Joint Commission

The proliferation of distributed energy resources (DERs) and the increasing frequency of high-impact events have introduced challenges for the reliability, resilience, and operational flexibility of modern electric power systems. Microgrids have emerged as a promising solution, enabling localized control, seamless transition between grid-connected and islanded modes, and enhanced integration of DERs. This article presents the design, implementation, and operational validation of the Bronzeville Community Microgrid (BCM), a pioneering utility-scale microgrid commissioned by Commonwealth Edison (ComEd) in Chicago, Illinois. The BCM integrates a diverse mix of customer loads and DERs, advanced automation, and a microgrid master controller (MMC) to manage dynamic operating modes and adaptive protection. The article details the technical architecture, control strategies, and functionality validation through hardware-in-the-loop simulations and field tests, demonstrating the BCM’s capabilities for planned islanding, grid reconnection, and clustering with the Illinois Institute of Technology campus microgrid. Lessons learned and strategic opportunities for future microgrid deployments are discussed, highlighting the role of microgrids in advancing resilient, distributed, and intelligent power systems.

Wheat end-product quality results from complex interactions among protein, starch, and fiber, further complicated by genetic and environmental variability, especially in commercial samples composed of multiple varieties from diverse regions. Eighteen composite samples of hard red spring wheat (HRSW) were prepared from 755 field samples to simulate commercial grain blending. These composites were analyzed to evaluate the influence of flour composition on product quality. A wide range of flour compositional properties was analyzed and associated with dough and end-product quality traits, as measured by GlutoPeak, Rapid Visco Analyzer, Farinograph, Extensograph, Alveograph, and loaf baking. The results indicated that dough and bread quality are not determined by protein or gluten content alone, but that protein, starch and fiber composition and structural variations play a crucial role. Flours with higher proportions of high-molecular-weight glutenin (HMW-GS) fractions, particularly those rich in Bx and Ax subunits, exhibited greater dough resistance, mixing strength, and bread volume. In contrast, lower-performing samples were characterized by reduced HMW/LMW, polymeric/monomeric protein ratios, and HMW-Bx content. Multivariate modeling showed strong predictive performance for loaf volume (R2 > 0.860) when protein, starch and fiber quality metrics were combined with protein content. These findings provide a data-driven framework for wheat flour classification and optimizing processing formulation.

The "2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease" provides recommendations to guide clinicians on the evaluation and treatment of adult patients with congenital heart disease. It incorporates new evidence to replace the "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease." A comprehensive literature search was conducted with a focus on literature published from 2017 to 2024; in some instances, older literature was also collected and reviewed. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants and published in English were identified from MEDLINE (via PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and CINAHL for selected searches. Recommendations from the "2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease" have been updated with new evidence to guide clinicians.

Corruption is classified as an extraordinary crime, necessitating the adoption of non-traditional law enforcement strategies. Recent developments allow judges to determine guilt or innocence based on evidence presented in court. This study examines the legal implications of judicial involvement in corruption investigations, with a particular emphasis on the evolving role of the dominus litis, traditionally reserved for public prosecutors. The research further explores reinterpretations of the negatief wettelijk principle and the concept of criminal awareness. Employing a normative juridical methodology, the study reviews relevant statutes, legal doctrines, and case law to inform its analysis. The findings suggest that judicial identification of suspects may undermine the principle of dominus litis and lead to institutional conflict between prosecutors and judges. This practice alters the application of the negatief wettelijk principle by enabling judges to form legal opinions before formal investigations are conducted. Additionally, the understanding of criminal awareness has shifted towards a more interpretive judicial approach. It is therefore essential to establish clear and equitable regulations governing judicial authority in corruption cases to ensure fair trials, prevent abuse of power, and maintain the balance and independence of law enforcement institutions.

Aims: Emergency NHS services are under considerable pressures from patient demand and ineffectual care and social pathways. This is especially felt within the mental health services where demand has grown from long periods of austerity and the Covid pandemic. To reduce demand on both ambulances and emergency departments Welsh ambulance implemented the roll out of mental health practitioners within its 999 call centres which has been very successful, however, the successful closure/treatment rate is less than half the callers. Over half of all mental health 999 callers require face to face intervention therefore ambulances within Wales need to implement mental health response vehicles in order to achieve this.Methods: To test this further between January and March this year a pilot was conducted in Aneurin Bevan University Health Board over a 9-week period operating Friday to Sunday 1 pm to 12 am.Results: The pilot achieved very positive outcomes in staff satisfaction and perceived patient satisfaction, along with 74% see, treat and close at scene rate, 7% conveyance to mental health facilities and 19% Emergency department conveyance rate.Conclusion: The project has been a huge success and demonstrates how working in partnerships across organisations can achieve significant success through overcoming barriers as and when they arise. Mental health patients can face long waits and psychological hardships whilst they wait for treatments. MHRV can provide not only rapid responsive assessments but also provide a therapeutic intervention to those patients, thereby improving quality of care to mental health patients and releasing further ED and ambulance resource to the general public.Finally, a national rollout of this way of working will require a significant investment, both financially and staffing; obtaining suitably qualified, experienced and skilled staff will represent a significant burden upon Welsh health boards or English Trusts. English ambulance trusts have already faced issues with recruiting staff into their services, which may be the same in WAST or if successful will mean that health boards will lose staff from within their organisations placing an additional burden upon their services (in 2023 the National Commissioning and Collaborative Unit reported that there were circa 500 mental health nurse vacancies across Wales).The authors propose that a partnership approach is required with the Welsh NHS executive, HEIW, Welsh universities and health boards to explore training options and create a national mental health education package for Wales. WAST will be able to train and equip its existing staff with mental health knowledge and skills to treat patients utilising the ambulance service.

Empiric extended-spectrum antibiotics are routinely prescribed for patients hospitalized with skin and soft tissue infections (SSTIs) despite low likelihoods of infection with multidrug-resistant organisms (MDROs). To evaluate whether computerized provider order entry (CPOE) prompts presenting patient-specific and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for noncritically ill patients admitted with SSTI. This cluster randomized clinical trial included 92 hospitals and assessed the effect of an antibiotic stewardship bundle that included CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults hospitalized with SSTI. The trial population included adults 18 years and older treated with empiric antibiotics for SSTI in non-intensive care unit (ICU) settings. Data were collected from January 2019 to December 2023. CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period when absolute risk of MDRO SSTI was estimated to be less than 10%, coupled with feedback and education. The primary outcome was empiric extended-spectrum antibiotic days of therapy (summed number of different extended-spectrum antibiotics targeting Pseudomonas and/or MDR gram-negative bacteria received per patient each calendar day). The secondary outcome was antipseudomonal days of therapy. Safety outcomes included days to ICU transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Among 118 562 patients admitted with SSTI at 92 hospitals, 67 033 (56.7%) were male and the mean (SD) age was 58.0 (17.5) years. A total of 57 837 patients were included in the baseline period and 60 725 in the intervention period. Receipt of any empiric extended-spectrum antibiotic during the baseline and intervention periods was 57.0% (16 855 of 29 595) and 56.0% (17 534 of 31 337), respectively, for the routine stewardship group compared with 55.4% (15 650 of 28 242) and 43.0% (12 647 of 29 388), respectively, for the CPOE group. Empiric extended-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens was 511.5 during the baseline period and 488.7 during the intervention period in the routine stewardship group and was 496.2 and 359.1, respectively, in the CPOE bundle group (rate ratio, 0.72; 95% CI, 0.67-0.79; P < .001). There was no evidence of inferiority in the CPOE bundle group for mean (SD) hospital length of stay (routine stewardship, 6.5 [3.8] days; CPOE bundle, 6.4 [3.8] days) and days to ICU transfer (routine stewardship, 6.3 [3.2] days; CPOE bundle, 6.3 [3.1] days). In this randomized clinical trial, CPOE prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI coupled with education and feedback significantly reduced use of extended-spectrum antibiotics without increasing admissions to ICUs or hospital length of stay. ClinicalTrials.gov Identifier: NCT05423756.

Given the risk of venous thromboembolism (DVT) and pulmonary embolism (PE) after large joint replacement, the role of thromboprophylaxis is crucial. This retrospective study aims to evaluate the effectiveness of aspirin as thromboprophylaxis in patients undergoing TKA or THA. In this retrospective review of a database of patients who underwent total hip and total knee replacements between 2021 and 2023, we divided patients into two groups: those with no anticoagulation therapy before surgery and those on chronic anticoagulant use prior to surgery. The primary endpoint was the number of patients with complications after aspirin use in the postoperative period. We collected patient demographic information, history of anticoagulant use, postoperative anticoagulant usage, comorbidities, type of surgery, reactions to anticoagulants, complications related to thromboembolism, length of hospital stay, and hospital readmissions. For patients who underwent elective THA or TKA, no significant difference in overall VTE or PE rates was detected when comparing aspirin with other anticoagulants. No mortality events were reported. However, there were differences in bleeding event rates between the aspirin group and other anticoagulant groups. Proper patient selection and early postoperative mobilization support the use of aspirin as a thromboprophylaxis therapy. The results of this study confirm that aspirin is a safe alternative to other anticoagulants in the postoperative management of THA and TKA.