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Articles 1 - 30 of 251
Full-Text Articles in Medicine and Health Sciences
Examining The Regulatory Value Of Multi-Route Mammalian Acute Systemic Toxicity Studies, Troy Seidle, Pilar Prieto, Anna Bulgheroni
Examining The Regulatory Value Of Multi-Route Mammalian Acute Systemic Toxicity Studies, Troy Seidle, Pilar Prieto, Anna Bulgheroni
Troy Seidle, PhD
Regulatory information requirements for pesticides call for submission of acute systemic toxicity data for up to three different exposure routes (oral, dermal, inhalation) for both active ingredients and formulated products. Similar multi-route testing is required in the European Union and elsewhere for industrial chemicals. To determine the value of acute toxicity testing by more than one route, oral-dermal and oralinhalation concordances among regulatory classifications were examined for large data sets of chemicals and pesticide active ingredients. Across all sectors examined, oral acute toxicity classifications for pure active substances were more severe than those derived from dermal data in more than …
An Evaluation Of The Us High Production Volume (Hpv) Chemical-Testing Programme: A Study In (Ir)Relevance, Redundancy And Retro Thinking, Andrew Nicholson, Jessica Sandler, Troy Seidle
An Evaluation Of The Us High Production Volume (Hpv) Chemical-Testing Programme: A Study In (Ir)Relevance, Redundancy And Retro Thinking, Andrew Nicholson, Jessica Sandler, Troy Seidle
Troy Seidle, PhD
Under the US Environmental Protection Agency (EPA) High Production Volume (HPV) Challenge Programme, chemical companies have volunteered to conduct screening-level toxicity tests on approximately 2800 widely-used industrial chemicals. Participating companies are committed to providing available toxicity information to the EPA and presenting testing proposals for review by the EPA and posting on the EPA Web site as public information. People for the Ethical Treatment of Animals (PETA) and a coalition of animal protection organisations have reviewed all the test plans submitted by the participating chemical companies for compliance with the original HPV framework, as well as with animal welfare guidelines …
Cross-Sector Review Of Drivers And Available 3rs Approaches For Acute Systemic Toxicity Testing, Troy Seidle, Sally Robinson, Tom Holmes, Stuart Creton, Pilar Prieto, Julia Scheel, Magda Chlebus
Cross-Sector Review Of Drivers And Available 3rs Approaches For Acute Systemic Toxicity Testing, Troy Seidle, Sally Robinson, Tom Holmes, Stuart Creton, Pilar Prieto, Julia Scheel, Magda Chlebus
Troy Seidle, PhD
Acute systemic toxicity studies are carried out in many sectors in which synthetic chemicals are manufactured or used and are among the most criticized of all toxicology tests on both scientific and ethical grounds. A review of the drivers for acute toxicity testing within the pharmaceutical industry led to a paradigm shift whereby in vivo acute toxicity data are no longer routinely required in advance of human clinical trials. Based on this experience, the following review was undertaken to identify (1) regulatory and scientific drivers for acute toxicity testing in other industrial sectors, (2) activities aimed at replacing, reducing, or …
A Modular One-Generation Reproduction Study As A Flexible Testing System For Regulatory Safety Assessment, Richard Vogel, Troy Seidle, Horst Spielmann
A Modular One-Generation Reproduction Study As A Flexible Testing System For Regulatory Safety Assessment, Richard Vogel, Troy Seidle, Horst Spielmann
Troy Seidle, PhD
The European Union’s Registration, Evaluation and Authorisation of Chemicals (REACH) legislation mandates testing and evaluation of approximately 30,000 existing substances within a short period of time, beginning with the most widely used “high production volume” (HPV) chemicals. REACH testing requirements for the roughly 3000 HPV chemicals specify three separate tests for reproductive toxicity: two developmental toxicity studies on different animal species (OECD Test Guideline 414) and a two-generation reproduction toxicity study (OECD TG 416). These studies are highly costly in both economic and animal welfare terms. OECD TG 416 is a fertility study intended to evaluate reproductive performance of animals …
Levels Of Citation Of Nonhuman Animal Studies Conducted At A Canadian Research Hospital, Anne Innis Dagg, Troy K. Seidle
Levels Of Citation Of Nonhuman Animal Studies Conducted At A Canadian Research Hospital, Anne Innis Dagg, Troy K. Seidle
Troy Seidle, PhD
The publication of scientific articles that receive few or no citations raises questions of the appropriate use of resources as well as ethics. In the case of animal research, the ethics issue extends beyond human patients to nonhuman animals, as the research subjects them to pain and, typically, to death. This study is a citation analysis of animal research conducted at Toronto's Hospital for Sick Children (HSC). Of the 594 publications (1990 to 1995) on animal research by affiliates of HSC, 29% received Iower than 10 citations in a 10-year period. We compare the research history of 13 "best" and …
Humane Society International’S Global Campaign To End Animal Testing, Troy Seidle
Humane Society International’S Global Campaign To End Animal Testing, Troy Seidle
Troy Seidle, PhD
The Research & Toxicology Department of Humane Society International (HSI) operates a multifaceted and science-driven global programme aimed at ending the use of animals in toxicity testing and research. The key strategic objectives include: a) ending cosmetics animal testing worldwide, via the multinational Be Cruelty-Free campaign; b) achieving near-term reductions in animal testing requirements through revision of product sector regulations; and c) advancing humane science by exposing failing animal models of human disease and shifting science funding toward human biology-based research and testing tools fit for the 21st century. HSI was instrumental in ensuring the implementation of the March 2013 …
The Fine-Scale Habitat Use Of Risso’S Dolphins Off Bardsey Island, Cardigan Bay (Uk), Marijke N. De Boer, Sonja Eisfeld, Mark P. Simmonds
The Fine-Scale Habitat Use Of Risso’S Dolphins Off Bardsey Island, Cardigan Bay (Uk), Marijke N. De Boer, Sonja Eisfeld, Mark P. Simmonds
Mark P. Simmonds, OBE
The main objectives of this study were (1) to estimate the population size of Risso’s dolphins off Bardsey Island using mark-recapture techniques (De Boer et al., 2013); and (2) to study habitat-use in relation to fine-scale oceanographic features. This work provides preliminary information on the habitat-use of Risso’s dolphins and will benefit future studies, along with the development of effective conservation measures for this species throughout the region.
Photo-Identification Methods Reveal Seasonal And Long-Term Site-Fidelity Of Risso’S Dolphins (Grampus Griseus) In Shallow Waters (Cardigan Bay, Wales), Marijke N. De Boer, Josephine Clark, Mardik F. Leopold, Mark P. Simmonds, Peter J.H. Reijnders
Photo-Identification Methods Reveal Seasonal And Long-Term Site-Fidelity Of Risso’S Dolphins (Grampus Griseus) In Shallow Waters (Cardigan Bay, Wales), Marijke N. De Boer, Josephine Clark, Mardik F. Leopold, Mark P. Simmonds, Peter J.H. Reijnders
Mark P. Simmonds, OBE
A photo-identification study on Risso’s dolphins was carried out off Bardsey Island in Wales (July to September, 1997-2007). Their local abundance was estimated using two different analytical techniques: 1) mark-recapture of well-marked dolphins using a “closed-population” model; and 2) a census technique based on the total number of iden-tified individual dolphins sighted over the study period. The mark-recapture estimates of 121 (left sides; 64 - 178, 95% CI; CV 0.24) and 145 dolphins (right sides; 78 - 213, 95% CI; CV 0.24) closely matched the census technique estimates (population size of 90 - 151). It was found that the dolphins …
Cetaceans And Marine Debris: The Great Unknown, Mark Peter Simmonds
Cetaceans And Marine Debris: The Great Unknown, Mark Peter Simmonds
Mark P. Simmonds, OBE
Plastics and other marine debris have been found in the gastrointestinal tracts of cetaceans, including instances where large quantities of material have been found that are likely to cause impairment to digestive processes and other examples, where other morbidity and even death have resulted. In some instances, debris may have been ingested as a result of the stranding process and, in others, it may have been ingested when feeding. Those species that are suction or “ram” feeders may be most at risk. There is also evidence of entanglement of cetaceans in marine debris. However, it is usually difficult to distinguish …
Controversies In Psychiatry And Dsm-5: The Relevance For Social Work (Occasional Essay), Jill Littrell, Jeffrey R. Lacasse
Controversies In Psychiatry And Dsm-5: The Relevance For Social Work (Occasional Essay), Jill Littrell, Jeffrey R. Lacasse
jill l littrell Dr.
This essay addresses recent controversies surrounding the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5—the first major revision of the DSM since 1994), as well as questions regarding the safety and efficacy of psychotropic medications discussed in the public domain. Mental health professionals across a wide range of professions have signed a petition to the DSM-5 Task Force protesting changes in the new edition, and critiques of psychiatric medications are increasingly disseminated in the media. These issues have particular relevance for children in foster care, who receive diagnoses and medication at high rates. The general …
The Controversy Over Antidepressant Drugs In An Era Of Evidence-Based Practice, Jill Littrell, Jeffrey Lacasse
The Controversy Over Antidepressant Drugs In An Era Of Evidence-Based Practice, Jill Littrell, Jeffrey Lacasse
jill l littrell Dr.
Questions regarding the efficacy of antidepressant drugs have been a recent focus of attention in the national news both in print and in the television media. Many clients will have questions regarding what they can believe and how they can address mood problems. Social workers constitute a greater percentage of the mental health work force than any other profession. Thus, social workers will probably be asked by clients about these issues. This article presents information on the efficacy of antidepressants for both the short and long term. It covers adverse effects and withdrawal symptoms. Clients' self-determination should be honored. However, …
Perspectives Emerging From Neuroscience On Why People Become Addicted And What To Do About It, Jill Littrell
Perspectives Emerging From Neuroscience On Why People Become Addicted And What To Do About It, Jill Littrell
jill l littrell Dr.
This paper reviews the new ideas emerging from neuroscience regarding the question of why some people are compelled to use drugs. During the process of drug exposure, the brain’s motivational system is changed in ways that co-opts the individual’s motivational system. Changes in the brain’s motivational structures along with changes in the brain’s self-regulatory structures compel an individual to drug use. Ways to reverse those changes in an addicted brain have been identified, as have ways to enhance self-regulatory control. The information from neuroscience offers a new perspective on “loss of control” as well as offering implications for treatment.
Create Workshop 2014: Leveraging Mobile Technology And Social Media In Behavioral Research, Andre M. Müller
Create Workshop 2014: Leveraging Mobile Technology And Social Media In Behavioral Research, Andre M. Müller
Andre M Müller
The 2014 CREATE workshop brought together some forty young health behavior researchers from thirteen different countries, all sharing an interest in mobile technology and social media research. The three- day workshop was held in Innsbruck, Austria,...
Making Women's Health Connections: Between Researchers And To Resources, Martha E. Meacham, Len L. Levin, Lisa A. Palmer, Elaine Martin
Making Women's Health Connections: Between Researchers And To Resources, Martha E. Meacham, Len L. Levin, Lisa A. Palmer, Elaine Martin
Lisa A. Palmer
The Lamar Soutter Library at the University of Massachusetts Medical School has recently completed the second year of a National Library of Medicine grant funded project; the Women’s Health Resources Dissemination Outreach Project. The goals include assisting women’s health researchers by providing them with access to information and making them more aware of opportunities and available resources. This, ultimately, enables both an improvement in women’s health and the advancement of women in academic medicine. Moreover, by supporting women’s health research and women researchers through the objectives of this project, women researchers build connections, knowledge, and skills. This facilitates meaningful contributions …
The Economics Of Implementing Population Health Strategies, Glen P. Mays
The Economics Of Implementing Population Health Strategies, Glen P. Mays
Glen Mays
Successful strategies to scale up and spread complex community-level interventions require an understanding of the resources required for implementation, how best to distribute them among supporting institutions, and how resource consumption and distribution varies across settings. This session reviews methods and early findings from the RWJF’s Public Health Delivery and Cost Studies (DACS) Initiative, which includes 12 inter-related studies examining the causes and consequences of variation in the costs of delivering complex community-level prevention strategies across more than 300 community settings in 12 states. Findings from these studies highlight the value of studying the economics of implementation, the measurement and …
Clear: Conversations: A Collaborative Regional Project To Help Patients Improve Their Health Visits, Michelle L. Eberle, Margot Malachowski, Alberta Richetelle, Monina Lahoz, Linda Mcintosh, Bradley Moore, Jen Searl, Judy Kronick
Clear: Conversations: A Collaborative Regional Project To Help Patients Improve Their Health Visits, Michelle L. Eberle, Margot Malachowski, Alberta Richetelle, Monina Lahoz, Linda Mcintosh, Bradley Moore, Jen Searl, Judy Kronick
Margot G Malachowski, MLS, AHIP
Objective: The National Network of Libraries of Medicine, New England Region’s Clear: Conversations project aimed to teach health literacy skills to help patients communicate better with their health care providers including how to: ask for simple language and slow down the provider, use teach-back, bring medications and supplements for a brown bag review, and get need-to-know information. Methods: Five organizations were awarded with Clear: Conversations materials that were adapted from a program created by Health Literacy Missouri. A highlight of the workshop was a role play between a health care provider and patient. Awardees were required to offer the workshop …
Report Of The Working Group On Animal Distress In The Laboratory, Marilyn Brown, Larry Carbone, Kathleen Conlee, Marian Dawkins, Ian J. Duncan, David Fraser, Gilly Griffin, Victoria A. Hampshire, Lesley A. Lambert, Joy A. Mench, David Morton, Jon Richmond, Bernard E. Rollin, Andrew N. Rowan, Martin L. Stephens, Hanno Würbel
Report Of The Working Group On Animal Distress In The Laboratory, Marilyn Brown, Larry Carbone, Kathleen Conlee, Marian Dawkins, Ian J. Duncan, David Fraser, Gilly Griffin, Victoria A. Hampshire, Lesley A. Lambert, Joy A. Mench, David Morton, Jon Richmond, Bernard E. Rollin, Andrew N. Rowan, Martin L. Stephens, Hanno Würbel
Andrew N. Rowan, DPhil
Finding ways to minimize pain and distress in research animals is a continuing goal in the laboratory animal research field. Pain and distress, however, are not synonymous, and often measures that alleviate one do not affect the other. Here, the authors provide a summary of a meeting held in February 2004 that focused on distress in laboratory animals. They discuss the difficulties associated with defining ‘distress,’ propose methods to aid in recognizing and alleviating distressful conditions, and provide recommendations for animal research conduct and oversight that would minimize distress experienced by laboratory animals.
The Three Rs: The Way Forward, Michael Balls, Alan M. Goldberg, Julia H. Fentem, Caren L. Broadhead, Rex L. Burch, Michael F.W. Festing, John M. Frazier, Coenraad F.M. Hendriksen, Margaret Jennings, Margot D.O. Van Der Kamp, David B. Morton, Andrew N. Rowan, Claire Russell, William M.S. Russell, Horst Spielmann, Martin Stephens, William S. Stokes, Donald W. Straughan, James D. Yager, Joanne Zurlo, Bert F.M. Van Zutphen
The Three Rs: The Way Forward, Michael Balls, Alan M. Goldberg, Julia H. Fentem, Caren L. Broadhead, Rex L. Burch, Michael F.W. Festing, John M. Frazier, Coenraad F.M. Hendriksen, Margaret Jennings, Margot D.O. Van Der Kamp, David B. Morton, Andrew N. Rowan, Claire Russell, William M.S. Russell, Horst Spielmann, Martin Stephens, William S. Stokes, Donald W. Straughan, James D. Yager, Joanne Zurlo, Bert F.M. Van Zutphen
Andrew N. Rowan, DPhil
This is the report of the eleventh of a series of workshops organised by the European Centre for the Validation of Alternative Methods (ECVAM), which was established in 1991 by the European Commission. ECVAM's main goal, as defined in 1993 by its Scientific Advisory Committee, is to promote the scientific and regulatory acceptance of alternative methods which are of importance to the biosciences and which reduce, refine or replace the use of laboratory animals. One of the first priorities set by ECVAM was the implementation of procedures which would enable it to become well-informed about the state-of-the-art of non-animal test …
Health Professionals’ Roles In Animal Agriculture, Climate Change, And Human Health, Aysha Z. Akhtar, Michael Greger, Hope Ferdowsian, Erica Frank
Health Professionals’ Roles In Animal Agriculture, Climate Change, And Human Health, Aysha Z. Akhtar, Michael Greger, Hope Ferdowsian, Erica Frank
Michael Greger, MD, FACLM
What we eat is rapidly becoming an issue of global concern. With food shortages, the rise in chronic disease, and global warming, the impact of our dietary choices seems more relevant today than ever. Globally, a transition is taking place toward greater consumption of foods of animal origin, in lieu of plantbased diets. With this transition comes intensification of animal agriculture that in turn is associated with the emergence of zoonotic infectious diseases, environmental degradation, and the epidemics of chronic disease and obesity. Health professionals should be aware of these trends and consider them as they promote healthier and more …
Opportunities And Future Directions For The National Health Security Preparedness Index, Glen P. Mays
Opportunities And Future Directions For The National Health Security Preparedness Index, Glen P. Mays
Glen Mays
This presentation examines options and opportunities for future development of the National Health Security Preparedness Index, created through a partnership of national public health and health care organizations led by the U.S. Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO).
Community Health Worker Interventions For Latinos With Type 2 Diabetes: A Systematic Review Of Randomized Controlled Trials, Tariana V. Little, Monica L. Wang, Eida M. Castro, Julio Jiménez, Milagros C. Rosal
Community Health Worker Interventions For Latinos With Type 2 Diabetes: A Systematic Review Of Randomized Controlled Trials, Tariana V. Little, Monica L. Wang, Eida M. Castro, Julio Jiménez, Milagros C. Rosal
Tariana V. Little
This systematic review aimed to synthesize glucose (HbA1c) outcomes of community health worker (CHW)-delivered interventions for Latinos with type 2 diabetes that were tested in randomized controlled trials and to summarize characteristics of the targeted populations and interventions, including the background, training, and supervision of the CHWs. Searches of PubMed and Google Scholar databases and references from selected articles identified 12 studies that met the inclusion criteria. Of these, seven reported statistically significant improvements in HbA1c. Study participants were largely low-income, female, and Spanish-speaking and had uncontrolled diabetes. The CHWs led the interventions alone, in pairs, or as part of …
Implementing The Massachusetts Child Trauma Project (Mctp) To Improve Services For Children With Complex Trauma In Child Welfare: Phase I Needs And Readiness Assessment, Charmaine B. Lo, Melodie Wenz-Gross, Jessica L. Griffin
Implementing The Massachusetts Child Trauma Project (Mctp) To Improve Services For Children With Complex Trauma In Child Welfare: Phase I Needs And Readiness Assessment, Charmaine B. Lo, Melodie Wenz-Gross, Jessica L. Griffin
Melodie Wenz-Gross
MCTP seeks to improve placement stability and outcomes for children with complex trauma in the care of the Massachusetts Department of Children and Families (DCF) by creating a sustainable capacity for providing evidence-based trauma interventions within provider agencies, and trauma-informed practices within DCF.
Carbon Dioxide For Euthanasia: Concerns Regarding Pain And Distress, With Special Reference To Mice And Rats, Kathleen Conlee, Martin Stephens, Andrew N. Rowan, Lesley A. King
Carbon Dioxide For Euthanasia: Concerns Regarding Pain And Distress, With Special Reference To Mice And Rats, Kathleen Conlee, Martin Stephens, Andrew N. Rowan, Lesley A. King
Andrew N. Rowan, DPhil
Carbon dioxide (CO2) is the most commonly used agent for euthanasia of laboratory rodents, used on an estimated tens of millions of laboratory rodents per year worldwide, yet there is a growing body of evidence indicating that exposure to CO2 causes more than momentary pain and distress in these and other animals. We reviewed the available literature on the use of CO2 for euthanasia (as well as anaesthesia) and also informally canvassed laboratory animal personnel for their opinions regarding this topic. Our review addresses key issues such as CO2 flow rate and final concentration, presence …
The Dynamics Of Medicaid & Public Health Spending: Implications For Aca Implementation, Glen P. Mays
The Dynamics Of Medicaid & Public Health Spending: Implications For Aca Implementation, Glen P. Mays
Glen Mays
We estimate the dynamics and interactions of governmental spending on Medicaid and other public health services in all 50 states over a 15 year period. Using a quasi-experimental design with instrumental variables estimation, we find evidence that increased Medicaid spending leads to reduced governmental spending on other public health services, consistent with a crowd-out effect. Over 10 years, such crowd-out has the potential to diminish the health status improvements generated through health insurance coverage expansions.
A Vision Becoming Reality, Gill Langley
A Vision Becoming Reality, Gill Langley
Gill Langley, PhD
Non-animal science in toxicology and health research has been progressing for decades, but only now is it being seen widely as advanced science. The emergence of novel human biology-based tools and models, combined with legislative and regulatory change, a 21st century concept for toxicology, continuing failures in the drug pipeline, and systematic critiques of animal models, have created a pivotal moment of change. The leading edge is starting to become the norm. Humans and other animals are likely to benefit as a result.
Estimates For Worldwide Laboratory Animal Use In 2005, Katy Taylor, Nicky Gordon, Gill Langley, Wendy Higgins
Estimates For Worldwide Laboratory Animal Use In 2005, Katy Taylor, Nicky Gordon, Gill Langley, Wendy Higgins
Gill Langley, PhD
Animal experimentation continues to generate public and political concern worldwide. Relatively few countries collate and publish animal use statistics, yet this is a first and essential step toward public accountability and an informed debate, as well as being important for effective policy-making and regulation. The implementation of the Three Rs (replacement, reduction and refinement of animal experiments) should be expected to result in a decline in animal use, but without regular, accurate statistics, this cannot be monitored. Recent estimates of worldwide annual laboratory animal use are imprecise and unsubstantiated, ranging from 28–100 million. We collated data for 37 countries that …
Volunteer Studies In Pain Research — Opportunities And Challenges To Replace Animal Experiments: The Report And Recommendations Of A Focus On Alternatives Workshop, C. K. Langley, Q. Aziz, C. Bountra, N. Gordon, P. Hawkins, A. Jones, G. Langley, T. Nurmikko, I. Tracey
Volunteer Studies In Pain Research — Opportunities And Challenges To Replace Animal Experiments: The Report And Recommendations Of A Focus On Alternatives Workshop, C. K. Langley, Q. Aziz, C. Bountra, N. Gordon, P. Hawkins, A. Jones, G. Langley, T. Nurmikko, I. Tracey
Gill Langley, PhD
Despite considerable research, effective and safe treatments for human pain disorders remain elusive. Understanding the biology of different human pain conditions and researching effective treatments continue to be dominated by animal models, some of which are of limited value. British and European legislation demands that non-animal approaches should be considered before embarking on research using experimental animals. Recent scientific and technical developments, particularly in human neuroimaging, offer the potential to replace some animal procedures in the study of human pain. A group of pain research experts from academia and industry met with the aim of exploring creatively the tools, strategies …
Considering A New Paradigm For Alzheimer’S Disease Research, Gillian R. Langley
Considering A New Paradigm For Alzheimer’S Disease Research, Gillian R. Langley
Gill Langley, PhD
Using Alzheimer’s disease as a case study, this review argues that it might be time to consider a new paradigm in medical research and drug discovery. The existing framework is overly dependent on often unvalidated animal models, particularly transgenic mice. Translational success remains elusive and costly late-stage drug failure is common. The conventional paradigm tends to overlook species differences and assumes that animal-based findings are generally applicable to humans. Could pathways-based research using advanced human-specific models probed with new tools, including those of systems biology, take centre stage? The current transition in chemical toxicology to a 21st-century paradigm could be …
The Validity Of Animal Experiments In Medical Research, Gill Langley
The Validity Of Animal Experiments In Medical Research, Gill Langley
Gill Langley, PhD
Other animals, such as mice, rats, rabbits, dogs and monkeys, are widely used as surrogates for humans in fundamental medical research. This involves creating disorders in animals by chemical, surgical or genetic means, with the aim of mimicking selected aspects of human illnesses. It is a truism that any model or surrogate is not identical to the target being modelled. So, in medical research, experiments using animals or cell cultures or even healthy volunteers instead of patients (being the target population with the target illness) will inevitably have limitations, although these will be greater or lesser depending on the model.
Aca Implementation In Kentucky: Experiences Of An Expansion State, Glen P. Mays
Aca Implementation In Kentucky: Experiences Of An Expansion State, Glen P. Mays
Glen Mays
Kentucky's implementation of the Affordable Care Act has included early successes with insurance coverage expansion through Medicaid and a state-operated health insurance exchange. Signals of improvements in health care accessibility and delivery of preventive services are evident in the first year after coverage expansions. Challenges associated with political opposition, delivery system transformation, and public health financing remain on the state's policy agenda.