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Background There is a need for evidence-based guidance on complementary medicines and therapies (CMT) use during pregnancy due to high prevalence of use and lack of guidance on the balance of benefit and harms. Aim Evaluate the extent to which current clinical practice guidelines relevant to Australian healthcare professionals make clear and unambiguous recommendations about CMT use in pregnancy, and synthesise these recommendations. Methods The search included EMBASE, PubMed, the National Health and Medical Research Council’s Clinical Practice Guidelines Portal, and websites of Australian maternity hospitals and professional/not-for-profit organisations for published guidelines on pregnancy care. Data were synthesised narratively. Guidelines were appraised by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Findings A total of 48 guidelines were found, of which 41% provided recommendations that were not limited to routine vitamin and mineral supplementation. There were wide variations in recommendations, particularly for vitamin D and calcium. There was some consensus on recommending ginger and vitamin B6 for nausea and vomiting, and additional supplementation for women with obesity. Guidelines generally scored poorly in the domains of editorial independence and rigour of development. Discussion There is a lack of guidance with regard to appropriate CMT use during pregnancy, which may result in less-than-optimal care. Inconsistency between guidelines may lead to variations in care. Conclusion Guidelines should include clear and unambiguous guidance on appropriate CMT use during pregnancy, be based on a structured search of the evidence and informed by stakeholder engagement.

BACKGROUND: Black women have greater than a three-fold risk of pregnancy-associated death compared to White women; cardiomyopathy is a leading cause of maternal mortality. OBJECTIVES: This study examined racial disparities in health outcomes among women with peripartum cardiomyopathy. STUDY DESIGN: Retrospective cohort of women with peripartum cardiomyopathy per the National Heart, Lung, and Blood Institute definition from January 2000–November 2017 from a single referral center. Selected health outcomes among Black and White women were compared; primary outcome was ejection fraction at diagnosis. Secondary outcomes included cardiovascular outcomes, markers of maternal morbidity, resource utilization, and subsequent pregnancy outcomes. RESULTS: Ninety-five women met inclusion criteria: 48% Black, 52% White. Nearly all peripartum cardiomyopathy diagnoses were postpartum (95.4% Black, 93% White, p=0.11). Ejection fraction at diagnosis was not different between Black and White women (26.8% ± 12.5 vs 28.7% ± 9.9, p=0.41). Though non-significant, fewer Black women had myocardial recovery to EF ≥ 55% (35% vs 53%, p = 0.07); however, 11 (24%) of Black women vs 1 (2%) White woman had an ejection fraction ≤ 35% at 6 – 12 months postpartum (p < 0.01). More Black women underwent implantable cardioverter defibrillator placement: n = 15 (33%) vs n = 7 (14%), p=0.03. Eight women (8.4%) died in the study period, not different by race (p = 0.48). Black women had higher rates of healthcare utilization. In the subsequent pregnancy, Black women had a lower initial ejection fraction (40% vs 55%, p = 0.007) and were less likely to recover postpartum (37.5% vs 55%, p = 0.02). CONCLUSIONS: Black and White women have similar mean ejection fraction at diagnosis of peripartum cardiomyopathy, but Black women have more severe left ventricular systolic dysfunction leading to worse outcomes, increased resource use, and lower ejection fraction entering the subsequent pregnancy.

Extensive clinical data from liver-mediated gene therapy trials have shown that dose-dependent immune responses against the vector capsid may impair or even preclude transgene expression if not managed successfully with prompt immune suppression. The goal of this preclinical study was to generate an adeno-associated viral (AAV) vector capable of expressing therapeutic levels of B-domain deleted factor VIII (FVIII) at the lowest possible vector dose to minimize the potential Risk of a capsid-mediated immune response in the clinical setting. Here, we describe the studies that identified the investigational agent SPK-8011, currently being evaluated in a phase 1/2 study (NCT03003533) in individuals with hemophilia A. In particular, the potency of our second-generation expression cassettes was evaluated in mice and in non-human primates using two different bioengineered capsids (AAV-Spark100 and AAV-Spark200). At 2 weeks after gene transfer, primates transduced with 2 × 1012 vg/kg AAV-Spark100-FVIII or AAV-Spark200-FVIII expressed FVIII antigen levels of 13% ± 2% and 22% ± 6% of normal, respectively. Collectively, these preclinical results validate the feasibility of lowering the AAV capsid dose for a gene-based therapeutic approach for hemophilia A to a dose level orders of magnitude lower than the first-generation vectors in the clinic., Graphical Abstract, The studies presented here represent the proof-of-concept work that generated the investigational agent SPK-8011, currently being evaluated in a phase 1/2 study (NCT03003533) for treatment of hemophilia A. Through a multi-pronged optimization approach, an adeno-associated viral vector capable of expressing therapeutic levels of hFVIII at the lowest possible vector dose was generated.

Biodistribution studies of adenovirus-based vaccines support their clinical development by evaluating their spread and persistence following in vivo administration. AZD1222 (ChAdox1 nCov-19) is a replication-deficient non-human adenovirus-vectored vaccine for coronavirus disease 2019. In this nonclinical study, the biodistribution of AZD1222 was assessed in mice for 29 days following intramuscular injection. Results show that AZD1222 was safe and well tolerated, with a spread that was largely confined to administration sites and the proximal sciatic nerve, with low levels observed in sites that are involved in rapid clearance of particulates by the reticuloendothelial system. Accordingly, levels of AZD1222 decreased from Day 2 to Day 29, indicating clearance. There were no quantifiable levels of AZD1222 in the blood, brain, spinal cord, and reproductive tissue, suggesting a lack of widespread or long-term distribution of AZD1222 vector DNA throughout the body following its administration.

Context Non-alcoholic fatty liver disease, characterized by excess fat accumulation in the liver, is considered the hepatic manifestation of metabolic syndrome. Recent findings have shown that high-intensity interval training (HIIT) can reduce liver fat but it is unclear whether this form of exercise is superior to traditional moderate-intensity continuous training (MICT). Objective The aim of this systematic review was to determine the effect of HIIT vs MICT on liver fat in adults. A secondary aim was to investigate the interaction between total weekly exercise volume and exercise-related energy expenditure and change in liver fat. Methods Relevant databases were searched up to December 2020 for randomized trials, comparing HIIT to control, MICT to control, or HIIT to MICT. Studies were excluded if they did not implement 2 or more weeks’ intervention or assess liver fat using magnetic resonance-based techniques. Weighted mean differences and 95% CIs were calculated. Regression analyses were undertaken to determine the interaction between weekly exercise volume in minutes and kilocalories (kcal) with change in liver fat content. Results Of the 28 268 studies screened, 19 were included involving 745 participants. HIIT and MICT both elicited moderate reductions in liver fat content when compared to control (HIIT: –2.85%, 95% CI, –4.86 to –0.84, P = .005, I2 = 0%, n = 114, low-certainty evidence; MICT: –3.14%, 95% CI, –4.45 to –1.82, P Conclusion HIIT elicits comparable improvements in liver fat to MICT despite often requiring less energy and time commitment. Further studies should be undertaken to assess the relative importance of aerobic exercise prescription variables, such as intensity, on liver fat.

Background: Endometriosis affects around 10% of women worldwide. Many women with endometriosis struggle with finding adequate pain management, and data from other countries suggest that women use cannabis, either legal or illicit, to help manage their endometriosis symptoms. The aim of this study was to determine use of cannabis where endometriosis was self-identified as a condition that was being treated with cannabis, as well as the impact of cannabis use on the usage on other pharmaceuticals. Materials and Methods: A cross-sectional online survey of those using cannabis for health-related conditions run between May and July 2019. This article reports on the subset of this larger data set for those reporting they had a diagnosis of endometriosis and/or polycystic ovary syndrome. Data were collected on demographics, modes of cannabis administration, symptoms treated, changes in pharmaceutical usage, and adverse events. Results: Two hundred thirteen valid responses were analyzed. Mean age of respondents was 32 years and 79.8% were current cannabis users. The most common outcomes that cannabis was used for were to improve pain relief (95.5%) and to improve sleep (95.5%). Respondents reported that their symptom was "much better" for pain (81%), sleep (79%), and nausea or vomiting (61%). Over three-quarters (81.4%) indicated cannabis had reduced their normal medication usage. Over half (59%) were able to completely stop a medication, most commonly (66%) analgesics. Opioids (40%) were the most common class of analgesic stopped. Conclusions: Cannabis is reported as an effective intervention for pain and other endometriosis symptoms with potential substitution effects on opioid usage.

Objective: To determine the acceptability and feasibility of acupuncture for the treatment of endometriosis-related chronic pelvic pain. Design: A prospective, randomized controlled feasibility study. Setting: Outpatient setting in Sydney, Australia. Subjects: Participants who were aged 18-45 years, had a confirmed laparoscopic diagnosis of endometriosis in the past 5 years, and had regular menstrual periods and mean pelvic pain scores ≥4/10. Interventions: Sixteen acupuncture treatments delivered by registered acupuncturists using a standardized point protocol over 8 weeks, twice per week plus usual care compared with usual care alone. Outcome measures: Primary outcome measures were feasibility, safety, and acceptability of the acupuncture intervention. Secondary outcomes were changes in self-reported pelvic pain scores, changes in quality of life as measured by the Endometriosis Health Profile (EHP-30), changes in descending pain modulation, and changes in systemic inflammation (plasma interleukin [IL-6] concentrations). Results: Twenty-nine participants were eligible to participate, with 19 participants completing the trial. There was unequal withdrawals between groups; the acupuncture group had a withdrawal rate of 14% compared with 53% in usual care. Adverse events were uncommon (6.7%) and generally mild. A 1.9 point decrease in median nonmenstrual pain scores and a 2.0 decrease in median menstrual pain scores between baseline and end of trial were observed in the acupuncture group only. Improvements in all domains of the EHP-30 were seen in the acupuncture group, with no changes seen in usual care. There was no difference between baseline and end of treatment in IL-6 concentrations for either group. Conclusions: Acupuncture was an acceptable, well-tolerated treatment and it may reduce pelvic pain and improve quality of life; however, usual care was not an acceptable control group. Trial Registration: anzctr.org.au: ACTRN12617000053325. Prospectively registered January 11, 2017.

AZD1222 (ChAdOx1 nCoV-19) is a COVID-19 vaccine that is not yet licensed for use during pregnancy. To support the inclusion of pregnant and breastfeeding people in AZD1222 clinical studies, a non-clinical developmental and reproductive toxicity study was performed to evaluate its effects on fertility and reproductive processes of female CD-1 mice during the embryofetal development phase, and postnatal outcomes during the littering phase. Immunogenicity assessments were also made in dams, fetuses, and pups. There were no vaccine-related unscheduled deaths throughout the study. Furthermore, there were no vaccine-related effects on female reproduction, fetal or pup survival, fetal external, visceral, or skeletal findings, pup physical development, and no abnormal gross pathology findings in pups or dams. Antibody responses raised in dams were maintained throughout gestation and postnatal periods, and seroconversion in fetuses and pups indicate placental and lactational transfer of immunoglobulins. Together with clinical data from non-pregnant people, these results support the inclusion of pregnant and breastfeeding people in AZD1222 clinical studies.

Study Objective To explore the prevalence and impact of dysmenorrhea, pelvic pain and menstrual symptoms on young women at school or in tertiary education. Design and Setting Cross-sectional online survey in Australia. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 to January 2018. Data were collected on sociodemographic data, menstrual cycle characteristics, dysmenorrhea, pelvic pain, and educational and social impact. Main Outcome Measures Information on menstrual and pelvic pain impact, academic absenteeism and presenteeism, impact on non-academic activities and interactions with teaching staff. Results and Conclusions Dysmenorrhea was reported by 92% of respondents. Dysmenorrhea was moderate (median 6.0 on a 0-10 numeric rating scale) and pain severity stayed relatively constant with age [rs(3804) = 0.012, P = .477]. Noncyclical pelvic pain at least once a month was reported by 55%. Both absenteeism and presenteeism related to menstruation were common. Just under half of women reported missing at least one class/lecture in the previous three menstrual cycles. The majority of young women at school (77%) and in tertiary education (70%) reported problems with classroom concentration during menstruation. Higher menstrual pain scores were strongly correlated with increased absenteeism and reduced classroom performance at both school and in tertiary education. Despite the negative impact on academic performance the majority of young women at school (60%) or tertiary education (83%) would not speak to teaching staff about menstruation.

Contains fulltext : 220431.pdf (Publisher’s version ) (Closed access) BACKGROUND: Disordered thyroid hormone transport, due to mutations in the SLC16A2 gene encoding monocarboxylate transporter 8 (MCT8), is characterised by intellectual and motor disability resulting from cerebral hypothyroidism and chronic peripheral thyrotoxicosis. We sought to systematically assess the phenotypic characteristics and natural history of patients with MCT8 deficiency. METHODS: We did an international, multicentre, cohort study, analysing retrospective data from Jan 1, 2003, to Dec 31, 2019, from patients with MCT8 deficiency followed up in 47 hospitals in 22 countries globally. The key inclusion criterion was genetically confirmed MCT8 deficiency. There were no exclusion criteria. Our primary objective was to analyse the overall survival of patients with MCT8 deficiency and document causes of death. We also compared survival between patients who did or did not attain full head control by age 1.5 years and between patients who were or were not underweight by age 1-3 years (defined as a bodyweight-for-age Z score

BACKGROUND: The emergence of cell-free fetal DNA (cfDNA) testing technology has disrupted the landscape of prenatal screening for trisomies 21 (T21) and 18 (T18). Publicly funded systems around the world are grappling with how to best integrate this more accurate but costly technology, as there is limited evidence about its incremental value in real-world conditions. The objectives of this study were to describe the population-based performance of Ontario’s prenatal screening program, which incorporates publicly funded cfDNA screening for specific indications, and the effect of cfDNA testing on the screening and diagnostic choices made by pregnant people. METHODS: We conducted a retrospective, descriptive cohort study using routinely collected data from Better Outcomes & Registry Network (BORN) Ontario, which captures linked population data for prenatal and neonatal health encounters across Ontario. We included all singleton pregnancies with an estimated due date between Sept. 1, 2016, and Mar. 31, 2019, that underwent publicly funded prenatal screening in Ontario, and a comparison cohort from Apr. 1, 2012, and Mar. 31, 2013. We assessed performance of the screening program for the detection of T21 or T18 by calculating sensitivity, specificity, positive predictive value and negative predictive value against diagnostic cytogenetic results or birth outcomes. We assessed the impact of the program by calculating the proportion of T21 screen-positive pregnancies undergoing subsequent cfDNA screening and invasive prenatal diagnostic testing. RESULTS: The study cohort included 373 682 pregnancies. The prenatal screening program had an uptake of 69.9%, a screen-positive rate and sensitivity of 1.6% and 89.9% for T21, and 0.2% and 80.5% for T18, respectively. The test failure rate for cfDNA screening was 2.2%. Invasive prenatal diagnostic testing decreased from 4.4% in 2012–2013 to 2.4% over the study period; 65.2% of pregnant people who received a screen-positive result from cfDNA testing went on to have invasive prenatal diagnostic testing. INTERPRETATION: This publicly funded screening program, incorporating cfDNA analysis for common aneuploidies, showed robust performance, a substantial reduction in invasive prenatal diagnostic testing and that pregnant people exercise autonomy in their choices about prenatal screening and diagnosis.

OBJECTIVES: To (i) quantify relationships between LBP symptoms, physical activity, and psychosocial characteristics in young adults and (ii) identify sub-classes of young adults with distinct pain trajectories. DESIGN: Prospective cohort study with 12 months follow-up METHODS: 120 adults (age 20.8±2.6 years, 99 women) participated. Participants completed a baseline survey that measured anxiety, depression, fear avoidance, quality of life, and history and impact of any LBP. Participants completed follow up surveys every 3 months for one year. Sub-classes based on pain trajectories over time were identified using latent class analysis and predictors of class membership at baseline were assessed. RESULTS: Individuals with LBP at baseline had lower physical quality of life scores than back-healthy participants (P = 0.01). Sub-class 1 (25% of individuals with LBP) had persistent moderate/high intensity of pain over the 1-year study period. Sub-class 2 (75%) had significantly improving pain over the 1-year study period. Higher fear avoidance (physical subscale) and pain interference at baseline were associated with greater odds of membership of sub-class 1 (odds ratios 1.2 (95% CI 1.01– 0.1.32) and 1.4, (95% CI 1.15 – 1.64) respectively). CONCLUSION: Most young adults with LBP had symptoms that improved over time. Levels of fear avoidance and pain interference may help to identify individuals at risk of persistent pain early in the lifespan.

Background Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery. Methods This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system. Results Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested. Conclusion These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Study Objective To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education. Design Cross-sectional online survey. Setting Australia-wide. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation. Main Outcome Measures Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis. Results The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as “abnormal” (P Conclusion Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

Mariam Fathima,1 Zeeta Bawa,1 Bernadette Mitchell,1 Juliet Foster,1 Carol Armour,1 Bandana Saini1,2 1Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia; 2School of Pharmacy, University of Sydney, Camperdown, New South Wales, AustraliaCorrespondence: Bandana Saini Rm No. N348, Building No A15The University of Sydney, Camperdown, New South Wales, 2006, AustraliaTel +61 2 93516789Fax +61 2 93514791Email bandana.saini@sydney.edu.auPurpose: To evaluate the effectiveness of a pilot community pharmacy care model for patients with chronic obstructive pulmonary disease (COPD) to improve: 1) inhaler technique; 2) medication adherence; and 3) uptake of non-pharmacological treatment and prevention activities.Patients and Methods: Forty “host” pharmacies in Sydney were invited to recruit eligible patients and to provide a counselling room/area in their pharmacy for service provision. Eligible patients were referred to two “consultant” pharmacists, specifically trained to deliver a specialized pharmacy COPD service which involved 3 in-pharmacy visits and 2 follow-up phone calls over a 6-month period. The service consisted of 1) inhaler technique assessment; 2) medication adherence assessment; and 3) referrals to the patient’s general practitioner (GP) to facilitate the uptake of non-pharmacological resources as well as to review COPD medications/devices, as required. Pre-post analyses were conducted using paired Student’s t-test and Wilcoxon Signed Rank Test for independent variables and chi-squared tests for proportional data.Results: Nine “host” pharmacies recruited 40 patients, of whom 37 completed the baseline Visit and 27 completed all Visits. A total of 270 interventions were provided by the “consultant” pharmacists with most provided at Visit 1 (176). The most common interventions were addressing patient gaps in COPD knowledge and inhaler technique. A total of 119 referrals were made to GPs for various reasons, the most common being for a COPD action plan, pulmonary rehabilitation, or pneumonia vaccination. There were significant improvements pre-post intervention in inhaler use competence, COPD knowledge, immunization rate for pneumonia, exacerbation rate and COPD plan ownership.Conclusion: In this pilot study, the specialized pharmacy-based COPD care model delivered by “consultant” pharmacists in community pharmacies provided significant health benefits for patients. Further research is needed to assess the model’s effectiveness in a larger population as well as when measured against standard care.Keywords: inhaler technique, medication review, consultant pharmacist, COPD

Background: Research trials testing the impact of community pharmacy services require adequate and appropriate recruitment of patients by participating pharmacists, however, this step presents an ongoing challenge. Objective: To identify factors affecting recruitment of patients in community pharmacies participating in a multi-center trial of a pharmacy asthma service in Australia (Pharmacy Trial Program – Asthma and Rhinitis Control (PTP-ARC). Methods: The PTP-ARC protocol required identification and recruitment of seven eligible asthma patients per pharmacy. Pharmacists responsible for sites that failed to recruit or retain any patients into the PTP-ARC trial participated in a semi-structured telephone interview about their experiences with these elements of the trial. The interviews were recorded, transcribed and coded using QSR International's NVivo 11 software. The analysis was conducted with reference to the COM-B framework (Capability, Opportunity, Motivation). Results: Pharmacists from 47 of 50 eligible pharmacies were interviewed. Seventeen factors were isolated and mapped to the COM-B framework. Psychological capability (recruitment hesitancy, research literacy and health literacy), physical capability (technological barriers, staffing issues and pharmacy busyness), physical opportunity (patient busyness, trial timing, study protocol, support and location), social opportunity (health literacy and supportive milieu), reflective motivation (incentive for participation, simplification) and automatic motivation (patient attitudes and pharmacist-felt experience) were factors affecting pharmacists' participation. Challenges identified included: issues with the software, unfamiliarity with research procedures generally (and specifically with the PTP-ARC protocols), the patients' lack of interest and pharmacists’ lack of time. Conclusions: To the best of our knowledge, this is the first study to focus on issues affecting patient recruitment into a pharmacy health services (asthma) trial in real time. To propel evidence-based trials towards practice implementation, user-friendly software, pharmacists’ training on research and patient-engagement and adequate remuneration to address pharmacist time issues need to be key foci for health services design and implementation research.

Objective Studies examining the use of smoking cessation treatment and related spending among enrollees with employer-sponsored health insurance are dated and limited in scope. We assessed changes in annual receipt of and spending on cessation medications approved by the US Food and Drug Administration (FDA) among tobacco users with employer-sponsored health insurance from 2010 to 2017. Methods We analyzed data on 439 865 adult tobacco users in 2010 and 344 567 adult tobacco users in 2017 from the IBM MarketScan Commercial Database. We used a negative binomial regression to estimate changes in receipt of cessation medication (number of fills and refills and days of supply). We used a generalized linear model to estimate spending (total, employers’, and out of pocket). In both models, covariates included year, age, sex, residence, and type of health insurance plan. Results From 2010 to 2017, the percentage of adult tobacco users with employer-sponsored health insurance who received any cessation medication increased by 2.4%, from 15.7% to 16.1% ( P < .001). Annual average number of fills and refills per user increased by 15.1%, from 2.5 to 2.9 ( P < .001) and days of supply increased by 26.4%, from 81.9 to 103.5 ( P < .001). The total annual average spending per user increased by 53.6%, from $286.40 to $440.00 ( P < .001). Annual average out-of-pocket spending per user decreased by 70.9%, from $70.80 to $20.60 ( P < .001). Conclusions Use of smoking cessation medications is low among smokers covered by employer-sponsored health insurance. Opportunities exist to further increase the use of cessation medications by promoting the use of evidence-based cessation treatments and reducing barriers to coverage, including out-of-pocket costs.

Introduction Cigarette smoking prevalence is higher among adults enrolled in Medicaid than adults with private health insurance. State Medicaid coverage of cessation treatments has been gradually improving in recent years; however, the extent to which this has translated into increased use of these treatments by Medicaid enrollees remains unknown. Aims and Methods Using Medicaid Analytic eXtract (MAX) files, we estimated state-level receipt of smoking cessation treatments and associated spending among Medicaid fee-for service (FFS) enrollees who try to quit. MAX data are the only national person-level data set available for the Medicaid program. We used the most recent MAX data available for each state and the District of Columbia (ranging from 2010 to 2014) for this analysis. Results Among the 37 states with data, an average of 9.4% of FFS Medicaid smokers with a past-year quit attempt had claims for cessation medications, ranging from 0.2% (Arkansas) to 32.9% (Minnesota). Among the 20 states with data, an average of 2.7% of FFS Medicaid smokers with a past-year quit attempt received cessation counseling, ranging from 0.1% (Florida) to 5.6% (Missouri). Estimated Medicaid spending for cessation medications and counseling for these states totaled just over $13 million. If all Medicaid smokers who tried to quit were to have claims for cessation medications, projected annual Medicaid expenditures would total $0.8 billion, a small fraction of the amount ($45.9 billion) that Medicaid spends annually on treating smoking-related disease. Conclusions The receipt of cessation medications and counseling among FFS Medicaid enrollees was low and varied widely across states. Implications Few studies have examined use of cessation treatments among Medicaid enrollees. We found that many FFS Medicaid smokers made quit attempts, but few had claims for proven cessation treatments, especially counseling. The receipt of cessation treatments among FFS Medicaid enrollees varied widely across states, suggesting opportunities for additional promotion of the full range of Medicaid cessation benefits. Continued monitoring of Medicaid enrollees’ use of cessation treatments could inform state and national efforts to help more Medicaid enrollees quit smoking.

Background The newly recognized General Practice Pharmacist (GPP) model in Australia, where non-dispensing pharmacists work in collaboration with general practitioners (primary care physicians) within their general practice/clinics represent an efficient yet novel approach for the management of chronic diseases. In chronic conditions, such as asthma, these models can help achieve optimal health outcomes, given current gaps between guidelines and practice. Objective The aim of this study was to elicit pharmacists’ views and recommendations about pragmatic models of collaboration between GPPs and general practitioners in providing asthma management services in future service delivery models. Methods Community pharmacists were recruited via convenience sampling and passive snowballing techniques. Qualitative, semi-structured, in-depth interviews were conducted. Recorded interviews were transcribed verbatim and analyzed utilizing NVivo® 11 software. Obtained data were content analyzed for emergent themes using the Braun and Clarke framework. Results Twenty-five interviews were conducted. Asthma management challenges in current practice and the implementation practicality of asthma care GPP models comprised the two major emerging themes. Pharmacists' time and workload constraints and patients' reluctance to seek pharmacists’ assistance to dispel misconceptions about asthma control were reported to be major barriers for the implementation of optimal asthma management services in community pharmacy. While a GPP dependent on several criteria. The development of specified channels for inter-professional communication for sharing of patient information and the willingness of stakeholders to accept and access such a model were reported. Funding and remuneration were considered critical factors by most participants. The professional self-autonomy of each healthcare professional involved in the GPP model was also highlighted as pertinent issue. Conclusions This study provides significant insights to create pragmatic scalable versions of a GPP care model that could facilitate better asthma care after key barriers and facilitators identified by participants are carefully addressed.

Purpose The aim of this study was to develop a valid educational intervention to improve knowledge and confidence using communication strategies when interacting with a person with aphasia. Design A quantitative, nonrandomized pretest/posttest research study was performed. Methods Pre- and postcourse assessments were completed with learning participants. This educational intervention was developed using the underlying theoretical concepts of the integrated behavioral model. Results Forty-nine new employees from the nursing department participated in this study, with 61% reporting less than 1 year of experience. Pre- to posttraining assessments on the Test of Knowledge of Aphasia improved from 3.7 to 5.8 (p ≤ .0001) for direct knowledge, from 5.5 to 8.2 (p ≤ .0001) for confidence self-efficacy, and from 5.3 to 7.6 (p ≤ .0001) for knowledge self-efficacy. Conclusion Results indicated this theory-driven educational training was effective in training employees from the nursing department working in an inpatient rehabilitation environment. Clinical Relevancy Improving communication effectiveness is critical for overall quality of care and patient safety.

To date in the COVID-19 pandemic, there has been a decrease in patients accessing emergency health services, (EHS) but research has been conducted in areas with a very high incidence of COVID-19. In an area with a low COVID-19 incidence, we estimate changes in EHS use.We compared EHS encounters in British Columbia from March 15 (the date of school and business closures) to May 15, 2020, when compared to the same period in 2019. We categorized EHS encounters into 18 presenting complaints and prespecified critical care complaints including major trauma, cardiac arrest, stroke, and ST-elevation myocardial infarction. We analyzed by descriptive methods.Comparing 2019 to 2020, total EHS encounters decreased from 83,925 (incidence rate 834 per 100,000 person-months) to 71,611 (incidence rate 701 per 100,000 person-months) for a decrease of 133 per 100,000 person-months (95% CI 126-141). The top 18 codes had a significant decrease in every category except respiratory and anxiety. Encounters for critically ill patients decreased significantly overall from 3019 to 2753 (incidence rate difference 3.1 per 100,000 person-months, 95% CI 1.6-4.5), including stroke, trauma, and STEMI, but the incidence of OHCA appeared stable.In a single province with a low incidence of COVID-19, there was a 15% reduction in overall EHS use and a 9% reduction in critical illness. EHS planners will need to match patient need with available resources.RéSUMé: OBJECTIFS: Jusqu’à présent dans la pandémie de Covid-19, il y a eu une diminution du nombre de patients ayant accès aux services de santé d'urgence, mais des recherches ont été menées dans des zones à très forte incidence de Covid-19. Dans une zone à faible incidence de Covid-19, nous estimons les changements dans l'utilisation des services de santé d’urgence. MéTHODES: Nous avons comparé les cas des services de santé d’urgence en Colombie-Britannique du 15 mars (date de fermeture des écoles et des entreprises) au 15 mai 2020, par rapport à la même période en 2019. Nous avons classé les cas des services de santé d’urgence en 18 plaintes de présentation et des plaintes de soins intensifs pré-spécifiées, y compris un traumatisme majeur, un arrêt cardiaque, un accident vasculaire cérébral et un infarctus du myocarde avec élévation du segment ST. Nous avons analysé par des méthodes descriptives. RéSULTATS : En comparant 2019 à 2020, le nombre total des cas des services de santé d’urgence est passé de 83 925 (taux d'incidence de 834 pour 100 000 personnes-mois) à 71 611 (taux d'incidence de 701 pour 100 000 personnes-mois) pour une diminution de 133 pour 100 000 personnes-mois (IC à 95 % 126 à 141). Les 18 codes principaux ont connu une diminution significative dans toutes les catégories, sauf respiratoire et anxiété. Les cas chez les patients gravement malades ont globalement diminué de manière significative de 3 019 à 2 753 (différence de taux d'incidence de 3,1 pour 100 000 personnes-mois, IC à 95 % de 1,6 à 4,5), y compris les accidents vasculaires cérébraux, les traumatismes et les STEMI, mais l'incidence des arrêts cardiaque hors hôpital semble stable. CONCLUSIONS: Dans une seule province avec une faible incidence de Covid-19, il y a eu une réduction de 15 % de l'utilisation globale des services de santé d’urgence et une réduction de 9 % des maladies graves. Les organisateurs des services de santé d’urgence devront faire correspondre les besoins des patients avec les ressources disponibles.

Limited existing evidence suggests that adults with intellectual and developmental disabilities (IDD) experience substantial disparities in numerous areas of health care, including quality ambulatory care. A multistate cohort of adults with IDD was analyzed for patterns of inpatient admissions and emergency department utilization. Utilization was higher (inpatient [RR = 3.2], emergency department visits [RR = 2.6]) for adults with IDD, particularly for ambulatory care–sensitive conditions (eg, urinary tract [RR = 6.6] and respiratory infections [RRs = 5.5–24.7]), and psychiatric conditions (RRs = 5.8–15). Findings underscore the importance of access to ambulatory care skilled in IDD-related needs to recognize and treat ambulatory care– sensitive conditions and to manage chronic medical and mental health conditions.

Emergency health services (EHS) have experienced a steady increase in demand from palliative patients accessing 9-1-1 during times of acute crisis, although the majority of these patients do not wi...

Introduction Progression in the field of paramedicine has resulted in the development of novel roles within the profession, including the role of advanced paramedics providing teleconsultations for frontline paramedics. Little is known about the experience of paramedics providing or receiving teleconsultations. This scoping review aimed to investigate paramedic perceptions of physician and paramedic-delivered teleconsultations. Methods A scoping review of MEDLINE, CINAHL and EBM Reviews as well as paramedic-specific journals and the grey literature was conducted. Articles were included if they examined advanced paramedics, paramedics, emergency ambulance crew or emergency medical technicians receiving teleconsultations, or physicians and advanced paramedics providing teleconsultations. Results A total of 7461 unique citations were identified. Two citations were ultimately included in the review. One study examined the delivery of teleconsultations by advanced paramedics and one by physicians, both from the perspective of paramedics. Paramedics delivering teleconsultations generally considered the experience to be positive, while those receiving paramedic-delivered teleconsultations felt the level of advice was appropriate and assisted in expanding their own knowledge base. Paramedics receiving physician-delivered teleconsultations reported variable understanding of the unique challenges of out-of-hospital care and tension in the relationship between paramedics and physicians. Conclusion Little literature was identified examining the perceptions of paramedics delivering or receiving physician-delivered or paramedic-delivered teleconsultations. Given the continuing expansion of teleconsultation programs for out-of-hospital staff, this represents a significantly understudied area.

This paper discusses how digital technologies including artificial intelligence (AI) reshape the work of lawyers and the organisations that they work for. We overview how AI is being used in legal services, and identify three distinct impacts: AI substitutes automatable legal tasks; AI enhances productivity of lawyers giving advice on the basis of AI-generated outputs; and legal expertise itself augments the deployment of AI when lawyers work as part of a multi-disciplinary team (MDT) encompassing a range of relevant professional expertise. Our survey of English solicitors shows that AI deployment is associated with MDTs, and that MDTs are less prevalent in law firms than in corporations. This latter finding is due to challenges that law firms face as mono-professional partnerships. We find evidence from our interviews that their challenges lie not so much in capital constraints, relaxed via alternative business structures in the UK, but in traditional law firms’ inability to recruit and retain talent other than those in the legal profession. Inadequate adaption is occurring in law firms shifting their structure from a funnel shape to a rocket shape with junior lawyers in partnership tournament working alongside a growing number of non-lawyers whose career paths offer no prospect of partnership.

Purpose Health-care practitioners' (HCPs) preferences for returning secondary findings (SFs) will influence guideline compliance, shared decision-making, and patient health outcomes. This study aimed to estimate HCPs' preferences and willingness to support the return (WTSR) of SFs in Canada. Methods A discrete choice experiment estimated HCPs' preferences for the following attributes: disease risk, clinical utility, health consequences, prior experience, and patient preference. We analyzed responses with an error component mixed logit model and predicted WTSR using scenario analyses. Results Two hundred fifty participants of 583 completed the questionnaire (completion rate: 42.9%). WTSR was significantly influenced by patient preference and SF outcome characteristics. HCPs' WTSR was 78% (95% confidence interval: 74–81%) when returning SFs with available medical treatment, high penetrance, severe health consequences, and patient's preference for return. Genetics professionals had a higher WTSR than HCPs of other types when returning SFs with clinical utility and patient preference to know. HCPs >55 years of age were more likely to return SFs compared with younger HCPs. Conclusion This study identified factors that influence WTSR of SFs and indicates that HCPs make tradeoffs between patient preference and other outcome characteristics. The results can inform clinical scenarios and models aiming to understand shared decision-making, patient and family opportunity to benefit, and cost-effectiveness.

Hydroxocobalamin (vitamin B12a) is an emerging treatment for vasoplegic syndrome (VS) associated with cardiopulmonary bypass (CPB). Given its cost and scarcity, an institutional guideline for its use as a rescue treatment in cases of suspected VS was developed. Hemodynamic variables and vasopressor requirements were reviewed for a series of 24 post-CPB patients who received B12a. Favorable changes in hemodynamic parameters and vasopressor requirements were seen after B12a administration although guideline criteria for VS were inconsistently met. These findings support the continued study of B12a in patients with CPB-associated VS.

Griscelli syndrome type 2 is a rare autosomal recessive disorder characterized by hypopigmentation, silvery hair, and immunological dysfunction with no primary neurological impairment. We report an 18-month-old girl with Griscelli syndrome type 2 who presented to the dermatology department for cutaneous granulomas that developed following live-attenuated vaccination. Two compound heterozygous variants in the RAB27A gene were subsequently identified. She developed hemophagocytic lymphohistiocytosis, the key immunological concern, at age 5 years.

OBJECTIVE To assess the association between the change in statewide smoke-free laws and the rate of preterm or low birth weight delivery hospitalizations. DATA SOURCE 2002-2013 Healthcare Cost and Utilization Project State Inpatient Databases. STUDY DESIGN Quasi-experimental difference-in-differences design. We used multivariate logistic models to estimate the association between the change in state smoke-free laws and preterm or low birth weight delivery hospitalizations. The analyses were also stratified by maternal race/ethnicity to examine the differential effects by racial/ethnic groups. DATA COLLECTION/EXTRACTION METHODS Delivery hospitalizations among women aged 15-49 years were extracted using the International Classification of Diseases, Ninth Revision, and Diagnosis-Related Group codes. PRINCIPAL FINDINGS Non-Hispanic black mothers had a higher rate of preterm or low birth weight delivery hospitalization than other racial/ethnic groups. Overall, there was no association between the change in smoke-free laws and preterm or low birth weight delivery rate. Among non-Hispanic black mothers, the change in statewide smoke-free laws was associated with a 0.9-1.9 percentage point (P

Hypoxic-ischemic encephalopathy is a major cause of death and disability in the newborn period. Experimental models have demonstrated that brain injury in hypoxic-ischemic encephalopathy occurs in two phases: primary energy failure and secondary energy failure. In primary energy failure, there is a cessation of oxidative metabolism and irreversible neuronal injury, followed by secondary energy failure due to glutamate release, elevation of intracellular calcium, reactive oxygen species formation, apoptotic cell death, and activation of the immune system. Secondary energy failure is the target of therapeutic intervention in neonatal hypoxic-ischemic encephalopathy. The sensitivities of cell types to hypoxic injury leads to the differences in injury pattern seen in term versus preterm infants. Current treatment recommendations include identification and treatment of seizures when present and prompt administration of therapeutic hypothermia if clinical parameters are met. This paper also discusses new treatment paradigms being developed, including erythropoietin, and the role of neuroimaging as a predictive tool for neurodevelopmental outcome.

Background Sleep disturbances (SD) are the most impactful and commonly reported symptoms in post-traumatic stress disorder (PTSD). Yet, they are often resistant to primary PTSD therapies. Research has identified two distinct SDs highly prevalent in PTSD; insomnia and nightmares. Those who report SDs prior to a traumatic event are at greater risk for developing PTSD; highlighting that sleep potentially plays a role in PTSD's pathology. To further understand the pathobiological mechanisms that lead to the development of PTSD, it is first imperative to understand the interplay which exists between sleep and PTSD on a biological level. The aim of this systematic review is to determine if biological or physiological markers are related to SD in PTSD. Methods A systematic literature search was conducted on the electronic databases; Medline, Embase, AMED and PsycINFO, using Medical Subject Headings and associated keywords. Results Sixteen studies were included in the final analyses. Physiological makers of autonomic function, and biochemical markers of HPA-axis activity; inflammatory processes; and trophic factor regulation were related to the severity of SDs in PTSD. Conclusion These findings add to the growing literature base supporting a central focus on sleep in research aiming to define the pathophysiological processes which result in PTSD, as well as emphasising the importance of specifically targeting sleep as part of a successful PTSD intervention strategy. Resolving SDs will not only reduce PTSD symptom severity and improve quality of life but will also reduce all-cause mortality, hospital admissions and lifetime healthcare costs for those with PTSD. Limitations of the current literature are discussed, and key recommendations future research must adhere to are made within.

IntroductionMany veterans do well reintegrating to civilian life following military service. Yet, many face difficulties in finding and securing work. Veterans are more likely than civilians to experience work difficulties, but there remains little research investigating contributing factors, particularly among samples of treatment-seeking veterans. As such, the study examines predictors of not working among UK treatment-seeking veterans.DesignThe study employed a cross-sectional design.MethodsOf 667 treatment-seeking UK veterans, 403 (Mage=50.94) provided information on a range of demographic variables, military-related experiences, the total number of physical health conditions and mental health outcomes. Work status was categorised as not working due to illness (Mage=48.15), not working due to other reasons (Mage=61.92) and currently working (Mage= 46.13).ResultsPrevalence rates of not working was 69%. Not working was predicted by a greater number of physical health problems as well as more years since leaving the military. Not working due to poor health was independently predicted by symptoms of post-traumatic stress disorder (PTSD) and younger age, while not working due to other reasons was predicted by older age.ConclusionsThe study revealed that treatment-seeking veterans of younger age with a high number of physical health difficulties, symptoms of PTSD and more years since leaving the military are most at risk of not working due to ill health. The findings have important implications for identifying veterans most at risk of not working and offer the opportunity to tailor rehabilitation programmes to promote successful veteran reintegration into civilian life.

Purpose: To report a study that assesses the influence of the distance between the distal end of a thoracic stent-graft and the first reentry tear (SG-FRT) on the progression of false lumen (FL) thrombosis in patients who underwent thoracic endovascular aortic repair (TEVAR). Materials and Methods: Three patient-specific geometrical models were reconstructed from postoperative computed tomography scans. Two additional models were created by artificially changing the SG-FRT distance in patients 1 and 2. In all 5 models, computational fluid dynamics simulations coupled with thrombus formation modeling were performed at physiological flow conditions. Predicted FL thrombosis was compared to follow-up scans. Results: There was reduced false lumen flow and low time-averaged wall shear stress (TAWSS) in patients with large SG-FRT distances. Predicted thrombus formation and growth were consistent with follow-up scans for all patients. Reducing the SG-FRT distance by 30 mm in patient 1 increased the flow and time-averaged wall shear stress in the upper abdominal FL, reducing the thrombus volume by 9.6%. Increasing the SG-FRT distance in patient 2 resulted in faster thoracic thrombosis and increased total thrombus volume. Conclusion: The location of reentry tears can influence the progression of FL thrombosis following TEVAR. The more distal the reentry tear in the aorta the more likely it is that FL thrombosis will occur. Hence, the distal landing zone of the stent-graft should be chosen carefully to ensure a sufficient SG-FRT distance.

Introduction Youth cigarette smoking decreased significantly over the last two decades in the United States. This study provides estimates and trends from 2011 to 2018 and factors associated with youth menthol and non-menthol smoking from 2016 to 2018. Methods Using data from the 2011–2018 National Youth Tobacco Surveys, past 30-day (current) menthol and non-menthol cigarette smoking were estimated for all youth (prevalence) and youth smokers (proportions). Trends were examined using Joinpoint regression, calculating the annual percent change (APC). Multivariate logistic regression analyses identified factors associated with menthol smoking. Results From 2011 to 2018, menthol cigarette smoking among current youth cigarette smokers significantly decreased from 57.3% to 45.7% (APC: −3.0%), while non-menthol (38.2% to 47.3% [APC: 2.9%]) and unknown menthol status (not sure\missing) (4.5% to 7.0% [APC: 7.1%]) significantly increased. Menthol cigarette smoking among high school, male, female, and non-Hispanic white current cigarette smokers decreased, but remained unchanged among middle school, non-Hispanic black, and Hispanic smokers. Significantly higher proportions of menthol cigarette smokers smoked on ≥20 days, ≥2 cigarettes per day, and ≥100 cigarettes in their lifetime compared to non-menthol smokers. Among current cigarette smokers, non-Hispanic blacks, Hispanics, flavored non-cigarette tobacco users, frequent smokers (≥20 days), those smoking 2–5 cigarettes per day, and those living with someone who uses tobacco had higher odds of menthol cigarette smoking. Conclusions In 2018, nearly half of current youth cigarette smokers smoked menthol cigarettes. While menthol cigarette smoking declined from 2011 to 2018 among all youth and among youth smokers, there was no change in menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school cigarette smokers. Implications This study finds that overall cigarette and menthol cigarette smoking declined in youth from 2011 to 2018. However, menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school youth cigarette smokers did not change. Information from this study can help inform efforts to reduce menthol cigarette smoking among US youth, particularly racial/ethnic minority populations.

Coaches consider various competencies (e.g. conditioning, nutrition, skills and tactics), when planning sessions, though rarely the impact of menstruation on the efficacy of training and competition performance for athletes. Given the impact menstrual symptoms can have on athletes, the management strategies that athletes may use to minimise any potential impact, and the mechanisms that provide barriers to greater coach athlete interaction require investigation and consideration. Therefore, this study aimed to investigate the strategies used by athletes to manage menstrual symptoms and the role coaches played in this process. An anonymous, 36-item questionnaire was developed and hosted on Qualtrics. Descriptive statistics and Chi-square statistics were used to analyse the data. One hundred and twenty-four valid responses from Australian athletes 16–45, with a mean age of 29 years, were received. Period pain (82%) and pre-menstrual symptoms (83%) were commonly reported and contributed to fatigue and to perceived reductions in performance during or just prior to the period (50.0% in training, 58.7% on ‘game day’). Contraceptive use was reported by 42% of athletes. Those reporting heavy menstrual bleeding (29.7%) were more likely to report increased fatigue (relative risk 1.6, 95% CI 1.07 to 2.32). Over three-quarters of athletes reported neither they nor their coaches altered training due to the menstrual cycle. Most athletes (76%) did not discuss menstruation with their coaches. Given the perceived negative impact on performance and potential risks with contraceptive usage during adolescence, coaches, trainers and athletes need to have a more open dialogue around the menstrual cycle.

The purpose of this study was to determine the association between corticomotor excitability (CME) of gluteus maximus (GM) and hip biomechanics during a single-leg drop-jump task. Thirty-two healthy individuals participated. The slope of the input-output curve (IOC) obtained from transcranial magnetic stimulation was used to assess CME of GM. The average hip extensor moment and peak hip flexion angle during the stance phase of the drop jump task was calculated. The slope of the IOC of GM was found to be a predictor of the average hip extensor moment (r

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees† over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications§; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments.¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3-7).

Introduction University-led higher education for paramedics has been in place for over 20 years, with students in these programs required to complete supervised clinical placements with an experienced paramedic mentor. This investigation aims to establish whether the non-rotation of paramedic students between paramedic mentors while on ambulance-based placements aids or hinders the undergraduate paramedic student's development of competencies. Methods Purposive and convenience sampling methods were used, with semi-structured group interviews conducted with second year undergraduate paramedic students for data collection. Thematic analysis was used to draw meaning from the collected data. Results Five key themes emerged from within the data. Students reported difficulties in maintaining relationships with their assigned mentors, particularly in situations where conflicting schedules and role changes necessitated frequent rotation between mentors. Students reported feeling there was great variety in the way competency-based learning is managed by paramedic mentors, leading to inconsistencies in assessment. Students also described comparing their own personality and clinical practice against mentors, in order to self-identify more appropriate mentors during the placements. Conclusion This research provides an initial insight into how paramedic students perceive the effects of non-rotational ambulance-based placements on the development of competencies. Based on the findings of this research it is not possible to draw firm conclusions as to whether the non-rotation of ambulance-based placements aids or hinders undergraduate student paramedics’ development of competencies. Further research is required in this area across a variety of settings in order to understand the applicability of these results.

Purpose Using cross-sectional data, we measured the association between electronic cigarette (e-cigarette) use and subsequent initiation and sustained use of cigarettes among U.S. youth. Methods Data were pooled from the 2015–2017 National Youth Tobacco Survey, a school-based survey of U.S. students in grades 6–12. Questions on current age and age of first use of different tobacco products (cigarettes, e-cigarettes, cigars, and smokeless tobacco) were used to ascertain the temporal sequence of tobacco product use. The pooled study population was 52,579 youth who 5 years before the survey had never smoked cigarettes. E-cigarette users were defined as those who used e-cigarettes before or without ever smoking cigarettes. Cigarette smoking was assessed with the following measures: ever smoking a cigarette at any time within the past 5 years and sustained smoking (smoked ≥1 year ago and within past 30 days). Adjusted odds ratios (AORs) were calculated, controlling for other tobacco product use and sociodemographics. Results Among never cigarette smokers as of 5 years before the survey, 17.4% used e-cigarettes, and 15.6% first smoked within the past 5 years. Compared with those who did not use e-cigarettes, those who used e-cigarettes had higher odds of ever smoking cigarettes within the past 5 years (AOR = 2.73) and had higher odds of sustained smoking (AOR = 1.55; all p Conclusions E-cigarette use is associated with subsequent initiation and sustained use of cigarettes among youth. Efforts are warranted to reduce youth use of all tobacco products, including e-cigarettes.

There is no denying that paramedic-led intubation is a contentious issue in out-of-hospital care. Guidelines for the management of COVID-19 are developed with both patient-centred care as well as provider safety in mind, with intubation the preferred airway management strategy in patients suspected to have contracted COVID-19 requiring airway protection or invasive ventilation. However, this has re-ignited a debate which began during the Severe Acute Respiratory Syndrome (SARS) outbreak in the early 2000s around whether the benefit of paramedic-led intubation outweighs the risks to providers during a pandemic. The aim of this commentary is to revisit the evidence around paramedic-led intubation and provide a perspective on paramedic-led intubation during the COVID-19 pandemic. It is hoped this will stimulate further discussion around the benefits and risks of paramedic intubation in the setting of a pandemic.

Objective: This study sought to investigate the perceptions, barriers and drivers associated with medicinal cannabis use among Australian women with primary dysmenorrhea. A qualitative study via virtual focus groups involving 26 women experiencing regular, moderate or greater menstrual pain explored categories including cost, associated stigma, current drug driving laws, community and workplace ethics as well as geographical isolation within the context of patient access under current Australian laws and regulations. Results: A qualitative descriptive analysis identified that dissatisfaction with current management strategies such as over-the-counter analgesic usage was the key driver for wanting to use medicinal cannabis. A number of significant barriers to use were identified including patient access to medical prescribers, medical practitioner bias, current drug driving laws, geographic location, and cost. Community and cultural factors such as the history of cannabis as an illicit drug and the resulting stigma, even when prescribed by a medical doctor, still existed and was of concern to our participants. Conclusion: Whilst medicinal cannabis is legal in all states and territories within Australia, several barriers to access exist that require government regulatory attention to assist in increasing patient adoption, including possible subsidization of cost. The high cost of legal, medicinal cannabis was a key factor in women’s choice to use illicit cannabis. Overall, the concerns raised by our participants are consistent with the broader findings of a recent Australian Senate inquiry report into barriers to patient access to medicinal cannabis in Australia, suggesting many of the issues are systematic rather than disease specific. Given the interest in use of medicinal cannabis amongst women with primary dysmenorrhea, clinical trials in this area are urgently needed.

Objective To examine how insertion and presence of intramuscular fine-wire electromyography electrodes (IFWEs) in lumbar multifidus affect paraspinal muscle strength, endurance, and activation in persons with and without recurrent lower back pain (RLBP) during activities that require high levels of muscle contraction. Design Case-control with randomization of conditions. Setting Clinical research laboratory. Participants Forty participants age 18 to 40 years were recruited (18 female; mean age = 25.5 years); 20 with a history of RLBP were compared to a matching control group of 20 without RLBP. Interventions Each participant was tested under three conditions over three sessions. On Session 1, the baseline condition, we assessed muscle performance without IFWE insertion. On Sessions 2 and 3, participants were randomly alternated between two experimental conditions: (1) wire-in, in which the IFWE was inserted and remained within the muscle during testing; and (2) wire-out, in which the IFWE was inserted and immediately removed. Main outcome measurements Lumbar spinal extensor peak strength, endurance, and normalized electromyography (EMG) amplitude during the endurance test. Results Individuals with RLBP showed a significant decrease in peak strength during conditions that involved IFWE insertion and tend to experience more pain during muscle testing. Both groups exhibited similar levels of performance and muscle activation during the endurance test. Conclusion Our findings indicate that individuals with RLBP exhibited reduced lumbar extensor strength in response to IFWE insertion to the deep paraspinal muscles. This behavior is different from those without RLBP. Researchers should carefully consider the use of IFWE in individuals with RLBP during high exertion activities.

Background: Reported trauma is associated with differences in the course and outcomes of depression and anxiety. However, no research has explored the association between reported trauma and patterns of clinically relevant symptoms of both depression and anxiety.Methods: We used network analysis to investigate associations between reported trauma and depression and anxiety symptom interactions in affected individuals from the Genetic Links to Anxiety and Depression (GLAD) Study (n = 17720), and population volunteers from the UK Biobank (n = 11120). Participants with current moderate symptoms of depression or anxiety were grouped into reporters and non-reporters of lifetime trauma. Networks of 16 depression and anxiety symptoms in the two groups were compared using the network comparison test.Results: In the GLAD Study, networks of reporters and non-reporters of lifetime trauma did not differ on any metric. In the UK Biobank, the symptom network of reporters had significantly greater density (7.80) than the network of non-reporters (7.05).Limitations: The data collected in the GLAD Study and the UK Biobank are self-reported with validated or semi-validated questionnaires.Conclusions: Reported lifetime trauma was associated with stronger interactions between symptoms of depression and anxiety in population volunteers. Differences between reporters and non-reporters may not be observed in individuals with severe depression and/or anxiety due to limited variance in the presentation of disorder.

Experiencing traumatic events is unfortunately commonplace and, in some cases, may lead to the onset of debilitating mental health disorders, such as post-traumatic stress disorder (PTSD). Current diagnostic criteria for PTSD results in high depression and anxiety comorbidity. Better understanding of biological mechanisms and pathways underlying PTSD could aid in more accurate case identification and stratification of treatments. Recent meta-analysis has identified chronic PTSD to be associated with increased expression of pro-inflammatory cytokines and alterations in neuronal structures which contribute to an overall reduction in brain volume. Despite this, there are currently no biological markers in clinical use to identify PTSD or monitor treatment. This case-control study (n = 40) aimed to identify differences in peripheral blood biomarkers, and biomarker combinations, able to distinguish PTSD participants from controls, and examine in a biopsychosocial framework. The levels of 5/37 biomarkers investigated were significantly altered in the serum of PTSD participants: HDL and LDL cholesterol, tPA, IL-8 and EGF. Biomarkers could be used in combination with psychological criteria, in a biopsychosocial model, to support clinical management decisions and ensure appropriate individual treatment pathways.

Quantitative assessment of the complex hemodynamic environment in type B aortic dissection (TBAD) through computational fluid dynamics (CFD) simulations can provide detailed insights into the disease and its progression. As imaging and computational technologies have advanced, methodologies have been developed to increase the accuracy and physiological relevance of CFD simulations. This study presents a patient-specific workflow to simulate blood flow in TBAD, utilising the maximum amount of in vivo data available in the form of CT images, 4D-flow MRI and invasive Doppler-wire pressure measurements, to implement the recommended current best practice methodologies in terms of patient-specific geometry and boundary conditions. The study aimed to evaluate and verify this workflow through detailed qualitative and quantitative comparisons of the CFD and in vivo data. Based on data acquired from five TBAD patients, a range of essential model inputs was obtained, including inlet flow waveforms and 3-element Windkessel model parameters, which can be utilised in further studies where in vivo flow data is not available. Local and global analysis showed good consistency between CFD results and 4D-MRI data, with the maximum velocity in the primary entry tear differing by up to 0.3 m/s, and 80% of the analysed regions achieving moderate or strong correlations between the predicted and in vivo velocities. CFD predicted pressures were generally well matched to the Doppler-wire measurements, with some deviation in peak systolic values. Overall, this study presents a validated comprehensive workflow with extensive data for CFD simulation of TBAD.

Pompe disease (PD) is a severe neuromuscular disorder caused by deficiency of the lysosomal enzyme acid alpha-glucosidase (GAA). PD is currently treated with enzyme replacement therapy (ERT) with intravenous infusions of recombinant human GAA (rhGAA). Although the introduction of ERT represents a breakthrough in the management of PD, the approach suffers from several shortcomings. Here, we developed a mouse model of PD to compare the efficacy of hepatic gene transfer with adeno-associated virus (AAV) vectors expressing secretable GAA with long-term ERT. Liver expression of GAA results in enhanced pharmacokinetics and uptake of the enzyme in peripheral tissues compared to ERT. Combination of gene transfer with pharmacological chaperones boosts GAA bioavailability, resulting in improved rescue of the PD phenotype. Scale-up of hepatic gene transfer to non-human primates also successfully results in enzyme secretion in blood and uptake in key target tissues, supporting the ongoing clinical translation of the approach., Pompe disease is currently treated with enzyme replacement therapy (ERT) with recombinant human acid alpha-glucosidase (GAA). Here, the authors show hepatic-directed gene therapy with AAV vectors enhances GAA bioavailability compared with ERT, resulting in improved rescue of the disease phenotype in mice and broad enzyme distribution in mice and non-human primates.

Background The impact of COVID-19 on physical and mental health and employment after hospitalisation with acute disease is not well understood. The aim of this study was to determine the effects of COVID-19-related hospitalisation on health and employment, to identify factors associated with recovery, and to describe recovery phenotypes. Methods The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a multicentre, long-term follow-up study of adults (aged ≥18 years) discharged from hospital in the UK with a clinical diagnosis of COVID-19, involving an assessment between 2 and 7 months after discharge, including detailed recording of symptoms, and physiological and biochemical testing. Multivariable logistic regression was done for the primary outcome of patient-perceived recovery, with age, sex, ethnicity, body-mass index, comorbidities, and severity of acute illness as covariates. A post-hoc cluster analysis of outcomes for breathlessness, fatigue, mental health, cognitive impairment, and physical performance was done using the clustering large applications k-medoids approach. The study is registered on the ISRCTN Registry (ISRCTN10980107). Findings We report findings for 1077 patients discharged from hospital between March 5 and Nov 30, 2020, who underwent assessment at a median of 5·9 months (IQR 4·9–6·5) after discharge. Participants had a mean age of 58 years (SD 13); 384 (36%) were female, 710 (69%) were of white ethnicity, 288 (27%) had received mechanical ventilation, and 540 (50%) had at least two comorbidities. At follow-up, only 239 (29%) of 830 participants felt fully recovered, 158 (20%) of 806 had a new disability (assessed by the Washington Group Short Set on Functioning), and 124 (19%) of 641 experienced a health-related change in occupation. Factors associated with not recovering were female sex, middle age (40–59 years), two or more comorbidities, and more severe acute illness. The magnitude of the persistent health burden was substantial but only weakly associated with the severity of acute illness. Four clusters were identified with different severities of mental and physical health impairment (n=767): very severe (131 patients, 17%), severe (159, 21%), moderate along with cognitive impairment (127, 17%), and mild (350, 46%). Of the outcomes used in the cluster analysis, all were closely related except for cognitive impairment. Three (3%) of 113 patients in the very severe cluster, nine (7%) of 129 in the severe cluster, 36 (36%) of 99 in the moderate cluster, and 114 (43%) of 267 in the mild cluster reported feeling fully recovered. Persistently elevated serum C-reactive protein was positively associated with cluster severity. Interpretation We identified factors related to not recovering after hospital admission with COVID-19 at 6 months after discharge (eg, female sex, middle age, two or more comorbidities, and more acute severe illness), and four different recovery phenotypes. The severity of physical and mental health impairments were closely related, whereas cognitive health impairments were independent. In clinical care, a proactive approach is needed across the acute severity spectrum, with interdisciplinary working, wide access to COVID-19 holistic clinical services, and the potential to stratify care. Funding UK Research and Innovation and National Institute for Health Research.

Cardiac catheterization associated with central vein cannulation can involve potential thrombotic and infectious complications due to multiple cannulation trials or improper placement. To minimize the risks, medical simulators are used for training. Simulators are also employed to test medical devices such as catheters before performing animal tests because they are more cost-effective and still reveal necessary improvements. However, commercial simulators are expensive, simplified for their purpose, and provide limited access sites. Inexpensive and anatomical cardiovascular simulators with central venous access for cannulation are sparse. Here, we developed an anatomically and physiologically accurate cardiovascular flow simulator to help train medical professionals and test medical devices. Our simulator includes an anatomical right atrium/ventricle, femoral and radial access sites, and considers the variability of arm position. It simulates physiological pulsatile blood flow with a setting for constant flow from 3 to 6 L/min and mimics physiological temperature (37°C). We demonstrated simulation by inserting a catheter into the system at radial/femoral access sites, passing it through the vasculature, and advancing it into the heart. We expect that our simulator can be used as an educational tool for cardiac catheterization as well as a testing tool that will allow for design iteration before moving to animal trials.

Background\udGeneralized anxiety and depression are extremely prevalent and debilitating. There is evidence for age and sex variability in symptoms of depression, but despite comorbidity it is unclear whether this extends to anxiety symptomatology. Studies using questionnaire sum scores typically fail to address this phenotypic complexity.\ud\udMethod\udWe conducted exploratory and confirmatory factor analyses on Generalized Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9) items to identify latent factors of anxiety and depression in participants from the Genetic Links to Anxiety and Depression Study (N = 35,637; 16–93 years). We assessed age- and sex-related variability in latent factors and individual symptoms using multiple logistic regression.\ud\udResults\udFour factors of mood, worry, motor, and somatic symptoms were identified (comparative fit index [CFI] = 0.99, Tucker–Lewis Index [TLI] = 0.99, root mean square error of approximation [RMSEA] = 0.07, standardized root mean square residuals [SRMR] = 0.04). Symptoms of irritability (odds ratio [OR] = 0.81) were most strongly associated with younger age, and sleep change (OR = 1.14) with older age. Males were more likely to report mood and motor symptoms (p

Endometriosis is known to impact work productivity. The COVID-19 pandemic resulted in a shift in working practices for many, with an increase in working from home and/or flexible working hours. The aim of this online cross-sectional study was to determine if these changes resulted in changes in symptom management and productivity in Australian people with endometriosis. Three hundred and eighty-nine people responded to the survey. The majority of respondents found that their endometriosis symptoms were much easier to manage, and they were more productive. A key factor was flexibility in work hours and the increased ability to self-manage their time.