Medicine and Health Sciences Commons^™

Examining Effective Translation And Implementation Methods For Equitable Access And Scaling Of Nutrition Programs—A Report From The “Biomarkers Of Nutrition For Development: Knowledge Indicating Dietary Sufficiency (Bond-Kids)” Project Working Group 4, Christina D. Economos, Juliana Cohen, Daniel J. Raiten, Omar Dary, Diane Debernardo, Boitshepo Giyose, Marianella Herrera-Cuenca, Deanna Hoelscher, Rachel Novotny, Angela Odoms-Young, Thomas N. Robinson, Mary Rozga, Mary Story, Donald Bundy

Health Sciences Faculty Publications

School-age years (5–19 y) are a critical development period, bridging early childhood and adulthood. Nutrition during this stage is essential for supporting physical, cognitive, and socioemotional/psychological well-being. Moreover, nutritional status in these years has lasting effects on lifelong health, well-being, productivity, and human capital. In 2022, the National Institutes of Health “Biomarkers of Nutrition for Development: Knowledge Indicating Dietary Sufficiency (BOND-KIDS)” Project was launched to explore how to advance the assessment and impact of nutrition programs and policies for school-age children. The aim of this study is to use an ecological approach and available evidence to develop actionable tools for …

New Mexico Snap-Ed College Food Insecurity Report, Belinda E. Vicuña, Yvonnie V. Baik, Elena E. Martinez, Mahtab Soleimani, Camille R. Velarde, Theresa H. Cruz

Reports & Documents

In New Mexico, 58% of college students experience some form of food insecurity. The College Food Insecurity Project—conducted by the University of New Mexico’s Division of Prevention and Population Sciences with support from the New Mexico Health Care Authority and USDA SNAP-Ed—examined how campus food pantries address student food needs across the state. Using a mixed-methods design, the study included semi-structured interviews with food pantry coordinators and staff at 13 institutions of higher education, on-site assessments using the Nutrition Environment Food Pantry Assessment Tool Plus (NEFPAT+), and content analysis of 15 college food pantry websites.

Findings revealed that campus …

Cmc Arthroplasty For Treatment Of The Painful And Arthritic Thumb: A Review Of Surgical Treatment Options With Preferred Technique, Jon E. Hammarstedt, Yehuda A. Masturov, Sebastian D. Arango, Jacob Zeitlin, Samuel H. Payne, Mark S. Rekant

Department of Medicine Faculty Papers

Arthritis of the first carpometacarpal joint is a prevalent and often disabling condition for many older adults. The diagnosis is typically established through a comprehensive patient history, physical examination, and confirmatory radiographs. Nonsurgical management with splinting and anti-inflammatory medication has demonstrated effectiveness. Several surgical options have proven effectiveness for those who fail nonsurgical management. Surgical options include silicone implantation, resection arthroplasty, tendon interposition, ligament reconstruction, denervation, and joint implant arthroplasty. In the following review, we will elaborate upon the array of therapeutic approaches, culminating in the delineation of our preferred method.

Increased Risk Of Renal Disease In Patients With Hidradenitis Suppurativa: A Retrospective Cohort Study Utilizing Trinetx, Tyler Hernandez, Christopher Haas

School of Medicine Faculty Publications

No abstract provided.

Understanding The Effects Of Real-Time Head Position Feedback On Postural Sway In Terms Of Changes In Underlying Deterministic And Stochastic Dynamical Processes, Steven J. Harrison, Benjamin De Bari, Ryan Poutre, Jeffrey M. Kinsella-Shaw

College of Humanities and Sciences Faculty Papers

Our perceptual systems detect information about how our body is moving relative to the surrounding environment. Such information is essential to our ability to maintain upright standing balance. Real-time postural feedback systems are technologies that appear to enhance our ability to detect information about the movements of our body, and as a consequence improve our capacity to control the posture of our body. Here we examine a system in which real-time measurements of head position were "felt" as changes in the intensity of vibration of tactors in a headband. Using this system, participants were able to stabilize their body posture, …

Erratum To <[Transplant Cell Ther 2023 Jul;29(7):438e1-438e16 Epub 2023 Mar 9]>, Melissa R Hines, Tristan E Knight, Kevin O Mcnerney, Mark B Leick, Tania Jain, Sairah Ahmed, Matthew J Frigault, Joshua A Hill, Michael D Jain, William T Johnson, Yi Lin, Kris M Mahadeo, Gabriela M Maron, Rebecca A Marsh, Sattva S Neelapu, Sarah Nikiforow, Amanda K Ombrello, Nirav N Shah, Aimee C Talleur, David Turicek, Anant Vatsayan, Sandy W Wong, Marcela V Maus, Krishna V Komanduri, Nancy Berliner, Jan-Inge Henter, Miguel-Angel Perales, Noelle V Frey, David T Teachey, Matthew J Frank, Nirali N Shah

Faculty, Staff and Student Publications

No abstract provided.

Patient Satisfaction Among Opioid Use Disorder Treatment Sample In An Opioid Treatment Program: A Mixed Method Research Study, Stanley Nkemjika

Department of Psychiatry and Human Behavior Faculty Papers

BACKGROUND/OBJECTIVES: Patient satisfaction is increasingly recognized as a key indicator of the effectiveness of substance use disorder (SUD) treatment. While some studies suggest disparities in satisfaction across treatment settings, there remains limited research examining these differences, particularly among vulnerable populations. This study aimed to assess patient perceptions of satisfaction with opioid use treatment services and explore how demographic and socioeconomic factors influence these experiences.

METHODS: Conducted between 1 February and 31 March 2025, the study took place at a longstanding Opioid Treatment Program in Philadelphia. A total of 217 participants receiving treatment were recruited through convenience sampling during routine clinic …

Final Analysis Of The Resonate-2 Study: Up To 10 Years Of Follow-Up Of First-Line Ibrutinib Treatment For Cll/Sll, Jan A Burger, Paul M Barr, Tadeusz Robak, Carolyn Owen, Alessandra Tedeschi, Anita Sarma, Piers E M Patten, Sebastian Grosicki, Helen Mccarthy, Fritz Offner, Edith Szafer-Glusman, Cathy Zhou, Anita Szoke, Lynne Neumayr, James P Dean, Paolo Ghia, Thomas J Kipps

Faculty, Staff and Student Publications

With up to 10 years of follow-up, we report results from the final analysis of RESONATE- 2, a phase 3 study of first-line ibrutinib vs chlorambucil for the treatment of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Patients aged ≥65 years with previously untreated CLL/SLL without del(17p) were randomly assigned to receive either single-agent ibrutinib (420 mg/d; n = 136) or chlorambucil (0.5-0.8 mg/kg; ≤12 cycles; n = 133). With a median follow-up of 9.6 years in the ibrutinib arm, the median progression-free survival (PFS) was 8.9 years (95% confidence interval [CI], 7.0 to not estimable [NE]) vs 1.3 years (95% …

Psychiatric Comorbidities In Hiv/Aids Patients And Its Overlap With Neurological Disorders, Boluwatife Samuel Fatokun, Olivier Uwishema, Nadine Mugisha, Bashirat Oluwatomi Abdulraheem, Claudia Valeria Rivera-Cazaño, Uwineza Jeanne D’Arc, Hillani Tadesse Bekele

All Works

Background: The prevalence of psychiatric and neurological disorders in populations with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) presents significant public health concerns including impaired quality of life, reduced antiretroviral therapy (ART) adherence, and elevated morbidity and mortality rates. Research suggests that these correlations translate to millions of people globally, given that over 25 million people are living with HIV/AIDS in the African region alone. Objective: This article explores the overlap in clinical presentation and pathophysiology between psychiatric and neurological conditions and seeks to fill current knowledge gaps regarding their co-occurrence, misdiagnosis, and impact on treatment outcomes. Methods: A comprehensive literature …

Longitudinal Characterization Of Males With X-Linked Creatine Transporter Deficiency: Final Results Of A Multiyear Observational Study, Judith S Miller, Cristan Farmer, Susan Blair, Simona Bianconi, Natacha Akshoomoff, Irina Anselm, Bruce A Barshop, Lindsey Becker, Amanda E Bennett, Leandra N Berry, Elizabeth M Berry-Kravis, Aleksandra Bruchey, Anna W Byars, Tricia Cimms, Kim M Cecil, Maxine Covello, Laura S Cubit, Tanvi Das, Robert J Davis, Madison Drye, Can Ficicioglu, John B Fulton, Robin P Goin-Kochel, Whitney Guthrie, Barbara E Hallinan, Fady Hannah-Shmouni, Kathryn E Gustafson, Dwight D Koeberl, Nicola Longo, Eva Mamak, Saadet Mercimek-Andrews, Claire Michalak, Forbes D Porter, Samar Rahhal, Linda Rees, Gail A Spiridigliozzi, Caitlin Stone, Nancy R Sullivan, V Reid Sutton, Rebecca P Thomas, Manisha Udhnani, Susan Waisbren, Michelle Xu, Lin Zhang, Melanie Brandabur, Audrey Thurm

Faculty, Staff and Students Publications

Background: The purpose of the Vigilan observational study (ClinicalTrials.gov, NCT02931682) was to prospectively assess the natural history and developmental course of creatine transporter deficiency (CTD).

Methods: Males with CTD aged 6 months to 65 years were evaluated at 6-month intervals for up to 4 years. Evaluations included neurodevelopmental assessments of intellectual functioning, adaptive functioning, and challenging behaviors and the onset and progression of medical comorbidities.

Results: Fifty participants (median age, 7.6 years) were enrolled. The predominant CTD phenotype consisted of significant intellectual disabilities and limited skill development over time. Most participants had a history of febrile or nonfebrile seizures, …

Distinct Molecular Responses Of Human Intestinal Organoids To Proton And Photon Radiation, Victoria Poplaski, Tajhal D Patel, Hoa Nguyen-Phuc, Amal Kambal, Lawrence Bronk, Mary K Estes, Cristian Coarfa, Sarah E Blutt

Faculty, Staff and Students Publications

Radiation exposure impairs rapidly renewing tissues like the intestinal epithelium, yet translational insights from murine models have been limited by species-specific responses. Here, we use human intestinal organoids (HIOs) derived from jejunal epithelium to evaluate human epithelial responses to low dose proton and photon (gamma) radiation. Gamma irradiation induces a unique developmental and metabolic shift in crypt-like organoids, including enrichment of amino acid metabolism pathways and activation of fetal-associated transcription factors and morphology. Integrated multi-omic profiling reveals serotonin biosynthesis as a central regenerative node. Human intestinal organoids can complement animal models and are emerging as a powerful tool in modeling …

Cohesin Haploinsufficiency Is Tolerated In Cbfb::Myh11-Driven Murine Acute Myeloid Leukemia, Shannon E Conneely, Alexis Quezada, Kristen J Kurtz, Nenggang Zhang, Josephine De La Fuente, Nesa Mercer, Jason H Rogers, Rogelio Aguilar, Geraldo Medrano, Margaret A Goodell, Paul P Liu, Debananda Pati, Rachel E Rau

Faculty, Staff and Students Publications

Cohesin gene mutations occur in many malignancies, including acute myeloid leukemia (AML). Loss-of-function mutations in the four major cohesin complex genes (RAD21, SMC3, SMC1a, and STAG2) occur across most major genetic subtypes of AML but are notably absent in AML harboring CBFB::MYH11, suggesting that cohesin mutations yield distinct biological outcomes dependent on the genetic AML driver. We hypothesized that CBFB::MYH11-expressing leukemias would be dependent on intact cohesin genes given their near-mutual exclusivity. To investigate this, we combined either germline or inducible heterozygous deletions in cohesin genes Smc3 or Rad21, respectively, with an inducible murine model of Cbfb::MYH11 AML. This approach …

A Single-Nucleus Transcriptomic Atlas Of The Adult Aedes Aegypti Mosquito, Olivia V Goldman, Alexandra E Defoe, Yanyan Qi, Yaoyu Jiao, Shih-Che Weng, Brittney Wick, Leah Houri-Zeevi, Priyanka Lakhiani, Takeshi Morita, Jacopo Razzauti, Adriana Rosas-Villegas, Yael N Tsitohay, Madison M Walker, Ben R Hopkins, Aedes Aegypti Mosquito Cell Atlas Consortium, Maximilian Haeussler, Omar S Akbari, Laura B Duvall, Helen White-Cooper, Trevor R Sorrells, Roshan Sharma, Hongjie Li, Leslie B Vosshall, Nadav Shai

Faculty, Staff and Students Publications

The female Aedes aegypti mosquito's remarkable ability to hunt humans and transmit pathogens relies on her unique biology. Here, we present the Aedes aegypti Mosquito Cell Atlas, a comprehensive single-nucleus RNA sequencing dataset of more than 367,000 nuclei from 19 dissected tissues of adult female and male Aedes aegypti, providing cellular-level resolution of mosquito biology. We identify novel cell types and expand our understanding of sensory neuron organization of chemoreceptors across all sensory tissues. Our analysis uncovers male-specific cells and sexually dimorphic gene expression in the antenna and brain. In female mosquitoes, we find that glial cells, rather than neurons, …

Complement Activation In Secondary Thrombotic Microangiopathies, Johann Morelle, Fernando Caravaca-Fontan, Fadi Fakhouri, Eleni Frangou, Annette Bruchfeld, Jürgen Floege, Safak Mirioglu, Sarah M Moran, Stefanie Steiger, Kate I Stevens, Onno Y K Teng, Selda Aydin, Anuja Java, Sjoerd A M E G Timmermans, Andreas Kronbichler

2020-Current year OA Pubs

Secondary thrombotic microangiopathies (TMAs) represent a heterogeneous group of diseases associated with a high risk of kidney failure and death despite available therapeutic strategies. Strong evidence implicates complement activation in the pathogenesis of secondary TMA, and emerging data increasingly suggest that pharmacological blockade of the complement improves the outcomes in patients with secondary TMA. Certain forms of secondary TMA, including postpartum TMA, TMA with coexisting hypertensive emergency and de novo TMA after kidney transplantation exhibit a high prevalence of pathogenic variants in complement genes, similar to those observed in primary atypical haemolytic uraemic syndrome. These conditions should be considered as …

Impact Of Surgical Refusal On Overall Survival In Patients With Rectal Cancer, Vishal Abhimutt Mahesh, Anjali Yadav, Harsheen Kaur Manaise, Berkay Demirors, Paola Berrios Jiminez, Angel Aguayo-Merly, Jade C. Bowers, Bansi P. Savaliya, Reed Popp, Ramin Shekouhi, Guido Chiriboga, Syeda Hoorulain Ahmed, Fatima Mubarak, Esinam Ekpeh, Emmanuel Gabriel

School of Medicine Faculty Publications

BACKGROUND/AIM: While surgery is a major component of treatment for managing rectal cancer, some individuals opt against it, potentially affecting their chances of survival. This study investigated the clinical and demographic elements linked to the decision to refuse surgery and assessed the potential impact of this decision on overall survival (OS). PATIENTS AND METHODS: We conducted a retrospective cohort study using the U.S. National Cancer Database to analyze factors linked to surgery refusal in patients with rectal cancer. Clinical, demographic and treatment characteristics were compared using Pearson chi-square and Wilcoxon rank-sum tests. RESULTS: Among the 115,066 patients with rectal cancer …

Exploring Student Success In A Clinical Neuroscience Course: A Pilot Study On Early Identification And Academic Advising In Physical Therapy Training, Bindu Balakrishnan, James Mathews, Elizabeth Deluca-Berg, Mohan Ganesan

Journal of Innovation in Health Sciences Education

Introduction: This study explored the impact of early identification and student academic advising on performance in the clinical neuroscience course using a mixed-method design. The researchers hypothesized that early identification of students experiencing academic difficulties, followed by comprehensive advising, would improve performance.

Methods: Twenty Doctor of Physical Therapy (DPT) students from the third trimester of the program participated in this mixed-methods study. Early identification was achieved through a quiz in the first week or early second week of the course, with students scoring below 70% offered voluntary enrollment. Nine students were assigned to the control group, while 11 received …

Exploring Health Care Professionals’ Perceptions Of Live Actor Avatar And Ai Avatar Simulated Patient Interactions, Leslie Rippon, Lorene Cobb, Marcia Downer, Alicia Mcgregor, Natalie Neubauer, Lauren Snowdon, Genevieve Zipp

Journal of Innovation in Health Sciences Education

Introduction: The increasing use of simulation in health care and advancing capabilities of virtual technology have increased the use of virtual avatars. Recently, the development of large language models has created an opportunity for virtual reality (VR) simulation through combination of VR and artificial intelligence (AI). This study sought to evaluate the perception of authenticity in prerecorded virtual simulated patient interactions using two different avatar platforms: AI avatar and live actor avatar.

Methods: Participants included 41 health professionals with patient care experience, of which 32 completed the post experience survey. Using a repeated measures mixed methods research design allowed …

Perceptions Of Respect Among Dental Hygiene Students: A Qualitative Study, Jennifer Fehrenbacher

Journal of Innovation in Health Sciences Education

Introduction: Respect for others is an attribute that honors the dignity of individuals. As such, it is a key component in the creation of a positive teacher–student environment that leads to academic success. Because of the subjective nature of the term respect, it is important to determine how specific students perceive it. The purpose of this qualitative study was to explore dental hygiene student perceptions of respect and inquire into their related academic success and care of their own patients. The insights gained from this study could be used to help guide teacher awareness of the needs of students …

Seroprevalence Of Small Ruminant Lentiviruses (Srlvs) And Peste Des Petits Ruminants Virus (Pprv) In Nonvaccinated Sheep And Goats In Sarawak, Malaysia, Bura Thlama Paul, Ali Saidu, Maria Eva Barudi, Faez Firdaus Abdullah Jesse, Juriah Kamaludeen, Suhaili Mustafa, Masnindah Malahubban, Ali Hanafiah Hakim, Krishnan Nair Balakrishnan, Mohd Azmi Mohd Lila

The Thai Journal of Veterinary Medicine

Small ruminant lentiviruses (SRLVs) and Peste des Petits Ruminants virus (PPRV) are economically important viral diseases that threaten small ruminant production globally. While previous studies have reported their serological status in Peninsular Malaysia, there is limited epidemiological information on their occurrence in East Malaysia. This study aimed to determine the seroprevalence and risk factors of SRLVs and PPRV among nonvaccinated sheep and goats from selected smallholder farms in Sarawak. A total of 245 serum samples collected from sheep (n = 117) and goat (n = 128) were screened using commercial ID Screen^® PPR competition (PPRC ver. 0821) and MVV/CAEV …

Arctic Barnabas Ministries: Another Giving Tradition

West Michigan District Dental Society Bulletin

Each Fall, a team of dedicated dental professionals travel from their West Michigan practices to the heart of Alaska to provide much-needed dental care to missionary families who serve in some of the state’s most remote regions. In this interview Dr. Devin Norman discusses the group's mission, the challenges they face, and the stories that have stayed with them.

Better To Give Than To Receive

West Michigan District Dental Society Bulletin

In this article Dr. Sarah Bouwkamp shares her experience joining a University of Michigan dental mission trip to Guatemala, serving patients in need and rediscovering the deeper purpose of dentistry.

Clinical Corner: Pearls From Local Dentists

West Michigan District Dental Society Bulletin

"Clinical Corner" is a section of the WMDDS Bulletin where local dentists share clinical pearls for fellow practitioners.

The Caroline Grace Medema Memorial Fund

West Michigan District Dental Society Bulletin

In this heartfelt letter from Brent and Lorene Medema, the family shares their story and reaction to the decision by the WMDDS Board of Directors to honor their late daughter through the Caroline Grace Medema Memorial Fund. The fund will provide financial support for pregnant women and children in need of dental care.

Wmdds Bulletin Fall 2025

West Michigan District Dental Society Bulletin

In the Fall 2025 issue, the reader will find the following feature articles:

• The Carolina Grace Medema Memorial Fund
• West Michigan Members in Missions: “Better to Give Than to Receive" and "Arctic Barnabas Ministries"
• Pearls from Local Dentists

Also included are your monthly tripartite update, news from West Michigan counties, the President's Message and Editor's Letter.

Cultivating Excellence: Academic Support For Diverse Nursing Students, Tara Flood, Dnp, Rn, Cbc

College of Nursing Posters

Introduction

Cultural experiences and the development of acumen in nursing school are deeply interconnected. Meaningful engagement with diverse cultures fosters empathy, self awareness, and nuanced communication that is essential for providing competent patientcentered care. The inclusion of an Academic Support team in nursing education is essential for nursing student success and for creating inclusive learning environments, particularly for students from diverse backgrounds.

Managing Anticoagulation In A Patient With Calciphylaxis And Mechanical Valve: A Therapeutic Dilemma, Qutaiba Qafisheh, Abdalhakim Shubietah, Mohanad Qwaider, Muath A. Baniowda, Abdalrahman Assaassa, Roaa Aljunaidi, Abubakar Nazir

Division of Cardiology Faculty Papers

BACKGROUND: Calciphylaxis is a rare, life-threatening vasculopathic syndrome most commonly seen in end-stage renal disease (ESRD) and associated with high mortality. Vitamin K antagonists complicate management in patients with mechanical valves by potentially exacerbating vascular calcification while remaining essential for thromboprophylaxis.

CASE PRESENTATION: A 50-year-old woman with ESRD on hemodialysis and a mechanical mitral valve on warfarin presented with severe abdominal pain and rapidly progressive necrotic ulcers. Despite broad-spectrum antibiotics and sodium thiosulfate, lesions worsened. Biopsies were nondiagnostic; however, the clinical phenotype was consistent with calciphylaxis. A multidisciplinary team transitioned anticoagulation from warfarin to subcutaneous unfractionated heparin (UFH) (333 U/kg …

Mosquito Classification And Explainability From Image Data Via Deep Learning Techniques, Farhat Binte Azam

USF Tampa Graduate Theses and Dissertations

According to the World Health Organization (WHO), mosquitoes are the deadliest animals on Earth, responsible for more human deaths annually than any other species. Mosquito-borne illnesses continue to pose severe risks to global health. In 2015 alone, there were an estimated 214 million malaria cases worldwide. Similarly, a 2016 report from the Centers for Disease Control and Prevention (CDC) revealed that Puerto Rico’s Department of Health received over 62,500 suspected cases of Zika, with 29,345 confirmed positive cases. In 2019, Southeast Asia experienced its worst dengue outbreak in recorded history. Of the approximately 4,500 mosquito species distributed across 34 genera, …

Rebound Bursting Selectively Enables Fast Dynamics In Dopamine Midbrain Neurons Projecting To The Dorsolateral Striatum, Strahinja Stojanovic, Christopher J. Knowlton, Richard Egger-Mackrodt, Johanna Mankel, Josef Shin, Stephan Lammel, Carmen C. Canavier, Jochen Roeper

School of Graduate Studies Faculty Publications

Dopamine (DA) midbrain neurons are involved in a wide array of key brain functions including movement control and reward-based learning. They are also critical for major brain disorders such as Parkinson's disease or schizophrenia. DA neurons projecting to distinct striatal territories are diverse with regard to their molecular makeup and cellular physiology, which are likely to contribute to the observed differences in temporal DA dynamics. Among these regions, the dorsolateral striatum (DLS) displays the fastest DA dynamics, which might control the moment-to-moment vigor and variability of voluntary movements. However, the underlying mechanisms for these DLS-specific fast DA fluctuations are unresolved. …

Why Aren’T More People Calling 988 For Mental Health Crises?, Michiko Ueda, Colleen M. Heflin, Yanhong Liu, Qingyi Yu, Seethalakshmi Ramanathan

Center for Policy Research

When someone is in a mental health crisis, calling 911 has long been the default response. However, 911 call centers are not well-equipped to handle mental health emergencies, and law enforcement dispatch can result in unnecessary arrests, hospitalizations, or crisis escalation. The 988 Suicide and Crisis Lifeline launched in 2022 is a free, confidential alternative, yet awareness remains low and misconceptions persist. Using data from a 2024 national online survey of nearly 1,900 U.S. adults ages 18-50, this brief summarizes findings about awareness of 988, willingness to use it, and concerns about the service. Results show that only 22% of …

A Literature Review Of The United States Of America’S Reliance On Imported Covid Personal Protective Equipment During The Pandemic, Pradip K. Shukla, Izzet Kosar, Hedieh Setayesh

Business Faculty Articles and Research

This paper provides a literature review of United States of America’s reliance on imported Covid Personal Protective Equipment (PPEs) during the Covid pandemic. The abstracted and cited articles show that the United States was too reliant on imported PPEs, primarily imported from Asia which led to shortages as the cases of Covid surged at various points during the waves of Covid cases. This supply and demand imbalance was not just an inconvenience such as the toilet paper shortage and other supply chain disruptions of basic commodities; this supply and demand imbalance had life and death impacts for many first responders, …