Exploring Programmatic Issues which Affect Continuing Legal Education in Kansas

This mixed methods research study identified common mandatory continuing legal education (MCLE) practices by Kansas providers and evaluated these against established adult and continuing education best practices

Intraseasonal Variations in Tropical Energy Balance: Relevance to Climate Sensitivity?

Intraseasonal variability of deep convection represents a fundamental mode of organization for tropical convection. While most studies of intraseasonal oscillations (ISOs) have focused on the spatial propagation and dynamics of convectively coupled circulations, here we examine the projection of ISOs on the tropically-averaged heat and moisture budget. One unresolved question concerns the degree to which observable variations in the "fast" processes (e.g. convection, radiative / turbulent fluxes) can inform our understanding of feedback mechanisms operable in the context of climate change. Our analysis use daily data from satellite observations, the Modern Era analysis for Research and Applications (MERRA), and other model integrations to address these questions: (i) How are tropospheric temperature variations related to that tropical deep convection and the associated ice cloud fractional amount (ICF), ice water path (IWP), and properties of warmer liquid clouds? (ii) What role does moisture transport play vis-a-vis ocean latent heat flux in enabling the evolution of deep convection to mediate PBL - free atmospheric temperature equilibration? (iii) What affect do convectively generated upper-tropospheric clouds have on the TOA radiation budget? Our methodology is similar to that of Spencer et al., (2007 GRL ) whereby a composite time series of various quantities over 60+ ISO events is built using tropical mean tropospheric temperature signal as a reference to which the variables are related at various lag times (from -30 to +30 days). The area of interest encompasses the global oceans between 20oN/S. The increase of convective precipitation cannot be sustained by evaporation within the domain, implying strong moisture transports into the tropical ocean area. The decrease in net TOA radiation that develops after the peak in deep convective rainfall, is part of the response that constitutes a "discharge" / "recharge" mechanism that facilitates tropical heat balance maintenance on these time scales. However, water vapor and hydrologic scaling relationships for this mode of variability cast doubt on the utility of ISO variations as proxies for climate sensitivity response to external radiatively forced (e.g. greenhouse gas-induced) climate change

Health information technology and digital innovation for national learning health and care systems

Health information technology can support the development of national learning health and care systems, which can be defined as health and care systems that continuously use data-enabled infrastructure to support policy and planning, public health, and personalisation of care. The COVID-19 pandemic has offered an opportunity to assess how well equipped the UK is to leverage health information technology and apply the principles of a national learning health and care system in response to a major public health shock. With the experience acquired during the pandemic, each country within the UK should now re-evaluate their digital health and care strategies. After leaving the EU, UK countries now need to decide to what extent they wish to engage with European efforts to promote interoperability between electronic health records. Major priorities for strengthening health information technology in the UK include achieving the optimal balance between top-down and bottom-up implementation, improving usability and interoperability, developing capacity for handling, processing, and analysing data, addressing privacy and security concerns, and encouraging digital inclusivity. Current and future opportunities include integrating electronic health records across health and care providers, investing in health data science research, generating real-world data, developing artificial intelligence and robotics, and facilitating public–private partnerships. Many ethical challenges and unintended consequences of implementation of health information technology exist. To address these, there is a need to develop regulatory frameworks for the development, management, and procurement of artificial intelligence and health information technology systems, create public–private partnerships, and ethically and safely apply artificial intelligence in the National Health Service

Looking beyond the numbers: Quality assurance procedures in the global network for women\u27s and children\u27s health research maternal newborn health registry

Background: Quality assurance (QA) is a process that should be an integral part of research to protect the rights and safety of study participants and to reduce the likelihood that the results are affected by bias in data collection. Most QA plans include processes related to study preparation and regulatory compliance, data collection, data analysis and publication of study results. However, little detailed information is available on the specific procedures associated with QA processes to ensure high-quality data in multi-site studies.Methods: The Global Network for Women\u27s and Children\u27s Health Maternal Newborn Health Registy (MNHR) is a prospective population-based registry of pregnancies and deliveries that is carried out in 8 international sites. Since its inception, QA procedures have been utilized to ensure the quality of the data. More recently, a training and certification process was developed to ensure that standardized, scientifically accurate clinical definitions are used consistently across sites. Staff complete a web-based training module that reviews the MNHR study protocol, study forms and clinical definitions developed by MNHR investigators and are certified through a multiple choice examination prior to initiating study activities and every six months thereafter. A standardized procedure for supervision and evaluation of field staff is carried out to ensure that research activites are conducted according to the protocol across all the MNHR sites.Conclusions: We developed standardized QA processes for training, certification and supervision of the MNHR, a multisite research registry. It is expected that these activities, together with ongoing QA processes, will help to further optimize data quality for this protocol

Durham County: a community diagnosis including secondary data analysis and qualitative data collection

The following section describes the community diagnosis process of Durham County during the 1999-2000 academic year. The community diagnosis was conducted by the Durham County Community Diagnosis team, six first year master’s students attending the University of North Carolina’s School of Public Health, Health Behavior and Health Education Program, in conjunction with the Durham County Health Department. This document was created to identify issues of interest that are significant for residents of Durham County, North Carolina. The document is divided into two main sections. The first section presents secondary data collected for Durham County. The second section addresses various topics that were discussed during interviews and focus groups with Durham County community members, community leaders, and services providers. During the interview process, many Durham County residents shared their thoughts, beliefs, and experiences to illustrate their most salient issues. A synopsis of the findings from both the secondary data and interviews with Durham County residents and service providers was presented at a community forum on March 4, 2000. The forum was intended as an opportunity for residents and service providers to discuss the progress of efforts to improve the quality of life of Durham County residents, applaud beneficial efforts, and offer suggestions for improvement in current strategies. Community diagnosis is an attempt by health professionals and other outsiders to gain a glimpse of what it is like to live in a particular community. The term community can be used broadly or in a more narrow sense. Community can be defined by the geographical boundaries that link individuals together; by the relational or social bonds that exist between individuals; and through the collective power that brings members together to act towards changing or maintaining the community. A community and its boundaries are self-defined by its inhabitants. Community is defined by multiple facets, including culture, values, and norms. Additionally, understanding the history of a community is instrumental to understanding patterns, norms, and activities in the community. Identification of the informal and formal leaders, their leadership style, and the power structure are also important in understanding how a community functions. Community diagnosis involves learning which health issues are most important to community members. Beyond understanding the relevant health issues, a community diagnosis also explores other factors that enhance and detract from community members’ abilities to achieve a desired quality of life. Many times decisions regarding changes in a community may result from assessments of statistical or quantitative data, such as morbidity and mortality rates, crime rates, high school drop out rates, or pregnancy rates. Statistical data provide an account of what is happening in the community. However, the numbers represented in quantitative data are unlikely to show why a certain behavior is occurring or may not be able to capture circumstances that non-numerical data provide. The purpose of the community diagnosis is to bring together these quantitative sources of data, also called secondary data, regarding community function, and qualitative data describing strengths, needs, and recommendations from service providers, community members, and community leaders. The qualitative aspect of the community diagnosis consists of interviews and focus groups with community members to provide a more personal or ethnographic approach to what is happening in the community. This qualitative or primary data is collected from residents who represent the many different segments of the community who may additionally identify with sub-groups within the community based on religion, educational status, social status, economic status, and geographic location in the community. Primary data examines community members’ thoughts and experiences to activate salient issues. It is important to note the limitations of using the secondary data presented in this document. A large portion of the available secondary data relied on 1990 U.S. census data and survey estimates that were at least five years old. As a result the available statistics may not reflect many changes that have occurred within the county, such as the rapid increase of the Hispanic/Latino population. Additionally, data regarding racial differences is presented dichotomously (“white” vs. “non-white”), and makes analysis of data in regards to the Hispanic/Latino population difficult. Lastly, statistics stratified by county make it difficult to assess more localized needs. Most prominent in the community diagnosis of Durham County is the concept of identity. In general, Durham residents do not identify themselves as county residents. Instead residents primarily identify themselves by their religious communities, local neighborhoods, schools, civic and political organizations, and by workplace. There are a great number of churches that have extensive histories in Durham and act as spiritual as well as social referents for community members. Within Durham County, there were examples of each definition of community. Attempting to address issues on the county level, it became apparent that there is a divide between perceptions of access to resources on a city level and access on a county level. While service providers noted that county services are available to rural residents, rural residents perceived their access to county services as limited. Although Durham County residents organize as several separate units to identify themselves, some common themes did emerge from our discussions. The most prominent theme was crime. Crime and its effects in an urban setting and within multiple segments of the county were brought forth. As a result, organization for larger community level change is being achieved through collaborations between neighborhoods, city officials, and county officials acting as Partners Against Crime (P.A.C.). However, residents noting the decrease in crime rates in the past year still consider crime as a top priority. It was also noted that community members residing in lower-income neighborhoods do not appear to benefit from this recent collaboration. As P.A.C. continues to grow and address crime and other issues of high priority to Durham County residents, hopefully members of lower-income neighborhoods will become more involved in this initiative and receive the benefits described by current P.A.C. members. The economy was often raised discussed during interviews and focus groups. Durham County is experiencing a booming economy, in part due to great many medical resources and technology industries. However, as job opportunities have become more technologically based and less factory and industry based, a substantial number of blue-collar jobs have been eliminated. The job prosperity available in Durham is beyond the reach of many former blue-collar workers and other residents without technical skills. Recommendations from community members imply continued support from community coalitions and suggest more training of technological skills to adult community members and in schools to meet the demands of the technological industry and the needs of Durham County residents. The Hispanic/Latino population has grown substantially and quickly in Durham County as well as the rest of the state. Understandably, there have not been adequate services and staff to address language barriers and special needs of this rapidly growing group. Several non-profit agencies have formed over the last few years to bridge this gap. On a policy level, supplemental or increased resources and staff allocations, and support and action from administrators are needed to bridge the language gap. The unmet language needs of the Latino population are likely to impact interaction between Latinos and non-Latinos in the county. In conclusion, throughout the 1999-2000 academic year, the Durham County Community Diagnosis Team’s glimpse into Durham County revealed a wealth of history, culture, knowledge, and skills. Additionally, Durham County represents several communities with a desire to increase their quality of life. Recommendations include acknowledging the needs of Durham County residents and focusing on the innate assets of Durham County residents in addressing these needs. Additionally, as a county, a multitude of resources and services are available to county residents yet are underutilized due to barriers of awareness and ease of accessibility. Increased efforts to make residents aware of existing community organizations and steps in accessing services will lead to more effective use of existing services and resources.Master of Public Healt

Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings

Recent World Health Organization (WHO) antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The First Look Study, referenced in the WHO recommendation, subsequently shows that the routine use of ultrasound during antenatal care in rural, low-income settings did not improve maternal, fetal or neonatal mortality, nor did it increase women\u27s use of antenatal care or the rate of hospital births. This article reviews the First Look Study, reconsidering the assumptions upon which it was built in light of these results, a supplemental descriptive study of interviews with patients and sonographers that participated in the First Look study intervention, and a review of the literature. Two themes surface from this review. The first is that focused emphasis on building the pregnancy risk screening skills of rural primary health care personnel may not lead to adaptations in referral hospital processes that could benefit the patient accordingly. The second is that agency to improve the quality of patient reception at referral hospitals may need to be manufactured for obstetric ultrasound screening, or remote pregnancy risk screening more generally, to have the desired impact. Stemming from the literature, this article goes on to examine the potential for complementarity between obstetric ultrasound screening and another approach encouraged by the WHO, the maternity waiting home. Each approach may address existing shortcomings in how the other is currently understood. This paper concludes by proposing a path toward developing and testing such a hybrid approach

Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries

BACKGROUND: Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. METHODS: Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers\u27 exam findings were compared to referred women\u27s recall. RESULTS: Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. CONCLUSIONS: Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital

Development and characterization of a Yucatan miniature biomedical pig permanent middle cerebral artery occlusion stroke model

BACKGROUND: Efforts to develop stroke treatments have met with limited success despite an intense need to produce novel treatments. The failed translation of many of these therapies in clinical trials has lead to a close examination of the therapeutic development process. One of the major factors believed to be limiting effective screening of these treatments is the absence of an animal model more predictive of human responses to treatments. The pig may potentially fill this gap with a gyrencephalic brain that is larger in size with a more similar gray-white matter composition to humans than traditional stroke animal models. In this study we develop and characterize a novel pig middle cerebral artery occlusion (MCAO) ischemic stroke model. METHODS: Eleven male pigs underwent MCAO surgery with the first 4 landrace pigs utilized to optimize stroke procedure and 7 additional Yucatan stroked pigs studied over a 90 day period. MRI analysis was done at 24 hrs and 90 days and included T2w, T2w FLAIR, T1w FLAIR and DWI sequences and associated ADC maps. Pigs were sacrificed at 90 days and underwent gross and microscopic histological evaluation. Significance in quantitative changes was determined by two-way analysis of variance and post-hoc Tukey’s Pair-Wise comparisons. RESULTS: MRI analysis of animals that underwent MCAO surgery at 24 hrs had hyperintense regions in T2w and DWI images with corresponding ADC maps having hypointense regions indicating cytotoxic edema consistent with an ischemic stroke. At 90 days, region of interest analysis of T1 FLAIR and ADC maps had an average lesion size of 59.17 cc, a loss of 8% brain matter. Histological examination of pig brains showed atrophy and loss of tissue, consistent with MRI, as well as glial scar formation and macrophage infiltration. CONCLUSIONS: The MCAO procedure led to significant and consistent strokes with high survivability. These results suggest that the pig model is potentially a robust system for the study of stroke pathophysiology and potential diagnostics and therapeutics