While automated alerts may enable early identification of sepsis, use of SIRS criteria alone has poor specificity, which was borne out by the low PPV in this study. Our study found that management of sepsis patients (as measured by AU and culture ordering) was better than expected and combined with the low PPV of this alert system resulted in our team rejecting widespread adoption of SIRS-based sepsis alerts.

Background: Inequities in healthcare-associated infections (HAI) incidence and prevention measures are critically important to understand (Chen,2021). While evaluations are beginning to characterize these disparities by infection type (Gettler, 2023), our work expands this by characterizing disparities by prevention strategies. By better understanding how evidence-based prevention strategies are implemented at the patient level, infection preventionists and hospital epidemiologists can better design strategies that provide equitable care to all patients. Methods: Beginning January 2023, gender, race, ethnicity, spoken language, and age group fields were added to daily chlorhexidine gluconate (CHG) treatment and C. difficile test order compliance data captured via electronic medical record. In July 2023, fields on recorded race, ethnicity, and gender were added to well-established foley and vascular access real-time peer audit tools that are used by infection preventionists (IPs). Each prevention strategy variable was summarized by demographic variables and differences in compliance were measured using chi-square tests. Results: 899 vascular audits and 420 foley audits were completed by IPs between July – December 2023. In 2023, there were 114,066 opportunities for CHG Treatment and 1,991 C. difficile test orders. Missing data varied by metric but ranged from 0-60%. Statistically significant differences by race were found in 3 of 8 components (i.e., intact seal, secured catheter and absence of dependent loop) in the foley audit (p < 0 .01) and compliance with C. difficile test ordering (p < 0 .01). No differences in race were found in vascular access audits or CHG treatment. No differences in gender or ethnicity were noted in foley, vascular access audits, CHG treatment compliance, or C. difficile testing. Differences in gender and age were found in CHG treatment compliance (p < 0 .001). Conclusions: By focusing more on patient level process measures rather than only presenting stratified outcomes data, we can identify targeted opportunities for improvement in health equity before our patients develop an HAI. Further evaluations should also focus on assessing the clinical relevance of statistical findings to better inform intervention strategies. Separately, efforts are needed to improve completeness and integrity of demographic data in the electronic medical record.

Background: In 2020, the American Society of Health System Pharmacist (ASHP) and Infectious Diseases Society of America (IDSA) published a consensus guideline for vancomycin management, recommending area under the curve (AUC) as the preferred monitoring strategy. These guidelines recommend doses of 15-20 mg/kg every 8 to 12 hours for most patients with normal renal function. However, in extreme body weights, standard dosing may deviate to provide a therapeutic AUC. The primary objective of this pharmacokinetic study is to evaluate the optimal vancomycin weight-based dosing strategy that achieves a therapeutic AUC of 400-600 stratified by body mass index (BMI). The secondary objective is to evaluate the incidence of acute kidney injury (AKI) based on BMI. Methods: Patients were identified from two sites within the Department of Veterans Affairs who received vancomycin for at least 48 hours and had at least one steady-state level from January 2015 through July 2022. Regimens with a frequency of ≤8 hours or patients with baseline creatine clearance of < 5 0 ml/min were excluded. Patients were categorized based on the Center for Disease Control BMI groups: healthy weight, overweight, or obese. The online vancomycin calculator, VancoPK©, was utilized to calculate AUC. Renal function at baseline and during vancomycin therapy was collected. Descriptive statistics were used for data analysis. Continuous outcomes were summarized using mean and standard deviation. The primary and secondary endpoints were analyzed using the analysis of variance and Fisher’s exact tests, respectively. Statistical significance was established at a p-value of < 0 .05. Results: A total of 347 unique vancomycin regimens were included: 120 in the healthy weight group, 101 in the overweight group, and 126 in the obese group. The average total daily doses that achieved a therapeutic AUC were 1971mg (15.6mg/kg/dose), 2298mg (15mg/kg/dose), and 2524mg (12.6mg/kg/dose) for the healthy weight, overweight, and obese groups, respectively. There was a statistically significant difference among these groups. AKI occurred in 10/254 (3.9%) unique patients: 2/89 (2.2%) in the healthy weight group, 3/71 (4.2%) in the overweight group, and 5/94 (5.3%) in the obese group. This did not reach statistical significance. Conclusions: Vancomycin dosing regimens largely followed guideline recommendations. However, the average vancomycin mg/kg/dose that achieved a therapeutic AUC decreased as BMI increased, which was a statistically significant trend. While further research is needed to draw clinically impactful conclusions, these findings suggest that a lower mg/kg vancomycin dose in obesity may be needed to achieve therapeutic targets.

Background: In August 2021, Saint Luke’s Health System (SLHS) transitioned Clostridioides difficile (C. diff.) testing from polymerase chain reaction (PCR)-only to two-step enzyme immunoassay (EIA) reflex following PCR+ for suspected C. diff. infection. Uncertainty in patient management may arise when PCR and EIA testing differ. Previous studies suggested that disease severity varies when a patient’s results demonstrate PCR+ and EIA- due to possible colonization. Clinicians may not treat if diarrhea self-resolves, patients remain stable, or alternate causes of diarrhea exist. We compared clinical outcomes of patients who received treatment to those who did not. Methods: This was a retrospective cross-sectional study from August 2021-August 2023 in a multi-site, integrated health system, comparing 181 inpatients with PCR+/EIA- C. diff. test results stratified by no treatment (0-48 hours of C. diff. targeted treatment), partial treatment (2-9 days), or full treatment (10+ days). The primary outcome was length of stay. Secondary outcomes were readmission rates, need for colectomy, intensive care unit (ICU) admission, and diarrhea resolution on day of discharge. Results: Of the 181 patients, 144 received full treatment, 17 had partial, and 20 had no treatment. Baseline characteristics were similar between groups. No significant difference was found for length of stay or any secondary outcomes (Table 1). Table 2 provides a subgroup of patients who received no treatment vs those receiving partial or full treatment. Conclusion: In this study, treatment exposure did not affect clinical outcomes for patients with PCR+/EIA- results, though sample sizes may limit generalizability. Further research is warranted regarding the clinical approach to PCR+/EIA-

Background: In September 2022, UNC Hospitals was awarded a Regional Emerging Special Pathogens Treatment Center (RESPTC) grant by the U.S. Department of Health and Human Services Administration for Strategic Preparedness and Response (ASPR) to care for up to two patients with viral hemorrhagic fever, or similar pathogen, and up to ten patients with novel respiratory pathogens. Intensive infection prevention efforts and timely multidisciplinary commitment was required to develop the Space, Strategy, Staff, and Stuff needed to care for patients with a special pathogen. Methods: Multiple space needs assessments were undertaken to acquire spaces for the care of patients, simulation training, and a dedicated laboratory. Strategies for developing the response plan required collaboration with hospital executives, nursing leadership, public health leaders, and regional partners. Staff were recruited across various disciplines to join the response team and were provided hands-on skills training which was assessed by post-training surveys. Specialized ‘stuff’ (i.e., PPE, training equipment, and waste management devices) were researched and procured for use by the team. Results: Patient care and dedicated laboratory space was identified within existing infrastructure, and renovation plans were developed to adapt the space for these specialized activities. A waste management plan that benefits the hospital for routine waste and allows for Category A waste management was approved. Fifty-three staff members were recruited from 3 main disciplines (RNs, MDs, Paramedics), and across numerous settings (Medicine Acute Care & ICU, Pediatric ICU & Stepdown, Air Care/Transport, Burn ICU, Surgery Stepdown, Emergency Medicine, Infection Prevention, Infectious Disease) were trained during five 4-hour training sessions, culminating in an exercise involving transporting a rule–out Ebola patient to the hospital’s special pathogens unit. Post-training evaluations demonstrated a very high level of confidence (‘strongly agree’) in staffs’ knowledge about the RESPTC site (92.3%), special pathogens (80.8%), collaboration needed for managing patient care (80.8%), and in their comfort with special PPE donning and doffing (73.1%). Conclusions: Using a systematic approach to develop Space, Strategy, Staff, and Stuff, a large academic hospital readied itself to become a new RESPTC site. Key lessons learned include the importance of a multidisciplinary response team; local, state, and regional coordination for care planning and delivery; and early community partnership development. Logistical infrastructure and waste management challenges continue to require partnership with hospital leadership to optimize workflows and patient care. Holistic decision-making around infrastructure has led to changes that benefit all hospital patients and offer efficiencies to

Disclosure: William Fischer: Consultant - Roche, Merck, Inhalon Biopharma; Speaker for ACGME - IMG. David J Weber: Consultant on vaccines: Pfizer; DSMB chair: GSK; Consultant on disinfection: BD, GAMA, PDI, Germitec