OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

Gas wells have often intersected mining resources, but unconventional shale well drilling has more recently challenged mines to balance the risk of interaction due to higher pressures and larger quantities of gas. Full extraction mining, such as the longwall method, induces ground movement that may influence the casings if wells are drilled within the mining area. The possibility of a casing shear would lead to the risk of unplanned gas migration into the mine. This has the potential to quickly overcome the ventilation system and reach the explosive range which, if ignited, can have catastrophic consequences on the health and safety of underground workers. The utilization of network software to model mine ventilation is a common practice in the mining industry as a predictive tool for planning and monitoring and can assist with a well breach scenario over a large mining area. This work focuses on a well breach in between two longwall panels after second panel mining with gas entering primarily through the gobs of the adjacent longwall panels. Applying the network software Ventsim, a gob zone and ventilation network were created to better understand the distribution of gas within the mine and the limitations and effectiveness of a ventilation system. The model shows both a transient flow simulation and steady state concentrations throughout the mine ventilation system. Using a standard Pittsburgh coal seam longwall ventilation scheme, we find that the system can dilute a significant inflow of up to 700 cfm of methane. © 2023, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

Team-based care approaches are effective at improving hypertension control and have been used in clinical practice to improve hypertension outcomes. This study implemented and evaluated the Hypertension Management Program (HMP), which was originally developed in a high-resource health setting, in a health system with fewer resources and a patient population disproportionately affected by hypertension. Our objectives were to describe how a health system could adapt HMP to meet their needs and calculate total program costs. HMP uses a team-based, patient-centered approach involving clinical pharmacists who contribute to managing patients who have hypertension and ultimately preventing premature death due to uncontrolled hypertension. HMP has 10 components (e.g., EHR patient registries and outreach lists, no copayment walk-in blood pressure checks). Our project involved implementing the key components of HMP in a federally qualified health center (FQHC) in South Carolina. Adaptations from the key components of HMP were made to fit the participants' settings. A mixed-methods evaluation assessed implementation processes, program costs, and implementation facilitators and barriers. From September 2018 to December 2019, clinical pharmacists conducted 758 hypertension management visits (HMVs) with 316 patients with hypertension. Total program costs for HMP were $325,532 overall and $16,277 per month. Monthly cost per patient was $3.62. The high engagement among clinical pharmacists, along with provider engagements, followed up by the subsequent referral of patients to HMP, facilitated the implementation process. Staff members observed improvements in hypertension control, which increased participation buy-in. Barriers included staff turnover, the perception among some providers that HMP took too much time, as well as perception of HMP as a pharmacy-specific initiative. A team-based, patient-centered approach to hypertension management can be adapted for FQHCs or similar settings that serve patient populations disproportionately affected by hypertension.

The objective of this study was to examine effectiveness of a Hypertension Management Program (HMP) in a Federally Qualified Health Center (FQHC). From September 2018 through December 2019, we implemented HMP in seven clinics of an FQHC in rural South Carolina. A pre/post evaluation design estimated the association of HMP with hypertension control rates and systolic blood pressure using electronic health record data among 3,941 patients. A chi-square test estimated change in mean control rates in pre- and intervention periods. A multilevel multivariable logistic regression model estimated the incremental impact of HMP on odds of hypertension control. Results showed that 53.4% of patients had controlled hypertension pre-intervention (September 2016-September 2018); 57.3% had controlled hypertension at the end of the observed implementation period (September 2018-December 2019) (p < 0.01). Statistically significant increases in hypertension control rates were observed in six of seven clinics (p < 0.05). Odds of controlled hypertension were 1.21 times higher during the intervention period compared to pre-intervention (p < 0.0001). Findings can inform the replication of HMP in FQHCs and similar health care settings, which play a pivotal role in caring for patients with health and socioeconomic disparities.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

Although the United Republic of Tanzania has made remarkable progress in scaling up HIV services, substantial gaps in pediatric coverage remain (Joint United Nations Programme on HIV/AIDS, 2013). Tanzania is among the countries with the world's lowest pediatric antiretroviral therapy coverage (Joint United Nations Programme on HIV/AIDS, 2013), and the Ministry of Health (MOH), Community, Development, Gender, Elderly and Children has prioritized expanding access to HIV testing, care, and treatment for children (United Republic of Tanzania Ministry of Health and Social Welfare, 2012). | | Improving the identification of children living with HIV is a critical first step to expanding treatment coverage. In countries with generalized HIV epidemics, ill children presenting to health facilities have a higher HIV prevalence than the general pediatric population (Cohn, Whitehouse, Tuttle, Lueck, & Tran, 2016; Kankasa et al., 2009; Preidis, 2013; Wagner et al., 2015). Offering routine opt-out HIV testing to at-risk pediatric subpopulations (those presenting to health care with signs of illness or for admission, malnutrition, or tuberculosis treatment) is a high-yield identification strategy (Mutanga et al., 2012). Because these children and their caregivers are actively seeking health services and are easy to reach, they present a unique opportunity to identify those most in need of HIV care and to initiate treatment rapidly.

The first three SARS-CoV-2 phylogenetic lineages classified as variants of concern (VOCs) in the United States (U.S.) from December 15, 2020 to February 28, 2021, Alpha (B.1.1.7), Beta (B.1.351), and Gamma (P.1) lineages, were initially detected internationally. This investigation examined available travel history of coronavirus disease 2019 (COVID-19) cases reported in the U.S. in whom laboratory testing showed one of these initial VOCs. Travel history, demographics, and health outcomes for a convenience sample of persons infected with a SARS-CoV-2 VOC from December 15, 2020 through February 28, 2021 were provided by 35 state and city health departments, and proportion reporting travel was calculated. Of 1,761 confirmed VOC cases analyzed, 1,368 had available data on travel history. Of those with data on travel history, 1,168 (85%) reported no travel preceding laboratory confirmation of SARS-CoV-2 and only 105 (8%) reported international travel during the 30 days preceding a positive SARS-CoV-2 test or symptom onset. International travel was reported by 92/1,304 (7%) of persons infected with the Alpha variant, 7/55 (22%) with Beta, and 5/9 (56%) with Gamma. Of the first three SARS-CoV-2 lineages designated as VOCs in the U.S., international travel was common only among the few Gamma cases. Most persons infected with Alpha and Beta variant reported no travel history, therefore, community transmission of these VOCs was likely common in the U.S. by March 2021. These findings underscore the importance of global surveillance using whole genome sequencing to detect and inform mitigation strategies for emerging SARS-CoV-2 VOCs.

The National Institute for Occupational Safety and Health (NIOSH) has been evaluating longwall mining-induced strata fractures and their impacts on casing stability of Marcellus shale gas wells located in longwall pillars. To understand the extent of overburden fractures after longwall mining, NIOSH researchers drilled a post-mining corehole into the fractured strata above the Pittsburgh coal seam longwall gob. Knowing the extent of the fracture zone height will help gas operators minimize the hazards of drilling into longwall gobs. The core was retrieved from the surface down to the top of the gob void. Various fractures were encountered varying from 35 to 64°, depending on lithologic type and relative closeness to the gob. The longwall panel dimension was 457-m wide and 3657-m long, in which the total fracture zone height was found to be at 141 m and the hydraulic connected fracture zone at 87.7 m above the top of the Pittsburgh seam. In addition to core drilling through the gob, FLAC3D modeling was also used to simulate the formation of fracture zone and the orientations of longwall-induced fractures. This study provides much-needed evidence on the fracture zone of Pittsburgh seam longwall gobs to help gas operators avoid potential hazards associated with drilling through highly fractured zones in longwall gobs. © 2022, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

BACKGROUND: Cardiopulmonary exercise testing has demonstrated clinical utility in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). However, to what extent exercise responses are independent of, or confounded by, aerobic fitness remains unclear. PURPOSE: To characterize and compare exercise responses in ME/CFS and controls with and without matching for aerobic fitness. METHODS: As part of the Multi-site Clinical Assessment of ME/CFS (MCAM) study, 403 participants (n = 214 ME/CFS; n = 189 controls), across six ME/CFS clinics, completed ramped cycle ergometry to volitional exhaustion. Metabolic, heart rate (HR), and ratings of perceived exertion (RPE) were measured. Ventilatory equivalent ([Formula: see text], [Formula: see text]), metrics of ventilatory efficiency, and chronotropic incompetence (CI) were calculated. Exercise variables were compared using Hedges' g effect size with 95% confidence intervals. Differences in cardiopulmonary and perceptual features during exercise were analyzed using linear mixed effects models with repeated measures for relative exercise intensity (20-100% peak [Formula: see text]). Subgroup analyses were conducted for 198 participants (99 ME/CFS; 99 controls) matched for age (5 years) and peak [Formula: see text] (~1 ml/kg/min-1). RESULTS: Ninety percent of tests (n = 194 ME/CFS, n = 169 controls) met standard criteria for peak effort. ME/CFS responses during exercise (20-100% peak [Formula: see text]) were significantly lower for ventilation, breathing frequency, HR, measures of efficiency, and CI and significantly higher for [Formula: see text], [Formula: see text] and RPE (p<0.05adjusted). For the fitness-matched subgroup, differences remained for breathing frequency, [Formula: see text], [Formula: see text], and RPE (p<0.05adjusted), and higher tidal volumes were identified for ME/CFS (p<0.05adjusted). Exercise responses at the gas exchange threshold, peak, and for measures of ventilatory efficiency (e.g., [Formula: see text]) were generally reflective of those seen throughout exercise (i.e., 20-100%). CONCLUSION: Compared to fitness-matched controls, cardiopulmonary responses to exercise in ME/CFS are characterized by inefficient exercise ventilation and augmented perception of effort. These data highlight the importance of distinguishing confounding fitness effects to identify responses that may be more specifically associated with ME/CFS.

Talaromycosis (penicilliosis) is an invasive mycosis that is endemic in tropical and subtropical Asia. Talaromycosis primarily affects individuals with advanced HIV disease and other immunosuppressive conditions, and the disease disproportionally affects people in low-income and middle-income countries, particularly agricultural workers in rural areas during their most economically productive years. Approximately 17 300 talaromycosis cases and 4900 associated deaths occur annually. Talaromycosis is highly associated with the tropical monsoon season, when flooding and cyclones can exacerbate the poverty-inducing potential of the disease. Talaromycosis can present as localised or disseminated disease, the latter causing cutaneous lesions that are disfiguring and stigmatising. Despite up to a third of diagnosed cases resulting in death, talaromycosis has received little attention and investment from regional and global funders, policy makers, researchers, and industry. Diagnostic and treatment modalities remain extremely insufficient, however control of talaromycosis is feasible with known public health strategies. This Viewpoint is a global call for talaromycosis to be recognised as a neglected tropical disease to alleviate its impact on susceptible populations.

INTRODUCTION: Early infant diagnosis (EID) and rapid antiretroviral therapy (ART) initiation are lifesaving interventions for HIV-infected infants. In Cameroon and Zambia, EID coverage for HIV-exposed infants (HEIs) is suboptimal and the time to ART initiation for infants infected with HIV often exceeds national standards despite numerous policy and training initiatives. METHODS: ICAP at Columbia University supported the Cameroon and Zambia Ministries of Health (MOHs) and local partners to implement quality improvement collaboratives (QICs) to improve EID coverage and ART initiation at 17 health facilities (HFs) in Cameroon (March 2016 to June 2017) and 15 HFs in Zambia (March 2017 to June 2018). In each country, MOH led project design and site selection. MOH and ICAP provided quality improvement training and monthly supportive supervision, which enabled HF teams to conduct root cause analyses, design and implement contextually appropriate interventions, conduct rapid tests of change, analyze monthly progress, and convene at quarterly learning sessions to compare performance and share best practices. RESULTS: In Cameroon, EID testing coverage improved from 57% (113/197 HEIs tested) during the 5-month baseline period to 80% (165/207) in the 5-month endline period. In Zambia, EID testing coverage improved from 77% (4,773/6,197) during the 12-month baseline period to 89% (2,144/2,420) during the 3-month endline period. In a comparison of the same baseline and endline periods, the return of positive test results to caregivers improved from 18% (36/196 caregivers notified) to 86% (182/211) in Cameroon and from 44% (94/214) to 79% (44/56) in Zambia. ART initiation improved from 44% (94/214 HIV-infected infants) to 80% (45/56) in Zambia; the numbers of HIV-infected infants in Cameroon were too small to detect meaningful differences. CONCLUSIONS: QICs improved coverage of timely EID and ART initiation in both countries. In addition to building quality improvement capacity and improving outcomes, the QICs resulted in a "change package" of successful initiatives that were disseminated within each country.

Ground falls in longwall gateroad entries remain a concern in modern longwall operations. The gateroads are subject to changing horizontal and vertical ground stress induced by longwall extraction. These stress changes can result in failure of the strata around an entry leading to large deformations of the entry roof, floor, and ribs. The gateroad support systems are required to control the failed strata while maintaining safe access to the longwall face and unimpeded ventilation. This paper presents research that was conducted to better understand the stability issues in gateroad excavations and to develop procedures for evaluating support and layout alternatives for longwall gateroads. Using the results of a field-monitoring program and numerical model analysis of case histories, a conceptual model of gateroad support needs was developed. The conceptual model formed the basis for developing a set of equations that can be used to estimate likely roof sag and support loading for given roof geology and longwall-induced loading conditions. The developed equations were used to compare predicted gateroad stability to field study results, showing satisfactory agreement. The calculation procedures are used to demonstrate their application in assessing support alternatives at a case study mine. It is concluded that the developed analysis procedures provide realistic assessments of likely ground stability and can be used to evaluate alternative gateroad support systems at operating longwall mines. © 2021, This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.

This paper presents the results of a unique study conducted by the National Institute for Occupational Safety and Health (NIOSH) from 2016 to 2019 to evaluate the effects of longwall-induced subsurface deformations on shale gas well casing integrity and underground miner safety and health. At both deep-cover and shallow-cover instrumentation sites, surface subsidence measurements, subsurface in-place inclinometer measurements, and underground pillar pressure measurements were conducted as longwall panels were mined. Comparisons of the deep-cover and shallow-cover test site results with those from a similar study under medium cover reveal an interesting longwall-induced response scenario. Under shallow and medium covers, measured horizontal displacements within the abutment pillar are one order of magnitude higher than those measured under deep cover. On the other hand, measured vertical compressions under deep cover are one order of magnitude higher than those under shallow and medium covers. However, FLAC3D simulations of the casings indicate that, in all three cases, the P-110 production casings remain intact under longwall-induced deformations and compressions, which has serious implications for future mine design in areas where shale gas wells have been drilled ahead of mining.

Longwall gateroad entries are subject to changing horizontal and vertical stress induced by redistribution of loads around the extracted panel. The stress changes can result in significant deformation of the entries that may include roof sag, rib dilation, and floor heave. Mine operators install different types of supports to control the ground response and maintain safe access and ventilation of the longwall face. This paper describes recent research aimed at quantifying the effect of longwall-induced stress changes on ground stability and using the information to assess support alternatives. The research included monitoring of ground and support interaction at several operating longwall mines in the U.S., analysis and calibration of numerical models that adequately represent the bedded rock mass, and observation of the support systems and their response to changes in stress. The models were then used to investigate the impact of geology and stress conditions on ground deformation and support response for various depths of cover and geologic scenarios. The research results were summarized in two regression equations that can be used to estimate the likely roof deformation and height of roof yield due to longwall-induced stress changes. This information is then used to assess the ability of support systems to maintain the stability of the roof. The application of the method is demonstrated with a retrospective analysis of the support performance at an operating longwall mine that experienced a headgate roof fall. The method is shown to produce realistic estimates of gateroad entry stability and support performance, allowing alternative support systems to be assessed during the design and planning stage of longwall operations.

BACKGROUND/SETTING: Only 47% of HIV-positive Sierra Leoneans knew their status in 2017, making expanded HIV testing a priority. National guidelines endorse provider-initiated HIV testing and counselling (PITC) to increase testing coverage, but PITC is rarely provided in Sierra Leone. In response, a Quality Improvement Collaborative (QIC) was implemented to improve PITC coverage amongst adult inpatients. METHODS: Ten hospitals received the intervention between October 2017 and August 2018; there were no control facilites. Each hospital aimed to improve PITC coverage to ≥ 95% of eligible patients. Staff received training on PITC and QIC methods and a package of PITC best practices and tools. They then worked to identify additional contextually-appropriate interventions, conducted rapid tests of change, and tracked performance using shared indicators and time-series data. Supportive supervision bolstered QI skills, and quarterly meetings enabled diffusion of innovations while spurring friendly competition. RESULTS: Baseline PITC coverage was 4%. The hospital teams tested diverse interventions using QI methods, including staff training; data review meetings; enhanced workflow processes and supervision; and patient education and sensitization activities Nine hospitals reached and sustained the 95% target, and all saw rapid and durable improvement, which was sustained for a median of six months. Of the 5,238 patients tested for HIV, 311 (6%) were found to be HIV-positive and were referred for treatment. HIV rapid test kit stockouts occurred during the project period, limiting PITC services in some cases. CONCLUSIONS: The intervention led to swift and sustained improvement in inpatient PITC coverage and to the diagnosis of hundreds of people living with HIV. Sierra Leone's Ministry of Health and Sanitation plans to take the initiative to national scale, with close attention to the issue of test kit stockouts.

BACKGROUND: Geenius HIV 1/2 Supplemental Assay (Geenius; Bio-Rad Laboratories) is the only Food and Drug Administration-approved HIV-1/HIV-2 antibody differentiation test for the second step in the HIV laboratory testing algorithm. We characterized the occurrence of true HIV-1 and HIV-2 infections as well as false results in 6 US clinical laboratories using Geenius. METHODS: We examined routine HIV testing outcome data from the time the laboratories began using the algorithm with Geenius until September 30, 2017. We calculated the positive predictive value for Geenius HIV-1 and HIV-2 reactivity separately. RESULTS: Of 5,046,684 specimens tested, 41,791 had reactive antigen/antibody test results. Most specimens with reactive antigen/antibody results were HIV-1 antibody-positive established infections (n = 32,421), 1,865 of which also had indeterminate HIV-2 bands present. Ninety-three specimens were HIV-2 antibody positive or untypable for HIV-1/HIV-2 antibody. Acute HIV-1 infections were found in 528 specimens; 881 specimens lacked the nucleic acid test to determine the possibility of acute HIV-1 infection. False-positive antigen/antibody test results were present in 7505 specimens. Few specimens (n = 363) had false-positive antigen/antibody results with indeterminate Geenius and negative HIV-1 nucleic acid test results. The positive predictive values of Geenius reactivity were 99.4% for HIV-1 and 4.3% for HIV-2. CONCLUSIONS: Routine testing using the laboratory testing algorithm with Geenius resulted in most specimens resolving as HIV negative or HIV-1 positive. The occurrence of indeterminate HIV-2 bands with a Geenius final assay interpretation of HIV-1 positive was more common than true HIV-2 infections. Reporting indeterminate HIV-2 results in this situation may cause confusion with interpreting HIV infection status.

QUALITY CHALLENGE: The Sierra Leone (SL) Ministry of Health and Sanitation's National Infection Prevention and Control Unit (NIPCU) launched National Infection and Prevention Control (IPC) Policy and Guidelines in 2015, but a 2017 assessment found suboptimal compliance with standards on environmental cleanliness (EC), waste disposal (WD) and personal protective equipment (PPE) use. METHODS: ICAP at Columbia University (ICAP), NIPCU and the Centers for Disease Control and Prevention (CDC) designed and implemented a Rapid Improvement Model (RIM) quality improvement (QI) initiative with a compressed timeframe of 6 months to improve EC, WD and PPE at eight purposively selected health facilities (HFs). Targets were collaboratively developed, and a 37-item checklist was designed to monitor performance. HF teams received QI training and weekly coaching and convened monthly to review progress and exchange best practices. At the final learning session, a "harvest package" of the most effective ideas and tools was developed for use at additional HFs. RESULTS: The RIM resulted in marked improvement in WD and EC performance and modest improvement in PPE. Aggregate compliance for the 37 indicators increased from 67 to 96% over the course of 4 months, with all HFs showing improvement. Average PPE compliance improved from 85 to 89%, WD from 63 to 99% and EC from 51 to 99%. LESSONS LEARNED: The RIM QIC approach is feasible and effective in SL's austere health system and led to marked improvement in IPC performance. The best practices are being scaled up and the RIM QIC methodology is being applied to other domains.

Longwall mining has a significant influence on gas wells located within longwall chain pillars. Subsurface subsidence and abutment pressure induced by longwall mining can cause excessive stresses and deformations in gas well casings. If the gas well casings are compromised or ruptured, natural gas could migrate into the mine workings, potentially causing a fire or explosion. By the current safety regulations, the gas wells in the chain pillars have to be either plugged or protected by adequate coal pillars. The current regulations for gas well pillar design are based on the 1957 Pennsylvania gas well pillar study. The study provided guidelines for gas well pillars by considering their support area and overburden depth as well as the location of the gas wells within the pillars. As the guidelines were developed for room-and-pillar mining under shallow cover, they are no longer applicable to modern longwall coal mining, particularly, under deep cover. Gas well casing of failures have occurred even though the chain pillars for the gas wells met the requirements by the 1957 study. This study, conducted by the National Institute for Occupational Safety and Health (NIOSH), presents seven cases of conventional gas wells penetrating through longwall chain pillars in the Pittsburgh Coal Seam. The study results indicate that overburden depth and pillar size are not the only determining factors for gas well stability. The other important factors include subsurface ground movement, overburden geology, weak floor, as well as the type of the construction of gas wells. Numerical modeling was used to model abutment pressure, subsurface deformations, and the response of gas well casings. The study demonstrated that numerical models are able to predict with reasonable accuracy the subsurface deformations in the overburden above, within, and below the chain pillars, and the potential location and modes of gas well failures, thereby providing a more quantifiable approach to assess the stability of the gas wells in longwall chain pillars.

Coal mine longwall gateroads are subject to changing loading conditions induced by the advancing longwall face. The ground response and support requirements are closely related to the magnitude and orientation of the stress changes, as well as the local geology. This paper presents the monitoring results of gateroad response and support performance at two longwall mines at a 180-m and 600-m depth of cover. At the first mine, a three-entry gateroad layout was used. The second mine used a four-entry, yield-abutment-yield gateroad pillar system. Local ground deformation and support response were monitored at both sites. The monitoring period started during the development stage and continued during first panel retreat and up to second panel retreat. The two data sets were used to compare the response of the entries in two very different geotechnical settings and different gateroad layouts. The monitoring results were used to validate numerical models that simulate the loading conditions and entry response for these widely differing conditions. The validated models were used to compare the load path and ground response at the two mines. This paper demonstrates the potential for numerical models to assist mine engineers in optimizing longwall layouts and gateroad support systems.

Chagas disease (also known as American trypanosomiasis) is caused by the protozoan parasite Trypanosoma cruzi (1,2). Vectorborne transmission via skin or mucosal contact with the feces of infected triatomine bugs mainly occurs in rural areas of Latin America but has been reported in the southern United States (3). The parasite also is transmissible congenitally and via blood transfusion, organ transplantation, and accidental laboratory exposures. The two drugs used for treating Chagas disease are benznidazole and nifurtimox (1,2), which have been used in Latin America since the 1970s and 1960s, respectively. In the absence of commercially available drugs approved by the Food and Drug Administration (FDA), benznidazole and nifurtimox have been available exclusively through CDC, under Investigational New Drug (IND) treatment protocols. On August 29, 2017, FDA approved a benznidazole product (Chemo Research, SL, in care of Exeltis*) for treatment of Chagas disease (4), which became commercially available on May 14, 2018. Therefore, effective May 14, 2018, benznidazole is no longer available through the CDC-sponsored IND program. This report summarizes selected characteristics of patients for whom CDC released benznidazole through that program from October 2011, when the IND went into effect, until mid-May 2018. The majority of the 365 patients included in intention-to-treat analyses were chronically infected adults who were born and became infected in Latin America. Physician requests for benznidazole should now be directed to the drug company Exeltis. The CDC-sponsored IND for nifurtimox remains in effect to provide an alternative therapeutic option to benznidazole when clinically appropriate. CDC will continue to provide reference diagnostic testing for T. cruzi infection and teleconsultative services regarding Chagas disease.

This report presents the results of experiments to evaluate a prototype fiber optic methane monitor exposed to smoke using a smoke chamber to simulate atmospheric conditions in an underground coal mine after a fire or explosion. The experiments were conducted using test fires of different combustible sources commonly found in mines —douglas-fir wood, SBR belt, and Pittsburgh seam coal. The experiments were designed to assess the response of the fiber optic methane sensor to different contaminants, different contaminant levels and different contaminant durations produced from the test fires. Since the prototype methane monitor detects methane by measuring absorption at a specific wavelength, optical power at the absorption wavelength (1650 nm) was measured as a function of smoke concentration and duration. The other sensor response parameter-methane response times-were measured between smoke tests to assess the impact of soot accumulation on the sensor. Results indicate that the sensor screen effectively prevented smoke from obscuring the optical beam within the sensor head, with minimal impact on the system optical power budget. Methane response times increased with smoke exposure duration, attributed to soot loading on the protective screen.

Longwall face ventilation is an important component of the overall coal mine ventilation system. Increased production rates due to higher-capacity mining equipment tend to also increase methane emission rates from the coal face, which must be diluted by the face ventilation. Increases in panel length, with some mines exceeding 6,100 m (20,000 ft), and panel width provide additional challenges to face ventilation designs. To assess the effectiveness of current face ventilation practices at a study site, a face monitoring study with continuous monitoring of methane concentrations and automated recording of longwall shearer activity was combined with a tracer gas test on a longwall face. The study was conducted at a U.S. longwall mine operating in a thick, bituminous coal seam and using a U-type, bleederless ventilation system. Multiple gob gas ventholes were located near the longwall face. These boreholes had some unusual design concepts, including a system of manifolds to modify borehole vacuum and flow and completion depths close to the horizon of the mined coalbed that enabled direct communication with the mine atmosphere. The mine operator also had the capacity to inject nitrogen into the longwall gob, which occurred during the monitoring study. The results show that emission rates on the longwall face showed a very limited increase in methane concentrations from headgate to tailgate despite the occurrence of methane delays during monitoring. Average face air velocities were 3.03 m/s (596 fpm) at shield 57 and 2.20 m/s (433 fpm) at shield 165. The time required for the sulfur hexafluoride (SF(6)) peak to occur at each monitoring location has been interpreted as being representative of the movement of the tracer slug. The rate of movement of the slug was much slower in reaching the first monitoring location at shield 57 compared with the other face locations. This lower rate of movement, compared with the main face ventilation, is thought to be the product of a flow path within and behind the shields that is moving in the general direction of the headgate to the tailgate. Barometric pressure variations were pronounced over the course of the study and varied on a diurnal basis.

Newborn screening (NBS) is intended to identify congenital conditions prior to the onset of symptoms in order to provide early intervention that leads to improved outcomes. NBS is a public health success, providing reduction in mortality and improved developmental outcomes for screened conditions. However, it is less clear to what extent newborn screening achieves the long-term goals relating to improved health, growth, development and function. We propose a framework for assessing outcomes for the health and well-being of children identified through NBS programs. The framework proposed here, and this manuscript, were approved for publication by the Secretary of Health and Human Services' Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC). This framework can be applied to each screened condition within the Recommended Uniform Screening Panel (RUSP), recognizing that the data elements and measures will vary by condition. As an example, we applied the framework to sickle cell disease and phenylketonuria (PKU), two diverse conditions with different outcome measures and potential sources of data. Widespread and consistent application of this framework across state NBS and child health systems is envisioned as useful to standardize approaches to assessment of outcomes and for continuous improvement of the NBS and child health systems. SIGNIFICANCE: Successful interventions for newborn screening conditions have been a driving force for public health newborn screening for over fifty years. Organizing interventions and outcome measures into a standard framework to systematically assess outcomes has not yet come into practice. This paper presents a customizable outcomes framework for organizing measures for newborn screening condition-specific health outcomes, and an approach to identifying sources and challenges to populating those measures.

The Centers for Disease Control and Prevention (CDC) Quarantine Stations distribute select lifesaving drug products that are not commercially available or are in limited supply in the United States for emergency treatment of certain health conditions. Following a retrospective analysis of shipment records, the authors estimated an average of 6.66 hours saved per shipment when drug products were distributed from quarantine stations compared to a hypothetical centralized site from CDC headquarters in Atlanta, GA. This evaluation supports the continued use of a decentralized model which leverages CDC's regional presence and maximizes efficiency in the distribution of lifesaving drugs.

The National Institute for Occupational Safety and Health (NIOSH) conducted an investigation of longwall face and bleeder ventilation systems using tracer gas experiments and computer network ventilation. The condition of gateroad entries, along with the caved material's permeability and porosity changes as the longwall face advances, determine the resistance of the airflow pathways within the longwall's worked-out area of the bleeder system. A series of field evaluations were conducted on a four-panel longwall district. Tracer gas was released at the mouth of the longwall section or on the longwall face and sampled at various locations in the gateroads inby the shield line. Measurements of arrival times and concentrations defined airflow/gas movements for the active/completed panels and the bleeder system, providing real field data to delineate these pathways. Results showed a sustained ability of the bleeder system to ventilate the longwall tailgate corner as the panels retreated.

OBJECTIVE: Children and adolescents are known to experience poor health care quality; some groups of children have poorer health care than others. We sought to examine trends over time in health care quality and disparities by race, Hispanic ethnicity, income, insurance, gender, rurality, and special health care needs. METHODS: Source data were extracted from the 2011 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) database, which contains aggregated data from many government and private sources for the years 2000 through 2009. The NHQR and NHDR approaches to calculating disparities and trends in quality and disparities were used. Within each quality measure with available data, results for demographic subgroups of children characterized by race/ethnicity, income, insurance, residence, special health care need, and gender were compared to those of a reference group to determine whether disparities existed and whether disparities had changed over time. RESULTS: Of 68 measures with data for calculating potential disparities, 50 showed disparities in quality for at least 1 comparison subgroup in the most recent year of data available, while 18 measures showed no such disparities. Of the 50 measures with current disparities, 39 measures had sufficient data to calculate trends. Among the 137 comparisons made within these 39 measures, there was no change in disparities over time for 126 comparisons, 3 comparisons worsened, and 8 comparisons improved. CONCLUSIONS: There was some progress in health care quality and reducing disparities in children's health care quality from 2000 to 2009; opportunities for targeting improvement strategies remain.

Due to prior major accidents in the United States underground coal mines, regulations concerning use of intake belt air were changed in 2008. Several safety requirements were introduced to combat the most acknowledged risk of using belt air; conveyor belt flammability. However, use of belt air increases airflow at the face area, which results in improved methane control. A definitive connection between belt air use and accident occurrence has not been established. Also, the frequency of belt air ventilation violations and their relation to other ventilation violations is not known, so reliable weighing of the benefits and risks is difficult. Based on data from 98 reports on underground belt entry fires the relationship among belt fires, ignitions, explosions, fatalities, and injury information was analyzed. Ignitions and explosions due to lack of ventilating air are much more common than belt fires. The number of injuries and fatalities resulting from these incidents far outnumbers those related to belt fires. Belt air related issues were further studied by researching an MSHA violations database. The number of belt air standard violations was expected to be significant enough to show the need to restrict its use. However, this was not found. It was concluded that because methane explosions and ignitions result in a much larger number of accidents, injuries, and fatalities, the benefit of additional air supplied to the face surpasses the risk of belt fires. Also, data showed that mines using belt air were not at greater risk than mines not using belt air.

NIOSH conducted a cooperative research study to provide direct measurements of changing reservoir conditions in longwall panel overburden. The field measurements documented changes in permeabilities, methane concentrations, fluid pressures, and the effects of adjacent gob gas ventholes (GGVs) on NIOSH boreholes drilled in the study panel. Three different stratigraphic horizons were monitored by the NIOSH boreholes. Results indicated that the gob gas venthole fracture network formed 24 to 46m (80 to 150 ft) ahead of the mining face. Overburden permeabilities within the same overburden test zones were ~1md prior to undermining, increasing to hundreds or thousands of md during undermining. Permeabilities measured seven months after undermining showed additional increases. The relationship between changing reservoir conditions, longwall face position, and surface movement is discussed. Recommendations are made to optimize GGV performance by evaluating changes in subsidence produced by mining, resulting in rock stresses that substantially influence induced fracture permeability. Mechanisms to account for the observed changes in reservoir conditions are reported.

Vaccinia virus is an orthopoxvirus used in the live vaccine against smallpox. Vaccinia virus infections can be transmissible and can cause severe complications in those with weakened immune systems. We report on a cluster of 4 cases of vaccinia virus infection in Maryland, USA, likely acquired at a martial arts gym.