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Aim: The congenital Zika Syndrome (CZS) often leads to severe motor impairment in affected children, making independent walking unlikely. Early introduction of motorized mobility through ride-on cars has been recommended for young children with severe motor impairment, enabling independent movement in various environments. This study aims to explore mothers' perceptions of their children's experiences while using ride-on cars at home and in the community, focusing on children with CZS., Methods: This is a qualitative and descriptive study design using the Photovoice method. Four mothers of children with CZS, participating in the 'Go Zika Go' intervention project, were included. The research involved the following six steps: 1) Presentation of guide questions and Photovoice training; 2) Participants capturing photos; 3) Individual interviews to contextualize the photos; 4) Transcription and data analysis using thematic analysis principles; 5) Validation of analyses by mothers; and 6) Exhibition of photos to the community., Results: The mothers and researchers selected the 21 most relevant photographs, which revealed five main themes related to the use of motorized ride-on cars: 1) Experiences of participation; 2) Independence in mobility; 3) Characteristics of mobility devices; 4) Family support; and 5) Accessibility of the environment., Conclusion: The narratives provided by participants, along with photographs depicting the daily lives of children with CZS, shed light on aspects of functionality, autonomy, and participation. The use of these devices contributes to overall equity, breaking down social and cultural barriers and enabling children with disabilities to be seen as equals by their peers.

Objectives: Strict social distancing and lockdown measures imposed to curb transmission during the early phase of the outbreak of the COVID-19 pandemic posed challenges to people's psychological wellbeing, limited access to social support, and disrupted routine mental health service delivery. In response, a consortium of mental health stakeholders from Goa, India launched the COVIDAV program, which provided pro-bono virtual psychiatric and counselling consultations across India through an online platform. This study describes the acceptability and feasibility of the program from the perspective of various stakeholders., Methods: Data were collected via a survey with clinicians who had volunteered on COVIDAV ( n = 40), in depth interviews of the clinicians ( n = 14), and focus group discussion with key collaborators ( n = 1). Process data were mapped at various stages during the online platform's development and use. The qualitative and quantitative data was analysed using thematic analysis and a descriptive analysis respectively., Results: Over 17 months, 63 clinicians conducted 2245 online sessions through the COVID platform, primarily accessed by youth across the country. The clinicians acknowledged the online platform's ability to enhance access and reduce stigma. Challenges included session time constraints, connectivity issues, and user interface inconsistencies that interfered with clients' accessibility to the services. High satisfaction rates amongst the service providers were reported, with 79.3% content with the service provision and 82.8% with pro bono contributions through the platform., Conclusions: This study illustrates the feasibility, flexibility, and applicability of a rapidly designed pro-bono online platform for delivering mental health care services through the collaboration of stakeholder groups in the mental health care, private, social, and governmental sector. Our findings highlight the potential of rapidly deployed digital platforms, developed via cross-sector partnerships, to meet mental health care needs during unprecedented global emergencies such as the COVID-19 pandemic.

Purpose: To explore the feasibility of an intervention using modified ride-on cars in terms of acceptability and potential changes in goal attainment, mobility, social function, and participation of children with Congenital Zika Syndrome (CZS)., Materials and Methods: A pre- and post-intervention feasibility study was conducted with children with CZS, levels IV and V of the Gross Motor Function Classification System (GMFCS). The intervention consisted of 12 weeks of training (3 times a week for 40 min per session) and 4 weeks of follow-up. The primary outcomes included adherence, satisfaction, and learning in mobility. Secondary outcomes encompassed goal attainment, mobility, social/cognitive function, and participation. Descriptive statistics were performed. To explore potential individual changes with the intervention, Wilcoxon test was used to analyze Pediatric Evaluation of Disability Inventory - Computer Adaptive Test (PEDI-CAT) data and Young Children's Participation and Environment Measure (YC-PEM)/Participation and Environment Measure for Children and Youth (PEM-CY), along with standard error measurements of the PEDI-CAT domains., Results: Four children participated (median age 4.75 years; two females: three at level V on the GMFCS). Adherence was 75% of the total intervention time, and family members reported being satisfied or very satisfied. Children showed gains in learning the use of the modified ride-on cars and an increase in goal attainment after the intervention. Individual changes were observed in the PEDI-CAT domains (mobility and social/cognitive), but there were no significant changes in participation outcomes., Conclusions: Children with CZS at GMFCS levels IV and V can learn to use motorized ride-on cars, attainment goals, and experience satisfaction.

Objectives: Adverse Childhood Experiences (ACEs) increase health risks leading to negative pregnancy outcomes, thus prompting the need for preconception care to address these risks. The aim of this study is to assess the association between ACEs score and self-report of having pre-pregnancy health conversations with a healthcare provider., Methods: Secondary analysis of PRAMS data from 2016 to 2020 was performed from 3 states and Washington, DC. ACEs score was categorized as 0 (low risk), 1-3 (intermediate risk), and ≥ 4 (high risk). Pre-pregnancy health conversations were measured using reports of being asked about the desire to have children, use birth control to prevent pregnancy, and/or improve health during any visit in the 12 months prior to pregnancy. Multivariate Poisson Regression was performed to adjust for potential confounders: age, race/ethnicity, income, education, insurance type, marital status, pregnancy intention, and parity., Results: A total of 10,448 PRAMS survey responses from 2016 to 2020 were included in the analysis. More than half of women reported having at least 1 ACE (51%). Those with an ACE score of ≥ 4 had 1.19 (95% CI: 1.01-1.41) times higher adjusted Prevalence Ratio (aPR) and those with an ACE score of 1-3 had about the same aPR 1.00 (95% CI: 0.93-1.09) of reporting pre-pregnancy health conversations with a healthcare provider compared to those with no ACEs. CONCLUSIONS FOR PRACTICE: The overall low percentage of respondents reporting receipt of pre-pregnancy health conversations with a health care provider indicates the need for these conversations to be had on a more routine basis., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: We examined racial/ethnic differences in the association between influenza vaccine recommendations from healthcare providers and maternal vaccination uptake., Methods: This cross-sectional study examined data from the Pregnancy Risk Assessment Monitoring System. We categorized respondents as non-Hispanic (NH) Whites, NH-Blacks, NH-Asians, American Indians/Alaska Natives, NH Other non-Whites, and Hispanics. We conducted multivariable logistical regression models to evaluate adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates included maternal age, marital status, education, insurance status before pregnancy, the number of previous live births, the number of prenatal care visits, and smoking status during pregnancy., Results: The prevalences of receiving influenza vaccine recommendations from healthcare providers and maternal vaccine were 80.01% and 50.42%, respectively. NH-Blacks are less likely to receive provider recommendations (AOR = 0.82; 95%CI 0.77-0.87) and be vaccinated (AOR = 0.76; 95%CI 0.72-0.80) than NH-Whites. Receiving provider recommendations was significantly associated with increased maternal influenza vaccine uptake (AOR = 15.50; 95% CI 14.51-16.55). The associations were significant for all racial/ethnic groups, with the highest among NH-Asians (AOR = 22.04; 95% CI 17.88-27.16) and the lowest among NH Other non-Whites (AOR = 11.07; 95% CI 8.25-14.86). Within NH-Asians, effectiveness among Chinese was highest (AOR = 29.39; 95% CI 18.10-47.71)., Conclusions: Racial/ethnic disparities in maternal influenza vaccine uptake and receiving vaccine recommendations from healthcare providers persisted. Further studies on the racial/ethnic disparities in maternal vaccination were warranted and tailored strategies are required to reduce this health disparity., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Arm injuries are common in youth fastpitch softball players. To characterize arm injuries and assess injury prevention knowledge, we administered a cross-sectional online survey and injury prevention quiz to high school fastpitch softball players, parents, and coaches. Associations between throwing habits and adverse arm outcomes were computed. Surveys were collected from 123 high school players, 59 parents, and 28 coaches, totaling 210 responses. Nearly half (48.8%) of players saw a doctor for arm pain. Riseball pitchers were less likely to undergo surgery than non-riseball pitchers (P = .008). Outfield/utility players trended toward more frequent arm pain compared to alternative position groups (P = .086). On injury prevention quizzes, players, parents, and coaches averaged scores of 56-65% correct, with players scoring below parents (P = .011) and coaches (P = .006). In conclusion, high school softball players frequently seek medical attention for arm pain, and injury prevention knowledge is consistently lacking.

Background: The COVID-19 pandemic negatively affected adolescent mental health due to school closures, isolation, family loss/hardships, and reduced health care access., Methods: We compared adolescent mental health in Rhode Island before versus during the pandemic, separately among middle and high schoolers. This serial cross-sectional study used Youth Risk Behavior Survey data from 2019 and 2021 (N = 7403). Multivariable logistic regression models estimated the association between year and mental health status, adjusting for sociodemographics., Results: Middle schoolers in 2021 had higher odds of ever seriously considering suicide (22.6% vs 16.7%) and ever attempting suicide (9.3% vs 6.1%) compared to 2019. Among high schoolers, those in 2021 had higher odds of experiencing persistent sadness/hopelessness in the past year (37.4% vs 32.0%). However, high schoolers in 2019 and 2021 had similar odds of considering suicide in the past year, while those in 2021 had lower odds of having attempted suicide in the past year (8.5% vs 14.6%)., Conclusion: The COVID-19 pandemic may have worsened multiple aspects of adolescent mental health in Rhode Island, particularly among middle schoolers., Implications for School Health Policy, Practice, and Equity: Promoting school connectedness, creating supportive environments, and diversifying the mental health workforce may help overcome adverse pandemic effects., (© 2023, American School Health Association.)

In Mozambique, cervical cancer is the most frequent cancer in women. However, studies about cervical cancer treatment and prognosis are scarce. We describe the clinical characteristics, treatment and survival of patients with cervical cancer admitted to Maputo Central Hospital (MCH) in 2016 to 2018. Sociodemographic, clinical and cancer-related data were retrieved from clinical records of patients admitted to the Oncology Service of the MCH with an incident cervical cancer in 2016 to 2018 (n = 407). The Pathology Service database was used to obtain information regarding pathological diagnosis. Survival data was obtained through the MCH Cancer Registry and clinical records. Odds ratios for the association between patients' characteristics and the diagnosis of advanced stage cancer were computed using logistic regression. Survival analyses were performed using the Kaplan-Meier estimator. A total of 91.2% of the patients were diagnosed with advanced disease (stage IIB-IV) and squamous cell carcinoma was the predominant histological subtype. Most of the patients underwent chemotherapy (93.1%) but <7% were submitted to surgery, radiotherapy or brachytherapy. Those living with HIV had 3.4-fold higher odds of advanced disease. Overall survival was 72.7% (95% confidence interval [CI]: 67.9-77.0) at 1-year and 51.0% (95%CI: 45.3-56.3) at 2-years. Those with early stage (IA-IIA) and asymptomatic at diagnosis had a significantly higher 2-year overall survival. In Mozambique, cervical cancer is diagnosed mostly in advanced stages, resulting in poor prognosis. This highlights the importance of HPV vaccination and screening, to decrease the burden of cervical cancer in this context., (© 2023 UICC.)

Background: Research shows associations between bullying victimization and substance use for teens. However, more research about this relationship for younger adolescents and across race/ethnicity is needed., Methods: Prevalence and pooled logistic regression analyses of 2019 Middle School Youth Risk Behavior Survey data from 13 states (N = 74,059 students) examined associations between self-reported bulling victimization (at school, electronically, and both) and having ever tried cigarette smoking, alcohol, or marijuana; used an electronic vapor product; or misused prescription pain medicine. Regression analyses were adjusted by age and sex/race/ethnicity., Results: All 3 measures of bullying victimization were significantly associated (p < .05) with the 5 substance use behaviors examined (adjusted prevalence ratios ranged from 1.29 to 2.32). These associations held across sexes. Significant associations were found within all 7 race/ethnicity categories, with the most associations reported for the non-Hispanic (NH) white, NH black or African American, Hispanic/Latino, and NH Asian groups., Conclusion: The association between bullying and substance use by middle school is a highly relevant issue to consider as students return to classrooms., (Published 2023. This article is a U.S. Government work and is in the public domain in the USA.)

Purpose: This cross-sectional study aimed to estimate the risks of adverse birth outcomes among pregnant smokers and the benefits of smoking cessation during pregnancy on birth outcomes across the United States., Methods: We performed an analysis of 203,437 pregnant women using data collected by the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2012 to 2017. PRAMS uses questionnaires and birth certificates to collect information about the socio-demographic characteristics of pregnant women, smoking status before and during pregnancy, and birth outcomes. We assessed the relationship between self-reported smoking status during pregnancy and preterm birth, low birth weight, and small-for-gestational-age using multivariable logistic regression models., Results: In our study population, 80.43% of pregnant women never smoked, 10.55% of pregnant women quit smoking during pregnancy, and 9.02% continued smoking during pregnancy. Puerto Rico had the highest prevalence of non-smokers (94.12%), while West Virginia had the lowest prevalence of non-smokers (60.54%). Pregnant women who had a higher education level, were married, had less than 5 types of stress, and had government or private insurance before pregnancy had a higher prevalence of smokers who quit during pregnancy (quit smokers) than those that continued smoking (continuous smokers). Compared to non-smokers, continuous smokers had a significantly higher risk of low birth weight (AOR: 1.91, 95% CI 1.80, 2.03), preterm birth (AOR: 1.31, 95% CI 1.21, 1.41), and small-for-gestational-age (AOR: 2.22, 95% CI 2.07, 2.39). However, the relationships between quitting smoking and preterm birth and small-for-gestational-age were not significant., Conclusion: Our models suggest that smoking cessation during pregnancy can prevent adverse birth outcomes by significantly reducing the risk of preterm birth and small-for-gestational-age to almost comparable to not smoking., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

During cadaveric dissection or prosection, medical students frequently encounter pathology that can be a springboard to further learning. We designed a novel educational activity linking anatomy, histology, and pathology that incorporated self-directed learning and teamwork, followed by feedback and instruction from pathologists. Post-activity, more than 97% of students rated the activity as useful (Likert scale of 1 to 5), indicating this activity should be continued in the future. Strengths included self-directed learning, content and design, and teamwork, peer, and faculty interactions. Clarity of assignment expectations, range of pathologies, and virtual presentation format remained areas for improvement., Competing Interests: Competing InterestsThe authors declare no competing interests., (© The Author(s) under exclusive licence to International Association of Medical Science Educators 2023.)

Objective: Influenza vaccination during pregnancy is highly recommended. We examined the association between maternal influenza vaccination and adverse birth outcomes., Methods: This cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) during 2012-2017. The primary exposure was the receipt of influenza vaccination during pregnancy. Low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) were the primary outcomes. We conducted multivariable logistic regression models to estimate the adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates used to adjust confounding included maternal age, marital status, education, race and ethnicity, insurance status before pregnancy, and smoking status. For a subgroup in 2012-2015, we analyzed the association between influenza vaccination in each trimester and adverse birth outcomes., Results: During 2012-2017, compared with unvaccinated women, women vaccinated during pregnancy had a lower risk of LBW and PTB. During 2012-2015, maternal influenza vaccination in the 1st and 3rd trimesters was associated with a reduced risk of LBW and PTB, and vaccination in the 3rd trimester had a greater protective effect than in the 1st trimester. Influenza vaccination was not associated with SGA regardless of trimester., Conclusions: Our findings suggest that influenza vaccination during pregnancy is a safe and effective way to protect newborns., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: Antenatal depression (AD) has been considered a risk factor for cesarean delivery (CD); however, the supporting data are inconsistent. We used a large, nationally representative dataset to evaluate whether there is an association between AD and CD among women delivering for the first time., Study Design: We utilized the 2016 to 2019 Multistate Pregnancy Risk Assessment Monitoring System (PRAMS) from the Centers for Disease Control. First-time parturients who reported depression in the 3 months prior to or at any point during their recent pregnancy were compared with those who did not. The mode of delivery was obtained through the birth certificate. Maternal demographics, pregnancy characteristics, and delivery characteristics were compared by the report of AD using bivariable analyses. Population-weighted multivariable regression was performed, adjusting for maternal age, race/ethnicity, insurance, pregnancy complications, preterm birth, and body mass index (BMI)., Results: Of the 61,605 people who met the inclusion criteria, 18.3% ( n  = 11,896) reported AD and 29.8% ( n  = 19,892) underwent CD. Parturients with AD were younger, more likely to be non-Hispanic white, publicly insured, use tobacco in pregnancy, deliver earlier, have lower levels of education, higher BMIs, and more medical comorbidities (hypertension and diabetes). After adjustment for these differences, there was no difference in risk of CD between those with AD compared with those without (adjusted odds ratio: 1.04; 95% confidence interval: 0.97-1.13)., Conclusion: In a large, population-weighted, nationally representative sample of first-time parturients, there was no association between AD and CD., Key Points: · Antenatal depression is increasingly common and has multiple known morbidities.. · Prior data on antenatal depression and cesarean delivery are mixed.. · We found no association between depression and cesarean delivery.., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: Despite a movement toward the inclusion of patient partners or advisors as part of the research team in all funded studies, few publications have discussed patient engagement from the patient partners' perspective., Methods: Qualitative interviews were conducted by independent qualitative researchers to collect and summarize the experiences and perspectives of the 16 Patient Partners (PPs) on the study team for PeRson EmPowered Asthma RElief (PREPARE), a large, pragmatic study of 1200 African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma. This study was funded by the Patient-Centered Outcomes Research Institute., Results: This paper, authored by the PPs themselves, summarizes qualitative interview findings. The journey of the PREPARE PPs began with a desire to learn more about asthma and advocate for other individuals with asthma. Many challenges, including intimidation and lack of trust, were overcome as the research team prioritized building a comfortable environment in which PPs' lived experiences, opinions, and cultural beliefs are valued, and in which PP voices are centered and respected. Over time, the PPs gained confidence in expressing ideas and feedback, and in taking ownership of their role as valued members of the research team. The PP experience has had tremendous personal and professional impact on the PPs themselves, while also modeling a change in the way researchers and PPs relate to and partner with each other., Conclusion: The partnership between PPs and researchers in the PREPARE study has elevated the PP role from external advisors to integral and empowered members of a collective research team, and the partnership developed and evolved over time., (© 2022. The Author(s).)

Purpose: Medical schools have faced various challenges in preparing their clinical students for the frontlines of a pandemic. This study investigated medical students' satisfaction with their institutions during the coronavirus disease 2019 (COVID-19) pandemic with the intention of guiding educators in future public health crises., Methods: In this cross-sectional study surveying students in clinical rotations, the primary outcome was overall satisfaction regarding medical schools' responses to the pandemic, and the four secondary outcomes were school communication, exposure to COVID-19, availability of personal protective equipment, and access to COVID-19 testing., Results: The survey was distributed to ten medical schools, of which 430 students responded for a response rate of 13.0%. While most students were satisfied (61.9%, n=266) with their schools' response, more than one in five (21.9%, n=94) were dissatisfied. Among the four secondary outcomes, communication with students was most predictive of overall satisfaction., Conclusion: In future crises, schools can best improve student satisfaction by prioritizing timely communication.

The present study aimed to identify larval trematodes shed by snails found in water bodies used by urban communities in a former schistosomiasis endemic area in the state of Piauí, in the Brazilian semiarid region. A malacological survey was performed followed by analysis of the cercariae shed by the snails after light exposure. Biomphalaria straminea specimens (n=1,224) were obtained from all seven collection sites. Cercariae shed by snails were i) single tailed, in which one type of cercariae was identified ( Echinostoma cercariae), and ii) with bifurcated tail (brevifurcate apharyngeate distome, brevifurcate pharyngeate distome, and longifurcate pharyngeate distome [strigeocercaria]). Brevifurcate apharyngeate distome were further examined and the presence of spikes in swimming membranes enabled the identification of Spirorchiidae cercariae in all individuals, demonstrating the absence of cercariae compatible with Schistosoma mansoni . Nevertheless, the accurate diagnosis of S. mansoni circulation in former endemic areas is still necessary.

Study Objectives: Women with sleep-disordered breathing (SDB) in pregnancy are at a greater risk of developing serious adverse perinatal outcomes. However, the pathogenesis of SDB in pregnancy is poorly understood. As nasal congestion is common in pregnancy, nasal obstruction may contribute to SDB in this population. This study aims to assess the impact of nasal dilator strips (NDS) on measures of SDB and their potential for use as a placebo condition., Methods: Pregnant women ≥ 18 years old, body mass index ≥ 27 kg/m 2 , and habitual snoring were enrolled. Participants completed 2 consecutive level III home sleep apnea tests and used NDS during the second test. Objective measures including respiratory event index and pulse transit time drop index, a measure of increased arterial stiffness, were compared across tests. Subjective assessments of participants' perceived impact of NDS use was also obtained., Results: 54 women, 59% White, 60% in the third trimester were enrolled. Median time between the 2 studies was 1 day (interquartile range [IQR] 4). There was no significant change between the night without NDS use and the night with NDS use in respiratory event index (5.30 [IQR 6.20] vs 4.80 [IQR 6.78], P  = .8) or pulse transit time drop index (6.8 [IQR 13.3] vs 6.6 [IQR 15.8], P  = .360). Subjective measures of sleep did not differ between the 2 nights., Conclusions: Despite the high prevalence of pregnancy-associated rhinitis, NDS do not have a significant impact on measures of SDB. Results from this study support the use of NDS as an appropriate placebo in prenatal clinical trials., Citation: Maxwell M, Sanapo L, Monteiro K, et al. Impact of nasal dilator strips on measures of sleep-disordered breathing in pregnancy. J Clin Sleep Med . 2022;18(2):477-483., (© 2022 American Academy of Sleep Medicine.)

Objective: Antenatal depression (AD) is frequently cited as a risk factor for cesarean delivery (CD) with limited supporting data., Study Design: We utilized 2016-2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey for the state of Rhode Island. Nulliparous women who reported AD (n=242) were compared to women who did not (n=1,081). Maternal demographics, pregnancy and delivery characteristics were compared by AD status using population-weighted bivariable analyses and multivariable logistic regression., Results: 17.7% reported AD, and 34% underwent CD. There was no difference in CD based on reported AD status (aOR 1.04; 95% CI 0.69, 1.56). However, there were significant differences between those reporting AD compared to those who did not: less education, more public insurance, use of Women, Infants and Children (WIC) benefits, tobacco use, and pre-gestational hypertension/diabetes., Conclusion: In this large, population-based, state representative sample, we found no difference in CD among recently delivered nulliparous women with and without AD.

Deficiency of 21-hydroxylase enzyme (CYP21A2) represents 90% of cases in congenital adrenal hyperplasia (CAH), an autosomal recessive disease caused by defects in cortisol biosynthesis. Computational prediction and functional studies are often the only way to classify variants to understand the links to disease-causing effects. Here we investigated the pathogenicity of uncharacterized variants in the CYP21A2 gene reported in Brazilian and Portuguese populations. Physicochemical alterations, residue conservation, and effect on protein structure were accessed by computational analysis. The enzymatic performance was obtained by functional assay with the wild-type and mutant CYP21A2 proteins expressed in HEK293 cells. Computational analysis showed that p.W202R, p.E352V, and p.R484L have severely impaired the protein structure, while p.P35L, p.L199P, and p.P433L have moderate effects. The p.W202R, p.E352V, p.P433L, and p.R484L variants showed residual 21OH activity consistent with the simple virilizing phenotype. The p.P35L and p.L199P variants showed partial 21OH efficiency associated with the non-classical phenotype. Additionally, p.W202R, p.E352V, and p.R484L also modified the protein expression level. We have determined how the selected CYP21A2 gene mutations affect the 21OH activity through structural and activity alteration contributing to the future diagnosis and management of CYP21A2 deficiency.

Night work increases diabetes risk. Misalignment between the central circadian “clock” and daily behaviors, typical in night workers, impairs glucose tolerance, likely due to internal misalignment between central and peripheral circadian rhythms. Whether appropriate circadian alignment of eating can prevent internal circadian misalignment and glucose intolerance is unknown. In a 14-day circadian paradigm, we assessed glycemic control during simulated night work with either nighttime or daytime eating. Assessment of central (body temperature) and peripheral (glucose and insulin) endogenous circadian rhythms happened during constant routine protocols before and after simulated night work. Nighttime eating led to misalignment between central and peripheral (glucose) endogenous circadian rhythms and impaired glucose tolerance, whereas restricting meals to daytime prevented it. These findings offer a behavioral approach to preventing glucose intolerance in shift workers.

Study Objective: To explore minority, adolescent birth and perinatal experiences to inform and improve quality of care for this unique group., Design: Mixed quantitative and qualitative study guided by Bourdieu's Social Fields framework., Setting: Clinic dedicated to parenting adolescents, and a local charter school founded to serve pregnant and parenting young adults., Participants: Sample size for quantitative data: n = 27; qualitative data: n = 14. Average age was 16.39 years (SD = 1.29); most self-identified as Latina/Hispanic or African American/Black/Afro-Caribbean/African., Interventions and Main Outcome Measures: We used 2 validated surveys: Birth Satisfaction Scale-Revised (BSS-R), and the Postpartum Worry Scale-Revised (PWS-R). The BSS-R has 10 items, and quantifies labor and delivery experiences. The PWS-R has 20 items, and quantifies maternal, infant, and social-emotional worries. The qualitative, semistructured 30-minute interviews with a subset of survey respondents further explored perinatal mental health, labor experiences, and support networks., Results: BSS-R data resulted in an average score of 25.14 (SD = 5.35), which correlated to moderate satisfaction with birth experience (range, 0-40 with 0 = most negative). The PWS-R average score of 55.79 (SD = 21.06) indicated elevated postpartum worry (range, 20-100 with 20 = most worry). Qualitative interviewees worried about relationships and newborn well-being; support networks fluctuated; distinct events, pain, and fear during labor dominated birth stories. Advice for peers included: tending to social support, stress, and self-care. Nonjudgmental communication, empathy, and emotional connection were desired attributes of their health care team. Participants had anxiety related to social networks and newborn care. Although birth experiences were moderately positive, they were also described as stressful. However, participants were resourceful, insightful, and took advantage of social supports., Conclusion: Birth experiences, patterns of stress, and support networks are uniquely identified and utilized by adolescent mothers. Being heard and feeling connected to providers empowered this group of young, minority adolescents. Participant advice could inform future educational courses, programs, and hospital innovations for perinatal adolescents., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize the effects of aging on the nanomechanical properties and 3D surface topographical parameters of an experimental Zirconia Toughened Alumina (ZTA) composite compared to its respective individual counterpart materials., Methods: Disk-shaped specimens comprised of three material groups were processed: 1) ZTA 70/30 (70% alumina reinforced with 30% second-generation 3Y-TZP); 2) Zpex (Second-generation 3Y-TZP), and; 3) Al 2 O 3 (High purity Alumina) (n = 10/material, 12 × 1 mm). After synthesis, ceramic powders were pressed, the green-body samples were sintered and polished. Nanoindentation testing was performed to record elastic modulus (E) and hardness (H). Interferometry was utilized to assess 3D surface roughness parameters (S a , S q ), while X-ray diffraction (XRD) and scanning electron microscope (SEM) assessed the crystalline content and microstructure. All tests were performed before and after simulated aging (134°C, 2.2 bar, 20 h). Statistical analyses were performed using linear mixed-model and least square difference pos-hoc tests (α = 5%)., Results: XRD spectra indicated increase of monoclinic peaks for Zpex (~18%) relative to ZTA 70/30 (~2.5%) after aging. Additionally, aging did not affect the surface roughness parameters of ZTA 70/30 and Al 2 O 3 , although a significant increase in S a was recorded for Zpex following aging (~90 nm) (p < 0.001). Al 2 O 3 yielded the highest H and E values (H:21 GPa, E: 254 GPa), followed by ZTA 70/30 (H: 13 GPa, E: 214 GPa) and Zpex (H:11 GPa, E: 167 GPa), all significantly different (p < 0.03)., Conclusion: ZTA 70/30 and Al 2 O 3 presented high hydrothermal stability with respect to all evaluated variables, where artificial aging significantly increased the monoclinic content and surface roughness of Zpex., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: As the incidence of youth pitching injuries and surgical procedures attributed to overuse has drastically increased, there are quality concerns about popular internet resources regarding arm care for youth pitchers., Purpose/hypothesis: To assess the medical advisability of online arm care recommendations for youth pitchers. It was hypothesized that websites contain misleading arm-care information that is discordant with medical advice., Study Design: Cross-sectional study., Methods: We reviewed the first 100 websites populated after a Google search for youth pitching recommendations . Websites were categorized by type (athletic organization, commercial, or educational) and content quality (medically advisable, discordant, or neutral), the latter with respect to the Pitch Smart guidelines used by Major League Baseball. Chi-square tests of independence and z tests of independent proportions were used to compare column proportions among categories of website content quality for each type of website source. Given the small sample sizes in some instances, the Fisher-Freeman-Halton exact test was performed to assess the relationship between website source type and quality of information., Results: Of the 99 qualifying websites, 76 were categorized as medically advisable, 16 as discordant, and 7 as neutral. In addition, 92% of educational websites and 94.7% of athletic organization websites featured exclusively advisable content, whereas only 54.8% of commercial websites were advisable. Of the 16 discordant websites, 15 were commercial sites. Educational websites were significantly more advisable and neutral in content when compared with discordant information, while commercial websites were significantly predictive of discordant content. Among the first 50 websites populated according to Google, 42 (84%) were advisable, 6 (12%) discordant, and 2 (4%) neutral. The remaining websites (n = 49) featured 34 (69.4%) that were advisable, 10 (20.4%) discordant, and 5 (10.2%) neutral., Conclusion: Study findings indicated that websites of an educational nature are predictive of medically advisable content, while commercial websites (eg, blogs) are associated with discordant information. The abundance and availability of inaccurate internet information should be appreciated by medical professionals and parents/coaches of youth baseball players., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: B.D.O. has received consulting fees from DePuy Synthes, Linvatec, and Musculoskeletal Transplant Foundation and royalties from Linvatec. He is also a paid associate editor for The American Journal of Sports Medicine. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

Background: The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family., Methods: A total of 389 patients enrolled under the CMS grant at Boston Children's Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales., Results: Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49-6.59]), missed school days (1.91 [1.09-3.36]), and parent and/or guardian missed workdays (2.72 [1.15-6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01)., Conclusions: The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Introduction: Prescription opioid misuse is a national crisis. Injured children often receive opioid medication at hospital discharge, but the role these prescriptions play in the opioid crisis has not been fully elucidated. Whether these opioids are administered, the duration of severe pain requiring opioids, and what the final disposition of unused opioids is in this population remain unknown., Methods: A survey of parent/guardian perceptions of their child's pain after injury, duration of opioid administration, opioid storage and disposal, and perceptions of opioid education was designed. During a 12-month period, parents of injured children admitted to an ACS Level 1 Pediatric Trauma Center were prospectively enrolled by convenience sample. Surveys were in two steps with an enrollment survey prior to discharge and a follow-up survey 7-10 days after discharge., Results: Seventy of 114 (61.4%) enrolled parents/guardians completed follow-up survey. Of the 79.1% that reported an opioid prescription for their child, 92.5% filled it. Of those reporting on opioid usage, 10.4% never used the opioid, 75% used opioids <3 days, 12.5% 4-7 days, 2% >7 days. Of those who filled the opioid prescription, 83.7% reported having leftover doses. Reasons for discontinuing opioids included the child no longer had pain (87.2%), the child ran out of medication (5.1%), other (7.7%). Regarding storage, 53.3% reported utilizing an unlocked bathroom cabinet, and 81.3% unlocked kitchen space. Of those reporting unused opioids, 83.3% reported not disposing them, and 38.2% reported no plan for disposal., Conclusion: The majority of parents/guardians of injured children report resolution of severe pain requiring opioids within 72 h of hospital discharge, and virtually all by 7 days. The majority of injured children were prescribed a greater number of doses than they needed to treat their pain. Many parents/guardians store opioids in unsecure locations and a significant proportion report no plan to dispose of unused opioid doses. Further investigation is warranted to quantify and address the gap between pain control needs and opioid prescribing practices. The rate of unsecure storage and plan to retain unused opioids are potential targets for discharge opioid education., Type of Study: Cross-sectional survey., Level of Evidence: Level IV., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Objectives: The hospital is often a challenging and unfamiliar environment for families. Hospitalization can increase stress and anxiety among children and caregivers. In this study, we are the first to explore the possible therapeutic effects of poetry on hospitalized pediatric patients' emotional wellbeing., Patients and Methods: Patients aged 8 to 17 years old admitted to the inpatient pediatric ward and their parents or guardians were eligible for inclusion. With the validated Pediatric Quality of Life Present Functioning Visual Analogue Scales, 6 items were measured before and after the poetry intervention for each participant: fear, sadness, anger, worry, fatigue, and pain in the present moment. The intervention itself consisted of poetry-based reading and writing exercises. Participants and parents also completed an open-ended qualitative survey on their experience., Results: Data from 44 participants were analyzed. Using the Wilcoxon signed rank test, we showed that the poetry intervention had a statistically significant reduction in 5 of the 6 Pediatric Quality of Life Present Functioning Visual Analogue Scales symptom measures: fear ( P = .021), sadness ( P = .004), anger ( P = .039), worry ( P = .041), and fatigue ( P < .001). Reduction in pain was not statistically significant ( P = .092). Six coded themes emerged from qualitative analysis: the poetry intervention facilitated (1) happiness and (2) family involvement, was viewed as a (3) good distraction and (4) screenless activity, and cultivated (5) creativity and (6) self-reflection., Conclusions: The poetry intervention led to statistically significant reductions in fear, sadness, anger, worry, and fatigue but not in pain. The study reveals promising results and serves as a starting point for future investigations on the therapeutic impact of poetry on hospitalized pediatric patients., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Charcot-Marie-Tooth disease (CMT) is a rare, chronic, progressive motor and sensory neuropathy affecting the peripheral nervous system. This study will explore the real-world impact of CMT. The trial is a digital study of approximately 2000 people in 6 countries with CMT ≥18 years. Participants will use a smartphone application to check eligibility, provide consent and contribute data. The dataset will include a personal profile, covering demographics, lifestyle, diagnosis and treatment and a selection of validated generic and disease-specific instruments. Participants will provide data for up to 2 years. Data analysis will be conducted upon registration of the 1000th participant and at 12-month intervals from launch. This study is designed to help researchers and clinicians understand the real-world impact of CMT and the unmet needs of patients. ClinicalTrials.gov identifier: NCT03782883.

Objective: To evaluate the effect of aging on the microstructural, mechanical, and optical properties of an experimental zirconia-toughened alumina composite with 80%Al 2 O 3 and 20%ZrO 2 (ZTA Zpex) compared to a translucent zirconia (Zpex) and Alumina., Methods: Disc-shaped specimens were obtained by uniaxial and isostatic pressing the synthesized powders (n = 70/material). After sintering and polishing, half of the specimens underwent aging (20 h, 134 °C, 2.2 bar). Crystalline content and microstructure were evaluated using X-ray diffraction and scanning electron microscopy, respectively. Specimens underwent biaxial flexural strength testing to determine the characteristic stress, Weibull modulus, and reliability. Translucency parameter (TP) and Contrast ratio (CR) were calculated to characterize optical properties., Results: ZTA Zpex demonstrated a compact surface with a uniform dispersion of zirconia particles within the alumina matrix, and typical alumina and zirconia crystalline content. ZTA Zpex and alumina exhibited higher CR and lower TP than Zpex. ZTA Zpex and Zpex showed significantly higher characteristic stress relative to alumina. While aging did not affect optical and mechanical properties of ZTA Zpex and alumina, Zpex demonstrated a significant increase in translucency, as well as a in characteristic stress. Alumina reliability was significantly lower than others at 300 MPa, ZTA Zpex and Zpex reliability decreased at 800 MPa, except for aged Zpex., Significance: While aging did not affect the mechanical nor the optical properties of ZTA Zpex and alumina, it did alter both properties of Zpex. The results encourage further investigations to engineer ZTA as a framework material for long span fixed dental prostheses specially where darkened substrates, such as titanium implant abutments or endodontically treated teeth, demand masking., (Copyright © 2020 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.)

Children with congenital Zika syndrome (CZS) present severe motor disability and can benefit from early powered mobility. The Go Zika Go project uses modified ride-on toy cars, which may advance the body functions, activities, and participation of children. This paper describes the study protocol aiming to assess the feasibility of a modified ride-on car intervention for children with CZS in Brazil. A mixed-methods design with a multiple 1-week baseline, 3-month intervention, and 1-month follow-up will be implemented. Modified ride-on car training sessions will be conducted three times a week at the participants' home or in the clinic. The primary outcome will be a narrative description of study feasibility (photovoice method, focus groups, parent feasibility questionnaire and assessment of learning powered mobility). Secondary outcomes will be switch activation, driving sessions journal, social-cognitive interactions, mobility (pediatric evaluation of disability inventory computer adaptive test), goal attainment scaling (GAS), and participation (young children's participation and environment measure). Go Zika Go is expected to be viable and to improve function, activity, and participation of children with CZS, providing a low-cost, evidence-based rehabilitation option that will be relevant to early child development in a global perspective.

Introduction: Trauma is the leading cause of mortality among children in the US. Injured children often receive narcotic pain medication throughout their hospital stays and upon discharge from pediatric trauma centers. While effective, narcotics carry significant risks. There is a dearth of knowledge regarding narcotic education, prescribing practices, and pain management training at pediatric trauma centers. We hypothesize that there is a lack of standardization in these practices among pediatric trauma centers nationally., Methods: A national survey was sent to medical directors at ACS-verified and state designated level 1 and 2 pediatric trauma centers. Data were collected over 6 months on discharge narcotic education and prescribing practices., Results: Of 97 surveys sent, 92 were returned (94.8% response). Responses show that narcotics are most commonly prescribed by residents (79.1%). Electronic Medical Record (EMR) prescribing is common (89.2%); however, only 1.75% of EMRs give recommendation to prescribe naloxone. Only 9.7% report a standardized format of narcotic education. Most healthcare staff providing narcotic education receive no training in nonpharmacological pain management (68.8%). Most centers report no formal process to reduce the quantity of discharge narcotics prescribed (71.0%). Respondents report many barriers to providing discharge narcotic education to patients and families, including staff training on how to provide discharge narcotic education, staff availability, patient/ parent literacy, and format of available educational resources., Conclusion: The study results show that there is lack of standardization in discharge narcotic education and prescription practices among pediatric trauma facilities nationally and highlight the need for a standardized narcotic prescribing and management protocol. Despite the growing national concern of opiate misuse, particularly among children, respondents report inability to deliver adequate narcotic education owing to various communication and systems barriers., Type of Study: Cross-sectional survey., Level of Evidence: Level IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A retrospective study compiling cases of feline lymphoma diagnosed during 12 years (2004-2016) in Southern Brazil was performed. A total of 125 cases of lymphoma diagnosed in cats were reviewed, and information including age, breed, sex and tumour topography were collected. FeLV and FIV immunohistochemical tests were performed, as well as immunophenotyping of lymphomas. The alimentary form represented the most common presentation (42/125), followed by mediastinal lymphoma (35/125). Out of 125 cases, 79 presented positive retroviral immunostaining in tumour tissue (52 FeLV alone, 14 FIV alone and 13 presented FIV and FeLV co-infections), 66/125 of the cases were of T-cell origin and 59/125 of the cases were of B-cell origin. The median age of cats with T-cell lymphoma was 120 months (10-240 months), and 60 months (6-204 months) for cats with B-cell lymphoma. The most frequent alimentary tumour presentation was the enteropathy-associated T-cell lymphoma (type 1), and the major type of mediastinal tumour observed was diffuse large B-cell lymphoma. Considering only mediastinal and alimentary lymphomas (n = 77), the prevalence of mediastinal lymphoma in FeLV-positive cats was 2.21 times higher than the prevalence of this type of tumour in FeLV-negative cats (P = .036). Mediastinal lymphoma was more frequently observed in younger cats, and the prevalence of mediastinal tumours in these animals was 3.06 times higher than the prevalence of this tumour form in old cats (P = .0125). The present study indicates that retroviral infections still play an important role in the development of feline lymphomas in southern Brazil., (© 2019 John Wiley & Sons Ltd.)

Background and Objectives: Food insecurity, defined as the lack of reliable access to sufficient quantities of affordable, nutritious food and present in 11.1% of the general population, has not been assessed in medical students. Food insecurity is related to adverse outcomes for both health and academics in undergraduate students. Assessing the presence of food insecurity in medical students, a population at high risk for burnout and depression, may allow for intervention in order to improve overall wellness in this population. The objectives of this study were to assess the prevalence of food insecurity in a medical student population and identify potential reasons for any measured food insecurity., Methods: We used a questionnaire that included the US Household Food Security Survey Module: Six-Item Short Form. The survey was emailed to all students enrolled at a Northeastern medical school (N=588) to assess food insecurity in the previous 3 months. The questionnaire included potential reasons for food insecurity., Results: The survey response rate was 22.4%. Food insecurity was present in 11.8% of these respondents. The main reasons selected for food insecurity were not being able to get to the store (33.9%), followed by insufficient funds (30.4%)., Conclusions: Prevalence of food insecurity in medical students may be similar to the general population. While the results of this study represent only one medical school, we believe these results are similar at other medical schools. Interventions to reduce food insecurity in this population are necessary to improve overall student wellness.

Purpose: To synthesize a zirconia-toughened alumina (ZTA) composite with 85% alumina matrix reinforced by 15% zirconia and to characterize its optical and mechanical properties before and after artificial aging, to be compared with a conventional dental zirconia (3Y-TZP)., Material and Methods: After syntheses, ZTA and 3Y-TZP powders were uniaxially and isostatically pressed. Green-body samples were sintered and polished to obtain 80 disc-shaped specimens per group (12 × 1 mm, ISO 6872:2015). The crystalline content and microstructure were characterized by X-ray diffraction (XRD) and scanning electron microscope (SEM). Optical properties were determined by the calculation of contrast ratio (CR) and translucency parameter (TP) using reflectance data. Mechanical properties were assessed by Vickers hardness, fracture toughness and biaxial flexural strength test (BFS). All analyses were conducted before and after artificial aging (20h, 134 °C, 0.22 MPa). Optical parameters and microhardness differences were evaluated through repeated-measures analysis of variance (p < 0.05). BFS data were analyzed using Weibull statistics (95% CI)., Results: The synthesis of the experimental ZTA composite was successful, with 98% of theoretical density, as shown in the SEM images. XRD patterns revealed typical zirconia and alumina crystalline phases. ZTA optical properties parameters showed no effect of aging, with a high CR and low TP values denoting a high masking-ability. 3Y-TZP presented lower masking-ability and aging significantly affected its optical properties. ZTA Vickers hardness, fracture toughness and Weibull parameters, including characteristic stress and Weibull modulus were not influenced by aging, while 3Y-TZP presented a significant decrease in characteristic stress and increase in fracture toughness after aging. The ZTA probability of survival for missions of 300 and 500 MPa was estimated at ~99% validating its use for 3-unit posterior fixed dental prostheses (FDP), and no different from conventional 3Y-TZP. At high-stress mission (800 MPa) a significant decrease in probability of survival was observed for aged 3Y-TZP (84%) and for immediate and aged ZTA (73 and 82% respectively)., Conclusion: The ZTA composite presented a dense microstructure, with preservation of the crystalline content, optical and mechanical properties after artificial aging, which encourages future research to validate its potential use for large span FDP., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Superior semicircular canal dehiscence (SSCD) is a rare inner ear disorder; currently, it is unknown whether the etiopathology underlying this structural irregularity affects neighboring structures. The goal is to investigate the prevalence of bone thinning in areas of the middle cranial fossa (MCF) floor in SSCD and non-SSCD patients., Methods: This retrospective study analyzed 100 patients from March 2011 to June 2017 at a tertiary referral center. 100 patients undergoing 118 SSCD repair surgeries (18 bilateral) were identified. 12 SSCD ears were excluded due to lack of pre-operative computed tomography (CT) scans or history of prior SSCD repair at an outside facility. Non-SSCD ears were identified from routinely-obtained CT scans for temporal bone fracture (fractured sides excluded) for a total of 101 ears; 26 non-SSCD ears were excluded due to lack of high-resolution imaging., Results: Univariate analyses reveal that SSCD diagnosis is associated with higher rates of geniculate ganglion (GG) dehiscence compared with non-SSCD controls (42.7 vs. 24%; χ 2 (1) = 9.69,P = 0.008). Individuals with SSCD depicted significantly thinner bone overlying the geniculate ganglion (GG) (0.23 ± 1.2 mm) compared to controls (0.28 ± 1.8 mm, (t(1 6 4)) = 2.1, P = 0.04). SSCD patients presented thinner bone overlying the internal auditory canal (IAC) (0.33 ± 1.3 mm) compared to patients without SSCD (0.46 ± 1.6 mm, (t(2 5 7) = 6.4, P < 0.001)., Conclusions: The increased prevalence of dehiscence of the MCF in this cohort of SSCD patients compared to non-SSCD patients suggests that the etiology underlying SSCD affects surrounding structures., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate whether quality improvement (QI) and patient safety (PS) training in preclerkship medical education resulted in students' development and retention of knowledge, application-based and perceived skills, and attitudes throughout clerkships., Method: A longitudinal QI/PS curriculum with multimodal curricular components was implemented in the preclerkship curriculum between 2015 and 2017 at the Warren Alpert Medical School of Brown University, Rhode Island. Assessments were administered at baseline (T1), end of year 1 (T2), Clinical Skills Clerkship (T3), and end of clerkships (T4) in the intervention cohort (n = 97). In 2018, T4 data for this cohort were compared with a prior control cohort (n = 97) at T4., Results: Results of knowledge-based multiple-choice questions (MCQs) (t[134] = -1.57, P < .001) and application-based skills (t[132] = -8.91, P < .001) demonstrated significant improvement from T1 to T2 (intervention cohort). Assessments of perceived skills showed significant growth from T1 to T2 (t[137] = -23.38, P < .001). Performance on application-based skills significantly improved from T2 to T3 (t[123] = -4.11, P < .001). Compared with the control cohort, the intervention cohort had significantly higher scores on MCQs (t[187.88] = 3.98, P < .001), application-based skills (t[72.69] = 6.40, P < .001), perceived skills (t[106.99] = 5.24, P < .001), and attitudes (t[152] = 5.86, P < .001)., Conclusions: Incorporation of preclerkship QI/PS training resulted in improvements in knowledge, application-based and perceived skills, and attitudes that were retained throughout clerkships.

The eukaryotic initiation factor 4E (eIF4E) specifically recognizes the 5' mRNA cap, a rate-limiting step in the translation initiation process. Although the 7-methylguanosine cap (MMGcap) is the most common 5' cap structure in eukaryotes, the trans-splicing process that occurs in several organism groups, including nematodes and flatworms, leads to the addition of a trimethylguanosine cap (TMGcap) to some RNA transcripts. In some helminths, eIF4E can have a dual capacity to bind both MMGcap and TMGcap. In the present work, we evaluated the distribution of eIF4E protein sequences in platyhelminths and we showed that only one gene coding for eIF4E is present in most parasitic flatworms. Based on this result, we cloned the Echinococcus granulosus cDNA sequence encoding eIF4E in Escherichia coli, expressed the recombinant eIF4E as a fusion protein to GST, and tested its ability to capture mRNAs through the 5' cap using pull-down assay and qPCR. Our results indicate that the recombinant eIF4E was able to bind preferentially 5'-capped mRNAs compared with rRNAs from total RNA preparations of E. granulosus. By qPCR, we observed an enrichment in MMG-capped mRNA compared with TMG-capped mRNAs among Eg-eIF4E-GST pull-down RNAs. Eg-eIF4E structural model using the Schistosoma mansoni eIF4E as template showed to be well preserved with only a few differences between chemically similar amino acid residues at the binding sites. These data showed that E. granulosus eIF4E can be used as a potential tool to study full-length 5'-capped mRNA, besides being a potential drug target against parasitic flatworms.

Background: Medical student reflection is integral for professional development. Preliminary findings suggest that short-format writing promotes reflection and identifies impactful experiences. We sought to determine whether reflective writing could be used as a clerkship needs assessment., Methods: During their surgical clerkship, medical students submitted "tweet"-format reflections and completed a standardized evaluation. "Tweet" content was analyzed using modified grounded theory methods and coded by valence, content, and reflection. Sub-coding was conducted to compare feedback between "tweets" and evaluations., Results: We analyzed 286 reflections and 214 evaluation comments; 176 "tweets" were reflective (62%). "Tweets" commented on "patient interaction" (53%), "educational experience" (38%), "physician interaction" (26%), and "career decisions" (10%). A significant difference was observed between "tweets" and evaluations with regard to the number that provided feedback on experiences with "critically ill or dying patients.", Conclusions: Reflections provided real-time reactions to impactful clerkship events, notably those involving critically ill or dying patients. This focus on illness may represent an unmet need for discussions related to end of life care. Overall, reflections provided more actionable feedback compared to evaluations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The generation of IgE-mediated food allergy in humans is silent and only diagnosed upon manifestation of clinical symptoms. While experimental models have been used to investigate some mechanisms of allergic sensitization, the generation of humoral immunity and memory remains to be elucidated. Here, we defined the evolution of allergen-specific B-cell responses during epicutaneous sensitization to foods., Methods: Wild-type and genetic knockout animals, and drug or antibody strategies for cell depletion and immunoglobulin signaling blockade were used to investigate epicutaneous sensitization and disease progression; we analyzed allergen-specific germinal centers and IgG1 + memory B cells by flow cytometry, evaluated humoral responses, and determined clinical reactivity (anaphylaxis)., Results: Epicutaneous sensitization caused microscopic skin damage, inflammation, and recruitment of activated dendritic cells to the draining lymph nodes. This process generated allergen-specific IgG1 + germinal center B cells, serum IgG1, and anaphylaxis that was mediated by the alternative pathway. Whether we used peanut and/or ovalbumin from the egg white for sensitization, the allergen-specific IgG1 + memory compartment predominantly exhibited an immature, pro-germinal center phenotype (PDL-2 - CD80 - CD35 + CD73 + ). Subsequent subclinical exposures to the allergen induced IgE + germinal center B cells, serum IgE, and likely activated the classical pathway of anaphylaxis., Conclusions: Our data demonstrate that IgG1 + B-cell immunity against food allergens in epicutaneous sensitization precedes the generation of IgE responses. Therefore, the assessment of allergen-specific cellular and humoral IgG1 + immunity may help to identify individuals at risk of developing IgE-mediated food allergy and hence provide a window for therapeutic interventions., (© 2018 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Students from health professional schools participated in a half-day interprofessional education workshop centered on substance use disorder training. One component was a patient panel featuring individuals with a history of opioid use disorder who described the impact of addiction on their lives and their road to recovery using varied treatment options. We hypothesized that interacting with individuals with opioid use disorder early in training would elicit more humanistic perspectives and decrease bias and stigma in future health care professionals. Methods: After participating in the panel experience, health professional students ( N  = 580) from medicine, nursing, pharmacy, physical therapy, and social work were asked to complete short, 5-minute, rapid reflections. Prompts asked students whether the panel changed their perception of individuals with substance use disorder, to reflect on their attitudinal changes or lack thereof, and how working in interprofessional teams could impact the management and treatment of these patients. Conventional content analysis was performed. Results: Eighty-nine percent of students who attended the session completed the rapid reflections ( n  = 514). Overall, approximately 70% ( n  = 369) of students indicated that their perceptions of individuals with substance use disorder had changed as a result of the patient panel, with students from pharmacy more likely to indicate a change in attitudes. Themes across all professions included a change toward a more humanistic perspective, value of hearing real patient stories, and learning about treatment and recovery options. Student responses described how interprofessional health care teams can provide more holistic care with a broader range of therapeutic options that may improve long-term outcomes. Conclusions: A patient panel experience is influential on interprofessional students' attitudes toward patients who suffer from opioid use disorder. Students identified an interprofessional approach as being a valuable component of management and treatment of these patients.

Despite the reduction in the prevalence of soil-transmitted helminthiases in many regions of the world, morbidity rates remain high in some rural regions. The Kato-Katz technique is a simple, inexpensive and field-applicable tool commonly used for the diagnosis and worm-burden characterization of these infections. Molecular studies have revolutionized our understanding of the epidemiology and evolutionary genetics of parasites. In this study we recovered helminthic DNA from Kato-Katz slides (n = 93) prepared in 2011 in the Brazilian Amazon. We achieved DNA recovery by polymerase chain reaction (PCR) in 84% of cases for Ascaris sp. and 75% of cases for hookworms. The sequencing confirmed the specific species of the amplicons. The slides stored for a few years could be analysed using this methodology, allowing access to DNA from a large collection of samples. We must consider the Kato-Katz thick smears as a source of helminth DNA. This can significantly reduce logistical difficulties in the field in terms of obtaining, preserving, transporting and initial processing of samples.

Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.

Introduction: There is a call to incorporate quality improvement and patient safety (QI/PS) content into undergraduate medical education, though limited literature exists on optimal teaching strategies. We designed a required, interactive workshop for first-year medical students to introduce principles of QI/PS, specifically focusing on student attitudes, knowledge, and skills., Methods: We used active learning principles from existing literature and included the application of QI/PS concepts, engaging in PDSA (plan, do, study, act) cycles, conducting root cause analyses, and creating a fishbone diagram. Evaluation of student knowledge included pre/post assessments with locally designed multiple-choice items and a case scenario from the Quality Improvement Knowledge Application Tool. Additional students' self-assessments included perceived knowledge and problem-solving skills. We also evaluated student satisfaction with the workshop., Results: Results on the direct assessment total score ( n = 136) indicated significant growth from pretest (65%) to posttest (89%). Indirect assessments ( n = 138) targeting perceived ability to define QI/PS principles, identify key components in a QI case scenario, explain the purpose of a fishbone diagram, apply a PDSA cycle, and create a fishbone diagram for a QI case scenario all significantly increased from pre- to postworkshop. The mean overall rating across the 2 years the workshop was administered ( n s = 134, 137) was 75% (i.e., good to very good)., Discussion: First-year medical students' knowledge and perceived skills significantly increased from start to end of the workshop. The workshop was placed in an appropriate stage of the curriculum and contained relevant information for our learners., Competing Interests: None to report.

Background: Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum., Materials and Methods: Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission)., Results: Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91)., Conclusion: This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.

Sociodemographically disadvantaged patients have worse outcomes on some quality measures that inform Medicare Advantage plan ratings. Performance measurement that does not adjust for sociodemographic factors may penalize plans that disproportionately serve disadvantaged populations. We assessed the impact of adjusting for socioeconomic and demographic factors (sex, race/ethnicity, dual eligibility, disability, rurality, and neighborhood disadvantage) on Medicare Advantage plan rankings for blood pressure, diabetes, and cholesterol control. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Plans that improved in ranking after adjustment enrolled higher proportions of disadvantaged enrollees. Adjusting quality measures for socioeconomic factors is important for equitable payment and quality reporting. Our study suggests that plans serving disadvantaged populations would have improved relative rankings for three important outcome measures if socioeconomic factors were included in risk-adjustment models.