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To characterize osseointegration as the percent of bone-implant contact (%BIC) along the surface (0.0 mm) as well as at surface profiles 0.5 mm and 1.0 mm lateral to the implant, determining any differences between early occlusally loaded and non-loaded implants. In ten adult female baboons, 120 dental implants were randomly placed in opposing mandibular and maxillary locations. Eighty sites had two groups of healing (no load) of either 1 (n = 40) or 2 (n = 40) months leading to 3 months of functional loading. These sites received full acid-etched surface implants. The 40 control implants represented healing only periods (no load) for 1 (n = 10), 2 (n = 10), 4 (n = 10), and 5 (n = 10) months. These implants were of a vertically split surface texture design (acid-etched and machined). Block sections and photomicrographs were obtained. Blinded histometric analyses determined the %BIC via a superimposed template. The unloaded groups (1, 2, and 4 months) had higher %BIC compared to the 5-month group (p

Objectives: Pregnant women prioritize the health of their pregnancy, and weight gain contributes to the pregnancy’s health. Women encounter different messages about gestational weight gain from various sources that can be confusing. This study aimed to increase our understanding of the processes influencing how women experience the gestational weight gain advice they receive. Methods: Grounded theory methodology was chosen. Women receiving prenatal care in a primary care setting were invited to participate in one-on-one interviews. Results: All fifteen participants had high educational attainment, fourteen were Caucasian, and five had an elevated pre-pregnancy body mass index. Six interconnected themes emerged from the data: (1) striving to have a healthy pregnancy; (2) experiencing influences; (3) feeling worried; (4) Managing ambiguity; (5) trusting a source of information; and (6) feeling relief. Conclusions for Practice: Physicians are perceived by pregnant women to be a source of trusted information about gestational weight gain and are therefore in a strategic position to help women achieve healthy weight gain during pregnancy.

Introduction With the ongoing physician shortage in the field of infectious diseases (ID), innovative models to care are needed to satisfy health care requirements, especially as we face the growing demand of the current coronavirus disease 2019 (COVID-19) pandemic. In New Mexico, Pharmacist Clinicians (PhC) are uniquely fitted to aid ID physicians through additional training and licensing that allows for a collaborative practice model. Objectives The primary objective of this study is to describe the integration of a PhC with a rounding ID attending, utilizing an innovative practice model at an academic medical center, and report providers' views as related to this new position. Methods This was a survey study directed toward primary treating teams and ID attendings, conducted after six months of the creation of the PhC position. One survey was designed specifically for primary treating teams and another survey for ID attendings only. Primary team providers were identified through a log kept by the PhC for every patient intervention. All providers were contacted via e-mail using the REDCap system to evaluate the PhC's communication and ID knowledge by answering three to five multiple choice questions. A quantitative method was used for data analysis. Results Sixty-one (56.5%) providers responded to the surveys. Overall, primary team respondents gave a positive valuation of the position. ID attendings also generally approved of the position and had a similar view to that of the primary teams. The PhC was found to be effective by 92.5% of respondents. The lowest scoring area was the physical exam. There was no significant difference when comparing responses between primary teams and ID attendings. Conclusion An inpatient pharmacist clinician is able to manage complex ID patients to the satisfaction of both ID physicians and members of the primary treating teams in an academic medical center.

Public acceptance of the HPV vaccine has not matched that of other common adolescent vaccines, and HPV vaccination rates remain below the Healthy People 2020 target of 80% compliance. The purpose of this study was to evaluate the capacity of nine pediatric clinics in a Federally Qualified Health Center organization to implement a systems-based intervention targeting office staff and providers using EHRs and a statewide immunization information system to increase HPV vaccination rates in girls and boys, ages 11 to 16 over a 16-month period. System changes included automated HPV prompts to staff, postcard reminders to parents when youths turned 11 or 12 years old, and monthly assessment of provider vaccination rates.During the intervention, 8960 patients (11–16 yo) were followed, with 48.8% girls (n = 4370) and 51.2% boys (n = 4590). For this study period, 80.5% of total patients received the first dose of the HPV vaccine and 47% received the second dose. For the first dose, 55.5% of 11 year old girls and 54.3% of 11 year old boys were vaccinated. For ages 12 to 16, first dose vaccination rates ranged from the lowest rate of 84.5% for 14 yo girls up to the highest rate of 90.5% for 13 yo boys. Logistic regression showed age was highly significantly associated with first dose completion (OR 1.565, 95% CI 1.501, 1.631) while males did not have a significant association with first dose completion compared to females. The intervention increased overall counts of first and second HPV vaccination rates.

Background The incidence of and mortality due to acute kidney injury is high in patients with traumatic shock. However, it is unclear how hemorrhage and trauma synergistically affect renal function, especially when timely volume resuscitation is not available. Method We hypothesized that trauma impairs renal tolerance to prolonged hemorrhagic hypotension. Sprague-Dawley rats were randomized into six groups: control, extremity trauma (ET), hemorrhage at 70 mm Hg (70-H), hemorrhage at 55 mm Hg (55-H), ET + 70 mm Hg (70-ETH), and ET + 55 mm Hg (55-ETH). Animals were anesthetized, and ET was induced via soft tissue injury and closed fibula fracture. Hemorrhage was performed via catheters 5 minutes after ET with target mean arterial pressure (MAP) clamped at 70 mm Hg or 55 mm Hg for up to 3 hours. Blood and urine samples were collected to analyze plasma creatinine (Cr), Cr clearance (CCr), renal oxygen delivery (DO2), urinary albumin, and kidney injury molecule-1 (KIM-1). Results Extremity trauma alone did not alter renal hemodynamics, DO2, or function. In 70-H, CCr was increased following hemorrhage, while Cr, renal vascular resistance (RVR), KIM-1, and albumin levels remained unchanged. Compared with 70-H, ET + 70 mm Hg exhibited increases in Cr and RVR with decreases in CCr and DO2. In addition, ET decreased the blood volume loss required to maintain MAP = 70 mm Hg by approximately 50%. Hemorrhage at 55 mm Hg and ET + 55 mm Hg exhibited a marked and similar decrease in CCr and increases in RVR, Cr, KIM-1, and albumin. However, ET greatly decreased the blood volume loss required to maintain MAP at 55 mm Hg and led to 50% mortality. Conclusion These results suggest that ET impairs renal and systemic tolerance to prolonged hemorrhagic hypotension. Thus, traumatic injury should be considered as a critical component of experimental studies investigating outcomes and treatment following hemorrhagic shock. Level of evidence This is an original article on basic science and does not require a level of evidence.

Obtaining accurate estimates of catch can be challenging for small-scale recreational fisheries. Using inner Shark Bay as a case-study, we investigated whether a state-wide phone-diary (PD) survey could provide robust estimates of boat-based fishing effort and catch (kept and total) of pink snapper (Chrysophrys auratus) and grass emperor (Lethrinus laticaudis). Estimates were compared with those from concurrent surveys for two spatial scales corresponding to the fishery and the three pink snapper stocks within the fishery. A supplementary access point (SAP) survey incorporated remote camera data and interviews with fishers at boat ramps. An aerial survey was used to adjust the SAP estimates, accounting for catches from boat fishers launching from remote beaches (SAP_Aerial). The SAP survey provided the most precise estimates but underestimated catches for one of the stocks. Estimated fishing effort from the SAP_Aerial survey was comparable to the PD survey (3% lower) for inner Shark Bay, as was the estimated kept catch of pink snapper (7% lower) and these estimates were considered robust (Relative Standard Error

Our institution previously initiated a perioperative surgical home initiative to improve quality and efficiency across the hospital arc of care of primary total knee arthroplasty and total hip arthroplasty patients. Phase II of this project aimed to (1) expand the perioperative surgical home to include revision total hip arthroplasties and total knee arthroplasties, hip preservation procedures, and reconstructions after oncologic resections; (2) expand the project to include the preoperative phase; and (3) further refine the perioperative surgical home goals accomplished in phase I.Phase II of the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies project ran from July 2018 to July 2019. The evaluated arc of care spanned from the preoperative surgical consult visit through 90 days postoperative in the expanded population described above.Mean length of stay decreased from 2.2 days to 2.0 days (P.001), 90-day readmission decreased from 3.0% to 1.6% (P.001), and Press-Ganey scores increased from 77.1 to 79.2 (97th percentile). Mean and maximum pain scores and opioid consumption remained unchanged (lowest P = .31). Annual surgical volume increased by 10%. Composite changes in surgical volume and cost reductions equaled $5 million.Application of previously successful health systems engineering tools and methods in phase I of Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies enabled additional evolution of an orthopedic perioperative surgical home to encompass more diverse and complex patient populations while increasing system-wide quality, safety, and financial outcomes. Improved process and outcomes metrics reflected increased efficiency across the episode of care without untoward effects.III Therapeutic.

Motor learning strategies (MLS) can be used to promote motor skills acquisition in children and youth with acquired brain injury (ABI). While occupational therapists (OTs) likely use MLS in clinical practice, research has not investigated the extent and variety of their application.

Objective Hypoglycemia can cause psychological distress in people with diabetes; however, less is understood about the emotional impact of hypoglycemia on their health care providers (HCPs). This article focuses on the experiences and emotions of HCPs caring for patients with diabetes. Methods This was a descriptive qualitative study from the InHypo-DM research program. Purposive sampling was used to recruit 20 HCPs from a variety of professions for 30- to 45-minute semi-structured interviews. An iterative analysis was conducted to identify the overarching themes. Results Three overarching themes encompassed the responses of participants when their patients experienced hypoglycemia. The first was a sense of professional responsibility, as participants felt they must have failed or inadequately fulfilled their professional duties. The second was a more personal range of emotions such as sadness and guilt. The final theme was how these emotions created a “call to action,” prompting participants to identify potential strategies to prevent future hypoglycemic events. Conclusion This qualitative study highlights the emotional impact of patients’ hypoglycemia on HCPs. Although it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected that these responses often became personal emotions. To ameliorate the negative impact of these responses on patient care, HCPs should engage in activities that enable them to anticipate and manage their own emotional responses. In addition, strategies to optimize hypoglycemia detection and prevention should be promoted.

Cystic fibrosis (CF) is a lethal autosomal recessive disorder that afflicts more than 70,000 people. People with CF experience multi-organ dysfunction resulting from aberrant electrolyte transport across polarized epithelia due to mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. CF-related lung disease is by far the most important determinant of morbidity and mortality. Here we report results from a multi-institute consortium in which single-cell transcriptomics were applied to define disease-related changes by comparing the proximal airway of CF donors (n = 19) undergoing transplantation for end-stage lung disease with that of previously healthy lung donors (n = 19). Disease-dependent differences observed include an overabundance of epithelial cells transitioning to specialized ciliated and secretory cell subsets coupled with an unexpected decrease in cycling basal cells. Our study yields a molecular atlas of the proximal airway epithelium that will provide insights for the development of new targeted therapies for CF airway disease. Single-cell RNA profiling of human cystic fibrosis proximal airway tissue reveals an overabundance of epithelial cells transitioning to specialized ciliated and secretory cells coupled with a decrease in cycling basal cells.

To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18–45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women’s health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Objective: Internationally, primary care practice had to transform in response to the COVID pandemic. Informatics issues included access, privacy, and security, as well as patient concerns of equity, safety, quality, and trust. This paper describes progress and lessons learned. Methods: IMIA Primary Care Informatics Working Group members from Australia, Canada, United Kingdom and United States developed a standardised template for collection of information. The template guided a rapid literature review. We also included experiential learning from primary care and public health perspectives. Results: All countries responded rapidly. Common themes included rapid reductions then transformation to virtual visits, pausing of non-COVID related informatics projects, all against a background of non-standardized digital development and disparate territory or state regulations and guidance. Common barriers in these four and in less-resourced countries included disparities in internet access and availability including bandwidth limitations when internet access was available, initial lack of coding standards, and fears of primary care clinicians that patients were delaying care despite the availability of televisits. Conclusions: Primary care clinicians were able to respond to the COVID crisis through telehealth and electronic record enabled change. However, the lack of coordinated national strategies and regulation, assurance of financial viability, and working in silos remained limitations. The potential for primary care informatics to transform current practice was highlighted. More research is needed to confirm preliminary observations and trends noted.

Background Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury. Methods A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes. Results Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications. Conclusions Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications.

Bidirectional quasi-static cyclic loading was applied to a subassembly of drywall partition walls integrated with cross-laminated timber rocking walls. Details aimed to reduce seismic damage to the...

BackgroundPatient-centred interventions to help patients with multimorbidity have had mixed results.AimTo assess the effectiveness of a provider-created, patient-centred, multi-provider case conference with follow-up, and understand under what circumstances it worked, and did not work.Design and settingMixed-methods design with a pragmatic randomised trial and qualitative study, involving nine urban primary care sites in Ontario, Canada.MethodPatients aged 18–80 years with ≥3 chronic conditions were referred to the Telemedicine IMPACT Plus intervention; a nurse and patient planned a multi-provider case conference during which a care plan could be created. The patients were randomised into an intervention or control group. Two subgroup analyses and a fidelity assessment were conducted, with the primary outcomes at 4 months being self-management and self-efficacy. Secondary outcomes were mental and physical health status, quality of life, and health behaviours. A thematic analysis explored the patients’ experiences of the intervention.ResultsA total of 86 patients in the intervention group and 77 in the control group showed no differences, except that the intervention improved mental health status in the subgroup with an annual income of ≥C$50 000 (β-coefficient 11.003, P = 0.006). More providers and follow-up hours were associated with poorer outcomes. Five themes were identified in the qualitative study: valuing the team, patients feeling supported, receiving a follow-up plan, being offered new and helpful additions to their treatment regimen, and experiencing positive outcomes.ConclusionOverall, the intervention showed improvements only for patients who had an annual income of ≥C$50 000, implying a need to address the costs of intervention components not covered by existing health policies. Findings suggest a need to optimise team composition by revising the number and type of providers according to patient preferences and to enhance the hours of nurse follow-up to better support the patient in carrying out the case conference’s recommendations.

Purpose: Pollution affects both health and climate change. There is no published research on the use of four environmental pollution exposure codes new to ICD-10-CM. The purpose of this research is to provide a baseline use of the four codes in Florida, the most frequent related principal diagnoses, demographics of patients exposed to environmental pollution, total charges, and associations of total charges that are related to environmental pollution. Principal Results: There were 341 patients in Florida who visited an ED due to environmental pollution exposure from 2016 to 2019 and 159 patients in Florida who were hospitalized. The total charges for all patients with a documented exposure to environmental pollution were $1,379,217 for ED patients and $9,933,752 for inpatients. The independent variables that were statistically significant in the ED regression model of total charges were other insurance (-0.361 parameter estimate, 0.017 p-value, -30.3% decrease to charges); and for-profit ownership (0.376 parameter estimate, 0.0005 p-value, 45.7% increase to charges). For the inpatient regression model, the independent variables that were statistically significant were Medicare (0.317 parameter estimate, 0.027 p-value, 37.3% increase to charges); LOS (0.091 parameter estimate

Seismic isolation is known to effectively mitigate the effects of horizontal ground shaking in building structures. Recent research has suggested that vertical excitation causes high-intensity slab vibrations that lead to nonstructural component damage. A detailed case study of the application of three-dimensional (3D) isolation in a realistic multi-story frame building is presented. Specifically, the seismic responses of hypothetical special concentric braced frame buildings with horizontal and 3D isolation are compared to evaluate the effectiveness of 3D isolation to mitigate the vertical ground shaking. Overall, 3D isolation with a relatively short isolation period (0.5 s) is adequate to significantly mitigate the vertical acceleration in a flexible frame building, including the amplification at mid-slab relative to adjacent columns, without compromising the usual reductions in horizontal responses.

Diet, lifestyle, and psychosocial factors might influence fertility for men and women, although evidence is mixed, and couple-based approaches are needed for assessing associations with reproductive outcomes. The Impact of Diet, Exercise, and Lifestyle (IDEAL) on Fertility Study is a prospective cohort with contemporaneous detailed follow-up of female partners of men enrolled in the Folic Acid and Zinc Supplementation Trial studying couples seeking infertility treatment (2016–2019). Follow-up of men continued for 6 months, while female partners were followed for 9 months while attempting pregnancy and throughout any resulting pregnancy (up to 18 months). Longitudinal data on diet, physical activity (including measurement via wearable device), sleep, and stress were captured at multiple study visits during this follow-up. A subset of women (IDEALplus) also completed daily journals and a body fat assessment via dual-energy x-ray absorptiometry. IDEAL enrolled 920 women, and IDEALPlus enrolled 218. We demonstrated the ability to enroll women in a prospective cohort study contemporaneous to a partner-enrolled randomized trial. In combination with data collected on male partners, IDEAL data facilitates a couple-based approach to understanding associations between lifestyle factors and infertility treatment outcomes. We describe in detail the study design, recruitment, data collection, lessons learned, and baseline characteristics.

BACKGROUND: The alcohol cue reactivity paradigm is increasingly used to screen medications for the treatment of alcohol use disorder (AUD) and other substance use disorders. Yet, its prospective association with craving and naturalistic drinking outcomes in clinical trials remains unknown. This study embedded repeated human laboratory assessments of alcohol cue reactivity within the context of a randomized controlled trial to examine the effects of varenicline tartrate (Chantix(®)), a partial agonist of α4β2 nicotinic acetylcholine receptors, on alcohol craving among treatment-seeking heavy drinkers with AUD. Our main objectives were to test whether varenicline, as compared to placebo, blunts alcohol-cue elicited craving and test whether alcohol cue reactivity observed in the human laboratory predicts subsequent alcohol craving and use during the remainder of the trial. DESIGN AND METHODS: This double-blind, randomized, two-site study compared the effects of varenicline (up to 2 mg/day) and placebo on responses to in vivo alcohol cue and affective picture cue exposure in the human laboratory. Forty-seven volunteers (18 females, 29 males), ages 23 to 67 years (M = 43.7, SD = 11.5), were recruited from the community via advertisements to participate in a clinical trial designed to study the effects of varenicline on alcohol use. Participants were randomized to either varenicline or placebo for 6 weeks. RESULTS: Varenicline did not attenuate cue-induced alcohol craving relative to placebo, but craving captured during the cue reactivity paradigm significantly predicted subsequent alcohol use in real-world settings during the clinical trial. Higher craving predicted heavier alcohol use. CONCLUSIONS: Our results are among the first to show alcohol cue-induced craving captured during a human laboratory paradigm predicts drinking outcomes in the context of a clinical trial.

Antimicrobial stewardship and outpatient parenteral antimicrobial therapy (OPAT) collide with the newest Joint Commission requirements for outpatient antimicrobial stewardship. The purpose of this paper was to present key stewardship areas applicable to OPAT and review the data behind them. Data on these topics is emerging. Long treatment durations are being challenged and oral routes are garnering evidence for treatment of traditionally intravenous-only regimens. Stability information and incorporation of pharmacokinetic and pharmacodynamic properties may lead to use of continuous infusions, once daily dosing, or long-acting lipoglycopeptides. Different models for patient follow-up, frequency of monitoring, and adverse effect profiles can be used. As the popularity and necessity of OPAT and stewardship programs increase, there is opportunity for multidisciplinary collaboration. While there are many overlapping stewardship principles in OPAT, there may be appropriately discordant principles in this unique scenario as well.

Purpose: Fertility preservation before therapy is underutilized for those diagnosed with cancer as an adolescent or young adult (AYA). The purpose of this study was to describe factors impacting utilization of fertility preservation consultations and procedures among AYAs at the University of Iowa Health Care (UIHC). Methods: Patients were identified by the oncology registry at UIHC. Disease site, histology, date of diagnosis, sex, race, ethnicity, insurance, and zip code data were gathered by the registrars. UIHC's electronic medical record was queried for fertility preservation consultation. The Reproductive Endocrinology and Infertility clinical database captured information about patients who underwent fertility preservation. Rural-urban commuting area codes measured rurality. Descriptive statistics and multivariate linear probability models were used to predict the probability of fertility preservation consultation and procedure. Results: From 2008 to 2017, 2932 AYAs were treated for an invasive malignancy at UIHC. Of the 440 (15%) who received a fertility preservation consultation, 156 (5%) underwent a fertility preservation procedure. Multivariate analyses showed that AYAs with public insurance coverage, those diagnosed with central nervous system (CNS) disease or melanoma, and those >30 years old at diagnosis had a significant decrease in the percentage point probability of having a consultation. The percentage point probability of undergoing a procedure was decreased for female patients, those with melanoma or carcinoma, those seen by a pediatric-based provider, and those diagnosed after 25 years of age. Conclusion: This study has important implications for practice and policy, particularly regarding insurance coverage and patient and provider characteristics leading to fertility preservation consultations and procedures for AYAs with cancer.

Peripheral vasoconstriction is the most critical compensating mechanism following hemorrhage to maintain blood pressure. On the battlefield, ketamine rather than opioids is recommended for pain management in case of hemorrhage, but effects of analgesics on compensatory vasoconstriction are not defined. We hypothesized that fentanyl impairs but ketamine preserves the peripheral vasoconstriction and blood pressure compensation following hemorrhage.Sprague-Dawley rats (11-13 weeks) were randomly assigned to control (saline vehicle), fentanyl, or ketamine-treated groups with or without hemorrhage (n = 8 or 9 for each group). Rats were anesthetized with Inactin (i.p. 10 mg/100 g), and the spinotrapezius muscles were prepared for microcirculatory observation. Arteriolar arcades were observed with a Nikon microscope, and vessel images and arteriolar diameters were recorded by using Nikon NIS Elements Imaging Software (Nikon Instruments Inc. NY). After baseline perimeters were recorded, the arterioles were topically challenged with saline, fentanyl, or ketamine at concentrations relevant to intravenous analgesic doses to determine direct vasoactive effects. After arteriolar diameters returned to baseline, 30% of total blood volume was removed in 25 minutes. Ten minutes after hemorrhage, rats were intravenously injected with an analgesic dose of fentanyl (0.6 μg/100 g), ketamine (0.3 mg/100 g), or a comparable volume of saline. For each drug or vehicle administration, the total volume injected was 0.1 mL/100 g. Blood pressure, heart rate, and arteriolar responses were monitored for 40 minutes.Topical fentanyl-induced vasodilation (17 ± 2%), but ketamine caused vasoconstriction (-15 ± 4%, p0.01). Following hemorrhage, intravenous ketamine did not affect blood pressure or respiratory rate, while fentanyl induced a slight and transient (5 minutes, p = 0.03 vs. saline group) decrease in blood pressure, with a profound and prolonged suppression in respiratory rate (10 minutes, with a peak inhibition of 57 ± 8% of baseline, p0.01). The compensatory vasoconstriction observed after hemorrhage was not affected by ketamine treatment. However, after fentanyl injection, although changes in blood pressure were transiently present, arteriolar constriction to hemorrhage was absent and replaced with a sustained vasodilation (78 ± 25% to 36 ± 22% of baseline during the 40 minutes after injection, p0.01).Ketamine affects neither systemic nor microcirculatory compensatory responses to hemorrhage, providing preclinical evidence that ketamine may help attenuate adverse physiological consequences associated with opioids following traumatic hemorrhage. Microcirculatory responses are more sensitive than systemic response for evaluation of hemodynamic stability during procedures associated with pain management.

IntroductionAirway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients.Materials and MethodsThe Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses.ResultsA total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98–1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07–1.64).ConclusionsIn the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.

This paper presents a new stochastic methodology for evaluating and quantifying the downtime of a structure in terms of a family of fragilities that represent the probability of exceeding p...

BackgroundThe prevalence of multimorbidity varies widely due to the lack of consensus in defining multimorbidity. This study aimed to measure the prevalence of multimorbidity in a primary care setting using two definitions of multimorbidity with two different lists of chronic conditions.MethodsWe conducted a cross-sectional study of 787,446 patients, aged 0 to 99 years, who consulted a family physician between July 2015 to June 2016. Multimorbidity was defined as ‘two or more’ (MM2+) or ‘three or more’ (MM3+) chronic conditions using the Fortin list and Chronic Disease Management Program (CDMP) list of chronic conditions. Crude and standardised prevalence rates were reported, and the corresponding age, sex or ethnic-stratified standardised prevalence rates were adjusted to the local population census.ResultsThe number of patients with multimorbidity increased with age. Age-sex-ethnicity standardised prevalence rates of multimorbidity using MM2+ and MM3+ for Fortin list (25.9, 17.2%) were higher than those for CDMP list (22.0%; 12.4%). Sex-stratified, age-ethnicity standardised prevalence rates for MM2+ and MM3+ were consistently higher in males compared to females for both lists. Chinese and Indians have the highest standardised prevalence rates among the four ethnicities using MM2+ and MM3+ respectively.ConclusionsMM3+ was better at identifying a smaller number of patients with multimorbidity requiring higher needs compared to MM2+. Using the Fortin list seemed more appropriate than the CDMP list because the chronic conditions in Fortin’s list were more commonly seen in primary care. A consistent definition of multimorbidity will help researchers and clinicians to understand the epidemiology of multimorbidity better.

BACKGROUND: Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings. METHODS: We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome. RESULTS: We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes. INTERPRETATION: Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.

Patients with cystic fibrosis (CF) are living longer due to advancements in treatment. We present a patient with CF in whom diagnoses of Human Immunodeficiency Virus (HIV) and severe pneumocystis pneumonia were delayed due to anchor bias. Our case highlights the importance of routine age-appropriate health screenings in patients with CF. In addition, we discuss the number of management challenges that may arise in patients with a dual diagnosis of CF and HIV.

While research supporting the psychological benefits of equine assisted psychotherapy and learning (EAPL) is expanding, little is known about the physiological impact this therapy has on the human and horse. The physical activity for younger adults may hold promise where other therapies have failed, but can this form of exercise therapy be physically demanding on the participant? Therefore, the objective of this study was to measure physiological responses of horse and human for those participating in an EAPL outpatient collegiate recovery program for substance use disorder (SUD). This pilot study assessed humans (n = 4) and horses (n = 5) participating in a collegiate recovery community EAPL SUD program. The six-week program included riding and ground activities for 1 hr/wk. Vital signs (heart and respiratory rates and pain rating) were recorded weekly at the beginning and end of each session. Human pain rating used the Wong-Baker Faces Pain Rating Scale and equines used the Equine Utrecht University Scale for Facial Assessment of Pain (EQUUS-FAP). T-tests were performed comparing measurements at the beginning and end of each session (P = 0.05). Pearson Correlations were used to determine relationships between human and horse vital signs. While no changes were seen in human heart rate, a significant decrease in respiratory rates and pain scores was found by the end of the session (Table 1). Horse heart and respiratory rates and EQUUS-FAP scores increased. A moderate correlation was determined for human and horse respiration rates (r=0.65, P = 0.00). Correlations became weaker when evaluating the other vital signs (Heart Rates: r=0.54, P = 0.00; Pain Rating Scores: r=0.27, P = 0.17). While relationships between horse and human vital signs were limited, it is important to note the differences in how the two physiologically respond to EAPL suggesting further research beyond this pilot study may be needed to investigate the physical demand of EAPL on the horse.

Delirium, sometimes referred to as encephalopathy, is an acute confusional state that is both common in hospitalized patients and associated with poor outcomes. For patients, families, and caregivers, delirium can be a traumatic experience. While delirium is one of the most common diagnoses encountered by the consulting neurologist, the majority of the time it will have been previously unrecognized as such by the care team. Neurologic syndromes such as dementia or aphasia can either be misdiagnosed as delirium or may coexist with it, necessitating careful neurologic assessment. Once the diagnosis of delirium has been established, a careful evaluation for predisposing and precipitating factors can help uncover modifiable contributors, which should be addressed as part of a multicomponent, primarily nonpharmacologic intervention. Importantly, delirium management, which begins with comprehensive prevention, should emphasize the humanity of the delirious patient and the challenges of caring for this vulnerable population. When considered, delirium represents an important opportunity for the neurologist to substantially enhance patient care.

Despite widespread advancements in and envisioned uses for artificial intelligence (AI), few examples of successfully implemented AI innovations exist in primary care (PC) settings.ObjectivesTo identify priority areas for AI and PC in Ontario, Canada.MethodsA collaborative consultation event engaged multiple stakeholders in a nominal group technique process to generate, discuss, and rank ideas for how AI can support Ontario PC.ResultsThe consultation process produced nine ranked priorities: 1) preventative care and risk profiling, 2) patient self-management of condition(s), 3) management and synthesis of information, 4) improved communication between PC and AI stakeholders, 5) data sharing and interoperability, 6-tie) clinical decision support, 6-tie) administrative staff support, 8) practitioner clerical and routine task support, and 9) increased mental health care capacity and support. Themes emerging from small group discussions about barriers, implementation issues, and resources needed to support the priorities included: equity and the digital divide; system capacity and culture; data availability and quality; legal and ethical issues; user-centered design; patient-centredness; and proper evaluation of AI-driven tool implementation.DiscussionFindings provide guidance for future work on AI and PC. There are immediate opportunities to use existing resources to develop and test AI for priority areas at the patient, provider, and system level. For larger-scale, sustainable innovations, there is a need for longer-term projects that lay foundations around data and interdisciplinary work.ConclusionStudy findings can be used to inform future research and development of AI for PC, and to guide resource planning and allocation.SUMMARYWhat is already known?–The field of artificial intelligence and primary care is underdeveloped.What does this paper add?–An environmental scan without geographic location restriction identified 110 artificial intelligence-driven tools with potential relevance to primary care that existed around the time of the study.–A multi-stakeholder consultation session identified nine priorities to guide future work on artificial intelligence and primary care in Ontario, Canada.–Priorities for artificial intelligence and primary care include provider, patient, and system level uses as well as foundational areas related to data and interdisciplinary communication.

Main objectiveTo determine how and to what extent COVID-19 has affected real-world, self-reported glycaemic management in Americans with type 1 or type 2 diabetes taking insulin and/or secretagogues, with or without infection.DesignA cross-sectional substudy using data from the Investigating Novel Predictions of Hypoglycemia Occurrence using Real-world Models panel survey.SettingUSA.ParticipantsAmericans 18–90 years old with type 1 or 2 diabetes taking insulin and/or secretagogues were conveniently sampled from a probability-based internet panel.Primary outcome measureA structured, COVID-19-specific questionnaire was administered to assess the impact of the pandemic (irrespective of infection) on socioeconomic, behavioural/clinical and psychosocial aspects of glycaemic management.ResultsData from 667 respondents (type 1 diabetes: 18%; type 2 diabetes: 82%) were analysed. Almost 25% reported A1c values ≥8.1%. Rates of severe and non-severe hypoglycaemia were 0.68 (95% CI 0.5 to 0.96) and 2.75 (95% CI 2.4 to 3.1) events per person-month, respectively. Ten respondents reported a confirmed or probable COVID-19 diagnosis. Because of the pandemic, 24% of respondents experienced difficulties affording housing; 28% struggled to maintain sufficient food to avoid hypoglycaemia; and 19% and 17% reported challenges accessing diabetes therapies and testing strips, respectively. Over one-quarter reported issues retrieving antihyperglycaemics from the pharmacy and over one-third reported challenges consulting with diabetes providers. The pandemic contributed to therapeutic non-adherence (14%), drug rationing (17%) and reduced monitoring (16%). Many struggled to keep track, and in control, of hypoglycaemia (12%–15%) and lacked social support to help manage their risk (19%). Nearly half reported decreased physical activity. Few statistically significant differences were observed by diabetes type.ConclusionsCOVID-19 was found to cause substantial self-reported deficiencies in glycaemic management. Study results signal the need for decisive action to restabilise routine diabetes care in the USA.Trial registration numberNCT04219514.

Background Invasive fungal disease (IFD) is a common and important complication in children with acute myeloid leukaemia (AML). We describe the epidemiology of IFD in a large multicentre cohort of children with AML. Methods As part of the retrospective multicentre cohort TERIFIC (The Epidemiology and Risk factors for Invasive Fungal Infections in immunocompromised Children) study, proven/probable/possible IFD episodes occurring in children with primary or relapsed/refractory AML from 2003 to 2014 were analysed. Crude IFD prevalence, clinical characteristics, microbiology and treatment were assessed. Kaplan-Meier survival analysis was used to estimate 6-month survival. Results There were 66 IFD episodes diagnosed in 63 children with AML. The majority (75.8%) of episodes occurred in the context of primary AML therapy. During primary AML therapy, the overall prevalence was 20.7% (95% CI 15.7%-26.5%) for proven/probable/possible IFD and 10.3% (95% CI 6.7%-15.0%) for proven/probable IFD. Of primary AML patients, 8.2% had IFD diagnosed during the first cycle of chemotherapy. Amongst pathogens implicated in proven/probable IFD episodes, 74.4% were moulds, over a third (37.9%) of which were non-Aspergillus spp. Antifungal prophylaxis preceded 89.4% of IFD episodes, most commonly using fluconazole (50% of IFD episodes). All-cause mortality at 6 months from IFD diagnosis was 16.7% with IFD-related mortality of 7.6% (all in cases of proven IFD). Conclusions IFD is a common and serious complication during paediatric AML therapy. Mould infections, including non-Aspergillus spp. predominated in this cohort. A systematic approach to the identification of patients at risk, and a targeted prevention strategy for IFD is needed.

IntroductionGiven the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians’ roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario.Methods and analysisWe will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians’ proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses.Ethics and disseminationApproval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.

Background: Individual and societal determinants can affect the need and propensity for healthcare utilization (HCU) following diabetes-related severe hypoglycemia (SH). This is the first US study to explore the real-world risk factors of HCU- versus non HCU-based SH. Methods: Data were collected online from a generalized cohort of Americans (≥18 years old) with type 1 or type 2 diabetes (T1D, T2D) on insulin and/or secretagogues. Multivariable logistic regression using backward selection was performed to identify the socio-demographic/clinical risk factors of past-year HCU- versus non HCU-based SH (daytime/nocturnal SH resulting in hospital or paramedical services). Results: Results are based on 642 (T1D: 22.7%; female: 46.3%) of 1694 baseline respondents who experienced ≥1 SH events (past year). People with T1D were 40.9 (SD:12.5) years old, while those with T2D were 45.4 (SD: 13.3) years old. Among T2D respondents, 42.5% were on insulin and secretagogues, 31.1% were on insulin alone, and 26.4% on secretagogues alone. Almost half (44.6%) of participants (T1D: 29.9%; T2D: 49.0%) reported ≥1 HCU-based SH events (past year). In the final backward logistic model, the odds of past-year HCU-based SH decreased significantly with female sex, increasing age, decreasing income, and suburban or rural (versus urban) living. Diabetes type did not have an independent effect. However, for individuals on combination insulin-secretagogue therapy, the adjusted odds of HCU-based SH were 2- and 3-times that of those on insulin alone and secretagogues alone, respectively. High A1C (versus Conclusion: Our study reveals several factors that can promote or reduce the odds of HCU-based SH. Therapeutic optimizations to mitigate non-essential HCU should prioritize patients on combination insulin-secretagogue therapy and those with poor glycemic control. Disclosure A. Ratzki-leewing: Consultant; Self; Eli Lilly and Company, Novo Nordisk, Other Relationship; Self; Sanofi. J. E. Black: None. B. L. Ryan: None. G. Zou: None. S. B. Harris: Advisory Panel; Self; Abbott Diabetes, Abvance Therapeutics, HLS Therapeutics Inc., Lilly Diabetes, Novo Nordisk A/S, Consultant; Self; Boehringer Ingelheim (Canada) Ltd., mdBriefCase, Other Relationship; Self; American Diabetes Association, AstraZeneca, Novo Nordisk Canada Inc., Sanofi. Funding Sanofi Global

ObjectivesThere are multiple instruments for measuring multimorbidity. The main objective of this systematic review was to provide a list of instruments that are suitable for use in studies aiming to measure the association of a specific outcome with different levels of multimorbidity as the main independent variable in community-dwelling individuals. The secondary objective was to provide details of the requirements, strengths and limitations of these instruments, and the chosen outcomes.MethodsWe conducted the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018105297). We searched MEDLINE, Embase and CINAHL electronic databases published in English and manually searched the Journal of Comorbidity between 1 January 2010 and 23 October 2020 inclusive. Studies also had to select adult patients from primary care or general population and had at least one specified outcome variable. Two authors screened the titles, abstracts and full texts independently. Disagreements were resolved with a third author. The modified Newcastle-Ottawa Scale was used for quality assessment.ResultsNinety-six studies were identified, with 69 of them rated to have a low risk of bias. In total, 33 unique instruments were described. Disease Count and weighted indices like Charlson Comorbidity Index were commonly used. Other approaches included pharmaceutical-based instruments. Disease Count was the common instrument used for measuring all three essential core outcomes of multimorbidity research: mortality, mental health and quality of life. There was a rise in the development of novel weighted indices by using prognostic models. The data obtained for measuring multimorbidity were from sources including medical records, patient self-reports and large administrative databases.ConclusionsWe listed the details of 33 instruments for measuring the level of multimorbidity as a resource for investigators interested in the measurement of multimorbidity for its association with or prediction of a specific outcome.

We present the case of a prepubescent man of African descent who developed a spitzoid melanocytic proliferation showing evidence of a novel promoter hijacking ALK-C2orf42 rearrangement, with atypical histology, clinically apparent metastatic disease, and abnormal cytogenetic findings, representing a rare genuine case of "Spitz melanoma of childhood." As our understanding of the distinct molecular biology of different tumors traditionally grouped as spitzoid melanocytic lesions evolves, it is becoming increasingly apparent that this group encompasses morphologically and genetically distinct entities. Accurate classification with detailed molecular analysis and prolonged clinical follow-up is essential to allow meaningful conclusions regarding prognostication and prediction of response to therapy.

RATIONALE: Novel coronavirus infectious disease (COVID-19) is caused by the severe acute respiratory distress syndrome related coronavirus 2 (SARS-CoV-2). Patients with underlying respiratory disease are considered at increased risk of contracting severe COVID-19. Many respiratory diseases including chronic obstructive pulmonary disease, asthma, and cystic fibrosis, have elevated inflammation driven by recruitment of neutrophils, known as neutrophilia, and contributes to disease pathogenesis. In response to viral infection, neutrophils are the first, and predominant, leukocyte recruited to the respiratory tract. Neutrophils release inflammatory mediators as part of the acute inflammatory response and contribute to pathogen clearance through virus internalization and killing, secretion of antimicrobial peptides and extracellular traps. It remains uncertain how critical the neutrophil response is in SARS-CoV-2 and to what extent this contributes to the cytokine response of the airways in COVID-19. We hypothesized that neutrophils are responsible for elevated inflammatory responses in patients who progress to severe COVID-19. Methods: To investigate, we developed a co-culture model of neutrophilic airways to study SARS-CoV-2 infection, combining primary human neutrophils and airway epithelial cells differentiated at the air-liquid interface. These cultures, with and without neutrophils, were infected with live SARS-CoV-2 and the inflammatory responses analyzed. In addition, extensive analysis of ACE2, neutrophils and inflammatory response, was performed comparing our models and COVID-19 patient and non-infected lung tissues. Results: ACE2 protein, the receptor binding to the S-protein of SARS-CoV-2, was predominantly expressed in submucosal glands, ciliated cells and in alveolar type 2 cells in human lung tissues. Surprisingly, substantial co-localization of ACE2 was also observed with neutrophil elastase and CD15 expressing neutrophils infiltrating the airways. Analysis of mono-and co-cultures of airway epithelial cells and neutrophils in the presence or absence of SARS-CoV-2 infection indicated significant increases in the expression of squamous epithelium associated cytokeratins, damage associated molecular patterns (DAMPS) and a downregulation of interleukin 8 (IL-8) specifically in the co-culture models. Airway supernatants from the basolateral and apical surfaces were profiled. In the neutrophil co-cultures significant increases in IFNγ, IL-1β, IL-6 and TNFα were observed in response to SARS-CoV-2 infection. Conclusions: In conclusion, we demonstrate that co-culture with neutrophils has a significant impact on SARS-CoV-2 infection, changing the inflammatory response and upregulating gene expression patterns associated with tissue remodeling and tissue damage. This study highlights the need to study SARS-CoV-2 infection in more complex, tissue-level models to fully understand the mechanisms driving the severe inflammatory response and the long-term consequences of infection.

Influenza vaccination is recommended for children following allogeneic haematopoietic stem cell transplant (HSCT), however there is limited evidence regarding its benefit. A prospective multicentre study was conducted to evaluate the immunogenicity of the inactivated influenza vaccine in children who have undergone HSCT compared with healthy age-matched controls. Participants were vaccinated between 2013 and 2016 according to Australian guidelines. Influenza-specific hemagglutinin inhibition antibody titres were performed prior to each vaccination and 4 weeks following the final vaccination. A nasopharyngeal aspirate for influenza was performed on participants that developed influenza-like illness. There were 86 children recruited; 43 who had undergone HSCT and 43 controls. For the HSCT group, seroprotection and seroconversion rates were 81.4% and 60.5% for H3N2, 41.9% and 32.6% for H1N1, and 44.2% and 39.5% for B strain respectively. There was a significant geometric mean fold increase to the H3N2 (GMFI 5.80, 95% CI 3.68–9.14, p

Although intensive multimodal treatment has improved outcomes for patients with high-risk neuroblastoma, the specific role of primary tumor resection remains controversial. Many studies have been designed to determine whether the extent of surgical resection impacts survival; however, these reports have demonstrated conflicting results. There is also ongoing debate regarding the timing of primary tumor resection, with subtle differences in the approach between the large pediatric oncology cooperative consortia. Most of the published literature to date has been approached from a surgical viewpoint. Although most evidence supports surgery as part of the local control approach for high-risk neuroblastoma, recommendations for timing and extent of surgical resection are not consistent. This review summarizes our current understanding from the perspectives of both the pediatric oncologist and pediatric surgeons and discusses how the objectives of neuroblastoma primary surgical resection are different from that of other malignancies. Furthermore, this commentary will address how retrospective surgical outcome data may be interpreted in the setting of modern era high-risk neuroblastoma treatment.

The increasing availability of hybrid PET/MRI systems has led to a breadth of new publications and opportunities for use of PET/MRI. While PET/CT has been a valuable tool for oncologic staging, including head and neck malignancy, there are several theoretical and practical advantages a PET/MRI system would have over PET/CT in head and neck imaging. This review article discusses the established role of PET/CT, early evidence for the role of PET/MRI, and protocol considerations for both PET/CT and PET/MRI as they apply to head and neck imaging.

Hypoglycemia is one of the most common adverse events for people living with type 1 or type 2 diabetes. To gain a deeper understanding of patients’ emotions regarding hypoglycemia, we conducted a descriptive qualitative study. Purposive sampling was used to recruit participants for a 30- to 45-minute semi-structured interview. The 16 participants included both women and men with either type 1 or type 2 diabetes, with a mean age of 53 years and mean time since diagnosis of 21 years. All participants had experienced more than one hypoglycemia event in the past year, ranging from nonsevere to severe. Data collection and analysis occurred in an iterative manner. Individual and team analyses of interviews were conducted to identify overarching themes and sub-themes. Thematic analysis revealed the unique interconnection among the emotions experienced by participants, including fear, anxiety, frustration, confidence, and hope. Time, experience, and reflection helped to build participants’ confidence in their ability to manage a hypoglycemia event. Patients’ emotions regarding hypoglycemia provide valuable insights into life with diabetes. Although hypoglycemia continues to evoke feelings of fear and anxiety, the role of hope may temper these emotions. Understanding the complex interplay of emotions concerning hypoglycemia can guide health care providers in improving clinical practice and promoting patient-centered interventions. Ultimately, health care providers can build patients’ hypoglycemia-related confidence by using a strengths-based approach.

Purpose: Given the ongoing desire to make health care more patient-centered and growing evidence supporting the provision of patient-centered care, it is important to have valid tools for measuring patient-centered care. The patient-centered clinical method (PCCM) is a conceptual framework for providing patient-centered care. A revision to the PCCM framework led to a corresponding need to enhance the Patient Perception of Patient-Centeredness (PPPC) questionnaire. The original PPPC was aligned with the components of the PCCM conceptual framework and developed to measure patient-centeredness from the patient’s perspective. The purpose of this study was to examine the factor structure of a revised version of the PPPC (ie, PPPC-R). Methods: Eleven new items were added to the original 14 items. The modified questionnaire was administered to patients in primary health care teams in Ontario, Canada. The confirmatory factor analysis was conducted on a subset of 381 patients who had seen a family physician. Results: The initial proposed 4-factor model first tested with a confirmatory factor analysis (CFA) did not fit adequately. Exploratory factor analysis was therefore used as a second step to modify the model and to identify weak items. A 3-factor exploratory model with 18 of the original 25 items was converted into a final hypothetical CFA model that had a good fit (χ2(132) = 176.795, P < 0.01; CFI = 0.991; RMSEA = 0.030). The third factor contained only 2 items and so is interpreted with caution. Conclusions: The validity of the PPPC-R is supported by some congruence between the conceptual framework (the PCCM) and the statistical analysis (CFA), but there is not a 1:1 correspondence. The components of the PCCM represent conceptually what is important when teaching, researching, and providing patient-centered care, whereas the PPPC-R represents patient-centered care as it is experienced by the patient.

Recreational fishing is popular in Australia and is managed by individual states in consultation with the Commonwealth for those fisheries that they regulate and also for Australian Marine Parks (AMPs). Fishers regularly access both state and offshore Commonwealth waters but this offshore component of the recreational fishery is poorly understood. Our study tested the functionality of existing state-based surveys in Western Australia (WA) and New South Wales (NSW) to better inform Commonwealth fisheries and AMP managers about recreational fishing in their jurisdictions. Catch estimates for nine species of interest to the Commonwealth were developed and two case study AMPs [Ningaloo (WA) and The Hunter (NSW)] were also chosen to test the ability of the state survey data to be disaggregated to the park scale. As each state’s fishery survey designs were contextual to their own management needs, the application of the data to Commonwealth jurisdictions were limited by their statistical power, however aspects of each states surveys still provided useful information. Continued evolution of state-wide survey methods, including collection of precise spatial data, and regional over-sampling would be beneficial, particularly where there are multiple stakeholder and jurisdictional interests. National coordination, to temporally align state surveys, would also add value to the existing approaches.